U.S. Judges Offer Addicts a Way to Avoid Prison

Todd Heisler/The New York Times

Emily Leitch of Brooklyn, with her son, Nazir, 4, was arrested for importing cocaine but went to “drug court” to avoid prison.

Federal judges around the country are teaming up with prosecutors to create special treatment programs for drug-addicted defendants who would otherwise face significant prison time, an effort intended to sidestep drug laws widely seen as inflexible and overly punitive.

The Justice Department has tentatively embraced the new approach, allowing United States attorneys to reduce or even dismiss charges in some drug cases.

The effort follows decades of success for “drug courts” at the state level, which legal experts have long cited as a less expensive and more effective alternative to prison for dealing with many low-level repeat offenders.

But it is striking that the model is spreading at the federal level, where judges have increasingly pushed back against rules that restrict their ability to make their own determination of appropriate sentences.

So far, federal judges have instituted programs in California, Connecticut, Illinois, New Hampshire, New York, South Carolina, Virginia and Washington. About 400 defendants have been involved nationwide.

In Federal District Court in Brooklyn on Thursday, Judge John Gleeson issued an opinion praising the new approach as a way to address swelling prison costs and disproportionate sentences for drug trafficking.

“Presentence programs like ours and those in other districts mean that a growing number of courts are no longer reflexively sentencing federal defendants who do not belong in prison to the costly prison terms recommended by the sentencing guidelines,” Judge Gleeson wrote.

The opinion came a year after Judge Gleeson, with the federal agency known as Pretrial Services, started a program that made achieving sobriety an incentive for drug-addicted defendants to avoid prison. The program had its first graduate this year: Emily Leitch, a Brooklyn woman with a long history of substance abuse who was arrested entering the country at Kennedy International Airport with over 13 kilograms of cocaine, about 30 pounds, in her luggage.

“I want to thank the federal government for giving me a chance,” Ms. Leitch said. “I always wanted to stand up as a sober person.”

The new approach is being prompted in part by the Obama administration, which previously supported legislation that scaled back sentences for crimes involving crack cocaine. The Justice Department has supported additional changes to the federal sentencing guidelines to permit the use of drug or mental health treatment as an alternative to incarceration for certain low-level offenders and changed its own policies to make those options more available.

“We recognize that imprisonment alone is not a complete strategy for reducing crime,” James M. Cole, the deputy attorney general, said in a statement. “Drug courts, re-entry courts and other related programs along with enforcement are all part of the solution.”

For nearly 30 years, the United States Sentencing Commission has established guidelines for sentencing, a role it was given in 1984 after studies found that federal judges were giving defendants widely varying sentences for similar crimes. The commission’s recommendations are approved by Congress, causing judges to bristle at what they consider interference with their judicial independence.

“When you impose a sentence that you believe is unjust, it is a very difficult thing to do,” Stefan R. Underhill, a federal judge in Connecticut, said in an interview. “It feels wrong.”

The development of drug courts may meet resistance from some Republicans in Congress.

“It is important that courts give deference to Congressional authority over sentencing,” Representative F. James Sensenbrenner Jr., Republican of Wisconsin, a member and former chairman of the Judiciary Committee, said in a statement. He said sentencing should not depend “on what judge happens to decide the case or what judicial circuit the defendant happens to be in.”

At the state level, pretrial drug courts have benefited from bipartisan support, with liberals supporting the programs as more focused on rehabilitation, and conservatives supporting them as a way to cut spending.

Under the model being used in state and federal courts, defendants must accept responsibility for their crimes and agree to receive drug treatment and other social services and attend regular meetings with judges who monitor their progress. In return for successful participation, they receive a reduced sentence or no jail time at all. If they fail, they are sent to prison.

The drug court option is not available to those facing more serious charges, like people accused of being high-level dealers or traffickers, or accused of a violent crime. (These programs differ from re-entry drug courts, which federal judges have long used to help offenders integrate into society after prison.)

In interviews, the federal judges who run the other programs pointed to a mix of reasons for their involvement.

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The New Old Age Blog: Why Can’t I Live With People Like Me?

“Aging in place” is the mantra of long-term care. Whether looking at reams of survey data, talking to friends or wishing on a star, who among us wouldn’t rather spend the final years — golden or less so — at home, surrounded by our cherished possessions, in our own bed, no cranky old coot as a roommate, no institutional smells or sounds, no lukewarm meals on a schedule of someone else’s making?

That works best, experts tell us, in dense cities, where we can hail a cab at curbside, call the superintendent when something breaks and have our food delivered from Fresh Direct or countless takeout restaurants. We’d have neighbors in the apartment above us, below us, just on the other side of the wall. Hearing their toilets flush and their children ride tricycles on uncarpeted floors is a small inconvenience compared to the security of knowing they are so close by in an emergency.

Urban planners, mindful that most Americans live in sprawling, car-reliant suburbs, are designing more elder-friendly, walkable communities, far from “real” cities. Houses and apartments are built around village greens, with pockets of commerce instead of distant strip malls. Some have community centers for congregate meals and activities; others share gardens, where people can get their hands in the warm spring dirt long after they can push a lawn mower.

All of this is a step in the right direction, despite the Potemkin-village look of so many of them. But it doesn’t take into account those who are too infirm to stay at home, even in cities or more manageable suburban environments. Some are alone, others with a loving spouse who by comparison is “well” but may not be for long, given the rigors of care-taking. It doesn’t take into account people who can’t afford a home health aide, who don’t qualify for a visiting nurse, who have no adult children to help them or whose children live far away.

But by now, aging in place, unrealistic for some, scary or unsafe for others and potentially very isolating, has become so entrenched as the right way to live out one’s life that not being able to pull it off seems a failure, yet another defeat at a time when defeats are all too plentiful. Are we making people feel guilty if they can’t stay at home, or don’t want to? Are we discouraging an array of other solutions by investing so much, program-wise and emotionally, in this sine qua non?

Regular readers of The New Old Age know that I am single, childless and terrified of falling off a ladder while replacing a light bulb, breaking a hip and lying on the floor, unattended, until my dog wails so loudly a neighbor comes by to complain. A MedicAlert pendant is not something that appeals to me at 65, but even if I give in to that, say at 75, I’m not sure my life will be richer for digging my heels in and insisting home is where I should be.

So I spend a lot of time thinking about the alternatives. I know enough to distinguish between naturally-occurring-retirement communities, or NORCs (some of which work better than others); age-restricted housing complexes (with no services); assisted living (which works fine when you don’t really need it and not so fine when you do); and continuing care retirement communities (which require big upfront payments and extensive due diligence to be sure the place doesn’t go belly up after you get there).

What I find so unappealing about all these choices is that each means growing old among people with whom I share no history. In these congregate settings, for the most part, people are guaranteed only two things in common: age and infirmity. Which brings us to what is known in the trade as “affinity” or “niche” communities,” long studied by Andrew J. Carle at the College of Health and Human Services at George Mason University in Fairfax, Va.

Mr. Carle, who trains future administrators of senior housing complexes, was a media darling a few years back, before the recession, with the first baby boomers approaching 65 and niche communities that included services for the elderly — not merely warm-weather developments adjacent to golf courses — expected to explode. In newspaper interviews as recently as 2011, Mr. Carle said there were “about 100 of them in existence or on the drawing board,” not counting the large number of military old-age communities.

Mr. Carle still believes that better economic times, when they come, will reinvigorate this sector of senior housing, after the failure of some in the planning stages and others in operation. In an e-mail exchange, Mr. Carle said there were now about 70 in operation, with perhaps 50 of those that he has defined as University Based Retirement Communities, adjacent to campuses and popular with alumni, as well as non-alumni, who enjoy proximity to the intellectual and athletic activities. Among the most popular are those near Dartmouth, Oberlin, the University of Alabama, Penn State, Notre Dame, Stanford and Cornell.

At the height of the “affinity” boom, L.G.B.T.-assisted living communities and nursing homes were all the rage, seen as a solution to the shoddy treatment that those of different sexual orientations in the pre-Stonewall generation experienced in generic facilities. A few failed, most never got built and, by all accounts, the only one to survive is the pricy Rainbow Vision community in Sante Fe, N.M.

A handful of nudist elder communities, and ones for old hippies, also fell by the wayside, perhaps too free-spirited for the task. According to Mr. Carle, despite the odds, at least one group of RV enthusiasts has added an assisted-living component to what began as collections of transient elderly, looking only for a parking spot and necessary water and power hook-ups for their trailers. Native Americans have made a go of an assisted-living community in Montana, and Asians have done the same in Northern California.

But professional affinity communities, which I find most appealing, are few and far between.

The storied Motion Picture & Television Country House and Hospital, a sliding-scale institution in the San Fernando Valley since 1940, survived near-closure in 2009 as a result of litigation, activism by the Screen Actors Guild and the local chapter of the Teamsters, and news media pressure. Among film legends who died there — along with cameramen, back-lot security guards and extras — were Mary Astor, Joel McCrea, Yvonne De Carlo and Stepin Fetchit.

