Sunday, December 12, 2010

Health - Push for Stricter Abortion Limits Is Expected in House

Health - Push for Stricter Abortion Limits Is Expected in House

Push for Stricter Abortion Limits Is Expected in House

Posted: 11 Dec 2010 11:10 PM PST

WASHINGTON — A leading Congressional opponent of abortion rights, who is in line to take charge of an influential House panel, plans to press for much stricter limits on the procedure.

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Brendan Smialowski for The New York Times

Representative Joe Pitts, left, who will lead an influential House subcommittee, is a strong opponent of abortion rights.

The selection of the lawmaker, Representative Joe Pitts, Republican of Pennsylvania, as chairman of the Energy and Commerce Subcommittee on Health presages a major shift on abortion and family planning, according to opponents and supporters of abortion rights.

Opponents of abortion gained about 45 seats in the midterm elections, and they count the next speaker, Representative John A. Boehner, Republican of Ohio, as a staunch ally, virtually guaranteeing more conflicts with the White House on the issue.

Mr. Pitts was chosen last week as the chairman of the subcommittee, which has jurisdiction over private health insurance, Medicaid and much of Medicare, as well as the Food and Drug Administration and the National Institutes of Health.

In urging Republican leaders to choose Mr. Pitts, the National Right to Life Committee said he had “made the protection of the sanctity of innocent human life the cornerstone of his service in the House.”

Representative Lois Capps, a California Democrat and an advocate of abortion rights, described Mr. Pitts as “one of the most anti-choice members” of the House. Given the midterm election results, Ms. Capps predicted that the new Congress would be “extremely hostile to a woman’s right to choose.”

Laurie Rubiner, vice president of the Planned Parenthood Federation of America, said Mr. Pitts was “as anti-choice as a member of Congress can be.”

House Republicans will have difficulty enacting their agenda, since Mr. Obama and a substantial number of senators support abortion rights. But the Republicans may ultimately be able to tighten restrictions in some areas.

Like most Republicans in Congress, Mr. Pitts said he wanted to repeal the health care law, which was passed by Congress on party-line votes without Republican support.

Short of that goal, Mr. Pitts said he was determined to ban federal subsidy payments to any health insurance plans that include coverage of abortion — a benefit now offered by many private health plans.

Under the new law, the federal government is expected to spend more than $450 billion in subsidies to help low- and middle-income people buy insurance from 2014 to 2019.

When Congress was writing the law, Representative Bart Stupak, Democrat of Michigan, led efforts to restrict the use of federal money for insurance plans covering abortion. Mr. Pitts, though less well known, was the chief Republican co-author of the “Stupak amendment.”

From his powerful new perch, Mr. Pitts said he would try again to impose those restrictions.

“The new health care law is riddled with loopholes that allow taxpayer subsidies for coverage that includes abortion,” Mr. Pitts said.

He has introduced a bill that would, with extremely limited exceptions, ban the use of federal subsidies “to pay for any abortion, or to cover any part of the costs of any health plan that includes coverage of abortion.”

Mr. Boehner strongly supports the proposed restrictions. “There is no cause more noble than the defense of human life,” Mr. Boehner said, evoking the memory of Representative Henry J. Hyde, Republican of Illinois, whom he described as “one of my all-time heroes.”

In a speech to the Right to Life Committee in June, Mr. Boehner explained the roots of his beliefs.

“I grew up in a small house in Cincinnati with a big family, 11 brothers and sisters,” Mr. Boehner said. “My parents sent all 12 of us to Catholic schools.” At those schools, he said, “we learned about deeper values, and respect for life was at the top of that list.”

Mr. Pitts, the son of missionaries, is the head of a Congressional group of about 70 social conservatives known as the Values Action Team.

In his new role, Mr. Pitts will work closely with the new chairman of the Energy and Commerce Committee, Representative Fred Upton, Republican of Michigan. In recent years, Mr. Upton, a moderate conservative, supported expansion of the Children’s Health Insurance Program and voted to allow the use of federal money for some types of embryonic stem cell research.

Mr. Upton opposes abortion but has worked with the Michigan affiliate of Planned Parenthood on some issues. He voted against a Republican proposal to cut off federal money for Planned Parenthood last year, while Mr. Pitts voted for it.

Mr. Boehner and Mr. Pitts have received 100 percent ratings from the National Right to Life Committee, indicating agreement with the group’s positions on major votes. Both received ratings of zero on the Planned Parenthood scorecard. Mr. Upton received scores of 83 percent from the anti-abortion group and 14 percent from Planned Parenthood.

Under the new law, health insurance plans are generally allowed to cover abortion. If they cover the procedure, they cannot use federal money to pay for it. People who enroll in such plans have to write two premium checks, one for abortion coverage and one for everything else, and insurers must keep the money in separate accounts.

City Critic: Organ Donation: Let the Market Rule?

Posted: 11 Dec 2010 09:37 PM PST

A year and a half ago, Angelica Nieves was doing fine, working as a housekeeper in a hotel and living on her own in Brooklyn. When she started experiencing a shortness of breath, her doctor said it was asthma.

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EXPERIMENT In New York, an organ preservation team will be ready to harvest available organs.

Soon, she couldn’t keep food down. Turns out it was congestive heart failure, the disease that had killed her mother when Ms. Nieves was a young girl. At 29, she recalled, “I thought my life was over. I was actually making arrangements for my funeral with my family.”

After three months at NewYork-Presbyterian/Columbia hospital, Ms. Nieves was released, with a machine in her chest to keep her blood flowing and a spot on the list for a heart transplant.

In New York City, on Long Island and in the Hudson Valley, there are 7,800 people on similar lists, all hoping for the heart or liver or kidney that could save their lives. Last year, 682 people received organs. Some of the others went on to wait another year. Hundreds died.

To try to improve those numbers, New York City is starting a pilot programin which, for the next five months, an organ-recovery team will trail ambulances responding to 911 calls, ready to leap in if the patient dies and is a viable donor. It’s a bold experiment: no other American city has even tried it. Yet officials have already warned that the program, financed with a $1.5 million grant, might not yield a single kidney.

Organ transplantation sometimes seems to defy the laws of supply and demand: thousands of New York bodies need organs they don’t have, and thousands more have organs that, because of an untimely demise, they no longer need. But the path between those two groups crisscrosses people’s religious beliefs, their feelings about death and bodily integrity and their ability to make their wishes known to their next of kin.

For some, it’s a simple choice: when they die, they would like their organs to be used to save someone else’s life. But New York State doesn’t make it easy. People can sign up when they renew their drivers’ licenses, though that’s only once a decade, or they can go online and fill out an off-putting form, then print it out and walk it to a mailbox.

A mailbox?

The New York Organ Donor Network has decided it’s not even worth rolling out its new education campaign until the state makes it easier for people to sign up. People on the waiting list, meanwhile, keep dying.

Some other countries take a more proactive approach: they regard everyone as a potential donor. If you don’t want anyone shopping your kidney around when you die, you have to say so in advance. The burden, that is, falls on those who opt out of the system, rather than those who opt in.

Something like that would do a lot to save American lives.

And it would never happen here. Can you imagine how it would play on the evening news? The government cutting open defenseless people and stealing their tender parts.

Some economists have suggested adjusting the supply-and-demand problem through market incentives. Instead of asking people to donate their organs, why not just pay for them? The suggestion seems to outrage many people, who perhaps picture greedy zillionaires carving up poor working stiffs with a diamond-encrusted scalpel. But what if it worked like this: while you’re healthy, you volunteer your kidneys. Then when you die, and the kidneys are removed, your family would be compensated for your funeral expenses. That doesn’t seem quite so outrageous, does it?

