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Rethinking Hormones, Again
By RONI RABIN, The New York Times, January 31, 2006
Candace Talmadge was determined to get through menopause without using hormones, and she tried just about every alternative treatment she could find, like soy tablets, herbs and acupuncture, a chiropractor and even an anti-anxiety medication.
Two months ago, Ms. Talmadge's doctor suggested that she consider hormone therapy, and she relented.
"There are always risks to any medication you take, whether it's traditional or nontraditional," said Ms. Talmadge, 51, an author from Lancaster, Tex. "But I've been going through hell. I think my doctor's attitude was, 'Do the benefits for you, right now, outweigh the risks?' "
Three and a half years after a landmark study stunned physicians by finding that hormone therapy had serious risks and did not prevent heart disease in postmenopausal women, many women continue to turn to hormones for relief. Many gynecologists continue to prescribe them as a first-line therapy for severe menopausal symptoms.
Debates over the study's findings remain heated, with doctors divided between those who believe in the power of hormone therapy to protect the heart and relieve menopausal symptoms and those who think that any heart benefits have been discredited.
Some researchers are testing a new theory, that hormone therapy is beneficial for the heart when it is initiated early, during a narrow "window of opportunity" around the time of menopause and before women develop an excessive buildup of atherosclerotic plaque.
A chief criticism of the hormone study, part of the national Women's Health Initiative, was that it included women much older than the average hormone user, who typically initiates therapy around the time of menopause. The average age of the participants in the study was 64. The average age of menopause is 51.4, and some studies suggest that women who initiate hormone therapy later may miss the chance to benefit from the treatment.
This month, a paper in The Journal of Women's Health added credence to that idea. It reported that women who started therapy soon after menopause reduced the risk of coronary heart disease 30 percent, but that the benefit appeared to diminish the longer women waited to initiate treatment. The paper, based on data from the Nurses' Health Study, the large observational trial that reported many years ago that estrogen protected women's hearts, suggested that timing the therapy was critical.
"We still don't have a final answer," said Dr. JoAnn Manson, the chief of preventive medicine at Brigham and Women's Hospital in Boston, an author of the new study and a principal investigator for the Women's Health Initiative.
The new report, she said, does not mean the findings of the health initiative are invalid, but that the picture is complex. Viewing hormone therapy as "good for all women or bad for all women is an oversimplification," she added.
Many doctors, however, have already made up their minds. "Personally, in my heart of hearts, I think there is a benefit," said Dr. Mary Jane Minkin, a clinical professor of obstetrics and gynecology at Yale. "However," Dr. Minkin said, "I'm politically incorrect if I say that."
Still, she said, the tenor of discussion about hormone therapy at the annual scientific meetings of the North American Menopause Society in the fall was substantially different from the scene in 2002, when the figures from the Women's Health Initiative set off a hormone panic.
"Three years ago, the message was, 'You're going to die if you don't stop taking this,' " said Dr. Minkin, who takes estrogen and is a paid speaker for drug companies that make the estrogen products she prescribes. At the meeting last fall, she said, the feeling was: "Gee, estrogen is pretty good stuff. If you need it for relief, you shouldn't be afraid to take it."
The Women's Health Initiative trials, among the largest randomized controlled clinical trials of hormone treatment, were carried out under the auspices of the National Heart, Lung and Blood Institute and other centers at the National Institutes of Health. One section included 16,608 postmenopausal women from 50 to 79 who were taking a popular combination of estrogen and progestin, which is a synthetic form of progesterone, or a placebo pill.
The trial was halted in 2002, when researchers concluded that after five years women who were taking the hormones were at increased risk for breast cancer, stroke and blood clots, and were not protected from heart disease. They were at significantly increased risk for heart attacks during the first year of treatment, but benefited from fewer fractures overall and initially appeared to have lower rates of colorectal cancer.
The other section included 10,739 women who had had hysterectomies and who were taking estrogen alone or a placebo. It was stopped prematurely in February 2004, when researchers concluded that after almost seven years the therapy increased the risk of stroke and clots in the leg and did not curb heart disease.
Women in the study who took estrogen alone actually developed fewer cases of heart disease and breast cancer. But the researchers said the differences were so slight that they might have been because of chance. The women on estrogen also benefited from fewer hip fractures.
Dr. Jacques Rossouw, project officer of the Women's Health Initiative, acknowledged that questions remained about the risks of hormone therapy for younger women who start treatment around menopause, but said the trials established that it should not be used to prevent cardiovascular disease in older women.
Dr. Rossouw noted that when the trials began in the 1990's the trend was for gynecologists to prescribe hormones to postmenopausal women of all ages for the express purpose of preventing heart disease. The Women's Health Initiative, he said, was intended to evaluate that practice.
"There's no evidence at this point — no good evidence — that hormone therapy prevents cardiovascular disease," he added. "We've established it doesn't work over all. There is a valid question about a subgroup of younger women. There's a zone of uncertainty there."
Dr. Rossouw said women who took estrogen alone faced fewer adverse side effects than those taking it in combination with progestin. That has led some experts to wonder whether the type of progesterone or the hormone formula in the trials may have been the real culprit.
Women who have not had hysterectomies have to take progesterone along with estrogen, because estrogen alone increases the risk of uterine cancer.
The Women's Health Initiative findings surprised many people in medicine because they flew in the face of the entrenched belief that estrogen protected postmenopausal women from heart disease. The findings were also at odds with the results of the Nurses' Health Study, which has followed more than 120,000 female nurses for several decades and which years ago found a correlation between estrogen treatment and a drastically reduced incidence of coronary heart disease.
The Women's Health Initiative was not the first large trial to report negative results about hormones and heart disease. The Heart and Estrogen-Progestin Replacement Study or HERS, had looked at whether combination hormone therapy would prevent a second heart attack and found that the risk actually increased in the first year of use.
Smaller clinical trials are under way to explore the "window of opportunity" theory, but they lack the health initiative's power of numbers, and they will track markers for heart disease, not heart attacks.
"What we're trying to do is reconcile why there is such a disconnect, or paradox, between the observational trials and the randomized controlled trials," said Dr. Isaac Schiff, chief of obstetrics and gynecology at Massachusetts General Hospital in Boston and chairman of a report on hormone therapy for the American College of Obstetricians and Gynecologists.
Simplified, the window of opportunity argument goes something like this: Most women do not develop heart disease until after menopause, because estrogen protects their blood vessels, keeping them smooth and free of plaque. But if women go without estrogen for a long period after menopause, they will develop atherosclerosis. At that point, estrogen may be harmful, because it increases the tendency to clot, raising the risk of a heart attack.
Even proponents concede that the idea is a hypothesis. "You can prevent the disease if it's not there yet, but you can't treat the disease with estrogen once it's there," said Dr. S. Mitchell Harman, director and president of the Kronos Longevity Research Institute in Phoenix. "That's our hypothesis. We haven't proven it."
The Kronos Early Estrogen Prevention Study, or Keeps, is one of two randomized placebo-controlled trials that will test the hypothesis. It will track markers of early atherosclerosis in 720 women initiating hormone therapy within three years of menopause. Another trial, sponsored by the National Institute of Aging, the Early vs. Late Intervention Trial With Estradiol, or Elite, will follow 504 postmenopausal women for an average of three years.
In addition, the investigators from the Women's Health Initiative have been tracking 1,000 women who were in their 50's when they enrolled in the estrogen-only trial. The research will measure their rates of coronary artery calcification.
Dr. Frederick Naftolin, chairman emeritus of obstetrics and gynecology and reproductive sciences at Yale and national co-principal investigator of the Keeps trial, said the findings of the Women's Health Initiative studies were counterintuitive.
"The relationship between the fall in estrogen and the rise in cardiovascular disease in women is incontrovertible," Dr. Naftolin said. "So why in the world would you not try to find out whether simply maintaining estrogen at the levels of reproductive life could be cardioprotective?"
On the other side, researchers say the cardioprotective theory has been discredited.
"Atherosclerosis starts well before the age of menopause," said Dr. Deborah Grady, a principal investigator in the HERS trial. "On top of that, why would you want a preventive intervention that has a lot of other side effects like blood clots? These people have a theory they don't want to give up on, no matter what."
Dr. Richard M. Fuchs, a cardiologist and clinical professor of medicine at Weill Medical College of Cornell University in New York, agreed.
"There is no good evidence that hormone therapy reduces the risk of heart disease, and there is reasonable evidence to say it increases heart disease and stroke, pulmonary embolism and breast cancer," Dr. Fuchs said. "My advice is all women should try to get off it."
The debate leaves women with severe menopausal symptoms in estrogen limbo. Hormone therapy continues to be considered the most effective treatment to relieve hot flashes, insomnia, night sweats and vaginal dryness. But the pills now come with an alarming warning, mandated by the Food and Drug Administration, about serious side effects.
Women are advised to take the lowest dose possible for the shortest period of time necessary. Some women find it hard to quit the hormones at any age, and women who have had their ovaries removed often take estrogen for decades.
There is no clear scientific evidence that lower doses of estrogen and progesterone are less harmful than the doses in the Women's Health Initiative studies.
