Doing Battle With the Insurance Company in a Fight to Stay Alive

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Rob Mattson for The New York Times

Gordon Hendrickson of Albuquerque won a long legal fight with his insurance company after it refused to cover his live-saving treatment for pancreatic cancer in Houston.

By Denise Grady, The New York Times – A glorious blend of forces came together to save Gordon Hendrickson’s life: smart doctoring, luck, kindness, and his own wisdom and abundant grit.

Only his insurance company tried to stand in the way.

Five years ago, when Mr. Hendrickson was 66, routine blood work found something amiss with his liver. One test led to another, and then to an awful diagnosis: pancreatic cancer, one of the deadliest kinds.

His doctors thought he was among the lucky few with pancreatic cancer found early enough to be cured by surgery. But they warned him not to have the surgery in his home city, Albuquerque. They said the operation he needed, a Whipple procedure, was so risky and complicated that it should be done only by a surgeon who performed it often and at a hospital with many similar cases. But neither was available locally.

Albuquerque’s population was less than half a million, and the entire state of New Mexico had fewer than two million people, not enough to give local surgeons much practice with a relatively uncommon operation.

An experienced surgeon and hospital can significantly increase the odds of survival for people with pancreatic cancer, studies have found. Lower complication rates can also minimize the cost.

Mr. Hendrickson, a retired administrator for the YMCA and the Spina Bifida Association, had taken care in choosing his internist, Dr. Kristine Bordenave. They liked and trusted each other, and one morning, Dr. Bordenave canceled her other appointments to spend hours on the phone finding a major cancer center that would quickly admit him. It turned out to be the M. D. Anderson Cancer Center in Houston.

But his insurer, the Presbyterian Health Plan, refused to pay for treatment in Houston. The company insisted that the operation be done in Albuquerque and sent him a list of five local surgeons.

He went to M. D. Anderson anyway. But because Presbyterian would not pay, the hospital required a $5,000 deposit. Mr. Hendrickson and his wife had little money and normally threw away any credit cards mailed to them. But his wife happened to have one new card that she had not gotten around to cutting up yet. They decided that this was the one time when they should not worry about money, and they used the card to pay the deposit.

“I was a person who wanted to live,” Mr. Hendrickson said, adding that he assumed it would be cheaper for the insurance company to let him die.

The surgeon at M. D. Anderson told him that without an operation he had virtually no chance of surviving, and even with an operation his chances would be slim. Despite the long odds and the high cost, insurers cover the Whipple operation in patients who are candidates for it — less than a quarter of those with pancreatic cancer — because it offers the only hope of a cure and can prolong life.

Figuring that a small chance was better than none, Mr. Hendrickson had the surgery. It went well. But he was left with more than $80,000 in medical bills, which Presbyterian Health Plan refused to pay.

Dr. Bordenave said she was appalled: “No patient fighting for their life should have to fight for their insurance too.”

Mr. Hendrickson waged a long battle with Presbyterian. “I fought with the insurance company for over a year,” he said.

After Presbyterian rejected two appeals, he took his case to a state review board, where he represented himself because he could not afford a lawyer. Presbyterian showed up with two lawyers, a doctor and a nurse. Dr. Bordenave and a gastroenterologist from Albuquerque testified on Mr. Hendrickson’s behalf.

Mr. Hendrickson and his wife had studied the details of their insurance policy and had also learned — with the help of M. D. Anderson — that in the previous five years, the five surgeons Presbyterian had recommended had performed a total of five Whipple operations.

Ultimately, Mr. Hendrickson won the case, and Presbyterian Health Plan paid the entire bill.

A spokesman for Presbyterian said the case had led the company to allow more patients to be treated at high-volume centers if there was evidence that the results would be better.

Mr. Hendrickson said it was “tough to stand up to attorneys and doctors. I don’t know why I was able to do it. I’m stubborn, I guess. I don’t like to be told what to do. Too many people, I know, they just let it go and they die.”

In June, Mr. Hendrickson went back to M. D. Anderson for a five-year checkup with his surgeon, a visit paid for by Presbyterian.

“He told me that I was cured of pancreatic cancer,” Mr. Hendrickson said in an e-mail message. “I shouted from the rooftops.”

When students love and do well in math and science, the rest of the world gains thoughtful important citizens.
image004.jpgCNN, December 22, 2007 – In the fifth grade, she started a math camp. By sixth grade, Isha Jain was breezing through college-level work and trigonometry classes. When she was in the eighth grade, she aced advanced calculus. Isha Jain thinks math and science are cool.

Her taste for science started at 9 when she created a paradigm to explain the molecular structure of candy. It sounds sweet, but also sophisticated — teachers in the U.S. and abroad have used her methods in the classroom. Before she was old enough to buy sweets at a PG-13 movie, her candy-making findings were featured at major scientific summits.

Recently, 16-year-old Isha used both skill sets to identify what causes growth spurts. Not only did she think her findings were cool, but so did the journal “Developmental Dynamics,” which published her work. The Siemens Competition in Math, Science and Technology went beyond just the thinking: It gave her a cool $100,000 scholarship.

Isha Jain, is now a 10th-grader at Freedom High School in Bethlehem, Pennsylvania. Jain recently placed fourth in the Zoology category of the Intel International Science and Engineering Research Fair for her project, “Cell Proliferation is Episodic and Pulsatile During Growth of Zebrafish Fins”. The energetic sophomore researched fin growth at the “fish lab” at Lehigh University to increase understanding of development that could be applied to humans.

