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Paris Journal: A French Dining Staple Is Losing Its Place at the Table

Written By Unknown on Rabu, 31 Juli 2013 | 13.57

Agnes Dherbeys for The New York Times

At Philippe Levin's bakery in Paris, traditional, slow-baked breads are still much sought after and business has never been better, he says.

PARIS — The French, it seems, are falling out of love. Not with free health care, or short workweeks, or long vacations in August.

But with bread.

The average Frenchman these days eats only half a baguette a day compared with almost a whole baguette in 1970 and more than three in 1900. Women, still the main shoppers in most families, eat about a third less than men, and young people almost 30 percent less than a decade ago.

The decline is so worrisome that Observatoire du Pain, the bakers' and millers' lobby, started a nationwide campaign in June that champions bread as promoting good health, good conversation and French civilization.

"Coucou, tu as pris le pain?" ("Hi there, have you picked up the bread?") is the campaign's slogan. Modeled on the American advertising campaign "Got Milk?" the bread slogan was plastered on billboards and inscribed on bread bags in 130 cities around the country.

"Eating habits are changing," said Bernard Valluis, a co-president of the lobby. "People are too busy or work too late to go to the bakery. Teenagers are skipping breakfast. Now when you see the word 'coucou,' we want it to be a reflex for consumers to say to themselves, 'Ah, I have to buy bread today.' "

The campaign's Web site, www.tuasprislepain.fr, explains that "France is a 'civilization of bread' and this food is part of the traditional meal 'à la française.' "

Bread is described as healthy and useful in avoiding weight gain. "It is rich in vegetal protein and fiber and low in fat; glucides are a source of energy," the Web site says, using the French word for carbohydrate.

If people on diets want "to avoid giving in to something with fat and sugar, bread is there," it says. "Its satiating effect allows you to wait for the next meal."

Then there is the congeniality effect: "Remember that buying fresh bread on the way home is a simple way of showing loved ones that you have thought about them and of giving them pleasure during the day."

At a bit more than a dollar a loaf, the basic baguette is one of the country's cheapest food staples. Ten billion baguettes are sold every year in France.

A national bread festival is held every May around the feast of Saint Honoré (the patron saint of bakers) so that the French can sample different breads, learn how bread is made and even learn how to become a baker.

And Paris holds an annual contest to select the city's best artisanal baguette maker, with the winner's breads then gracing the tables of President François Hollande at the Élysée Palace for a year. Last month, after an afternoon of tasting 152 baguettes, the jury chose Ridha Khadher, who left Tunisia as a teenager 24 years ago to become a baker in France.

"It's a great honor for a Tunisian to be elected best baguette maker," Mr. Khadher said. "I wonder what the president is going to think about our baguettes."

Bread is ceding its place on the table to rivals like breakfast cereals, pasta and rice. France may still enjoy the highest density of independent bakeries in the world (32,000), but in 1950 there were 54,000.

According to Steven L. Kaplan, an American historian whom even the French consider the world's foremost authority on French bread, breadmaking has followed two trends in the last century: a steady decline in the quality of most products, and the emergence of a new breed of artisanal bakers devoted to excellence and tradition.

The decline in quality started in 1920 with the transition from slow breadmaking with a sourdough base to a quick process using yeast. Mechanization in the 1960s contributed to the making of bread that lacked taste and aroma.

The trend began to reverse itself in the 1980s. French millers provided bakers with a better flour and more marketing support. The renowned Parisian baker Lionel Poilâne blended large-scale production with artisanal practices like lengthy sourdough fermentation and wood oven baking.

Then in 1993, the government came to the rescue with a decree that created a special designation: "the bread of French tradition." That bread has to be made exclusively with flour, salt, water and leavening — no additives.

The "tradition," as it is called, is more expensive than the ordinary baguette, which uses additives, a fast-rising process and mechanization, and accounts for about 75 percent of the country's bread sales.

"The methods for making the two breads are not at all the same," said Philippe Levin, a baker in Paris's Ninth Arrondissement on the Right Bank with 25 years in the business. "The secret to making a good tradition is time, time, time. Fermentation is very, very slow. The aromas, the sugar have to emerge. It takes a good three and a half, four hours from start to finish."

To show the difference, he sliced a tradition and then a classic baguette in half and lengthwise as if to make a sandwich.

"Look at all the uneven cavities, the beautiful golden brown crust," he said of the tradition. "Smell the aroma, sweet and spicy. Every one is made by hand. It's magnificent!"

As for the baguette, "It's different, whiter, done by machine."

Mr. Levin sells more traditions than baguettes, even though the baguettes cost 20 cents less. On Sunday mornings his traditions are so sought after that he sets up a special table for customers, who often have to line up down the block.

Both Mr. Levin and Mr. Kaplan, the historian, say the bread lobby's campaign is more cuckoo than coucou.

"My quality has never been better," Mr. Levin said. "My business, too."

Mr. Kaplan was more critical. "This campaign looks like the inside of a white baguette: insipid," he said. "It's asking people to buy bread as part of their routine, like washing your hands or brushing your teeth. We need to talk about bread as an object of pleasure. We need to celebrate breads that make your taste buds dance."


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Antibiotics Maker in Deals for 2 Rivals

Cubist said it would pay Optimer shareholders $10.75 a share in cash upfront, and an additional $5 a share contingent on Optimer's meeting certain sales milestones.

The total value of $15.75 a share is a premium of about 19 percent to Optimer's closing price of $13.29 on Tuesday, but it represents a discount minus the contingent payment.

For Trius, Cubist said it would pay $13.50 a share in cash and an extra $2 a share if Trius meets certain sales targets. The collective $15.50-a-share offer is about 32 percent more than Trius's Tuesday closing price of $11.71.

Cubist, known for its Cubicin antibiotic, would gain a late-stage Trius drug that has shown promise in treating skin infections. From Optimer, Cubist will acquire the antibacterial Dificid, which brought in sales of about $19 million in the quarter that ended June.

Brian Skorney, an analyst at Robert W. Baird, said that while he did not think Cubist would get a lot of value out of the Optimer deal, he did not think that "it's going to wind up looking like a bad deal."

He added that he saw risk in some overlap in Trius and Cubist products.

Cubist shares rose about 6 percent to $60.25 in after-hours trading, after closing at $57. Trius shares were trading up at $13.69, and Optimer was down at $12.24 after hours.


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United Nations May Fall Short in Food Aid for Syria

WASHINGTON — The United Nations' food agency said Tuesday that it might not be able to meet its goal of aiding three million Syrians in July.

The agency, the World Food Program, had reached only 2.4 million people as fighting intensified in areas near Damascus and Homs, Elisabeth Byrs, the agency's senior public information officer, said Tuesday in an interview.

"Dispatches of food are slower because of the situation right now," Ms. Byrs said.

Steve Taravella, a senior spokesman for the food agency in Washington, said that it had 700 trucks in the country, but that convoys had been unable to reach many distribution points in the past several weeks.

Eight trucks carrying more than 300 metric tons of flour were attacked in June — it was unclear by whom — in Deir al-Zour, in northeast Syria, and only four were able to distribute food. The flour was intended to go to 13,600 families, Mr. Taravella said, but the agency could distribute aid to only about 6,700 of them. On May 29, another armed group in the village of Tal Menes seized a truck carrying flour that was headed to Aleppo.

In June, the World Food Program provided about 2.5 million people with food inside Syria, aiding the greatest number of people in Aleppo. The group operates seven food warehouses and dozens of distribution points in Syria.

A typical food basket from the agency contains rice, bulgur, wheat, sugar, pasta, vegetable oil and lentils, according to the group's Web site. The World Food Program also provides families with a monthly ration of 11 pounds of bread per person.

"We won't know for a few weeks whether we will reach our goal," Mr. Taravella said. "But we announced the findings because we want the humanitarian community to understand the scope of the need."

Ms. Byrs said she was particularly worried about the people in Homs, where fighting has increased in the past several days. As of Monday, the agency had reached about 300,000 people there this month, but Ms. Byrs said she believed that more than 2,500 people were trapped in the Old City without access to any aid.

"The monthly distribution to Homs is still ongoing; 92 percent of the allocation has been dispatched, but the besieged areas of the Old City are out of reach for us," she said. "We cannot reach them because of the military operation."

