Texas Monthly: Sign Language Interpreters Bring Live Music to the Deaf

On the last night of the 2012 Lollapalooza music festival in Chicago, the sun set over a crowd of thousands who had stood for hours waiting to see Jack White, the headliner. A figure strode onto the stage, setting off a cascade of cheers.

But it was not Jack White, the singer-guitarist, it was Barbie Parker, the festival’s lead sign language interpreter.

Ms. Parker, a Texas native, and members of her Austin-based company, LotuSIGN, had interpreted more than 20 bands’ sets for deaf and hard of hearing festival attendees that weekend. As evidenced by the positive reception she received, her interpretations had won over a good part of the hearing audience as well.

At live music shows, Ms. Parker, 45, does not just sign lyrics — she communicates the entire musical experience. She mouths the words. She plays air guitar and air drums. She jams along with the bands.

“Music is such a large part of who I am,” she said. “I want to be able to open up that experience.”

Ms. Parker was bored in her accounting job and had two young children when she enrolled in her first formal American Sign Language class at San Antonio College about 20 years ago. She became fascinated with interpretation after reading a book about it at her local library and, in a chance encounter just hours after reading it, met the sister of a friend who happened to be an American Sign Language interpreter.

Ms. Parker is now an integral part of Austin’s deaf community. Her two adult sons are proficient in A.S.L., and her company has provided sign language interpretation at music festivals across the country for several years. Next week, she and other LotuSIGN interpreters will take the stage with artists at the South by Southwest music festival in Austin for the sixth year in a row.

The number of deaf and hard of hearing music fans taking advantage of interpretation at free shows held at Auditorium Shores as part of SXSW has risen noticeably in the past few years, Frank Schaefer, the officer manager for the festival, said in an e-mail. The increase can be attributed, at least in part, to a growing number of interpreters who specialize in that kind of work.

A good interpreter is adept at signing, but Ms. Parker also wants her team to impart the emotions and feelings music conveys. Lauren Kinast, 44, who lost her hearing gradually, attended a Rolling Stones concert signed by LotuSIGN interpreters. Ms. Kinast had listened to the Stones growing up, but when she saw Ms. Parker and a colleague interpret their music, she came away with a greater appreciation of the band.

“Everything made it different, better,” Ms. Kinast typed in an interview. “Having the songs interpreted in my language, understanding the emotions behind it, the meaning behind it, and being a part of the concert experience just took my love for them several notches up.”

Ms. Parker first gained recognition in the mid-2000s for interpreting music at the funeral of the parent of a well-known member of the deaf community in Austin. At one point during the service, she needed to sign an emotional musical performance.

“The singer got inspired, so the interpreting had to get inspired,” Ms. Parker said. The signing seemed to further stir the singer, which further moved Ms. Parker. “There was a kind of reverb,” she said. “The deaf audience was just — I just saw these jaws drop open like, ‘Oh, that’s what it’s like.’ ”

After that, she began receiving requests to interpret at weddings, children’s recitals and, of course, live shows. In 2007, she started her own company, Alive Performance Interpreting, which in 2009 became LotuSIGN.

“They’re five-star interpreters,” said Stacy Landry, the program manager for the local government’s deaf and hard of hearing services in Travis County. (Ms. Parker has obvious clout in the field — her traditional interpreting services were used in January when she intepreted President Obama’s Inaugural Address in Washington.)

LotuSIGN interpreters specialize in analyzing lyrics for the artist’s intent in a song. But sign language interpretation, no matter where it takes place, is about more than translating words into gestures and signs. The interpreter must communicate an overall experience by expressing the speaker’s tone, the meaning behind phrases and idioms, and even if someone’s cellphone interrupts an otherwise-silent lecture hall.

One year, Ms. Parker interpreted at a Sheryl Crow concert held to celebrate of one of Lance Armstrong’s Tour de France titles. He was asked to take over on the drums for one of Ms. Crow’s songs.

“Well,” Ms. Parker said, “he wasn’t any good.”

Ms. Parker let the discomfort show on her face as she imitated Mr. Armstrong’s uneven drumming. She nodded subtly to assure perplexed members of the deaf audience that she was indeed doing this on purpose.

As the audience reacted, Ms. Parker saw a deaf man elbow the hearing man next to him and cringe. The hearing man nodded and made a similar pained face.

“They had this shared experience,” Ms. Parker said. The deaf man was truly part of the crowd.

LotuSIGN is working to mentor others in the hope of expanding access to live events. “You can’t do it without a lot of experience,” Ms. Parker said. “It is the hardest work I have ever done.”

Kathryn Jepsen is the deputy editor of Symmetry magazine.

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Well: A Rainbow of Root Vegetables

This week’s Recipes for Health is as much a treat for the eyes as the palate. Colorful root vegetables from bright orange carrots and red scallions to purple and yellow potatoes and pale green leeks will add color and flavor to your table.

Since root vegetables and tubers keep well and can be cooked up into something delicious even after they have begun to go limp in the refrigerator, this week’s Recipes for Health should be useful. Root vegetables, tubers (potatoes and sweet potatoes, which are called yams by most vendors – I mean the ones with dark orange flesh), winter squash and cabbages are the only local vegetables available during the winter months in colder regions, so these recipes will be timely for many readers.

Roasting is a good place to begin with most root vegetables. They sweeten as they caramelize in a hot oven. I roasted baby carrots and thick red scallions (they may have been baby onions; I didn’t get the information from the farmer, I just bought them because they were lush and pretty) together and seasoned them with fresh thyme leaves, then sprinkled them with chopped toasted hazelnuts. I also roasted a medley of potatoes, including sweet potatoes, after tossing them with olive oil and sage, and got a wonderful range of colors, textures and tastes ranging from sweet to savory.

Sweet winter vegetables also pair well with spicy seasonings. I like to combine sweet potatoes and chipotle peppers, and this time in a hearty lentil stew that we enjoyed all week.

Here are five colorful and delicious dishes made with root vegetables.

Spicy Lentil and Sweet Potato Stew With Chipotles: The combination of sweet potatoes and spicy chipotles with savory lentils is a winner.

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Roasted Carrots and Scallions With Thyme and Hazelnuts: Toasted hazelnuts add a crunchy texture and nutty finish to this dish.

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Carrot Wraps: A vegetarian sandwich that satisfies like a full meal.

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Rainbow Potato Roast: A multicolored mix that can be vegan, or not.

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Leek Quiche: A lighter version of a Flemish classic.

