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Good News for Mental Illness in Health Law
By RICHARD A. FRIEDMAN, M.D., The New York Times, July 9, 2012
Americans with mental illness had good reason to celebrate when the Supreme Court upheld President Obama’s Affordable Care Act. The law promises to give them something they have never had before: near-universal health insurance, not just for their medical problems but for psychiatric disorders as well.
Until now, people with mental illness and substance disorders have faced stingy annual and lifetime caps on coverage, higher deductibles or simply no coverage at all.
This was supposed to be fixed in part by the Mental Health Parity and Addiction Equity Act of 2008, which mandated that psychiatric illness be covered just the same as other medical illnesses. But the law applied only to larger employers (50 or more workers) that offered a health plan with benefits for mental health and substance abuse. Since it did not mandate universal psychiatric benefits, it had a limited effect on the disparity between the treatment of psychiatric and nonpsychiatric medical diseases.
Now comes the Affordable Care Act combining parity with the individual mandate for health insurance. As Dr. Dilip V. Jeste, president of the American Psychiatric Association, told me, “This law has the potential to change the course of life for psychiatric patients for the better, and in that sense it is both humane and right.”
To get a sense of the magnitude of the potential benefit, consider that about half of Americans will experience a major psychiatric or substance disorder at some point, according to an authoritative 2005 survey. Yet because of the stigma surrounding mental illness, poor access to care and inadequate insurance coverage, only a fraction of those with mental illness receive treatment.
For example, surveys show that only about 50 percent of Americans with a mood disorder had psychiatric treatment in the past year — leaving the rest at high risk of suicide, to say nothing of the high cost to society in absenteeism and lost productivity. The World Health Organization ranks major depression as the world’s leading cause of disability.
One of the health care act’s pillars is to forbid the exclusion of people with pre-existing illness from medical coverage. By definition, a vast majority of adult Americans with a mental illness have a pre-existing disorder. Half of all serious psychiatric illnesses — including major depression, anxiety disorders and substance abuse — start by 14 years of age, and three-fourths are present by 25, according to the National Comorbidity Survey. These people have specifically been denied medical coverage by most commercial insurance companies — until now.
From an epidemiologic and public health perspective, the provision that young people can remain on their parents’ insurance until they turn 26 is a no-brainer: By this age, the bulk of psychiatric illness has already developed, and there is solid evidence that we can positively change the course of psychiatric illness by early treatment.
Mental disorders are chronic lifelong diseases, characterized by remission and relapse for those who respond to treatment, or persistent symptoms for those who do not. In schizophrenia, for example, relapse is common, even with the best treatment. It makes no sense to tell someone with this condition that his lifetime mental health benefit is just 60 days of inpatient hospitalization.
Psychiatric illness is treatable, but it is rarely curable; it may remit for a while, but it doesn’t go away. That is why the current limits on treatment are as irrational as they are cruel — the discriminatory hallmark of commercial medical insurance.
No more. The Affordable Care Act treats psychiatric illness like any other and removes obstacles to fair and rational treatment.
Older people with mental illness will also benefit, because the law will eventually fill in the notorious gap in Medicare drug coverage known as the “doughnut hole.” The law will immediately require drug companies to give a 50 percent discount on brand-name drugs and then gradually provide subsidies until the gap closes in 2020.
On the other hand, poor people with mental illness still have cause for concern. The new law would have expanded Medicaid to insure 17 million more Americans, but the Supreme Court ruled that states could decline to accept this expansion without losing their existing Medicaid funds. In states that opt out of the Medicaid expansion, poor people with mental illness may find themselves in a terrible predicament: They earn too much to qualify for Medicaid, yet not enough to get the federal subsidy to pay for insurance.
But on the whole, the Affordable Care Act is reason to cheer. Americans with mental illness finally have the prize that has eluded patients and clinicians for decades: the recognition that psychiatric illness should be on a par with all other medical disorders, and the near-universal mandate to make that happen.
Richard A. Friedman is a professor of psychiatry at Weill Cornell Medical College.
Study Says Meeting Contraception Needs Could Cut Maternal Deaths by a Third
By SABRINA TAVERNISE, The New York Times, July 9, 2012
A new study by researchers at Johns Hopkins University shows that fulfilling unmet contraception demand by women in developing countries could reduce global maternal mortality by nearly a third, a potentially great improvement for one of the world’s most vulnerable populations.
The study, published on Tuesday in The Lancet, a British science journal, comes ahead of a major family planning conference in London organized by the British government and the Bill and Melinda Gates Foundation that is an attempt to refocus attention on the issue. It has faded from the international agenda in recent years, overshadowed by efforts to combat AIDS and other infectious diseases, as well as by ideological battles.
