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History > 2013 > USA > Health (II)




Judge Blocks

North Dakota Abortion Restrictions


July 22, 2013
The New York Times


A federal judge on Monday blocked enforcement of North Dakota’s recently enacted ban on most abortions, calling it “invalid and unconstitutional.”

The law under challenge, which was set to take effect Aug. 1, would have imposed by far the country’s most stringent limit on abortions. With few exceptions, it would bar the procedure once a fetal heartbeat is detected, often about six weeks into pregnancy — a point when many women are not aware they are pregnant.

From the moment in March when it was adopted, most legal experts said that the law would not survive because it posed a direct challenge to Supreme Court guidelines, which state that a woman has a right to an abortion until the fetus is viable outside the womb. Viability must be determined by a physician and often occurs around 24 weeks into pregnancy.

Some anti-abortion leaders and politicians argued that the presence of a heartbeat is in itself a form of viability. They expressed hope that the Supreme Court would revisit the issue.

When he signed the bill, Gov. Jack Dalrymple, a Republican, called it “a legitimate attempt by a state legislature to discover the boundaries of Roe v. Wade.”

In a withering opinion issued on Monday, Judge Daniel L. Hovland of Federal District Court in North Dakota said he had no choice but to block the law. He described it as “in direct contradiction to a litany of United States Supreme Court cases addressing restraints on abortion.”

“The State has extended an invitation to an expensive court battle over a law restricting abortions that is a blatant violation of the constitutional guarantees afforded to all women,” Judge Hovland wrote. His decision on Monday imposed a temporary injunction, until the issue is decided at a trial.

The Center for Reproductive Rights, a group based in New York, brought the suit to block the law on behalf of the Red River Women’s Clinic in Fargo, the state’s only abortion clinic.

North Dakota’s law is the most far-reaching among scores of restrictive abortion statutes, many of them under court challenge, that have been passed by state governments in recent years.

An Arkansas law to bar abortions at 12 weeks of pregnancy, which, like North Dakota’s, was tied to detection of a fetal heartbeat, was blocked in May by a federal judge in Little Rock.

A dozen states, most recently Texas, have adopted laws barring abortions at 20 weeks after conception on the theory that the fetus can feel pain at that point. This approach, too, is inconsistent with Supreme Court doctrine and in the three states where it has been challenged in court so far — Arizona, Idaho and Georgia — it has been blocked.

In a different line of attack, anti-abortion groups have promoted stricter rules for abortion facilities, requiring clinics in certain states to meet costly building standards and requiring that abortion doctors have admitting privileges at nearby hospitals.

Medical groups call these measures unnecessary for patient safety. The Red River clinic, which relies on a doctor who flies in weekly, says it will be forced to close if the state’s admitting privileges law takes effect. The clinic’s court challenge to the rule is pending.

    Judge Blocks North Dakota Abortion Restrictions, NYT, 22.7.2013,






Texas Senate Vote

Puts Bill Restricting Abortion

Over Final Hurdle


July 13, 2013
The New York Times


AUSTIN, Tex. — The Texas Senate gave final passage on Friday to one of the strictest anti-abortion measures in the country, legislation championed by Gov. Rick Perry, who rallied the Republican-controlled Legislature late last month after a Democratic filibuster blocked the bill and intensified already passionate resistance by abortion-rights supporters.

The bill, which Mr. Perry is expected to sign, bans abortions after 20 weeks of pregnancy and holds abortion clinics to the same standards as hospital-style surgical centers, among other requirements. Its supporters say that the strengthened requirements for the structures and doctors will protect women’s health; opponents argue that the restrictions are actually intended to put financial pressure on the clinics that perform abortions and will force many of them to shut their doors.

Debate over the bill has ignited fierce exchanges between lawmakers, and tense confrontations between opponents of the bill, who have worn orange, and supporters of the bill wearing blue. Signs and slogans have been everywhere, bearing long, impassioned arguments or the simple scrawl on a young man’s orange shirt, a Twitter-esque “@TXLEGE: U R dumb.”

The bill had come nearly this far before: a version had been brought to the Senate in the previous session of the Legislature, in June, and was killed by State Senator Wendy Davis, a Democrat from Fort Worth, with an 11-hour filibuster that stalled the bill until after the deadline for ending the session. The filibuster became an overnight sensation on Twitter and other forms of social media, with more than 180,000 people viewing the filibuster live online.

Almost immediately, however, Governor Perry called for another special session to reconsider the bill. When the bill passed the House of Representatives after a contentious day and a half of proposed amendments and floor debate, Mr. Perry said he looked forward to the next step of the process, as “the Senate continues its important work in support of women’s health and protecting the lives of our most vulnerable Texans.”

The fight has been heavy with symbols. The House bill’s author, Representative Jodie Laubenberg, a Republican from Parker, dangled a pair of baby shoes before her as she spoke on Tuesday; Representative Senfronia Thompson, who offered an early amendment to the bill, was flanked by colleagues holding wire hangers, representing the brutal abortion methods they said would return if legitimate clinics were run out of business.

Ms. Laubenberg has said that the bill would close no facilities, adding, “It is time these clinics put patients ahead of profits.”

Supporters of the bill in the Legislature have been angered by the language of their opponents. During floor debate on Tuesday, Representative Jason Villalba, a Republican of Dallas, said that “I shall stand with Texas women, but I shall stand here no longer and be accused of conducting a ‘war on women.'  ” He said “we care for and we fight for human baby lives,” and he showed a sonogram of his own child at 13 weeks. “I will fight, and I will fight, and I will fight to protect my baby,” he said.

The bill is opposed by many doctors, including leaders of the American Congress of Obstetricians and Gynecologists and the Texas Medical Association; the gynecologists’ group has run advertisements locally that question the scientific underpinnings of the legislation and tell legislators to “Get out of our exam rooms.”

The Senate took up the bill on Friday afternoon, but people had begun lining up for seats in the third-floor Senate gallery early in the morning, a line that stretched from that floor into the basement of the Capitol. Department of Public Safety officers, their numbers swelled in anticipation of crowds and tumult, searched every bag and confiscated anything that could be thrown — including, for part of the day and until the practice became an object of derision online, tampons. But Department of Public Safety officials stated that the searches had turned up jars “suspected to contain” urine, feces and paint, along with glitter and confetti.

Senators worked through the evening surrounded by tumult and ruckus. Shouts, chants and singing could be heard outside of the chamber, and as the final amendment was voted down protesters tried to chain themselves to the railing of the Senate gallery and were taken out.

Though defeated in the Legislature, State Senator Royce West, a Democrat who represents Dallas, said the next step was clear: the ink from Mr. Perry’s signature on the bill is not likely to be dry for long before a lawsuit is filed.

“I’m a lawyer,” Mr. West said. “The reality is, I’m used to being in court. We believe the whole thing is unconstitutional.”

Mr. West would not comment on any specific legal strategy, but the many amendments and discussion of them during deliberations over the bill were clearly intended to build a record that could eventually be reviewed by the courts.

The Democrats who opposed the bill never had the votes to defeat it — Mr. West, during discussion of proposed amendments, said, “We know the bill is going to pass.” But State Senator Kirk Watson, the chairman of the Senate Democratic caucus, posted a Facebook photo on Wednesday of an orange T-shirt with a slogan about why the fight has continued. It read: “A foregone conclusion has never stopped a group of citizens committed to ideals of democracy and liberty from taking a stand and fighting with everything they’ve got. This is Texas, baby. Remember the Alamo.”

    Texas Senate Vote Puts Bill Restricting Abortion Over Final Hurdle,
    NYT, 13.7.2013,






The Contraception Battle


July 1, 2013
The New York Times


Last week saw two major developments in the legal and political battle over the Obama administration’s sound decision to require most employers to provide free insurance coverage of contraceptives for women under the new health care law — one of them positive and the other a blow to the mandate and to religious liberty.

The contraceptive coverage is an important advance in public health. Standing up to resistance from religious organizations, the Obama administration issued a final, simplified rule on Friday that allows houses of worship to exclude contraceptive coverage from their health plans for employees and their dependents. Other nonprofit religious and church-affiliated organizations like hospitals, universities and charities that object to contraceptive coverage on religious grounds will not have to contract, arrange or pay for the coverage. Instead, insurance companies or third-party administrators will have to arrange separate no-payment plans for contraceptive services.

Details of how this will work remain to be ironed out. But the administration has gone further than fairness or the First Amendment require to reach a compromise that respects the concerns of some religious entities without sacrificing an employee’s right to make her own decisions regarding contraceptives and not to conform to the religious beliefs of her employer.

Unfortunately, that vital principle of individual religious liberty was lost on the United States Court of Appeals for the 10th Circuit, in Denver. In a ruling issued on Thursday, it bought the argument that requiring the health plan of a private for-profit employer to cover birth control without a co-pay violated the employer’s freedom.

The case was brought by the owners of Hobby Lobby, a craft store chain that describes itself as “a faith-based company.” The First Amendment does not exempt religious entities from complying with neutral laws of general applicability, like the contraceptive mandate, much less private profit-making corporations. Yet, in an en banc ruling, the appellate court blocked the government from imposing fines on Hobby Lobby for not complying and allowed its challenge to the mandate to proceed, finding merit in its religious freedom claim.

Hobby Lobby argued that the contraception mandate violates the Religious Freedom Restoration Act, a 1993 federal statute that bars the federal government from taking actions that “substantially burden a person’s exercise of religion” unless that action advances a compelling government interest and is the “least restrictive means” of achieving it. The mandate’s promotion of women’s health and autonomy is plainly a compelling interest.

But the court should never have reached that question. Contrary to the majority opinion, a corporation like Hobby Lobby is plainly not a “person” covered by the Restoration Act. In any case, the contraceptive rule still leaves the company’s owners free to rail about the different forms of birth control to which they object and to try to convince employees not to use them. As the Justice Department cogently argued, the burden imposed on any religion is trivial in allowing employees to make their own independent decisions to obtain free contraceptives.

Marci Hamilton, a professor at Cardozo School of Law and an expert on the Restoration Act, rightly called the 10th Circuit’s interpretation of the law “a fantasy” that badly undermines rules forbidding corporations from discriminating on the basis of religion.

    The Contraception Battle, NYT, 1.7.2013,






A Damaging Decision on Generic Drugs


June 28, 2013
The New York Times


Consumers grievously harmed by generic drugs may find it virtually impossible to win compensation for their injuries as a result of a Supreme Court decision issued on Monday. By a narrow 5-to-4 margin, the court overturned lower court rulings that had awarded a New Hampshire woman $21 million for pain and suffering and other damages.