Gary Becker, the Nobel laureate who teaches economics at the University of Chicago, has proposed something even more radical: paying people to part with their organs now, while they are still using them. You’ve got two kidneys but you can get by with one. You’ve got only one liver but you don’t really need that meaty chunk at the end. How does $30,000 sound?

In an interview, he said the idea should not be that shocking. As long as exchanges were carefully regulated, no one would be forced into it. It would solve an otherwise intractable problem. And unlike the current system, in which friends and relatives are often guilted into becoming donors, a market-based approach would compensate families fairly for their discomfort and risk.

Elaine Berg, president of the New York Organ Donor Network, cites a very different kind of incentive. When people arrange for their dying family members to become organ donors, she said, “it helps them through the grief process, and it’s the final thing they can do for their relatives.”

I’m a member of one of those donor families. When my Aunt Sandy died 12 years ago, her organs went on to save three people’s lives. I can’t say it lessened the experience of her loss one little bit, but it did extend the generosity she had always shown.

I’m also in a recipient family. My more-or-less cousin Matt has been on and off the waiting list for a new heart for years. He doesn’t condone paying for organs. “Just doesn’t pass the smell test,” he says. A few years ago, Matt got the phone call he had been waiting for, which (along with his supportive family, he made me promise to add) saved his life. At age 37, he got a new heart. Counting the one he was born with, it is his fourth.

As for Angelica Nieves, she is still waiting for that call. Machines like the one that’s keeping her alive tend to last about two years, of which 14 months have already passed.

“There’s days I wake up crying, ‘What if I don’t get a heart?’ I go to sleep crying,” she admitted. “But every day that goes by I thank God I made it another day.” What else can she do?

E-mail: citycritic@nytimes.com

Vital Signs: Childhood: Sick in Day Care May Mean Healthier in School

Posted: 10 Dec 2010 10:30 PM PST

Young children in day care get more ear and respiratory tract infections than other children their age, a new study reports. But once they reach elementary school, they are sick less often.

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The Quebec Longitudinal Study of Child Development followed 1,238 Canadian children from 5 months old, in 1998, to 8 years, in 2006. The researchers compared the infection rates of children in large and small day care centers with the illness rates of those cared for at home, differentiating between children who started day care at younger and older preschool ages.

Children who started going to large-group care centers before age 2 ½ had 61 percent more ear and respiratory infections with fever than those at home, but once they reached elementary school, they had 21 percent fewer respiratory infections and 43 percent fewer ear infections (with no difference in gastrointestinal infections).

The study was published this week in Archives of Pediatrics & Adolescent Medicine. The lead author, Dr. Sylvana Côté, a professor of social and preventive medicine at the University of Montreal, said the results should be comforting to parents who worry about the health of children in day care. These children may be at an advantage during the school years, she said, because “when they are learning to read and write, they don’t miss many days of school.”

Vital Signs: Risks: Hospital Admissions for Dog Bites Are on the Rise

Posted: 10 Dec 2010 10:30 PM PST

The number of Americans hospitalized for dog bites almost doubled over a 15-year-period, increasing to 9,500 in 2008 from 5,100 in 1993, a new government study reports.

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The increase vastly exceeded population growth, and pet ownership increased only slightly during the same period, said the report’s author, Anne Elixhauser, a senior research scientist with the Agency for Healthcare Research and Quality.

The report was an analysis of emergency visits and inpatient stays that drew on data from the Nationwide Emergency Department Sample for 2008 and from the Nationwide Inpatient Sample for 1993-2008.

“It’s really kind of frightening, and unfortunately, we’re at a loss to explain it,” Dr. Elixhauser said. “It’s a pretty hefty increase.”

About 866 people a day went to the emergency room with dog bites in 2008, and about 26 people were admitted each day.

Children under 5 and adults 65 and older were most likely to be hospitalized after a bite, and residents of rural areas made four times as many emergency room visits and had three times as many hospital admissions for dog bites than those from nonrural areas, the report said.

Almost half of the hospitalized patients needed treatment for skin and tissue infections, and more than half needed procedures like skin grafts or wound debridement. Treatment cost an average of $18,200 per person.

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Economic View: Following the Money, Doctors Ration Care

Posted: 11 Dec 2010 10:17 PM PST

UNEQUAL access to health care is hardly a new phenomenon in the United States, but the country is moving toward rationing on a scale that is unprecedented here. Wealthy people will always be able to buy most of what they want. But for everyone else, if we stay on the current course, the lines are likely to get longer and longer.

David G. Klein

The underlying problem is that doctors are reimbursed at different rates, depending on whether they see a patient with private insurance, Medicare or Medicaid. As demand increases relative to supply, many doctors are likely to turn away patients whose coverage would pay the lower rates.

Let’s see how this works. Medicare is the major federal health program for the elderly, who vote at high rates and are politically influential, and so it is relatively well financed. Medicaid, which serves poorer people, is paid for partly by state governments, and the poor have less political clout than the elderly, so it is less well financed. Depending on the state and on the malady, it is common for Medicaid to reimburse at only 40 percent to 80 percent the rate of Medicare. Private insurance pays more than either.

A result is that physicians often make Medicaid patients wait or refuse to see them altogether. Medicare patients are also beginning to face lines, as doctors increasingly prefer patients with private insurance.

Access to health care will become problematic, and not only because the population is aging and demand is rising. Unfortunately, the new health care legislation is likely to speed this process. Under the new law, tens of millions of additional Americans will receive coverage, through Medicaid or private insurance. The new recipients of private insurance will gain the most, but people previously covered through Medicaid will lose.

Ideally, higher demand for medical care would prompt increases in supply, which in turn would lower prices and expand access. But the health care sector does not always work this way.

Doctors are highly regulated and in that manner restricted in supply. The Association of American Medical Colleges estimates that the United States could face a shortage of 150,000 doctors in the next 15 years. To its credit, the new health care bill does improve incentives for general practitioners, but still, supply probably will not keep up with the crush of demand.

We could go further by giving greater scope to nurse practitioners, admitting more immigrant doctors, reforming malpractice law and allowing cheap, retail “Wal-Mart style” medical care, all to increase access and affordability. Yet these changes do not seem to be in the offing, so access is likely to decline.

The health care bill will further privilege private insurance coverage by offering many individuals new subsidies for its purchase. That will create incentives for employers to game the system, dropping or discouraging coverage and sending their workers to buy health insurance on the more expensive federally subsidized exchanges. That will strain the federal health care budget. This problem is outlined by Amy Monahan and Daniel Schwarcz, law professors at the University of Minnesota, in their new paper “Will Employers Undermine Health Care Reform by Dumping Sick Employees?”

There is also the danger that a few governors with tight budgets will shirk their Medicaid responsibilities, with an eye toward sending potential recipients to the federally subsidized insurance exchanges. In both cases, the quest for a better deal will strain the federal budget.

The American system of federalism, with its checks and balances and slow policy evolution, has many strengths, but it has also helped create this crazy quilt of health care reimbursement rates. The more demand-side pressure is placed on medical supply, the more Medicaid and Medicare reimbursements rates will determine who and what is rationed.

One option is to simply allow budget pressures to dominate, forcing down even private insurance reimbursements. Most people would end up with low, Medicaid-like reimbursement rates, and would endure long waits and low-quality service. But wealthier people could jump the line by paying more. Think of “Medicaid for everyone” but the rich.

