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2014 > USA > Health (I)
Robert Mitton, 58, whose heart is failing,
has become a proponent of the idea
that people should be able
to get help dying.
Photograph:
Matthew Staver for The New York Times
‘Aid in Dying’ Movement Takes Hold in Some States
NYT
7.2.2014
https://www.nytimes.com/2014/02/08/
us/easing-terminal-patients-path-to-death-legally.html
The F.D.A.’s Blatant Failure on Food
JULY 30, 2014
The New York Times
The Opinion Pages | Op-Ed Contributor
By RUTH REICHL
EVERY year, antibiotic-resistant infections kill at least 23,000
Americans and make another two million sick, according to the Centers for
Disease Control and Prevention. That’s why a recent ruling by the United States
Second Circuit Court of Appeals is so appalling.
It allows the federal Food and Drug Administration to leave an antibiotic used
in animal feed on the market even if the agency openly states that the drug’s
use is not safe and increases the risk of antibiotic resistance in people. This
means that the dangerous misuse of antibiotics in industrial livestock and
poultry can continue unabated.
For years industrial meat and poultry producers have fed healthy animals
antibiotics to fatten them up fast. The antibiotics also prevent disease in what
are often overcrowded, unsanitary conditions. This practice breeds
antibiotic-resistant bacteria that threaten us all.
The F.D.A. has issued a toothless voluntary guidance document for the industry,
which requires no action to reduce antibiotic use and will therefore do little
to nothing to stop the spread of antibiotic-resistant superbugs.
Why should we be concerned? Because the superbugs bred on industrial farms can
easily travel to us in our food — as in the recent antibiotic-resistant
salmonella outbreak linked to Foster Farms chicken that has sickened over 600
people. The superbugs also get into our water and our soil. Some of the
antibiotic-resistant bacteria can cause life-threatening infections.
While prescribing unnecessary antibiotics to people is one widely known cause of
the problem, the C.D.C. and leading medical groups have identified the misuse of
drugs in livestock and poultry operations as another important contributor. Dr.
Thomas R. Frieden, the C.D.C. director, has said of antibiotic resistance, “If
we don’t act now, our medicine cabinet will be empty and we won’t have the
antibiotics we need to save lives.” That’s a truly terrifying prospect.
And it’s one we don’t need to face. Although many industrial farmers claim that
cleaning up their act will cost the rest of us at the cash register, responsible
producers from Missouri to Denmark are already raising healthy livestock and
poultry at competitive prices without the use of unnecessary drugs. Some
mainstream food companies and their suppliers are starting to move in that
direction, but it’s time all of the big meat and poultry firms joined them.
A fifth-generation pork producer, Russ Kremer of Missouri, is showing the way.
In 1989, after an antibiotic-resistant infection from one of his pigs nearly
killed him, he realized the danger of his antibiotic-dependent methods and
decided to start over. He now raises pigs the natural way — free-roaming and
without drugs — for his company, Heritage Acres Food. Today, buyers of his pork
include Chipotle and Costco. He also leads a thriving pork cooperative, showing
dozens of producers that they, too, can make similar conversions at a profit.
And Mr. Kremer is hardly alone. In Denmark, one of the world’s largest pork
exporters, industrial farmers have cut overall antibiotic use by more than 40
percent while increasing production. The European Union, with its additional 27
member nations, also prohibits the misuse of growth-promoting antibiotics.
While the F.D.A. continues to drag its feet, it’s time for cooks and consumers
to step in. We can play an important, proactive role in protecting against
superbugs by changing the marketplace. Insist that your supermarkets stock meat
and poultry raised without antibiotics. Demand that your restaurants do the
same. An increasing number of major food companies, including Whole Foods,
Chick-fil-A, Chipotle, Applegate and Panera Bread, have gotten on board, proof
that as we vote with our wallets and our roasting pans, producers will rise to
meet us.
Food should be delicious. It should also be good for you. We shouldn’t have to
worry that we’re endangering our health each time we put a morsel of meat into
our mouths. Rather than protecting the unsafe practices of the country’s animal
agriculture industry, it’s time the F.D.A. followed its mandate and put
America’s health first.
Ruth Reichl, a food writer and author, is a former restaurant critic for The New
York Times and editor of Gourmet.
A version of this op-ed appears in print on July 31, 2014,
on page A23 of the New York edition with the headline:
The F.D.A.’s Blatant Failure on Food.
The F.D.A.’s Blatant Failure on Food, NYT,
30.7.2014,
http://www.nytimes.com/2014/07/31/opinion/the-fda-blatant-failure-on-food.html
An Ominous Health Care Ruling
JULY 22, 2014
The New York Times
The Opinion Pages | Editorial
By THE EDITORIAL BOARD
Millions of low- and moderate-income people who signed up for
health insurance with the help of federal tax-credit subsidies could find
themselves without coverage or facing big premium bills if a destructive
decision handed down by a federal appeals court in Washington on Tuesday is not
reversed. It would be a crippling blow to the ability of the Affordable Care Act
to reduce the ranks of the uninsured with grievous consequences for vulnerable
customers.
For now, consumers are expected to retain their coverage and tax credits while
this and similar suits in other jurisdictions wend their way through the court
system. Just hours after the ruling in Washington, a federal appeals court panel
in Richmond, Va., ruled the opposite way, finding that Congress intended to make
the tax credits available nationwide.
Under the decision of a three-judge panel of the United States Court of Appeals
for the District of Columbia Circuit, people living in 36 states, mostly led by
Republican governors or legislatures, would be in jeopardy because their states
refused to set up “exchanges” or electronic marketplaces on which individuals
can shop for insurance plans and apply for subsidies based on their incomes.
For the most part, the political leaders in those states wanted nothing to do
with what they deride as Obamacare, and left it up to the federal government to
set up exchanges for their residents. People fortunate enough to live in the 14
states and the District of Columbia that have set up their own exchanges would
escape the effect of this mindless and harmful ruling.
The 2-to-1 decision issued by the panel hinged on how to interpret language in
the Affordable Care Act that most experts agree was poorly drafted and would
ordinarily have been corrected by a Congressional conference committee. In this
instance, there was no conference committee because the law was passed on a
take-it-or-leave-it vote in the House to avoid a Republican filibuster in the
Senate.
Two Republican-appointed judges on the panel, taking an incredibly narrow and
blinkered view, concluded that the language in the law allows the Internal
Revenue Service to provide tax-credit subsidies only on exchanges established by
the states. They decided that the statute’s wording does not allow subsidies on
federally created exchanges — even though those exchanges carry out exactly the
same purpose and, in effect, act on behalf of the states. The administration had
expected most states to create their own exchanges, but most handed that task to
the federal government.
The third judge, a Democratic appointee, called the majority opinion what it
clearly was, a “not-so-veiled attempt to gut” the health care law. He argued
that the law sought to achieve “near-universal coverage” of all Americans and
that this could only be achieved with the help of subsidies working in tandem
with a mandate that most Americans obtain health insurance or pay a penalty. It
defies common sense to think that Congress really intended that there be no
subsidies at all in 36 states.
The Obama administration is expected to appeal the decision to the full
appellate court, whose 11 members include seven Democratic and four Republican
appointees. What is needed is common sense in interpreting the law, not
ideological opposition to Obamacare.
The three-judge appeals panel on the Court of Appeals for the Fourth Circuit,
based in Richmond, while acknowledging ambiguities in the language of the law,
unanimously and properly upheld the subsidies as a permissible exercise of
discretion by the I.R.S.
A version of this editorial appears in print on July 23, 2014,
on page A24 of the New York edition with the headline:
An Ominous Health Care Ruling.
An Ominous Health Care Ruling, NYT, 22.7.2014,
http://www.nytimes.com/2014/07/23/opinion/an-ominous-health-care-ruling.html
Jury Awards $23.6 Billion
in Florida Smoking Case
JULY 19, 2014
The New York Times
By FRANCES ROBLES
MIAMI — A jury in northwestern Florida awarded a staggering $23
billion judgment late Friday against the country’s second-largest tobacco
company for causing the death of a chain smoker who died of lung cancer at the
age of 36.
The company, the R. J. Reynolds Tobacco Company, promised a prompt appeal.
Michael Johnson Sr. died in 1996 after smoking for more than 20 years. In 2006,
his widow, Cynthia Robinson, of Pensacola, sued R. J. Reynolds the maker of the
Kool brand cigarettes her husband had smoked, arguing that the company had
deliberately concealed the health hazards its product caused.
The four-week trial ended Wednesday. The jury deliberated for 18 hours over two
days, first awarding $17 million in compensatory damages and then emerging at 10
p.m. Friday with a $23.6 billion punitive judgment.
“When they first read the verdict, I know I heard ‘million,’ and I got so
excited,” Ms. Robinson said in a phone interview Saturday. “Then the attorney
informed me that was a ‘B’ — billion. It was just unbelievable.”
She said Mr. Johnson, a longshoreman and hotel shuttle bus driver to whom she
was married from 1990 until his death six years later, began smoking around age
13. He often lit a fresh cigarette with the butt end of another.
“He really did smoke a lot,” she said.
He had two children, who are now 23 and 29.
“The damages awarded in this case are grossly excessive and impermissible under
state and constitutional law,” J. Jeffery Raborn, vice president and assistant
general counsel for R. J. Reynolds, said Saturday in a statement. “This verdict
goes far beyond the realm of reasonableness and fairness and is completely
inconsistent with the evidence presented. We plan to file post-trial motions
with the trial court promptly and are confident that the court will follow the
law and not allow this runaway verdict to stand.”
Such efforts by the industry are often successful. In October 2002, a Los
Angeles jury awarded $28 billion in punitive damages against Philip Morris USA.
In August 2011, an appeals court reduced the punitive damages to $28 million.
The Florida case was among the thousands of the so-called “Engle progeny” cases
that stemmed from a 2006 court decision ruling that smokers could not file
class-action suits but were free to do so individually.
That decision reversed a $145 billion verdict in a class action awarded in 2000
on behalf of a Miami Beach pediatrician, Howard A. Engle. An appeals court
voided the award, saying it was excessive and the cases of individual smokers
were too disparate to be considered as a class.
The plaintiffs petitioned the Florida Supreme Court, which upheld the
decertification of the class but permitted individuals to sue, which set the
stage for Ms. Robinson’s lawsuit.
Friday’s verdict was the highest granted to an Engle progeny case.
Ms. Robinson was represented by Christopher M. Chestnut, based in Georgia, and
Willie E. Gary and Howard M. Acosta, both based in Florida.
“The jury just got it,” Mr. Chestnut said. “The jury was outraged with the
concealment and the conspiracy to conceal that smoking was not only addictive
but that there were deadly chemicals in cigarettes.”
He said the jury seemed most persuaded by 1994 C-Span footage of tobacco
industry executives claiming smoking did not cause cancer and was not addictive,
and by 60-year-old internal documents showing the company knew otherwise.
Scott P. Schlesinger, a Fort Lauderdale, Fla., lawyer who has sued big tobacco
but was not involved in the Robinson case, said a verdict this large is not
typical.
“There have not been multibillion-dollar punishments in the Engle cases for one
reason: We are afraid to ask for them. We are afraid of what will happen in the
appellate process,” he said. “This verdict is important because it goes back to
an ongoing saga that goes back to 1990. People have been filing suit one by one,
and we have been winning about 70 percent of them.”
Correction: July 19, 2014
An earlier version of this article misstated the location of Willie E. Gary, a
lawyer for Cynthia Robinson. He is based in Florida, not Georgia.
A version of this article appears in print on July 20, 2014, on page A17 of the
New York edition with the headline: Jury Awards $23.6 Billion in Florida Smoking
Case.
Jury Awards $23.6 Billion in Florida Smoking
Case, NYT, 19.7.2014,
http://www.nytimes.com/2014/07/20/business/
jury-awards-23-6-billion-in-florida-smoking-case.html
Evidence of H.I.V. Found
in a Child Said to Be Cured
JULY 10, 2014
The New York Times
By DONALD G. McNEIL Jr.
A child in Mississippi who was thought to have been cured of
H.I.V. with aggressive drug treatment immediately after birth is now showing
signs of infection with the virus, federal health officials announced Thursday —
a serious setback to hopes for a cure for AIDS.
The report in March 2013 that the child had apparently been cured raised the
possibility that aggressive early treatment might be able to reverse infections
in newborns — and perhaps even in newly infected adults. About 2.3 million
people around the world were newly infected with H.I.V. in 2012, the last year
for which figures were available; 260,000 were infants infected at birth or
immediately afterward.
With hopes raised by the Mississippi case, doctors had made plans for a
worldwide clinical trial in which about 450 babies — chosen because their
infected mothers had no testing or treatment before the births — would be put on
the three-drug regimen called triple therapy.
If those who were infected with H.I.V. showed no virus after 48 weeks of
treatment, the plan was to stop their drugs and see if they had been cured
before the virus had a chance to establish a reservoir of infected cells.
But not a single baby has yet been enrolled in the trial, and in light of the
failure to cure the Mississippi baby, “We’ve got to go back and look at the
trial’s design,” said Dr. Anthony S. Fauci, a leading AIDS expert who is the
director of the National Institute of Allergy and Infectious Diseases.
Asked how he felt about Thursday’s announcement, he said: “It’s obviously
disappointing, but I was not surprised. I’ve been chasing these reservoirs for
the last 25 years, and I know this virus has a really uncanny way of hiding
itself.”
Before the Mississippi baby, only one other person had been considered cured of
H.I.V. That was an adult, Timothy Brown, previously known as the anonymous
“Berlin patient,” who had a transplant of blood stem cells to treat his leukemia
after his bone marrow was wiped out with drugs and radiation. The new stem cells
were from a matching donor who also had a relatively rare mutation that creates
blood cells lacking the surface receptor that H.I.V. uses to enter the cell.
Then last March, a second baby, born in Long Beach, Calif., appeared to have
been cured after early and aggressive treatment. But doctors had been hesitant
to declare that cure as definitively as they did in Mississippi case.
The mother in Mississippi had disappeared with her baby for several months after
treatment began, and pediatricians assumed when they saw the baby again that it
would be teeming with the virus. Instead, exhaustive tests found none in blood
or tissue, and that remained true until several weeks ago when the virus was
detected in the child’s blood during a routine office visit. By contrast, the
California baby could not ethically be taken off antiretroviral drugs, which is
the only sure test of whether the virus will rebound.
When the virus enters the body, it first invades the CD4 white blood cells and
makes millions of copies of itself. It then starts entering lymph cells in the
gut and elsewhere and uses its RNA core to make DNA mirror images of itself that
then integrate themselves into the DNA of the cell, creating the reservoir.
After that, even if antiretroviral drugs suppress the ability of any
free-floating RNA to copy itself, the DNA persists, waiting to act as a template
for new RNA if the drugs are ever stopped.
The Mississippi case stirred worldwide excitement last year when it was
described in The New England Journal of Medicine. Dr. Deborah Persaud, an
associate professor at Johns Hopkins Children’s Center and the lead author of
the report, said at the time that it was “proof of principle that we can cure
H.I.V. infection if we can replicate this case.”
On Thursday, Dr. Persaud said the fact that the child had remained virus-free
for two years was “unprecedented.” Normally, the virus rebounds in a few weeks.
The child’s virus was identical to the mother’s, so there was no doubt that it
was the virus passed at birth, not a later infection.
Dr. Fauci said the viral load was 16,000 copies of the virus per cubic
millimeter of blood. “You sometimes get a blip of 100 copies or 500 copies, but
16,000 is not a blip,” Dr. Fauci said. “That is an unequivocal relapse.”
The child is now on triple therapy and is expected to stay that way, presumably
for life unless a new route to a cure is found.
Last March, after the existence of the Long Beach baby was revealed, a leading
AIDS researcher said there were anecdotal reports of five more such cases in
Canada and three in South Africa.
It is very rare for children in wealthy countries to be born with H.I.V. because
most mothers are routinely tested in pregnancy and, if infected, put on triple
therapy. Only in rare cases do mothers get no testing or prenatal care at all,
and those are usually homeless and mentally ill women, as was the case in Long
Beach.
A version of this article appears in print on July 11, 2014, on page A1 of the
New York edition with the headline: Evidence of H.I.V. Found in a Child Said to
Be Cured.
Evidence of H.I.V. Found in a Child Said to Be
Cured, NYT, 10.7.2014,
http://www.nytimes.com/2014/07/11/health/
signs-of-infection-seen-in-child-believed-to-have-been-cured-of-hiv.html
Obama Weighs Steps
to Cover Contraception
JULY 4, 2014
The New York Times
By ROBERT PEAR and ADAM LIPTAK
WASHINGTON — The Obama administration, reeling from back-to-back
blows from the Supreme Court this week, is weighing options that would provide
contraceptive coverage to thousands of women who are about to lose it or never
had it because of their employers’ religious objections.
The administration must move fast. Legal and health care experts expect a rush
to court involving scores of employers seeking to take advantage of the two
decisions, one involving Hobby Lobby Stores, which affects for-profit
businesses, and the other on Wheaton College that concerns religiously
affiliated nonprofit groups. About 100 cases are pending.
One proposal the White House is studying would put companies’ insurers or health
plan administrators on the spot for contraceptive coverage, with details of
reimbursement to be worked out later.
Another would give the administration itself a larger role in
offering cost-free coverage to women who cannot get it through their employers,
although the option for a new government entitlement appears unrealistic for
financial and political reasons.
The White House is under such pressure that no one has been able to work out
details of how the alternatives would be financed or administered.
Administration officials said they were determined to ensure the broadest
possible coverage of contraceptives for the largest number of women without
requiring employers to violate their religious beliefs.
Mark L. Rienzi, a lawyer who represented both Hobby Lobby and Wheaton College,
said the administration had the tools to make an alternative solution work. “The
government can find other ways to deliver contraceptives to people without
forcing nuns and religious colleges to participate,” he said.
That is not the way Justice Sonia Sotomayor looks at it. In her dissent in the
Wheaton College case on Thursday, she said the challenge facing the government
was “daunting — if not impossible.”
Still, the administration has another motivation to act as quickly as possible:
It is eager to court the votes of women dismayed by the rulings. The Democratic
National Committee is already urging voters to fight back against the Hobby
Lobby decision and to “stand up for Obamacare” in the November elections. The
Supreme Court said that family-owned for-profit corporations like Hobby Lobby
were not required to provide coverage of contraceptives if they objected on
religious grounds.
Whatever the choice, no plan can be turned around in two weeks, or two months.
It took more than two years for the administration to figure out how to provide
contraceptive coverage for women at nonprofit groups that have religious
objections. That arrangement allowed religious organizations to fill out a form
that would transfer the delivery of free coverage under the Affordable Care Act
to others.
But many of the nonprofit groups say that even notifying an insurer of their
objections through the opt-out form would make them complicit in a moral wrong.