“My project involved looking at the rate of cell division within Zebrafish fin bone segments,” explains Jain. “The goal was to understand the pattern of bone growth in this model system. The Zebrafish serves as an excellent paradigm for human morphological development.”

Isha, who has always liked math and numbers, outlined the role that her math skills played in her research. “There were two mathematical components in my analysis. I integrated (using rectangular approximations) the data sets and compared the ratios in two different bone rays with the ratio of their volumes. Also, to statistically verify the results, the F-ratio test statistic and the computer program Minitab was used.”

In addition to the prestigious Intel award, Isha has also garnered a United States Air Force 2nd place award, the Endocrine Society Honorable Mention Award and the Cook Group Incorporated award. Cook is the leading manufacturer of non-invasive medical devices and has offered Isha an internship to work on genetic experiments.

Isha won the PA State 24 Challenge Championship Finals in 2003, competing at the Platinum Masters level. Her sister, Raina, was also a PA State winnner in 2004.

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Left, 15-year-old Isha plans to continue her research by analyzing fin growth mutants and the gene expressions of associated growth markers. Right, a young Isha hoists the 2003 PA State Platinum Masters trophy she won in Harrisburg.

Photos © 2006 Suntex International Inc. / Isha Jain

By Kevin Sack, The New York Times, December 25, 2007 – Sacramento – A year that began with great ambition for major expansions of health insurance here and in other state capitals is ending with considerable uncertainty, as a second wave of change runs headlong into a darkening economy and political divisions over how to apportion the cost.

Though the governors of three big states – California, Illinois and Pennsylvania – proposed sweeping plans to restructure health care this year, none will finish 2007 with bills passed and signed. In each state, the initiatives confronted entrenched opposition from insurance and other business lobbies that made it far more difficult to build a consensus for change than in the smaller New England states that acted in recent years.

Yet it also was a year of intriguing achievement, here above all, where the Republican governor, Arnold Schwarzenegger, and the Democratic Assembly speaker, Fabian Núñez, drew up a bipartisan blueprint for bringing near-universal coverage to the country’s most populous state.

Mr. Schwarzenegger and Mr. Núñez have yet to close the deal by gaining the support of the State Senate. But they demonstrated in their yearlong negotiations that a consensus on basic principles could be reached, perhaps setting a template for other states and for Washington.

“It’s significant that what they’ve been talking about in California is similar to what many of the leading Democratic presidential candidates are talking about as well,” said Larry Levitt, vice president of the Kaiser Family Foundation, which researches health care issues. “There seems to be some convergence at least on the part of those supporting universal health care on how to get there.”

In addition to being the most populous state, California has among the country’s highest proportions of uninsured residents, about 20 percent. Indeed, there are more uninsured in California than there are total residents of Massachusetts, Maine or Vermont, the states that have set the pace for overhauling health care. Success here, therefore, would send a signal that such plans could be enacted in states with the heaviest burdens.

The Schwarzenegger-Núñez plan, which passed the Democratic-controlled Assembly last week, expands on the universal coverage law that Massachusetts passed in 2006. That state now requires insurance companies to offer coverage regardless of an applicant’s health status and mandates that most residents have insurance by Dec. 31, or face a tax penalty of $219.

State officials project that more than 300,000 previously uninsured people will sign up in time, a third of them in a surge over the last month. That has put Massachusetts more than halfway to its goal of insuring everyone.

The downside, and one noted by states with widening budget gaps, is that the program is expected to exceed its first-year budget by at least $150 million. And state officials are struggling to prevent double-digit premium increases next year.

Whether the momentum that began with State of the State addresses last January will continue into 2008 is not clear. It had been widely felt by health reform advocates that this nonelection year provided the best political climate for change.

Now the focus may shift to the presidential campaign, where the leading candidates for the Democratic nomination have each proposed major overhauls. Some state leaders may be tempted to wait out the year to gauge whether the next president will push for a national health plan that might subsume state efforts.

The essential problem, meanwhile, continues to worsen. The Census Bureau reported that the number of uninsured grew to 47 million in 2006, a one-year increase of 2.2 million. The share of United States residents who had employer-based coverage dropped to 60 percent from 64 percent in 2000, according to the Economic Policy Institute, a liberal research group. And though the rate of growth has slowed, the cost of employer-sponsored premiums still rose by 6.1 percent in 2007, more than double the inflation rate, according to the Kaiser Family Foundation.

Because of its national influence, California will continue to command attention as Mr. Schwarzenegger and Mr. Núñez try to bring along the Senate president pro tem, Don Perata, a Democrat. While supportive of universal coverage, Mr. Perata has said he is concerned about the plan’s $14.4 billion price tag when the state faces a budget gap of commensurate size.

As in Massachusetts, the California plan would mandate coverage for most individuals. It would raise money to subsidize policies for low-income residents through what Mr. Schwarzenegger calls shared responsibility – a tax on hospital revenues, a hefty increase in tobacco taxes and assessments on employers who do not contribute to their workers’ health care.

In a California innovation, the assessment rates would be graduated according to the size of the company. If the Senate passes the measure, voters will be asked to approve the revenue measures in a November referendum that would become the truest test of public support for change.

California, of course, is an idiosyncratic state, and at no time more than now, with its movie star governor and his mantra of “postpartisanship.” But even in a state as comparatively progressive as this one, the coalition that has formed around overhauling health care is notable.