Many women have quit hormones. One published study based on a nationally representative survey of 3,853 women older than 50 reported that hormone use dropped to 12 percent in the first half of 2004 from 28 percent in 2002. The number of estrogen prescriptions dispensed dropped to 24.7 million in the first eight months of 2005 from 45.2 million in the same period in 2002, according to IMS Health, a pharmaceutical information and consulting company.
Even women who have stopped taking hormones remain puzzled. Ronna Sussman, 64, of Greenwich Conn., quit hormones based on her doctor's advice after the health initiative results because her diabetes already increases her risk of heart disease. Years earlier, a doctor had advised to stay on hormones for the very same reason.
"It's like with coffee," Ms. Sussman said. "Today it's the best thing in the world for you. Five years ago, coffee was the worst thing. You don't know what to believe."
Even if researchers eventually find hormone therapy protective against heart disease, it may not be used again solely for that purpose. Dr. Wulf H. Utian, executive director of the North American Menopause Society, said:
"Twenty years ago, estrogen was the only game in town to consider for preventing cardiovascular disease in women, as well as for combating osteoporosis. Today, there's smoking cessation, dietary changes, antihypertensive drugs, diabetic agents. There's no way that estrogen is going to be as effective as those groups of drugs. It doesn't make sense."
HINTS OF DIASPORA Archaeologists found the remains of at least 180 people – European, Indian and African – near the ruins of a colonial church in Campeche, Mexico.
At Burial Site, Teeth Tell Tale of Slavery
By JOHN NOBLE WILFORD, The New York Times, January 31, 2006
While remodeling the central plaza in Campeche, a Mexican port city that dates back to colonial times, a construction crew stumbled on the ruins of an old church and its burial grounds. Researchers who were called in discovered the skeletal remains of at least 180 people, and four of those studied so far bear telling chemical traces that are in effect birth certificates.
The particular mix of strontium in the teeth of the four, the researchers concluded, showed that they were born and spent their early years in West Africa. Some of their teeth were filed and chipped to sharp edges in a decorative practice characteristic of Africa.
Because other evidence indicated that the cemetery was in use starting around 1550, the archaeologists believe they have found the earliest remains of African slaves brought to the New World.
In a report to be published in The American Journal of Physical Anthropology, the archaeology team led by T. Douglas Price of the University of Wisconsin concluded, "Thus these individuals are likely to be among the earliest representatives of the African diaspora in the Americas, substantially earlier than the subsequent, intensive slave trade in the 18th century."
Dr. Price said last week that a more precise dating would be attempted soon with radiocarbon analysis of the excavated bones. Maps and other records of Campeche, on the Yucatán Peninsula, indicate that the burial ground was used from the mid-16th century into the 17th. A pre-1550 medallion was found in a grave.
Other archaeologists and historians who were not involved in the research said they knew of no earlier skeletal remains of African-born slaves that had been found in the Americas. Dr. Price said that a colleague in the research, Vera Tiesler of the Autonomous University of the Yucatán, who is a historian of the colonial period, thought the slave burials occurred in the cemetery's first years. She directed the excavations.
The fact that the burials were found in ruins of a colonial church could mean "that they had some kind of status or were converted to Christianity," said Richard H. Steckel, a professor at Ohio State University who studies health and nutrition of pre-Columbian American Indians.
Although ample records attest to the presence of African slaves in the New World at this time, Dr. Steckel, who had no part in the discovery, said: "Much less is known about their health. So, if researchers can document the stature, degenerative joint disease, dental decay, trauma and so forth, then it could be quite interesting."
William D. Phillips, a University of Minnesota professor who is a historian of Old World and New World slavery and who was not involved in this research, said it was not surprising to find African remains in the Yucatán at this time.
Dr. Phillips and other historians said colonial Campeche was an important Spanish gateway to the Americas and would have had substantial traffic in slaves. Within a few years of the first voyage of Columbus, in 1492, they noted, Africans were shipped to the Caribbean and then the mainland. Their numbers increased steadily as sugar plantations were established by the Spanish on the islands, then in Mexico and coastal Peru.
"Some experts suggest that more Africans than Europeans went to Spanish America in the period up to 1600," Dr. Phillips said.
Herbert S. Klein, a historian of Latin America at Stanford and an author of studies on slavery in the region, said, "The slave trade was in full development by the mid-16th century and would have brought African slaves to Mexico, though the primary work force remained Amerindians."
In time, as European diseases reduced Indian populations, the demand for labor from Africa increased. Over a span of four centuries after Columbus, it is estimated, as many as 12 million Africans were placed in bondage and brought across the Atlantic to ports throughout the Americas.
If any older slave burials have been excavated, Dr. Klein has not seen reports of them in the professional literature, he said. The most likely places for any earlier finds, he added, would be in Santo Domingo in the Dominican Republic or in Cuba, where African slaves were first introduced.
The site in Campeche was discovered in 2000. As researchers examined the remains, they determined that some belonged to Europeans and Indians. Then they were drawn to a few with the distinctive dental mutilations, their first clue that these were probably people born in Africa.
Upon further examination, James Burton, the third member of the team, said four of the individuals "were like something we'd never seen."
Dr. Burton and Dr. Price, who are colleagues at the Laboratory of Archaeological Chemistry at Wisconsin, and Dr. Tiesler embarked on the strontium studies, supported by the National Science Foundation. Such strontium research, often applied in physical anthropology, is a part of their broader investigation of social mobility — where people were born and how near or far from home they eventually settled — in ancient Mexico and Central America, known as Mesoamerica.
At least 10 skeletons appeared to be African, the researchers reported, and four had teeth with "unusually high" combinations of two isotopes of the element strontium. An isotope is a slight variation of a chemical element, with a different mass but otherwise the same as the basic element.
In this case, the ratios of the isotopes strontium 87 and strontium 86 were consistent with those in the teeth and bones of people who were born and grew up in West Africa. A comparison with strontium measurements of people born in Mesoamerica showed no similarities with the four specimens.
These strontium signatures enter the body through the food chain as nutrients pass from bedrock through soil and water to plants and animals. Different geologies yield different isotopic strontium ratios. This is locked permanently in tooth enamel from birth and infancy, an important tool to trace the migration of individuals.
The researchers said the findings showed that these four appeared to be original migrants to the New World, not their children. Five other individuals thought to be African slaves had isotope ratios expected for people born around Campeche, hence from a later generation.
"In a community occupied for several generations, only a relatively small proportion of the individuals in a cemetery would be expected to come from the first generation," they wrote in the report.
The four individuals, the researchers said, appeared to have come from the area around Elmina, Ghana, a major West African port in the slave trade.
This was also the region of origin of some of the slaves found in the 17th- and 18th-century African Burial Ground, uncovered in 1991 in Lower Manhattan.
Where Science and Public Policy Intersect, Researchers Offer a Short Lesson on Basics
By CORNELIA DEAN, The New York Times, January 31, 2006
WASHINGTON, Jan. 27 — Congress took a science class this month, and some experts would like to make it a regular part of the curriculum.
"It's not that we are inattentive; it's just that we have the war on terrorism, the Iraq initiative, Social Security, the budget, the list goes on and on," said Representative Sherwood Boehlert, a New York Republican and head of the House Science Committee.
Beyond that, Mr. Boehlert said, "everyone boasts that they are for science-based policy until the scientific consensus leads to an unwelcome conclusion, and then they want to go to Plan B."
So now, when scientific questions pervade legislation on issues like climate change and stem cell research, there is growing concern that Congressional misunderstanding can produce misguided policy.
To fight such misunderstanding, Mr. Boehlert and others sponsored the Jan. 23 briefing, organized by the Center for Health and the Global Environment at Harvard.
Capitol Hill has briefings by the dozen every year in which industry, academic and activist groups address diverse topics related to science.
Some criticize these briefings as little more than showboating. But Mr. Boehlert, like many others, thinks they are "absolutely" useful. And the briefing was unusual in that its subject was not avian flu, the budget for NASA or any other relatively narrow issue, but rather "how science works."
And some on Capitol Hill, notably Representative Rush Holt, a New Jersey Democrat and a physicist, say Congress should address the lack of knowledge and understanding of science by establishing something similar to the Office of Technology Assessment, an agency that advised Congress until it was abolished after Republicans won control of the House in 1994. Prospects for that are uncertain.
Not everyone thought defining science was even possible, in such a short session. "It makes me extremely tired that they are going to do this again," said Sheila Jasanoff, a professor of science and technology studies at the Kennedy School of Government at Harvard, who has written widely on how science policy is made. "There is no easily graspable definition."
Robert Ferguson, who runs the Center for Science and Public Policy, which also presents briefings to Congress, argued that one of the speakers, Donald Kennedy, editor of the journal Science, had himself politicized the field in editorials on the dangers of climate change, marking him as having political motives.
He sent critiques of Dr. Kennedy by e-mail to prospective members of the audience so they could "decide if attending the event is worth your time."
But the briefing's subject apparently struck a chord. More than 100 committee staff members, Congressional aides and at least one senator, Jeff Bingaman, Democrat of New Mexico, crammed into a basement meeting room. With all of the seats filled, people leaned on walls, sat on the floor and spilled out into the hall.
Dr. Eric Chivian, who directs the Harvard center, said he got the idea for the briefing while following the debate over intelligent design and noticing what he called widespread misunderstanding about science.
