Sunday, June 26, 2011

Health - In Medicine, New Isn’t Always Improved

Health - In Medicine, New Isn’t Always Improved

In Medicine, New Isn’t Always Improved

Posted: 26 Jun 2011 02:03 AM PDT

IT is an American impulse to covet the new and improved — whether it’s a faster computer, a smarter cellphone or a more fuel-efficient car. And in medicine, too, new drugs, devices and procedures have advanced patient care.

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Gary Neill

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C.J. Gunther for The New York Times

Kathleen Herlihy-Paoli, above at Marblehead, Mass., received two all-metal artificial hips two years ago.

But the promise of innovation can also prove a trap, a situation now playing out with dire consequences for possibly tens of thousands of people who received artificial hips intended to let them remain active.

The implants, known as metal-on-metal hips, were regarded by device makers and surgeons as a major advance over previous designs that used both metal and plastic. Now federal regulators and medical researchers are scrambling to determine how many implant recipients have been injured by the devices, which can shed dangerous metallic debris through wear.

In a highly unusual move, the Food and Drug Administration last month ordered manufacturers of all metal hips to undertake emergency studies of patients. And lawmakers and others are now calling for a tightening of how the F.D.A. scrutinizes new implants — both before and after they are sold.

A review of the medical world’s embrace of the metal-on-metal hips over the past decade — including interviews with doctors, industry consultants, regulators, medical experts and patients — shows how innovation’s lure led almost everyone to seize on a product promoted as a breakthrough without convincing evidence that it was better or even as good as existing options.

“As a non-American, I don’t completely understand it, but there is a phenomenon in the U.S., the latest and the greatest,” said Dr. Henrik Malchau, who practiced as an orthopedic surgeon in Sweden before going to Massachusetts General Hospital in Boston. “There was a patient demand to get these implants on the misconception that the latest was the best.”

For many manufacturers, the constant churning of new products can be a business necessity, a way to gain an edge on competitors while maintaining or even raising prices. But in recent years, a host of supposed innovations have imploded not long after introduction.

Several heavily promoted artificial spinal disks, claimed by their makers to be major innovations, proved no better than previous ones. After the blockbuster diabetes drug Avandia was linked to heart attacks, a federal study concluded that older drugs were safer and worked better for most patients. And a new heart device component from Medtronic started fracturing after it was implanted in more than 200,000 patients; at least 12 people died in connection with that product.

Some experts, like Dr. Malchau, said they used a special type of metal-on-metal implant known as a resurfacing device in specific patients — mainly taller, middle-age men — because data showed that they worked in that small group. But as with many innovations, metal hips were marketed to all comers. For example, about 65 percent of the implants went to women and older patients, according to an estimate by a consulting firm, Exponent Inc. As it turned out, those two groups appear most prone to failures involving the devices.

“The vast majority of the ‘innovations’ on which we have spent money with respect to orthopedics over the past two decades have not resulted in improved patient outcomes,” said Dr. Kevin J. Bozic, an orthopedic surgeon and professor at the University of California, San Francisco, who has written about artificial joints’ impact on health care costs.

Last year, DePuy, the orthopedics division of Johnson & Johnson, recalled one of its all-metal hips, the ASR, which was failing at a high rate. Another manufacturer, Zimmer Holdings, also briefly halted sales of one of its metal models, the Durom.  DePuy, Zimmer and other companies and doctors have said that most patients who received metal hips have done well.

Experts like Dr. Bozic suggest that big gambles on innovation are justified in dealing with diseases, like some cancers, where current treatments are ineffective. But they say that calculus should shift sharply when existing treatments are highly effective, and that doctors need to use better yardsticks before embracing new technologies in those cases or adopt changes slowly.

THE modern artificial hip, which was developed by a British surgeon, Dr. John Charnley, in the 1960s, uses a relatively simple design. A metal “ball” made of cobalt and chromium replaces the top of the thigh bone, while a “cup,” typically made of plastic, serves as an artificial hip socket. By the 1990s, the devices were considered highly effective, with studies then finding that implants still worked a decade after surgery in 95 percent of patients.

Metal-on-metal implants, in which the cup is also made of a metal alloy, had been tried during those early decades, but were largely abandoned after tests found that patients had metal particles in their blood or organs, raising concerns about long-term health risks like cancer.

Google to End Health Records Service After It Fails to Attract Users

Posted: 24 Jun 2011 10:00 PM PDT

Google is giving up on its vision of helping people live healthier lives with online personal health records.

When Google Health was introduced in 2008, Marissa Mayer, a Google executive, said it would be a “large ongoing initiative” that the company hoped would attract millions of regular users.

But Google Health never really caught on. In a posting on the company’s blog on Friday, Aaron Brown, senior product manager for Google Health, wrote that the goal was to “translate our successful consumer-centered approach from other domains to health care and have a real impact on the day-to-day health experiences of millions of our users.”

Yet, after three years, Mr. Brown said, “Google Health is not having the broad impact we had hoped it would.”

In the drive to apply information technology to health care, personalized health records are the element that relies most heavily on individual motivation and efforts. They are controlled by the consumer, and require individuals to put in, update and edit their health data. By contrast, the federal government has begun a five-year campaign to accelerate the adoption of electronic patient records by hospitals and doctors, with the incentive payments to physicians topping $40,000.

Personal health records, analysts say, are a new concept to most people, and early users have found them difficult to use. “Personal health records have been a technology in search of a market,” said Lynne A. Dunbrack, an analyst at IDC Health Insights, a research firm.

In a survey earlier this year, IDC Health Insights found that 7 percent of consumers had tried online personal health records, and fewer than half of those continued to use them.

Google is by no means the only company to abandon the field of consumer health records. Revolution Health, for example, retired its personal health record service last year, citing few users.

Suppliers of online personal health records include WebMD, Microsoft, RelayHealth and Dossia. But analysts note that what success these offerings have had has often been in partnership with insurers and health providers, while Dossia is an employer-sponsored personal health record.

Adam Bosworth, a former manager of Google Health, who left in 2007 before the service was introduced, said the service could not overcome the obstacle of requiring people to laboriously put in their own data.

“In the end,” Mr. Bosworth said, “it was an experiment that did not have a compelling consumer proposition.”

The consumer technologies that catch on, he said, inform or entertain users, or enable social communication. Mr. Bosworth said he learned that in his own health information technology company, Keas. The business started in 2009, but switched its approach last November to focus on social games to encourage participation in wellness programs.

Technology companies have often underestimated the complexity of the health field, assuming that fresh ideas and new digital tools will bring quick results, said Dr. David J. Brailer, the national coordinator for health information technology in the Bush administration.

When that does not happen, they pull back, Dr. Brailer said. The Google experience, he said, fit that pattern, and the company had been pulling resources from Google Health for some time.

“For a long while, everybody knew that Google Health was dead, except Google,” said Dr. Brailer, who is the chief executive of Health Evolution Partners, an investment fund.

Google is also shutting down its PowerMeter service, which let consumers track their energy use.

A Stronger Net Security System Is Deployed

Posted: 24 Jun 2011 09:40 PM PDT

A small group of Internet security specialists gathered in Singapore this week to start up a global system to make e-mail and e-commerce more secure, end the proliferation of passwords and raise the bar significantly for Internet scam artists, spies and troublemakers.

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Bill Woodcock, center, speaking on Internet security in Singapore.

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Dan Kaminsky, a network security researcher, says Internet users will “be able to authenticate everyone and everything.”

“It won’t matter where you are in the world or who you are in the world, you’re going to be able to authenticate everyone and everything,” said Dan Kaminsky, an independent network security researcher who is one of the engineers involved in the project.

The Singapore event included an elaborate technical ceremony to create and then securely store numerical keys that will be kept in three hardened data centers there, in Zurich and in San Jose, Calif. The keys and data centers are working parts of a technology known as Secure DNS, or DNSSEC. DNS refers to the Domain Name System, which is a directory that connects names to numerical Internet addresses. Preliminary work on the security system had been going on for more than a year, but this was the first time the system went into operation, even though it is not quite complete.