The proportion of international population assistance funds that went to family planning fell to just 6 percent in 2008, down from 55 percent in 1995, while spending on H.I.V./AIDS represented 74 percent of the total in 2008, up from just 9 percent in 1995, according to Rachel Nugent, a professor of global health at the University of Washington, who cited figures from the United Nations Population Fund.
But population growth has continued to surge, with the United Nations estimating last year that the world’s population, long expected to stabilize, will instead keep growing. Population experts warn that developing countries, particularly those in sub-Saharan Africa, where fertility continues to be high and shortages of food and water are worsening, will face deteriorating conditions if family sizes do not shrink.
“Family planning kind of faded from the radar screen, and now it is coming back,” said John May, a visiting fellow at the Center for Global Development and author of a book, “World Population Policies: Their Origin, Evolution, and Impact.”
“There is a realization from many different places that population issues are not going away,” he said.
The issue of family planning is fraught in the United States, where government assistance often gets caught up in political battles. Contraception has again become controversial this political season, though the United States remains a major donor.
The Gates Foundation and the British government are pressing the issue. About $4 billion is expected to be pledged at the London conference to provide family planning services to 120 million women from the world’s poorest countries over the next eight years.
“We hear time and again from women out in the field that they want the ability to plan their families,” said Gary Darmstadt, director of family health at the Gates Foundation, who spoke by telephone from London. “We felt we needed to shine a light back onto the importance of this issue and get the conversation going.”
Maternal deaths have declined dramatically since 1990, down by a third, according to the World Health Organization.
But about 16 percent of the world’s population lives in countries where fertility is still more than four children per woman, Mr. May said. The numbers of people are expected to more than triple in these places during this century, an issue that is urgent not only for their economies and environment, but also for the women themselves, who women’s rights advocates argue would benefit from more power to decide about bearing children.
The Lancet study, which the Gates Foundation financed, draws on maternal mortality and survey data from the United Nations and World Health Organization to estimate the annual number of maternal deaths in 172 countries and the share that could be preventable by the use of contraception.
Birth control reduces health risks, the researchers said, by delaying first pregnancies, which carry higher risks in very young women; cutting down on unsafe abortions, which account for 13 percent of all maternal deaths in developing countries; and controlling dangers associated with pregnancies that are too closely spaced.
The authors of the Lancet study, researchers at the Bloomberg School of Public Health at Johns Hopkins, found that the number of maternal deaths in those countries in 2008 would have nearly doubled without contraception. They acknowleged, however, that maternal mortality record-keeping is weak in developing countries, a limitation of the study. They also found that an additional 29 percent of the deaths could have been prevented if women who wanted birth control would have received it, a concept called unmet need that is estimated using surveys of mothers in developing countries.
Even so, simply providing contraceptives to people who are not using them and who say they want to avoid pregnancy might not be enough to actually do so, and Professor Nugent said the study’s conclusions might be optimistic.
The lack of birth control in poor countries has become an important issue for Melinda Gates, who argued in highly personal remarks in April that birth control should not be controversial, because it improves women’s lives.
“Somewhere along the way we got confused by our own conversation and we stopped trying to save these lives,” she said. She added: “We’re not talking about abortion. We’re not talking about population control. What I’m talking about is giving women the power to save their lives.”
C.I.A. Vaccine Ruse May Have Harmed the War on Polio
By DONALD G. McNEIL Jr., The New York Times, July 9, 2012
Did the killing of Osama bin Laden have an unintended victim: the global drive to eradicate polio?
In Pakistan, where polio has never been eliminated, the C.I.A.’s decision to send a vaccination team into the Bin Laden compound to gather information and DNA samples clearly hurt the national polio drive. The question is: How badly?
After the ruse by Dr. Shakil Afridi was revealed by a British newspaper a year ago, angry villagers, especially in the lawless tribal areas on the Afghan border, chased off legitimate vaccinators, accusing them of being spies.
And then, late last month, Taliban commanders in two districts banned polio vaccination teams, saying they could not operate until the United States ended its drone strikes. One cited Dr. Afridi, who is serving a 33-year sentence imposed by a tribal court, as an example of how the C.I.A. could use the campaign to cover espionage.
“It was a setback, no doubt,” conceded Dr. Elias Durry, the World Health Organization’s polio coordinator for Pakistan. “But unless it spreads or is a very longtime affair, the program is not going to be seriously affected.”
He and other leaders of the global war on polio say they have recovered from worse setbacks. The two districts, North and South Waziristan, are in sparsely populated mountains where transmission is less intense than in urban slums. Only about 278,000 children under age 5 — the vaccine target population — live there. By contrast, in northern Nigeria, where polio is being beaten after years of public resistance to the vaccine campaign, children number in the millions.
Also, Dr. Durry said, vaccinators reached 225,000 Waziristan youngsters in early June, before the ban. All will need several doses to be fully protected, but each dose buys time.