International aid groups have had difficulty delivering supplies since the Syrian war began more than two years ago. At the start of the fighting, the Syrian Arab Red Crescent was the only organization delivering aid and providing medical care to civilians. President Bashar al-Assad blocked all other groups from establishing operations.

Since then, organizations like the World Food Program and the United Nations Refugee Agency have found ways to deliver aid in rebel-held regions, but they still have difficulty reaching areas controlled by Mr. Assad's government. And when aid does arrive there, it does not always go to those most in need.

"There are thousands of examples of this, where civilians are in need of care but have no access to it because the regime continues to take advantage of directing it only to supporters," said Alexander Page, a Syrian activist living abroad.

Médecins Sans Frontières, also known as Doctors Without Borders, runs five hospitals in northern Syria in areas controlled by the rebels but has not received official authorization to work in the country. It said last month that a measles epidemic was sweeping through northern Syria and that its medical teams had vaccinated more than 75,000 children in Aleppo, Raqqah and Idlib Provinces. But the fighting has hampered the vaccination campaign, the group said in a statement. People have avoided standing in line for the vaccinations for fear they might attract airstrikes or rocket attacks, it said.

Ms. Byrs said it costs the World Food Program $29.3 million to $30 million each week to finance aid operations. The organization is seeking $763 million in contributions through the end of the year to help up to seven million Syrians, including four million people in Syria and almost three million refugees in neighboring countries.


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Well: How Exercise Changes Fat and Muscle Cells

Phys Ed

Gretchen Reynolds on the science of fitness.

Exercise promotes health, reducing most people's risks of developing diabetes and growing obese. But just how, at a cellular level, exercise performs this beneficial magic — what physiological steps are involved and in what order — remains mysterious to a surprising degree.

Several striking new studies, however, provide some clarity by showing that exercise seems able to drastically alter how genes operate.

Genes are, of course, not static. They turn on or off, depending on what biochemical signals they receive from elsewhere in the body. When they are turned on, genes express various proteins that, in turn, prompt a range of physiological actions in the body.

One powerful means of affecting gene activity involves a process called methylation, in which methyl groups, a cluster of carbon and hydrogen atoms, attach to the outside of a gene and make it easier or harder for that gene to receive and respond to messages from the body. In this way, the behavior of the gene is changed, but not the fundamental structure of the gene itself. Remarkably, these methylation patterns can be passed on to offspring – a phenomenon known as epigenetics.

What is particularly fascinating about the methylation process is that it seems to be driven largely by how you live your life. Many recent studies have found that diet, for instance, notably affects the methylation of genes, and scientists working in this area suspect that differing genetic methylation patterns resulting from differing diets may partly determine whether someone develops diabetes and other metabolic diseases.

But the role of physical activity in gene methylation has been poorly understood, even though exercise, like diet, greatly changes the body. So several groups of scientists recently set out to determine what working out does to the exterior of our genes.

The answer, their recently published results show, is plenty.

Of the new studies, perhaps the most tantalizing, conducted principally by researchers affiliated with the Lund University Diabetes Centre in Sweden and published last month in PLoS One, began by recruiting several dozen sedentary but generally healthy adult Swedish men and sucking out some of their fat cells. Using recently developed molecular techniques, the researchers mapped the existing methylation patterns on the DNA within those cells. They also measured the men's body composition, aerobic capacity, waist circumference, blood pressure, cholesterol levels and similar markers of health and fitness.

Then they asked the men to start working out. Under the guidance of a trainer, the volunteers began attending hourlong spinning or aerobics classes approximately twice a week for six months. By the end of that time, the men had shed fat and inches around their waists, increased their endurance and improved their blood pressure and cholesterol profiles.

Less obviously, but perhaps even more consequentially, they also had altered the methylation pattern of many of the genes in their fat cells. In fact, more than 17,900 individual locations on 7,663 separate genes in the fat cells now displayed changed methylation patterns. In most cases, the genes had become more methylated, but some had fewer methyl groups attached. Both situations affect how those genes express proteins.

The genes showing the greatest change in methylation also tended to be those that had been previously identified as playing some role in fat storage and the risk for developing diabetes or obesity.

"Our data suggest that exercise may affect the risk for Type 2 diabetes and obesity by changing DNA methylation of those genes," says Charlotte Ling, an associate professor at Lund University and senior author of the study.

Meanwhile, other studies have found that exercise has an equally profound effect on DNA methylation within human muscle cells, even after a single workout.

To reach that conclusion, scientists from the Karolinska Institute in Stockholm and other institutions took muscle biopsies from a group of sedentary men and women and mapped their muscle cell's methylation patterns. They then had the volunteers ride stationary bicycles until they had burned about 400 calories. Some rode strenuously, others more easily.

Afterward, a second muscle biopsy showed that DNA methylation patterns in the muscle cells were already changing after that lone workout, with some genes gaining methyl groups and some losing them. Several of the genes most altered, as in the fat cell study, are known to produce proteins that affect the body's metabolism, including the risk for diabetes and obesity.

Interestingly, the muscle cell methylation changes were far more pronounced among the volunteers who had ridden vigorously than in those who had pedaled more gently, even though their total energy output was the same.

The overarching implication of the study's findings, says Juleen Zierath, a professor of integrative physiology at the Karolinska Institute and senior author of the study, is that DNA methylation changes are probably "one of the earliest adaptations to exercise" and drive the bodily changes that follow.

Of course, the intricacies of that bogglingly complex process have yet to be fully teased out. Scientists do not know, for instance, whether exercise-induced methylation changes linger if someone becomes sedentary, or if resistance training has similar effects on the behavior of genes. Nor is it known whether these changes might be passed on from one generation to the next. But already it is clear, Dr. Ling says, that these new findings "are additional proof of the robust effect exercise can have on the human body, even at the level of our DNA."


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F.D.A. Strengthens Warnings on Lariam, an Anti-Malaria Drug

Written By Unknown on Selasa, 30 Juli 2013 | 13.58

The Food and Drug Administration announced on Monday that a commonly used anti-malaria drug must carry the so-called black box warning on its label because of the danger that the drug could cause serious neurological and psychiatric side effects, some of which can become permanent.

The drug, mefloquine hydrochloride — better known by its brand name, Lariam — has long been known to cause side effects that include ringing in the ears, depression and hallucinations. The announcement on Monday clarified that some of the symptoms, like dizziness and loss of balance, could become permanent. And some of the psychiatric symptoms, the agency said, could persist for months or even years after a patient ceases taking the drug. A black box warning is reserved for drugs whose side effects are considered the most severe. The agency warned patients and caregivers to be alert for these side effects and to stop use of the drug if a patient develops neurological or psychiatric symptoms.

Mefloquine was developed by the United States Army, and it entered the commercial market in 1989. Roche, the brand-name manufacturer, no longer sells Lariam in the United States, but generic versions are available.

For years, the drug was favored by travelers not only because of its effectiveness but also because it could be taken once a week, rather than once a day, said Dr. David O. Freedman, director of the travelers' clinic at the University of Alabama at Birmingham. As warnings on its label steadily increased in severity over the last decade, Dr. Freedman said that his clinic had shifted to other drugs. Ten to 20 percent of his patients traveling to malaria-prone areas now receive a mefloquine prescription, he said.

Mefloquine is the third-most-prescribed anti-malaria drug in the United States, with about 119,000 prescriptions being written for the drug from January of this year through June, according to the research firm IMS Health. Nearly 2.4 million prescriptions were written for the most common anti-malaria drug, hydroxychloroquine, during the same period.

The drug has taken on a dark mythology among many travelers, who have long traded stories about the vivid dreams or strange hallucinations they experienced while taking Lariam. It has also been implicated in cases of violence among military personnel, although others have noted that serious side effects are rare.

The drug's side effects may play a role in the sentencing trial next month of Staff Sgt. Robert Bales, who pleaded guilty in June to killing 16 Afghan civilians in 2012.

John Henry Browne, Sergeant Bales's lawyer, said that his client had been given mefloquine on previous deployments, but that he had no confirmation that the soldier was given it on his most recent trip to Afghanistan. Fellow soldiers have testified that Sergeant Bales had been drinking that night. And, in June, Sergeant Bales admitted that he illegally used steroids, which may also have affected his behavior.

