Uganda Fights Stigma and Poverty to Take On Breast Cancer

KAMPALA, Uganda — Mary Namata unbuttoned her dress in an examining room at Mulago Hospital, revealing a breast taut and swollen with grape-size tumors that looked as if they might burst through the skin.

“How long have you had this?” a doctor asked gently. Ms. Namata, 48, an elegant woman with stylishly braided hair and a flowing, traditional Ugandan dress, looked away, shamefaced.

“About a year,” she murmured. The truth, she admitted later, was closer to four years.

Such enormous tumors, rare in developed countries, are typical here. Women in Uganda, trapped by stigma, poverty and misinformation, often do not see help for breast cancer until it is too late.

For Ms. Namata, though, there was still hope that the cancer had not yet spread beyond the breast, her doctors said. Treatment could prolong her life, maybe even cure her — if it started soon.

But would she be treated in time? Women in Africa often face perilous delays in treatment as a result of scarce resources, incompetence and corruption. Would Ms. Namata wind up like so many women here, with disease so far gone that doctors can offer nothing but surgery to remove rotting flesh, morphine for pain and antibacterial powder to kill the smell of festering tumors that break through the skin?

Cancer has long been neglected in developing countries, overshadowed by the struggle against more acute threats like malaria and AIDS. But as nations across the continent have made remarkable progress against infectious diseases once thought too daunting to tackle, more people are living long enough to develop cancer, and the disease is coming to the forefront. Given the strides poor countries have made against other health problems, they should also be able to improve the treatment of cancer, public health experts increasingly say. 

Two years ago, the United Nations began a global campaign against noncommunicable diseases — cancer, diabetes, heart and lung disease — noting that they hit the poor especially hard. Worldwide, at least 7.6 million people a year die from cancer, and 70 percent of those deaths occur in poor and moderate-income countries, according to the World Health Organization.

Breast cancer takes a particularly harsh toll. It is the world’s most common cancer in women and their leading cause of cancer death, with 1.6 million cases a year and more than 450,000 deaths.

Survival rates vary considerably from country to country and even within countries. In the United States, about 20 percent of women who have breast cancer die from it, compared with 40 to 60 percent in poorer countries. The differences depend heavily on the status of women, their awareness of symptoms and the availability of timely care. At the same time, scientists’ deepening insights into the genetic basis of cancer have introduced a complicated new dimension into the care of women globally.

Uganda is trying to improve the treatment of all types of cancer in ways that make sense in a place with limited resources. A new hospital and clinic, paid for by the Ugandan government, have been added to the Uganda Cancer Institute in Kampala, though they have not yet opened, for lack of equipment. A research center is being built.

But women like Ms. Namata, with breast cancer so advanced that there is just a tiny window of time, if any, in which to save their lives, will be among the toughest challenges here.

“The terrible part about breast cancer is that if we just did what we already know how do in other places, we could make major shifts in survival,” said Dr. Benjamin O. Anderson, who heads the Breast Health Global Initiative, based at the Fred Hutchinson Cancer Research Center in Seattle. 

There is a pressing need for action because breast cancer is “escalating,” the initiative says, predicting that incidence and death rates in developing countries will increase by more than 50 percent in the next 20 years.

The breast cancer rate in Africa seems to be increasing, though cervical cancer kills more women in the sub-Saharan regions. It is not clear whether breast cancer is actually becoming more common, or is just being detected and reported more often, but physicians consider it a looming threat. Compared with breast cancer patients in developed countries, those in Africa tend to be younger, and they are more likely to die, in large part because of late diagnosis and inadequate treatment.

Doctors also suspect that more aggressive types of tumors may be more common in young African women, as they appear to be in young black women in the United States, though there is not enough pathology data from Africa to know for sure. Among women who die young (ages 15 to 49) from breast cancer, 72 percent are in developing countries, and many leave small children.

“The story of breast cancer here is a miserable one,” said Dr. Fred Okuku, an oncologist at the Uganda Cancer Institute in Kampala, which treats about 200 women a year for breast cancer. “There is little information for the people who need to be helped. Only a few know how to read and write. Many don’t have TV or radio. There is no word for cancer in most Ugandan languages. A woman finds a lump in her breast, and cancer doesn’t cross her mind. It’s not in her vocabulary.”

Mary Namata’s Story

Ms. Namata, a gracious woman with a radiant smile, lives in Buddo, a village outside Kampala, in a three-room tin-roof house with no electricity or indoor plumbing. Lush jackfruit and papaya trees surround the house, which Ms. Namata shares with two granddaughters and her elderly mother, who is blind and a bit senile. Ms. Namata used to farm, but now looks after her mother and the girls, while their mother — Ms. Namata’s only daughter — works as a hairdresser to support the entire family. Ms. Namata and her husband parted ways long ago.

In late July, sitting on the cement floor with her granddaughters close by her side and her mother listening from a couch, Ms. Namata said that she had first noticed a lump in her right breast four years before, and that a doctor had told her the breast would most likely have to be removed.

Her mother broke into the story, shaking her head angrily and insisting that no woman should have her breast cut off.

Mastectomy is far more common in Africa than in developed countries, even for small lumps, because the technology may not be available to make sure that a lumpectomy is done properly. 

Ms. Namata went on, saying she had planned to have the surgery, but friends and relatives talked her out of it, telling her that it would just spread the cancer and kill her. Instead, she decided to try herbal treatments, which her daughter took out a loan to pay for.

Herbs are popular here, widely used for stomach trouble and coughs, and many people try them for cancer. They are sold in shops and from vans parked along busy roads, and are peddled door to door by Masai tribesmen from Kenya. In Kampala not far from the cancer institute, herb peddlers in a van hawked remedies for ulcers, diabetes, toothaches and syphilis over a loudspeaker, and offered a yellow plastic container labeled Healthy Booster for $7 to treat cancer.

Ms. Namata’s tumors kept growing and her breast began to hurt so much that she could not sleep. A hospice program for people with advanced cancer gave her morphine. Finally, on July 17, the pain drove her back to the breast clinic at Mulago. The clinic is held only once a week, and does not have enough doctors to see all the patients who show up; many are sent home week after week and told to come back another time.

On this day, more than 100 women jammed its benches and dim corridors, where a guard called out warnings to beware of pickpockets. Ms. Namata was among the lucky few who were called in to be examined.

A team of American doctors happened to be visiting. Dr. Constance D. Lehman, a radiologist at the Fred Hutchinson center and the director of breast imaging at the University of Washington, used ultrasound to scan Ms. Namata’s armpit, and then performed a needle biopsy. A pathologist from the Hutchinson center, Dr. Margaret Porter, studied the biopsy slide under a microscope. 

Despite the large tumors, the doctors were hopeful. The cancer did not seem to have spread, and the cells did not look terribly aggressive, Dr. Porter said.

But it would be important to treat her quickly, maybe with chemotherapy or a hormonal treatment first to shrink the tumors and make it easier to perform a mastectomy.

“I’m so nervous that she’ll fall through the cracks,” Dr. Lehman said. “She’s at a point where she is curable.”

