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History > 2009 > USA > Health (II)





Loren Capelli

A Cadaver, for the Sake of Science


















WHO Says

Swine Flu Pandemic

Is Imminent


April 30, 2009
Filed at 2:43 a.m. ET
The New York Times


MEXICO CITY (AP) -- Global health authorities warned Wednesday that swine flu was threatening to bloom into a pandemic, and the virus spread farther in Europe even as the outbreak appeared to stabilize at its epicenter. A toddler who succumbed in Texas became the first death outside Mexico.

New cases and deaths finally seemed to be leveling off in Mexico, where 160 people have been killed, after an aggressive public health campaign. But the World Health Organization said the global threat is nevertheless serious enough to ramp up efforts to produce a vaccine against the virus.

''It really is all of humanity that is under threat during a pandemic,'' WHO Director General Margaret Chan said in Geneva. ''We do not have all the answers right now, but we will get them.''

It was the first time the WHO had declared a Phase 5 outbreak, the second-highest on its threat scale, indicating a pandemic could be imminent.

The first U.S. death from the outbreak was a Mexico City toddler who traveled to Texas with family and died Monday night at a Houston hospital. U.S. Health and Human Services Secretary Kathleen Sebelius predicted the child would not be the last U.S. death from swine flu.

The virus, a mix of pig, bird and human genes to which people have limited natural immunity, had spread to at least nine countries. In the United States, nearly 100 have been sickened in 11 states.

Eight states closed schools Wednesday, affecting 53,000 students in Texas alone, and President Barack Obama said wider school closings might be necessary to keep crowds from spreading the flu. Mexico has already closed schools nationwide until at least May 6.

''Every American should know that the federal government is prepared to do whatever is necessary to control the impact of this virus,'' Obama said, highlighting his request for $1.5 billion in emergency funding for vaccines.

Just north of the Mexican border, 39 Marines were being confined to their California base after one contracted swine flu. Senators questioned Homeland Security Secretary Janet Napolitano about her decision not to close the border, action she said ''has not been merited by the facts.''

Ecuador joined Cuba and Argentina in banning travel either to or from Mexico, and other nations considered similar bans. In France, President Nicolas Sarkozy met with cabinet ministers to discuss swine flu, and the health minister said France would ask the European Union to suspend flights to Mexico.

The U.S., the European Union and other countries have discouraged nonessential travel to Mexico. Some countries have urged their citizens to avoid the United States and Canada as well. Health officials said such bans would do little to stop the virus.

Germany and Austria became the latest countries to report swine flu infections Wednesday, with cases already confirmed in Canada, Britain, Israel, New Zealand and Spain.

In addition to the 160 deaths, the virus is believed to have sickened 2,498 people across Mexico. But only 1,311 suspected swine flu patients remained hospitalized, and a closer look at daily admissions and deaths at Mexico's public hospitals suggests the outbreak may have peaked during three grim days last week when thousands of people complained of flu symptoms.

Scientists believe that somewhere in the world, months or even a year ago, a pig virus jumped to a human and mutated, and has been spreading between humans ever since. Unlike with bird flu, doctors have no evidence suggesting a direct pig-to-human infection from this strain, which is why they haven't recommended killing pigs.

Medical detectives have not zeroed in on where the outbreak began. One of the seven deaths in Mexico directly attributed to swine flu was that of a Bangladeshi immigrant, said Mexico's chief epidemiologist, who suggested that someone could have brought the virus from Pakistan or Bangladesh.

Miguel Angel Lezana, the epidemiologist, said the unnamed Bangladeshi had lived in Mexico for six months and was recently visited by a brother who arrived from Bangladesh or Pakistan and was reportedly ill. The brother has left Mexico and his whereabouts are unknown, Lezana said.

By March 9, the first symptoms were showing up in the Mexican state of Veracruz, where pig farming is a key industry in mountain hamlets and where small clinics provide the only health care.

The earliest confirmed case was there: a 5-year-old boy who was one of hundreds of people in the town of La Gloria whose flu symptoms left them struggling to breathe.

Days later, a door-to-door tax inspector was hospitalized with acute respiratory problems in the neighboring state of Oaxaca, infecting 16 hospital workers before she became Mexico's first confirmed death.

Neighbors of the inspector, Maria Adela Gutierrez, said Wednesday that she fell ill after pairing up with a temporary worker from Veracruz who seemed to have a very bad cold. Other people from La Gloria kept going to jobs in Mexico City despite their illnesses, and could have infected people in the capital.

The deaths were already leveling off by the time Mexico announced the epidemic April 23. At hospitals Wednesday, lines of anxious citizens seeking care for flu symptoms dwindled markedly.

The Mexican health secretary, Jose Angel Cordova, said getting proper treatment within 48 hours of falling ill ''is fundamental for getting the best results'' and said the country's supply of medicine was sufficient.

Cordova has suggested the virus can be beaten if caught quickly and treated properly. But it was neither caught quickly nor treated properly in the early days in Mexico, which lacked the capacity to identify the virus, and whose health care system has become the target of widespread anger and distrust.

In case after case, patients have complained of being misdiagnosed, turned away by doctors and denied access to drugs. Monica Gonzalez said her husband, Alejandro, already had a bad cough when he returned to Mexico City from Veracruz two weeks ago and soon developed a fever and swollen tonsils.

As the 32-year-old truck driver's symptoms worsened, she took him to a series of doctors and finally a large hospital. By then, he had a temperature of 102 and could barely stand.

''They sent him away because they said it was just tonsillitis,'' she said. ''That hospital is garbage.''

That was April 22, a day before Mexico's health secretary announced the swine flu outbreak. But the medical community was already aware of a disturbing trend in respiratory infections, and Veracruz had been identified as a place of concern.

Gonzalez finally took her husband to Mexico City's main respiratory hospital, ''dying in the taxi.'' Doctors diagnosed pneumonia, but it may have been too late: He has suffered a collapsed lung and is unconscious. Doctors doubt he will survive.

Swine flu has symptoms nearly identical to regular flu -- fever, cough and sore throat -- and spreads like regular flu, through tiny particles in the air, when people cough or sneeze. People with flu symptoms are advised to stay at home, wash their hands and cover their sneezes.

While epidemiologists stress it is humans, not pigs, who are spreading the disease, sales have plunged for pork producers around the world. Egypt began slaughtering its roughly 300,000 pigs on Wednesday, even though no cases have been reported there. WHO says eating pork is safe, but Mexicans have even cut back on their beloved greasy pork tacos.

Pork producers are trying to get people to stop calling the disease swine flu, and Obama notably referred to it Wednesday only by its scientific name, H1N1. U.N. animal health expert Juan Lubroth noted some scientists say ''Mexican flu'' would be more accurate, a suggestion already inflaming passions in Mexico.