At a postvote news conference beneath the Capitol rotunda last week, Mr. Schwarzenegger and Mr. Núñez stood with the chairman of Safeway grocery stores and the president of the San Diego Chamber of Commerce, as well as leaders of unions representing service workers, government employees and carpenters.

Andrew L. Stern, president of the Service Employees International Union, seemed to speak for many of those in attendance when he said in an interview that successful health reform would depend on “not letting the perfect be the enemy of the good.”

Against that backdrop, the bipartisan partnership between Mr. Schwarzenegger and Mr. Núñez seemed almost unremarkable. The two men need each other – Mr. Schwarzenegger to play on the big stage he enjoys, Mr. Núñez to leave a legacy before term limits may force him from office – and they praise each other lavishly in public.

That is not to say support for their plan is universal; it won not a single Republican vote in the Assembly. Some unions oppose it because they fear that mandatory insurance policies would not be affordable, even with government subsidies. The California Nurses Association opposes the plan because it would preserve private insurance rather than replacing it with universal government coverage.

Other governors, in more centrist states, made less headway this year in overcoming opposition generated by efforts to contain health costs and to raise the revenues needed to subsidize premiums.

Illinois’ Democratic governor, Rod R. Blagojevich, got nowhere with his proposals to pay for universal access to insurance by taxing gross business receipts and assessing employers who do not offer coverage to their employees. He then instigated a fight with his legislature and provoked a lawsuit by using his executive authority to widen eligibility for state-subsidized insurance programs.

In Pennsylvania, Gov. Edward G. Rendell, also a Democrat, failed to persuade his politically divided legislature to cover the state’s 900,000 uninsured through an employer assessment. Like the California leaders, Mr. Rendell has now proposed increasing cigarette taxes, as well as raiding the surplus in a state fund designed to help doctors pay for malpractice insurance.

In both New York and Connecticut, governors expect to receive plans for universal health coverage from advisory groups in 2008 and then to begin their own legislative battles.

“It remains incredibly difficult for states by themselves to get all the uninsured covered,” said Robert Blendon, a Harvard professor of health policy and political analysis. “There just is not a consensus on who should pay.”

While only a few states considered universal coverage plans, it was an active year for more incremental measures, said Laura Tobler, a health policy analyst for the National Conference of State Legislatures.

Maryland and Texas joined the 15 states that have created programs to subsidize insurance for small businesses and individuals, she said. Four states effectively guaranteed that all children could be insured through expanded eligibility for Medicaid and the State Children’s Health Insurance Program, known as S-chip. An additional 13 states passed more modest expansions for children.

Any continuation of that trend in 2008 would likely depend on Congress and President Bush settling their considerable differences over financing for S-chip.

Mr. Bush this year twice vetoed large increases approved by the Democratic-controlled Congress, and his administration used regulatory powers to restrict the ability of states to extend the program beyond its original target: the children of the working poor.

Intelligent Discussion of the Brain, and Brain Research
From Potential of the Mind to Diseases of the Brain
Charlie Rose Science Series With Pfizer Sponsoring

Panel: Sir Paul Nurse MD [Nobel Prize Winner]; Eric R. Kandel MD, PhD [Nobel Prize Winner]; Helen S. Mayberg MD; Catherine Lord, PhD; Donald Price MD

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The Washington Post, December 21, 2007 – The $3.1 billion merger between Web search king Google and online ad giant DoubleClick approved by U.S. regulators yesterday may create an advertising powerhouse of unrivaled reach and knowledge of Internet users’ lives, desires and interests.

The acquisition of DoubleClick combined with Google’s search function and the data it collects from people as they use the Internet could result in Web surfers seeing more advertising that corresponds to their online activities. The trade-off, some say, is that users would lose control over more of their private information to Google.

Given its global scope, the deal still requires approval by the European Union, which has been more strict than the United States on antitrust reviews. The ambitions of big U.S. companies such as Microsoft have been curbed by European regulators.

Privacy advocates and Google’s rivals have shifted their lobbying to Europe, where Google has a larger share of the online-search market.

The deal is one of many big-money mergers between Internet companies and advertising firms this year and heralds the era of data-based advertising, as companies seek more ways to acquire data about what people are doing on the Internet and to deliver highly targeted advertising to them. The fear is that the collection of so much personal data by one firm could expose it to theft and abuse via the Web or even cellphones.

Google has excelled at “contextual advertising,” or sending text-based ads to Google users that relate to their search topics. For example, if a user searches for a specific automobile, Google will send car ads with search results.

DoubleClick is the Internet’s leading company for producing display advertising for Web sites — banners ads, video and such. The company has provided display advertising for almost every major online publisher, including Web sites for Sports Illustrated, About.com and PriceGrabber.com.

Combined Google and DoubleClick technology could evolve so it delivers precisely targeted display and video advertising to the customers most likely to buy their advertisers’ products.

Online is the fastest-growing sector in advertising, expanding at an annual rate of about 20 percent, far outpacing television, radio or outdoor. Because the Internet can tell advertisers a great deal about who sees their ads — where they live, how much time they spend looking at the ad, which site they saw it on — companies such as Google are buying companies with the most sophisticated tools to deliver ads to Internet users.

The deal was approved without conditions in a 4 to 1 vote yesterday by the Federal Trade Commission. The FTC said it does not think it is approving a Web advertising monopoly, though one commissioner and some others disagreed.