The decision leaves little recourse for people harmed by generic drugs, which now account for more than 80 percent of all prescriptions. It is imperative that the Food and Drug Administration write protective regulations holding generic companies liable for any harm their products cause.

There is no doubt that the New Hampshire woman, Karen Bartlett, suffered horrific injuries after taking a generic version of an anti-inflammatory drug, sulindac, for shoulder pain. She developed a very rare but extremely severe reaction in which two-thirds of her skin sloughed off. She was left permanently disfigured, legally blind, and with permanent damage to her lungs and esophagus.

The high court has now cut off her last pathway to compensation. In 2011, it ruled that generic-drug manufacturers could not be held liable for failing to warn consumers about a drug’s dangers because they must generally use the same safety label as the brand-name version they are copying. Now the court has also held that consumers cannot sue generic manufacturers for failing to design a safer drug because the generic must be chemically equivalent to the brand-name drug.

The New Hampshire case involved a conflict between state laws and court decisions requiring manufacturers to design products that are not “unreasonably dangerous” (based on an analysis of whether the potential for harm exceeds the usefulness of a product) and federal laws that restrict the ability of generic companies to take corrective action on their own.

The majority opinion, written by Justice Samuel Alito Jr., argued that the generic company Mutual Pharmaceutical had no way to comply with New Hampshire law because it had no power to unilaterally change the chemical composition or the warning label, and thus could not be held liable.

The four dissenting moderate liberals argued persuasively that the company could, in fact, comply with state law without changing the drug’s label or ingredients. It could continue to sell the drug and pay compensation for any harm it caused as a cost of doing business, or it could remove the drug from the market.

The decision leaves the regulation of generic drugs in a perilous state. A report released Monday by Public Citizen, the consumer advocacy group, listed 434 generic drugs for which no brand-name product remains on the market to initiate changes in the warning labels to flag newly discovered risks. Even so, the generic companies have an obligation to notify the F.D.A. about any risks they detect so that the agency can work with them to modify the warning labels.

For a more permanent solution, the F.D.A. told the high court it was considering a rule that would allow generic manufacturers, like brand-name manufacturers, to change their labeling in some circumstances. That could once again make them liable — and rightly so — for harm and allow consumers to sue them if they failed to warn of dangers.

    A Damaging Decision on Generic Drugs, NYT, 28.6.2013,






Contraceptives Stay Covered in Health Law


June 28, 2013
The New York Times


WASHINGTON — Despite strong resistance from religious organizations, the Obama administration said Friday that it was moving ahead with a rule requiring most employers to provide free insurance coverage of contraceptives for women, a decision that has touched off a legal and political battle likely to rage for another year.

The final rule, issued under the new health care law, adopts a simplified version of an approach proposed by the government in February to balance the interests of women with the concerns of the Roman Catholic Church and other employers with religious objections to providing coverage for contraceptives.

After considering more than 400,000 comments, administration officials refused to budge on the basic principle. The rule, they said, is very similar to their proposal. An exemption is included for churches. But many Catholic hospitals, schools, universities and other religious institutions will have to take steps so that coverage is available to employees and their dependents.

The issue figured prominently in last year’s elections as President Obama and other Democrats pressed their advantage with female voters. At the same time, Catholic bishops waged a national campaign arguing that the federal policy infringed on religious freedom and violated the church’s social and moral teachings on birth control and abortion.

Cardinal Timothy M. Dolan of New York, president of the United States Conference of Catholic Bishops, said the group was reviewing the final rule.

Democrats describe the mandate for coverage of birth control as one of the chief benefits of the 2010 health care law, a boon to women and their health.

“The health care law guarantees millions of women access to recommended preventive services at no cost,” said Kathleen Sebelius, the secretary of health and human services. “Today’s announcement reinforces our commitment to respect the concerns of houses of worship and other nonprofit religious organizations that object to contraceptive coverage, while helping to ensure that women get the care they need, regardless of where they work.”

Republicans say the requirement shows how intrusive and onerous the law is.

The rule does not satisfy the concerns of certain religious organizations or businesses whose owners have religious objections to contraceptive coverage.

The United States Court of Appeals for the 10th Circuit, in Denver, said Thursday that the owners of Hobby Lobby, a craft store chain that describes itself as “a faith-based company,” could pursue their case against the rule.

Eric C. Rassbach, a deputy general counsel of the Becket Fund for Religious Liberty, which has represented plaintiffs in that case and others challenging the law, said the final rule did nothing to meet the objections of his clients.

“The government tinkered with some mechanisms in the rule, but did not really get at the religious conscience questions,” Mr. Rassbach said. “So there is a fundamental conflict that will have to be resolved in court.”

Under the rule, women are to have access to contraceptives without any premium, deductible, co-payment or other fees.

Some religious employers do not want their employees to have coverage of contraceptives, even if someone else pays for it.

A number of federal judges deferred decisions until the White House issued a final regulation. Publication of the rule clears the way for courts to act.

Under the new health care law, employers with more than 50 employees will generally be required to offer health insurance to employees, or the employers will be subject to financial penalties.

Among the “essential health benefits” that must be provided are preventive services. In particular, the administration says, most health plans must cover sterilization and the full range of contraceptive methods approved by the Food and Drug Administration, including emergency contraceptive pills, like those known as ella and Plan B One-Step.

Under the rule issued Friday, the government said certain “religious employers” — primarily houses of worship — may exclude contraceptive coverage from their health plans for employees and their dependents. In effect, they will be exempt from the federal requirement to provide contraceptive coverage.

The rule also lays out what it describes as an accommodation for other nonprofit religious and church-affiliated organizations, like hospitals, universities and charities, that object to contraceptive coverage but do not qualify for the exemption.

Under the rule, these organizations will not have to contract, arrange or pay for contraceptive coverage to which they object on religious grounds.

Instead, the administration said, such coverage will be “separately provided to women enrolled in their health plans at no cost.”

Under this arrangement, a nonprofit religious employer must notify its insurer that it objects to contraceptive coverage. The insurer must then notify people in the health plan that it will arrange or pay for contraceptive services as long as they remain in the health plan.

Many employers serve as their own insurers and hire outside companies to administer benefits and pay claims. In such cases, the administration said, the “third-party administrator” must inform people in an employer-sponsored health plan that it is “providing or arranging separate no-cost payments for contraceptive services.”

Administration officials said the cost of contraceptive services would, for insurers, be offset by savings that result from the fact that women would be healthier and will have fewer births.

To reimburse third-party administrators for the cost of contraceptive services, the government said it would reduce the fees charged to certain health insurance companies for the privilege of selling insurance in federal marketplaces, or exchanges, being established in more than 30 states. Insurers will then be required to share some of those savings with third-party administrators for the self-insured health plans of religious employers that object to contraceptive coverage.

The reduction in user fees would reflect the cost of contraceptive services, as well as “an allowance for administrative costs and margin,” or profit. The government would require third-party administrators to provide detailed information about the payments they made or arranged.

Federal officials had difficulty explaining how these arrangements would work in practice. They said they were leaving the details to employers, insurers and third-party administrators.

The Labor Department said it had the authority to require third-party administrators to provide, or arrange for an insurance company or other entity to provide, payment for contraceptive services.

The final rule is the administration’s fourth attempt in 20 months to articulate a policy requiring contraceptive coverage.

Senator Patty Murray, Democrat of Washington, said: “Today’s ruling strikes a fair balance between religious liberties and the reproductive rights of all women. Access to contraception shouldn’t be dictated by a woman’s employer.”

But Patrick J. Reilly, president of the Cardinal Newman Society, which promotes Catholic education, said the final rule did not respect the religious freedom of religious employers. “Now the lawsuits can proceed,” he said.

    Contraceptives Stay Covered in Health Law, 28.6.2013,






Judge Orders All Restrictions Lifted

on Some ‘Morning-After’ Pills


June 5, 2013
The New York Times


A federal appeals court in New York on Wednesday ordered that some types of emergency contraceptives be made available for now to women of all ages without a prescription, adding another layer of confusion to a complex and intensely political fight over the drug’s availability.

In a brief ruling, the United States Court of Appeals for the Second Circuit ordered that the federal government lift all age and sales restrictions for two-pill versions of emergency contraceptives until the court finally rules on an appeal by the federal government, which is trying to maintain limits on the drug’s over-the-counter availability.

Two-pill versions of the drug, and all but one brand of the one-pill version, are now available without a prescription only to women 17 and older. In April, a federal district judge ruled that all versions of the so-called morning-after contraceptive be made available over-the-counter to all ages. The Obama administration appealed that ruling and asked that the judge’s order be postponed until the appeals court renders a final judgment. All briefs in the case are due Aug. 14.

The Food and Drug Administration last month ruled that Plan-B One-Step, but not other one-pill brands, be made available without a prescription for girls and women ages 15 and older. Purchasers are still required to show identification to verify their age. The appeals court’s interim ruling Wednesday does not change that brand’s availability.

Officials with the F.D.A., the Health and Human Services department and the Justice Department said they were reviewing Wednesday’s decision.

Both the one-pill and two-pill emergency contraceptives involve the same ingredient, the hormone levonorgestrel. But the distinction between the two versions has been invoked primarily for legal or technical reasons.

The appeals court on Wednesday did not explain why it permitted two-pill versions to be sold over-the-counter, but not any one-pill versions, which have been overtaking the United States market. However, the original lawsuit, filed nearly a decade ago, referred to two-pill versions because there were no one-pill versions at the time. Legal experts said the appeals court might have decided Wednesday that the government had less of a chance of succeeding in its appeal regarding two-pill versions.

The issue of emergency contraception is fraught with political sensitivities for the Obama administration. Conservative groups object to the drug itself, arguing that it may encourage young people to have unprotected sex. Some anti-abortion groups also contend that the drug is tantamount to an abortion pill, despite strong scientific evidence that the pill only prevents fertilization and does not act after an egg is fertilized.

Scientists have long argued against the need for any restrictions on the pill’s sale, saying that studies show it is safer than many common over-the-counter drugs, including acetaminophen. And women’s rights groups have advocated for the drug as a safe option for women in an emergency.

Supporters of lifting all restrictions note that most people who use the drug are not adolescents, but that having any age limits at all requires pharmacies to make access to the pills more difficult for everyone, since government-issued picture identification is needed, and some people do not have such identification or may not have it readily available.