"The new F.D.A. report raises new questions of long-term and permanent side effects," Mr. Browne said in an e-mail message Monday. "This is a fast-developing issue."


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Despite Two New Studies on Motives for Monogamy, the Debate Continues

The golden lion tamarin, a one-pound primate that lives in Brazil, is a stunningly monogamous creature. A male will typically pair with a female and they will stay close for the rest of their lives, mating only with each other and then working together to care for their young.

To biologists, this deeply monogamous way of life — found in 9 percent of mammal species — is puzzling. A seemingly better evolutionary strategy for male mammals would be to spend their time looking for other females with which to mate.

"Monogamy is a problem," said Dieter Lukas of the University of Cambridge in a telephone news conference on Monday. "Why should the male keep to one female?"

The evolution of monogamy has inspired many different ideas. "These hypotheses have been suggested for the past 40 years, and there's been no resolution of the debate," said Kit Opie of the University College London in an interview.

On Monday, Dr. Opie and Dr. Lukas each published a large-scale study of monogamy that they hoped would resolve the debate. But they ended up coming to opposing conclusions, which means the debate over monogamy continues.

Dr. Lukas, co-author of a paper in the journal Science with Tim Clutton-Brock of Cambridge, looked at 2,545 species of mammals, tracing their mating evolution from their common ancestor some 170 million years ago.

The scientists found that mammals shifted from solitary living to monogamy 61 times over their evolution. They then searched for any factors that these mammals had in common. They concluded that monogamy evolves when females become hostile with one another and live in ranges that do not overlap. When females live this way, they set up so much distance between one another that a single male cannot prevent other males from mating with them. Staying close to one female became a better strategy. Once males began doing so, they sometimes evolved to provide care to their offspring as well.

For his study, Dr. Opie and his colleagues examined 230 primate species, because monogamy is especially high in that group. They came down in favor of a different hypothesis: the threat of infanticide drove the evolution of monogamy.

"What we found was a very neat pathway for primates to evolve monogamy," Dr. Opie said.

In many species of mammals, males will sometimes kill the young offspring of other males. Scientists have proposed that they do so because nursing females do not ovulate. By killing a female's offspring, a male then gains the chance to have offspring of his own with her.

In The Proceedings of the National Academy of Sciences, Dr. Opie and his colleagues argue that in many primate species, males responded to the threat of infanticide by sticking with females after they gave birth.

Dr. Opie offered possible explanations for why his team and Dr. Lukas's came to different conclusions. It is possible that the forces driving the evolution of monogamy in primates are different than in other mammals. Dr. Opie also noted that he and his colleagues had used a more powerful type of statistics, known as Bayesian probability, to reconstruct the evolution of monogamy.

"They don't use the latest methods, which is a bit of a pity," Dr. Opie said.

But Jacobus Boomsma of the University of Copenhagen, who was not involved in either study, found Dr. Lukas's paper to be superior. "It makes perfect sense to me," he said.

Sergey Gavrilets, an evolutionary biologist at the University of Tennessee, also favored Dr. Lukas's conclusions. But he also noted that neither study tested all of scientists' proposed explanations, like monogamy's benefits in lowering the risk of sexually transmitted diseases or the possibility that females chose to mate with males who repeatedly brought them food.

"It is still unknown how these other scenarios fare," Dr. Gavrilets said.


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Program Compelling Outpatient Treatment for Mental Illness Is Working, Study Says

For some people with severe mental illness, life is a cycle of hospitalization, skipped medication, decline and then rehospitalization. They may deny they have psychiatric disorders, refuse treatment and cascade into out-of-control behavior that can be threatening to themselves or others.

Now, a study has found that a controversial program that orders these patients to receive treatment when they are not hospitalized has had positive results. Patients were much less likely to end up back in psychiatric hospitals and were arrested less often. Use of outpatient treatment significantly increased, as did refills of medication. Costs to the mental health system and Medicaid of caring for these patients dropped by half or more.

The study evaluated the program run by New York State, known as Kendra's Law because it was enacted after Kendra Webdale was pushed to her death on the New York City subway tracks by a man with untreated schizophrenia in 1999. Forty-four other states have some form of Kendra's Law, but New York's is by far the most developed because the state has invested significant resources into paying for it, experts say.

From the start, Kendra's Law has had staunch defenders and detractors. But the new analysis, led by researchers at Duke University and published in The American Journal of Psychiatry, joins a series of studies that suggest the program can be helpful for patients who, while they constitute only a small number of the people with mental illness, are some of the most difficult and expensive to care for.

"Is Kendra's Law a good thing?" said Dr. Paul S. Appelbaum, director of the Division of Law, Ethics and Psychiatry at Columbia University's medical school, who has not been involved in any of the research. While "none of these studies are perfect," he said, "these programs are likely to be helpful for a group of patients who are often called revolving-door patients."

In the shadow of the massacres in Newtown, Conn.; Aurora, Colo.; and Tucson, programs like these are drawing renewed attention — even though people who commit such crimes are not always those who would qualify for measures like Kendra's Law. This year, the sweeping gun control law New York passed augmented some aspects of Kendra's Law and extended it until 2017.

The program, which costs New York $32 million for the 2,000 to 2,500 people under court order each year, provides intensive monitoring by caseworkers, who are supposed to ensure that patients attend therapy and adhere to medication. Under the law, New York also spends $125 million a year for enhanced outpatient mental health services for others.

Among other states, North Carolina's program is also well-developed, while California has hardly financed its program. Proponents of the program say they hope New York's experience will persuade other states to invest.

Some opponents say programs like this — called outpatient commitment or assisted outpatient treatment — infringe on civil liberties of people who have not been involuntarily committed to hospitals. Others worry that intensively monitoring patients in the community could increase costs or shift services away from other people with mental illness — something the authors say can happen in states that, unlike New York, fail to put money into the program.

Robert Bernstein, president of the Bazelon Center for Mental Health Law in Washington, said good mental health care should not have to lean "on the courts to intervene rather than getting involved earlier and better" to persuade patients to accept non-coerced treatment.

He said New York's success "may not be the court order," but the "whole array of services that New York attaches" to the program. "If outpatient commitment was so beneficial either clinically or financially, states would have flocked to use it," he said.

The Duke study examined costs for 634 people who received court orders between January 2004 and December 2005. It compared costs in the year before the court orders, the year after and two years after. Jeffrey Swanson, a psychiatry professor at Duke and lead author of the study, said the results suggested that "if you pour some money into assisted outpatient treatment, if you target it correctly, there are some significant savings."

A co-author, Dr. Marvin Swartz, head of Duke's social and community psychiatry division, said a study in 2010 by the team found that patients "were less likely to return to the hospital, if they went to the hospital they had shorter lengths of stay, they were more likely to be adherent to medication, and generally they functioned better in the community."

Michael and Barbara Biasotti would agree. Ms. Biasotti's daughter became ill at 23. Now 41, she has been hospitalized more than 20 times, Ms. Biasotti said.


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Well: Scientists Seek to Rein In Diagnoses of Cancer

A group of experts advising the nation's premier cancer research institution has recommended changing the definition of cancer and eliminating the word from some common diagnoses as part of sweeping changes in the nation's approach to cancer detection and treatment.

The recommendations, from a working group of the National Cancer Institute, were published on Monday in The Journal of the American Medical Association. They say, for instance, that some premalignant conditions, like one that affects the breast called ductal carcinoma in situ, which many doctors agree is not cancer, should be renamed to exclude the word carcinoma so that patients are less frightened and less likely to seek what may be unneeded and potentially harmful treatments that can include the surgical removal of the breast.

The group, which includes some of the top scientists in cancer research, also suggested that many lesions detected during breast, prostate, thyroid, lung and other cancer screenings should not be called cancer at all but should instead be reclassified as IDLE conditions, which stands for "indolent lesions of epithelial origin."

While it is clear that some or all of the changes may not happen for years, if it all, and that some cancer experts will profoundly disagree with the group's views, the report from such a prominent group of scientists who have the backing of the National Cancer Institute brings the discussion to a higher level and will most likely change the national conversation about cancer, its definition, its treatment and future research.

"We need a 21st-century definition of cancer instead of a 19th-century definition of cancer, which is what we've been using," said Dr. Otis W. Brawley, the chief medical officer for the American Cancer Society, who was not directly involved in the report.