The Americans huddled with a Ugandan surgical resident, who suggested admitting Ms. Namata to the hospital immediately. The Americans were delighted. But Ms. Namata declined, saying she had to find someone to care for her mother and granddaughters. She promised to return.

The American doctors, busy examining other patients, did not learn until later that she had left. Crestfallen, they wondered if she would come back. 

A First Step to Progress

Breast cancer in Africa is usually not diagnosed until it has reached Stage 4, the final stage, when it has invaded organs or bones and cannot be cured. If doctors could just find the disease a bit earlier — known as “downstaging” — and start treatment at Stage 3, before the cancer has spread to distant parts of the body, they could increase a woman’s odds of survival by 30 percentage points, according to the 2012 World Breast Cancer Report, published by the International Prevention Research Institute.

Downstaging could be accomplished by getting women like Ms. Namata into the clinic as soon as they notice a lump. But finding cases earlier will require sending health workers into rural areas to educate and examine women, Dr. Okuku said.

Earlier diagnosis here would not require mammograms to search for tiny tumors too small to feel. Instead, American experts hope to help downstage breast cancer in Uganda by teaching doctors to use ultrasound to examine lumps that women have already noticed, and quickly identify those who most urgently need treatment. Ultrasound works better than mammography in younger women, and can help to distinguish cysts and other benign growths from lumps that need biopsies.

In July, a team led by Dr. Lehman gave a course on ultrasound to doctors from Mulago Hospital and the cancer institute, which share a campus in Kampala. Dr. Lehman hopes eventually to set up a more efficient breast clinic, where women waiting to be seen would sort themselves into “more and less worrisome groups” by matching their symptoms to images on a laminated card. The images would include photographs of bulging tumors in the breast so that someone like Ms. Namata could move to a high-priority group.

“I know that paradigm can work, and I know it can be translated to countries around the world,” Dr. Lehman said. 

She and most other breast cancer specialists say that the last thing Africa needs is to mimic the screening programs in richer countries that offer mammograms every year or two to all healthy women over the age of 40 or 50. There are nowhere near enough trained people in Africa to run the machines, maintain them and read the scans. In Uganda, a donated mammography van was used for a cancer-education program — not for mammograms.

Experts say that emphasizing mammograms could divert resources from the many women who urgently need care for palpable lumps that can easily be found without mammograms. In any case, mammography would not do a good job of finding tumors in the large proportion of African patients under 50, because younger women have dense breast tissue that hides tumors from X-rays.

Even in Western countries, there are growing concerns about potential harm from mammography, because it can identify minute growths that might never progress but are nonetheless given aggressive treatments with significant side effects.

To transfer such screening-mammography programs to Africa “feels wrong,” Dr. Lehman said. “It feels like we’re infecting them with our problems, rather than really sharing with them our triumphs.”

The Birth of an Activist

Gertrude Nakigudde is an accountant for an international freight forwarding firm in Kampala. Twelve years ago when she was 28, she noticed a lump in her breast. Assuming she was too young to have cancer, she did not see a doctor for about a year.

By then, she had Stage 2 breast cancer — a tumor more than two centimeters in diameter that may have spread to nearby lymph nodes — and needed a mastectomy and chemotherapy.

The treatments came as a tremendous shock. No one warned her that her hair would fall out, or that she would vomit. The government did not help to pay for chemotherapy (as it does now), so she had to buy the drugs, syringes and gloves herself. Once, on a hot day, her medication deteriorated in the heat on the way to the hospital and had to be thrown away; no one had told her it had to be kept cold. Radiation treatment was recommended, but the machine was broken, so she gave up and went without it.

An activist was born.

She joined forces with other patients to form the Uganda Women’s Cancer Support Organization. It now has about 50 members. 

Its volunteers visit the cancer institute and the breast clinic at Mulago Hospital to counsel other women and hand out pamphlets, bras and breast prostheses. Most of all, they try to spread the word that breast cancer can be cured if it is treated early, and to dispel stigma and misinformation. Some women believe that cancer is always fatal, which becomes a self-fulfilling prophecy by keeping them away from doctors.

Patients encounter demoralizing drug shortages and mistakes like lost biopsies that can lead to dangerous delays in care. Chemotherapy is supposed to be free at the cancer institute, but if it runs out of drugs, patients have to buy their own. And the drugs do run out, because the government agency that supplies them does not consistently order enough. In addition, some drugs have become harder to obtain because problems with counterfeit chemotherapy drugs from India have led the institute to stop buying from that country, which has been an important supplier.

A number of women in Ms. Nakigudde’s group have been deserted by husbands or boyfriends because they have cancer, she said, counting herself among them. Some have been fired from work for taking time off for treatment. It is not uncommon for women to try to keep the disease a secret, for fear that if word gets out, no one will marry their children. Women with one breast are sometimes shunned as witches or as having been cursed by a witch.

Ms. Nakigudde said one of the biggest problems for breast cancer patients is that the cancer institute does not yet offer surgery or radiation, so women must seek those treatments at Mulago Hospital, which is huge, disorganized and intimidating. Its radiation machine, the only one in the country, is a rickety cobalt unit long past its prime. There is such a demand for treatment — patients are referred here from Kenya, Rwanda and South Sudan — that the machine is kept running night and day.

Ms. Nakigudde and other group members have also tried to expose what they describe as a culture of bribery that delays or denies treatment. The hospital has two tiers: free, public wards for the poor, and a private one for those who can pay. Paying patients are generally treated more quickly. Ms. Nakigudde said her group receives numerous reports from women who are supposed to receive free care but say they are being pressured to pay surgeons and other hospital employees for everything from being admitted to shortening the wait for surgery or radiation.

Her group has been working with a bioethics committee at Makerere University (whose medical students train at Mulago) to find a way to discipline doctors and end the demands for money.

A spokesman for Mulago Hospital, Enock Kusasira, confirmed that there were problems, noting that it is a massive complex open to the public and teeming with 7,000 people on any given day — 5,000 patients and their relatives, and 2,000 employees. 

“There are those incidents,” Mr. Kusasira said. “What can you do about them?”

He attributed some bribetaking to students and con men who steal white coats and pose as hospital employees, something widely acknowledged to occur. But hospital employees are not highly paid, and Mr. Kusasira said some patients do not want to wait their turn and “lure these workers into temptation.”

Ultimately, Ms. Nakigudde said, the best hope may lie in the continuing expansion of the cancer institute, where bribery is not entrenched. Its expansion cannot come too soon. Now, it is a cluster of one-story tin-roof buildings with too many patients and not enough chemotherapy. The tumor ward often has 35 patients for its 25 beds. In mid-July, a half-dozen patients lay on mattresses on the floor, tucked wherever they fit. Relatives slept on mats under the beds. Most of the patients had advanced cancer, and some had come here to die.

The new hospital will bring the institute’s first operating rooms, and administrators hope to add a radiation center. They also want to improve its pathology labs so they can perform tests that will help determine which treatments will best suit each patient. In addition, a new cancer research center with another clinic is being built with money from Uganda, the United States Agency for International Development, and the Hutchinson center in Seattle.

