Scant Proof Is Found to Back Up Claims by Energy Drinks

Energy drinks are the fastest-growing part of the beverage industry, with sales in the United States reaching more than $10 billion in 2012 — more than Americans spent on iced tea or sports beverages like Gatorade.

Their rising popularity represents a generational shift in what people drink, and reflects a successful campaign to convince consumers, particularly teenagers, that the drinks provide a mental and physical edge.

The drinks are now under scrutiny by the Food and Drug Administration after reports of deaths and serious injuries that may be linked to their high caffeine levels. But however that review ends, one thing is clear, interviews with researchers and a review of scientific studies show: the energy drink industry is based on a brew of ingredients that, apart from caffeine, have little, if any benefit for consumers.

“If you had a cup of coffee you are going to affect metabolism in the same way,” said Dr. Robert W. Pettitt, an associate professor at Minnesota State University in Mankato, who has studied the drinks.

Energy drink companies have promoted their products not as caffeine-fueled concoctions but as specially engineered blends that provide something more. For example, producers claim that “Red Bull gives you wings,” that Rockstar Energy is “scientifically formulated” and Monster Energy is a “killer energy brew.” Representative Edward J. Markey of Massachusetts, a Democrat, has asked the government to investigate the industry’s marketing claims.

Promoting a message beyond caffeine has enabled the beverage makers to charge premium prices. A 16-ounce energy drink that sells for $2.99 a can contains about the same amount of caffeine as a tablet of NoDoz that costs 30 cents. Even Starbucks coffee is cheap by comparison; a 12-ounce cup that costs $1.85 has even more caffeine.

As with earlier elixirs, a dearth of evidence underlies such claims. Only a few human studies of energy drinks or the ingredients in them have been performed and they point to a similar conclusion, researchers say — that the beverages are mainly about caffeine.

Caffeine is called the world’s most widely used drug. A stimulant, it increases alertness, awareness and, if taken at the right time, improves athletic performance, studies show. Energy drink users feel its kick faster because the beverages are typically swallowed quickly or are sold as concentrates.

“These are caffeine delivery systems,” said Dr. Roland Griffiths, a researcher at Johns Hopkins University who has studied energy drinks. “They don’t want to say this is equivalent to a NoDoz because that is not a very sexy sales message.”

A scientist at the University of Wisconsin became puzzled as he researched an ingredient used in energy drinks like Red Bull, 5-Hour Energy and Monster Energy. The researcher, Dr. Craig A. Goodman, could not find any trials in humans of the additive, a substance with the tongue-twisting name of glucuronolactone that is related to glucose, a sugar. But Dr. Goodman, who had studied other energy drink ingredients, eventually found two 40-year-old studies from Japan that had examined it.

In the experiments, scientists injected large doses of the substance into laboratory rats. Afterward, the rats swam better. “I have no idea what it does in energy drinks,” Dr. Goodman said.

Energy drink manufacturers say it is their proprietary formulas, rather than specific ingredients, that provide users with physical and mental benefits. But that has not prevented them from implying otherwise.

Consider the case of taurine, an additive used in most energy products.

On its Web site, the producer of Red Bull, for example, states that “more than 2,500 reports have been published about taurine and its physiological effects,” including acting as a “detoxifying agent.” In addition, that company, Red Bull of Austria, points to a 2009 safety study by a European regulatory group that gave it a clean bill of health.

But Red Bull’s Web site does not mention reports by that same group, the European Food Safety Authority, which concluded that claims about the benefits in energy drinks lacked scientific support. Based on those findings, the European Commission has refused to approve claims that taurine helps maintain mental function and heart health and reduces muscle fatigue.

Taurine, an amino acidlike substance that got its name because it was first found in the bile of bulls, does play a role in bodily functions, and recent research suggests it might help prevent heart attacks in women with high cholesterol. However, most people get more than adequate amounts from foods like meat, experts said. And researchers added that those with heart problems who may need supplements would find far better sources than energy drinks.

Hiroko Tabuchi contributed reporting from Tokyo and Poypiti Amatatham from Bangkok.

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The Long Life of the ‘Perfect’ Woman

What did happen to Elsie Scheel, the “perfect” woman mentioned in an article in Wednesday’s New York Times that described how people considered overweight had a slightly lower risk of dying than those of normal weight?

A century ago, at age 24, Miss Scheel was the subject of a spate of news media coverage after the “medical examiner of the 400 ‘co-eds’ ” at her college, Cornell University, described her as the epitome of “perfect health,” according to a 1912 New York Times article. That article and others also gave her dimensions: 5-foot-7 and 171 pounds, which would have corresponded to a body mass index of 27, putting Miss Scheel in the overweight category. Miss Scheel, it turns out, lived a long life, dying in 1979 in St. Cloud, Fla., three days shy of her 91st birthday.

But though it may be tempting to conclude that Miss Scheel’s longevity exemplifies the benefits of a not-too-low B.M.I, her case is only one anecdote, of course. And, according to family members and to hints provided in early articles, she was a person who valued being active and athletic, had a strong and confident attitude, and, as a daughter of a doctor and a mother of a doctor, may have been steeped in healthy habits that were much more relevant to her survival than her weight.

“She never took an aspirin or a Tylenol,” a granddaughter, Karen Hirsh Meredith, of Broken Arrow, Okla., said in an interview Wednesday. She kept up hobbies like stamp collecting and wrote pieces for the St. Cloud newspaper. And, Ms. Meredith said, “she was still driving late in life.”

Ms. Meredith said she did not recall her grandmother having any illnesses or being hospitalized except for shortly before she died, when she went into the hospital with stomach pain. She ended up having surgery for a perforated bowel and died the next day, Ms. Meredith said.

A death notice said Miss Scheel, who was Mrs. Hirsh when she died, had been a “practical nurse,” although Ms. Meredith said the family believed she did not work after she had children. In 1918 she married Frederick Rudolph Hirsh, an architect who supervised the building of the New York Public Library and who was a widower with two children, Frederick Jr. and Mary. He died in 1933 at 68, leaving his wife to raise a son, John, and a daughter, Elise. She moved to Florida from Mount Vernon, N.Y., in the 1940s and never remarried.

Miss Scheel’s mother, Sophie Bade Scheel, a physician educated at New York Medical College, maintained an active medical practice at a time when relatively few women did. And Miss Scheel may have benefited from good genes: her three siblings were 79, 88 and 93 when they died.

Published reports from 1912 and 1913 provide glimpses of the type of person Miss Scheel was and of her immediate-post-"perfect” experience.

She participated in many sports, playing basketball at Cornell. “I play a guard, where my weight helps,” she told a newspaper. She was a suffragette and, the Times article said, “doesn’t know what fear is.”

She ate only three meals every two days, loved beefsteak and shunned candy and caffeine. An article in The Oregonian asked her about her advice for healthy living, reporting that “Miss Scheel feels that the average girl does too much of the wrong sort of thing — too many dances and not enough good bracing tramps. I just got back from a 25-mile tramp to Enfield Falls.”

Some of the news media coverage was catty, even brutal. And it was extremely detailed. Her particulars — the size of her chest, waist and hips — were compared to the Venus de Milo.

A day after the Times article, The New York Herald ran a story about Miss Scheel above the fold on its front page: “Brooklyn Venus Much Too Large is Verdict of Physical Culturists.” These “physical culturists” claimed that Miss Scheel’s weight and height “cannot be reconciled with the accepted ideal of female beauty.”

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Employers Must Offer Family Health Care, Affordable or Not, Administration Says

WASHINGTON — In a long-awaited interpretation of the new health care law, the Obama administration said Monday that employers must offer health insurance to employees and their children, but will not be subject to any penalties if family coverage is unaffordable to workers.

The requirement for employers to provide health benefits to employees is a cornerstone of the new law, but the new rules proposed by the Internal Revenue Service said that employers’ obligation was to provide affordable insurance to cover their full-time employees. The rules offer no guarantee of affordable insurance for a worker’s children or spouse. To avoid a possible tax penalty, the government said, employers with 50 or more full-time employees must offer affordable coverage to those employees. But, it said, the meaning of “affordable” depends entirely on the cost of individual coverage for the employee, what the worker would pay for “self-only coverage.”

The new rules, to be published in the Federal Register, create a strong incentive for employers to put money into insurance for their employees rather than dependents. It is unclear whether the spouse and children of an employee will be able to obtain federal subsidies to help them buy coverage — separate from the employee — through insurance exchanges being established in every state. The administration explicitly reserved judgment on that question, which could affect millions of people in families with low and moderate incomes.

Many employers provide family coverage to full-time employees, but many do not. Family coverage is much more expensive, and the employee’s share of the premium is typically much larger.

