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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The ConsUmer: Questions About a Robotic Surgery

Ever since it was approved by the Food and Drug Administration in 2005, robotic surgery for hysterectomy has been heavily advertised. Surgeons promise that using the da Vinci robotic device will bring better results and an easier recovery, and many hospitals claim that patients will experience less pain and fewer complications, getting back on their feet faster.

The company that makes da Vinci robotic surgery equipment promoted it last May at free health workshops organized by the federal Office on Womens’ Health. On Sunday, the Liberty Science Museum in Jersey City will host its first “Let’s Operate Day,” offering guests “hands-on” practice peering into video monitors and using da Vinci’s robot arms to pick up and manipulate small objects.

The cost of the new technology is rarely mentioned. But last week, a new study that evaluated outcomes in more than a quarter of a million American women raised questions about the manufacturer’s claims. The paper, published in The Journal of the American Medical Association, compared outcomes in 264,758 women who had either laparoscopic or robotically assisted hysterectomy at 441 hospitals between 2007 and 2010. Both methods are minimally invasive and involve smaller incisions than open abdominal surgery.

The researchers found no overall difference in complication rates between the two groups, and no difference in the rates of blood transfusion, even though one of the claims regarding robotic surgery is that it causes less blood loss.

But the researchers did find a big difference in cost. Robotically assisted surgery for hysterectomy costs on average about one-third more than laparoscopic surgery.

“It’s important to separate the marketing from the data,” said Dr. Jason D. Wright, the study’s lead author, an assistant professor of obstetrics and gynecology at Columbia University Medical Center. “For the surgeon, there is a greater degree of movement and control of the instruments and the visualization is better.

“But the ultimate question is, does this change outcomes for patients? This study suggests that there really is not a lot of difference as far as quantifiable outcomes.”

The majority of patients in both groups left the hospital in less than two days, though patients who had robotic surgery were slightly more likely to go home that early: 80 percent went home in less than two days, compared with 75 percent of those who had laparoscopic surgery.

But the cost of robotic surgeries was significantly higher, with a median cost to the hospital of $8,868, compared with $6,679 for laparoscopic hysterectomy. The study did not look at the difference in patients’ bills, but according to Newchoicehealth.com, the average patient price for a laparoscopic hysterectomy ranges from $7,700 in Dallas to $11,600 in Los Angeles.

With laparoscopic surgery — sometimes called keyhole surgery — narrow instruments and a small video camera are inserted through tiny incisions; the surgeon sees the image on a monitor and can cut and sew tissue with the instruments. With robotically assisted surgery, the surgeon sits at a console with a 3-dimensional view of the surgical site, and computer technology translates his or her hand movements into precise, scaled movements of the instruments.

Even without offering clear advantages the proportion of hysterectomies performed robotically has increased rapidly, up to nearly 10 percent of hysterectomies in 2010 from less than 1 percent in 2007, Dr. Wright said. Minimally invasive surgeries for hysterectomies are increasing across the board, he found, even at hospitals not performing robotic surgery.

Dr. Myriam J. Curet, chief medical adviser to Intuitive Surgical, which makes the da Vinci systems, did not dispute the study’s findings, but said the important message was that more women were able to receive minimally invasive surgeries because more options were available.

“That’s good for patients and for the health care system,” Dr. Curet said. Women who are not candidates for laparoscopic surgery might still be candidates for robotically-assisted surgery, she added.

Right now, however, it is not clear how to identify which women would benefit from robotic surgery and which would do well with a less expensive method.

The growing use of robotic surgery in hospitals will continue to drive up health costs, said Joel S. Weissman, of Brigham and Women’s Hospital and a co-author of an editorial published with the study.

“Once you have that robot, the tendency is to use it for all kinds of things, for which it may or may not have great value,” Dr. Weissman said. Studies like this one, he said, demonstrate the waste of health care dollars on “something that costs a lot more and doesn’t offer any added benefit over current treatment options.”

Each year approximately 600,000 American women have hysterectomies, according to the Centers for Disease Control and Prevention. By age 60, one in three American women has had her uterus removed, often along with her ovaries and cervix.

Critics who say far too many hysterectomies are done in the United States worry that all the attention to surgical method distracts from the question of whether patients should be having the surgery at all.