"I suspected the same was true in the Congress," Dr. Chivian said, adding that he thought it would be useful to consider "how science should advise policy makers in the most effective way."
Dr. Chivian invited Dr. Kennedy and Harvey V. Fineberg, president of the Institute of Medicine, the medical arm of the National Academy of Sciences, to speak.
The worth of any scientific finding, Dr. Kennedy told the crowd, is not the prominence of the researchers responsible, the prestige of their institutions or the authority of their funding agencies, but whether other researchers achieve the same results.
Dr. Kennedy did not refer explicitly to a scandal that is roiling science, and Science — the discovery that highly praised cloning experiments in South Korea survived the magazine's peer review process to win publication, only to be declared fraudulent. But he said: "Peer review is not a process that guarantees truth. If it were, no one would ever repeat experiments."
Replication, he said, "is the ultimate test of truth in science."
Dr. Fineberg spoke of the way scientific knowledge was turned into information useful to society, a process that he said the National Academy encouraged through its regular production of reports on topics as diverse as national security and arsenic in drinking water.
The academy's reports are influential, he said, because of its reputation for integrity, because of its avoidance of conflict of interest, because researchers who produce its findings are volunteers and because "nothing is kept back."
Some of the attendees were participants in another effort to bring scientific expertise to the Hill, a fellowship program run by the American Association for the Advancement of Science, the nation's largest scientific organization and the publisher of Science. The program places scientists with doctorates in Congressional offices and government agencies.
The fellows pressed the speakers on their proper role in policy making, the difference between scientific assessments and value judgments, the difficulties of dealing with low-probability-high-consequence problems like bird flu, and the necessity of scientists' making themselves heard in matters of policy, something Dr. Fineberg called "a civic obligation."
Chris Weaver, who has a doctorate in atmospheric science and is working as a program fellow at the Environmental Protection Agency, said the briefing was "the kind of thing we should be having more of."
But outside of forums like the House Science Committee, whose "excellent" staff has grown in recent years, Mr. Boehlert said, conversations like this are few.
"You'll find the odd congressman like Al Gore who will sit down with the boffins and say, explain it to me," said Daniel S. Greenberg, author of "Science, Money and Politics" (2001), and for many years the editor of the newsletter Science and Government Report. "But if you look at the voting, it's mostly along party lines." He added, "I don't think many congressmen could answer 10 basic questions" about science.
Mr. Holt, who has a doctorate in physics and was assistant director of the plasma physics laboratory at Princeton when he ran for Congress in 1998, jokes that he and Representative Vernon J. Ehlers, a Michigan Republican and also a physicist, are a two-man bipartisan physics caucus.
"Depending on how you count it, there's somewhere between a small handful and a large handful who have science backgrounds" in Congress, he said.
Mr. Holt has introduced legislation to establish what he calls the Center for Science and Technology Assessment. It would be a kind of successor to the O.T.A. and would be housed in the Government Accountability Office.
"I think there is a widespread if not total recognition that we need better technological assessment and advice to Congress," Mr. Holt said. "We are trying to find the right mechanism."
But not everyone agrees that such an agency would make a big difference. It is true that the Office of Technology Assessment is "much mourned," Mr. Greenberg and others say.
"If you could bring it back or establish something else to deal with these problems, it would be useful," he added.
But he blames politics for what he sees as a Congressional failure to take good action on science issues. "I don't think the worsening of the product of the Capitol — and it certainly has gotten worse — is attributable to the absence" of the office, he said.
Others say the National Academy of Sciences or the Congressional Research Service can provide information to lawmakers if they request it.
Mr. Boehlert said the prospects for Mr. Holt's proposal appeared dim. "I am for it," he said, "but in the present climate, when we are struggling to make ends meet, it's unlikely we are going to expand a support staff operation for the Congress. It's not a high priority."
That makes briefings like the one this month all the more important, Mr. Boehlert said, especially because scientists like Dr. Kennedy, a biologist by training, and Dr. Fineberg, a medical doctor, were on hand to make the case for science.
After the briefing ended, attendees crowded around the speakers, peppering them with more questions and comments. One of the fellows had a suggestion for Dr. Chivian.
"Do this again," she said, "but next time get a larger room."
Really? The Claim: Baby Deliveries Are in Sync With the Moon
By ANAHAD O'CONNOR, The New York Times, January 31, 2006
THE FACTS Is there any link between childbirth and the lunar cycle? Many ancient cultures looked upon the moon as a sign of fertility, and since Roman times people have blamed full moons for all sorts of human behaviors, hence the word lunacy, from the Latin word for moon.
But as mysterious and alluring as the link between full moons and births may sound, scientific studies suggest that it is more romance than reality.
Over the years, more than a dozen different studies in several countries have looked for a connection, and almost all have found none.
One of the most recent, published last year in The American Journal of Obstetrics and Gynecology, examined about 564,000 births across 62 lunar cycles in North Carolina between 1997 and 2001.
The lunar cycle, the study found, had no predictable influence on deliveries or birth complications at all.
Another study, which appeared much earlier in The New England Journal of Medicine, looked at thousands of births across 51 lunar cycles. It also reached that conclusion.
But scientists have found several factors that do affect workloads in maternity wards.
Most births occur in the summer and in September and October, said Kathleen Capitulo, the director of the Kravis Children's Hospital and Women's Center at Mount Sinai Medical Center.
There are also weekly cycles. Most childbirths occur later in the week, she said, because many women prefer having labor induced before the weekend, full moon or not.
THE BOTTOM LINE Studies show that workloads in maternity wards are not affected by the full moon.
The Tampa VAMC Polytrauma Rehabilitation Center in Tampa, Fla., is one of four special rehabilitation centers created to treat the most severely wounded soldiers. One of the soldiers, Sgt. Antwain Vaughn, was visited by his 1-month-old daughter, Liyah.
The Wounded: A New Kind of Care in a New Era of Casualties
By ERIK ECKHOLM, The New York Times, January 31, 2006
TAMPA, Fla. — Morning rounds at the Tampa veterans hospital, and a phalanx of specialists stands at Joshua Cooley's door.
Inert in his bed, the 29-year-old Marine reservist is a survivor of an Iraq car bombing and a fearsome scramble of wounds: profound brain injury, arm and facial fractures, third-degree burns, tenacious infections of the central nervous system. Each doctor, six in all on a recent day, is here to monitor some aspect of his care.
As they cluster at the threshold, one gently closes the door — not to shield their patient from bad news, but to avoid overstimulating the nervous system of a man whose frontal lobe has been ripped by shrapnel. Not that the news right now is good: Corporal Cooley is spiking a fever, presumably because of his newest problem, blood clots in his left leg.
The doctors sort through a calculus of competing interests. Should they prescribe a blood thinner to dissolve the dangerous clots, even though that could cause more bleeding in the brain? Or should they just wait? At this point, the doctors decide, the clots pose the greater risk.
Thousands of miles from the battlefield, intricate medical choices have become routine here, at one of four special rehabilitation centers the government created last year to treat the war's most catastrophically wounded troops.
"These soldiers were kept alive," said Dr. Steven G. Scott, the Tampa center's director. "Now it's up to us to try and give them some meaningful life."
With their concentrated batteries of specialists and therapists, these centers are developing a new model of advanced care, a response to the distinctive medical conundrum of the Iraq war. With better battlefield care and protective gear, the military is saving more of the wounded, yet the insurgents' heavy reliance on car bombs and buried explosives means the survivors are more damaged — and damaged in more different ways — than ever before.
To describe the maimed survivors of this ugly new war, a graceless new word, polytrauma, has entered the medical lexicon. Each soldier arriving at Tampa's Polytrauma Rehabilitation Center, inside the giant veterans hospital, brings a whole world of injury. The typical patient, Dr. Scott said, has head injuries, vision and hearing loss, nerve damage, multiple bone fractures, unhealed body wounds, infections and emotional or behavioral problems. Some have severed limbs or spinal cords.
"Two years ago we started seeing injured soldiers coming back of a different nature," recalled Dr. Scott, who is also the hospital's chief of physical medicine and rehabilitation. Then last spring, with a Congressional mandate, the Department of Veterans Affairs created the four new centers, formalizing changes that a few top veterans hospitals were already starting to make.
After weeks or months of intensive care in military hospitals, more than 215 soldiers and a few more each week — still a tiny fraction of the roughly 16,000 soldiers who have been wounded in Iraq — have been sent here or to the other centers, inside V.A. hospitals in California, Minnesota and Virginia.
The surge in complex casualties, doctors found, required major reorganizing, enabling them to focus extraordinary medical and therapeutic expertise on each patient and to offer counseling, housing and other aid to their often shellshocked wives, children and parents.
"In the outside world you might have two or three consultants seeing a patient," said Dr. Andrew Koon, a specialist in internal medicine who was checking laboratory results on a portable computer during bedside rounds. "Here it's not unusual to have 10 specialists on board."
The multiple wounds have required medical balancing acts and unusual cooperation across departments. One quadriplegic patient was so weakened by recurring infections that doctors had to wait a year before removing shrapnel from his neck. In other cases, the risk of new infection has delayed treatment of the spasms that some paralyzed patients suffer, which can require an implanted pump to inject medicine into the spinal column.
