The hormone of laddishness

Oestrogen, not testosterone, is what makes a male act like a male

IN ALL species that practise sexual reproduction, males and females show gender-specific behaviours. These range from the way they mate to the way they defend—or fail to defend—their territory. Both males and females start out with the same template at birth, but then something acts on the male to masculinise him for life. But nobody knows just how that happens.

It is well known that sex hormones like oestrogen, which is typically seen as a female hormone, and testosterone, similarly seen as a male one, play a role in shaping the neural circuits in the developing brain, and that much of that moulding takes place before birth. It has also been established that testosterone, as well as being a fully functional hormone in its own right, can be (and often is) converted into oestrogen in the body.

Male mice experience a short-lived testosterone surge on the day they are born. It lasts less than 36 hours and the level then remains low until puberty. (In human males, there appears to be a similar neonatal surge.) This pulse of testosterone is believed to be a key event in the masculinisation of the brain. Nirao Shah and his colleagues at the University of California, San Francisco wanted to find out which neurons in the brain were responding to it. What they discovered was a surprise.

It was reasonable to think, as many people did, that androgen receptors—which respond to male hormones—were mediating the manly transformation. But androgen receptors were found to be nearly non-existent in the brains of newborn animals. Dr Shah could not find them earlier in development either, such as just after the fetal testes first started putting out testosterone in a 13-day-old embryo. Without male hormone receptors to respond to testosterone, the researchers started to suspect androgen receptors were not the players they had been assumed to be. Nor, perhaps, was testosterone.

In their study, published this week in Neuron, the researchers decided to look at male mice which had been genetically engineered to lack androgen receptors in their nervous systems. These males still had androgen receptors in their muscles and elsewhere, so they had masculine bodies, and they experienced the testosterone surge and responded to normally circulating testosterone. But their brains were simply not able to detect it.

The mice were compared with normal males in tests of masculinity. In one, a female was put into the cage. Interestingly, the genetically modified mice still showed the classic male-mating repertoire—mounting, penetration and ejaculation. But the researchers noted that they mounted less often, were less apt to penetrate and did not stick at it for as long as the normal mice. Another test turned up similar results. Typically, a strange male entering another male’s cage is met with a fight. Again, the mutant mice behaved appropriately, but they were much less aggressive, spent less time fighting and they took longer breaks between attacks. The same was found for scent-marking. Like normal males, the mutant mice urinated in various spots around their cage (unlike females, who create a single latrine). But they deposited significantly fewer urine marks than the normal males.

Because male-typical behaviours developed as the result of a burst of testosterone, but in the absence of receptors for the hormone, the researchers suspect that the testosterone in the surge is being converted into oestrogen to carry out the newborn sexual-differentiation. “Masculinisation of neural pathways in response to the testosterone surge at birth proceeds primarily under the control of oestrogen,” they conclude. Androgen receptors are not the master regulators for male behaviours, but rather, the researchers say, a “gain control mechanism” which amplifies such behaviours—or, when the receptors are absent, dials laddish behaviour down.

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Full article: http://www.economist.com/science-technology/displaystory.cfm?story_id=16004382&source=hptextfeature

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Our Big Problem

Obesity is spreading—and eating away at America’s economy and health. Theodore Dalrymple on how society can bite back.

These days, it seems, almost everyone has a habit that he can’t control. For millions of people, this habit is overeating.

Never have so many human mastodons bestridden the earth as now. At one time, not so very long ago, such mastodons were rare enough to be curiosities, charitably thought by others to be the victims of their “glands.” We had such a fat boy at school: His cheeks were so adipose that his eyes had become mere slits. We thought that he was ill rather than a member of a cultural avant garde.

In America, more than a third of the adult population is now obese (obesity being defined as having a body-mass index more than 30). This is nearly three times as many as in 1960, and half as many again as in 1990.

But the increase has been greatest among those known as the morbidly obese—that is to say those with a BMI of more than 40. As a proportion of the population they have increased in America by more than six times since 1960, and three times since 1990. They are now about 6% of adults.

The cultural meaning of obesity has changed at the same time. For most of human history, fatness has been a sign of prosperity, of having risen, socially and economically, above the day-to-day struggle to obtain enough to eat. But sadly now, in Western societies, obesity is concentrated among the poorest and least educated. In America, blacks are 50% more likely to be obese than whites, and Hispanics 20% more likely.

I once saw the change in cultural meaning of body size happening before my very eyes, when I practiced briefly in the mid-1970s as a doctor in Zululand in South Africa. The women who still lived in a traditional way, in mud huts, wanted to be fattened up for their menfolk, who saw in a fat wife a sign of their own success and prestige. These women would ask for medicine to become even fatter than they already were. By contrast, the young women who attended university wanted medicine to make them thinner than they already were. It almost seems as if, for human beings, there is no contentment with their body size.

If overeating is not in itself a disease, it certainly has health consequences. By now, there surely cannot be anybody left who does not know that obesity causes Type II diabetes, any more than there are smokers who do not know that smoking is bad for them. When I started out as a doctor, Type II diabetes was often known as maturity-onset diabetes, but as children have grown fatter and fatter, maturity has nothing to do with it.

The economic consequences of fat are enormous, if health economists are to be believed. Obesity-related medical costs were 9.1% of all annual medical costs in 2006, up from 6.5% in 1998, according to a study released last year from the Centers for Disease Control and Prevention and RTI International, a nonprofit research institute. The annual health-care costs of obesity in America have risen from $74 billion in 1998 to $147 billion in 2008.

According to a paper presented at the Obesity Society’s annual conference last year, fat people are less productive than thin. They take more time off work because of their various ailments, and when they are at work the morbidly obese produce less, equivalent to 22 days of lost production per year. The health-care costs and lost production caused by obesity are driving American manufacturers to locate to countries where the population, for the time being, still has a lean and hungry look.

The fiscal consequences of obesity for America have also just increased, with the recent passage of the health-reform bill. Obesity is disproportionately concentrated among those previously uninsured, who will now presumably have access to more care, possibly including expensive bariatric surgery. Indeed, obesity is associated causatively to so many expensive diseases (rather as smoking is) that the health-care costs of treating the impoverished obese are likely to be enormous. Since treatment is unlikely by itself to make this sector of the population more employable or productive, America has just assumed an economic cost without an economic benefit. Truly, economics is the dismal science.

Is there no hope, then? In one rather peculiar sense there is. The whole world is becoming fatter, not just America. Not long ago in Bangkok I observed some children, obviously of the elite, emerging from a school. There are not many fat people in Thailand, but these children were fat.

Like so many of their counterparts in the West, they seemed unable, or unwilling, to progress further than a few yards without refreshing themselves with sweetened drinks and fast fatty food. And they were being collected by chauffeurs or adoring parents so that they might be spared the rather minimal exercise afforded by going home by public transportation.

As yet in Thailand, the poor mostly cannot afford to be fat, but that time will come, and then the great reversal will occur: The elite will abandon its fattening habits, and take seriously the advice of the late Duchess of Windsor: that one can be neither too rich nor too thin.

In the West, the march (or waddle) of obesity is in step with other social (or antisocial) developments. Obesity in Britain, for example, has increased pari passu with the splintering of families: and now it is never too early to teach children lack of self-control.

The connection between the fragmentation of the family and obesity is easy to understand. Of course, there is no one-to-one correspondence between the two phenomena—in human affairs there never is such a close fit—but there is nevertheless a strong and comprehensible correspondence.

For much of the population, family meals are a ritual of the past: Thirty-six percent of British children never eat a meal at a table with another member of their family or household (we have now passed the milestone long desired by radical social reformers, more children being born illegitimate than legitimate). In the homes of the poor, the unemployed and the single parents that I used to visit as a doctor, I would find no evidence of cooking ever having been done there. Fatty take-away meals and ready-prepared foods heated in the microwave were the diet, together with almost constant snacks. There was not even a table to eat at: an absence that was not the consequence of raw poverty, since the flat-screen television would have been large enough, turned horizontal, to serve as a dining table.

In these circumstances, children graze or forage; but unlike previous hunter gatherers, they do not come up against a scarcity of food, but rather a surfeit of it. Nothing is easier for them than to overindulge, and the appetite grows with the feeding. Their tastes never develop beyond the most instantly gratifying types of food, sugary and fatty, and they eat like children for the rest of their lives; they never learn the discipline of subordinating their appetite to the exigencies of family life and social convention. They are like Pooh Bear, for whom it is always time for a little something. It is hardly surprising if, like Pooh Bear’s, their waistlines expand until they can’t fit into a normal seat.

Family and social meals are among the most powerful teachers of self-control in the human repertoire. They teach that the appetite of the moment is not, or rather ought not to be, the sole determinant of one’s behavior. The pattern of grazing or foraging independently of everyone else teaches precisely the opposite lesson. It is hardly surprising that those who do not experience family or social meals early in life exhibit the lack of self-control that underlies so much modern social pathology in the midst of plenty.

These social, or antisocial, developments have taken place precisely at a time when electronic means of entertainment have become available to all. For the uneducated, the world is an intolerably dull and slow-moving place by comparison with the excitement available at the press of a button or the flick of a switch. Why, then, move off your couch and risk the ennui of the real world? You can satisfy your appetite and occupy the vacuum of your mind at the same time, at most wriggling like a maggot in sawdust. The availability of constant entertainment is one of the causes of obesity.

By taking on responsibility for the health consequences of obesity, the government has given itself the locus standi to interfere in many aspects of human existence. If obesity kills, is it not the government’s duty to prevent it? He who pays the doctor decides the prophylaxis. Positive encouragement of healthy eating won’t work, nor mere printed warnings that some foods are unhealthy (people who are prepared to eat doughnuts with pink and blue icing are unlikely to desist on learning that they contain nothing good for the bowels or any other organ).

As usual, therefore, prohibition beckons. Regulation of the sugar and fat content of ready-prepared and fast foods is likely to be proposed and perhaps eventually accepted, though not without a very fierce rear-guard action by the food industry. If John Doe will not eat his greens, Uncle Sam will make him, if necessary by restricting the availability of other foods. No one will raise moral psychology of the question of obesity, for fear of sounding uncompassionate and reactionary.

In search for an amelioration, the temptation is to an intemperate authoritarianism, forgetting that the avoidance of obesity, pace the Duchess of Windsor, is not the whole purpose of life. But teaching children to cook and eat together might help overcome the crudity of their eating habits: the price of more refined, and in this instance nonfattening, pleasures always being effort.

To reduce the attraction of fast food, prepared meals and soft drinks, and to save the planet from polystyrene dishes, a system of returnable deposits on packaging might be tried. This would slow down fast food a little, and tip the balance in favor of home preparation.

No doubt the government will also promote sports as a remedy for and preventive of obesity. This, of course, would be an extremely irresponsible solution, for sports are already, even with the slothful population that we have, by far the most common cause of injury in Western societies. If the obese were suddenly to start exercising, emergency rooms would not be able to cope. For the sake of our health, let us have no sports.

Theodore Dalrymple is the pen name of Anthony Daniels, a British physician. His latest book is “The New Vichy Syndrome.”

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Full article and photos: http://online.wsj.com/article/SB10001424052748704423504575212281013855148.html

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Traveling a Primeval Medical Landscape

The world was young, leafy green and overrun with dinosaurs so many eons ago that stories from prehistoric times are mostly fantasy and supposition. But the medical world was exactly that young, primitive and full of unusual creatures barely a century ago, giving historians ample fodder for true stories stranger than any fantasy.

Few of them surpass the biography of the man often credited with founding modern American surgery: William Halsted, professor of surgery at Johns Hopkins, and lifelong drug addict. Gerald Imber’s new biography is the first retelling of Halsted’s story in many decades and a particularly expert and thought-provoking narrative.

Halsted was born in New York in 1852, the not especially promising son of a wealthy family. A mediocre student, he wandered through Yale leaving behind no record of ever borrowing a book from its library.

He chose medicine not from any affinity for the sick and the suffering (and suffer they did back then, with filthy hospitals, no antibiotics and primitive anesthesia). Rather, the cabalistic secrets of the anatomy lab drew him in, and he fell in love with the complex structures of the body’s interior and their arcane nomenclature.

As Halsted completed surgical training in New York, giant scientific revolutions were remodeling his field. These included rapid improvements in anesthesia and clear demonstrations of the paramount importance of hygiene. Halsted was wildly enthusiastic about both developments.

His obsession with cleanliness was to serve him well through his career. But his enthusiasm for the new anesthetics was his undoing. One of the most effective local anesthetics in those days was cocaine, and within a few months of testing it on himself he had a bad drug habit.

He also soon acquired the addict’s other bad habits: he lied, missed work, made endless excuses. Finally, a medical paper he published on cocaine anesthesia was such gibberish that his career in New York was effectively over.

But Halsted, still only 34, was undaunted. After a long European vacation and a stint in the 19th-century equivalent of drug rehab, he took a train down to Baltimore, where friends secured him a job at the new Johns Hopkins hospital.

Unfortunately, his cocaine addiction had been “treated” with morphine and, unknown to all, he arrived in his new life in the grips of a double-barreled addiction.

Dr. Imber, a plastic surgeon and clinical assistant professor of surgery at Weill Medical College of Cornell University, makes the intense strangeness of Halsted’s subsequent career a gripping story.

As a surgeon, Halsted was extraordinary; he soon advanced to chief at Hopkins and pioneered treatments for breast cancer, hernias and gallstones. His knowledge of anatomy and his meticulous technique meant lengthy operations but negligible complication rates, even though antibiotics were still decades away.

Halsted the addict, however, was a mess. He would disappear for long stretches (his summer vacations routinely lasted five months); no one knew quite where he went. His behavior was erratic; friendly to colleagues and patients one moment and hostile the next, he would bow out of operations at the last minute, and his residents pretty much ran his service without him. “The Professor” was often missing in action.

Some advocates for drug legalization cite Halsted as a prime example of the functioning addict. Dr. Imber does not disagree: “The story belies the conventional wisdom concerning long-term drug use.”

Certainly, in the unregulated Wild West of 19th-century medicine Dr. Halsted functioned, much as Nero functioned as a Roman statesman. Whether either could function in our world of sober professional accountability is still grist for debate.

Another travelogue through the primeval medical landscape is provided by Molly Caldwell Crosby in “Asleep,” the story of epidemic encephalitis lethargica, one of history’s great unsolved medical mysteries.

The epidemic began during World War I and spread around the world, in lockstep with the influenza pandemic. Patients would simply fall asleep. Some died in their sleep. Some awoke months later, healthy. Still others awoke but were left with lasting neurologic problems.

This disease has made a previous literary appearance: The patients in Oliver Sacks’s “Awakenings” suffered from encephalitis lethargica before they developed end-stage Parkinson’s disease. Children were often left with bizarre behavioral disorders. (Ms. Crosby includes the grisly story of a little girl who survived encephalitis only to develop a self-mutilation syndrome and pluck out both eyes and most of her teeth.)

Many of the great neurologists of the early 20th century cut their diagnostic teeth on this epidemic. All suspected it was somehow related to the flu, but without brain imaging or sophisticated blood tests they could offer only learned guesswork. Ultimately, the epidemic fizzled out, and sporadic cases now occur only very rarely.

Ms. Crosby, a journalist, tells her story through case histories of the afflicted (among them J. P. Morgan Jr.’s wife, Jessie, and Ms. Crosby’s own grandmother). She has given herself an immensely difficult assignment: describing a puzzle without a solution requires preternatural narrative control. Unfortunately, in this instance the confusion among the experts is only compounded by Ms. Crosby’s own painful lack of medical expertise.

She tries to compensate with style and color, including a great deal of breathlessly atmospheric scene-setting and ominous verbal drumbeats. (“Dying of encephalitis lethargica would not prove to be the tragedy; surviving it would.”) But we crave an answer to the mystery, and instead all we get is a wordy circular slog in the primitive muck.

Abigail Zuger, M.D., New York Times

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Full article and photo: http://www.nytimes.com/2010/04/27/health/27zuger.html

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Fish versus Flax

Q. How does flaxseed oil compare with fish oil in nutritional benefits?

A. Flaxseed oil and fish oil are believed to have similar nutritional benefits, but it takes much more flaxseed oil to obtain these possible benefits, said Dr. Sheldon S. Hendler, co-editor of the “PDR for Nutritional Supplements,” the standard reference in the field.

The strongest evidence, from studies of omega-3 fatty acids in fish oil, is for a reduction of triglycerides, a form of fat found in the blood. Other possible benefits include anti-inflammatory activity; action against blood clots and arterial plaque; and protection of the neurons and retina.

Both oils contain omega-3 fatty acids. In fish oil, the major ones are EPA (eicosapentaenoic acid) and DHA (docosahexaenoic acid), while in flaxseed oil, the major one is alpha-linolenic acid (ALA), a precursor of EPA and DHA, which is converted to those fatty acids in the body.

The possible health benefits are mainly attributable to EPA and DHA, Dr. Hendler said. “The most studied effect is their ability to lower abnormally elevated serum triglycerides, a risk factor for cardiovascular disease, particularly in those with diabetes,” he said.

The recommended amount of EPA plus DHA for this condition is four grams daily, about one teaspoonful, Dr. Hendler said, but it takes 40 grams, or about three tablespoonsful or more, of ALA to produce four grams of EPA and DHA in the body.