The three centers are fortresses made up of five layers of physical, electronic and cryptographic security, making it virtually impossible to tamper with the system. Four layers are active now. The fifth, a physical barrier, is being built inside the data center.

The technology is viewed by many computer security specialists as a ray of hope amid the recent cascade of data thefts, attacks, disruptions and scandals, including break-ins at Citibank, Sony, Lockheed Martin, RSA Security and elsewhere. It allows users to communicate via the Internet with high confidence that the identity of the person or organization they are communicating with is not being spoofed or forged.

Internet engineers like Mr. Kaminsky want to counteract three major deficiencies in today’s Internet. There is no mechanism for ensuring trust, the quality of software is uneven, and it is difficult to track down bad actors.

One reason for these flaws is that from the 1960s through the 1980s the engineers who designed the network’s underlying technology were concerned about reliable, rather than secure, communications. That is starting to change with the introduction of Secure DNS by governments and other organizations.

The event in Singapore capped a process that began more than a year ago and is expected to be complete after 300 so-called top-level domains have been digitally signed, around the end of the year. Before the Singapore event, 70 countries had adopted the technology, and 14 more were added as part of the event. While large countries are generally doing the technical work to include their own domains in the system, the consortium of Internet security specialists is helping smaller countries and organizations with the process.

The United States government was initially divided over the technology. The Department of Homeland Security included the .gov domain early in 2009, while the Department of Commerce initially resisted including the .us domain because some large Internet corporations opposed the deployment of the technology, which is incompatible with some older security protocols.

Internet security specialists said the new security protocol would initially affect Web traffic and e-mail. Most users should be mostly protected by the end of the year, but the effectiveness for a user depends on the participation of the government, Internet providers and organizations and businesses visited online. Eventually the system is expected to have a broad effect on all kinds of communications, including voice calls that travel over the Internet, known as voice-over-Internet protocol.

“In the very long term it will be voice-over-I.P. that will benefit the most,” said Bill Woodcock, research director at the Packet Clearing House, a group based in Berkeley, Calif., that is assisting Icann, the Internet governance organization, in deploying Secure DNS.

Secure DNS makes it possible to make phone calls over the Internet secure from eavesdropping and other kinds of snooping, he said.

Security specialists are hopeful that the new Secure DNS system will enable a global authentication scheme that will be more impenetrable and less expensive than an earlier system of commercial digital certificates that proved vulnerable in a series of prominent compromises.

The first notable case of a compromise of the digital certificates — electronic documents that establish a user’s credentials in business or other transactions on the Web — occurred a decade ago when VeriSign, a prominent vendor of the certificates, mistakenly issued two of them to a person who falsely claimed to represent Microsoft.

Last year, the authors of the Stuxnet computer worm that was used to attack the Iranian uranium processing facility at Natanz were able to steal authentic digital certificates from Taiwanese technology companies. The certificates were used to help the worm evade digital defenses intended to block malware.

In March, Comodo, a firm that markets digital certificates, said it had been attacked by a hacker based in Iran who was trying to use the stolen documents to masquerade as companies like Google, Microsoft, Skype and Yahoo.

“At some point the trust gets diluted, and it’s just not as good as it used to be,” said Rick Lamb, the manager of Icann’s Secure DNS program.

The deployment of Secure DNS will significantly lower the cost of adding a layer of security, making it more likely that services built on the technology will be widely available, according to computer network security specialists. It will also potentially serve as a foundation technology for an ambitious United States government effort begun this spring to create a system to ensure “trusted identities” in cyberspace.

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The Health Consumer: Sit Up Straight. Your Back Thanks You.

Posted: 24 Jun 2011 11:33 PM PDT

EVERYONE wants to avoid back trouble, but surprisingly few of us manage to escape it. Up to 80 percent of Americans experience back pain at some point in their lives, and each year 15 percent of all adults are treated for such problems as herniated discs, spinal stenosis or lumbar pain.

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Mary Ann Wilmarth, chief of physical therapy at Harvard University Health Services, has 13-year-old Cassidy do yoga exercises to improve her posture.

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But back pain is notoriously difficult, and expensive, to remedy.

“The treatments are varied, and we don’t have great science showing what works best for particular patients,” said Brook I. Martin, an instructor of orthopedic surgery at Dartmouth Medical School. “There are questions about the safety and efficacy of a surprising number of therapies, including some types of surgery.”

Those with back pain inevitably end up with higher overall medical costs than those without, studies suggest. Dr. Martin has found that patients with back pain spend about $7,000 annually on health care, while people without back pain spend just $4,000 a year. (Insurers will pay the majority of these costs, but patients often bear some of these expenses in the form of insurance co-payments and deductibles.) These estimates don’t include costs for lost work days or diminished productivity.

Some back problems, of course, can’t be avoided. Over time, spinal vertebrae naturally degenerate and spinal facets become inflamed, causing stress and discomfort.

“The majority of back pain is the result of muscle and ligament strain or weakness, and can often be prevented by developing core strength and proper posture,” said Dr. Daniel Mazanec, associate director of the Center for Spine Health at the Cleveland Clinic.

Maintaining good posture not only helps you look better (there’s a reason inept people are called slouches), it improves muscle tone, makes breathing easier and is one of the best ways to stave off back and neck pain, not to mention the dreaded dowager’s hump of old age.

“Posture is the key,” said Mary Ann Wilmarth, chief of physical therapy at Harvard University Health Services. “If your spine is not balanced, you will inevitably have problems in your back, your neck, your shoulders and even your joints.”

Sitting a little straighter now? Good. Here’s some advice that will help you make it a daily habit and stave off expensive back problems to boot.

THE D.I.Y. APPROACH First, try correcting your slouching habits on your own. Stand up and lift your chin slightly; align your ears over your shoulders and your shoulders over your hips. Place your hands on your hips and pitch forward about two inches.

There should be a slight inward curve in your lower back, an outward curve in your upper back, and another inward curve at your neck. Maintain this posture and sit down.

When you are sitting or driving for long periods of time, place a cushion or rolled-up towel between the curve of your lower spine and the back of your seat. Supporting your lower back will maintain the natural curve of your spine; when the back is supported, the shoulders more naturally fall into place, said Dr. Wilmarth.

Maintaining good posture requires abdominal and back strength. “It’s not enough to just sit up straight if your core muscles are weak,” said Dr. Praveen Mummaneni, a spine surgeon at the University of California, San Francisco. Consider taking a Pilates class, which focuses on developing one’s core — the muscles and connective tissues that hold the spine in place — or hire a physical therapist to create a personalized exercise plan.

A CUBICLE CURE If you sit at a desk all day, ask your human resources department if they have an ergonomics expert on staff (some large companies do) who can assess your work area. An ergonomist can make sure your chair, desk and keyboard are at the optimal height and can adjust your sitting posture.

If no expert is on hand, make adjustments yourself. The center of your computer screen should be at eye level, and the desk height should allow your forearms to rest comfortably at a 90-degree angle. Work with your feet flat on the floor and your back against the chair.

Whether you work in an office or at home, get up and stretch every 30 to 60 minutes. Sitting for long periods puts pressure on discs and fatigues muscles. And most workers spend the majority of their days sitting down. A recent study published in The European Heart Journal found that Americans are sedentary for an average of 8.5 hours a day.

“Stretching helps break bad patterns and allows your muscles to return to neutral,” said Dr. Wilmarth.

Stand up and place your hands on your lower back, as if you were sliding them into your back pockets. Gently push your hips forward and slightly arch your back. Sit back down and circle your shoulders backward, with your chin tucked, about 10 times.

Not likely to remember? Set your phone or computer alarm to remind you to stand up and stretch each hour. An iPhone app called Alarmed has a feature that allows you to create regular reminders throughout the day.