In 2012, according to an annual survey by the Kaiser Family Foundation, premiums for employer-sponsored health insurance averaged $5,615 a year for single coverage and $15,745 for family coverage. The employee’s share of the premium averaged $951 for individual coverage and more than four times as much, $4,316, for family coverage.

Starting in 2014, most Americans will be required to have health insurance. Low- and middle-income people can get tax credits to help pay their premiums, unless they have access to affordable coverage from an employer.

In its proposal, the Internal Revenue Service said, “Coverage for an employee under an employer-sponsored plan is affordable if the employee’s required contribution for self-only coverage does not exceed 9.5 percent of the employee’s household income.”

The rules, though labeled a proposal, are more significant than most proposed regulations. The Internal Revenue Service said employers could rely on them in making plans for 2014.

In writing the law, members of Congress often conjured up a picture of employees working year-round at full-time jobs. But in drafting the rules, the I.R.S. wrestled with the complex reality of part-time, seasonal and temporary workers.

In addition, the administration expressed concern that some employers might try to evade the new requirements by firing and rehiring employees, manipulating their work hours or using temporary staffing agencies. The rules include several provisions to prevent such abuse.

The law says an employer with 50 or more full-time employees may be subject to a tax penalty if it fails to offer coverage to “its full-time employees (and their dependents).”

Employers asked for guidance, and the Obama administration provided it, saying that a dependent is an employee’s child under the age of 26.

“Dependent does not include the spouse of an employee,” the proposed rules say.

Thus, employers must offer coverage to children of an employee, but do not have to make it affordable. And they do not have to offer coverage at all to the spouse of an employee.

The administration said that the rules — which apply to private businesses, nonprofit organizations and state and local government agencies — would require changes at many work sites.

“A number of employers currently offer coverage only to their employees, and not to dependents,” the I.R.S. said. “For these employers, expanding their health plans to add dependent coverage will require substantial revisions to their plans.”

In view of this challenge, the agency said it would grant a one-time reprieve to employers who fail to offer coverage to dependents of full-time employees, provided they take steps in 2014 to come into compliance. Under the rules, employers must offer coverage to employees in 2014 and must offer coverage to dependents as well, starting in 2015.

The new rules apply to employers that have at least 50 full-time employees or an equivalent combination of full-time and part-time employees. A full-time employee is a person employed on average at least 30 hours a week. And 100 half-time employees are considered equivalent to 50 full-time employees.

Thus, the government said, an employer will be subject to the new requirement if it has 40 full-time employees working 30 hours a week and 20 half-time employees working 15 hours a week.

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Hispanic Pregnancies Fall in U.S. as Women Choose Smaller Families

ORLANDO, Fla. — Hispanic women in the United States, who have generally had the highest fertility rates in the country, are choosing to have fewer children. Both immigrant and native-born Latinas had steeper birthrate declines from 2007 to 2010 than other groups, including non-Hispanic whites, blacks and Asians, a drop some demographers and sociologists attribute to changes in the views of many Hispanic women about motherhood.

As a result, in 2011, the American birthrate hit a record low, with 63 births per 1,000 women ages 15 to 44, led by the decline in births to immigrant women. The national birthrate is now about half what it was during the baby boom years, when it peaked in 1957 at 122.7 births per 1,000 women of childbearing age.

The decline in birthrates was steepest among Mexican-American women and women who immigrated from Mexico, at 25.7 percent. This has reversed a trend in which immigrant mothers accounted for a rising share of births in the United States, according to a recent report by the Pew Research Center. In 2010, birthrates among all Hispanics reached their lowest level in 20 years, the center found.

The sudden drop-off, which coincided with the onset of the recession, suggests that attitudes have changed since the days when older generations of Latinos prized large families and more closely followed Roman Catholic teachings, which forbid artificial contraception.

Interviews with young Latinas, as well as reproductive health experts, show that the reasons for deciding to have fewer children are many, involving greater access to information about contraceptives and women’s health, as well as higher education.

When Marucci Guzman decided to marry Tom Beard here seven years ago, the idea of having a large family — a Guzman tradition back in Puerto Rico — was out of the question.

“We thought one, maybe two,” said Ms. Guzman Beard, who gave birth to a daughter, Attalai, four years ago.

Asked whether Attalai might ever get her wish for a little brother or sister, Ms. Guzman Beard, 29, a vice president at a public service organization, said: “I want to go to law school. I’m married. I work. When do I have time?”

The decisions were not made in a vacuum but amid a sputtering economy, which, interviewees said, weighed heavily on their minds.

Latinos suffered larger percentage declines in household wealth than white, black or Asian households from 2005 to 2009, and, according to the Pew report, their rates of poverty and unemployment also grew more sharply after the recession began.

Prolonged recessions do produce dips in the birthrate, but a drop as large as Latinos have experienced is atypical, said William H. Frey, a sociologist and demographer at the Brookings Institution. “It is surprising,” Mr. Frey said. “When you hear about a decrease in the birthrate, you don’t expect Latinos to be at the forefront of the trend.”

D’Vera Cohn, a senior writer at the Pew Research Center and an author of the report, said that in past recessions, when overall fertility dipped, “it bounced back over time when the economy got better.”

“If history repeats itself, that will happen again,” she said.

But to Mr. Frey, the decrease has signaled much about the aspirations of young Latinos to become full and permanent members of the upwardly mobile middle class, despite the challenges posed by the struggling economy.

Jersey Garcia, a 37-year-old public health worker in Miami, is in the first generation of her family to live permanently outside of the Dominican Republic, where her maternal and paternal grandmothers had a total of 27 children.

“I have two right now,” Ms. Garcia said. “It’s just a good number that I can handle.”

“Before, I probably would have been pressured to have more,” she added. “I think living in the United States, I don’t have family members close by to help me, and it takes a village to raise a child. So the feeling is, keep what you have right now.”

But that has not been easy. Even with health insurance, Ms. Garcia’s preferred method of long-term birth control, an IUD, has been unaffordable. Birth control pills, too, with a $50 co-payment a month, were too costly for her budget. “I couldn’t afford it,” she said. “So what I’ve been doing is condoms.”

According to research by the National Latina Institute for Reproductive Health, the overwhelming majority of Latinas have used contraception at some point in their lives, but they face economic barriers to consistent use. As a consequence, Latinas still experience unintended pregnancy at a rate higher than non-Hispanic whites, according to the institute.

And while the share of births to teenage mothers has dropped over the past two decades for all women, the highest share of births to teenage mothers is among native-born Hispanics.

“There are still a lot of barriers to information and access to contraception that exist,” said Jessica Gonzáles-Rojas, 36, the executive director of the institute, who has one son. “We still need to do a lot of work.”

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Well: Exercise and the Ever-Smarter Human Brain

Anyone whose resolve to exercise in 2013 is a bit shaky might want to consider an emerging scientific view of human evolution. It suggests that we are clever today in part because a million years ago, we could outrun and outwalk most other mammals over long distances. Our brains were shaped and sharpened by movement, the idea goes, and we continue to require regular physical activity in order for our brains to function optimally.

Phys Ed

Gretchen Reynolds on the science of fitness.

The role of physical endurance in shaping humankind has intrigued anthropologists and gripped the popular imagination for some time. In 2004, the evolutionary biologists Daniel E. Lieberman of Harvard and Dennis M. Bramble of the University of Utah published a seminal article in the journal Nature titled “Endurance Running and the Evolution of Homo,” in which they posited that our bipedal ancestors survived by becoming endurance athletes, able to bring down swifter prey through sheer doggedness, jogging and plodding along behind them until the animals dropped.

Endurance produced meals, which provided energy for mating, which meant that adept early joggers passed along their genes. In this way, natural selection drove early humans to become even more athletic, Dr. Lieberman and other scientists have written, their bodies developing longer legs, shorter toes, less hair and complicated inner-ear mechanisms to maintain balance and stability during upright ambulation. Movement shaped the human body.

But simultaneously, in a development that until recently many scientists viewed as unrelated, humans were becoming smarter. Their brains were increasing rapidly in size.

Today, humans have a brain that is about three times larger than would be expected, anthropologists say, given our species’ body size in comparison with that of other mammals.

To explain those outsized brains, evolutionary scientists have pointed to such occurrences as meat eating and, perhaps most determinatively, our early ancestors’ need for social interaction. Early humans had to plan and execute hunts as a group, which required complicated thinking patterns and, it’s been thought, rewarded the social and brainy with evolutionary success. According to that hypothesis, the evolution of the brain was driven by the need to think.

But now some scientists are suggesting that physical activity also played a critical role in making our brains larger.

To reach that conclusion, anthropologists began by looking at existing data about brain size and endurance capacity in a variety of mammals, including dogs, guinea pigs, foxes, mice, wolves, rats, civet cats, antelope, mongooses, goats, sheep and elands. They found a notable pattern. Species like dogs and rats that had a high innate endurance capacity, which presumably had evolved over millenniums, also had large brain volumes relative to their body size.