In a written statement, the commission said the merged companies would not control the user-data market, pointing out that Google’s chief rivals — Microsoft, Yahoo and Time Warner — “have at their disposal valuable stores of data not available to Google.”

In a statement on Google’s corporate blog after the FTC vote, David C. Drummond, the company’s general counsel, wrote: “Perhaps most importantly, the FTC’s decision publicly affirms what we and numerous independent analysts have been saying for months: our acquisition does not threaten competition in what is a robust, innovative, and quickly evolving online advertising space.”

FTC commissioner Pamela Jones Harbour disagreed, writing in her dissent: “I make alternate predictions about where this market is heading, and the transformative role the combined Google/DoubleClick will play if the proposed acquisition is consummated.”

Privacy advocates were more forceful in their criticism of the proposed takeover.

“Google will be able to develop the most detailed profile of users around the world,” said Jeffrey Chester, executive director of the Center for Digital Democracy. “It will become the world’s private ministry of information.”

Google’s rivals, led by Microsoft and AT&T, expressed concern about Google’s ability to use the data aggregated by the merger to muscle out competitors in the online advertising market. Google’s recent experiments to expand its advertising reach into other media, such as mobile phones and television, have also set off alarms among competitors and privacy advocates.

Microsoft bought an Internet-ad shop earlier this year, paying $6 billion for aQuantive, a Seattle firm that combines traditional media campaigns with search-based and new-media techniques, all built on user data.

Microsoft and AT&T declined to comment on the Google-DoubleClick merger approval.

Some in the advertising industry reacted to the FTC vote with caution but generally with less alarm than others.

“As with most mergers, they have beneficial aspects of the merger and slightly potentially troubling aspects of the merger,” said Kevin Lee, executive chairman of Didit, which advises advertisers on how to spend their online marketing budgets. “This will make it easier to buy across different media types and across different targeting methodologies all at the same time, but the more troubling aspect is the reduction of competition.”

Asked about the potential privacy concerns of the deal, Robert D. Liodice, president of the Association of National Advertisers, was more blunt.

“Doesn’t everyone know everything about everybody anyway?” said Liodice, whose group asked the FTC to review the Google-DoubleClick merger. “We’ve got identity theft going on everywhere. We have a national issue of people not being able to trust whether their private information is secure or not. I view the potential concern about the Google-DoubleClick deal as a drop in the bucket compared to the national issues at play.”

Though the FTC noted its concerns about deal’s privacy implications, the panel said it does not think it has the authority to consider privacy in an antitrust review.

“This merger, and their forays into other media, helps Google follow you if you want them to — and even if you don’t — across a huge expanse of the globe,” said Joseph Turow, a professor at the University of Pennsylvania’s Annenberg School for Communication.

More people use Google than any other search engine; 65 percent of all Internet searches are conducted through Google. In the third quarter of this year, the company reported revenue of $4.2 billion. Google shares closed at $689.69 yesterday, up $12.32.

DoubleClick’s 2006 revenue was about $150 million, according to a number of reports. Its $3.1 billion price demonstrated Google’s zeal to buy the company and the growth potential Google sees in online advertising.

Europe’s approach to privacy policies tends to be more strict than that taken in the United States. Privacy is explicitly enshrined as a fundamental human right in the European Union’s constitution — but the E.U. regulatory body reviewing the merger has said it will focus on antitrust issues and complete its review by April 2.

“The E.U. is a bigger potential roadblock than the FTC was, but it’s hard to say if they’d actually block the merger,” said Blair Levin, an analyst at Stifel Nicolaus. “It’s a possibility but by no means a certainty.”

If the European Commission were to impose conditions on the merger, Google could collect different data about its users in the United States and Europe. The company declined to say whether it would do that.

The FTC is considering alternative ways to address the privacy issues inherent to data-gathering in online advertising. Separate from the merger review, the FTC issued a call for comments on five self-regulatory privacy principles for online advertising companies.

Centers for Disease Control, and the U.S. Department of Health and Human Services have concluded that blood lead concentrations above 10 mcg/dL are hazardous to children’s development. In a PBS news presentation on Thursday, December 20, 2007, it was announced that the recently studied imported toys contained enough lead to harm the development of young children.
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Herbert L. Needleman, M.D., is a leading expert on the effects of lead poisoning on children.

NeedlemanHe is a pediatrician and child psychiatrist at the University of Pittsburgh Medical Center, and is known for groundbreaking studies on the developmental implications of lead exposure. In the 1970s, measuring lead levels in children’s teeth, Needleman provided the first evidence that even low levels of lead, lower IQ, shorten attention spans and delay language skills. Needleman conducted follow-up studies on these children and showed that their deficits persisted, resulting in learning disabilities and school failure.

Needleman designed the first forward study of lead exposure in the uterus and showed it was associated with cognitive deficits later in life. His recent research shows that boys with high levels of lead in their bones have greater odds of developing aggressive or delinquent behavior, such as bullying, vandalism and shoplifting.

Needleman’s research and advocacy was instrumental in federal regulations banning lead from gasoline and paint as well as the removal of lead from government housing. The federal Centers for Disease Control and Prevention also issued guidelines for pediatric lead poisoning diagnosis and treatment due, in part, to his research.

Needleman is the founder of the Alliance to End Childhood Lead Poisoning, now called the Alliance for Healthy Homes, a national nonprofit working to prevent and eliminate home hazards such as lead, mold, radon and pesticides.