AN EXERCISE PLAN Habits are hard to break. A physical therapist can show you how to align your spine and provide you with exercises to both strengthen your core and loosen up stiff neck, back, arm and leg muscles (tight hamstrings can contribute to back pain).

The American Physical Therapy Association’s Web site (www.moveforwardpt.com) offers a simple tool that lets you search for physical therapists by ZIP code and specialty.

Most insurers cover physical therapy, although some may insist that you get a referral from a physician before they will authorize a visit.

If you decide to go out of network or to bypass your insurer, you’ll pay $150 to $250 for an initial assessment. Follow-up visits will be $50 or so less. Most experts say you can address basic posture issues in just one to three sessions.

A CLASS IN POISE If you want a more systematic, long-term approach to posture change, consider the Alexander technique, a method that teaches you how recognize and release habitual tension that interferes with good posture.

Not all doctors in the United States are familiar with the technique, but recent research suggests that it can help with lower back pain as well as posture. A study published in The British Medical Journal found that lessons in the technique helped patients with chronic back pain. A 2011 study published in Human Movement Science concluded that the Alexander technique increased the responsiveness of muscles and reduced stiffness in patients with lower back pain.

Try one session to see if it’s for you. If so, consider committing to 10 lessons. Individual lessons cost $60 to $125, depending on the teacher’s experience. Insurers will not reimburse you; group lessons may be more affordable. To find a teacher, go to the Web site of the American Society for the Alexander Technique.

Still slouching? A study published in The European Journal of Social Psychology found that subjects who were told to sit up straight with good posture gave themselves higher ratings and had more self-confidence on a given task than those who were told to slouch.

Moral: Sitting pretty yields immediate, not just long-term, benefits.

Indiana Law to Cut Planned Parenthood Funding Is Blocked

Posted: 24 Jun 2011 11:00 PM PDT

WASHINGTON — A federal judge ruled Friday that the State of Indiana could not cut off money for Planned Parenthood clinics providing health care to low-income women on Medicaid.

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The judge, Tanya Walton Pratt of the Federal District Court in Indianapolis, blocked provisions of a new state law that penalized Planned Parenthood because some of its clinics performed abortions. The law, she said, conflicts with the federal Medicaid statute, which generally allows Medicaid beneficiaries to choose their health care providers.

Planned Parenthood provides services other than abortion, including family planning and screenings for cancer and sexually transmitted diseases.

In issuing a preliminary injunction late Friday, Judge Pratt said the state law “will exact a devastating financial toll on Planned Parenthood of Indiana and hinder its ability to continue serving patients’ general health needs.”

The law took effect immediately when it was signed on May 10 by Gov. Mitch Daniels, a Republican.

As of June 20, the judge said, Planned Parenthood of Indiana stopped treating its Medicaid patients and laid off two of its three specialists in sexually transmitted diseases. The judge said that “only a small percentage” of Planned Parenthood’s services involved abortion.

“States do not have carte blanche to expel otherwise competent Medicaid providers,” Judge Pratt said. And “there are no allegations that Planned Parenthood of Indiana is incompetent or that it provides inappropriate or inadequate care.”

The ruling has national significance. At least a half-dozen states have taken aim at Planned Parenthood because its clinics perform abortions, about one-fourth of all those performed in the United States.

Judge Pratt gave “some measure of deference” to a ruling by the Obama administration, which on June 1 denied approval for the changes that Indiana wanted to make in its Medicaid program.

The federal government could terminate some or all of Indiana’s Medicaid money if the state persisted in violating federal Medicaid law.

“The public interest tilts in favor of granting an injunction,” Judge Pratt declared. “The federal government has threatened partial or total withholding of federal Medicaid dollars to the State of Indiana, which could total well over $5 billion annually and affect nearly one million Hoosiers.”

Moreover, she said: “Denying the injunction could pit the federal government against the State of Indiana in a high-stakes political impasse. And if dogma trumps pragmatism and neither side budges, Indiana’s most vulnerable citizens could end up paying the price as the collateral damage of a partisan battle.”

Marcus J. Barlow, a spokesman for the Indiana Family and Social Services Administration, said the state would comply with the preliminary injunction, but could also appeal.

Bryan Corbin, a spokesman for the Indiana attorney general, Greg Zoeller, said the state was likely to seek review by the United States Court of Appeals for the Seventh Circuit, in Chicago.

Since the law was signed, Judge Pratt said, Planned Parenthood of Indiana has seen a surge in donations from supporters. But, she said, “these donations were something of an aberration.”

“Common sense suggests that as headlines fade, passions will cool and donations will level off,” the judge said. “Thus, with the passage of time, Planned Parenthood of Indiana will be forced to confront the dire financial effects” of the new state law.

State officials argued that Indiana could exclude Planned Parenthood from its Medicaid program because states have the authority to determine who is a “qualified” provider. But, the judge said, that determination cannot be based on factors unrelated to a provider’s Medicaid services.

For years, federal law has banned the use of Medicaid money to pay for abortion except in certain cases of rape or incest or danger to the life of a pregnant woman.

The Indiana law goes much further. It prohibits state agencies from entering contracts with or making grants to “any entity that performs abortions or maintains or operates a facility where abortions are performed.” It also terminates existing state contracts with such entities. The law does not apply to hospitals.

Planned Parenthood of Indiana and two of its patients filed the suit, challenging the new restrictions as “a blatant violation” of federal law. Judge Pratt agreed, finding the Indiana measure “unlawfully narrows Medicaid recipients’ choice of qualified providers.”

F.D.A. Urges Less Use of Anemia Drugs

Posted: 24 Jun 2011 09:36 PM PDT

WASHINGTON — Federal drug regulators said on Friday that three drugs that had been widely used to treat anemia in both kidney and cancer patients were so dangerous to the heart that doctors should consider avoiding the medicines altogether in some patients and using less of them in others.

Erik Jacobs for The New York Times

Epogen is a erythropoietin-stimulating drug used by kidney and cancer patients suffering from anemia.

The Food and Drug Administration concluded that there were no risk-free doses of Epogen, Aranesp and Procrit, and that doctors should use the medicines only in patients suffering from severe anemia. Doctors have used the medicines in the past to make patients feel better and as a way to increase chemotherapy doses in cancer patients.

But there is growing evidence that the drugs may have cost many patients their lives by causing deadly strokes and other heart problems, as well as speeding the growth of cancer tumors.

“This is a very big deal,” said Dr. Jay Wish, a professor of medicine at Case Western Reserve University in Cleveland. “It’s going to hit the dialysis population right now in a big way.”

The medicines have cost the federal government more than $60 billion since they were introduced in 1989, and for years they were the biggest single drug expense in the federal Medicare program. The medicines have been big money makers for oncologists — who earn a mark-up for many of the medicines they prescribe — as well as dialysis providers.

But as Congress debates ways of saving money in the Medicare program, some critics have pointed to these medicines — known collectively as erythropoietin-stimulating agents — as examples of how poorly the federal government controls expenses in the program. The United States is among only a few industrialized countries that do not routinely assess whether new drugs or devices are worth providing to patients whose care is paid for by the government. Those decisions are largely left up to doctors, many of whom have financial incentives to use the drugs or devices. Indeed, doctors in the United States used far more Epogen, Aranesp and Procrit than doctors in Europe and elsewhere who did not profit from their use.

“Sixty billion dollars have gone out the window on these drugs, and what do we have to show for it?” asked Dennis Cotter, president of Medical Technology and Practice Patterns, a nonprofit health policy research institute in Bethesda, Md. Citing government estimates that as much as $800 billion in health care expenses may be wasted annually, Mr. Cotter said, “It’s time we had a sound way of assessing the value of these technologies.”