New York State’s volunteer firefighters are all welcome to a refurbished facility in the Catskill region that offers far more in the way of care and activities, including a state-of-the-art gym, than when I visited there five years ago. At that time, the residents amused themselves by activating the fire alarm to summon the local hook and ladder company, which didn’t mind a bit.

Then there is Nalcrest, the retirement home for unionized letter carriers. Even as post offices nationwide are preparing to eliminate Saturday service, and snail mail becomes an artifact, the National Association of Letter Carriers holds monthly fees around the $500 mark, is located in central Florida so its members no longer have to brave rain and sleet to complete their appointed rounds, and bans dogs, the bane of their existence.

So why not aged journalists? We surely have war stories to embroider as we rock on the porch. Perhaps a mimeograph machine to produce an old-fashioned, dead-tree newspaper, which some of us will miss once it has given way to Web sites like this one. Pneumatic tubes, one colleague suggested, to whisk our belongings upstairs when we can no longer carry them. Other colleagues wondered about welcoming both editors and reporters. How can these two groups, which some consider natural adversaries, complain about each others’ tin ears or missed deadlines if we’re not segregated?

I disagree. The joy of this profession is its collaboration. We did the impossible day after day when young. We belong together when old.

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Phys Ed: What Housework Has to Do With Waistlines

Phys Ed

Gretchen Reynolds on the science of fitness.

One reason so many American women are overweight may be that we are vacuuming and doing laundry less often, according to a new study that, while scrupulously even-handed, is likely to stir controversy and emotions.

The study, published this month in PLoS One, is a follow-up to an influential 2011 report which used data from the U.S. Bureau of Labor Statistics to determine that, during the past 50 years, most American workers began sitting down on the job. Physical activity at work, such as walking or lifting, almost vanished, according to the data, with workers now spending most of their time seated before a computer or talking on the phone. Consequently, the authors found, the average American worker was burning almost 150 fewer calories daily at work than his or her employed parents had, a change that had materially contributed to the rise in obesity during the same time frame, especially among men, the authors concluded.

But that study, while fascinating, was narrow, focusing only on people with formal jobs. It overlooked a large segment of the population, namely a lot of women.

“Fifty years ago, a majority of women did not work outside of the home,” said Edward Archer, a research fellow with the Arnold School of Public Health at the University of South Carolina in Columbia, and lead author of the new study.

So, in collaboration with many of the authors of the earlier study of occupational physical activity, Dr. Archer set out to find data about how women had once spent their hours at home and whether and how their patterns of movement had changed over the years.

He found the information he needed in the American Heritage Time Use Study, a remarkable archive of “time-use diaries” provided by thousands of women beginning in 1965. Because Dr. Archer wished to examine how women in a variety of circumstances spent their time around the house, he gathered diaries from both working and non-employed women, starting with those in 1965 and extending through 2010.

He and his colleagues then pulled data from the diaries about how many hours the women were spending in various activities, how many calories they likely were expending in each of those tasks, and how the activities and associated energy expenditures changed over the years.

As it turned out, their findings broadly echoed those of the occupational time-use study. Women, they found, once had been quite physically active around the house, spending, in 1965, an average of 25.7 hours a week cleaning, cooking and doing laundry. Those activities, whatever their social freight, required the expenditure of considerable energy. (The authors did not include child care time in their calculations, since the women’s diary entries related to child care were inconsistent and often overlapped those of other activities.) In general at that time, working women devoted somewhat fewer hours to housework, while those not employed outside the home spent more.

Forty-five years later, in 2010, things had changed dramatically. By then, the time-use diaries showed, women were spending an average of 13.3 hours per week on housework.

More striking, the diary entries showed, women at home were now spending far more hours sitting in front of a screen. In 1965, women typically had spent about eight hours a week sitting and watching television. (Home computers weren’t invented yet.)

By 2010, those hours had more than doubled, to 16.5 hours per week. In essence, women had exchanged time spent in active pursuits, like vacuuming, for time spent being sedentary.

In the process, they had also greatly reduced the number of calories that they typically expended during their hours at home. According to the authors’ calculations, American women not employed outside the home were burning about 360 fewer calories every day in 2010 than they had in 1965, with working women burning about 132 fewer calories at home each day in 2010 than in 1965.

“Those are large reductions in energy expenditure,” Dr. Archer said, and would result, over the years, in significant weight gain without reductions in caloric intake.

What his study suggests, Dr. Archer continued, is that “we need to start finding ways to incorporate movement back into” the hours spent at home.

This does not mean, he said, that women — or men — should be doing more housework. For one thing, the effort involved is such activities today is less than it once was. Using modern, gliding vacuum cleaners is less taxing than struggling with the clunky, heavy machines once available, and thank goodness for that.

Nor is more time spent helping around the house a guarantee of more activity, over all. A telling 2012 study of television viewing habits found that when men increased the number of hours they spent on housework, they also greatly increased the hours they spent sitting in front of the TV, presumably because it was there and beckoning.

Instead, Dr. Archer said, we should start consciously tracking what we do when we are at home and try to reduce the amount of time spent sitting. “Walk to the mailbox,” he said. Chop vegetables in the kitchen. Play ball with your, or a neighbor’s, dog. Chivvy your spouse into helping you fold sheets. “The data clearly shows,” Dr. Archer said, that even at home, we need to be in motion.

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Global Health: After Measles Success, Rwanda to Get Rubella Vaccine

Rwanda has been so successful at fighting measles that next month it will be the first country to get donor support to move to the next stage — fighting rubella too.

On March 11, it will hold a nationwide three-day vaccination campaign with a combined measles-rubella vaccine, hoping to reach nearly five million children up to age 14. It will then integrate the dual vaccine into its national health service.

Rwanda can do so “because they’ve done such a good job on measles,” said Christine McNab, a spokeswoman for the Measles and Rubella Initiative. M.R.I. helped pay for previous vaccination campaigns in the country and the GAVI Alliance is helping financing the upcoming one.

Rubella, also called German measles, causes a rash that is very similar to the measles rash, making it hard for health workers to tell the difference.

Rubella is generally mild, even in children, but in pregnant women, it can kill the fetus or cause serious birth defects, including blindness, deafness, mental retardation and chronic heart damage.

Ms. McNab said that Rwanda had proved that it can suppress measles and identify rubella, and it would benefit from the newer, more expensive vaccine.

The dual vaccine costs twice as much — 52 cents a dose at Unicef prices, compared with 24 cents for measles alone. (The MMR vaccine that American children get, which also contains a vaccine against mumps, costs Unicef $1.)

More than 90 percent of Rwandan children now are vaccinated twice against measles, and cases have been near zero since 2007.

The tiny country, which was convulsed by Hutu-Tutsi genocide in 1994, is now leading the way in Africa in delivering medical care to its citizens, Ms. McNab said. Three years ago, it was the first African country to introduce shots against human papilloma virus, or HPV, which causes cervical cancer.

In wealthy countries, measles kills a small number of children — usually those whose parents decline vaccination. But in poor countries, measles is a major killer of malnourished infants. Around the world, the initiative estimates, about 158,000 children die of it each year, or about 430 a day.

Every year, an estimated 112,000 children, mostly in Africa, South Asia and the Pacific islands, are born with handicaps caused by their mothers’ rubella infection.

Thanks in part to the initiative — which until last year was known just as the Measles Initiative — measles deaths among children have declined 71 percent since 2000. The initiative is a partnership of many health agencies, vaccine companies, donors and others, but is led by the American Red Cross, the United Nations Foundation, the Centers for Disease Control and Prevention, Unicef and the World Health Organization.

This article has been revised to reflect the following correction:

Correction: February 27, 2013

An earlier version of this article misstated the source of the financing for the upcoming vaccination campaign in Rwanda. It is being financed by the GAVI Alliance, not the Measles and Rubella Initiative.

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Books: Gauging Faces and Bodies in the Botox Age

You never know what a little vanity will do for a person’s health. Some people bloom in their quest for physical improvement, others wither, and a few are completely destroyed. Despite centuries’ worth of efforts to penetrate the complicated thickets where health and beauty intertwine, there is always more to explore, as two new books make clear.

Dr. Eric Finzi, a dermatologist in the Washington area, has produced what may be the first authorized biography of botulinum toxin, the fearsome poison that, bottled into mild-mannered Botox, enhances foreheads everywhere. This little molecule does its good work by paralyzing muscles: In the forehead it inactivates the frown-producing corrugators, while used elsewhere on the head and body it can alleviate migraine headaches, stop problem sweating and ease the spasticity associated with a range of neurological diseases.

But even those who know all about the drug’s physical effects will be intrigued by Dr. Finzi’s narrative, because it turns out that cosmetic Botox may not be all about vanity after all. Research studies, including some by Dr. Finzi, have found that the substance appears to alleviate depression more safely and perhaps more effectively than the usual treatments.

That result at first seems trivial and obvious: If you stop frowning at people, they’ll like you more  and treat you better, and you won’t feel so blue. But the process turns out to be considerably more sophisticated and complicated, because it appears to apply even to people without visible frown lines.