Of some 90 soldiers with extreme injuries who were treated in Tampa over the last year only one has died, of a rare form of meningitis. The drama here is more excruciatingly drawn out: Over months and months of painstaking physical and psychological therapy, the patients and their families start learning the boundaries of their future lives.
Quiet Struggles
The medical challenges are often persistent and daunting, but the real focus of the new centers is rehabilitation. Even as doctors battle drug-resistant bacteria blown into wounds with Iraqi dirt, patients start relearning to talk and focus their thoughts, to walk and run or maneuver a wheelchair. Some go home in almost normal shape; for others, simply swallowing is a milestone.
To spend several recent days here is to witness a panorama of quiet struggles. A young man with brain and nerve damage slowly fits big round pegs into big round holes. Another beams after jogging a full minute for the first time since his injury, but cannot voice his mix of pride and impatience because shrapnel destroyed the language center in his brain.
A quadriplegic is lifted by a giant sling from his bed to a high-tech wheelchair, which he has learned to drive with a mouthpiece.
Progress on these wards can be measured in agonizing increments.
Corporal Cooley, a 6-foot 6-inch former deputy sheriff, arrived in Tampa on Sept. 29 after more than two months at the Bethesda Naval Hospital outside Washington. His doctors and relatives were encouraged when, after another couple of months, he wriggled his fingers and feet, and answered yes-no questions with blinks.
"They got him to make noises the other day," offered his wife, Christina. "He's doing really well." At "rehab rounds" one recent day, assorted therapists took up Corporal Cooley's case, reporting on small steps forward and compromises along the way.
The speech therapist said he was responding to questions with blinks about 30 percent of the time when she was alone with him, but less if distracted. She described her gingerly efforts to train him to swallow, using thin pudding, apple sauce and ice chips.
The respiratory therapist said his tracheotomy had to be changed to a larger, cuffed device that would allow them to expand his lower right lung.
The speech therapist groaned, "That will make it harder to swallow." They agreed that the lung had to take priority, but the speech therapist added, "Let's get rid of that cuffed trach as soon as possible."
Brain injuries — the signature wounds inflicted by the blast waves and flying shrapnel of explosives — are pervasive, and they tend to dictate the arc of care.
"It's really the brain injury that directs how we approach other impairments," Dr. Barbara Sigford, V.A.'s national director of physical medicine and rehabilitation and chief of the Minneapolis polytrauma center, said in a telephone interview. "Many types of rehab rely on intact thinking, learning and memory skills."
Using advanced prosthetic limbs, for example, requires control of specific muscles; patients without that capacity must use simpler models. Blind people are normally taught to navigate using their memory of the environment; if memory is spotty, they must find other ways.
In the recreational therapy room in Tampa on a recent day, several men are being led through a round of Uno, a card game that involves matching numbers and colors. Some play well. Some fumble trying to pick up cards. One rocks in frustration at his inability to summon the word "blue."
Sgt. Antwain Vaughn, 31, an Army combat engineer who took a roadside blast in the face on Aug. 31, arrives late and in a wheelchair. A padded helmet covers a large indentation where his shattered skull will receive a metal plate.
Sergeant Vaughn came to Tampa after two months on a ventilator and feeding tube. In addition to brain damage, facial fractures, pulmonary problems, blood clots and infections, he lost an eye and has trouble with complex tasks, something the card game could help.
Here he has learned to swallow and eat and in daily therapy, when he is feeling up to it, he is working to reclaim a life. But this time, he will not join the game. "My head's hurting a lot," he quietly tells the group.
Head injuries have also left some soldiers in a peculiar psychological box. Before Iraq, most head injuries at the Tampa hospital involved car accidents, said Dr. Rodney D. Vanderploeg, the chief of neuropsychology. Though it may seem counterintuitive, soldiers with penetrating brain injuries, in which a fragment crashed through their skulls, are far more likely to remember the attack and its bloody aftermath, perhaps including the deaths of friends, he said.
These memories often cause great psychological stress. But psychotherapy becomes especially difficult if injury has impaired a patient's insight and understanding.
Making Progress
In the hallways, the banter tends to be upbeat, as perhaps it needs to be for patients and staff. A patient shows off his stair-climbing wheelchair. Others compare the merits of prosthetic leg models. Nearly every patient vows, not always realistically, that he will get back on his feet and more.
"The way I see it, if I get able to walk a little bit, then eventually I'm going to walk a lot," said Specialist Charles Mays, 31, who was left with multiple fractures and partial paralysis of his legs after being blasted out of his Humvee by a vertically buried rocket south of Baghdad.
Sometimes the hallways bring success stories like Specialist Nicholas Boutin, who was slowly walking on his own to speech therapy in a hockey helmet, apparently not at all self-conscious about the red pit where an artificial eye will be implanted or about the large dent where a piece of skull will be replaced.
Specialist Boutin, 21, had arrived in Tampa just five weeks before, mute and hardly able to swallow, his right arm and leg almost useless. During a midnight patrol in a village near Samarra, an insurgent dropped a grenade into his Bradley fighting vehicle. Fragments sprayed into his face and the left side of his brain, leaving him with Broca's aphasia — able to comprehend but not to speak.
He weathered fungal infections, facial pain where nerves were damaged and the destruction of his pituitary gland and a maxillary sinus, the kind of internal wound that can torment a person for life.
But now, after hard hours each day in therapy, he can jog briefly and write messages with his right hand. As speech therapists coax the right side of his brain to take over lost functions from the left, he has begun to make one-word responses and spontaneously utter a few words at a time. Soon he will head home to Georgia for continued therapy.
"Yes," he uttered instantly when asked if he felt he was progressing. Determination gleamed from his remaining eye.
Behind closed doors, though, bravado sometimes gives way to depression, explosive anger, survivors' guilt. Some patients sit quietly with glum faces or obsess endlessly about their buddies and time in Iraq.
As much as the nurses are often buoyed by their patients' progress, they say the relentless intensity of the work can sometimes bring them to tears. They spend as much time interacting with stressed-out relatives as with the patients.
"Relatives take out their frustrations on the nurses," said Laureen G. Doloresco, assistant nursing chief. "It's also hard on the nurses because of the youth of the patients. Many of them have sons the same age."
Support Systems
At the bedsides of many of these young men are their equally young wives, whose lives have also been wrenched onto unexpected paths.
Before he was sent to Iraq last Jan. 1, Corporal Cooley and his wife were partners on the vice/narcotics squad of a sheriff's department in central Florida. They married just before his deployment.
Soon after the car bombing on July 5, she and her husband's parents were summoned to the American military hospital in Landstuhl, Germany, and warned to expect the worst.
After the car bomb detonated, near the town of Hit, Corporal Cooley had been pulled from his burning amtrack, an armored vehicle, unconscious and with a gaping hole in his head. The medics had at first refused to load him onto the evacuation helicopter, Christina Cooley later learned. They changed their minds when they heard a moan.
Ms. Cooley recalled telling doctors that they were showing her the wrong patient, that this bloated figure was not her husband. She was convinced only after she saw his tattoos.
She also saw, though, that he was breathing on his own. Days later, he was flown to the Bethesda Naval Hospital, and for two months, his wife and the in-laws she still barely knew shared a hotel room and spent their days around Corporal Cooley's bed in intensive care.
Here in Tampa, despite continued medical setbacks like the blood clots, attention was turning to his potential for physical and mental recovery.
So far, he had been put in a chair for a few hours a day and strapped into a "tilt board" at a 45-degree angle for 10 minutes at a time, to forestall the drops in blood pressure that occur when long-prone patients raise up.
His wife finds hope where she can.
Corporal Cooley often stares vacantly, she said, and "you don't know if he's there." But one day when she asked him, "Who's my hero?" he pointed a finger toward himself.
Their home county, outside Tampa, has raised money that she plans to use on an accessible house.
"I hope he'll walk through the door of that house," she said. "If not, I'll take him as a vegetable. I'll take care of him the rest of my life. I love that man to death."
Overhearing her, Dr. Scott, the center's director, marshaled his characteristic optimism. "He can already move both legs," he said. "It's possible he can be rehabbed to walk. How far he'll go we just don't know."
The polytrauma centers themselves remain works in progress, sharing lessons with one another and with the major military hospitals by videophone, and pushing scientific inquiry into the myriad, often invisible effects of explosive blasts.
The Department of Veterans Affairs says it has not calculated the cost of establishing the centers, bolstering their staffs and treating patients so long and intensively. The Tampa hospital's director, Forest Farley Jr., said that here alone, it was "several millions of dollars."
Though the average stay in polytrauma centers is 40 days, many patients remain for months and some for more than a year. In the end, a few must go to nursing homes, but most go home, where they receive continued care at less-specialized veterans hospitals, with oversight from the centers. Some require round-the-clock home aides and therapists and costly equipment, paid for by the government on top of monthly disability payments. Even so, wives or parents often must give up their jobs.
For the worst off, the ongoing annual costs — largely hidden costs of this war — can easily be several hundred thousand dollars or more.
"We expect to follow these patients for the rest of their lives," Dr. Scott said. "But I have a great deal of concern about our country's long-term commitment to these individuals. Will the resources be there over time?"