C. Claiborne Ray, New York Times

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Full article and photo: http://www.nytimes.com/2010/04/27/science/27qna.html

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The Search for Genes Leads to Unexpected Places

HUNTER Edward M. Marcotte and colleagues at the University of Texas at Austin have found hundreds of genes involved in human disorders.

Edward M. Marcotte is looking for drugs that can kill tumors by stopping blood vessel growth, and he and his colleagues at the University of Texas at Austin recently found some good targets — five human genes that are essential for that growth. Now they’re hunting for drugs that can stop those genes from working. Strangely, though, Dr. Marcotte did not discover the new genes in the human genome, nor in lab mice or even fruit flies. He and his colleagues found the genes in yeast.

“On the face of it, it’s just crazy,” Dr. Marcotte said. After all, these single-cell fungi don’t make blood vessels. They don’t even make blood. In yeast, it turns out, these five genes work together on a completely unrelated task: fixing cell walls.

Crazier still, Dr. Marcotte and his colleagues have discovered hundreds of other genes involved in human disorders by looking at distantly related species. They have found genes associated with deafness in plants, for example, and genes associated with breast cancer in nematode worms. The researchers reported their results recently in The Proceedings of the National Academy of Sciences.

The scientists took advantage of a peculiar feature of our evolutionary history. In our distant, amoeba-like ancestors, clusters of genes were already forming to work together on building cell walls and on other very basic tasks essential to life. Many of those genes still work together in those same clusters, over a billion years later, but on different tasks in different organisms.

Studies like this offer a new twist on Charles Darwin’s original ideas about evolution. Anatomists in the mid-1800s were fascinated by the underlying similarities of traits in different species — the fact that a bat’s wing, for example, has all the same parts as a human hand. Darwin argued that this kind of similarity — known as homology — was just a matter of genealogy. Bats and humans share a common ancestor, and thus they inherited limbs with five digits.

Some 150 years of research have amply confirmed Darwin’s insight. Paleontologists, for example, have brought ambiguous homologies into sharp focus with the discovery of transitional fossils. A case in point is the connection between the blowholes of whales and dolphins and the nostrils of humans. Fossils show how the nostrils of ancestral whales moved from the tip of the snout to the top of the head.

In the 1950s, the study of homology entered a new phase. Scientists began to discover similarities in the structure of proteins. Different species have different forms of hemoglobin, for example. Each form is adapted to a particular way of life, but all descended from one ancestral molecule.

When scientists started sequencing DNA, they were able to find homologies between genes as well. From generation to generation, genes sometimes get accidentally copied. Each copy goes on to pick up unique mutations. But their sequence remains similar enough to reveal their shared ancestry.

A trait like an arm is encoded in many genes, which cooperate with one another to build it. Some genes produce proteins that physically join together to do a job. In other cases, a protein encoded by one gene is required to switch on other genes.

It turns out that clusters of these genes — sometimes called modules — tend to keep working together over the course of millions of years. But they get rewired along the way. They respond to new signals, and act to help build new traits.

In an influential 1997 paper, Sean B. Carroll of the University of Wisconsin, Neil Shubin of the University of Chicago and Cliff Tabin of Harvard Medical School coined a term for these borrowed modules: “deep homology.”

Since then, scientists have gotten a far more detailed look at many examples of deep homology. Dr. Carroll and his colleagues, for example, recently figured out how the spots on a fly’s wing evolved through rewiring modules. A tiny fly called Drosophila guttifera sports a distinctive pattern of 16 polka dots on its wings. Dr. Carroll and his colleagues discovered that the module of genes that sets the location of the spots is the same module that lays out the veins and sensory organs in the wings of many fly species. The module was later borrowed in Drosophila guttifera to lay down dots, too.

Our own eyes are also the product of deep homology. The light-sensing organs of jellyfish seem very different from our eyes, for example, but both use the same module of genes to build light-catching molecules.

Scientists are also discovering that our nervous system shares an even deeper homology with single-celled organisms. Neurons communicate with each other by forming connections called synapses. The neurons use a network of genes to build a complete scaffolding to support the synapse. In February, Alexandre Alié and Michael Manuel of the National Center for Scientific Research in France reported finding 13 of these scaffold-building genes in single-celled relatives of animals known as choanoflagellates.

No one is sure what choanoflagellates use these neuron-building genes for. The one thing that is certain is that they don’t build neurons with them.

Until now, scientists have simply stumbled across examples of deep homology. Dr. Marcotte wondered if it was possible to speed up the pace of discovery.

The evidence for deep homologies, he reasoned, might already be waiting to be found in the scientific literature — specifically, in the hundreds of thousands of studies scientists have conducted on how various genes worked in various species.

Scientists have identified thousands of genes that can give rise to diseases in humans when they mutate. Other researchers have systematically mutated each of the 6,600 genes in yeast and observed how the mutant yeast fare under different conditions. If Dr. Marcotte could analyze data like these, he reasoned, he might find gene modules doing different things in distantly related species.

Dr. Marcotte and his colleagues amassed a database of 1,923 associations between genes and diseases in humans. They added more than 100,000 additional associations between genes and traits in species including mice, yeast and nematode worms.

The scientists then searched for related genes that produced different traits in different species. They discovered, for example, that five genes known to help build blood vessels were closely related to five genes that yeast cells use to fix their cell walls.

Discovering these shared genes then allowed Dr. Marcotte and his colleagues to make new discoveries. Their database had a total of 67 genes that fix cell walls in yeast. If yeast and humans inherited an ancient gene module, we might use related versions of other yeast genes to build blood vessels.

The scientists studied the 62 other wall-fixing yeast genes. To do so, they found related versions in frogs and watched how each one behaved in the developing frog embryo. The scientists discovered that five of the additional yeast genes also made proteins found in developing blood vessels. To see how important these proteins were for building blood vessels, the scientists shut down, one by one, the genes that carried the instructions for each protein, and observed how frog embryos developed.

“We ended up with a dramatic loss of blood vessels,” said John Wallingford, a University of Texas developmental biologist and co-author of the study. Dr. Marcotte wondered if humans might also share modules with much more distantly related organisms: plants. He and his colleagues expanded their database with 22,921 associations between genes and traits scientists have found in the mustard plant Arabidopsis thaliana.

To their surprise, the scientists discovered 48 modules shared by plants and people. “There was a lot of screaming in the halls for that one,” Dr. Marcotte said.

The scientists picked out one particularly strange module shared by plants and people for closer study. In humans, the genes have been linked to a rare genetic disorder called Waardenburg syndrome. It is caused by a disturbance in a group of cells in embryos called neural crest cells. Normally, the neural crest cells crawl through the embryo and form a strip running along the back. They then give rise to nerve cells, pigment-producing cells and some bones of the skull. People with Waardenburg syndrome have symptoms scattered across the parts of the body produced by neural crest cells. They may include deafness; widely spaced eyes; a white forelock of hair; and white patches on their face.

The scientists discovered that two Waardenburg-linked genes matched mustard plant genes for sensing gravity. If these genes are disabled by a mutation, a plant can’t grow upright.

Dr. Marcotte and his colleagues found three more gravity-sensing plant genes in their database. They decided to see if any of the three also played a role in Waardenburg syndrome.

The scientists found that one of the gravity-sensing plant genes became active in the neural crest cells of frog embryos. When they silenced the gene in those neural crest cells, the embryos became deformed.

Dr. Carroll (who also writes a science column for The New York Times) saw the new research as a logical progression from early studies. “It warms our hearts that deep homology is gaining traction like this,” he said.

“This is a very effective way to find human disease genes,” said David Platchetzski of the University of California, Davis, who was not involved in the study. “You can move forward much more quickly.”

Carl Zimmer, New York Times

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Full article and photo: http://www.nytimes.com/2010/04/27/science/27gene.html

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Mind Over Meds

One day several years ago, I was reaching the end of my first visit with a patient, J.J., who had come to see me for anxiety and insomnia. He was a salesman for a struggling telecommunications company, and he was having trouble managing the strain on his finances and his family. He was sleeping poorly, and as soon as he opened his eyes in the early morning, the worries began. “I wake up with a list of things to worry about,” he said. “I just go through the list, and it seems to get longer every day.”

A psychiatric interview has a certain rhythm to it. You start by listening to what your patient says for a few minutes, without interrupting, all the while sorting through possible diagnoses. This vast landscape of distress has been mapped into a series of categories in psychiatry’s diagnostic manual, DSM-IV. The book breaks down mental suffering into 16 groups of disorders, like mood disorders, anxiety disorders, psychotic disorders, eating disorders and several others. As I listened to J.J. (a nickname that he agreed I could use to protect his privacy), it was clear to me that he had one of the anxiety disorders, but which one? In order to systematically rule in or rule out the disorders, I asked J.J. dozens of questions. “Do you have panic attacks?” “Do you get fearful in crowded situations?” “Have you ever experienced a traumatic event that later caused flashbacks or nightmares?”

Each of J.J.’s answers provided me with a clue, closing off one possibility while opening up others. At its best, when you are working with an intelligent, insightful patient, the process is fun, involving a series of logical calculations, much like working a Sudoku puzzle. Finally, toward the end of the hour, I felt confident that I had arrived at J.J.’s diagnosis. “I think you have what we call ‘generalized anxiety disorder,’ ” I told him. It may start with a defined series of causes, as was true for J.J., but then it spirals outward, blanketing the world with potential threat. J.J. worried about what the future would bring and experienced a predictable series of physical symptoms: insomnia, muscle tension, irritability and poor concentration.

“I’m going to write you a prescription for a medication called Zoloft,” I said, picking up my prescription pad. He asked what was causing his anxiety, and I began one of the stock neurochemical explanations that psychiatrists typically offer patients about low serotonin levels in the brain. The treatment involved “filling up the tank” by prescribing a medication like Zoloft, Celexa or Paxil.

“So Dr. Freud, the causes are all in the brain? Isn’t there some explanation in my childhood?” It was a good-natured tease.

“I specialize in prescribing medications,” I said with a smile. I was a psychopharmacologist and specialized in medication rather than psychotherapy. “I can refer you to a good therapist in the area if you’d like.”

After J.J. left my office, I realized, uncomfortably, that somehow, over the course of the decade following my residency, my way of thinking about patients had veered away from psychological curiosity. Instead, I had come to focus on symptoms, as if they were objective medical findings, much the way internists view blood-pressure readings or potassium levels. Psychiatry, for me and many of my colleagues, had become a process of corralling patients’ symptoms into labels and finding a drug to match.

Leon Eisenberg, an early pioneer in psychopharmacology at Harvard, once made the notable historical observation that “in the first half of the 20th century, American psychiatry was virtually ‘brainless.’ . . . In the second half of the 20th century, psychiatry became virtually ‘mindless.’ ” The brainless period was a reference to psychiatry’s early infatuation with psychoanalysis; the mindless period, to our current love affair with pills. J.J., I saw, had inadvertently highlighted a glaring deficiency in much of modern psychiatry. Ultimately, his question would change the way I thought about my field, and how I practiced.

I originally became interested in psychiatry primarily because of my father: he is a psychiatrist practicing in San Francisco. But there was a darker side to my career choice. My mother suffered severe mental illness, with debilitating depressions and paranoid thoughts. One autumn day during my junior year in college, she committed suicide. Psychiatry then became personal, a way for me to come to terms with her illness.

I majored in psychology at U.C. Berkeley, and at U.C. San Francisco I labored through medical school’s rites of passage in order to qualify for a psychiatric residency. Eventually, on a steamy July day in 1992, I stood on a Boston street, far from home, gazing at Massachusetts General Hospital (known as M.G.H.), where I was about to start my training.

This was a momentous time at M.G.H. Prozac was introduced four years earlier and became the best-selling psychiatric medication of all time. Zoloft and Paxil, two similar medications, were in the pipeline, and many of the key clinical trials for these antidepressants were conducted by psychiatrists at M.G.H. who were to become my mentors. M.G.H. and other top programs were enthralled with neurobiology, the new medications and the millions of dollars in industry grants that accompanied them. It was hard not to get caught up in the excitement of the drug approach to treatment. Psychopharmacology was infinitely easier to master than therapy, because it involved a teachable, systematic method. First, we memorized the DSM criteria for the major disorders, then we learned how to ask the patient the right questions, then we pieced together a diagnosis and finally we matched a medication with the symptoms.

But learning the formal techniques of therapy was like navigating without a compass. While I learned how to form an alliance with my patients and begin a good dialogue, becoming a skillful therapist requires much more practice than busy psychiatry residencies allow.

When my father did his residency at U.C.S.F. in the 1950s, he learned therapy well, because, with few medications available, it was the main treatment psychiatrists could offer their patients. Psychiatric residencies focused on therapy, and many residents extended their training further by enrolling in postgraduate psychoanalytic institutes. When modern medications came on the scene, my father adapted by incorporating them into his therapy practice, as did many of his colleagues. I call this the “golden” generation of psychiatrists, those currently approaching retirement age, who were skilled at offering the full package of effective psychiatric treatments to patients.

The newer generation of psychiatrists, who graduated in the 1980s and afterward, trained in programs that were increasingly skeptical of therapy and that emphasized a focus on medications. M.G.H. was by far the most influential of these modern programs. Graduates of the M.G.H. program and its sister program at nearby McLean Hospital have fanned out throughout the country, becoming chairmen of departments and leaders of the National Institute of Mental Health.

A result is that psychiatry has been transformed from a profession in which we talk to people and help them understand their problems into one in which we diagnose disorders and medicate them. This trend was most recently documented by Ramin Mojtabai and Mark Olfson, two psychiatric epidemiologists who found that the percentage of visits to psychiatrists that included psychotherapy dropped to 29 percent in 2004-5 from 44 percent in 1996-97. And the percentage of psychiatrists who provided psychotherapy at every patient visit decreased to 11 percent from 19 percent.

While it is tempting to blame only the biologically oriented psychiatrists for this shift, that would be simplistic. Other forces are at work as well. Insurance companies typically encourage short medication visits by paying nearly as much for a 20-minute medication visit as for 50 minutes of therapy. And patients themselves vote with their feet by frequently choosing to see psychopharmacologists rather than therapists. Weekly therapy takes time and is arduous work. If a daily pill can cure depression and anxiety just as reliably, why not choose this option?

In fact, during my 15-to-20-minute medication visits with patients, I was often gratified by the effectiveness of the medications I prescribed. For perhaps a quarter of them, medications worked so well as to be nearly miraculous. But over time I realized that the majority of patients need more. One young woman I saw was referred to me by a nurse practitioner for treatment of depression that had not responded to several past antidepressants. She was struggling to raise two young children and was worried that she was doing a poor job of it. Her husband worked full time and was rarely available to help. She cried throughout our initial interview. I started her on Effexor and referred her to a social-worker colleague. She improved initially, but over the years since, her symptoms have waxed and waned. When she reports a worsening of her anxiety or depression, my first instinct is to do one of three things — switch medications, increase her dosage or add another. Over the course of 15 or 20 minutes, this is about all I can offer.

My treatment of this young woman follows the “split treatment” model, but a less charitable description is “fragmented care.” Like the majority of psychiatrists in the United States, I prescribe the medications, and I refer to a professional lower in the mental-health hierarchy, like a social worker or a psychologist, to do the therapy. The unspoken implication is that therapy is menial work — tedious and poorly paid.

But over the past few years, research studies have shown that therapy is just as effective as medications for many conditions, and that medications themselves often work through the power of placebo. In one study, for example, researchers did a meta-analysis of studies submitted by drug companies to the F.D.A. on seven new antidepressants, involving more than 19,000 patients. It turned out that antidepressants are, indeed, effective, because on average patients taking the pills showed a 40 percent drop in depression scores. But placebo was also a powerful antidepressant, causing a 30 percent drop in depression scores. This meant that about three-quarters of the apparent response to antidepressants pills is actually due to the placebo effect.

Nobody knows exactly how the mysterious placebo effect works, but it is clear that it has impacts on the brain that can be seen as clearly as medication effects. In one study conducted by pain researchers at the University of Michigan, subjects were given an ache-inducing injection of saline into their jaws and were placed in a PET scanner. They were then told that they would be given an intravenous pain treatment, but the “treatment” was merely more saline solution, acting as a placebo. The PET scan showed that the endogenous endorphin system in the brains of the subjects was activated. The patients believed so strongly that they were receiving effective treatment that their brains followed suit. Presumably, a corresponding brain change occurs when depressed patients are given placebo pills.

Like placebo, psychotherapy has typically been considered a “nonbiological” treatment, but it has become clear that therapy, like placebo, also leads to measurable changes in the brain. In an experiment conducted at U.C.L.A. several years ago, with subjects suffering from obsessive-compulsive disorder, researchers assigned some patients to treatment with Prozac and others to cognitive behavior therapy. They found that patients improved about equally well with the two treatments. Each patient’s brain was PET-scanned before and after treatment, and patients showed identical changes in their brain circuits regardless of the treatment.

In depression treatment, too, pills and therapy each lead to brain changes, but in this case they appear to be intriguingly distinct. In studies by Helen Mayberg, a professor of psychiatric neurology at Emory University, depressed patients given cognitive behavior therapy showed decreased activity in the frontal lobe, the brain center that might be responsible for the overmagnification of life’s problems that leads to depression in some patients. And they showed increased brain activity in parts of the limbic system, a brain region associated with strong emotion. But Mayberg found that when patients were given medication, their brain activities changed in the opposite direction, stimulating the frontal lobe and damping down the limbic system. “Our imaging results suggest that you can correct the depression network along a variety of pathways,” she said.