Some consider all contraception to be wrong; others object only to devices and
drugs like the so-called morning-after pill that they believe may cause
abortions. One such objector was Wheaton College, a Christian liberal arts
school in Illinois, and the Supreme Court granted it a temporary exemption in
the ruling on Thursday.
That move divided the court along gender lines, with Justices Ruth Bader
Ginsburg and Elena Kagan joining Justice Sotomayor’s unsparing dissent. They
said the court majority had endorsed the opt-out form just three days earlier in
the Hobby Lobby case, in which Justice Stephen G. Breyer joined the three female
justices in dissent in the 5-to-4 ruling.
The court’s conservative majority — all men — was sanguine about the
availability of other ways for the administration to deliver coverage for every
form of birth control approved by the Food and Drug Administration.
Yet officials are struggling to make sense of a sunny sentence in the court’s
order on Thursday exempting Wheaton from the opt-out form. “Nothing in this
interim order affects the ability of the applicant’s employees and students to
obtain, without cost, the full range of F.D.A.-approved contraceptives,” the
majority said in the unsigned opinion.
It said Wheaton could merely notify the government of its religious objections
in writing rather than send the opt-out form to its coverage providers.
The difference sounds trivial. But it could create quite a roadblock for the
Department of Health and Human Services, Justice Sotomayor wrote in dissent.
“Does the court intend for H.H.S. to rely on the filing of lawsuits by every
entity claiming an exemption?” she asked. She questioned whether the government
was supposed to create “a database that tracks every employer’s insurer or
third-party administrator nationwide.”
Wheaton said it would have no difficulty sending a notice to the secretary of
Health and Human Services.
The contraceptive coverage requirement is just one of many provisions in rules
adopted under the Affordable Care Act, but it has become one of the most
significant, both politically and symbolically, overshadowing many other
important provisions.
In early 2011, Obama administration officials said they wanted to require
insurers to offer contraceptives to women free of charge.
The administration has made progress toward its goal, as millions of women have
gained access to birth control without co-payments or other charges. But in the
process, the administration has become entangled in scores of court cases,
fighting with priests and nuns and other religious believers over details of the
health insurance coverage they provide and receive.
The battles are sure to continue for a year or more, with religious objectors
emboldened by victories this week. Justice Samuel A. Alito Jr., in writing the
majority opinion in the Hobby Lobby case, said it seemed likely that the cost of
providing the four drugs and devices that many religious groups object to “would
be minor when compared with the overall cost” of the health care law.
Justice Alito wrote approvingly of the idea of shifting contraceptive costs to
insurance companies, calling it “an approach that is less restrictive than
requiring employers to fund contraceptive methods that violate their religious
beliefs.”
But on Thursday the majority made the cost-shifting much harder to accomplish.
The general idea is to require insurance companies and plan administrators to
deliver coverage when they are told about an employer’s religious objections.
They would bear the costs or receive reimbursement from the government.
The situation is more complicated when employers self-insure. There, the
administration says, outside plan administrators may obtain a “compensating
reduction” in the fees paid by insurers to participate in the insurance
exchanges established by the health care law. Those adjustments, the
administration has said, will not cost much.
Some religious organizations are using that arrangement. But employee benefits
experts said it was not working well, in part because insurers and third-party
administrators have had to foot the bill for contraceptive coverage without any
immediate offset or reimbursement.
“They are not being paid, and they have no prospect of being reimbursed,” said
Christopher E. Condeluci, a lawyer for the Self-Insurance Institute of America.
The Obama administration says the cost of providing contraceptives will be
offset by savings that result from greater use of birth control, “fewer
unplanned pregnancies” and improvement in women’s health. But, Mr. Condeluci
said, “It may be years before the savings are realized.”
A version of this article appears in print on July 5, 2014, on page A1 of the
New York edition with the headline: Obama Weighs Steps to Cover Contraception.
Obama Weighs Steps to Cover Contraception,
NYT, 4.7.2014,
http://www.nytimes.com/2014/07/05/us/politics/
obama-weighs-steps-to-cover-contraception.html
Supreme Court Rejects
Contraceptives Mandate
for Some Corporations
JUNE 30, 2014
The New York Times
By ADAM LIPTAK
WASHINGTON — The Supreme Court ruled on Monday that requiring
family-owned corporations to pay for insurance coverage for contraception under
the Affordable Care Act violated a federal law protecting religious freedom.
The 5-to-4 decision, which applied to two companies owned by Christian families,
opened the door to challenges from other corporations to many laws that may be
said to violate their religious liberty.
Justice Samuel A. Alito Jr., writing for the court’s five more conservative
justices, said a federal religious-freedom law applied to for-profit
corporations controlled by religious families. He added that the requirement
that the companies provide contraception coverage imposed a substantial burden
on the companies’ religious liberty. He said the government could provide the
coverage in other ways.
Justice Ruth Bader Ginsburg, writing for the court’s four-member liberal wing,
said the contraception coverage requirement was vital to women’s health and
reproductive freedom. Justices Stephen G. Breyer and Elena Kagan joined almost
all of the dissent, but they said there was no need to take a position on
whether corporations may bring claims under the religious liberty law.
On that point, Justice Ginsburg, joined by Justice Sonia Sotomayor, said the
court’s decision “is bound to have untoward effects” in other settings.
“The court’s expansive notion of corporate personhood,” Justice Ginsburg wrote,
“invites for-profit entities to seek religion-based exemptions from regulations
they deem offensive to their faiths.”
The contraception coverage requirement was challenged by two
corporations whose owners say they try to run their businesses on religious
principles: Hobby Lobby, a chain of crafts stores, and Conestoga Wood
Specialties, which makes wood cabinets
The health care law and related regulations require many employers to provide
female workers with comprehensive insurance coverage for a variety of methods of
contraception. The companies objected to some of the methods, saying they are
tantamount to abortion because they can prevent embryos from implanting in the
womb. Providing insurance coverage for those forms of contraception would, the
companies said, make them complicit in the practice.
The companies said they had no objection to other forms of contraception,
including condoms, diaphragms, sponges, several kinds of birth control pills and
sterilization surgery.
The Obama administration said it did not question the sincerity of the
companies’ beliefs, and it has offered exemptions to other groups on such
grounds.
A federal judge has estimated that a third of Americans are not subject to the
requirement that their employers provide coverage for contraceptives. Small
employers need not offer health coverage at all; religious employers like
churches are exempt; religiously affiliated groups may claim an exemption; and
some insurance plans that had not previously offered the coverage are
grandfathered in.
But the administration said that for-profit corporations like Hobby Lobby and
Conestoga Wood must comply with the law or face fines.
The companies challenged the coverage requirement under the Religious Freedom
Restoration Act of 1993. The law was a response to a 1990 Supreme Court decision
that declined to recognize religious exceptions under the First Amendment’s free
exercise clause to generally applicable laws. Congress effectively reversed that
decision.
“What this law basically says,” President Bill Clinton said before signing the
bill, “is that the government should be held to a very high level of proof
before it interferes with someone’s free exercise of religion.”
The threshold question in the new case was whether the companies were permitted
to raise a claim under the law.
The companies argued that they were, and they said the coverage requirement
imposed a “substantial burden” on religious practices by subjecting Hobby Lobby,
for instance, to fines of $1.3 million a day if it chose not to offer
comprehensive coverage, and to different fines of $26 million a year if it
stopped offering insurance entirely.
Some scholars responded that the company would be better off financially if it
dropped coverage, and so does not face a substantial burden.
The administration argued that requiring insurance plans to include
comprehensive coverage for contraception promotes public health and ensures that
“women have equal access to health care services.” The government’s briefs added
that doctors, rather than employers, should decide which form of contraception
is best.
A supporting brief from the Guttmacher Institute, a research and policy group,
said that many women cannot afford the most effective means of birth control and
that the law will reduce unintended pregnancies and abortions.
Supreme Court Rejects Contraceptives Mandate
for Some Corporations,
NYT, 30.6.2014,
http://www.nytimes.com/2014/07/01/us/
supreme-court-ruling-in-contraceptive-case-is-awaited.html
A Unanimous Supreme Court:
Abortion Rights Lose a Buffer
JUNE 26, 2014
The New York Times
The Opinion Pages | Editorial
By THE EDITORIAL BOARD
In the world as Supreme Court Justice Antonin Scalia imagines it,
anti-abortion advocates resemble Eleanor McCullen, a self-described “mother and
grandmother” who stands outside a reproductive-health clinic in Boston and
attempts to gently “counsel” approaching women out of getting an abortion.
He also sees lawmakers and judges conspiring to silence the voices of those like
Ms. McCullen by establishing buffer zones on public sidewalks around those
clinics.
Out in the real world, of course, all anti-abortion advocates are not Ms.
McCullen, and buffer-zone laws like the one in Massachusetts — which set a
35-foot area around clinic entrances — are a considered response to a
decades-long threat to public safety, largely in the form of harassment,
physical intimidation and worse by people opposed to abortion.
Television network producers raced past demonstrators outside the Supreme Court
with copies of the decision on Thursday.
Yet on Thursday the Supreme Court, in McCullen v. Coakley, struck down that law
for violating the First Amendment. Massachusetts’s buffer zone, it held,
burdened “substantially more speech than necessary” to protect public safety. If
individual protesters try to block a clinic entrance or harass a prospective
client, the court said, Massachusetts already has laws on the books to deal with
them.
This ignores what actually happens on the ground. As the factual record of the
case made clear, Massachusetts has, like most states, endured a long and
sometimes violent history of protest at reproductive-health clinics, including
the 1994 murders of two Planned Parenthood workers by an abortion opponent.
As both opponents and defenders of abortion rights have converged on the clinics
over the years, initially peaceful protests have escalated into shoving matches,
with women caught in the middle.
An earlier law setting a “floating” buffer zone of six feet had proved
impossible to enforce, police officers testified. “Everybody is in everybody’s
face, no matter what,” one captain said. “It’s almost like a goalie’s crease out
there.” The 35-foot buffer, the police said, was by far the most effective way
of keeping the peace, maintaining public safety and still respecting freedom of
speech.
The justices have firsthand experience with striking that delicate balance. The
Supreme Court building’s own buffer zone, which includes its vast plaza and is
far larger than 35 feet, prohibits “demonstrations, picketing, speechmaking,” or
any other conduct that is “reasonably likely to draw a crowd or onlookers.” Yet
all manner of viewpoints are expressed without difficulty every day on the
sidewalk in front of the court.
The McCullen ruling, written by Chief Justice John Roberts Jr., was,
surprisingly, unanimous, but Justice Scalia correctly called it a “specious
unanimity,” and filed a fuming concurrence in which he agreed only with the
final outcome.
He was upset by the majority’s assertion that the law did not discriminate
against the content of any speech or against any speaker’s viewpoint. But what
appeared to infuriate Justice Scalia most was the court’s failure to understand
that the “obvious purpose” of buffer-zone laws is to “protect” women from having
to hear any speech against abortion. He would have also overturned the court’s
ruling in 2000 that upheld a Colorado law creating a smaller, floating buffer
zone around health clinics.
Chief Justice Roberts’s opinion does not discuss that ruling. It narrowly
focuses on the law’s challengers, whom it characterized as offering “counseling
and information,” and engaging in “personal, caring, consensual conversations.”
But paper leaflets and polite words are not the real threats women face in
trying to exercise their constitutional right to an abortion.
A version of this editorial appears in print on June 27, 2014, on page A28 of
the New York edition with the headline: Abortion rights lose a buffer.
A Unanimous Supreme Court: Abortion Rights
Lose a Buffer, NYT, 26.6.2014,
http://www.nytimes.com/2014/06/27/opinion/
a-unanimous-supreme-court-abortion-rights-lose-a-buffer.html
Advocating Pill,
U.S. Signals Shift to Prevent AIDS
MAY 14, 2014
The New York Times
By DONALD G. McNEIL Jr
Federal health officials recommended Wednesday that hundreds
of thousands of Americans at risk for AIDS take a daily pill that has been shown
to prevent infection with the virus that causes it.
If broadly followed, the advice could transform AIDS prevention in the United
States — from reliance on condoms, which are effective but unpopular with many
men, to a regimen that relies on an antiretroviral drug.
It would mean a 50-fold increase in the number of prescriptions for the drug,
Truvada — to 500,000 a year from fewer than 10,000. The drug costs $13,000 a
year, and most insurers already cover it.
The guidelines tell doctors to consider the drug regimen, called PrEP, for
pre-exposure prophylaxis, for gay men who have sex without condoms;
heterosexuals with high-risk partners such as drug injectors or male bisexuals
who have unprotected sex; patients who regularly have sex with anyone they know
is infected; and anyone who shares needles or injects drugs.
Officials at the Centers for Disease Control and Prevention have long been
frustrated that the number of H.I.V. infections in the United States has barely
changed in a decade, stubbornly holding at 50,000 a year, despite 30 years of
official advice to rely on condoms to block transmission.
Although there is no guarantee that gay men will adopt the drug regimen, federal
officials say something must be done because condom use is going down. In a
C.D.C. survey in November, the number of gay men reporting recent unprotected
sex rose nearly 20 percent from 2005 to 2011.
Nevertheless, advocates for the drug regimen were elated at Wednesday’s
announcement.
“This is wonderful,” said Damon L. Jacobs, a therapist in Manhattan who is HIV
negative, has been on the regimen since 2011 and runs a Facebook page promoting
it. “When an institution like the C.D.C. makes a statement, it makes a profound
difference to the doctors who are ambivalent.”
Dr. Jonathan Mermin, director of the C.D.C.’s national center for AIDS and other
sexually transmitted diseases, said the new guidelines should save many lives.
“On average, it takes a decade for a scientific breakthrough to be adopted,” he
said. “We hope we can shorten that time frame and increase people’s survival.”
While many antiretroviral drugs could in theory be used for the drug regimen,
the only pill approved for that purpose by the Food and Drug Administration is
Truvada, made by Gilead Sciences.
Truvada, a mix of tenofovir and emtricitabine, is considered relatively safe
with few side effects. Generic versions are made in India, and it has become the
backbone of AIDS treatment in poor countries.
Common side effects include headache, stomach pain and weight loss. Rare but
serious ones include liver and kidney damage.
Officially, the C.D.C. is endorsing the drug regimen only in conjunction with
condoms. But health officials say they know that some people will stop using
them. Many gay men, including Mr. Jacobs, report doing just that.
That raises their risk of contracting other diseases, like syphilis and
gonorrhea. But health officials argue that the benefits of taking the drug
regimen outweigh the risks.
Continue reading the main story
Ask Well
Do you have a question about Truvada? Or the new recommendation that all
Americans at high risk for H.I.V. take this drug? Your question may be answered
by our reporter, Donald G. McNeil, Jr.
“Making the perfect the enemy of the good is something we’ve got to get over,”
said Dr. Anthony S. Fauci, director of the National Institute of Allergy and
Infectious Diseases and the country’s best-known AIDS doctor. “I strongly
support the C.D.C. doing this.”
Syphilis and gonorrhea can usually be cured with antibiotics,
but H.I.V. lasts for life and is fatal if left untreated. Even those treated
properly often develop early heart disease and other problems.
Since 2010, three separate studies using Truvada have shown that when taken
daily it can vastly reduce the chances of infection. That held true for gay men,
heterosexual couples and drug injectors. In the study of gay men, known as
iPrEx, men whose blood tests showed they had taken their pill every day were 99
percent protected.
The new guidelines say patients should have an H.I.V. test before starting the
regimen, to make sure they are not already infected. (Prophylaxis involves doses
of two drugs, but anyone with the disease should be on triple therapy.)
Patients should be retested every three months to be sure that they are still
H.I.V. negative, that they are not developing side effects from the drug and
that they have not caught any other sexually transmitted diseases.
While many AIDS specialists endorse the drug regimen, it has not caught on among
doctors as a whole.
A survey of 1,175 infectious disease specialists in the United States and Canada
published in December showed that 74 percent supported it, but only 9 percent
had actually prescribed it.
“There’s a lot of inertia among doctors, and a strong statement from the C.D.C.
will be pretty valuable for overcoming that,” said Dr. Demetre C. Daskalakis, an
AIDS specialist at Mount Sinai Hospital in New York who has many patients on the
regimen.
Also, the drug regimen has not caught on among gay men, who are by far the
largest risk group.
Advocates said there were several reasons there had been little clamor for the
drug regimen. First, while many doctors prescribe statins as prophylaxis against
heart attacks, for example, only AIDS specialists are likely to prescribe AIDS
drugs as prophylaxis. But uninfected gay men have no reason to see AIDS
specialists, and usually see general practitioners if they see doctors at all.
Also, Truvada is expensive. However, private insurers and state Medicaid
programs have thus far generally covered such prescriptions, and Gilead has a
program covering co-pays and giving Truvada to the uninsured.
“In my experience, it’s a simple process to get the meds approved,” Dr.
Daskalakis said.
Another reason is that Gilead does not advertise Truvada for prophylaxis, even
though the F.D.A. approved it for that use in 2012 and Gilead does advertise it
for treatment, for which it was approved in 2004.
A company spokeswoman said it had no plans to do so, but it does make grants to
gay organizations that espouse the drug regimen.
Not advertising helps Gilead avoid controversy.
Michael Weinstein, president of the AIDS Healthcare Foundation, has called
Truvada a “party drug” and argued that the drug regimen would encourage men to
avoid condoms and thus increase the infection rate. He called the release of the
guidelines “a shameful chapter in the history of the C.D.C.”
That debate has played out on gay websites, where men favoring the drug regimen
are often stigmatized as “Truvada whores.” (The term was coined in a 2012
Huffington Post article whose author has since publicly regretted his stance.)
“People are reacting out of fear,” Mr. Jacobs said. “Gay men who embraced the
condom message and survived the trauma of 30 years ago have PTSD. This is a
paradigm shift, and people don’t like change.”
Recently, a lash against the backlash has emerged, with a few men proudly
wearing “Truvada Whore” T-shirts, just as others proudly wear “Queer” or “H.I.V.
Positive” ones.
Adam Zeboski, a test counselor for the San Francisco AIDS Foundation, makes and
sells “Truvada Whore” T-shirts to raise money for the foundation.
“People are both very supportive and very offended,” he said. “By reclaiming the
‘Truvada Whore’ term, we’re taking the power away from those who use it against
us.”
A version of this article appears in print on May 15, 2014,
on page A1 of the New York edition with the headline:
Advocating Pill, U.S. Signals Shift to Prevent AIDS.
