History > 2012 > USA > Health (I)

Women’s Health Care at Risk

February 28, 2012
The New York Times


A wave of mergers between Roman Catholic and secular hospitals is threatening to deprive women in many areas of the country of ready access to important reproductive services. Catholic hospitals that merge or form partnerships with secular hospitals often try to impose religious restrictions against abortions, contraception and sterilization on the whole system.

This can put an unacceptable burden on women, especially low-income women and those who live in smaller communities where there are fewer health care options. State regulators should closely examine such mergers and use whatever powers they have to block those that diminish women’s access to medical care.

Gov. Steve Beshear of Kentucky, for example, recently turned down a bid by a Catholic health system to merge with a public hospital that is the chief provider of indigent care in Louisville. He cited concerns about loss of control of a public asset and restrictions on reproductive services.

The nation’s 600 Catholic hospitals are an important part of the health care system. They treat one-sixth of all hospital patients, and are sometimes the only hospital in a small community. They receive most of their operating income from public insurance programs like Medicare and Medicaid and from private insurers, not from the Catholic Church. They are free to deliver care in accord with their religious principles, but states and communities have an obligation to make sure that reproductive care remains available. This should be a central goal for government officials who have a role in approving such consolidations.

As Reed Abelson wrote in a recent report in The Times, these mergers are driven by shifts in health care economics. Some secular hospitals are struggling to survive and eager to be rescued by financially stronger institutions, which in many cases may be Catholic-affiliated. By one estimate, 20 mergers between Catholic and non-Catholic hospitals have been announced over the past three years and more can be expected.

The 2009 “Ethical and Religious Directives” issued by the United States Conference of Catholic Bishops warns that Catholic institutions should avoid entering into partnerships “that would involve them in cooperation with the wrongdoing of other providers.” Catholic hospitals have refused to terminate pregnancies, provide contraceptive services, offer a standard treatment for ectopic pregnancies, or allow sterilization after caesarean sections (women seeking tubal ligations are then forced to have a second operation elsewhere, exposing them to additional risks).

In one case, the sole hospital in a rural area in southeastern Arizona announced in 2010 that it would partner with an out-of-state Catholic health system, and would immediately adhere to Catholic directives that forbid certain reproductive health services. As a result, a woman whose doctors wanted to terminate a pregnancy to save her life had to be sent 80 miles away for treatment. A coalition of residents, physicians and activists campaigned against the merger and it was called off before it was finalized.

Over the past 15 years, MergerWatch, an advocacy group based in New York City, has helped block or reverse 37 mergers and reached compromises in 22 others that saved at least some reproductive services. As mergers become more common, state and local leaders would be wise to block proposals that restrict health services.

    Women’s Health Care at Risk, NYT, 28.2.2012,
    http://www.nytimes.com/2012/02/29/opinion/womens-health-care-at-risk.html

Life, With Dementia

February 25, 2012
The New York Times
By PAM BELLUCK

SAN LUIS OBISPO, Calif. — Secel Montgomery Sr. stabbed a woman in the stomach, chest and throat so fiercely that he lost count of the wounds he inflicted. In the nearly 25 years he has been serving a life sentence, he has gotten into fights, threatened a prison official and been caught with marijuana.

Despite that, he has recently been entrusted with an extraordinary responsibility. He and other convicted killers at the California Men’s Colony help care for prisoners with Alzheimer’s disease and other types of dementia, assisting ailing inmates with the most intimate tasks: showering, shaving, applying deodorant, even changing adult diapers.

Their growing roster of patients includes Joaquin Cruz, a convicted killer who is now so addled that he thinks he sees his brother in the water of a toilet, and Walter Gregory, whose short-term memory is ebbing even as he vividly recalls his crime: stabbing and mutilating his girlfriend with a switchblade.

“I cut her eyes out, too,” Mr. Gregory declared recently.

Dementia in prison is an underreported but fast-growing phenomenon, one that many prisons are desperately unprepared to handle. It is an unforeseen consequence of get-tough-on-crime policies — long sentences that have created a large population of aging prisoners. About 10 percent of the 1.6 million inmates in America’s prisons are serving life sentences; another 11 percent are serving over 20 years.

And more older people are being sent to prison. In 2010, 9,560 people 55 and older were sentenced, more than twice as many as in 1995. In that same period, inmates 55 and older almost quadrupled, to nearly 125,000, a Human Rights Watch report found.

While no one has counted cognitively impaired inmates, experts say that prisoners appear more prone to dementia than the general population because they often have more risk factors: limited education, hypertension, diabetes, smoking, depression, substance abuse, even head injuries from fights and other violence.

Many states consider over-50 prisoners elderly, saying they age up to 15 years faster.

With many prisons already overcrowded and understaffed, inmates with dementia present an especially difficult challenge. They are expensive — medical costs for older inmates range from three to nine times as much as those for younger inmates. They must be protected from predatory prisoners. And because dementia makes them paranoid or confused, feelings exacerbated by the confines of prison, some attack staff members or other inmates, or unwittingly provoke fights by wandering into someone else’s cell.

“The dementia population is going to grow tremendously,” says Ronald H. Aday, a sociologist and the author of “Aging Prisoners: Crisis in American Corrections.” “How are we going to take care of them?”

Some prison systems are confronting that now. Many would like to transfer demented inmates to nursing homes, but their often-violent crimes make states reluctant to parole them and nursing homes reluctant to take them.

New York has taken the top-dollar route, establishing a separate unit for cognitively impaired inmates and using professional caregivers, at a cost of about $93,000 per bed annually, compared with $41,000 in the general prison population. Pennsylvania and other states are giving mental health workers special dementia training.

But some struggling prison systems, including those in Louisiana and California, are taking a less expensive but potentially riskier approach. They are training prisoners to handle many of the demented inmates’ daily needs.

“Yeah, they did something horrible to end up here,” said Cheryl Steed, a psychologist at the California Men’s Colony, where prisoners who help inmates with dementia are called Gold Coats because their yellow jackets contrast with the standard-issue blue. But without them, she said, “we wouldn’t be able to care for our dementia patients very well.”

After escorting Joaquin Cruz to an appointment, James Evers, a Gold Coat, was returning him to their adobe-colored cellblock when they encountered corrections officers strip-searching inmates for missing tools.

Mr. Cruz, 60, who barely recalls that he is in prison for killing someone who sold him fake cocaine, grew confused and resistant when guards tried searching him. “He has Alzheimer’s,” Mr. Evers managed to explain. “It’s not that he’s refusing to do what you’re asking.”

At the prison, shadowed by seacoast mountains, Gold Coats are paid $50 a month and have better knowledge of impaired prisoners’ conditions than many prison guards. Gold Coats, trained by the Alzheimer’s Association and given thick manuals on dementia, were the first to notice when Mr. Cruz began putting his boots on the wrong feet and “started pulling down his pants and going to the bathroom wherever he was,” said Phillip Burdick, a Gold Coat who is serving a life sentence for beating a man to death with a hammer.

Gold Coats report these changes, often at weekly support group meetings with Dr. Steed. They identify “different tricks and strategies to get guys to do what they need to do,” she said.

Before the program was started in 2009, demented inmates frequently caused fights, hitting those they considered threatening or disturbing other prisoners by encroaching on their turf. “The whole atmosphere was hostile,” said Bettina Hodel, a psychologist who started the program and once narrowly avoided being struck herself. Now, Gold Coats absorb much of that behavior.

“I been swung at, got a big fat lip, and my glasses have been broken,” said Ramon Cañas, a Gold Coat who killed a hitchhiker who stole his car. He said Gold Coats — there are currently six of them for about 40 inmates — often wear surgical gloves because they are exposed to “a lot of body fluids.”

Protecting the Vulnerable

But they also protect demented inmates from prisoners who try assaulting, abusing or robbing them. When Steven Berry, a Gold Coat, caught two inmates picking a demented prisoner’s pockets, he barreled toward them. “Got the stuff back,” reported Mr. Berry, a former Navy signalman who killed his sister-in-law and tried to kill his wife.

Gold Coats get harassed and called snitches for seeming to side with prison officials and because of the perks they receive. In the dining hall, to help dementia patients who, as Mr. Burdick says, “start forgetting basic things like what is a spork for,” Gold Coats sit with them at special “slow eater” tables, where meals are allowed to stretch beyond the usual 10 to 12 minutes.

When a prisoner tried stealing a patient’s dessert, Mr. Montgomery, one of the Gold Coats, snarled, “You got to give him his cookie back.”

“Who are you, the PO-lice?” the inmate barked. Mr. Montgomery retorted, “Yes, I’m the PO-lice!”

More inmates have dementia than prison officials realize, experts say. Prison routines can mask symptoms like forgetfulness. Corrections officers are used to punishing aggressive inmates, not evaluating them for Alzheimer’s.

“Not responding to questions appropriately, being belligerent — it’s just considered bad behavior,” said Sharen Barboza, director of clinical operations for MHM Services, a prison mental health provider that trains prison officials.

New York’s Unit for the Cognitively Impaired, begun five years ago, has so far cared for 84 inmates, but “there’s a number of people in the system that we really haven’t tapped,” said Paul Kleinman, the program’s psychologist. “They’re not being identified properly.”

Alzheimer’s currently affects 5.4 million Americans, a number expected to double by 2040. Experts believe that Alzheimer’s disease in prisons could grow two or three times as fast, said John Wilson, senior clinical operations specialist for MHM, because “protective factors that might mitigate developing dementia are slim to none in prison — things like complex jobs, rich social environment, leisure activities.”

Realizing that California, with nearly 13,000 inmates 55 and older, could not adequately care for demented prisoners, Dr. Hodel, when she was starting the Gold Coat program, asked the regional chapter of the Alzheimer’s Association to train inmates to help. The chapter’s area director, Sara Bartlett, worried that she and Arlene Stepputat, then the program director, would not be safe as “women in a man’s prison.” She doubted whether violent felons could provide sensitive care.

Both women were surprised that inmates seemed more receptive, with less-complicated emotional ties to the patients than many of the people they trained to care for relatives at home. “They were much easier to work with,” Ms. Stepputat said.

Heriberto G. Sanchez, chief psychologist of the California Men’s Colony, said prisoners “were appreciative that someone from the outside world thought they could do this.” One wrote in an evaluation, “Thank you for allowing me to feel human.”

The prison requires that Gold Coats have “a clean behavior record for about 5 to 10 years,” Dr. Steed said. So far, only one Gold Coat has been removed, because “he had problems” with dementia patients’ messy eating and other behaviors, Dr. Hodel said.

For inmates, the job has attractions. It pays better than other prison work and polishes a prisoner’s record.

Two Gold Coats have received parole.

One of them, Shawn Henderson, who got 25 years to life for a 1985 double murder and was twice denied parole, was released last February. Doing a job where “you get spit on, feces thrown on you, urine on you, you get cursed out” helped teach him to cope outside prison, said Mr. Henderson, 46. “Now when I come into an encounter like that on the street, I can be a lot more compassionate,” he said. “And I don’t look at telling authorities as snitching anymore.”

Gold Coats conduct exercise classes and run meetings designed to stimulate memory and lessen disorientation. They escort inmates to doctors, acting as their intermediaries.

And they often need to be deft. One 73-year-old inmate stands by a gate most mornings, waiting for his long-dead mother to pick him up. Sometimes he refuses to shower, afraid of missing her. Mr. Evers coaxes him inside, telling him that his mother “wants you to shower before she gets here.”

More subtlety is required for Mr. Gregory, 71, who is serving a life sentence for brutalizing his girlfriend with a switchblade — throwing her body parts in the trash and getting caught, he said, when “I went right back to the room that I killed her in and had sex with another” woman. He does not believe he has dementia, but his gradually accumulating symptoms include breaking a mop over an inmate’s head and writing to outside agencies under the delusion that he will be granted parole.

To assist Mr. Gregory, Samuel Baxter, a Gold Coat who fatally shot a co-worker, firing six times, gently reminds him about bed making and schedules. “You have to allow Mr. Gregory to come to you,” Mr. Baxter said.

There are limits to what Gold Coats can do. They can file patients’ fingernails, for instance, but not clip them because that constitutes a professional caregiving responsibility that cannot legally be delegated to inmates. And there are indignities, like cleaning up after inmates who urinate on the floor.

“A year ago,” Mr. Baxter said, “I couldn’t have said, ‘You know what man, I’m going to go help this grown man get in the shower,’ ” and “get in there and help these guys wash theirself off.”

Gold Coats say they are moved by the work. “I’m a person who was broken,” said Mr. Burdick, who during 35 years in prison lost a wife to AIDS and a 16-year-old daughter to suicide. Dementia patients often “don’t even say thank you,” he said, but “they just pat me like that and I know what that means.”

Mr. Cañas said: “I didn’t have any feelings about other people. I mean, in that way, I was a predator.” Now, he said, “I’m a protector.”

Still, the Gold Coats have not figured out how to help Leon Baham.

When Mr. Baham, 71, received a dementia diagnosis a year ago, a psychiatrist, Dr. Russell Marks, noted that he pined for his wife “almost as though at moments he didn’t realize” that his crime had been “murdering the woman he was tearful about.”

In a recent interview, Mr. Baham recalled the murder hazily: “Blood everywhere. She said, ‘Sweetheart.’ ”

He has repeatedly been placed in the crisis center, once after “he urinated on the floor, he was banging his head on the cage, he needed a spit mask to prevent his spitting on others,” and he was “threatening to kill persons that he believed stole his watch,” Dr. Marks said.

After trying to enter the wrong cell, he told Dr. Steed, “I’m going to kill myself,” adding, “I don’t want to live this way.”

He was sent to a psychiatric hospital, returning less depressed. But he often sits confused in the yard. “I forget why I was going out there,” Mr. Baham said. “I’m slipping a little bit.”

Still, he resists the Gold Coats’ help and believes that he would have to pay them. Oblique assistance, like Mr. Burdick bringing him a jacket, is all he accepts so far.

“I don’t need them, you know,” Mr. Baham said.

 

‘I Was a Monster’

The compassion Secel Montgomery is required to show in his job as a Gold Coat was nowhere to be seen in the killing he committed in 1987. He wanted money for alcohol, and when his former sister-in-law refused, “I knocked her unconscious, tied her up and stabbed her.” Then he washed his hands and called his wife for a ride.

He grabbed things that had his fingerprints on them, but left his infant nephew there alone. “I figured that’s kidnapping,” he explained.

Mr. Montgomery, sentenced to 26 years to life, spent 17 years in a high-security prison for “disobeying orders,” he said. He made contraband alcohol called “pruno.”

Only in 2000, after Mr. Montgomery, 47, was found with marijuana, accused of threatening a prison official and locked in the “hole,” did he decide to change. “I was a monster,” he said.

Families of demented inmates seem unperturbed that prisoners like Mr. Montgomery now have so much responsibility. Laura Eklund, Mr. Cruz’s niece, said prison officials have asked if his relatives wanted him paroled, but the family has declined. “To be honest, the care he’s receiving in prison, we could not match,” she said.

When Mr. Cruz spies his own reflection, he often believes it is his brother Sergio. To keep him from getting agitated, his cell mirror has been covered with tape. But now when he looks into a toilet, he calls: “Hey, my brother, he’s down there. I can’t get him out.”