Authorities have sought to keep the crisis in context. In the U.S. alone, health officials say about 36,000 people die every year from flu-related causes.

Mexico's government said it remains too early to ease restrictions that have shut down public life in the overcrowded capital and much of the country. Pyramids, museums and restaurants were closed to keep crowds from spreading contagion.

''None of these measures are popular. We're not looking for that -- we're looking for effectiveness,'' Mexico City Mayor Marcelo Ebrard said. ''The most important thing to protect is human life.''


Associated Press writers Olga Rodriguez in Oaxaca, Mexico, E. Eduardo Castillo in Mexico City, Lauran Neergaard and Tom Raum in Washington, Juan A. Lozano in Houston, Mike Stobbe in Atlanta, Patrick McGroarty in Berlin and Maamoun Youssef in Cairo contributed to this report.

    WHO Says Swine Flu Pandemic Is Imminent, NYT, 30.4.2009, http://www.nytimes.com/aponline/2009/04/30/world/AP-MED-Swine-Flu.html






First U.S. Death

From Swine Flu Is Reported


April 30, 2009
The New York Times


President Obama confirmed the first death outside of Mexico from swine flu on Wednesday, and recommended that schools with confirmed cases of swine flu “strongly consider temporarily closing.”

“This is obviously a serious situation, serious enough to take the utmost precautions,” Mr. Obama said.

The president’s remarks, his most extensive on the outbreak since it began, came as fears the spread of the disease around the world deepened on Wednesday.

The number of confirmed cases of the disease continued to rise in Europe. In France, the health minister took the extraordinary step of calling for a suspension of all flights from the European Union to Mexico, the epicenter of the outbreak, even as a Mexican health official said that the death toll appeared to be stabilizing.

Dr. Richard Besser, acting director of the Centers for Disease Control and Prevention, said Wednesday in an interview with CNN that the first American death of the disease was a 23-month-old child in Texas. He gave no other details about the child. President Obama said his “thoughts and prayers” were with the child’s family.

Mr. Obama spoke a day after he had asked Congress to provide $1.5 billion in emergency funds to fight the disease, and his comments appeared to reflect a deepening sense of the risk the still ill-understood flu might pose.

This strain of the flu is suspected to have killed more than 150 people in Mexico and has been confirmed in at least seven countries around the globe, from Spain to Canada to New Zealand.

By urging parents to make contingency plans in the event of school closings — simply placing children in crowded day-care centers was “not a good solution,” he noted — Mr. Obama indicated that his administration was contemplating the possibility, at least, of a serious increase in the flu’s prevalence.

France’s request to suspend all flights from the European Union to Mexico would be made at a meeting of European Union health ministers, due to be held Thursday in Luxembourg, French Health Minister Roselyne Bachelot said. The World Health Organization has argued against such travel bans, arguing that they are an ineffective way to stop to spread of the disease.

Cuba and Argentina have both banned flights to Mexico, while the C.D.C. has advised Americans only to “avoid all nonessential travel to Mexico.”

Mexico’s health secretary, Jose Cordova said late Tuesday that emergency measures to curb the disease’s spread there appeared to be having an impact. The Mexican death toll, he said, was “more or less stable.” More than 2,000 people are believed to have been sickened by swine flu there.

Mexico City, one of the world’s largest cities, has taken drastic preventative steps, shutting down schools, gyms, swimming pools, restaurants, and movie theaters. Many people on the streets have donned masks in hopes of protection.

Schools are closed throughout Mexico, affecting some 33 million students. Many tourist sites — including museums and archaeological sites — have been put off limits.

The number of confirmed swine flu cases in the United States rose Wednesday to 66 in six states, with 45 in New York, 11 in California, six in Texas, two in Kansas and one each in Indiana and Ohio, but cities and states suspected more. In New York, the city’s health commissioner said “many hundreds” of schoolchildren were ill at a school where some students had confirmed cases.

Germany confirmed three cases of the disease, becoming the third European country to report cases. The country’s disease control agency, the Robert Koch-Institut, said the three include a 22-year-old woman hospitalized in Hamburg; a man in his late 30s being treated at a hospital in Regensburg, north of Munich, and a 37-year-old woman from another southern town.

Health and airport authorities in Munich said the first direct flight carrying vacationers back to Germany since the outbreak of the disease in Mexico was expected and might be quarantined if passengers showed symptoms of swine flu.

Spain said Wednesday that the number of confirmed cases of the flu had risen from two to four, including one in the northern Basque region, all in people who had recently returned from Mexico. The health ministry said authorities were now observing 59 suspected cases.

In London, Prime Minister Gordon Brown told parliament that three more cases of swine flu had been confirmed in Britain, one of them a 12-year-old girl, in addition to a Scottish couple, bringing the total to five. All three had recently travelled from Mexico, had mild symptoms and were responding to treatment, he said. A school attended by the 12-year-old in southwest England had been temporarily closed, he added.

Canada has 13 confirmed cases, all of which are mild, Canada’s chief public health officer, Dr. David Butler-Jones, said Tuesday.In all, the United Nations global health body, the World Health Organization, has confirmed 105 cases of swine flu in seven countries. More than half of those — 66 — are in the United States.

New Zealand officials said on Wednesday that 14 cases had been confirmed there. New Zealand has been screening all arriving air passengers, and Dr. Fran McGrath, the deputy director of public health, said that five foreign travelers were being treated under quarantine for mild cases of the flu. All five were being “kept in isolation” at an undisclosed location in Auckland.

Also on Wednesday, at least 10 countries — from China to Russia to Ukraine to Ecuador — have established bans on the importing all pork products, despite a declaration from the W.H.O. that the virus cannot be transmitted by eating pork.

“There is no risk of infection from this virus from consumption of well-cooked pork and pork products,” the W.H.O. said in a statement.

Egypt on Wednesday went further, ordering the culling of all pigs in the Arab country as a precaution against swine flu, the country’s health minister said. While most Egyptians are Muslim and do not eat pork, it is available, and is mostly consumed by the Christian minority and foreigners.

"It is decided to slaughter all swine herds present in Egypt, starting from today," Health Minister Hatem el-Gabali said in a statement published by state news agency MENA.

Numerous countries in Europe, Asia and Latin America have been screening arriving passengers, including thermal facial scans and on-board checks of air travelers. Several countries have set up diagnostic and quarantine facilities for travelers suspected of being ill.

Five cruise lines, including the world’s two largest, Carnival and Royal Caribbean, said they were immediately stopping all port calls in Mexico. Princess Cruises, Holland America and Norwegian Cruise Line also said they were suspending Mexican stopovers. Cruises to Mexico accounted for about 7 percent of cruise traffic worldwide in 2008, according to the Cruise Line Industry Association.