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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 to finance 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: March 1, 2013

An article on Tuesday about a coming measles-rubella vaccination campaign in Rwanda misstated the source of the vaccine and some financing for the campaign. The vaccine and financing are being provided by the GAVI Alliance, not by the Measles and Rubella Initiative.

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New Attention to First Lady

CLINTON, Miss. — To her admirers, Michelle Obama is the patron saint of quinoa, charged with reducing the nation’s dangerous obesity rate and helping children eat better. To her detractors, she is the fun-killer, possessed with crushing America’s cookies.

But either way Mrs. Obama has taken her message once again on the road and is making clear that her campaign for healthy school lunches and fewer fat children will not be deterred.

“Now is truly the time to double down on our efforts,” she told state officials on Wednesday at an elementary school here, where she also entertained a giant group of students with a cooking contest in the cafeteria between school chefs and the celebrity food personality Rachael Ray.

Signaling that her “Let’s Move” campaign, now in its third year, will remain a central part of her own policy agenda, Mrs. Obama began a three-city tour to promote new federal school lunch policies, beginning here in Mississippi, where childhood obesity rates have fallen even as the overall rate remains the highest in the nation. “I am beyond thrilled to be back here in Mississippi,” Mrs. Obama said as lawmakers rose with their smartphones to snap photographs of her.

In 2011, the Centers for Disease Control and Prevention said that nearly 40 percent of Mississippi residents were obese. But in 2007, with the blessing of Gov. Haley Barbour, the state began to attack the problem with legislation intended to reduce fat in school lunches and to increase exercise programs.

From 2005 to 2011, obesity declined 13.3 percent among elementary school children in the state, according to the Robert Wood Johnson Foundation. Similar new federal standards for school lunches were set by the Healthy Hunger-Free Kids Act, which began in the current school year. Promoting that federal legislation, which has been relatively hard fought, is a centerpiece of Mrs. Obama’s campaign.

“Your schools did hard work, replaced their fryers with steamers, hallelujah, and started serving more fruits and vegetables and whole grains,” Mrs. Obama said. She added, “The results of these efforts speak for themselves.”

Ms. Ray, who has worked in the White House garden and championed the healthy eating of Mrs. Obama’s campaign, said that her interest in healthy food in schools stemmed from the notion that “every American needs to be concerned about the health of our nation’s kids.” The visit to the school here will be featured on her television program.

After meeting with adults, Mrs. Obama repaired to the school cafeteria for the school chef cook-off contest, where scores of children in red shirts, which matched the bowls of apples on the tables, waited for her arrival by talking, squirming and struggling to contain their excitement.

Mrs. Obama has attracted the praise of obesity experts, chefs, nutritionists and others who applaud her White House garden, her school lunch efforts and her focus on exercise, recently demonstrated in an appearance on NBC’s “Late Night With Jimmy Fallon” doing the “mom dance.” She has also found herself in the cross hairs of conservatives and other critics who see her efforts as meddlesome, frivolous or undignified.

Recently, Mrs. Obama has come under increased scrutiny after flying largely under the radar since the end of the 2012 presidential campaign. On Sunday, she announced the winner of the best picture award at the Oscars via satellite from the White House, which caused a minor national kerfuffle as some pondered the propriety of her appearance.

In The Washington Post on Wednesday, the columnist Courtland Milloy went on a full-frontal attack of both the first lady’s agenda and the attention to her appearance, which he implied she had invited. “Enough with the broccoli and Brussels sprouts,” he wrote, “to say nothing about all the attention paid to her arms, hair, derrière and designer clothes. Where is that intellectually gifted Princeton graduate, the Harvard-educated lawyer and mentor to the man who would become the first African-American president of the United States?”

Her dancing with middle school students, doing push-ups on “The Ellen DeGeneres Show,” running out for tapas with her girlfriends and clipping her locks into modern bangs both thrill and deeply annoy a nation that projects much onto its first ladies.

She will continue her tour on Thursday in Chicago, where she will announce a physical fitness initiative in schools with the tennis player Serena Williams and Education Secretary Arne Duncan. From there, Mrs. Obama will continue on to Missouri to promote adjustments in the food offerings at Walmart and discuss changes to other food businesses. She is traveling with Sam Kass, the senior policy adviser for her White House healthy food initiative.

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Advanced Breast Cancer May Be Rising Among Young Women, Study Finds

The incidence of advanced breast cancer among younger women, ages 25 to 39, may have increased slightly over the last three decades, according to a study released Tuesday.

But more research is needed to verify the finding, which was based on an analysis of statistics, the study’s authors said. They do not know what may have caused the apparent increase.

Some outside experts questioned whether the increase was real, and expressed concerns that the report would frighten women needlessly.

The study, published in The Journal of the American Medical Association, found that advanced cases climbed to 2.9 per 100,000 younger women in 2009, from 1.53 per 100,000 women in 1976 — an increase of 1.37 cases per 100,000 women in 34 years. The totals were about 250 such cases per year in the mid-1970s, and more than 800 per year in 2009.

Though small, the increase was statistically significant, and the researchers said it was worrisome because it involved cancer that had already spread to organs like the liver or lungs by the time it was diagnosed, which greatly diminishes the odds of survival.

For now, the only advice the researchers can offer to young women is to see a doctor quickly if they notice lumps, pain or other changes in the breast, and not to assume that they cannot have breast cancer because they are young and healthy, or have no family history of the disease.

“Breast cancer can and does occur in younger women,” said Dr. Rebecca H. Johnson, the first author of the study and medical director of the adolescent and young adult oncology program at Seattle Children’s Hospital.

But Dr. Johnson noted that there is no evidence that screening helps younger women who have an average risk for the disease and no symptoms. “We’re certainly not advocating that young women get mammography at an earlier age than is generally specified,” she said.

Expert groups differ about when screening should begin; some say at age 40, others 50.

Breast cancer is not common in younger women; only 1.8 percent of all cases are diagnosed in women from 20 to 34, and 10 percent in women from 35 to 44. However, when it does occur, the disease tends to be more deadly in younger women than in older ones. Researchers are not sure why.

The researchers analyzed data from SEER, a program run by the National Cancer Institute to collect cancer statistics on 28 percent of the population of the United States. The study also used data from the past when SEER was smaller.

The study is based on information from 936,497 women who had breast cancer from 1976 to 2009. Of those, 53,502 were 25 to 39 years old, including 3,438 who had advanced breast cancer, also called metastatic or distant disease.

Younger women were the only ones in whom metastatic disease seemed to have increased, the researchers found.