Most hysterectomies are prescribed for conditions that are not life-threatening, and advocates worry that women are not fully informed of the long-term harms, which may include a loss of sexual responsiveness, depression and chronic constipation, and higher risk for osteoporosis and heart disease, said Nora W. Coffey, the founder of the nonprofit Hysterectomy Educational Resources and Services Foundation.

“That’s the conversation we should be having,” Ms. Coffey said.

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Nora W. Coffey and other experts emphasize that women considering a hysterectomy should discuss all options with their doctors.

¶Ask what the alternatives are and whether watchful waiting is an option. Remember that it is irreversible, regardless of how the surgery is done.

¶Learn about the nonreproductive functions of the uterus, ovaries and cervix, and the potential long-term consequences associated with their removal, as well as the function of the ovaries and cervix.

¶If you proceed, discuss the advantages and disadvantages of different surgical methods with your doctor. Interview several surgeons and inquire about the cost and how much insurance will cover. Your co-pay may vary depending on the surgical method.

¶Tell your surgeon if you do not want your ovaries and cervix removed.

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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: Ask Well: The Nutrients in Fruits and Veggies

The colorful skin of an apple, grape or tomato is certainly chockfull of nutrients. But by no means are the outer layers of most fruits and vegetables the prime source of their nutrition.

Part of what makes some fruits and vegetables so rich with color – wax and pesticides notwithstanding – are pigments in the skin that have healthful antioxidant properties. Resveratrol, for example, is found in the skin of red grapes and other fruits. But lycopene, one of the pigments that gives tomatoes and bell peppers their deep red color, is distributed throughout.

Indeed, many vitamins and nutrients are found in the skin as well as the flesh. Take apples. According to the United States Department of Agriculture, a large red apple with its skin intact contains about 5 grams of fiber, 13 milligrams of calcium, 239 milligrams of potassium, and 10 milligrams of vitamin C. But remove the skin, and it still contains about 3 grams of fiber, 11 milligrams of calcium, 194 milligrams of potassium, and plenty of its vitamin C and other nutrients.

Another example is the sweet potato. The U.S.D.A. says that a 100-gram serving of sweet potato cooked with its skin contains 2 grams of protein, 3 grams of fiber, and 20 milligrams of vitamin C. But the same sized serving of sweet potato without skin that has been boiled — a process that further leaches away some of its nutrients — still boasts 1.4 grams of protein, 2.5 grams of fiber, and 13 milligrams of vitamin C.

You can lose the skin, in other words, without losing all the benefits.

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Well: The Benefits of Exercising Outdoors

While the allure of the gym — climate-controlled, convenient and predictable — is obvious, especially in winter, emerging science suggests there are benefits to exercising outdoors that can’t be replicated on a treadmill, a recumbent bicycle or a track.

You stride differently when running outdoors, for one thing. Generally, studies find, people flex their ankles more when they run outside. They also, at least occasionally, run downhill, a movement that isn’t easily done on a treadmill and that stresses muscles differently than running on flat or uphill terrain. Outdoor exercise tends, too, to be more strenuous than the indoor version. In studies comparing the exertion of running on a treadmill and the exertion of running outside, treadmill runners expended less energy to cover the same distance as those striding across the ground outside, primarily because indoor exercisers face no wind resistance or changes in terrain, no matter how subtle.

The same dynamic has been shown to apply to cycling, where wind drag can result in much greater energy demands during 25 miles of outdoor cycling than the same distance on a stationary bike. That means if you have limited time and want to burn as many calories as possible, you should hit the road instead of the gym.

But there seem to be other, more ineffable advantages to getting outside to work out. In a number of recent studies, volunteers have been asked to go for two walks for the same time or distance — one inside, usually on a treadmill or around a track, the other outdoors. In virtually all of the studies, the volunteers reported enjoying the outside activity more and, on subsequent psychological tests, scored significantly higher on measures of vitality, enthusiasm, pleasure and self-esteem and lower on tension, depression and fatigue after they walked outside.

Of course, those studies were small-scale, short-term — only two walks — and squishy in their scientific parameters, relying heavily on subjective responses. But a study last year of older adults found, objectively, that those who exercised outside exercised longer and more often than those working out indoors. Specifically, the researchers asked men and women 66 or older about their exercise habits and then fitted them all with electronic gadgets that measured their activity levels for a week. The gadgets and the survey showed that the volunteers who exercised outside, usually by walking, were significantly more physically active than those who exercised indoors, completing, on average, about 30 minutes more exercise each week than those who walked or otherwise exercised indoors.