In California, Gov. Arnold Schwarzenegger declared a state of emergency. But the nation’s highest number of cases continued to be in New York City, where 45 people were confirmed to have swine flu.

In Washington, Congress held hearings Wednesday to address the seriousness of the outbreak.

“I really think we need to be prepared for the worsening of the situation,” Rear Adm. Anne Schuchat, the C.D.C.’s interim science and public health deputy director, told a Senate Appropriations health subcommittee. “It’s more of a marathon than a sprint,” she said, echoing what Dr. Besser had said on Sunday, when the country first declared swine flu a public health emergency.

Senator Tom Harkin, the Iowa Democrat who heads the subcommittee, noted that “there’s a lot of anxiety right now across the country.”

Reporting was contributed by Liz Robbins, Donald G. McNeil Jr., Anahad O’Connor and Anne Barnard from New York; Nicholas Confessore from Albany; David Stout and Brian Knowlton from Washington; Marc Lacey from La Gloria, Mexico; Alan Cowell from London; Ian Austen from Ottawa; and Keith Bradsher from Hong Kong; and Victor Homola from Berlin.

    First U.S. Death From Swine Flu Is Reported, NYT, 30.4.2009, http://www.nytimes.com/2009/04/30/health/30flu.html?hp






Swine Flu

Claims First American Victim,

C.D.C. Says


April 29, 2009
Filed at 9:37 a.m. ET
The New York Times


ATLANTA (AP) -- The CDC on Wednesday confirmed the nation's first swine flu death in the current outbreak, a 23-month-old child in Texas.

The first swine flu death outside of Mexico was confirmed by Centers for Disease Control and Prevention spokesman Dave Daigle.

The acting head of the CDC called the confirmation tragic, but said it's too soon to say just how fast the swine flu virus is spreading.

Dr. Richard Besser said in a nationally broadcast network interview that health authorities had anticipated that the virus would cause deaths, and said that ''as a pediatrician and a parent, my heart goes out to the family.''

But Besser said on NBC's ''Today'' show that it's too soon to say if the death in Texas suggests the virus is spreading to more states. Nor would he say whether officials think it will become a nationwide problem.

He also said he does not believe the flu strain has become more dangerous.

Besser went on to note that even with seasonal flu, there are always some people who can't resist it very well, and said authorities need to learn more about the threat.

Children, especially those younger than age 5, are particularly vulnerable to flu and its complications, and every year children die from seasonal flu.

According to the CDC, more than 20,000 children younger than age 5 are hospitalized every year because of seasonal flu. In the 2007-08 flu season, the CDC received reports that 86 children nationwide died from flu complications.

As of April 11, CDC had received reports of 53 seasonal flu-related deaths in children during the current seasonal flu season.

    Swine Flu Claims First American Victim, C.D.C. Says, NYT, 29.4.2009, http://www.nytimes.com/aponline/2009/04/29/us/AP-US-Swine-Flu-Death.html






Swine Flu Vaccine

May Be Months Away,

Experts Say


April 29, 2009
The New York Times


Federal officials said it would take until January, or late November at the earliest, to make enough vaccine to protect all Americans from a possible epidemic of swine flu.

And beyond the United States and a few other countries that also make vaccines, some experts said it could take years to produce enough swine flu vaccine to satisfy global demand.

Although production is much faster than would have been possible even a few years ago, it still may not be in time to avert death and illness if the virus starts spreading widely and becomes more virulent, some experts said.

In this country, the biggest problem is that despite years of effort, the country is still relying on half-century-old technology to make the flu vaccines.

Federal authorities have spent years and more than a billion dollars trying to shift vaccine production to a faster, more reliable method — one that involves growing the vaccine viruses in vats of cells rather than in hen’s eggs, the old technology. And there are numerous small companies developing totally new approaches that might allow for the production of huge volumes of vaccines in a matter of weeks.

But the cell-based production is not quite ready, and some of the newer techniques are not proven enough to satisfy many experts.

“Those are all great technologies, but it isn’t going to happen in time,” said Dr. Greg Poland, head of the vaccine research program at the Mayo Clinic.

Federal officials have not yet made a decision on whether the swine flu is enough of a threat to warrant vaccine production. But they are taking the initial steps.

A potential problem is that producing swine flu vaccine might interfere with production of the seasonal flu vaccine for next winter.

“We would have to most likely make a compromise,” Andrin Oswald, chief executive of the vaccine division at the drug maker Novartis, said in an interview.

But Robin Robinson, who runs the emergency preparation research program for the federal Department of Health and Human Services, said most manufacturers would have finished producing the bulk of seasonal vaccine by June.

If production of the swine flu vaccine were to start right after that, the first 50 million to 80 million doses would be available by September, Dr. Robinson said.

A full 600 million doses, enough to provide the required two shots for each American, could be finished by January. If immune stimulants called adjuvants were added to the vaccine, that could reduce the dosage needed by each person, allowing enough doses to be ready by late November, he said.

The vaccine industry is in a much stronger position to respond now than it was five years ago, when the United States had only two flu vaccine suppliers and was hit by a severe shortage.

Now there are five suppliers to the domestic market. And the vaccine industry, once a backwater of the pharmaceutical industry, is attracting new investments, lured by government subsidies and higher prices for vaccines.

Still, a study done with the World Health Organization and the International Federation of Pharmaceutical Manufacturers and Associations estimated that it would probably take four years of production to satisfy fully global demand for a vaccine to protect against the bird flu strain that has concerned health authorities for the last few years.

Similar projections might apply to the swine flu vaccine, some experts say.

“The bottom line is there won’t be enough vaccine quickly enough and the vaccine will largely go to the countries that already produce the vaccine,” because countries will restrict exports in a pandemic, said Dr. David Fedson, an independent expert on pandemic preparedness.

The federal government is encouraging manufacturers to set up production in the United States, since all companies but one, Sanofi-Aventis, now import their flu vaccines.

The government also gave $1.3 billion, spread among several manufacturers, to develop ways of producing the vaccine in vats of animal cells rather than in eggs. Cell culture is less vulnerable to contamination and the process could save at least a few weeks.

The results so far have been mixed. Solvay, which was awarded the biggest federal grant, nearly $300 million, decided it was economically too risky to build a flu vaccine plant in the United States. (Most of the grant money had not yet left federal coffers and will not be lost, Dr. Robinson said.) Sanofi-Aventis has also put cell culture production on the back burner, Dr. Robinson said.

But Novartis is building a cell culture flu vaccine factory in Holly Springs, N.C., which might be ready for use in 2010 or 2011. The federal government is providing nearly $500 million in construction costs and guaranteed vaccine purchases.