Visits to the cancer institute surged to 2,800 in 2012 from 1,800 in 2011. Its six oncologists, the only ones in the country, are struggling to keep up; each one might see 40 patients a day. A tent had to be pitched at the outpatient clinic to hold the overflow from the waiting room.

Dr. Jackson Orem, the director of the cancer institute, said, “We have become a victim of our own success.”

What is needed ultimately, he said, is a nationwide cancer program involving clinics in remote areas and a system to refer patients who need specialized treatment to the cancer institute.

“My prayer,” Dr. Orem, 51, said, “is to see that by the time I retire, there is a system in place, a safety net for cancer patients.” 

  

Treatment Begins

A week after seeing the American doctors — who by now had gone home — Ms. Namata traveled two hours back to Mulago by bus, two motor-scooter taxis and another bus.

Expecting to be admitted, she hauled a suitcase, a plastic jug holding more than a gallon of water and, because hospitals here do not provide sheets or blankets, an enormous roll of bedding. The pressure of the bedroll against her breast clearly pained her. The activist, Ms. Nakigudde, had put in a word for her, and a surgeon had agreed to see her. Led by a member of the group, Ms. Namata squeezed through the crowded corridors.

The surgeon examined her but did not admit her, telling her instead to return the following Monday for a mastectomy. Drug treatment would come after the operation, he said, giving advice contrary to that offered by the American physicians. She hauled her belongings home.

The next Monday, she was admitted to Mulago Hospital. She waited for a week in constant pain before another surgeon finally examined her, only to tell her, as the American doctors had, that it would be better for her to take drugs to try to shrink the tumors before surgery because they were so large that it would not be possible to close the wound. She left the hospital frustrated and frightened, beginning to doubt that she would survive.

But she made her way to the cancer institute, where she began receiving chemotherapy on Aug. 19.

Her hair, expertly braided by her daughter, is now gone. Her skin has darkened, a common side effect of chemotherapy that African women find particularly distressing, for aesthetic reasons, but also because H.I.V. treatment does the same thing, and people assume they have AIDS.

“I look like a scarecrow,” Ms. Namata said. “I don’t want to eat or drink.”

She calls Ms. Nakigudde just about every night for advice on what to eat, and reassurance that her hair will grow back.

The cancer institute has run out of chemotherapy drugs again, so she must buy them herself, and is struggling to scrape together the cash. Sometimes, rather than asking her daughter for money, she borrows from other people.

But the tumors seem to be shrinking. She no longer needs morphine. In a few months, she hopes to have surgery. And she prays that she will live.

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Breaking Through Cancer’s Shield

For more than a century, researchers were puzzled by the uncanny ability of cancer cells to evade the immune system. They knew cancer cells were grotesquely abnormal and should be killed by white blood cells. In the laboratory, in Petri dishes, white blood cells could go on the attack against cancer cells. Why, then, could cancers survive in the body?  

The answer, when it finally came in recent years, arrived with a bonus: a way to thwart a cancer’s strategy. Researchers discovered that cancers wrap themselves in an invisible protective shield. And they learned that they could break into that shield with the right drugs.

When the immune system is free to attack, cancers can shrink and stop growing or even disappear in lucky patients with the best responses. It may not matter which type of cancer a person has. What matters is letting the immune system do its job.

So far, the drugs have been tested and found to help patients with melanoma, kidney and lung cancer. In preliminary studies, they also appear to be effective in breast cancer, ovarian cancer and cancers of the colon, stomach, head and neck, but not the prostate. 

It is still early, of course, and questions remain. Why do only some patients respond to the new immunotherapies? Can these responses be predicted? Once beaten back by the immune system, how long do cancers remain at bay?

Still, researchers think they are seeing the start of a new era in cancer medicine.

“Amazing,” said Dr. Drew Pardoll, the immunotherapy research director at Johns Hopkins School of Medicine. This period will be viewed as an inflection point, he said, a moment in medical history when everything changed.

“A game-changer,” said Dr. Renier J. Brentjens, a leukemia specialist at Memorial Sloan-Kettering Cancer Center.

“A watershed moment,” said his colleague, Dr. Michel Sadelain. (Both say they have no financial interests in the new drugs; Dr. Pardoll says he holds patents involving some immunotherapy drugs, but not the ones mentioned in this article.)

Researchers and companies say they are only beginning to explore the new immunotherapies and develop others to attack cancers, like prostate, that seem to use different molecules to evade immune attacks. They are at the earliest stages of combining immunotherapies with other treatments in a bid to improve results.

“I want to be very careful that we do not overhype and raise patients’ expectations so high that we can never meet them,” said Dr. Alise Reicin, a vice president at Merck for research and development.

But the companies have an incentive to speed development of the drugs. They are expected to be expensive, and the demand huge. Delays of even a few months mean a huge loss of potential income.

Nils Lonberg, a senior vice president at Bristol-Myers Squibb, notes that immunotherapy carries a huge advantage over drugs that attack mutated genes. The latter approach all but invites the cancer to escape, in the same way bacteria develop resistance to antibiotics.

By contrast, immunotherapy drugs are simply encouraging the immune system to do what it is meant to do; it is not going to adapt to evade the drugs.

“We are hoping to set up a fair fight between the immune system and the cancer,” Dr. Lonberg said.

Lowering Defenses

The story of the new cancer treatments started with the discovery of how cancers evade attacks. It turned out that they use the body’s own brakes, which normally shut down the immune system after it has done its job killing virus-infected cells.

One braking system, for example, uses a molecule, PD-1, on the surface of T-cells of the immune system. If a target cell has molecules known as PD-L1 or PD-L2 on its surface, the T-cell cannot attack it.

So some cancer cells drape themselves in those molecules. The effect, when T-cells are near, is like turning off a light switch. The T-cells just shut down.

Cancers that do not use PD-L1 or PD-L2 are thought to use other similar systems, just starting to be explored. Body systems have a lot of redundancy to tamp down immune attacks. But for now, the PD system showed researchers how cancer cells can evade destruction.

“That is what has been realized in the past few years,” said Ira Mellman, vice president of research oncology at Genentech. “Tumor cells are making use of this brake.”

The discovery led to an idea: Perhaps a drug that covered up any of those PD molecules, on the cancer cells or on white blood cells, would allow the immune system to do its job.

(There is another immunotherapy strategy — to take white blood cells out of the body and program them with genetic engineering to attack a cancer. Studies have just begun and are promising. But researchers note that this is a very different sort of treatment that is highly labor-intensive and has been successful so far in only a few types of cancer.)

The first indication that a cancer’s protective shield might be breached came in 2010, after a trial of the drug ipilimumab in patients with otherwise untreatable melanoma. The drug unleashes the immune system, letting it overwhelm tumors even if they have a protective shield

Patients who took the drug survived an average of 10 months, or 4 months longer than those randomly assigned to a different treatment. And about 20 percent of patients who responded have now survived up to 10 years. It was the first drug to improve survival for patients with metastatic melanoma in a randomized trial.  