Amgen, a large biotechnology company, was built on the sales of Epogen and Aranesp. Johnson & Johnson sells Procrit, which is manufactured by Amgen. Dr. Roger M. Perlmutter, executive vice president for research at Amgen, said the company supported the new F.D.A. warnings, which will be placed on the labels that educate doctors.

“The revised label also provides physicians with more individualized treatment guidance by distinguishing between patients undergoing dialysis as compared with those who are not on dialysis,” Dr. Perlmutter said.

Epogen, Aranesp and Procrit work by spurring the body’s production of red blood cells, which ferry oxygen to the body’s tissues. Professional athletes, particularly cyclists, have used the drugs (often improperly) to improve performance. They were developed to help dialysis patients cut down on blood transfusions, but Amgen and Johnson & Johnson soon persuaded doctors that the drugs helped both kidney and cancer patients feel better even when not suffering severe anemia. The consulting payments that the companies made to top doctors, including those who wrote guidelines for the drugs’ uses, may have played an important role in doctors’ enthusiasm.

The drugs are expensive, and that means they have been particularly profitable for oncologists and nephrologists. But sales have been falling since 2007, when studies renewed concerns that the drugs might cause heart attacks and strokes and spur the growth of cancer.

Friday’s warning about the drug’s risks is the most severe yet and will likely reduce uses of the drugs in kidney patients by as much as a third, Dr. Wish said.

“I think it’s fairly draconian and is an overreaction,” said Dr. Wish, who has consulted for makers of the drugs. “They’re scaring everyone away.”

Dr. Daniel Coyne, a professor of medicine at Washington University in St. Louis, asked why any patient would willingly risk a fatal stroke or heart attack just to reduce the number of blood transfusions they might require while on dialysis. He said he would probably cut the dose of the medicine he provided to dialysis patients by a third or more and eliminate it from the care of many patients not yet on dialysis. He and other nephrologists predicted that the F.D.A. warning would change the way Medicare paid for the drug.

“This is a shockingly bold statement by the F.D.A., but is firmly evidence-based,” Dr. Coyne said.

German E.Coli Sickens 8 in France

Posted: 25 Jun 2011 11:20 PM PDT

PARIS — The deadly German E. coli strain that killed at least 45 people has resurfaced in France, where officials said a cluster of eight people have fallen ill, apparently from eating contaminated sprouts grown in France.

Sprouts were also identified as the source of the German outbreak. French officials have not yet determined if the two episodes are connected.

But public health experts in the United States said the new outbreak raised concerns that contaminated seeds from a common supplier might be the ultimate source of the E. coli bacteria. If those seeds are still in circulation, other outbreaks could occur.

The French health authorities said that seven of those who had become sick attended a charity event at a children’s play center in Bègles, a suburb of Bordeaux, on June 8. Most of the people who became ill recalled eating gazpacho garnished with sprouts.

French investigators traced the sprouts served at the event to seeds bought at a garden store chain, Jardiland, according to a news release from Frédéric Lefebvre, a secretary of state attached to the economy ministry.

Mr. Lefebvre said the seeds were supplied by a British company, Thompson & Morgan. Although the link between the seeds and the illness had not been definitively established, he called on French retailers to pull the company’s seeds for fenugreek, mustard and arugula from shelves.

In a statement Saturday, Thompson & Morgan said it had not received any reports of problems with its seeds. “We note that the French outbreak was localized to a specific event, which would indicate to us that something local in the Bordeaux area, or the way the product has been handled and grown, is responsible for the incident rather than our seeds,” the statement said.

The company said it was cooperating with British health authorities as they looked into the matter.

The company also distributes seeds in the United States.

The German outbreak began in early May and has sickened more than 3,800 people, nearly 900 of them with a serious complication involving acute kidney failure. Nearly all the cases involved people who lived or had traveled in Germany.

German authorities have blamed the outbreak on bean sprouts grown by a German commercial sprouter, which shut down on June 5. American health experts said the French outbreak was worrisome because it suggested that the ultimate source of the deadly bacteria — a rare and highly virulent E. coli strain known as O104:H4 — had not been found and contained.

“If there’s no linear connection from the first outbreak, then the simplest and the most ominous explanation is there’s an upstream source and that’s very concerning because that stuff could still be being distributed,” said Dr. Phillip Tarr, a professor of microbiology at the Washington University School of Medicine in St. Louis.

Dr. Tarr said it was still too early to draw firm conclusions about the cause of the latest round of illnesses. He said it was possible, although unlikely, that someone sickened in the earlier outbreak had prepared food served at the event in France and so passed on the infection.

“Traceback here is absolutely critical because that killer organism could be sitting around viable and not contained,” he said.

William E. Keene, a senior epidemiologist at the Oregon Public Health Division, said it was urgent to find out if the seeds used by the German grower had come from the same source as the seeds linked to the French cases.

At least five of the French cases involved kidney failure, and tests on two of those people showed they were infected with the O104:H4 strain. The eight people infected in the Bègles area were adults, age 31 to 78. In addition, two children were sickened in another town and they were presumed also to have E. coli infections, although it was not clear if they had the same strain.

Motherlode: I Found My Mom Through Facebook

Posted: 25 Jun 2011 04:07 PM PDT

“MOMMY, Mommy, she found me, she found me.” 

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From left: Jami and Alexander Dorf and Terri Barber, Alexander's birth mother.

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Stephen Savage

Sixteen-year-old Alexander Dorf stood at the top of the stairs in his Tenafly, N.J., home two years ago, grinning broadly at his mother, Jami. He had just gotten a message on his Facebook wall that he’d been waiting for all his life. 

From a Florida woman named Terri Barber, it read: “Hi, I was just wondering if your parents’ names are Jamie & Jeff?” Alexander recognized the name; he had searched the Internet for it himself with no luck. It belonged to the woman who had given birth to him. 

Ms. Dorf and her husband, who had adopted Alexander as an infant, were not surprised. Ms. Barber had reached out to them, too, a few beats after the e-mail to Alexander. “I sent Alex a message because I found him first, but I only asked him if you and Jeff were his parents,” Ms. Barber wrote. “I said nothing else. ... Please let me know if it’s O.K. if we speak.... Please don’t be upset.” 

The Internet is changing nearly every chapter of adoption. It can now start with postings by couples looking for birth mothers who want to place children, and end years later with birth mothers looking to reunite with children they’ve placed. A process that once relied on gatekeepers and official procedures can now be largely circumvented with a computer, Wi-Fi and some luck.  

“It used to be a slow process,” says Anya Luchow, a psychologist who facilitates an adoption support group in Bergen County, N.J., that includes the Dorfs. “And when the children were minors, it was one that their adoptive parents could control.”

Now, says Leanne Jaffe, a Manhattan therapist (herself an adoptee) who specializes in adoption issues: “Kids, at the most vulnerable time for developing identity, are plugged in online. Either they are savvy enough to find their birth parents, or they spend time in places like Facebook, where their birth parents can find them.”

There are stories of children as young as 13 approached by birth parents online, and of children being contacted before they had been told they were adopted. Among the most cautionary of tales is that of Aimee L. Sword, who was convicted of having sex with her biological son, who was 14 at the time, and whom she found on Facebook when yearly updates from his adoptive family stopped coming. “It’s uncharted territory,”  Dr. Luchow says. What are the new rules? They are being made up as the participants — adoptees and their parents — go along.

•

When Linda Wachtel and her husband, Zev, adopted their daughter, Jessi, 19 years ago, things were different. Open adoption was still rare. Birth mothers were kept at arm’s length. 

They did have Jessi’s birth mother’s first name, Sharyn, but were not certain of her last; she knew them as Linda and Steve (Zev, they thought, was too easy to find). For awhile they used an 800 number to communicate, set up, per the norm at the time, so that their whereabouts remained secret. A few years in, they disconnected that line. 

The Wachtels assumed Jessi would eventually want to meet her birth mother but thought they would be in charge of the timing. 