    Swine Flu Vaccine May Be Months Away, Experts Say, NYT, 29.4.2009, http://www.nytimes.com/2009/04/29/business/economy/29vaccine.html


















Jon Han

 Dealing With the Swine Flu Outbreak        NYT        29.4.2009

















Dealing With the Swine Flu Outbreak


April 29, 2009
The New York Times


To the Editor:

Re “U.S. Declares Health Emergency as Cases of Swine Flu Emerge” (front page, April 27):

As someone who has worked in a nursing home for many years, I’ve seen outbreaks of infections. And I’ve seen our rapid responses to contain and prevent their spreading by quarantining. So I’m frankly quite baffled by our government’s response, or lack of it, to the swine flu outbreak.

We now know that the only confirmed outbreak in New York City is at St. Francis Preparatory School, where you reported that students visited Mexico on spring break. Once it became apparent last week that the source of the flu was Mexico, why wasn’t our immediate response to prevent passage into Mexico or out to the United States? And if we delayed in doing that, why aren’t we doing that now? Isn’t the job of our government to protect us?

Sandy Meyers

Bronx, April 28, 2009

To the Editor:

The rabid anti-immigration-ism that is stoked by mistruths and omissions of the mainstream media, especially on television but in newspapers as well, is a continuing public health menace when outbreaks of infectious disease like the swine flu occurs — in that immigrants without green cards will not feel free to seek medical care at health institutions.

The vigilante atmosphere is self-sabotaging and as mentioned is in and of itself a public health hazard because, similar to the critical census-taking protocol, it relies on people to identify themselves in an atmosphere of racism, hate, xenophobia and scapegoating.

A many-pronged approach by local, state and federal institutions needs to address this obstacle to isolating and treating outbreaks of contagious illnesses. Cindy Shapiro

Beulah, Mich., April 27, 2009

To the Editor:

The Senate should not have delayed acting on the nomination of Gov. Kathleen Sebelius of Kansas as health and human services secretary, so a permanent director of the Centers for Disease Control and Prevention could be appointed.

The secretary of homeland security and the White House press secretary, Robert Gibbs, are not the usual individuals to decide on the status of a public health emergency.

Bertrand M. Bell

New York, April 28, 2009

The writer is a professor of medicine at the Albert Einstein College of Medicine.

To the Editor:

Re “The New Swine Flu” (editorial, April 28): Here are the nonmedical problems associated with this potential pandemic disease:

The Republicans in Congress took $900 million out of the stimulus bill that was to be used as an “insurance policy” against possible pandemics.

There are thousands of people coming across our border from Mexico, and if the news reports are to be taken seriously, most are coming into the United States with virtually no screening or questions asked.

The party of “no,” the same Republicans on Capitol Hill, have until recently been blocking action on the nomination of Gov. Kathleen Sebelius to become secretary of health and human services, leaving a huge void at the top of the agency that has the responsibility to protect us from pandemics.

The alerts and warnings that have gone up worldwide are a very good thing indeed. America might want to look at temperature-screening devices at all entry points into this country starting today! The last thing we need right now is an epidemic of swine flu that could become a global pandemic.

Henry A. Lowenstein

New York, April 28, 2009

To the Editor:

Re “Officials Point to Swine Flu in New York” (front page, April 26):

Dare we ask why this happening? While its exact origin is still unclear, this pathogen, and many others (like avian influenza), originated from animals being raised or eaten for food.

As the world moves toward raising the majority of animals in the unnatural setting of factory farms, it is likely that more, and worse, such pathogens will arise. What will it take for us, and our public health leaders, to question our addiction to meat and tolerance of factory farming? The meat industry is environmentally devastating, incredibly inhumane and now potentially the end to us all. Edward Machtinger

San Francisco, April 26, 2009

The writer is an associate professor of medicine and director of the Women’s H.I.V. Program, University of California, San Francisco.

To the Editor:

The Centers for Disease Control and Prevention lists staying home from school or work as one of the several precautionary measures for dealing with the swine flu. Common sense also tells people who are sick to limit contact with others. Yet for millions of people, that step could result in loss of wages or disciplinary action at work.

Ensuring that those who are ill can stay home, or keep their sick children home, is exactly why we need to guarantee a minimum number of paid sick days to all workers. Every one of us needs this critical protection carried out before the country faces a pandemic.

We urge Congress to take action on the Healthy Families Act and employers to assure workers that they will not be punished for following guidelines from the nation’s health experts.

Ellen Bravo

Milwaukee, April 27, 2009

The writer coordinates Family Values @ Work: A Multi-State Consortium, a network of state groups working for policies like paid sick days.

To the Editor:

A recent Times article (“Texas Governor’s Secession Talk Stirs Furor,” April 18) quoted Gov. Rick Perry of Texas expressing sympathy for secessionist sentiment in his home state: “If Washington continues to thumb their nose at the American people, who knows what may come of that?”

But on April 26, you report that “Gov. Rick Perry of Texas asked the C.D.C. to send 37,430 doses of Tamiflu.”

It would appear that the governor has realized that membership has its privileges. David D. Turner

New York, April 26, 2009

    Dealing With the Swine Flu Outbreak, NYT, 29.4.2009, http://www.nytimes.com/2009/04/29/opinion/l29flu.html?hpw






U.S. Declares

Public Health Emergency

Over Swine Flu


April 27, 2009
The New York Times


Responding to what some health officials feared could be the leading edge of a global pandemic emerging from Mexico, American health officials declared a public health emergency on Sunday as 20 cases of swine flu were confirmed in this country, including eight in New York City.

Other nations imposed travel bans or made plans to quarantine air travelers as confirmed cases also appeared in Mexico and Canada and suspect cases emerged elsewhere.

Top global flu experts struggled to predict how dangerous the new A (H1N1) swine flu strain would be as it became clear that they had too little information about Mexico’s outbreak — in particular how many cases had occurred in what is thought to be a month before the outbreak was detected, and whether the virus was mutating to be more lethal, or less.

“We’re in a period in which the picture is evolving,” said Dr. Keiji Fukuda, deputy director general of the World Health Organization. “We need to know the extent to which it causes mild and serious infections.”

Without that knowledge — which is unlikely to emerge soon because only two laboratories, in Atlanta and Winnipeg, Canada, can confirm a case — his agency’s panel of experts was unwilling to raise the global pandemic alert level, even though it officially saw the outbreak as a public health emergency and opened its emergency response center.

As a news conference in Washington, Homeland Security Secretary Janet Napolitano called the emergency declaration “standard operating procedure,” and said she would rather call it a “declaration of emergency preparedness.”

“It’s like declaring one for a hurricane,” she said. “It means we can release funds and take other measures. The hurricane may not actually hit.”

American investigators said they expected more cases here, but noted that virtually all so far had been mild and urged Americans not to panic.