“It was spectacular,” said Dr. Axel Hoos, vice president for oncology research and development at GlaxoSmithKline, who helped develop the drug when he was at Bristol-Myers Squibb. “Until that tipping point, immunotherapy had a bad name. It didn’t work.”

The drug was approved for melanoma in March 2011, with a high price tag — $120,000 for a course of therapy.

It had another drawback. By unleashing the immune

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Patients Mired in Costly Credit From Doctors

The dentist set to work, tapping and probing, then put down his tools and delivered the news. His patient, Patricia Gannon, needed a partial denture. The cost: more than $5,700. 

Ms. Gannon, 78, was staggered. She said she could not afford it. And her insurance would pay only a small portion. But she was barely out of the chair, her mouth still sore, when her dentist’s office held out a solution: a special line of credit to help cover her bill. Before she knew it, Ms. Gannon recalled, the office manager was taking down her financial details.

But what seemed like the perfect answer — seemed, in fact, like just what the doctor ordered — has turned into a quagmire. Her new loan ensured that the dentist, Dr. Dan A. Knellinger, would be paid in full upfront. But for Ms. Gannon, the price was steep: an annual interest rate of about 23 percent, with a 33 percent penalty rate kicking in if she missed a payment.

She said that Dr. Knellinger’s office subsequently suggested another form of financing, a medical credit card, to pay for more work. Now, her minimum monthly dental bill, roughly $214 all told, is eating up a third of her Social Security check. If she is late, she faces a penalty of about $50.

“I am worried that I will be paying for this until I die,” says Ms. Gannon, who lives in Dunedin, Fla. Dr. Knellinger, who works out of Palm Harbor, Fla., did not respond to requests for comment.

In dentists’ and doctors’ offices, hearing aid centers and pain clinics, American health care is forging a lucrative alliance with American finance. A growing number of health care professionals are urging patients to pay for treatment not covered by their insurance plans with credit cards and lines of credit that can be arranged quickly in the provider’s office. The cards and loans, which were first marketed about a decade ago for cosmetic surgery and other elective procedures, are now proliferating among older Americans, who often face large out-of-pocket expenses for basic care that is not covered by Medicare or private insurance.

The American Medical Association and the American Dental Association have no formal policy on the cards, but some practitioners refuse to use them, saying they threaten to exploit the traditional relationship between provider and patient. Doctors, dentists and others have a financial incentive to recommend the financing because it encourages patients to opt for procedures and products that they might otherwise forgo because they are not covered by insurance. It also ensures that providers are paid upfront — a fact that financial services companies promote in marketing material to providers.

One of the financing companies, iCare Financial of Atlanta, which offers financing plans through providers’ offices, asks providers on its Web site: “How much money are you losing everyday by not offering iCare to your patients?” Over the last three years, the company’s enrollment has grown 320 percent. Another company posted a video online that shows patients suddenly vanishing outside a medical office because they cannot afford treatment. The company offers a financing plan as a remedy, with the scene on the video shifting to a smiling doctor with dollar signs headed toward him. 

A review by The New York Times of dozens of customer contracts for medical cards and lines of credit, as well as of hundreds of court filings in connection with civil lawsuits brought by state authorities and others, shows how perilous such financial arrangements can be for patients — and how advantageous they can be for health care providers.

Many of these cards initially charge no interest for a promotional period, typically six to 18 months, an attractive feature for people worried about whether they can afford care. But if the debt is not paid in full when that time is up, costly rates — usually 25 to 30 percent — kick in, the review by The Times found. If payments are late, patients face additional fees and, in most cases, their rates increase automatically. The higher rates are often retroactive, meaning that they are applied to patients’ original balances, rather than to the amount they still owe.

For patients, the financial consequences can be dire.

Ms. Gannon said she was happy with her dental care, despite the cost, and there was no suggestion that Dr. Knellinger had done anything wrong. But attorneys general in a several states have filed lawsuits claiming that other dentists and professionals have misled patients about the financial terms of the cards, employed high-pressure sales tactics, overcharged for treatments and billed for unauthorized work.

The New York attorney general’s office found that health care providers had pressured patients into getting credit cards from one company, CareCredit, a unit of General Electric, which gave some providers discounts based on the volume of transactions. Patients, the investigation found, were misled about the terms of the credit cards, and in some instances, duped into believing that they were agreeing to a payment plan with dental offices when, in fact, they were being pushed into high-cost credit.

In June, CareCredit reached a pact with Eric T. Schneiderman, the New York attorney general, to improve protections for consumers, and a spokeswoman said the company “does not incentivize providers to have patients open accounts” or give referral fees to providers.

In Ohio, the attorney general has sued the operators of several hearing aid clinics, claiming that they misled customers about using medical credit cards to pay for batteries and warranties. 

Cameron P. Kmet, a chiropractor in Anchorage, Alaska, said he had stopped offering medical cards. “One missed payment can really ruin a patient’s life,” he said. Mr. Kmet now runs a company that administers payment plans directly between providers and patients, with annual interest rates around 8 percent.

Regarding medical credit cards, Mr. Kmet said he had urged providers to ask themselves “whether this is something that you would recommend to a family member or friend.” The answer, he said, is usually no.

While medical credit cards resemble other credit cards, there is a critical difference: they are usually marketed by caregivers to patients, often at vulnerable times, such as when those patients are in pain or when their providers have recommended care they cannot readily afford. In addition to G.E., large banks like Wells Fargo and Citibank, as well as several specialized financial services companies, offer credit through practitioners’ offices.

The growth of this form of consumer credit is difficult to quantify because data on medical credit cards specifically, as opposed to credit cards generally, is unavailable. But credit cards of all types are playing a growing role in financing medical care. In 2010, people in the United States charged about $45 billion in health care costs on credit cards, according to the consulting firm McKinsey & Company. 

“When the economy got worse, our business got better,” said Katie Kessing, an iCare spokeswoman. In 2010, a little more than a thousand dentists offered the iCare finance plan — a program that requires patients to pay 30 percent down as well as a fee of 15 percent of the total procedure cost. The number of participating providers has since risen to 4,200. Russell A. Salton, the chief executive of Access One MedCard, a credit card company in Charlotte, N.C., said demand for specialized cards — the MedCard has an annual interest rate of 9.25 percent — is driven by providers interested in removing an “obstacle to providing valuable care.” The company says the number of hospitals offering its credit cards has grown about 25 percent a year in recent years.

While neither national medical or dental associations have formal policies, ADA Business Enterprises, a profit-making arm of the American Dental Association that connects dentists and businesses, endorses G.E.’s CareCredit, whose cards are used by more than seven million people nationwide.

“Cardholders tell us they like using CareCredit because it gives them the ability to plan, budget and pay for certain elective health care procedures over time,” said Cristy Williams, the spokeswoman for CareCredit. She said the company had improved consumer protections, going so far as to telephone “senior cardholders with significant first transactions to confirm their understanding of the program and terms.”