And, said Dr. Bruce Aylward, the W.H.O.’s chief of polio eradication, vaccination teams are posted at highway checkpoints, train stations and bus stations. They give drops to all the children they find.
The truth probably won’t emerge until the summer spike of polio cases tapers off in the fall. The virus likes hot weather, and the summer monsoons flood the sewage-choked gutters where it lurks.
Paralyzed children may also be found in neighboring countries with better surveillance, as they have been before just over the China and Tajikistan borders. Genetic testing will show whether the strains are Pakistan-based.
By contrast, if the eradicators are winning, local paralysis cases will slowly shrink to zero, as they have in India, a former epicenter which has not had a case in almost a year and a half. And the virus will no longer be found in sewage samples from Pakistani cities, as it is now.
Local anger was at its height last July, when The Guardian exposed the C.I.A. connection. It was confirmed by Defense Secretary Leon E. Panetta in January. Public outrage flared again in May after Dr. Afridi was sentenced. A coalition of aid groups protested to David Petraeus, the director of Central Intelligence.
“There could hardly have been a more stupid venture, and there was bound to be a backlash, especially for polio,” said Dr. Zulfiqar A. Bhutta, a vaccine specialist at Aga Khan University in Pakistan.
Dr. Bhutta, who also heads the government’s research ethics committee, said both Dr. Afridi and the C.I.A. could be “sued or worse.” To establish their credibility, Dr. Afridi’s teams vaccinated whole neighborhoods in Abbottabad without permission.
The setback was just one more in the endless war on polio, which was supposed to have been over by 2000. The fight is against the last 1 percent of cases. Paralysis cases worldwide have shrunk from 350,000 in the 1980s to about 600 now.
Victory gets tantalizingly close, and then recedes, forcing health authorities to appeal for another $1 billion, as they did recently in Geneva.
Nigeria had only 62 cases last year; Pakistan had 198. For every known case, there are about 200 carriers with no symptoms, experts believe. Thus far in Pakistan this year, only 22 confirmed cases have been found. But the virus is still in sewage samples, meaning people are still shedding it.
Paradoxically, Dr. Afridi was not offering polio vaccine, but hepatitis B vaccine.
Exactly why has not been elucidated, but there is a possible explanation: Hepatitis vaccine is injected, while polio vaccine is oral drops. If the objective was to gather DNA — which Dr. Afridi’s team apparently failed to do — it would be easy to aspirate a little blood into each needle.
Also, “hepatitis B could be kept under the radar,” Dr. Bhutta said. “For polio, there are too many players and agencies,” he said.
But polio is the vaccine with a long history of controversy among Muslims in many countries, so Pakistanis who were not familiar with the difference turned on polio vaccinators.
Rumors about polio vaccine abound: that it is a Western plot to sterilize girls, that it is unclean under Islamic law, that it contains the AIDS virus. The W.H.O. and the United Nations Fund for Children, which oversee the campaign, have asked Islamic scholars, including top Saudi clerics, to issue fatwas saying the vaccine is safe and should be given.
Five years ago in Afghanistan, when Taliban sympathizers beat vaccinators, Unicef and the W.H.O. successfully appealed to the Taliban leader Mullah Muhammad Omar for letters of protection their teams could carry.
Now they are trying to open talks with the local commanders in Pakistan.
“They know we don’t have any control over drone strikes,” Dr. Aylward said. “And I’ve yet to meet a parent who prefers a paralyzed kid. The Taliban commanders face these same issues — but they have grievances that need to be addressed.”
Vaccination would be more welcome if other services were added, like care to prevent deaths in childbirth, Dr. Bhutta said.
Pakistan’s polio failures started long before a Navy SEAL team killed Bin Laden. A “mafia” of local leaders was pocketing gasoline money, putting children on the payroll, fielding ghost teams and faking statistics, Dr. Durry said. More than 300,000 children lived in areas considered too dangerous to enter.
Then, in early 2011, stung by India’s success and with the W.H.O. threatening to issue travel warnings, the prime minister rolled out a new plan.
Officials were ordered to recruit mothers as vaccinators, and stipends for them went up. . Fundamentalist imams were lobbied to endorse the vaccine. “Knock on wood, the program is functioning well,” Dr. Durry said.
Some observers remain skeptical. Aamir Latif, Karachi bureau chief of the national Online News, said resistance remained strong in some tribal areas.
Heidi Larson, an anthropologist at the London School of Hygiene and Tropical Medicine who has produced a “vaccine confidence index” said trust dropped precipitously after the Guardian article. Unicef said its own surveys of 200,000 Pakistani households showed no such declines.
Vaccine refusals, they said, went up in only one province, Baluchistan, and then only after the drive got much more aggressive. “Mothers were saying, ‘My child got drops too many times,’ ” said Dr. Julie Hall, leader of Unicef’s polio program.