Studies haven’t yet established why, physiologically, exercising outside might improve dispositions or inspire greater commitment to an exercise program. A few small studies have found that people have lower blood levels of cortisol, a hormone related to stress, after exerting themselves outside as compared with inside. There’s speculation, too, that exposure to direct sunlight, known to affect mood, plays a role.

But the take-away seems to be that moving their routines outside could help reluctant or inconsistent exercisers. “If outdoor activity encourages more activity, then it is a good thing,” says Jacqueline Kerr, a professor at the University of California, San Diego, who led the study of older adults. After all, “despite the fitness industry boom,” she continues, “we are not seeing changes in national physical activity levels, so gyms are not the answer.”

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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: Susan Love's Illness Gives New Focus to Her Cause

During a talk last spring in San Francisco, Dr. Susan Love, the well-known breast cancer book author and patient advocate, chided the research establishment for ignoring the needs of people with cancer. “The only difference between a researcher and a patient is a diagnosis,” she told the crowd. “We’re all patients.”

It was an eerily prescient lecture. Less than two months later, Dr. Love was given a diagnosis of acute myelogenous leukemia. She had no obvious symptoms and learned of her disease only after a checkup and routine blood work.

“Little did I know I was talking about myself,” she said in an interview. “It was really out of the blue. I was feeling fine. I ran five miles the day before.”

Dr. Love, a surgeon, is best known as the author of the top-selling “Dr. Susan Love’s Breast Book” (Da Capo Press, 2010) now in its fifth edition. She is also president of the Dr. Susan Love Research Foundation, which focuses on breast cancer prevention and research into eradicating the disease. But after decades of tireless advocacy on behalf of women with breast cancer, Dr. Love found herself in an unfamiliar role with an unfamiliar disease.

“There is a sense of shock when it happens to you,” she said. “In some ways I would have been less shocked if I got breast cancer because it’s so common, but getting leukemia was a world I didn’t know. Even when you’re a physician, when you get shocking news like this you sort of forget everything you know and are scared the same as everybody else.”

Because Dr. Love’s disease was caught early, she had a little time to seek second opinions and choose her medical team. She chose City of Hope in Duarte, Calif., because of its extensive experience in bone marrow transplants. At 65, Dr. Love was startled to learn she was considered among the “elderly” patients for this type of leukemia.

She was admitted to the hospital and underwent chemotherapy. Because her blood counts did not rebound after the treatment, her stay lasted a grueling seven weeks.

She went home for just two weeks, and then returned to the hospital for a bone-marrow transplant, with marrow donated by her younger sister, Elizabeth Love De Garcia, 53, who lives in Mexico City.

Although the transplant itself was uneventful, the next four weeks were an ordeal. Dr. Love developed pain and neuropathy from the chemotherapy drugs. Dr. Love’s wife, Dr. Helen Cooksey; daughter, Katie Love-Cooksey, 24; and siblings offered round-the-clock support. Ms. Love-Cooksey slept in the hospital every night. “I wasn’t very articulate during that time, but I always had my family there,” Dr. Love said. “They were great advocates for me.”

The transplant “is quite an amazing thing,” Dr. Love said. Her blood type changed from O positive to B positive, the same type as her sister. She also has inherited her sister’s immune system, and a lifelong allergy to nickel has disappeared. “I can wear cheap jewelry now,” she said. She returned to work last month.

Dr. Love has been told her disease is in remission, though her immune system remains compromised and she is more susceptible to infection. So she avoids crowds, air travel and other potential sources of cold and flu viruses.

While Dr. Love has always been a strong advocate for women undergoing cancer treatment, she says her disease and treatment has strengthened her understanding of what women with breast cancer and other types of cancer go through during treatments.

“There are little things like having numb toes or having less stamina to building muscles back up after a month of bed rest,” she said. “There is significant collateral damage from the treatment that is underestimated by the medical profession. There’s a sense of ‘You’re lucky to be alive, so why are you complaining?’ ”

Dr. Love says her experience has emboldened her in her quest to focus on the causes of disease rather than new drugs to treat it.

“I think I’m more impatient now and in more of a hurry,” she said. “I’ve been reminded that you don’t know how long you have. There are women being diagnosed every day. We don’t have the luxury to sit around and come up with a new marketing scheme. We have to get rid of this disease, and there is no reason we can’t do it.”