Lead exposure causes reduced IQ, learning disabilities, developmental delays, reduced height, poorer hearing, and a host of other health problems in young children. Many of these effects are thought to be irreversible. In later years, lead-poisoned children are much more likely to drop out of school, become juvenile delinquents and engage in criminal and other anti-social behavior. As reported in the New England Journal of Medicine, researchers found that even at low levels, lead exposure in children can significantly impact IQ and even delay puberty in young girls.

At higher levels, lead can damage a child’s kidneys and central nervous system and cause anemia, coma, convulsions and even death. According to the Centers for Disease Control and Prevention (CDC), about 310,000 of the nation’s 20 million children under the age of six have blood lead levels high enough to impair their ability to think, concentrate and learn.
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David Bellinger, PhD is a Professor of Neurology at Harvard Medical School/Children’s Hospital in the department of Neurology. David Bellinger focuses on two broad classes of early insults to the developing nervous system, exogenous chemical exposures, (e.g., lead, fluoride, mercury, and cocaine), and endogenous metabolic insults related to serious medical conditions (e.g., congenital heart lesions). The specific aims of the chemical exposure studies are (1) to develop new strategies for exposure assessment, (2) to define the “behavioral signature”, if any, associated with different exposure scenarios, (3) to identify factors that function as effect modifiers (i.e., that either enhance or mitigate the magnitude or presentation of toxicant-related effects), and (4) to evaluate exposure abatement interventions. The specific aims of the studies on endogenous insults related to medical conditions are to characterize the associated behavioral risks.

Superman couldn’t see through lead, but doctors and psychologists did, exposing lead’s damaging effects on children’s psychological development. Lead is everywhere-in house paint, in car exhaust, even in water pipes and food cans. As a result, lead is also in our blood and bones. In the 1970’s, experts thought that children who had less than 30 micrograms of lead per deciliter of blood (30mcg / dl) were safe from its effects. However, a research team headed by pediatrician Herbert Needleman and later joined by psychologist David Bellinger exposed how dangerous even a little lead exposure can be. Dr. Needleman and his team first tested how much lead was in the baby teeth of 2335 first and second graders with no symptoms of lead poisoning. The researchers then had the 58 children with the highest lead levels and the 100 with the lowest lead levels complete a series of tests, and had teachers rate the children’s behavior. The researchers found that the high-lead children had lower IQ’s, less verbal competence, worse speech processing, and worse attention than did the low-lead children.

Lead also affected the children’s behavior: teachers consistently judged the high-lead children to have more difficulty following directions, to be more hyperactive, and to have lower overall functioning than did the low-lead children. According to the federal guidelines at the time of this study (1979), children in both the high- and low-lead groups had relatively low levels of lead in their blood. Dr. Needleman and colleagues’ results clearly showed that the high-lead children experienced significant cognitive and behavioral problems. These researchers have also demonstrated that children from both impoverished and affluent backgrounds suffer from high lead exposure, underscoring how widespread the problem is.

Significance

Needleman’s study was among the first to raise public awareness about the effects of environmental pollutants on children’s psychological development. Prior to this study and the ensuing body of research that it inspired, environmental influences on intelligence and behavior were under-appreciated. These researchers showed that even small amounts of a common metal like lead have strong effects on children’s intelligence and personality.

This body of research also ushered in an emphasis on “behavioral toxicity,” not just “somatic toxicity.” Researchers had previously focused almost exclusively on pollutants’ relationships to diseases like cancer. Needleman’s team showed that pollutants often affect children’s behavior and cognitive functioning long before disease develops. By using these psychological measures, researchers may be able to slow, stop, or even reverse the progress of disease.

By Jane E. Brody, The New York Times, Dec 11, 2007 – My husband, at 74, is the baby of his bridge group, which includes a woman of 85 and a man of 89. This challenging game demands an excellent memory (for bids, cards played, rules and so on) and an ability to think strategically and read subtle psychological cues. Never having had a head for cards, I continue to be amazed by the mental agility of these septua- and octogenarians.

The brain, like every other part of the body, changes with age, and those changes can impede clear thinking and memory. Yet many older people seem to remain sharp as a tack well into their 80s and beyond. Although their pace may have slowed, they continue to work, travel, attend plays and concerts, play cards and board games, study foreign languages, design buildings, work with computers, write books, do puzzles, knit or perform other mentally challenging tasks that can befuddle people much younger.

But when these sharp old folks die, autopsy studies often reveal extensive brain abnormalities like those in patients with Alzheimer’s. Dr. Nikolaos Scarmeas and Yaakov Stern at Columbia University Medical Center recall that in 1988, a study of “cognitively normal elderly women” showed that they had “advanced Alzheimer’s disease pathology in their brains at death.” Later studies indicated that up to two-thirds of people with autopsy findings of Alzheimer’s disease were cognitively intact when they died.

“Something must account for the disjunction between the degree of brain damage and its outcome,” the Columbia scientists deduced. And that something, they and others suggest, is “cognitive reserve.”

Cognitive reserve, in this theory, refers to the brain’s ability to develop and maintain extra neurons and connections between them via axons and dendrites. Later in life, these connections may help compensate for the rise in dementia-related brain pathology that accompanies normal aging.

Exercise: Mental …

As Cathryn Jakobson Ramin relates in her new book, “Carved in Sand: When Attention Fails and Memory Fades in Midlife” (HarperCollins), the brains of animals exposed to greater physical and mental stimulation appear to have a greater number of healthy nerve cells and connections between them. Scientists theorize that this excess of working neurons and interconnections compensates for damaged ones to ward off dementia.