Clearly, mental illness is a brain disease, though we are still far from working out the details. But just as clearly, these problems in neurobiology can respond to what have traditionally been considered “nonbiological” treatments, like psychotherapy. The split between mind and body may be a fallacy, but the split between those who practice psychopharmacology and those specializing in therapy remains all too real.

After I saw J.J., I decided that I wanted to try to change my approach to treatment. I gradually began to carve out room in my schedule for longer visits with my patients. I endeavored to do what’s called “supportive” therapy, a technique favored by many therapists and involving basic problem solving and emotional support. It is a bit like what a friend would do for another friend offering advice in times of trouble, but more elaborate and with an accompanying raft of studies endorsing its effectiveness in psychiatry.

When I started to probe my patients, I realized I barely knew most of them. I had exuberantly documented their moods, sleep habits, energy levels and whether they had suicidal thoughts, but I didn’t know what made them tick as people. For example, I had treated Jane (her middle name), a health care administrator in her 40s, for depression and bulimia for many years, focusing on a complicated combination of medications like Effexor, Provigil and Xanax. Then she had a depressive relapse. This time, rather than simply adjusting her medication, I asked her what was going on in her life. I found out that her boss had recently given her an impossible assignment to complete and had berated her when the results were not to his liking. It seemed clear to me that her depression was partly triggered by the fact that she blamed herself for her boss’s poor communication skills and managerial lapses. I encouraged her to question that assumption each time it popped into her mind. Over the next few visits, she improved — relating better to her boss, able to take his criticism with a grain of salt and feeling more confident.

But while my simple therapeutic suggestions were helpful, as Jane and I continued to explore her work issues in detail, she said that she often lacked focus on the job. Knowing that poor concentration can be a symptom of depression, I asked if she associated her distractibility with periods of sadness. But she said there was no such correlation with her moods.

I wondered if she might have an adult version of attention deficit disorder. Indeed, carefully reviewing her years in school, I saw she was always easily distracted but overcame this problem by working extra hard, and managed to achieve good grades. Even now, her job performance was consistently rated as excellent, but the extra work this entailed sapped her energy.

I decided to prescribe her a version of Ritalin, the standard treatment for A.D.D. The next month, she said she felt that this medication had turned her life around. Not only did she feel more focused and productive at work, but she was more apt to get things done at home, which in turn enhanced her mood, indirectly improving her depression.

Is Jane’s story an argument for psychiatrists providing both medication and some sort of psychotherapy? I think it is. This does not mean that dedicated psychotherapists are not crucial — they are, because they can provide the in-depth therapy that psychopharmacologists will never have time to deliver. When our patients need more from us than just medication, however, we should be prepared to provide it. Oddly, managed-care companies discourage us from doing psychotherapy, arguing that it is cheaper to have psychiatrists do 20-minute medication visits every three months and to hire a lower paid non-M.D. for more frequent therapy visits. But the few studies that have analyzed the economics of these arrangements have found that integrated treatment actually saves money. Mantosh Dewan, the chairman of psychiatry at SUNY Upstate Medical University in Syracuse, found that when psychiatrists do both medication and psychotherapy, the overall amount of money paid out by insurance companies is actually less than when the treatment is split between psychiatrists and psychotherapists. When patients see only one provider, they require fewer visits overall.

It may be time to consider whether the term “psychopharmacologist” is actually doing damage to the field of psychiatry. The American Society of Clinical Psychopharmacology defines “psychopharmacology” on its Web site as “the study of the use of medications in treating mental disorders.” But in a recent article, three Harvard psychiatrists (interestingly, two of them from Mass General) have pointed out that no other medical specialty has carved out a separate “pharmacology”subspecialty. Good doctoring, they remind us, involves perfecting all the skills relevant to healing and deploying them when needed.

During my mother’s last months, she isolated herself from her family, so I don’t know what kind of treatment she was receiving before her death. But I do know what kind of treatment I would have hoped for her. She needed medication to combat her paranoia and the emotional pain of her depression. She needed someone who could expertly probe her thought process, in order to understand the fateful logic that led her to conclude that the only solution was to end her own life. She needed treatment that was intensive and exquisitely coordinated.

Such care is not always capable of saving damaged lives. But it is the best that we can do. It’s what we owe our patients — and ourselves.

Daniel Carlat is an associate clinical professor of psychiatry at Tufts University School of Medicine and the publisher of The Carlat Psychiatry Report. His book, “Unhinged: the Trouble With Psychiatry,” will be published in May.

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Full article and photo: http://www.nytimes.com/2010/04/25/magazine/25Memoir-t.html

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Promises the Pill Could Never Keep

AN end to poverty. A cure for divorce. The elimination of unwed pregnancy. Fifty years ago next month, when the Food and Drug Administration announced that it would approve the oral contraceptive, these were the highest expectations for it. At the same time, few of its promoters in 1960 imagined how the pill, as it quickly became known, would become a powerful tool for transforming women’s lives.

In 1954, John Rock, the doctor who was leading the research on the pill, expressed the breathless excitement shared by many of his colleagues: An oral contraceptive, he said, “would be the greatest aid ever discovered to the happiness and security of individual families — indeed, to mankind” because “the greatest menace to world peace and decent standards of life today is not atomic energy but sexual energy.”

At an international medical conference in Bombay a few years after F.D.A. approval, another doctor unfurled a rolled package of birth control pills into the packed auditorium and announced that the pill would solve India’s problems of hunger and poverty by leveling off its population. As it turned out, the pill had little effect on India’s or any other developing country’s population — because most women lacked access to medical clinics that could provide them with prescriptions and follow-up exams.

In the United States, some people claimed the pill would free married couples from fears of unwanted pregnancy, improving their sex lives and lowering the divorce rate. “With my wife on the pill, any moment is the right moment for love,” one euphoric husband said in 1969. “Unpremeditated sex is marvelous!”

Not every husband, though, found the pill quite so beneficial. Dr. Robert W. Kistner, a doctor at Harvard who was an early advocate of the pill, wrote in Ladies’ Home Journal: “Many wives feel sexually liberated by birth-control pills. But some husbands feel enslaved. It’s as if their sense of maleness and self-esteem has been threatened.” Kistner warned that “if the wives assumed the dominant role in the sex act or became the least bit animalistic,” husbands might become impotent.

Whether men found the pill a boon for or a deterrent to their sex lives, the annual divorce rate more than doubled in the 1960s and ’70s from 9 of every 1,000 married women to 23.

Others predicted that the pill would prevent pregnancy among “naughty little girls,” Rock’s description of sexually active single women. But the pill did not prevent unwed pregnancy, which in 1980 increased to 18 percent of all births, from 5 percent in 1960. Until 1972, several states barred the prescribing of contraceptives to unmarried women, and even where it was legal, many women were afraid to ask their doctors for the pill. In any case, as late as 1972, three-fourths of sexually active young, single women rarely or never used any form of birth control, a national study showed.

Just as the optimists were wrong about the pill’s effect on population, marriage and unwed pregnancy, so were pessimists who feared that the pill would unleash some kind of sexual chaos. A 1966 article in U.S. News and World Report asked, “What is the pill doing to the moral patterns of the nation?” and “Is the pill regarded as a license for promiscuity? Can its availability to all women of childbearing age lead to sexual anarchy?”

The answers turned out to be negative. The “sexual revolution” began largely among college students in the 1950s, before the pill was available, and did not reach the mainstream until the late 1960s. In 1968, Science News reported that despite the “flood tide of publicity over oral contraception and its moral impact,” the pill had little effect on the sexual behavior of unmarried men and women. One doctor at the time explained it this way: “The presence of the pill does not make people decide to have sex. It is after they decide to have sex that they go get the pill.”

In spite of all the missed predictions, there were at least two people who understood the pill’s revolutionary potential from the beginning: Margaret Sanger, who had first imagined a contraceptive pill in 1912, and Katharine McCormick, a wealthy feminist — both elderly women who had been advocates for women’s rights since the early 20th century, and who teamed up in the 1950s to bring the pill project to fruition. Sanger and McCormick financed the research and found the scientists to conduct it.

Sanger and McCormick anticipated how the pill would be a tool for women’s emancipation. And, indeed, the minute the F.D.A. announced it would be approved, millions of women rushed to their doctors for prescriptions. They would use the pill to gain control of not only their fertility, but also their lives. They could decide whether to have children, and when. They could take advantage of new opportunities for education, work and participation in public life that opened up in the years following the pill’s approval.

Today, women no longer need to choose between having a family and a career. At the pill’s 50th anniversary, that alone is well worth celebrating.

Elaine Tyler May, a professor of history at the University of Minnesota, is the author, most recently, of the forthcoming “America and the Pill.”

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Full article and photo: http://www.nytimes.com/2010/04/25/opinion/25may.html

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With health-care reform, it’s nag, nag, nag

Following the passage of Democratic health-care reform legislation, President Obama assured the country that it was a “middle-of-the-road, centrist approach” instead of an intrusive, government power grab. But the government seems incapable of resisting the nannying impulse that undermines this claim.

So health reform includes a 10 percent tax on the use of indoor tanning beds. (Someone needs to stop this slow-motion Chernobyl.) The law also requires fast-food restaurants to post their calorie counts at the drive-through window, lest anyone be under the impression that a Big Mac is health food.

Recently, Rep. Henry Waxman (D-Calif.) called for a ban on chewing tobacco in major league baseball. A lawyer for the players’ association said, “We can go back to the players and say, ‘Congress feels strongly about this. You ought to think about it. Look what’s happened on other issues Congress felt strongly about.’ ” And concerned scientists raised the prospect of legal limits on the salt content of processed foods. There is safety in blandness.

Most symbolically, this year’s White House Easter Egg Roll pointedly did not include the distribution of teeth-rotting, obesity-inducing candy. “Every goodie bag,” according to one account, “was stuffed with pre-screened fruit, and the grounds were filled with exercise stations.” One can only imagine the joy on young faces when they got their apple and their workout.

I can hardly be called a libertarian. Legalizing drugs is a foolish idea because addiction robs people of liberty. Restaurant smoking bans have improved my life and my appetite. But freedom implies some leeway for personal risk and minor, pleasurable foolishness. Democrats in particular seem to be afflicted with Mary Poppins Syndrome: They will not rest until Americans are practically perfect in every way.

This tendency has added relevance because of the passage of health-care reform. When the provision of health insurance to every American becomes a direct responsibility of government, nearly every health matter becomes a public matter. Why not regulate tanning at beaches? Wouldn’t mandatory, subsidized sunscreen save billions in health costs? Why not a jelly doughnuts tax? Why not make saturated fat a controlled substance? Shouldn’t children on tricycles be required to wear safety helmets?

For some of us, the problem is not the tyranny but the nagging. As the public role in health care expands dramatically, health-care controversies become politicized. The health enthusiasms of a president, an influential congressman or an interest group can become public policy or public pressure. After all: “Look what’s happened on other issues Congress felt strongly about.”

This is one of the reasons the health-care debate is not going away. Initially, some Democrats hoped the public would be quickly converted to the virtues of health-care reform — a hope that died amid growing public disapproval. Now Democrats seek to change the subject with a populist assault on Wall Street. But this lacks minimal credibility, precisely because Obama focused public attention almost entirely on health care for nearly a year and a half instead of pursuing financial reform.

The health-care issue will not fade, because Obama has opened a raucous debate on the size and role of government that he cannot simply close. America is experiencing an outbreak of political philosophy. It is like the Constitutional Convention — except that the participants are throwing food at each other and making rude gestures. It is like the Federalist Papers — in comic book form.

There is no doubt that the American health-care system, in some ways, has been an unholy mess — a collection of perverse incentives, costly practices and gaps in coverage. Democrats seek to rationalize the system. But when the federal government imposes rationality — writing insurance regulations, mandating the individual purchase of coverage, cutting the disbursements to doctors and hospitals, requiring calorie disclosure at the Burger King drive-through — the power of government necessarily expands. Is government even capable of rationalizing a complex system on this scale? Even if it is, is the possibility of a more organized, rational system worth the risk of abuse?

In a country where there is a record level of distrust in government, skepticism on these questions is not surprising. Obama’s overreach on health reform has created an unexpectedly broad opposition coalition, including independents and conservatives, people who fear that health costs will rise and the quality of care will fall, and people who fear that the Federal Reserve is controlling America through fluoridation.

And those of us who fear apples at Easter.

Michael Gerson, Washington Post

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Full article: http://www.washingtonpost.com/wp-dyn/content/article/2010/04/22/AR2010042204210_pf.html

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The Claim: For Better Muscle Tone, Go Lighter and Repeat

Lifting heavy weights makes you big and bulky — or at least that’s the conventional wisdom. It’s the reason many women (and some men) who want slim and “toned” physiques opt for lighter weights, lifted more times.

But the notion is not supported by science. Producing bulky muscles requires not just heavy weights but heavy calorie consumption as well, typically far above the 2,000 daily calories recommended for many adults.

For people who lift weights to tone up and slim down, experts say, a regimen that includes a combination of challenging weights and fewer repetitions can help significantly. In a 2002 study, for example, scientists looked at what happened when women performed various resistance exercises at different weights and repetitions (85 percent of their maximum ability for 8 reps, versus 45 percent for 15). Subjects lifting more weight fewer times burned more energy and had a greater metabolic boost after exercise.

In another study published last year, scientists followed 122 women for six years. They found that those who were assigned to do resistance exercises three times a week — sets of 8 reps at 70 to 80 percent of their ability — lost the most weight and body fat. A similar two-year study of women who did strength training with challenging weight twice weekly found similar effects on body and “intra-abdominal” fat.

THE BOTTOM LINE

For better tone, try fewer reps and more challenging weights.

Anahad O’Connor, New York Times

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Full article: http://www.nytimes.com/2010/04/06/health/06real.html

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An Elite Team of Sleuths, Saving Lives in Obscurity

Millions of people know what C.D.C. and F.D.A. stand for. Far fewer recognize E.I.S., though they may owe their lives to it.

The E.I.S. is the Epidemic Intelligence Service, an arm of the federal Centers for Disease Control and Prevention. Its cadre of 160 elite medical detectives — many of them young doctors at the start of their careers — serve two-year hitches that are part adventure, part drudgery.

Suitcases packed, they are poised to fly anywhere on short notice to investigate outbreaks of pneumonia, diarrhea, high fevers, mysterious rashes and many other health threats. Borrowing a term from news reporting, E.I.S. detectives like to call themselves “shoe-leather epidemiologists;” they also like to wear ties and lapel pins displaying their logo — a hole in the well-worn sole of a shoe over a map of the world.

Since its creation in 1951, the service has become a bulwark in the nation’s defense system against disease, often acting as the public’s emergency room. Its doctors have helped identify Legionnaires’ disease, Lyme disease, and toxic shock syndrome from superabsorbent tampons; stop outbreaks of diphtheria and other diseases before they could spread uncontrollably; discover the deadly Ebola and Lassa viruses; and trace paralyzing cases of polio to defective batches of the Salk vaccine. Other E.I.S. investigations have led the Food and Drug Administration to remove potentially lethal products from the market.

Indeed, the E.I.S. “may have saved your life, though you were probably unaware of it,” Mark Pendergrast writes in his new book, “Inside the Outbreaks,” the first history of the program, being published next week by Houghton Mifflin Harcourt.

I was among the 500 graduates of the service whom Mr. Pendergrast interviewed for the book. (He has no connection to the program.) The book describes a number of triumphs — and occasional roadblocks — told chronologically as vignettes, with bits of history interspersed.

Among them are examples of government officials’ suppressing critical health information — and a few surprises about the E.I.S.’s contributions to public health, including some that may come as news to the program’s more than 3,000 graduates.

For example, few colleagues I asked knew that an E.I.S. investigation of a 1953 outbreak of nervous-system damage in children led Chicago to create the nation’s first poison control center. Pediatricians had assumed the cause was viral encephalitis; a medical sleuth, visiting the children’s homes and neighborhood, discovered that many were eating paint chips containing lead and correctly linked the outbreak to lead poisoning.

The service had been founded two years earlier by Dr. Alexander D. Langmuir, a supremely self-confident epidemiologist who had gotten his start in the New York State Health Department and later taught at Johns Hopkins.

Seizing on a frightening outbreak of hemorrhagic fever that had killed 3,000 United Nations troops in Korea, Dr. Langmuir convinced federal officials that the nation needed a quick-response squadron of epidemiologists to investigate outbreaks. At the outset, E.I.S. recruits earned military credit; even today they sometimes wear uniforms and have military ranks. Many found the service a career-changing experience, because they realized they could help far more people through public health than they could in clinical practice.

Then and now, many graduates of the program stay for careers at the C.D.C., while others form the backbone of state and local health departments and become leaders in academic medical centers.

Tall, deep-voiced and domineering, Dr. Langmuir was a showman who delighted in hearing E.I.S. officers relate their adventures riding camels and exhuming bodies. But Mr. Pendergrast leaves no doubt that he was a genius and a visionary.

To colleagues who said that vaccines and antibiotics were making infectious diseases obsolete, he replied that the field still provided “a happy hunting ground for major discoveries and contributions.” The new service quickly took on his personality.