To that end, the Wachtels were open with their daughter, who has two brothers who are not adopted, and who was always curious about her genetic roots. As the Internet became a part of life, both Ms. Wachtel and Jessi herself would do Google searches for Sharyn periodically, but come up empty. “Mostly I wanted to know what she looked like,” Jessi says. 

One day, two years ago, Ms. Wachtel happened upon her son’s Facebook page, left open on a computer screen in their home. On a whim, she typed “Sharyn” and “Padula,” which was one possible last name. Up popped a photo that “was eerily familiar,” Ms. Wachtel says. “It was like looking at my daughter.”

Creating a new e-mail account — lindasteve92 — Ms. Wachtel e-mailed.  “Hi Sharyn,” Ms. Wachtel recalls writing, “I’m Jessi’s mother. I know it must be fairly shocking to get this.”

Lisa Belkin covers family life for The Times and writes the Motherlode blog for nytimes.com.

G-20 Officials Agree on Steps to Stabilize Food Prices and Improve Supplies

Posted: 23 Jun 2011 10:15 PM PDT

PARIS — Agriculture ministers from the Group of 20 leading economies agreed Thursday on measures intended to lift global production and improve supplies of basic foods, while mitigating price swings.

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Lionel Bonaventure/Reuters

France's President Nicolas Sarkozy spoke at the G-20 meeting on Wednesday.

The agreements were hailed as important steps, although some advocates said they did not go far enough, especially in tackling biofuel subsidies.

The initiatives included a database on food stocks to be managed by the United Nations’ Food and Agriculture Organization in Rome; a joint international research program on wheat; support for research into rice production; and a “rapid response forum” among Group of 20 members to assess and respond to food crises.

While investment in production was encouraged, the ministers did not offer specifics.

The ministers also agreed, in hard bargaining late Wednesday night, to remove export restrictions on food for humanitarian purposes and reaffirmed their opposition to export bans — an issue that will be taken up by the World Trade Organization. They asked the World Food Program to develop a pilot program for regional humanitarian food reserves.

“Concrete, very precise and ambitious measures will be taken,” the chairman of the meeting, the French agricultural minister, Bruno Le Maire, told reporters. “Better transparency in agricultural markets will translate into less price volatility.”

The president of the World Bank, Robert B. Zoellick, called the steps “modest,” saying, “It’s just a start, but it’s progress.” Mr. Zoellick was pleased, he said in an interview, that the Group of 20 had finally focused on agriculture and the continuing crisis he sees in food supply, especially for poorer countries with weaker links to the world’s financial and commodity markets.

Food stocks of wheat and corn are too low, he suggested, given the increasing demand for livestock feed in China, India and the developing world, where people are eating more meat. Keeping up with that demand will not allow a growth in emergency food stocks unless more action is taken, he said. And if there is an unforeseen event or disastrous weather, these stocks might quickly disappear, and prices would soar.

“We’re in a danger zone for a number of years,” he said. “If you get a bad weather event, you get hammered.”

The 24-page declaration was the result of months of negotiations. China and India, in particular, had been reluctant to release data on their food stocks, which are considered strategic information. Final agreement was obtained only at a dinner Wednesday night that was attended by, among others, President Nicolas Sarkozy of France and Pascal Lamy, the chief of the World Trade Organization.

In general, Mr. Zoellick said, the Group of 20 allowed countries like China and India to take more collective responsibility for world crises and challenges. “This is where the G-20 can work, as long as they don’t feel ordered around by the bigger countries,” he said, citing the agreement by Beijing and New Delhi on food stocks. “They know it’s in their interest to do it.”

This first-of-a-kind meeting was called by France, the current holder of the Group of 20 and Group of 8 presidencies, after world food prices hit record levels this year, raising concerns about a replay of the riots in some countries in 2007 and 2008.

The current spike — driven by drought in Western Europe, a Russian export ban last summer and bad weather in Canada and Australia — contributed to the social and political unrest in the Arab world this year.

In recent weeks there has been a slight letup in food prices, but the main wheat futures contract traded in Chicago remains up about 50 percent from its level a year ago. And few analysts expect a major retrenchment in prices in the months ahead.

There was no agreement on the possible role of speculators in financial and food markets.

There was also no accord on whether or how to cut or end subsidies on biofuels. In the declaration, the ministers merely said they would “continue to address the challenges and opportunities posed by biofuels.”

“The problem is not biofuels in themselves,” said the Food and Agriculture Organization’s director general, Jacques Diouf. “The problem is the policies adopted by certain governments to encourage the development of biofuels.”

Olivier De Schutter, a professor whom the United Nations has asked to report on food issues, said: “The final declaration is particularly disappointing on biofuels. There is a consensus among international agencies that this has been a major factor in the price increases of basic food commodities over the past four years.”

In the United States, about 37 percent of the corn crop in 2010 went to ethanol, and the figure will be no lower this year, Mr. De Schutter said. The American agriculture secretary, Tom Vilsack, noted that the issue was alive in Congress and said it was “likely that we will see changes in the way in which the industry is supported.”

Lives Restored: Expert on Mental Illness Reveals Her Own Fight

Posted: 24 Jun 2011 12:06 PM PDT

HARTFORD — Are you one of us?

Lives Restored

A Therapist's Demons

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Damon Winter/The New York Times

“So many people have begged me to come forward, and I just thought â€" well, I have to do this. I owe it to them. I cannot die a coward,” said Marsha M. Linehan, a psychologist at the University of Washington.

The patient wanted to know, and her therapist — Marsha M. Linehan of the University of Washington, creator of a treatment used worldwide for severely suicidal people — had a ready answer. It was the one she always used to cut the question short, whether a patient asked it hopefully, accusingly or knowingly, having glimpsed the macramé of faded burns, cuts and welts on Dr. Linehan’s arms:

“You mean, have I suffered?”

“No, Marsha,” the patient replied, in an encounter last spring. “I mean one of us. Like us. Because if you were, it would give all of us so much hope.”

“That did it,” said Dr. Linehan, 68, who told her story in public for the first time last week before an audience of friends, family and doctors at the Institute of Living, the Hartford clinic where she was first treated for extreme social withdrawal at age 17. “So many people have begged me to come forward, and I just thought — well, I have to do this. I owe it to them. I cannot die a coward.”

No one knows how many people with severe mental illness live what appear to be normal, successful lives, because such people are not in the habit of announcing themselves. They are too busy juggling responsibilities, paying the bills, studying, raising families — all while weathering gusts of dark emotions or delusions that would quickly overwhelm almost anyone else.

Now, an increasing number of them are risking exposure of their secret, saying that the time is right. The nation’s mental health system is a shambles, they say, criminalizing many patients and warehousing some of the most severe in nursing and group homes where they receive care from workers with minimal qualifications.

Moreover, the enduring stigma of mental illness teaches people with such a diagnosis to think of themselves as victims, snuffing out the one thing that can motivate them to find treatment: hope.

“There’s a tremendous need to implode the myths of mental illness, to put a face on it, to show people that a diagnosis does not have to lead to a painful and oblique life,” said Elyn R. Saks, a professor at the University of Southern California School of Law who chronicles her own struggles with schizophrenia in “The Center Cannot Hold: My Journey Through Madness.” “We who struggle with these disorders can lead full, happy, productive lives, if we have the right resources.”

These include medication (usually), therapy (often), a measure of good luck (always) — and, most of all, the inner strength to manage one’s demons, if not banish them. That strength can come from any number of places, these former patients say: love, forgiveness, faith in God, a lifelong friendship.

But Dr. Linehan’s case shows there is no recipe. She was driven by a mission to rescue people who are chronically suicidal, often as a result of borderline personality disorder, an enigmatic condition characterized in part by self-destructive urges.

“I honestly didn’t realize at the time that I was dealing with myself,” she said. “But I suppose it’s true that I developed a therapy that provides the things I needed for so many years and never got.”