Observing this, Dr. Stern, a neuropsychologist, and others set out to determine how people can develop cognitive reserve. They have learned thus far that there is no “quick fix” for the aging brain, and little evidence that any one supplement or program or piece of equipment can protect or enhance brain function — advertisements for products like ginkgo biloba to the contrary.

Nonetheless, well-designed studies suggest several ways to improve the brain’s viability. Though best to start early to build up cognitive reserve, there is evidence that this account can be replenished even late in life.

Cognitive reserve is greater in people who complete higher levels of education. The more intellectual challenges to the brain early in life, the more neurons and connections the brain is likely to develop and perhaps maintain into later years. Several studies of normal aging have found that higher levels of educational attainment were associated with slower cognitive and functional decline.

Dr. Scarmeas and Dr. Stern suggest that cognitive reserve probably reflects an interconnection between genetic intelligence and education, since more intelligent people are likely to complete higher levels of education.

But brain stimulation does not have to stop with the diploma. Better-educated people may go on to choose more intellectually demanding occupations and pursue brain-stimulating hobbies, resulting in a form of lifelong learning. In researching her book, Ms. Ramin said she found that novelty was crucial to providing stimulation for the aging brain.

“If you’re doing the same thing over and over again, without introducing new mental challenges, it won’t be beneficial,” she said in an interview. Thus, as with muscles, it’s “use it or lose it.” The brain requires continued stresses to maintain or enhance its strength.

So if you knit, challenge yourself with more than simply stitched scarves. Try a complicated pattern or garment. Listening to opera is lovely, but learning the libretto (available in most libraries) stimulates more neurons. In my 60s I took up knitting and crocheting and am now learning Spanish. My husband is a fanatical puzzle-doer who recently added Sudoku to the crosswords and double-crostics he carries around with him.

In 2001, Dr. Scarmeas published a long-term study of cognitively healthy elderly New Yorkers. On average, those who pursued the most leisure activities of an intellectual or social nature had a 38 percent lower risk of developing dementia. The more activities, the lower the risk.

Long-term studies in other countries, including Sweden and China, have also found that continued social interactions helped protect against dementia. The more extensive an older person’s social network, the better the brain is likely to work, the research suggests. Especially helpful are productive or mentally stimulating activities pursued with other people, like community gardening, taking classes, volunteering or participating in a play-reading group.

… and Physical

Perhaps the most direct route to a fit mind is through a fit body. As Sandra Aamodt, editor of Nature Neuroscience, and Sam Wang, a neuroscientist at Princeton University, recently stated on The New York Times’s Op-Ed page, physical exercise “improves what scientists call ‘executive function,’ the set of abilities that allows you to select behavior that’s appropriate to the situation, inhibit inappropriate behavior and focus on the job at hand in spite of distractions. Executive function includes basic functions like processing speed, response speed and working memory, the type used to remember a house number while walking from the car to a party.”

Although executive function typically declines with advancing years, “elderly people who have been athletic all their lives have much better executive function than sedentary people of the same age,” Dr. Aamodt and Dr. Wang reported.

And not just because cognitively healthy people tend to be more active. When inactive people in their 70s get more exercise, executive function improves, an analysis of 18 studies showed. Just walking fast for 30 to 60 minutes several times a week can help. And compared with those who are sedentary, people who exercise regularly in midlife are one-third as likely to develop Alzheimer’s in their 70s. Even those who start exercising in their 60s cut their risk of dementia in half.

Exercise may help by improving blood flow (and hence oxygen and nutrients) to the brain, reducing the risk of ministrokes and clogged blood vessels, and stimulating growth factors that promote the formation of new neurons and neuronal connections.

New York Times Full Feed – Dec. 17, 2007 – Three months ago, when the authorities announced that they had seized a large cache of counterfeit drugs from a EuroGulf Trading warehouse deep inside a sprawling free trade zone here, they gave no hint of the raid’s global significance.

But an examination of the case reveals its link to a complex supply chain of fake drugs that ran from China through Hong Kong, the United Arab Emirates, Britain and the Bahamas, ultimately leading to an Internet pharmacy whose American customers believed they were buying medicine from Canada, according to interviews with regulators and drug company investigators in six countries.

The seizure highlights how counterfeit drugs move in a global economy, and why they are so difficult to trace. And it underscores the role played by free trade zones — areas specially designated by a growing number of countries to encourage trade, where tariffs are waived and there is minimal regulatory oversight.

The problem is that counterfeiters use free trade zones to hide — or sanitize — a drug’s provenance, or to make, market or relabel adulterated products, according to anticounterfeiting experts.

”Free trade zones allow counterfeiters to evade the laws of the country because often times the regulations are lax in these zones,” said Ilisa Bernstein, director of pharmacy affairs at the United States Food and Drug Administration. ”This is where some of the Internet sellers work,” she added.

Dubai is particularly attractive to counterfeiters because of its strategic location on the Persian Gulf between Asia, Europe and Africa. Records show that nearly a third of all counterfeit drugs confiscated in Europe last year came from the United Arab Emirates. ”Three or four years ago, Dubai did not even appear on the radar screen,” said an investigator for a major American drug company who is based in China and requested anonymity because he did not have authority to speak for his employer.