The researchers also looked at recent experiments in which mice and rats were systematically bred to be marathon runners. Lab animals that willingly put in the most miles on running wheels were interbred, resulting in the creation of a line of lab animals that excelled at running.

Interestingly, after multiple generations, these animals began to develop innately high levels of substances that promote tissue growth and health, including a protein called brain-derived neurotrophic factor, or BDNF. These substances are important for endurance performance. They also are known to drive brain growth.

What all of this means, says David A. Raichlen, an anthropologist at the University of Arizona and an author of a new article about the evolution of human brains appearing in the January issue of Proceedings of the Royal Society B, is that physical activity may have helped to make early humans smarter.

“We think that what happened” in our early hunter-gatherer ancestors, he says, is that the more athletic and active survived and, as with the lab mice, passed along physiological characteristics that improved their endurance, including elevated levels of BDNF. Eventually, these early athletes had enough BDNF coursing through their bodies that some could migrate from the muscles to the brain, where it nudged the growth of brain tissue.

Those particular early humans then applied their growing ability to think and reason toward better tracking prey, becoming the best-fed and most successful from an evolutionary standpoint. Being in motion made them smarter, and being smarter now allowed them to move more efficiently.

And out of all of this came, eventually, an ability to understand higher math and invent iPads. But that was some time later.

The broad point of this new notion is that if physical activity helped to mold the structure of our brains, then it most likely remains essential to brain health today, says John D. Polk, an associate professor of anthropology at the University of Illinois at Urbana-Champaign, and co-author, with Dr. Raichlen, of the new article.

And there is scientific support for that idea. Recent studies have shown, he says, that “regular exercise, even walking,” leads to more robust mental abilities, “beginning in childhood and continuing into old age.”

Of course, the hypothesis that jogging after prey helped to drive human brain evolution is just a hypothesis, Dr. Raichlen says, and almost unprovable.

But it is compelling, says Harvard’s Dr. Lieberman, who has worked with the authors of the new article. “I fundamentally agree that there is a deep evolutionary basis for the relationship between a healthy body and a healthy mind,” he says, a relationship that makes the term “jogging your memory” more literal than most of us might have expected and provides a powerful incentive to be active in 2013.

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This post has been revised to reflect the following correction:

Correction: December 31, 2012

An earlier version of this article misstated the name of a scientific journal. It is the Proceedings of the Royal Society B, not the Proceedings of the Royal Society Biology.

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Well: Exercise and the Ever-Smarter Human Brain

Anyone whose resolve to exercise in 2013 is a bit shaky might want to consider an emerging scientific view of human evolution. It suggests that we are clever today in part because a million years ago, we could outrun and outwalk most other mammals over long distances. Our brains were shaped and sharpened by movement, the idea goes, and we continue to require regular physical activity in order for our brains to function optimally.

Phys Ed

Gretchen Reynolds on the science of fitness.

The role of physical endurance in shaping humankind has intrigued anthropologists and gripped the popular imagination for some time. In 2004, the evolutionary biologists Daniel E. Lieberman of Harvard and Dennis M. Bramble of the University of Utah published a seminal article in the journal Nature titled “Endurance Running and the Evolution of Homo,” in which they posited that our bipedal ancestors survived by becoming endurance athletes, able to bring down swifter prey through sheer doggedness, jogging and plodding along behind them until the animals dropped.

Endurance produced meals, which provided energy for mating, which meant that adept early joggers passed along their genes. In this way, natural selection drove early humans to become even more athletic, Dr. Lieberman and other scientists have written, their bodies developing longer legs, shorter toes, less hair and complicated inner-ear mechanisms to maintain balance and stability during upright ambulation. Movement shaped the human body.

But simultaneously, in a development that until recently many scientists viewed as unrelated, humans were becoming smarter. Their brains were increasing rapidly in size.

Today, humans have a brain that is about three times larger than would be expected, anthropologists say, given our species’ body size in comparison with that of other mammals.

To explain those outsized brains, evolutionary scientists have pointed to such occurrences as meat eating and, perhaps most determinatively, our early ancestors’ need for social interaction. Early humans had to plan and execute hunts as a group, which required complicated thinking patterns and, it’s been thought, rewarded the social and brainy with evolutionary success. According to that hypothesis, the evolution of the brain was driven by the need to think.

But now some scientists are suggesting that physical activity also played a critical role in making our brains larger.

To reach that conclusion, anthropologists began by looking at existing data about brain size and endurance capacity in a variety of mammals, including dogs, guinea pigs, foxes, mice, wolves, rats, civet cats, antelope, mongooses, goats, sheep and elands. They found a notable pattern. Species like dogs and rats that had a high innate endurance capacity, which presumably had evolved over millenniums, also had large brain volumes relative to their body size.

The researchers also looked at recent experiments in which mice and rats were systematically bred to be marathon runners. Lab animals that willingly put in the most miles on running wheels were interbred, resulting in the creation of a line of lab animals that excelled at running.

Interestingly, after multiple generations, these animals began to develop innately high levels of substances that promote tissue growth and health, including a protein called brain-derived neurotrophic factor, or BDNF. These substances are important for endurance performance. They also are known to drive brain growth.

What all of this means, says David A. Raichlen, an anthropologist at the University of Arizona and an author of a new article about the evolution of human brains appearing in the January issue of Proceedings of the Royal Society Biology, is that physical activity may have helped to make early humans smarter.

“We think that what happened” in our early hunter-gatherer ancestors, he says, is that the more athletic and active survived and, as with the lab mice, passed along physiological characteristics that improved their endurance, including elevated levels of BDNF. Eventually, these early athletes had enough BDNF coursing through their bodies that some could migrate from the muscles to the brain, where it nudged the growth of brain tissue.

Those particular early humans then applied their growing ability to think and reason toward better tracking prey, becoming the best-fed and most successful from an evolutionary standpoint. Being in motion made them smarter, and being smarter now allowed them to move more efficiently.

And out of all of this came, eventually, an ability to understand higher math and invent iPads. But that was some time later.

The broad point of this new notion is that if physical activity helped to mold the structure of our brains, then it most likely remains essential to brain health today, says John D. Polk, an associate professor of anthropology at the University of Illinois at Urbana-Champaign, and co-author, with Dr. Raichlen, of the new article.

And there is scientific support for that idea. Recent studies have shown, he says, that “regular exercise, even walking,” leads to more robust mental abilities, “beginning in childhood and continuing into old age.”

Of course, the hypothesis that jogging after prey helped to drive human brain evolution is just a hypothesis, Dr. Raichlen says, and almost unprovable.

But it is compelling, says Harvard’s Dr. Lieberman, who has worked with the authors of the new article. “I fundamentally agree that there is a deep evolutionary basis for the relationship between a healthy body and a healthy mind,” he says, a relationship that makes the term “jogging your memory” more literal than most of us might have expected and provides a powerful incentive to be active in 2013.

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Surgery Returns to NYU Langone Medical Center

Chang W. Lee/The New York Times

Senator Charles E. Schumer spoke at a news conference Thursday about the reopening of NYU Langone Medical Center.

NYU Langone Medical Center opened its doors to surgical patients on Thursday, almost two months after Hurricane Sandy overflowed the banks of the East River and forced the evacuation of hundreds of patients.

While the medical center had been treating many outpatients, it had farmed out surgery to other hospitals, which created scheduling problems that forced many patients to have their operations on nights and weekends, when staffing is traditionally low. Some patients and doctors had to postpone not just elective but also necessary operations for lack of space at other hospitals.

The medical center’s Tisch Hospital, its major hospital for inpatient services, between 30th and 34th Streets on First Avenue, had been closed since the hurricane knocked out power and forced the evacuation of more than 300 patients, some on sleds brought down darkened flights of stairs.

“I think it’s a little bit of a miracle on 34th Street that this happened so quickly,” Senator Charles E. Schumer of New York said Thursday.

Mr. Schumer credited the medical center’s leadership and esprit de corps, and also a tour of the damaged hospital on Nov. 9 by the administrator of the Federal Emergency Management Agency, W. Craig Fugate, whom he and others escorted through watery basement hallways.

“Every time I talk to Fugate there are a lot of questions, but one is, ‘How are you doing at NYU?’ ” the senator said.

The reopening of Tisch to surgery patients and associated services, like intensive care, some types of radiology and recovery room anesthesia, was part of a phased restoration that will continue. Besides providing an essential service, surgery is among the more lucrative of hospital services.

The hospital’s emergency department is expected to delay its reopening for about 11 months, in part to accommodate an expansion in capacity to 65,000 patient visits a year, from 43,000, said Dr. Andrew W. Brotman, its senior vice president and vice dean for clinical affairs and strategy.