The impetus behind the call for change is a growing concern among doctors, scientists and patient advocates that hundreds of thousands of men and women are undergoing needless and sometimes disfiguring and harmful treatments for premalignant and cancerous lesions that are so slow growing they are unlikely to ever cause harm.

The advent of highly sensitive screening technology in recent years has increased the likelihood of finding these so-called incidentalomas — the name given to incidental findings detected during medical scans that most likely would never cause a problem. However, once doctors and patients are aware a lesion exists, they typically feel compelled to biopsy, treat and remove it, often at great physical and psychological pain and risk to the patient. The issue is often referred to as overdiagnosis, and the resulting unnecessary procedures to which patients are subjected are called overtreatment.

Cancer researchers warned about the risk of overdiagnosis and overtreatment as a result of new recommendations from a government panel that heavy smokers be given an annual CT scan. While the policy change, announced on Monday but not yet made final, has the potential to save 20,000 lives a year, some doctors warned about the cumulative radiation risk of repeat scans as well as worries that broader use of the scans will lead to more risky and invasive medical procedures.

Officials at the National Cancer Institute say overdiagnosis is a major public health concern and a priority of the agency. "We're still having trouble convincing people that the things that get found as a consequence of mammography and P.S.A. testing and other screening devices are not always malignancies in the classical sense that will kill you," said Dr. Harold E. Varmus, the Nobel Prize-winning director of the National Cancer Institute. "Just as the general public is catching up to this idea, there are scientists who are catching up, too."

One way to address the issue is to change the language used to describe lesions found through screening, said Dr. Laura J. Esserman, the lead author of the report in The Journal of the American Medical Association and the director of the Carol Franc Buck Breast Care Center at the University of California, San Francisco. In the report, Dr. Esserman and her colleagues said they would like to see a multidisciplinary panel convened to address the issue, led by pathologists, with input from surgeons, oncologists and radiologists, among others.

"Ductal carcinoma in situ is not cancer, so why are we calling it cancer?" said Dr. Esserman, who is a professor of surgery and radiology at the University of California, San Francisco.

Such proposals will not be universally embraced. Dr. Larry Norton, the medical director of the Evelyn H. Lauder Breast Center at Memorial Sloan-Kettering Cancer Center, said the larger problem is that doctors cannot tell patients with certainty which cancers will not progress and which cancers will kill them, and changing terminology does not solve that problem.

"Which cases of D.C.I.S. will turn into an aggressive cancer and which ones won't?" he said, referring to ductal carcinoma in situ. "I wish we knew that. We don't have very accurate ways of looking at tissue and looking at tumors under the microscope and knowing with great certainty that it is a slow-growing cancer."

Dr. Norton, who was not part of the report, agreed that doctors do need to focus on better communication with patients about precancerous and cancerous conditions. He said he often tells patients that even though ductal carcinoma in situ may look like cancer, it will not necessarily act like cancer — just as someone who is "dressed like a criminal" is not actually a criminal until that person breaks the law.

"The terminology is just a descriptive term, and there's no question that has to be explained," Dr. Norton said. "But you can't go back and change hundreds of years of literature by suddenly changing terminology."

But proponents of downgrading cancerous conditions with a simple name change say there is precedent for doing so. The report's authors note that in 1998, the World Health Organization changed the name of an early-stage urinary tract tumor, removing the word "carcinoma" and calling it "papillary urothelial neoplasia of low malignant potential." When a common Pap smear finding called "cervical intraepithelial neoplasia" was reclassified as a low-grade lesion rather than a malignancy, women were more willing to submit to observation rather than demanding treatment, Dr. Esserman said.

"Changing the language we use to diagnose various lesions is essential to give patients confidence that they don't have to aggressively treat every finding in a scan," she said. "The problem for the public is you hear the word cancer, and you think you will die unless you get treated. We should reserve this term, 'cancer,' for those things that are highly likely to cause a problem."

The concern, however, is that since doctors do not yet have a clear way to tell the difference between benign or slow-growing tumors and aggressive diseases with many of these conditions, they treat everything as if it might become aggressive. As a result, doctors are finding and treating scores of seemingly precancerous lesions and early-stage cancers — like ductal carcinoma in situ, a condition called Barrett's esophagus, small thyroid tumors and early prostate cancer.

But even after years of aggressively treating those conditions, there has not been a commensurate reduction in invasive cancer, suggesting that overdiagnosis and overtreatment are occurring on a large scale.

The National Cancer Institute working group also called for a greater focus on research to identify both benign and slow-growing tumors and aggressive diseases, including the creation of patient registries to learn more about lesions that appear unlikely to become cancer.

Some of that research is already under way at the National Cancer Institute. Since becoming director of the institute three years ago, Dr. Varmus has set up a list of "provocative questions" aimed at encouraging scientists to focus on critical areas, including the issue of overdiagnosis and molecular tests to distinguish between slow-growing and aggressive tumors.

Another National Cancer Institute program, the Barrett's Esophagus Translational Research Network, or Betrnet, is focused on changes in the esophageal lining that for years have been viewed as a precursor to esophageal cancer. Although patients with Barrett's are regularly screened and sometimes treated by burning off the esophageal lining, data now increasingly suggest that most of the time, Barrett's is benign and probably does not need to be treated at all. Researchers from various academic centers are now working together and pooling tissue samples to spur research that will determine when Barrett's is most likely to become cancerous.

"Our investigators are not just looking for ways to detect cancer early, they are thinking about this question of when you find a cancer, what are the factors that might determine how aggressively it will behave," Dr. Varmus said. "This is a long way from the thinking 20 years ago, when you found a cancer cell and felt you had a tremendous risk of dying."


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News Analysis: The Hype Over Hospital Rankings

Written By Unknown on Senin, 29 Juli 2013 | 13.57

LAST week U.S. News and World Report released its annual list of "Best Hospitals." Web sites are being updated to celebrate victories. (Johns Hopkins ranks No. 1!) Magazines will be plump with advertising. (NewYork-Presbyterian is first in New York and tied for seventh nationally!) And, because I am a reporter covering health care, my in-box is accumulating e-mails from the "Honor Roll" of the Top 18 hospitals.

But what does this annual exercise mean for patients? And what does it say about American health care?

After all, Harvard and Princeton, which tied for No. 1 in the magazine's 2013 Top 10 national universities list, didn't take out ads to proclaim their triumph; they will fill their classrooms no matter. And as in the college ratings, there are no big surprises in the top hospital group: they are the big academic medical centers — the Mayo Clinic, Massachusetts General Hospital, the Cleveland Clinic. More to the point, even though you might well fly across the country for four years of schooling, you are far more likely to stay near your home for medical care.  No one's flying to Mayo in Minnesota to get inhalers for asthma, even though it ranks No. 1 for pulmonary medicine.

But American hospitals are a bit like restaurants, competing for your business (and donations). As such they go all out to promote their brand, even though hospitals and doctors are not permitted to advertise in many other countries.

For American hospitals large and small, it clearly pays to advertise, particularly in these tough economic times and with the Affordable Care Act poised to throw tens of millions of newly insured patients into the market. But for patients the rankings and, especially, the subsequent promotions generally have limited benefit, experts say.

"Nearly every hospital has a banner out front saying they're a 'top hospital' for something in some rating system," said Dr. Nicholas Osborne, a Robert Wood Johnson Clinical Scholar at the University of Michigan. "Those ratings have become more important for hospital marketing than for actually helping patients find the best care."

What's more, Dr. Osborne compared the outcomes of two ranking programs — one by U.S. News and World Report and the other by Healthgrades — and found a "large discordance" in their results. "The two biggest rating systems come up with completely different lists," he said. "What does that tell you?"

If such advertising often adds little in the way of useful information, it certainly adds to health care costs. Hospitals with more than 400 beds spent an average of $2.18 million on advertising in 2010, surveys have found.

"We're pushing $3 trillion in health expenditures, and one-third of that is waste," said Dr. Eric Topol, chief academic officer at Scripps Health in California. "Those TV commercials saying 'I got my cancer care at X hospital' are a shame, definitely wasteful."

To be fair, U.S. News cautions that its national ratings reflect how hospitals perform in treating "technically challenging" cases and that the list is merely a starting point after which "patients have to do their own research."