In the early 1950s, for example, an E.I.S. investigating team provided surprising evidence that malaria had virtually disappeared from the United States, overturning the conventional wisdom that it was still a leading cause of fever throughout the South.

At the same time, Dr. Langmuir made some decisions that would probably be condemned today. In 1955, the future of the new Salk polio vaccine was suddenly thrown into doubt when some recipients became paralyzed, apparently by a virus the vaccine maker had failed to kill.

Dr. Langmuir swiftly set up an investigative team that found that the defective vaccine came from Cutter Laboratories, one of six drug companies licensed to make and distribute vaccine. The five other manufacturers were allowed to resume production and sales.

But cases also occurred among recipients of the polio vaccine made by Wyeth Laboratories. In a little-known attempt to salvage the overall program, Dr. Langmuir suppressed reports of these cases.

In 1962, Dr. Langmuir publicly supported the Sabin oral polio vaccine despite evidence that it had led to eight cases of paralysis. He buried the data in a paper published two years later.

Dr. Langmuir retired from the service in 1970, but its propensity for secrecy lived on. In 1985, after a baffling outbreak of salmonellosis linked to salad bars in Oregon, E.I.S. investigators found a vial of salmonella with the same bacterial fingerprints in the laboratory of a nurse who had worked for the cult leader Bhagwan Shree Rajneesh. the service refused to report its investigation for years, on the ground that it would provoke copycat attacks.

The service’s reputation was bolstered after the 9/11 attacks, when it played a leading role in the investigation of the deliberate release of anthrax spores through the postal system. But its accomplishments are generally based on strengthening the nation’s system to report common and unusual diseases, and then discerning patterns of infection and spread.

Gradually, the E.I.S. expanded to include veterinarians, nurses, dentists, statisticians, social workers, even lawyers. Depending on the nature of the outbreak, its detectives may conduct door-to-door interviews and surveys, mapping cases and venturing abroad.

When I was a member of the service, in 1963-65, for instance, two of my colleagues went to Bolivia to investigate a plague outbreak and bring back a sample of the causative bacterium. To get it, they had to exhume a body to remove a finger and isolate the bacterium from the marrow. The specimen eventually became part of the collection of potential agents at the government’s biological warfare center at in Maryland.

Despite his penchant for secrecy, Dr. Langmuir knew the value of publicity, and his subordinates learned from his example. During an outbreak of hepatitis from raw shellfish taken from Raritan Bay in New Jersey in 1961, Dr. D. A. Henderson, an E.I.S. graduate then working at the C.D.C., likened the risk to “playing Russian roulette on the half shell.” His pithy comment, widely reported in the news media, earned a mild reprimand from his superiors. (Dr. Henderson later led the W.H.O. team that eradicated smallpox, and after 9/11 he advised the United States government on bioterrorism.)

The E.I.S. was Alexander Langmuir’s family. He demanded full loyalty and was upset when one of his “boys” left.

When Dr. E. Russell Alexander announced that he was leaving to join the faculty at the University of Washington, Dr. Langmuir told him he would “never make it in academia.” (The prediction proved wrong.) And when Dr. Henderson began organizing the team that eventually eradicated smallpox, Dr. Langmuir opposed involving the E.I.S. and told his subordinate to take what he wanted and get out. The two later reconciled.

I, too, was a victim. When I joined the E.I.S. in 1963, Dr. Langmuir appointed me editor of The Morbidity and Mortality Weekly Report, over which he had won control in a bureaucratic battle with another agency. He wanted to change its emphasis on vital statistics, which he said made for dull reading, and he preached the importance of promptly feeding information to the public on a “need-to-know basis.” So I included many reports of current outbreaks, in effect making the report a weekly newspaper.

In those days, doctors were not required to report cases of rubella, even though it can lead to severe birth defects in the babies of pregnant women who contract it. So I played journalist, calling epidemiologists in many states to track the disease’s spread and obstetricians to learn that some were performing first-trimester abortions.

My accounts unnerved and angered Dr. Langmuir, and he contradicted his early statements by insisting that the weekly report stick to its archive function. He sent me packing to help run a measles immunization program in Africa. I accepted the punishment enthusiastically, never expecting that my African adventures would eventually make me part of the Henderson team that eradicated smallpox.

By the time of his death, in 1993, Dr. Langmuir had soured on the service he created, saying it had outlived its usefulness and should be abolished. Yet as other countries have adopted smaller versions of the E.I.S., his contributions to global health have outlived him, and so has his formidable legacy as a giant of public health.

Lawrence K. Altman, M.D., New York Times

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Full article and photo: http://www.nytimes.com/2010/04/06/health/06docs.html

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ObamaCare and the Constitution

If Congress can force you to buy insurance, Article I limits on federal power are a dead letter.

The constitutional challenges to ObamaCare have come quickly, and the media are portraying them mostly as hopeless gestures—the political equivalent of Civil War re-enactors. Discussion over: You lost, deal with it.

The press corps never dismissed the legal challenges to the war on terror so easily, but then liberals have long treated property rights and any limits on federal power to regulate commerce as 18th-century anachronisms. In fact, the legal challenges to ObamaCare are serious and carry enormous implications for the future of American liberty.

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The most important legal challenge turns on the “individual mandate”—the new requirement that almost every U.S. citizen must buy government-approved health insurance. Failure to comply will be punished by an annual tax penalty that by 2016 will rise to $750 or 2% of income, whichever is higher. President Obama opposed this kind of coercion as a candidate but has become a convert. He even argued in a September interview that “I absolutely reject that notion” that this tax is a tax, because it is supposedly for your own good.

Florida Attorney General Bill McCollum and 13 other state AGs—including Louisiana Democrat Buddy Caldwell—claim this is an unprecedented exercise of state power. Never before has Congress required people to buy a private product to qualify as a law-abiding citizen.

As the Congressional Budget Office noted in 1994, “Federal mandates typically apply to people as parties to economic transactions, rather than as members of society.” The only law in the same league is conscription, though in that case the Constitution gives Congress the explicit power to raise a standing army.

Democrats claim the mandate is justified under the Commerce Clause, because health care and health insurance are a form of interstate commerce. They also claim the mandate is constitutional because it is structured as a tax, which is legal under the 16th Amendment. And it is true that the Supreme Court has ruled as recently as 2005, in the homegrown marijuana case Gonzales v. Raich, that Congress can regulate essentially economic activities that “taken in the aggregate, substantially affect interstate commerce.”

But even in Raich the High Court did not say that the Commerce Clause can justify any federal regulation, and in other modern cases the Court has rebuked Congress for overreaching. In U.S. v. Lopez(1995), the High Court ruled that carrying a gun near a school zone was not economically significant enough to qualify as interstate commerce, while in Morrison (2000) it overturned a law about violence against women on the same grounds.

All human activity arguably has some economic footprint. So if Congress can force Americans to buy a product, the question is what remains of the government of limited and enumerated powers, as provided in Article I. The only remaining restraint on federal power would be the Bill of Rights, though the Founders considered those 10 amendments to be an affirmation of the rights inherent in the rest of the Constitution, not the only restraint on government. If the insurance mandate stands, then why can’t Congress insist that Americans buy GM cars, or that obese Americans eat their vegetables or pay a fat tax penalty?

The mandate did not pose the same constitutional problems when Mitt Romney succeeded in passing one in Massachusetts, because state governments have police powers and often wider plenary authority under their constitutions than does the federal government. Florida’s constitution also has a privacy clause that underscores the strong state interest in opposing Congress’s health-care intrusion.

As for the assertion that the mandate is really a tax, this is an attempt at legal finesse. The mandate is the legal requirement to buy a certain product, while the tax is the means of enforcement. This is not a true income or even excise tax. Congress cannot, merely by invoking a tax, blow up the Framers’ attempt to restrain government under Article I.

The states also have a strong case with their claim that ObamaCare upsets the Constitution’s federalist framework by converting the states into arms of the federal government. The bill requires states to spend billions of dollars to rearrange their health-care markets and vastly expands who can enroll in Medicaid, whether or not states can afford it.

Florida already spends a little over a quarter of its budget on Medicaid, and under ObamaCare that will expand by at least 50% as some 1.3 million new people enroll. Those benefits, and the burden of setting up the new exchanges, will cost Florida $149 million in 2014 and $1.05 billion annually by 2018. The state will either have to cut other priorities or raise taxes. In legal essence, ObamaCare infringes on state sovereignty and unconstitutionally conscripts state officials.

Less potent, at least to our reading, is the challenge on behalf of state laws that bar or exempt their citizens from the mandate. Virginia passed such a law earlier this year, and Attorney General Ken Cuccinelli is suing on those grounds. But while such efforts serve as healthy political protest, federal laws that are constitutional are supreme under the 10th Amendment, and states can’t “nullify” a Congressional action.

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Judicial and media liberals are trying to dismiss these challenges as a revanchist attempt to repeal the New Deal, or, worse, as a way to restore the states’s rights of Jim Crow. Modern liberals genuinely believe the federal government can order the states and individuals to do anything as long as it is in pursuit of their larger social agenda. They also want to deter more state Attorneys General from joining these lawsuits.

The AGs should not be deterred, because the truth is that ObamaCare breaks new constitutional ground. Neither the House nor Senate Judiciary Committees held hearings on the law’s constitutionality, and we are not aware of any Justice Department opinion on the matter. Judges have an obligation not to be so cavalier in dismissing claims on behalf of political liberty. Under the Constitution, American courts don’t give advisory opinions. They rule on specific cases, and the states have a good one to make.

Democrats may have been able to trample the rules of the Senate to pass their unpopular bill on a narrow partisan vote, but they shouldn’t be able to trample the Constitution as well.

Editorial, Wall Street Journal

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Full article: http://online.wsj.com/article/SB10001424052748704896104575140063408610580.html

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The ObamaCare Writedowns—II

Democrats blame a vast CEO conspiracy.

So the wave of corporate writedowns—led by AT&T’s $1 billion—isn’t caused by ObamaCare after all. The White House claims CEOs are reducing the value of their companies and returns for shareholders merely out of political pique.

A White House staffer told the American Spectator that “These are Republican CEOs who are trying to embarrass the President and Democrats in general. Where do you hear about this stuff? The Wall Street Journal editorial page and conservative Web sites. No one else picked up on this but you guys. It’s BS.” (We called the White House for elaboration but got no response.)

In other words, CEOs who must abide by U.S. accounting laws under pain of SEC sanction, and who warned about such writedowns for months, are merely trying to ruin President Obama’s moment of glory. Sure.

Presumably the White House is familiar with the Financial Standard Accounting Board’s 1990 statement No. 106, which requires businesses to immediately restate their earnings in light of their expected future retiree health liabilities. AT&T, Deere & Co., AK Steel, Prudential and Caterpillar, among others, are simply reporting the corporate costs of the Democratic decision to raise taxes on retiree drug benefits to finance ObamaCare.

When the Medicare prescription drug plan was debated in 2003, many feared that companies already offering such coverage would cash out and dump the costs on government. So Congress created a modest subsidy, equal to 28% of the cost of these plans for seniors who would otherwise enroll in Medicare. This subsidy is tax-free, and companies used to be allowed to deduct the full cost of the benefit from their corporate income taxes (beyond the 72% employer portion).

Democrats chose to eliminate the full exclusion and said they were closing a loophole. But whatever it’s called, eliminating it “will be highly destabilizing for retirees who rely upon employer sponsored drug coverage” and “will impose a dramatic and immediate impact on company financial statements.”

That’s how the AFL-CIO put it in a December 10 letter. The Communications Workers of America and the International Brotherhood of Electrical Workers—also known as the AT&T and Verizon workforce—were opposed too. So much for White House claims that reporting these facts is partisan.

As for whether this change is better tax policy, the new health-care bill creates a similar $5 billion fund that will subsidize health costs for early retirees between the ages of 55 and 64. These payments won’t be subject to taxation, and companies will likely be able to deduct the full cost of such coverage. (The language is vague and some experts disagree.) The Democrats now feigning tax outrage—but who are really outraged by political appearances—didn’t think twice about writing the same loophole back into the tax code. This new reinsurance program was a priority of the United Auto Workers.

The deeper concern—apart from imposing senseless business losses in a still-uncertain economy—is that companies will start terminating private retiree coverage, which in turn will boost government costs. The Employee Benefit Research Institute calculates that the 28% subsidy on average will run taxpayers $665 in 2011 and that the tax dispensation is worth $233. The same plan in Medicare costs $1,209.

Given that Congress has already committed the original sin of creating a drug entitlement that crowds out private coverage, $233 in corporate tax breaks to avoid spending $1,209 seems like a deal. If one out of four retirees is now moved into Medicare, the public fisc will take on huge new liabilities.

Meanwhile, Democrats have responded to these writedowns not by rethinking their policy blunder but by hauling the CEOs before Congress on April 21 for an intimidation session. The letter demanding their attendance from House barons Henry Waxman and Bart Stupak declared that “The new law is designed to expand coverage and bring down costs, so your assertions are a matter of concern.”

Perhaps Mr. Waxman should move his hearing to the Syracuse Carrier Dome. The Towers Watson consulting firm estimates that the total writeoffs will be as much as $14 billion, and the 3,500 businesses that offer retiree drug benefits are by law required to report and expense their losses this quarter or next. But ’twas a famous victory, ObamaCare.

Editorial, Wall Street Journal

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Full article: http://online.wsj.com/article/SB10001424052702304370304575151760348759360.html

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In Therapy, Cellphones Ring True

Though the interruption may be jarring, I rather welcome the twang of bluegrass or the toll of church bells coming from a patient’s cellphone during a psychotherapy session. Here’s why.

A psychiatrist’s office is a place for confidences, so I have taken care to make it a private space. My consulting room is separated from the adjacent waiting room by two parallel walls. The office door is also double. A white noise machine in the hallway further ensures that no one can hear what transpires inside the office. Patients control the movement of information, in and out.

In this kind of secluded place it is easier to reflect and discover thoughts just at the edge of awareness. With this kind of privacy it is easier for patients to be open.

But such a byzantine arrangement creates certain limitations. What patient’s spouse has not wondered, “Is the therapist getting the full story?” Inside the consulting room a therapist hears only the patient’s perspective. Having first boxed ourselves in, how can we help patients to think outside the box?

A solution to this dilemma presents itself when my patient answers that cellphone call. The isolation of the office is shattered; the patient has allowed someone from his or her life to enter. And I have the privilege of witnessing the person across from me interacting spontaneously with that world.

Most patients handle calls with a quick apology; then they switch off their phones, surprised they had forgotten to do so before coming in. Some screen their calls, always available to selected callers.

Others do not make anything at all of interruptions and answer every time their theme song sounds. Even their brief conversations can be revealing. “I’m seeing my shrink.” “I’m with Doc S.” Who knew they had pet names for me? To one family, I’m “The Big B” (though I stand 5-feet-2 in heels.)

A mother receives a call from her teenage daughter. One theme of our sessions has been how to deal with the daughter’s “demanding behavior.” The volume is up; I hear both sides. The daughter is insistent about something trivial; mother is endlessly patient, even solicitous. Now I see that this child hasn’t been getting consistent feedback that her behavior is problematic. Guilt has driven my patient to conceal her anger. She is surprised to learn from me how successful she has become at this deception and how counterproductive it is.

When another patient’s husband calls to learn the results of her medical tests, I sense his tenderness; this counterbalances my knowledge of their sexual difficulties.

A calliope blares from the coat pocket of another patient, a young man. “I bet a hundred dollars it’s my sister!” he says. Clearly she calls him a lot, and he kind of loves it. Oddly, he rarely mentions her in therapy. Now I learn why. He had been afraid to disrupt the sweetness of his sibling relationship by uncovering its competitive core.

I am witness to another patient, a physician, juggling a potpourri of calls: colleague needs urgent consultation; child wants sleep-over; spouse craves takeout; nurses worry about wound infections, fevers, bleeding. I really get the stress involved in ceaselessly shifting from matters of trivial consequence to those with life and death stakes.

Sometimes patients hand me their phones to hear their messages. We play them and discuss whether we discern the same nuanced implications between the lines.

And patients show me those little glowing screens with photos of pets and progeny, apartments they might rent, last week’s rash (for diagnosis and for empathy). I see messes that have become the focus of family fights: the kid’s room with wet towels piled atop clean clothes; the cluttered dining room table that hasn’t allowed for dinner parties.

In trying to grasp the infinite complexity of an individual’s mind, it helps to narrow the focus by closing out the world and creating a place of privacy. But, for understanding the context — the life a patient inhabits outside the office — it helps to let in some of the sights and sounds. The pictures are worth a thousand words; so are the voices. Home videos, now available on most mobile devices, are coming soon to my office.

Barbara Schildkrout is a psychiatrist in Boston.

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Full article: http://www.nytimes.com/2010/03/23/health/23cases.html

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The Claim: Eat Six Small Meals a Day Instead of Three Big Ones

The notion behind eating smaller, more frequent meals is simple: spreading out one’s daily calories over six meals stimulates the metabolism, keeping it going at a faster pace and thereby burning more calories.

Some studies have found modest health benefits to eating smaller meals, but often the research involved extremes, like comparing the effects of two or three large daily meals with those of a dozen or more snacks. Six meals, according to some weight-loss books and fad diets, is a more realistic approach.