In the meantime, NYU Langone is setting up an urgent care center with 31 bays and an observation unit, which will be able to treat some emergency patients. It will initially not accept ambulances, but might be able to later, Dr. Brotman said. Nearby Bellevue Hospital Center, which was also evacuated, opened its emergency department to noncritical injuries on Monday.

Labor and delivery, the cancer floor, epilepsy treatment and pediatrics and neurology beyond surgery are expected to open in mid-January, Langone officials said. While some radiology equipment, which was in the basement, has been restored, other equipment — including a Gamma Knife, a device using radiation to treat brain tumors — is not back.

The flooded basement is still being worked on, and electrical gear has temporarily been moved upstairs. Mr. Schumer, a Democrat, said that a $60 billion bill to pay for hurricane losses and recovery in New York and New Jersey was nearing a vote, and that he was optimistic it would pass in the Senate with bipartisan support. But the measure’s fate in the Republican-controlled House is far less certain.

The bill includes $1.2 billion for damage and lost revenue at NYU Langone, including some money from the National Institutes of Health to restore research projects. It would also cover Long Beach Medical Center in Nassau County, Bellevue, Coney Island Hospital and the Veterans Affairs hospital in Manhattan.

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New York’s Mental Health System Thrashed by Services Lost to Storm

Marcus Yam for The New York Times

Dr. Richard Rosenthal, physician in chief of behavioral services for Continuum hospitals, at St. Luke’s-Roosevelt Hospital Center.

When a young woman in the grip of paranoid delusions threatened a neighbor with a meat cleaver one Saturday last month, the police took her by ambulance to the nearest psychiatric emergency room. Or rather, they took her to Beth Israel Medical Center, the only comprehensive psychiatric E.R. functioning in Lower Manhattan since Hurricane Sandy shrank and strained New York’s mental health resources.

The case was one of 9,548 “emotionally disturbed person” calls that the Police Department answered in November, and one of the 2,848 that resulted in transportation to a hospital, a small increase over a year earlier.

But the woman was discharged within hours, to the shock of the mental health professionals who had called the police. It took four more days, and strong protests from her psychiatrist and caseworkers, to get her admitted for two weeks of inpatient treatment, said Tony Lee, who works for Community Access, a nonprofit agency that provides supportive housing to people with mental illness, managing the Lower East Side apartment building where she lives.

Psychiatric hospital admission is always a judgment call. But in the city, according to hospital records and interviews with psychiatrists and veteran advocates of community care, the odds of securing mental health treatment in a crisis have worsened significantly since the hurricane. The storm’s surge knocked out several of the city’s largest psychiatric hospitals, disrupted outpatient services and flooded scores of coastal nursing homes and “adult homes” where many mentally ill people had found housing of last resort.

One of the most affected hospitals, Beth Israel, recorded a 69 percent spike in psychiatric emergency room cases last month, with its inpatient slots overflowing. Instead of admitting more than one out of three such cases, as it did in November 2011, it admitted only one out of four of the 691 emergency arrivals this November, records show. Capacity was so overtaxed that ambulances had to be diverted to other hospitals 15 times in the month, almost double the rate last year, in periods typically lasting for eight hours, officials said.

Dr. Richard Rosenthal, physician in chief of behavioral services for Continuum Health Partners, Beth Israel’s parent organization, said he was proud of how much Continuum’s hospitals had done to handle psychiatric overflow since storm damage shuttered Bellevue Hospital Center, the city’s flagship public hospital; NYU Langone Medical Center; and the Veterans Affairs Hospital. But these days, he said, as he walks on Amsterdam Avenue between Continuum’s Roosevelt hospital on West 59th Street and its St. Luke’s hospital on West 114th Street, he notices more mentally ill people in the streets than he has seen in years.

“When you have the most vulnerable folks, all you need is one chink in the system and you lose them,” Dr. Rosenthal said. “Whether they lost their housing, or the outpatient services they usually go to were closed and they were lost to follow-up, they have become disconnected, with predictable results.”

Similar patterns are playing out in Brooklyn, where Maimonides Medical Center has been overwhelmed with mental health emergencies from the Coney Island vicinity since Coney Island Hospital, one of the city’s largest acute care psychiatric hospitals, suspended operations, hospital officials said.

“Triage has reached a different level: You have to get sicker to get in,” said Dr. Andrew Kolodny, the chairman of psychiatry at Maimonides, citing a 56 percent increase in psychiatric emergency room visits there from Oct. 26 to Dec. 7, compared with the same period last year, and a 24 percent rise in admissions. The increase in admissions was possible only with emergency permission from the state to exceed licensed limits.

“Not only is there decreased capacity, because Bellevue and Coney Island are off line,” Dr. Kolodny added, “but there’s increased demand because the storm or the loss of their residence has been a stressor for mental illness.”

The storm battered a mental health system that still relies heavily on private nursing homes and substandard adult homes to house people with mental illness. Such institutions have a sordid history of neglect and exploitation, and the courts have repeatedly found that their overuse by the state isolated thousands of people in violation of the Americans With Disabilities Act.

Plans are under way to increase supportive housing — dwellings where mentally ill people can live relatively independently, with support services. But even before Hurricane Sandy, the expansion fell far short of demand.

The storm underscored the fragility of the system. Many disabled evacuees who were sent first to makeshift school shelters lost access to the psychiatric medications that kept their symptoms at bay, Dr. Kolodny said. Even those lucky enough to have the drugs they need are at greater risk of relapse as they experience crowded living conditions. “If they’re now sleeping in a gym with 100 people, that can tip them over the edge and start making them really paranoid,” he said.

On Staten Island, where the chief of psychiatry at Richmond University Medical Center says psychiatric resources have been stretched to the limit, clergy members report that mentally ill people transferred to a large adult home in New Brighton from one that was washed away in Far Rockaway, Queens, are now showing up at church rectories, begging for socks and underwear.

“It’s heartbreaking, because they just found us by chance,” said Margaret Moschetto, a missionary at the Church of Assumption-St. Paul in New Brighton. “They were just walking around the neighborhood. They really didn’t know where they were.”

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Is the Cure for Cancer Inside You?

Claudia Steinman saw her husband’s BlackBerry blinking in the dark. It had gone untouched for several days, in a bowl beside his keys, the last thing on anybody’s mind. But about an hour before sunrise, she got up to get a glass of water and, while padding toward the kitchen, found an e-mail time-stamped early that morning — “Sent: Monday, Oct. 3, 2011, 5:23 a.m. Subject: Nobel Prize. Message: Dear Dr. Steinman, I have good news for you. The Nobel Assembly has today decided to award you the Nobel Prize in Physiology or Medicine for 2011.” Before she finished reading, Claudia was hollering at her daughter to wake up. “Dad got the Nobel!” she cried. Alexis, still half-asleep, told her she was crazy. Her father had been dead for three days.

Steinman: Photograph by Ingbert Grüttner/Rockefeller University. Dendritic cell: Rockefeller University Press.

Ralph Steinman in 1983. He would become his most compelling experiment.

Dendritic cell: Rockefeller University Press.

The cell Steinman hoped would save his life looks something like a sea anemone or a ruffled shrimp dumpling.

The Nobel Foundation doesn’t allow posthumous awards, so when news of Ralph Steinman’s death reached Stockholm a few hours later, a minor intrigue ensued over whether the committee would have to rescind the prize. It would not, in fact; but while newspapers stressed the medal mishap (“Nobel jury left red-faced by death of laureate”), they spent less time on the strange story behind the gaffe. That Steinman’s eligibility was even in question, that he’d been dead for just three days instead of, say, three years, was itself a minor miracle.

In the spring of 2007, Steinman, a 64-year-old senior physician and research immunologist at Rockefeller University in New York, had come home from a ski trip with a bad case of diarrhea, and a few days later he showed up for work with yellow eyes and yellow skin — symptoms of a cancerous mass the size of a kiwi that was growing on the head of his pancreas. Soon he learned that the disease had made its way into nearby lymph nodes. Among patients with his condition, 80 percent are dead within the first year; another 90 percent die the year after that. When he told his children about the tumor over Skype, he said, “Don’t Google it.”

But for a man who had spent his life in the laboratory, who brought copies of The New England Journal of Medicine on hiking trips to Vermont and always made sure that family vacations overlapped with scientific symposia, there was only one way to react to such an awful diagnosis — as a scientist. The outlook for pancreatic cancer is so poor, and the established treatments so useless, that any patient who has the disease might as well shoot the moon with new, untested therapies. For Steinman, the prognosis offered the opportunity to run one last experiment.