Advocating Pill, U.S. Signals Shift to
Prevent AIDS,
NYT, 14.5.2014,
http://www.nytimes.com/2014/05/15/health/
advocating-pill-us-signals-shift-to-prevent-aids.html
The Tobacco Ties That Bind
APRIL 10, 2014
The Opinion Pages|Op-Ed Contributor
The New York Times
By PETER B. BACH
I DON’T smoke, but if during the day I wanted to buy
cigarettes, I could walk into the CVS pharmacy across the street from my office,
or the Walgreens two blocks away, and get them. They’re kept right behind the
cash register.
But beginning this fall, that is going to change. CVS pharmacies will stop sales
of all tobacco products. Walgreens, well, won’t.
So, here’s a quiz. Which chain do you think is more heavily celebrated on the
website of the American Cancer Society? Well, it’s not CVS. Instead,
testimonials and profiles hailing Walgreens abound. There is a glowing profile
of the Walgreens chief executive that focuses on his tireless efforts to promote
healthy living in his workplace and stores. There is no mention of the tobacco
sales at the front of those stores.
The Cancer Society is the brass ring of advocacy partnerships. It ranks in the
Top 10 of Forbes magazine’s largest United States charities in the donations it
receives, and is the largest cancer charity. Its reputation as a vanguard of
tobacco control efforts makes its support of Walgreens particularly sanitizing.
The society was, for instance, one of the first organizations to decide that
people who applied for research grants could not have any ties to the tobacco
industry.
Christopher Hansen, the president of the advocacy arm of the Cancer Society,
defends the organization’s relationship with the cigarette and cigar vendor. He
told me that Walgreens had an extensive presence in poor communities, and that
his organization had worked with the chain for decades in those communities on
cancer prevention efforts. Of course, cigarettes wreak far more damage in poor
communities than in wealthy ones.
In the society’s defense, it did considerable work to let the world know about
the CVS announcement by sending out news releases, granting interviews praising
the move, and taking out sizable newspaper ads. But when it was asked to sign an
open letter calling on other pharmacy chains like Walgreens to follow suit, the
Cancer Society wouldn’t sign it.
Mr. Hansen told me that the Cancer Society was working behind the scenes with
Walgreens in an attempt to get it to change its policies and that that seemed
like a more effective way to achieve its goal. He acknowledged that the society
received donations from the pharmacy chain, and that the chain fund-raises for
the Cancer Society from its customers, through things like keypad donations at
checkout counters. When I asked what this all added up to in dollars per year,
he would not disclose the amount his organization received through sources like
direct contributions and point-of-sale donations.
The truth, though, is that the amount does not matter much. Even a few million
dollars is pennies to Walgreens compared with the revenue it earns from
cigarette sales.
Walgreens wouldn’t give an exact number for that either, but CVS reported it
would lose $2 billion a year in revenue when it stopped selling cigarettes.
As I was wrapping up my interviews, Robert Smith, the senior director of cancer
screening for the society, emailed me with an “F.Y.I.” He had unearthed a link
between Walgreens and my nonprofit hospital, Memorial Sloan Kettering Cancer
Center, which has a charity event called “Cycle for Survival,” which raises
money to support research programs in rare cancers. One of the event sponsors is
the Duane Reade Charitable Foundation, a nonprofit affiliate of the pharmacy
chain Duane Reade, which is owned by Walgreens.
Mr. Smith implied that this information could become public if I published my
critique, and warned of potential “blowback.” This suggests that relationships
between sellers of cigarettes and nonprofit cancer entities can be found
anywhere, whether a direct relationship between a cigarette seller and cancer
advocacy organization where each promotes the other’s brand, or a more winding
road through a string of charities.
Yes, fig-leafing is widespread. Companies regularly donate money to charities
and earn awards and recognition for doing so, even as some of their practices
undermine the very goals of the charity they support. Oil companies donate to
environmental causes even as they ravage the environment.
Certainly Walgreens has shown leadership in offering antismoking programs to its
employees and customers. But at the end of the day a corporate vision “to be the
first choice in health and daily living for everyone in America” is incongruous
with selling the leading cause of preventable death at your cash registers.
Making it harder for people to smoke yields enormous health benefits; some are
nearly immediate. When the city of Helena, Mont., instituted a ban on smoking in
the workplace and public spaces, rates of admissions for heart attacks fell
about 40 percent over six months, only to rise once the city stopped enforcing
the law. Were the Cancer Society to publicly call on its donor to follow CVS’s
lead, others such as Rite Aid would feel enormous pressure to fall in line.
Limiting sales and reducing the convenience of buying cigarettes would reduce
smoking rates, particularly among the young. But don’t believe me; you can read
this same assertion on the website of the American Cancer Society.
Peter B. Bach, a pulmonary physician,
directs the Center for Health Policy and Outcomes
at Memorial Sloan Kettering Cancer Center in New York.
The Tobacco Ties That Bind, NYT, 10.4.2014
http://www.nytimes.com/2014/04/11/opinion/the-tobacco-ties-that-bind.html
Judge Won’t Block Rules
on Abortion Drug in Arizona
MARCH 31, 2014
The New York Times
By JOHN SCHWARTZ
A federal judge in Tucson has refused to block some of the
strictest rules in the nation on the use of abortion drugs.
The rules, which were approved by the Arizona Legislature in 2012 and will take
effect on Tuesday, restrict the use of a medication to induce abortions during
the early stages of pregnancy to the first seven weeks.
The rules also restrict the use of the drug, mifepristone, to protocols approved
by the Food and Drug Administration in 2000. That early approval called for the
drug to be given in higher doses than is customary today, and only in doctors’
offices in the first seven weeks of pregnancy. Since those rules were first
approved, doctors have found that a lower dose of the drug is effective, and
that it can be safely taken outside doctors’ offices through the ninth week of
pregnancy.
The new restrictions, argued Planned Parenthood, one of the plaintiffs in the
case, would force many women to undergo unnecessary surgical abortions, and
would prevent some women from getting an abortion at all — especially in
Northern Arizona, where the only abortion provider offers only the medication
route. The plaintiffs sought a temporary restraining order to block the rules
while a legal challenge could work its way through the courts.
In denying the request on Monday, the judge, David C. Bury of United States
District Court, wrote that Arizona’s rules will not unduly burden a woman’s
constitutional right to an abortion, since the alternative of surgical abortions
remains available. The fact that some women may have to travel hundreds of miles
to clinics, twice, under the restrictions, and that the process will cost more,
he wrote, “do not qualify as irreparable harm.”
Judge Bury, who was appointed by President George W. Bush, wrote that it is
“unlikely that plaintiffs will prevail on the merits of the constitutional
claims.” In seeking an injunction, he wrote, the plaintiffs “have not
established serious questions going to the merits nor that the hardship balance
tips sharply towards them.”
Attempts to require the narrow F.D.A. standards have been passed in several
Republican-led states, and lawmakers have argued they are protecting women’s
health from unauthorized, “off-label” use of drugs.
Similar laws have been overturned in North Dakota and annulled by Oklahoma’s
Supreme Court. Courts in Ohio and Texas let the laws stand with some exceptions,
including considerations of the health of patients who might face risks from
surgical abortion.
Arizona’s attorney general, Tom Horne, said in a telephone interview that the
state needed to prove only that it had a rational basis for the law, and that
the F.D.A. rule provided that. He said that Judge Bury’s finding that the
plaintiffs were unlikely to win the case on the merits “would be an indication
that we’re likely to win.”
Planned Parenthood said it would continue to press its legal challenge to the
law.
Cecile Richards, president of the Planned Parenthood Federation of America, said
in a statement, “It is outrageous that politicians are interfering in a doctor’s
ability to provide the highest quality medical care for women in Arizona.”
She added, “This is not over — we will continue to fight for Arizona women with
everything we’ve got.”
A version of this article appears in print on April 1, 2014,
on page A17 of the New York edition with the headline:
Judge Won’t Block Rules on Abortion Drug.
Judge Won’t Block Rules on Abortion Drug in
Arizona,
NYT, 31.3.2014,
http://www.nytimes.com/2014/04/01/us/politics
/judge-wont-block-rules-on-abortion-drugs.html
Justices Seem Open
to
Religious Claims by Companies
MARCH 25,
2014
The New York Times
By ADAM LIPTAK
WASHINGTON
— In a long and lively argument that touched on medical science and moral
philosophy, the Supreme Court on Tuesday seemed ready to accept that at least
some for-profit corporations may advance claims based on religious freedom.
Such a ruling would echo the court’s 2010 decision in Citizens United, which
recognized free speech rights for corporations. But it would be only a first
step in the court’s analysis of the lawfulness of a part of the Affordable Care
Act that requires many employers to provide insurance coverage for
contraception.
The justices seemed closely divided along ideological lines on other parts of
the case. But Justice Anthony M. Kennedy, who probably holds the crucial vote,
seemed frustrated with some of the Obama administration’s positions.
The questioning was sometimes technical but often unusually blunt and direct.
Justice Kennedy asked Solicitor General Donald B. Verrilli Jr., for instance,
whether for-profit corporations “could be forced in principle to pay for
abortions” and be powerless to object on religious grounds.
Mr. Verrilli said that was right, though he added that there was no such law.
Chief Justice John G. Roberts Jr. jumped in. “Flesh it out a little more,” he
said. “There is no law on the books that does what?”
Squirming, Mr. Verrilli said, “That requires for-profit corporations to provide
abortions.”
Chief Justice Roberts looked puzzled. “I thought that’s what we had before us,”
he said.
The two companies that challenged the law — Hobby Lobby, a chain of crafts
stores, and Conestoga Wood Specialties, which makes furniture — say that some
drugs and intrauterine devices are tantamount to abortion. Those claims are not
generally accepted by scientists.
Mr. Verrilli said he did not question the sincerity of the companies’ beliefs.
“With all due respect,” he added, “we’ve got about two million women who rely on
the I.U.D. as a method of birth control in this country. I don’t think they
think they are engaged in abortion in doing that.”
By the end of the argument, there seemed to be a tentative consensus that the
two companies, both controlled by religious families, could be allowed to claim
rights under the relevant law, the Religious Freedom Restoration Act of 1993,
without opening the floodgates to objections from major public corporations.
“You picked great plaintiffs,” Justice Sonia Sotomayor told Paul D. Clement, a
lawyer for the companies.
Chief Justice Roberts said the court could limit its decision to privately held
corporations. “Whether it applies in the other situations is a question that
we’ll have to await another case when a large publicly traded corporation comes
in and says, ‘We have religious principles,’ ” he said, adding that this was
“the sort of situation I don’t think is going to happen.”
Justice Samuel A. Alito Jr. asked about news reports that “Denmark recently
prohibited kosher and halal slaughter methods because they believe that they are
inhumane.”
“Now suppose,” he said, “Congress enacted something like that here. What would a
corporation that is a kosher or halal slaughterhouse do? They would have no
recourse whatsoever. They couldn’t even get a day in court.”
Justice Elena Kagan suggested that the two companies before the court could
press their claims but should not win.
The justices signaled the importance of the case by scheduling 90 minutes for
the argument rather than the usual hour. The first round of questions to Mr.
Clement also seemed meant to establish how much was at stake.
Justice Kagan said the companies’ interpretation of the 1993 law could transform
the legal system.
“Your understanding of this law, your interpretation of it, would essentially
subject the entire U.S. Code to the highest test in constitutional law,” she
said. It would allow, she continued, employers to object on religious grounds to
laws banning sexual discrimination and child labor and to laws requiring a
minimum wage and family leave.
Justice Sotomayor asked similar questions about the implications of a ruling in
favor of the companies for blood transfusions, vaccines and “products made of
pork.”
Mr. Clement responded that there was no reason to fear “a parade of horribles,”
and that religious objections could be handled case by case.
Justice Kagan said that would be unwieldy. “Everything would be piecemeal, and
nothing would be uniform,” she said.
Much of the argument concerned whether the coverage requirement imposed a
serious burden on the companies, a threshold question under the 1993 law. The
companies remained free, some justices said, not to offer health insurance at
all, pay a tax and emerge financially better off. On that point, the court’s
liberal wing seemed to have Justice Kennedy’s support.
“How is the employer hurt?” he asked.
But Chief Justice Roberts said that approach ignored another problem. “I thought
that part of the religious commitment of the owners was to provide health care
for its employees,” he said.
Justice Kennedy also seemed to side with his more liberal colleagues when they
said religious objections that imposed burdens on others should not be allowed.
Here, Justice Kennedy expressed solicitude for “the rights of the employees.”
“The employee may not agree with the religious beliefs of the employer,” he
said. “Does the religious beliefs just trump? Is that the way it works?”
But Justice Kennedy also had significant and possibly crucial reservations about
the Obama administration’s carrying out of the contraceptive coverage
requirement. It was hard to see, he suggested, how the requirement could
simultaneously be a compelling government interest and yet be subject to a web
of exemptions and accommodations for religious groups and others.
A decision in the two consolidated cases — Sebelius v. Hobby Lobby Stores, No.
13-354, and Conestoga Wood Specialties v. Sebelius, No. 13-356 — is expected by
the end of June, two years after a closely divided court upheld another
provision of the Affordable Care Act, one requiring most Americans to obtain
health insurance or pay a penalty.
At the time, the decision created tension and bitterness on the court. But the
references to it on Tuesday were lighthearted.
When Mr. Clement said his clients would face annual penalties if they failed to
provide health insurance, Justice Sotomayor corrected him, relying on a
distinction that played a role in Chief Justice Roberts’s 2012 opinion upholding
the law.
“It’s not called a penalty,” she said. “It’s called a tax.”
Chief Justice Roberts agreed, to laughter in the courtroom. “She’s right about
that,” he said.
Later, Justice Kennedy, who dissented in the 2012 case, playfully asked Mr.
Verrilli whether “the constitutionality of the whole act has to be examined
before we accept your view.”
Mr. Verrilli’s response was also greeted with laughter. “I think it has been
examined, Your Honor, is my recollection,” he said.
A version of
this article appears in print on March 26, 2014,
on page A13 of
the New York edition with the headline:
Justices Seem
Open to Religious Claims by Companies.
Justices Seem Open to Religious Claims by Companies,
NYT, 25.3.2014,
http://www.nytimes.com/2014/03/26/us/politics/
conraceptive-coverage-challenge-supreme-court.html
Smoking Proves Hard to Shake
Among the Poor
MARCH 24, 2014
The New York Times
By SABRINA TAVERNISE
and ROBERT GEBELOFF
MANCHESTER, Ky. — When smoking first swept the United States
in the early decades of the 20th century, it took hold among the well-to-do.
Cigarettes were high-society symbols of elegance and class, puffed by doctors
and movie stars. By the 1960s, smoking had exploded, helped by the distribution
of cigarettes to soldiers in World War II. Half of all men and a third of women
smoked.
But as evidence of smoking’s deadly consequences has accumulated, the broad
patterns of use by class have shifted: Smoking, the leading cause of preventable
death in the country, is now increasingly a habit of the poor and the working
class.
While previous data established that pattern, a new analysis of federal smoking
data released on Monday shows that the disparity is increasing. The national
smoking rate has declined steadily, but there is a deep geographic divide. In
the affluent suburbs of Washington, only about one in 10 people smoke, according
to the analysis, by the Institute for Health Metrics and Evaluation. But in
impoverished places like this — Clay County, in eastern Kentucky — nearly four
in 10 do.
“It’s just what we do here,” said Ed Smith Jr., 51, holding up his cigarette in
a hand callused from his job clearing trees away from power lines. Several of
his friends have died of lung cancer, and he has tried to quit, but so far has
not succeeded.
“I want to see my grandson grow up,” he said.
The new study, which evaluated federal survey data from 1996 to 2012 to produce
smoking rates by county, offered a rare glimpse beneath the surface of
state-level data. It found that affluent counties across the nation have
experienced the biggest, and fastest, declines in smoking rates, while progress
in the poorest ones has stagnated. The findings are particularly stark for
women: About half of all high-income counties showed significant declines in the
smoking rate for women, but only 4 percent of poor counties did, the analysis
found.
This growing gap in smoking rates between rich and poor is helping drive
inequality in health outcomes, experts say, with, for example, white women on
the lowest rungs of the economic ladder now living shorter lives.
“Smoking is leaving these fancy places, these big urban areas,” said Ali H.
Mokdad, a researcher at the Institute for Health Metrics and Evaluation and an
author of the study. “But it has remained in these poor and rural areas. They
are getting left behind.”
Americans with a high school education or less make up 40 percent of the
population, but they account for 55 percent of the nation’s 42 million smokers,
according to a New York Times analysis of health survey data obtained from the
Minnesota Population Center, at the University of Minnesota. Since 1997, the
smoking rate for adults has fallen 27 percent, but among the poor it has
declined just 15 percent, according to the analysis. And among adults living in
deep poverty in the South and Midwest, the smoking rate has not changed at all.
Health experts say this finer understanding of who still smokes shows that
public health officials need to refocus antismoking efforts on the poor and
working class. Michael P. Eriksen, dean of the school of public health at
Georgia State University, who ran the federal Office on Smoking and Health under
President Bill Clinton, said public programs aimed at struggling Americans were
patchy, even as tobacco companies successfully targeted them. Researchers have
shown that tobacco companies make corporate contributions to local causes, aim
advertising campaigns at low-income areas and even sell cigarettes more cheaply
in those areas.
With the national smoking rate stabilizing in more recent years, experts say
that reaching poor and working-class smokers, whose problems often include
alcohol and drug abuse and mental illness, is crucial to achieving further
declines and reducing the heavy financial burden that smoking puts on the health
care system.
“The real conclusion here is we need to figure out clever ways to reach these
groups,” Mr. Eriksen said. “The effort has been pitiful so far compared to the
potential benefit to society from getting these people to stop smoking.”
Clay County, where just 7 percent of residents have a college degree and the
poverty rate is double the nation’s, is trying. Manchester, the county seat, a
small cluster of gas stations, municipal buildings and fast-food restaurants,
banned smoking in restaurants, stores and bars in 2012. The hospital runs a
smoking cessation program that offers free nicotine patches and gum in an effort
to reach low-income smokers.
Still, progress has been slow. By the Institute for Health Metrics and
Evaluation’s analysis, Clay’s smoking rate in 2012, at 36.7 percent, was the
highest of any United States county with a population of at least 15,000, and
had not changed much since 1996.
“Smoking cessation is our biggest uphill battle,” said Jeremy Hacker, the
hospital’s community outreach coordinator. While smoking is no longer normal in
big cities, he said, in Clay, “it’s not viewed as a problem.”
“Smokers aren’t seen as the minority,” he continued.
When Mitzi Jackson, who works at a loan company, went on a trip to New York
recently, the only person she saw smoking was the friend she was traveling with.
He was hustled off sidewalks and away from doors. “I thought he would be
arrested,” she said.
In contrast, visiting Clay County is like traveling back in time. Its smoking
rate was last seen in the country as a whole in 1970. A pack of cigarettes costs
about $5 here, roughly half the cost in New York, where state and city taxes
raise the price. Few people interviewed said they were glad to be smoking, but
many said it was one of the few pleasures they could afford.