Mr. Montgomery said he tries to reassure Mr. Cruz, but if Mr. Cruz is locked in his cell, Mr. Montgomery — still a prisoner, after all — cannot enter even if he is allowed out of his own cell. He will call to Mr. Cruz through a tiny window in the thick metal door. “All I can do is say, ‘Cruz, come here, come here, come here,’ but he’ll stand there,” staring helplessly into the toilet and agonizing. “ ‘See, see, look, see.’ ”

    Life, With Dementia, NYT, 25.2.2012,
    http://www.nytimes.com/2012/02/26/health/dealing-with-dementia-among-aging-criminals.html

Ulric Neisser Is Dead at 83; Reshaped Study of the Mind

February 25, 2012
The New York Times
By DOUGLAS MARTIN

Ulric Neisser, a psychological researcher who helped lead a postwar revolution in the study of the human mind by advancing the understanding of mental processes like perception and memory, died on Feb. 17 in Ithaca, N.Y. He was 83.

The cause was complications of Parkinson’s disease, his son Mark said.

Advances in information theory, computers and experimental methods after World War II enabled scientists to challenge the dominant psychological discipline, behaviorism. Behaviorism examines stimuli to the senses and the resulting responses. In its purest permutation, it rejects the idea that the mind even exists.

Dr. Neisser (pronounced NICE-er), who loved to challenge orthodoxy and devise theoretical frameworks, sought to prove that people could think and to describe how they did it. He even named the new field with the title of his 1967 book, “Cognitive Psychology.” It set forth ideas advanced by him and other scientists that internal mental processes not only mattered, but could also be studied and measured.

“He galvanized this whole discipline,” James E. Cutting, chairman of the psychology department of Cornell University, said in an interview.

As computer technology advanced in the 1960s, students of the mind began to imagine it as an information processing system. Work in information theory, growing out of code-breaking operations in World War II, fed into the new discipline. So did new theories of linguistics that posited an innate structure to the mind.

James R. Pomerantz, a psychology professor at Rice University, said in an interview that Dr. Neisser’s genius was to combine these new understandings in constructing a new view of the mind, much as a paleontologist assembles a dinosaur skeleton from scattered fossils. The result, Dr. Pomerantz said, was “a single coherent way of thinking how the mind works.”

Dr. Neisser’s work showed that memory is a reconstruction of the past, not an accurate snapshot of it. He found that however much people think they are remembering actual events, they are really remembering memories — and probably memories of memories. The mind, he said, conflates things.

In a much-publicized experiment the day after the space shuttle Challenger exploded in 1986, Dr. Neisser asked students to write down their immediate experience upon hearing the news. Nearly three years later, he asked them to recount it. A quarter of the accounts were strikingly different, half were somewhat different, and less than a tenth had all the details correct. All were confident that their latter accounts were completely accurate.

Another memory experiment compared the testimony of John W. Dean III, the former aide to President Richard M. Nixon, during the Senate Watergate hearings with tapes of Mr. Dean’s conversations that the president had secretly recorded. He found discrepancies in detail after detail.

But Dr. Neisser said the testimony was accurate about the most important truths: that there really had been a cover-up, and that Nixon did approve it.

He also made observations about perception. In one experiment, he had participants watch groups throwing balls on a video screen. As they watched, a woman walked through the room carrying an open umbrella. Few remembered seeing her. Dr. Neisser called this phenomenon “selective looking”; other psychologists christened it “inattentional blindness.”

One result of this work on perception and memory was to cast doubt on accounts of remembered child abuse that swept the United States in the early 1980s. Dr. Neisser called into question the widely held view that extremely vivid memories cannot be false. He worked with the False Memory Syndrome Foundation and served on its board.

In 1995, Dr. Neisser headed an American Psychological Association task force that examined research suggesting that intelligence varied among ethnic groups. The panel ended up questioning the tests themselves, or, in his phrase, the assumption that “there’s something wrong with children who score low on intelligence tests.”

“Once you make that assumption,” he said, “all your later theory and research suffers from a built-in bias. To ask what’s wrong with black children is to assume that something is the matter — to locate the problem in the mind of the child.”

Ulrich Gustav Neisser was born in Kiel, Germany, on Dec. 8, 1928, and his family immigrated to the United States in 1933. He later dropped the “h” in his first name to sound more American, he said. His boyhood friends called him Dickie, and he was later known as Dick. He grew up in Swarthmore, Pa.; Washington and New York. His father, Hans, a noted economist, expected him to be a scientist. The boy had a chemistry set he did not use.

He went to Harvard and found psychology more interesting than physics. He was attracted to the Gestalt school of psychology, which takes a complex, holistic view of mental processes but lacks the scientific rigor of what became cognitive psychology. He even did some unsuccessful research on extrasensory perception, citing in an autobiographical statement “a soft spot in my heart for exciting but unlikely hypotheses.”

His contrariness extended to his own work. In 1976, he wrote “Cognition and Reality,” a book that challenged much of the field of cognitive psychology, arguing that it ignored the real world in favor of the laboratory.

Dr. Neisser earned an undergraduate degree in psychology from Harvard, a master’s degree from Swarthmore College and a doctorate from Harvard. He went on to teach and do research at Brandeis, Cornell and Emory College.

His marriage to Anna Gabrielle Peirce ended in divorce. His second wife, Arden Seidler, died before him. Besides his son Mark, he is survived by three other children from his first marriage, Philip, Tobias and Juliet Neisser; a son, Joseph, from his second marriage; a stepdaughter, Jennifer Seidler; a sister, Marianne Selph; and a grandson.

Dr. Neisser came to the realization that his own memory was as fragile as those of his research subjects. For years, he had said that he was listening to a baseball game on the radio when he heard about the attack on Pearl Harbor on Dec. 7, 1941. Finally, he said, it dawned on him that he could not have been listening to a baseball game in December.

In a graduation speech at the New School for Social Research in 1998, Dr. Neisser asked how the graduates could be sure they remembered anything accurately. He told them they could not be sure. Then he struck a more hopeful note, adding: “This is a graduation, your graduation, or perhaps your son’s or your daughter’s; for that reason you are not likely to forget it. Everything is happening just as it should, just as you will remember it years from now.”

    Ulric Neisser Is Dead at 83; Reshaped Study of the Mind, NYT, 25.2.2012,
    http://www.nytimes.com/2012/02/26/us/ulric-neisser-who-reshaped-thinking-on-the-mind-dies-at-83.html

Virginia Lawmakers Backtrack on Conception Bill

February 23, 2012
The New York Times
By SABRINA TAVERNISE

Republican lawmakers in Virginia changed course on another piece of conservative legislation on Thursday, with the State Senate voting to suspend consideration of a bill that would define life as beginning at conception.

It was an abrupt reversal for Republicans, and came hours after a Senate committee voted to approve the legislation for consideration by the full body. There was broad speculation that Gov. Bob McDonnell was behind the move.

“This is a major disgrace for the Republican leadership,” said Don Blake, who runs the Virginia Christian Alliance, a conservative group that backed the bill. Republicans should have had the votes to pass the bill, he said, and the fact that they opted to suspend it raised suspicions of the governor’s involvement.

“Pro-life groups are concerned that the governor had a hand in this,” Mr. Blake said. A spokesman for Mr. McDonnell, a Republican who is mentioned as a possible candidate for vice president, did not respond to messages seeking comment.

The rapid-fire procedural maneuvering came one day after Mr. McDonnell ordered Republicans in the House of Delegates to soften a bill requiring a vaginal ultrasound before an abortion. The new version, which requires a noninvasive abdominal ultrasound, appeared aimed at defusing a mounting controversy over the bill that included spoofs on television shows.

The stalling of the legislation on Thursday also illustrated the divisions among Republicans over the bill. Opponents say it would confer legal status from the moment of conception and, in the process, cause huge legal uncertainties and lead to the banning of abortion. It would quickly be challenged in court, they say.

The eight members of the party on the Education and Health Committee approved the bill on a party-line vote in the morning, only to have it sent back several hours later with orders that it not be considered again this legislative season, scheduled to end in two weeks.

The measure, known as the personhood bill, could be revived in the next session, which opens early next year — timing that critics of the bill point out falls safely outside the electoral cycle.

“This takes it off the late-night shows,” said one Democratic aide who asked not to be identified by name because she was not authorized to speak publicly on the matter.

Delegate Bob Marshall, the bill’s sponsor, said he had approached the governor about the bill once at a reception, but did not get a positive response. Still, he had fresh hopes for it, after it passed the committee Thursday. “This could not have happened without the consent of the leadership,” he said.

State Senator Richard L. Saslaw, a Democrat who made the motion to shelve the legislation, said that he did not know whether Mr. McDonnell had intervened, but that the bill was far enough to the right that the governor would probably not have relished the prospect of signing it.

“I’m shocked that it got out of the House,” he said. “The people of Mississippi had the good sense to vote that thing down. What does that say?”

    Virginia Lawmakers Backtrack on Conception Bill, NYT, 23.2.2012,
    http://www.nytimes.com/2012/02/24/us/virginia-lawmakers-backtrack-on-conception-bill.html

Governor of Virginia Shifts Position on Abortion Bill

February 22, 2012
The New York Times
By SABRINA TAVERNISE

Gov. Bob McDonnell of Virginia backed down on Wednesday on a bill requiring women to have a vaginal ultrasound before undergoing an abortion. It was a sudden change of position for a conservative governor who is viewed as having political ambitions on the national stage.

The bill had drawn intense national attention in recent days, with a large protest by women’s health groups over the weekend and spoofs on left-leaning television shows.

In a political year that was suppposed to be all about the economy, this was the second instance in a month in which a public outcry organized in part by women’s health advocates through social media caused a reversal on the issue of abortion.

The governor’s decision not to support the bill capped several days of brinkmanship in which opponents of the measure lobbied furiously against it, galvanizing opposition by drawing on the image of male lawmakers mandating a procedure that requires inserting a probe into the vagina. One Democrat was prompted to denounce it as a “rape” bill.

Opponents presented what they said were 33,000 signatures protesting the measure. At the same time, the mostly Republican supporters in the legislature kept putting off debate on the measure, raising suspicions that the governor might be balking.

Finally, on Wednesday afternoon, Mr. McDonnell, a rising star in the Republican Party who is often talked about as a candidate for vice president, told Republican delegates to make changes that softened the requirements in the legislation. Some political analysts speculated that the decision was made with an eye to a broader national audience that might not look favorably on the passage of such a conservative bill.

This month the Susan G. Komen for the Cure foundation yielded to pressure by affiliates and women’s rights advocates and reversed its decision to largely end decades of partnership with Planned Parenthood.

In Virginia, in a written statement issued minutes before the House of Delegates was to debate the bill on Wednesday afternoon, Mr. McDonnell said that after discussion with doctors, lawyers and legislators, he had concluded that amendments were needed. He called for changes stipulating that the ultrasound be abdominal rather than vaginal. A doctor would be required to offer the next level of ultrasound, most often vaginal, but a woman would be free to reject it.

“Mandating an invasive procedure in order to give informed consent is not a proper role for the state,” the governor said in the statement.

The Family Foundation, a strong backer of the ultrasound bill, made reference to the Komen decision in a note to supporters blasting Mr. McDonnell’s reversal, saying that it was “extremely disappointed in this outcome,” particularly, it said, “given the strong pro-life credentials of this governor.”

The change — which passed the House in a vote of 65 to 32 — softens the bill considerably, but did not abolish the requirement that women have an ultrasound. If it is signed into law, Virginia would become the 10th state to require such procedures, though the requirement has been stayed by court rulings in two states, Oklahoma and North Carolina.

Specifically, the bill’s new wording would require a doctor to offer the woman a different type of ultrasound if the fetus is not viewable through an abdominal screening, but not require her to have one.

That opponents of the bill were successful in getting the language softened was a major success for them, particularly considering that vaginal ultrasounds are often administered before abortions anyway. A spokeswoman for Planned Parenthood said the group routinely includes ultrasounds “as part of the thorough medical practice of abortion care,” and gives the woman the option of viewing the image. But the group said a legal requirement that women undergo such a screening was politically motivated and “is the very definition of government intrusion.”

Supporters of the bill hoped such a requirement would lead some women to change their minds about having abortions, as vaginal ultrasounds usually show detailed images. Many women’s advocates called the bill an effort to shame women and said it intruded on their privacy.

Republicans, for their part, said the bill had been blown out of perspective by Democrats and liberal groups. State Senator Richard Black said that he participated in a call-in event on Wednesday morning with hundreds of constituents and that just one mentioned the ultrasound bill.

Abortion legislation was a “tiny part” of the larger body of hundreds of bills in play in the legislature, State Senator Steve Martin said. “It’s simply not a primary focus,” he said. “It only appears to be because people call me from New York newspapers acting as if it’s some big deal.”

Democrats savored their victory, giving a news conference after the House debate, but said they were hoping the bill would still be killed.

“This is definitely a retreat for the governor,” said State Senator Janet Howell, a Democrat from Northern Virginia. “The national spotlight and ridicule has had an impact. The Republicans are scrambling for an out.”

But there was some concern among Democrats over a companion bill in the State Senate that has language identical to that in the old version. It is unlikely Senate Republicans would openly defy the governor and pass that bill, but Democrats said they were watching closely.

Besides, they said, the watered-down bill is still objectionable. “It’s still putting up a barrier to a woman trying to exercise her constitutional right,” said Delegate Charniele Herring, a Democrat.

In yet another twist, the Republican sponsor of the Senate bill, Jill Vogel, said she would withdraw the legislation altogether, though it was not clear whether the rules would allow her to do so after its passage.

Delegate Bob Marshall, a Republican who had supported the bill, said the companion measure, which is due to be voted on as early as Thursday in a Senate committee, might not clear that hurdle, raising the specter of complete collapse of the ultrasound bill and giving Mr. McDonnell a way out of having to sign it.

“This is a high-stakes game,” Mr. Marshall said. “Everything is on a razor’s edge.”

Most political analysts agreed that Mr. McDonnell was seeking to defuse an embarrassing and unmanageable situation — especially at a moment when he seems to be shifting his gaze to a national, and more centrist, audience. .

“Pragmatism trumped ideology today,” said Daniel Palazzolo, a professor or political science at the University of Richmond.

Erik Eckholm and Jennifer Preston contributed reporting.

    Governor of Virginia Shifts Position on Abortion Bill, NYT, 22.2.2012,
    http://www.nytimes.com/2012/02/23/us/governor-of-virginia-calls-for-changes-in-abortion-bill.html

Report Affirms Lifesaving Role of Colonoscopy

February 22, 2012
The New York Times
By DENISE GRADY

A new study provides what independent researchers call the best evidence yet that colonoscopy — perhaps the most unloved cancer screening test — prevents deaths. Although many people have assumed that colonoscopy must save lives because it is so often recommended, strong evidence has been lacking until now.

In patients tracked for as long as 20 years, the death rate from colorectal cancer was cut by 53 percent in those who had the test and whose doctors removed precancerous growths, known as adenomatous polyps, researchers reported on Wednesday in The New England Journal of Medicine. The test examines the inside of the intestine with a camera-tipped tube.

“For any cancer screening test, reduction of cancer-related mortality is the holy grail,” said Dr. Gina Vaccaro, a gastrointestinal oncologist at the Knight Cancer Institute at Oregon Health and Science University who was not involved in the research. “This study does show that mortality is reduced if polyps are removed, and 53 percent is a very robust reduction.”

Colorectal tumors are a major cause of cancer death in the United States and one of the few cancers that that can be prevented with screening. This year, more than 143,000 new cases and 51,000 deaths are expected. Incidence and death rates have been declining for about 20 years, probably because of increased use of screening tests and better treatments. But only about 6 in 10 adults are up to date on getting screened for colorectal cancer, according to federal estimates.