People who remain skeptical about the ability to eradicate breast cancer should look to the history of cervical cancer, she said. Decades ago, a woman with an abnormal Pap smear would be advised to undergo hysterectomy. Now a vaccine exists that can protect women from the infection that causes most cervical cancers.

“We need to focus more on the cause of breast cancer,” she said. “I’m still very impressed with the fact that cancer of the cervix went from being a disease that robbed women of their fertility, if not their lives, to having a vaccine to prevent it.”

Dr. Love, who wrote a book called “Live a Little!,” said illness has also made her grateful that she didn’t put off her “bucket list” and that she has traveled the world and focused on work she finds challenging and satisfying.

“It just reminds you that none of us are going to get out of here alive, and we don’t know how much time we have,” she said. “I say this to my daughter, whether it’s changing the world or having a good time, that we should do what we want to do. I drink the expensive wine now.”

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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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Cuomo Bucks Tide With Bill to Lift Abortion Limits

ALBANY — Bucking a trend in which states have been seeking to restrict abortion, Gov. Andrew M. Cuomo is putting the finishing touches on legislation that would guarantee women in New York the right to late-term abortions when their health is in danger or the fetus is not viable.

Mr. Cuomo, seeking to deliver on a promise he made in his recent State of the State address, would rewrite a law that currently allows abortions after 24 weeks of pregnancy only if the pregnant woman’s life is at risk. The law is not enforced, because it is superseded by federal court rulings that allow late-term abortions to protect a woman’s health, even if her life is not in jeopardy. But abortion rights advocates say the existence of the more restrictive state law has a chilling effect on some doctors and prompts some women to leave the state for late-term abortions.

Mr. Cuomo’s proposal, which has not yet been made public, would also clarify that licensed health care practitioners, and not only physicians, can perform abortions. It would remove abortion from the state’s penal law and regulate it through the state’s public health law.

Abortion rights advocates have welcomed Mr. Cuomo’s plan, which he outlined in general terms as part of a broader package of women’s rights initiatives in his State of the State address in January. But the Roman Catholic Church and anti-abortion groups are dismayed; opponents have labeled the legislation the Abortion Expansion Act.

The prospects for Mr. Cuomo’s effort are uncertain. The State Assembly is controlled by Democrats who support abortion rights; the Senate is more difficult to predict because this year it is controlled by a coalition of Republicans who have tended to oppose new abortion rights laws and breakaway Democrats who support abortion rights.

New York legalized abortion in 1970, three years before it was legalized nationally by the Supreme Court in Roe v. Wade. Mr. Cuomo’s proposal would update the state law so that it could stand alone if the broader federal standard set by Roe were to be undone.

“Why are we doing this? The Supreme Court could change,” said a senior Cuomo administration official, who spoke on the condition of anonymity because the governor had not formally introduced his proposal.

But opponents of abortion rights, already upset at the high rate of abortions in New York State, worry that rewriting the abortion law would encourage an even greater number of abortions. For example, they suggest that the provision to allow abortions late in a woman’s pregnancy for health reasons could be used as a loophole to allow unchecked late-term abortions.

“I am hard pressed to think of a piece of legislation that is less needed or more harmful than this one,” the archbishop of New York, Cardinal Timothy M. Dolan, wrote in a letter to Mr. Cuomo last month. Referring to Albany lawmakers in a subsequent column, he added, “It’s as though, in their minds, our state motto, ‘Excelsior’ (‘Ever Upward’), applies to the abortion rate.”

National abortion rights groups have sought for years to persuade state legislatures to adopt laws guaranteeing abortion rights as a backup to Roe. But they have had limited success: Only seven states have such measures in place, including California, Connecticut and Maryland; the most recent state to adopt such a law is Hawaii, which did so in 2006.

“Pretty much all of the energy, all of the momentum, has been to restrict abortion, which makes what could potentially happen in New York so interesting,” said Elizabeth Nash, state issues manager at the Guttmacher Institute, a research group that supports abortion rights. “There’s no other state that’s even contemplating this right now.”

In most statehouses, the push by lawmakers has been in the opposite direction. The past two years has seen more provisions adopted at the state level to restrict abortion rights than in any two-year period in decades, according to the Guttmacher Institute; last year, 19 states adopted 43 new provisions restricting abortion access, while not a single significant measure was adopted to expand access to abortion or to comprehensive sex education.