By RONI RABIN, The New York Times, January 31, 2006
Candace Talmadge was determined to get through menopause without using hormones, and she tried just about every alternative treatment she could find, like soy tablets, herbs and acupuncture, a chiropractor and even an anti-anxiety medication.
Two months ago, Ms. Talmadge's doctor suggested that she consider hormone therapy, and she relented.
"There are always risks to any medication you take, whether it's traditional or nontraditional," said Ms. Talmadge, 51, an author from Lancaster, Tex. "But I've been going through hell. I think my doctor's attitude was, 'Do the benefits for you, right now, outweigh the risks?' "
Three and a half years after a landmark study stunned physicians by finding that hormone therapy had serious risks and did not prevent heart disease in postmenopausal women, many women continue to turn to hormones for relief. Many gynecologists continue to prescribe them as a first-line therapy for severe menopausal symptoms.
Debates over the study's findings remain heated, with doctors divided between those who believe in the power of hormone therapy to protect the heart and relieve menopausal symptoms and those who think that any heart benefits have been discredited.
Some researchers are testing a new theory, that hormone therapy is beneficial for the heart when it is initiated early, during a narrow "window of opportunity" around the time of menopause and before women develop an excessive buildup of atherosclerotic plaque.
A chief criticism of the hormone study, part of the national Women's Health Initiative, was that it included women much older than the average hormone user, who typically initiates therapy around the time of menopause. The average age of the participants in the study was 64. The average age of menopause is 51.4, and some studies suggest that women who initiate hormone therapy later may miss the chance to benefit from the treatment.
This month, a paper in The Journal of Women's Health added credence to that idea. It reported that women who started therapy soon after menopause reduced the risk of coronary heart disease 30 percent, but that the benefit appeared to diminish the longer women waited to initiate treatment. The paper, based on data from the Nurses' Health Study, the large observational trial that reported many years ago that estrogen protected women's hearts, suggested that timing the therapy was critical.
"We still don't have a final answer," said Dr. JoAnn Manson, the chief of preventive medicine at Brigham and Women's Hospital in Boston, an author of the new study and a principal investigator for the Women's Health Initiative.
The new report, she said, does not mean the findings of the health initiative are invalid, but that the picture is complex. Viewing hormone therapy as "good for all women or bad for all women is an oversimplification," she added.
Many doctors, however, have already made up their minds. "Personally, in my heart of hearts, I think there is a benefit," said Dr. Mary Jane Minkin, a clinical professor of obstetrics and gynecology at Yale. "However," Dr. Minkin said, "I'm politically incorrect if I say that."
Still, she said, the tenor of discussion about hormone therapy at the annual scientific meetings of the North American Menopause Society in the fall was substantially different from the scene in 2002, when the figures from the Women's Health Initiative set off a hormone panic.
"Three years ago, the message was, 'You're going to die if you don't stop taking this,' " said Dr. Minkin, who takes estrogen and is a paid speaker for drug companies that make the estrogen products she prescribes. At the meeting last fall, she said, the feeling was: "Gee, estrogen is pretty good stuff. If you need it for relief, you shouldn't be afraid to take it."
The Women's Health Initiative trials, among the largest randomized controlled clinical trials of hormone treatment, were carried out under the auspices of the National Heart, Lung and Blood Institute and other centers at the National Institutes of Health. One section included 16,608 postmenopausal women from 50 to 79 who were taking a popular combination of estrogen and progestin, which is a synthetic form of progesterone, or a placebo pill.
The trial was halted in 2002, when researchers concluded that after five years women who were taking the hormones were at increased risk for breast cancer, stroke and blood clots, and were not protected from heart disease. They were at significantly increased risk for heart attacks during the first year of treatment, but benefited from fewer fractures overall and initially appeared to have lower rates of colorectal cancer.
The other section included 10,739 women who had had hysterectomies and who were taking estrogen alone or a placebo. It was stopped prematurely in February 2004, when researchers concluded that after almost seven years the therapy increased the risk of stroke and clots in the leg and did not curb heart disease.
Women in the study who took estrogen alone actually developed fewer cases of heart disease and breast cancer. But the researchers said the differences were so slight that they might have been because of chance. The women on estrogen also benefited from fewer hip fractures.
Dr. Jacques Rossouw, project officer of the Women's Health Initiative, acknowledged that questions remained about the risks of hormone therapy for younger women who start treatment around menopause, but said the trials established that it should not be used to prevent cardiovascular disease in older women.
Dr. Rossouw noted that when the trials began in the 1990's the trend was for gynecologists to prescribe hormones to postmenopausal women of all ages for the express purpose of preventing heart disease. The Women's Health Initiative, he said, was intended to evaluate that practice.
"There's no evidence at this point — no good evidence — that hormone therapy prevents cardiovascular disease," he added. "We've established it doesn't work over all. There is a valid question about a subgroup of younger women. There's a zone of uncertainty there."
Dr. Rossouw said women who took estrogen alone faced fewer adverse side effects than those taking it in combination with progestin. That has led some experts to wonder whether the type of progesterone or the hormone formula in the trials may have been the real culprit.
Women who have not had hysterectomies have to take progesterone along with estrogen, because estrogen alone increases the risk of uterine cancer.
The Women's Health Initiative findings surprised many people in medicine because they flew in the face of the entrenched belief that estrogen protected postmenopausal women from heart disease. The findings were also at odds with the results of the Nurses' Health Study, which has followed more than 120,000 female nurses for several decades and which years ago found a correlation between estrogen treatment and a drastically reduced incidence of coronary heart disease.
The Women's Health Initiative was not the first large trial to report negative results about hormones and heart disease. The Heart and Estrogen-Progestin Replacement Study or HERS, had looked at whether combination hormone therapy would prevent a second heart attack and found that the risk actually increased in the first year of use.
Smaller clinical trials are under way to explore the "window of opportunity" theory, but they lack the health initiative's power of numbers, and they will track markers for heart disease, not heart attacks.
"What we're trying to do is reconcile why there is such a disconnect, or paradox, between the observational trials and the randomized controlled trials," said Dr. Isaac Schiff, chief of obstetrics and gynecology at Massachusetts General Hospital in Boston and chairman of a report on hormone therapy for the American College of Obstetricians and Gynecologists.
Simplified, the window of opportunity argument goes something like this: Most women do not develop heart disease until after menopause, because estrogen protects their blood vessels, keeping them smooth and free of plaque. But if women go without estrogen for a long period after menopause, they will develop atherosclerosis. At that point, estrogen may be harmful, because it increases the tendency to clot, raising the risk of a heart attack.
Even proponents concede that the idea is a hypothesis. "You can prevent the disease if it's not there yet, but you can't treat the disease with estrogen once it's there," said Dr. S. Mitchell Harman, director and president of the Kronos Longevity Research Institute in Phoenix. "That's our hypothesis. We haven't proven it."
The Kronos Early Estrogen Prevention Study, or Keeps, is one of two randomized placebo-controlled trials that will test the hypothesis. It will track markers of early atherosclerosis in 720 women initiating hormone therapy within three years of menopause. Another trial, sponsored by the National Institute of Aging, the Early vs. Late Intervention Trial With Estradiol, or Elite, will follow 504 postmenopausal women for an average of three years.
In addition, the investigators from the Women's Health Initiative have been tracking 1,000 women who were in their 50's when they enrolled in the estrogen-only trial. The research will measure their rates of coronary artery calcification.
Dr. Frederick Naftolin, chairman emeritus of obstetrics and gynecology and reproductive sciences at Yale and national co-principal investigator of the Keeps trial, said the findings of the Women's Health Initiative studies were counterintuitive.
"The relationship between the fall in estrogen and the rise in cardiovascular disease in women is incontrovertible," Dr. Naftolin said. "So why in the world would you not try to find out whether simply maintaining estrogen at the levels of reproductive life could be cardioprotective?"
On the other side, researchers say the cardioprotective theory has been discredited.
"Atherosclerosis starts well before the age of menopause," said Dr. Deborah Grady, a principal investigator in the HERS trial. "On top of that, why would you want a preventive intervention that has a lot of other side effects like blood clots? These people have a theory they don't want to give up on, no matter what."
Dr. Richard M. Fuchs, a cardiologist and clinical professor of medicine at Weill Medical College of Cornell University in New York, agreed.
"There is no good evidence that hormone therapy reduces the risk of heart disease, and there is reasonable evidence to say it increases heart disease and stroke, pulmonary embolism and breast cancer," Dr. Fuchs said. "My advice is all women should try to get off it."
The debate leaves women with severe menopausal symptoms in estrogen limbo. Hormone therapy continues to be considered the most effective treatment to relieve hot flashes, insomnia, night sweats and vaginal dryness. But the pills now come with an alarming warning, mandated by the Food and Drug Administration, about serious side effects.
Women are advised to take the lowest dose possible for the shortest period of time necessary. Some women find it hard to quit the hormones at any age, and women who have had their ovaries removed often take estrogen for decades.
There is no clear scientific evidence that lower doses of estrogen and progesterone are less harmful than the doses in the Women's Health Initiative studies.