‘I Was in Hell’

She learned the central tragedy of severe mental illness the hard way, banging her head against the wall of a locked room.

Marsha Linehan arrived at the Institute of Living on March 9, 1961, at age 17, and quickly became the sole occupant of the seclusion room on the unit known as Thompson Two, for the most severely ill patients. The staff saw no alternative: The girl attacked herself habitually, burning her wrists with cigarettes, slashing her arms, her legs, her midsection, using any sharp object she could get her hands on.

The seclusion room, a small cell with a bed, a chair and a tiny, barred window, had no such weapon. Yet her urge to die only deepened. So she did the only thing that made any sense to her at the time: banged her head against the wall and, later, the floor. Hard.

“My whole experience of these episodes was that someone else was doing it; it was like ‘I know this is coming, I’m out of control, somebody help me; where are you, God?’ ” she said. “I felt totally empty, like the Tin Man; I had no way to communicate what was going on, no way to understand it.”

Her childhood, in Tulsa, Okla., provided few clues. An excellent student from early on, a natural on the piano, she was the third of six children of an oilman and his wife, an outgoing woman who juggled child care with the Junior League and Tulsa social events.

People who knew the Linehans at that time remember that their precocious third child was often in trouble at home, and Dr. Linehan recalls feeling deeply inadequate compared with her attractive and accomplished siblings. But whatever currents of distress ran under the surface, no one took much notice until she was bedridden with headaches in her senior year of high school.

Her younger sister, Aline Haynes, said: “This was Tulsa in the 1960s, and I don’t think my parents had any idea what to do with Marsha. No one really knew what mental illness was.”

Soon, a local psychiatrist recommended a stay at the Institute of Living, to get to the bottom of the problem. There, doctors gave her a diagnosis of schizophrenia; dosed her with Thorazine, Librium and other powerful drugs, as well as hours of Freudian analysis; and strapped her down for electroshock treatments, 14 shocks the first time through and 16 the second, according to her medical records. Nothing changed, and soon enough the patient was back in seclusion on the locked ward.

Drug Makers Win Two Supreme Court Decisions

Posted: 23 Jun 2011 09:56 PM PDT

WASHINGTON — The Supreme Court on Thursday handed drug companies two significant victories, one limiting suits from people injured by generic drugs and the other striking down a law that banned some commercial uses of prescription data.

Daniel Rosenbaum for The New York Times

Bridget C. Asay of Vermont said a law on prescription data was meant to prevent “invasive marketing.” The state lost the case.

In the first case, Pliva v. Mensing, No. 09-993, the court split 5 to 4 along ideological lines in ruling that the makers of generic drugs — which account for 75 percent of prescriptions dispensed nationwide — may not be sued under state law for failing to warn customers about the risks associated with their products.

Two years ago, in Wyeth v. Levine, the court decided the same question in the context of brand-name drugs but came to the opposite conclusion. That decision was based in large part on the fact that such drug companies can sometimes change the labels on their products without permission from the Food and Drug Administration.

Justice Clarence Thomas, writing for the majority on Thursday, acknowledged that in the eyes of injured consumers, the new distinction between generic and brand-name drugs “makes little sense.” But he said it followed from the way the two kinds of companies are treated under federal law.

The manufacturers of generic drugs, he said, must use the same warning labels as the corresponding brand-name drugs, and they may not unilaterally alter those labels. That means, Justice Thomas wrote, that makers of generic drugs are caught in an impossible bind: they can comply with a state law requiring them to change their labels or the federal law prohibiting changes, but not both.

Given that impossibility, federal law pre-empts state law under the Constitution’s supremacy clause, he wrote.

In dissent, Justice Sonia Sotomayor said the majority opinion invented “new principles of pre-emption law out of the air” and will lead to “absurd consequences.”

“As the majority itself admits,” Justice Sotomayor wrote, “a drug consumer’s right to compensation for inadequate warnings now turns on the happenstance of whether her pharmacist filled her prescription with a brand-name drug or a generic.”

The decision considered three consolidated cases brought by women who took generic metoclopramide, which is sold under the brand name Reglan. They took the drug for stomach ailments and developed a serious neurological disorder. Appeals courts ruled against the drug makers, saying that the federal regulatory regime did not block claims under state law.

The Supreme Court reversed those decisions on Thursday, rejecting what Justice Thomas called the “fair argument,” that the defendants should have at least tried to persuade the federal drug agency to let them use a safer label.

But the process of asking the agency to change a label, he wrote, can be as complicated as a children’s board game.

“If they had done so,” Justice Thomas wrote of a possible request for a label change, “and if the F.D.A. decided there was sufficient supporting information, and if the F.D.A. undertook negotiations with the brand-name manufacturer, and if adequate label changes were decided on and implemented, then the manufacturers would have started a Mouse Trap game that eventually led to a better label on generic metoclopramide.”

Chief Justice John G. Roberts Jr. and Justices Antonin Scalia, Anthony M. Kennedy and Samuel A. Alito Jr. voted with the majority.

In her dissent, Justice Sotomayor wrote that she agreed that the makers of generic drugs could not unilaterally change their labels. But she said that did not allow them to remain idle after learning of safety issues.

“Had the manufacturers invoked the available mechanism for initiating label changes,” she wrote, “they may well have been able to change their labels in sufficient time to warn” the women injured by their drugs.

The majority opinion, Justice Sotomayor said, may reduce the demand for generic drugs and put doctors in an ethical bind.

Justice Ruth Bader Ginsburg, Stephen G. Breyer and Elena Kagan joined the dissent.

In a second decision on Thursday, Sorrell v. IMS Health, No. 10-779, a six-justice majority of the court struck down a Vermont law that banned some but not all uses of prescription information collected by pharmacies.

Anticlotting Drug Shows Promise to Displace a Longtime Standard

Posted: 24 Jun 2011 07:24 AM PDT

A proposed new anticlotting drug for people with irregular heartbeats has been shown to prevent more strokes with less bleeding risk than the existing treatment, the drug makers Bristol-Myers Squibb and Pfizer said late Wednesday. The announcement sent their stocks soaring on Thursday.

The news appeared to brighten the prospects for millions of people with a heart rhythm problem called atrial fibrillation, doctors and analysts said. Many have been taking a drug called warfarin or not treating their dangerous conditions at all for fear of excess bleeding.

“This is great news for patients and doctors,” said Dr. Christopher P. Cannon, a leading cardiologist who was not involved in the research. “It shows the new class of anticoagulants works better than the only thing we’ve had available for 50 years.”

Dr. Cannon, an associate professor at Harvard Medical School whose hospital research group performs trials for other drug companies, said he was thinking of switching both his parents to the new drug from warfarin.

The results, however, are tentative. The drug, known as apixaban, or the brand name Eliquis, has not yet been submitted to the Food and Drug Administration for approval, nor have the full study results been released.

The companies said they planned to release the study on Aug. 28 at the European Society of Cardiology meeting in Paris and file for approval in the United States and Europe later in the year. Eliquis was approved in Europe last month to prevent clots in patients receiving hip or knee replacement surgery.

C. Anthony Butler, a pharmaceuticals analyst for Barclays Capital, said Eliquis had vaulted to the front of a potential $8.5 billion market in treating atrial fibrillation. “I don’t know how doctors can say they’re not going to use this,” Mr. Butler said, noting that Bristol-Myers Squibb and Pfizer, both based in new York, are “marketing powerhouses.”

The pill has two major competitors emerging in the market to prevent strokes and clots. Pradaxa, from Boehringer Ingelheim, was approved by the F.D.A. last year, and Xarelto, from Bayer and Johnson & Johnson, is under F.D.A. review. Eliquis, according to the companies’ statement, holds a significant safety advantage.

“I feel very excited about it, but you know, we have to see all the data,” said Dr. Valentin Fuster, director of the heart center at Mount Sinai Medical Center and former president of the American Heart Association. Dr. Fuster is heading an expert group next week that is expected to call for studies comparing the latest anticlotting medicines head-to-head against each other.