Cancer screening tests have come in for greater scrutiny recently. A government panel recommended in October that men no longer get the P.S.A. blood screening test for prostate cancer after concluding it did not save lives. The new study on colonoscopy has limitations — it is not a randomized clinical trial — but some experts say it nonetheless was well done and helps answer questions about the effectiveness of the procedure.

Earlier research had proved that removing precancerous polyps could greatly reduce the incidence of colorectal cancer. But a major question remained: Did removing the polyps really save lives? In theory, it was possible that doctors were finding growths that would not have killed the patient, or missing ones that could be fatal.

“This study puts that argument to rest,” said Dr. David A. Rothenberger, a professor and deputy chairman of surgery at the University of Minnesota Masonic Cancer Center. He was not part of the study.

Robert A. Smith, the senior director for cancer control at the American Cancer Society, said, “This is a very big deal.”

A team of researchers led by Dr. Sidney J. Winawer, a gastroenterologist at Memorial Sloan-Kettering Cancer Center in New York City, followed 2,602 patients who had adenomatous polyps removed during colonoscopies from 1980 to 1990. Doctors compared their death rate from colorectal cancer with that of the general population, where 25.4 deaths from the disease would have been expected in a group the same size. But among the polyp group, there were only 12 deaths from colorectal cancer, which translates into a 53 percent reduction in the death rate.

The new study did not compare colonoscopy with other ways of screening for colorectal cancer and so does not fully resolve a longstanding medical debate about which method is best. Tests other than colonoscopy look for blood in the stool or use different techniques to examine the intestine. All the tests are unpleasant, and people are often reluctant to have them.

Although doctors have differed about which method is best, they agree that it is important to get over the squeamishness and have some type of test, usually starting at age 50. Screening is worthwhile because colorectal cancer is one of the few types of cancer (cervical and skin cancer are others) in which premalignant growths have been identified and the disease can be prevented if those growths are detected and cut out. Research indicates that not every polyp turns into cancer, but that nearly every colorectal tumor starts out as an adenomatous polyp.

Even if intestinal cancer has already developed, it can still be cured if it is found early and treated.

“Not all adenomas become cancers, and not all cancers cause death,” said Ann Zauber, the lead author of the study and a statistician at Sloan-Kettering. But in many cases, she said, “we have gotten those that would have had the potential to go on and cause a cancer death.”

Dr. Smith, at the American Cancer Society, said the new study on colonoscopy was well done, and noted that changes in death rates can be difficult to measure because they require long-term studies like this one.

But Dr. Harold C. Sox, an emeritus professor of medicine at Dartmouth Medical School and former editor of a leading medical journal, Annals of Internal Medicine, cautioned that the new study was not the last word. He said it was not clear that the same reduction in the death rate found in the study would occur in the general population.

Nonetheless, he said, “I suspect that removing polyps does reduce colorectal cancer mortality.”

The type of evidence in this study, based on looking back at patient records, is not considered as reliable as that from a randomized controlled study, in which groups of patients are picked at random to have one treatment or another and then compared over time.

Dr. Sox also said that because all of the patients in the study had adenomatous polyps, it is not certain that the findings would apply exactly to the general population, in which this type of polyp is found in about 15 percent of women and 25 percent of men.

In addition, Dr. Sox said, the people with polyps were part of a study that provided high-quality colonoscopy, so they may not have been comparable to the general population.

Other studies have found that doctors vary in their ability to find polyps, that certain types of polyps are hard to detect and that colonoscopy is better at finding polyps in the lower part of the intestine than in its upper reaches.

Other screening tests look for blood in the stool, and if it is found, the patient is advised to have a colonoscopy. Another test, sigmoidoscopy, examines only the lower part of the colon. Barium enemas with X-rays can also show some abnormal growths. But sigmoidoscopy and barium enemas are not used much anymore in the United States.

Stool tests need to be done once a year; many people do not comply. In fact, a study from Spain in the same issue of the journal as Dr. Winawer’s article found that when people were offered a stool test, only 34.2 percent took it. The figure for colonoscopy was even worse: 24.6 percent.

Colonoscopy does not have to be done every year: If there are no polyps, it is recommended just once every 10 years. People with polyps are usually told to have the test every three years.

But colonoscopy is expensive, costing hundreds or thousands of dollars, depending on whether polyps are removed and on the part of the country where it is done. It also carries small risks of bleeding or perforation of the intestine. And it requires sedation as well as strong, foul-tasting laxatives to clean out the intestines so that the doctor can look for polyps.

“Any screening is better than none,” Dr. Winawer said. “The best test is the one that gets done, and that gets done well.”

His study was paid for by the National Cancer Institute, Memorial Sloan-Kettering Cancer Center and private foundations dedicated to colon cancer.

    Report Affirms Lifesaving Role of Colonoscopy, NYT, 22.2.2012,
    http://www.nytimes.com/2012/02/23/health/colonoscopy-prevents-cancer-deaths-study-finds.html

Renato Dulbecco, 97, Dies; Won Prize for Cancer Study

February 20, 2012
The New York Times
By DENISE GELLENE

Dr. Renato Dulbecco, a virologist who shared a Nobel Prize in 1975 for his role in drawing a link between genetic mutations and cancer, died on Sunday at his home in the La Jolla section of San Diego. He would have turned 98 on Wednesday.

The National Research Council of Italy, where he had worked for many years, announced his death. He was a former president of the Salk Institute for Biological Research in San Diego.

Through a series of experiments that began in the late 1950s, Dr. Dulbecco showed that certain viruses could insert their own genes into infected cells and trigger uncontrolled cell growth, a hallmark of cancer.

The discovery provided the first solid evidence that cancer was caused by genetic mutations, a breakthrough that changed the way scientists thought about cancer and the effects of carcinogens, like some hair dyes and tobacco smoke.

“His research was the beacon that clearly showed that changes in the genome can lead to cancer,” said Inder M. Verma, a biologist and former colleague of Dr. Dulbecco’s at the Salk Institute.

Dr. Dulbecco shared the 1975 Nobel for physiology or medicine with a former student, Howard M. Temin, and another researcher, David Baltimore. Dr. Temin, who died in 1994, and Dr. Baltimore studied viruses that carry their genetic information in the form of RNA.

Dr. Dulbecco looked at viruses that use DNA to store their genetic information. Dr. Dulbecco went on to study breast cancer, pioneering a technique for identifying cancer cells by their genetic signature — the unique proteins displayed on their surface. In 1986, he proposed cataloguing all human genes to gain deeper insights into cancer, providing the intellectual impetus for the Human Genome Project, which was completed in 2003.

Renato Dulbecco was born on Feb. 22, 1914, in Catanzaro, Italy, the son of a civil engineer. He loved tinkering as a child; he assembled a vacuum-tube radio so his mother could listen to opera, and built a working electronic seismograph. He graduated from high school at 16 and went on to the University of Torino, receiving his medical degree in 1936.

Inducted into the Italian Army as a medical officer in World War II, he was eventually ordered to the Russian front. He recalled that when the train taking him there stopped in Warsaw, he saw railway laborers wearing yellow stars. When he asked about them, he was told that the workers were Jews who would be killed when their work was done. He was horrified. “That was my turning point,” Dr. Dulbecco said in an oral history.

In Russia, he dislocated his shoulder and was sent home to recuperate. But instead of returning to the Army after his recovery, he hid in a village about 40 miles from Torino and joined the resistance. He remained in the village for the rest of the war, tending to injured partisans.

After Germany surrendered, he got involved with the Committee for National Liberation in Torino and joined the postwar city council. But he soon tired of politics and returned to the University of Torino to study physics and conduct biological research.

In 1947, a former University of Torino professor, Dr. Salvador Luria, recruited Dr. Dulbecco to Indiana University in Bloomington to study phages, viruses that infect bacteria. There, he shared a laboratory with James D. Watson, who received a Nobel in 1962 for his role in discovering the structure of DNA. Dr. Dulbecco’s mentor, Dr. Luria, shared a Nobel in 1969 for discoveries about the genetics of bacteria.

Dr. Dulbecco joined the faculty of the California Institute of Technology in Pasadena in 1949, driving his family to the West Coast in “an old car,” as he recalled, hitched to a small trailer carrying their belongings. Shortly after his arrival, he shifted his studies to animal viruses; Cal Tech had received a $100,000 gift to finance the research and was looking for someone to do it. With Dr. Marguerite Vogt, who became a longtime collaborator, he developed a method of determining the amount of polio virus present in cell culture, a step that was essential to development of the Sabin polio vaccine.

Dr. Dulbecco soon turned his attention to the connection between viruses and cancer; he was intrigued by the work of his student Dr. Temin, who wrote his thesis on the topic. Dr. Dulbecco started the research at Cal Tech and completed it at Salk, where he moved in 1962.

Working with Dr. Vogt and others, he experimented with viruses that were known to cause tumors in animals. In the 1950s, no viruses had yet been linked to human cancers. Since then, a handful of viruses have been shown to cause cancer in people, including the human papillomavirus, which is responsible for most cervical cancers.

Dr. Dulbecco believed his research had broad implications for cancer prevention. In his Nobel lecture, he urged governments to test the likelihood of new chemical substances causing mutations before allowing them on the market. He also called for severe restrictions on tobacco use.

“While we spend our life asking questions about the nature of cancer and ways to prevent or cure it,” he said, “society merrily produces oncogenic substances and permeates the environment with them.”

Dr. Dulbecco left Salk in 1972 to serve as a director of the Imperial Cancer Fund in London. He returned to Salk in 1977 and was its president from 1988 to 1992. He received the prestigious Albert Lasker Basic Medical Research Award in 1964. He became an American citizen in 1953.

His first marriage ended in divorce. His survivors include his wife, Maureen; a daughter from his first marriage, Maria Vittoria; a daughter from his second marriage, Fiona Linsey; and a grandchild. A son from his first marriage, Peter, died some years ago.

    Renato Dulbecco, 97, Dies; Won Prize for Cancer Study, NYT, 20.2.2012,
    http://www.nytimes.com/2012/02/21/us/dr-renato-dulbecco-nobel-laureate-dies-at-97.html

The ‘Safe, Legal, Rare’ Illusion

February 18, 2012
The New York Times
By ROSS DOUTHAT

AMID the sound and fury of the latest culture-war battles — first over breast cancer dollars and Planned Parenthood, and then over the White House’s attempt to require that religious employers cover contraception and potential abortifacients — it’s easy to forget that there is at least some common ground in American politics on sex, pregnancy, marriage and abortion.

Even the most pro-choice politicians, for instance, usually emphasize that they want to reduce the need for abortion, and make the practice rare as well as safe and legal. Even the fiercest conservative critics of the White House’s contraception mandate — yes, Rick Santorum included — agree that artificial birth control should be legal and available. And both Democrats and Republicans generally agree that the country would be better off with fewer pregnant teenagers, fewer unwanted children, fewer absent fathers, fewer out-of-wedlock births.

Where cultural liberals and social conservatives differ is on the means that will achieve these ends. The liberal vision tends to emphasize access to contraception as the surest path to stable families, wanted children and low abortion rates. The more direct control that women have over when and whether sex makes babies, liberals argue, the less likely they’ll be to get pregnant at the wrong time and with the wrong partner — and the less likely they’ll be to even consider having an abortion. (Slate’s Will Saletan has memorably termed this “the pro-life case for Planned Parenthood.”)

The conservative narrative, by contrast, argues that it’s more important to promote chastity, monogamy and fidelity than to worry about whether there’s a prophylactic in every bedroom drawer or bathroom cabinet. To the extent that contraceptive use has a significant role in the conservative vision (and obviously there’s some Catholic-Protestant disagreement), it’s in the context of already stable, already committed relationships. Monogamy, not chemicals or latex, is the main line of defense against unwanted pregnancies.

The problem with the conservative story is that it doesn’t map particularly well onto contemporary mores and life patterns. A successful chastity-centric culture seems to depend on a level of social cohesion, religious intensity and shared values that exists only in small pockets of the country. Mormon Utah, for instance, largely lives up to the conservative ideal, with some of America’s lowest rates of teenage pregnancies, out-of-wedlock births and abortions. But many other socially conservative regions (particularly in the South) feature higher rates of unwed and teenage parenthood than in the country as a whole.

Liberals love to cite these numbers as proof that social conservatism is a flop. But the liberal narrative has glaring problems as well. To begin with, a lack of contraceptive access simply doesn’t seem to be a significant factor in unplanned pregnancy in the United States. When the Alan Guttmacher Institute surveyed more than 10,000 women who had procured abortions in 2000 and 2001, it found that only 12 percent cited problems obtaining birth control as a reason for their pregnancies. A recent Centers for Disease Control and Prevention study of teenage mothers found similar results: Only 13 percent of the teens reported having had trouble getting contraception.

At the same time, if liberal social policies really led inexorably to fewer unplanned pregnancies and thus fewer abortions, you would expect “blue” regions of the country to have lower teen pregnancy rates and fewer abortions per capita than demographically similar “red” regions.

But that isn’t what the data show. Instead, abortion rates are frequently higher in more liberal states, where access is often largely unrestricted, than in more conservative states, which are more likely to have parental consent laws, waiting periods, and so on. “Safe, legal and rare” is a nice slogan, but liberal policies don’t always seem to deliver the “rare” part.

What’s more, another Guttmacher Institute study suggests that liberal states don’t necessarily do better than conservative ones at preventing teenagers from getting pregnant in the first place. Instead, the lower teenage birth rates in many blue states are mostly just a consequence of (again) their higher abortion rates. Liberal California, for instance, has a higher teen pregnancy rate than socially conservative Alabama; the Californian teenage birth rate is only lower because the Californian abortion rate is more than twice as high.

These are realities liberals should keep in mind when tempted to rail against conservatives for rejecting the intuitive-seeming promise of “more condoms, fewer abortions.” What’s intuitive isn’t always true, and if social conservatives haven’t figured out how to make all good things go together in post-sexual-revolution America, neither have social liberals.

At the very least, American conservatives are hardly crazy to reject a model for sex, marriage and family that seems to depend heavily on higher-than-average abortion rates. They’ve seen that future in places like liberal, cosmopolitan New York, where two in five pregnancies end in abortion. And it isn’t a pretty sight.

    The ‘Safe, Legal, Rare’ Illusion, NYT, 18.2.2012,
    http://www.nytimes.com/2012/02/19/opinion/sunday/douthat-the-safe-legal-rare-illusion.html

Dr. Richard K. Olney,

Felled by the Disease He Studied,

Is Dead at 64

February 2, 2012
The New York Times
By JOHN SCHWARTZ

Dr. Richard K. Olney, a leading physician and pioneer in clinical research on amyotrophic lateral sclerosis, also known as Lou Gehrig’s disease, died of the disease on Jan. 27 at his home in Corte Madera, Calif. He was 64.

His death was announced by the University of California, San Francisco, where Dr. Olney had been the director of the A.L.S. Treatment and Research Center before learning in 2004 that he himself had the disease.

A.L.S. is a degenerative condition of the nerves in the brain and spinal cord that gradually robs the patient of the ability to use the muscles, trapping the victim in an increasingly unresponsive body.

Many A.L.S. patients die within two years, but Dr. Olney survived more than eight after his diagnosis. In that time he was able to see both of his children get married and to see the birth of his first grandchild, who is named after him.

“That’s why he lived so long: he was fighting to see those important milestones,” said Dr. Catherine Lomen-Hoerth, a neurologist who was trained at the clinic by Dr. Olney, and who took over in 2004 when the illness forced him to retire. She then directed his care.

Nicholas T. Olney, Dr. Olney’s son, said that his father maintained a disciplined and upbeat outlook through the course of his illness. “Once he accepted his diagnosis, he had this attitude that he could make the most of each day,” he recalled. “He didn’t let the next muscle group, the next ability he lost, get him down.”