While the C.I.A. ruse hurt, Dr. Bhutta said, he still believes that Pakistan will eliminate polio.
“Tragic as it is, I’m confident resistance will die down,” he said. “The rational religious establishment is engaged now, and the lunatic fringe is just the lunatic fringe.”
In Dieting, Magic Isn’t a Substitute for Science
By GINA KOLATA, The New York Times, July 9, 2012
Is a calorie really just a calorie? Do calories from a soda have the same effect on your waistline as an equivalent number from an apple or a piece of chicken?
For decades the question has percolated among researchers — not to mention dieters. It gained new momentum with a study published last month in The Journal of the American Medical Association suggesting that after losing weight, people on a high-fat, high-protein diet burned more calories than those eating more carbohydrates.
We asked Dr. Jules Hirsch, emeritus professor and emeritus physician in chief at Rockefeller University, who has been researching obesity for nearly 60 years, about the state of the research. Dr. Hirsch, who receives no money from pharmaceutical companies or the diet industry, wrote some of the classic papers describing why it is so hard to lose weight and why it usually comes back.
The JAMA study has gotten a lot of attention. Should people stay on diets that are high in fat and protein if they want to keep the weight off?
What they did in that study is they took 21 people and fed them a diet that made them lose about 10 to 20 percent of their weight. Then, after their weight had leveled off, they put the subjects on one of three different maintenance diets. One is very, very low in carbohydrates and high in fat, essentially the Atkins diet. Another is the opposite — high in carbohydrates, low in fat. The third is in between. Then they measured total energy expenditure — in calories burned — and resting energy expenditure.
They report that people on the Atkins diet were burning off more calories. Ergo, the diet is a good thing. Such low-carbohydrate diets usually give a more rapid initial weight loss than diets with the same amount of calories but with more carbohydrates. But when carbohydrate levels are low in a diet and fat content is high, people lose water. That can confuse attempts to measure energy output. The usual measurement is calories per unit of lean body mass — the part of the body that is not made up of fat. When water is lost, lean body mass goes down, and so calories per unit of lean body mass go up. It’s just arithmetic. There is no hocus-pocus, no advantage to the dieters. Only water, no fat, has been lost.
The paper did not provide information to know how the calculations were done, but this is a likely explanation for the result.
So the whole thing might have been an illusion? All that happened was the people temporarily lost water on the high-protein diets?
Perhaps the most important illusion is the belief that a calorie is not a calorie but depends on how much carbohydrates a person eats. There is an inflexible law of physics — energy taken in must exactly equal the number of calories leaving the system when fat storage is unchanged. Calories leave the system when food is used to fuel the body. To lower fat content — reduce obesity — one must reduce calories taken in, or increase the output by increasing activity, or both. This is true whether calories come from pumpkins or peanuts or pâté de foie gras.
To believe otherwise is to believe we can find a really good perpetual motion machine to solve our energy problems. It won’t work, and neither will changing the source of calories permit us to disobey the laws of science.
Did you ever ask whether people respond differently to diets of different compositions?
Dr. Rudolph Leibel, now an obesity researcher at Columbia University, and I took people who were of normal weight and had them live in the hospital, where we diddled with the number of calories we fed them so we could keep their weights absolutely constant, which is no easy thing. This was done with liquid diets of exactly known calorie content.
We kept the number of calories constant, always giving them the amount that should keep them at precisely the same weight. But we wildly changed the proportions of fats and carbohydrates. Some had practically no carbohydrates, and some had practically no fat.
What happened? Did people unexpectedly gain or lose weight when they had the same amount of calories but in a diet of a different composition?
No. There was zero difference between high-fat and low-fat diets.
Why is it so hard for people to lose weight?
What your body does is to sense the amount of energy it has available for emergencies and for daily use. The stored energy is the total amount of adipose tissue in your body. We now know that there are jillions of hormones that are always measuring the amount of fat you have. Your body guides you to eat more or less because of this sensing mechanism.
But if we have such a sensing mechanism, why are people fatter now than they used to be?
This wonderful sensing mechanism involves genetics and environmental factors, and it gets set early in life. It is not clear how much of the setting is done before birth and how much is done by food or other influences early in life. There are many possibilities, but we just don’t know.
So for many people, something happened early in life to set their sensing mechanism to demand more fat on their bodies?
Yes.
What would you tell someone who wanted to lose weight?
I would have them eat a lower-calorie diet. They should eat whatever they normally eat, but eat less. You must carefully measure this. Eat as little as you can get away with, and try to exercise more.
There is no magic diet, or even a moderately preferred diet?
No. Some diets are better or worse for medical reasons, but not for weight control. People come up with new diets all the time — like, why not eat pistachios at midnight when the moon is full? We have gone through so many of these diet possibilities. And yet people are always coming up to me with another one.