Dr. Archie Bleyer, a clinical research professor in radiation medicine at the Knight Cancer Institute at the Oregon Health and Science University in Portland who helped write the study, said scientists needed to verify the increase in advanced breast cancer in young women in the United States and find out whether it is occurring in other developed Western countries. “This is the first report of this kind,” he said, adding that researchers had already asked colleagues in Canada to analyze data there.

“We need this to be sure ourselves about this potentially concerning, almost alarming trend,” Dr. Bleyer said. “Then and only then are we really worried about what is the cause, because we’ve got to be sure it’s real.”

Dr. Johnson said her own experience led her to look into the statistics on the disease in young women. She had breast cancer when she was 27; she is now 44. Over the years, friends and colleagues often referred young women with the disease to her for advice.

“It just struck me how many of those people there were,” she said.

Dr. Donald A. Berry, an expert on breast cancer data and a professor of biostatistics at the University of Texas’ M. D. Anderson Cancer Center in Houston, said he was dubious about the finding, even though it was statistically significant, because the size of the apparent increase was so small — 1.37 cases per 100,000 women, over the course of 30 years.

More screening and more precise tests to identify the stage of cancer at the time of diagnosis might account for the increase, he said.

“Not many women aged 25 to 39 get screened, but some do, but it only takes a few to account for a notable increase from one in 100,000,” Dr. Berry said.

Dr. Silvia C. Formenti, a breast cancer expert and the chairwoman of radiation oncology at New York University Langone Medical Center, questioned the study in part because although it found an increased incidence of advanced disease, it did not find the accompanying increase in deaths that would be expected.

A spokeswoman for an advocacy group for young women with breast cancer, Young Survival Coalition, said the organization also wondered whether improved diagnostic and staging tests might explain all or part of the increase.

“We’re looking at this data with caution,” said the spokeswoman, Michelle Esser. “We don’t want to invite panic or alarm.”

She said it was important to note that the findings applied only to women who had metastatic disease at the time of diagnosis, and did not imply that women who already had early-stage cancer faced an increased risk of advanced disease.

Dr. J. Leonard Lichtenfeld
, deputy chief medical officer of the American Cancer Society, said he and an epidemiologist for the society thought the increase was real.

“We want to make sure this is not oversold or that people suddenly get very frightened that we have a huge problem,” Dr. Lichtenfeld said. “We don’t. But we are concerned that over time, we might have a more serious problem than we have today.”

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‘Bloodless’ Lung Transplants for Jehovah’s Witnesses

Eric Kayne for The New York Times

SHARING HOME AND FAITH A Houston couple hosted Gene and Rebecca Tomczak, center, in October so she could get care nearby.

HOUSTON — Last April, after being told that only a transplant could save her from a fatal lung condition, Rebecca S. Tomczak began calling some of the top-ranked hospitals in the country.

She started with Emory University Hospital in Atlanta, just hours from her home near Augusta, Ga. Then she tried Duke and the University of Arkansas and Johns Hopkins. Each advised Ms. Tomczak, then 69, to look somewhere else.

The reason: Ms. Tomczak, who was baptized at age 12 as a Jehovah’s Witness, insisted for religious reasons that her transplant be performed without a blood transfusion. The Witnesses believe that Scripture prohibits the transfusion of blood, even one’s own, at the risk of forfeiting eternal life.

Given the complexities of lung transplantation, in which transfusions are routine, some doctors felt the procedure posed unacceptable dangers. Others could not get past the ethics of it all. With more than 1,600 desperately ill people waiting for a donated lung, was it appropriate to give one to a woman who might needlessly sacrifice her life and the organ along with it?

By the time Ms. Tomczak found Dr. Scott A. Scheinin at The Methodist Hospital in Houston last spring, he had long since made peace with such quandaries. Like a number of physicians, he had become persuaded by a growing body of research that transfusions often pose unnecessary risks and should be avoided when possible, even in complicated cases.

By cherry-picking patients with low odds of complications, Dr. Scheinin felt he could operate almost as safely without blood as with it. The way he saw it, patients declined lifesaving therapies all the time, for all manner of reasons, and it was not his place to deny care just because those reasons were sometimes religious or unconventional.

“At the end of the day,” he had resolved, “if you agree to take care of these patients, you agree to do it on their terms.”

Ms. Tomczak’s case — the 11th so-called bloodless lung transplant attempted at Methodist over three years — would become the latest test of an innovative approach that was developed to accommodate the unique beliefs of the world’s eight million Jehovah’s Witnesses but may soon become standard practice for all surgical patients.

Unlike other patients, Ms. Tomczak would have no backstop. Explicit in her understanding with Dr. Scheinin was that if something went terribly wrong, he would allow her to bleed to death. He had watched Witness patients die before, with a lifesaving elixir at hand.

Ms. Tomczak had dismissed the prospect of a transplant for most of the two years she had struggled with sarcoidosis, a progressive condition of unknown cause that leads to scarring in the lungs. The illness forced her to quit a part-time job with Nielsen, the market research firm.

Then in April, on a trip to the South Carolina coast, she found that she was too breathless to join her frolicking grandchildren on the beach. Tethered to an oxygen tank, she watched from the boardwalk, growing sad and angry and then determined to reclaim her health.

“I wanted to be around and be a part of their lives,” Ms. Tomczak recalled, dabbing at tears.

She knew there was danger in refusing to take blood. But she thought the greater peril would come from offending God.

“I know,” she said, “that if I did anything that violates Jehovah’s law, I would not make it into the new system, where he’s going to make earth into a paradise. I know there are risks. But I think I am covered.”

Cutting Risks, and Costs

The approach Dr. Scheinin would use — originally called “bloodless medicine” but later re-branded as “patient blood management” — has been around for decades. His mentor at Methodist, Dr. Denton A. Cooley, the renowned cardiac pioneer, performed heart surgery on hundreds of Witnesses starting in the late 1950s. The first bloodless lung transplant, at Johns Hopkins, was in 1996.

But nearly 17 years later, the degree of difficulty for such procedures remains so high that Dr. Scheinin and his team are among the very few willing to attempt them.

In 2009, after analyzing Methodist’s own data, Dr. Scheinin became convinced that if he selected patients carefully, he could perform lung transplants without transfusions. Hospital administrators resisted at first, knowing that even small numbers of deaths could bring scrutiny from federal regulators.

“My job is to push risk away,” said Dr. A. Osama Gaber, the hospital’s director of transplantation, “so I wasn’t really excited about it. But the numbers were very convincing.”

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Off the Dribble: Salley Offers a Healthy Assist

When Carmelo Anthony went on a vegetarian diet a few weeks ago and caused the biggest culinary conundrum in sports since fried chicken and beer had starring roles in the Red Sox clubhouse, John Salley could only shake his head.