As he explained in an interview with The New York Times in 2005, Dr. Olney first experienced stiffness in his right leg and loss of coordination in 2003. The initial diagnosis was a herniated disk. He underwent surgery, but his physical slide continued.

By May 2005, he had noticed that his right arm was growing stiff and slow. He then gave himself a common test for A.L.S.: counting the number of times he could tap his fingers in 10 seconds. He knew that he could normally tap 65 times; he had slowed to 55.

“I knew I had A.L.S. then,” Dr. Olney recalled.

A quiet man, Dr. Olney did not seek publicity until he was struck by the disease. When he retired from the clinic, he set up an endowment and agreed to cooperate with journalists in order to build support for the institution. “He wanted to make sure the A.L.S. center would continue after he was gone,” Dr. Lomen-Hoerth said.

In a statement, Lucie Bruijn, chief scientist of the A.L.S. Association, remembered Dr. Olney “not only as a courageous person with A.L.S., but someone who was an outstanding clinician and scientist who made major contributions both for patients and the scientific field.”

Richard Knox Olney was born on Dec. 15, 1947, in Munich, to Lt. Col. Frank and Frances Olney. His family later settled in Norman, Okla. He graduated Phi Beta Kappa from the University of Oklahoma in 1968 with a bachelor’s degree in chemistry, mathematics and zoology, and earned a degree in medicine from Baylor College of Medicine in 1973. He received further medical training at the University of California, Los Angeles, and the University of Oregon Health Sciences Center.

At U.C.S.F. he was known as a hard worker whose hours stunned his colleagues. “He had always told me that the extra time he put in was where he got to do the fun stuff, like research,” said his son, Nick, who is will begin his medical residency in neurology this fall.

In addition to his son, Dr. Olney is survived by his wife of 38 years, the former Paula Louise Zucal; a daughter, Amy Koch Olney Dobbs; his brother, Frank Jr.; and his grandson.

Dr. Olney and his son were working on a research paper together during his final months, focused on the use of nerve responses to predict the likely course of illness in A.L.S. patients. Dr. Lomen-Hoerth will help Nick Olney finish the paper.

Toward the end, Dr. Olney communicated with the world through a computer that responded to his eye movements, with the words appearing on a screen.

Since October, his ability to breathe had gradually diminished. But he continued to send and receive e-mail, and visited the clinic the week before he died to take part in a research project.

As he got ready to leave, Dr. Lomen-Hoerth recalled: “One of the last things he tapped out was, ‘goodbye.’ I think he knew it was his last visit.”

“That,” she added, “was a hard thing to see on the screen.”

    Dr. Richard K. Olney, Felled by the Disease He Studied, Is Dead at 64, NYT, 2.2.2012,
    http://www.nytimes.com/2012/02/03/us/dr-richard-k-olney-als-researcher-dies-at-64.html

Path Is Found for the Spread of Alzheimer’s

February 1, 2012
The New York Times
By GINA KOLATA

Alzheimer’s disease seems to spread like an infection from brain cell to brain cell, two new studies in mice have found. But instead of viruses or bacteria, what is being spread is a distorted protein known as tau.

The surprising finding answers a longstanding question and has immediate implications for developing treatments, researchers said. And they suspect that other degenerative brain diseases like Parkinson’s may spread in a similar way.

Alzheimer’s researchers have long known that dying, tau-filled cells first emerge in a small area of the brain where memories are made and stored. The disease then slowly moves outward to larger areas that involve remembering and reasoning.

But for more than a quarter-century, researchers have been unable to decide between two explanations. One is that the spread may mean that the disease is transmitted from neuron to neuron, perhaps along the paths that nerve cells use to communicate with one another. Or it could simply mean that some brain areas are more resilient than others and resist the disease longer.

The new studies provide an answer. And they indicate it may be possible to bring Alzheimer’s disease to an abrupt halt early on by preventing cell-to-cell transmission, perhaps with an antibody that blocks tau.

The studies, done independently by researchers at Columbia and Harvard, involved genetically engineered mice that could make abnormal human tau proteins, predominantly in the entorhinal (pronounced en-toh-RYE-nal) cortex, a sliver of tissue behind the ears, toward the middle of the brain, where cells first start dying in Alzheimer’s disease. As expected, tau showed up there. And, as also expected, entorhinal cortex cells in the mice started dying, filled with tangled, spaghettilike strands of tau.

Over the next two years, the cell death and destruction spread outward to other cells along the same network. Since those other cells could not make human tau, the only way they could get the protein was by transmission from nerve cell to nerve cell.

And that, said Dr. Samuel E. Gandy, associate director of the Alzheimer’s Disease Research Center at Mount Sinai School of Medicine in New York, was “very unexpected, very intriguing.”

Although the studies were in mice, researchers say they expect that the same phenomenon occurs in humans because the mice had a human tau gene and the progressive wave of cell death matched what they see in people with Alzheimer’s disease.

One study, by Karen Duff and Dr. Scott A. Small and their colleagues at the Taub Institute for Research on Alzheimer’s Disease and the Aging Brain at Columbia University Medical Center, was published on Wednesday in the journal PLoS One. The other, by Dr. Bradley T. Hyman, director of the Alzheimer’s Disease Research Center at Massachusetts General Hospital, and his colleagues, is to be published in the journal Neuron.

Both groups of researchers were inspired by the many observations over the years that Alzheimer’s starts in the entorhinal cortex and spreads.

But, said Dr. Small, “what do we mean by ‘spreads?’ ”

Researchers knew that something set off Alzheimer’s disease. The most likely candidate is a protein known as beta amyloid, which accumulates in the brain of Alzheimer’s patients, forming hard, barnaclelike plaques. But beta amyloid is very different from tau. It is secreted and clumps outside cells. Although researchers have looked, they have never seen evidence that amyloid spreads from cell to cell in a network.

Still, amyloid creates what amounts to a bad neighborhood in memory regions of the brain. Then tau comes in — some researchers call it “the executioner” — piling up inside cells and killing them. If some cells take longer than others to succumb to the bad neighborhood, that would explain the spread of the disease in the brain, and there would be no need to blame something odd, like the spread of tau from cell to cell.

Studies in humans, though, could not determine whether that hypothesis was correct. They involved autopsy and brain imaging studies and were “indirect and inconclusive,” Dr. Small said.

Looking at the brains of people who have died of the disease, Dr. Duff said, is like looking at a wrecked car and trying to figure out the accident’s cause. Faulty brakes? Broken struts?

The question of which hypothesis was correct — tau spreading cell to cell, or a bad neighborhood in the brain and cells with different vulnerabilities to it — remained unanswerable. Dr. Hyman said he tried for 25 years to find a good way to address it. One of his ideas was to find a patient or two who had had a stroke or other injury that severed the entorhinal cortex from the rest of the brain. If the patient developed Alzheimer’s in the entorhinal cortex — and it remained contained there — he would have evidence that the disease spread like an infection. But he never found such patients.

The solution came when researchers were able to develop genetically engineered mice that expressed abnormal human tau, but only in their entorhinal cortexes. Those mice offered the cleanest way to get an answer, said John Hardy, an Alzheimer’s researcher at University College London who was not involved in either of the new studies.

There is another advantage, too, Dr. Hyman said. The mice give him a tool to test ways to block tau’s spread — and that, he added, “is one of the things we’re excited about.”

But if tau spreads from neuron to neuron, Dr. Hardy said, it may be necessary to block both beta amyloid production, which seems to get the disease going, and the spread of tau, which continues it, to bring Alzheimer’s to a halt.

He and others are also asking if other degenerative diseases spread through the brain because proteins pass from nerve cell to nerve cell.

Dr. Hardy thought he saw provocative human evidence that it might be happening in Parkinson’s disease. Two Parkinson’s patients being treated by a colleague had fetal brain cells implanted to replace dead and dying neurons. When the patients died, years later, autopsies showed they still had the fetal cells, but they had balls of a Parkinson’s disease protein, synuclein, inside. The most obvious way that could happen, the researchers reasoned, was if the toxic protein had spread from the patient’s diseased cells to the healthy fetal cells. But they could not rule out the bad-neighborhood hypothesis.

Now, Dr. Hardy said, with the mouse studies, the issue of a bad neighborhood is settled. The answer in Alzheimer’s disease, he said, “is that isn’t possible.”

“That is what is different between these papers and all the others,” Dr. Hardy said. “It isn’t a bad neighborhood. It is contagion from one neuron to another.”

    Path Is Found for the Spread of Alzheimer’s, NYT, 1.2.2012,
    http://www.nytimes.com/2012/02/02/health/research/alzheimers-spreads-like-a-virus-in-the-brain-studies-find.html

I Had Asperger Syndrome. Briefly.

January 31, 2012
The New York Times
By BENJAMIN NUGENT

Manchester, N.H.

FOR a brief, heady period in the history of autism spectrum diagnosis, in the late ’90s, I had Asperger syndrome.

There’s an educational video from that time, called “Understanding Asperger’s,” in which I appear. I am the affected 20-year-old in the wannabe-hipster vintage polo shirt talking about how keen his understanding of literature is and how misunderstood he was in fifth grade. The film was a research project directed by my mother, a psychology professor and Asperger specialist, and another expert in her department. It presents me as a young man living a full, meaningful life, despite his mental abnormality.

“Understanding Asperger’s” was no act of fraud. Both my mother and her colleague believed I met the diagnostic criteria laid out in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. The manual, still the authoritative text for American therapists, hospitals and insurers, listed the symptoms exhibited by people with Asperger disorder, and, when I was 17, I was judged to fit the bill.

I exhibited a “qualified impairment in social interaction,” specifically “failure to develop peer relationships appropriate to developmental level” (I had few friends) and a “lack of spontaneous seeking to share enjoyment, interests, or achievements with other people” (I spent a lot of time by myself in my room reading novels and listening to music, and when I did hang out with other kids I often tried to speak like an E. M. Forster narrator, annoying them). I exhibited an “encompassing preoccupation with one or more stereotyped and restricted patterns of interest that is abnormal either in intensity or focus” (I memorized poems and spent a lot of time playing the guitar and writing terrible poems and novels).

The general idea with a psychological diagnosis is that it applies when the tendencies involved inhibit a person’s ability to experience a happy, normal life. And in my case, the tendencies seemed to do just that. My high school G.P.A. would have been higher if I had been less intensely focused on books and music. If I had been well-rounded enough to attain basic competence at a few sports, I wouldn’t have provoked rage and contempt in other kids during gym and recess.

The thing is, after college I moved to New York City and became a writer and met some people who shared my obsessions, and I ditched the Forsterian narrator thing, and then I wasn’t that awkward or isolated anymore. According to the diagnostic manual, Asperger syndrome is “a continuous and lifelong disorder,” but my symptoms had vanished.

Last year I sold a novel of the psychological-realism variety, which means that my job became to intuit the unverbalized meanings of social interactions and create fictional social encounters with interesting secret subtexts. By contrast, people with Asperger syndrome and other autism spectrum disorders usually struggle to pick up nonverbal social cues. They often prefer the kind of thinking involved in chess and math, activities at which I am almost as inept as I am at soccer.

The biggest single problem with the diagnostic criteria applied to me is this: You can be highly perceptive with regard to social interaction, as a child or adolescent, and still be a spectacular social failure. This is particularly true if you’re bad at sports or nervous or weird-looking.

As I came into my adult personality, it became clear to me and my mother that I didn’t have Asperger syndrome, and she apologized profusely for putting me in the video. For a long time, I sulked in her presence. I yelled at her sometimes, I am ashamed to report. And then I forgave her, after about seven years. Because my mother’s intentions were always noble. She wanted to educate parents and counselors about the disorder. She wanted to erase its stigma.

I wonder: If I had been born five years later and given the diagnosis at the more impressionable age of 12, what would have happened? I might never have tried to write about social interaction, having been told that I was hard-wired to find social interaction baffling.

The authors of the next edition of the diagnostic manual, the D.S.M.-5, are considering a narrower definition of the autism spectrum. This may reverse the drastic increase in Asperger diagnoses that has taken place over the last 10 to 15 years. Many prominent psychologists have reacted to this news with dismay. They protest that children and teenagers on the mild side of the autism spectrum will be denied the services they need if they’re unable to meet the new, more exclusive criteria.

But my experience can’t be unique. Under the rules in place today, any nerd, any withdrawn, bookish kid, can have Asperger syndrome.

The definition should be narrowed. I don’t want a kid with mild autism to go untreated. But I don’t want a school psychologist to give a clumsy, lonely teenager a description of his mind that isn’t true.

Benjamin Nugent, the director of creative writing

at Southern New Hampshire University,

is the author of “American Nerd: The Story of My People.”

    I Had Asperger Syndrome. Briefly., NYT, 31.1.2012,
    http://www.nytimes.com/2012/02/01/opinion/i-had-asperger-syndrome-briefly.html

Asperger’s History of Over-Diagnosis

January 31, 2012
The New York Times
By PAUL STEINBERG

WASHINGTON

Asperger syndrome and Aspies — the affectionate name that people diagnosed with Asperger syndrome call themselves — seem to be everywhere.

Considered to be at the high-functioning end of the autism spectrum, Asperger syndrome has become more loosely defined in the past 20 years, by both the mental health profession and by lay people, and in many instances is now synonymous with social and interpersonal disabilities. But people with social disabilities are not necessarily autistic, and giving them diagnoses on the autism spectrum often does a real disservice. An expert task force appointed by the American Psychiatric Association is now looking into the possibility of changing the way we diagnose Asperger. True autism reflects major problems with receptive language (the ability to comprehend sounds and words) and with expressive language. Pitch and tone of voice in autism are off-kilter. Language delays are common, and syntactic development is compromised; in addition, there can be repetitive motor movements.

Eventually, biological markers, now in the beginning stages of development, will help in separating autism-spectrum disorders from social disabilities. For example, researchers at the University of Pittsburgh Medical Center have recently developed three-dimensional brain scans that look at brain wiring. In preliminary studies people with autism-spectrum disorders appear to have too much wiring and disorganized wiring in areas involved with language acquisition.

Nevertheless, children and adults with significant interpersonal deficits are being lumped together with children and adults with language acquisition problems. Currently, with the loosening of the diagnosis of Asperger, children and adults who are shy and timid, who have quirky interests like train schedules and baseball statistics, and who have trouble relating to their peers — but who have no language-acquisition problems — are placed on the autism spectrum.

In recent years speculation has abounded that Albert Einstein must have had Asperger syndrome. Christopher Hitchens speculated that his intellectual hero George Orwell must have had Asperger. Indeed, Orwell had major problems fitting in at British preparatory schools — not surprisingly, he hated the totalitarian tenor of teachers and school administrators — but someone on the autism spectrum could probably never have become a police officer in Lower Burma, as Orwell did. Similarly, writers like Charles Morris have noted that Warren Buffett is thought to have a condition on the autism spectrum, presumably Asperger syndrome.

A 1992 United States Department of Education directive contributed to the over-diagnosis of Asperger syndrome. It called for enhanced services for children diagnosed as being on the autism spectrum and for children with “pervasive developmental disorder — not otherwise specified (P.D.D.-N.O.S.),” a diagnosis in which children with social disabilities could be lumped. The diagnosis of Asperger syndrome went through the roof. Curiously, in California, where children with P.D.D.-N.O.S. were not given enhanced services, autism-spectrum diagnoses did not increase. Too little science and too many unintended consequences.