By RICHARD A. FRIEDMAN, M.D., The New York Times, July 9, 2012
Americans with mental illness had good reason to celebrate when the Supreme Court upheld President Obama’s Affordable Care Act. The law promises to give them something they have never had before: near-universal health insurance, not just for their medical problems but for psychiatric disorders as well.
Until now, people with mental illness and substance disorders have faced stingy annual and lifetime caps on coverage, higher deductibles or simply no coverage at all.
This was supposed to be fixed in part by the Mental Health Parity and Addiction Equity Act of 2008, which mandated that psychiatric illness be covered just the same as other medical illnesses. But the law applied only to larger employers (50 or more workers) that offered a health plan with benefits for mental health and substance abuse. Since it did not mandate universal psychiatric benefits, it had a limited effect on the disparity between the treatment of psychiatric and nonpsychiatric medical diseases.
Now comes the Affordable Care Act combining parity with the individual mandate for health insurance. As Dr. Dilip V. Jeste, president of the American Psychiatric Association, told me, “This law has the potential to change the course of life for psychiatric patients for the better, and in that sense it is both humane and right.”
To get a sense of the magnitude of the potential benefit, consider that about half of Americans will experience a major psychiatric or substance disorder at some point, according to an authoritative 2005 survey. Yet because of the stigma surrounding mental illness, poor access to care and inadequate insurance coverage, only a fraction of those with mental illness receive treatment.
For example, surveys show that only about 50 percent of Americans with a mood disorder had psychiatric treatment in the past year — leaving the rest at high risk of suicide, to say nothing of the high cost to society in absenteeism and lost productivity. The World Health Organization ranks major depression as the world’s leading cause of disability.
One of the health care act’s pillars is to forbid the exclusion of people with pre-existing illness from medical coverage. By definition, a vast majority of adult Americans with a mental illness have a pre-existing disorder. Half of all serious psychiatric illnesses — including major depression, anxiety disorders and substance abuse — start by 14 years of age, and three-fourths are present by 25, according to the National Comorbidity Survey. These people have specifically been denied medical coverage by most commercial insurance companies — until now.
From an epidemiologic and public health perspective, the provision that young people can remain on their parents’ insurance until they turn 26 is a no-brainer: By this age, the bulk of psychiatric illness has already developed, and there is solid evidence that we can positively change the course of psychiatric illness by early treatment.
Mental disorders are chronic lifelong diseases, characterized by remission and relapse for those who respond to treatment, or persistent symptoms for those who do not. In schizophrenia, for example, relapse is common, even with the best treatment. It makes no sense to tell someone with this condition that his lifetime mental health benefit is just 60 days of inpatient hospitalization.
Psychiatric illness is treatable, but it is rarely curable; it may remit for a while, but it doesn’t go away. That is why the current limits on treatment are as irrational as they are cruel — the discriminatory hallmark of commercial medical insurance.
No more. The Affordable Care Act treats psychiatric illness like any other and removes obstacles to fair and rational treatment.
Older people with mental illness will also benefit, because the law will eventually fill in the notorious gap in Medicare drug coverage known as the “doughnut hole.” The law will immediately require drug companies to give a 50 percent discount on brand-name drugs and then gradually provide subsidies until the gap closes in 2020.
On the other hand, poor people with mental illness still have cause for concern. The new law would have expanded Medicaid to insure 17 million more Americans, but the Supreme Court ruled that states could decline to accept this expansion without losing their existing Medicaid funds. In states that opt out of the Medicaid expansion, poor people with mental illness may find themselves in a terrible predicament: They earn too much to qualify for Medicaid, yet not enough to get the federal subsidy to pay for insurance.
But on the whole, the Affordable Care Act is reason to cheer. Americans with mental illness finally have the prize that has eluded patients and clinicians for decades: the recognition that psychiatric illness should be on a par with all other medical disorders, and the near-universal mandate to make that happen.
Richard A. Friedman is a professor of psychiatry at Weill Cornell Medical College.
Study Says Meeting Contraception Needs Could Cut Maternal Deaths by a Third
By SABRINA TAVERNISE, The New York Times, July 9, 2012
A new study by researchers at Johns Hopkins University shows that fulfilling unmet contraception demand by women in developing countries could reduce global maternal mortality by nearly a third, a potentially great improvement for one of the world’s most vulnerable populations.
The study, published on Tuesday in The Lancet, a British science journal, comes ahead of a major family planning conference in London organized by the British government and the Bill and Melinda Gates Foundation that is an attempt to refocus attention on the issue. It has faded from the international agenda in recent years, overshadowed by efforts to combat AIDS and other infectious diseases, as well as by ideological battles.