Dubai is vulnerable because of the huge volume of goods that move through its free trade areas, and because of what is perceived by some in the pharmaceutical industry to be a murky line of authority for rooting out counterfeits there. ”It is not clear that the normal Dubai customs authorities have jurisdiction,” said Rubie Mages, a director of global security for Pfizer.

The authorities in Dubai do show a willingness to act when drug company investigators tip them to possible counterfeits, as they did in the raid announced earlier this year. ”Dubai has taken a big step in fighting the counterfeiters,” said Ahmed Butti Ahmed, director general of Dubai customs.

But significant quantities of fake drugs are still getting through, international health officials say. And as countries create more free zones, counterfeiters have more options. ”What happens is they move around,” said Ms. Bernstein of the F.D.A. Sometimes, in an attempt to avoid detection, they move products between free zones.

”It’s not just the U.A.E. trade zones that are a problem, but free zones around the world,” said Steve Allen, a senior investigator for Pfizer, who was in Dubai early this month to talk to customs officials.

One problem area, counterfeiting experts say, is the Colon Free Trade Zone, situated next to the Panama Canal.

In June, the Panamanian authorities raided a warehouse there that was used by an Australian, George Adams, to run his Internet pharmacy business. No charges were filed in connection with that raid, but about $50,000 in drugs were seized, Mr. Adams said. Several months earlier, Mr. Adams had been arrested for trying to sell counterfeit Viagra. He said he was ”set up” and denies any wrongdoing.

Mr. Allen, of Pfizer, said his latest concern involves counterfeit shipments passing through Jordan and Mauritius, an island east of Africa.

In July, the authorities in Dubai said fake drugs from Mauritius had been seized at a free zone next to the Dubai airport. There were more than half a million pills of counterfeit Plavix, a blood-thinning drug made by the French company Sanofi-Aventis.

The Dubai health authorities say they do not know who made it.

Some pills, a government official said at the time, contained cement powder.

A Suspicious Shipment

On May 22, 2006, British customs officials made a troubling discovery at Heathrow Airport in London. They intercepted 846 pounds of pharmaceuticals, mostly counterfeits of products made by such well-known companies as Merck, Novartis, AstraZeneca, Pfizer and Procter & Gamble. Some medication contained traces of metal.

These were not just lifestyle drugs; this medicine was supposed to treat high blood pressure, high cholesterol, osteoporosis and acid reflux, among other ailments.

Where the drugs came from and where they were going struck inspectors as odd.

The shipment had arrived from the United Arab Emirates en route to its next destination: the Bahamas. This was not a route the drug companies used, said Nimo Ahmed, head of intelligence for the British drug regulatory agency. ”What triggered this particular interception was that the pharmaceutical companies had conducted some awareness training with customs in Heathrow to explain suspicious routes,” Mr. Ahmed said.

Pfizer took a particular interest in the case. Thousands of pills of its cholesterol-fighting drug Lipitor had been among those counterfeited, the company said.

Pfizer, which runs one of the industry’s most sophisticated anticounterfeiting operations, contacted Bahamian law enforcement officials in the hope they would investigate the intended recipient of the Heathrow cache. In early June, the Bahamian authorities followed up and raided the Personal Touch Pharmacy in Freeport, seizing nearly $4 million in drugs, some of which turned out to be counterfeit, investigators said.

Eventually it was determined that the pharmacy did $8 million in annual business. The question was, with whom?

Meanwhile, back in London, there was the matter of tracing the drugs back to their source. That led to one of the many free trade zones in the United Arab Emirates. Those zones are major revenue producers for the emirates and, according to a 2006 State Department report, 17 of them were in operation, with 11 more in development.

”The government in Dubai, believing in the liberal market, adopted this concept,” said Mohammed Y. Rai Al Boom, a spokesman for the Dubai Airport Free Zone Authority. ”It is very convenient to get products in and out of Dubai.”

Mr. Ahmed, the British health official, said the zones were set up to encourage legitimate trade. ”They will process packages quicker, receive fees for them, and if everything is done legitimately it’s a win-win for everybody,” he said. But, he added, ”counterfeiters are using it as a way to hide where their products are originally sourced.”

Free zones act as way stations for goods moving around the globe. Since most of the shipments do not officially enter the country, there are fewer bureaucratic entanglements. In the emirates’ zones, the usual requirement for local ownership of companies is waived, and there are no import and export fees or income tax.

Shipping records showed that the Heathrow container came from a company located in a free zone in Sharjah, one of the emirates.

Drug company investigators say that shortly after the raid in the Bahamas, an effort was made to hide additional drug stock by moving it from Sharjah to the Jebel Ali Free Zone.

Afaque Ahmed Khan, a business executive in Dubai, has seen Jebel Ali grow from nothing. ”It’s literally like someone walking in the sand and placing his figure on a spot and saying, ‘This here is going to be the transit point for trade, globally,”’ Mr. Khan said. ”And that’s what happened, literally.”

By far the biggest and oldest free zone in Dubai, Jebel Ali is home to some 6,000 companies. A major new airport is being built to complement the seaport, where millions of containers from boats around the world are unloaded each year.

The counterfeit drugs were put in warehouse VC-08, which belonged to Euro Gulf, a trading house that sells laundry, household cleaning and personal care products, according to its Web site. ”Our proactive international strategy has resulted in an increase in exports to more than 40 countries worldwide,” the Web site said.