In December 2011, as President Obama was running for re-election, his secretary of health and human services, Kathleen Sebelius, took the unprecedented step of overruling an F.D.A. plan to lift all age restrictions. Ms. Sebelius said she was concerned that there were not enough studies to prove that the drug was safe for girls as young as 11. Mr. Obama supported her decision, saying that as a father of young girls, the idea of making the drug available to them without a prescription made him uncomfortable.

The administration sought to strike a balance in May, supporting a change that made Plan B One-Step available to girl ages 15 and older without a prescription, and directed drugstores to sell that pill openly, rather than locking it up behind a counter.

The F.D.A. said it had restricted its decision to Plan B One-Step because the manufacturer, Teva Pharmaceuticals, filed an amended application to lower the age of availability to 15. The F.D.A. also said that more studies would be required to show that girls under age 17 could understand how to take two pills instead of just one.

The next day, the government appealed the broader federal court order, issued in April by Judge Edward R. Korman of Federal District Court for the Eastern District of New York, who accused the government of placing politics ahead of science. The judge issued a similarly scathing response to the government’s appeal, singling out what he called the “bad-faith, politically motivated decision of Secretary Sebelius, who lacks any medical or scientific expertise.”


Katie Thomas contributed reporting.

    Judge Orders All Restrictions Lifted on Some ‘Morning-After’ Pills, NYT, 5.6.2013,






Joblessness Shortens

Lifespan of Least Educated White Women,

Research Says


May 30, 2013
The New York Times


Researchers have known for some time that life expectancy is declining for the country’s least educated white women, but they have not been able to explain why. A new study has found that the two factors most strongly associated with higher death rates were smoking and not having a job.

The aim of the study, which is being published Thursday in The Journal of Health and Social Behavior, was to explain the growing gap in mortality between white women without a high school diploma and those with a high school diploma or more.

The study found that the odds of dying for the least educated women were 37 percent greater than for their more educated peers in any given year in the period of 1997 to 2001. The odds had risen to 66 percent by the period of 2002 to 2006. The authors controlled for age.

The researchers used a health survey conducted by the National Center for Health Statistics, drawing on data from about 47,000 women ages 45 to 84. The study weighed more than a dozen factors to see which were causing the divergence in mortality rates. Poverty, obesity, homeownership, marital status and alcohol consumption were among the factors investigated.

But they mattered little. As it turned out, smoking was important, as had long been established, but researchers were surprised that joblessness had a dramatic effect, even after controlling for factors that employment would have generated, like income and health insurance.

“What is it about employment that has this huge impact on mortality, beyond the material resources it brings?” said Jennifer Karas Montez, the study’s lead author, a researcher at the Harvard Center for Population and Development Studies.

The study was an attempt to explain the reasons behind the troubling trend of declining life expectancy for the least educated Americans, particularly women. A study last year found that white women without a high school diploma lost five years of life expectancy between 1990 and 2008, a measure of decline last seen among Russians in the economic chaos that came after the fall of the Soviet Union. This year, researchers at the University of Wisconsin found that mortality for women had gone up in more than 40 percent of the counties in the United States since the early 1990s.

But the study raised more questions than it answered, in particular about why employment status affects physical health. Ms. Montez said there was some evidence that having a job offered intangible benefits that could improve health, including a sense of purpose and control in life, as well as providing networks that help to reduce social isolation.

One concern was that people who were not working were jobless because they were sick, but Ms. Montez said they did not find evidence for that.

Sarah Damaske, an assistant professor of labor studies and employment relations and sociology at Pennsylvania State University, said women who were not in the labor force, a minority now compared to the 1950s, were more likely to have been disadvantaged from the outset, coming from family backgrounds and economic circumstances that tended to produce poorer health outcomes.

    Joblessness Shortens Lifespan of Least Educated White Women, Research Says,
    NYT, 30.5.2013,






Heroes of Uncertainty


May 27, 2013
The New York Times


We’re living in an empirical age. The most impressive intellectual feats have been achieved by physicists and biologists, and these fields have established a distinctive model of credibility.

To be an authoritative figure, you want to be coolly scientific. You want to possess an arcane body of technical expertise. You want your mind to be a neutral instrument capable of processing complex quantifiable data.

The people in the human sciences have tried to piggyback on this authority model. For example, the American Psychiatric Association has just released the fifth edition of the Diagnostic Statistical Manual of Mental Health Disorders. It is the basic handbook of the field. It defines the known mental diseases. It creates stable standards, so that insurance companies can recognize various diagnoses and be comfortable with the medications prescribed to treat them.

The recent editions of this manual exude an impressive aura of scientific authority. They treat mental diseases like diseases of the heart and liver. They leave the impression that you should go to your psychiatrist because she has a vast body of technical knowledge that will allow her to solve your problems. With their austere neutrality, they leave a distinct impression: Psychiatrists are methodically treating symptoms, not people.

The problem is that the behavorial sciences like psychiatry are not really sciences; they are semi-sciences. The underlying reality they describe is just not as regularized as the underlying reality of, say, a solar system.

As the handbook’s many critics have noted, psychiatrists use terms like “mental disorder” and “normal behavior,” but there is no agreement on what these concepts mean. When you look at the definitions psychiatrists habitually use to define various ailments, you see that they contain vague words that wouldn’t pass muster in any actual scientific analysis: “excessive,” “binge,” “anxious.”

Mental diseases are not really understood the way, say, liver diseases are understood, as a pathology of the body and its tissues and cells. Researchers understand the underlying structure of very few mental ailments. What psychiatrists call a disease is usually just a label for a group of symptoms. As the eminent psychiatrist Allen Frances writes in his book, “Saving Normal,” a word like schizophrenia is a useful construct, not a disease: “It is a description of a particular set of psychiatric problems, not an explanation of their cause.”

Furthermore, psychiatric phenomena are notoriously protean in nature. Medicines seem to work but then stop. Because the mind is an irregular cosmos, psychiatry hasn’t been able to make the rapid progress that has become normal in physics and biology. As Martin Seligman, a past president of the American Psychological Association, put it in The Washington Post early this year, “I have found that drugs and therapy offer disappointingly little additional help for the mentally ill than they did 25 years ago — despite billions of dollars in funding.”

All of this is not to damn people in the mental health fields. On the contrary, they are heroes who alleviate the most elusive of all suffering, even though they are overmatched by the complexity and variability of the problems that confront them. I just wish they would portray themselves as they really are. Psychiatrists are not heroes of science. They are heroes of uncertainty, using improvisation, knowledge and artistry to improve people’s lives.

The field of psychiatry is better in practice than it is in theory. The best psychiatrists are not austerely technical, like the official handbook’s approach; they combine technical expertise with personal knowledge. They are daring adapters, perpetually adjusting in ways more imaginative than scientific rigor.

The best psychiatrists are not coming up with abstract rules that homogenize treatments. They are combining an awareness of common patterns with an acute attention to the specific circumstances of a unique human being. They certainly are not inventing new diseases in order to medicalize the moderate ailments of the worried well.

If the authors of the psychiatry manual want to invent a new disease, they should put Physics Envy in their handbook. The desire to be more like the hard sciences has distorted economics, education, political science, psychiatry and other behavioral fields. It’s led practitioners to claim more knowledge than they can possibly have. It’s devalued a certain sort of hybrid mentality that is better suited to these realms, the mentality that has one foot in the world of science and one in the liberal arts, that involves bringing multiple vantage points to human behavior.

Hippocrates once observed, “It’s more important to know what sort of person has a disease than to know what sort of disease a person has.” That’s certainly true in the behavioral sciences and in policy making generally, though these days it is often a neglected truth.

    Heroes of Uncertainty, NYT, 27.5.2013,






Barbara Brenner,

Breast Cancer Iconoclast,

Dies at 61


May 20, 2013
The New York Times


Barbara Brenner, who led the group Breast Cancer Action and shaped it in her own combative image, pillorying the medical establishment, industrial polluters and even other cancer research advocates, died May 10 at her home in San Francisco. She was 61.

Suzanne Lampert, her partner of 38 years, confirmed the death, of amyotrophic lateral sclerosis. Ms. Brenner also had breast cancer, though it had been in remission.

She championed causes for most of her adult life, protesting the Vietnam War as a college student and working on women’s rights, civil rights and employment discrimination as a lawyer. She became Breast Cancer Action’s first executive director in 1995, two years after undergoing treatment for the disease and a year before it recurred.

Ms. Brenner led the group until 2010, when illness forced her to retire. During the 15 years of her leadership, the group increased its membership to 50,000 from 3,500 and intensified its focus on demanding research into the causes of breast cancer, particularly links to environmental pollutants like chemicals in food and the water supply, an area of research rife with unreliable data.

Ms. Brenner was among the first to question what she called the “pinkwashing” of America: the proliferation of pink ribbons and products carrying labels stating that part of the purchase price would go to breast cancer research. Her group started a campaign, “Think Before You Pink,” urging consumers to look into how much money was donated and where it went.

In one of many fiery posts on her blog, Healthy Barbs, she attacked another breast cancer group, Susan G. Komen for the Cure, for teaming up with KFC to produce pink buckets of chicken. Fried chicken, she said, promotes obesity, which is a risk factor for breast cancer.

Dr. Otis W. Brawley, the chief medical and scientific officer of the American Cancer Society, called Ms. Brenner “a dear friend,” but added, “I didn’t agree with her, probably 40 or 50 percent of the time.”

One point of difference was over whether environmental factors play a major role in cancer. Ms. Brenner thought they did; Dr. Brawley is skeptical.

Breast Cancer Action gained respect for its policy, developed by Ms. Brenner, of not accepting donations from companies that make money from diagnosing or treating cancer, or whose products or processes might cause cancer. That meant no money from drug, oil, tobacco or chemical companies, or from cancer treatment centers or health insurers. That policy freed the group to hold such companies accountable.

Breast Cancer Action is now among the plaintiffs in a case being considered by the Supreme Court that challenges the right of Myriad Genetics Inc. to patent genes to maintain a monopoly on a blood test used to look for mutations that greatly increase the risk of cancer.

The policy also let Ms. Brenner speak her mind, which she often did. At a medical conference, she stood up and scolded a researcher who had described patients as failing a treatment. Patients do not fail treatments, she told him — treatments fail patients.

Ms. Brenner was unapologetic about being so blunt. She told Ms. magazine in 2005, “We serve no purpose in being nice.”

Barbara Ann Brenner was born on Oct. 7, 1951, in Baltimore, the third of seven children. Her father, Morton, worked in finance in the clothing industry, and her mother, Bettie, was a librarian. Besides Ms. Lampert, her survivors include five siblings, Joseph, Mark, Richard, Lawrence and Nanci Grail. A sister, Ruth Newman, also died from amyotrophic lateral sclerosis.