An alternative is giving most people means-tested vouchers for a fixed amount of insurance coverage — which can run out or face up-front caps — making Medicaid and Medicare less of a blank check. The cost explosion would be checked by shifting more of the burden onto consumers. We would have better incentives for consumer-oriented care, and cost control, but we would be making an explicit public decision, at some point or another, to let some people do without medical care.

Recently the Arizona state government restricted transplant coverage for Medicaid patients, but it remains to be seen whether such measures can be applied to Medicare recipients. President Obama already has reversed some of the planned, budget-saving cuts to Medicare.

AN entirely different approach is suggested by the system in Singapore, where the government requires savings (say 10 percent to 12 percent of income), patients pay for medical care from those savings, and the government takes care of additional catastrophic expenses. That system has a good record for cost control and access, but would Americans accept so much required saving?

The default course is to maintain or extend Medicare reimbursement rates, raise taxes considerably and accept that Medicaid recipients will face worsening health care access. If you hear of a new solution to the health care puzzle, put aside the politics and instead think through the endgame. Ask not about the rhetoric, but rather about the reimbursement rates.

Tyler Cowen is a professor of economics at George Mason University.

Patient Money: Snoring: What to Do When a Punch in the Shoulder Fails

Posted: 10 Dec 2010 10:30 PM PST

DR. ELIZABETH WALTON, a 43-year-old internist in Atlanta and the mother of twin 4-year-old boys, has a common, if sometimes embarrassing, health problem. She snores — loudly. And she has tried to fix it with a variety of things, including a machine that blows air down her throat and an oral appliance that looks something like a mouthguard worn by a hockey player.

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Tami Chappell for The New York Times

Dr. Elizabeth Walton at her home in Atlanta with an oral appliance she uses for sleep apnea.

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The appliance works, and Dr. Walton is finally sleeping more easily. (So is her partner.) And because she was told she had obstructive sleep apnea, a more serious disorder than simple snoring, her treatments have been mostly covered by insurance.

Still, she estimates she has spent hundreds of dollars in deductibles, co-payments and fees.

Dr. Walton would have preferred not to go through so much expensive trial and error: “Unfortunately, it’s the nature of this condition.”

Almost half of the adult population snores at least occasionally. Snoring occurs when air flows past relaxed tissues in the throat, causing them to vibrate. Nasal congestion can also contribute to the racket.

“We laugh and joke about snoring,” said Dr. Nancy A. Collop, president elect of the American Academy of Sleep Medicine, “but it can be pretty annoying and disruptive to couples.”

What’s more, while ordinary snoring in itself does not present health problems, it may be a sign of a sleep apnea, as it was in Dr. Walton’s case. Patients suffering from sleep apnea have airways that are so obstructed they stop or nearly stop breathing during sleep.

The lack of oxygen wakens them, usually with a gasp, frequently during the night. “All people with sleep apnea snore,” said Dr. Collop, “but not all people who snore have sleep apnea.”

If you find you suffer from plain old snoring and not sleep apnea, do not expect insurance to cover your treatments. How far you decide to go will depend on a combination of what you and your spouse are comfortable with, what works for you and what you can afford.

Here are a few ways to determine which treatment is right for you or the loud sleeper in your family:

THE GIMMICKS Search for snoring remedies on the Web and you will find dozens of products, including special pillows, mouth and nose devices, special throat exercises and even advice on learning to play the didgeridoo, a wind instrument, to strengthen throat muscles and tissues. By and large, these products are marketed without much evidence of results.

“For the most part, you can save your money,” said Dr. Collop. Instead, she and other sleep experts recommend that most patients start with lifestyle changes that may reduce or eliminate snoring. All are free or low-cost.

Lose weight. Extra weight can restrict throat tissue and cause snoring, so losing weight is often advised for overweight snorers.

Sleep on your side. When you lie on your back, the base of your tongue and soft palate fall to the back wall of your throat, often causing snoring.

Avoid alcohol before bed. Alcohol or sedatives can relax throat muscles and make snoring worse. Avoiding alcohol three or four hours before going to sleep can help, said Dr. Collop.

Clear nasal passages. This is relevant only for people whose snoring starts in their noses. Take a hot shower before bed, or use a saline solution to help clear nasal passages. Check for allergens and dust mites in your bedroom, especially if you are congested only at night. Over-the-counter nasal strips that you put on the outside of your nose before bed may also help. They cost $10 to $12 for a pack of 30.

If none of this eases your snoring, you will need to see a doctor to be evaluated for sleep apnea. About 50 percent of people who snore loudly have the condition. Other symptoms include daytime sleepiness and extensive fatigue.

A SLEEP STUDY To find out if you have sleep apnea, you will most likely need to spend the night in a sleep clinic, where specialists will track your blood oxygen levels, breathing and other movements to see if you are waking frequently at night.

These tests are often covered by insurance if your doctor suspects sleep apnea. They can cost from $1,500 to $3,000, depending on where you live and how extensive your study is.

If you do not have insurance coverage or you cannot afford the co-pay, ask your doctor about performing some of the tests at home with special equipment. If you must go to a sleep lab without coverage, ask for a price similar to what an insurer would pay, not what you would be billed as a private patient.

Secret Cable Discusses Pfizer’s Actions in Nigeria Case

Posted: 10 Dec 2010 10:00 PM PST

Pfizer was accused of hiring investigators “to uncover corruption links” to Nigeria’s former attorney general and apply pressure to drop lawsuits against the company over a controversial 1996 test of antibiotics on children with meningitis, according to a secret State Department cable that related a company official’s account.

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Pius Utomi Ekpei/Agence France-Presse â€" Getty Images

Michael Aondoakaa, a former attorney general in Nigeria, settled a case with Pfizer.

Pfizer, the world’s largest drug company, denied the cable’s allegation, which was contained in documents released by WikiLeaks. The cable indicated that the information alleging corruption on the part of the attorney general was spread through the media to publicly pressure him to drop the lawsuits.

“Any notion that the company hired investigators in connection to the former attorney general is simply preposterous,” Christopher Loder, a spokesman at Pfizer’s New York headquarters, said on Friday.

The former attorney general, Michael K. Aondoakaa, told The Associated Press that he knew nothing of any Pfizer attempt to investigate him. “If they were doing it behind my back, it’s very unfortunate,” he was quoted as saying.

Last fall, Mr. Aondoakaa dismissed a $6 billion lawsuit and criminal charges as part of a settlement agreement with Pfizer, after allegations that the drug maker’s experiment with antibiotics resulted in the deaths of Nigerian children. Pfizer contested the cause of the children’s deaths, but ultimately settled with the country for $75 million in one case, according to a Pfizer filing in November. Mr. Loder said the money was to pay Nigeria’s lawyers in the case.

Last year, the Nigerian state of Kano, where the experiments occurred, also accepted a $75 million settlement to drop criminal charges and a civil suit seeking more than $2 billion. Mr. Aondoakaa was not involved in the Kano settlement.

In the cable, dated April 20, 2009, United States officials described an April 9 meeting in Lagos with Enrico Liggeri, Pfizer’s company manager in Nigeria.

“According to Liggeri,” the cable says, “Pfizer had hired investigators to uncover corruption links to federal attorney general Michael Aondoakaa to expose him and put pressure on him to drop the federal cases. He said Pfizer’s investigators were passing this information to local media.”

The cable continued: “A series of damaging articles detailing Aondoakaa’s ‘alleged’ corruption ties were published in February and March. Liggeri contended that Pfizer had much more damaging information on Aondoakaa and that Aondoakaa’s cronies were pressuring him to drop the suit for fear of further negative articles.”