Anthony’s diet was blamed for his sluggish play and the Knicks’ 3-4 record during the 15-day fast.

Anthony admitted that his body felt “depleted out there.”

But Salley, the former N.B.A. player, said that if Anthony had eaten a vegetarian diet correctly, he would have felt invigorated and anything but depleted.

And not just for two weeks but for the entire season.

For Salley, many of his salad days in the N.B.A. really were salad days. Particularly kale salad.

Salley, a 6-foot-11 power forward and center, became a vegetarian in January 1991 after he felt he had to make changes in his lifestyle, much like Anthony’s stated desire for “clarity in his life.”

Vegetarians do not eat meat, fish or poultry, but may eat dairy products like cheese, eggs, yogurt or milk.

Salley had read a story about the Celtics’ Robert Parish, whom he had always admired, and his interest in yoga and a red-meat-free diet.

While Parish’s regimen was not total vegetarian, he recently said that it made a difference in his career, helping him withstand the rigors of playing center against behemoths in the paint.

“My diet consisted of chicken, fish, seafood, salad, pasta and organic when possible,” he said. “I had very little sugar and drank a gallon of water every day. I also ate rice and beans, peas, cabbage, mustard, collards greens and assorted nuts. I would always focus on healthy eating. My success depended on my body and I tried to do right by it. ”

His body responded with 20 years of service in his Hall of Fame career. Parish retired at 43.

Salley was striving for similar health and success.

“I was 27, and I felt I had to change my life,” Salley said. “My knees were sore, my joints ached, I had back problems and my cholesterol was 275. ”

When he was with the Pistons, Salley visited a nutritionist in Detroit who advised him to eliminate fried foods and adopt a macrobiotic diet (grains and vegetables).

Salley, invigorated and healthy, had his best season in 1991. A defensive specialist, he had more energy and quickness and averaged a career best 9.5 points a game.

He kept his healthy diet a secret from his burly Bad Boy Piston steak-and-pork-chop teammates, who included Bill Laimbeer, Rick Mahorn and Dennis Rodman.

“I would tell them all the time,” Salley said, “if you go into a steak house it’s not that they have a certain thing inside the dead flesh or they cook it differently. They make it the same way everybody else does. All you’re doing is eating dead food.”

Salley would search out health food restaurants with a few tables or just counter service for his diet staples of quinoa, kale, spinach, stir fried vegetables, brown rice and wheatgrass on the menu.

“It was hard to find places in 1991,” he said. “So many times I would go into restaurants and ask the cook to steam my vegetables and make me the lightest fish.”

But it was worth it.

“I was playing so well it was crazy,” he said.

During his career, Salley, who retired in 2000, won four championships with the Detroit Pistons, the Chicago Bulls and the Los Angeles Lakers.

He now follows a vegan diet, which eliminates all dairy foods in addition to animal products.

“I’m eating raw,” said Salley, 48. “And I make all my food with no sugar, no salt and no oil.”

Salley is familiar with Anthony’s foray into vegetarian living. The Knicks star followed the Daniel Fast based on the book of Daniel in the Bible, which espouses a diet of mainly liquid and vegetables.

“He felt depleted because you need to find a natural source of vitamin B12,” Salley said.

B12 is not found in any significant amounts in plant food, and a deficiency can cause fatigue, weakness and tingling in the legs.

It can also cause irritability. Anthony said his diet might have caused him to lash out at Kevin Garnett in a game against the Boston Celtics.

“He didn’t take any supplements to help his body,” Salley said. “He did not get his body to heal. It’s like cutting yourself and not putting a Band-Aid on. He just got part of the plan right.”

Salley is working to make sure children get the plan right with food choices. He spreads the word about healthy eating in the community, having lobbied Congress for more vegetarian options in school lunches.

Although Anthony may have struggled to maintain his vegetarian diet, other N.B.A players and athletes have embraced it.

James Jones of the Miami Heat and Anthony’s teammate A’mare Stoudemire are vegetarians.

Baseball’s Prince Fielder, the triathlete Brendan Brazier, the mixed martial artist Mac Danzig, the bodybuilder Derek Tresize and the tennis player Serena Williams are among athletes who are vegans or vegetarians.

Dr. Joel Kahn, a clinical professor of medicine at Wayne State University School of Medicine and medical director of wellness programs, preventive cardiology, and cardiac rehabilitation at Detroit Medical Center, has counseled Salley and other athletes about the benefits of vegan and vegetarian diets.

“A plant-based, whole-food diet low on sugar and gluten is very anti-inflammatory and ideal for rapid recovery from workouts,” he said.

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Well: Savory Pie Recipes for Health

Pie is an indulgence often saved for holiday time. But this week Martha Rose Shulman shows us how to bake a pie and eat it too, without the guilt. She offers savory vegetable pies, showcased in whole grain crusts. She writes:

This week I slowed down and made pies: savory ones filled with vegetables … I used a number of different crusts for my winter pies. My favorite remains the whole wheat yeasted olive oil crust that I have used before in this column, but I also worked with a simple Mediterranean crust made with a mix of whole wheat flour, all-purpose flour and olive oil. And for those of you who are gluten-free, I made another foray into gluten-free pastry and produced one I liked a lot, which was a mix of buckwheat flour, millet flour and potato starch. It had a strong nutty flavor that worked well with a very savory, very vegan, tofu and mushroom “quiche.” They are all simple to mix together and easy to roll or press out. And if you don’t feel like dealing with a crust, just use Greek phyllo. The important things, after all, are the savory vegetables inside.

Here are recipes for a pie crust and four savory winter vegetable pies.

Whole Wheat Mediterranean Pie Crust: A simple Mediterranean crust made with a mix of whole wheat flour, all-purpose flour and olive oil.

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Mixed Greens Galette With Onions and Chickpeas: A tasty way to use bagged greens in a dish with Middle Eastern overtones.

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Goat Cheese, Chard and Herb Pie in a Phyllo Crust: A garlicky mix of greens and your choice of herbs inside a crispy phyllo crust.

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Tofu Mushroom ‘Quiche’: A vegan dish with a deep, rich flavor.

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Winter Tomato Quiche: Canned tomatoes can be used in the off season for a delicious dinner.

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Living With Cancer: Arrivals and Departures

After being nursed and handed over, the baby’s wails rise to a tremolo, but I am determined to give my exhausted daughter and son-in-law a respite on this wintry evening. Commiserating with the little guy’s discomfort — gas, indigestion, colic, ontological insecurity — I swaddle, burp, bink, then cradle him in my arms. I begin walking around the house, swinging and swaying while cooing in soothing cadences: “Yes, darling boy, another one bites the dust, another one bites the dust.”