Dr. Finzi calls it “noncosmetic cosmetic surgery” and traces the postulated mechanism to some of the lesser-known work of William James and Charles Darwin. Both thinkers argued that facial expressions are not just the outward manifestations of emotion, but vital links in the unconscious neurological processes that create emotion. In other words, if you cannot smile, you will never be as happy as if you could, and if you cannot frown, you will be unable to experience the full intensity of the negative emotions manifested by frowning, depression included.

This “facial feedback hypothesis” has found some modern confirmation in a study showing that injections of Botox into the forehead seem to inhibit activation of the amygdala, the brain structure thought to regulate all gut-wrenching emotion.

Dr. Finzi expands his narrative with a discussion of the subtleties of common facial expressions, including homage to interested parties like Norman Cousins and his idea that laughter could cure disease.

But the book’s major focus is the frown: Dr. Finzi offers anecdotes suggesting that taming overactive corrugators may save marriages and boost careers, and then, spinning some of the still largely debatable theories linking depression and anger with chronic disease, he postulates that Botox treatments may someday prove to help forestall heart disease and cancer.

That’s quite a set of achievements for one bad little molecule, gram for gram the most potent toxin we know. Dr. Finzi is no stylist, but the momentum of his argument keeps the reader with him for the duration (and undoubtedly quite a few overactive corrugators will be soothed into submission as a result).

The complexities of the face almost pale in comparison with those of the torso, as Abigail C. Saguy makes clear in “What’s Wrong With Fat?” “Once you put down this book you will never hear the word ‘obesity’ the same way again,” she promises, and she is absolutely correct.

Dr. Saguy, a sociologist at U.C.L.A., methodically teases out all the overtones of the loaded words we use to describe big bodies. These bodies are, after all, neither good nor bad, just big.

But “fat” often implies the coexistence of sloth, gluttony and self-indulgence. “Obesity” equals disease to medical professionals, while in the world of public health it is a raging epidemic with substantial global mortality. Those immersed in the conventional ideals of beauty see being overweight as an aesthetic disaster, but others find it sexually irresistible, and to activists “fat” has become a rallying cry, with weight-based discrimination a violation of social justice as deplorable as that stemming from race or gender.

In fact, the concept of bigness has become so laden with overtones good and bad — guilt, blame, fear, anger and desire, among others — that finding a value-free way to describe men and women who are larger than average has become almost impossible. “Heavy,” “plus-size,” “corpulent” and “fleshy” all carry weighty implications in one sphere or another.

Dr. Saguy analyzes it all, and asks why. She winds up paying particular attention to the debate in the medical world over the actual health consequences of being fat: Studies keep confounding the reigning supposition that thin is best with evidence that modestly overweight may be even better. Meanwhile, those who are larger than average are routinely blamed for their size, a phenomenon augmented by deplorably simplistic media coverage (unlike anorexia, interestingly enough, which is remarkably free of the same connotations of personal fault).

Much of Dr. Saguy’s text is academic and requires some determination to penetrate, but she also provides immensely readable nuggets, notably a brief discussion of her experiences attending an annual convention of the National Association to Advance Fat Acceptance, where, seven months pregnant, she underwent a funhouse-mirror body-image transformation worthy of Alice in Wonderland. Like Dr. Finzi’s narrative deficiencies, hers fade into unimportance in the face of fascinating and illuminating material.

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Mediterranean Diet Can Cut Heart Disease, Study Finds

About 30 percent of heart attacks, strokes and deaths from heart disease can be prevented in people at high risk if they switch to a Mediterranean diet rich in olive oil, nuts, beans, fish, fruits and vegetables, and even drink wine with meals, a large and rigorous new study found.

The findings, published on the New England Journal of Medicine’s Web site on Monday, were based on the first major clinical trial to measure the diet’s effect on heart risks. The magnitude of the diet’s benefits startled experts. The study ended early, after almost five years, because the results were so clear it was considered unethical to continue.

The diet helped those following it even though they did not lose weight and most of them were already taking statins, or blood pressure or diabetes drugs to lower their heart disease risk.

“Really impressive,” said Rachel Johnson, a professor of nutrition at the University of Vermont and a spokeswoman for the American Heart Association. “And the really important thing — the coolest thing — is that they used very meaningful end points. They did not look at risk factors like cholesterol of hypertension or weight. They looked at heart attacks and strokes and death. At the end of the day, that is what really matters.”

Until now, evidence that the Mediterranean diet reduced the risk of heart disease was weak, based mostly on studies showing that people from Mediterranean countries seemed to have lower rates of heart disease — a pattern that could have been attributed to factors other than diet.

And some experts had been skeptical that the effect of diet could be detected, if it existed at all, because so many people are already taking powerful drugs to reduce heart disease risk, while other experts hesitated to recommend the diet to people who already had weight problems, since oils and nuts have a lot of calories.

Heart disease experts said the study was a triumph because it showed that a diet is powerful in reducing heart disease risk, and it did so using the most rigorous methods. Scientists randomly assigned 7,447 people in Spain who were overweight, were smokers, had diabetes or other risk factors for heart disease to follow the Mediterranean diet or a low-fat one.

Low-fat diets have not been shown in any rigorous way to be helpful, and they are also very hard for patients to maintain — a reality born out in the new study, said Dr. Steven E. Nissen, chairman of the department of cardiovascular medicine at the Cleveland Clinic Foundation.

“Now along comes this group and does a gigantic study in Spain that says you can eat a nicely balanced diet with fruits and vegetables and olive oil and lower heart disease by 30 percent,” he said. “And you can actually enjoy life.”

The study, by Dr. Ramon Estruch, a professor of medicine at the University of Barcelona, and his colleagues, was long in the planning. The investigators traveled the world, seeking advice on how best to answer the question of whether a diet alone could make a big difference in heart disease risk. They visited the Harvard School of Public Health several times to consult Dr. Frank M. Sacks, a professor of cardiovascular disease prevention there.

In the end, they decided to randomly assign subjects at high risk of heart disease to three groups. One would be given a low-fat diet and counseled on how to follow it. The other two groups would be counseled to follow a Mediterranean diet. At first the Mediterranean dieters got more intense support. They met regularly with dietitians while the low-fat group just got an initial visit to train them in how to adhere to the diet followed by a leaflet each year on the diet. Then the researchers decided to add more intensive counseling for them, too, but they still had difficulty staying with the diet.

One group assigned to a Mediterranean diet was given extra virgin olive oil each week and was instructed to use at least 4 tablespoons a day. The other group got a combination of walnuts, almonds and hazelnuts and was instructed to eat about an ounce of them each day. An ounce of walnuts, for example, is about a quarter cup — a generous handful. The mainstays of the diet consisted of at least 3 servings a day of fruits and at least two servings of vegetables. Participants were to eat fish at least three times a week and legumes, which include beans, peas and lentils, at least three times a week. They were to eat white meat instead of red, and, for those accustomed to drinking, to have at least 7 glasses of wine a week with meals.

They were encouraged to avoid commercially made cookies, cakes and pastries and to limit their consumption of dairy products and processed meats.

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The Texas Tribune: Advocates Seek Mental Health Changes, Including Power to Detain

Matt Rainwaters for Texas Monthly

The Sherman grave of Andre Thomas’s victims.

SHERMAN — A worried call from his daughter’s boyfriend sent Paul Boren rushing to her apartment on the morning of March 27, 2004. He drove the eight blocks to her apartment, peering into his neighbors’ yards, searching for Andre Thomas, Laura Boren’s estranged husband.

Expanded coverage of Texas is produced by The Texas Tribune, a nonprofit news organization. To join the conversation about this article, go to texastribune.org.

For more articles on mental health and criminal justice in Texas, as well as a timeline of the Andre Thomas case: texastribune.org

Matt Rainwaters for Texas Monthly

Laura Boren

He drove past the brightly colored slides, swings and bouncy plastic animals in Fairview Park across the street from the apartment where Ms. Boren, 20, and her two children lived. He pulled into a parking spot below and immediately saw that her door was broken. As his heart raced, Mr. Boren, a white-haired giant of a man, bounded up the stairwell, calling out for his daughter.

He found her on the white carpet, smeared with blood, a gaping hole in her chest. Beside her left leg, a one-dollar bill was folded lengthwise, the radiating eye of the pyramid facing up. Mr. Boren knew she was gone.

In a panic, he rushed past the stuffed animals, dolls and plastic toys strewn along the hallway to the bedroom shared by his two grandchildren. The body of 13-month-old Leyha Hughes lay on the floor next to a blood-spattered doll nearly as big as she was.

Andre Boren, 4, lay on his back in his white children’s bed just above Leyha. He looked as if he could have been sleeping — a moment away from revealing the toothy grin that typically spread from one of his round cheeks to the other — except for the massive chest wound that matched the ones his father, Andre Thomas (the boy was also known as Andre Jr.), had inflicted on his mother and his half-sister as he tried to remove their hearts.