But those caveats are lost in the subsequent barrage of advertising. And the magazine encourages hospitals to post its seal of approval. In return, the U.S. News Web site is bursting with hospital advertising.

Some critics decry the glut of hospital self-promotion as not just wasteful and costly, but also potentially dangerous.

"There are general fraud laws, but there is no law specific to hospital advertising, and there should be," said Robert Steinbuch, a professor of law at the University of Arkansas at Little Rock, who studies the topic. "I can't tell you how many hospitals say, 'We have state-of-the-art CAT scanners' — there is no such thing! It's an old technology."

IN a country where numerous organizations — including Yelp — accredit, rate and rank hospital care, some accolades may indicate excellence and some don't mean that much at all, he added. And while teams of academics and scores of for-profit companies are developing "quality" metrics to guide health care reform and to help patients shop for their care, it turns out that rating a hospital accurately is extremely complicated. For one thing, hospitals that take on sicker patients might have more complications after surgery.

Yet even smaller hospitals tend to advertise their profit-making departments, like cardiology, even though they may not offer the full range of heart services.

"If they advertise cardiac care and don't have angioplasty, that's essentially fraud," Mr. Steinbuch said, adding that if a patient dies, "that could be considered criminally negligent homicide."

But health care advertising is probably here to stay. "Hospital advertising sets up an arms war, so that hospitals feel they can't survive without aggressive marketing," said Dr. Topol of Scripps Health.

And even skeptics concede that health care ratings, when properly developed and employed, may help hospitals improve their performance and provide patients with valuable information.

If you have a rare lung condition that has flummoxed local doctors, for example, you may want to fly to Mayo since U.S. News has ranked it No. 1 in pulmonary medicine. And if a dozen hospitals in your area offer hip replacements, a search of regional rankings on the magazine's Web site will yield some useful statistics. But take all those hospital advertisements with a grain of salt.

Indeed, with thousands of good hospitals across the nation, the best selling point for routine medical care may simply be convenience: some studies show that patients prefer nearby hospitals with worse results over ones with better outcomes farther away.

Elisabeth Rosenthal is a reporter for The New York Times who is writing a yearlong series about the cost of health care, "Paying Till It Hurts."

This article has been revised to reflect the following correction:

Correction: July 27, 2013

An earlier version of this article misstated the approximate amount spent on health expenditures mentioned by Dr. Eric Topol. He said the amount was pushing $3 trillion, not $3 billion.


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G.O.P. Senators See an Upside in a Problematic Issue: Abortion

But what is bringing all these marquee political names together is not the Iowa State Fair or a Tea Party rally on the National Mall. Rather, they are all talking discreetly about how to advance a bill in the Senate to ban abortion at 20 weeks after fertilization.

A similar ban passed the House last month, and Senate Democrats quickly pronounced it doomed to fail in their chamber. It is almost certain to be defeated there, and even if it were not, President Obama would veto it. But backers of the ban are eager to bring to the floor of the Senate the same impassioned debate over abortion that has been taking place in state legislatures around the country.

Plans under discussion among the staff members of a handful of Republican senators and anti-abortion groups would involve bringing the measure up for a vote, probably as part of debate over a spending measure, sometime after Congress returns from its August recess. Because of the Senate's porous rules for introducing amendments, people on both sides of the issue say they believe a vote is more than likely if the legislation comes together.

"I think there's significant support across the country for the idea that after 20 weeks, abortion should be significantly limited," said Mr. Rubio, who has taken a leading role in trying to generate support for the bill. "Irrespective of how people may feel about the issue," he added, "we're talking about five months into a pregnancy. People certainly feel there should be significant restrictions on that."

Republicans are hardly unanimous about the wisdom of entangling themselves in a national battle over abortion rights; many believe that the party should remain focused on addressing economic issues and fighting Mr. Obama's health care overhaul.

"I'm focused on energy, the economy and what's happening with the president's health care law," said Senator John Barrasso of Wyoming, a member of the Republican leadership. Asked whether he thought abortion was a distraction for his party, he stuck to a popular Republican refrain: "I'm completely focused on jobs, the economy, the health care law."

Democrats, meanwhile, are wary of the damage that a "no" vote on second-trimester abortion restrictions could inflict on some of their more vulnerable senators up for re-election in 2014, particularly in Arkansas, Louisiana and North Carolina, where legislatures have recently imposed strict limits. On Friday, the governor of North Carolina said he would sign into law new regulations on abortion clinics.

"Look, I've taken a lot of tough votes," said Senator Mary L. Landrieu, Democrat of Louisiana, who added that she doubted she could support a ban at 20 weeks. "That's what I'm here for, to take votes. And if we have to take it, we take it."

The success of new limits on when, how and where abortions can be done has invigorated the Republican base like few other issues this year. Because of such intensity, anti-abortion groups say they have found interest among the newer generation of Republican senators, especially those seeking to build up, or in some cases repair, their standing with conservative voters.

Some see even broader appeal. Though the issue of reproductive rights has been problematic for Republicans — who have been embarrassed by comments like those of Todd Akin, the Missouri Senate candidate who said that women's bodies blocked pregnancy in cases of rape — those supporting 20-week bans say the dynamics of this debate are less alienating to swing voters than fights over contraception.

And some conservatives see this as the only winning social issue they have left in their political arsenal. Unlike same-sex marriage, which has steadily gained support, recent polls have shown that the public believes that abortions later in pregnancy should be restricted. A Washington Post-ABC News poll last week found that 56 percent of Americans said they would prefer to impose limits on abortions after 20 weeks rather than the 24-week standard established by the Supreme Court in Roe v. Wade.

Anti-abortion activists said that after the recently approved House measure and success in states like Texas, which approved a 20-week ban this month, they saw an opportunity they could not pass up.

"We really thought it was a moment to be very ambitious," said Marjorie Dannenfelser, the president of the Susan B. Anthony List, one of the groups pushing for the Senate to take up the 20-week ban.

Abortion rights groups say the real goal of these laws, all of which challenge Supreme Court precedent, is to get another case before the court in the hopes that the justices will further restrict abortion rights. "These bills are not happenstance," said Donna Crane, policy director of Naral Pro-Choice America. "These bills are a calculated, cold strategy."

Mr. Cruz of Texas, for his part, is trying to build a larger following among Republicans beyond his home state. He visited Iowa last weekend to meet with evangelical pastors and other members of the state's conservative establishment. Joining him was Senator Rand Paul of Kentucky, who has also expressed interest in signing onto a 20-week bill, according to Ms. Dannenfelser and a spokeswoman for the senator.

Mr. Rubio of Florida, who has been discussing for months how to introduce this issue into the Senate, is also eager to raise his national profile. But he must first overcome some of the doubts conservatives have about him for his pivotal role in helping the Senate pass an immigration bill with a provision to eventually grant citizenship to immigrants here illegally.

Mr. Portman of Ohio, who was on Mitt Romney's short list to become the Republican vice-presidential nominee last year and who has told his colleagues that he would like to be deeply involved in the 20-week legislation, is trying to rebuild conservative support that he lost back home in March after he spoke out in favor of same-sex marriage. (One Republican who saw internal poll numbers after Mr. Portman's announcement said the senator's unfavorable ratings jumped by double digits and were especially high in the southern part of Ohio, where his core support is.)

Drafting a bill, however, will require conservatives to resolve a fundamental disagreement: how to find constitutional justification for a nationwide ban despite their reservations about giving the government broad regulatory powers.

This has been especially challenging for Senator Mike Lee of Utah, one of the Senate's leading anti-abortion voices. He strongly opposes a bill that uses as its legal rationale the commerce clause of the Constitution, which many conservatives consider a violation of their principles.

Some in the Republican leadership express similar doubts, including Senator John Cornyn of Texas, the No. 2 leader. He said he supported the 20-week ban that passed in his home state this month, but added: "I think that this can adequately be taken care of at the state level. And so there may not be a need for the federal government to get involved."

Then there is the issue of how new abortion regulations might be perceived among women. So far, none of the four Republican women in the Senate have stepped forward to get involved.

Senator Deb Fischer of Nebraska, who has a solidly anti-abortion voting record, said, "I'm focused on a lot of other issues now."