The proportion of international population assistance funds that went to family planning fell to just 6 percent in 2008, down from 55 percent in 1995, while spending on H.I.V./AIDS represented 74 percent of the total in 2008, up from just 9 percent in 1995, according to Rachel Nugent, a professor of global health at the University of Washington, who cited figures from the United Nations Population Fund.
But population growth has continued to surge, with the United Nations estimating last year that the world’s population, long expected to stabilize, will instead keep growing. Population experts warn that developing countries, particularly those in sub-Saharan Africa, where fertility continues to be high and shortages of food and water are worsening, will face deteriorating conditions if family sizes do not shrink.
“Family planning kind of faded from the radar screen, and now it is coming back,” said John May, a visiting fellow at the Center for Global Development and author of a book, “World Population Policies: Their Origin, Evolution, and Impact.”
“There is a realization from many different places that population issues are not going away,” he said.
The issue of family planning is fraught in the United States, where government assistance often gets caught up in political battles. Contraception has again become controversial this political season, though the United States remains a major donor.
The Gates Foundation and the British government are pressing the issue. About $4 billion is expected to be pledged at the London conference to provide family planning services to 120 million women from the world’s poorest countries over the next eight years.
“We hear time and again from women out in the field that they want the ability to plan their families,” said Gary Darmstadt, director of family health at the Gates Foundation, who spoke by telephone from London. “We felt we needed to shine a light back onto the importance of this issue and get the conversation going.”
Maternal deaths have declined dramatically since 1990, down by a third, according to the World Health Organization.
But about 16 percent of the world’s population lives in countries where fertility is still more than four children per woman, Mr. May said. The numbers of people are expected to more than triple in these places during this century, an issue that is urgent not only for their economies and environment, but also for the women themselves, who women’s rights advocates argue would benefit from more power to decide about bearing children.
The Lancet study, which the Gates Foundation financed, draws on maternal mortality and survey data from the United Nations and World Health Organization to estimate the annual number of maternal deaths in 172 countries and the share that could be preventable by the use of contraception.
Birth control reduces health risks, the researchers said, by delaying first pregnancies, which carry higher risks in very young women; cutting down on unsafe abortions, which account for 13 percent of all maternal deaths in developing countries; and controlling dangers associated with pregnancies that are too closely spaced.
The authors of the Lancet study, researchers at the Bloomberg School of Public Health at Johns Hopkins, found that the number of maternal deaths in those countries in 2008 would have nearly doubled without contraception. They acknowleged, however, that maternal mortality record-keeping is weak in developing countries, a limitation of the study. They also found that an additional 29 percent of the deaths could have been prevented if women who wanted birth control would have received it, a concept called unmet need that is estimated using surveys of mothers in developing countries.
Even so, simply providing contraceptives to people who are not using them and who say they want to avoid pregnancy might not be enough to actually do so, and Professor Nugent said the study’s conclusions might be optimistic.
The lack of birth control in poor countries has become an important issue for Melinda Gates, who argued in highly personal remarks in April that birth control should not be controversial, because it improves women’s lives.
“Somewhere along the way we got confused by our own conversation and we stopped trying to save these lives,” she said. She added: “We’re not talking about abortion. We’re not talking about population control. What I’m talking about is giving women the power to save their lives.”
C.I.A. Vaccine Ruse May Have Harmed the War on Polio
By DONALD G. McNEIL Jr., The New York Times, July 9, 2012
Did the killing of Osama bin Laden have an unintended victim: the global drive to eradicate polio?
In Pakistan, where polio has never been eliminated, the C.I.A.’s decision to send a vaccination team into the Bin Laden compound to gather information and DNA samples clearly hurt the national polio drive. The question is: How badly?
After the ruse by Dr. Shakil Afridi was revealed by a British newspaper a year ago, angry villagers, especially in the lawless tribal areas on the Afghan border, chased off legitimate vaccinators, accusing them of being spies.
And then, late last month, Taliban commanders in two districts banned polio vaccination teams, saying they could not operate until the United States ended its drone strikes. One cited Dr. Afridi, who is serving a 33-year sentence imposed by a tribal court, as an example of how the C.I.A. could use the campaign to cover espionage.
“It was a setback, no doubt,” conceded Dr. Elias Durry, the World Health Organization’s polio coordinator for Pakistan. “But unless it spreads or is a very longtime affair, the program is not going to be seriously affected.”
He and other leaders of the global war on polio say they have recovered from worse setbacks. The two districts, North and South Waziristan, are in sparsely populated mountains where transmission is less intense than in urban slums. Only about 278,000 children under age 5 — the vaccine target population — live there. By contrast, in northern Nigeria, where polio is being beaten after years of public resistance to the vaccine campaign, children number in the millions.
Also, Dr. Durry said, vaccinators reached 225,000 Waziristan youngsters in early June, before the ban. All will need several doses to be fully protected, but each dose buys time.