The downside to this diagnosis lies in evidence that children with social disabilities, diagnosed now with an autism-spectrum disorder like Asperger, have lower self-esteem and poorer social development when inappropriately placed in school environments with truly autistic children. In addition, many of us clinicians have seen young adults denied job opportunities, for example in the Peace Corps, when inappropriately given a diagnosis of Asperger syndrome instead of a social disability. George Orwell might never have been able to write his brilliant essay about the shooting of an elephant if Asperger syndrome had been part of his permanent medical record.

Given that humans are social animals, interpersonal intelligence is perhaps the most important natural human skill — as valuable as or more valuable than verbal-linguistic intelligence and logical-mathematical intelligence (to use the terminology of the Harvard psychologist Howard Gardner), the skills focused on in school. Social disabilities are not at all trivial, but they become cheapened by the ubiquity of the Asperger diagnosis, and they become miscast when put in the autism spectrum.

In his 2009 book “Parallel Play,” Tim Page, a former music critic for The Washington Post, describes his relief in being given an Asperger syndrome diagnosis as an adult and thus having an explanation for his longstanding social difficulties. But the rubric of a “social disability” would be more accurate than “autism spectrum” for people like Mr. Page, and potentially just as relieving. In addition, adults and children who have normal expressive and receptive language skills can benefit more fully from social-skills programs than adults and children with true autism. In fact, Tim Page learned a large measure of his social skills from an Emily Post course, just as Warren Buffett credits a Dale Carnegie program with changing his life.

For Mr. Buffett and Mr. Page, these social skills do not come naturally and automatically. But these men are able to compensate more completely than a truly autistic child or adult whose language deficiencies and cognitive deficits can often put him at a level of functioning in the mentally retarded range.

Many people, now inappropriately labeled as Aspies, make the world a richer, more interesting place. Their quirky absorptions in, say, physics, baseball stats or investment strategies add enormously to human advancement. Unlike adults with a Peter Pan syndrome who never move beyond adolescence, children and young adults with significant social disabilities tend to grow quite effectively into their adult lives. Their seriousness and singularity of focus fit more compatibly with the interests of older adults rather than the interests of their childhood or young adult peers.

For better or worse, though, Asperger syndrome has become a part of our cultural landscape. Comments about a person’s having “a touch of Asperger’s” seem to be part of everyday conversations. Even an episode of “South Park” last year was devoted to Asperger syndrome. We can only hope that better physiological markers distinguishing between the autism-spectrum disorders and pure social disabilities can stem this tide of ever more pathologizing.

But, as Martha Denckla, a pediatric neurologist at Johns Hopkins University, has lamented, the only Americans in the future who will perhaps not be labeled as having a touch of Asperger syndrome will be politicians and lobbyists. Members of the political establishment may have other kinds of psychopathology; but, unlike the rest of us, they at least cannot be thought of as Aspies.

Paul Steinberg is a psychiatrist.

    Asperger’s History of Over-Diagnosis, NYT, 31.1.2012,
    http://www.nytimes.com/2012/02/01/opinion/aspergers-history-of-over-diagnosis.html

Not Diseases, but Categories of Suffering

January 29, 2012
The New York Times
By GARY GREENBERG

Scotland, Conn.

YOU’VE got to feel sorry for the American Psychiatric Association, at least for a moment. Its members proposed a change to the definition of autism in the fifth edition of their Diagnostic and Statistical Manual of Mental Disorders, one that would eliminate the separate category of Asperger syndrome in 2013. And the next thing they knew, a prominent psychiatrist was quoted in a front-page article in this paper saying the result would be fewer diagnoses, which would mean fewer troubled children eligible for services like special education and disability payments.

Then, just a few days later, another front-pager featured a pair of equally prominent experts explaining their smackdown of the A.P.A.’s proposal to eliminate the “bereavement exclusion” — the two months granted the grieving before their mourning can be classified as “major” depression. This time, the problem was that the move would raise the numbers of people with the diagnosis, increasing health care costs and the use of already pervasive mind-altering drugs, as well as pathologizing a normal life experience.

Fewer patients, more patients: the A.P.A. just can’t win. Someone is always mad at it for its diagnostic manual.

It’s not the current A.P.A.’s fault. The fault lies with its predecessors. The D.S.M. is the offspring of odd bedfellows: the medical industry, with its focus on germs and other biochemical causes of disease, and psychoanalysis, the now-largely-discredited discipline that attributes our psychological suffering to our individual and collective history.

This tension has been high since at least 1917. That’s when Thomas Salmon, a future head of the A.P.A. — which was founded in 1844 — noted that psychiatry’s “classification of mental diseases is chaotic.” He worried that “this condition of affairs discredits the science of psychiatry and reflects unfavorably upon our association” and urged his membership to forge a diagnostic system “that would meet the scientific demands of the present day.”

The American Psychiatric Association has been trying to do just that ever since, mostly by leaving behind ideas about the meaning of our suffering in favor of observation and treatment of its symptoms. In 1980, it hit on the strategy of adopting a medical rhetoric, organizing those symptoms into neat disease categories and checklists of precisely described criteria and publishing them in the hefty — and, according to its chief author, “very scientific-looking” — D.S.M.-III.

That book, with its more than 200 objectively described diagnoses, would have made Dr. Salmon proud. By meeting the scientific demands of the day, it was credited by many with having rescued psychiatry from the brink of extinction, and its subsequent revisions have been the cornerstone of the profession’s survival as a medical specialty.

But as all those Diagnostic and Statistical Manuals have stated clearly in their introductions, while the book seems to name the mental illnesses found in nature, it actually makes “no assumption that each category of mental disorder is a completely discrete entity with absolute boundaries dividing it from other mental disorders or no mental disorder.” And as any psychiatrist involved in the making of the D.S.M. will freely tell you, the disorders listed in the book are not “real diseases,” at least not like measles or hepatitis. Instead, they are useful constructs that capture the ways that people commonly suffer. The manual, they go on, was primarily written to give physicians, schooled in the language of disease, a way to recognize similarities and differences among their patients and to talk to one another about them. And it has been fairly successful at that.

Still, “people take it literally,” one psychiatrist who worked on the manual told me. “That is its strength in a political sense.” And even if the A.P.A. benefits mightily from that misperception, the troubles on the front page are not the organization’s fault. They are what happens when we expect the D.S.M. to be what it is not. “The D.S.M. has been taken too seriously,” another expert told me. “It’s the victim of its success.”

Psychiatrists would like the book to deserve a more serious take, and thus to be less subject to these embarrassing diagnostic squabbles. But this is going to require them to have what the rest of medicine already possesses: the biochemical markers that allow doctors to sort the staph from the strep, the malignant from the benign. And they don’t have these yet. They aren’t even close. The human brain, after all, may be the most complex object in the universe. And the few markers, the genes and the neural networks, that have been implicated in mental disorders do not map well onto the D.S.M.’s categories.

“We’re like Cinderella’s older stepsisters,” a psychiatrist told me the other day. “We’re trying to stick our fat feet into the delicate slipper so the prince can take us to the ball. But we ain’t going to the ball right now.” Which is why we might feel a little sorry for the beleaguered A.P.A.

On the other hand, given that the current edition of the D.S.M. has earned the association — which holds and tightly guards its naming rights to our pain — more than $100 million, we might want to temper our sympathy. It may not be dancing at the ball, but once every mental health worker, psychology student and forensic lawyer in the country buys the new book, it will be laughing all the way to the bank.

 

Gary Greenberg, a psychotherapist and the author of “Manufacturing Depression,”

is writing a book about the making of the fifth edition

of the Diagnostic and Statistical Manual of Mental Disorders.

    Not Diseases, but Categories of Suffering, NYT, 29.1.2012,
    http://www.nytimes.com/2012/01/30/opinion/the-dsms-troubled-revision.html

Narrowing the Definition of Autism

January 27, 2012
The New York Times

To the Editor:

Re “New Autism Rule Will Trim Many, a Study Suggests” (front page, Jan. 20): Narrowing the definition of autism is a bad idea and narrows the opportunities to make significant inroads in helping children affected by this condition, their families and our nation.

Autism still has many mysteries, but it is clear that early intervention makes a tremendous difference. A tighter definition means that parents, teachers and caregivers will wait longer to consider giving children specialized attention and care. It will mean less support for parents struggling to help their children communicate, adapt to social challenges and cope with a world that often feels overwhelming.

By addressing all these issues early, we have a chance to change the course of this condition, enabling people with autism to reach their full potential and requiring fewer publicly financed services for the rest of their lives.

As we learn that autism is not just from genes and brain but also from a child’s response to a challenging environment, why make that environment even more challenging?

MARTHA HERBERT
Cambridge, Mass., Jan. 20, 2012

The writer is a pediatric neurologist at Harvard Medical School and Massachusetts General Hospital and author of the forthcoming “The Autism Revolution.”


To the Editor:

Under the proposed changes in criteria discussed in the article, a person would have to exhibit at least two repetitive behaviors to receive a diagnosis of autism, Asperger syndrome or “pervasive developmental disorder, not otherwise specified.”

Students with whom we work who have such a diagnosis exhibit numerous difficulties with social interaction that impede their acceptance and functioning in the classroom and elsewhere but often have no repetitive behaviors.

To exclude these students from the services and supports they need throughout their education would be a great injustice and an attempt to save money now without considering the effect of their being unprepared to function fully as adults in our society.

Changing the criteria to decrease the percentage seems dishonest and unethical.

HEATHER KNICKERBOCKER
KATHY WAEHLER
Hackettstown, N.J., Jan. 20, 2012

The writers, social workers, are learning support specialists in the Disability Services Office at Centenary College.


To the Editor:

Your article quotes Dr. David J. Kupfer, a psychiatrist and chairman of the American Psychiatric Association task force making the revisions to the definition of autism, as saying: “It involves a use of treatment resources. It becomes a cost issue.”

While many services provided to people with autism, Asperger syndrome and “pervasive developmental disorder, not otherwise specified,” can be quite costly, if these services are not covered by the educational system and/or by insurance, some families will face financial and/or emotional ruin.

If the proposed changes go through, and if some people in need of services are no longer able to obtain them, and if their families are unable to afford them, we will all pay a tremendous cost in the long run when many of these people become adults who are unable to care for themselves or live independent lives.

JON SINGER
Tenafly, N.J., Jan. 21, 2012

The writer is founder of Drive4Rebecca, a nonprofit that raises money for autism research and education, and author of “The Special Needs Parent Handbook.”


To the Editor:

Excluding the higher functioning children means that schools will have to do more to make regular classrooms hospitable to them without the early intervention based accommodations mandated by the Individuals With Disabilities Education Act.

In particular, teachers will have to stop requiring children to work in groups, share personal reflections and do organizationally demanding interdisciplinary projects — all of which are challenging for the sort of child who, rightly or wrongly, has sometimes received a diagnosis of mild autism/Asperger.

The new American Reform Math is also problematic for this population, since it waters down the actual math and teaches it less systematically.

KATHARINE BEALS
Philadelphia, Jan. 23, 2012

The writer is a lecturer at the University of Pennsylvania Graduate School of Education and the author of “Raising a Left-Brain Child in a Right-Brain World.”


To the Editor:

After reading your Jan. 20 article and an earlier front-page article about the two young people with Asperger syndrome who found their soul mates (“Navigating Love and Autism,” Dec. 26), I’m left with a question about autism in less disruptive forms.

I’m old enough to remember when classmates and friends who were “different” were ridiculed by some but accepted as more or less charming eccentrics by most. We called them “clunky.” They were clueless in amusing ways, but were accepted because they more than compensated for it in others. We had time to develop close relationships. We tended to fill in one another’s chinks, and friends were protective.

Could it be that a culture that rewards superficiality and short attention spans evolves into a culture with a narrower definition of the term “normal”?

ROSE SEEMANN
Aurora, Colo., Jan. 21, 2012

    Narrowing the Definition of Autism, NYT, 27.1.2012,
    http://www.nytimes.com/2012/01/28/opinion/narrowing-the-definition-of-autism.html

A Specialists’ Debate on Autism

Has Many Worried Observers

January 20, 2012
The New York Times
By AMY HARMON

A debate among medical professionals over how to define autism has spilled over into the public domain, stirring anger and fear among many parents and advocates of those with the neurological disorder, even as some argue that the diagnosis has been too loosely applied.

A study reported on Thursday found that proposed revisions to the American Psychiatric Association’s definition would exclude about three-quarters of those now diagnosed with milder forms of autism called Asperger syndrome or “pervasive developmental disorder, not otherwise specified,” also known as P.D.D.-N.O.S. These are people who have difficulties with social interaction but do not share the most severe impairments of children with classic autism.

“He was right on the border, they told me when he got the diagnosis; that’s what scares me,” said Amanda Forman of Flourtown, Pa., whose 5-year-old son was diagnosed two years ago with P.D.D.-N.O.S. After receiving play therapy, occupational therapy and 17 hours a week of behavioral therapy, the boy, who was once unresponsive to other children and engaged in self-destructive behavior, may enter a mainstream kindergarten class next year, his mother said. “What if he has to be re-evaluated? If the criteria were stricter, he might not get these services that have been helping him so much.”

The proposed revisions, which would take effect in 2013, are likely to have practical implications for those who would once have qualified for services that experts say can improve an individual’s abilities to socialize, learn and ultimately live independently. But they have also ignited a broad discussion over the value of a diagnosis for behavior differences, and how to fairly apportion services at a time when resources are shrinking.

The Diagnostic and Statistical Manual, now under revision, is the standard reference for mental disorders, driving research, treatment and insurance decisions. Since 1994, when recognition of Asperger syndrome was first included as an autism-spectrum disorder, diagnosis of the condition has surged.

Over the last decade, the number of 6- to 21-year-olds with autism in public schools has quadrupled, according to the Department of Education. Such students may get private school placement, a classroom aide or curriculum adaptations. In recent years, 29 states have passed laws requiring insurance companies to provide behavioral therapies and other forms of care to people with an autism diagnosis.

“We have to make sure not everybody who is a little odd gets a diagnosis of autism or Asperger disorder,” said Dr. David J. Kupfer, a professor of psychiatry at the University of Pittsburgh and chairman of the task force making the revisions, which are still subject to change. “It involves a use of treatment resources. It becomes a cost issue.”

But some autism advocates argue that acknowledging the neurological basis for socially odd behaviors has benefits beyond eligibility for services, promoting cultural tolerance and a degree of self-understanding that may be lost without it.

“Having a diagnosis helps people understand why we process thoughts and emotions differently and make positive changes,” said Michael John Carley, director of the Global and Regional Asperger Syndrome Partnership, which urged members to call the psychiatric association to complain. “Sadly, we may be heading back to the days when our differences are seen through the lens of character deficits rather than in the context of brain wiring.”

Even within the medical community, the number of people who would not be eligible for an autism diagnosis under the new criteria is a matter of dispute. Some may fall under a new category, “social and communication disorder,” though it is not clear what kind of aid, if any, they would be eligible for as a result.

Catherine Lord, the director of the Institute for Brain Development at NewYork-Presbyterian Hospital, and a member of the committee overseeing the revisions, said that the goal was to ensure that autism was not used as a “fallback diagnosis” for children whose primary trait might be, for instance, an intellectual disability or aggression.

She said the committee’s own data shows that very few who currently have a diagnosis would be dropped. And another analysis of the effect of the proposed new definition, published this month in The Journal of the American Academy of Child and Adolescent Psychiatry, found that roughly 40 percent of individuals with Asperger syndrome would not be given a diagnosis under the new definition. That study suggested that altering the criteria slightly could recapture most of those who would otherwise be excluded.