“I’d love to quit but I just can’t, I’m too addicted,” said Becky Johnson, 60,
as she screwed the gas cap on her aging station wagon outside Bowling’s Quick
Stop, a convenience store whose electronic slot machines draw a crowd of smokers
most afternoons. Asked why she smoked, she said, “Bored, I guess.”
Until the mid-1960s, when the dangers of smoking became clear, high school and
college graduates smoked at about the same rates. But since then, the rate has
declined much more rapidly among college graduates. In the last 15 years, the
decline has been twice as large among adults with a college degree, according to
the Times analysis. Gaps have also widened between the employed and the
unemployed, and between those with health insurance and those without.
Clay County has some of the worst health outcomes in the nation, and many said
smoking seemed almost safe compared with the raging drug epidemic in the area.
“Smoking is one of the last things to worry about in this county,” said Barbara
Bowling, an owner of Mike’s Discount Tobacco, which has drive-through windows
under a billboard that says, “Let’s Talk God.” She said she was angry when she
found out her daughter was smoking, but at least she was not using drugs.
“Just sit and watch the parking lot for a day,” Mrs. Bowling said. “If smoking
is the worst thing that’s happening, praise the Lord.”
Others expressed a fatalism common among poor Americans, who often control
little of the circumstances of their lives.
“My dad’s attitude was, ‘Well, I’m going to die of something,’ “ said Lynn
Bargo, 35, a part-time cosmetology student who works at a Best Western hotel.
Her father, a smoker, died of lung cancer at 71. She said smoking was dwarfed by
drug use: At the salon where she works, some clients come in high and
occasionally lose consciousness while she does their hair.
Still, government interventions can make a difference, researchers say. While
the smoking rate has largely been stuck for Americans living in deep poverty in
the South, it has fallen significantly among that income group in the Northeast,
where strong antismoking measures such as those enacted under former Mayor
Michael R. Bloomberg in New York have been taken.
Even in Clay County, change could be coming. When Manchester’s ban on smoking in
public places went into effect, it was hard to tell who at the Huddle House
restaurant hated it more: the clientele or the staff. Two years later, Mike
Feltner, a cook, was puffing stealthily on an electronic cigarette (Marlboro
flavor) while cooking eggs. He said all four of the smokers on the staff now
used the devices, which he said were considerably cheaper than his old
two-pack-a-day habit. He put the savings toward a down payment on a house.
“This is a new phase in this town,” he said. “Everybody’s doing it. Young
people, old people, everyone.”
Sabrina Tavernise reported from Manchester,
and Robert Gebeloff from New York.
A version of this article appears in print on March 25, 2014,
on page A17 of the New York edition with the headline:
In a New Divide, Smoking Is Becoming a Habit of the Poor.
Smoking Proves Hard to Shake Among the
Poor, NYT, 24.3.2014,
http://www.nytimes.com/2014/03/25/health/
smoking-stays-stubbornly-high-among-the-poor.html
Abortion Law Pushes Texas Clinics
to Close Doors
MARCH 6, 2014
The New York Times
By MANNY FERNANDEZ
McALLEN, Tex. — Shortly before a candlelight vigil on the
sidewalk outside, employees of the last abortion clinic in the Rio Grande Valley
in South Texas shut the doors early Thursday evening, making legal abortion
unavailable in the poorest part of the state in the wake of tough new
restrictions passed last year by the Texas Legislature.
The closings on Thursday of two clinics operated by Whole Woman’s Health — the
one here in McAllen and another in the East Texas city of Beaumont — are part of
a wave of clinic closings brought on by the new law.
There were 44 facilities that performed abortions in Texas in 2011, abortion
providers said. After the two closings on Thursday, there are now 24, they said.
When the law is fully implemented in September, that number is expected to drop
to six.
“It’s heartbreaking for us,” said Amy Hagstrom Miller, the chief executive of
Whole Woman’s Health, which has challenged provisions of the law in court. “It’s
been a very difficult decision. I tried everything I can. I just can’t keep the
doors open.”
Anti-abortion groups said some of the reasons for the clinic closings were
“deplorable conditions,” violations of state safety regulations and high staff
turnover, accusations the operators denied. Still, abortion opponents expressed
satisfaction that the two clinics, which together treated nearly 3,000 patients
annually, were shutting their doors.
“We are pleased that women will never again receive substandard care from either
of these abortion facilities,” said Joe Pojman, executive director of Texas
Alliance for Life.
Abortion was a heated political issue last year in Texas, when Republican
lawmakers, backed by Gov. Rick Perry, passed some of the toughest restrictions
in the country, despite a marathon filibuster that turned State Senator Wendy
Davis into a national political figure. The politics have since been toned down.
Ms. Davis did not attend the clinic closings on Thursday and has not emphasized
the issue in her campaign for governor.
But the real-world impact has played out in the months since the law passed.
In McAllen, the shuttering of the city’s only abortion clinic has increased the
costs, the time and the travel distance for women seeking abortions. Women have
been making a roughly four-hour, 240-mile trip to San Antonio or a five-hour,
310-mile trip to Austin to get abortions. There had been only two clinics that
performed abortions in the Rio Grande Valley, but by the end of the day Thursday
there were none. The other one in nearby Harlingen closed days ago.
Activity at the McAllen clinic had slowed recently. It stopped performing
abortions last year after parts of the law went into effect. On Tuesday, the
aftercare room, where women who had received abortions were taken to recuperate,
was cluttered with boxes of files as workers prepared for Thursday.
“Sometimes on my lunch break, I’ll come back here, and I’ll just sit here,” said
Lucy Carreon, the clinic’s patient advocate, who is moving to San Antonio to
work at the Whole Woman’s Health facility there. “It’s very sad. I can’t believe
it.”
The leaders of Whole Woman’s Health, which operates clinics in Texas and two
other states, said they closed the ones in McAllen and Beaumont in large part
because of one restriction in the law: the requirement that doctors who perform
abortions have admitting privileges at a hospital within 30 miles.
Ms. Miller said that nearly all their doctors were unable to obtain admitting
privileges at nearby hospitals, and that some hospitals declined to even provide
doctors with applications for admitting privileges.
Another part of the law, which takes effect in September, requires clinics to
meet surgical-center standards, meaning all abortions, including nonsurgical
procedures, must take place in hospital-style operating rooms. It is that
requirement that abortion providers say will probably reduce the number of
clinics in the state to six and that Ms. Miller said played a role in the
decision to close the McAllen and Beaumont clinics.
Republican supporters of the law said it would protect women’s health and hold
abortion clinics to safer standards. Opponents said that it was an
unconstitutional attempt by Republicans at a backdoor ban on abortion and was
designed to force clinics to close. Mr. Perry has stated that one of his goals
in office is to “make abortion, at any stage, a thing of the past,” and another
Republican leader, Lt. Gov. David Dewhurst, suggested last year on Twitter that
shutting clinics was part of the purpose of the law, known as House Bill 2.
In a statement, Ms. Davis, who is running for governor against Attorney General
Greg Abbott, a Republican who has defended the law in court, pointed out the
other services the clinics provided, beyond abortions, that were now unavailable
to many women.
“These health centers provide lifesaving preventive care, cancer screenings and
birth control to Texan women,” she said. “Politicians like Greg Abbott are
forcing their personal political agenda and threatening the health of women
across the Rio Grande Valley.”
Even before the full regulations kick in, women in rural areas have already had
more difficulty getting abortions than those living in urban centers like
Houston and Dallas.
In the West Texas city of Lubbock, Planned Parenthood closed the only clinic
there providing abortions, sending many women on a five-hour trip to Dallas or
to Albuquerque, some 320 miles away. The closing of the clinic in Beaumont has
made Houston the nearest option, more than an hour’s drive away. A clinic in
Corpus Christi, which is closer to McAllen than San Antonio but is still more
than two hours away, is closing in September because of the surgical-center
requirements.
In McAllen, the problems associated with traveling 240 miles to San Antonio one
way — including additional costs for gas, lodging or child care — have caused
some women to go to Mexico to buy a widely available “abortion pill” that can
induce miscarriages and that abortion providers and advocates said poses
significant health risks. Ms. Carreon, the patient advocate, said she believed
30 to 40 women who had contacted the clinic since last year had decided on their
own to take the pill.
Some women interviewed at the McAllen clinic said they had considered taking the
30-minute trip to Mexico to get the pill — a drug called misoprostol known by
the brand-name Cytotec — but ultimately decided against it.
“Honestly, I think they’ll go south of the border, if they have to,” said a
23-year-old woman who was one of the last patients to be seen at the clinic and
who went to San Antonio for an abortion last month. “It’s cheaper and it’s
closer. To go to San Antonio is so much more of a hassle and costs a lot more.”
On the day of her appointment in San Antonio, the woman, who asked that her name
not be used, said she left with a friend at about 3 a.m. to arrive at the clinic
by 8 a.m. She had to spend the entire day there waiting to be seen. The San
Antonio clinic, it turned out, was packed with patients from the Rio Grande
Valley area.
Lucinda Holt contributed reporting from Lubbock, Tex.
A version of this article appears in print on March 7, 2014,
on page A1 of the New York edition with the headline:
Abortion Law Pushes Clinics To Close Doors.
Abortion Law Pushes Texas Clinics to Close
Doors, NYT, 6.3.2014,
http://www.nytimes.com/2014/03/07/us/
citing-new-texas-rules-abortion-provider-is-shutting-last-clinics-in-2-regions.html
Early Treatment Is Found
to Clear H.I.V. in a 2nd Baby
MARCH 5, 2014
The New York Times
By DONALD G. McNEIL Jr.
BOSTON — When scientists made the stunning announcement last
year that a baby born with H.I.V. had apparently been cured through aggressive
drug treatment just 30 hours after birth, there was immediate skepticism that
the child had been infected in the first place.
But on Wednesday, the existence of a second such baby was revealed at an AIDS
conference here, leaving little doubt that the treatment works. A leading
researcher said there might be five more such cases in Canada and three in South
Africa.
And a clinical trial in which up to 60 babies who are born infected will be put
on drugs within 48 hours is set to begin soon, another researcher added.
If that trial works — and it will take several years of following the babies to
determine whether it has — the protocol for treating all 250,000 babies born
infected each year worldwide will no doubt be rewritten.
“This could lead to major changes, for two reasons,” said Dr. Anthony S. Fauci,
executive director of the National Institute for Allergy and Infectious
Diseases. “Both for the welfare of the child, and because it is a huge proof of
concept that you can cure someone if you can treat them early enough.”
The announcement was the third piece of hopeful news in two days about the virus
that causes AIDS.
On Tuesday, scientists reported that injections of long-lasting AIDS drugs
fended off infection in monkeys, and on Wednesday, researchers announced a “gene
editing” advance that might enable immune cells to repel the virus.
The first infant to make an apparent recovery from H.I.V. infection, now famous
as the “Mississippi baby,” was described last March at the Conference on
Retroviruses and Opportunistic Infections, the same annual meeting where the new
case was reported on Wednesday.
The Mississippi child, now more than 3 years old, is still virus-free, said Dr.
Deborah Persaud, a virologist who has run ultrasensitive tests on both children
in her lab at the Johns Hopkins Children’s Center in Baltimore.
The second baby, a girl born at Miller Children’s Hospital in Long Beach,
Calif., is now 9 months old and apparently free of the virus that causes AIDS.
Her mother, who has advanced AIDS and is mentally ill, arrived in labor; she had
been prescribed drugs to protect her baby but had not taken them.
Four hours after the birth, a pediatrician, Dr. Audra Deveikis, drew blood for
an H.I.V. test and immediately started the baby on three drugs — AZT, 3TC and
nevirapine — at the high doses usually used for treatment of the virus.
The normal preventive regimen for newborns would be lower doses of two drugs;
doctors usually do not use the more aggressive treatment until they are sure the
baby is infected, and then sometimes not in the first weeks.
“Of course I had worries,” Dr. Deveikis said in an interview here. “But the
mother’s disease was not under control, and I had to weigh the risk of
transmission against the toxicity of the meds.”
“I’d heard of the Mississippi baby, I’d watched the video,” she added. “I knew
that if you want to prevent infection, early treatment is critical.”
The Long Beach baby is now in foster care, she said. The mother is still alive
as well.
It is incorrect to describe the baby as “cured” or even as “in remission”
because she is still on the drugs, Dr. Persaud said. But because the most
sensitive blood tests can find no virus capable of replicating, she describes
the baby as “having sero-reverted to H.I.V.-negative.”
Both DNA and RNA of the virus were found in the baby’s early blood and spinal
fluid samples, so Dr. Persaud said it was virtually certain she was infected at
birth. The virus began to disappear six days after birth and was undetectable
within 11 days.
It is considered medically unethical to stop the baby’s drugs now, but Dr.
Deveikis and Dr. Yvonne J. Bryson, a pediatric AIDS expert at the University of
California, Los Angeles, who is also working on the case, said they would
consider stopping them briefly to see what happens if the baby is still
virus-free at age 2.
Dr. Bryson is one of three investigators who will lead the clinical trial
seeking 60 babies.
Obstetricians and pediatricians in the United States, South Africa and Brazil
will be alerted to watch for babies being born to mothers who have not taken
drugs to prevent mother-child transmission and to get them on full
antiretroviral treatment immediately, even before the first blood test has been
finished. (In the United States, fewer than 200 children each year are born with
H.I.V.)
The trial will be funded by Dr. Fauci’s institute and be part of the Impact
series of trials concentrating on preventing viral transmission to newborns.
“When we described the Mississippi baby, we were met with some skepticism,” she
said. The Long Beach baby “was definitely infected.”
The Mississippi baby was born to a mother who got no prenatal care and was
unaware that she was infected. Worried doctors at a local hospital transferred
the baby to the University of Mississippi Medical Center, where a pediatrician,
Dr. Hannah B. Gay, started aggressive antiretroviral treatment about 30 hours
after birth.
Then, 18 months later, the mother stopped taking the baby to appointments and
stopped giving the drugs. Five months later, when she came to an appointment,
doctors feared the baby would be teeming with virus.
Instead, to their astonishment, they found none. And Dr. Persaud’s testing has
found none, despite using tests normally able to detect dormant virus in adult
patients on successful treatment.
Although antiretrovirals prevent the virus from replicating, a small amount
usually persists in reservoirs throughout the body, integrated into the DNA of
cells. Dr. Persaud’s test can activate those cells and force them to “spit out”
the virus, where it can be detected.
Dr. Steven G. Deeks, an AIDS expert at the University of California, San
Francisco, said the Long Beach baby offered more convincing evidence that
starting therapy virtually at birth seems to kill the virus before it
establishes a permanent reservoir.
“But it sure would be nice to have a way to decide when to stop” the treatment,
he added. “That’s the next question.”
A version of this article appears in print on March 6, 2014,
on page A1 of the New York edition with the headline:
Early Treatment Found to Clear H.I.V. in 2nd Baby.
Early Treatment Is Found to Clear H.I.V. in
a 2nd Baby, NYT, 5.3.2014,
http://www.nytimes.com/2014/03/06/health/
second-success-raises-hope-for-a-way-to-rid-babies-of-hiv.html
A Genetic Entrepreneur Sets His Sights
on Aging and Death
MARCH 4, 2014
The New York Times
By ANDREW POLLACK
J. Craig Venter is the latest wealthy entrepreneur to think he
can cheat aging and death. And he hopes to do so by resorting to his first love:
sequencing genomes.
On Tuesday, Dr. Venter announced that he was starting a new company, Human
Longevity, which will focus on figuring out how people can live longer and
healthier lives.
To do that, the company will build what Dr. Venter says will be the largest
human DNA sequencing operation in the world, capable of processing 40,000 human
genomes a year.
The huge amount of DNA data will be combined with huge amounts of other data on
the health and body composition of the people whose DNA is sequenced, in the
hope of gleaning insights into the molecular causes of aging and age-related
illnesses like cancer and heart disease.
Slowing aging, if it can be done, could be a way to prevent many diseases, an
alternative to treating one disease a time.
“Your age is your No. 1 risk factor for almost every disease, but it’s not a
disease itself,” Dr. Venter said in an interview. Still, his company will also
work on treating individual diseases of aging.
Human Longevity said it had raised $70 million, most of it from wealthy
individuals, some of whom have backed his existing company, Synthetic Genomics.
Dr. Venter said the largest of those investors is K. T. Lim, a Malaysian
billionaire who runs Genting Berhad, a gambling conglomerate.
A “not insignificant” part of the funding comes from Illumina, the dominant
manufacturer of DNA sequencing machines, Dr. Venter said. Human Longevity has
ordered two of Illumina’s new top-of-the-line HiSeq X Ten systems, each of which
has a list price of $10 million.
Dr. Venter is known most for having run a privately funded effort to sequence
the first human genome, racing to a tie against the publicly funded Human Genome
Project in 2000. More recently Dr. Venter has laid claim to creating what some
have called the first synthetic cell.
Last year, Google’s chief executive, Larry Page, announced that his company was
creating an anti-aging company, Calico, which is being run by Arthur D.
Levinson, the former chief executive of Genentech. Oracle’s chief executive,
Lawrence J. Ellison, has financed anti-aging research through his foundation.
With the cost of sequencing falling rapidly, other groups are also undertaking
large sequencing efforts aimed at finding clues to diseases. Regeneron
Pharmaceuticals and announced an effort to sequence 100,000 human genomes in
January.
Just this week, scientists reported that a genetic study of 150,000 people
revealed a mutation that reduces the risk of developing Type 2 diabetes.
Illumina says that with its new X Ten system, the cost to sequence one human
genome will be below $1,000.
Dr. Venter said his company planned to sequence the genomes of people who are
healthy and sick, from infants to centenarians. The company will also sequence
the people’s microbiomes — the microbes living on and in them. And it has signed
a contract with another company, Metabolon, which can measure chemicals in their
blood.
Some outside scientists praised the effort.
“I feel strongly that is a wonderful scientific thing to do,” said Dr. Thomas
Perls, a professor at Boston University School of Medicine who has been studying
the genetics of centenarians. “He’s looking at throwing a lot of money at this
to do a lot of science quickly.”
Dr. Perls said most people should be able to live to their late 80s, and if they
don’t it is probably because of unhealthy lifestyles, not genetics. But the
ability to live to 105 or longer is strongly driven by genetics, he said. These
people seem to have genetic variations that protect them from the diseases of
aging.
Still, it is not clear how quickly, if at all, this data sifting will yield
usable insights and how Human Longevity will make money. The company said it
planned to sell data to pharmaceutical companies and eventually to benefit from
drugs and diagnostic tests derived from its findings. It is also considering
offering stem cell therapy.