And, said Dr. Bruce Aylward, the W.H.O.’s chief of polio eradication, vaccination teams are posted at highway checkpoints, train stations and bus stations. They give drops to all the children they find.
The truth probably won’t emerge until the summer spike of polio cases tapers off in the fall. The virus likes hot weather, and the summer monsoons flood the sewage-choked gutters where it lurks.
Paralyzed children may also be found in neighboring countries with better surveillance, as they have been before just over the China and Tajikistan borders. Genetic testing will show whether the strains are Pakistan-based.
By contrast, if the eradicators are winning, local paralysis cases will slowly shrink to zero, as they have in India, a former epicenter which has not had a case in almost a year and a half. And the virus will no longer be found in sewage samples from Pakistani cities, as it is now.
Local anger was at its height last July, when The Guardian exposed the C.I.A. connection. It was confirmed by Defense Secretary Leon E. Panetta in January. Public outrage flared again in May after Dr. Afridi was sentenced. A coalition of aid groups protested to David Petraeus, the director of Central Intelligence.
“There could hardly have been a more stupid venture, and there was bound to be a backlash, especially for polio,” said Dr. Zulfiqar A. Bhutta, a vaccine specialist at Aga Khan University in Pakistan.
Dr. Bhutta, who also heads the government’s research ethics committee, said both Dr. Afridi and the C.I.A. could be “sued or worse.” To establish their credibility, Dr. Afridi’s teams vaccinated whole neighborhoods in Abbottabad without permission.
The setback was just one more in the endless war on polio, which was supposed to have been over by 2000. The fight is against the last 1 percent of cases. Paralysis cases worldwide have shrunk from 350,000 in the 1980s to about 600 now.
Victory gets tantalizingly close, and then recedes, forcing health authorities to appeal for another $1 billion, as they did recently in Geneva.
Nigeria had only 62 cases last year; Pakistan had 198. For every known case, there are about 200 carriers with no symptoms, experts believe. Thus far in Pakistan this year, only 22 confirmed cases have been found. But the virus is still in sewage samples, meaning people are still shedding it.
Paradoxically, Dr. Afridi was not offering polio vaccine, but hepatitis B vaccine.
Exactly why has not been elucidated, but there is a possible explanation: Hepatitis vaccine is injected, while polio vaccine is oral drops. If the objective was to gather DNA — which Dr. Afridi’s team apparently failed to do — it would be easy to aspirate a little blood into each needle.
Also, “hepatitis B could be kept under the radar,” Dr. Bhutta said. “For polio, there are too many players and agencies,” he said.
But polio is the vaccine with a long history of controversy among Muslims in many countries, so Pakistanis who were not familiar with the difference turned on polio vaccinators.
Rumors about polio vaccine abound: that it is a Western plot to sterilize girls, that it is unclean under Islamic law, that it contains the AIDS virus. The W.H.O. and the United Nations Fund for Children, which oversee the campaign, have asked Islamic scholars, including top Saudi clerics, to issue fatwas saying the vaccine is safe and should be given.
Five years ago in Afghanistan, when Taliban sympathizers beat vaccinators, Unicef and the W.H.O. successfully appealed to the Taliban leader Mullah Muhammad Omar for letters of protection their teams could carry.
Now they are trying to open talks with the local commanders in Pakistan.
“They know we don’t have any control over drone strikes,” Dr. Aylward said. “And I’ve yet to meet a parent who prefers a paralyzed kid. The Taliban commanders face these same issues — but they have grievances that need to be addressed.”
Vaccination would be more welcome if other services were added, like care to prevent deaths in childbirth, Dr. Bhutta said.
Pakistan’s polio failures started long before a Navy SEAL team killed Bin Laden. A “mafia” of local leaders was pocketing gasoline money, putting children on the payroll, fielding ghost teams and faking statistics, Dr. Durry said. More than 300,000 children lived in areas considered too dangerous to enter.
Then, in early 2011, stung by India’s success and with the W.H.O. threatening to issue travel warnings, the prime minister rolled out a new plan.
Officials were ordered to recruit mothers as vaccinators, and stipends for them went up. . Fundamentalist imams were lobbied to endorse the vaccine. “Knock on wood, the program is functioning well,” Dr. Durry said.
Some observers remain skeptical. Aamir Latif, Karachi bureau chief of the national Online News, said resistance remained strong in some tribal areas.
Heidi Larson, an anthropologist at the London School of Hygiene and Tropical Medicine who has produced a “vaccine confidence index” said trust dropped precipitously after the Guardian article. Unicef said its own surveys of 200,000 Pakistani households showed no such declines.
Vaccine refusals, they said, went up in only one province, Baluchistan, and then only after the drive got much more aggressive. “Mothers were saying, ‘My child got drops too many times,’ ” said Dr. Julie Hall, leader of Unicef’s polio program.