Yet some parents of severely autistic children who are nonverbal, and may need constant care to avoid injuring themselves and others, say they would welcome a narrowing of the spectrum.

“Everyone on the spectrum benefits when money and services available are applied more specifically and appropriately to the individual needs of each person affected,” said Mark L. Olson, of Henderson, Nev., whose daughter, 16, does not speak. Mr. Olson has argued on his blog that those with more severe needs have been overshadowed by people with the Asperger diagnosis, who have typical intelligence and language development.

Many comments, on the Web site of The New York Times and elsewhere, expressed the view that autism was overdiagnosed: “Come on, 1 in 100 children today?” one commenter wrote. “This pathology did not exist in the past because we did not label it.”

And even some parents of autistic children noted in the debate this week that a diagnosis can be a double-edged sword.

“With it, a child gets needed services,” wrote one Boston parent, whose son has a language impairment that makes socializing difficult. “The downside is that a child will be perceived by his peers as being abnormal and shunned socially. I noticed a huge change after my son was diagnosed. Once he got the autism label he rarely got birthday party invitations, for instance.”

But like many parents, Ms. Forman, who requested that her maiden name be used to shield her son, said she sought the diagnosis only because her son so badly needed the services it would secure.

“I didn’t know that feeling was so prevalent, that autism is so overdiagnosed,” she said, having read many of the comments on Web sites. “I just know the amount of work I do for him, and that’s not something I would do if I didn’t have to do it.

“It’s not the easy way out for anybody.”

    A Specialists’ Debate on Autism Has Many Worried Observers, NYT, 20.1.2012,
    http://www.nytimes.com/2012/01/21/us/as-specialists-debate-autism-some-parents-watch-closely.html

New Definition of Autism Will Exclude Many, Study Suggests

January 19, 2012
The New York Times
By BENEDICT CAREY

Proposed changes in the definition of autism would sharply reduce the skyrocketing rate at which the disorder is diagnosed and might make it harder for many people who would no longer meet the criteria to get health, educational and social services, a new analysis suggests.

The definition is now being reassessed by an expert panel appointed by the American Psychiatric Association, which is completing work on the fifth edition of its Diagnostic and Statistical Manual of Mental Disorders, the first major revision in 17 years. The D.S.M., as the manual is known, is the standard reference for mental disorders, driving research, treatment and insurance decisions. Most experts expect that the new manual will narrow the criteria for autism; the question is how sharply.

The results of the new analysis are preliminary, but they offer the most drastic estimate of how tightening the criteria for autism could affect the rate of diagnosis. For years, many experts have privately contended that the vagueness of the current criteria for autism and related disorders like Asperger syndrome was contributing to the increase in the rate of diagnoses — which has ballooned to one child in 100, according to some estimates.

The psychiatrists’ association is wrestling with one of the most agonizing questions in mental health — where to draw the line between unusual and abnormal — and its decisions are sure to be wrenching for some families. At a time when school budgets for special education are stretched, the new diagnosis could herald more pitched battles. Tens of thousands of people receive state-backed services to help offset the disorders’ disabling effects, which include sometimes severe learning and social problems, and the diagnosis is in many ways central to their lives. Close networks of parents have bonded over common experiences with children; and the children, too, may grow to find a sense of their own identity in their struggle with the disorder.

The proposed changes would probably exclude people with a diagnosis who were higher functioning. “I’m very concerned about the change in diagnosis, because I wonder if my daughter would even qualify,” said Mary Meyer of Ramsey, N.J. A diagnosis of Asperger syndrome was crucial to helping her daughter, who is 37, gain access to services that have helped tremendously. “She’s on disability, which is partly based on the Asperger’s; and I’m hoping to get her into supportive housing, which also depends on her diagnosis.”

The new analysis, presented Thursday at a meeting of the Icelandic Medical Association, opens a debate about just how many people the proposed diagnosis would affect.

The changes would narrow the diagnosis so much that it could effectively end the autism surge, said Dr. Fred R. Volkmar, director of the Child Study Center at the Yale School of Medicine and an author of the new analysis of the proposal. “We would nip it in the bud.”

Experts working for the Psychiatric Association on the manual’s new definition — a group from which Dr. Volkmar resigned early on — strongly disagree about the proposed changes’ impact. “I don’t know how they’re getting those numbers,” Catherine Lord, a member of the task force working on the diagnosis, said about Dr. Volkmar’s report.

Previous projections have concluded that far fewer people would be excluded under the change, said Dr. Lord, director of the Institute for Brain Development, a joint project of NewYork-Presbyterian Hospital, Weill Medical College of Cornell University, Columbia University Medical Center and the New York Center for Autism.

Disagreement about the effect of the new definition will almost certainly increase scrutiny of the finer points of the psychiatric association’s changes to the manual. The revisions are about 90 percent complete and will be final by December, according to Dr. David J. Kupfer, a professor of psychiatry at the University of Pittsburgh and chairman of the task force making the revisions.

At least a million children and adults have a diagnosis of autism or a related disorder, like Asperger syndrome or “pervasive developmental disorder, not otherwise specified,” also known as P.D.D.-N.O.S. People with Asperger’s or P.D.D.-N.O.S. endure some of the same social struggles as those with autism but do not meet the definition for the full-blown version. The proposed change would consolidate all three diagnoses under one category, autism spectrum disorder, eliminating Asperger syndrome and P.D.D.-N.O.S. from the manual. Under the current criteria, a person can qualify for the diagnosis by exhibiting 6 or more of 12 behaviors; under the proposed definition, the person would have to exhibit 3 deficits in social interaction and communication and at least 2 repetitive behaviors, a much narrower menu.

Dr. Kupfer said the changes were an attempt to clarify these variations and put them under one name. Some advocates have been concerned about the proposed changes.

“Our fear is that we are going to take a big step backward,” said Lori Shery, president of the Asperger Syndrome Education Network. “If clinicians say, ‘These kids don’t fit the criteria for an autism spectrum diagnosis,’ they are not going to get the supports and services they need, and they’re going to experience failure.”

Mark Roithmayr, president of the advocacy organization Autism Speaks, said that the proposed diagnosis should bring needed clarity but that the effect it would have on services was not yet clear. “We need to carefully monitor the impact of these diagnostic changes on access to services and ensure that no one is being denied the services they need,” Mr. Roithmayr said by e-mail. “Some treatments and services are driven solely by a person’s diagnosis, while other services may depend on other criteria such as age, I.Q. level or medical history.”

In the new analysis, Dr. Volkmar, along with Brian Reichow and James McPartland, both at Yale, used data from a large 1993 study that served as the basis for the current criteria. They focused on 372 children and adults who were among the highest functioning and found that overall, only 45 percent of them would qualify for the proposed autism spectrum diagnosis now under review.

The focus on a high-functioning group may have slightly exaggerated that percentage, the authors acknowledge. The likelihood of being left out under the new definition depended on the original diagnosis: about a quarter of those identified with classic autism in 1993 would not be so identified under the proposed criteria; about three-quarters of those with Asperger syndrome would not qualify; and 85 percent of those with P.D.D.-N.O.S. would not.

Dr. Volkmar presented the preliminary findings on Thursday. The researchers will publish a broader analysis, based on a larger and more representative sample of 1,000 cases, later this year. Dr. Volkmar said that although the proposed diagnosis would be for disorders on a spectrum and implies a broader net, it focuses tightly on “classically autistic” children on the more severe end of the scale. “The major impact here is on the more cognitively able,” he said.

Dr. Lord said that the study numbers are probably exaggerated because the research team relied on old data, collected by doctors who were not aware of what kinds of behaviors the proposed definition requires. “It’s not that the behaviors didn’t exist, but that they weren’t even asking about them — they wouldn’t show up at all in the data,” Dr. Lord said.

Dr. Volkmar acknowledged as much but said that problems transferring the data could not account for the large differences in rates.

Amy Harmon contributed reporting.

    New Definition of Autism Will Exclude Many, Study Suggests, NYT, 19.1.2012,
    http://www.nytimes.com/2012/01/20/health/research/new-autism-definition-would-exclude-many-study-suggests.html

My So-Called Bipolar Life

January 17, 2012
The New York Times
By JAMIE STIEHM

Washington

OVER the last few weeks, “Homeland,” Showtime’s new psychological thriller, has had quite a rush. Claire Danes, the show’s incandescent star, was nominated for, and then won, the Golden Globe for best actress in a TV drama series; the show also won for best TV drama. Why do I care? Because I know her character all too well.

Not in every sense, of course. I’m not a blond C.I.A. agent, and I’ve never hunted down or fallen in love with suspected terrorists. But as fans of the show — including, it’s said, President Obama — know, that’s not the only important part of Carrie Mathison, the character played by Ms. Danes. Like me, Carrie has bipolar disorder.

My sister Meredith Stiehm is a writer and consulting producer for the show, and she drew on my experience with the disorder to portray Carrie’s character. Not long ago, I retold the tale of my single manic episode to her, sharpening memories of that day in all its colors.

It was a painful testament to my sister’s skill that scenes that might have been of just passing interest to other viewers pushed me to tears, because in a real way they carried an uncanny emotional resonance.

And yet for all that, I feel the show’s creators, writers and producers, and Ms. Danes, have done us all a public service: perhaps, with the show’s glowing reception, Americans can finally talk openly about bipolar disorder.

Meredith’s interest in my condition is not, of course, limited to her work as a writer. After the manic episode landed me in the Johns Hopkins hospital years ago, Meredith stayed with me at home for a week to help me get back to the regular simplicity of sleeping and waking. One of the first things they tell you about the condition is that sleep really is the “chief nourisher in life’s feast,” as Macbeth put it. I have a mild case, so sleep, and lithium under the care of a doctor, have helped me stay healthy ever since.

My sister knows my back pages well, and while writing the script, she asked me about that spell of several sunny October days. Dormant memories awakened: I was a reporter for The Baltimore Sun, and I was filing stories in the newsroom faster than ever before. It’s strangely fitting that I worked in journalism, which at its best also has its share of frenetic late nights, deadlines and homing in on people. As a reporter at The Sun once said to me, “This is a manic-depressive business.”

Didn’t I know it. A “hypomanic” state, which precedes an episode of mania, is in fact an enhanced, alert, productive mood where one can feel exhilarated and immune to life’s dangers. I seemed to see into people’s hearts when I smiled at them. My speech sped up so much few could understand me.

I ran around Baltimore’s Inner Harbor at high speed, exulting in all my energy. For several days, I woke up at dawn to see the sunrise and take pictures of it. I felt sure something big was going to happen soon in Baltimore and only I could foresee it.

Similarly, a haunted Carrie is convinced that a big terrorist attack is looming large. Her furious focus on her quarry under time pressure leads to sleepless nights and reckless risks, behavior that is both symptom and contributing cause of bipolar illness. Her elevated mood cycles higher and higher, and she falls rapturously in love with the married Marine who she thinks is working for Al Qaeda, played with minute precision by Damian Lewis. Viewers can’t totally dismiss her visions — but then again, she’s not rational. In the hospital ward, she demands a green pen to write everything down, her voice racing faster and faster. Meredith had bottled my mercurial emotions so exactly it hurt.

Bipolar extremes can be truly hard to watch, excruciating even in memory. To see that experience depicted so intensely by Ms. Danes was like peering at a portrait gallery of my own psyche.

As I recovered, I found comfort in company. My colleagues could not have been more gracious. But at the end of the show’s first season (spoiler alert), poor Carrie has lost her job and appears left in a lonely place, about to undergo electroconvulsive therapy.

However, contrary to widespread belief, electroconvulsive therapy is extremely effective. A family friend, Dr. Leon Rosenberg, a geneticist and former dean of Yale Medical School, has the same malady. As a patient overwhelmed by suicidal depression, he made remarkable progress after electroconvulsive therapy. As a doctor, he described his own case in a medical journal and discusses his descent and recovery with students.

Yes, the show cuts close to home at points, but it gets the lead character’s story right. How rare to see a sparkling and spirited representation of what it’s actually like to walk through life with bipolar disorder. So let a thousand conversations bloom. Secrets held up to light and air lose their power in the public square. Spies know it as keepers, and writers know it as tellers.

Jamie Stiehm, a journalist, is writing a biography of the social reformer Lucretia Mott.

    My So-Called Bipolar Life, NYT, 17.1.2012,
    http://www.nytimes.com/2012/01/18/opinion/my-so-called-bipolar-life.html

U.S. to Force Drug Firms to Report Money Paid to Doctors

January 16, 2012
The New York Times
By ROBERT PEAR

WASHINGTON — To head off medical conflicts of interest, the Obama administration is poised to require drug companies to disclose the payments they make to doctors for research, consulting, speaking, travel and entertainment.

Many researchers have found evidence that such payments can influence doctors’ treatment decisions and contribute to higher costs by encouraging the use of more expensive drugs and medical devices.

Consumer advocates and members of Congress say patients may benefit from the new standards, being issued by the government under the new health care law. Officials said the disclosures increased the likelihood that doctors would make decisions in the best interests of patients, without regard to the doctors’ financial interests.

Large numbers of doctors receive payments from drug and device companies every year — sometimes into the hundreds of thousands or millions of dollars — in exchange for providing advice and giving lectures. Analyses by The New York Times and others have found that about a quarter of doctors take cash payments from drug or device makers and that nearly two-thirds accept routine gifts of food, including lunch for staff members and dinner for themselves.

The Times has found that doctors who take money from drug makers often practice medicine differently from those who do not and that they are more willing to prescribe drugs in risky and unapproved ways, such as prescribing powerful antipsychotic medicines for children.

Under the new standards, if a company has just one product covered by Medicare or Medicaid, it will have to disclose all its payments to doctors other than its own employees. The federal government will post the payment data on a Web site where it will be available to the public.

Manufacturers of prescription drugs and devices will have to report if they pay a doctor to help develop, assess and promote new products — or if, for example, a pharmaceutical sales agent delivers $25 worth of bagels and coffee to a doctor’s office for a meeting. Royalty payments to doctors, for inventions or discoveries, and payments to teaching hospitals for research or other activities will also have to be reported.

The Obama administration estimates that more than 1,100 drug, device and medical supply companies will have to file reports, generating “large amounts of new data.” Federal officials said they would inspect and audit drug company records to make sure the reports were accurate and complete.

Companies will be subject to a penalty up to $10,000 for each payment they fail to report. A company that knowingly fails to report payments will be subject to a penalty up to $100,000 for each violation, up to a total of $1 million a year.

Top executives are potentially liable because a senior official of each company — the chief executive, chief financial officer or chief compliance officer — must attest to the accuracy of each report.

The new requirements, or something very similar, will take effect soon; in fact, they are overdue. Under the new health care law, the administration was supposed to establish payment-reporting procedures by Oct. 1, 2011. The public will have until Feb. 17 to comment on the proposals, which are broadly consistent with the expectations of industry and consumer groups. After considering the comments, Medicare officials will issue final rules with the force of law.

Consumer advocates have long demanded details of the financial ties between doctors and drug and device companies.

Allan J. Coukell, a pharmacist and consumer advocate at the Pew Charitable Trusts, said: “Patients want to know they are getting treatment based on medical evidence, not a lunch or a financial relationship. They want to know if their doctor has a financial relationship with a pharmaceutical company, but they are often uncomfortable asking the doctor directly.”

In an introduction to the proposed rules, the Obama administration says that patients can benefit when doctors and the industry work together to develop life-saving drugs and devices. But, it said, these relationships can also “lead to conflicts of interests that may affect clinical decision-making” and “threaten the underlying integrity of the health care system.”