(Ms. Brenner refused to subscribe to the popular term for the illness — Lou Gehrig’s disease — saying the image of a hale and hearty athlete that the name evokes is wrong for so devastating an affliction.)

Ms. Brenner graduated from Smith College and attended law school at Georgetown but left after a year, having decided, she said, that the law had little to do with justice. She enrolled in graduate school at the Woodrow Wilson School of Public and International Affairs at Princeton, where she met Ms. Lampert.

After working for the American Civil Liberties Union in Los Angeles, Ms. Brenner resumed her law studies, earning a degree from the University of California, Berkeley.

As tart as Ms. Brenner was with opponents, she was compassionate with women seeking information about breast cancer. Angela Wall, Breast Cancer Action’s communications director, said Ms. Brenner would often tell callers who had just received a cancer diagnosis, “I’m sorry to say, welcome to the sisterhood.”

As her neurological disease worsened, Ms. Brenner lost the ability to speak, eat or walk and wore a neck brace. But she continued to blog until a few days before her death. Her final post ended with a blessing from the Jewish tradition, wishing her readers peace.

Ms. Lampert said, “I always told her that I would make sure her obituary said she died after a long battle with the breast cancer industry.”

    Barbara Brenner, Breast Cancer Iconoclast, Dies at 61, NYT, 20.5.2013,






The Health Toll of Immigration


May 18, 2013
The New York Times


BROWNSVILLE, Tex. — Becoming an American can be bad for your health.

A growing body of mortality research on immigrants has shown that the longer they live in this country, the worse their rates of heart disease, high blood pressure and diabetes. And while their American-born children may have more money, they tend to live shorter lives than the parents.

The pattern goes against any notion that moving to America improves every aspect of life. It also demonstrates that at least in terms of health, worries about assimilation for the country’s 11 million illegal immigrants are mistaken. In fact, it is happening all too quickly.

“There’s something about life in the United States that is not conducive to good health across generations,” said Robert A. Hummer, a social demographer at the University of Texas at Austin.

For Hispanics, now the nation’s largest immigrant group, the foreign-born live about three years longer than their American-born counterparts, several studies have found.

Why does life in the United States — despite its sophisticated health care system and high per capita wages — lead to worse health? New research is showing that the immigrant advantage wears off with the adoption of American behaviors — smoking, drinking, high-calorie diets and sedentary lifestyles.

Here in Brownsville, a worn border city studded with fast-food restaurants, immigrants say that happens slowly, almost imperceptibly. In America, foods like ham and bread that are not supposed to be sweet are. And children lose their taste for traditional Mexican foods like cactus and beans.

For the recently arrived, the quantity and accessibility of food speaks to the boundless promise of the United States. Esther Angeles remembers being amazed at the size of hamburgers — as big as dinner plates — when she first came to the United States from Mexico 15 years ago.

“I thought, this is really a country of opportunity,” she said. “Look at the size of the food!”

Fast-food fare not only tasted good, but was also a sign of success, a family treat that new earnings put in reach.

“The crispiness was delicious,” said Juan Muniz, 62, recalling his first visit to Church’s Chicken with his family in the late 1970s. “I was proud and excited to eat out. I’d tell them: ‘Let’s go eat. We can afford it now.’ ”

For others, supersize deals appealed.

“You work so hard, you want to use your money in a smart way,” said Aris Ramirez, a community health worker in Brownsville, explaining the thinking. “So when they hear ‘twice the fries for an extra 49 cents,’ people think, ‘That’s economical.’ ”

For Ms. Angeles, the excitement of big food eventually wore off, and the frantic pace of the modern American workplace took over. She found herself eating hamburgers more because they were convenient and she was busy in her 78-hour-a-week job as a housekeeper. What is more, she lost control over her daughter’s diet because, as a single mother, she was rarely with her at mealtimes.

Robert O. Valdez, a professor of family and community medicine and economics at the University of New Mexico, said, “All the things we tell people to do from a clinical perspective today — a lot of fiber and less meat — were exactly the lifestyle habits that immigrants were normally keeping.”

As early as the 1970s, researchers found that immigrants lived several years longer than American-born whites even though they tended to have less education and lower income, factors usually associated with worse health. That gap has grown since 1980. Less clear, however, was what happened to immigrants and their American-born offspring after a lifetime in the United States.

Evidence is mounting that the second generation does worse. Elizabeth Arias, a demographer at the National Center for Health Statistics, has made exploratory estimates based on data from 2007 to 2009, which show that Hispanic immigrants live 2.9 years longer than American-born Hispanics. The finding, which has not yet been published, is similar to those in earlier studies.

Still, the data does not break down by generation. Ms. Arias cautioned that subsequent generations — for example, grandchildren and great-grandchildren — may indeed improve as they rise in socioeconomic status, which in the United States is strongly correlated with better health.

Other research suggests that some of the difference has to do with variation among American-born Hispanics, most of whom still do better than the rest of the American population. Puerto Ricans born in the continental United States, for example, have some of the shortest life spans and even do worse than whites born in the United States, according to research by Professor Hummer, dragging down the numbers for American-born Hispanics. But Mexican immigrant men live about two years longer than Mexican-American men, according to the estimates by Ms. Arias.

Why is a harder question to answer, researchers say. Some point to smoking. Andrew Fenelon, a researcher at Brown University, found in 2011 that half of the three-year life expectancy advantage that Hispanic immigrants had over American-born Hispanics was because they smoked less. The children of immigrants adopt health behaviors typical of Americans in their socioeconomic group. For second-generation Hispanics, the group tends to be lower income, with higher rates of smoking and drinking.

Other researchers say culture contributes. Foreign-born Hispanics are less likely than American-born Hispanics to be raising children alone, and more likely to be part of large kinship networks that insulate them from harsh American economic realities that can lead to poor health.

“I’d love to have my wife at home taking care of the kids and making sure they eat right, but I can’t afford to,” said Camilo Garza, a 34-year-old plumber and maintenance worker whose grandfather immigrated from Mexico. “It costs money to live in the land of the free. It means both parents have to work.”

As a result, his family eats out almost every night, leaving his dining table abandoned.

“It’s a decoration,” said Mr. Garza, who is overweight and a smoker. “It’s a place where we set groceries before sticking them in the refrigerator.”

The lifestyle takes its toll. The county in which Brownsville is situated, Cameron, has some of the highest rates of obesity and diabetes in the country. The numbers are made worse by a lack of physical activity, including walking. Immigrants said they felt so conspicuous during early attempts to walk along the shoulder of the roads that they feared people would suspect they were here illegally. Ms. Angeles recalled that strolling to a dollar store provoked so many stares that she felt like “a bean in rice.”

“In Mexico, we ate healthily and didn’t even know it,” said Ms. Angeles, who has since developed diabetes. “Here, we know the food we eat is bad for us. We feel guilty. But we eat it anyway.”

Still, immigrants have better health outcomes than the American-born. A 2006 analysis by Gopal K. Singh, a researcher at the Department of Health and Human Services, and Robert A. Hiatt, a professor of epidemiology and biostatistics at the University of California, San Francisco, found that immigrants had at least a 20 percent lower overall cancer mortality rate than their American-born counterparts.

Mortality rates from heart disease were about 16 percent lower, for kidney disease 18 percent lower, and for liver cirrhosis 24 percent lower.

“When my daughter was born, my doctor told me that if I wanted to see her 15th birthday I needed to lose the weight,” said Gerry Ortiz, 37, a first-generation Mexican-American in Brownsville. He managed to lose 75 pounds, motivated in part by his grandfather, a farmer in rural Mexico who at 93 still rides his bicycle every day. He stares down at the family from a black-and-white photograph hanging in Mr. Ortiz’s living room. Four of the family’s six siblings are obese and have diabetes.

And health habits in Mexico are starting to look a lot like those in the United States. Researchers are beginning to wonder how long better numbers for the foreign-born will last. Up to 40 percent of the diet of rural Mexicans now comes from packaged foods, according to Professor Valdez.

“We are seeing a huge shift away from traditional diets,” he said. “People are no longer growing what they are eating. They are increasingly going to the market, and that market is changing.”

Joseph B. McCormick, the regional dean of the University of Texas School of Public Health in Brownsville, said, “The U.S. culture has crept across the border.”

Perhaps more immediate is the declining state of Hispanic health in the United States. Nearly twice as many Hispanic adults as non-Hispanic white adults have diabetes that has been diagnosed, a rate that researchers now say may have a genetic component, particularly in those whose ancestry is Amerindian from Central and South America, Dr. McCormick said.

Hispanic adults are also 14 percent more likely to be obese, according to 2010 data from the Centers for Disease Control and Prevention. The rate is even higher for Hispanic children, who are 51 percent more likely to be obese than non-Hispanic white children.

“We have a time bomb that’s going to go off,” said Dr. Amelie G. Ramirez, a professor of epidemiology and biostatistics at the University of Texas Health Science Center in San Antonio. “Obesity rates are increasing. Diabetes is exploding. The cultural protection Hispanics had is being eroded.”

But at least for now, the older generation is still enjoying its advantage. In the De Angeles snack bar, a favorite meeting place for elderly Brownsvillians, one regular who is 101 still walks across the bridge to Mexico. Maria De La Cruz, a 73-year-old who immigrated to the United States in her 40s, says her secret is raw garlic, cooked cactus and exercise, all habits she acquired from her father, a tailor who died at 98.

“He had very pretty legs, like mine,” she said, laughing. “You want to see them?”

    The Health Toll of Immigration, NYT, 18.5.2013,






Abortion Law in Arkansas

Is Blocked by U.S. Judge


May 17, 2013
The New York Times


A federal judge on Friday temporarily blocked enforcement of one of the country’s most stringent abortion laws, an Arkansas ban on the procedure at the 12th week of pregnancy, saying the law was likely to be declared unconstitutional.

Adopted in March, the law was the sharpest challenge yet to the standard set by the Supreme Court. Roe v. Wade in 1973 and later decisions determined that a woman has a right to an abortion up to the point that a fetus is viable outside the womb, usually around 24 weeks.

Abortion rights groups quickly brought a legal challenge, resulting in Friday’s preliminary injunction, which was issued by Judge Susan Webber Wright of Federal District Court in Little Rock. The injunction will prevent the law from taking effect on its scheduled date of Aug. 16 and will remain in place until the judge hears final arguments and rules on its constitutionality.