But don’t count on it. As long as total caloric and nutrient intake stays the same, then metabolism, at the end of the day, should stay the same as well. One study that carefully demonstrated this, published in 2009 in The British Journal of Nutrition, involved groups of overweight men and women who were randomly assigned to very strict low-calorie diets and followed for eight weeks. Each subject consumed the same number of calories per day, but one group took in three meals a day and the other six.

Both groups lost significant and equivalent amounts of weight. There was no difference between them in fat loss, appetite control or measurements of hormones that signal hunger and satiety. Other studies have had similar results.

For a more reliable metabolic boost, studies show, try exercise.

THE BOTTOM LINE

There is no solid evidence that six small meals a day instead of three will speed metabolism.

Anahad O’Connor, New York Times

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Full article: http://www.nytimes.com/2010/03/23/health/23really.html

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When Your Looks Take Over Your Life

Is there a part of you that you hate to look at and perhaps try to hide from others? Do you glance at your image in distress whenever you pass a reflective surface?

Many of us are embarrassed by or dissatisfied with some body part or other. I recall that from about age 11 through my early teens I sat in class with my hand over what I thought was an ugly bump on my nose. And I know a young woman of normal weight who refuses to sit down in a subway car because she thinks it makes her thighs look huge.

But what if such self-consciousness about a perceived facial or body defect becomes all consuming, an obsession or paranoia that keeps the person from focusing on school or work, pursuing normal social activities, even leaving the house to shop or see a doctor? What if it leads to attempted suicide?

Such are the challenges facing tens of thousands of Americans who suffer from body dysmorphic disorder, or B.D.D., a syndrome known for more than a century but recognized only recently by the official psychiatric diagnostic manual. Even more recently, effective treatments have been developed for the disorder, and its emotional and neurological underpinnings have begun to yield to research.

New Findings

A pioneering researcher, Dr. Jamie D. Feusner, and his colleagues at the David Geffen School of Medicine at the University of California, Los Angeles, recently found patterns of brain activity in people with B.D.D. that appeared to differ from those of others. The differences showed up in areas involved in visual processing. The more severe the symptoms, the more the person’s brain activity on imaging scans differed, on average, from normal levels, the researchers reported in the February issue of The Archives of General Psychiatry.

These brain changes may help explain how people can become overly focused on a perceived defect of their face, hair, skin or facial or body shape that others may not notice — indeed, that may not even exist. Some turn to alcohol and drugs to try to cope with the extreme distress. Others seek cosmetic surgery — which fails to relieve anxiety and can even make the problem worse, leaving scars where nothing was apparent before.

Some men have a form of B.D.D. called muscular dysmorphic disorder, thinking they look puny and weak when in fact their muscles are highly developed through compulsive weight training.

Dr. Katharine A. Phillips, a professor of psychiatry at Brown Medical School, is perhaps the best known authority on B.D.D. and the author, most recently, of “Understanding Body Dysmorphic Disorder: An Essential Guide” (Oxford University Press, 2009).

In an interview, Dr. Phillips described how crippling the disorder can become for those who spend hours in front of a mirror trying to “fix” their “ugly hair” or disguise a facial blemish only they can see. Some pick at an unnoticeable mark on their skin until they do indeed have a visible lesion. Some won’t leave the house unless they can totally cover their face and hair. Those who do go out without masking the area of concern sometimes suddenly flee and hide when they think someone has noticed it or is staring at them.

Many trace their problem to a childhood emotional trauma, like being teased about their looks, parental neglect, distress over parents’ divorce, or emotional, sexual or physical abuse. But Dr. Phillips says most people survive such traumas without developing B.D.D., especially if other factors in their lives lift their self-esteem.

Rather, she explained, the disorder seems to have a combination of genetic, emotional and neurobiological underpinnings.

“It’s likely that the genes a person is born with provide an essential foundation for B.D.D. to develop,” Dr. Phillips wrote. She noted that in about 20 percent of cases, a parent, a sibling or a child also had the disorder. Imaging studies done by Dr. Feusner, Dr. Phillips and others suggest that some brain circuits may be overactive in people with the disorder.

One presumed factor — societal emphasis on looks — is far less important than you might think. Dr. Phillips said the incidence of B.D.D. was nearly the same all over the world, regardless of cultural influences. Also, unlike eating disorders, which mainly affect women seeking supermodel thinness, nearly as many men as women have body dysmorphic disorder.

Which Treatments Work?

The good news is that even though research into the causes of the disorder is in its relative infancy, treatments have been found to help a large percentage of those affected, as long as their problem is recognized and they manage to overcome their embarrassment long enough to get to a qualified therapist.

The two most effective approaches are cognitive behavioral therapy and treatment with serotonin-enhancing drugs, either alone or in combination. In cognitive therapy, patients gradually learn to reorder their thinking, expose their “defect” to others and view themselves more realistically as whole individuals rather than seeing only the presumed defect.

In studies using serotonin-enhancing drugs, half to three-quarters of people with B.D.D. have improved, although Dr. Phillips warned that it can take as long as three months to see the benefit of a proper dose. (Moreover, there is still controversy about how many people achieve long-lasting benefits from the serotonin drugs.)

What does not work is plastic surgery and other cosmetic treatments. Even if the treatments modify one presumed defect, the person is likely to come up with another, and another, and another, leading to a vicious cycle of costly and often deforming as well as ineffective remedies.

Most important, Dr. Phillips said, is not to give up. Effective treatment is out there and it can make a tremendous difference — even a lifesaving difference. Her new book lists centers around the country that specialize in treating B.D.D.

Jane E. Brody, New York Times

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Full article: http://www.nytimes.com/2010/03/23/health/23brody.html

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Research Offers Clue Into How Hearts Can Regenerate in Some Species

Doctors who have treated heart attack patients with injections of stem cells have had little success so far in making the heart regenerate its stricken tissues. Researchers have now discovered that in nature, hearts are regenerated in a quite different way, one that does not depend on stem cells.

The finding may explain the lack of clinical success with the stem cells, as well as suggest new approaches.

Humans can regenerate the liver but cannot replace limbs and other organs. But fish and amphibians can grow new fins or limbs, and the zebra fish, which has been adopted by researchers as a laboratory organism, can even regenerate its heart after the bottom fifth has been lopped off. The fish are sluggish for a while but regrow the missing part of their heart in a month.

The human heart does have a very limited capacity to generate new heart muscle cells — about half the cells are replaced over the course of a person’s lifetime. But this regenerative capacity does not accelerate in response to a heart attack. Instead, the damaged cells are replaced by scar tissue, which does not contract.

Researchers assumed that the situation is different in the zebra fish because of stem cells that could generate more heart muscle cells after injury. A report in 2006 by Kenneth D. Poss and colleagues at Duke University offered confirmation that stem cells are the source of the repair process. Stem cells are general purpose cells that generate the mature, functional cells of the body.

But two independent reports in the journal Nature on Thursday contradict the stem cell idea, reporting that the mature heart muscle cells are the principal source for regenerating the zebra fish heart.

One of the reports is by Dr. Poss, who has revised his earlier findings. The second study effectively rules out stem cells, saying their contribution could be only marginal at best. The report is from a team led by Chris Jopling and Juan Carlos Izpisúa Belmonte of the Center for Regenerative Medicine in Barcelona, Spain.

The Barcelona team genetically engineered the zebra fish’s heart muscle cells so that when they proliferated they would synthesize a fluorescent green protein. After cutting off the bottom of the heart and letting it regenerate, they found that all the cells in the new part of the heart glowed green, proving that existing heart muscle cells were the principal or only source of the new tissue.

Nature’s recipe for regeneration, at least in this case, is evidently to take the mature cells and walk them back in development to a stemlike state. The second step is for these stemlike heart muscle cells to grow and divide, generating replacement tissue. This contrasts with the assumption that tissues would be generated from stem cells that differentiate, or mature, into adult cells.

“If you look at how mother nature does it, the muscle cells don’t go back to the embryonic state, they just dedifferentiate a little,” Dr. Izpisúa Belmonte said. “So we should look at how animals do it and try to imitate them.”

Zebra fish and mammals are separated by a long evolutionary distance and yet, surprisingly, the first step in the regeneration process, the dedifferentiation of heart muscle cells, occurs in mammals as well. In zebra fish the structure of the muscle fiber disintegrates as the cells dedifferentiate. The same process can be seen after injury in the hearts of mice, rats and dogs, Dr. Izpisúa Belmonte said, but the cells get stuck in the second process, that of proliferating to form new tissue.

“This opens a new vista,” he said, “because all we need do is to induce the proliferation of these cells in mammals.”

Charles Murry, an expert on heart cell biology at the University of Washington in Seattle, said the two reports raised the tantalizing question of why human hearts could not complete the regeneration process. In human hearts, too, Dr. Murry said, the muscle cells dedifferentiate after injury and double up their DNA, a necessary precursor to cell division. But they do not finish the process, for reasons that are so far unknown.

Learning how to overcome that block may not be so easy, in Dr. Murry’s view. “It’s tempting to say ‘Let’s do it how nature does it,’ ” he said, “but we don’t know how nature does it. Some of the best molecular biologists in the world have been working on this for a couple of decades and it hasn’t cracked yet.”

Many heart patients have received injections of stem cells, often ones taken from their own bone marrow. But the beneficial effects have generally been unremarkable. “Many of the cell-based treatment protocols have proven modestly effective at best,” Stefan Janssens of the University of Leuven in Belgium concludes in the current Annual Review of Medicine.

Dr. Murry agreed that results had been disappointing, but said both approaches, using stem cell treatments and trying to understand nature’s favored recipe for regeneration, should be pursued in parallel.

Nicholas Wade, New York Times

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Full article: http://www.nytimes.com/2010/03/25/science/25heart.html

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With health bill, Obama has sown the seeds of a budget crisis

When historians recount the momentous events of recent weeks, they will note a curious coincidence. On March 15, Moody’s Investors Service — the bond rating agency — published a paper warning that the exploding U.S. government debt could cause a downgrade of Treasury bonds. Just six days later, the House of Representatives passed President Obama’s health-care legislation costing $900 billion or so over a decade and worsening an already-bleak budget outlook.

Should the United States someday suffer a budget crisis, it will be hard not to conclude that Obama and his allies sowed the seeds, because they ignored conspicuous warnings. A further irony will not escape historians. For two years, Obama and members of Congress have angrily blamed the shortsightedness and selfishness of bankers and rating agencies for causing the recent financial crisis. The president and his supporters, historians will note, were equally shortsighted and self-centered — though their quest was for political glory, not financial gain.

Let’s be clear. A “budget crisis” is not some minor accounting exercise. It’s a wrenching political, social and economic upheaval. Large deficits and rising debt — the accumulation of past deficits — spook investors, leading to higher interest rates on government loans. The higher rates expand the budget deficit and further unnerve investors. To reverse this calamitous cycle, the government has to cut spending deeply or raise taxes sharply. Lower spending and higher taxes in turn depress the economy and lead to higher unemployment. Not pretty.

Greece is experiencing such a crisis. Until recently, conventional wisdom held that only developing countries — managed ineptly — were candidates for true budget crises. No more. Most wealthy societies with aging populations, including the United States, face big gaps between their spending promises and their tax bases. No one in Congress could be unaware of this.

Two weeks before the House vote, the Congressional Budget Office released its estimate of Obama’s budget, including its health-care program. From 2011 to 2020, the cumulative deficit is almost $10 trillion. Adding 2009 and 2010, the total rises to $12.7 trillion. In 2020, the projected annual deficit is $1.25 trillion, equal to 5.6 percent of the economy (gross domestic product). That assumes economic recovery, with unemployment at 5 percent. Spending is almost 30 percent higher than taxes. Total debt held by the public rises from 40 percent of GDP in 2008 to 90 percent in 2020, close to its post-World War II peak.

To criticisms, Obama supporters make two arguments. First, the CBO says the plan reduces the deficit by $143 billion over a decade. Second, the legislation contains measures (an expert panel to curb Medicare spending, emphasis on “comparative effectiveness research”) to control health spending. These rejoinders are self-serving and unconvincing.

Suppose the CBO estimate is correct. So? The $143 billion saving is about 1 percent of the projected $12.7 trillion deficit from 2009 to 2020. If the administration has $1 trillion or so of spending cuts and tax increases over a decade, all these monies should first cover existing deficits — not finance new spending. Obama’s behavior resembles a highly indebted family’s taking an expensive round-the-world trip because it claims to have found ways to pay for it. It’s self-indulgent and reckless.

But the CBO estimate is misleading, because it must embody the law’s many unrealistic assumptions and gimmicks. Benefits are phased in “so that the first 10 years of [higher] revenue would be used to pay for only six years of spending” increases, a former CBO director, Douglas Holtz-Eakin, wrote in the New York Times on March 20. Holtz-Eakin also noted the $70 billion of premiums for a new program of long-term care that reduce present deficits but will be paid out in benefits later. Then there’s the “doc fix” — higher Medicare reimbursements under separate legislation that would cost about $200 billion over a decade.

Proposals to control health spending face restrictions that virtually ensure failure. Consider the “Independent Payment Advisory Board” aimed at Medicare. “The Board is prohibited from submitting proposals that would ration care, increase revenues or change benefits, eligibility or Medicare beneficiary cost sharing,” says a summary by the Henry J. Kaiser Family Foundation. What’s left? Similarly, findings from “comparative effectiveness research” — intended to identify ineffective care — “may not be construed as mandates, guidelines or recommendations for payment, coverage or treatment.” What’s the point then?

So Obama is flirting with a future budget crisis. Moody’s emphasizes two warning signs: rising debt and loss of confidence that government will deal with it. Obama fulfills both. The parallels with the recent financial crisis are striking. Bankers and rating agencies engaged in wishful thinking to rationalize self-interest. Obama does the same. No one can tell when or whether a crisis will come. There is no magic tipping point. But Obama is raising the chances.

Robert J. Samuelson, Washington Post

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Full article: http://www.washingtonpost.com/wp-dyn/content/article/2010/03/28/AR2010032802353.html

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Federally funded abortions are in our future

Health care is the next-to-last thing I want to write about. The last thing is abortion, so this column is a banquet of tortures.

Usually, I would not return so soon to a topic that I tend to associate with the pleasures of head-banging, but broad misunderstanding about what’s in the health-care-reform law justifies another lap.

Still cloudy is whether the new law of the land allows funding for abortions and whether President Obama’s executive order is of any real (judicially enforceable) value. The answer to the latter is in little dispute. It is no. An executive order cannot override a statute.

As to the funding issue, well, it’s intentionally complicated. And suffice to say, it shouldn’t be.

Defenders argue that: (1) nowhere does the bill say funds will go toward abortion; (2) the Hyde Amendment, which prohibits federal funding for abortion, applies.

Both assertions are true — up to a point. The issue isn’t what the bill says; it’s what it doesn’t say.

No one should apologize for being confused, by the way. If not for the patient tutoring of brilliant lawyers, Capitol Hill staffers, medical experts and others, I would be hugging my knees alternately muttering “Who’s Jacob?” and “Ibid, Subsection C (1)(a).”

To the first argument: Of course the bill doesn’t explicitly state that it appropriates abortion funding. In fact, it takes pains to use terminology that seems to explicitly forbid it. But other areas are swampier. And, indeed, funds could be used to pay for abortion under circumstances that predictably will evolve.

History and precedent tell us this much.

For one thing, the Hyde Amendment is a rider that must be lobbied and attached each year to the annual Labor/Health and Human Services appropriations bill. Under its terms, the amendment applies only to those funds.

Rather than following the usual course of funding community health centers (CHCs) through the Labor/HHS budget, the health-care-reform measure does an end run around Hyde by directly appropriating billions of dollars into a new CHC fund.

Because the Obama administration’s “fix-it” bill did not include the abortion-ban language proposed by Rep. Bart Stupak (D-Mich.), those billions appropriated to CHCs simply are not covered by Hyde.

Now, the president’s executive order purports to address this gap by extending the Hyde Amendment to these dollars as well. The problem is that, regardless of Obama’s stated intentions, he can’t actually do this without an act of Congress.

As Dorinda Bordlee, an attorney with the Bioethics Defense Fund, wrote: “If a president could do that, there would be no need to have a majority of Congress pass the Hyde Amendment each and every year to prevent abortion funding using Medicaid dollars for low-income government health care. Instead, we could have simply prevailed on each president to issue an executive order saying agencies can’t use Medicaid money for abortion. Congress controls the purse strings, not the president. That’s Civics 101.”

It is telling that the nation’s largest abortion provider — Planned Parenthood — is claiming “victory” because “we were able to keep the Stupak abortion ban out of the final legislation and President Obama did not include the Stupak language in his executive order.”

Several supporters of the bill have argued that this debate is otherwise irrelevant because abortions aren’t performed at CHCs. While currently true, this doesn’t mean that CHCs wouldn’t like to offer abortion among their reproductive services.

Under the new law, they can. There’s nothing to stop them.

Here’s why. By statute, CHCs are required to provide all “required primary health care services,” defined to include “health services related to . . . obstetrics or gynecology that are furnished by physicians.”

Federal courts long have held that when a statute requires provision of health services under such broad categories, then the statute must be construed to include abortion unless it explicitly excludes it. Voilà.

One may believe that poor women should have affordable access to abortion. This is a reasonable position and it is likely to be the result of this bill. But it is not what Americans have been led to believe is true, nor is it what most want. A January Quinnipiac University poll found that 67 percent of Americans oppose public funding for abortion, down from 72 percent in December.