The administration does not try to define the difference between proper and improper payments. It says simply that public reporting of the financial ties between doctors and drug and device companies “will permit patients to make better-informed decisions when choosing health care professionals and making treatment decisions.”

The new standards carry out legislation championed by Senators Charles E. Grassley, Republican of Iowa, and Herb Kohl, Democrat of Wisconsin. The legislation was included in the 2010 health care overhaul.

“The goal is to let the sun shine in and make information available to foster accountability,” Mr. Grassley said.

Christopher L. White, executive vice president of the Advanced Medical Technology Association, which represents makers of medical devices, said the payment data could be used by federal law enforcement agencies, plaintiffs’ lawyers and whistleblowers.

“Some companies fear that doctors may no longer want to engage in consulting arrangements, and such reluctance could chill innovation,” Mr. White said.

Matthew D. Bennett, a senior vice president of the Pharmaceutical Research and Manufacturers of America, said the industry “supported transparency of physician payment information.” However, he said, it is important that payment data be presented in a proper context, emphasizing that interactions between doctors and drug companies played a critical role in improving care, educating doctors and fostering appropriate use of medicines.

Medicare and Medicaid, the programs for older Americans, the disabled and the poor, spend more than $100 billion a year on drugs and devices.

Although the Congressional Budget Office does not predict immediate savings, it has said that, “over time, disclosure has the potential to reduce spending,” by reducing instances of overprescribing.

The law also requires drug and device companies to report the amount of “any ownership or investment interest” held by doctors or their immediate family members, other than holdings of publicly traded stocks.

The administration intends to apply the same disclosure requirements to doctor-owned companies that distribute medical devices. Such companies allow doctors to benefit financially from sales of devices they use in surgery.

    U.S. to Force Drug Firms to Report Money Paid to Doctors, NYT, 16.1.2012,
    http://www.nytimes.com/2012/01/17/health/policy/us-to-tell-drug-makers-to-disclose-payments-to-doctors.html

Louise J. Kaplan, Psychoanalyst and Author, Dies at 82

January 16, 2012
The New York Times
By DOUGLAS MARTIN

Louise J. Kaplan, a psychoanalyst and author who used a psychological lens, literary allusion and a feminist sensibility to soberly define and explain seemingly titillating topics like sexual perversity and fetishes, died on Jan. 9 in Manhattan. She was 82.

The cause was pancreatic cancer, her daughter, Ann E. Kaplan, said.

Dr. Kaplan’s 1991 book, “Female Perversions: The Temptations of Emma Bovary,” drew wide attention with its thesis that women’s perversions are more subtle than men’s. When, for example, a woman compulsively dresses as a sex object or longs obsessively for luxury items, Dr. Kaplan argued, the activity is a masquerade unconsciously intended to channel lust and sexual aggression in socially acceptable female roles.

Dr. Kaplan used the character of Madame Bovary — depicted by Flaubert as an adulterous provincial housewife — to illustrate how women are enslaved by stereotypes. Treating Madame Bovary as if she were a patient, she found self-defeating perversion in behaviors like fetishistic longing for upper-class finery, expensive boots and elegant trinkets, and dressing sometimes to look masculine and at other times to look extravagantly feminine.

Michael Vincent Miller, writing in The New York Times Book Review, praised Dr. Kaplan for resisting the tendency to reduce literature to symptoms, noting that she respected “both the texture of the novel and Flaubert’s complex attitude toward his character.”

In 1996, Susan Streitfeld directed a movie based on the book, “Female Perversions.” The main character, Eve, played by Tilda Swinton, is a successful trial lawyer who navigates episodes drawn from case studies in Dr. Kaplan’s book. Excerpts from the book appear in the film in surprising places: embroidery on a pillowcase reads, “Perversions are rarely what they seem”; graffiti delivers the message “Perverse scenarios are about desperate need.”

Variety called the film “a hard-core feminist meditation” that was “stunningly beautiful and intriguingly complex.” Other reviewers noted that the sex scenes were, for once, not gratuitous.

In 2006, Dr. Kaplan returned to her psychosexual musings to write “Cultures of Fetishism.” Like the earlier book, it examined how perversities of both men and women limit their human vitality. Her broad definition of fetish cultures included the old Chinese custom of foot-binding and the advent of reality television.

Another of Dr. Kaplan’s seven books, “Oneness and Separateness: From Infant to Individual” (1978), investigated how babies become aware that they are separate beings, a moment she called a “second birth.” Another, “Adolescence: The Farewell to Childhood” (1984), viewed puberty as a tug of war in adolescents between striving for adult power and unconsciously mourning the separation from their parents.

Her 1987 book, “The Family Romance of the Impostor-Poet Thomas Chatterton,” told the story of an 18th-century youth who wrote verse in the name of a fictitious medieval priest, whose work he claimed to have found in a church attic. Chatterton committed suicide at 17, and after his deception became known, Romantic poets like Wordsworth and Keats praised his talent.

Dr. Kaplan chose to psychoanalyze the young man, theorizing that the death of his father before the boy was born set Chatterton on a search for a father figure, which he found in his make-believe poet.

Louise Janet Miller was born in Brooklyn on Nov. 18, 1929, graduated from Brooklyn College and earned her doctorate from New York University. She practiced as a psychoanalyst and held posts that included director of the mother-infant research nursery at N.Y.U. in the mid-1970s. She was a protégée of Dr. Margaret Mahler, the psychoanalyst known for her research on child development, which Dr. Kaplan helped carry on at the research foundation named for Dr. Mahler.

Dr. Kaplan’s husband, Donald, with whom she helped edit American Imago, a psychoanalytic journal, died in 1994. In addition to her daughter, Dr. Kaplan is survived by a son, David, and two granddaughters.

Some of Dr. Kaplan’s insights could be as quirky as they were perspicacious. She noted in her book on adolescence that humans’ closest genetic relative, the chimpanzee, loses curiosity at 5 or 6, but that humans continue exploring, investigating and inventing until the onset of senility. “Humans of all eras, in all societies, all ages of life,” she wrote, “are more like baby chimps.”

    Louise J. Kaplan, Psychoanalyst and Author, Dies at 82, NYT, 16.1.2012,
    http://www.nytimes.com/2012/01/17/books/louise-j-kaplan-psychoanalyst-and-author-dies-at-82.html

Wylie Vale Jr., Groundbreaking Endocrinologist, Dies at 70

January 15, 2012
The New York Times
By NICHOLAS WADE

Wylie W. Vale Jr., an eminent endocrinologist who helped identify the hormones through which the brain governs basic bodily functions and who was involved in a combative race for the Nobel Prize, died on Jan. 3 at his vacation home in Hana, Hawaii. He was 70.

The cause was not yet known, his wife, Mary Elizabeth, said.

Dr. Vale spent most of his career at the Salk Institute in San Diego, where he led efforts to identify the group of hormones involved in bodily functions like growth, reproduction and temperature. Their discovery was a landmark in the history of endocrinology, coming after more than 30 years of bitter competition.

The Nobel Prize went to others, but Dr. Vale “really, in the long run, had the biggest impact in the field,” said Bert O’Malley, an endocrinologist at the Baylor College of Medicine.

The first part of Dr. Vale’s career was spent as the principal scientist in the laboratory run by Roger Guillemin, who was locked in a 20-year race with a rival, Andrew Schally, to identify the hormones first.

The Guillemin-Schally war, described by Dr. Schally as “many years of vicious attacks and bitter retaliation,” ended in a draw in 1977 when the Nobel medicine committee gave each man a quarter share of a prize, the other half going to Dr. Rosalyn Yalow.

But the race was not over. An unexpected second phase erupted when Dr. Vale split from Dr. Guillemin and started competing against his former mentor to find the remaining hormones.

The serene campus of the Salk Institute, a plaza that overlooks the Pacific Ocean, then became the home to two laboratories locked in a race for scientific glory, as Dr. Vale and Dr. Guillemin sought to prove that each could succeed without the other’s help.

“They sharpened their swords and went at it full bore,” said Ronald Evans, a hormone expert at the Salk Institute.

Dr. Vale’s first target was the master hormone known as CRF, or corticotrophin releasing factor, which integrates and controls the body’s response to stress. Dr. Guillemin and Dr. Schally had spent seven years trying to isolate CRF before giving up and moving on to easier targets. Dr. Vale discovered CRF in 1981 and the next year found a second hormone, called the growth hormone releasing factor, or GRF, which had also eluded the older scientists. GRF controls the body’s growth.

Endocrinologists watched in amazement as the battle over the hormones raged. But they let the fight continue, mostly because of the importance of finding the hormones, but also because the dueling labs had acquired expertise in processing hundreds of thousands of sheep, pig and beef brains obtained from slaughterhouses for the research. It was a semi-industrial operation in which few others cared to join.

Despite the pressure of the competition, first with Dr. Schally and then with his own mentor, Dr. Vale maintained his easygoing Texan style and sense of humor. By contrast, Dr. Guillemin, born in Dijon, France, in 1924, brought an immigrant’s intensity to his work. He was also, like his rival Dr. Schally, loath to share credit for his lab’s achievements with his younger colleagues.

Toward the end of the fight with Dr. Schally, Dr. Vale became disenchanted with his mentor’s single-minded quest for scientific renown. During his search for GRF, Dr. Vale wrote the chemical formula for the hormone — it had not yet been published — on a large blackboard, which the members of Dr. Guillemin’s lab could see through the window every morning as they left the Salk parking lot. The formula was a decoy, intended to mislead the rival team. Dr. Vale kept the correct version on a piece of paper in his wallet.

Dr. Guillemin was aghast at the challenge from his scientific “son,” a man whom he had trained for his doctorate. Though he succeeded in finding the CRF and GRF hormones independently, in both cases Dr. Vale’s lab beat him to the punch.

Wylie Walker Vale Jr. was born in Houston on July 3, 1941. He attended Rice University and, after hearing Dr. Guillemin lecture on the releasing factors, as the brain’s hormones are known, joined Dr. Guillemin’s lab at the Baylor College of Medicine, earning his Ph.D. in 1964.

Dr. Vale’s principal task was to detect the releasing factors’ whereabouts in the large volumes of tissue from the sheep hypothalamus, a region at the base of the mammalian brain. He helped Dr. Guillemin to his first success, the identification of TRF, or thyrotropin releasing factor. Like the other releasing factor hormones, TRF is produced in the hypothalamus and reaches its target cells in the pituitary gland, just below the base of the brain. A second hormone, which is released by the pituitary in response to TRF, controls the thyroid gland and the body’s temperature control system.

In 1970, Dr. Guillemin moved his team to the Salk Institute. Over the next three years, Dr. Vale played a central role in the lab’s discovery of LRF, the releasing factor that controls the whole reproductive system, and somatostatin, a releasing factor hormone that inhibits the body’s growth.

Dr. Vale founded two companies to exploit his discoveries. One, Neurocrine Biosciences, is testing drugs that block the action of CRF that may help manage clinical depression. The other, AcceleronPharma, is testing drugs for treating anemia.

He also served as president of the American Endocrine Society and was a member of the National Academy of Sciences.

Besides his wife, who is known as Betty and whom he met in high school in Houston, Dr. Vale is survived by two daughters, Elizabeth Gandhi and Susannah Howieson; his father, Wylie; a brother, Shannon; and a granddaughter.

After Dr. Vale’s competition with Dr. Guillemin ended and the two men had reconciled, Dr. Guillemin recalled how a psychiatrist friend had advised him at the time to reread the Oedipus myth.

At a tribute on Dr. Vale’s 65th birthday, Dr. Guillemin quoted Freud’s analysis of the myth: “Part of any son worth his salt is planning the killing of the father he loves and taking his kingdom.”

    Wylie Vale Jr., Groundbreaking Endocrinologist, Dies at 70, NYT, 15.1.2011,
    http://www.nytimes.com/2012/01/16/science/wylie-vale-jr-groundbreaking-endocrinologist-dies-at-70.html

It’s Still the ‘Age of Anxiety.’ Or Is It?

January 14, 2012
3:00 pm
The New York Times
Opinionator - A Gathering of Opinion From Around the Web
By DANIEL SMITH

Anxiety: We worry. A gallery of contributors count the ways.

It’s hard to believe that anyone but scholars of modern literature or paid critics have read W.H. Auden’s dramatic poem “The Age of Anxiety” all the way through, even though it won a Pulitzer Prize in 1948, the year after it was published. It is a difficult work — allusive, allegorical, at times surreal. But more to the point, it’s boring. The characters meet, drink, talk and walk around; then they drink, talk and walk around some more. They do this for 138 pages; then they go home.

Auden’s title, though: that people know. From the moment it appeared, the phrase has been used to characterize the consciousness of our era, the awareness of everything perilous about the modern world: the degradation of the environment, nuclear energy, religious fundamentalism, threats to privacy and the family, drugs, pornography, violence, terrorism. Since 1990, it has appeared in the title or subtitle of at least two dozen books on subjects ranging from science to politics to parenting to sex (“Mindblowing Sex in the Real World: Hot Tips for Doing It in the Age of Anxiety”). As a sticker on the bumper of the Western world, “the age of anxiety” has been ubiquitous for more than six decades now.

But is it accurate? As someone who has struggled with chronic anxiety for many years, I have my doubts. For one thing, when you’ve endured anxiety’s insults for long enough — the gnawed fingernails and sweat-drenched underarms, the hyperventilating and crippling panic attacks — calling the 20th century “The Age of Anxiety” starts to sound like calling the 17th century “The Age of the Throbbing Migraine”: so metaphorical as to be meaningless.

From a sufferer’s perspective, anxiety is always and absolutely personal. It is an experience: a coloration in the way one thinks, feels and acts. It is a petty monster able to work such humdrum tricks as paralyzing you over your salad, convincing you that a choice between blue cheese and vinaigrette is as dire as that between life and death. When you are on intimate terms with something so monumentally subjective, it is hard to think in terms of epochs.

And yet it is undeniable that ours is an age in which an enormous and growing number of people suffer from anxiety. According to the National Institute of Mental Health, anxiety disorders now affect 18 percent of the adult population of the United States, or about 40 million people. By comparison, mood disorders — depression and bipolar illness, primarily — affect 9.5 percent. That makes anxiety the most common psychiatric complaint by a wide margin, and one for which we are increasingly well-medicated. Last spring, the drug research firm IMS Health released its annual report on pharmaceutical use in the United States. The anti-anxiety drug alprazolam — better known by its brand name, Xanax — was the top psychiatric drug on the list, clocking in at 46.3 million prescriptions in 2010.

Just because our anxiety is heavily diagnosed and medicated, however, doesn’t mean that we are more anxious than our forebears. It might simply mean that we are better treated — that we are, as individuals and a culture, more cognizant of the mind’s tendency to spin out of control.

Earlier eras might have been even more jittery than ours. Fourteenth-century Europe, for example, experienced devastating famines, waves of pillaging mercenaries, peasant revolts, religious turmoil and a plague that wiped out as much as half the population in four years. The evidence suggests that all this resulted in mass convulsions of anxiety, a period of psychic torment in which, as one historian has put it, “the more one knew, the less sense the world made.” Nor did the monolithic presence of the Church necessarily help; it might even have made things worse. A firm belief in God and heaven was near-universal, but so was a firm belief in their opposites: the Devil and hell. And you could never be certain in which direction you were headed.

It’s hard to imagine that we have it even close to as bad as that. Yet there is an aspect of anxiety that we clearly have more of than ever before: self-awareness. The inhabitants of earlier eras might have been wracked by nerves, but none fixated like we do on the condition. Indeed, none even considered anxiety a condition. Anxiety didn’t emerge as a cohesive psychiatric concept until the early 20th century, when Freud highlighted it as “the nodal point at which the most various and important questions converge, a riddle whose solution would be bound to throw a flood of light upon our whole mental existence.”