Many women have quit hormones. One published study based on a nationally representative survey of 3,853 women older than 50 reported that hormone use dropped to 12 percent in the first half of 2004 from 28 percent in 2002. The number of estrogen prescriptions dispensed dropped to 24.7 million in the first eight months of 2005 from 45.2 million in the same period in 2002, according to IMS Health, a pharmaceutical information and consulting company.
Even women who have stopped taking hormones remain puzzled. Ronna Sussman, 64, of Greenwich Conn., quit hormones based on her doctor's advice after the health initiative results because her diabetes already increases her risk of heart disease. Years earlier, a doctor had advised to stay on hormones for the very same reason.
"It's like with coffee," Ms. Sussman said. "Today it's the best thing in the world for you. Five years ago, coffee was the worst thing. You don't know what to believe."
Even if researchers eventually find hormone therapy protective against heart disease, it may not be used again solely for that purpose. Dr. Wulf H. Utian, executive director of the North American Menopause Society, said:
"Twenty years ago, estrogen was the only game in town to consider for preventing cardiovascular disease in women, as well as for combating osteoporosis. Today, there's smoking cessation, dietary changes, antihypertensive drugs, diabetic agents. There's no way that estrogen is going to be as effective as those groups of drugs. It doesn't make sense."
HINTS OF DIASPORA Archaeologists found the remains of at least 180 people – European, Indian and African – near the ruins of a colonial church in Campeche, Mexico.
At Burial Site, Teeth Tell Tale of Slavery
By JOHN NOBLE WILFORD, The New York Times, January 31, 2006
While remodeling the central plaza in Campeche, a Mexican port city that dates back to colonial times, a construction crew stumbled on the ruins of an old church and its burial grounds. Researchers who were called in discovered the skeletal remains of at least 180 people, and four of those studied so far bear telling chemical traces that are in effect birth certificates.
The particular mix of strontium in the teeth of the four, the researchers concluded, showed that they were born and spent their early years in West Africa. Some of their teeth were filed and chipped to sharp edges in a decorative practice characteristic of Africa.
Because other evidence indicated that the cemetery was in use starting around 1550, the archaeologists believe they have found the earliest remains of African slaves brought to the New World.
In a report to be published in The American Journal of Physical Anthropology, the archaeology team led by T. Douglas Price of the University of Wisconsin concluded, "Thus these individuals are likely to be among the earliest representatives of the African diaspora in the Americas, substantially earlier than the subsequent, intensive slave trade in the 18th century."
Dr. Price said last week that a more precise dating would be attempted soon with radiocarbon analysis of the excavated bones. Maps and other records of Campeche, on the Yucatán Peninsula, indicate that the burial ground was used from the mid-16th century into the 17th. A pre-1550 medallion was found in a grave.
Other archaeologists and historians who were not involved in the research said they knew of no earlier skeletal remains of African-born slaves that had been found in the Americas. Dr. Price said that a colleague in the research, Vera Tiesler of the Autonomous University of the Yucatán, who is a historian of the colonial period, thought the slave burials occurred in the cemetery's first years. She directed the excavations.
The fact that the burials were found in ruins of a colonial church could mean "that they had some kind of status or were converted to Christianity," said Richard H. Steckel, a professor at Ohio State University who studies health and nutrition of pre-Columbian American Indians.
Although ample records attest to the presence of African slaves in the New World at this time, Dr. Steckel, who had no part in the discovery, said: "Much less is known about their health. So, if researchers can document the stature, degenerative joint disease, dental decay, trauma and so forth, then it could be quite interesting."
William D. Phillips, a University of Minnesota professor who is a historian of Old World and New World slavery and who was not involved in this research, said it was not surprising to find African remains in the Yucatán at this time.
Dr. Phillips and other historians said colonial Campeche was an important Spanish gateway to the Americas and would have had substantial traffic in slaves. Within a few years of the first voyage of Columbus, in 1492, they noted, Africans were shipped to the Caribbean and then the mainland. Their numbers increased steadily as sugar plantations were established by the Spanish on the islands, then in Mexico and coastal Peru.
"Some experts suggest that more Africans than Europeans went to Spanish America in the period up to 1600," Dr. Phillips said.
Herbert S. Klein, a historian of Latin America at Stanford and an author of studies on slavery in the region, said, "The slave trade was in full development by the mid-16th century and would have brought African slaves to Mexico, though the primary work force remained Amerindians."
In time, as European diseases reduced Indian populations, the demand for labor from Africa increased. Over a span of four centuries after Columbus, it is estimated, as many as 12 million Africans were placed in bondage and brought across the Atlantic to ports throughout the Americas.
If any older slave burials have been excavated, Dr. Klein has not seen reports of them in the professional literature, he said. The most likely places for any earlier finds, he added, would be in Santo Domingo in the Dominican Republic or in Cuba, where African slaves were first introduced.
The site in Campeche was discovered in 2000. As researchers examined the remains, they determined that some belonged to Europeans and Indians. Then they were drawn to a few with the distinctive dental mutilations, their first clue that these were probably people born in Africa.
Upon further examination, James Burton, the third member of the team, said four of the individuals "were like something we'd never seen."
Dr. Burton and Dr. Price, who are colleagues at the Laboratory of Archaeological Chemistry at Wisconsin, and Dr. Tiesler embarked on the strontium studies, supported by the National Science Foundation. Such strontium research, often applied in physical anthropology, is a part of their broader investigation of social mobility — where people were born and how near or far from home they eventually settled — in ancient Mexico and Central America, known as Mesoamerica.
At least 10 skeletons appeared to be African, the researchers reported, and four had teeth with "unusually high" combinations of two isotopes of the element strontium. An isotope is a slight variation of a chemical element, with a different mass but otherwise the same as the basic element.
In this case, the ratios of the isotopes strontium 87 and strontium 86 were consistent with those in the teeth and bones of people who were born and grew up in West Africa. A comparison with strontium measurements of people born in Mesoamerica showed no similarities with the four specimens.
These strontium signatures enter the body through the food chain as nutrients pass from bedrock through soil and water to plants and animals. Different geologies yield different isotopic strontium ratios. This is locked permanently in tooth enamel from birth and infancy, an important tool to trace the migration of individuals.
The researchers said the findings showed that these four appeared to be original migrants to the New World, not their children. Five other individuals thought to be African slaves had isotope ratios expected for people born around Campeche, hence from a later generation.
"In a community occupied for several generations, only a relatively small proportion of the individuals in a cemetery would be expected to come from the first generation," they wrote in the report.
The four individuals, the researchers said, appeared to have come from the area around Elmina, Ghana, a major West African port in the slave trade.
This was also the region of origin of some of the slaves found in the 17th- and 18th-century African Burial Ground, uncovered in 1991 in Lower Manhattan.
Where Science and Public Policy Intersect, Researchers Offer a Short Lesson on Basics
By CORNELIA DEAN, The New York Times, January 31, 2006
WASHINGTON, Jan. 27 — Congress took a science class this month, and some experts would like to make it a regular part of the curriculum.
"It's not that we are inattentive; it's just that we have the war on terrorism, the Iraq initiative, Social Security, the budget, the list goes on and on," said Representative Sherwood Boehlert, a New York Republican and head of the House Science Committee.
Beyond that, Mr. Boehlert said, "everyone boasts that they are for science-based policy until the scientific consensus leads to an unwelcome conclusion, and then they want to go to Plan B."
So now, when scientific questions pervade legislation on issues like climate change and stem cell research, there is growing concern that Congressional misunderstanding can produce misguided policy.
To fight such misunderstanding, Mr. Boehlert and others sponsored the Jan. 23 briefing, organized by the Center for Health and the Global Environment at Harvard.
Capitol Hill has briefings by the dozen every year in which industry, academic and activist groups address diverse topics related to science.
Some criticize these briefings as little more than showboating. But Mr. Boehlert, like many others, thinks they are "absolutely" useful. And the briefing was unusual in that its subject was not avian flu, the budget for NASA or any other relatively narrow issue, but rather "how science works."
And some on Capitol Hill, notably Representative Rush Holt, a New Jersey Democrat and a physicist, say Congress should address the lack of knowledge and understanding of science by establishing something similar to the Office of Technology Assessment, an agency that advised Congress until it was abolished after Republicans won control of the House in 1994. Prospects for that are uncertain.
Not everyone thought defining science was even possible, in such a short session. "It makes me extremely tired that they are going to do this again," said Sheila Jasanoff, a professor of science and technology studies at the Kennedy School of Government at Harvard, who has written widely on how science policy is made. "There is no easily graspable definition."
Robert Ferguson, who runs the Center for Science and Public Policy, which also presents briefings to Congress, argued that one of the speakers, Donald Kennedy, editor of the journal Science, had himself politicized the field in editorials on the dangers of climate change, marking him as having political motives.
He sent critiques of Dr. Kennedy by e-mail to prospective members of the audience so they could "decide if attending the event is worth your time."
But the briefing's subject apparently struck a chord. More than 100 committee staff members, Congressional aides and at least one senator, Jeff Bingaman, Democrat of New Mexico, crammed into a basement meeting room. With all of the seats filled, people leaned on walls, sat on the floor and spilled out into the hall.
Dr. Eric Chivian, who directs the Harvard center, said he got the idea for the briefing while following the debate over intelligent design and noticing what he called widespread misunderstanding about science.