“You just can’t believe that it’s real,” said Sherry Boren, Laura Boren’s mother. “You’re hoping that it’s not, that it’s a dream or something, that you’re going to wake up at any minute.”

Mr. Thomas, who confessed to the murders of his wife, their son and her daughter by another man, was convicted in 2005 and sentenced to death at age 21. While awaiting trial in 2004, he gouged out one of his eyes, and in 2008 on death row, he removed the other and ate it.

At least twice in the three weeks before the crime, Mr. Thomas had sought mental health treatment, babbling illogically and threatening to commit suicide. On two occasions, staff members at the medical facilities were so worried that his psychosis made him a threat to himself or others that they sought emergency detention warrants for him.

Despite talk of suicide and bizarre biblical delusions, he was not detained for treatment. Mr. Thomas later told the police that he was convinced that Ms. Boren was the wicked Jezebel from the Bible, that his own son was the Antichrist and that Leyha was involved in an evil conspiracy with them.

He was on a mission from God, he said, to free their hearts of demons.

Hospitals do not have legal authority to detain people who voluntarily enter their facilities in search of mental health care but then decide to leave. It is one of many holes in the state’s nearly 30-year-old mental health code that advocates, police officers and judges say lawmakers need to fix. In a report last year, Texas Appleseed, a nonprofit advocacy organization, called on lawmakers to replace the existing code with one that reflects contemporary mental health needs.

“It was last fully revised in 1985, and clearly the mental health system has changed drastically since then,” said Susan Stone, a lawyer and psychiatrist who led the two-year Texas Appleseed project to study and recommend reforms to the code. Lawmakers have said that although the code may need to be revamped, it will not happen in this year’s legislative session. Such an undertaking requires legislative studies that have not been conducted. But advocates are urging legislators to make a few critical changes that they say could prevent tragedies, including giving hospitals the right to detain someone who is having a mental health crisis.

From the time Mr. Thomas was 10, he had told friends he heard demons in his head instructing him to do bad things. The cacophony drove him to attempt suicide repeatedly as an adolescent, according to court records. He drank and abused drugs to try to quiet the noise.

bgrissom@texastribune.org

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Drone Pilots Found to Get Stress Disorders Much as Those in Combat Do

U.S. Air Force/Master Sgt. Steve Horton

Capt. Richard Koll, left, and Airman First Class Mike Eulo monitored a drone aircraft after launching it in Iraq.

The study affirms a growing body of research finding health hazards even for those piloting machines from bases far from actual combat zones.

“Though it might be thousands of miles from the battlefield, this work still involves tough stressors and has tough consequences for those crews,” said Peter W. Singer, a scholar at the Brookings Institution who has written extensively about drones. He was not involved in the new research.

That study, by the Armed Forces Health Surveillance Center, which analyzes health trends among military personnel, did not try to explain the sources of mental health problems among drone pilots.

But Air Force officials and independent experts have suggested several potential causes, among them witnessing combat violence on live video feeds, working in isolation or under inflexible shift hours, juggling the simultaneous demands of home life with combat operations and dealing with intense stress because of crew shortages.

“Remotely piloted aircraft pilots may stare at the same piece of ground for days,” said Jean Lin Otto, an epidemiologist who was a co-author of the study. “They witness the carnage. Manned aircraft pilots don’t do that. They get out of there as soon as possible.”

Dr. Otto said she had begun the study expecting that drone pilots would actually have a higher rate of mental health problems because of the unique pressures of their job.

Since 2008, the number of pilots of remotely piloted aircraft — the Air Force’s preferred term for drones — has grown fourfold, to nearly 1,300. The Air Force is now training more pilots for its drones than for its fighter jets and bombers combined. And by 2015, it expects to have more drone pilots than bomber pilots, although fighter pilots will remain a larger group.

Those figures do not include drones operated by the C.I.A. in counterterrorism operations over Pakistan, Yemen and other countries.

The Pentagon has begun taking steps to keep pace with the rapid expansion of drone operations. It recently created a new medal to honor troops involved in both drone warfare and cyberwarfare. And the Air Force has expanded access to chaplains and therapists for drone operators, said Col. William M. Tart, who commanded remotely piloted aircraft crews at Creech Air Force Base in Nevada.

The Air Force has also conducted research into the health issues of drone crew members. In a 2011 survey of nearly 840 drone operators, it found that 46 percent of Reaper and Predator pilots, and 48 percent of Global Hawk sensor operators, reported “high operational stress.” Those crews cited long hours and frequent shift changes as major causes.

That study found the stress among drone operators to be much higher than that reported by Air Force members in logistics or support jobs. But it did not compare the stress levels of the drone operators with those of traditional pilots.

The new study looked at the electronic health records of 709 drone pilots and 5,256 manned aircraft pilots between October 2003 and December 2011. Those records included information about clinical diagnoses by medical professionals and not just self-reported symptoms.

After analyzing diagnosis and treatment records, the researchers initially found that the drone pilots had higher incidence rates for 12 conditions, including anxiety disorder, depressive disorder, post-traumatic stress disorder, substance abuse and suicidal ideation.

But after the data were adjusted for age, number of deployments, time in service and history of previous mental health problems, the rates were similar, said Dr. Otto, who was scheduled to present her findings in Arizona on Saturday at a conference of the American College of Preventive Medicine.

The study also found that the incidence rates of mental heath problems among drone pilots spiked in 2009. Dr. Otto speculated that the increase might have been the result of intense pressure on pilots during the Iraq surge in the preceding years.

The study found that pilots of both manned and unmanned aircraft had lower rates of mental health problems than other Air Force personnel. But Dr. Otto conceded that her study might underestimate problems among both manned and unmanned aircraft pilots, who may feel pressure not to report mental health symptoms to doctors out of fears that they will be grounded.

She said she planned to conduct two follow-up studies: one that tries to compensate for possible underreporting of mental health problems by pilots and another that analyzes mental health issues among sensor operators, who control drone cameras while sitting next to the pilots.

“The increasing use of remotely piloted aircraft for war fighting as well as humanitarian relief should prompt increased surveillance,” she said.

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Well: Depression May Stifle Shingles Vaccine Response

Depression may lower the effectiveness of the shingles vaccine, a new study found.

The research showed that adults with untreated depression who received the vaccine mounted a relatively weak immune response. But those who were taking antidepressants showed a normal response to the vaccine, even when symptoms of depression persist.

Shingles, an acute and painful rash, strikes a million Americans each year, mostly older adults. Health officials recommend that those over 60 get vaccinated against the condition, which is caused by reactivation of the same virus that causes chickenpox, varicella-zoster.

In the new study, published in the journal Clinical Infectious Diseases, researchers followed a group of 92 older men and women for two years. Forty of the subjects had a major depressive disorder; they were matched with 52 control subjects of similar age. The researchers measured their immune responses to the shingles vaccine and a placebo shot.

Compared with the control patients, those with depression were poorly protected by the vaccine. But the patients who were being treated for their depression showed a boost in immunity — what the researchers called a “normalization” of the immune response. It is unclear why that was the case.

The authors of the study speculated that treatment of older people with depression might increase the effectiveness of the flu shot and other vaccines as well.

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Well: Getting Patients to Think About Costs

A colleague and I recently got into a heated discussion over health care spending. It wasn’t that he disagreed with me about the need to rein in costs; but he said he was frustrated every time he tried to do so.

Earlier that week, for example, he had tried to avoid ordering a costly M.R.I. scan for a patient who had been suffering from headaches. After a thorough examination, my colleague was convinced the headaches were the result of stress.

But the patient was not.

“She wouldn’t leave until she got that M.R.I.,” my colleague said. Even after he had explained his conclusions several times, proposed a return visit in a month to reassess the situation and ran so far overtime that his office nurse knocked on the door to make sure nothing had gone awry, the patient continued to insist on getting the expensive study.

When my colleague finally evoked cost – telling the woman that while an M.R.I. might ferret out rare causes, it didn’t make sense to spend the enormous fee on something of such marginal benefit – the woman became belligerent. “She yelled that this was her head we were talking about,” he recalled. “And expensive tests like this were the reason she had health insurance.”

Face flushed, he paused to take a deep breath. “Yeah, I may be all for controlling costs,” he finally said. “But are our patients?”

According to a new study in the journal Health Affairs, his concern about patients may not be far off the mark.

A growing number of initiatives aimed at controlling spiraling health care costs have been championed in recent years, aiming to replace the current model in which doctors are reimbursed for every office visit, test or procedure performed. These programs range from pay-for-performance, where doctors can earn more money by meeting predetermined quality “goals” like controlling patients’ blood sugar or high blood pressure, to accountable care organizations, where clinicians and hospitals in partnership are paid a lump sum to cover all care.

Their uninspired monikers aside, all of these plans share one defining feature: doctors are to be the key agents of change. Whether linked with quality measures, bundled payments or satisfaction scores, it is the doctors’ behavior and choice of treatments that result in savings, goes the thinking.

But as the new study reveals, doctors need to take into account more than just symptoms and diseases when deciding what to prescribe and offer. They must also consider their patients’ opinions and willingness to be cost conscious when it comes to their own care.