In the long struggle that was to come, Steinman would try anything and everything that might extend his life, but he placed his greatest hope in a field he helped create, one based on discoveries for which he would earn his Nobel Prize. He hoped to reprogram his immune cells to defeat his cancer — to concoct a set of treatments from his body’s own ingredients, which could take over from his chemotherapy and form a customized, dynamic treatment for his disease. These would be as far from off-the-shelf as medicines can get: vaccines designed for the tumor in his gut, made from the products of his plasma, that could only ever work for him.

Steinman would be the only patient in this makeshift trial, but the personalized approach for which he would serve as both visionary and guinea pig has implications for the rest of us. It is known as cancer immunotherapy, and its offshoots have just now begun to make their way into the clinic, and treatments have been approved for tumors of the skin and of the prostate. For his last experiment, conducted with no control group, Steinman would try to make his life into a useful anecdote — a test of how the treatments he assembled might be put to work. “Once he got diagnosed with cancer, he really started talking about changing the paradigm of cancer treatment,” his daughter Alexis says. “That’s all he knew how to do. He knew how to be a scientist.”

First, Steinman needed to see his tumor. Not an M.R.I. or CT scan, but the material itself. The trouble was that most people with his cancer never have surgery. If there’s cause to think the tumor has spread — and there usually is — it may not be worth the risk of having it removed, along with the bile duct, the gallbladder, large portions of the stomach and the duodenum. Luckily for Steinman, early scans showed that his tumor was a candidate for resection. On the morning of April 3, 2007, less than two weeks after his diagnosis, he went in for the four-hour procedure at Memorial Sloan-Kettering Cancer Center, just across the avenue from his office at Rockefeller University.

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Risks: Pedestrian Accidents More Deadly in Men

More than twice as many men as women die in pedestrian-vehicle accidents. Now researchers have partly determined why.

Writing online last month in the journal Injury Prevention, investigators considered the contribution of three factors: distance walked, number of accidents and fatalities per collision.

Researchers using data from a variety of sources found that men and women walk similar distances and that men are involved in slightly more accidents per mile. Only 1 percent of the difference in death rates is attributable to distance walked, they found, and 20 percent to an increased number of accidents among men.

The rest — 79 percent of the variation — owes to the fact that when there is a collision, men die at roughly twice the rate of women. According to the National Highway Traffic Safety Administration, 4,280 pedestrians died in traffic accidents in 2010, and 2,946 — 69 percent — were men.

Why? No one knows, but the lead author, Dr. Motao Zhu, an assistant professor of epidemiology at West Virginia University, suggested two possibilities: “Maybe males are more likely to cross roads with speed limits higher than 50 miles per hour,” he said. “Also, males may be more likely to be impaired by alcohol and drugs. Most people know it’s not safe to drive drunk, but it’s not safe to walk drunk either.”

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Genetic Gamble : Drugs Aim to Make Several Types of Cancer Self-Destruct

C.J. Gunther for The New York Times

Dr. Donald Bergstrom is a cancer specialist at Sanofi, one of three companies working on a drug to restore a tendency of damaged cells to self-destruct.

For the first time ever, three pharmaceutical companies are poised to test whether new drugs can work against a wide range of cancers independently of where they originated — breast, prostate, liver, lung. The drugs go after an aberration involving a cancer gene fundamental to tumor growth. Many scientists see this as the beginning of a new genetic age in cancer research.

Great uncertainties remain, but such drugs could mean new treatments for rare, neglected cancers, as well as common ones. Merck, Roche and Sanofi are racing to develop their own versions of a drug they hope will restore a mechanism that normally makes badly damaged cells self-destruct and could potentially be used against half of all cancers.

No pharmaceutical company has ever conducted a major clinical trial of a drug in patients who have many different kinds of cancer, researchers and federal regulators say. “This is a taste of the future in cancer drug development,” said Dr. Otis Webb Brawley, the chief medical and scientific officer of the American Cancer Society. “I expect the organ from which the cancer came from will be less important in the future and the molecular target more important,” he added.

And this has major implications for cancer philanthropy, experts say. Advocacy groups should shift from fund-raising for particular cancers to pushing for research aimed at many kinds of cancer at once, Dr. Brawley said. John Walter, the chief executive officer of the Leukemia and Lymphoma Society, concurred, saying that by pooling forces “our strength can be leveraged.”

At the heart of this search for new cancer drugs are patients like Joe Bellino, who was a post office clerk until his cancer made him too sick to work. Seven years ago, he went into the hospital for hernia surgery, only to learn he had liposarcoma, a rare cancer of fat cells. A large tumor was wrapped around a cord that connects the testicle to the abdomen. “I was shocked,” he said in an interview this summer.

Companies have long ignored liposarcoma, seeing no market for drugs to treat a cancer that strikes so few. But it is ideal for testing Sanofi’s drug because the tumors nearly always have the exact genetic problem the drug was meant to attack — a fusion of two large proteins. If the drug works, it should bring these raging cancers to a halt. Then Sanofi would test the drug on a broad range of cancers with a similar genetic alteration. But if the drug fails against liposarcoma, Sanofi will reluctantly admit defeat.

“For us, this is a go/no-go situation,” said Laurent Debussche, a Sanofi scientist who leads the company’s research on the drug.

The genetic alteration the drug targets has tantalized researchers for decades. Normal healthy cells have a mechanism that tells them to die if their DNA is too badly damaged to repair. Cancer cells have grotesquely damaged DNA, so ordinarily they would self-destruct. A protein known as p53 that Dr. Gary Gilliland of Merck calls the cell’s angel of death normally sets things in motion. But cancer cells disable p53, either directly, with a mutation, or indirectly, by attaching the p53 protein to another cellular protein that blocks it. The dream of cancer researchers has long been to reanimate p53 in cancer cells so they will die on their own.

The p53 story began in earnest about 20 years ago. Excitement ran so high that, in 1993, Science magazine anointed it Molecule of the Year and put it on the cover. An editorial held out the possibility of “a cure of a terrible killer in the not too distant future.”

Companies began chasing a drug to restore p53 in cells where it was disabled by mutations. But while scientists know how to block genes, they have not figured out how to add or restore them. Researchers tried gene therapy, adding good copies of the p53 gene to cancer cells. That did not work.

Then, instead of going after mutated p53 genes, they went after half of cancers that used the alternative route to disable p53, blocking it by attaching it to a protein known as MDM2. When the two proteins stick together, the p53 protein no longer functions. Maybe, researchers thought, they could find a molecule to wedge itself between the two proteins and pry them apart.

The problem was that both proteins are huge and cling tightly to each other. Drug molecules are typically tiny. How could they find one that could separate these two bruisers, like a referee at a boxing match?

In 1996, researchers at Roche noticed a small pocket between the behemoths where a tiny molecule might slip in and pry them apart. It took six years, but Roche found such a molecule and named it Nutlin because the lab was in Nutley, N.J.

But Nutlins did not work as drugs because they were not absorbed into the body.

Roche, Merck and Sanofi persevered, testing thousands of molecules.

At Sanofi, the stubborn scientist leading the way, Dr. Debussche, maintained an obsession with p53 for two decades. Finally, in 2009, his team, together with Shaomeng Wang at the University of Michigan and a biotech company, Ascenta Therapeutics, found a promising compound.

The company tested the drug by pumping it each day into the stomachs of mice with sarcoma.

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The Neediest Cases: The Daughter of a Sick Woman Falls Prey to a Craigslist Scam

Sitting side by side on their living room sofa, Patricia Morales and her daughter, Katherine, could be any mother-daughter duo. Both have dark hair, dark eyes and welcoming, infectious smiles.

Librado Romero/The New York Times

Patricia Morales, 62, at home in the Bronx. Her treatment for ailments like rheumatoid arthritis and hepatitis C led to depression.

2012-13 Campaign

Previously recorded:

$3,375,394

Recorded Wednesday:

182,251

*Total:

$3,557,645

Last year to date:

$3,320,812

*Includes $709,856 contributed to the Hurricane Sandy relief efforts.

For the past 100 years, The New York Times Neediest Cases Fund has provided direct assistance to children, families and the elderly in New York. To celebrate the 101st campaign, an article will appear daily through Jan. 25. Each profile will illustrate the difference that even a modest amount of money can make in easing the struggles of the poor.

Last year donors contributed $7,003,854, which was distributed to those in need through seven New York charities.

The Youngest Donors

If your child or family is using creative techniques to raise money for this year’s campaign, we want to hear from you. Drop us a line on Facebook or talk to us on Twitter.

But the ties that bind them go beyond their genes, beyond the bodies they were born with.

“It’s called a neck ring. It’s a silver curved barbell, one inch,” Katherine, 20, said as she swept aside her shoulder-length black hair to show the piercing in the back of her neck, a show of solidarity with her mother. She had it done when she was 16. “I wanted to know what it felt like for my mom.”