Catherine J. Arnold, pharmaceuticals analyst for Credit Suisse, wrote investors a note Thursday predicting that Bristol-Myers Squibb and Pfizer would sell more than $3 billion a year of the drug. Doctors have clamored for an anticlotting drug with less risk of bleeding, Ms. Arnold wrote. The companies released enough information to prove their research was truly a milestone, she said.

The newer drugs are all expected to be much more expensive than warfarin, which costs pennies a day. Pradaxa costs about $6 a day.

Bayer’s stock plummeted 6.3 percent on the news in European trading, a loss of nearly $3 billion in market value, its biggest decline in two years. Johnson & Johnson fell 0.6 percent to $65.67. Boehringer Ingelheim is a private company.

Shares of Bristol-Myers Squibb soared 5.7 percent to $29.33 on Thursday whiled Pfizer rose 1.8 percent, to $20.65. Bristol discovered the drug and Pfizer joined in a development deal in 2007.

The companies’ study of Eliquis against warfarin included 18,201 patients with atrial fibrillation and at least one other risk factor for stroke. It not only met the primary end-point of “noninferiority” in preventing strokes — a necessity for F.D.A. approval — but also showed it was actually superior in preventing strokes and avoiding major bleeding, the companies said.

Warfarin has been the warhorse drug for anticlotting purposes for decades. But warfarin is inconvenient because it requires frequent monitoring to assure patients are not taking too much, which elevates bleeding risk, or too little, increasing the risk of a devastating stroke. Some foods and other drugs have a pronounced effect on warfarin levels, but not on the new drugs.

Khirbet Al-Jouz Journal: Need Overwhelms Makeshift Clinic in Syria Camp

Posted: 23 Jun 2011 02:30 AM PDT

KHIRBET AL-JOUZ, Syria — Mohamed Marei awoke to the wails of a sick child arriving at his makeshift medical clinic, where he and half a dozen other men were living, having fled their homes to escape a violent government crackdown in the country’s rural northwest.

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Daniel Etter for The New York Times

Stocks of medicines, some of them smuggled from Turkey. Thirty people in the camp share one asthma inhaler.

The New York Times

The child was suffering with diarrhea and a fever, like many others here, said Mr. Marei, who gave him an injection and sent him away. Another child then came in with a bandaged leg, soon followed by Noufa al-Ali and her 27-year-old son, Abu Mohamed. He held an empty IV bag over her arm, but it could not be replaced. The clinic had run out, so Mr. Marei removed the needle and threw the bag in a corner.

Ms. Ali had been in good health until “all the killing and death” that drove them here, said her son. They have resisted crossing the border to Turkey, where aid organizations run formal refugee camps, because they want to return to their home in the village of Ashtouria. “But we won’t go back until this regime falls,” said Ms. Ali, 48.

There are no indications that will happen soon. In the meantime, activists say there is an acute need for medical care in the makeshift refugee camps scattered on the Syrian side of the border. Khirbet al-Jouz is one camp of many, and the demand for treatment here strains its capacity. So Mr. Marei, a pharmacist with a fractured shoulder and little medical training, struggles to make do.

The more than 10,000 Syrian refugees in Turkey receive medical care from the Turkish Red Crescent, a local version of the Red Cross. Life is far more difficult for the thousands who remain in Syria and seek shelter in forests and fruit orchards on the floor of a valley ringed by rugged mountains.

They live in abandoned buildings, cars or clumps of shabby tents assembled from tarps and blankets. Their camps are administered by no one and receive little assistance. Turkey began delivering food and bottled water to Khirbet al-Jouz this week, but refugee leaders say their assistance does not extend to medical aid.

“There are many serious medical cases in the camp which need the attention of a doctor,” said Peter Bouckaert, emergencies director for Human Rights Watch, who has conducted research in the camps of the Syrian border zone. “Given the unsanitary conditions and the heat in the camp, it really could put people’s lives at risk.”

Mr. Marei’s clinic is in an abandoned two-room concrete structure on the edge of an apple orchard. Its floors are strewn with thin mattresses, blankets and tiny glass teacups, and many of its windows are broken. One room houses more than half a dozen men who sprawl across its floors at night and then sit in its open air entryway during the day.

They spend their time drinking cups of strong coffee and watching Arabic news channels for any mention of the popular uprising that has gripped Syria since March and has posed an unprecedented challenge to four decades of rule by the family of President Bashar al-Assad.

The clinic’s second room serves as both an examination space and a pharmacy. Most of the space is taken up by a pile of supplies smuggled in over the mountains from Turkey or brought here by Mr. Marei, who grabbed what he could from his pharmacy when he fled his hometown of Jisr al-Shoughour before an assault by government tanks and troops.

Diapers and a few bottles of milk sit in one corner, but there is no way to provide prenatal care for the 25 pregnant women here, Mr. Marei said. More than 50 people have heart problems and three have kidney ailments, but there is no medicine. There is a crate of asthma medicine but only one inhaler, shared by more than 30 people.

“There was not time to take everything,” he said. “When the army came I took what I could and left quickly.”

Idlib is a rural province, and in many of its towns and villages pharmacists provide many people’s primary medical care. Mr. Marei said he was “used to playing both roles,” but was worried by the enormous need and the lack of supplies.

He also lacks the training to provide anything beyond basic care, or the equipment to perform surgical procedures.

“There are things I see here that I do not know how to treat,” he said.

Nevertheless, he does what he can, sometimes working from sunrise until after midnight. In the rush to flee Jisr al-Shoughour, he was injured when he fell off the back of a crowded pickup truck, fracturing his right shoulder. He has nothing stronger than over-the-counter painkillers to treat the symptoms.

“I did not know the situation would be this bad or last this long,” he said. “I have been here for 10 days, and I only brought with me enough medicine for one day or two.”

The International Committee of the Red Cross and its local partner, the Syrian Arab Red Crescent, announced Tuesday that the government had agreed to grant them “wider access to areas of unrest,” although the agreement has yet to be carried out.

Despite the severe shortcomings at Mr. Marei’s clinic, few here seemed pleased at the prospect of Red Crescent doctors arriving. The people here are deeply wary of their government, and rumors spread Tuesday that the Red Crescent had been infiltrated by the mukhabarat, the secret police. Mr. Marei said he thought people would trust only “their doctors from home, before the revolution,” and would be afraid to talk to the Red Crescent.

Ibrahim, a driver who brings in the wounded and takes people to the border, was more direct.

“Do you think a government that kills its own people is really going to let the Red Crescent come here to help us?” he asked. “Of course not. They are mukhabarat. They will come to see this place and collect intelligence on what we are doing here. Maybe they will attack us.”

Recipes for Health: Asparagus With Gremolata, Lemon and Olive Oil

Posted: 23 Jun 2011 11:30 PM PDT

This is a classic way to serve asparagus in the Italian region of Lombardy.

Recipes for Health

Martha Rose Shulman presents food that is vibrant and light, full of nutrients but by no means ascetic, fun to cook and to eat.

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2 garlic cloves, finely minced

1/4 cup finely chopped flat-leaf parsley

2 teaspoons finely chopped lemon zest

2 pounds asparagus, trimmed

Salt and freshly ground pepper

2 tablespoons fresh lemon juice

2 tablespoons extra virgin olive oil

1. Once you have finely chopped the garlic, parsley and lemon zest, chop them together on a cutting board until well combined. (This mixture is the gremolata.) Transfer to a bowl. Warm a serving platter.

2. Steam or boil the asparagus in salted water until tender, four to five minutes. Remove from the heat, and toss with the gremolata. Add salt and pepper to taste. Mix together the lemon juice and olive oil, and drizzle over the asparagus. Serve hot or warm.

Yield: Serves six.

Advance preparation: You can prepare the gremolata an hour or two before you cook the asparagus.