The speed and the scope of the world’s response showed the value of preparations made because of the avian flu and SARS scares, public health experts said.

The emergency declaration in the United States lets the government free more money for antiviral drugs and give some previously unapproved tests and drugs to children. One-quarter of the national stockpile of 50 million courses of antiflu drugs will be released.

Border patrols and airport security officers are to begin asking travelers if they have had the flu or a fever; those who appear ill will be stopped, taken aside and given masks while they arrange for medical care.

“This is moving fast and we expect to see more cases,” Dr. Richard Besser, acting director of the Centers for Disease Control and Prevention, said at the news conference with Ms. Napolitano. “But we view this as a marathon.”

He advised Americans to wash their hands frequently, to cover coughs and sneezes and to stay home if they felt ill; but he stopped short of advice now given in Mexico to wear masks and not kiss or touch anyone. He praised decisions to close individual schools in New York and Texas but did not call for more widespread closings.

Besides the eight New York cases, officials said they had confirmed seven in California, two in Kansas, two in Texas and one in Ohio. The virus looked identical to the one in Mexico believed to have killed 103 people — including 22 people whose deaths were confirmed to be from swine flu — and sickened about 1,600. As of Sunday night, there were no swine flu deaths in the United States, and one hospitalization.

Other governments tried to contain the infection amid reports of potential new cases including in New Zealand and Spain.

Dr. Fukuda of the W.H.O. said his agency would decide Tuesday whether to raise the pandemic alert level to 4. Such a move would prompt more travel bans, and the agency has been reluctant historically to take actions that hurt member nations.

Canada confirmed six cases, at opposite ends of the country: four in Nova Scotia and two in British Columbia. Canadian health officials said the victims had only mild symptoms and had either recently traveled to Mexico or been in contact with someone who had.

Other governments issued advisories urging citizens not to visit Mexico. China, Japan, Hong Kong and others set up quarantines for anyone possibly infected. Russia and other countries banned pork imports from Mexico, though people cannot get the flu from eating pork.

In the United States, the C.D.C. confirmed that eight students at St. Francis Preparatory School in Fresh Meadows, Queens, had been infected with the new swine flu. At a news conference on Sunday, Mayor Michael R. Bloomberg said that all those cases had been mild and that city hospitals had not seen a surge in severe lung infections.

On the streets of New York, people seemed relatively unconcerned, in sharp contrast to Mexico City, where soldiers handed out masks.

Hong Kong, shaped by lasting scars as an epicenter of the SARS outbreak, announced very tough measures. Officials there urged travelers to avoid Mexico and ordered the immediate detention of anyone arriving with a fever higher than 100.4 degrees Fahrenheit after traveling through any city with a confirmed case, which would include New York.

Everyone stopped will be sent to a hospital for a flu test and held until it is negative. Since Hong Kong has Asia’s busiest airport hub, the policy could severely disrupt international travel.

The central question is how many mild cases Mexico has had, Dr. Martin S. Cetron, director of global migration and quarantine for the Centers for Disease Control, said in an interview.

“We may just be looking at the tip of the iceberg, which would give you a skewed initial estimate of the case fatality rate,” he said, meaning that there might have been tens of thousands of mild infections around the 1,300 cases of serious disease and 80 or more deaths. If that is true, as the flu spreads, it would not be surprising if most cases were mild.

Even in 1918, according to the C.D.C., the virus infected at least 500 million of the world’s 1.5 billion people to kill 50 million. Many would have been saved if antiflu drugs, antibiotics and mechanical ventilators had existed.

Another hypothesis, Dr. Cetron said, is that some other factor in Mexico increased lethality, like co-infection with another microbe or an unwittingly dangerous treatment.

Flu experts would also like to know whether current flu shots give any protection because it will be months before a new vaccine can be made.

There is an H1N1 human strain in this year’s shot, and all H1N1 flus are descendants of the 1918 pandemic strain. But flus pick up many mutations, and there will be no proof of protection until the C.D.C. can test stored blood serum containing flu shot antibodies against the new virus. Those tests are under way, said an expert who sent the C.D.C. his blood samples.


Reporting was contributed by Sheryl Gay Stolberg from Washington, Jack Healy from New York, Keith Bradsher from Hong Kong and Ian Austen from Ottawa.

    U.S. Declares Public Health Emergency Over Swine Flu, NYT, 27.4.2009, http://www.nytimes.com/2009/04/27/world/27flu.html?hpw







Morning-After Pills


April 24, 2009
The New York Times

In a further break from the Bush administration’s ideologically driven policies on birth control, the Food and Drug Administration has agreed to let 17-year-olds get the morning-after emergency contraceptive pills without a doctor’s prescription. It is a wise move that complies with a recent order by a federal judge, based on voluminous evidence in F.D.A. files that girls that young can use the pills safely.

For much of the Bush administration, the agency — ignoring the advice of its own scientists — refused to let the pills be sold over the counter to anyone. It insisted that women obtain a prescription, a time-consuming process that could often render the pills useless. The morning-after medication, actually two pills taken in sequence, blocks a pregnancy if taken within 72 hours of intercourse and is most effective within the first 24 hours.

Facing intense Congressional and legal pressure, the F.D.A. finally relented in 2006 and made the pills available to women 18 and older without a prescription. So far there has been no measurable effect on abortion or teenage pregnancy rates. But individual women in distress have surely benefited from easier access.

Now the agency has announced that it will not appeal a federal judge’s ruling that it must lower the age limit by another year. Still to be determined is how the F.D.A. will respond to the judge’s additional order that it consider removing any age restrictions, as recommended by health authorities. There is no indication that the manufacturer plans to seek the agency’s permission to market to girls 16 or younger.

    Morning-After Pills, NYT, 24.4.2009, http://www.nytimes.com/2009/04/24/opinion/24fri3.html






Advances Elusive

in the Long Drive to Cure Cancer


April 24, 2009
The New York Times


In 1971, flush with the nation’s success in putting a man on the Moon, President Richard M. Nixon announced a new goal. Cancer would be cured by 1976, the bicentennial.

When 1976 came and went, the date for a cure, or at least substantial progress, kept being put off. It was going to happen by 2000, then by 2015.

Now, President Barack Obama, discussing his plans for health care, has vowed to find “a cure” for cancer in our time and said that, as part of the economic stimulus package, he would increase federal money for cancer research by a third for the next two years.

Cancer has always been an expensive priority. Since the war on cancer began, the National Cancer Institute, the federal government’s main cancer research entity, with 4,000 employees, has alone spent $105 billion. And other government agencies, universities, drug companies and philanthropies have chipped in uncounted billions more.

Yet the death rate for cancer, adjusted for the size and age of the population, dropped only 5 percent from 1950 to 2005. In contrast, the death rate for heart disease dropped 64 percent in that time, and for flu and pneumonia, it fell 58 percent.