Her mother then turned around and outlined with her finger two lengthy scars that run down her back.

“I’ve had a lot of physical problems,” Ms. Morales, 62, said. Shaking her head at her daughter’s piercing, she added, “I’ve had rods put in my upper and lower spine, but I could never do that.”

The rods were surgically planted to treat herniated discs, the result of having a cruel combination of osteoporosis, hepatitis C, fibromyalgia and rheumatoid arthritis. Ms. Morales contracted hepatitis C from a blood transfusion she received in 1972 after the birth of her only son, she said.

“I didn’t even know about it until 10 years ago,” she said. “My liver blood count was a little high.”

Since the diagnosis, Ms. Morales, a former schoolteacher, has ridden the arduous highs and lows common to patients with hepatitis C. Her treatments for the disease, which debilitates the liver over time, have included pills and injections that can cause depression. Ms. Morales, a single parent, found an unforgiving salve in alcohol.

“I was depressed; I was totally drunk,” she said. “I didn’t want to live anymore.”

Then, about a year ago, she reached a turning point when visiting her hepatitis C specialist.

“I was 210 pounds,” she said. “The doctor said: ‘You have to stop drinking. You have to lose weight.’ ”

To help combat the depression, her doctor referred her to Jewish Association Serving the Aging, a beneficiary agency of UJA-Federation of New York, one of the organizations supported by The New York Times Neediest Cases Fund. She began weekly counseling sessions with a social worker and started taking an antidepressant medication. The federation drew about $600 from the fund in May so that Ms. Morales could buy a mattress.

“I had a horrible bed,” she said. “I felt like I was sleeping on rocks, and with rods in my back, I was waking up every hour.”

After several months of therapy and starting a diet, Ms. Morales was on her way to losing 60 pounds. Today, she weighs 148.

Light was starting to show itself again when the family took an unexpected financial hit this summer. While taking time off from attending Hostos Community College, Katherine Morales looked for work on Craigslist.

“I saw my mom, and I realized I needed to get a job,” Katherine said shyly. “This guy asked me to be his personal assistant, and he asked me to wire money.”

Offering $400 a week, the man requested help transferring almost $2,000 from what he said was his wife’s account. He transferred the money to Katherine’s account, asking her to wire it to a bank account in Malaysia.

Shortly after she wired the money, the bank froze the account, which Katherine and her mother shared. It was then that Katherine realized she had been the victim of a scam. The money transferred into her account turned out to have been stolen, and she was responsible for repaying it.

Katherine went to detectives immediately with more than 20 pages of evidentiary e-mails, but found that she was unable to file a complaint.

“They told me it wasn’t enough,” she said. “These things happen all the time.”

They lost almost $2,000.

Ms. Morales lives on a fixed income. She receives just over $700 a month from Social Security and $200 month in food stamps. The rent for the apartment she shares with her daughter in the Throgs Neck neighborhood of the Bronx is $230, and Ms. Morales has a monthly combined phone and cable bill of $140. Ms. Morales has a son, but he is unable to help the family.

Falling behind on her bills, Ms. Morales turned once again to JASA for help paying a combined phone and cable bill of nearly $200, a grant the agency drew from the Neediest Cases Fund.

“It was terrible, because my intention was to help my mom,” said Katherine, who has since found a part-time job at a vitamin shop.

Ms. Morales has been feeling much better, but she is nervous about an appointment with her hepatitis C specialist in January.

“I’m taking things one day at a time, but I’m looking forward to someone taking care of me,” she said. “I want to live a little bit longer, but not that long.”

“Why are you putting a time limit on it?” Katherine said, jokingly. “Seventy’s the new 20!” she added, nudging her mother in the side. “Remember, the doctor said you wouldn’t live past your late 50s, but you did.”

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Stigma Fading, Marijuana Common in California

Jim Wilson/The New York Times

At a San Francisco concert in 2010, marijuana use was general while signatures were collected for a measure to decriminalize it.

LOS ANGELES — Let Colorado and Washington be the marijuana trailblazers. Let them struggle with the messy details of what it means to actually legalize the drug. Marijuana is, as a practical matter, already legal in much of California.

No matter that its recreational use remains technically against the law. Marijuana has, in many parts of this state, become the equivalent of a beer in a paper bag on the streets of Greenwich Village. It is losing whatever stigma it ever had and still has in many parts of the country, including New York City, where the kind of open marijuana use that is common here would attract the attention of any passing law officer.

“It’s shocking, from my perspective, the number of people that we all know who are recreational marijuana users,” said Gavin Newsom, the lieutenant governor. “These are incredibly upstanding citizens: Leaders in our community, and exceptional people. Increasingly, people are willing to share how they use it and not be ashamed of it.”

Marijuana can be smelled in suburban backyards in neighborhoods from Hollywood to Topanga Canyon as dusk falls — what in other places is known as the cocktail hour — often wafting in from three sides. In some homes in Beverly Hills and San Francisco, it is offered at the start of a dinner party with the customary ease of a host offering a chilled Bombay Sapphire martini.

Lighting up a cigarette (the tobacco kind) can get you booted from many venues in this rigorously antitobacco state. But no one seemed to mind as marijuana smoke filled the air at an outdoor concert at the Hollywood Bowl in September or even in the much more intimate, enclosed atmosphere of the Troubadour in West Hollywood during a Mountain Goats concert last week.

Arnold Schwarzenegger, the former Republican governor, ticked off the acceptance of open marijuana smoking in a list of reasons he thought Venice was such a wonderful place for his morning bicycle rides. With so many people smoking in so many places, he said in an interview this year, there was no reason to light up one’s own joint.

“You just inhale, and you live off everyone else,” said Mr. Schwarzenegger, who as governor signed a law decriminalizing possession of small amounts of marijuana.

Some Californians react disdainfully to anyone from out of state who still harbors illicit associations with the drug. Bill Maher, the television host, was speaking about the prevalence of marijuana smoking at dinner parties hosted by Sue Mengers, a retired Hollywood agent famous for her high-powered gatherings of actors and journalists, in an interview after her death last year. “I used to bring her pot,” he said. “And I wasn’t the only one.”

When a reporter sought to ascertain whether this was an on-the-record conversation, Mr. Maher responded tartly: “Where do you think you are? This is California in the year 2011.”

John Burton, the state Democratic chairman, said he recalled an era when the drug was stigmatized under tough antidrug laws. He called the changes in thinking toward marijuana one of the two most striking shifts in public attitude he had seen in 40 years here (the other was gay rights).

“I can remember when your second conviction of having a single marijuana cigarette would get you two to 20 in San Quentin,” he said.

In a Field Poll of California voters conducted in October 2010, 47 percent of respondents said they had smoked marijuana at least once, and 50 percent said it should be legalized. The poll was taken shortly before Californians voted down, by a narrow margin, an initiative to decriminalize marijuana.

“In a Republican year, the legalization came within two points,” said Chris Lehane, a Democratic consultant who worked on the campaign in favor of the initiative. He said that was evidence of the “fact that the public has evolved on the issue and is ahead of the pols.”

A study by the California Office of Traffic Safety last month found that motorists were more likely to be driving under the influence of marijuana than under the influence of alcohol.

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Global Update: African Children Still at Risk of Pneumonia Despite Ceramic Stoves

Small ceramic indoor stoves, such as those sold by women in AIDS self-help groups in Africa, do save fuel and cut down on eye-irritating smoke, a new study has found — but they do not save children from pneumonia.

The study, published in The American Journal of Tropical Medicine and Hygiene, compared 168 households in rural Kenya that used either “upesi jiko” stoves or traditional three-stone indoor fires. The former — the name means “quick stove” in Swahili — has a locally made ceramic firebox that sells for $3. Clay and mud must be built up around it to insulate it and support the pot.

Since it uses less wood, it saves local forests. But it has no chimney, so the smoke stays indoors.

Biweekly visits by researchers found that children in both the stove and open-fire homes got pneumonia equally often. Pneumonia is a leading cause of death for infants in poor countries, and a 2008 study showed that the fine particles and toxic gases in cooking smoke inflame their lungs, doubling the pneumonia risk.

Two years ago, Secretary of State Hillary Rodham Clinton committed $50 million in American aid to help the Global Alliance for Clean Cookstoves get 100 million efficient stoves into households by 2020. But experts are still divided over which stove to pursue; chimneys do not solve all the problems, and stoves with fans burn more cleanly but are expensive and fragile.

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Mind: A Misguided Focus on Mental Illness in Gun Control Debate

The gunman, Adam Lanza, 20, has been described as a loner who was intelligent and socially awkward. And while no official diagnosis has been made public, armchair diagnosticians have been quick to assert that keeping guns from getting into the hands of people with mental illness would help solve the problem of gun homicides.