In seeking comment, Pfizer would say only that Mr. Liggeri was still employed as a manager in Nigeria, but it would not say whether the company had talked with him since the cable became public. Mr. Aondoakaa was not charged with any offenses.

Another part of the cable covers discussions a week earlier with Mr. Liggeri and two Pfizer lawyers about the state settlement, which had been tentatively reached even as federal negotiations continued. That part of the cable appears to accurately reflect the details of the state settlement announced in July 2009. It included $35 million for the families, $30 million for state health care programs and $10 million in legal fees.

Pfizer was sued in Nigeria after reports that it had tested an experimental antibiotic called Trovan on 100 children during a 1996 meningitis epidemic. Another 100 children were given an approved antibiotic, ceftriaxone. Families later charged they had not been properly informed and that the standard antibiotic dose was too low. Some children died and others suffered brain damage, paralysis, deafness or blindness during the trial, first disclosed by The Washington Post.

Pfizer said its researchers acted ethically. The company said deaths and injuries were caused by the meningitis, an inflammation of membranes covering the brain and spinal cord.

Trovan was approved in Europe and the United States for adults in 1997 but banned in Europe and restricted in the United States in 1999 after reports of liver failure and deaths.

In the leaked cable, the embassy describes Mr. Liggeri and two Pfizer lawyers briefing the ambassador and an economics deputy about the state settlement. In a meeting, “EconDep,” who was not otherwise identified, met with Mr. Liggeri. In addition to referring to Mr. Aondoakaa, the cable says Mr. Liggeri complained the lawsuits were “wholly political in nature.”.

Mr. Liggeri, contacted by e-mail early Saturday morning in Nigeria, declined to comment on the cable and referred questions to a spokesman at Pfizer headquarters.

The cable was first published Friday by the British newspaper The Guardian and the Spanish newspaper El Pais.

Andrew W. Lehren contributed reporting.

Chicago News Cooperative: Staffs Worry About Shifts in County Health System

Posted: 11 Dec 2010 10:17 PM PST

As Tia Speat strode through the quiet halls of Oak Forest Hospital last week passing out fliers about the nurses union’s contract negotiations with Cook County officials, angry nurses accosted her with questions and complaints about proposed cuts in service and staff.

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Jose More/Chicago News Cooperative

A new plan would increase the patient load at John H. Stroger Jr. Hospital of Cook County.

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The Stroger emergency room could get even more crowded once two South Side hospitals reduce inpatient services.

As the county health system shifts strategy to deliver care with leaner resources, many who provide medical services say they are approaching a breaking point. An analysis by the nurses union predicted that the county health system’s 2011 budget would cut about 1,000 jobs, including 114 nurses and 19 doctors, to help close a $487 million countywide budget gap.

After the Cook County Board of Commissioners approved staff reductions and closed eight clinics in 2007, an independent board was appointed to oversee the health system. Toni Preckwinkle, the newly elected County Board president, said “the system was hacked with an ax” during that round of cuts, and she has been an outspoken supporter of the independent board, which recently submitted its budget to her.

The budget is based on a plan called Vision 2015, which the independent board adopted last summer. The plan is designed to shape budgets and operations over the next five years, shifting the focus of the health system to primary-care service from inpatient care. Because the new plan sets out an overall strategy, Ms. Preckwinkle has said, the pending staff reductions will be more in line with long-range goals and less painful.

Lucio Guerrero, a spokesman for the Cook County Health and Hospitals System, said: “We’re cutting superexpensive services that are underutilized and adding services that are needed in the communities. This isn’t just an exercise in the bottom line; this is a medical model that makes sense for the next five years.”

“I don’t blame people for not really trusting us,” Mr. Guerrero added. “Maybe in the past they didn’t have a reason to. With the independent board, it’s a different day.”

Under Vision 2015, emergency and inpatient services at Oak Forest Hospital will be eliminated, and at Provident Hospital in Bronzeville inpatient care will be greatly scaled back, meaning that many of the sickest patients from the South Side and south suburbs will have to travel to John H. Stroger Jr. Hospital of Cook County on the West Side. The cuts would be offset by increases in primary care and outpatient services at Oak Forest, Provident and Stroger and county clinics.

Many nurses are not convinced that the plan is workable. The layoffs will most likely be heaviest at Oak Forest, where nurses said staffing levels had been winnowed to bare-bones levels. They are already hard-pressed to give adequate attention to patients, the nurses said.

If county officials are going to close inpatient units, “they should just do it, instead of expecting us to work miracles in a horrible situation,” said Kathy McKinney, a registered nurse. “I’m just tired. I still love my career, but I dread coming to work at this place.”

The County Board’s finance committee will begin deliberations on the budget Tuesday.

The health system, like all county departments, was ordered to trim 21 percent from last year’s budget, even as federal aid was being reduced. Doctors and nurses say the budget squeeze could not come at a worse time, with rising unemployment producing an influx of newly uninsured patients.

On Dec. 22, the National Nurses Organizing Committee, which represents 1,300 registered nurses in the county health system, will tally the results of a mail-in vote that would authorize union leaders to call a strike to protest the staffing cuts and other concerns. Administrators at Stroger Hospital, the largest institution in the health system, have prepared a contingency plan that would include early release or transfer of patients to other hospitals, cancellation of elective surgery, mandatory 12-hour shifts and other measures.

The Service Employees International Union’s Doctors Council, which represents 500 county doctors, is also in the midst of contract negotiations. In a recent report, it described the county system as “cut to the bone.”

Kari.lydersen@gmail.com

Full Wallets, but Using Health Program for Poor

Posted: 11 Dec 2010 09:37 PM PST

AFTER immigrating to New York City from China in the 1970s, Z. Y. Tung and his wife worked hard — he as a bank manager, she as a public school secretary — lived frugally and saved every penny they could for the next generation.

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Barbara Fernandez for The New York Times

FEARS LAWSUIT A Florida man resorted to “spousal refusal” so that his ailing wife's care would be paid for.

Until five years ago, when his wife, Wen Mei Hu, racked by bone-marrow cancer, had to be put in a nursing home, where the bills ran past $100,000 a year, threatening to quickly drain the couple’s life savings of $500,000. The nursing home told him not to worry: If he signed a document essentially refusing to support his wife of several decades, Medicaid, the federal insurance program for the indigent, would pick up the bill.

“What about me, because I am responsible?” Mr. Tung inquired. He was told that only millionaires had to pay such high costs, and reluctantly, seeing no other choice, he agreed.

Last year, more than 1,200 people in New York City officially turned their backs on their husbands and wives to qualify for Medicaid, triple the number of people five years ago. The practice, known as “spousal refusal,” is becoming more common as the population ages and the cost of nursing care rises — and it is coming under increasing attack by government officials looking to curb ballooning Medicaid expenses.

In a recent report, Lt. Gov. Richard Ravitch warned that spousal refusal could be abused as “an entitlement for the less needy” and urged state officials to rethink it, noting that long-term care accounts for nearly half the state’s Medicaid spending.

Lawyers for the elderly argue the tactic of spousal refusal is legal nationwide, and it is most commonly used in New York and Florida, where 136 people refused to support a sick spouse last year.

Without the option of spousal refusal, lawyers say, American health care is like a ghoulish lottery. Those who need doctors’ care for illnesses like cancer or heart disease are covered by Medicare, the insurance program for the elderly, while those who need more custodial care for Alzheimer’s or stroke must pay for it themselves or dispose of their assets to qualify for Medicaid.

The federal government allows a healthy spouse to keep a house, a car, up to about $2,700 a month in income and up to about $110,000 in other resources. Anything above that must be spent on nursing care before Medicaid kicks in.