Also in March, North Dakota passed an even more restrictive law, banning abortions at the sixth week of pregnancy, which is before many women even know they are pregnant. The Center for Reproductive Rights, a New York-based group that challenged the Arkansas law, along with the American Civil Liberties Union, said it planned to file a plea in North Dakota to block that law before it takes effect on Aug. 1.

In both states, the sharp time limits were linked by legislators to the detection of fetal heartbeats. They were the first victories for an impatient faction of the anti-abortion movement that wants to strike major blows against abortion rather than chipping away at Roe v. Wade with less sweeping rules that are more likely to pass constitutional muster.

Their hope, dismissed as wishful thinking by many established leaders of the anti-abortion movement like National Right to Life and the Roman Catholic Church, is that the Supreme Court might be willing to adopt a radical new framework for regulating abortion.

Arguing against the preliminary injunction on Friday, lawyers for Arkansas claimed it was too early to pass judgment on the law because it had not taken effect. They also said the law was true to the spirit of Supreme Court rulings because it would permit a large majority of abortions, which already occur before 12 weeks, to proceed and would encourage pregnant women and doctors to seek earlier, “safer and more humane abortions.”

But the judge, as expected by many legal experts, agreed with the challengers’ statement that “the U.S. Supreme Court has held unequivocally that a state may not ban abortion prior to viability.”

State Senator Jason Rapert, the author of the 12-week ban, said Friday that he was “obviously disappointed” by the injunction. He said he hoped the court, before making a final decision, would allow new arguments and evidence from a coalition of conservative legal groups.

Even without the law, Arkansas now has one of the country’s strictest abortion limits. In another law passed this spring that took effect immediately, it became one of 10 states to ban abortions at 20 weeks. These measures also appear to violate the Supreme Court’s viability threshold and have been blocked in a few states, but no legal challenge has been filed in Arkansas.

    Abortion Law in Arkansas Is Blocked by U.S. Judge, NYT, 17.5.2013,






The Murky World of Hospital Prices


May 16, 2013
The New York Times


Last week, the federal government made public a vast trove of information on the list prices charged by hospitals for a large array of procedures commonly performed on hospitalized patients. It was a good start toward providing greater transparency in hospital billing, which has long been shrouded in secrecy. But it fell short of providing full information that patients need to make informed decisions about which hospitals to use and which insurance to buy.

The data was compiled from hospital claims submitted to Medicare by more than 3,300 hospitals seeking fee-for-service reimbursements for the 100 most common inpatient treatments in fiscal-year 2011. The prices at issue — sometimes called “chargemaster” prices — are not what most people pay. They are far higher than what Medicare pays, which is close to the real cost of providing the service, and also higher than what private insurers pay because they negotiate for discounts.

The only patients likely to be charged the full listed prices are those with little or no insurance and no purchaser to bargain on their behalf. Many insured patients also face higher premiums or co-payments because their plans reimburse the hospitals based on discounts from the listed prices. The listed prices varied wildly from one part of the country to another and even within the same city or region, seemingly without any good reason or any relationship to the quality of care delivered.

For example, a Times analysis published Friday found that the Bayonne Medical Center in New Jersey typically charged $99,689 for treating each case of chronic lung disease, 17 times as much as Medicare paid in reimbursement. The price for a joint replacement with artificial hips or knees ranged from a low of $5,300 in a hospital in Ada, Okla., to a high of $223,000 at a hospital in Monterey Park, Calif., a 40-fold difference that cannot be explained by regional differences in wages, the sickness of the patients, or a hospital’s teaching responsibilities. The charge for treating heart failure patients in hospitals in Jackson, Miss., ranged from $9,000 to $51,000.

The huge differences in list prices have been posted on a government Web site. But for consumers to compare one hospital with another in a meaningful way, they need to know a lot more — including the rates that have been negotiated between hospitals and insurers, the listed prices for outpatient treatments, and the quality of care provided, a difficult measurement that is in its infancy.

    The Murky World of Hospital Prices, NYT, 16.5.2013,






Philadelphia Abortion Doctor

Guilty of Murder in Late-Term Procedures


May 13, 2013
The New York Times


PHILADELPHIA — A doctor who was responsible for cutting the spines of babies after botched abortions was convicted Monday of three counts of first-degree murder in a case that became a sharp rallying cry for anti-abortion activists.

The doctor, Kermit Gosnell, 72, operated a clinic in West Philadelphia catering to poor women that prosecutors called a “house of horrors.”

The case turned on whether the late-term pregnancies Dr. Gosnell terminated resulted in live births. His lawyer, Jack McMahon, argued that because Dr. Gosnell injected a drug in utero to stop the heart, the deliveries were stillbirths, and movements that witnesses testified to observing — a jerked arm, a cry, swimming motions — were mere spasms.

But after deliberating 10 days, the jury found Dr. Gosnell guilty in the deaths of victims known as Baby A, Baby C and Baby D. He was found not guilty of murdering Baby E.

Prosecutors have said they will seek the death penalty when the trial moves into the sentencing phase next Tuesday.

While abortion rights groups argued that Dr. Gosnell operated far outside the legalities and norms of women’s health care, abortion opponents seized on the case to raise questions about the ethics of late-term abortions. Put simply, they asked why a procedure done to a living baby outside the womb is murder, but destroying a fetus of similar gestation before delivery can be legal.

“What we need to learn from the Gosnell case is that late-term abortion is infanticide,” the Daily Beast columnist Kirsten Powers wrote last week, after starting an online furor earlier with a column suggesting that the news media had ignored the case for ideological reasons.

Abortion rights supporters said it was opponents who politicized the trial. What abortion opponents really sought from the trial, they said, was an acceleration of restrictions at the state level to effectively end legal abortion.

“Justice was served to Kermit Gosnell today and he will pay the price for the atrocities he committed,” Ilyse Hogue, president of Naral Pro-Choice America, said in a statement. “Anti-choice politicians, and their unrelenting efforts to deny women access to safe and legal abortion care, will only drive more women to back-alley butchers like Kermit Gosnell.”

In recent weeks, the case was cited in Congress to support restricting abortions past 20 weeks of pregnancy, and it was invoked by an anti-abortion political action committee in radio ads to attack the Democratic candidate for governor of Virginia, Terry McAuliffe.

Although the trial has not brought new issues or tactics to America’s long-running abortion wars, it provided an emotional jolt through five weeks of graphic testimony and an earlier grand jury report.

“This is a visual argument that no one would ever want to have,” said Marjorie Dannenfelser, president of the Susan B. Anthony List, which works to elect women opposed to abortion. “But if we’re going to have it, let’s go ahead and have it. What are the limits? What are we as a society willing to forbear?”

She and others predicted greater support for laws banning abortions past 20 weeks, which have been adopted in several states in recent years, on the disputed theory that fetuses of that age feel pain. Dr. Gosnell was found guilty of 24 counts of performing an abortion beyond 24 weeks, the limit in Pennsylvania.

Opponents of the restrictions argue that later abortions are very rare: fewer than 1.3 percent are past 20 weeks of gestation, according to the Centers for Disease Control and Prevention. Abortion rights activists say restrictions before fetal viability, generally 24 weeks, violate the constitutional protections of Roe v. Wade.

Nonetheless, “the imagery” of later abortion “is very powerful,” said Elizabeth Nash, state issues manager for the Guttmacher Institute, a research group that supports abortion access. “In 2010 Nebraska banned abortion at 20 weeks post-fertilization,” she said. “That bill was seen as the type of bill that was going to catch fire across the country. It did.”

Dr. Gosnell was also convicted of involuntary manslaughter in the death of a 41-year-old patient, Karnamaya Mongar, who died of an overdose of sedatives. Among lesser charges, he was found guilty of 211 counts of not waiting 24 hours after consulting with a patient before performing an abortion.

Activists on both sides debated whether the deplorable conditions at Dr. Gosnell’s clinic — including broken equipment, bloodstained recovery chairs and an untrained staff giving anesthesia and other drugs — could be found at other clinics.

Anti-abortion groups cited the case to press for more regulations of clinics. “By pulling back the secrecy that cloaks this industry that preys on women’s misery, we have a real agenda moving forward,” said Charmaine Yoest, the president of Americans United for Life, which pushes for stricter clinic rules.

But abortion rights groups attacked the regulations as a backdoor route to shut clinics by requiring costly but medically unneeded upgrades, like wider hallways and bigger closets.

“What’s going on with these laws is really about the agenda of having abortion eventually made illegal again,” said Nancy Northup, president of the Center for Reproductive Rights in Washington, which has challenged the laws in court. “And if that were to happen, unfortunately you’d have a lot more Gosnells out there.”

The scathing grand jury report in 2011 on Dr. Gosnell’s clinic, the Women’s Medical Society, on Lancaster Avenue, detailed how despite complaints and malpractice suits, no inspector had visited in 16 years. The clinic was raided only after a tip that it operated as an illegal prescription mill. A month after the report, Gov. Tom Corbett fired six employees of the Health and State departments.

In the witness box, clinic employees said live births occurred regularly, and they believed Dr. Gosnell’s explanation for snipping necks with surgical scissors — to “ensure fetal demise” — was accepted practice in late-term abortions. An abortion doctor who testified for the prosecution said such practice was unheard of.

One witness, Steven Massof, testifying under a plea agreement to avoid first-degree murder charges, instructed jurors to feel the backs of their own necks and said, “It’s like a beheading.”

Another former employee, Adrienne Moton, sobbed as she described the death of Baby A, aborted when his teenage mother was about 29 weeks pregnant. Ms. Moton was so upset she took a cellphone photograph of him, which was shown in court. She said Dr. Gosnell had joked that the baby was big enough to walk to a bus stop.

Ms. Moton, who also testified under a plea agreement, said she cut the neck of Baby D, who was delivered into a toilet while its mother, given a large dose of a drug to dilate the cervix, waited for Dr. Gosnell to arrive.

Another clinic worker said she followed Dr. Gosnell’s instructions and cut the neck of Baby C after it moved an arm. The doctor told her was an “involuntary movement.”

Dr. Gosnell was originally charged with seven counts of first-degree murder, but Judge Jeffrey P. Minehart of Common Pleas Court earlier threw out three other cases of infants said to have been born alive, known as Baby B, Baby F and Baby G.

Several weeks into the trial, which began March 18, anti-abortion activists and some conservative commentators accused the national news media of skipping it, a charge amplified across social media.

On April 15, President Obama’s spokesman was asked if he was following the trial. “The president is aware” of the case, said Jay Carney, the White House spokesman.