Senator Lisa Murkowski of Alaska said, "It's not something that is really on my priority list."

This article has been revised to reflect the following correction:

Correction: July 28, 2013

An earlier version of this article misidentified Todd Akin's home state. It is Missouri, not Indiana.


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Recipes for Health: Two Tomatillo Salsas

Andrew Scrivani for The New York Times

I've always had a weakness for green salsa made with tomatillos, so when I stumbled upon a stall at a small farmers' market selling beautiful firm, purple-tinged tomatillos last week, I bought them on impulse. I let the other produce at the market guide my decisions about the taco fillings I now knew I'd be working on in the coming days. That wasn't difficult; the same farmer who had the tomatillos had pink-skinned potatoes and red onions. I bought corn and squash, cilantro and beautiful green beans at other stands. And now I had a great destination for the serrano chiles that were ready in my garden.

Recipes for Health

Tomatillos, which are closer botanically to the gooseberry than to the tomato, have a wonderful acidic tang. They're low in calories and a good source of iron, magnesium, phosphorus and copper, as well as dietary fiber, vitamin C, vitamin K, niacin, potassium and manganese. To get the best out of them they should be simmered or grilled for about 10 minutes, until they're soft and the color has gone from pale green to olive. You can use them for a quick, blended salsa and also for a cooked salsa, which has a rounder, seared flavor. I made both last week and used them with different taco fillings. The salsas keep well in the refrigerator and I'm enjoying the leftovers with just about everything I make, from scrambled eggs to grilled fish to plain corn tortillas that I crisp in the microwave.

Two Tomatillo Salsas

I could eat both of these green salsas with a spoon. The quick fresh salsa is the tangier of the two.

Quick Fresh Tomatillo Salsa

1 pound tomatillos, husked and rinsed

2 to 4 jalapeño or serrano chiles, seeded for a milder salsa, coarsely chopped

1/4 cup chopped onion, soaked for 5 minutes in cold water, drained and rinsed

1/4 to 1/2 cup coarsely chopped cilantro (to taste)

Salt to taste (about 1/2 teaspoon)

1/4 to 1/2 cup water, as needed

1. Place the tomatillos in a saucepan, cover with water and bring to a boil. Reduce the heat and simmer for 8 to 10 minutes, flipping them over halfway through, until softened and olive green. Remove from the heat. Transfer to a blender. Add the chiles, onion, cilantro, and 1/4 cup water to the blender and blend to a coarse puree. Transfer to a bowl, add salt, and thin out as desired with water. Taste and adjust salt, and set aside for at least 30 minutes before serving, to allow the flavors to develop.

Yield: 2 cups, serving 8

Nutritional information per serving: 21 calories; 1 gram fat; 0 grams saturated fat; 0 grams polyunsaturated fat; 0 grams monounsaturated fat; 0 milligrams cholesterol; 4 grams carbohydrates; 1 gram dietary fiber; 146 milligrams sodium (based on 1/2 teaspoon salt); 1 gram protein

Cooked Tomatillo Salsa

1 pound fresh tomatillos, husked and rinsed, or 2 13-ounce cans, drained

2 or 3 jalapeño or serrano chiles, stemmed, seeded for a milder salsa

1/4 cup chopped white onion, soaked for 5 minutes in cold water, then drained and rinsed

2 large garlic cloves, peeled

1/2 cup chopped cilantro

1 tablespoon grapeseed oil, sunflower oil or canola oil

2 cups chicken stock or vegetable stock

Salt to taste (1/2 to 1 teaspoon)

1. Place the tomatillos in a saucepan, cover with water and bring to a boil. Reduce the heat and simmer for 8 to 10 minutes, flipping them over halfway through, until softened and olive green. Drain and place in a blender. Add the chiles, chopped onion, garlic, salt, and cilantro sprigs. Blend until smooth.

2. Heat the oil in a large, heavy saucepan or skillet over medium-high heat until it ripples. Drizzle in a drop of tomatillo purée to test the heat. If it makes a lot of noise and sputters immediately, the oil is hot enough. Add the tomatillo purée, and stir constantly until it thickens and begins to stick to the pan, about 5 minutes. When you run your spoon down the middle of the pan it should leave a canal. Stir in the stock, bring to a simmer, and simmer 10 to 15 minutes, stirring often. The sauce should coat the front and back of your spoon. Taste and adjust seasoning. Remove from the heat. Serve warm or at room temperature.

Yield: 2 cups, serving 8

Advance preparation: Both salsas will keep for 3 to 4 days in the refrigerator. You will need to thin out the fresh salsa with water. The cooked salsa freezes well.

Nutritional information per serving: 40 calories; 2 grams fat; 0 grams saturated fat; 1 gram polyunsaturated fat; 0 grams monounsaturated fat; 0 milligrams cholesterol; 4 grams carbohydrates; 1 gram dietary fiber; 153 milligrams sodium (based on 1/2 teaspoon salt); 1 gram protein

Martha Rose Shulman is the author of "The Very Best of Recipes for Health."


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Well: Understanding Eczema to Treat It

Summer is both a blessing and curse for millions of people afflicted with a common chronic skin condition called eczema. The dry, red and usually intolerably itchy patches often recede when the air is warm and damp and skin is exposed more often to sunlight.

Yet, for many of the 15 million Americans with eczema, shedding the clothes may be embarrassing and, in the case of children, may result in teasing and exclusion. Even for those who are comfortable in a bathing suit, swimming in a pool can be problematic if sensitivity to chlorine worsens the condition.

In industrialized countries, eczema has become two or three times more common in recent decades. Only part of this rise can be attributed to better diagnosis. Now between 15 and 30 percent of children and 2 percent to 10 percent of adults have eczema, which nearly always begins in the first five years of life. Fortunately, in more than two-thirds of children with eczema, the condition resolves on its own before adolescence.

The medical name for eczema is atopic dermatitis, which reflects the immunological nature of the condition. It is more common among children living in cities than those in rural areas. According to the so-called hygiene hypothesis, exposure to infectious agents early in life offers protection against allergic diseases. The more hygienic a child's environment, the greater the risk.

Eczema is not contagious, but more than one member of a family may be afflicted. The condition seems to have a genetic component. In identical twins, 77 percent will both have eczema, but it occurs in both fraternal twins only 15 percent of the time. My sons, who are identical twins, had eczema as young children, and one still has it in his 40s.

Another indication is the fact that people with celiac disease (a gluten intolerance) are three times more likely to have eczema; relatives of celiac patients are twice as likely to have eczema.

Eczema is often called "the itch you can't scratch," though a wiser description would be "the itch you shouldn't scratch." Scratching can make the lesions worse and expose the skin to infection.

"Scratching the spot when it's itchy brings relief only as long as you scratch it," said my son, Lorin. "After scratching, the itch generally stays the same or worsens. It's better not to scratch, though sometimes the itch is so intense that scratching feels compulsory."

Although there is no known cure for eczema, flare-ups can nearly always be minimized and sometimes prevented, and recent research has identified factors involved in its development that may lead to new treatments to control it more effectively.

Normal skin provides a remarkably effective physical and chemical barrier to substances in the environment. It also prevents substances that should remain in the body from escaping.

As Dr. Thomas Bieber, a dermatologist at the University of Bonn in Germany, explained in The New England Journal of Medicine, the hallmark of eczema is an alteration in the skin that allows essential water to escape and environmental allergens (like those from pollen, dust mites and food) to enter. The result is dry, itchy, inflamed patches that are sometimes misdiagnosed as psoriasis.

Eczematous skin also lacks normal amounts of a natural antimicrobial agent called cathelicidin, leaving it susceptible to infections that can be hard to control. More than 90 percent of people with eczema have colonies of the bacterium Staphylococcus aureus growing on their skin and contributing to the skin's allergic sensitivity and inflammation, Dr. Bieber reported. Scratching the lesions enhances the ability of these bacteria to further disrupt the skin's barrier function.

While it has long been known that the skin's outermost layer functions poorly in people with eczema, researchers at the University of Rochester have identified another reason eczematous skin is susceptible to invasion by allergens. Dr. Anna De Benedetto and co-authors showed that a protective protein called claudin-1 is significantly weakened in the skin of eczema patients but not in those with normal skin or other skin conditions.