Still, the perception, fed by the medical profession and its marketers, and by popular sentiment, is that cancer can almost always be prevented. If that fails, it can usually be treated, even beaten.

The good news is that many whose cancer has not spread do well, as they have in the past. In some cases, like early breast cancer, drugs introduced in the past decade have made an already good prognosis even better. And a few rare cancers, like chronic myeloid leukemia, can be controlled for years with new drugs. Cancer treatments today tend to be less harsh. Surgery is less disfiguring, chemotherapy less disabling.

But difficulties arise when cancer spreads, and, often, it has by the time of diagnosis. That is true for the most common cancers as well as rarer ones.

With breast cancer, for example, only 20 percent with metastatic disease — cancer that has spread outside the breast, like to bones, brain, lungs or liver — live five years or more, barely changed since the war on cancer began.

With colorectal cancer, only 10 percent with metastatic disease survive five years. That number, too, has hardly changed over the past four decades. The number has long been about 30 percent for metastatic prostate cancer, and in the single digits for lung cancer.

As for prevention, progress has been agonizingly slow. Only a very few things — stopping smoking, for example — make a difference. And despite marketing claims to the contrary, rigorous studies of prevention methods like high-fiber or low-fat diets, or vitamins or selenium, have failed to find an effect.

What has happened? Is cancer just an impossibly hard problem? Or is the United States, the only country to invest so much in cancer research, making fundamental mistakes in the way it fights the cancer war?

Researchers say the answer is yes on both counts. Cancer is hard — it is not one disease or, if it is, no one has figured out the weak link in cancer cells that would lead to a cure. Instead, cancer investigators say, the more they study cancer, the more complex it seems. Many are buoyed by recent progress in cancer molecular biology, but confess they have a long way to go.

There also are unnecessary roadblocks. Research lurches from fad to fad — cancer viruses, immunology, genomics. Advocacy groups have lobbied and directed research in ways that have not always advanced science.

And for all the money poured into cancer research, there has never been enough for innovative studies, the kind that can fundamentally change the way scientists understand cancer or doctors treat it. Such studies are risky, less likely to work than ones that are more incremental. The result is that, with limited money, innovative projects often lose out to more reliably successful projects that aim to tweak treatments, perhaps extending life by only weeks.

“Actually, that is the biggest threat,” said Dr. Robert C. Young, chancellor of the Fox Chase Cancer Center in Philadelphia. “Every organization says, ‘Oh, we want to fund high-risk research.’ And I think they mean it. But as a matter of fact, they don’t do it.”

A recent New York Times/CBS News poll found the public divided about progress. Older people, more likely to have friends or relatives who had died of cancer, were more dubious — just 26 percent said a lot of progress had been made. The figure was 40 percent for middle-aged people, who may be more likely to know people who, with increased screening, had received a cancer diagnosis and seemed fine.

Yet the grim facts about cancer can be lost among the positive messages from the news media, advocacy groups and medical centers, and even labels on foods and supplements, hinting that they can fight or prevent cancer. The words tend to be carefully couched, but their impression is unmistakable and welcomed: cancer is preventable if you just eat right and exercise. If you are screened regularly, cancers can be caught early and almost certainly will be cured. If by some awful luck, your cancer is potentially deadly, miraculous new treatments and more in the pipeline could cure you or turn your cancer into a manageable disease.

Unfortunately, as many with cancer have learned, the picture is not always so glowing.

Phyllis Kutt, 61, a retired teacher in Cambridge, Mass., believed the advertisements and public service announcements. She thought she would never get cancer — she is a vegetarian, she exercises, she is not overweight, she does not smoke. And only two people in her extended family ever had cancer.

Then, in May 2006, Ms. Kutt’s mammogram showed a foggy spot. The radiologist decided it was insignificant, but six months later, her internist found a walnut-sized lump in her right breast close to her armpit. It was the area that had been foggy on the mammogram.

“I was in real shock,” Ms. Kutt said. “How could this be happening to me?”

Still, it looked as if she would be fine. There was no sign of cancer in her lymph nodes, and her surgeon removed the tumor.

Ms. Kutt, her husband and her oncologist were worried, though, and decided on aggressive treatment — four months of chemotherapy followed by 33 rounds of radiation. When it ended, she thought she was finished with cancer.

“My doctors never used the word ‘cure’ and I bless them for that,” Ms. Kutt said. “But they do celebrate the end of chemo and they celebrate the end of radiation.”

Last May the cancer came back, as a string of tiny lumps under her arm and a lump on her bicep. CT scans revealed she also had tumors in her lungs.

But cancer is curable, she thought. There are amazing new treatments. She found out otherwise.

It turns out that, with few exceptions, mostly childhood cancers and testicular cancer, there is no cure once a cancer has spread. The best that can be done is to keep it at bay for a while.

Last June, Ms. Kutt started a new regimen — three weeks of chemotherapy, followed by a week off. She is also taking a new drug, Avastin.

“I am still on that and will be forever until the cancer progresses and I change to other drugs or some new drugs are developed, or I die,” she said.

The hardest part is explaining to friends and family.

“People will say to me, ‘So when is your treatment going to be over?’ ” Ms. Kutt said. “That’s the perception. You get treated. You’re done. You’re cured.”

“I think some of my family members still believe that,” she added. “Even though I told them, they forget. I get cards from my nieces, ‘How are you doing? You’ll be done soon, right?’ ”

Dr. Leonard Saltz, a colon cancer specialist at Memorial Sloan-Kettering Cancer Center, deals with misperceptions all the time. “People too often come to us expecting that the newest drugs can cure widespread metastatic cancer,” Dr. Saltz said. “They are often shocked to find that the latest technology is not a cure.”

One reason for the misunderstanding, he said, is the words that cancer researchers and drug companies often use. “Sometimes by accident, sometimes deliberately, sometimes with the best intentions, sometimes not, we may paint a picture that is overly rosy,” he said.

For example, a study may state that a treatment offers a “significant survival advantage” or a “highly significant survival advantage.” Too often, Dr. Saltz says, the word “significant” is mistaken to mean “substantial,” and “improved survival” is often interpreted as “cure.”

Yet in this context, “significant” means “statistically significant,” a technical way of saying there is a difference between two groups of patients that is unlikely to have occurred by chance. But the difference could mean simply surviving for a few more weeks or days.

Then there is “progression-free survival,” which doctors, researchers and companies use to mean the amount of time from the start of treatment until the tumor starts growing again. It does not mean that a patient lives longer, only that the cancer is controlled longer, perhaps for weeks or, at best, months. A better term would be “progression-free interval,” Dr. Saltz said. “You don’t need the word ‘survival’ in there.”