Nursing home care cost an average of $123,000 a year in New York City and $135,000 a year on Long Island in 2008, according to the latest available state data, or twice as much as the tuition of the most prestigious colleges and more than the income of all but the top 20 percent of American households.

Howard Krooks, a lawyer who practices in Boca Raton, Fla., and Rye Brook, N.Y., said spousal refusal was becoming more popular with bad economic times. “There’s no question it’s playing a pivotal role in people’s ability to finance long-term care,” he said. “They need help.”

The way it works: the healthy spouse refuses to share the marital assets, and the sick spouse assigns his or her “right of support” to the state. The state will then pick up the cost of nursing home care, or in New York, home health care, as well. But there is a catch: the state, through the local governments that help administer Medicaid, can sue the healthy spouse to recover the cost of the care.

That’s what happened to Mr. Tung.

In April, he received a letter from the city asking him to disclose his resources so that he might “contribute” to the care of his wife. Mr. Tung, who is now 79 and lives in Midwood, Brooklyn, readily submitted all of his financial information, he said, because he thought that the amount of the contribution would be voluntary and he was more than willing to pay, say, $10,000 a year or so.

“I am an honest person,” he said. “I am willing to pay something for my wife.”

His monthly income, $2,817, was low enough. But his assets, mostly mutual funds and stocks carefully socked away over the years, came to $550,000 — $440,000 over the limit. The city asked that he pay $270,000, the bill for five years of home care. (His wife left the nursing home after a short time.) His lawyer, Pauline Yeung-Ha, negotiated a settlement of $150,000, which Mr. Tung has paid.

If he had known this would happen, he said, he would have lived a less abstemious life. “If I know before, long ago, I spend all the money,” he said. “It’s very easy, very easy. Just buy a common house. It’s comic, you know.”

Lawyers generally advise that even with the potential of being sued, spousal refusal makes sense because Medicaid pays less for nursing home care than private clients do.

One of Mr. Krooks’s clients, an 86-year-old semiretired accountant who lives in Miami Beach, put his wife, who has Alzheimer’s, in a nursing home after she became aggressive.

He had a long-term care insurance policy, but it did not cover his expenses, so he resorted to spousal refusal.

Without it, “I would be bankrupt pretty soon,” he said, speaking on the condition of anonymity for fear of facing a lawsuit to recover the money.

While many state and local governments do not openly acknowledge the spousal refusal option, New York City actually provides a form letter for it.

Use of Cholera Vaccine in Haiti Is Now Viewed as Viable

Posted: 10 Dec 2010 10:40 PM PST

The World Health Organization is shifting its position in favor of vaccinating against cholera, acknowledging a growing clamor for ways to slow Haiti’s outbreak.

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Damon Winter/The New York Times

Health workers are delivering bodies of cholera victims to a mass grave because the central morgue no longer accepts them.

So far, the cholera vaccine has seen little use in Haiti, where the disease has killed more than 2,000 people and is still spreading. However, major obstacles remain, including supply shortages, transportation problems and the need to administer the vaccine several times for it to be effective.

But the Pan American Health Organization, which represents the W.H.O. in the Western Hemisphere, recently learned that there might be one million to two million doses of vaccine in the world, not just the 200,000 it originally thought, Dr. Jon K. Andrus, the Pan American organization’s deputy director, said Friday. “We recognize that it’s time to rethink our position,” he said. “We don’t want to miss an opportunity.”

His organization will hold a meeting of experts in Washington next Friday to consider whether to buy those doses and move them to Haiti.

Even if the group agrees to move forward, there would be no quick fix. Most of the doses are in bulk form, and it could take up to two months to have them ready, Dr. Andrus said. Also, the vaccines have not been tested by the W.H.O.

Also on Friday, Dr. Paul Farmer, who is well known for fighting AIDS in Haiti, endorsed broader use of the vaccine there, and called for creating emergency stockpiles of millions of doses to keep cholera from spreading to other countries.

He endorsed measures like searching Haiti’s central mountains for people too sick to reach clinics, using antibiotics even in moderate cases and rebuilding the water and sanitation networks shattered by January’s earthquake.

Other cholera experts, including a different team from Harvard Medical School, where Dr. Farmer teaches, have also called for stockpiling millions of doses to stop outbreaks, as is now done with measles vaccine and the flu drug Tamiflu.

There are only two brands of cholera vaccine in the world: Dukoral, made in Sweden, which is W.H.O.-approved and costs $40 per dose, and Shanchol, introduced last year by India’s Shantha Biotechnics at $6 a dose.

Though not approved by the World Health Organization, Shanchol was created at the International Vaccine Institute in Seoul, South Korea, under a grant from the Bill & Melinda Gates Foundation and designed to meet W.H.O. standards.

Cholera is widespread in India, Nepal, Bangladesh and Pakistan, and is estimated to kill more than 100,000 people a year in that region. Genetic testing has shown that Haiti’s outbreak is a strain from that area.

Until recently, cholera vaccines were little used. Older injectable ones protected less than half of those who were given them, and protection waned after a few months. The new vaccines are oral, making them easier to give, but they require two doses at least a week apart in adults and three in children and start providing protection a week later.

A spokeswoman for Doctors Without Borders, which is fighting cholera in Haiti, said it had no position on vaccines yet because they were not available and needed too much time to work.

Creating a global stockpile against future outbreaks is “a separate issue” from the Haiti response, where doctors are going full out just to get dying people rehydrated, Dr. Andrus said.

Building one would be very expensive, but he noted that donor nations like the United States and Canada, foundations, and philanthropic groups have raised billions of dollars for vaccines against polio and other disease. They might help build a cholera stockpile now that better vaccines are being made, he said.

Long Road for Lawyer Defending the Health Care Law

Posted: 09 Dec 2010 11:10 PM PST

WASHINGTON — Memo to the third floor at Justice Department headquarters: Ian Gershengorn will soon be pacing the corridors again.

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Drew Angerer/The New York Times

Ian Gershengorn, a lawyer charged with defending the administration’s health care overhaul, in his office at the Justice Department in Washington.

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Drew Angerer/The New York Times

Representing the United States “puts the fear of God in you a little bit,” Ian Gershengorn says.

When preparing for oral arguments in big cases, Mr. Gershengorn makes a habit of walking long laps around the building’s rectangular core, first past the civil and antitrust divisions, then the Office of Professional Responsibility and the appellate branches, mumbling to himself while hunched over note cards. People try not to stare.

There has been a lot of pacing lately. Since March, it has fallen to Mr. Gershengorn, 43, a deputy assistant attorney general, to defend the Obama administration against nearly two dozen legal challenges to the president’s health care overhaul. For the moment, the burden of defending the constitutionality of President Obama’s signature legislative achievement falls squarely on Mr. Gershengorn and his team of more than a dozen litigators.

The health care cases have turned Mr. Gershengorn into something of a courthouse circuit-rider, traveling week after week to Virginia and then Florida and on to Michigan to repeat the same arguments.

He faces perhaps his biggest test on Thursday when he returns to Pensacola, Fla., with the uphill task of turning around a federal district judge, Roger Vinson, whose preliminary rulings have been forthrightly antagonistic. The lawsuit was filed by governors and attorneys general from 20 states, all but one of them Republican.

The redundancy of the hearings has done little to ease Mr. Gershengorn’s anxiety each time he prepares to represent the United States in a landmark case that will most likely be decided by the Supreme Court.

“It puts the fear of God in you a little bit,” he said in an interview in his office. “I start to get the feeling in the pit of my stomach. I start to pace around the building a little more, and become more irritable.” Paraphrasing Samuel Johnson, he added: “Nothing focuses the mind quite like an execution.”