I kid you not! How could such grim phrases spring from my lips into the newborn’s ears? Where did they come from?

I blame his mother and her best friend. They sang along as this song was played repeatedly at the skating rink to which I took them every other Saturday in their tweens. Why would an infatuated grandma croon a mordant lullaby, even if the adorable one happily can’t understand a single word? He’s still whimpering, twisting away from me, and understandably so.

Previously that day, I had called a woman in my cancer support group. I believe that she is dying. I do not know her very well. She has attended only two or three of our get-togethers where she described herself as a widow and a Christian.

On the phone, I did not want to violate the sanctity of her end time, but I did want her to know that she need not be alone, that I and other members of our group can “be there” for her. Her dying seems a rehearsal of my own. We have the same disease.

“How are you doing, Kim?” I asked.

“I’m tired. I sleep all the time,” she sighed, “and I can’t keep anything down.”

“Can you drink … water?” I asked.

“A little, but I tried a smoothie and it wouldn’t set right,” she said.

“I hope you are not in pain.”

“Oh no, but I’m sleeping all the time. And I can’t keep anything down.”

“Would you like a visit? Is there something I can do or bring?” I asked.

“Oh, I don’t think so, no thanks.”

“Well,” I paused before saying goodbye, “be well.”

Be well? I didn’t even add something like, “Be as well as you can be.” I was tongue-tied. This was the failure that troubles me tonight.

Why couldn’t I say that we will miss her, that I am sorry she is dying, that she has coped so well for so long, and that I hope she will now find peace? I could inform an infant in my arms of our inexorable mortality, but I could not speak or even intimate the “D” word to someone on her deathbed.

Although I have tried to communicate to my family how I feel about end-of-life care, can we always know what we will want? Perhaps at the end of my life I will not welcome visitors, either. For departing may require as much concentration as arriving. As I look down at the vulnerable bundle I am holding, I marvel that each and every one of us has managed to come in and will also have to manage to go out. The baby nestles, pursing his mouth around the pacifier. He gazes intently at my face with a sly gaze that drifts toward a lamp, turning speculative before lids lower in tremulous increments.

Slowing my jiggling to his faint sucking, I think that the philosopher Jacques Derrida’s meditation on death pertains to birth as well. Each of these events “names the very irreplaceability of absolute singularity.” Just as “no one can die in my place or in the place of the other,” no one can be born in this particular infant’s place. He embodies his irreplaceable and absolute singularity.

Perhaps we should gestate during endings, as we do during beginnings. Like hatchings, the dispatchings caused by cancer give people like Kim and me a final trimester, more or less, in which we can labor to forgive and be forgiven, to speak and hear vows of devotion from our intimates, to visit or not be visited by acquaintances.

Maybe we need a doula for dying, I reflect as melodious words surface, telling me what I have to do with the life left to be lived: “To love that well, which thou must leave ere long.”

“Oh little baby,” I then whisper: “Though I cannot tell who you will become and where I will be — you, dear heart, deliver me.”

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Susan Gubar is a distinguished emerita professor of English at Indiana University and the author of “Memoir of a Debulked Woman,” which explores her experience with ovarian cancer.

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Well: Caffeine Linked to Lower Birth Weight Babies

New research suggests that drinking caffeinated drinks during pregnancy raises the risk of having a low birth weight baby.

Caffeine has long been linked to adverse effects in pregnant women, prompting many expectant mothers to give up coffee and tea. But for those who cannot do without their morning coffee, health officials over the years have offered conflicting guidelines on safe amounts during pregnancy.

The World Health Organization recommends a limit of 300 milligrams of caffeine a day, equivalent to about three eight-ounce cups of regular brewed coffee. The American College of Obstetricians and Gynecologists stated in 2010 that pregnant women could consume up to 200 milligrams a day without increasing their risk of miscarriage or preterm birth.

In the latest study, published in the journal BMC Medicine, researchers collected data on almost 60,000 pregnancies over a 10-year period. After excluding women with potentially problematic medical conditions, they found no link between caffeine consumption – from food or drinks – and the risk of preterm birth. But there was an association with low birth weight.

For a child expected to weigh about eight pounds at birth, the child lost between three-quarters of an ounce to an ounce in birth weight for each 100 milligrams of average daily caffeine intake from all sources by the mother. Even after the researchers excluded from their analysis smokers, a group that is at higher risk for complications and also includes many coffee drinkers, the link remained.

One study author, Dr. Verena Sengpiel of the Sahlgrenska University Hospital in Sweden, said the findings were not definitive because the study was observational, and correlation does not equal causation. But they do suggest that women might put their caffeine consumption “on pause” while pregnant, she said, or at least stay below two cups of coffee per day.

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This post has been revised to reflect the following correction:

Correction: February 20, 2013

An earlier version of this article described incorrectly the relationship between the amount of caffeine a pregnant woman drank and birth weight. For a child expected to weigh about eight pounds at birth, the child lost between three-quarters of an ounce to an ounce in birth weight for each 100 milligrams of average daily caffeine intake by the mother, not for each day that she consumed 100 milligrams of caffeine.

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A Digital Shift on Health Data Swells Profits

Jeff Swensen for The New York Times

Dr. Vivek Reddy, a neurologist at the University of Pittsburgh Medical Center, also works on its digital records effort.

It was a tantalizing pitch: come get a piece of a $19 billion government “giveaway.”

The approach came in 2009, in a presentation to doctors by Allscripts Healthcare Solutions of Chicago, a well-connected player in the lucrative business of digital medical records. That February, after years of behind-the-scenes lobbying by Allscripts and others, legislation to promote the use of electronic records was signed into law as part of President Obama’s economic stimulus bill. The rewards, Allscripts suggested, were at hand.

But today, as doctors and hospitals struggle to make new records systems work, the clear winners are big companies like Allscripts that lobbied for that legislation and pushed aside smaller competitors.

While proponents say new record-keeping technologies will one day reduce costs and improve care, profits and sales are soaring now across the records industry. At Allscripts, annual sales have more than doubled from $548 million in 2009 to an estimated $1.44 billion last year, partly reflecting daring acquisitions made on the bet that the legislation would be a boon for the industry. At the Cerner Corporation of Kansas City, Mo., sales rose 60 percent during that period. With money pouring in, top executives are enjoying Wall Street-style paydays.