As a doctor who tries to be honest with patients, Dr. Saltz says he sees the allure of illusions.

“It would be very hard and insensitive to say, ‘All I’ve got is a drug that will cost $10,000 a month and give you an average survival benefit of a month or two,’ ” he said. “The details are very, very tough to deal with.”

That does not help Ms. Kutt, who chafes at the way breast cancer is presented — the pink ribbons, the celebration of survivors, the emphasis on early detection, as though that will insure you will never get an incurable cancer.

She knows she frightens people with her bald head, so obviously a cancer patient. When someone is on crutches with a broken ankle, strangers offer condolences and ask about the injury. But people avert their eyes when they see Ms. Kutt. Only once, she said, did a stranger approach, and that was a woman who also had breast cancer.

And in her online discussion group of women with metastatic disease, some said they had been asked to leave breast cancer support groups. Members whose cancer had not spread considered themselves survivors, and those whose cancer had spread were too grim a reminder of what could happen.

“It’s fear,” Ms. Kutt said. “You’re part of the death group.”

    Advances Elusive in the Long Drive to Cure Cancer, NYT, 24.4.2009, http://www.nytimes.com/2009/04/24/health/policy/24cancer.html






With Son in Remission,

Family Looks for Coverage


April 21, 2009
The New York Times


HUMBLE, Tex. — When Danna Walker left the second-floor conference room and returned tearily to her desk — where someone had already deposited a packing box for her belongings — her first thought was not of the 14 years she had worked for DHL or the loss of her $37,000-a-year salary.

It was of Jake. In three months, once her benefits ran out, how in the world would she provide health insurance for Jake, her mountainous, red-headed 21-year-old son, who had learned three years earlier that he had metastatic testicular cancer?

Since the day she was laid off in October, Ms. Walker and her husband, Russ, co-owner of a struggling feed store here on the outskirts of Houston, have mounted a largely fruitless quest to find affordable coverage for Jake’s pre-existing condition. Their odyssey has become all too familiar to millions of newly uninsured Americans who suddenly find themselves one diagnosis away from medical and financial devastation.

The Walkers, both 46, are among nine million people who have lost employer-sponsored insurance since December 2007, according to projections by the Kaiser Family Foundation. Some have qualified for government insurance, and others have bought individual policies. But an estimated four million have joined the ranks of the uninsured, heightening the urgency in Washington to close the coverage gaps in American health care.

Like many others, the Walkers live on a knife’s edge of risk. Without insurance to cover her high blood pressure or his diabetes, they defer doctors’ visits when possible and obtain their prescriptions — nine between the two of them — for $4 apiece at Wal-Mart.

But their primary concern has been finding insurance for Jake, who, after four operations, two stem cell transplants and round after grueling round of chemotherapy, has been cancer-free for a year.

He continues to face a significant threat of recurrence and requires regular monitoring for at least two years. His twice-a-year CT scans cost $3,000 each, and quarterly blood tests and X-rays run more than $1,000.

Late last month, in a race against the clock, the Walkers obtained a short-term policy for Jake through Oklahoma State University, where he is a junior studying animal science on a scholarship. Doing so could be crucial to his future insurability because federal law allows insurers to deny coverage for pre-existing conditions when there has been a gap in coverage of at least 63 days.

With a week to spare, they scraped together $335 to pay the quarterly premium by delaying a house payment and pleading with the power company for a 10-day extension. But the policy will expire on May 16, and its coverage limits will afford minimal protection against bankruptcy if the cancer returns before then.

Now the Walkers face the possibility that Jake will no longer be seen at Houston’s renowned M.D. Anderson Cancer Center, which they credit for his remission.

“You realize how vulnerable you really are,” said Ms. Walker, who exhibits the maternal ferocity of a black bear. “You just — not give up — but you just feel that you’re at a loss, that you’re at your wits’ end. I ask myself, ‘Do I really have to lose my home to save my son’s life?’ ”

Neither of the Walkers has been able to land a job with the kind of large group coverage that would disregard Jake’s health status. His cancer history effectively makes him uninsurable on the individual market. He is too old to qualify for Medicaid as a child, and it is virtually impossible in Texas to qualify as an able-bodied adult.

Because the Walkers own their modest house, they have been told they do not merit other government assistance. With little predictable income beyond Ms. Walker’s $688 unemployment check every two weeks, the family cannot afford the state’s high-risk insurance pool or continuation coverage through the federal Cobra law.

To date, Jake’s treatment has cost nearly $2 million. Almost all of it has been paid by Cigna under a preferred-provider family policy that Ms. Walker paid $426.28 a month for through DHL, the troubled shipping company where she worked as a billing agent.

Until last fall, Mr. Walker was the co-owner of a business that supplied DHL with trucks and drivers, but it too fell victim to downsizing. The feed store, the last in an area where suburbs are swallowing ranchland, has been losing money.

What has made the Walkers feel most helpless, though, is that their son has been left so exposed, after all he has endured.

“Your job as a parent is to protect your children at any cost,” Ms. Walker said. “I really felt like I had let him down.”

At 6-foot-2 and 285 pounds, Jacob Walker often dwarfs the prize livestock he parades in the show ring. He first noticed that his left testicle had become larger than the other as a senior in high school. He waited a few weeks to tell his parents so he would not miss the county fair, where his favorite heifer and goat both won grand-champion ribbons. By then, the cancer had spread to his abdomen, and he received a Stage 3 diagnosis.

Over the next two years, surgeons would remove the testicle and slice off diseased sections of his abdomen and liver. The chemotherapy preceding the stem cell transplants was so toxic that it peeled his skin.

Through it all, Jake maintained an optimistic determination. “Life’s tough,” he would say. “Sometimes you have to get a helmet and run with it.”

His mother left the hospital once in 26 days during the stem cell transplants. When he started college online from his hospital bed, she read to him from his world-literature text. His father, not often given to emotion, started telling his son every day that he loved him, before going home to cry. During Jake’s chemotherapy, his buddies in Future Farmers of America shaved their heads in solidarity.

Late in 2007, Jake’s doctors at Texas Children’s Hospital told him that they had done all they could and gave him a 20 percent chance of surviving the next year. The Walkers were not ready to quit, and sought out Dr. Lance C. Pagliaro, a specialist at M. D. Anderson.

Dr. Pagliaro recommended an experimental chemotherapy regimen, and Jake has shown no sign of cancer since the treatments ended in March 2008. “Needless to say, we’re very pleased with how he’s doing,” Dr. Pagliaro said.

But during Jake’s check-up in December, Ms. Walker told the hospital that her son would be uninsured at the end of January. She said a hospital official then told her that if she was not able to pay up front, she should take her son elsewhere.