Arguing against stricter gun-control measures, Representative Mike Rogers, Republican of Michigan and a former F.B.I. agent, said, “What the more realistic discussion is, ‘How do we target people with mental illness who use firearms?’ ”

Robert A. Levy, chairman of the Cato Institute, told The New York Times: “To reduce the risk of multivictim violence, we would be better advised to focus on early detection and treatment of mental illness.”

But there is overwhelming epidemiological evidence that the vast majority of people with psychiatric disorders do not commit violent acts. Only about 4 percent of violence in the United States can be attributed to people with mental illness.

This does not mean that mental illness is not a risk factor for violence. It is, but the risk is actually small. Only certain serious psychiatric illnesses are linked to an increased risk of violence.

One of the largest studies, the National Institute of Mental Health’s Epidemiologic Catchment Area study, which followed nearly 18,000 subjects, found that the lifetime prevalence of violence among people with serious mental illness — like schizophrenia and bipolar disorder — was 16 percent, compared with 7 percent among people without any mental disorder. Anxiety disorders, in contrast, do not seem to increase the risk at all.

Alcohol and drug abuse are far more likely to result in violent behavior than mental illness by itself. In the National Institute of Mental Health’s E.C.A. study, for example, people with no mental disorder who abused alcohol or drugs were nearly seven times as likely as those without substance abuse to commit violent acts.

It’s possible that preventing people with schizophrenia, bipolar disorder and other serious mental illnesses from getting guns might decrease the risk of mass killings. Even the Supreme Court, which in 2008 strongly affirmed a broad right to bear arms, at the same time endorsed prohibitions on gun ownership “by felons and the mentally ill.”

But mass killings are very rare events, and because people with mental illness contribute so little to overall violence, these measures would have little impact on everyday firearm-related killings. Consider that between 2001 and 2010, there were nearly 120,000 gun-related homicides, according to the National Center for Health Statistics. Few were perpetrated by people with mental illness.

Perhaps more significant, we are not very good at predicting who is likely to be dangerous in the future. According to Dr. Michael Stone, professor of clinical psychiatry at Columbia and an expert on mass murderers, “Most of these killers are young men who are not floridly psychotic. They tend to be paranoid loners who hold a grudge and are full of rage.”

Even though we know from large-scale epidemiologic studies like the E.C.A. study that a young psychotic male who is intoxicated with alcohol and has a history of involuntary commitment is at a high risk of violence, most individuals who fit this profile are harmless.

Jeffery Swanson, a professor of psychiatry at Duke University and a leading expert in the epidemiology of violence, said in an e-mail, “Can we reliably predict violence?  ‘No’ is the short answer. Psychiatrists, using clinical judgment, are not much better than chance at predicting which individual patients will do something violent and which will not.”

It would be even harder to predict a mass shooting, Dr. Swanson said, “You can profile the perpetrators after the fact and you’ll get a description of troubled young men, which also matches the description of thousands of other troubled young men who would never do something like this.”

Even if clinicians could predict violence perfectly, keeping guns from people with mental illness is easier said than done. Nearly five years after Congress enacted the National Instant Criminal Background Check System, only about half of the states have submitted more than a tiny proportion of their mental health records.

How effective are laws that prohibit people with mental illness from obtaining guns? According to Dr. Swanson’s recent research, these measures may prevent some violent crime. But, he added, “there are a lot of people who are undeterred by these laws.”

Adam Lanza was prohibited from purchasing a gun, because he was too young. Yet he managed to get his hands on guns — his mother’s — anyway. If we really want to stop young men like him from becoming mass murderers, and prevent the small amount of violence attributable to mental illness, we should invest our resources in better screening for, and treatment of, psychiatric illness in young people.

All the focus on the small number of people with mental illness who are violent serves to make us feel safer by displacing and limiting the threat of violence to a small, well-defined group. But the sad and frightening truth is that the vast majority of homicides are carried out by outwardly normal people in the grip of all too ordinary human aggression to whom we provide nearly unfettered access to deadly force.

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The New Old Age Blog: In the Middle: Why Elderly Couples Fight

George and Gracie (let’s call them that because using their real names would make them even unhappier than they already appear to be) are in their 80s and have been married for more than 65 years. Until recently they seemed to ride the waves that are inevitable in any marriage that spans nearly seven decades; through good and bad, they were partners and best friends.

But lately — ever since her hospitalization and his fall — they have been arguing more bitterly than usual (“Do you have to make such a mess in the kitchen?”), criticizing each other (“Why haven’t you dealt with the insurance company yet?”), withdrawing from each other, and generally making each other more miserable, more often than ever before.

This kind of degenerative relationship is not uncommon among the elderly in even the happiest marriages, marriage therapists and geriatricians said. But that is small comfort to either the couple in the middle of the maelstrom, or the children who care for them, as evidenced by a number of postings on caregiver blogs. As some of the children have wondered there: “Why can’t we all just get along?”

Therapists and others who work with the elderly said the first step to addressing the problem is understanding where it came from.

“A key question is whether the marital bickering is part of a lifelong marital style or a change,” said Dr. Linda Waite, director of the Center on Demography and Economics of Aging at NORC/University of Chicago. Is it new behavior – or just new to the grown children who are suddenly so deeply enmeshed in their parents’ lives that they are only now noticing that something is amiss?

How much of the problem is really just the marriage style? “Some couples like to fight and argue – it keeps their adrenaline going,” said Dr. Nancy K. Schlossberg, professor emerita of counseling psychology at the University of Maryland and author of “Overwhelmed: Coping With Life’s Ups and Downs.”

Sometimes the best judges of whether there is a problem are outsiders, said Dr. William Dale, chief of geriatrics at the University of Chicago Geriatrics Medicine. Pay attention if someone says, “‘Gee, Mom seems more argumentative or withdrawn than the last time I saw her,’” Dr. Dale advised.

If the tone or severity of the marital tensions seem new, then it is important to find out why. The causes could be mental or physical, doctors say.

On the mental front, increased anger and fighting could be one of the first signs of mild cognitive impairment, a precursor of dementia or Alzheimer’s, in one or both of the spouses, said Dr. Lisa Gwyther, director of the Duke Center for Aging Family Support Program and an associate professor in the department of psychiatry and behavioral sciences.

Dr. Dale concurs: “There is good evidence that the earliest signs of cognitive impairment are often emotional changes” — anger, anxiety, depression — “rather than cognitive ones” — memory, abstract thought.

But these early signs of cognitive decline can be so subtle that neither the spouses themselves, or their grown children, recognize them for what they are, Dr. Gwyther said. So husband and wife blame each other for the changes and allow feelings of hurt and resentment to grow.

Withdrawing from activities that used to give them pleasure can be a telltale sign of mild cognitive impairment – and can trigger anger and arguments.

“In one couple, the husband just didn’t want to participate in the holidays — the wife got angry and said he was being lazy and stubborn,” said Dr. Gwyther. But the truth was that his cognitive decline made all the activity overwhelming, and he didn’t want anyone to know that he was anxious about not remembering everyone’s names and embarrassing himself.

Suspicion and paranoia can also accompany mild cognitive decline and precipitate distrust and hurtful accusations. Dr. Gwyther recalled another woman who “called her daughter frantic because she said her husband dropped her at her chemo appointment, went to park the car, and didn’t return to get her.” The woman couldn’t imagine that her husband could possibly have lost his sense of time and direction, Dr. Gwyther added. She took it personally, complaining to her daughter that “your father doesn’t seem to care any more.”

Dr. Dale told of a spouse who accused her mate of infidelity because “she was convinced that when he was out grocery shopping he was really having an affair.”

Hoarding, an early symptom of mild cognitive impairment, can also create tension in a marriage. (For new treatments, see this recent post by my colleague Paula Span.)

When one couple came to a counseling session with Dr. Norman Abeles, emeritus professor of psychology and former director of psychological clinic at Michigan State University, the hoarding spouse finally said she did it because she thought that they would run out of money, “even though there was enough money to go around.” Dr. Abeles said that incident led to her diagnosis of mild cognitive impairment.

Adding to the confusion, mild cognitive impairment, or M.C.I., comes and goes. “There are good days and bad days, good hours and bad hours,” said Dr. Gwyther. “Alzheimer’s and dementia don’t start on Tuesday — it’s a slow insidious onset.” But the diagnosis is becoming more common: The Institute for Dementia Research and Prevention predicts that 1 in 6 women, and 1 in 10 men, who live past the age of 55 will develop dementia in their lifetime.

“Spouses find it difficult to know when their partner with M.C.I. is acting differently, usually badly, due to the advancing illness or due to ‘willful’ personality issues,” said Dr. Dale, citing a 2007 study in the journal Family Relations exploring the problems this can create for couples.