Prediction: Abortions will be performed at community health centers. You can bet your foreclosed mortgage on that. There was always a will by this administration, and now there’s a way.

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In a recent column I wrote that Margaret Chase Smith was the first woman elected to the U.S. Senate. She was the first elected to both houses. The first woman elected to the Senate was Hattie Caraway of Arkansas.

Kathleen Parker, Washington Post

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Full article: http://www.washingtonpost.com/wp-dyn/content/article/2010/03/26/AR2010032603066.html

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The ObamaCare Writedowns

The corporate damage rolls in, and Democrats are shocked!

It’s been a banner week for Democrats: ObamaCare passed Congress in its final form on Thursday night, and the returns are already rolling in. Yesterday AT&T announced that it will be forced to make a $1 billion writedown due solely to the health bill, in what has become a wave of such corporate losses.

This wholesale destruction of wealth and capital came with more than ample warning. Turning over every couch cushion to make their new entitlement look affordable under Beltway accounting rules, Democrats decided to raise taxes on companies that do the public service of offering prescription drug benefits to their retirees instead of dumping them into Medicare. We and others warned this would lead to AT&T-like results, but like so many other ObamaCare objections Democrats waved them off as self-serving or “political.”

Perhaps that explains why the Administration is now so touchy. Commerce Secretary Gary Locke took to the White House blog to write that while ObamaCare is great for business, “In the last few days, though, we have seen a couple of companies imply that reform will raise costs for them.” In a Thursday interview on CNBC, Mr. Locke said “for them to come out, I think is premature and irresponsible.”

Meanwhile, Henry Waxman and House Democrats announced yesterday that they will haul these companies in for an April 21 hearing because their judgment “appears to conflict with independent analyses, which show that the new law will expand coverage and bring down costs.”

In other words, shoot the messenger. Black-letter financial accounting rules require that corporations immediately restate their earnings to reflect the present value of their long-term health liabilities, including a higher tax burden. Should these companies have played chicken with the Securities and Exchange Commission to avoid this politically inconvenient reality? Democrats don’t like what their bill is doing in the real world, so they now want to intimidate CEOs into keeping quiet.

On top of AT&T’s $1 billion, the writedown wave so far includes Deere & Co., $150 million; Caterpillar, $100 million; AK Steel, $31 million; 3M, $90 million; and Valero Energy, up to $20 million. Verizon has also warned its employees about its new higher health-care costs, and there will be many more in the coming days and weeks.

As Joe Biden might put it, this is a big, er, deal for shareholders and the economy. The consulting firm Towers Watson estimates that the total hit this year will reach nearly $14 billion, unless corporations cut retiree drug benefits when their labor contracts let them.

Meanwhile, John DiStaso of the New Hampshire Union Leader reported this week that ObamaCare could cost the Granite State’s major ski resorts as much as $1 million in fines, because they hire large numbers of seasonal workers without offering health benefits. “The choices are pretty clear, either increase prices or cut costs, which could mean hiring fewer workers next winter,” he wrote.

The Democratic political calculation with ObamaCare is the proverbial boiling frog: Gradually introduce a health-care entitlement by hiding the true costs, hook the middle class on new subsidies until they become unrepealable, but try to delay the adverse consequences and major new tax hikes so voters don’t make the connection between their policy and the economic wreckage. But their bill was such a shoddy, jerry-rigged piece of work that the damage is coming sooner than even some critics expected.

Editorial, Wall Street Journal

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Full article: http://online.wsj.com/article/SB10001424052748704100604575146002445136066.html

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Looking for Medical Miracles in Medieval Manuscripts

Manuscripts from the Middle Ages may contain some useful potions to cure present-day illnesses.

Did monks in the Middle Ages know more about medicine than we thought? A German medical historian is combing medieval manuscripts looking for recipes that could be helpful today. Pharmaceutical companies have taken a keen interest in his research.

“This medication is delicious,” says Johannes Mayer, 56, looking ecstatic. “And it actually helps against digestive disorders and colds.”

Its composition is as surprising as its effect: Caraway soaked in vinegar, dates pickled in red wine, dried ginger and green pepper. All of this is crushed with a mortar and pestle and combined with baking soda and honey to make a sticky paste.

The name of the remedy is also odd: Diaspolis. “We have no idea what this is supposed to mean,” says Mayer, a medical historian. “The scribe apparently made a mess of things.”

Mayer, a renowned expert on medieval monastic medicine, is sitting in a neon-lit room full of overflowing bookshelves in the Würzburg Institute of the History of Medicine. Detailed copies of handwritten documents from the Middle Ages are on the desk in front of him. His favorite recipe, with its strange name, is from the “Lorsch pharmacopoeia,” the oldest existing book of monastic medicine, written around 795 A.D., in the Lorsch Imperial Abbey near the southwestern German city of Worms.

Plants, Herbs and Bits of Animals

Together with pharmacists, doctors, classical scholars and a Cistercian priest who also holds a doctorate in biology, Mayer is attempting, for the first time, to systematically document the medicinal knowledge of monks and nuns, as well as to evaluate its effectiveness. Until the first universities were established in Europe, medical knowledge was concentrated in monasteries, for the most part, because their residents were among the chosen few who could read and write. There were no hospitals then, but most monasteries had at least a healer and an infirmary.

The Würzburg scientists painstakingly decode the manuscripts to determine which plants, minerals and animal materials are described, and how they were dosed and combined. Then they test the recipes for their pharmacological efficacy.

Mayer and his fellow team members have already identified about 600 healing plants, of which they have studied about 120 in greater detail. The research project is financed in large part by pharmaceutical companies, which hope that the traditional remedies will provide inspiration for new drugs that will presumably be mostly natural.

But the marketability of some recipes will likely be limited. For the treatment of a swollen ankle, for example, the “Lorsch Pharmacopeia” recommends: “A mouse ground with oil relieves the symptoms.”

Obscure passages can also be found in “Macer floridus,” another standard work of monastic medicine. “When a pregnant woman takes in the scent of the wilting flower through her nose, this shall abort the fruit of the womb,” a monk wrote in punchy Latin hexameter. He was referring to the flower of the wild arum plant. The same effect could be achieved, he added, “if the crushed root is inserted into the uterus from below with a small wool suppository.”

‘Surgery Was Quite Difficult’

Monks giving abortion tips? The medical historian doesn’t find this outlandish at all. “The Catholic Church only formulated its rigid position on abortion in the 19th century,” Mayer explains. It was not as clear in the past, he adds. Besides, members of religious orders with medical responsibilities must have known how to remove dead fetuses from the womb. “As we know, surgery was still quite difficult at the time.”

The abortion method involving the suppository could even have worked. “Arum is quite toxic,” says Mayer. However, the intervention was probably not completely safe for the pregnant woman. “In the Middle Ages, toxic substances were used very often,” Mayer explains. “The people in the monasteries knew about the risks and side effects, but they often had no better alternatives.”

Scientists are now fairly certain that autumn crocus, for example, is effective against gout, but a few milligrams too much are deadly. To prevent a large dose of the toxin from entering the blood of a patient all at once, tiny portions of the plant were baked into cookies.

Some recipes seem bizarre at first, but upon closer inspection prove to be not so odd, after all. The God-fearing chemists smeared a paste of cheese mold, soft sheep dung and honey onto “boils on the lower legs.” “We will never conduct a clinical study of this,” says Mayer, smiling, “but it’s plausible that an antibiotic could arise from this mixture.”

Aloe Vera as a Laxative

The Würzburg scientists were able to demonstrate that a substantial share of modern herbalism goes back to monastic medicine. Aloe vera was used in the Middle Ages as a laxative, and fennel and caraway were administered for flatulence, hops as a soporific and St. John’s Wort to lift the spirits.

Currant seeds were considered the treatment of choice for rashes, which the monks and nuns learned from the Arabs, like many other things. “We now know,” says Mayer, “that the seeds contain gamma-linolenic acid, an effective anti-inflammatory agent.”

The Arabs also attributed an anti-inflammatory effect to valerian, which led to its being prescribed in Europe for the treatment of wounds and lung ailments.

“In that case, however, the monks made a mistake,” says Mayer. He notes that valerian, which grows in present-day Iran, does contain anti-inflammatory substances, but the European variety doesn’t.

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Full article and photo: http://www.spiegel.de/international/zeitgeist/0,1518,685432,00.html

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ObamaCare Day One

Companies are already warning about higher health-care costs.

Democrats dragged themselves over the health-care finish line in part by repeating that voters would like the plan once it passed. Let’s see what they think when they learn their insurance costs will jump right away.

Even before President Obama signed the bill on Tuesday, Caterpillar said it would cost the company at least $100 million more in the first year alone. Medical device maker Medtronic warned that new taxes on its products could force it to lay off a thousand workers. Now Verizon joins the roll of businesses staring at adverse consequences.

In an email titled “President Obama Signs Health Care Legislation” sent to all employees Tuesday night, the telecom giant warned that “we expect that Verizon’s costs will increase in the short term.” While executive vice president for human resources Marc Reed wrote that “it is difficult at this point to gauge the precise impact of this legislation,” and that ObamaCare does reflect some of the company’s policy priorities, the message to workers was clear: Expect changes for the worse to your health benefits as the direct result of this bill, and maybe as soon as this year.

Mr. Reed specifically cited a change in the tax treatment of retiree health benefits. When Congress created the Medicare prescription drug benefit in 2003, it included a modest tax subsidy to encourage employers to keep drug plans for retirees, rather than dumping them on the government. The Employee Benefit Research Institute says this exclusion—equal to 28% of the cost of a drug plan—will run taxpayers $665 per person next year, while the same Medicare coverage would cost $1,209.

In a $5.4 billion revenue grab, Democrats decided that this $665 fillip should be subject to the ordinary corporate income tax of 35%. Most consulting firms and independent analysts say the higher costs will induce some companies to drop drug coverage, which could affect about five million retirees and 3,500 businesses. Verizon and other large corporations warned about this outcome.

U.S. accounting laws also require businesses to immediately restate their earnings in light of the higher tax burden on their long-term retiree health liabilities. This will have a big effect on their 2010 earnings.

While the drug tax subsidy is for retirees, companies consider their benefit costs as a total package. The new bill might cause some to drop retiree coverage altogether. Others may be bound by labor contracts to retirees, but then they will find other ways to cut costs. This means raising costs or reducing coverage for other employees. So much for Mr. Obama’s claim that if you like your coverage, you can keep it—even at Fortune 500 companies.

In its employee note, Verizon also warned about the 40% tax on high-end health plans, though that won’t take effect until 2018. “Many of the plans that Verizon offers to employees and retirees are projected to have costs above the threshold in the legislation and will be subject to the 40 percent excise tax.” These costs will start to show up soon, and, as we repeatedly argued, the tax is unlikely to drive down costs. The tax burden will simply be spread to all workers—the result of the White House’s too-clever decision to tax insurers, rather than individuals.

A Verizon spokesman said the company is merely addressing employee questions about ObamaCare, not making a political statement. But these and many other changes were enabled by the support of the Business Roundtable that counts Verizon as a member. Verizon CEO Ivan Seidenberg’s health-reform ideas are 180 degrees from Mr. Obama’s, but Verizon’s shareholders and 900,000 employees and retirees will still pay the price.

Businesses around the country are making the same calculations as Verizon and no doubt sending out similar messages. It’s only a small measure of the destruction that will be churned out by the rewrite of health, tax, labor and welfare laws that is ObamaCare, and only the vanguard of much worse to come.

Editorial, Wall Street Journal

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Full article: http://online.wsj.com/article/SB10001424052748703312504575141642402986422.html

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What Republicans Should Do Now

Repeal and reform will be a winning issue this fall.

Democrats are celebrating victory. The public outcry against what they’ve done doesn’t seem to bother them. They take it as validation that they are succeeding at transforming America.

But we’ve seen this movie before and it won’t end happily for Democrats. Their morale rose when the stimulus passed in February 2009. The press hailed it as a popular answer to joblessness and a sluggish economy. At the time, Democrats thought it brightened their chances in the 2009 gubernatorial elections.

But a flawed bill, bumbling implementation, and unfulfilled expectations turned the stimulus into a big drag on Democrats in Virginia and New Jersey. A CBS News/New York Times poll recently reported that only 6% of Americans believe the stimulus package created jobs.

Democratic hopes that passing health-care reform will help them politically will be unfulfilled because ObamaCare only benefits a small number of people in the short run. Until the massive subsidies to insurance companies fully ramp up in 2017, this bill will be more pain than gain for most Americans.

For example, changes in insurance regulations in 2011 and two new mandates in 2014 that force everyone to buy insurance and require everyone to be charged a similar price regardless of age or health will cause insurance premiums to rise more than they would have otherwise. The 10 million people who have a health savings account will also be hurt starting in 2011. With each passing year after that, they will be able to put less away tax free for medical expenses.

ObamaCare cuts $1.8 billion in support for Medicare Advantage this October, another $5.8 billion in October 2011, and an additional $9.2 billion right before the 2012 presidential election. This will increase premiums and reduce benefits for the 4.5 million people in the program.

Drug companies will start raising prices to pay billions in new taxes they will have to pay starting next year. New taxes on medical devices and insurance companies will show up in higher prices and premiums before long.

Polls may show a temporary increase in the president’s popularity, but underlying public opinion about this law is not likely to change just because the president hits the trail to sell it. After all, he made 58 speeches before the measure passed, including two in prime time.

Before that string of speeches the public was in favor of the concept of health-care reform by a ratio of 2 to 1. Afterward, about 60% of the public was opposed to the president’s plan. Those who strongly opposed outnumbered those strongly in favor by 2 to 1 or better in most polls.

Tens of millions of ordinary people watched the deliberations, studied the proposals, and made up their minds. Their concerns about spending, deficits and growing government power are not going away.

Nor is their opposition to ObamaCare. According to a new CNN poll, majorities of Americans believe that they will pay more for medical care, the federal deficit will increase, and that government will be too involved in health care under the president’s plan.

Democrats claim they’ve rallied their left-wing base. But that base isn’t big enough to carry the fall elections, particularly after the party alienated independents and seniors. The only way Democrats win a base election this year will be if opponents of this law stay home.

To keep that from happening, Republican candidates must focus on ObamaCare’s weaknesses. It will cost $2.6 trillion in its first decade of operation and is built on Madoff-style financing. For example, it double counts Social Security payroll taxes, long-term care premiums, and Medicare savings in order to make it appear more fiscally responsible. In reality, ObamaCare isn’t $143 billion in the black, as Democrats have claimed, but $618 billion in the red. And giving the IRS $10 billion to hire about 16,000 agents to enforce the new taxes and fees in ObamaCare will drive small business owners crazy.

Republicans have a powerful rallying cry in “repeal, replace and reform.” Few voters will want to keep onerous mandates that hit individuals and taxes that hobble economic growth. Rather than spending a trillion dollars on subsidies for insurance companies and Medicaid expansion, as ObamaCare does, Republicans should push for giving individuals the same health-insurance tax break businesses get, which would cost less.

Republicans must also continue to press for curbing junk lawsuits, enabling people to buy insurance across state lines, increasing the amount of money they can sock away tax free for medical expenses, and permitting small businesses to pool risk.

Opponents of ObamaCare have decisively won the battle for public opinion. As voters start to feel the pain of this new program, Republicans will be in a stronger position if they stay in the fight, make a principled case, and lay out a competing vision.

Mr. Rove, the former senior adviser and deputy chief of staff to President George W. Bush, is the author of “Courage and Consequence,” published this month by Threshold Editions.

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Full article: http://online.wsj.com/article/SB10001424052748703312504575142032773435558.html

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A generous dose of caution on health reform

The conventions of political pontification do not allow for admissions of uncertainty or ambivalence. Thus, Sunday night’s House debate on health care featured bombastic declarations from both sides about the impending disaster (Republicans) or nirvana (Democrats) being ushered in.

In fact, the occasion called for more humility than hyperbole, however unlikely that may have been given the setting. If I were a member of Congress, my floor speech before casting a yes vote would have boiled down to:

Gee, I hope this works.

One of the astonishing aspects of the health-care debate is how little is actually known about the implications of a change this far-reaching. Everyone has a theory, and a model to match, but even some of the most fundamental questions remain the subject of debate.

On the most basic of all — does having health insurance lead to better health? — the evidence is solid but not unanimous. The Institute of Medicine, reviewing the literature in 2009, found that “the body of evidence on the health consequences of health insurance is stronger than ever before. . . . Simply stated: Health insurance coverage matters.”

But a study that same year by Richard Kronick, a former health-care adviser to President Bill Clinton, found “little evidence to suggest that extending insurance coverage to all adults would have a large effect on the number of deaths in the United States. ” Kronick’s study has been criticized because it did not adjust for the fact that those in poor health are more likely to seek insurance. But the disagreement underscores the difficulty of knowing precisely what changes are in store.

To take another example, one common assertion has been that the uninsured end up getting health care — just more expensive health care, in emergency rooms and when conditions have worsened, with the costs passed on to the rest of the population. The notion that the tab is being picked up one way or another makes intuitive sense.