When claudin-1 is reduced, the "tight junctions" between skin cells become leaky and permeable to environmental allergens and infectious agents. If future studies confirm these findings, developing treatments that strengthen this barrier should improve control of eczema.

Current treatment focuses on reducing inflammation, loss of moisture and colonization by bacteria. Doctors typically recommend a prescription steroid, used topically in tiny amounts, coupled with an over-the-counter moisturizer applied generously right after showering to hold water in the skin. Only mild, nondrying bath soaps should be used.

Overly expensive and exotic skin products are not necessary, according to Dr. Lisa A. Beck, a dermatologist at the University of Rochester. But finding the most helpful products may require trial and error.

For example, my son tried several steroids before finding that mometasone furoate, the generic version of Elocon, is most effective for him. He has also used coal tar-based shampoo, like Neutrogena T/Gel, for occasional eczema on his scalp.

In selecting a moisturizer (often called an emollient), choose a product that contains no scent, which itself can be a skin irritant.

An acquaintance who suffered for years with widespread eczema finally found relief last year when her doctor suggested she try taking a nonsedating antihistamine, like loratadine (Claritin), fexofenadine (Allegra) or cetirizine (Zyrtec).

Sweat can trigger an outbreak, so it is best to shower as soon as possible after a sweat-inducing activity. Stress can provoke flare-ups in some people with eczema, so measures to reduce stress may be helpful.

Food allergies show up as eczema in some patients. Eliminating one potential culprit at a time, like dairy products, eggs or nuts, may reveal an eczema-inducer.

Some people develop a form of eczema that results from skin contact with an irritant, not unlike a reaction to poison ivy. Contact eczema is often an occupational disease stemming from exposure to detergents, for example, or various cleaning agents or wet cement. The condition may show up only after the skin is exposed to sunlight. People with eczema on their hands are usually advised to wear cotton-lined waterproof gloves when washing dishes or working with irr


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Obama Intends to Let Health Care Law Prove Critics Wrong by Succeeding

Written By Unknown on Minggu, 28 Juli 2013 | 13.57

GALESBURG, Ill. — President Obama waved aside persistent Republican criticism of his signature health care law last week, saying in a New York Times interview that the overhaul would become vastly more popular once "all the nightmare scenarios" from his adversaries proved wrong.

The president accused Republicans of "all kinds of distortions" about the legislation. He said bluntly that his administration had a simple plan to build support for the law, which continues to be viewed with suspicion by large numbers of Americans. "We're going to implement it," he said.

Mr. Obama said he decided to delay a requirement that businesses provide insurance to their employees because of concerns expressed by executives about its administrative burdens. Some companies that already provide insurance had balked at provisions requiring them to show proof. The president said delaying that part of the law for a year would give the Treasury Department and other agencies a chance to make it "a little bit simpler" for companies to comply.

But he rejected criticism that by delaying the provision he had exceeded his constitutional authority.

"This is the kind of routine modifications or tweaks to a large program that's starting off that in normal times in a normal political atmosphere would draw a yawn from everybody," Mr. Obama said. "The fact that something like this generates a frenzy on Republicans is consistent with the fact that they've voted to repeal this thing 38 times without offering an alternative that is plausible."

Mr. Obama said members of Congress who questioned his power to delay the provision should "make that case." But he pointedly suggested that the criticism had less to do with the substance of the issue and more to do with political efforts to undermine his presidency.

"There's not an action that I take that you don't have some folks in Congress who say that I'm usurping my authority," Mr. Obama said in the interview. "Some of those folks think I usurp my authority by having the gall to win the presidency. And I don't think that's a secret."

Administration officials have begun an intensive nationwide effort to enroll millions of people in new health insurance marketplaces created by the health care law starting on Oct. 1. That effort could determine how successful the law is in expanding coverage to millions of uninsured Americans.

Mr. Obama conceded that there would be "some glitches" during the rollout of the insurance marketplaces. But he predicted that millions would enroll, and he said that some people who already have insurance would find their insurance premiums going down by "20 percent, 30 percent or 50 percent." He said that would help turn around people's opinions about the law.

He also said he expected the law, called the Affordable Care Act, to ultimately contribute to lower health care costs for the federal government. He said that would allow Congress to restore spending from across-the-board cuts, which he said was vital to helping middle-class families.

"Me just making more speeches explaining it in and of itself won't do it," he said. "The test of this is going to be, is it working? And if it works, it will be pretty darn popular."


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A Race to Save the Orange by Altering Its DNA

CLEWISTON, Fla. — The call Ricke Kress and every other citrus grower in Florida dreaded came while he was driving.

"It's here" was all his grove manager needed to say to force him over to the side of the road.

The disease that sours oranges and leaves them half green, already ravaging citrus crops across the world, had reached the state's storied groves. Mr. Kress, the president of Southern Gardens Citrus, in charge of two and a half million orange trees and a factory that squeezes juice for Tropicana and Florida's Natural, sat in silence for several long moments.

"O.K.," he said finally on that fall day in 2005, "let's make a plan."

In the years that followed, he and the 8,000 other Florida growers who supply most of the nation's orange juice poured everything they had into fighting the disease they call citrus greening.

To slow the spread of the bacterium that causes the scourge, they chopped down hundreds of thousands of infected trees and sprayed an expanding array of pesticides on the winged insect that carries it. But the contagion could not be contained.

They scoured Central Florida's half-million acres of emerald groves and sent search parties around the world to find a naturally immune tree that could serve as a new progenitor for a crop that has thrived in the state since its arrival, it is said, with Ponce de León. But such a tree did not exist.

"In all of cultivated citrus, there is no evidence of immunity," the plant pathologist heading a National Research Council task force on the disease said.

In all of citrus, but perhaps not in all of nature. With a precipitous decline in Florida's harvest predicted within the decade, the only chance left to save it, Mr. Kress believed, was one that his industry and others had long avoided for fear of consumer rejection. They would have to alter the orange's DNA — with a gene from a different species.

Oranges are not the only crop that might benefit from genetically engineered resistance to diseases for which standard treatments have proven elusive. And advocates of the technology say it could also help provide food for a fast-growing population on a warming planet by endowing crops with more nutrients, or the ability to thrive in drought, or to resist pests. Leading scientific organizations have concluded that shuttling DNA between species carries no intrinsic risk to human health or the environment, and that such alterations can be reliably tested.

But the idea of eating plants and animals whose DNA has been manipulated in a laboratory — called genetically modified organisms, or G.M.O.'s — still spooks many people. Critics worry that such crops carry risks not yet detected, and distrust the big agrochemical companies that have produced the few in wide use. And hostility toward the technology, long ingrained in Europe, has deepened recently among Americans as organic food advocates, environmentalists and others have made opposition to it a pillar of a growing movement for healthier and ethical food choices.

Mr. Kress's boss worried about damaging the image of juice long promoted as "100 percent natural."

"Do we really want to do this?" he demanded in a 2008 meeting at the company's headquarters on the northern rim of the Everglades.

Mr. Kress, now 61, had no particular predilection for biotechnology. Known for working long hours, he rose through the ranks at fruit and juice companies like Welch's and Seneca Foods. On moving here for the Southern Gardens job, just a few weeks before citrus greening was detected, he had assumed his biggest headache would be competition from flavored waters, or persuading his wife to tolerate Florida's humidity.

But the dwindling harvest that could mean the idling of his juice processing plant would also have consequences beyond any one company's bottom line. Florida is the second-largest producer of orange juice in the world, behind Brazil. Its $9 billion citrus industry contributes 76,000 jobs to the state that hosts the Orange Bowl. Southern Gardens, a subsidiary of U.S. Sugar, was one of the few companies in the industry with the wherewithal to finance the development of a "transgenic" tree, which could take a decade and cost as much as $20 million.

An emerging scientific consensus held that genetic engineering would be required to defeat citrus greening. "People are either going to drink transgenic orange juice or they're going to drink apple juice," one University of Florida scientist told Mr. Kress.

And if the presence of a new gene in citrus trees prevented juice from becoming scarcer and more expensive, Mr. Kress believed, the American public would embrace it. "The consumer will support us if it's the only way," Mr. Kress assured his boss.

His quest to save the orange offers a close look at the daunting process of genetically modifying one well-loved organism — on a deadline. In the past several years, out of public view, he has considered DNA donors from all over the tree of life, including two vegetables, a virus and, briefly, a pig. A synthetic gene, manufactured in the laboratory, also emerged as a contender.