Dr. Pagliaro pledged that he would do what he could to make sure that Jake would be seen. “To deny him the relatively inexpensive follow-up that is so crucial,” he said in an interview, “just makes absolutely no sense.”

But the doctor has yet to intercede with the business office about waiving fees, saying it would be premature. Last month, when the Walkers showed up for an appointment with Jake’s oncologist, only a last-minute dispensation enabled him to be seen without payment in advance. The Walkers left with the impression they would be billed $700; the hospital says it will be $1,507. In either event, they have no way to pay it.

The hospital has suggested that Jake have his next tests elsewhere and send the results to Dr. Pagliaro to review, with payment to be negotiated in advance.

The Walkers are now completing the voluminous paperwork to apply for M. D. Anderson’s charity care program for Texas residents. The hospital, which had $2.2 billion in net patient revenue last year, spent $209 million on such uncompensated care.

But Dr. Ron Walters, the hospital’s vice president for medical operations, said economic pressures had made it more difficult to assist patients who were not under active treatment. Dr. Walters said it had been “good financial counseling” to advise the Walkers to explore other options, and questioned whether they would qualify for charity care because they had assets. Among the criteria, he said, is whether a patient can receive comparable treatment elsewhere.

Dr. Walters said requests for deferred payment by uninsured patients had risen tenfold in four years. But Ms. Walker said she could not help taking the hospital’s stance personally.

“You feel like you’ve been kicked to the curb,” she said. “It’s like, ‘As long as you have insurance, we’re willing to go over the moon to see you and make sure that everything is taken care of.’ And the minute you don’t, they don’t want you.”

The Walkers had not heard about the Texas Health Insurance Risk Pool, which provides coverage to 26,550 otherwise uninsurable people. Once they learned about it, they concluded they could not afford the most useful policy for Jake, a plan with a $1,000 deductible that would cost $414 a month.

Now they are revisiting whether they might extend their P.P.O. coverage under Cobra, which allows laid-off workers to continue their insurance at full price for up to 18 months. When Ms. Walker first investigated, she learned it would cost $1,359 a month to replicate her coverage.

The recently enacted federal stimulus package includes a 65 percent subsidy for nine months of Cobra coverage for the newly unemployed. That would reduce the Walkers’ price to $476 a month, which they said they still could not afford.

They are now inquiring about whether they can cover only Jake. If they can find a policy for him for less than $200 a month, Ms. Walker said, she would find a way.

“It will happen,” she said, “if I have to walk up and down the street and collect tin cans.”


Brent McDonald contributed reporting.

    With Son in Remission, Family Looks for Coverage, NYT, 21.4.2009, http://www.nytimes.com/2009/04/21/us/21uninsured.html







A Cadaver, for the Sake of Science


April 2, 2009
The New York Times


To the Editor:

Dead Body of Knowledge,” by Christine Montross (Op-Ed, March 27), was a welcome reminder of the value of human dissection.

An anatomical image is just an image. But the cadaver is the medical student’s first patient and the first encounter with the emotional burden of becoming a physician. The impact is nowhere more apparent than in the student’s initial reaction to dissection.

The sight and smell of the body, the sounds of cutting and sawing, and the feel of human flesh have effects both empathic and repulsive. These sensations provide the earliest opportunity to examine how doctors manage (or mismanage) the inevitable emotions associated with patient care.

Taught properly, dissection of the cadaver allows students to examine themselves. Gary J. Kennedy

Bronx, March 30, 2009

The writer, a professor of psychiatry at the Albert Einstein College of Medicine, is the co-author of “Cadaver Conference: A Psychiatrist in the Gross Anatomy Course.”

To the Editor:

In my human anatomy class, I came to appreciate the uniqueness of the individual human body. I found that structures like arteries, veins, ducts and even organs vary greatly from what is shown in textbooks or on computer scans.

Dissecting the human cadaver proved to be a truly visceral experience. Seeing, touching, smelling, moving muscles and bones helped me as an anatomy student (and later as an anatomy instructor) to use a very important organ, my brain, to decipher the complexity and beauty of the human body, both on an intellectual and an emotional level.

I agree with Christine Montross. Cadaver dissection is indeed a vital part of the anatomy curriculum.

Ginger Nathanson

Long Valley, N.J., March 28, 2009

To the Editor:

No research demonstrates that learning anatomy using medical imaging is inferior to the information gained through the brief dissection of the one cadaver allotted to each medical student.

The role of technology and medical imaging will inevitably increase in anatomy courses. New digital tools like the ones we are developing at Stanford have been shown to greatly enhance the learning experience. We now have the ability to visualize and interact with anatomical information that was previously inaccessible.

Teaching anatomy cannot be couched in an either-or framework; instead, technology and cadavers should enhance each other. Only well-designed, validated studies will provide answers to the issues introduced by Christine Montross.

W. Paul Brown

Stanford, Calif., March 30, 2009

The writer, a dentist, is a consulting associate professor in the Division of Anatomy at Stanford University.

To the Editor:

I am disappointed to read in Christine Montross’s article that medical schools are contemplating the transfer of anatomy from actual cadavers to virtual reality because of cost.

As a first-year medical student, I find that most of our time is spent relentlessly memorizing the exhaustive body of knowledge that has accumulated through the years of research and science. It would be a great disservice to the future of medicine to remove the single most important tool first- and second-year medical students can physically access.

The cadavers present information that is simply inaccessible through the computer. Could we simulate the systemic spread, consistency and color of the many cancers discovered in the bodies? Would we empathize in the same way looking through a monitor? Would a three-dimensional view be fully reproduced on a two-dimensional screen?

It is my view that the answer to these, and countless more, is no.

Locke Uppendahl

Kansas City, Kan., March 27, 2009

To the Editor:

Most important, cadaver dissection enables students to appreciate the enormous amount of anatomical variation among human beings. A computer program cannot convey the fact that physical phenomena like aberrant arteries, accessory glandular tissue or atrophied muscles belong to a particular formerly living person.

Dissection allows students to recognize people as truly unique individuals in body and in spirit, each with their own “irregularities.”

Without going into the lab, students may fail to consider a fundamental tenet of medicine: no two patients are identical, and therefore all medical care must be individualized. Geoff Rubin

New York, March 27, 2009

The writer is a first-year medical student at the Columbia College of Physicians and Surgeons.

To the Editor:

Christine Montross has perfectly described the value and beauty of the human body when compared with electronic imaging. In pathology we often say “a picture is worth a thousand words, but a specimen is worth a thousand pictures.”

Dennis G. O’Neill

Manchester, Conn., March 27, 2009

The writer, a medical doctor, is director of the department of pathology and laboratory services at Manchester Memorial Hospital.

    A Cadaver, for the Sake of Science, NYT, 2.4.2009, http://www.nytimes.com/2009/04/02/opinion/l02cadaver.html