Even as reporters from national newspapers arrived in Courtroom 304 of the Criminal Justice Center, a blog war continued between abortion-rights supporters, who had written of Dr. Gosnell’s abuses from the time of his indictment, and conservatives, who continued to fault broadcast television for a “blackout.”

On Monday, there were 29 reporters in the courtroom and a row of television crews on the sidewalk.


Jon Hurdle reported from Philadelphia,

and Trip Gabriel from New York.

    Philadelphia Abortion Doctor Guilty of Murder in Late-Term Procedures,
    NYT, 13.5.2013,






Hospital Mergers

Reset Abortion-Access Battle


May 12, 2013
The New York Times


MOUNT VERNON, Wash. — Politicians seeking to restrict access to abortion, a marked trend this year from North Dakota to Arkansas, tend not to get much traction in this part of the country.

Washington is heavily Democratic, leaning left especially on social issues. A majority of voters even put into law a statutory right to abortion in 1970 — the only state ever to do that. The governor, Jay Inslee, a Democrat, is pushing the Legislature even now to pass a law at a special session on Monday requiring health insurers to pay for elective abortions, another first for the state if it makes it to Mr. Inslee’s desk.

But now a wave of proposed and completed mergers between secular and Roman Catholic hospitals, which are barred by church doctrine from performing procedures that could harm the unborn, is raising the prospect that unelected health care administrators could go where politicians could not.

The merger wave is mirrored around the country, driven by the shifting economic landscape in health care and the looming changes in federal regulation. Previous Catholic takeovers in Kentucky, Illinois and Pennsylvania have made news and drawn scrutiny.

The concentration of mergers here, through happenstance and history — Catholic nuns arrived in Washington with the first waves of settlers in the 1850s — is particularly pronounced. If all the proposed religious and secular combinations go through, almost half of the hospital beds in the state — the highest percentage in the nation, and up from less than a third at the beginning of last year — would be controlled by the Catholic health systems, according to Merger Watch, a nonprofit group in New York that tracks hospitals.

Another wrinkle is that many Washingtonians are not that keen on religion to start with. A poll by Gallup conducted throughout 2012 put the state at 12th from the bottom in percentage of people who described themselves as “very religious.” It is also one of only two states — Oregon is the other — where voters have approved a physician-assisted suicide law for terminally ill people. Centuries of Catholic teaching hold suicide as a mortal sin.

“You happen to be the hot zone,” Sarah A. Dunne, the legal director of the American Civil Liberties Union of Washington, said on a recent evening to a group of 75 or so residents here in Mount Vernon who are opposing the mergers.

Skagit Valley Hospital in Mount Vernon, about an hour north of Seattle, has joined with two other small local hospitals in seeking a merger partner and is entertaining bids from two Catholic and two secular hospitals. A decision is expected this summer.

The A.C.L.U. has been “exploring plans for possible litigation,” as Ms. Dunne put it in an interview, over whether mergers involving religious and secular hospitals that get taxpayer support could violate a provision of the State Constitution barring public funds for religious purposes. Ten counties out of 39 in the state would have 100 percent of their hospital beds in Catholic health system hands by year’s end if all the proposed mergers went through, according to the A.C.L.U.

“Frankly, I wish we could do nothing,” said Vince Oliver, the chief executive at the 43-bed Island Hospital in nearby Anacortes, which is one of the three hospitals, including Skagit Valley, that are shopping for a partner. “But the future for a small independent hospital is not a very rosy picture right now,” he said.

Catholic hospital leaders said that changes in the medical and economic landscape could threaten service to millions of Americans in rural and suburban areas who might have no choices at all if their local hospital closed or shrank, and that Catholic partners — driven by a mission to serve the underserved — are uniquely fitted to help. The issue is not availability of abortion or consult to the dying, they say, which will still be available in secular institutions not that far away, but access to care at all.

“The Catholic health system is in many of the communities we’re in because other health care providers have not wanted to serve those communities and have not had a commitment to serve every human being,” said Peter Adler, a senior vice president at PeaceHealth, a Catholic hospital system based in the Pacific Northwest that is one of the bidders for the three hospitals in northwest Washington.

But critics said that Catholic hospitals do not, in fact, serve every human being because they deny certain reproductive services or end-of-life care that could help a dying patient end his or her suffering.

“It’s a collision course,” said Suzanne Holland, a science and values professor in the department of religion at the University of Puget Sound, referring to the potential of constriction in health care options from economic change, and at the same time restricted choice on moral grounds at hospitals operated through a lens of religious doctrine.

Professor Holland, a Catholic and a lesbian, said she already tried to avoid going to a Catholic hospital near her because she was concerned that administrators there would not recognize the rights of her civil union partner.

A spokesman for the United States Conference of Catholic Bishops, which issues rules for Catholic care providers called the “Ethical and Religious Directives,” said that procedures deemed by the church to be immoral are bright lines that cannot be crossed.

Anything relating to abortion is one such line, but anything making it easier for a person to end his or her own life, as Washington’s Death with Dignity law does, would also be prohibited, said the Rev. Thomas Weinandy, the executive director of the Conference of Catholic Bishops’ Secretariat for Doctrine.

Washington’s assisted suicide law, passed by the voters in 2008, gives all hospitals and individual caregivers the option to participate. And that creates a very mixed, complicated picture on the merger front, with physicians and pharmacists, even in secular hospitals that back the program, able to decide for themselves whether to be involved.

The question at formerly secular hospitals under new Catholic control is therefore not whether helping terminal patients die would be allowed on the premises — clearly not, church authorities said — but what kind of private, confidential advice a physician would have the authority to give about end-of-life options under the state law, including where legal services to ease death might be obtained.

“If you go to a Catholic medical institution, you’re going to get medical advice that is in keeping with the moral norms of that institution,” Father Weinandy said. “We think Catholic medical advice is the best medical advice to give.”

The Religious Directives document puts it even more assertively: “The professional-patient relationship is never separated, then, from the Catholic identity of the health care institution.”

But Mr. Adler, the spokesman for PeaceHealth, said that in his organization, at least, the confidentiality of a physician’s advice is protected.

“The conversation between patients and their physicians at PeaceHealth we consider sacred,” he said.

    Hospital Mergers Reset Abortion-Access Battle, NYT, 12.5.2013,






Hospital Billing Varies Wildly,

U.S. Data Shows


May 8, 2013
The New York Times


A hospital in Livingston, N.J., charged $70,712 on average to implant a pacemaker, while a hospital in nearby Rahway, N.J., charged $101,945.

In Saint Augustine, Fla., one hospital typically billed nearly $40,000 to remove a gallbladder using minimally invasive surgery, while one in Orange Park, Fla., charged $91,000.

In one hospital in Dallas, the average bill for treating simple pneumonia was $14,610, while another there charged over $38,000.

Data being released for the first time by the government on Wednesday shows that hospitals charge Medicare wildly differing amounts — sometimes 10 to 20 times what Medicare typically reimburses — for the same procedure, raising questions about how hospitals determine prices and why they differ so widely.

The data for 3,300 hospitals, released by the federal Center for Medicare and Medicaid Services, shows wide variations not only regionally but among hospitals in the same area or city.

Government officials said that some of the variation might reflect the fact that some patients were sicker or required longer hospitalization.

Nonetheless, the data is likely to intensify a long debate over the methods that hospitals use to determine their charges.

Medicare does not actually pay the amount a hospital charges but instead uses a system of standardized payments to reimburse hospitals for treating specific conditions. Private insurers do not pay the full charge either, but negotiate payments with hospitals for specific treatments. Since many patients are covered by Medicare or have private insurance, they are not directly affected by what hospitals charge.

Experts say it is likely that the people who can afford it least — those with little or no insurance — are getting hit with extremely high hospitals bills that may bear little connection to the cost of treatment.

“If you’re uninsured, they’re going to ask you to pay,” said Gerard Anderson, the director of the Johns Hopkins Center for Hospital Finance and Management.

The debate over medical costs is growing louder, spurred partly by President Obama’s overhaul of the health insurance system.

Hospitals, in particular, have come under scrutiny for charges that are widely viewed as difficult to comprehend, even for experts. “Our goal is to make this information more transparent,” Jonathan Blum, the director of the agency’s Center for Medicare, said in an interview.

The data covers bills submitted from virtually every hospital in the country in 2011 for the 100 most common treatments and procedures performed in hospitals, like hip replacements, heart operations and gallbladder removal.

The hospitals were not given the data before its release by Medicare officials.

Some hospitals contacted Tuesday said that the higher bills they sent to Medicare reflected the fact that they were either teaching hospitals or they had treated sicker patients.

For example, billing records showed that Keck Hospital of the University of Southern California charged, on average, $123,885, for a major artificial joint replacement, six times the average amount that Medicare reimbursed for the procedure and a rate significantly higher than the average for other Los Angeles area hospitals.

“Academic medical centers have a higher cost structure, and higher acuity patients who suffer from many health complications,” the hospital said.

The hospital added that it wrote off any difference between what it charged and what Medicare paid, rather than seeking to collect it from patients. Centinela Hospital Medical Center, also in Los Angeles and owned by Prime Healthcare Services, charged $220,881 for the same procedure.

A spokesman said the hospital served a sicker and older patient base.

The data showing the range of hospital bills does not explain why one hospital charges significantly more for a procedure than another one. And Medicare does pay slightly higher treatment rates to certain hospitals — like teaching facilities or hospitals in areas with high labor costs.

Mr. Blum, the Medicare official, said he would have anticipated variations of two- to threefold at the most in the difference between what hospitals charge.

However, hospitals submitted bills to Medicare that were, on average, about three to five times what the agency typically pays to treat a condition, an analysis of the data by The New York Times indicates. And variations between what hospitals charge may be even greater.

Mr. Blum said he could not explain the reasons for that large difference.

An official at the American Hospital Association, a trade group, said there was a cat-and-mouse game between hospitals and insurers that affects what hospitals charge.

As insurers demand bigger discounts from a hospital, a facility may raise its charges to protect its bottom line, that official, Caroline Steinberg, said. “The hospital raises its rate to cover the discount,” said Ms. Steinberg, who is the group’s vice president for trends analysis.

Robert Zirkelbach, a spokesman for America’s Health Insurance Plans, the nation’s largest association of health insurers, said some member companies were reporting sharp price increases of 20 to 30 percent for some services. Some insurers are seeking similar price increases from policy holders.

“There’s very little transparency out there about what doctors and hospitals are charging for services,” Mr. Zirkelbach said. “Much of the public policy focus has been on health insurance premiums and has largely ignored what hospitals and doctors are charging.”