The researchers conducted more than 20 patient focus groups and asked the participants to imagine themselves with various symptoms and a choice of diagnostic and treatment options that varied only slightly in effectiveness but significantly in cost. They were asked, for example, to choose between an M.R.I. or a CT scan for a severe long-standing headache, with the M.R.I. being much more expensive but also more likely to catch some extremely rare problems.

When it came to their own treatment, “patients for the most part did not want cost to play any role in decision-making,” said Dr. Susan Dorr Goold, one of the study authors and a professor of internal medicine and health management and policy at the University of Michigan in Ann Arbor. Most did not want their doctors to take expenditures into account, and many made it clear that they would ask for the significantly more expensive medications, procedures or diagnostic studies, even if those options were only slightly better than the cheaper alternatives. “That puts doctors, whose primary responsibility is to their individual patients, in a very difficult position.”

A majority of the participants refused to consider the expenses borne by insurers or by society as a whole when making their choices. Some doubted that one individual’s efforts would have any real overall impact and so gave up considering cost-savings altogether. Others said they would go out of their way to choose the more expensive options, viewing such decisions as acts of defiance and a kind of well-deserved “payback” after years of paying insurance premiums.

Underlying all of these comments was the belief that cost was synonymous with quality. Even when the focus group leaders reminded participants that the differences between proposed options were nearly negligible, participants continued to choose the more expensive options as if it were beyond question that they must be more efficacious or foolproof.

The study’s findings are disheartening. But Dr. Goold and her co-investigators believe that public beliefs and attitudes about cost and quality can be changed. They cite the dramatic transformation in attitudes about end-of-life care as an example of how initiatives to improve understanding can lead people to make higher quality and more cost-effective decisions, like choosing hospices over hospitals.

“We need to begin to talk about these issues in a way that doesn’t turn it into a discussion pitting money against life, and we need to find ways of getting people to think about not spending money on things that offer marginal benefit” Dr. Goold said. “Because it’s going to be tough otherwise trying to implement any cost-saving measures, if patients don’t accept them.”

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Ask an Expert: Questions About Hearing Loss? A Help Desk

This week’s Ask the Expert features Neil J. DiSarno, who will answer questions about hearing loss. Dr. DiSarno is the chief staff officer for audiology at the American Speech-Language-Hearing Association. From 1998 to 2012 he was chairman of the department of communication sciences and disorders at Missouri State University. Following are the types of questions that Dr. DiSarno is prepared to answer.

Neil J. DiSarno of the American Speech-Language-Hearing Association.

¶My wife has told me she believes I’m not hearing as well as I used to. What sort of specialist should I see and what can I expect?

¶I’ve been told that I should consider using hearing aids. If I decide to, how much better am I likely to hear?

¶I’ve noticed that my 2-year-old granddaughter’s speech is not developing properly. Neither her mother or the pediatrician seem to be concerned, but I suspect there is a problem. What do you suggest?

¶I use hearing aids, but still have great difficulty hearing conversation in restaurants and in large group settings. Is this common and is there something more that I can do to improve my ability to function in those settings?

Please leave your questions in the comments section. Answers will be posted on Wednesday, Feb. 27. (Unfortunately, not all questions may be answered.)

Booming: Living Through the Middle Ages offers news and commentary about baby boomers, anchored by Michael Winerip. You can connect with Michael Winerip on Facebook here. You can follow Booming via RSS here or visit nytimes.com/booming and reach us by e-mail at booming@nytimes.com.

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Well: Certain Television Fare Can Help Ease Aggression in Young Children, Study Finds

Experts have long known that children imitate many of the deeds — good and bad — that they see on television. But it has rarely been shown that changing a young child’s viewing habits at home can lead to improved behavior.

In a study published Monday in the journal Pediatrics, researchers reported the results of a program designed to limit the exposure of preschool children to violence-laden videos and television shows and increase their time with educational programming that encourages empathy. They found that the experiment reduced the children’s aggression toward others, compared with a group of children who were allowed to watch whatever they wanted.

“Here we have an experiment that proposes a potential solution,” said Dr. Thomas N. Robinson, a professor of pediatrics at Stanford, who was not involved in the study. “Giving this intervention — exposing kids to less adult television, less aggression on television and more prosocial television — will have an effect on behavior.”

While the research showed “a small to moderate effect” on the preschoolers’ behavior, he added, the broader public health impact could be “very meaningful.”

The new study was a randomized trial, rare in research on the effects of media on children. The researchers, at Seattle Children’s Research Institute and the University of Washington, divided 565 parents of children ages 3 to 5 into two groups. Both were told to track their children’s media consumption in a diary that the researchers assessed for violent, didactic and prosocial content, which they defined as showing empathy, helping others and resolving disputes without violence.

The control group was given advice only on better dietary habits for children. The second group of parents were sent program guides highlighting positive shows for young children. They also received newsletters encouraging parents to watch television with their children and ask questions during the shows about the best ways to deal with conflict. The parents also received monthly phone calls from the researchers, who helped them set television-watching goals for their preschoolers.

The researchers surveyed the parents at six months and again after a year about their children’s social behavior. After six months, parents in the group receiving advice about television-watching said their children were somewhat less aggressive with others, compared with those in the control group. The children who watched less violent shows also scored higher on measures of social competence, a difference that persisted after one year.

Low-income boys showed the most improvement, though the researchers could not say why. Total viewing time did not differ between the two groups.

“The take-home message for parents is it’s not just about turning off the TV; it’s about changing the channel,” said Dr. Dimitri A. Christakis, the lead author of the study and a professor of pediatrics at the University of Washington.

“We want our children to behave better,” Dr. Christakis said, “and changing their media diet is a good way to do that.”

Until she began participating in Dr. Christakis’s trial, Nancy Jensen, a writer in Seattle, had never heard of shows like Nickelodeon’s “Wonder Pets!,” featuring cooperative team players, and NBC’s “My Friend Rabbit,” with its themes of loyalty and friendship.

At the time, her daughter Elizabeth, then 3, liked“King of the Hill,”a cartoon comedy geared toward adults that features beer and gossip. In hindsight, she said, the show was “hilariously funny, but completely inappropriate for a 3-year-old.”

These days, she consults Common Sense Media, a nonprofit advocacy group in San Francisco, to make sure that the shows her daughter watches have some prosocial benefit. Elizabeth, now 6, was “not necessarily an aggressive kid,” Ms. Jensen said. Still, the girl’s teacher recently commended her as very considerate, and Ms. Jensen believes a better television diet is an important reason.

The new study has limitations, experts noted. Data on both the children’s television habits and their behavior was reported by their parents, who may not be objective. And the study focused only on media content in the home, although some preschool-aged children are exposed to programming elsewhere.

Children watch a mix of “prosocial but also antisocial media,” said Marie-Louise Mares, an associate professor of communications at the University of Wisconsin, Madison. “Merely being exposed to prosocial media doesn’t mean that kids take it that way.”

Even educational programming with messages of empathy can be misunderstood by preschoolers, with negative consequences. A study published online in November in The Journal of Applied Developmental Psychology found that preschoolers shown educational media were more likely to engage in certain forms of interpersonal aggression over time.

Preschoolers observe relationship conflict early in a television episode but do not always connect it to the moral lesson or resolution at the end, said Jamie M. Ostrov, the lead author of the November study and an associate professor of psychology at the University of Buffalo.

Preschoolers watch an estimated 4.1 hours of television and other screen time daily, according to a 2011 study. Dr. Ostrov advised parents to watch television with their young children and to speak up during the relationship conflicts that are depicted. Citing one example, Dr. Ostrov counseled parents to ask children, “What could we do differently here?” to make it clear that yelling at a sibling is not acceptable.

He also urged parents to stick with age-appropriate programming. A 3-year-old might misunderstand the sibling strife in the PBS show“Arthur,” he said, or stop paying attention before it is resolved.

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Fat Dad: Baking for Love

Fat Dad

Dawn Lerman writes about growing up with a fat dad.

My grandmother Beauty always told me that the way to a man’s heart was through his stomach, and by the look of pure delight on my dad’s face when he ate a piece of warm, homemade chocolate cake, or bit into a just-baked crispy cookie, I grew to believe this was true. I had no doubt that when the time came, and I liked a boy, that a batch of my gooey, rich, chocolaty brownies would cast him under a magic spell, and we would live happily ever.

But when Hank Thomas walked into Miss Seawall’s ninth grade algebra class on a rainy, September day and smiled at me with his amazing grin, long brown hair, big green eyes and Jimi Hendrix T-shirt, I was completely unprepared for the avalanche of emotions that invaded every fiber of my being. Shivers, a pounding heart, and heat overcame me when he asked if I knew the value of 1,000 to the 25th power. The only answer I could think of, as I fumbled over my words, was “love me, love me,” but I managed to blurt out “1E+75.” I wanted to come across as smart and aloof, but every time he looked at me, I started stuttering and sweating as my face turned bright red. No one had ever looked at me like that: as if he knew me, as if he knew how lost I was and how badly I needed to be loved.