Blaming is often easier than understanding. Another of Dr. Gwyther’s patients was furious at her husband for not filing their taxes. “He’s a C.P.A.,” she said. “How could we owe back taxes?” It did not occur to her that he might be unable to handle that task — and was too frightened about his deteriorating mental focus to let her know.

But as harmful as mental decline can be for a marriage, it is just part of the equation. Physical ailments – even those that seem completely unrelated to marital relations – “can upset the equilibrium of the marriage,” according to a study in The Canadian Medical Association Journal.

“Most men get angry at what’s happened to them when they get ill, women get angry and scared when he’s not what he used to be — so they fight,” said Dr. Schlossberg.

Chronic illnesses, like diabetes, arthritis and heart disease, can have a strong negative effect on mood, said Dr. Waite, who will soon be publishing a study on the subject. Diabetes is so often accompanied by depression that Dr. Waite said “one of my colleagues argues that that it is even part of the disease.”

And ailments can have an effect on a couple’s sex life — which can compound the marital problems, doctors said.

“Diabetes brings on neuropathy,” said Dr. Waite. “That means touching and feeling in sex is not as rewarding.” Without the pleasures of affectionate touching — whether a passing hug at the sink or more — tensions can build. That’s why, if a couple is having problems with sex, they are more likely to have problems in the relationship — and vice versa, according to a 2007 New England Journal of Medicine study of sex and health among older adults.

Other changes in circumstances — retirement, shifting roles, the loss of autonomy, disparities in health and abilities — can wreak havoc. Losing independence can feel like losing oneself — and if you don’t know who you are any more, how can you know how to relate to your spouse?

“Fighting may come from a misguided notion that you can regain power by asserting it over your spouse,” said Dr. Schlossberg, whose observations are echoed in a 1984 study in The Canadian Journal of Medicine. “It doesn’t work, it’s false power – but they’ll try anything.”

The sheer exhaustion that can come from being the caregiving spouse is also bound to “make them stressed and angry,” said Dr. Waite. Not to mention guilty and resentful — never a prescription for happy marital relations.

“Part of the trap for the caregiver is the idea that you have to do it all, and the guilt you feel when you cannot live up to it,” said Dr. Gordon Herz, a psychologist in private practice in Madison, Wisc. Not surprisingly, resentment can soon follow, Dr. Herz added, because it is hard to admit to anyone that, “‘this is too much for me.’”

What can outside caregivers — children or other loved ones — do about these golden marriages on the rocks? Should they intervene — or butt out? And can marital therapy help — or is it too late to change?

Share your thoughts and experiences — and on Tuesday we will try to provide some advice from experts.

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Dr. William F. House, Inventor of Cochlear Implant, Dies

Dr. William F. House, a medical researcher who braved skepticism to invent the cochlear implant, an electronic device considered to be the first to restore a human sense, died on Dec. 7 at his home in Aurora, Ore. He was 89.

The cause was metastatic melanoma, his daughter, Karen House, said.

Dr. House pushed against conventional thinking throughout his career. Over the objections of some, he introduced the surgical microscope to ear surgery. Tackling a form of vertigo that doctors had believed was psychosomatic, he developed a surgical procedure that enabled the first American in space to travel to the moon. Peering at the bones of the inner ear, he found enrapturing beauty.

Even after his ear-implant device had largely been supplanted by more sophisticated, and more expensive, devices, Dr. House remained convinced of his own version’s utility and advocated that it be used to help the world’s poor.

Today, more than 200,000 people in the world have inner-ear implants, a third of them in the United States. A majority of young deaf children receive them, and most people with the implants learn to understand speech with no visual help.

Hearing aids amplify sound to help the hearing-impaired. But many deaf people cannot hear at all because sound cannot be transmitted to their brains, however much it is amplified. This is because the delicate hair cells that line the cochlea, the liquid-filled spiral cavity of the inner ear, are damaged. When healthy, these hairs — more than 15,000 altogether — translate mechanical vibrations produced by sound into electrical signals and deliver them to the auditory nerve.

Dr. House’s cochlear implant electronically translated sound into mechanical vibrations. His initial device, implanted in 1961, was eventually rejected by the body. But after refining its materials, he created a long-lasting version and implanted it in 1969.

More than a decade would pass before the Food and Drug Administration approved the cochlear implant, but when it did, in 1984, Mark Novitch, the agency’s deputy commissioner, said, “For the first time a device can, to a degree, replace an organ of the human senses.”

One of Dr. House’s early implant patients, from an experimental trial, wrote to him in 1981 saying, “I no longer live in a world of soundless movement and voiceless faces.”

But for 27 years, Dr. House had faced stern opposition while he was developing the device. Doctors and scientists said it would not work, or not work very well, calling it a cruel hoax on people desperate to hear. Some said he was motivated by the prospect of financial gain. Some criticized him for experimenting on human subjects. Some advocates for the deaf said the device deprived its users of the dignity of their deafness without fully integrating them into the hearing world.

Even when the American Academy of Ophthalmology and Otolaryngology endorsed implants in 1977, it specifically denounced Dr. House’s version. It recommended more complicated versions, which were then under development and later became the standard.

But his work is broadly viewed as having sped the development of implants and enlarged understanding of the inner ear. Jack Urban, an aerospace engineer, helped develop the surgical microscope as well as mechanical and electronic aspects of the House implant.

Karl White, founding director of the National Center for Hearing Assessment and Management, said in an interview that it would have taken a decade longer to invent the cochlear implant without Dr. House’s contributions. He called him “a giant in the field.”

After embracing the use of the microscope in ear surgery, Dr. House developed procedures — radical for their time — for removing tumors from the back portion of the brain without causing facial paralysis; they cut the death rate from the surgery to less than 1 percent from 40 percent.

He also developed the first surgical treatment for Meniere’s disease, which involves debilitating vertigo and had been viewed as a psychosomatic condition. His procedure cured the astronaut Alan B. Shepard Jr. of the disease, clearing him to command the Apollo 14 mission to the moon in 1971. In 1961, Shepard had become the first American launched into space.

In presenting Dr. House with an award in 1995, the American Academy of Otolaryngology-Head and Neck Surgery Foundation said, “He has developed more new concepts in otology than almost any other single person in history.”

William Fouts House was born in Kansas City, Mo., on Dec. 1, 1923. When he was 3 his family moved to Whittier, Calif., where he grew up on a ranch. He did pre-dental studies at Whittier College and the University of Southern California, and earned a doctorate in dentistry at the University of California, Berkeley. After serving his required two years in the Navy — and filling the requisite 300 cavities a month — he went back to U.S.C. to pursue an interest in oral surgery. He earned his medical degree in 1953. After a residency at Los Angeles County Hospital, he joined the Los Angeles Foundation of Otology, a nonprofit research institution founded by his brother, Howard. Today it is called the House Research Institute.

Many at the time thought ear surgery was a declining field because of the effectiveness of antibiotics in dealing with ear maladies. But Dr. House saw antibiotics as enabling more sophisticated surgery by diminishing the threat of infection.

When his brother returned from West Germany with a surgical microscope, Dr. House saw its potential and adopted it for ear surgery; he is credited with introducing the device to the field. But again there was resistance. As Dr. House wrote in his memoir, “The Struggles of a Medical Innovator: Cochlear Implants and Other Ear Surgeries” (2011), some eye doctors initially criticized his use of a microscope in surgery as reckless and unnecessary for a surgeon with good eyesight.

Dr. House also used the microscope as a research tool. One night a week he would take one to a morgue for use in dissecting ears to gain insights that might lead to new surgical procedures. His initial reaction, he said, was how beautiful the bones seemed; he compared the experience to one’s first view of the Grand Canyon. His wife, the former June Stendhal, a nurse, often helped.

She died in 2008 after 64 years of marriage. In addition to his daughter, Dr. House is survived by a son, David; three grandchildren; and two great-grandchildren.

The implant Dr. House invented used a single channel to deliver information to the hearing system, as opposed to the multiple channels of competing models. The 3M Company, the original licensee of the House implant, sold its rights to another company, the Cochlear Corporation, in 1989. Cochlear later abandoned his design in favor of the multichannel version.

But Dr. House continued to fight for his single-electrode approach, saying it was far cheaper, and offered voluminous material as evidence of its efficacy. He had hoped to resume production of it and make it available to the poor around the world.

Neither the institute nor Dr. House made any money on the implant. He never sought a patent on any of his inventions, he said, because he did not want to restrict other researchers. A nephew, Dr. John House, the current president of the House institute, said his uncle had made the deal to license it to the 3M Company not for profit but simply to get it built by a reputable manufacturer.

Reflecting on his business decisions in his memoir, Dr. House acknowledged, “I might be a little richer today.”

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