A new National Bureau of Economic Research paper by Michael Anderson, Carlos Dobkin and Tal Gross questions this assumption. The researchers examined health-care consumption by 19-year-olds who had just been dropped from their parents’ coverage. They found that not having insurance resulted in a 40 percent reduction in emergency room visits — “contradicting the conventional wisdom that the uninsured are more likely to visit” the emergency room and a 61 percent drop in hospital admissions.

“Overall, these results suggest that an expansion in health insurance coverage would substantially increase the amount of care that currently uninsured individuals receive and require an increase in net expenditures,” the authors write. Emergency room visits could increase by 13 million annually, and hospital admissions by 3.8 million, they project.

So prudence is in order when tinkering with such an interconnected system and when making confident predictions about the effects of reform, for good or ill. Will younger adults, who account for about half the population of uninsured non-elderly adults, sign up for coverage — or will they pay the fine instead? How will that decision affect premium levels and the adequacy of federal subsidies?

Will the expansion of coverage create a shortage of health-care providers and result in higher prices, or will, for example, higher Medicaid payments for primary-care doctors stem an exodus of doctors from the program? Will employers add coverage because workers facing the mandate to obtain insurance will press for it, or will they drop it because it will be cheaper to pay the penalty and let employees fend for themselves?

Will increased coverage of preventive care save money because diseases will be caught earlier — or will the added cost of widespread screening exceed the economic benefits? The Congressional Budget Office has concluded that, “for most preventive services, expanded utilization leads to higher, not lower, medical spending overall.”

The legislation is a risk worth taking. Millions of Americans are without insurance, a national scandal that should have been addressed long ago. Rising health-care costs threaten the nation’s fiscal security, and the new law holds the promise of beginning to stem the increases.

The status quo is unsustainable. A new study by the Urban Institute shows how, without reform, the numbers of the uninsured will rise, employers will continue to drop coverage and premiums will climb.

Still, for those who express cocky certitude about how this is going to turn out, the best prescription is a generous dose of caution.

Ruth Marcus, Washington Post

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Full article: http://www.washingtonpost.com/wp-dyn/content/article/2010/03/23/AR2010032302347.html

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Stupak’s fall from pro-life grace

Stupak.

Etymology: Eponym for Rep. Bart Stupak.

Function: verb

1: In a legislative process, to obstruct passage of a proposed law on the basis of a moral principle (i.e., protecting the unborn), accumulating power in the process, then at a key moment surrendering in exchange for a fig leaf, the size of which varies according to the degree of emasculation of said legislator and/or as a reflection of just how stupid people are presumed to be. (Slang: backstabber.)

Poor Bart Stupak. The man tried to be a hero for the unborn, and then, when all the power of the moment was in his frail human hands, he dropped the baby. He genuflected when he should have dug in his heels and gave it up for a meaningless executive order.

Now, in the wake of his decision to vote for a health-care bill that expands public funding for abortion, he is vilified and will forever be remembered as the guy who Stupaked health-care reform and the pro-life movement.

Of all the disappointed activists, Brian Burch, president of CatholicVote.org and creator of StandWithStupak.com, was perhaps the most demonstrative in his support of pro-life Democrats. He even created a video with a remake of the final battle scene from “Braveheart.”

A helmeted British Barack Obama says, “Our cavalry will ride them down like grass. . . . Full attack!” Whereupon, Stupak, eyeglasses incongruously perched on his blue-painted face, commands his pitchfork army, “Steady. . . . Hold, hold, hold.”

Alas, Stupak couldn’t hold.

Ultimately, he was weak and overwhelmed by raw political power. History is no stranger to such moments, but this one needs to be understood for what it was. A deception.

The executive order promising that no federal funds will be used for abortion is utterly useless, and everybody knows it. First, the president can revoke it as quickly as he signs it.

Second, an order cannot confer jurisdiction in the courts or establish any grounds for suing anybody in court, according to a former White House counsel. The order is therefore judicially unenforceable.

Finally, an executive order cannot trump or change a federal statute.

One can reasonably surmise that Obama, a former constitutional law professor, is well aware of the uselessness of his promise. Perhaps this is why he didn’t mention it during the bill-signing ceremony Tuesday.

Stupak, too, knew that the executive order was merely political cover for him and his pro-life colleagues. He knew it because several members of the U.S. Conference of Catholic Bishops explained it to him, according to sources. The only way to prevent public funding for abortion was for his amendment to be added to the Senate bill.

Clearly, House Speaker Nancy Pelosi and the president didn’t want that. What they did want was the abortion funding that the Senate bill allowed.

Thus, the health-care bill passed because of a mutually understood deception — a pretense masquerading as virtue. No wonder Stupak locked his doors and turned off his phones on Sunday, according to several pro-life lobbyists who camped outside his office.

The ticktock of what transpired during the final 72 hours before the vote will keep political science students — and psychologists — happily lost in research for years. Meanwhile, whatever Americans feel about the health-care bill and its relative merits, they should disabuse themselves of any idea that this was an honest play.

Ironically, the day before the vote, Obama said: “We are not bound to win, but we are bound to be true. We are not bound to succeed, but we are bound to let whatever light we have shine.”

Democrats were bound to win, all right, but truth and light had nothing to do with it.

Stupak’s clumsy fall from grace is a lesson in human frailty. In a matter of hours, he went from representing the majority of Americans who don’t want public money spent on abortion to leading the army on the other side.

Something must have gone bump in the night.

Whatever it was, demonizing Stupak seems excessive and redundant given punishments to come. Already he has lost a speaking invitation to the Illinois Catholic Prayer Breakfast next month. His political future, otherwise, may have been foretold by a late-night anecdote.

After the Sunday vote, a group of Democrats, including Stupak, gathered in a pub to celebrate. In a biblical moment, New York Rep. Anthony Weiner was spotted planting a big kiss on Stupak’s cheek.

To a Catholic man well versed in the Gospel, this is not a comforting gesture.

Kathleen Parker, Washington Post

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Full article: http://www.washingtonpost.com/wp-dyn/content/article/2010/03/23/AR2010032302841.html

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Now, Can We Have Health-Care Reform?

ObamaCare doubles down on a failing system.

A certain kind of person—we get emails from them all the time—understands exactly nothing about the health-care debate, but thinks they know who the villain is: the insurance industry.

Barack Obama is not one of them. In the desperate hours he played to public ignorance. But from the beginning, the industry was his ally because he set out to solve its biggest problem—which is not the same as America’s biggest problem.

We’ll let Angela Braly, CEO of insurer WellPoint, take the story from here. She was recently hauled before Congress to justify her company’s proposed 39% rate hike in California. She explained the source was two-fold: rising medical costs and healthier customers dropping their coverage, forcing the sick to pick up the tab.

Now this sounds like two problems, but for WellPoint and other insurers it’s really only one problem. Once everyone is required by government mandate to buy insurance, the industry’s survival is no longer threatened: It can just pass its skyrocketing costs along to customers. Once customers can no longer refuse to buy the industry’s product, the problem of costs won’t be fixed, but it no longer is the insurance industry’s problem.

There, in that one sentence, we give you the failure of ObamaCare, the failure of the congressional health-care debate, the failure of health-care politics in this country.

Health insurers, and indeed Corporate America as a whole, are like monkeys who are caught by staking a glass jar to the ground with a shiny trinket inside. They won’t let go so they can’t get their hands out of the jar. That trinket is the ruinous and regressive $250 billion-a-year tax benefit for employer-provided insurance.

Corporate America isn’t brave enough to argue against a direct subsidy to its employment costs, no matter how perverse its impact in insulating consumers from the true cost of their health care choices. Insurers are not brave enough to say: Give us a tax code that lets us go back to being insurers rather than a tax laundromat for the middle class’s health-care spending.

Almost any bill would have been worth having that fundamentally fixed this tax distortion, regardless of its other elements.

We say this because any bill, including the one signed by the president yesterday, will be revisited many times in the future. Millions of pages of rules will be written by regulators before we see how it really works. Congress itself will return in predictable ways: It will reverse the proposed Medicare cuts that created ObamaCare’s illusion of fiscal probity. It will tighten the mandate that requires insurers to cover the sick at favorable prices. It will not tighten the requirement that the young and healthy buy insurance at prices that subsidize the old and unhealthy.

More and more tax money will have to be found to keep the jalopy on the road. More and more administrative controls on medicine will attempt vainly to keep the jalopy from bankrupting the nation.

Under the law just signed, employers have even more incentive than they did yesterday to lavish excessive health insurance on their high-end employees. They have less incentive to cover low-end workers, or even hire them.

For the young, healthy or anyone not stumbling into a giant tax handout, buying insurance at the inflated prices available in the marketplace would be an even crazier financial decision today than it was yesterday—because now you can wait and buy it when you’re sick.

For insurers, the check is in the mail: So watered down is the individual mandate that it must accelerate the industry’s death spiral if not for the massive subsidies the government now has obliged itself to provide to keep the industry afloat and allow insurers to continue scalping their 15% off the top for serving as gatekeeper to a tax loophole.

When all is said and done, with unerring accuracy, ObamaCare has ended up doubling down on the system’s existing perversities. The one thing it doesn’t do (though it would be perfectly consistent with the Democratic goal of universal access) is incentivize a health-care marketplace based on competition in price and quality.

A world-class hospital in India does heart surgery the equal of any heart surgery in America, but does so at one-tenth the cost (and increasingly attracts a world-wide clientele). The reason is not what you think: low-paid doctors and nurses. The reason is that competition works in medicine as it does in everything else when the patient cares about getting value for money. This is the great low-hanging fruit of health-care reform. It continues to hang.

Holman W. Jenkins, Wall Street Journal

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Full article: http://online.wsj.com/article/SB10001424052748703621104575139732486806838.html

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Republicans and ObamaCare

Democrats insisted on the most liberal bill they could pass.

In Washington, political defeats always produce finger-pointing, so the conventional wisdom has suddenly turned on a dime and decided that Republicans were wrong to have opposed ObamaCare. White House press secretary Robert Gibbs was especially taken yesterday with blogger and Bush speechwriter David Frum’s argument that if only Republicans had negotiated with Democrats, they could have somehow made the bill less awful than it is.

Mr. Frum now makes his living as the media’s go-to basher of fellow Republicans, which is a stock Beltway role. But he’s peddling bad revisionist history that would have been even worse politics. The truth is that Democrats never had any intention of working with Republicans, except to pick off two or three Senators and calling it “bipartisanship.” This worked for Democrats on the stimulus, and they had hoped to do it again on health care.

In the House, Republicans were frozen out from the start. Three Chairmen—Charlie Rangel, Henry Waxman and George Miller—holed up last spring to write the most liberal bill they could get through the House. Republicans were told that unless they embraced the “public option,” there was nothing to discuss.

As for the White House, House GOP leaders John Boehner and Eric Cantor in May sent a letter to President Obama “respectfully” requesting a meeting to discuss ideas. The White House didn’t respond. Mr. Obama’s first deadline for House passage was July, and only after public opinion turned against the bill did he begin to engage Republican ideas. Yet in his September address to Congress attempting to revive his bill, he made no concession save pilot projects for tort reform.

In the Senate, a group of Republicans did negotiate with Finance Chairman Max Baucus for months, even as Senators Chris Dodd and Ted Kennedy were crafting a bill that mirrored the liberal House product. GOP Senators Chuck Grassley, Olympia Snowe and Orrin Hatch are hardly strangers to working with Democrats. In 2007, they helped Mr. Baucus expand the children’s insurance program over President Bush’s opposition.

Senate liberals kept tugging Mr. Baucus to the left, however, and eventually the White House ordered him to call off negotiations. Senator Snowe still voted for the Finance Committee bill, though even she fell away on the floor as Majority Leader Harry Reid insisted on pushing the public option and tried, as Ms. Snowe put it, to “ram it” and “jam it” through the Senate.

In the end, Republicans couldn’t as a matter of principle support even 50% of a bill that was such a huge and reckless expansion of government. If they had, they would have rightly lost the support of their own most loyal supporters. In the end, too, the bill was so unpopular—59% opposed in a Sunday CNN survey—that 34 House Democrats voted no and Mr. Reid is resorting to reconciliation to get the “fixes” of more taxes and spending through the Senate.

Meanwhile, some conservatives on cable-TV and the Web have taken to complaining that if only Senate Minority Leader Mitch McConnell had been tougher, he could have killed the bill. Really? Every Republican in Congress voted no. How many more votes is a Minority Leader supposed to get?

The reality is that ObamaCare is the price of two GOP electoral defeats caused by the failure of the DeLay Congress and a dismal Bush second term. The 2003 Medicare prescription drug benefit compromised the GOP on spending and legislative bullying. Republicans had a chance to do better on health care in 2005 but put their chips on Social Security and failed. Mitt Romney also gave Democrats renewed political confidence when he signed a prototype of ObamaCare into law in Massachusetts, though he now claims that these fraternal policy twins aren’t related.

Republicans also suffered bad luck that gave Senate Democrats reached their 60 votes only after former Alaska Senator Ted Stevens was unjustly indicted, Minnesota’s Al Franken stole a recount from hapless Norm Coleman, and Pennsylvania’s Arlen Specter jumped ship.

A new President nearly always gets what he wants on his top legislative priority, especially when he has such big majorities in Congress to work with. Republicans nonetheless managed to keep their Members together, turn public opinion against the bill despite nearly unanimous media support for it, and in the end came a few votes short. They would have won if Mr. Obama and Nancy Pelosi hadn’t been so willing to put so many of their Members at risk by pushing a partisan program and flouting normal Congressional rules.

The GOP’s goal now should first be to remove some of the uglier parts of the bill in Senate reconciliation. Then they need to focus on taking back as many seats as possible this fall. Rather than publicly crowing that ObamaCare will deliver them the House—a hard task and a risky expectations game—they’d do better to concentrate on continuing to educate the public about what ObamaCare is going to do to insurance premiums, federal deficits, taxes and the quality of medical care.

Many Republicans are already calling for “repeal” of ObamaCare, and that’s fine with us, though they should also be honest with voters about the prospects. The GOP can’t repeal anything as long as Mr. Obama is President, even if they take back Congress in November. That will take two large electoral victories in a row. What they can do now is take credit for fighting on principle, hold Democrats accountable for their votes and the consequences, and pledge if elected in November to stop cold Mr. Obama’s march to ever-larger government.

Editorial, Wall Street Journal

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Full article: http://online.wsj.com/article/SB10001424052748704117304575138071192342664.html

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Inside the Pelosi Sausage Factory

Michigan Rep. Bart Stupak sold his anti-abortion soul for a toothless executive order.

Last week Republican Rep. Mike Pence posted on his Facebook site that famous Schoolhouse Rock video titled “How a Bill Becomes a Law.” It’s clearly time for a remake.

Never before has the average American been treated to such a live-action view of the sordid politics necessary to push a deeply flawed bill to completion. It was dirty deals, open threats, broken promises and disregard for democracy that pulled ObamaCare to this point, and yesterday the same machinations pushed it across the finish line.

You could see it all coming a week ago, when New York Rep. Louise Slaughter let leak a breathtaking strategy whereby the House would not actually vote on the unpopular Senate bill. The House would instead vote on a “reconciliation” fix to that bill, and in the process “deem” the underlying legislation—with its Cornhusker kickbacks and Louisiana purchases—passed.

The Slaughter Solution was both blunt admission and warning. House Speaker Nancy Pelosi did not have 216 votes to pass the Senate bill, there never was going to be majority “support” for it, but they’d pass it anyway. The final days were a simple death watch, to see how the votes would be bought, bribed or bullied, and how many congressional rules gamed, to get the win.

President Obama flew to Pennsylvania (home to five wavering House Democrats), Missouri (three wavering), Ohio (eight), and Virginia (four) to hold rallies with small, supportive crowds. In four days, Mr. Obama held 64 meetings or calls with congressmen. The goal was to let undecideds know that the president had them in his crosshairs, that he still had pull with the base, and he’d use it against them. By Saturday the tactic had yielded yes votes from at least half the previously undecided members of those states.

As for those who needed more persuasion: California Rep. Jim Costa bragged publicly that during his meeting in the Oval Office, he’d demanded the administration increase water to his Central Valley district. On Tuesday, Interior pushed up its announcement, giving the Central Valley farmers 25% of water supplies, rather than the expected 5% allocation. Mr. Costa, who denies there was a quid pro quo, on Saturday said he’d flip to a yes.

Florida Rep. Suzanne Kosmas (whose district is home to the Kennedy Space Center) admitted that in her own Thursday meeting with the president, she’d brought up the need for more NASA funding. On Friday she flipped to a yes. So watch the NASA budget.

Democrats inserted a new provision providing $100 million in extra Medicaid money for Tennessee. Retiring Tennessee Rep. Bart Gordon flipped to a yes vote on Thursday.

Outside heavies were enlisted to warn potential no votes that unions and other Democrats would run them out of Congress. Al Lawson, a Tallahassee liberal challenging Blue Dog Florida Rep. Allen Boyd in a primary, made Mr. Boyd’s previous no vote the centerpiece of his criticism. The SEIU threatened to yank financial support for New York’s Michael McMahon. The liberal Working Families Party said it would deny him a ballot line. Obama deputy campaign manager Steve Hildebrand vowed to challenge South Dakota Rep. Stephanie Herseth Sandlin if she voted no. New York’s Scott Murphy was targeted as a part of a $1.3 million union-financed ad campaign to pressure him to flip. Moveon.Org spent another $36,000 on ads in his district and promised a primary. Messrs. Boyd and Murphy caved on Friday.