She said roughly 80 percent of patients who opted for the deferred interest paid off their debts before they were charged any interest. She and others in the industry said the credit cards and credit lines had helped patients afford otherwise prohibitively expensive care not paid for at all, or in its entirety, by insurance providers. 

But state authorities and care advocates in California, Florida, Illinois, Michigan and elsewhere say that older people — many of them grappling with dwindling savings and mounting debt — are running into trouble with medical credit cards and loans.

“The cards prey on seniors’ trust,” said Lisa Landau, who heads the health care unit at the New York attorney general’s office.

Minnesota’s attorney general, Lori Swanson, is investigating the use of medical credit cards, which she said could come with “hidden tripwires and other perils.”

Interviews with patients, along with the review of contracts and lawsuits, show just how significant those perils can be.

Carl Dorsey, 74, recalled his experience at Aspen Dental Management, a nationwide chain that has come under scrutiny for its practices. Mr. Dorsey said that after a dentist at Aspen’s office in Seekonk, Mass., told him that he needed dentures, at a cost of $2,634, he was urged to take out a medical credit card. He was charged the full cost upfront, financial statements reviewed by The Times show. Mr. Dorsey, who made about $800 a month working as a used-car salesman, in addition to receiving Social Security, has since fallen behind on his payments. The lapse set off a penalty interest rate of nearly 30 percent. Mr. Dorsey said he was being pursued by debt collectors. 

“This whole ordeal has been devastating,” said Mr. Dorsey, who along with other patients is part of a civil lawsuit filed against Aspen in a federal court in upstate New York. He said he still needed dentures, noting that the ones he received from Aspen were unusable.  

Diane Koi-Thompson said that her father, Harold Koi-Than, did not realize that he had signed up for a CareCredit card during a dental visit. She said Mr. Koi-Than, 82, was shocked when a company representative called his home near Niagara Falls, N.Y., saying he had missed a payment. “My dad had no idea he had a credit card, let alone that he was behind on it,” Ms. Koi-Thompson said. She said her father was upset because he is normally meticulous with his finances and thought his memory was failing. Mr. Koi-Than, through a family member, was able to cancel the credit card.

The industry’s growth is being driven by people seeking dental care and devices like hearing aids, which are not covered by Medicare.

Dental care is a large and expensive gulf, according to Tricia Neuman, the director of Medicare policy research at the Kaiser Family Foundation. The new federal health care law, she said, will not change that. “Lack of dental coverage remains a huge concern and expense,” Ms. Neuman said.

Working with care providers, financial services companies have rushed to fill the void. To make medical cards attractive, some companies offer them without checking patients’ credit histories. The cards can be arranged in minutes, with no upfront charges. Such features are attractive selling points.

“Your patient does not require good credit,” First Health Funding of Salt Lake City, Utah says on its Web site. On the site of another lender, the words “No Credit Check” flash in bright letters. First Health Funding did not respond to requests for comment.

Lawyers and others who assist patients say such features make it easy for people who are already on a weak financial footing to take on new debt.

“Ultimately, this credit facilitates a bad financial decision that will haunt a patient because it adds to indebtedness,” said Ellen Cheek, who runs a legal help line for older people through Bay Area Legal Services in Tampa, Fla. 

Such critics also say that because there are no industrywide standards for pricing care — costs vary from practice to practice — the cards could encourage providers to charge more for treatment.

Brian Cohen, the lawyer representing Mr. Dorsey, said the cards enabled providers to “bill whatever they want for care, regardless of whether the cost is reasonable.”

State authorities say health care finance in general, and medical credit cards in particular, are a growing worry. In 2010, Aspen Dental, the chain where Mr. Dorsey signed up for a card, reached a settlement with Pennsylvania authorities over claims that, among other things, it had failed to tell patients that missing a payment would mean the rate would rocket from zero to nearly 30 percent. A review of court records and online forums shows hundreds of customer complaints against Aspen, which is based in Syracuse. A civil case brought on behalf of customers is pending in a federal court in upstate New York.

Kasey Pickett, a spokeswoman for Aspen, which is fighting the lawsuit, said the accusations were “entirely without merit.”

Aspen provides mandatory training for office employees who discuss financing with patients, according to Ms. Pickett. “We know that for many patients,” she said, “the availability of third-party financing may be the only way that they are able to afford the care they need.”

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The Soaring Cost of a Simple Breath

OAKLAND, Calif. — The kitchen counter in the home of the Hayes family is scattered with the inhalers, sprays and bottles of pills that have allowed Hannah, 13, and her sister, Abby, 10, to excel at dance and gymnastics despite a horrific pollen season that has set off asthma attacks, leaving the girls struggling to breathe.

Asthma — the most common chronic disease that affects Americans of all ages, about 40 million people — can usually be well controlled with drugs. But being able to afford prescription medications in the United States often requires top-notch insurance or plenty of disposable income, and time to hunt for deals and bargains. 

The arsenal of medicines in the Hayeses’ kitchen helps explain why. Pulmicort, a steroid inhaler, generally retails for over $175 in the United States, while pharmacists in Britain buy the identical product for about $20 and dispense it free of charge to asthma patients. Albuterol, one of the oldest asthma medicines, typically costs $50 to $100 per inhaler in the United States, but it was less than $15 a decade ago, before it was repatented.

“The one that really blew my mind was the nasal spray,” said Robin Levi, Hannah and Abby’s mother, referring to her $80 co-payment for Rhinocort Aqua, a prescription drug that was selling for more than $250 a month in Oakland pharmacies last year but costs under $7 in Europe, where it is available over the counter.

The Centers for Disease Control and Prevention puts the annual cost of asthma in the United States at more than $56 billion, including millions of potentially avoidable hospital visits and more than 3,300 deaths, many involving patients who skimped on medicines or did without.

“The thing is that asthma is so fixable,” said Dr. Elaine Davenport, who works in Oakland’s Breathmobile, a mobile asthma clinic whose patients often cannot afford high prescription costs. “All people need is medicine and education.”