While the C.I.A. ruse hurt, Dr. Bhutta said, he still believes that Pakistan will eliminate polio.
“Tragic as it is, I’m confident resistance will die down,” he said. “The rational religious establishment is engaged now, and the lunatic fringe is just the lunatic fringe.”
In Dieting, Magic Isn’t a Substitute for Science
By GINA KOLATA, The New York Times, July 9, 2012
Is a calorie really just a calorie? Do calories from a soda have the same effect on your waistline as an equivalent number from an apple or a piece of chicken?
For decades the question has percolated among researchers — not to mention dieters. It gained new momentum with a study published last month in The Journal of the American Medical Association suggesting that after losing weight, people on a high-fat, high-protein diet burned more calories than those eating more carbohydrates.
We asked Dr. Jules Hirsch, emeritus professor and emeritus physician in chief at Rockefeller University, who has been researching obesity for nearly 60 years, about the state of the research. Dr. Hirsch, who receives no money from pharmaceutical companies or the diet industry, wrote some of the classic papers describing why it is so hard to lose weight and why it usually comes back.
The JAMA study has gotten a lot of attention. Should people stay on diets that are high in fat and protein if they want to keep the weight off?
What they did in that study is they took 21 people and fed them a diet that made them lose about 10 to 20 percent of their weight. Then, after their weight had leveled off, they put the subjects on one of three different maintenance diets. One is very, very low in carbohydrates and high in fat, essentially the Atkins diet. Another is the opposite — high in carbohydrates, low in fat. The third is in between. Then they measured total energy expenditure — in calories burned — and resting energy expenditure.
They report that people on the Atkins diet were burning off more calories. Ergo, the diet is a good thing. Such low-carbohydrate diets usually give a more rapid initial weight loss than diets with the same amount of calories but with more carbohydrates. But when carbohydrate levels are low in a diet and fat content is high, people lose water. That can confuse attempts to measure energy output. The usual measurement is calories per unit of lean body mass — the part of the body that is not made up of fat. When water is lost, lean body mass goes down, and so calories per unit of lean body mass go up. It’s just arithmetic. There is no hocus-pocus, no advantage to the dieters. Only water, no fat, has been lost.
The paper did not provide information to know how the calculations were done, but this is a likely explanation for the result.
So the whole thing might have been an illusion? All that happened was the people temporarily lost water on the high-protein diets?
Perhaps the most important illusion is the belief that a calorie is not a calorie but depends on how much carbohydrates a person eats. There is an inflexible law of physics — energy taken in must exactly equal the number of calories leaving the system when fat storage is unchanged. Calories leave the system when food is used to fuel the body. To lower fat content — reduce obesity — one must reduce calories taken in, or increase the output by increasing activity, or both. This is true whether calories come from pumpkins or peanuts or pâté de foie gras.
To believe otherwise is to believe we can find a really good perpetual motion machine to solve our energy problems. It won’t work, and neither will changing the source of calories permit us to disobey the laws of science.
Did you ever ask whether people respond differently to diets of different compositions?
Dr. Rudolph Leibel, now an obesity researcher at Columbia University, and I took people who were of normal weight and had them live in the hospital, where we diddled with the number of calories we fed them so we could keep their weights absolutely constant, which is no easy thing. This was done with liquid diets of exactly known calorie content.
We kept the number of calories constant, always giving them the amount that should keep them at precisely the same weight. But we wildly changed the proportions of fats and carbohydrates. Some had practically no carbohydrates, and some had practically no fat.
What happened? Did people unexpectedly gain or lose weight when they had the same amount of calories but in a diet of a different composition?
No. There was zero difference between high-fat and low-fat diets.
Why is it so hard for people to lose weight?
What your body does is to sense the amount of energy it has available for emergencies and for daily use. The stored energy is the total amount of adipose tissue in your body. We now know that there are jillions of hormones that are always measuring the amount of fat you have. Your body guides you to eat more or less because of this sensing mechanism.
But if we have such a sensing mechanism, why are people fatter now than they used to be?
This wonderful sensing mechanism involves genetics and environmental factors, and it gets set early in life. It is not clear how much of the setting is done before birth and how much is done by food or other influences early in life. There are many possibilities, but we just don’t know.
So for many people, something happened early in life to set their sensing mechanism to demand more fat on their bodies?
Yes.
What would you tell someone who wanted to lose weight?
I would have them eat a lower-calorie diet. They should eat whatever they normally eat, but eat less. You must carefully measure this. Eat as little as you can get away with, and try to exercise more.
There is no magic diet, or even a moderately preferred diet?
No. Some diets are better or worse for medical reasons, but not for weight control. People come up with new diets all the time — like, why not eat pistachios at midnight when the moon is full? We have gone through so many of these diet possibilities. And yet people are always coming up to me with another one.