None of that would have happened without the health records legislation that was included in the 2009 economic stimulus bill — and the lobbying that helped produce it. Along the way, the records industry made hundreds of thousands of dollars of political contributions to both Democrats and Republicans. In some cases, the ties went deeper. Glen E. Tullman, until recently the chief executive of Allscripts, was health technology adviser to the 2008 Obama campaign. As C.E.O. of Allscripts, he visited the White House no fewer than seven times after President Obama took office in 2009, according to White House records.

Mr. Tullman, who left Allscripts late last year after a boardroom power struggle, characterized his activities in Washington as an attempt to educate lawmakers and the administration.

“We really haven’t done any lobbying,” Mr. Tullman said in an interview. “I think it’s very common with every administration that when they want to talk about the automotive industry, they convene automotive executives, and when they want to talk about the Internet, they convene Internet executives.”

Between 2008 and 2012, a time of intense lobbying in the area around the passage of the legislation and how the rules for government incentives would be shaped, Mr. Tullman personally made $225,000 in political contributions. While tens of thousands of those dollars went to the Democratic Senatorial Campaign Committee, money was also being sprinkled toward Senator Max Baucus, the Democratic senator from Montana who is chairman of the Senate Finance Committee, and Jay D. Rockefeller, the Democrat from West Virginia who heads the Commerce Committee. Mr. Tullman said his recent personal contributions to various politicians had largely been driven by his interest in supporting President Obama and in seeing his re-election.

Cerner’s lobbying dollars doubled to nearly $400,000 between 2006 and last year, according to the Center for Responsive Politics. While its political action committee contributed a little to some Democrats in 2008, including Senator Baucus, its contributions last year went almost entirely to Republicans, with a large amount going to the Mitt Romney campaign.

Current and former industry executives say that big digital records companies like Cerner, Allscripts and Epic Systems of Verona, Wis., have reaped enormous rewards because of the legislation they pushed for. “Nothing that these companies did in my eyes was spectacular,” said John Gomez, the former head of technology at Allscripts. “They grew as a result of government incentives.”

Executives at smaller records companies say the legislation cemented the established companies’ leading positions in the field, making it difficult for others to break into the business and innovate. Until the 2009 legislation, growth at the leading records firms was steady; since then, it has been explosive. Annual sales growth at Cerner, for instance, has doubled to 20 percent from 10 percent.

“We called it the Sunny von Bülow bill. These companies that should have been dead were being put on machines and kept alive for another few years,” said Jonathan Bush, co-founder of the cloud-based firm Athenahealth and a first cousin to former President George W. Bush. “The biggest players drew this incredible huddle around the rule-makers and the rules are ridiculously favorable to these companies and ridiculously unfavorable to society.”

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National Briefing | South: Abortion Curbs Clear Senate in Arkansas

The State Senate voted 25 to 7 on Monday to ban most abortions 20 weeks into a pregnancy. The measure goes back to the House to consider an amendment that added exceptions for rape and incest. The legislation is based on the belief that fetuses can feel pain 20 weeks into a pregnancy, and is similar to bans in several other states. Opponents say it would require mothers to deliver babies with fatal conditions. Gov. Mike Beebe has said he has constitutional concerns about the proposal but has not said whether he will veto it.

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Allure of Self-Insurance Draws Concern Over Costs

WASHINGTON — Federal and state officials and consumer advocates have grown worried that companies with relatively young, healthy employees may opt out of the regular health insurance market to avoid the minimum coverage standards in President Obama’s sweeping law, a move that could drive up costs for workers at other companies.

Companies can avoid many standards in the new law by insuring their own employees, rather than signing up with commercial insurers, because Congress did not want to disrupt self-insurance arrangements that were seen as working well for many large employers.

“The new health care law created powerful incentives for smaller employers to self-insure,” said Deborah J. Chollet, a senior fellow at Mathematica Policy Research who has been studying the insurance industry for more than 25 years. “This trend could destabilize small-group insurance markets and erode protections provided by the Affordable Care Act.”

It is not clear how many companies have already self-insured in response to the law or are planning to do so. Federal and state officials do not keep comprehensive statistics on the practice.

Self-insurance was already growing before Mr. Obama signed the law in 2010, making it difficult to know whether the law is responsible for any recent changes. A study by the nonpartisan Employee Benefit Research Institute found that about 59 percent of private sector workers with health coverage were in self-insured plans in 2011, up from 41 percent in 1998.

But experts say the law makes self-insurance more attractive for smaller employers. When companies are self-insured, they assume most of the financial risk of providing health benefits to employees. Instead of paying premiums to insurers, they pay claims filed by employees and health care providers. To avoid huge losses, they often sign up for a special kind of “stop loss” insurance that protects them against very large or unexpected claims, say $50,000 or $100,000 a person.

Such insurance serves as a financial backstop for the employer if, for example, an employee is found to have cancer, needs an organ transplant or has a premature baby requiring intensive care.

In a report to clients last year, SNR Denton, a law firm, wrote, “Faced with mandates to offer richer benefits with less cost-sharing, small and midsize employers in particular are increasingly considering self-insuring.”

Officials from California, Maine, Minnesota, Utah, Washington and other states expressed concern about the potential proliferation of these arrangements at a recent meeting of the National Association of Insurance Commissioners.

Stop-loss insurers can and do limit the coverage they provide to employers for selected employees with medical problems. As a result, companies with less healthy work forces may find self-insuring more difficult.

Christina L. Goe, the top lawyer for the Montana insurance commissioner, said that stop-loss insurance companies were generally “free to reject less healthy employer groups because they are not subject to the same restrictions as health insurers.”

Insurance regulators worry that commercial insurers — and the insurance exchanges being set up in every state to offer a range of plan options to consumers — will be left with disproportionate numbers of older, sicker people who are more expensive to insure.

That, in turn, could drive up premiums for uninsured people seeking coverage in the exchanges. Since the federal government will subsidize that coverage, it, too, could face higher costs, as would some employees and employers in the traditional insurance market.

Large employers with hundreds or thousands of employees have historically been much more likely to insure themselves because they have cash to pay most claims directly.

Now, employee benefit consultants are promoting self-insurance for employers with as few as 10 or 20 employees.

Raeghn L. Torrie, the chief financial officer of Autonomous Solutions, a developer of robotic equipment based in Petersboro, Utah, said her business started a self-insured health plan for its 44 employees on Jan. 1 as a way to cope with the uncertainties created by the new law.

“We have a pretty young, healthy group of employees,” she said.