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Trusting the Doctor

We drove along the dirt and gravel roads of western Massachusetts, on our way to the Umpachene Falls.
Every summer my family and I stay for a few days at my best friend’s lake house in the Berkshires and engage in our silly rituals. Jumping off the dock into Lake Garfield while shouting “Kowabunga!” Paddling the kayak across the lake to visit the photographer whose dog once jumped onto the kayak’s deck to see if he’ll do it again. And going to the Falls.
We passed the occasional penned horses and llamas, ignored the sign warning us that, somewhere up ahead, a bridge was out, and turned into a grassy parking lot. We could hear their roar, muted by a wall of trees. I turned to my 9-year-old daughter, who was sitting in the back seat of our rental car, and asked, “Do you think you’ll do it this year?”
She nodded tentatively. Her 12-year-old brother, a three-year veteran of the falls, tried to reassure her. “It’ll be easy!” She smiled, her confidence slightly bolstered.
As the Umpachene River dumps into the Konkapot River, it creates a graded set of falls. Some are so mild we can traverse them with a simple step, but the lower portion of the river culminates in a six-foot drop, behind which is a shallow cave. Years ago we discovered that if we thrust ourselves into the falls, holding our breath while withstanding the force of the water, we could make it to the other side and sit in the cave breathing freely, the water inches from our faces.
It had rained the previous night, so the rush of water was particularly heavy, and cold. My buddy and I stood to one side. As was our routine, he went first.
We have been best friends since playing Little League baseball together 35 years ago, and I would follow him anywhere, without question. He disappeared under the falls. I waited a few seconds, and followed. The water was frigid and powerful, but only for a few moments. To make it to the cave was thrilling.
We emerged after a minute to find my son at the ready. As he dove into the falls, I turned again to my daughter, asking her if she was all set.
She nodded and came over to me. I wrapped my arms around her and we turned, our backs to the falls. “When I count to three, hold your breath and I’ll pull you through. O.K.?”
“Yes,” she squeaked, and closed her eyes. I counted, and she took a deep breath as we collapsed into the wall of water.
When I returned to clinic the following week, I got some rotten news. One of my patients, a 63-year-old man with leukemia, had relapsed after having been in remission for two years.
“O.K., so what’s next?” he asked.
His wife was sitting next to him, still processing that his cancer had returned. He was the type of person who didn’t dwell on questions of how this could have happened, or what if he had tried a different therapy. He also adored his wife, and more than once had whispered to me conspiratorially, “Can you believe I’m married to a girl as beautiful as her?” She was pragmatic, and made decisions deliberately; he was the romantic.
“You need to seriously consider a bone marrow transplant. It’s your only chance of being cured,” I answered.
His wife spoke up. “Well, you told us this might happen, so I did some reading.” She then asked a series of highly intelligent questions about the nuts and bolts of the procedure, his likelihood of finding a bone marrow match, complications, and his chance of being cured. He remained quiet.
When we had finished she turned to him. “I can’t tell what you’re thinking. What do you want to do?”
He smiled, in a way that indicated he appreciated that she would ask so many questions on his behalf, and that she cared for him enough to be bothered by his silence.
“Awww, you know I’m not smart enough to understand all these big words you two are using. I trust the doctor, and if he says this is what I should do, then I’ll do it.”
“Now wait a minute,” I jumped in. “I know you’re a smart guy. If I’m not being clear in explaining the transplant, I need to start over and describe it better.”
He smiled again. “Doc, I get what you’re saying. But no matter how much I understand it, I trust you, and I’m going to do what you suggest.”
I fought the urge to start in again, to outline each step of the transplant procedure so he could decide for himself what course to take. I was also reassured that his wife was there, advocating for him. Because in the end, aren’t most of our major life decisions based on simple trust? Like falling backward into a waterfall.

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Fat and Thin Find Common Ground

When binge eating disorder gained legitimacy as a full-fledged mental condition in the latest edition of the Diagnostic and Statistical Manual of Mental Disorders in May, many people in the eating disorders and obesity communities wondered: Will this inspire us to finally get along?
It was a good question, since historically, the two groups have been at odds.
Unlike people with anorexia or bulimia, who tend to be excessively thin, many binge eaters are overweight or obese. And much of the focus of anti-obesity efforts — listing calories at restaurants, banning cupcakes in schools, sending students home with body mass index “report cards” — are decried by eating disorder activists, who say such measures can encourage anorexia or bulimia.
Anti-obesity activists, in turn, worry that the eating disorder community minimizes the medical risks of obesity, which the American Medical Association classified as a disease in June, and plays down the discrimination many obese people face.
“They come out of different traditions,” said Kelly Brownell, dean of the Sanford School of Public Policy at Duke University. “Obesity was mainly dealt with in medical professions, and eating disorders were dealt with more in psychology professions.”
But binge eating disorder, symptoms of which include consuming enormous amounts of food in a two-hour window without purging at least once a week for three months, could bridge the gap between the two worlds, while also reducing the stereotype that only thin people suffer from eating disorders.
“We cannot address obesity and not eating disorders,” said Chevese Turner, 45, founder of the Binge Eating Disorder Association, which lobbied heavily for binge eating disorder’s inclusion in the D.S.M.-5. In September, clinicians, researchers and advocates who work in the eating disorders and obesity communities, or have struggled with the food and weight issues themselves, held a Congressional briefing in Washington to focus attention on the intersection of obesity and eating disorders.
“Part of what drives me crazy is that the obesity community and policymakers dismiss eating disorders as a small group of people, when in fact it is 30 million and growing – with more and more evidence that the focus on obesity and restriction, and growing weight stigma in the culture, is contributing to this rise,” said Ms. Turner, who spoke at the event.
Susan Rappaport knows all about this. At 26 and a petite 5-foot-4, she weighed nearly 200 pounds — the result, she maintains, of years of dieting. She would starve herself during the day and then get out of bed in the middle of the night to binge.
When she told her doctor that she thought she had an eating disorder, he brushed it off, said Ms. Rappaport, 50, who now weighs about 120 pounds and runs the NuYu Revolution Fitness Studio on the Upper West Side of Manhattan. “It was like, ‘You’re not skinny enough to have an eating disorder.’ But I was a fat eating disordered person.”
Indeed, an September study in Pediatrics found that nearly half of adolescents with eating disorders had a history of obesity, but because of their higher weight their symptoms often went unrecognized and untreated. Other studies have found that among individuals with a current or past history of binge eating disorder, approximately 20 percent are of normal weight, 40 percent are overweight and 40 percent are obese.
“I don’t want to say that the eating disorder is causing their obesity; some people with B.E.D. are normal weight,” said Jennifer J. Thomas, co-director of the Eating Disorders Clinical and Research Program at Massachusetts General Hospital and the co-author of “Almost Anorexic,” a book about sub-threshold eating disorders. “But there’s definitely a huge overlap, and if the two communities aren’t working together there is a huge missed opportunity.”
Statistics from the 2001-2003 National Co-Morbidity Survey Replication reported a 3.1 percent prevalence of binge eating disorder among women and 1.9 percent among men. Nearly 39.8 percent of respondents with binge eating disorder were obese.
Still, despite differences in physical characteristics and symptoms, those suffering from an eating disorder like anorexia or bulimia and those with obesity have “shared psychological components, commonalities and underpinnings,” said Dr. Scott Kahan, director of the Strategies to Overcome and Prevent (STOP) Obesity Alliance at the George Washington University School of Public Health and Health Services, a nonprofit obesity policy organization.
“Low self esteem is extremely common in both, as is body dissatisfaction. They are both very much environmentally driven. Both place excessive emphasis on appearance and body size. In the same way, many of the same psychological underpinnings play into both.”
Another area where the two fields converge is weight stigma, said Rebecca Puhl, deputy director of the Rudd Center for Food Policy and Obesity at Yale. A July study in PLoS One found that the more people feel stigmatized or bullied about their weight, the greater their risk for obesity. Other studies have shown that experiencing weight bias contributes to risk of eating disorders.
Jenni Schaefer, 37, Dr. Thomas’s co-author, is adamant that the two groups work together to ease confusion among recovering patients. “Recently, a teenager in recovery from bulimia said to me, ‘My therapist tells me not to talk about my weight and that my body is fine. But my doctor keeps weighing me and says that I need to lose weight,’” Ms. Schaefer said.
She had a similar experience with her own recovery from a 10-year struggle with anorexia. “My body had changed far more quickly than my mind. While that was confusing in and of itself, it was even more difficult to understand why my doctors were giving me different perspectives regarding my new weight. In many ways, I hit a standstill at that point. I didn’t know what to do.”
With all this in mind, a growing number of eating disorder treatment facilities are treating obese patients with and without binge eating disorder in groups with anorexics and bulimics.
“It makes no sense to separate people based on their size,” said Dr. Susan McClanahan, founder of Insight Behavioral Health, which has four locations in Chicago.
She is aware of the inherent conflict. “You’re telling one group ‘You have to eat’ and the other ‘It’s O.K. not to eat everything on your plate,” she continued. “But I think it’s been a real relief for the anorexics to see someone who is overweight and have them realize, ‘They’re just a person, it’s nothing to be afraid of.’ And the overweight folks can say, ‘Just because you’re skinny doesn’t mean you’re going to be happy.’ You can be absolutely miserable when you’re thin.”
Many treatment methodologies are also similar within the two groups, like eating regular meals, not skipping meals and learning to listen to one’s body for cues of hunger or fullness.
Some patients say that being in a mixed group is helpful. Ann Schaffer, 46, an administrative assistant and musician in Chicago, has struggled with binge eating disorder off and on for 12 years. At her heaviest Ms. Schaffer, who is 5-foot-7, weighed 207 pounds and found it challenging to be in the same room with 80-pound anorexics.
“Sometimes it was almost like envy — ‘I wish I had your problem,” Ms. Schaffer recalled. “After a while it was like camaraderie. The problem is not the food; the problems are the issues in your life, and you turn to food because you can’t handle them.”
This model of treating the two groups together is not without controversy. At Walden Behavioral Care in Waltham, Mass., individuals with binge eating and anorexia used to attend the same groups, but that stopped about five years ago.
“Patients were uncomfortable,” said Stu Koman, a clinical psychologist and the clinic’s founder and chief executive. “A lot of what they were dealing with in therapy was their discomfort at being in the group with someone who was anorexic, rather than focusing on what they needed to focus on: these binge episodes. The anorexic patients were terrified that they would end up looking like the heavier patients suffering from B.E.D.”
One thing nearly everyone agrees on is that the cultural conversation around food and body size must shift, along with media messages promoting images of waiflike models and an estimated $61 billion a year weight loss industry, in which the vast majority of dieters regain their weight within five years.
“The focus should be on behaviors, not weight,” said Dianne Neumark-Sztainer, a professor in the School of Public Health at the University of Minnesota, who has written extensively on obesity prevention and eating disorders.
“We know from our research that talking about weight and diets is not effective, and for many leads to weight gain over time,” said Dr. Sztainer, the author of “I’m, Like, So Fat!” “We really want to focus on providing a community that makes it easy to engage in healthy eating and physical activity.”
Dr. Brownell believes that the two communities could work together as a powerful political force, sharing a goal of better food- and health-related messages and policies. “Better access to healthy, locally grown foods might be such an example,” he said. “The extreme presence in our society of unhealthy, highly processed foods are a problem for both of these camps. Some people respond by eating too much, and others respond by extreme control so it becomes an eating disorder. A healthy food environment would be a benefit in both worlds.”
Resource:http://well.blogs.nytimes.com/2013/10/10/can-the-fat-and-thin-just-get-along/?ref=health&_r=0