Ms. Steinberg said that the Affordable Care Act required that hospital charges be limited for patients who qualify.

“That’s driving all of the rates for uninsured patients towards the same amount that Medicare pays,” she said.

That big variation in what hospitals charge Medicare exists even in procedures that are standardized and do not involve patient complications, the Times analysis of the data shows.

For a cardiac procedure in which a small tube, or stent, is implanted to open up a clogged blood vessel, the average hospital charge is over four times the average Medicare payment.

In addition, bills submitted by profit-making hospitals to Medicare are typically higher than those submitted by nonprofit centers, the analysis found.

Government hospitals typically billed Medicare less than either nonprofit or profit-making hospitals, the data shows.

Medicare payments represent about 91 cents of every dollar that a hospital spends on treatment, Ms. Steinberg said.

Mr. Anderson, the hospital finance expert, said that private insurers negotiated rates with hospitals that were typically about 30 percent above what Medicare pays. He understands that hospitals will often charge above the Medicare rate, but he said the huge premiums at some hospitals make no sense.

“If you’re charging 10 percent more or 20 percent more than what it costs to deliver the service, that’s an acceptable profit margin,” Mr. Anderson said. “Charging 400 percent more than what it costs has no rational basis in it at all.”

    Hospital Billing Varies Wildly, U.S. Data Shows, NYT, 8.5.2013,






Psychiatry’s Guide

Is Out of Touch With Science,

Experts Say


May 6, 2013
The New York Times


Just weeks before the long-awaited publication of a new edition of the so-called bible of mental disorders, the federal government’s most prominent psychiatric expert has said the book suffers from a scientific “lack of validity.”

The expert, Dr. Thomas R. Insel, director of the National Institute of Mental Health, said in an interview Monday that his goal was to reshape the direction of psychiatric research to focus on biology, genetics and neuroscience so that scientists can define disorders by their causes, rather than their symptoms.

While the Diagnostic and Statistical Manual of Mental Disorders, or D.S.M., is the best tool now available for clinicians treating patients and should not be tossed out, he said, it does not reflect the complexity of many disorders, and its way of categorizing mental illnesses should not guide research.

“As long as the research community takes the D.S.M. to be a bible, we’ll never make progress,” Dr. Insel said, adding, “People think that everything has to match D.S.M. criteria, but you know what? Biology never read that book.”

The revision, known as the D.S.M.-5 and the first since 1994, has stirred unprecedented questioning from the public, patient groups and, most fundamentally, senior figures in psychiatry who have challenged not only decisions about specific diagnoses but the scientific basis of the entire enterprise. Basic research into the biology of mental disorders and treatment has stalled, they say, confounded by the labyrinth of the brain.

Decades of spending on neuroscience have taught scientists mostly what they do not know, undermining some of their most elemental assumptions. Genetic glitches that appear to increase the risk of schizophrenia in one person may predispose others to autism-like symptoms, or bipolar disorder. The mechanisms of the field’s most commonly used drugs — antidepressants like Prozac, and antipsychosis medications like Zyprexa — have revealed nothing about the causes of those disorders. And major drugmakers have scaled back psychiatric drug development, having virtually no new biological “targets” to shoot for.

Dr. Insel is one of a growing number of scientists who think that the field needs an entirely new paradigm for understanding mental disorders, though neither he nor anyone else knows exactly what it will look like.

Even the chairman of the task force making revisions to the D.S.M., Dr. David J. Kupfer, a professor of psychiatry at the University of Pittsburgh, said the new manual was faced with doing the best it could with the scientific evidence available.

“The problem that we’ve had in dealing with the data that we’ve had over the five to 10 years since we began the revision process of D.S.M.-5 is a failure of our neuroscience and biology to give us the level of diagnostic criteria, a level of sensitivity and specificity that we would be able to introduce into the diagnostic manual,” Dr. Kupfer said.

The creators of the D.S.M. in the 1960s and ’70s “were real heroes at the time,” said Dr. Steven E. Hyman, a psychiatrist and neuroscientist at the Broad Institute and a former director at the National Institute of Mental Health. “They chose a model in which all psychiatric illnesses were represented as categories discontinuous with ‘normal.’ But this is totally wrong in a way they couldn’t have imagined. So in fact what they produced was an absolute scientific nightmare. Many people who get one diagnosis get five diagnoses, but they don’t have five diseases — they have one underlying condition.”

Dr. Hyman, Dr. Insel and other experts said they hoped that the science of psychiatry would follow the direction of cancer research, which is moving from classifying tumors by where they occur in the body to characterizing them by their genetic and molecular signatures.

About two years ago, to spur a move in that direction, Dr. Insel started a federal project called Research Domain Criteria, or RDoC, which he highlighted in a blog post last week. Dr. Insel said in the blog that the National Institute of Mental Health would be “reorienting its research away from D.S.M. categories” because “patients with mental disorders deserve better.” His commentary has created ripples throughout the mental health community.

Dr. Insel said in the interview that his motivation was not to disparage the D.S.M. as a clinical tool, but to encourage researchers and especially outside reviewers who screen proposals for financing from his agency to disregard its categories and investigate the biological underpinnings of disorders instead. He said he had heard from scientists whose proposals to study processes common to depression, schizophrenia and psychosis were rejected by grant reviewers because they cut across D.S.M. disease categories.

“They didn’t get it,” Dr. Insel said of the reviewers. “What we’re trying to do with RDoC is say actually this is a fresh way to think about it.” He added that he hoped researchers would also participate in projects funded through the Obama administration’s new brain initiative.

Dr. Michael First, a psychiatry professor at Columbia who edited the last edition of the manual, said, “RDoC is clearly the way of the future,” although it would take years to get results that could apply to patients. In the meantime, he said, “RDoC can’t do what the D.S.M. does. The D.S.M. is what clinicians use. Patients will always come into offices with symptoms.”

For at least a decade, Dr. First and others said, patients will continue to be diagnosed with D.S.M. categories as a guide, and insurance companies will reimburse with such diagnoses in mind.

Dr. Jeffrey Lieberman, the chairman of the psychiatry department at Columbia and president-elect of the American Psychiatric Association, which publishes the D.S.M., said that the new edition’s refinements were “based on research in the last 20 years that will improve the utility of this guide for practitioners, and improve, however incrementally, the care patients receive.”

He added: “The last thing we want to do is be defensive or apologetic about the state of our field. But at the same time, we’re not satisfied with it either. There’s nothing we’d like better than to have more scientific progress.”

    Psychiatry’s Guide Is Out of Touch With Science, Experts Say, NYT, 6.5.2013,






Emil Frei III,

Who Put Cancer Cures in Reach,

Dies at 89


May 4, 2013
The New York Times


Dr. Emil Frei III, an oncologist whose trailblazing use of combination chemotherapy — in which anticancer drugs are administered simultaneously rather than singly — helped make certain cancers curable for the first time, died on Tuesday at his home in Oak Park, Ill. He was 89.

His daughter Judy Frei confirmed the death.

Combination chemotherapy is now a standard treatment for a wide range of cancers, including breast, bone and testicular cancers, and has been credited with saving millions of lives worldwide.

A clinician, researcher and administrator, Dr. Frei (pronounced “fry”) held senior leadership positions at three prominent cancer centers: the National Cancer Institute, part of the National Institutes of Health; the M. D. Anderson Cancer Center in Houston; and the Dana-Farber Cancer Institute in Boston.

At his death, Dr. Frei was the emeritus director and emeritus physician-in-chief of Dana-Farber. He was also the Richard and Susan Smith distinguished professor of medicine emeritus at Harvard Medical School.

When Dr. Frei began his research at midcentury, chemotherapy with even a single drug, much less multiple ones, was considered a treatment of last resort.

“It was known that these drugs were cell-killers: some of them were derived from mustard gas,” Dr. Harold E. Varmus, the current director of the National Cancer Institute and a winner of the 1989 Nobel Prize in Physiology or Medicine, said Friday. “They were developed initially as toxic agents, not different from drugs that were used in warfare.”

In the mid-1950s, Dr. Frei, along with Dr. Emil J. Freireich, a colleague at the National Cancer Institute, and others, began investigating a multipronged assault on childhood leukemia that entailed using these drugs in combination, with each attacking a different aspect of cancer-cell physiology.

As the two men and their colleagues found, administering a cocktail of anticancer drugs let each drug be given in smaller quantities. This mitigated the drugs’ toxic effects on the patient without diminishing their combined attack on the cancer.

“If you give 60 percent of each dose, it’s the same as giving 100 percent of one or the other,” said Dr. Freireich, who is now at M. D. Anderson. “But the effect on the tumor is additive.”

When Dr. Frei and Dr. Freireich began their work, childhood leukemia was invariably fatal. By 1965, after a decade of clinical trials and refinements, the methods they devised, which involved combining as many as four drugs, had increased the survival rate to about 40 percent five years after treatment.

Today, childhood leukemia has a long-term survival rate of more than 80 percent.

“There are recurrences, but the incidence is low,” Dr. Freireich said. “These are lifetime cures. Compared to the general population, their survival rate is the same as for people who hadn’t had leukemia.”

The two men then applied their approach to Hodgkin’s disease, also rendering it curable in many cases.

Emil Frei III, familiarly known as Tom, was born in St. Louis on Feb. 21, 1924.

In 1898, his paternal grandfather founded Emil Frei & Associates, a stained-glass company in the city that is still well known, and Emil III was expected to pursue the family calling. But he became interested in medicine in his youth after reading “Rats, Lice and History,” Hans Zinsser’s 1935 “biography” of typhus.

Serving in the Navy in World War II, he was sent for premedical studies at Colgate University and medical studies at Yale, from which he earned an M.D. in 1948. He later served with the Navy Medical Corps in the Korean War.

Dr. Frei joined the staff of the National Cancer Institute in the mid-1950s. He was later chief of the leukemia section and chief of medicine there.

In 1965, he moved to M. D. Anderson, where he was the associate scientific director of clinical research and the chairman of the division of experimental therapeutics. He joined the institute now known as Dana-Farber as physician in chief in 1972 and became its director the next year.

At all three institutions, Dr. Frei also trained a generation of researchers and clinicians.

Dr. Frei’s first wife, the former Elizabeth Smith, whom he married in 1948, died in 1986; his second wife, the former Adoria Smetana Brock, whom he married in 1987, died in 2009. Besides his daughter Judy, his survivors include three other daughters, Mary, Alice and Nancy Frei; a son, Emil IV; a brother, Bob; and 10 grandchildren.