"I suspected the same was true in the Congress," Dr. Chivian said, adding that he thought it would be useful to consider "how science should advise policy makers in the most effective way."
Dr. Chivian invited Dr. Kennedy and Harvey V. Fineberg, president of the Institute of Medicine, the medical arm of the National Academy of Sciences, to speak.
The worth of any scientific finding, Dr. Kennedy told the crowd, is not the prominence of the researchers responsible, the prestige of their institutions or the authority of their funding agencies, but whether other researchers achieve the same results.
Dr. Kennedy did not refer explicitly to a scandal that is roiling science, and Science — the discovery that highly praised cloning experiments in South Korea survived the magazine's peer review process to win publication, only to be declared fraudulent. But he said: "Peer review is not a process that guarantees truth. If it were, no one would ever repeat experiments."
Replication, he said, "is the ultimate test of truth in science."
Dr. Fineberg spoke of the way scientific knowledge was turned into information useful to society, a process that he said the National Academy encouraged through its regular production of reports on topics as diverse as national security and arsenic in drinking water.
The academy's reports are influential, he said, because of its reputation for integrity, because of its avoidance of conflict of interest, because researchers who produce its findings are volunteers and because "nothing is kept back."
Some of the attendees were participants in another effort to bring scientific expertise to the Hill, a fellowship program run by the American Association for the Advancement of Science, the nation's largest scientific organization and the publisher of Science. The program places scientists with doctorates in Congressional offices and government agencies.
The fellows pressed the speakers on their proper role in policy making, the difference between scientific assessments and value judgments, the difficulties of dealing with low-probability-high-consequence problems like bird flu, and the necessity of scientists' making themselves heard in matters of policy, something Dr. Fineberg called "a civic obligation."
Chris Weaver, who has a doctorate in atmospheric science and is working as a program fellow at the Environmental Protection Agency, said the briefing was "the kind of thing we should be having more of."
But outside of forums like the House Science Committee, whose "excellent" staff has grown in recent years, Mr. Boehlert said, conversations like this are few.
"You'll find the odd congressman like Al Gore who will sit down with the boffins and say, explain it to me," said Daniel S. Greenberg, author of "Science, Money and Politics" (2001), and for many years the editor of the newsletter Science and Government Report. "But if you look at the voting, it's mostly along party lines." He added, "I don't think many congressmen could answer 10 basic questions" about science.
Mr. Holt, who has a doctorate in physics and was assistant director of the plasma physics laboratory at Princeton when he ran for Congress in 1998, jokes that he and Representative Vernon J. Ehlers, a Michigan Republican and also a physicist, are a two-man bipartisan physics caucus.
"Depending on how you count it, there's somewhere between a small handful and a large handful who have science backgrounds" in Congress, he said.
Mr. Holt has introduced legislation to establish what he calls the Center for Science and Technology Assessment. It would be a kind of successor to the O.T.A. and would be housed in the Government Accountability Office.
"I think there is a widespread if not total recognition that we need better technological assessment and advice to Congress," Mr. Holt said. "We are trying to find the right mechanism."
But not everyone agrees that such an agency would make a big difference. It is true that the Office of Technology Assessment is "much mourned," Mr. Greenberg and others say.
"If you could bring it back or establish something else to deal with these problems, it would be useful," he added.
But he blames politics for what he sees as a Congressional failure to take good action on science issues. "I don't think the worsening of the product of the Capitol — and it certainly has gotten worse — is attributable to the absence" of the office, he said.
Others say the National Academy of Sciences or the Congressional Research Service can provide information to lawmakers if they request it.
Mr. Boehlert said the prospects for Mr. Holt's proposal appeared dim. "I am for it," he said, "but in the present climate, when we are struggling to make ends meet, it's unlikely we are going to expand a support staff operation for the Congress. It's not a high priority."
That makes briefings like the one this month all the more important, Mr. Boehlert said, especially because scientists like Dr. Kennedy, a biologist by training, and Dr. Fineberg, a medical doctor, were on hand to make the case for science.
After the briefing ended, attendees crowded around the speakers, peppering them with more questions and comments. One of the fellows had a suggestion for Dr. Chivian.
"Do this again," she said, "but next time get a larger room."
Really? The Claim: Baby Deliveries Are in Sync With the Moon
By ANAHAD O'CONNOR, The New York Times, January 31, 2006
THE FACTS Is there any link between childbirth and the lunar cycle? Many ancient cultures looked upon the moon as a sign of fertility, and since Roman times people have blamed full moons for all sorts of human behaviors, hence the word lunacy, from the Latin word for moon.
But as mysterious and alluring as the link between full moons and births may sound, scientific studies suggest that it is more romance than reality.
Over the years, more than a dozen different studies in several countries have looked for a connection, and almost all have found none.
One of the most recent, published last year in The American Journal of Obstetrics and Gynecology, examined about 564,000 births across 62 lunar cycles in North Carolina between 1997 and 2001.
The lunar cycle, the study found, had no predictable influence on deliveries or birth complications at all.
Another study, which appeared much earlier in The New England Journal of Medicine, looked at thousands of births across 51 lunar cycles. It also reached that conclusion.
But scientists have found several factors that do affect workloads in maternity wards.
Most births occur in the summer and in September and October, said Kathleen Capitulo, the director of the Kravis Children's Hospital and Women's Center at Mount Sinai Medical Center.
There are also weekly cycles. Most childbirths occur later in the week, she said, because many women prefer having labor induced before the weekend, full moon or not.
THE BOTTOM LINE Studies show that workloads in maternity wards are not affected by the full moon.
The Tampa VAMC Polytrauma Rehabilitation Center in Tampa, Fla., is one of four special rehabilitation centers created to treat the most severely wounded soldiers. One of the soldiers, Sgt. Antwain Vaughn, was visited by his 1-month-old daughter, Liyah.
The Wounded: A New Kind of Care in a New Era of Casualties
By ERIK ECKHOLM, The New York Times, January 31, 2006
TAMPA, Fla. — Morning rounds at the Tampa veterans hospital, and a phalanx of specialists stands at Joshua Cooley's door.
Inert in his bed, the 29-year-old Marine reservist is a survivor of an Iraq car bombing and a fearsome scramble of wounds: profound brain injury, arm and facial fractures, third-degree burns, tenacious infections of the central nervous system. Each doctor, six in all on a recent day, is here to monitor some aspect of his care.
As they cluster at the threshold, one gently closes the door — not to shield their patient from bad news, but to avoid overstimulating the nervous system of a man whose frontal lobe has been ripped by shrapnel. Not that the news right now is good: Corporal Cooley is spiking a fever, presumably because of his newest problem, blood clots in his left leg.
The doctors sort through a calculus of competing interests. Should they prescribe a blood thinner to dissolve the dangerous clots, even though that could cause more bleeding in the brain? Or should they just wait? At this point, the doctors decide, the clots pose the greater risk.
Thousands of miles from the battlefield, intricate medical choices have become routine here, at one of four special rehabilitation centers the government created last year to treat the war's most catastrophically wounded troops.
"These soldiers were kept alive," said Dr. Steven G. Scott, the Tampa center's director. "Now it's up to us to try and give them some meaningful life."
With their concentrated batteries of specialists and therapists, these centers are developing a new model of advanced care, a response to the distinctive medical conundrum of the Iraq war. With better battlefield care and protective gear, the military is saving more of the wounded, yet the insurgents' heavy reliance on car bombs and buried explosives means the survivors are more damaged — and damaged in more different ways — than ever before.
To describe the maimed survivors of this ugly new war, a graceless new word, polytrauma, has entered the medical lexicon. Each soldier arriving at Tampa's Polytrauma Rehabilitation Center, inside the giant veterans hospital, brings a whole world of injury. The typical patient, Dr. Scott said, has head injuries, vision and hearing loss, nerve damage, multiple bone fractures, unhealed body wounds, infections and emotional or behavioral problems. Some have severed limbs or spinal cords.
"Two years ago we started seeing injured soldiers coming back of a different nature," recalled Dr. Scott, who is also the hospital's chief of physical medicine and rehabilitation. Then last spring, with a Congressional mandate, the Department of Veterans Affairs created the four new centers, formalizing changes that a few top veterans hospitals were already starting to make.
After weeks or months of intensive care in military hospitals, more than 215 soldiers and a few more each week — still a tiny fraction of the roughly 16,000 soldiers who have been wounded in Iraq — have been sent here or to the other centers, inside V.A. hospitals in California, Minnesota and Virginia.
The surge in complex casualties, doctors found, required major reorganizing, enabling them to focus extraordinary medical and therapeutic expertise on each patient and to offer counseling, housing and other aid to their often shellshocked wives, children and parents.
"In the outside world you might have two or three consultants seeing a patient," said Dr. Andrew Koon, a specialist in internal medicine who was checking laboratory results on a portable computer during bedside rounds. "Here it's not unusual to have 10 specialists on board."
The multiple wounds have required medical balancing acts and unusual cooperation across departments. One quadriplegic patient was so weakened by recurring infections that doctors had to wait a year before removing shrapnel from his neck. In other cases, the risk of new infection has delayed treatment of the spasms that some paralyzed patients suffer, which can require an implanted pump to inject medicine into the spinal column.