For the time being, Mr. Gershengorn and his colleagues hold an unblemished record. In the only two cases where judges have ruled on the merits — in Detroit and in Lynchburg, Va. — the federal government has prevailed.

But a ruling is expected any day in Richmond, Va., where Judge Henry E. Hudson, like Judge Vinson, has expressed skepticism about the law’s central provision, which requires most Americans to obtain insurance starting in 2014.

Mr. Gershengorn said he would not be surprised if district judges left the appellate courts to sort through a scramble of contradictory opinions.

“You try not to get too caught up in the ebb and flow of individual decisions,” he said. “I think we are right on the law and that ultimately we are going to prevail.”

As director of the Justice Department’s Federal Programs Branch, Mr. Gershengorn oversees one of the most captivating dockets in American jurisprudence. It is his office’s job to represent the government against constitutional challenges, and its caseload includes the “don’t ask, don’t tell” policy on gay and bisexual members of the military, the rights of suspected terrorists held at Guantánamo Bay, Cuba, and rules governing embryonic stem cell research.

“Every day,” Mr. Gershengorn said, “I deal with two or three cases of a lifetime.”

The Justice Department’s top leadership handpicked Mr. Gershengorn to handle the health care cases in the lower courts, said Thomas J. Perrelli, an associate attorney general. Mr. Gershengorn has reviewed and approved the written briefs in every case, and has personally argued the administration’s position in three courtrooms.

Shortly after Mr. Obama took office, Mr. Perrelli recruited Mr. Gershengorn to the Justice Department from the national litigation firm of Jenner & Block, where each worked in the Washington office. He took a substantial pay cut and now earns above $170,000 a year.

Mr. Gershengorn grew up outside Boston, where his father is a cardiologist and his mother a state court judge. Two sisters have also worked as Justice Department lawyers, as did Mr. Gershengorn’s wife. The couple have three sons.

Mr. Gershengorn graduated from Harvard and Harvard Law, and clerked for both Judge Amalya L. Kearse on the Court of Appeals for the Second Circuit, in Manhattan, and Justice John Paul Stevens on the Supreme Court. He then served as counsel to Deputy Attorney General Jamie Gorelick in the Clinton administration.

Ms. Gorelick said she found Mr. Gershengorn to be honest, simultaneously soft-spoken and determined, and possessed of intelligence and humility beyond his years. “He was a real star,” she said, “and it does not surprise me that he was picked for one of the toughest jobs for a lawyer in the Obama administration.”

Mr. Perrelli said Mr. Gershengorn excelled at Jenner & Block, where he specialized in both telecommunications law and Indian sovereignty disputes, mastering complex issues involving novel legal theories. That, Mr. Perrelli said, made him an ideal fit for the health care cases.

The attacks on the law have been various, but the central argument is that Congress exceeded its authority under the Commerce Clause of the Constitution by passing a bill that will penalize Americans for not obtaining health insurance.

To do so, the plaintiffs argue, is to regulate inactivity, and if allowed would remove any reasonable limits on federal power.

House Passes Bill Averting Cut in Medicare Reimbursements

Posted: 10 Dec 2010 07:22 AM PST

WASHINGTON — The House gave final approval on Thursday to a bill that would avert a 25 percent cut in Medicare payments to doctors by freezing reimbursement rates at current levels until the end of next year.

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House Vote: Medicare Reimbursements

The bill goes now to President Obama, who hailed the action by Congress and promised to sign the legislation.

The House vote was 409 to 2. The Senate approved the measure by unanimous consent on Wednesday.

AARP, the lobby for older Americans, had pushed for the legislation, saying it was needed to ensure that Medicare beneficiaries could continue seeing the doctors who care for them.

Many doctors had said they would limit the number of their Medicare patients if payments were cut on Jan. 1 under a statutory formula established by Congress.

Doctors had sought a small increase in Medicare payments, to reflect their rising costs. Still, the American Medical Association thanked Congress for approving the legislation with a one-year delay in the reimbursement cut.

Dr. Cecil B. Wilson, president of the association, said doctors had “spent this year in limbo” because of uncertainty about Medicare payments.

The Congressional Budget Office said that because of the reimbursement freeze, Medicare will spend $15 billion more than it would have if the cuts had occurred.

The cost will be offset by changing a provision of the new health care law that offers subsidies to lower-income people to help them buy health insurance, starting in 2014. The bill allows the government to recoup more of any overpayments that people might receive if they misstate their income or earn more than they expect in a given year.

Under the law, the repayment is limited to $250 a year for an individual and $400 for a family. Under the bill, the limits would be linked to a person’s income and could be as high as $1,750 for an individual and $3,500 for a family.

The bill also allows children’s hospitals to regain access to significant discounts on costly drugs prescribed for the treatment of rare diseases and disorders. Under the new health care law, children’s hospitals lost access to the discounts they had on such products, known as orphan drugs.

Representative Henry A. Waxman, Democrat of California and chairman of the Energy and Commerce Committee, blamed an error in the health care law for the loss of access.

Ted Slafsky, the executive director of Safety Net Hospitals for Pharmaceutical Access, a nonprofit group, welcomed the action by Congress. And he urged lawmakers to allow rural hospitals and free-standing cancer hospitals to obtain the same discounts.

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World Briefing | Africa: Congo Republic: Polio Outbreak

Posted: 10 Dec 2010 11:00 PM PST

A rare and unusually fatal outbreak of polio has caused more than 200 deaths in the Congo Republic, a Unicef spokesman said Friday. The disease usually strikes children under 5, but most of those affected have been young men between the ages of 15 and 24, said Martin Dawes, the agency’s West Africa spokesman. He said 42 percent of the cases had been fatal. The vast majority have occurred in the coastal city of Pointe-Noire. The World Health Organization, Unicef and Rotary International said they began a vaccination campaign in the region last month. International aid groups have begun emergency immunizations in Pointe-Noire and will continue them through the end of the year.

U.S. Report Details Harm of Even Light Smoking

Posted: 09 Dec 2010 11:20 PM PST

WASHINGTON (Reuters) — Cigarette smoke causes immediate damage to a person’s lungs and DNA even in small amounts, including from secondhand smoke, federal officials said Thursday in a new report.

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Surgeon General Regina Benjamin urged taxes, bans and treatment to reduce smoking.

Taxes, bans and treatment must all be pursued to bring smoking rates down, said the surgeon general, Dr. Regina M. Benjamin. “The chemicals in tobacco smoke reach your lungs quickly every time you inhale, causing damage immediately,” she said in a statement.

“Inhaling even the smallest amount of tobacco smoke can also damage your DNA, which can lead to cancer,” Dr. Benjamin said.

The report said that tobacco companies deliberately designed cigarettes and other tobacco products to be addictive and that they released new products portrayed as safer that were in fact just as dangerous and addictive.

A third of people who ever try cigarettes become daily smokers, Dr. Benjamin said.

The report notes that studies have shown that cigarettes kill 443,000 people every year in the United States — one in every five people who die — from cancer, heart disease, lung disease and other causes.

The Centers for Disease Control and Prevention says efforts to reduce smoking have stalled in recent years. Between 1998 and 2008, the number of smokers fell by 3.5 percent, to 20.6 percent from 24.1 percent.

Health and Human Services Secretary Kathleen Sebelius said cigarette use resulted in more than $193 billion annually in health care costs and loss of productivity.