Hank, who was a year older than me, was very popular and accomplished. Unlike other boys who were popular for their looks or athletic skills, Hank was smart and talented. He played piano and guitar, and composed the most beautiful classical and rock concertos that left both teachers and students in awe.

Unlike Hank, I had not quite come into my own yet. I was shy, had raggedy messy hair that I tied back into braids, and my clothes were far from stylish. My mother and sister had been on the road touring for the past year with the Broadway show “Annie.” My sister had been cast as a principal orphan, and I stayed home with my dad to attend high school. My dad was always busy with work and martini dinners that lasted late into the night. I spent most of my evenings at home alone baking and making care packages for my sister instead of coercing my parents to buy me the latest selection of Gloria Vanderbilt jeans — the rich colored bluejeans with the swan stitched on the back pocket that you had to lay on your bed to zip up. It was the icon of cool for the popular and pretty girls. I was neither, but Hank picked me to be his math partner anyway.

With every equation we solved, my love for Hank became more desperate. After several months of exchanging smiles, I decided to make Hank a batch of my homemade chocolate brownies for Valentine’s Day — the brownies that my dad said were like his own personal nirvana. My dad named them “closet” brownies, because when I was a little girl and used to make them for the family, he said that as soon as he smelled them coming out of the oven, he could imagine dashing away with them into the closet and devouring the whole batch.

After debating for hours if I should make the brownies for Hank with walnuts or chips, or fill the centers with peanut butter or caramel, I got to work. I had made brownies hundreds of times before, but this time felt different. With each ingredient I carefully stirred into the bowl, my heart began beating harder. I felt like I was going to burst from excitement. Surely, after Hank tasted these, he would love me as much as I loved him. I was not just making him brownies. I was l showing him who I was, and what mattered to me. After the brownies cooled, I sprinkled them with a touch of powdered sugar and wrapped them with foil and red tissue paper. The next day I placed them in Hank’s locker, with a note saying, “Call me.”

After seven excruciating days with no call, some smiles and the usual small talk in math class, I conjured up the nerve to ask Hank if he liked my brownies.

“The brownies were from you?” he asked. “They were delicious.”

Then Hank invited me to a party at his house the following weekend. Without hesitation, I responded that I would love to come. I pleaded with my friend Sarah to accompany me.

As the day grew closer, I made my grandmother Beauty’s homemade fudge — the chocolate fudge she made for Papa the night before he proposed to her. Stirring the milk, butter and sugar together eased my nerves. I had never been to a high school party before, and I didn’t know what to expect. Sarah advised me to ditch the braids as she styled my hair, used a violet eyeliner and lent me her favorite V-neck sweater and a pair of her best Gloria Vanderbilt jeans.

When we walked in the door, fudge in hand, Hank was nowhere to be found. Thinking I had made a mistake for coming and getting ready to leave, I felt a hand on my back. It was Hank’s. He hugged me and told me he was glad I finally arrived. When Hank put his arm around me, nothing else existed. With a little help from Cupid or the magic of Beauty’s recipes, I found love.

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Fat Dad’s ‘Closet’ Brownies

These brownies are more like fudge than cake and contain a fraction of the flour found in traditional brownie recipes. My father called them “closet” brownies, because when he smelled them coming out of the oven he could imagine hiding in the closet to eat the whole batch. I baked them in the ninth grade for a boy that I had a crush on, and they were more effective than Cupid’s arrow at winning his heart.

6 tablespoons unsalted butter, plus extra for greasing the pan
8 ounces bittersweet chocolate, chopped, or semisweet chocolate chips
3/4 cup brown sugar
2 eggs at room temperature, beaten
1 teaspoon vanilla extract
1/4 cup flour
1/2 cup chopped walnuts (optional)
Fresh berries or powdered sugar for garnish (optional)

1. Preheat oven to 350 degrees.

2. Grease an 8-inch square baking dish.

3. In a double boiler, melt chocolate. Then add butter, melt and stir to blend. Remove from heat and pour into a mixing bowl. Stir in sugar, eggs and vanilla and mix well.

4. Add flour. Mix well until very smooth. Add chopped walnuts if desired. Pour batter into greased baking pan.

5. Bake for 35 minutes, or until set and barely firm in the middle. Allow to cool on a rack before removing from pan. Optional: garnish with powdered sugar, or berries, or both.

Yield: 16 brownies

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Dawn Lerman is a New York-based health and nutrition consultant and founder of Magnificent Mommies, which provides school lectures, cooking classes and workshops. Her series on growing up with a fat father appears occasionally on Well.

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Well: Afraid to Speak Up to Medical Power

The slender, weather-beaten, elderly Polish immigrant had been diagnosed with lung cancer nearly a year earlier and was receiving chemotherapy as part of a clinical trial. I was a surgical consultant, called in to help control the fluid that kept accumulating in his lungs.

During one visit, he motioned for me to come closer. His voice was hoarse from a tumor that spread, and the constant hissing from his humidified oxygen mask meant I had to press my face nearly against his to understand his words.

“This is getting harder, doctor,” he rasped. “I’m not sure I’m up to anymore chemo.”

I was not the only doctor that he confided to. But what I quickly learned was that none of us was eager to broach the topic of stopping treatment with his primary cancer doctor.

That doctor was a rising superstar in the world of oncology, a brilliant physician-researcher who had helped discover treatments for other cancers and who had been recruited to lead our hospital’s then lackluster cancer center. Within a few months of the doctor’s arrival, the once sleepy department began offering a dazzling array of experimental drugs. Calls came in from outside doctors eager to send their patients in for treatment, and every patient who was seen was promptly enrolled in one of more than a dozen well-documented treatment protocols.

But now, no doctors felt comfortable suggesting anything but the most cutting-edge, aggressive treatments.

Even the No. 2 doctor in the cancer center, Robin to the chief’s cancer-battling Batman, was momentarily taken aback when I suggested we reconsider the patient’s chemotherapy plan. “I don’t want to tell him,” he said, eyes widening. He reeled off his chief’s vast accomplishments. “I mean, who am I to tell him what to do?”

We stood for a moment in silence before he pointed his index finger at me. “You tell him,” he said with a smile. “You tell him to consider stopping treatment.”

Memories of this conversation came flooding back last week when I read an essay on the problems posed by hierarchies within the medical profession.

For several decades, medical educators and sociologists have documented the existence of hierarchies and an intense awareness of rank among doctors. The bulk of studies have focused on medical education, a process often likened to military and religious training, with elder patriarchs imposing the hair shirt of shame on acolytes unable to incorporate a profession’s accepted values and behaviors. Aspiring doctors quickly learn whose opinions, experiences and voices count, and it is rarely their own. Ask a group of interns who’ve been on the wards for but a week, and they will quickly raise their hands up to the level of their heads to indicate their teachers’ status and importance, then lower them toward their feet to demonstrate their own.

It turns out that this keen awareness of ranking is not limited to students and interns. Other research has shown that fully trained physicians are acutely aware of a tacit professional hierarchy based on specialties, like primary care versus neurosurgery, or even on diseases different specialists might treat, like hemorrhoids and constipation versus heart attacks and certain cancers.

But while such professional preoccupation with privilege can make for interesting sociological fodder, the real issue, warns the author of a courageous essay published recently in The New England Journal of Medicine, is that such an overly developed sense of hierarchy comes at an unacceptable price: good patient care.

Dr. Ranjana Srivastava, a medical oncologist at the Monash Medical Centre in Melbourne, Australia, recalls a patient she helped to care for who died after an operation. Before the surgery, Dr. Srivastava had been hesitant to voice her concerns, assuming that the patient’s surgeon must be “unequivocally right, unassailable, or simply not worth antagonizing.” When she confesses her earlier uncertainty to the surgeon after the patient’s death, Dr. Srivastava learns that the surgeon had been just as loath to question her expertise and had assumed that her silence before the surgery meant she agreed with his plan to operate.

“Each of us was trying our best to help a patient, but we were also respecting the boundaries and hierarchy imposed by our professional culture,” Dr. Srivastava said. “The tragedy was that the patient died, when speaking up would have made all the difference.”

Compounding the problem is an increasing sense of self-doubt among many doctors. With rapid advances in treatment, there is often no single correct “answer” for a patient’s problem, and doctors, struggling to stay up-to-date in their own particular specialty niches, are more tentative about making suggestions that cross over to other doctors’ “turf.” Even as some clinicians attempt to compensate by organizing multidisciplinary meetings, inviting doctors from all specialties to discuss a patient’s therapeutic options, “there will inevitably be a hierarchy at those meetings of who is speaking,” Dr. Srivastava noted. “And it won’t always be the ones who know the most about the patient who will be taking the lead.”

It is the potentially disastrous repercussions for patients that make this overly developed awareness of rank and boundaries a critical issue in medicine. Recent efforts to raise safety standards and improve patient care have shown that teams are a critical ingredient for success. But simply organizing multidisciplinary lineups of clinicians isn’t enough. What is required are teams that recognize the importance of all voices and encourage active and open debate.