Dr. Eric J. Topol, director of the Scripps Translational Science Institute, said
that while the new company might well expand knowledge, “translating that to
meaningful drug therapies is likely a long ways off.” He added, “We have no way
of knowing whether longevity will be favorably influenced.”
While Dr. Venter is known for groundbreaking science — and for his flair for
publicizing his efforts — his track record in business is mixed. Although his
previous company, Celera Genomics, succeeded in sequencing one of the first
human genomes, it failed to make a business of selling its data to
pharmaceutical companies because data from the rival Human Genome Project was
available free.
Maintaining a proprietary edge could be a problem for Human Longevity as well,
since many other companies and academic institutions are doing genomic studies.
While Dr. Venter may be correct in saying his new company’s human genome
sequencing capacity will be greater than that of others, it does not appear to
be that much greater. The Broad Institute in Cambridge, Mass., for instance,
recently bought the equivalent of 1.4 Illumina X Ten systems.
Dr. Venter said his company hoped to increase its capacity to 100,000 genomes a
year. But even at $1,000 per genome, that would mean the company would be
spending $100 million a year just on sequencing, not counting all the other
studies it wants to do. That is a large expense to offset, and it means that the
$70 million it has raised so far will not go very far.
Obtaining the genomes to sample could also take time. Human Longevity said it
would collaborate with the Moores Cancer Center at the University of California,
San Diego and offer to sequence the DNA of the tumors of all patients, as well
as the DNA from healthy cells. At first, patients would not be charged for this;
eventually, the company hopes to sell such a service.
Many cancer centers are already testing selected genes in tumors, looking for
mutations that could suggest which treatments would be best for patients. It is
not yet clear how much more would be gained by sequencing the entire genome of
the tumor cells.
Human Longevity will be based in San Diego, also the location of Synthetic
Genomics, which is trying to use sophisticated genetic engineering techniques to
create organisms that can produce fuel, chemicals and medicines. The J. Craig
Venter Institute, a nonprofit research center, also has a branch there.
Dr. Venter will be chairman and chief executive of Human Longevity. His
co-founders, who will be vice chairmen, are Dr. Peter H. Diamandis, chairman of
the X Prize Foundation, and Dr. Robert Hariri, founder and chief scientific
officer of cell therapy operations at the biotechnology company Celgene.
Dr. Diamandis said the goal was not to make people live forever, but rather to
make “100 years old the next 60.”
Dr. Venter, who is 67, sounds as if he might not need the company to succeed. “I
feel like I have at least 20 or 30 years left in my career,” he said.
A version of this article appears in print on March 5, 2014,
on page B1 of the New York edition with the headline:
A Genetic Entrepreneur Sets His Sights on Aging and Death.
A Genetic Entrepreneur Sets His Sights on
Aging and Death,
NYT, 4.3.2014,
http://www.nytimes.com/2014/03/05/business/
in-pursuit-of-longevity-a-plan-to-harness-dna-sequencing.html
Obesity Rate for Young Children
Plummets 43% in a Decade
FEB. 25, 2014
The New York Times
By SABRINA TAVERNISE
Federal health authorities on Tuesday reported a 43 percent
drop in the obesity rate among 2- to 5-year-old children over the past decade,
the first broad decline in an epidemic that often leads to lifelong struggles
with weight and higher risks for cancer, heart disease and stroke.
The drop emerged from a major federal health survey that experts say is the gold
standard for evidence on what Americans weigh. The trend came as a welcome
surprise to researchers. New evidence has shown that obesity takes hold young:
Children who are overweight or obese at 3 to 5 years old are five times as
likely to be overweight or obese as adults.
A smattering of states have reported modest progress in reducing childhood
obesity in recent years, and last year the federal authorities noted a slight
decline in the obesity rate among low-income children. But the figures on
Tuesday showed a sharp fall in obesity rates among all 2- to 5-year-olds,
offering the first clear evidence that America’s youngest children have turned a
corner in the obesity epidemic. About 8 percent of 2- to 5-year-olds were obese
in 2012, down from 14 percent in 2004.
“This is the first time we’ve seen any indication of any significant decrease in
any group,” said Cynthia L. Ogden, a researcher for the Centers for Disease
Control and Prevention, and the lead author of the report, which will be
published in JAMA, The Journal of the American Medical Association, on
Wednesday. “It was exciting.”
She cautioned that these very young children make up a tiny fraction of the
American population and that the figures for the broader society had remained
flat, and had even increased for women over 60. A third of adults and 17 percent
of youths are obese, the federal survey found. Still, the lower obesity rates in
the very young bode well for the future, researchers said.
There was little consensus on why the decline might be happening, but many
theories.
Children now consume fewer calories from sugary beverages than they did in 1999.
More women are breast-feeding, which can lead to a healthier range of weight
gain for young children. Federal researchers have also chronicled a drop in
overall calories for children in the past decade, down by 7 percent for boys and
4 percent for girls, but health experts said those declines were too small to
make much difference.
Barry M. Popkin, a researcher at the University of North Carolina at Chapel Hill
who has tracked American food purchases in a large data project, said families
with children had been buying lower-calorie foods over the past decade, a
pattern he said was unrelated to the economic downturn.
He credited those habits, and changes in the federally funded Special
Supplemental Nutrition Program for Women, Infants and Children, for the decline
in obesity among young children. The program, which subsidizes food for
low-income women, reduced funding for fruit juices, cheese and eggs and
increased it for whole fruits and vegetables.
Another possible explanation is that some combination of state, local and
federal policies aimed at reducing obesity is starting to make a difference.
Michelle Obama, the first lady, has led a push to change young children’s eating
and exercise habits and 10,000 child care centers across the country have signed
on. The news announcement from the C.D.C. included a remark from Mrs. Obama: “I
am thrilled at the progress we’ve made over the last few years in obesity rates
among our youngest Americans.”
New York City under Mayor Michael R. Bloomberg also made a major push to combat
obesity. The city told restaurants to stop using artificial trans fats in
cooking and required chain restaurants to display calorie information on their
menus.
Many scientists doubt that anti-obesity programs actually work, but proponents
of the programs say a broad set of policies applied systematically over a period
of time can affect behavior.
The obesity rate for preschoolers — 2- to 5-year-olds — has fluctuated over the
years, but Dr. Ogden said the pattern became clear with a decade’s worth of
data. About one in 12 children in this age group was obese in 2012. Rates for
blacks (one in nine) and Hispanics (one in six) were much higher.
Researchers welcomed the drop but cautioned that only time will tell if the
progress will be sustained.
“This is great news, but I’m cautious,” said Ruth Loos, a professor of
preventive medicine at the Icahn School of Medicine at Mount Sinai hospital in
New York. “The picture will be clearer when we have a few more years of data.”
Still, she added that the 2- to 5-year-olds “might be riding a new wave,” in
which changes in habits and environment over many years are finally sinking in.
She noted that people who are now 60 years old caught the beginning of what she
called the obesity wave that carried the next generation with it.
“Once the obesity epidemic emerged in the 1980s, it took us a while to realize
that something bad was happening,” Dr. Loos said. “We’ve been trying to educate
parents and families about healthy lifestyles, and maybe it’s finally having an
effect.”
Tom Baranowski, a professor of pediatrics at Baylor College of Medicine, said
there was not enough data to determine whether the decline would spread to older
children. Since 2003, the rate for youths over all — ages 2 to 19 — has remained
flat, said Dr. Ogden, author of the C.D.C. report.
But 2- to 5-year-olds are perhaps the most significant age group, as it is in
those years that obesity — and all the disease risk that comes with it — becomes
established, and it is later very difficult to shake, said Dr. Jeffrey P.
Koplan, a professor of medicine and public health at Emory University in
Atlanta.
“You have to say maybe some real progress is taking place at the very time it
can have the most impact,” Dr. Koplan said. He said he believed the decline was
real, as the finding followed several studies that detected patterns of decline
among young children, including one by researchers in Massachusetts and the
large study by the C.D.C. of low-income children.
“The weight of evidence is becoming more marked,” he said. Still, he cautioned
that the age group was only a small slice of American society: “One blossom
doesn’t make a spring.”
A version of this article appears in print on February 26, 2014,
on page A1 of the New York edition with the headline:
Obesity Dropped 43% Among Young Children in Decade.
Obesity Rate for Young Children Plummets
43% in a Decade,
NYT, 25.2.2014,
http://www.nytimes.com/2014/02/26/health/
obesity-rate-for-young-children-plummets-43-in-a-decade.html
When Doctors Need to Lie
FEB. 22, 2014
The New York Times
By SANDEEP JAUHAR
I ONCE had the unenviable task of informing a 22-year-old
Jamaican man that he was suffering from severe heart failure and would probably
need a heart transplant. The man’s father warned me that his son would be
devastated to hear the diagnosis. “It would mean a lot to me if you could go
back in and tell him he’s going to be all right,” the father pleaded. “Please
tell him that if he does the things you say, he’s going to be O.K.”
Though physicians are obligated to disclose all relevant medical information to
their patients, it was obvious that this young man wasn’t prepared to hear the
news I had to present. He was lying on his stomach, crying, refusing to turn
around to talk to me. So I told him exactly what his father had requested. Then,
over several days, I eased him into the knowledge of his true condition. Doctors
sometimes have to know how to keep secrets.
The moral basis for withholding information from such a patient is clear: Above
all, physicians must do no harm. The underlying philosophy is paternalism.
Paternalism derives from the image of the paternal figure, the father, in a
family. The father is motivated by an interest in his children’s welfare. He
acts on their behalf, but not at their behest. The beneficiaries — his children
— may even repudiate the actions taken on their behalf.
Such paternalism was once widely accepted in medicine. In the mid-19th century,
the American Medical Association’s code of ethics stated that physicians had a
“sacred duty” to “avoid all things which have a tendency to discourage the
patient and depress his spirits.” But times have changed. The prevailing ethical
mantra in medicine is patient autonomy. Today, patients own their health
information. They have the right to direct their own care, and to do so they
must be fully informed. As doctors, we no longer “care for” as much as “care
with” our patients through their illnesses.
While this is a welcome development, it should not obscure the fact that there
is still a place for old-fashioned paternalism in medicine — though the decision
to defy a patient’s wishes or withhold information is one of the trickiest that
we doctors face.
When I started my medical internship, in 1998, I viewed patient autonomy as an
absolute good, an ethical imperative that trumped all others. I had learned in
medical school about some of the most infamous breaches of autonomy in the
history of medicine. For example, in the Tuskegee experiment, a clinical study
conducted by the United States Public Health Service between 1932 and 1972,
black men with syphilis were intentionally left untreated, despite the
availability of penicillin, in order to study the disease’s complications.
I also learned that even well-meaning paternalism can be damaging. The
doctor-patient relationship is founded on trust, and any instrument of
paternalistic interference not only compromises the relationship but also can
erode faith in the profession. Studies have shown that patients who have been
deceived by their physicians, even if the deception is well intentioned, have
reported immense frustration and even thoughts of suicide. Who are we as doctors
to decide which truths our patients can handle?
Patients may of course experience regret because of what they later regard as
their bad decisions. But many people argue, as the medical ethicist Katie Watson
did last month in the Journal of the American Medical Association, that the cost
of regret must be balanced against the “dignity of risk”: the fact that pain or
regret can also be an opportunity for growth. “To the degree decisional regret
is harmful,” Professor Watson wrote, “the regressive remedy of eliminating or
reducing competent adults’ decision-making authority is worse.”
But as I have learned over the years, autonomy can be a double-edged sword. It
may conflict with other moral virtues, such as a doctor’s obligation to do the
best for his patients. Surely the standard for a patient’s ability to make his
own decision should be raised as the consequences of the decision become more
severe. If an ill-advised decision could cost your patient his life, are you not
compelled as a physician to prevent him from harming himself?
Year after year I continue to struggle with these issues. No ethic in medicine
is absolute.
OF course, even when a doctor believes that a paternalistic approach is
justified, he should aim to keep it as “soft” as possible. Soft paternalism
involves negotiation, persuading a patient to see things from your point of
view. Hard paternalism, on the other hand, is coercive. It is what parents
routinely practice. As a parent, you are duty-bound to prevent your children
from making bad decisions or doing harm to their bodies.
Even so, there may be a place in medicine for hard paternalism, too. I am
reminded of a patient I took care of some years ago. Fifty-something, he had
received a stent to open up a blocked coronary artery. A few days after the
procedure, while on blood thinners to keep the stent from clotting, he started
bleeding into his lungs. He needed to be intubated with a breathing tube or he
was going to die. However, I was informed that he had told doctors that he never
wanted to be intubated.
The bleeding was a reversible complication I had seen several times. I was sure
that with a few days of ventilatory support, it would stop and we would be able
to pull out the tube. The alternative was to watch him drown in his own blood. I
didn’t know the quality of the discussion he’d had with the other doctors, and I
couldn’t talk to him because he was nearly unconscious from lack of oxygen.
So with a troubled heart I intubated him. He had a rocky course. The bleeding in
his lungs continued for several days, requiring large blood transfusions, but it
eventually stopped. He had protracted fevers. After a few days, his condition
improved. A week after that, the breathing tube was removed.
When I went to see him, he didn’t recognize me. “When you were really sick, I
was one of the doctors who made the decision to put in the breathing tube,” I
said. He nodded, eyeing me curiously. “I know you didn’t want the tube,” I went
on, “but if we didn’t put it in, you would have died.”
He nodded again. “I’ve been through a lot,” he finally said, his voice hoarse
from two weeks of intubation.
“I know,” I replied.
“But thank you,” he said.
Sandeep Jauhar is a cardiologist
and the author of the forthcoming memoir
“Doctored: The Disillusionment of an American Physician.”
A version of this op-ed appears in print on February 23, 2014,
on page SR9 of the New York edition with the headline:
When Doctors Need to Lie.
When Doctors Need to Lie, NYT, 22.2.2014,
http://www.nytimes.com/2014/02/23/opinion/sunday/when-doctors-need-to-lie.html
Inside a Mental Hospital Called Jail
FEB. 8, 2014
The New York Times
Nicholas Kristof
CHICAGO — THE largest mental health center in America is a
huge compound here in Chicago, with thousands of people suffering from manias,
psychoses and other disorders, all surrounded by high fences and barbed wire.
Just one thing: It’s a jail. The only way to get treatment is to be arrested.
Psychiatric disorders are the only kind of sickness that we as a society
regularly respond to not with sympathy but with handcuffs and incarceration. And
as more humane and cost-effective ways of treating mental illness have been cut
back, we increasingly resort to the law-enforcement toolbox: jails and prisons.
More than half of prisoners in the United States have a mental health problem,
according to a 2006 Justice Department study. Among female inmates, almost
three-quarters have a mental disorder.
In the jail here, some prisoners sit on their beds all day long, lost in their
delusions, oblivious to their surroundings, hearing voices, sometimes talking
back to them. The first person to say that this system is barbaric is their
jailer.
“It’s criminalizing mental illness,” the Cook County sheriff, Thomas Dart, told
me as he showed me the jail, on a day when 60 percent of the jail’s intake
reported that they had been diagnosed with mental illness. Dart says the system
is abhorrent and senseless, as well as an astronomically expensive way to treat
mental illness — but that he has no choice but to accept schizophrenic, bipolar,
depressive and psychotic prisoners delivered by local police forces.
People are not officially incarcerated because of psychiatric ailments, but
that’s the unintended effect. Sheriff Dart says that although some mentally ill
people commit serious crimes, the great majority are brought in for offenses
that flow from mental illness.
One 47-year-old man I spoke to, George, (I’m not permitted to use last names for
legal reasons) is bipolar, hears voices and abuses drugs and alcohol. He said he
had been arrested five times since October for petty offenses. The current
offense is criminal trespass for refusing to leave a Laundromat.
The sheriff says such examples are common and asks: “How will we be viewed, 20,
30, 50 years from now? We’ll be looked on as the ones who locked up all the
mentally ill people.
“It really is one of those things so rich with irony: The same society that
abhorred the idea that we lock people up in mental hospitals, now we lock people
up in jails.”
A few data snapshots:
• Nationwide in America, more than three times as many mentally ill people are
housed in prisons and jails as in hospitals, according to a 2010 study by the
National Sheriffs’ Association and the Treatment Advocacy Center.
• Mentally ill inmates are often preyed upon while incarcerated, or disciplined
because of trouble following rules. They are much more likely than other
prisoners, for example, to be injured in a fight in jail, the Justice Department
says.
• Some 40 percent of people with serious mental illnesses have been arrested at
some point in their lives.
In the 1800s, Dorothea Dix led a campaign against the imprisonment of the
mentally ill, leading to far-reaching reforms and the establishment of mental
hospitals. Now we as a society have, in effect, returned to the 1800s.
Among those jailed here is Russell, 46, who is being held for burglarizing a
garage. He has been diagnosed with severe depression and said that he
self-medicates with alcohol and drugs. Most of his adult life has been spent
behind bars for one offense after another, and he said he became aware of his
mental health problems when he was being clubbed by a thug with a baseball bat
and realized that he was enjoying it.
“I just want to be normal,” he said as we spoke in a large dormitory room for
inmates with psychiatric problems. “I want to have a job. I’ve never had a job.
I want to be able to say hi to a co-worker.” He stopped, and there were tears in
his eyes.
In 1955, there was one bed in a psychiatric ward for every 300 Americans; now
there is one for every 3,000 Americans, the 2010 study said. So while more
effective pharmacological treatments are theoretically available, they are often
very difficult to access for people who are only borderline functional.
“Some people come here to get medication,” says Ardell Hall, a superintendent of
a women’s unit at the jail. “They commit a crime to get in.”
India, a 42-year-old woman, suffers from manic depression and post-traumatic
stress disorder. She said she tried at various times to get psychiatric care but
found it almost impossible, so she self-medicates when on the outside with
heroin — and has spent almost all of her adult life in jails and prisons on a
succession of nonviolent offenses relating to drugs and shoplifting.
TAXPAYERS spend as much as $300 or $400 a day supporting
patients with psychiatric disorders while they are in jail, partly because the
mentally ill require medication and extra supervision and care.
“Fiscally, this is the stupidest thing I’ve seen government do,” Dart says. It
would be far cheaper, he adds, to manage the mentally ill with a case worker on
the outside than to spend such sums incarcerating them.
Cook County has implemented an exemplary system for mental health support for
inmates. While in jail, they often stabilize. Then they are released, go off
their medications and the cycle repeats.
One woman in the jail, Kristen, said she had been diagnosed with depression and
anxiety disorders. On the outside, her prescription medication cost $100 a
month, so she skipped it.
“When I’m not on my medicine on a regular basis, I don’t make decisions well,”
she said, explaining her long arrest record for theft and narcotics offenses. I
asked her if access to medicine would keep her out of jail, and she said: “I
don’t know if that’s necessarily true, to be totally honest. But it would help.”