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After Aetna, Pondering Health Care

Posted: 09 Dec 2010 09:30 PM PST

When tensions between the Obama administration and the nation’s health insurers were at their highest earlier this year, Ronald A. Williams, the chief executive of Aetna, stood out as one of the few industry voices that still resonated within the White House.

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Fred R. Conrad/The New York Times

As he stepped down as Aetna’s chief executive in late November, Ronald A. Williams seemed fairly disillusioned about what was accomplished by the new law.

He stayed above the fray even as other executives were drawn into noisy disputes with lawmakers over the health care law.

A soft-spoken executive whose pragmatism and focus on detail are credited with helping turn Aetna around, Mr. Williams advocated for the insurance industry when it was under fierce political attack.

Democratic leaders, including President Obama, cast insurers as villains, sharply criticizing them for raising rates at the expense of their customers and abandoning people when they became ill by canceling their coverage.

As he stepped down as Aetna’s chief executive in late November, Mr. Williams, 61, seemed fairly disillusioned about what was accomplished by the new law.

He said he felt he had no choice but to persevere throughout the legislative battle, despite what he described as “the exceedingly poor tone shown by leadership in demonizing a whole industry.”

“Ultimately,” he said, “I believe it was important to be at the table.” But Mr. Williams also reflects the insurers’ deep ambivalence about the final legislation. While he says he does not support repealing the law, he has only faint praise for what it may do. When asked to describe its greatest achievement, he cites “heightened awareness.”

He and other major insurers did succeed in helping to ward off creation of a government-run health plan. Still, Mr. Williams and other executives worry about the law’s effect over the coming years.

Len Nichols, a health economist and policy analyst at George Mason University, said: “You have truly conflicted insurers. On the one hand, insurers could be looking to 30 to 50 million new customers. On the other hand, they are looking at having to change their business model.”

And insurers have clearly not given up hope that they will be able to influence the final shape of the rules, including refinements in the final regulations just released by the government that dictate how insurers have to spend their premium dollars. “There are many opportunities to change the law,” Mr. Williams said. “It’s not etched in stone.”

Insurers are already looking ahead to some provisions, like exactly what benefits they must include in the new plans to be offered in the state-run exchanges and exactly how much more they can charge older and sicker individuals under the rules requiring them to cover everyone. Mr. Williams, for one, is also sharply critical of the $60 billion in new taxes levied on the insurers, which he claims will result in higher premiums at a time when the industry is under attack for not offering less expensive policies. “You can’t make the product more affordable by putting taxes on it,” he said.

He is also dismissive of the administration’s attempts at flexibility by granting one-year waivers to certain plans or exemptions for certain states. “It creates a supplicant environment in society,” he said. He argues it would be better to slow the overall adoption of the new law.

Despite saying he was unprepared for the ruthlessness of the political process, Mr. Williams emerged as one of the most prominent industry representatives. He had dozens of meetings on Capitol Hill, frequently testifying before Congress, and also meeting with the president or his staff.

“Ron was the industry’s emissary to the White House,” said Wendell Potter, a former insurance executive who has become a vocal critic of the industry. While some of his colleagues were viewed as pushing too hard for their own narrow interests, the administration “found him to be the most reasonable,” he said.

Mr. Williams rarely speaks of his childhood, or any topic of a personal nature. He grew up in a poor neighborhood in Chicago and is one of the few African-Americans to run a large corporation.

Growing up, he says he watched his friends and neighbors struggle to get medical care. When his mother was told she had breast cancer in 1972, Mr. Williams said he witnessed how hard it was for someone, even with insurance, to try to find appropriate treatment. He is unsure whether she got the best care she could have.

Benefits of Estrogen Are Debated

Posted: 09 Dec 2010 11:10 PM PST

Certain women who take estrogen to relieve menopausal symptoms may be protected from breast cancer, according to data released Thursday at the San Antonio Breast Cancer Symposium.

The finding, an analysis of data from a study known as the Women’s Health Initiative, drew criticism. Other studies have shown that hormone combinations that include estrogen and progestin increase breast cancer risk.

The new analysis involved women who had had hysterectomies and as a result took only estrogen. The study, by Dr. Joseph Ragaz, an oncologist and clinical professor at the University of British Columbia, showed a statistically significant lower risk of breast cancer among estrogen users who did not have a family history of breast cancer.

The finding applies only to women who have had hysterectomies; a woman with a uterus who seeks menopause treatment must use estrogen plus progestin to prevent uterine cancer.

Dr. Ragaz said he wanted to call attention to the health initiative data to reassure women and to encourage more study of the role estrogen alone may play.

“Estrogen alone for women who suffer menopause symptoms is actually safe and may be highly protective,” he said.

The report met with skepticism from other experts. Four years ago, the health initiative reported that women who used estrogen alone did not face higher breast cancer risk and might have a lower risk, said Dr. Rowan Chlebowski, a professor of medicine at the University of California, Los Angeles. “There is nothing new here,” he said.

Mixed Result for Bone Drug in Cancer Study

Posted: 09 Dec 2010 11:10 PM PST

The results of a new study are tempering hopes that a drug used to treat bone loss might also help stave off relapses of breast cancer, especially for younger women, researchers said Thursday.

The clinical trial found that women with early breast cancer who were treated with the bone drug zoledronic acid did not have fewer recurrences of their cancer than women who did not receive the drug. The results surprised and disappointed some experts because they conflicted with the findings of a previous, widely publicized trial.

“Most people in the breast cancer community were very hopeful that this would be a positive study,” Dr. Sharon Giordano of the M. D. Anderson Cancer Center in Houston said in an interview. She was not involved in the study but is to deliver a commentary about it on Friday at the San Antonio Breast Cancer Symposium, where the results will be presented.

Still, Dr. Giordano and others said the latest results would not be the final word because additional studies were under way. Moreover, the new study suggested that the bone drug could help stave off recurrences for women well past menopause.

Zoledronic acid, sold by Novartis under the name Zometa, is one of a class of bone drugs known as bisphosphonates. It is approved to prevent fractures and other skeletal problems that can occur when breast cancer or other tumors spread to the bone.

A study published in The New England Journal of Medicine in February 2009 suggested that zoledronic acid would be useful in treating the cancer itself. In that trial, the bone drug reduced the risk of breast cancer recurrence or spread by about a third.

A leading theory for that effect was that the breakdown of bone provided substances that stimulate tumor growth. Drugs that slow that breakdown deprive tumors of those substances.

But the new study contradicts those findings. This study involved 3,360 patients, mainly in Britain, who had their breast tumors removed by surgery and underwent whatever chemotherapy or other treatment their physicians chose to prevent recurrence. Half the patients also received intravenous infusions of zoledronic acid for five years.

After nearly five years, the number of women who had had a recurrence or had died without a recurrence was about the same — 403 in the control group and 404 in the group receiving zoledronic acid. Those receiving the bone drug had a somewhat lower risk of dying, but the difference was not statistically significant.

However, the bone drug did seem to help women in the study who were at least five years past menopause, who accounted for about 30 percent of the participants. Among these women, there were 116 recurrences for those who got zoledronic acid compared with 147 in the control group, a risk reduction of 27 percent. Their risk of death was reduced 29 percent, with 86 deaths among those who got the drug compared with 120 deaths in the control group.

Dr. Robert E. Coleman of the University of Sheffield in England, the lead investigator of the study, said this suggested that zoledronic acid could help prevent relapse or spread only in the absence of estrogen or some other substance no longer produced by postmenopausal women.

In the study from nearly two years ago, the 1,800 participants were all premenopausal but were given a drug that shut down their ovaries, preventing them from making estrogen.