Nutritional information per serving (six servings): 76 calories; 1 gram saturated fat; 0 grams polyunsaturated fat; 3 grams monounsaturated fat; 0 milligrams cholesterol; 7 grams carbohydrates; 3 grams dietary fiber; 2 milligrams sodium (does not include salt to taste); 3 grams protein

Martha Rose Shulman is the author of "The Very Best of Recipes for Health."

Well: Giving Asparagus an Italian Accent

Posted: 24 Jun 2011 11:27 AM PDT

Well: Pictures to Warn the World About Smoking

Posted: 24 Jun 2011 08:56 AM PDT

Well: Triathlon for a Former Quadriplegic

Posted: 24 Jun 2011 09:11 AM PDT

Well: Epilepsy From the Patient’s Point of View

Posted: 24 Jun 2011 11:46 AM PDT

Well: Coming Out With Mental Illness

Posted: 23 Jun 2011 09:25 AM PDT

The New Old Age: Overtreatment Stories

Posted: 24 Jun 2011 09:55 AM PDT

Editorial: Drug Marketing and Free Speech

Posted: 24 Jun 2011 03:30 PM PDT

Pharmaceutical companies, which spend billions of dollars a year promoting their products to doctors, have found that it is very useful to know what drugs a doctor has prescribed in the past. Many use data collected from prescriptions processed by pharmacies — a doctor’s name, the drugs and the dosage — to refine their marketing practices and increase sales.

The Supreme Court on Thursday made it harder for states to protect medical privacy with laws that regulate such practices. In 2007, Vermont passed a law that forbade the sale of such records by pharmacies and their use for marketing purposes. The ruling upheld a lower court decision that struck down the law as unconstitutional.

Justice Anthony Kennedy, writing for the 6-to-3 majority, said the law violates First Amendment rights by imposing a “burden on protected expression” on specific speakers (drug marketers) and specific speech (information about the doctors and what they prescribed). It is unconstitutional because it restricts the transfer of that information and what the marketers have to say.

In dissent, Justice Stephen Breyer explains that the law’s only restriction is on access to data “that could help pharmaceutical companies create better sales messages.” He notes that any speech-related effects are “indirect, incidental, and entirely commercial.” By applying strict First Amendment scrutiny to this ordinary economic regulation, he warns, the court threatens to substitute “judicial for democratic decision-making.”

The law would have been upheld, Justice Breyer says, if the court had treated it as a restriction on commercial speech, which is less robustly protected than political speech. The court’s majority unwisely narrows the gap between commercial and political speech, and makes it harder to protect consumers.

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World Briefing | EUROPE: Britain: New Smoking Ban Is Pressed

Posted: 23 Jun 2011 10:05 PM PDT

On a vote of 78 to 66, the British House of Commons agreed Wednesday to consider outlawing smoking in private vehicles carrying children in an effort to reduce exposure to secondhand smoke. The vote ordered the government to draft a ban.

Curing the Pelvic Headache

Posted: 25 Jun 2011 03:40 PM PDT

The appeal of conversion stories often depends on descriptions of the darkness before enlightenment: we enjoy learning in detail about the presalvation misery, debauchery or sinfulness. The more detail, the better. The English novelist Tim Parks understands that principle. In his urbane, droll, weird yet far from charmless account of the pain and misery suffered by his body in general, and by his bladder, prostate, penis and related bits in particular, the conversion is from a cerebral, anxious, hunched-over and compulsively verbal kvetch (not his term, but the literal “squeeze” makes the Yiddish word seem appropriate) to something resembling the opposite.

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Illustration by Alain Pilon

TEACH US TO SIT STILL

A Skeptic’s Search for Health and Healing

By Tim Parks

Illustrated. 322 pp. Rodale. $25.99.

Like the reformed sinner who diverts his audience with lurid, prolonged accounts of nights in the fleshpots, Parks gives an amusing, anxiously over-the-top confession of his former condition: “I was nothing but tension. . . . I brushed my teeth ferociously, as if I wanted to file them down. I yanked on my socks as if determined to thrust my toes right through them. . . . When I pushed a command button, I did so as if it was my personal strength that must send the elevator to the sixth floor, or raise the door of the garage. While I shaved I tensed my jaw, while I read I tensed my throat, while I ate (too fast) I tensed my forehead, while I talked I tensed my shoulders, while I listened I tensed my neck, while I drove I tensed everything.”

This passage — much longer without my ellipses — extends over an entire page. The next paragraph begins, “And this is only the briefest summary of my chronically maladjusted state.”

In a hallmark of conversion narratives, the original mania reproduces itself as a mirror image: in the old days, hyperbolically anxious; in the new, hyperbolically anxious to enumerate the old anxiety. To his credit, Parks doesn’t pretend otherwise. Moreover, his personal account, never preachy, engages some serious matters about contemporary life, notably what it’s like to be a patient, as nearly all of us, sooner or later, are or will be.

With due respect to the ranks of excellent, humane and dedicated physicians, the following list will be all too familiar: the cheerily vague or uncertain diagnosis; conflicting or ambiguous opinions; the surgeon eager to do whatever his expertise and training have perfected; the humiliating procedures and instruments (Parks provides grotesque illustrations of penis-probers, stirrup-chairs, medical cross-sections of the groin); the ­physician-friend or physician-relative who becomes impatient with the patient-friend’s ambivalent feelings or ambivalent symptoms; symptoms treated as irrelevant because they don’t fit a profile; the expensive practitioner who is immensely more courteous and attentive than most, but not really different; the moment when the patient realizes the doctor’s “we” does not necessarily mean “you and I, dear patient” but more likely “my colleagues and staff and me.” The patient is one who is acted upon.

On his journey out of such passivity and misery, Parks discovers a book that offers him a first step away from pain, from the frequent urination wrecking his sleep, from the many frightful or nasty episodes involving what the Monty Python crew used to call the naughty bits. This book has the clumsy (Parks’s term), ludicrous yet arresting title “A Headache in the Pelvis.” (There’s a clumsy quality in Parks’s own title, quite possibly deliberate and intended to evoke the pathos of ailments that are embarrassing but serious matters. The subtitle makes this duality explicit. Parks gives his readers a sympathetic, even moving alteration between comedy and real desperation, in fluctuating measures regulated by “a skeptic” and his need for “health and healing.”)

“A Headache in the Pelvis,” in Parks’s account, replaces the reigning medical approach to “chronic prostatitis” as a matter of organs and their interconnecting tubes. Instead, this book by a urologist (Rodney Anderson) and a psychologist (David Wise) emphasizes muscles, particularly tension in pelvic muscles. A chapter about the technique of “paradoxical relaxation” fascinates Parks: concentrating on a tense muscle in the pelvic floor and not trying to relax it. “Harder than learning the piano,” as Parks quotes Wise, who himself suffered decades of pelvic pain, before his breakthrough. (A moment of Web surfing discloses that “A Headache in the Pelvis” is in its sixth edition, and has attracted many fervid testimonials.)

But for Parks and his own pelvic headaches (or mental pelvic aches?), that book is no more than a useful guide away from unsatisfactory medical thinking. The ultimate conversion, the revealed prize of his quest, is to Vipassana meditation: “Something happened. In the midst of the usual fierce pains, with a strange naturalness and inevitability, my consciousness at last fused with my upper lip: the breath, the lip, the mind, these apparently incompatible entities did, in fact, fit together, flow together, were one. I was my lip bathed in soft breath. . . . Then, as if at the touch of a switch, the scalding rigid tensing thighs and hips dissolved. In a moment, the lower body sank into suppleness.”

This is conventional but it isn’t silly. Though he can fall into the language of a devotee’s cant (“a powerful sense of nowness,” “I was in the cup, I was sticky with melon”), Parks is for the most part an aware, droll and intelligent guide to both his woe and to his salvation from it.

Robert Pinsky’s “Selected Poems” was published in April.
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