But customs officials in Dubai had been alerted to what was inside. They swept in, found counterfeit drugs and charged seven people with various crimes.

A Canadian Pharmacy

In the Bahamas, investigators had also made an important discovery. The computers at Personal Touch Pharmacy were connected to a server hosting a Canadian Internet pharmacy Web site.

The site belonged to RxNorth, described by one trade association as the world’s first major online pharmacy.

A founder, Andrew Strempler, had been the subject of numerous profiles, including one in The New York Times in 2005 that described how at the age of 30 he had two Dodge Vipers, a Jaguar and a yellow Lamborghini with a license plate that reads ”RX Boss.”

The article reported that Mr. Strempler’s innovation ”created a whole new Canadian industry that has plugged a niche in America’s troubled health care system almost overnight, providing about $800 million worth of low-cost drugs a year to two million uninsured and underinsured Americans, many elderly.” Drugs have traditionally been cheaper in Canada because of its health care system.

The big pharmaceutical companies were not pleased. Pfizer and Merck cut off his supplies, forcing Mr. Strempler to buy from other wholesalers.

That was not Mr. Strempler’s only setback. According to the Manitoba Pharmaceutical Association newsletter, the group’s discipline committee concluded that in 2001 Mr. Strempler had improperly filled ”in excess of 10,000 orders for medications for patients residing in the United States of America without receiving prescriptions from a medical practitioner or dentist licensed to practice in Canada.”

Mr. Strempler’s online business began to unravel last year when Edward Hector, a former customer service employee, complained to a Canadian television station about the company’s business practices. In a recent interview, Mr. Hector said he was told, ”Under no circumstances are you to tell any customer that their medication comes from the Bahamas.” Mr. Hector said he left RxNorth in May 2006 after working there for a little more than a year.

Mr. Strempler did not return telephone messages seeking comment, but he has publicly defended his products. The television station also quoted him as saying customers were not told about the Bahamas because medicine coming through there might actually originate in Europe or Australia. It was not clear if he knew the true source of drugs being dispensed by the company in the Bahamas.

In fact, drug company investigators say, some of them were coming from China, a country known for producing counterfeit medicine.

”We traced the source of the medicines and determined that they had been manufactured in China,” said Ms. Mages of Pfizer. From the mainland it went to Hong Kong, then to the United Arab Emirates and the Bahamas, where individual prescriptions were filled and put into packets and addressed.

”Instead of sending it directly to the patient, it then went back to the U.K., where U.K. postage would be affixed, and then it would be mailed to the U.S.,” Ms. Mages said. ”This was done to lend credibility to the medicine.”

Drug company investigators say they believe that at least some of the counterfeit drugs seized at the Jebel Ali zone were following that same route.

Mr. Ahmed, the British health official, said circuitous routes were used to avoid customs checks. ”The chance of getting intercepted lessens if they use this route,” he said. And Ms. Mages cited another reason: ”The whole purpose of going through multiple points of entry is to disguise the source.”

In August and September of last year, the F.D.A. intercepted 5,000 packages from the online pharmacy. At the same time, the agency also warned Americans not to buy 10 drugs from RxNorth or related Web sites because preliminary testing had found counterfeits.

The drugs named were: Lipitor, Crestor and Zetia, for cholesterol; Diovan and Hyzaar, for high blood pressure; Actonel for osteoporosis; Nexium for reflux disease; Celebrex for arthritis pain; Arimidex for breast cancer; and Propecia for baldness.

Trail’s End

Mr. Strempler has not been charged with any crime relating to RxNorth, and published reports say about a year ago he transferred dispensing operations to another Canadian online pharmacy.

The F.D.A. declined to comment on RxNorth. Health Canada, the national health agency, said it ”cannot comment on ongoing investigations, specific companies or alleged violations with respect to possible counterfeit activity.”

In the Bahamas, a pharmacist and office manager for Personal Touch Pharmacy face trial next year on conspiracy and fraud charges, said Garvin Gaskin, chief counsel for the office of attorney general in the Bahamas.

In Dubai, seven officials associated with Euro Gulf were convicted recently and sent to prison, customs officials said. ”We have been successful in getting customs authorities to work with us to inspect and to seize questionable goods, but we still have a long way to go,” Ms. Mages said.

And Mr. Ahmed, the British health official, said he expected individuals to be tried next year on charges relating to RxNorth’s links to Britain. He declined to elaborate.

But a critical piece of the puzzle remains missing — who made the counterfeit drugs? Investigators had obtained the license number of a truck that brought the suspect medicine into Hong Kong from mainland China. But that turned out to be a dead end.

And even if investigators do find the factory, there is no shortage of Chinese companies making fake, subpotent or adulterated drug products.

”Some of them in the morning, they manufacture good drugs and in the afternoon and evening they manufacture counterfeit medicine,” said Dr. Mohammed Abu Elkhair, a health official in Abu Dhabi who helped organize a conference last month in the capital city to educate United Arab Emirates officials on how to combat counterfeit medicine.

In October, The New York Times reported that scores of Chinese chemical companies were exporting drug ingredients even though they were not licensed to do so.

Calling counterfeit medicine a growing global threat, Dr. Abu Elkhair said one only had to look at a mass poisoning in Panama last year to understand the seriousness of the problem. More than a hundred people died there because the government had unwittingly mixed a counterfeit ingredient made by a chemical company in China into cold medicine.

”The people there lost faith in the whole health care system, not just in the drug regulations authority,” he said.

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