All the while Mrs. Pelosi was desperately working to provide cover with a Congressional Budget Office score that would claim the bill “saved” money. To do it, Democrats threw in a further $66 billion in Medicare cuts and another $50 billion in taxes. Huzzah! In the day following the CBO score, about a half-dozen Democrats who had spent the past months complaining the bill already had too many taxes and Medicare cuts now said they were voting to reduce the deficit.

Even with all this, by Friday Mrs. Pelosi was dealing with a new problem: The rule changes and deals winning her votes were losing her votes, too. The public backlash against “deem and pass” gave several wary Democrats—such as Massachusetts’s Stephen Lynch and California’s Dennis Cardoza—a new excuse to vote no.

Mrs. Pelosi jettisoned deem and pass. Once-solid Democrat yes votes wanted their own concessions. Oregon’s Pete DeFazio threatened to lead a revolt unless changes were made to Medicare payments to benefit his state. On Saturday Mrs. Pelosi cut a deal to give 17 states additional Medicare money.

By the weekend, all the pressure and threats and bribes had left the speaker three to five votes short. Her remaining roadblock was those pro-life members who’d boxed themselves in on abortion, saying they would vote against the Senate bill unless it barred public funding of abortion. Mrs. Pelosi’s first instinct was to go around this bloc, getting the votes elsewhere. She couldn’t.

Into Saturday night, Michigan’s Bart Stupak and Mrs. Pelosi wrangled over options. The stalemate? Any change that gave Mr. Stupak what he wanted in law would lose votes from pro-choice members. The solution? Remove it from Congress altogether, having the president instead sign a meaningless executive order affirming that no public money should go to pay for abortions.

The order won’t change the Senate legal language—as pro-choice Democrats publicly crowed within minutes of the Stupak deal. Executive orders can be changed or eliminated on a whim. Pro-life groups condemned the order as the vote-getting ruse it was. Nevertheless, Mr. Stupak and several of his colleagues voted yes, paving the way to Mrs. Pelosi’s final vote tally of 219.

Even in these waning minutes, Senate Democrats were playing their own games. Republicans announced they had found language in the House reconciliation bill that could doom this entire “fix” in the Senate. Since many House Democrats only agreed to vote for the Senate bill on promises that the sidecar reconciliation would pass, this was potentially a last-minute killer.

Senate Democrats handled it by deliberately refusing to meet with Republicans and the Senate parliamentarian to get a ruling, lest it be unfavorable and lose House votes. The dodge was a clear dereliction of duty, but Democrats figure the Senate parliamentarian won’t dare derail this process after ObamaCare passes. They are probably right.

So there you have it, folks: “How a Bill Becomes a Law,” at least in Obama-Pelosi land. Perhaps the most remarkable Democratic accomplishment this week was to make the process of passing ObamaCare as politically toxic as the bill itself.

President Obama was elected by millions of Americans attracted to his promise to change Washington politics. These were voters furious with earmarks, insider deals and a lack of transparency. They were the many Americans who, even before this week, held Congress in historic low esteem. They’ll remember this spectacle come November.

Ms. Strassel writes the Journal’s weekly Potomac Watch column from Washington.

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Full article: http://online.wsj.com/article/SB10001424052748703775504575136133814210008.html

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US Health Care — Good for America, Bad for the World

Obama has made history. His health care package is the most important reform America has seen in decades. But what is good for the US may not be a positive for the president himself — nor for the rest of the world.

Germany’s Iron Chancellor, as Otto von Bismarck is known, was never a huge fan of democracy. Bismarck led the country from 1871 to 1890 — and preferred to keep the process of governing away from the public eye. Lawmaking, he once pointed out, was not all that different from what a butcher does. “The less people know about how sausages and laws are made,” he famously said, “the better they will sleep.”

US President Barack Obama has a significantly different view of democracy than Bismarck did, but the German’s observation remains valid. For more than a year, Obama watched his healthcare reform churn through the law-making grinder. His political opponents sliced piece after piece from his most important domestic political project — Obama himself even grabbed the knife occasionally. The public show was such that American voters slowly lost faith in the president’s health care reform plan. On Sunday evening, it finally made it through the House of Representatives. Obama’s apron, though, is splattered with blood.

There is little doubt that the reform package, which guarantees health care coverage for 95 percent of Americans, is one for the history books. It was a scandal that the world’s richest country for so long offered its citizens such pitiful protection against illness or injury. It seems entirely possible that, in 10 years time, Americans will find it hard to believe that they didn’t always have the right to health insurance. In the long fight for the reform project’s eventual passage, Obama showed himself to be persistent and pugnacious. The accusation that Obama has accomplished nothing vanished in a single House vote.

The First Promise Has Been Fulfilled

Nevertheless, he cannot really celebrate the reform that he promised for so long. Since his campaign, Obama has provided two primary justifications for universal health care. First, was the moral necessity to eliminate the existential risks posed by illness or injury to more than 40 million Americans without coverage. The second justification was an economic one — rising health care costs, so goes the argument, must be brought under control in order to reduce stress on the US budget.

The first promise has been fulfilled — the new legislation demonstrates solidarity with those unable to afford health coverage and with those who were refused insurance. The second promise, however, has been postponed. The reform bill only half-heartedly addresses the reduction of health care costs and those measures aimed at savings can easily be skirted. Insurance companies will get millions of new customers, but no real competition. Their shares are currently skyrocketing — they are the true winners of US health care reform.

The president, in other words, won the moral debate, but he is paying a high price. The bid to introduce social reforms of the 1960s, providing health insurance to the poor and elderly, was also deeply controversial. And back then the Republicans also made huge efforts to block the reforms. Congress, though, passed the bill with a clear majority in the end, with votes from both parties. This time Obama has failed to get a single Republican to back his health care reform and polls show that there is a deep public mistrust.

Obama’s show of strength, in fact, most closely resembles the fight for greater civil rights for African-Americans in the South during the 1960s. Democratic President Lyndon B. Johnson pushed through the Civil Rights Act because he believed it was the right thing to do. But he did it in the clear knowledge that the Democrats would have to pay a heavy political price.

Concerned about Re-election

Obama has made it clear that he too is less concerned about the political consequences than about doing the right thing. “We rose above the weight of our politics,” he said after the bill was passed. “When faced with crisis, we did not shrink from our challenges. We overcame them. We did not avoid our responsibilities, we embraced it. We did not fear our future, we shaped it.”

However, many Democrats are deeply concerned about their prospects for re-election and have only hesitantly followed their president. It is difficult to say whether mid-term elections in November will bring punishment or reward for passing the reform. One thing, however, seems clear: the debate over health care is far from over.

Even during the vote in the House of Representatives on Sunday, the Republicans were trying out what will likely become their new campaign message. Who will be forced to pay for the $940 billion reform? Can America afford it now? Can America afford it at all?

Obama counters by saying that the reform will pay for itself, indeed, he claims, it will ultimately save money. Nonetheless the billions of dollars he is currently juggling seem to be making many Americans feel faint.

Further Successes Doubtful

The debate will dominate the next few months — and will no doubt also have an impact on the other projects that Obama is finally planning to tackle. The attention that the president will have to continue to pay to health care, in fact, makes further successes that much more doubtful.

Every other issue has become a sideshow, particularly those outside the borders of America. The Afghanistan mission: of marginal interest. Protecting the environment: postponed. Peace in the Middle East: off in the distance. Sanctions against Iran: delayed. Europe: not even worth a trip.

The one remaining global superpower has succumbed to navel gazing. The nature of Obama’s hard-fought victory means little will change in the near future. On the contrary: Now he must explain to the country and to his own party why the entire health care journey, as all-encompassing as it turned out to be, was worth it in the end. He will have little time for anything else.

Such a realization should not spoil the celebration over health care for the Americans themselves. But the rest of the world won’t be joining the party quite so enthusiastically.

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Full article: http://www.spiegel.de/international/world/0,1518,684952,00.html

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The Health Vote and the Constitution—II

The House can’t approve the Senate bill in the same legislation by which it approves changes to the Senate bill.

In just a few days the House of Representatives is expected to act on two different pieces of legislation: the Senate version of the health-care bill (the one that contains the special deals, “Cadillac” insurance plan taxes, and abortion coverage) and an amendatory bill making changes in the Senate bill. The House will likely adopt a “self-executing” rule that “deems” passage of the amendatory bill as enactment of the Senate bill, without an actual vote on the latter.

This enables the House to enact the Senate bill while appearing only to approve changes to it. The underlying Senate bill would then go to the president for signature, and the amendatory bill would go to the Senate for consideration under reconciliation procedures (meaning no filibuster).

This approach appears unconstitutional. Article I, Section 7 clearly states that bills cannot be presented to the president for signature unless they have been approved by both houses of Congress in the same form. If the House approves the Senate bill in the same legislation by which it approves changes to the Senate bill, it will fail that requirement.

Rep. Louise Slaughter (D., N.Y.), chair of the House Rules Committee and prime mover behind this approach, has released a letter from Yale Law School’s Jack Balkin asserting that a “rule which consolidates a vote on a bill and accompanying amendments, or, as in this case, a reconciliation measure and an amended bill, is within the House’s powers under Article I, Section 5, Clause 2.”

But that does not actually address the point at issue. No one doubts that the House can consolidate two bills in a single measure; the question is whether, having done so, it may then hive the resulting bill into two parts, treating one part as an enrolled bill ready for presidential signature and the other part as a House bill ready for senatorial consideration. That seems inconsistent with the principle that the president may sign only bills in the exact form that they have passed both houses. A combination of two bills is not in “the same form” as either bill separately.

Defenders of the Democratic strategy say that a self-executing rule has been used many times before by both parties. But never in this way. Most of the time a self-executing rule is used to incorporate amendments into a pending bill without actual votes on the amendments, where the bill is then subject to a final vote by the House and Senate. That usage may be a dodge around House rules, but it does not violate the Constitution. I am not aware of any instance where a self-executing rule has been used to send one bill to the president for signature and another to the Senate for consideration by means of a single vote.

Self-executing rules have also been used to increase the debt ceiling by virtue of adopting a budget resolution. That procedure is questionable, but because budget resolutions are not laws, this usage does not have the feature of using one vote to send a bill to the president and at the same time to send a different bill to the Senate. There may have been other questionable uses of self-executing rules, but not often enough or in prominent enough cases to establish a precedent that would overcome serious constitutional challenge.

Whether the courts would entertain such a challenge is a harder question. The “enrolled bill doctrine,” announced by the Supreme Court in Marshall Field v. Clark (1892), holds that the courts will not question whether a bill certified as having passed both houses of Congress was properly enacted. More recently, in United States v. Munoz-Flores (1990), in a footnote, the Supreme Court stated that Field concerned only the “evidence” the courts would consider in such a challenge and that when “a constitutional provision is implicated,” the enrolled bill doctrine would not apply. These holdings are not easy to reconcile. The D.C. Circuit, in a 1995 case, essentially said that it did not understand the Munoz-Flores footnote and thus would not follow it.

The Supreme Court might well hold that Field governs only questions of historical fact, while Munoz-Flores governs questions of constitutional interpretation. In Field, the question was what text passed the two houses of Congress; there was no doubt that only what the two houses passed could be treated as law. Here, by contrast, there will be no dispute about what occurred in the House; the question will be whether using a self-executing rule in this way is consistent with Article I, Section 7. It is one thing for the Supreme Court to defer to Congress on questions of what Congress did, and quite another to defer to Congress on the meaning of the Constitution. Indeed, in United States v. Ballin, decided the same year as Field, the Court ruled, “The Constitution empowers each House to determine its own rules of proceedings. It may not by its rules ignore constitutional restraints . . . .”

One thing is sure: To proceed in this way creates an unnecessary risk that the legislation will be invalidated for violation of Article I, Section 7. Will wavering House members want to use this procedure when there is a nontrivial probability that the courts will render their political sacrifice wasted effort? To hazard that risk, the House leadership must have a powerful motive to avoid a straightforward vote.

Mr. McConnell, a former federal judge on the U.S. Court of Appeals for the Tenth Circuit, is a law professor at Stanford University and director of the Stanford Constitutional Law Center.

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Full article: http://online.wsj.com/article/SB10001424052748703580904575131460390057440.html

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The ObamaCare Crossroads

The vote is really about who commands the country’s medical resources.

With the House’s climactic vote on ObamaCare tomorrow, Democrats are on the cusp of a profound and historic mistake, comparable in our view to the Smoot-Hawley tariff and FDR’s National Industrial Recovery Act. Everyone is preoccupied now with the politics, but ultimately at stake on Sunday is the kind of country America will be.

The consequences of this bill will not only be destructive for the health-care system and the country’s fiscal condition, though those will be bad enough. Inextricably bound up in a plan as far-reaching and ambitious as ObamaCare are also larger questions about the role of government, the dynamism of American enterprise and the nature of a free society. Above anything else, this explains why Democrats have had such trouble convincing the public, let alone their own Members.

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Most acutely in the balance is the future of U.S. medicine. On the opposing page we reprint a 1996 essay by the great Milton Friedman that is more relevant than ever. Drawing from Alexander Solzhenitsyn’s novel “The Cancer Ward,” the late Nobel laureate traces the ways that national health care fundamentally alters “the consensual relation between the patient and the physician.”

In our world of infinite wants but finite resources, there are only two ways to allocate any good or service: either through prices and the choices of millions of individuals, or through central government planning and political discretion. This choice is inexorable. Stripped of its romantic illusions, ObamaCare is really about who commands the country’s medical resources. It vastly accelerates the march toward a totally state-driven system, in contrast to reforms that would fix today’s distorted status quo by putting consumers in control.

Friedman lays out how the country arrived at our current pass, starting with the World War II-era decision to offer tax subsidies for employer-sponsored coverage only. Like the company store, this inefficient and inequitable preference encourages workers to be paid in kind rather than cash, and over the years the third-party payer system it entrenched has inhibited competition and desensitized patients to the costs of their own care. With the 1965 creation of Medicare for seniors and Medicaid for the poor, government has come to play the leading role in shaping the way care is paid for and provided.

Naturally, the result has been high and rising costs. Since 1962, the share of the economy devoted to health care has risen to about 17% from 6%. Today, health entitlements account for about 5% of GDP but on current trend will rise to 7% in 2025 and about 15% in 2062.

That is the problem President Obama inherited, as it were. Yet rather than fundamentally changing these incentives, he chose instead to create a new middle-class insurance entitlement that will transform the way U.S. health care is financed, and thus delivered. Such a “universal” system has been the core liberal aspiration since the age of Bismarck. But time and again this political ambition has been thwarted by American individualism, distrust of government power, the checks and balances of the political system, and, every so often, good judgment in Washington.

Once the health-care markets are put through Mr. Obama’s de facto nationalization, costs will further explode. The Congressional Budget Office estimates ObamaCare will cost taxpayers $200 billion per year when fully implemented and grow annually at 8%, even under low-ball assumptions. Soon the public will reach its taxing limit, and then something will have to give on the care side. In short, medicine will be rationed by politics, no doubt with the same subtlety and wisdom as Congress’s final madcap dash toward 216 votes.

As in the Western European and Canadian welfare states, doctors, hospitals and insurance companies will over time become public utilities. Government will set the cost-minded priorities and determine what kinds of treatment options patients are allowed to receive. Medicare’s price controls will be exported to the remnants of the private sector.

All bureaucratized systems also restrict access to specialists and surgeries, leading to shortages and delays of months or years. This will be especially the case for the elderly and grievously ill, and for innovation in procedures, technologies and pharmaceuticals.

Eventually, quality and choice—the best attributes of American medicine in spite of its dysfunctions—will severely decline.

Democrats deny this reality, but government rationing will become inevitable given that overall federal spending is already at 25% of GDP and heading north, and Medicare’s unfunded liabilities are roughly two and a half times larger than the entire U.S. economy in 2008. The ObamaCare bill already contains one of the largest tax increases outside the Great Depression or the world wars, including a major new tax on investment income—and no one seriously believes it will be enough.

So a vote for ObamaCare is also a vote against the vitality of American capitalism. Business elites have mostly held their tongues, or calculated that they can later dump their health-care liabilities on the government. Yet ObamaCare will lead to much higher levels of taxation across society. The tax wedge—the share of labor costs that never reaches workers but instead goes straight to government—will start flying towards the 50% that prevails today in most of Europe. In America, without the same welfare state obligations, it hovers near 30%.

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A self-governing democracy can of course decide that it wants to become this kind of super-welfare state. But if the year-long debate over ObamaCare has proven anything, it is that Americans want no such thing. There is no polling majority or any bipartisan support, much less a rough national consensus, for this expansion of government power. The election of Scott Brown in Massachusetts for Ted Kennedy’s seat, of all things, was as direct a referendum as you could have.

So if the health bill passes in the House, it will only do so the way it did in the Senate, with a narrow partisan majority, abetted by political bribery and intimidation, budget gimmicks and procedural deceptions. An entitlement the country can’t afford and doesn’t want may pass because of sheer ideological willfulness. The ugliness of the bill, and of its passage, means that some or all of it might be repealable, but far better not to make the tragic mistake in the first place.

Editorial, Wall Street Journal

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Full article: http://online.wsj.com/article/SB10001424052748704207504575130321235660474.html

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