After that, the number of thinkers and artists who sought to solve this riddle increased exponentially. By 1977, the psychoanalyst Rollo May was noting an explosion in papers, books and studies on the subject. “Anxiety,” he wrote, “has certainly come out of the dimness of the professional office into the bright light of the marketplace.”

None of this is to say that ours is a serene age. Obviously it isn’t. It is to say, however, that we shouldn’t be possessive about our uncertainties, particularly as one of the dominant features of anxiety is its recursiveness. Anxiety begins with a single worry, and the more you concentrate on that worry, the more powerful it gets, and the more you worry. One of the best things you can do is learn to let go: to disempower the worry altogether. If you start to believe that anxiety is a foregone conclusion — if you start to believe the hype about the times we live in — then you risk surrendering the battle before it’s begun.

To receive immediate updates and new posts subscribe to the Anxiety RSS feed.

Daniel Smith is the author of the forthcoming book “Monkey Mind: A Memoir of Anxiety” (Simon & Schuster, July 2012). His work has appeared in The Atlantic, Granta, n+1, New York, The New York Times Magazine and elsewhere. He writes regularly about anxiety at his Web site, The Monkey Mind Chronicles.

This post has been revised to reflect the following correction:

Correction: January 15, 2012

An opinion essay on Jan. 15 about the prevalence of anxiety disorders erroneously attributed a distinction to the anti-anxiety drug alprazolam, or Xanax. It was the only psychiatric medication among the top 15 — not the top 25 — prescription drugs in the United States in 2010. A summary accompanying the article also referred incorrectly to Xanax. It was prescribed 46.3 million times in the United States in 2010, as the article correctly noted — not to 46 million people.

    It’s Still the ‘Age of Anxiety.’ Or Is It?, NYT, 14.1.2012,
    http://opinionator.blogs.nytimes.com/2012/01/14/its-still-the-age-of-anxiety-or-is-it/

Frederica Sagor Maas, Silent-Era Scriptwriter, Dies at 111

January 14, 2012
The New York Times
By DOUGLAS MARTIN

She told of Hollywood moguls chasing naked would-be starlets, the women shrieking with laughter. She recounted how Joan Crawford, new to the movies, relied on her to pick clothes. Almost obsessively, she complained about how many of her story ideas and scripts were stolen and credited to others.

Frederica Sagor Maas told all — and maybe more — in interviews and in her memoirs, which she published in 1999 at the age of 99. Before dying on Jan. 5 in La Mesa, Calif., at 111, Mrs. Maas was one of the last living links to cinema’s silent era. She wrote dozens of stories, adaptations and scripts, sat with Greta Garbo at the famed long table in MGM’s commissary, and adapted to sound in the movies, and then to color.

Perhaps most satisfying, Mrs. Maas outlived pretty much anybody who might have disagreed with her version of things. “I can get my payback now,” she said in an interview with Salon in 1999. “I’m alive and thriving and, well, you S.O.B.’s are all below.”

(She was also the 44th-oldest person in the world, according to the Gerontology Research Group, which keeps records of such things and which announced her death.)

Mrs. Maas’s life was like the plot of an old-fashioned movie. She dropped out of college to scout Broadway for movie ideas. She moved to Hollywood, rejected encouragement to be an actress and wrote for the Universal, MGM, Paramount and Fox studios. After the industry had no further use for her work, she almost committed suicide.

Much later, after giving up on Hollywood, Mrs. Maas said she would have preferred to be a “wash lady.”

Still, Hollywood gave her stories to tell: about meeting Crawford, whom she called “a gum-chewing dame,” and helping her find the sort of tailored clothes she herself favored; about seeing Clara Bow dancing naked on a table at a Jazz Age blowout. Sex, she wrote, became as “humdrum as washing your face or cleansing your teeth.”

Frederica Sagor, one of four daughters, was born on July 6, 1900, in a cold-water railroad flat at 101st Street near Madison Avenue in Manhattan. Her parents, Jewish immigrants from Russia, shortened their name from Zagosky. Frederica gave up plans to be a doctor and studied journalism at Columbia. She worked a summer as a copy girl for The New York Globe.

She joined the movie industry, and left school, after answering a want ad for an assistant to the story editor at Universal Pictures in New York. Getting the job, she learned about movies by seeing ones she liked three or four times, studying them frame by frame.

“I was fierce in my passion for this new medium,” she wrote in her memoir, “The Shocking Miss Pilgrim: A Writer in Early Hollywood.”

In 1924, Frederica Sagor moved to Hollywood to write for Preferred Pictures. She helped adapt “The Plastic Age,” a popular novel about collegiate life, for a 1925 movie that was a hit for Clara Bow. (Five years older than Bow, she outlived her by more than 46.) After that success, she signed with MGM, where, she said, others took credit for her work. In a studio system with armies of writers, she added, that was not unusual.

“Unless you wanted to quit the business, you just kept your mouth shut,” she wrote.

She moved on to Tiffany Productions, where she got credit for the flapper comedies “That Model From Paris” (1926) and “The First Night” (1927).

She married a screenwriter, Ernest Maas, in 1927, and went on to write scripts both with him and by herself. For her story for “Rolled Stockings” (1927), starring Louise Brooks, she was credited not only on the screen but on the poster as well, a rarity then.

The couple’s lives began a downward spiral when they lost $10,000 in the 1929 stock market crash. They survived by writing movie reviews and turned out screenplays, but all but one were rejected. The exception was a joint effort, “The Shocking Miss Pilgrim,” a 1947 release from which Mrs. Maas took the title for her memoir. The film was about a young stenographer who becomes the first woman ever hired by a Boston shipping office, but even that was twisted by the Hollywood homogenizers. Written as a study of a woman’s empowerment, “Miss Pilgrim” was turned into a frothy musical starring Betty Grable.

Impoverished and disillusioned, the couple drove to an isolated hilltop at sunset in 1950 with the intention of asphyxiating themselves. But they could not go through with it, Mrs. Maas said. Suddenly clutching each other, they cried and turned off the ignition.

“We had each other and we were alive,” Mrs. Maas told the online magazine Salon.

The couple had no children, and Mrs. Maas left no immediate survivors. Mr. Maas died at 94 in 1986.

Neither of the two returned to the industry. To get a job as a typist in an insurance agency, Mrs. Maas lied about her age, saying she was 40 when she was actually 50. She advanced to adjuster.

As for movies, Mrs. Maas stopped going. “I think the product they’re making today,” she said in 1999, “is even worse than the product we made in the early days.”

    Frederica Sagor Maas, Silent-Era Scriptwriter, Dies at 111, NYT, 15.1.2012,
    http://www.nytimes.com/2012/01/15/arts/frederica-sagor-maas-scriptwriter-from-the-silent-era-dies-at-111.html

An Engineered Doomsday

January 7, 2012
The New York Times

Scientists have long worried that an influenza virus that has ravaged poultry and wild birds in Asia might evolve to pose a threat to humans. Now scientists financed by the National Institutes of Health have shown in a laboratory how that could happen. In the process they created a virus that could kill tens or hundreds of millions of people if it escaped confinement or was stolen by terrorists.

We nearly always champion unfettered scientific research and open publication of the results. In this case it looks like the research should never have been undertaken because the potential harm is so catastrophic and the potential benefits from studying the virus so speculative.

Unless the scientific community and health officials can provide more persuasive justifications than they have so far, the new virus, which is in the Netherlands, ought to be destroyed. Barring that, it should be put in a few government-controlled laboratories with the highest containment rating, known as biosafety level 4. That is how the United States and Russia contain samples of smallpox, which poses nowhere near the same danger of global devastation.

In the future, it is imperative that any such experiments be rigorously analyzed for potential dangers — preferably through an international review mechanism, but also by governmental funding agencies — before they are undertaken, not after the fact as is happening in this case.

The most frightening research was done by scientists at the Erasmus Medical Center in Rotterdam, who sought to discover how likely it is that the “bird flu” virus, designated A(H5N1), might mutate from a form that seldom infects or spreads among humans into a form highly transmissible by coughing or sneezing. Thus far the virus has infected close to 600 humans and killed more than half of them, a fatality rate that far exceeds the 2 percent rate in the 1918 influenza pandemic that killed as many as 100 million people.

Working with ferrets, the animal that is most like humans in responding to influenza, the researchers found that a mere five genetic mutations allowed the virus to spread through the air from one ferret to another while maintaining its lethality. A separate study at the University of Wisconsin, about which little is known publicly, produced a virus that is thought to be less virulent.

These findings led to an unprecedented request from an American federal advisory board that the researchers and the two scientific journals that plan to publish the studies omit any details that might help terrorists figure out how to unleash a devastating pandemic. That presumably includes details on how the engineered virus was made and details on the precise mutations that allowed it to go airborne.

We doubt that anything at all should be published, but it seems clear that something will be.

The two journals reviewing the papers seem inclined to follow the advisory board’s recommendations that the research be published in a redacted form, provided there is some way for researchers who need the information to gain access to the full details. The Erasmus team believes that more than 100 laboratories and perhaps 1,000 scientists around the world need to know the precise mutations to look for. That would spread the information far too widely. It should suffice to have a few of the most sophisticated laboratories do the analyses.

Defenders of the research in Rotterdam claim it will provide two major benefits for protecting global health. First, they say the findings could prove helpful in monitoring virus samples from infected birds and animals. If genetic analysis found a virus somewhere that was only one or two mutations away from going airborne, public health officials would then know to bear down aggressively in that area to limit human contact with infected poultry and ramp up supplies of vaccines and medicines.

But it is highly uncertain, even improbable, that the virus would mutate in nature along the pathways prodded in a laboratory environment, so the benefit of looking for these five mutations seems marginal.

A second postulated benefit is that the engineered virus can be used to test whether existing antiviral drugs and vaccines would be effective against it and, if they come up short, design new drugs and vaccines that can neutralize it. But genetic changes that affect transmissibility do not necessarily change the properties that make a virus susceptible to drugs or to the antibodies produced by a vaccine, so that approach may not yield much useful new information.

We cannot say there would be no benefits at all from studying the virus. We respect the researchers’ desire to protect public health. But the consequences, should the virus escape, are too devastating to risk.

    An Engineered Doomsday, NYT, 7.1.2012,
    http://www.nytimes.com/2012/01/08/opinion/sunday/an-engineered-doomsday.html

The Virtual Anatomy, Ready for Dissection

January 7, 2012
The New York Times
By NATASHA SINGER

PEOPLE wear 3-D glasses for new movies like “The Adventures of Tintin.” But for medical school?

The answer is yes at the New York University School of Medicine, which is using 3-D technology to update a rite of passage for would-be doctors: anatomy class.

In a basement lab at NYU Langone Medical Center in Manhattan last month, students in scrubs and surgical gloves hovered over cadavers on gurneys, preparing, as would-be doctors have for centuries, to separate rib cages and examine organs. But the dead are imperfect stand-ins for the living. Death — and embalming fluid — take a toll.

So, in an adjacent classroom, a group of students wearing 3-D glasses made by Nvidia, a graphics processing firm, dissected a virtual cadaver projected on a screen. Using a computer to control the stereoscopic view, they swooped through the virtual body, its sections as brightly colored as living tissue. First, the students scrutinized layers of sinewy pink muscles layered over ivory bones. Then, with the click of a mouse, they examined a close-up of the heart, watching as deep blue veins and bright red arteries made the heart pump.

Compared with the real cadavers in the lab next door, the virtual one seemed as dynamic as Imax.

“It’s like a living digital textbook,” said John J. Qualter, a research assistant professor of educational informatics at the medical school who helped design the 3-D installation.

The virtual human body is the creation of BioDigital Systems, a medical visualization firm in Manhattan that Mr. Qualter helped to found. It develops animations of the anatomy for drug makers like Novartis, medical device makers like Medtronic, television shows like “Mystery Diagnosis” and medical schools.

The virtual body, introduced last month at N.Y.U., represents an unusual collaboration between industry and academia. The companies, which originally paid BioDigital to develop medical animations of certain body parts for commercial purposes, agreed to let the design firm freely use the digital models for educational purposes. In recognition of N.Y.U.’s involvement, the company has pledged a small share of future revenue to the medical school.

But the medical students were merely testing an early incarnation of an ambitious project.

BioDigital plans to develop the virtual cadaver further on its new medical education Web site, biodigitalhuman.com, with the aim of providing a searchable, customizable map of the human body. Right now, Mr. Qualter said, the site is available only in a beta version. But in the coming months, the company plans to offer its code to, say, health Web sites that want to embed images of the respiratory system, or to doctors who want to show animations of prostate cancer surgery to patients.

“We wanted to use our data visualization to improve knowledge of complex health topics,” Mr. Qualter said. His firm hopes to position the virtual body as the health education equivalent of Google Maps — available as a free, easy-to-use public Web site and in an upgraded, fee-based professional version.

“We want to become a scalable model,” Mr. Qualter said, “a Google Earth for the human body.”

Mr. Qualter and his business partner, Frank Sculli, a software engineer, founded BioDigital Systems in 2002 to help companies and institutions use 3-D storytelling to make medical topics more comprehensible and compelling. For instance, the firm created an animated heart to demonstrate how an implant from Medtronic could fix a prolapsed heart valve. At N.Y.U., the firm worked with the medical school to develop animations of operations for surgical education.

Those kinds of commissions helped make BioDigital successful as a small business. But its executives concluded that its growth potential would be limited if they remained focused on one-off projects for limited audiences. Last year, they decided to combine all of their commissioned medical illustrations into one virtual human.

“As a private company, as a service business, we can make a couple of million dollars annually,” Mr. Qualter said. But, as a product firm with a searchable map of the human body to market, he said, the company has greater potential to increase revenue and improve health education. “Once the BioDigital Human is really being used by a lot of people, we can leverage that.”

IT is too soon to tell whether studying a digital human model will help medical students understand anatomy more deeply than they can by dissecting cadavers alone. But the virtual body certainly offers some advantages.

In the N.Y.U. lab, Chana Rich, a 21-year-old first-year student from Fairfield, Conn., dissected an older, female cadaver. But the dead woman had undergone a number of surgeries during her lifetime, and her body was now missing its appendix, spleen and right lung.

“She’s skinny and female,” Ms. Rich said, “so sometimes it’s hard to visualize the smaller vessels.”

A few minutes later, Ms. Rich was in the projection room, isolating the liver of the virtual cadaver and examining the blood vessels connected to it.

“In a cadaver, if you remove an organ, you cannot add it back in as if it were never removed,” she said as she adjusted her 3-D glasses. “Plus, this is way more fun than a textbook.”

But her colleague, Susanna Jeurling, a first-year medical student from Washington, disagreed. Dissecting a real cadaver, she said, gives students a unique, tactile understanding of the body.

“I don’t think this will ever replace cadavers,” said Ms. Jeurling, 24. “There’s something about being able to hold it and turn it in your hand.”

Administrators at the medical school say they have no plans to phase out dissection, an educational method that dates back to the Ptolemaic era. The 3-D digital human body is merely a complementary teaching method, said Dr. Marc M. Triola, associate dean for educational informatics.

“It’s an amazing blend of one of the oldest medical education techniques and the absolute newest,” Dr. Triola said.

The Virtual Anatomy, Ready for Dissection, NYT, 7.1.2012,
    http://www.nytimes.com/2012/01/08/business/the-human-anatomy-animated-with-3-d-technology.html