In his Pulitzer Prize-winning book, “The Emperor of All Maladies: A Biography of Cancer,” published in 2010, the doctor and author Siddhartha Mukherjee wrote of Dr. Frei making rounds on a pediatric oncology ward.

“He was charming, soft-spoken and careful,” Dr. Mukherjee wrote. “To watch him manage critically ill children and their testy, nervous parents was to watch a champion swimmer glide through water — so adept in the art that he made artistry vanish.”

One of those children was Edward M. Kennedy Jr., a son of the Massachusetts senator. In 1973, at 12, young Ted Kennedy lost a leg to osteosarcoma, an aggressive form of bone cancer.

A patient of Dr. Frei’s at Dana-Farber, he underwent intensive chemotherapy for nearly two years afterward. He has remained free of cancer ever since.

“I honestly believe that Dr. Frei saved my life,” Mr. Kennedy, now 51 and a lawyer and disability rights advocate in New Haven, said in an interview on Thursday. “My father obviously had incredible resources in terms of being able to identify the most capable people. And of all the people in the world, he asked Dr. Frei to take care of me.”

    Emil Frei III, Who Put Cancer Cures in Reach, Dies at 89, NYT, 4.5.2013,






Suicide Rates Rise Sharply in U.S.


May 2, 2013
The New York Times


Suicide rates among middle-aged Americans have risen sharply in the past decade, prompting concern that a generation of baby boomers who have faced years of economic worry and easy access to prescription painkillers may be particularly vulnerable to self-inflicted harm.

More people now die of suicide than in car accidents, according to the Centers for Disease Control and Prevention, which published the findings in Friday’s issue of its Morbidity and Mortality Weekly Report. In 2010 there were 33,687 deaths from motor vehicle crashes and 38,364 suicides.

Suicide has typically been viewed as a problem of teenagers and the elderly, and the surge in suicide rates among middle-aged Americans is surprising.

From 1999 to 2010, the suicide rate among Americans ages 35 to 64 rose by nearly 30 percent, to 17.6 deaths per 100,000 people, up from 13.7. Although suicide rates are growing among both middle-aged men and women, far more men take their own lives. The suicide rate for middle-aged men was 27.3 deaths per 100,000, while for women it was 8.1 deaths per 100,000.

The most pronounced increases were seen among men in their 50s, a group in which suicide rates jumped by nearly 50 percent, to about 30 per 100,000. For women, the largest increase was seen in those ages 60 to 64, among whom rates increased by nearly 60 percent, to 7.0 per 100,000.

Suicide rates can be difficult to interpret because of variations in the way local officials report causes of death. But C.D.C. and academic researchers said they were confident that the data documented an actual increase in deaths by suicide and not a statistical anomaly. While reporting of suicides is not always consistent around the country, the current numbers are, if anything, too low.

“It’s vastly underreported,” said Julie Phillips, an associate professor of sociology at Rutgers University who has published research on rising suicide rates. “We know we’re not counting all suicides.”

The reasons for suicide are often complex, and officials and researchers acknowledge that no one can explain with certainty what is behind the rise. But C.D.C. officials cited a number of possible explanations, including that as adolescents people in this generation also posted higher rates of suicide compared with other cohorts.

“It is the baby boomer group where we see the highest rates of suicide,” said the C.D.C.’s deputy director, Ileana Arias. “There may be something about that group, and how they think about life issues and their life choices that may make a difference.”

The rise in suicides may also stem from the economic downturn over the past decade. Historically, suicide rates rise during times of financial stress and economic setbacks. “The increase does coincide with a decrease in financial standing for a lot of families over the same time period,” Dr. Arias said.

Another factor may be the widespread availability of opioid drugs like OxyContin and oxycodone, which can be particularly deadly in large doses.

Although most suicides are still committed using firearms, officials said there was a marked increase in poisoning deaths, which include intentional overdoses of prescription drugs, and hangings. Poisoning deaths were up 24 percent over all during the 10-year period and hangings were up 81 percent.

Dr. Arias noted that the higher suicide rates might be due to a series of life and financial circumstances that are unique to the baby boomer generation. Men and women in that age group are often coping with the stress of caring for aging parents while still providing financial and emotional support to adult children.

“Their lives are configured a little differently than it has been in the past for that age group,” Dr. Arias said. “It may not be that they are more sensitive or that they have a predisposition to suicide, but that they may be dealing with more.”

Preliminary research at Rutgers suggests that the risk for suicide is unlikely to abate for future generations. Changes in marriage, social isolation and family roles mean many of the pressures faced by baby boomers will continue in the next generation, Dr. Phillips said.

“The boomers had great expectations for what their life might look like, but I think perhaps it hasn’t panned out that way,” she said. “All these conditions the boomers are facing, future cohorts are going to be facing many of these conditions as well.”

Nancy Berliner, a Boston historian, lost her 58-year-old husband to suicide nearly two years ago. She said that while the reasons for his suicide were complex, she would like to see more attention paid to prevention and support for family members who lose someone to suicide.

“One suicide can inspire other people, unfortunately, to view suicide as an option,” Ms. Berliner said. “It’s important that society becomes more comfortable with discussing it. Then the people left behind will not have this stigma.”

    Suicide Rates Rise Sharply in U.S., NYT, 2.5.2013,






Cancers Share Gene Patterns, Studies Affirm


May 1, 2013
The New York Times


Scientists have discovered that the most dangerous cancer of the uterine lining closely resembles the worst ovarian and breast cancers, providing the most telling evidence yet that cancer will increasingly be seen as a disease defined primarily by its genetic fingerprint rather than just by the organ where it originated.

The study of endometrial cancer — the cancer of the uterine lining — and another of acute myeloid leukemia, published simultaneously on Wednesday by Nature and The New England Journal of Medicine, are part of a sprawling, ambitious project by the National Institutes of Health to scrutinize DNA aberrations in common cancers.

Over the past year, as part of this project, researchers have reported striking genetic changes in breast, colon and lung cancers that link them to other cancers. One kind of breast cancer was closely related to ovarian cancer. Colon cancers often had a genetic change found in breast cancer. And about half of squamous cell lung cancers might be attacked by drugs being developed for other cancers.

The endometrial cancer and leukemia efforts alone involved more than 100 researchers who studied close to 400 endometrial tumors and 200 leukemias. Endometrial cancer is the most common gynecological cancer in American women and strikes nearly 50,000 of them a year, killing about 8,000. Acute myeloid leukemia, the most prevalent acute adult leukemia, is diagnosed in about 14,000 Americans a year and kills about 10,000.

“This is exploring the landscape of cancer genomics,” said Dr. David P. Steensma, a leukemia researcher at the Dana-Farber Cancer Institute who was not involved with the studies. “Many developments in medicine are about treatments or tests that are only useful for a certain period of time until something better comes by. But this is something that will be useful 200 years from now. This is a landmark that will stand the test of time.”

Dr. Douglas Levine of Memorial Sloan Kettering Cancer Center, the principal investigator on the endometrial cancer study, said the group scoured the country for samples of this cancer.

The cancer has long been evaluated by pathologists who examine thin slices of endometrial tumors under a microscope and put them in one of two broad categories. But the method is not ideal. In general, one category predicts a good prognosis and tumors that could be treated with surgery and radiation, while the other holds a poorer prognosis and requires chemotherapy after surgery. But pathologists often disagree about how to classify the tumors and can find it difficult to distinguish between the two types, Dr. Levine said.

The new genetic analysis of hundreds of tumors found patterns of genetic aberrations that more precisely classify the tumors, dividing them into four distinct groups. About 10 percent of tumors that had seemed easily treated with the old type of exam now appear to be more deadly according to the genetic analysis and would require chemotherapy.

Another finding was that many endometrial cancers had a mutation in a gene that had been seen before only in colon cancers. The mutation disables a system for repairing DNA damage, resulting in 100 times more mutations than typically occur in cancer cells.

“That was a complete surprise,” Dr. Levine said.

It turned out to be good news. Endometrial cancers with the mutation had better outcomes, perhaps because the accumulating DNA damage is devastating to cancer cells.

Another surprise was that the worst endometrial tumors were so similar to the most lethal ovarian and breast cancers, raising the tantalizing possibility that the three deadly cancers might respond to the same drugs.

Jeff Boyd, executive director of the Cancer Genome Institute at Fox Chase Cancer Center, who was not involved with the new research, said the similarity among breast, ovarian and endometrial tumors was the best example yet of the idea that cancers are more usefully classified by their gene mutations than by where they originate. Though many scientists believe this view is correct, Dr. Boyd said, “It is very rewarding — I can’t overstate it” to see it validated with real data.

While the genetics of endometrial cancer had gone largely unstudied until now, acute myeloid leukemia has been investigated for decades, in part because leukemia cells are so accessible. They are in the blood and bone marrow.

Using microscopes and special staining methods, researchers had already discovered, for example, that chromosomes in these leukemia cells are often broken or hooked together in strange ways. They also knew that some chromosomal alterations were associated with a good prognosis, and others with a bad one. Patients with a good prognosis can usually be treated with chemotherapy alone while those with a worse prognosis need the expensive, difficult and risky treatment of last resort: a bone marrow transplant. It comes with a 10 percent death rate.

The problem was that the traditional methods for categorizing the leukemia were imprecise, said Dr. Timothy Ley of Washington University in St. Louis, who led the study with Richard Wilson, also of Washington University. Nearly half the acute myeloid leukemias had normal chromosomes. There was no good way to decide which treatment these patients needed. Some did well with chemotherapy; some did poorly.

“It was a huge conundrum,” Dr. Ley said. “For patients who cannot be cured with chemotherapy, we have a potentially curative therapy. But picking the right patients for a transplant was very difficult.”

The new study of 200 acute myeloid leukemias identified at least 260 genes that were mutated in at least 2 of the 200 leukemia samples, finding virtually all of the common genetic malfunctions that occur in it. Now researchers have a new foundation for assessing which cancers will be lethal unless the patient gets a risky bone marrow transplant and which can be treated with chemotherapy alone.

“We have the basic playbook,” Dr. Ley said. “We finally know what the major pathways are and what all the major mutations look like.” And knowing which genes are mutated also allows researchers to investigate drugs that target those genes.

The next step will be for investigators to determine which mutations lead to good or bad outcomes.

“Within two or three years, risk assessment may be dramatically better,” Dr. Ley said. “It certainly sets the stage for the next era of therapy.”

    Cancers Share Gene Patterns, Studies Affirm, NYT, 1.5.2013,




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