As Sheriff Dart puts it: “We’ve systematically shut down all the mental health
facilities, so the mentally ill have nowhere else to go. We’ve become the de
facto mental health hospital.”
Do we really want to go back two centuries? Doesn’t that seem not only inhumane
but also deluded — on our part?
I invite you to comment on this column on my blog,
On the Ground.
Please also join me on Facebook and Google+,
watch my YouTube videos and follow me on Twitter.
A version of this op-ed appears in print on February 9, 2014,
on page SR1 of the New York edition with the headline:
Inside a Mental Hospital Called Jail.
Inside a Mental Hospital Called Jail, NYT,
8.2.2014,
http://www.nytimes.com/2014/02/09/opinion/sunday/
inside-a-mental-hospital-called-jail.html
‘Aid in Dying’ Movement
Takes Hold in Some States
FEB. 7, 2014
The New York Times
By ERIK ECKHOLM
DENVER — Helping the terminally ill end their lives, condemned
for decades as immoral, is gaining traction. Banned everywhere but Oregon until
2008, it is now legal in five states. Its advocates, who have learned to shun
the term “assisted suicide,” believe that as baby boomers watch frail parents
suffer, support for what they call the “aid in dying” movement will grow
further.
In January, the New Mexico Supreme Court authorized doctors to provide lethal
prescriptions and declared a constitutional right for “a competent, terminally
ill patient to choose aid in dying.” Last May, the Vermont Legislature passed a
law permitting it, joining Montana, Oregon and Washington. This spring,
advocates are strongly promoting “death with dignity” bills in Connecticut and
other states.
Public support for assisted dying has grown in the past half-century but depends
in part on terminology. In a Gallup Poll conducted in May, for example, 70
percent of respondents agreed that when patients and their families wanted it,
doctors should be allowed to “end the patient’s life by some painless means.” In
1948, that share was 37 percent, and it rose steadily for four decades but has
remained roughly stable since the mid-1990s.
Yet in the same 2013 poll, only 51 percent supported allowing doctors to help a
dying patient “commit suicide.”
About 3,000 patients a year, from every state, contact the advocacy group
Compassion & Choices for advice on legal ways to reduce end-of-life suffering
and perhaps hasten their deaths.
Giving a fading patient the opportunity for a peaceful and dignified death is
not suicide, the group says, which it defines as an act by people with severe
depression or other mental problems.
But overt assistance to bring on death, by whatever name, remains illegal in
most of the country. And so for Robert Mitton of Denver, 58 and with a failing
heart, the news from New Mexico last month was bittersweet.
“I am facing my imminent death,” he said, asking why people in Montana and New
Mexico “are able to die with dignity and I am not.”
“This should be a basic human right.”
Husky and garrulous, with a graying ponytail, Mr. Mitton does not look like a
dying man. But his doctors say that he must undergo extensive open-heart surgery
in the coming months or face a nearly certain and painful end.
A previous operation to replace his aortic valve was so brutal, he says, that
now, with his prior implant failing, he will not endure the surgery again. He
wants a doctor’s help to end his life before he becomes too helpless to act.
Mr. Mitton’s frustrated quest draws attention to the limited choices facing
patients in the large majority of states that bar the practice.
Opponents say that actively ending a life, no matter how frail a person is, is a
moral violation and that patients might be pushed to die early for the
convenience of others.
“The church teaches that life is sacred from conception through to natural
death,” Archbishop Michael J. Sheehan of Santa Fe, N.M., told legislators at a
recent breakfast as he criticized the court decision there.
“This assisted-suicide thing concerns me,” Archbishop Sheehan added, according
to The New Mexican. “I foresee dangerous consequences.”
Mr. Mitton’s predicament illustrates a seldom-discussed side of the debate: the
anguish experienced, and the sometimes desperate measures taken, by some
patients in states where doctors who knowingly prescribe lethal drugs, or
relatives who help a patient obtain them, can be subject to felony charges of
“assisted suicide.”
Oregon’s Death With Dignity Act, which took effect in 1997, authorized
prescriptions for lethal doses when two doctors agree that a patient will die
within six months and is freely choosing this path.
More than a decade passed before another state followed suit. In 2008, voters in
Washington approved a similar law. In 2012, after a political battle, voters in
Massachusetts narrowly defeated such a measure. But last May, the Vermont
Legislature approved one.
In response to lawsuits, state courts in Montana in 2009 and now New Mexico have
said that aid in dying is legal, distinguishing it from the crime of assisted
suicide.
By law and medical standards, only genuine residents who have relationships with
local doctors can qualify for the prescriptions in any of these states, so
patients like Mr. Mitton cannot move in at the last minute.
There is a quiet, constant demand all over the country for a right to die on
one’s own terms, said Barbara Coombs Lee, president of Compassion & Choices, and
that demand is likely to grow, she said, as the baby boomers age.
Her group counsels people who call for advice, Ms. Lee said, describing options
but not encouraging them to end their lives or providing direct help.
Callers who seem to be mentally disturbed and suicidal, she said, are referred
to a suicide hotline. If they are facing imminent suffering and death and seek
some control, the group urges them first to arrange for palliative or hospice
care as they consider their next steps.
“People should get the best care, but also have a choice to accelerate the time
of death if the very best care cannot make their remaining days acceptable,” she
said.
One method for some is to simply halt vital treatments, such as dialysis or
insulin. Another is to turn off a pacemaker or, like Mr. Mitton, refuse an
unwanted new treatment. An increasingly popular choice, she said — “for patients
who are truly, emotionally and spiritually ready to die” — is to stop eating and
drinking.
Others try to accumulate medications that would bring a peaceful death.
But it makes a tremendous difference, Ms. Lee said, to live where the law
permits assisted dying. Too often people seek alternatives in shame and secrecy,
sometimes making frantic international trips for lethal drugs or using more
violent means to kill themselves.
Research in Oregon indicates that for many patients, just knowing the option is
there has proved a great comfort, she noted. Of the 122 patients who obtained
lethal drugs in 2013, only 71 used them, the rest dying naturally with the pills
in a drawer.
Mr. Mitton is an unusual case because, unlike the more typical candidates with
advanced cancer or A.L.S., he is refusing a potentially lifesaving procedure
that would be covered by public insurance. He suffered heart damage from
rheumatic fever in his teens. In 1999, in an open-heart operation followed by an
unusually rough recovery, doctors replaced his failing aortic valve with one
made of bovine tissue.
A decade and a half later, the replacement valve is deteriorating fast, and his
heart is ever less efficient at pumping blood. Once a self-described “crazy
hot-dog skier” and a devotee since childhood of Florida Gators football, he is
growing weaker and feeling more pain.
His doctors at the Denver Health Medical Center say he will probably die within
six months.
“They said that the only way to take care of this is to rip me open again, and
that’s not what I’m going to do,” he said in the apartment he shares here with
his cat.
If a less daunting treatment were available, he might try it, Mr. Mitton said.
But he was told he does not qualify for newer, less invasive surgical methods.
As his ability to work fades, he is also desperately worried about money and
says he would choose to die rather than enter a shelter or even a hospice.
His younger sister in North Carolina, Holly Mitton-Cowan, said by telephone,
“I’m trying not to cry, but I respect his decision.”
Mr. Mitton is exploring the international underground market for pentobarbital,
a drug used in executions and animal euthanasia. In the past, patients have
obtained it by mail order or in person in Latin America or China. But the drug
has become scarce, and governments have cracked down on illicit trade.
If he can get some liquid pentobarbital, Mr. Mitton said, when the time is right
he will sit in his easy chair and mix it into a salty dog — a vodka, grapefruit
juice and salt cocktail that was his first drink as a teenager.
If not, he said, he may resort to what some call a “chemical suicide,” mixing
household chemicals to produce a deadly cloud of hydrogen sulfide gas and
leaving behind a toxic mess. He is also pondering a heroin overdose.
Whatever the means, he said, “I think it’s best if I’m by myself. That way,
nobody could get into trouble.”
A version of this article appears in print on February 8, 2014,
on page A1 of the New York edition with the headline:
‘Aid in Dying’ Movement Takes Hold in Some States.
‘Aid in Dying’ Movement Takes Hold in Some
States, NYT, 7.2.2014,
http://www.nytimes.com/2014/02/08/us/
easing-terminal-patients-path-to-death-legally.html
CVS Plans to End
Sales of Tobacco Products by Oct. 1
FEB. 5, 2014
The New York Times
By STEPHANIE STROM
CVS/Caremark, the country’s largest drugstore chain, announced
on Wednesday that it planned to stop selling cigarettes and other tobacco
products by October.
The company’s move was yet another sign of its metamorphosis into becoming more
of a health care provider than a largely retail business, with its stores
offering more miniclinics and health advice to aid customers visiting its
pharmacies.
While the company’s decision will cost it an estimated $2 billion in sales from
tobacco buyers, that is a mere dent in its overall sales of $123 billion in
2012.
“We have about 26,000 pharmacists and nurse practitioners helping patients
manage chronic problems like high cholesterol, high blood pressure and heart
disease, all of which are linked to smoking,” said Larry J. Merlo, chief
executive of CVS. “We came to the decision that cigarettes and providing health
care just don’t go together in the same setting.”
CVS does not sell electronic cigarettes, the highly popular but debated devices
that deliver nicotine without tobacco and emit a rapidly vanishing vapor instead
of smoke. It said it was waiting for guidance on the devices from the Food and
Drug Administration, which has expressed interest in regulating e-cigarettes.
Some major retail stores like Walmart and convenience stores still sell
cigarettes and other tobacco products, although antismoking groups and health
care professionals will probably use CVS’s decision to try to pressure others to
consider doing so. Municipalities have also begun enacting legislation governing
where cigarettes can be sold.
Kathleen Sebelius, secretary of Health and Human Services, said in a statement
that the CVS decision was “an unprecedented step in the retail industry” and
predicted it would have “considerable impact.”
Ms. Sebelius said that each day, some 3,200 children under 18 will try a
cigarette and 700 will go on to become daily smokers. That means, she said, that
5.6 million American children alive today will die premature deaths because of
diseases linked to smoking.
“Today’s CVS/Caremark announcement helps bring our country closer to achieving a
tobacco-free generation,” she said. “I hope others will follow their lead in
this important step to curtail tobacco use.”
Nik Modi, an investment analyst who follows tobacco stocks at RBC Capital
Markets, said he doubted CVS’s move would have a major impact on tobacco sales,
noting that roughly three-quarters of cigarette sales occur in convenience
stores. Additionally, he said, “the dollar channel recently started to get into
the tobacco space because they were losing foot traffic to other channels as
cigarettes are key to driving in-store traffic.”
On Tuesday, CVS executives met with executives from tobacco companies to discuss
its decision. “Obviously, you would expect they would be disappointed with this
decision,” Mr. Merlo said. “At the same time, I think they understand the
paradox we faced as an organization.”
When San Francisco first proposed banning the sale of tobacco products in
pharmacies in 2008, the Walgreen Company sued, contending it was unfair to place
such restrictions on drugstore operators and not on grocery and discount stores
with pharmacies inside.
Two years later, the city came back two with a ban that included all stores with
embedded pharmacies. That prompted retailers like Safeway and Costco to stop
selling cigarettes in their stores with pharmacies.
A number of municipalities in Massachusetts, including Boston, have similar bans
in place, a few of which also include prohibitions on the sale of e-cigarettes.
Otis W. Brawley, chief medical officer at the American Cancer Society, said
other local government entities were weighing similar measures. “If you’re in
the business of promoting health and providing health care, it’s very
hypocritical to be selling tobacco products,” Dr. Brawley said. “It just doesn’t
make sense and in fact is almost a conflict of interest.”
On Wednesday, Walgreens said it had been assessing its sales of tobacco products
for some time. “We will continue to evaluate the choice of products our
customers want, while also helping to educate them and providing smoking
cessation products and alternatives that help to reduce the demand for tobacco
products,” the company said in a statement.
Rite-Aid, another large chain, said in a statement it continually reviewed
product mix to make sure it suits the needs and desires of customers.
As for driving away customers to competitors, Troyen A. Brennan, the executive
vice president and chief medical officer for CVS, said: “It’s obvious that the
average person will just find somewhere else to buy cigarettes. What we’re
thinking about is if others want to emulate this business decision we’ve made,
then over time that will make cigarettes less available — and scientific
literature does suggest that a reduction in the availability of cigarettes
reduces smoking.”
Dr. Brennan, together with Steven A. Schroeder of the Smoking Cessation
Leadership Center at the University of California, San Francisco, wrote an op-ed
article making the case for eliminating tobacco products from drugstores in The
Journal of the American Medical Association published online on Wednesday.
Some 18 percent of American adults smoke, down from 42 percent in 1965. In
places like New York City, which has used a combination of steep taxes on
cigarettes and bans on smoking in most places to discourage smokers, the decline
is even greater, down to 14 percent.
But health experts remain concerned because the rate of decline has stagnated
over the last decade, and some 480,000 deaths each year are linked to smoking.
From 1999 to 2003, for example, the smoking prevalence among high school girls
dropped 37 percent, according to the Centers for Disease Control, but from 2003
to 2007, the decline was only 2.3 percent.
Earlier this month, a group of seven advocacy organizations including the
American Heart Association and the Campaign for Tobacco-Free Kids called on
governments to take steps to reduce smoking rates to less than 10 percent over
the next decade and ensure no American is exposed to secondhand smoke within
five years.
“We have seen the decrease in initiation of smoking plateau, particularly among
some populations of young people, and we’ve been working very hard on those
populations that have been stubbornly hard to reduce but we need to redouble our
efforts,” said Risa Lavizzo-Mourey, the chief executive of the Robert Wood
Johnson Foundation, which has played a large role in developing programs,
strategies and policies that have been used to reduce smoking in this country.
“Decreasing the availability of tobacco products as CVS is doing is an important
and bold step toward making it harder for people to get access to these harmful
products.”
Coincidentally, the F.D.A. announced on Tuesday the start of a national
education program aimed at preventing smoking among youth. The ads, which will
be distributed across social media platforms, try to show teenagers the toll
that smoking takes on the body in memorable ways, such as a young man who uses a
pair of pliers to pull a stained tooth from his mouth to buy a pack of
cigarettes and a young woman who complains about having to go outside in the
rain to talk to her boyfriend, a smoker.
A shortage of primary care doctors and expanding access to health care coverage
under the Affordable Care Act is turning drugstore chains into big players in
the nation’s health care system. Consumers routinely get flu shots in
drugstores, for instance, and clinics staffed by nurse practitioners or
physician assistants and offering basic care for common ailments like strep
throat or pink eye are popping up everywhere from Walgreens to Walmart.
A report last year by Accenture predicted such so-called retail clinics were
poised to grow at a rate of 25 to 30 percent over the next few years, which
would swell the number to 2,800 in 2015, from 1,400 in 2012.
CVS’s 800 MinuteClinics already account for most of such outlets, and Mr. Merlo
said the company hoped to add another 700 for a total of 1,500 by 2017. For that
reason, he said, the decision to stop selling tobacco products “was really more
of a discussion about how to position the company for future growth.”
The company estimated that the decision would erase 17 cents in earnings per
share of stock annually, but that it had identified ways of offsetting the
impact on profits. (The earnings hit this year will only be 6 cents to 9 cents a
share while the company works through its remaining inventory of tobacco
products.)
The company hopes to make up some of the lost revenue and income with a smoking
cessation program that it is starting this spring with the goal of getting half
a million Americans to stop smoking. “This is a great example of how we’re
evolving from a retail company to a health care company,” said Helena Foulkes,
executive vice president for CVS. “This is the kind of offering we can bring to
clients like insurance plans and companies, many of which will pay for such a
program.”
CVS Plans to End Sales of Tobacco Products
by Oct. 1, NYT, 5.2.2014,
http://www.nytimes.com/2014/02/06/business/
cvs-plans-to-end-sales-of-tobacco-products-by-october.html
Texas Woman
Is Taken Off Life Support After Order
JAN. 26, 2014
The New York Times
By MANNY FERNANDEZ$
HOUSTON — A Fort Worth hospital that kept a pregnant,
brain-dead woman on life support for two months, followed a judge’s order on
Sunday and removed her from the machines, ending her family’s legal fight to
have her pronounced dead and to challenge a Texas law that prohibits medical
officials from cutting off life support to a pregnant woman.
On Friday, a state district judge ordered John Peter Smith Hospital to remove
the woman, Marlise Muñoz, from life-support machines by 5 p.m. on Monday. The
judge ruled that the state law barring doctors from withdrawing “life-sustaining
treatment” to pregnant women did not apply to Ms. Muñoz because she was
brain-dead and therefore legally dead. The hospital had refused to honor the
family’s request to disconnect her, claiming that the law prevented them from
doing so until they could perform a cesarean delivery.
But on Sunday, the hospital decided against appealing the judge’s decision and
announced that it would follow his ruling. The J.P.S. Health Network, which runs
John Peter Smith Hospital as part of the taxpayer-financed county hospital
district, said in a statement that the past several weeks had been difficult for
both the family of Ms. Muñoz and her caregivers, but it defended its handling of
the case.
“J.P.S. Health Network has followed what we believed were the demands of a state
statute,” said a spokeswoman, Jill Labbe. “From the onset, J.P.S. has said its
role was not to make nor contest law but to follow it.”
At roughly the same time, about 11:30 a.m., Ms. Muñoz was disconnected from the
machines as her family gathered at her bedside in the hospital’s I.C.U. Her body
was released to her husband, Erick Muñoz, the family’s lawyers and a relative
said.
Mr. Muñoz, 26, a firefighter in a town near Fort Worth, had found his wife on
the kitchen floor in late November after she suffered an apparent blood clot in
her lungs. He, as well as his wife’s parents, Lynne and Ernest Machado, had
argued that she had died shortly after arriving at the hospital and they said
they were disturbed by the move to keep her on life support.
“The Muñoz and Machado families will now proceed with the somber task of laying
Marlise Muñoz’s body to rest, and grieving over the great loss that has been
suffered,” Mr. Muñoz’s lawyers, Heather L. King and Jessica Hall Janicek, said
in a statement. “May Marlise Muñoz finally rest in peace, and her family find
the strength to complete what has been an unbearably long and arduous journey.”
The hospital did not dispute that Ms. Muñoz was brain-dead, saying in court
papers that she met the clinical criteria two days after she was first brought
to the hospital. But the hospital’s lawyer said the law still applied to her,
insisting it was part of the Texas Legislature’s “commitment to the life and
health of unborn children.” The lawyer, Larry M. Thompson, pointed to a section
of the Texas Penal Code that states a person may commit criminal homicide by
causing the death of a fetus.
The law “must convey legislative intent to protect the unborn child, otherwise
the Legislature would have simply allowed a pregnant patient to decide to let
her life, and the life of her unborn child, end,” wrote Mr. Thompson, with the
Tarrant County district attorney’s office, which represented the hospital.