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With New Abortion Restrictions, Ohio Walks a Narrow Legal Line

CLEVELAND — Angela H., married with two children, became pregnant accidentally and, after medical complications during her last pregnancy and severe postpartum depression, said neither she nor her family was ready for another child.

Under a law that took effect in Ohio this month, the Cleveland abortion clinic she visited had to offer her a chance not only to view an ultrasound of the fetus but also to watch its beating heart, which she said she resented.

“It’s a hard decision for anybody to make,” she said of abortion, asking that her surname not be published out of privacy concerns. “To make it more difficult by passing these laws and making women feel guilty is terrible.”

Ohio has become a laboratory for what anti-abortion leaders call the incremental strategy — passing a web of rules designed to push the hazy boundaries of Supreme Court guidelines without flagrantly violating them. Many of the rules, critics say, are designed to discourage women from getting abortions or to hamper clinic operations, even forcing some to close. 

The mandated discussion of fetal heartbeats is one of a cascade of abortion restrictions adopted in Ohio over the years, from a waiting period to curbs on the medication-induced abortions preferred by many women. The pace has quickened since John R. Kasich became governor in 2011, cementing Republican domination of state politics. Avowedly anti-abortion, Mr. Kasich said through a spokesman that he considered the restrictions he signed this year “reasonable.”

These laws have passed without the national drama provoked by far-reaching abortion bans that were approved, then overturned in court, in states like Arkansas and North Dakota. But taken together, they affect patients and clinics in myriad ways — in the view of the laws’ proponents, rightly making women think twice before ending a pregnancy and ensuring clinic safety or, in the view of opponents, imposing heartless obstacles and guilt on women who are seeking a legal procedure.

“In Ohio, the last few years have been fantastic if you support the pro-life movement,” said Mike Gonidakis, the president of Ohio Right to Life. His group has even lobbied against a more sweeping ban on early-term abortions, incurring the wrath of more restless abortion foes. But he says, “We’ve been able to craft pro-life laws that can withstand court scrutiny.”

On Wednesday, the American Civil Liberties Union filed a challenge in state court to the heartbeat mandate and other new restrictions, asserting that they were adopted in violation of the Ohio Constitution’s “single subject” rule because they were part of an unrelated budget bill.

More broadly, abortion-rights advocates call the incremental strategy, which has been refined by several national groups and pursued in a number of states, an insidious way to limit access to abortion and shame women who in many cases already have to walk past shouting protesters to enter clinics.

“If you can’t outlaw abortion outright, just make it harder and harder to get,” said Chrisse France, the executive director of Preterm, a large nonprofit abortion clinic on the East Side of Cleveland that performs about 4,900 abortions a year, mainly for low-income women. “They say they’re doing this to protect women’s health, but some of the laws are actually harmful, and some are just cruel.”

Conversations with patients at Preterm revealed diverse reactions to the mandated waiting period and counseling, but no sign that any women were changing course.

Madelyn Puterbaugh, 23, said that her birth control had failed and that it was “not the right time” for her to bear a child. She said she had turned down the chance to view the fetal heartbeat. “I didn’t look,” she said. “I thought I’d be too sad.”

She went ahead with the abortion, but said she had not minded the required 24-hour wait between the counseling and the procedure. “They gave me a lot to think about,” she said, “but it’s my choice.”

Ohio has long required abortion clinics to have a formal transfer agreement with a nearby hospital for emergency care, something physicians say is medically unnecessary because hospitals are required to treat emergency patients. Now, a new measure bars public hospitals from signing such agreements — a shift that could force two or three of the state’s remaining 11 clinics to close because they cannot find willing partners. 