Since their patient’s death, Dr. Srivastava and the surgeon have worked together to discuss patient cases, articulate questions and describe their own uncertainties to each other and in patients’ notes. “We have tried to remain cognizant of the fact that we are susceptible to thinking about hierarchy,” Dr. Srivastava said. “We have tried to remember that sometimes, despite our best intentions, we do not speak up for our patients because we are fearful of the consequences.”

That was certainly true for my lung cancer patient. Like all the other doctors involved in his care, I hesitated to talk to the chief medical oncologist. I questioned my own credentials, my lack of expertise in this particular area of oncology and even my own clinical judgment. When the patient appeared to fare better, requiring less oxygen and joking and laughing more than I had ever seen in the past, I took his improvement to be yet another sign that my attempt to talk about holding back chemotherapy was surely some surgical folly.

But a couple of days later, the humidified oxygen mask came back on. And not long after that, the patient again asked for me to come close.

This time he said: “I’m tired. I want to stop the chemo.”

Just before he died, a little over a week later, he was off all treatment except for what might make him comfortable. He thanked me and the other doctors for our care, but really, we should have thanked him and apologized. Because he had pushed us out of our comfortable, well-delineated professional zones. He had prodded us to talk to one another. And he showed us how to work as a team in order to do, at last, what we should have done weeks earlier.

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Phys Ed: Getting the Right Dose of Exercise

Phys Ed

Gretchen Reynolds on the science of fitness.

A common concern about exercise is that if you don’t do it almost every day, you won’t achieve much health benefit. But a commendable new study suggests otherwise, showing that a fairly leisurely approach to scheduling workouts may actually be more beneficial than working out almost daily.

For the new study, published this month in Exercise & Science in Sports & Medicine, researchers at the University of Alabama at Birmingham gathered 72 older, sedentary women and randomly assigned them to one of three exercise groups.

One group began lifting weights once a week and performing an endurance-style workout, like jogging or bike riding, on another day.

Another group lifted weights twice a week and jogged or rode an exercise bike twice a week.

The final group, as you may have guessed, completed three weight-lifting and three endurance sessions, or six weekly workouts.

The exercise, which was supervised by researchers, was easy at first and meant to elicit changes in both muscles and endurance. Over the course of four months, the intensity and duration gradually increased, until the women were jogging moderately for 40 minutes and lifting weights for about the same amount of time.

The researchers were hoping to find out which number of weekly workouts would be, Goldilocks-like, just right for increasing the women’s fitness and overall weekly energy expenditure.

Some previous studies had suggested that working out only once or twice a week produced few gains in fitness, while exercising vigorously almost every day sometimes led people to become less physically active, over all, than those formally exercising less. Researchers theorized that the more grueling workout schedule caused the central nervous system to respond as if people were overdoing things, sending out physiological signals that, in an unconscious internal reaction, prompted them to feel tired or lethargic and stop moving so much.

To determine if either of these possibilities held true among their volunteers, the researchers in the current study tracked the women’s blood levels of cytokines, a substance related to stress that is thought to be one of the signals the nervous system uses to determine if someone is overdoing things physically. They also measured the women’s changing aerobic capacities, muscle strength, body fat, moods and, using sophisticated calorimetry techniques, energy expenditure over the course of each week.

By the end of the four-month experiment, all of the women had gained endurance and strength and shed body fat, although weight loss was not the point of the study. The scientists had not asked the women to change their eating habits.

There were, remarkably, almost no differences in fitness gains among the groups. The women working out twice a week had become as powerful and aerobically fit as those who had worked out six times a week. There were no discernible differences in cytokine levels among the groups, either.

However, the women exercising four times per week were now expending far more energy, over all, than the women in either of the other two groups. They were burning about 225 additional calories each day, beyond what they expended while exercising, compared to their calorie burning at the start of the experiment.

The twice-a-week exercisers also were using more energy each day than they had been at first, burning almost 100 calories more daily, in addition to the calories used during workouts.

But the women who had been assigned to exercise six times per week were now expending considerably less daily energy than they had been at the experiment’s start, the equivalent of almost 200 fewer calories each day, even though they were exercising so assiduously.

“We think that the women in the twice-a-week and four-times-a-week groups felt more energized and physically capable” after several months of training than they had at the start of the study, says Gary Hunter, a U.A.B. professor who led the experiment. Based on conversations with the women, he says he thinks they began opting for stairs over escalators and walking for pleasure.

The women working out six times a week, though, reacted very differently. “They complained to us that working out six times a week took too much time,” Dr. Hunter says. They did not report feeling fatigued or physically droopy. Their bodies were not producing excessive levels of cytokines, sending invisible messages to the body to slow down.

Rather, they felt pressed for time and reacted, it seems, by making choices like driving instead of walking and impatiently avoiding the stairs.

Despite the cautionary note, those who insist on working out six times per week need not feel discouraged. As long as you consciously monitor your activity level, the findings suggest, you won’t necessarily and unconsciously wind up moving less over all.

But the more fundamental finding of this study, Dr. Hunter says, is that “less may be more,” a message that most likely resonates with far more of us. The women exercising four times a week “had the greatest overall increase in energy expenditure,” he says. But those working out only twice a week “weren’t far behind.”

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Personal Health: Getting the Right Addiction Treatment

“Treatment is not a prerequisite to surviving addiction.” This bold statement opens the treatment chapter in a helpful new book, “Now What? An Insider’s Guide to Addiction and Recovery,” by William Cope Moyers, a man who nonetheless needed “four intense treatment experiences over five years” before he broke free of alcohol and drugs.

As the son of Judith and Bill Moyers, successful parents who watched helplessly during a 15-year pursuit of oblivion through alcohol and drugs, William Moyers said his near-fatal battle with addiction demonstrates that this “illness of the mind, body and spirit” has no respect for status or opportunity.

“My parents raised me to become anything I wanted, but when it came to this chronic incurable illness, I couldn’t get on top of it by myself,” he said in an interview.

He finally emerged from his drug-induced nadir when he gave up “trying to do it my way” and instead listened to professional therapists and assumed responsibility for his behavior. For the last “18 years and four months, one day at a time,” he said, he has lived drug-free.

“Treatment is not the end, it’s the beginning,” he said. “My problem was not drinking or drugs. My problem was learning how to live life without drinking or drugs.”

Mr. Moyers acknowledges that treatment is not a magic bullet. Even after a monthlong stay at a highly reputable treatment center like Hazelden in Center City, Minn., where Mr. Moyers is a vice president of public affairs and community relations, the probability of remaining sober and clean a year later is only about 55 percent.

“Be wary of any program that claims a 100 percent success rate,” Mr. Moyers warned. “There is no such thing.”

“Treatment works to make recovery possible. But recovery is also possible without treatment,” Mr. Moyers said. “There’s no one-size-fits-all approach. What I needed and what worked for me isn’t necessarily what you or your loved one require.”

As with many smokers who must make multiple attempts to quit before finally overcoming an addiction to nicotine, people hooked on alcohol or drugs often must try and try again.

Nor does treatment have as good a chance at succeeding if it is forced upon a person who is not ready to recover. “Treatment does work, but only if the person wants it to,” Mr. Moyers said.

Routes to Success

For those who need a structured program, Mr. Moyers described what to consider to maximize the chances of overcoming addiction to alcohol or drugs.

Most important is to get a thorough assessment before deciding where to go for help. Do you or your loved one meet the criteria for substance dependence? Are there “co-occurring mental illnesses, traumatic or physical disabilities, socioeconomic influences, cultural issues, or family dynamics” that may be complicating the addiction and that can sabotage treatment success?

While most reputable treatment centers do a full assessment before admitting someone, it is important to know if the center or clinic provides the services of professionals who can address any underlying issues revealed by the assessment. For example, if needed, is a psychiatrist or other medical doctor available who could provide therapy and prescribe medication?

Is there a social worker on staff to address challenging family, occupational or other living problems? If a recovering addict goes home to the same problems that precipitated the dependence on alcohol or drugs, the chances of remaining sober or drug-free are greatly reduced.

Is there a program for family members who can participate with the addict in learning the essentials of recovery and how to prepare for the return home once treatment ends?

Finally, does the program offer aftercare and follow-up services? Addiction is now recognized to be a chronic illness that lurks indefinitely within an addict in recovery. As with other chronic ailments, like diabetes or hypertension, lasting control requires hard work and diligence. One slip need not result in a return to abuse, and a good program will help addicts who have completed treatment cope effectively with future challenges to their recovery.

How Families Can Help

“Addiction is a family illness,” Mr. Moyers wrote. Families suffer when someone they love descends into the purgatory of addiction. But contrary to the belief that families should cut off contact with addicts and allow them to reach “rock-bottom” before they can begin recovery, Mr. Moyers said that the bottom is sometimes death.

“It is a dangerous, though popular, misconception that a sick addict can only quit using and start to get well when he ‘hits bottom,’ that is, reaches a point at which he is desperate enough to willingly accept help,” Mr. Moyers wrote.