Ms. Muñoz, 33, was 14 weeks pregnant with her second child when she first
arrived at the hospital, on Nov. 26, and on Sunday had been at the end of her
22nd week of pregnancy. The fetus was not viable, the hospital acknowledged in
court papers. It suffered from hydrocephalus — an abnormal accumulation of fluid
in the cavities of the brain — as well as a possible heart problem, and the
lower extremities were deformed. One of Mr. Muñoz’s lawyers said medical records
indicated some of the doctors treating his wife had recommended taking her off
life support.
Groups that oppose abortion had expressed support for the hospital’s legal
argument. A statement released by the National Black Pro-Life Coalition and
Operation Rescue said that the fetus deserved not to be killed, and that
numerous people had expressed an interest in adopting the child when it was
born, even if it had disabilities.
It was unclear on Sunday who would end up paying the hospital bill. Hospital
officials had said previously that they were focused on caring for Ms. Muñoz,
and that it was inappropriate for them to comment on or estimate the cost of a
patient’s care. “At the appropriate time, the finance department will pursue the
customary avenues to identify payers and reimbursement,” Ms. Labbe said.
A version of this article appears in print on January 27, 2014,
on page A9 of the New York edition with the headline:
Texas Woman Is Taken Off Life Support After Order.
Texas Woman Is Taken Off Life Support After
Order, NYT, 26.1.2014,
http://www.nytimes.com/2014/01/27/us/
texas-hospital-to-end-life-support-for-pregnant-brain-dead-woman.html
List of Smoking-Related Illnesses
Grows Significantly in U.S. Report
JAN. 17, 2014
The New York Times
By SABRINA TAVERNISE
WASHINGTON — In a broad review of scientific literature, the
nation’s top doctor has concluded that cigarette smoking — long known to cause
lung cancer and heart disease — also causes diabetes, colorectal and liver
cancers, erectile dysfunction and ectopic pregnancy.
In a report to the nation to be released on Friday, the acting surgeon general,
Dr. Boris D. Lushniak, significantly expanded the list of illnesses that
cigarette smoking has been scientifically proved to cause.
The other health problems the report names are vision loss, tuberculosis,
rheumatoid arthritis, impaired immune function and cleft palates in children of
women who smoke.
Smoking has been known to be associated with these illnesses, but the report was
the first time the federal government concluded that smoking causes them.
The finding does not mean that smoking causes all cases of the health problems
and diseases listed in the report, but that some of the cases would not have
happened without smoking. The surgeon general has added to the list of
smoking-related diseases before. Bladder cancer was added in 1990 and cervical
cancer in 2004.
The report is not legally binding, but is broadly held as a standard for
scientific evidence among researchers and policy makers.
Experts not involved in writing the report said the findings were a
comprehensive summary of the most current scientific evidence, and while they
might not be surprising to researchers, they were intended to inform the public
as well as doctors and other medical professionals about the newest proven risks
of smoking.
“I thought the science was very well done and up to date,” said Dr. Robert
Wallace, a professor of epidemiology and internal medicine at the University of
Iowa, who helped review the report.
The report comes 50 years after the pivotal 1964 surgeon general’s report in
which the government concluded for the first time that smoking caused lung
cancer. That report was credited with starting to change public attitudes toward
smoking, which has declined sharply. In 1965, about 43 percent of adults were
smokers; in 2012, about 18 percent were.
But that decline has slowed in recent years, and the new report calls for
stronger action in combating smoking. Smoking is the largest cause of premature
death in the country, killing more than 400,000 people a year. The report notes
that far more Americans have died prematurely from cigarette smoking than in all
the wars ever fought by the United States.
The report concluded that the evidence was insufficient to say that smoking
caused prostate cancer. The evidence was suggestive, but not definite, that
smoking causes breast cancer.
The document also celebrates the public health success of smoking’s decline
since Dr. Luther Terry, the surgeon general in 1964, released his landmark
finding. Smoking was deeply embedded in American culture at the time. Half of
adult men were smokers, and a third of women. Even doctors smoked.
That report was so controversial that it was released on a Saturday when
Congress was on recess to minimize the political repercussions, said Dr. Richard
D. Hurt, a professor of medicine at the Mayo Clinic.
Dr. Judith Fradkin, a diabetes scientist at the National Institutes of Health,
who was not involved in the report, said the evidence that smoking increases the
risk of Type 2 diabetes had been gathering for about 20 years.
While smoking causes most cases of lung cancer, it causes only a small fraction
of liver and colorectal cancers. A current smoker is 25 times as likely to
develop lung cancer as someone who has never smoked, but only about 1.5 times as
likely to develop liver cancer.
“It’s a fairly modest association, but because so many people smoke, it’s still
an important cause of these cancers,” said Neal Freedman, an epidemiologist at
the National Cancer Institute.
He pointed out that the surgeon general last looked at the effect of smoking on
liver cancer in 2004, and found the evidence only suggestive. Since then, 90 new
studies have been published allowing the surgeon general to conclude smoking is
a cause.
The report also finds that the risks of lung cancer are far higher today than in
past decades, even though smokers today consume fewer cigarettes. In 1959, women
who smoked were 2.7 times as likely as women who never smoked to develop lung
cancer, and by 2010, the additional risk had jumped nearly tenfold. For men, the
risk doubled over the same period. The report said changes in cigarettes’
design, namely to the filter, contributed to the increased deadliness.
“It is stunning that the risk of a premature death from smoking is greater than
it was 50 years ago,” said Matthew Myers, head of the Campaign for Tobacco-Free
Kids, an advocacy group.
A version of this article appears in print on January 17, 2014,
on page A15 of the New York edition with the headline:
List of Smoking-Related Illnesses Grows Significantly
in U.S. Report.
List of Smoking-Related Illnesses Grows
Significantly in U.S. Report,
NYT, 17.12014,
http://www.nytimes.com/2014/01/17/
science/list-of-smoking-related-illnesses-grows-significantly-in-us-report.html
Tobacco, Firearms and Food
JAN. 14, 2014
The New York Times
Let’s say your beliefs include the notion that hard work will
bring good things to you, that the golden rule is a nice idea though it may
occasionally have limits, and that it’s more or less every person for him or
herself. Your overall guiding force is not altruism, but you’re not immoral;
you’re a good citizen, and you don’t break any major laws. This could describe
many of us; most, maybe.
Now suppose you’re in the business of producing, marketing or selling tobacco or
firearms — products known to sometimes kill others. You need not be a corporate
executive or a criminal arms dealer; you might be a retailer of cigarettes, a
person who sells them along with magazines, a marketer, a gun shop owner. In any
case, your conscience is clear: you’re selling regulated legal products and, as
long as you’re obeying the regulations, you’re doing nothing illegal. (“Wrong”
is a judgment call.)
You sleep well, believing that the government would further regulate your
product if it were necessary. And if regulations were to change, you’d change
with them. But to act otherwise — to hold back your energy from production or
sales just because of moral or social pressure — would be foolish, and put you
at a competitive disadvantage.
For many years after knowing about the lethal nature of tobacco, our government
did little or nothing to limit its consumption. That’s changed gradually in the
last 50 years, and more dramatically since 1998, because of successful lawsuits
and because the Food and Drug Administration often tries to pursue its mission.
(For a variety of reasons not worth going into, firearms are more challenging to
regulate. Let’s leave it at that for now.)
O.K., so suppose we pass legislation that discourages you from producing or
selling tobacco or firearms while at the same time actively encouraging you —
supporting you — to change to producing apples or cotton or washing machines or
screwdrivers; as long as you could see a way to increase profit, you’d probably
look at the new opportunity. After all, it’s not as if you want to produce
agents of death. You want to make the best living you can selling stuff that’s
legal and that people want. Markets change, and flexibility is important, and
the government can and does affect your business, even if it’s by inaction.
Now let’s apply this same way of thinking to the major food categories — and for
the purposes of this discussion there are only three — and what it’s like to be
a farmer or producer, or a manufacturer, processor, distributor, retailer of
this stuff. Again, you’re agnostic about what you sell, but you’re
profit-conscious. And the government can and does affect your business; it can
help your business (“you didn’t build it yourself”) or hurt it, as it should if
your business is harming others.
Let’s call the first food group industrially produced animal products. Producing
and selling as much as possible is the way to go here, since the penalties for
damage your product does to human and animal health and to the environment
(including climate) are virtually nonexistent. You can treat the animals as you
like and damn the consequences, from salmonella contamination to antibiotic
resistance to water contamination to, of course, cruelty. There are even
incentives, in the form of subsidized prices for animal feed.
The next group is most easily labeled junk food; you might call it
“hyperprocessed.” This comprises aisles and aisles of “edibles” sold in
supermarkets and restaurants, and is often “food” that’s unrecognizable as such,
ranging from soda and other sugar-sweetened beverages to things like chicken
nuggets and Pringles and tens of thousands of other examples. These are mostly
made from commodity crops, especially corn, soybeans and wheat. Federal
subsidies abound in many forms here, from direct payments (in theory, these are
ending, to be replaced by a bizarre form of crop insurance) to the ethanol
mandate to virtually unregulated land use that permits toxic overapplication of
fertilizers and other chemicals. There is also that same failure to recognize
the public health and environmental costs of what is probably the least healthy
diet a wealthy nation could devise. You could even say that the Supplemental
Nutrition Assistance Program (SNAP, usually called food stamps) acts as a
subsidy to junk food, since nothing limits using food stamps for food that
promotes disease. It’s worth noting that for the past century the bulk of
university research, much of it paid for with tax dollars, has gone into
figuring out how to increase the yield of the crops and processes that turn out
this junk that sickens.
Then, in the third group, there’s everything else, from fruits and vegetables —
absurdly called “specialty crops” by the Department of Agriculture — to animals
raised in sustainable and even humane ways. But here, disincentives abound:
farmers may be encouraged to allow some land to go fallow, but not to be planted
in specialty crops, and research money, subsidies, insurance, market promotion
and access to credit are directed toward industrial food production,
distribution and sales. These inefficiencies make most of this real food, which
is health-promoting and closer to environmentally neutral, appear to be more
expensive. (Only “appear,” though. If you account for the costs of environmental
and public health damage, industrially produced junk food and animal products
actually cost more.)
In a neutral (“free”) market, there’d be more room for producers and processors
of fruits and vegetables to make money by responding to increased demand for
wholesome fruits and vegetables without competing with subsidized junk food. In
a sane — let’s say properly regulated — market, there’d be incentives for
agriculture that benefited both grower and consumer with products that were less
damaging to the environment and public health. Food stamps, for example, would
be restricted to use for nourishing food. Direct subsidies might be used to
encourage new farmers who wanted to grow “specialty crops” rather than for
farmers working thousands of acres of corn.
One could imagine a government that encourages more life-giving (and less
disease-causing) agriculture just as one can acknowledge that sanity prevails
when government steeply taxes tobacco and encourages its farmers to move on to
something else. (I’m not saying, by the way, that tobacco farmers have been
treated fairly; much more could have been done — and still could be done — to
help them transition to other profitable crops.)
Of course this is disruptive; change the status quo, and someone is hurt. But
the public health disaster created by our commodity-pushing agricultural
policies is only getting worse, and calls for the same kind of action in
industrial agriculture that we’ve seen in tobacco and, to a lesser extent, in
guns. That kind of action will happen only when we have political
representatives who care about food, health and the environment.
We can pressure corporations all we want, and what we’ll get, mostly, is
healthier junk food. Really, though, as long as sugar is profitable and 100
percent unrestricted (and subsidized and protected!), marketers will try to get
2-year-olds hooked on soda and Gatorade.
But the job of government is not to encourage profitable businesses at the cost
of public health; it’s to regulate them so that the public is served. Who is
this country for, anyway?
Tobacco, Firearms and Food, NYT, 14.1.2014,
http://www.nytimes.com/2014/01/15/opinion/bittman-tobacco-firearms-and-food.html
The Asbestos Scam, Part 2
The Opinion Pages|Op-Ed Columnist
The New York Times
Six weeks ago, I wrote a column about a ridiculous lawsuit
being brought by Carolyn McCarthy, a congresswoman from Long Island. A smoker
for most of her life, McCarthy has lung cancer. Yet her lawyers claimed that it
was her “exposure” to asbestos, through the work clothes of her father and
brother, both boilermakers, that triggered her cancer. Though McCarthy certainly
deserves our sympathy as she fights cancer, it is hard to see her lawsuit as
anything but an undeserved money grab — and the latest twist in asbestos
litigation, the longest running tort in American history, with no end in sight.
Then again, maybe there is finally an end in sight. Late Friday afternoon, Judge
George Hodges, a federal bankruptcy judge in North Carolina, wrote a
breathtaking decision, in which he essentially pulled the lid off another form
of asbestos scam. Though he shrank from labeling the actions of the plaintiffs’
lawyers involved in asbestos litigation as “fraudulent,” he did describe the
litigation as “infected with the impropriety of some law firms.” It’s a
potential game-changer.
There are two reasons it can be difficult to write about asbestos lawsuits. The
first is that the modern-day plaintiff truly is sick — if not with lung cancer
then with mesothelioma, a deadly disease that results from extensive exposure to
asbestos decades earlier. Given the rules of American society, mesothelioma
victims undoubtedly deserve compensation from whichever company used the product
that caused their illness.
The second reason is that asbestos litigation has become more complicated than
3-D chess. For years, it was easy to explain the scam: People who weren’t sick
were being diagnosed with asbestosis by doctors being paid by asbestos lawyers.
That has largely ended — hence the current emphasis on mesothelioma lawsuits,
which have the added advantage (for the lawyers) of being potentially
multimillion-dollar cases. Today, with around 100 companies having been
bankrupted by asbestos litigation, and $37 billion set aside in trusts for
victims, you would think the litigation would be winding down. Guess again.
Enter Garlock Sealing Technologies, a maker of gaskets. For years, it was on the
periphery of asbestos litigation because, while its gaskets had once contained
asbestos, it was a kind that had 1/100th of the risk of the more commonly used
product. In addition, the asbestos was sealed, usually behind far-more-dangerous
asbestos insulation made by some other, more culpable, company.
Stephen Macadam, the chief executive of EnPro, Garlock’s parent company, told me
that he had expected that the litigation pressure would ease on Garlock as other
companies succumbed to bankruptcy and set up trusts for victims. Instead, the
opposite happened. Garlock became a prime target, precisely because it was still
standing.
For years, Garlock had made calculated decisions about how to deal with its
asbestos litigation. It fought some cases and settled others. But, by 2010,
inundated with mesothelioma cases, it too filed for bankruptcy protection. Then
it did something different. It fought back.
The judge allowed the company to do a deep dive into 15 cases that Garlock had
previously settled. For a victim to demand money from Garlock, he or she had to
stipulate that Garlock’s gasket had been a primary exposure to asbestos. To
maximize the money they could get from Garlock, they would deny, under oath,
other exposures to the products of the bankrupt companies that had set up
trusts.
But as Garlock soon discovered, no sooner had the victims settled then they
would file documents with a dozen or more trusts stipulating the opposite: that
they had had “meaningful and credible exposure” to asbestos from the bankrupt
companies. (The plaintiffs’ lawyers, who control the trusts, have successfully
fought to keep this information confidential.) Judge Hodges, in his decision,
seemed thunderstruck that this pattern occurred in every case that Garlock
investigated. The phrase he used to describe this behavior was “withholding
evidence.”
It would have been helpful if this decision had come a decade or more ago,
before so many companies were forced into bankruptcy. But maybe, just maybe,
other companies will start to follow Garlock’s example and finally put an end to
the asbestos scam.
As to why anyone should care whether innocent companies have to pay millions to
asbestos victims and their lawyers, I would offer three reasons. First, when
victims get more than they should under the rules, it means that someone else
down the road will wind up with less than he or she should. Second, litigation
designed to bring innocent companies to their knees is an impediment to economic
growth and job creation.
And, finally, there is the rule of law, which the asbestos lawyers suing Garlock
clearly flouted. We are very good in this country at pointing out the failure of
other countries’ judicial systems to abide by the rule of law. Shouldn’t we be
just as rigorous when the failure is our own?
A version of this op-ed appears in print on January 14, 2014,
on page A27 of the New York edition with the headline:
The Asbestos Scam, Part 2.
The Asbestos Scam, Part 2, NYT, 13.1.2014,
http://www.nytimes.com/2014/01/14/opinion/nocera-the-asbestos-scam-part-2.html
Abortion Rights: Uphold Buffer Zones
JAN. 13, 2014
The new York Times
By THE EDITORIAL BOARD
Abortion is one of the most emotionally fraught issues in
American society, and public discussion often turns into an attack on the women
who choose to exercise their constitutionally protected rights.
That is essentially what happened for years outside reproductive-health clinics
in Massachusetts, where dozens of anti-abortion protesters have gathered since
the late 1980s in an organized effort to stop women from getting abortions. Some
held up signs or handed out leaflets, while others surrounded the arriving cars
of doctors and patients or chained themselves together and physically blocked
clinic entrances.
Eventually, protesters in support of abortion rights started
showing up, and the two groups pushed and jockeyed for better position. As a
result, women approaching the clinic had to endure a frenetic gauntlet of
activists. Many were intimidated, and some chose to leave rather than confront
the crowds. Police arrested some protesters for harassment and other violations
but had trouble keeping the peace.
In response to this public-safety problem, Massachusetts passed a law in 2007
that created a 35-foot buffer zone around clinic entrances. Within the zone,
which is the width of about two parking spaces and marked by a yellow line, only
patients and clinic employees are permitted. Protesters — whether anti-abortion
or pro-abortion rights — must stay behind the yellow line.
On Wednesday, in McCullen v. Coakley, the Supreme Court is scheduled to consider
whether this law violates the protesters’ free speech rights under the First
Amendment. While that is the legal question before the court, the broader issue
at stake is protecting women’s access to abortion, which is under assault around
the country by lawmakers and protesters alike.
The anti-abortion protesters who challenged the law argue that it improperly
restricts speech based on content because it applies only at clinics where
abortions are performed. They also say that it favors the voices of those who
support abortion rights because it allows clinic workers inside the buffer zone.
Far from limiting speech, the law is a prime example of a state’s power to
protect public safety, even if it has incidental effects on some speech. The
history of abortion protests in Massachusetts surely merits such a response. In
addition to regular incidents of harassment and intimidation, in 1994 a man
named John Salvi III went on a shooting spree in two clinics outside Boston,
killing two employees and injuring five others.
Before the current law was enacted, Massachusetts legislators
tried numerous other solutions, including a smaller, “floating” buffer zone —
which set an 18-foot perimeter around clinic entrances and made it unlawful to
approach within 6 feet of anyone in that zone, if done without the person’s
consent to engage “in oral protest, education or counseling.”