Other measures wrapped into the state budget bill this year, and signed by Governor Kasich, include a requirement that women seeking an abortion be told the probable odds that their pregnancy would go to full term if they changed their minds; a diversion of federal welfare money to so-called crisis pregnancy centers; new financing for rape-crisis centers on the condition that they provide no abortion referrals; and a tightening of parental consent requirements for minors.  

To avoid passing money to Planned Parenthood, the state also ended competitive bidding for federal family planning grants, giving priority to public agencies. As a result, some nonprofit women’s health centers that have no connection to Planned Parenthood or abortion also face drastic cuts.

The newest rules follow a flurry of changes in 2011, when, among other things, the state banned abortions, except to save the mother’s life, once the fetus is viable. Fearing potential criminal charges, clinic doctors around the state have stopped performing abortions beyond the 22nd week of pregnancy, even in cases involving severe birth defects or serious medical conditions.

Since a federal court allowed it here in 2011 after years of litigation, Ohio has been the only state to require what doctors call an outdated, less safe and less effective regimen for medication abortions.

The law mandates adherence to the original Food and Drug Administration approval, which called for three times the drug dosage now standard and authorized the method only through seven weeks of pregnancy. As a result, while later studies showed them to be safe through nine weeks, medication abortions can no longer be offered in the eighth and ninth weeks of pregnancy.

Similar restrictions on medication abortion were passed this year in Texas and are under court challenge; they have been voided as unconstitutional barriers in North Dakota and in Oklahoma, which is seeking a review by the Supreme Court.

At Preterm, the annual number of nonsurgical abortions plummeted to 90 in 2012 from more than 600 in earlier years. But “there’s no evidence that this cut down on abortion,” said Ms. France, the clinic director. “Women just said, ‘Never mind, I’ll get a surgical abortion.’ ”

In Ohio, as elsewhere, abortions have declined over all in recent years, although there was a slight uptick to 25,473 reported procedures in 2012, with black women accounting for a growing share. Whether the new laws have significantly reduced the numbers or simply made abortions more fraught is disputed.

Mr. Gonidakis, of Ohio Right to Life, said he felt sure the measures had persuaded many women to change their minds and predicted that even more, when confronted with the fetal heartbeat and other information, would do so in the future.

“There are so many families waiting to adopt,” he added, offering an alternative that crisis pregnancy centers and others are increasingly promoting.

In the coming months, Mr. Gonidakis said, his organization plans to focus its lobbying on the easing of state adoption rules and an increase in tax breaks for adoptive parents.

But other anti-abortion groups and conservative legislators are pressing ahead with a proposal to ban abortion altogether once a fetal heartbeat is detectable, as early as six weeks into pregnancy

Resource:http://www.nytimes.com/2013/10/10/us/with-new-abortion-restrictions-ohio-walks-fine-line.html?pagewanted=1&_r=0&ref=health

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 Rights Advocates Suing U.N. Over the Spread of Cholera in Haiti

Advocates for Haitian victims of the deadly cholera epidemic that first afflicted their country three years ago said they were taking the extraordinary step on Wednesday of suing the United Nations, asserting that the organization’s peacekeeping force in Haiti was responsible for introducing the disease through sewage contamination from its barracks

The lawsuit, which the advocates said they would file in Federal District Court in Manhattan on Wednesday morning, will be the strongest action they have taken in pressing the United Nations to acknowledge at least some culpability for the outbreak of cholera, a highly contagious scourge spread through human feces that had been largely absent from Haiti for 100 years.

Cholera has killed more than 8,300 Haitians and sickened more than 650,000 in the earthquake-ravaged country, the poorest in the Western Hemisphere, since it first reappeared in October 2010. While the worst of the epidemic has eased, it still kills about 1,000 Haitians a year.

United Nations officials have said they are committed to eradicating the cholera, but they have not conceded that the organization was inadvertently responsible for causing it. They also have asserted diplomatic immunity from any negligence claims, a position that has deeply angered many Haitians who consider it a betrayal of United Nations principles. 

Haitian leaders, while dependent on the United Nations to help maintain stability and provide other important services, have also expressed unhappiness over the cholera issue. In an address last Thursday at the annual United Nations General Assembly opening session, Haiti’s prime minister, Laurent Lamothe, spoke of what he called the “moral responsibility” of the United Nations in the outbreak, and said the efforts to combat it had been far from sufficient.

Forensic studies, including one ordered by the United Nations, have identified the culprit bacteria as an Asian strain imported to Haiti by Nepalese members of the United Nations peacekeeping force, known as the United Nations Stabilization Mission in Haiti, which was first authorized in 2004 and maintains about 8,700 soldiers and police officers there, drawn from more than three dozen member states. The forensic studies have also linked the spread of the cholera to a flawed sanitation system at the Nepalese peacekeeper base, which contaminated a tributary that feeds Haiti’s largest river, used by Haitians for drinking and bathing.

Beatrice Lindstrom, a spokeswoman for the Institute for Justice and Democracy in Haiti, the Boston-based rights group that prepared the lawsuit, said in a telephone interview that the listed plaintiffs were five cholera victims, who were seeking redress for themselves and all afflicted Haitians and their families. Ms. Lindstrom said the institute had decided to file the suit in New York because it is the site of United Nations headquarters and has an enormous Haitian expatriate population.

“We are asking for the judge to find the United Nations liable,” she said. “It has violated its legal obligations through reckless actions that brought cholera to Haiti.” The lawsuit did not specify the amount of compensation sought, which Ms. Lindstrom said would be “determined at trial.”

It was far from clear that the lawsuit would be accepted by the court, which affords broad latitude to diplomatic protections for the United Nations against such litigation. These protections are partly rooted in the formal legal conventions created with the inception of the United Nations after World War II. “The majority view is that the U.N. and U.N. entities are immune from domestic lawsuits,” said Jordan J. Paust, a professor of international law at the Law Center of the University of Houston.

Eight months ago, Ban Ki-moon, the secretary general of the United Nations, informed Haitian leaders that it would not accept claims for compensation made by victims of the outbreak, citing a provision of the Convention on the Privileges and Immunities of the United Nations.

Ms. Lindstrom said the United Nations had also rebuffed her group’s attempts to address the issue. “They’ve refused to sit down for a conversation with the victims, or with us,” she said.

Navi Pillay, the top human rights official at the United Nations, suggested on Tuesday from her headquarters in Geneva that Haiti’s cholera victims were entitled to some compensation, although she did not specify who should provide it.

Farhan Haq, a spokesman for Mr. Ban, declined to comment on the lawsuit but asserted that the United Nations remained dedicated to helping Haiti overcome the epidemic.

“The United Nations is working on the ground with the government and people of Haiti both to provide immediate and practical assistance to those affected,” Mr. Haq said in a statement, “and to put in place better infrastructure and services for all.” 

Resource:http://www.nytimes.com/2013/10/09/world/americas/rights-advocates-suing-un-over-the-spread-of-cholera-in-haiti.html?ref=health&_r=0

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