Dr. Michael Gnant of the Medical University of Vienna, who was the lead investigator of the earlier study, said at a news conference at the San Antonio symposium that the new results strengthened his belief in zoledronic acid.

But Dr. Giordano said that conclusions based on a subset of patients must be regarded with caution and that they should not change medical practice. She and others said there were other differences between the trials that might explain the divergent outcomes.

One thing experts agreed on was that zoledronic acid should now not be given to younger women with functioning ovaries unless the cancer had spread to their bones. That is true not only because the new trial showed no cancer benefit for these women but also because the drug can destroy jawbones in some patients.

The new study was sponsored by the University of Sheffield. Dr. Coleman and Dr. Gnant are paid consultants for Novartis, which contributed some money.

Just last week, a study published in The Lancet showed that zoledronic acid reduced the risk of disease progression and improved survival in patients with multiple myeloma, a cancer of the bone marrow.

Life Expectancy Drops Slightly, Bucking Established Trend

Posted: 10 Dec 2010 08:39 AM PST

Life expectancy in the United States has dropped slightly — by about a month — after inching up in most years, the government reported Thursday.

The preliminary report indicates that a baby born in 2008 can expect to live 77.8 years if current trends continue. That is down a bit from a high of 77.9 years for 2007. A similar dip occurred in 2005, and life expectancy also dropped in 1993.

The lead author of the report, Arialdi Miniño, called the change minuscule and said it would take years of data to determine if it was a trend.

Life expectancy was down for both men and women. The gap between blacks and whites closed a little, to a 4.6-year difference in life expectancy; it topped 70 years for black men for the first time. Over all, women continue to live longer, until about 80, compared with 75 for men.

The cause of the slip in overall life expectancy is not known.

“It’s something to keep our eyes on,” said Kenneth E. Thorpe, a health policy professor at Emory University in Atlanta. He suggested that it could be related to rising obesity rates.

The report was released Thursday by the National Center for Health Statistics, which is part of the Centers for Disease Control and Prevention in Atlanta. It is based on nearly all the death certificates for 2008; a final report will be issued later.

Life expectancy figures for Hispanics have not been included in the annual reports because of unreliable data. In October, the C.D.C. released its first calculation for Hispanics, which showed that those born in 2006 could expect to outlive whites by more than two years and blacks by more than seven.

Stroke fell from the No. 3 leading cause of death for the first time in five decades. It was surpassed by chronic lower respiratory diseases, which include asthma, emphysema and chronic bronchitis. The swap in position may be due in part to changes in the definition of the respiratory disease category, which increased 8 percent. Heart disease and cancer continue to be the two top killers, accounting for about half of all deaths.

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Clinic Serving Performers in Pornography Is Closed

Posted: 09 Dec 2010 11:20 PM PST

LOS ANGELES — State health officials ordered a clinic that serves the pornography industry to close Thursday and denied its application for an operating license.

The Adult Industry Medical Healthcare Foundation clinic has tested and treated adult performers for sexually transmitted diseases without a license for over a decade, say officials. Health officials told its operators in May that they must apply for a license or shut down.

Jonathan Fielding, director of the Los Angeles County Department of Public Health, said the clinic’s operators had submitted an incomplete application and had failed to provide the necessary information after it was requested several times.

Officials delivered the cease-and-desist order to the clinic, based in Sherman Oaks, a day after a pornographic film performer, Derrick Burts, said he had waited over a month for the clinic to refer him to a physician and release his medical records after he tested positive for the virus that causes AIDS on Oct. 8.

“I waited to get linked with medical care, but they would hang up on me when I called,” Mr. Burts said Thursday. After positive tests for chlamydia and gonorrhea, he said, the clinicians “gave me pills and a shot.”

Calls and an e-mail to a clinic operator were not answered Thursday. Steven Hirsch, founder of Vivid Entertainment, a pornography production company that provides financial support to the clinic, said its closing would be temporary.

“The clinic serves as a resource for adult performers,” Mr. Hirsch said. “We believe they’ve done an admirable job since the day they opened.”

In the case of Mr. Burts’s positive test for H.I.V., Mr. Hirsch said: “They immediately contacted us and told us the situation. Other performers were quarantined, tested and retested.”

Ged Kenslea, a spokesman for AIDS Healthcare Foundation, said the manner in which the clinic reported performers’ test results to their employers — often via a database accessible to producers and talent agents with a password — violated privacy laws. Health officials said that privacy violations did not factor into their denial of a license.

Well: Pass the Pasta!

Posted: 10 Dec 2010 10:49 AM PST

Well: Searching for a Snoring Solution

Posted: 10 Dec 2010 08:14 AM PST

Well: Medical Illustrations as Art

Posted: 10 Dec 2010 11:24 AM PST

Prescriptions: Pfizer Recalls Blood Pressure Drug Overseas

Posted: 10 Dec 2010 04:49 PM PST

Prescriptions: Sequencing Machine Helped Trace Cholera in Haiti

Posted: 10 Dec 2010 09:05 AM PST

Urban Athlete: Step Hits Its Stride Again

Posted: 09 Dec 2010 10:30 PM PST

FOR many, the very mention of step aerobics evokes images of exercisers in leg warmers and leotards, even though other classes have come to dominate group schedules at gyms today. In New York City, however, this seemingly faded fad from the 1990s is far from dead.

Where to Take a Class

Y.M.C.A. (800) 872-9622, ymca.net.

NEW YORK HEALTH & RACQUET CLUB (888) 777-9740, nyhrc.com.

EQUINOX (212) 774-6363, equinox.com.

REEBOK SPORTS CLUB/NY (212) 362-6800, thesportsclubla.com.

Step, developed in the late 1980s, is a cardiovascular workout done on an adjustable platform. By raising or lowering the platform, exercisers can adjust the intensity and the impact of the workout.

Although the number of participants in the United States and Canada declined 1 percent from 2000 to 2009, step programs remain the most commonly offered type of aerobics, based on a 2008 survey of more than 3,000 clubs by the International Health, Racquet and Sportsclub Association, an industry trade group. Nearly 10.8 million people participated in step in 2009, the association said.

The Y.M.C.A. has 25 weekly step sessions at 10 New York City locations and has increased the number of classes at some sites, like the one in Brooklyn Heights. Anne Fosteris, the Healthy Lifestyles director there, said she recently added two more classes to one already offered. “There was no demand for step, and all of sudden, people were asking for it again,” she said.

Many beginners are just learning moves like the V step, which requires you to step up and down in a V shape, or a step with a hamstring curl. But others like Camille Trani, a retiree in Carroll Gardens, Brooklyn, have been taking the classes for years. Ms. Trani, 64, is a regular at Y classes and has been a fan of step for more than a decade.

“For me it’s a great workout, and I feel like I’ve had so much fun doing it,” she said. “I’m in my 60s, but doing step makes me feel like I’m in my 20s.”

The New York Health & Racquet Club also considers step a staple in its portfolio. It recently started a new class called Snow Bunnies, which joins traditional moves with more athletic ones like squats, lunges and plyometric, or rapidly repeated, jumps off the step.

Even some gyms known for offering the latest in fitness haven’t shied away from step. The Reebok Sports Club/NY on the Upper West Side has two classes a week, and various Equinox locations have three classes, including a new one called Climb-Max. That program features a combination of cardio and strength moves off the step, some done with slanted risers.

Rachael Stein, 28, a catalog producer from Manhattan who takes the Climb-Max classes, is an accidental convert. She said she decided to try step because she liked taking other classes with the teacher.

“It makes me not want to dread cardio,” she said. “The gym only offers it once a week, but I like it so much that if they had more classes, I would definitely be in them.”

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