Rather, he urged families to remain engaged, to keep open the lines of communication and regularly remind the addict of their love and willingness to help if and when help is wanted. But, he added, families must also set firm boundaries — no money, no car, nothing that can be quickly converted into the substance of abuse.

Whether or not the addict ever gets well, Mr. Moyers said, “families have to take care of themselves. They can’t let the addict walk over their lives.”

Sometimes families or friends of an addict decide to do an intervention, confronting the addict with what they see happening and urging the person to seek help, often providing possible therapeutic contacts.

“An intervention can be the key that interrupts the process and enables the addict to recognize the extent of their illness and the need to take responsibility for their behavior,”Mr. Moyers said.

But for an intervention to work, Mr. Moyers said, “the sick person should not be belittled or demeaned.” He also cautioned families to “avoid threats.” He noted that the mind of “the desperate, fearful addict” is subsumed by drugs and alcohol that strip it of logic, empathy and understanding. It “can’t process your threat any better than it can a tearful, emotional plea.”

Resource Network

Mr. Moyer’s book lists nearly two dozen sources of help for addicts and their families. Among them:

Alcoholics Anonymous World Services www.aa.org;

Narcotics Anonymous World Services www.na.org;

Substance Abuse and Mental Health Services Administration treatment finder www.samhsa.gov/treatment/;

Al-Anon Family Groups www.Al-anon.alateen.org;

Nar-Anon Family Groups www.nar-anon.org;

Co-Dependents Anonymous World Fellowship www.coda.org.

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This is the second of two articles on addiction treatment. The first can be found here.

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For Families Struggling with Mental Illness, Carolyn Wolf Is a Guide in the Darkness

When a life starts to unravel, where do you turn for help?

Melissa Klump began to slip in the eighth grade. She couldn’t focus in class, and in a moment of despair she swallowed 60 ibuprofen tablets. She was smart, pretty and ill: depression, attention deficit disorder, obsessive-compulsive disorder, either bipolar disorder or borderline personality disorder.

In her 20s, after a more serious suicide attempt, her parents sent her to a residential psychiatric treatment center, and from there to another. It was the treatment of last resort. When she was discharged from the second center last August after slapping another resident, her mother, Elisa Klump, was beside herself.

“I was banging my head against the wall,” the mother said. “What do I do next?” She frantically called support groups, therapy programs, suicide prevention lines, anybody, running down a list of names in a directory of mental health resources. “Finally,” she said, “somebody told me, ‘The person you need to talk to is Carolyn Wolf.’ ”

That call, she said, changed her life and her daughter’s. “Carolyn has given me hope,” she said. “I didn’t know there were people like her out there.”

Carolyn Reinach Wolf is not a psychiatrist or a mental health professional, but a lawyer who has carved out what she says is a unique niche, working with families like the Klumps.

One in 17 American adults suffers from a severe mental illness, and the systems into which they are plunged — hospitals, insurance companies, courts, social services — can be fragmented and overwhelming for families to manage. The recent shootings in Newtown, Conn., and Aurora, Colo., have brought attention to the need for intervention to prevent such extreme acts of violence, which are rare. But for the great majority of families watching their loved ones suffer, and often suffering themselves, the struggle can be boundless, with little guidance along the way.

“If you Google ‘mental health lawyer,’ ” said Ms. Wolf, a partner with Abrams & Fensterman, “I’m kinda the only game in town.”

On a recent afternoon, she described in her Midtown office the range of her practice.

“We have been known to pull people out of crack dens,” she said. “I have chased people around hotels all over the city with the N.Y.P.D. and my team to get them to a hospital. I had a case years ago where the person was on his way back from Europe, and the family was very concerned that he was symptomatic. I had security people meet him at J.F.K.”

Many lawyers work with mentally ill people or their families, but Ron Honberg, the national director of policy and legal affairs for the National Alliance on Mental Illness, said he did not know of another lawyer who did what Ms. Wolf does: providing families with a team of psychiatrists, social workers, case managers, life coaches, security guards and others, and then coordinating their services. It can be a lifeline — for people who can afford it, Mr. Honberg said. “Otherwise, families have to do this on their own,” he said. “It’s a 24-hour, 7-day-a-week job, and for some families it never ends.”

Many of Ms. Wolf’s clients declined to be interviewed for this article, but the few who spoke offered an unusual window on the arcane twists and turns of the mental health care system, even for families with money. Their stories illustrate how fraught and sometimes blind such a journey can be.

One rainy morning last month, Lance Sheena, 29, sat with his mother in the spacious family room of her Long Island home. Mr. Sheena was puffy-eyed and sporadically inattentive; the previous night, at the group home where he has been living since late last summer, another resident had been screaming incoherently and was taken away by the police. His mother, Susan Sheena, eased delicately into the family story.

“I don’t talk to a lot of people because they don’t get it,” Ms. Sheena said. “They mean well, but they don’t get it unless they’ve been through a similar experience. And anytime something comes up, like the shooting in Newtown, right away it goes to the mentally ill. And you think, maybe we shouldn’t be so public about this, because people are going to be afraid of us and Lance. It’s a big concern.”

Her son cut her off. “Are you comparing me to the guy that shot those people?”

“No, I’m saying that anytime there’s a shooting, like in Aurora, that’s when these things come out in the news.”

“Did you really just compare me to that guy?”

“No, I didn’t compare you.”

“Then what did you say?”

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In Nigeria, Polio Vaccine Workers Are Killed by Gunmen

At least nine polio immunization workers were shot to death in northern Nigeria on Friday by gunmen who attacked two clinics, officials said.

The killings, with eerie echoes of attacks that killed nine female polio workers in Pakistan in December, represented another serious setback for the global effort to eradicate polio.

Most of the victims were women and were shot in the back of the head, local reports said.

A four-day vaccination drive had just ended in Kano State, where the killings took place, and the vaccinators were in a “mop-up” phase, looking for children who had been missed, said Sarah Crowe, a spokeswoman for the United Nations Children’s Fund, one of the agencies running the eradication campaign.

Dr. Mohammad Ali Pate, Nigeria’s minister of state for health, said in a telephone interview that it was not entirely clear whether the gunmen were specifically targeting polio workers or just attacking the health centers where vaccinators happened to be gathering early in the morning. “Health workers are soft targets,” he said.

No one immediately took responsibility, but suspicion fell on Boko Haram, a militant Islamist group that has attacked police stations, government offices and even a religious leader’s convoy.

Polio, which once paralyzed millions of children, is now down to fewer than 1,000 known cases around the world, and is endemic in only three countries: Nigeria, Pakistan and Afghanistan.

Since September — when a new polio operations center was opened in the capital and Nigeria’s president, Goodluck Jonathan, appointed a special adviser for polio — the country had been improving, said Dr. Bruce Aylward, chief of polio eradication for the World Health Organization. There have been no new cases since Dec. 3.

While vaccinators have not previously been killed in the country, there is a long history of Nigerian Muslims shunning the vaccine.

Ten years ago, immunization was suspended for 11 months as local governors waited for local scientists to investigate rumors that it caused AIDS or was a Western plot to sterilize Muslim girls. That hiatus let cases spread across Africa. The Nigerian strain of the virus even reached Saudi Arabia when a Nigerian child living in hills outside Mecca was paralyzed.

Heidi Larson, an anthropologist at the London School of Hygiene and Tropical Medicine who tracks vaccine issues, said the newest killings “are kind of mimicking what’s going on in Pakistan, and I feel it’s very much prompted by that.”

In a roundabout way, the C.I.A. has been blamed for the Pakistan killings. In its effort to track Osama bin Laden, the agency paid a Pakistani doctor to seek entry to Bin Laden’s compound on the pretext of vaccinating the children — presumably to get DNA samples as evidence that it was the right family. That enraged some Taliban factions in Pakistan, which outlawed vaccination in their areas and threatened vaccinators.

Nigerian police officials said the first shootings were of eight workers early in the morning at a clinic in the Tarauni neighborhood of Kano, the state capital; two or three died. A survivor said the two gunmen then set fire to a curtain, locked the doors and left.

“We summoned our courage and broke the door because we realized they wanted to burn us alive,” the survivor said from her bed at Aminu Kano Teaching Hospital.

About an hour later, six men on three-wheeled motorcycles stormed a clinic in the Haye neighborhood, a few miles away. They killed seven women waiting to collect vaccine.

Ten years ago, Dr. Larson said, she joined a door-to-door vaccination drive in northern Nigeria as a Unicef communications officer, “and even then we were trying to calm rumors that the C.I.A. was involved,” she said. The Iraq and Afghanistan wars had convinced poor Muslims in many countries that Americans hated them, and some believed the American-made vaccine was a plot by Western drug companies and intelligence agencies.

Since the vaccine ruse in Pakistan, she said, “Frankly, now, I can’t go to them and say, ‘The C.I.A. isn’t involved.’ ”

Dr. Pate said the attack would not stop the newly reinvigorated eradication drive, adding, “This isn’t going to deter us from getting everyone vaccinated to save the lives of our children.”

Aminu Abubakar contributed reported from Kano, Nigeria.

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