“It’s an extraordinary moment in terms of the degree to which there is government interference in a woman’s ability to make these basic health care decisions,” said Andrea Miller, the president of NARAL Pro-Choice New York. “For New York to be able to send a signal, a hopeful sign, a sense of the turning of the tide, we think is really important.”

Abortion rights advocates say that even though the Roe decision supersedes state law, some doctors are hesitant to perform late-term abortions when a woman’s health is at risk because the criminal statutes remain on the books.

“Doctors and hospitals shouldn’t be reading criminal laws to determine what types of health services they can offer and provide to their patients,” said M. Tracey Brooks, the president of Family Planning Advocates of New York State.

For Mr. Cuomo, the debate over passing a new abortion law presents an opportunity to appeal to women as well as to liberals, who have sought action in Albany without success since Eliot Spitzer made a similar proposal when he was governor. But it also poses a challenge to the coalition of Republicans and a few Democrats that controls the State Senate, the chamber that has in the past stood as the primary obstacle to passing abortion legislation in the capital.

The governor has said that his Reproductive Health Act would be one plank of a 10-part Women’s Equality Act that also would include equal pay and anti-discrimination provisions. Conservative groups, still stinging from the willingness of Republican lawmakers to go along with Mr. Cuomo’s push to legalize same-sex marriage in 2011, are mobilizing against the proposal. Seven thousand New Yorkers who oppose the measure have sent messages to Mr. Cuomo and legislators via the Web site of the New York State Catholic Conference.

A number of anti-abortion groups have also formed a coalition called New Yorkers for Life, which is seeking to rally opposition to the governor’s proposal using social media.

“If you ask anyone on the street, ‘Is there enough abortion in New York?’ no one in their right mind would say we need more abortion,” said the Rev. Jason J. McGuire, the executive director of New Yorkers for Constitutional Freedoms, which is part of the coalition.

Members of both parties say that the issue of reproductive rights was a significant one in November’s legislative elections. Democrats, who were bolstered by an independent expenditure campaign by NARAL, credit their victories in several key Senate races in part to their pledge to fight for legislation similar to what Mr. Cuomo is planning to propose.

Republicans, who make up most of the coalition that controls the Senate, have generally opposed new abortion rights measures. Speaking with reporters recently, the leader of the Republicans, Dean G. Skelos of Long Island, strenuously objected to rewriting the state’s abortion laws, especially in a manner similar to what the governor is seeking.

“You could have an abortion up until the day the child would be born, and I think that’s just wrong,” Mr. Skelos said. He suggested that the entire debate was unnecessary, noting that abortion is legal in New York State and saying that is “not going to be changed.”

The Senate Democratic leader, Andrea Stewart-Cousins of Yonkers, who is the sponsor of a bill that is similar to the legislation the governor is drafting, said she was optimistic that an abortion measure would reach the Senate floor this year.

“New York State’s abortion laws were passed in 1970 in a bipartisan fashion,” she said. “It would be a sad commentary that over 40 years later we could not manage to do the same thing.”

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Livestrong Tattoos as Reminder of Personal Connections, Not Tarnished Brand

As Jax Mariash went under the tattoo needle to have “Livestrong” emblazoned on her wrist in bold black letters, she did not think about Lance Armstrong or doping allegations, but rather the 10 people affected by cancer she wanted to commemorate in ink. It was Jan. 22, 2010, exactly a year since the disease had taken the life of her stepfather. After years of wearing yellow Livestrong wristbands, she wanted something permanent.

A lifelong runner, Mariash got the tattoo to mark her 10-10-10 goal to run the Chicago Marathon on Oct. 10, 2010, and fund-raising efforts for Livestrong. Less than three years later, antidoping officials laid out their case against Armstrong — a lengthy account of his practice of doping and bullying. He did not contest the charges and was barred for life from competing in Olympic sports.

“It’s heartbreaking,” Mariash, of Wilson, Wyo., said of the antidoping officials’ report, released in October, and Armstrong’s subsequent confession to Oprah Winfrey. “When I look at the tattoo now, I just think of living strong, and it’s more connected to the cancer fight and optimal health than Lance.”

Mariash is among those dealing with the fallout from Armstrong’s descent. She is not alone in having Livestrong permanently emblazoned on her skin.