The zone, modeled on a Colorado law that the Supreme Court upheld in 2000,
quickly proved unworkable, as police struggled to play referee against
protesters who violated the 6-foot limit. The fixed buffer zone came about after
years of consultation with police officers and is the first law that has
succeeded in keeping a clear path for women trying to get into the clinics (more
than two-thirds of whom go to the clinics for health care appointments, not
abortions).
The government may reasonably impose “time, place, and manner” restrictions on
speech, provided that they are neutral as to content and allow other channels of
communication. The Massachusetts law does both. It is aimed at certain clinics
because that is where the public-safety risk exists. And anti-abortion
protesters may still picket, hand out leaflets and speak freely to women outside
the buffer zone. Eleanor McCullen, the lead plaintiff in the case, testified
that while standing outside the zone she had personally persuaded more than 80
women not to go through with a planned abortion.
That is, of course, their choice. But the vast majority of women who do choose
to end a pregnancy do not do so lightly, contrary to the condescending
assumptions of anti-abortion activists and lawmakers. The Supreme Court should
uphold this sensible law and allow women to make choices free from intimidation,
harassment or worse.
A version of this editorial appears in print
on January 14, 2014, on page A26
of the New York edition with the headline:
The justices should uphold sensible buffer zones at clinics.
Abortion Rights: Uphold Buffer Zones, NYT,
13.1.2014,
http://www.nytimes.com/2014/01/14/opinion/abortion-rights-uphold-buffer-zones.html
Access to Abortion Falling
as States Pass Restrictions
January 3, 2014
The New York Times
By ERIK ECKHOLM
A three-year surge in anti-abortion measures in more than half
the states has altered the landscape for abortion access, with supporters and
opponents agreeing that the new restrictions are shutting some clinics,
threatening others and making it far more difficult in many regions to obtain
the procedure.
Advocates for both sides are preparing for new political campaigns and court
battles that could redefine the constitutional limits for curbing the right to
abortion set by the 1973 Roe v. Wade decision and later modifications by the
Supreme Court.
On Monday, in a clash that is likely to reach the Supreme Court, a federal
appeals court in New Orleans will hear arguments on a Texas requirement that
abortion doctors have admitting privileges at local hospitals — a measure that
caused one-third of the state’s abortion clinics to close, at least temporarily.
Advocates for abortion rights, taking heart from recent signs in Virginia and
New Mexico that proposals for strong or intrusive controls may alienate voters,
hope to help unseat some Republican governors this year as well as shore up the
Democratic majority in the United States Senate.
Anti-abortion groups aim to consolidate their position in dozens of states and
to push the Senate to support a proposal adopted by the Republican-controlled
House for a nationwide ban on most abortions at 20 weeks after conception.
“I think we are at a potential turning point: Either access to abortion will be
dramatically restricted in the coming year or perhaps the pushback will begin,”
said Suzanne Goldberg, director of the Center for Gender and Sexuality Law at
Columbia University.
The anti-abortion groups, for their part, feel emboldened by new tactics that
they say have wide public appeal even as they push the edges of Supreme Court
guidelines, including costly clinic regulations and bans on late abortions.
“I’m very encouraged,” said Carol Tobias, president of National Right to Life.
“We’ve been gaining ground in recent years with laws that are a stronger
challenge to Roe.”
“I think it is more difficult to get an abortion in the country today,” she
said.
The new laws range from the seemingly petty to the profound. South Dakota said
that weekends and holidays could not count as part of the existing 72-hour
waiting period, meaning that in some circumstances women could be forced to wait
six days between their first clinic visit and an abortion.
Laws passed last year by Arkansas and North Dakota to ban abortions early in
pregnancy, once a fetal heartbeat was detected, were hailed by some as landmarks
if quickly rejected by federal courts. But bans on abortion at 20 weeks, also an
apparent violation of constitutional doctrine, remain in force in nine states.
In Roe and later decisions, the Supreme Court said that women have a right to an
abortion until the fetus is viable outside the womb — at about 24 weeks of
pregnancy with current technology — and that any state regulations must not
place an “undue burden” on that right.
In 2013 alone, 22 states adopted 70 different restrictions, including
late-abortion bans, doctor and clinic regulations, limits on medication
abortions and bans on insurance coverage, according to a new report by the
Guttmacher Institute, a research group that supports abortion rights.
Anti-abortion legislation in the states exploded after the major conservative
gains in the 2010 elections, the report said, resulting in more than 200
measures in 30 states over the last three years.
Americans United for Life, an anti-abortion group, has a similar count,
describing the flood of new laws as “life-affirming legislation designed to
protect women from the harms inherent in abortion.”
Twenty-four states have barred abortion coverage by the new health exchanges and
nine of them forbid private insurance plans, as well, from covering most
abortions.
A dozen states have barred most abortions at 20 weeks of pregnancy, based on a
theory of fetal pain that has been rejected by major medical groups. Such laws
violate the viability threshold and have been struck down in three states, but
proponents hope the Supreme Court will be open to a new standard.
A partial test is expected this month, when the Supreme Court announces whether
it will hear Arizona’s appeal to reinstate its 20-week ban, which was overturned
by federal courts.
Many legal experts expect the court to decline the case, but this would not
affect the status of similar laws in effect in Texas and elsewhere. Still, those
on both sides are watching closely because if the court does take it, the basis
of four decades of constitutional law on abortion could be upended.
“If they take the Arizona case, it seems like at least four of the justices are
willing to reconsider the viability line as the point at which states can ban
abortions,” said Caitlin Borgmann, an expert on reproductive rights at the City
University of New York School of Law.
The many strands of attack came together in Texas, which in a tumultuous special
session in July required doctors performing abortions to have local hospital
admitting privileges, imposed costly surgery-center standards on abortion
clinics, sharply limited medication abortions and adopted a 20-week ban.
The admitting privileges requirement immediately forced about one-third of some
30 clinics in the state to stop performing abortions and left much of South
Texas without any abortion clinics.
A federal judge called the rule medically unnecessary and halted enforcement,
but the state appealed successfully to the United States Court of Appeals for
the Fifth Circuit to reinstate it pending a trial.
On Monday, that appeals court, in New Orleans, will hear arguments. The case
against the rule, being argued by groups including Planned Parenthood, the
Center for Reproductive Rights and the American Civil Liberties Union, was
supported in a brief by the American Medical Association and the American
College of Obstetricians and Gynecologists, which said it served no valid
purpose.
Texas officials asserted that the requirement promotes safety and that any
burdens on women have been exaggerated. Some Supreme Court justices have already
said that they expect eventually to hear the case.
Courts have temporarily blocked similar admitting-privilege requirements in
Alabama, Mississippi, North Dakota and Wisconsin.
Another provision of the Texas law with potentially vaster impact, set to take
effect in September, imposes surgery-center standards for clinics, even those
that perform only the safest early-stage procedures or nonsurgical medication
abortions. The requirement could leave the state with as few as eight abortion
centers, according to Planned Parenthood.
“Any one of the restrictions passed in the last several years would be bad, but
taken together, we are witnessing a catastrophe for Texas women,” said Cecile
Richards, president of the Planned Parenthood Federation of America.
Amid all the setbacks, abortion rights groups say they see encouraging signs.
A referendum to impose a 20-week ban in Albuquerque was defeated. Although Texas
adopted some of the country’s most stringent controls, State Senator Wendy
Davis’s filibuster in June energized women and led to her campaign for governor.
In Virginia, these groups say, Attorney General Kenneth T. Cuccinelli II’s
strong anti-abortion stance became a liability, contributing to his defeat in
the governor’s race.
“I honestly believe we have shifted the momentum,” said Ilyse Hogue, the
president of Naral Pro-Choice America.
Ms. Hogue predicted that candidates less hostile to abortion rights would put up
strong races against Republicans running for governor in, for example, Ohio,
Michigan, Wisconsin and Kansas.
Ms. Tobias, of National Right to Life, responded, “The other side is getting
more people activated, but so are we.”
The proliferation of state restrictions is recreating a legal patchwork.
“Increasingly, access to abortion depends on where you live,” said Jennifer
Dalven, director of the reproductive freedom project at the American Civil
Liberties Union.
She added, “That’s what it was like pre-Roe.”
Access to Abortion Falling as States Pass
Restrictions, NYT, 3.1.2014,
http://www.nytimes.com/2014/01/04/us/
women-losing-access-to-abortion-
as-opponents-gain-ground-in-state-legislatures.html
A Brain Is Dead, a Heart Beats On
January 3, 2014
The New York Times
By NORIMITSU ONISHI
SAN FRANCISCO — It started out as an operation to treat an
increasingly common medical problem in America, childhood sleep apnea. It has
become an anguished fight over the fate of a 13-year-old girl who, though
pronounced legally dead by doctors, remains alive in the opinion of her
religious parents.
The girl, Jahi McMath, was declared brain-dead after complications from surgery
on Dec. 9 at Children’s Hospital Oakland, which wanted to remove her from a
ventilator. But her heart continues to beat, and her family protested the
removal in court, so she has remained connected to the machine.
On Friday, amid acrimonious battles in three courts, an Alameda County Superior
Court judge mediated an agreement that could allow the child to be moved to
another facility willing to take her, even though the hospital has declared her
dead.
As arguments in the courts continue, the girl will remain connected to the
ventilator at least until Tuesday, under the judge’s order. In the meantime,
family members are scrambling to identify a facility that will accept the girl
and doctors willing to carry out procedures that will keep her heart beating
during the transfer.
Nailah Winkfield, the girl’s mother, said she was hopeful that Friday’s
agreement would facilitate her daughter’s move.
“I believe in God, and I believe that if he wanted her dead, he would have taken
her already,” Ms. Winkfield, a Baptist, said by phone. “Her heart is beating,
her blood is flowing. She moves when I go near her and talk to her. That’s not a
dead person.”
Jahi was admitted to Children’s Hospital last month, and underwent three
surgical procedures that included removing her tonsils and adenoids. She
subsequently “suffered serious complications” that resulted in her death,
according to court documents submitted by the hospital. The family’s lawyer said
in a court filing that Jahi suffered “large blood loss and, as a result, she
suffered a heart attack and a loss of oxygen to her brain.”
The hospital determined two days later that the girl was legally dead, and later
sought to remove the ventilator. The family objected, asserting that the
heartbeat was proof that she remained alive. In a document filed in Federal
Court, the family’s lawyer stated that the girl’s parents are “Christians with
firm religious beliefs that as long as the heart is beating, Jahi is alive.”
Doctors who have examined the girl, including a court-appointed neurologist,
have all declared her brain-dead. The judge issued a temporary restraining order
blocking the hospital from removing her from the ventilator. The order was
extended until Tuesday.
Judges in three separate courts have turned down the family’s request to order
Children’s Hospital to insert tracheotomy and feeding tubes so she can be
transported to another facility. Hospital officials have said that they would
not allow the procedures to be carried out on the premises.
The family has attacked the hospital, saying it is effectively standing in the
way of Jahi’s move to another facility.
“We just want them to get out of the way,” said Omari Sealey, the girl’s uncle.
Christopher Dolan, the family’s lawyer, said a few facilities had agreed to
accept Jahi, including the New Beginnings Community Center in Medford, N.Y. The
center, which treats people with traumatic brain injury and other disabilities,
did not return calls seeking comment, but said on its website that Jahi “has
been defined as a deceased person yet she has all the functional attributes of a
living person despite her brain injury.” It did not say whether it was prepared
to admit the girl.
Under the agreement reached Friday, the hospital will release the girl to the
Alameda County coroner, a move that will officially classify the girl as dead,
before the family can transfer Jahi elsewhere.
“It is hard for a mother to receive a death certificate for a child who has a
heart beating,” Mr. Dolan said. “It’s an awkward situation.”
The agreement does not require the hospital to perform the procedures that will
help the girl’s heart to keep beating during the transfer, or to allow an
outside doctor to carry them out on hospital premises, as Mr. Dolan had
requested.
“This is an important medical and legal victory for our hospital and all medical
facilities, that they can’t be forced to perform surgery,” said Sam Singer, a
spokesman for Children’s Hospital.
Lt. Riddic Bowers of the Alameda County Coroner’s Bureau said that once the
bureau issued a death certificate and a release form, a deceased person’s
relatives were free to dispose of the body according to their wishes.
David Magnus, director of the Stanford Center for Biomedical Ethics, said it was
unlikely that a long-term care facility would accept a patient who has been
issued a death certificate.
“There’s no reported case of a correct diagnosis of brain death where anybody
comes back,” he said. He added that while death occurs after an hour because of
a lack of blood flowing into the brain, Jahi has not had blood flowing into her
brain since at least Dec. 12.
This article has been revised
to reflect the following
correction:
Correction: January 4, 2014
An earlier version of a picture caption with this article
misidentified the husband of Nailah Winkfield.
He is Marvin Winkfield, not Martin.
A Brain Is Dead, a Heart Beats On, NYT,
3.1.2014,
http://www.nytimes.com/2014/01/04/us/a-brain-is-dead-a-heart-beats-on.html
Emergency Visits
Seen Increasing With Health Law
January 2, 2014
The New York Times
By SABRINA TAVERNISE
Supporters of President Obama’s health care law had predicted
that expanding insurance coverage for the poor would reduce costly emergency
room visits because people would go to primary care doctors instead. But a
rigorous new experiment in Oregon has raised questions about that assumption,
finding that newly insured people actually went to the emergency room a good
deal more often.
The study, published in the journal Science, compared thousands of low-income
people in the Portland area who were randomly selected in a 2008 lottery to get
Medicaid coverage with people who entered the lottery but remained uninsured.
Those who gained coverage made 40 percent more visits to the emergency room than
their uninsured counterparts during their first 18 months with insurance.
The pattern was so strong that it held true across most demographic groups,
times of day and types of visits, including those for conditions that were
treatable in primary care settings.
The findings cast doubt on the hope that expanded insurance coverage will help
rein in emergency room costs just as more than two million people are gaining
coverage under the Affordable Care Act. And they go against one of the central
arguments of the law’s supporters, that extending insurance to large numbers of
Americans would reduce emergency room use, and eventually save money.
In remarks in New Mexico in 2009, Mr. Obama said: “I think that it’s very
important that we provide coverage for all people because if everybody’s got
coverage, then they’re not going to the emergency room for treatment.”
The study suggests that the surge in the numbers of insured people may put even
greater pressure on emergency rooms, at least in the short term. Nearly 25
million uninsured Americans could gain coverage under the law, about half of
them through Medicaid. The first policies took effect on Wednesday.
“I suspect that the finding will be surprising to many in the policy debate,”
said Katherine Baicker, an economist at Harvard University’s School of Public
Health and one of the authors of the study.
An administration spokeswoman, Tara McGuinness, said that the time frame was too
short to expect much of a change, and that over the longer term, use would most
likely decline. She pointed to a longer-term study in Massachusetts, which
expanded coverage for its residents in 2006, that found an 8 percent decline in
emergency department use over a period of several years.
“Medicaid saves lives and improves health outcomes,” Ms. McGuinness said.
“Plenty of studies show that.”
But many economists say that the emphasis on emergency room use, both in policy
and in political speeches, is misplaced, as it makes up only a small part of
health care costs in the United States. A federal government health survey found
that emergency departments accounted for about 4 percent of total health
spending in 2010, far less than inpatient hospital visits, which accounted for
about 31 percent. Certain populations, however, like low-income people with
chronic illnesses, have much higher rates of use.
Dr. Baicker and Amy Finkelstein, an economist at the Massachusetts Institute of
Technology, another author, said the increased use of emergency rooms is driven
by a basic economic principle: When services get less expensive, people use them
more. Previous studies have found that uninsured people face substantial
out-of-pocket costs that can put them in debt when they go to the emergency
room. Medicaid reduces those costs.
Medicaid coverage also reduces the costs of going to a primary care doctor, and
a previous analysis of data from the Oregon experiment found that such visits
also increased substantially.
“This is just one piece of an increase we found across every type of care,” said
Bill J. Wright, an author of the new study who is the associate director of the
Center for Outcomes Research and Education in Portland, a part of Providence
Health and Services, a large health care provider.
The study’s authors emphasized that Medicaid had many benefits. Previous
analyses from the experiment found that gaining coverage reduced the incidence
of depression and increased feelings of financial stability.
The study drew on data from the Oregon Health Insurance Experiment that included
about 90,000 low-income Oregonians and randomly assigned about 30,000 of them
access to Medicaid. Health experts say the experiment’s design — random
assignment of coverage through a lottery — allowed them to isolate and evaluate
the effects of the program. Such designs are the gold standard in medical
research, but are rarely used for domestic health care policy.
Some experts noted that the study measured only the first 18 months after people
gained coverage, and that old habits of relying on the emergency room are often
hard to shake. It also takes time to find a primary care doctor and make an
appointment.
“How to use a plan and when to seek emergency department care involves a
learning curve that doesn’t happen overnight,” said Sara Rosenbaum, a health
researcher at George Washington University who was not involved in the study.
Amitabh Chandra, a professor and director of health policy research at the
Harvard Kennedy School of Government, said people may often use the emergency
room because they need its services. Medicine has become increasingly complex,
with teams of specialists using highly sophisticated equipment for treatments
that often go beyond the capabilities of the family doctor.
“We often say, ‘If this person had just received preventative care at a doctor’s
office, we would not have seen emergency room use,' ” said Dr. Chandra, who was
not involved in the study. “But there is only so much that prevention can do.”
Professor Rosenbaum pointed out that a lot of the recent growth in emergency
department use has been among the privately insured people, not the uninsured.
She said insurers often recommend going to the emergency room for quick
specialty care, like for stomach pain.
Dr. Wright said that many participants in Oregon were already connected to a
primary care doctor, and that it was unlikely that the rise in use had much to
do with a lack of access to a physician. The study’s lesson, he said, was that
new coverage needed to be accompanied by broader changes to the way care was
delivered, like those in Oregon and under Mr. Obama’s new law.
Heidi Allen, an assistant professor at Columbia University and an author of the
study, said much of the non-urgent emergency department use among patients she
interviewed happened because those patients could not get same-day appointments
with their primary care doctors.
Dr. Chandra, who helped conduct another analysis of emergency department use in
Massachusetts after the overhaul, called the Oregon study, with its strong
design and clear result, “breathtaking.” In contrast, studies from Massachusetts
have come up with conflicting findings. His study, for example, found that
emergency room use did not change.
“You would conclude what you wanted to conclude depending on which side of
political aisle you were on,” he said, adding, “Now we have an answer.”
Emergency Visits Seen Increasing With
Health Law, NYT, 2.1.2014,
http://www.nytimes.com/2014/01/03/health/
access-to-health-care-may-increase-er-visits-study-suggests.html
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