Of some 90 soldiers with extreme injuries who were treated in Tampa over the last year only one has died, of a rare form of meningitis. The drama here is more excruciatingly drawn out: Over months and months of painstaking physical and psychological therapy, the patients and their families start learning the boundaries of their future lives.
Quiet Struggles
The medical challenges are often persistent and daunting, but the real focus of the new centers is rehabilitation. Even as doctors battle drug-resistant bacteria blown into wounds with Iraqi dirt, patients start relearning to talk and focus their thoughts, to walk and run or maneuver a wheelchair. Some go home in almost normal shape; for others, simply swallowing is a milestone.
To spend several recent days here is to witness a panorama of quiet struggles. A young man with brain and nerve damage slowly fits big round pegs into big round holes. Another beams after jogging a full minute for the first time since his injury, but cannot voice his mix of pride and impatience because shrapnel destroyed the language center in his brain.
A quadriplegic is lifted by a giant sling from his bed to a high-tech wheelchair, which he has learned to drive with a mouthpiece.
Progress on these wards can be measured in agonizing increments.
Corporal Cooley, a 6-foot 6-inch former deputy sheriff, arrived in Tampa on Sept. 29 after more than two months at the Bethesda Naval Hospital outside Washington. His doctors and relatives were encouraged when, after another couple of months, he wriggled his fingers and feet, and answered yes-no questions with blinks.
"They got him to make noises the other day," offered his wife, Christina. "He's doing really well." At "rehab rounds" one recent day, assorted therapists took up Corporal Cooley's case, reporting on small steps forward and compromises along the way.
The speech therapist said he was responding to questions with blinks about 30 percent of the time when she was alone with him, but less if distracted. She described her gingerly efforts to train him to swallow, using thin pudding, apple sauce and ice chips.
The respiratory therapist said his tracheotomy had to be changed to a larger, cuffed device that would allow them to expand his lower right lung.
The speech therapist groaned, "That will make it harder to swallow." They agreed that the lung had to take priority, but the speech therapist added, "Let's get rid of that cuffed trach as soon as possible."
Brain injuries — the signature wounds inflicted by the blast waves and flying shrapnel of explosives — are pervasive, and they tend to dictate the arc of care.
"It's really the brain injury that directs how we approach other impairments," Dr. Barbara Sigford, V.A.'s national director of physical medicine and rehabilitation and chief of the Minneapolis polytrauma center, said in a telephone interview. "Many types of rehab rely on intact thinking, learning and memory skills."
Using advanced prosthetic limbs, for example, requires control of specific muscles; patients without that capacity must use simpler models. Blind people are normally taught to navigate using their memory of the environment; if memory is spotty, they must find other ways.
In the recreational therapy room in Tampa on a recent day, several men are being led through a round of Uno, a card game that involves matching numbers and colors. Some play well. Some fumble trying to pick up cards. One rocks in frustration at his inability to summon the word "blue."
Sgt. Antwain Vaughn, 31, an Army combat engineer who took a roadside blast in the face on Aug. 31, arrives late and in a wheelchair. A padded helmet covers a large indentation where his shattered skull will receive a metal plate.
Sergeant Vaughn came to Tampa after two months on a ventilator and feeding tube. In addition to brain damage, facial fractures, pulmonary problems, blood clots and infections, he lost an eye and has trouble with complex tasks, something the card game could help.
Here he has learned to swallow and eat and in daily therapy, when he is feeling up to it, he is working to reclaim a life. But this time, he will not join the game. "My head's hurting a lot," he quietly tells the group.
Head injuries have also left some soldiers in a peculiar psychological box. Before Iraq, most head injuries at the Tampa hospital involved car accidents, said Dr. Rodney D. Vanderploeg, the chief of neuropsychology. Though it may seem counterintuitive, soldiers with penetrating brain injuries, in which a fragment crashed through their skulls, are far more likely to remember the attack and its bloody aftermath, perhaps including the deaths of friends, he said.
These memories often cause great psychological stress. But psychotherapy becomes especially difficult if injury has impaired a patient's insight and understanding.
Making Progress
In the hallways, the banter tends to be upbeat, as perhaps it needs to be for patients and staff. A patient shows off his stair-climbing wheelchair. Others compare the merits of prosthetic leg models. Nearly every patient vows, not always realistically, that he will get back on his feet and more.
"The way I see it, if I get able to walk a little bit, then eventually I'm going to walk a lot," said Specialist Charles Mays, 31, who was left with multiple fractures and partial paralysis of his legs after being blasted out of his Humvee by a vertically buried rocket south of Baghdad.
Sometimes the hallways bring success stories like Specialist Nicholas Boutin, who was slowly walking on his own to speech therapy in a hockey helmet, apparently not at all self-conscious about the red pit where an artificial eye will be implanted or about the large dent where a piece of skull will be replaced.
Specialist Boutin, 21, had arrived in Tampa just five weeks before, mute and hardly able to swallow, his right arm and leg almost useless. During a midnight patrol in a village near Samarra, an insurgent dropped a grenade into his Bradley fighting vehicle. Fragments sprayed into his face and the left side of his brain, leaving him with Broca's aphasia — able to comprehend but not to speak.
He weathered fungal infections, facial pain where nerves were damaged and the destruction of his pituitary gland and a maxillary sinus, the kind of internal wound that can torment a person for life.
But now, after hard hours each day in therapy, he can jog briefly and write messages with his right hand. As speech therapists coax the right side of his brain to take over lost functions from the left, he has begun to make one-word responses and spontaneously utter a few words at a time. Soon he will head home to Georgia for continued therapy.
"Yes," he uttered instantly when asked if he felt he was progressing. Determination gleamed from his remaining eye.
Behind closed doors, though, bravado sometimes gives way to depression, explosive anger, survivors' guilt. Some patients sit quietly with glum faces or obsess endlessly about their buddies and time in Iraq.
As much as the nurses are often buoyed by their patients' progress, they say the relentless intensity of the work can sometimes bring them to tears. They spend as much time interacting with stressed-out relatives as with the patients.
"Relatives take out their frustrations on the nurses," said Laureen G. Doloresco, assistant nursing chief. "It's also hard on the nurses because of the youth of the patients. Many of them have sons the same age."
Support Systems
At the bedsides of many of these young men are their equally young wives, whose lives have also been wrenched onto unexpected paths.
Before he was sent to Iraq last Jan. 1, Corporal Cooley and his wife were partners on the vice/narcotics squad of a sheriff's department in central Florida. They married just before his deployment.
Soon after the car bombing on July 5, she and her husband's parents were summoned to the American military hospital in Landstuhl, Germany, and warned to expect the worst.
After the car bomb detonated, near the town of Hit, Corporal Cooley had been pulled from his burning amtrack, an armored vehicle, unconscious and with a gaping hole in his head. The medics had at first refused to load him onto the evacuation helicopter, Christina Cooley later learned. They changed their minds when they heard a moan.
Ms. Cooley recalled telling doctors that they were showing her the wrong patient, that this bloated figure was not her husband. She was convinced only after she saw his tattoos.
She also saw, though, that he was breathing on his own. Days later, he was flown to the Bethesda Naval Hospital, and for two months, his wife and the in-laws she still barely knew shared a hotel room and spent their days around Corporal Cooley's bed in intensive care.
Here in Tampa, despite continued medical setbacks like the blood clots, attention was turning to his potential for physical and mental recovery.
So far, he had been put in a chair for a few hours a day and strapped into a "tilt board" at a 45-degree angle for 10 minutes at a time, to forestall the drops in blood pressure that occur when long-prone patients raise up.
His wife finds hope where she can.
Corporal Cooley often stares vacantly, she said, and "you don't know if he's there." But one day when she asked him, "Who's my hero?" he pointed a finger toward himself.
Their home county, outside Tampa, has raised money that she plans to use on an accessible house.
"I hope he'll walk through the door of that house," she said. "If not, I'll take him as a vegetable. I'll take care of him the rest of my life. I love that man to death."
Overhearing her, Dr. Scott, the center's director, marshaled his characteristic optimism. "He can already move both legs," he said. "It's possible he can be rehabbed to walk. How far he'll go we just don't know."
The polytrauma centers themselves remain works in progress, sharing lessons with one another and with the major military hospitals by videophone, and pushing scientific inquiry into the myriad, often invisible effects of explosive blasts.
The Department of Veterans Affairs says it has not calculated the cost of establishing the centers, bolstering their staffs and treating patients so long and intensively. The Tampa hospital's director, Forest Farley Jr., said that here alone, it was "several millions of dollars."
Though the average stay in polytrauma centers is 40 days, many patients remain for months and some for more than a year. In the end, a few must go to nursing homes, but most go home, where they receive continued care at less-specialized veterans hospitals, with oversight from the centers. Some require round-the-clock home aides and therapists and costly equipment, paid for by the government on top of monthly disability payments. Even so, wives or parents often must give up their jobs.
For the worst off, the ongoing annual costs — largely hidden costs of this war — can easily be several hundred thousand dollars or more.
"We expect to follow these patients for the rest of their lives," Dr. Scott said. "But I have a great deal of concern about our country's long-term commitment to these individuals. Will the resources be there over time?"