Now the tattoos are a complicated, internationally recognized symbol of both an epic crusade against cancer and a cyclist who stood defiant in the face of accusations for years but ultimately admitted to lying.

The Internet abounds with epidermal reminders of the power of the Armstrong and Livestrong brands: the iconic yellow bracelet permanently wrapped around a wrist; block letters stretching along a rib cage; a heart on a foot bearing the word Livestrong; a mural on a back depicting Armstrong with the years of his now-stripped seven Tour de France victories and the phrase “ride with pride.”

While history has provided numerous examples of ill-fated tattoos to commemorate lovers, sports teams, gang membership and bands that break up, the Livestrong image is a complex one, said Michael Atkinson, a sociologist at the University of Toronto who has studied tattoos.

“People often regret the pop culture tattoos, the mass commodified tattoos,” said Atkinson, who has a Guns N’ Roses tattoo as a marker of his younger days. “A lot of people can’t divorce the movement from Lance Armstrong, and the Livestrong movement is a social movement. It’s very real and visceral and embodied in narrative survivorship. But we’re still not at a place where we look at a tattoo on the body and say that it’s a meaningful thing to someone.”

Geoff Livingston, a 40-year-old marketing professional in Washington, D.C., said that since Armstrong’s confession to Winfrey, he has received taunts on Twitter and inquiries at the gym regarding the yellow Livestrong armband tattoo that curls around his right bicep.

“People see it and go, ‘Wow,’ ” he said, “But I’m not going to get rid of it, and I’m not going to stop wearing short sleeves because of it. It’s about my family, not Lance Armstrong.”

Livingston got the tattoo in 2010 to commemorate his brother-in-law, who was told he had cancer and embarked on a fund-raising campaign for the charity. If he could raise $5,000, he agreed to get a tattoo. Within four days, the goal was exceeded, and Livingston went to a tattoo parlor to get his seventh tattoo.

“It’s actually grown in emotional significance for me,” Livingston said of the tattoo. “It brought me closer to my sister. It was a big statement of support.”

For Eddie Bonds, co-owner of Rabbit Bicycle in Hill City, S.D., getting a Livestrong tattoo was also a reflection of the growth of the sport of cycling. His wife, Joey, operates a tattoo parlor in front of their store, and in 2006 she designed a yellow Livestrong band that wraps around his right calf, topped off with a series of small cyclists.

“He kept breaking the Livestrong bands,” Joey Bonds said. “So it made more sense to tattoo it on him.”

“It’s about the cancer, not Lance,” Eddie Bonds said.

That was also the case for Jeremy Nienhouse, a 37-year old in Denver, Colo., who used a Livestrong tattoo to commemorate his own triumph over testicular cancer.

Given the diagnosis in 2004, Nienhouse had three rounds of chemotherapy, which ended on March 15, 2005, the date he had tattooed on his left arm the day after his five-year anniversary of being cancer free in 2010. It reads: “3-15-05” and “LIVESTRONG” on the image of a yellow band.

Nienhouse said he had heard about Livestrong and Armstrong’s own battle with the cancer around the time he learned he had cancer, which alerted him to the fact that even though he was young and healthy, he, too, could have cancer.

“On a personal level,” Nienhouse said, “he sounds like kind of a jerk. But if he hadn’t been in the public eye, I don’t know if I would have been diagnosed when I had been.”

Nienhouse said he had no plans to have the tattoo removed.

As for Mariash, she said she read every page of the antidoping officials’ report. She soon donated her Livestrong shirts, shorts and running gear. She watched Armstrong’s confession to Winfrey and wondered if his apology was an effort to reduce his ban from the sport or a genuine appeal to those who showed their support to him and now wear a visible sign of it.

“People called me ‘Miss Livestrong,’ ” Mariash said. “It was part of my identity.”

She also said she did not plan to have her tattoo removed.

“I wanted to show it’s forever,” she said. “Cancer isn’t something that just goes away from people. I wanted to show this is permanent and keep people remembering the fight.”

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Doctor and Patient: 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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Well: The Well Flu Quiz

What surface is the most friendly to the flu virus? Where’s the best place to stand when you’re talking to a sick person? And how are Australians curbing germs in schools? To find out these answers and more, take the Well Flu Quiz.

With contributions from Laura Geggel and Tara Parker-Pope.

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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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