In Marshfield, Mo., J. Richard Jones, the president of Label Solutions, an industrial label-printing company with 42 employees, said he switched to a self-insurance plan this year “to hold down costs that were going up because of government regulation under Obamacare.”

The Township of Freehold, N.J., made a similar decision in January to gain more control over benefits and costs for its 260 employees.

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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, chocolatey 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 lie 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 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 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 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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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: Straining to Hear and Fend Off Dementia

At a party the other night, a fund-raiser for a literary magazine, I found myself in conversation with a well-known author whose work I greatly admire. I use the term “conversation” loosely. I couldn’t hear a word he said. But worse, the effort I was making to hear was using up so much brain power that I completely forgot the titles of his books.

A senior moment? Maybe. (I’m 65.) But for me, it’s complicated by the fact that I have severe hearing loss, only somewhat eased by a hearing aid and cochlear implant.

Dr. Frank Lin, an otolaryngologist and epidemiologist at Johns Hopkins School of Medicine, describes this phenomenon as “cognitive load.” Cognitive overload is the way it feels. Essentially, the brain is so preoccupied with translating the sounds into words that it seems to have no processing power left to search through the storerooms of memory for a response.

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Katherine Bouton speaks about her own experience with hearing loss.

A transcript of this interview can be found here.

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Over the past few years, Dr. Lin has delivered unwelcome news to those of us with hearing loss. His work looks “at the interface of hearing loss, gerontology and public health,” as he writes on his Web site. The most significant issue is the relation between hearing loss and dementia.

In a 2011 paper in The Archives of Neurology, Dr. Lin and colleagues found a strong association between the two. The researchers looked at 639 subjects, ranging in age at the beginning of the study from 36 to 90 (with the majority between 60 and 80). The subjects were part of the Baltimore Longitudinal Study of Aging. None had cognitive impairment at the beginning of the study, which followed subjects for 18 years; some had hearing loss.

“Compared to individuals with normal hearing, those individuals with a mild, moderate, and severe hearing loss, respectively, had a 2-, 3- and 5-fold increased risk of developing dementia over the course of the study,” Dr. Lin wrote in an e-mail summarizing the results. The worse the hearing loss, the greater the risk of developing dementia. The correlation remained true even when age, diabetes and hypertension — other conditions associated with dementia — were ruled out.

In an interview, Dr. Lin discussed some possible explanations for the association. The first is social isolation, which may come with hearing loss, a known risk factor for dementia. Another possibility is cognitive load, and a third is some pathological process that causes both hearing loss and dementia.

In a study last month, Dr. Lin and colleagues looked at 1,984 older adults beginning in 1997-8, again using a well-established database. Their findings reinforced those of the 2011 study, but also found that those with hearing loss had a “30 to 40 percent faster rate of loss of thinking and memory abilities” over a six-year period compared with people with normal hearing. Again, the worse the hearing loss, the worse the rate of cognitive decline.

Both studies also found, somewhat surprisingly, that hearing aids were “not significantly associated with lower risk” for cognitive impairment. But self-reporting of hearing-aid use is unreliable, and Dr. Lin’s next study will focus specifically on the way hearing aids are used: for how long, how frequently, how well they have been fitted, what kind of counseling the user received, what other technologies they used to supplement hearing-aid use.

What about the notion of a common pathological process? In a recent paper in the journal Neurology, John Gallacher and colleagues at Cardiff University suggested the possibility of a genetic or environmental factor that could be causing both hearing loss and dementia — and perhaps not in that order. In a phenomenon called reverse causation, a degenerative pathology that leads to early dementia might prove to be a cause of hearing loss.

The work of John T. Cacioppo, director of the Social Neuroscience Laboratory at the University of Chicago, also offers a clue to a pathological link. His multidisciplinary studies on isolation have shown that perceived isolation, or loneliness, is “a more important predictor of a variety of adverse health outcomes than is objective social isolation.” Those with hearing loss, who may sit through a dinner party and not hear a word, frequently experience perceived isolation.

Other research, including the Framingham Heart Study, has found an association between hearing loss and another unexpected condition: cardiovascular disease. Again, the evidence suggests a common pathological cause. Dr. David R. Friedland, a professor of otolaryngology at the Medical College of Wisconsin in Milwaukee, hypothesized in a 2009 paper delivered at a conference that low-frequency loss could be an early indication that a patient has vascular problems: the inner ear is “so sensitive to blood flow” that any vascular abnormalities “could be noted earlier here than in other parts of the body.”

A common pathological cause might help explain why hearing aids do not seem to reduce the risk of dementia. But those of us with hearing loss hope that is not the case; common sense suggests that if you don’t have to work so hard to hear, you have greater cognitive power to listen and understand — and remember. And the sense of perceived isolation, another risk for dementia, is reduced.

A critical factor may be the way hearing aids are used. A user must practice to maximize their effectiveness and they may need reprogramming by an audiologist. Additional assistive technologies like looping and FM systems may also be required. And people with progressive hearing loss may need new aids every few years.

Increasingly, people buy hearing aids online or from big-box stores like Costco, making it hard for the user to follow up. In the first year I had hearing aids, I saw my audiologist initially every two weeks for reprocessing and then every three months.

In one study, Dr. Lin and his colleague Wade Chien found that only one in seven adults who could benefit from hearing aids used them. One deterrent is cost ($2,000 to $6,000 per ear), seldom covered by insurance. Another is the stigma of old age.

Hearing loss is a natural part of aging. But for most people with hearing loss, according to the National Institute on Deafness and Other Communication Disorders, the condition begins long before they get old. Almost two-thirds of men with hearing loss began to lose their hearing before age 44. My hearing loss began when I was 30.

Forty-eight million Americans suffer from some degree of hearing loss. If it can be proved in a clinical trial that hearing aids help delay or offset dementia, the benefits would be immeasurable.

“Could we do something to reduce cognitive decline and delay the onset of dementia?” he asked. “It’s hugely important, because by 2050, 1 in 30 Americans will have dementia.

“If we could delay the onset by even one year, the prevalence of dementia drops by 15 percent down the road. You’re talking about billions of dollars in health care savings.”

Should studies establish definitively that correcting hearing loss decreases the potential for early-onset dementia, we might finally overcome the stigma of hearing loss. Get your hearing tested, get it corrected, and enjoy a longer cognitively active life. Establishing the dangers of uncorrected hearing might even convince private insurers and Medicare that covering the cost of hearing aids is a small price to pay to offset the cost of dementia.

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Katherine Bouton is the author of the new book, “Shouting Won’t Help: Why I — and 50 Million Other Americans — Can’t Hear You,” from which this essay is adapted.

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This post has been revised to reflect the following correction:

Correction: February 14, 2013

An article on Tuesday about hearing loss and dementia misidentified the city in which the Medical College of Wisconsin is located. It is in Milwaukee, not in Madison.

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Prostate Cancer Study Suggests Shorter Treatments

Men with high-risk prostate cancer treated with only 18 months of hormone therapy live just as long as those treated for a more standard 36 months, a new study has found.

If the study results are applied in practice, it could mean much shorter treatment, sparing men months of unpleasant side effects, researchers said Tuesday.

“This may well change the standard of care,” said Dr. Bruce J. Roth, a prostate cancer specialist at Washington University in St. Louis. “Three years of hormonal therapy was almost picked randomly, and there’s nothing magical about that duration.”

Dr. Roth was not involved in the study, but he moderated a news conference for the Genitourinary Cancers Symposium, which will take place starting Thursday in Orlando, Fla., and is where the results will be presented.

Hormone therapy is essentially chemical castration, in which drugs are used to block the body’s production of testosterone, which fuels prostate tumor growth.

The side effects, including hot flashes, loss of sexual desire, fatigue and the weakening of bones and muscles, make life “quite miserable,” said Dr. Abdenour Nabid of Sherbrooke University Hospital Center in Sherbrooke, Quebec, who was the lead investigator.

The study involved 630 patients with localized but high-risk prostate cancer who were treated with radiation therapy and hormone therapy. While that description fits only a small portion of the 240,000 new cases of prostate cancer diagnosed each year in the United States, the results would still apply to thousands of men, researchers said.

After a median follow-up of about six and a half years, 77.1 percent of the men who received 36 months of therapy were still alive, as were 76.2 percent of the men treated for 18 months.

While slightly more men receiving the longer treatment were alive at five years, the difference was not statistically significant, and for the patients already followed for 10 years, the survival rates were similar. The death rate specifically from prostate cancer was also the same after 10 years.

There were also no statistically significant differences in the rate of biochemical failure — when the P.S.A. marker rises — or in the spread of cancer to the bone, Dr. Nabid said. The difference between the two therapy durations on the quality of the patients’ lives is still being studied.

Dr. David I. Quinn, medical director of the University of Southern California Norris Cancer Hospital, said the results “will change the approach for men who’ve got the worst localized prostate cancer that we see.” He said the results went against some previous studies that suggested that “more is better.”

But Dr. Michael J. Morris, associate professor at the Memorial Sloan-Kettering Cancer Center, said that 630 patients might be too few to draw “a relatively sweeping conclusion.” A study meant to prove that two treatments are equivalent may need to be much larger, he said.

Dr. Matthew R. Smith, professor of medicine at Massachusetts General Hospital, said it might be “overreaching” to make a conclusion yet because not many trial patients had died. “I think we need longer follow-up,” he said.

Dr. Nabid, the principal investigator, said that patients would be followed for two or three more years but that he was confident the results would hold up.

The trial enrolled patients at 10 hospitals in Quebec from October 2000 to January 2008. The drugs used were bicalutamide and goserelin, sold by AstraZeneca as Casodex and Zoladex, respectively, but now subject to generic competition. AstraZeneca paid for the study.

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Bloomberg Lauds Companies for Cutting Salt Content

Mayor Michael R. Bloomberg, in the midst of a long-running campaign to change the eating habits of New Yorkers and consumers across the country, declared a victory against salt on Monday, as 21 companies, from Kraft and Goya to FreshDirect, said they had met the first stage in reductions in salt content in foods.

After focusing on reducing trans fats and smoking, Mr. Bloomberg turned his attention to salt in 2010, announcing that about 30 companies had signed up to reduce salt in foods by 25 percent within five years, as a way of lowering consumers’ blood pressure and saving lives lost to heart attack and stroke.

“These companies have a huge presence on our shelves and in our diets,” Mr. Bloomberg said at a news conference at City Hall as he announced the results, surrounded by a half-dozen executives of food companies.

The first stage focused on the low-hanging fruit — salsa, dips, bacon, ketchup, barbecue sauce, cold cuts, processed cheese, salad dressing, canned beans and pizza — foods whose salt content is so high that reducing it up to a point probably would not be noticed by many consumers.

Mr. Bloomberg called them “some of America’s most beloved and iconic foods,” suggesting that the cuts might have a disproportionately salutary effect. But Dr. Thomas A. Farley, the city’s health commissioner, said he did not know how much salt the results so far had removed from the average person’s diet.

One side effect of the salt reduction drive is that food companies are looking for salt substitutes to make food taste better.

The main way to do that is to add potassium chloride instead of sodium chloride, said Russ Moroz, vice president for research at Kraft Foods. But because potassium tends to have a bitter, mineral taste, other ingredients have to be added. He said these were proprietary secrets, and he declined to name them.

Potassium is good, Dr. Farley said, because it lowers blood pressure and most people do not get enough of it. It is removed from fruits and vegetable during processing, he said. Mr. Bloomberg said he thought fears of additives were overdone.

But a salt industry scientist said Monday that too much potassium could be bad for the kidneys, and that the “cocktail of chemical constituents” added to balance the bitterness and enhance the salty taste could present unknown risks, as those ingredients were undisclosed.

“They do it with one eye on the lab and the other eye on the label,” said Morton Satin, vice president for science and research at the Salt Institute, a trade association. “They make sure it’s below the level that the F.D.A. requires for it to be on the label.”

Mr. Satin said that the link between high blood pressure and salt was just “a theory,” and that reducing salt too much could have harmful effects, like iodine deficiency in children, a cause of mental retardation, and diabetes.

Some companies said reducing salt proved to be a popular marketing tool. Goya reported that it had reduced salt in its regular canned beans by 5 or 6 percent, without any drop in sales. “We tasted them, and you really wouldn’t notice the difference,” Joseph Perez, senior vice president of Goya Foods, said Monday.

Mr. Bloomberg said it might surprise many people to know that bread and rolls were the “biggest contributor” to salt in the diet. Eating a muffin, he said, could be worse than eating a small bag of Lays potato chips.

Bread makers are hard to spot on the list of companies that have pledged to reduce salt, perhaps, Mr. Satin said, because it is more difficult to make bread without salt. However, some companies, like Au Bon Pain, have reduced salt in some baked goods.

On an irreverent note, Mr. Bloomberg said that he loved Subway sandwiches and would eat his favorite, the Italian B.M.T. — it includes salami, pepperoni and ham — regardless of the salt content, but that he was glad that it now contained 27 percent less.

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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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