Trial trees that withstood the disease in his greenhouse later succumbed in the field. Concerns about public perception and potential delays in regulatory scrutiny put a damper on some promising leads. But intent on his mission, Mr. Kress shrugged off signs that national campaigns against genetically modified food were gaining traction.

Only in recent months has he begun to face the full magnitude of the gap between what science can achieve and what society might accept.

Millenniums of Intervention

Even in the heyday of frozen concentrate, the popularity of orange juice rested largely on its image as the ultimate natural beverage, fresh-squeezed from a primordial fruit. But the reality is that human intervention has modified the orange for millenniums, as it has almost everything people eat.

Before humans were involved, corn was a wild grass, tomatoes were tiny, carrots were only rarely orange and dairy cows produced little milk. The orange, for its part, might never have existed had human migration not brought together the grapefruit-size pomelo from the tropics and the diminutive mandarin from a temperate zone thousands of years ago in China. And it would not have become the most widely planted fruit tree had human traders not carried it across the globe.

The varieties that have survived, among the many that have since arisen through natural mutation, are the product of human selection, with nearly all of Florida's juice a blend of just two: the Hamlin, whose unremarkable taste and pale color are offset by its prolific yield in the early season, and the dark, flavorful, late-season Valencia.

Because oranges themselves are hybrids and most seeds are clones of the mother, new varieties cannot easily be produced by crossbreeding — unlike, say, apples, which breeders have remixed into favorites like Fuji and Gala. But the vast majority of oranges in commercial groves are the product of a type of genetic merging that predates the Romans, in which a slender shoot of a favored fruit variety is grafted onto the sturdier roots of other species: lemon, for instance, or sour orange. And a seedless midseason orange recently adopted by Florida growers emerged after breeders bombarded a seedy variety with radiation to disrupt its DNA, a technique for accelerating evolution that has yielded new varieties in dozens of crops, including barley and rice.

Its proponents argue that genetic engineering is one in a continuum of ways humans shape food crops, each of which carries risks: even conventional crossbreeding has occasionally produced toxic varieties of some vegetables. Because making a G.M.O. typically involves adding one or a few genes, each containing instructions for a protein whose function is known, they argue, it is more predictable than traditional methods that involve randomly mixing or mutating many genes of unknown function.

But because it also usually involves taking DNA from the species where it evolved and putting it in another to which it may be only distantly related — or turning off genes already present — critics of the technology say it represents a new and potentially more hazardous degree of tinkering whose risks are not yet fully understood.

If he had had more time, Mr. Kress could have waited for the orange to naturally evolve resistance to the bacteria known as C. liberibacter asiaticus. That could happen tomorrow. Or it could take years, or many decades. Or the orange in Florida could disappear first.

Plunging Ahead

Early discussions among other citrus growers about what kind of disease research they should collectively support did little to reassure Mr. Kress about his own genetic engineering project.

"The public will never drink G.M.O. orange juice," one grower said at a contentious 2008 meeting. "It's a waste of our money."

"The public is already eating tons of G.M.O.'s," countered Peter McClure, a big grower.

"This isn't like a bag of Doritos," snapped another. "We're talking about a raw product, the essence of orange."

The genetically modified foods Americans have eaten for more than a decade — corn, soybeans, some cottonseed oil, canola oil and sugar — come mostly as invisible ingredients in processed foods like cereal, salad dressing and tortilla chips. And the few G.M.O.'s sold in produce aisles — a Hawaiian papaya, some squash, a fraction of sweet corn — lack the iconic status of a breakfast drink that, Mr. Kress conceded, is "like motherhood" to Americans, who drink more of it per capita than anyone else.

If various polls were to be believed, a third to half of Americans would refuse to eat any transgenic crop. One study's respondents would accept only certain types: two-thirds said they would eat a fruit modified with another plant gene, but few would accept one with DNA from an animal. Fewer still would knowingly eat produce that contained a gene from a virus.

There also appeared to be an abiding belief that a plant would take on the identity of the species from which its new DNA was drawn, like the scientist in the movie "The Fly" who sprouted insect parts after a DNA-mixing mistake with a house fly.

Asked if tomatoes containing a gene from a fish would "taste fishy" in a question on a 2004 poll conducted by the Food Policy Institute at Rutgers University that referred to one company's efforts to forge a frost-resistant tomato with a gene from the winter flounder, fewer than half correctly answered "no." A fear that the genetic engineering of food would throw the ecosystem out of whack showed in the surveys too.

Mr. Kress's researchers, in turn, liked to point out that the very reason genetic engineering works is that all living things share a basic biochemistry: if a gene from a cold-water fish can help a tomato resist frost, it is because DNA is a universal code that tomato cells know how to read. Even the most distantly related species — say, humans and bacteria — share many genes whose functions have remained constant across billions of years of evolution.

"It's not where a gene comes from that matters," one researcher said. "It's what it does."

Mr. Kress set the surveys aside.

He took encouragement from other attempts to genetically modify foods that were in the works. There was even another fruit, the "Arctic apple," whose genes for browning were switched off, to reduce waste and allow the fruit to be more readily sold sliced.

"The public is going to be more informed about G.M.O.'s by the time we're ready," Mr. Kress told his research director, Michael P. Irey, as they lined up the five scientists whom Southern Gardens would underwrite. And to the scientists, growers and juice processors at a meeting convened by Minute Maid in Miami in early 2010, he insisted that just finding a gene that worked had to be his company's priority.

The foes were formidable. C. liberibacter, the bacterium that kills citrus trees by choking off their flow of nutrients — first detected when it destroyed citrus trees more than a century ago in China — had earned a place, along with anthrax and the Ebola virus, on the Agriculture Department's list of potential agents of bioterrorism. Asian citrus psyllids, the insects that suck the bacteria out of one tree and inject them into another as they feed on the sap of their leaves, can carry the germ a mile without stopping, and the females can lay up to 800 eggs in their one-month life.

Mr. Kress's DNA candidate would have to fight off the bacteria or the insect. As for public acceptance, he told his industry colleagues, "We can't think about that right now."

The 'Creep Factor'

Trim, silver-haired and described by colleagues as tightly wound (he prefers "focused"), Mr. Kress arrives at the office by 6:30 each morning and microwaves a bowl of oatmeal. He stocks his office cabinet with cans of peel-top Campbell's chicken soup that he heats up for lunch. Arriving home each evening, he cuts a rose from his garden for his wife. Weekends, he works in his yard and pores over clippings about G.M.O.'s in the news.

For a man who takes pleasure in routine, the uncertainty that marked his DNA quest was disquieting. It would cost Southern Gardens millions of dollars just to perform the safety tests for a single gene in a single variety of orange. Of his five researchers' approaches, he had planned to narrow the field to the one that worked best over time.

But in 2010, with the disease spreading faster than anyone anticipated, the factor that came to weigh most was which could be ready first.

To fight C. liberibacter, Dean Gabriel at the University of Florida had chosen a gene from a virus that destroys bacteria as it replicates itself. Though such viruses, called bacteriophages ("phage" means to devour), are harmless to humans, Mr. Irey sometimes urged Mr. Kress to consider the public relations hurdle that might come with such a strange-sounding source of the DNA. "A gene from a virus," he would ask pointedly, "that infects bacteria?"

But Mr. Kress's chief concern was that Dr. Gabriel was taking too long to perfect his approach.

A second contender, Erik Mirkov of Texas A&M University, was further along with trees he had endowed with a gene from spinach — a food, he reminded Mr. Kress, that "we give to babies." The gene, which exists in slightly different forms in hundreds of plants and animals, produces a protein that attacks invading bacteria.

Even so, Dr. Mirkov faced skepticism from growers. "Will my juice taste like spinach?" one asked.

"Will it be green?" wondered another.

"This gene," he invariably replied, "has nothing to do with the color or taste of spinach. Your body makes very similar kinds of proteins as part of your own defense against bacteria."

When some of the scientist's promising trees got sick in their first trial, Mr. Kress agreed that he should try to improve on his results in a new generation of trees, by adjusting the gene's placement. But transgenic trees, begun as a single cell in a petri dish, can take two years before they are sturdy enough to place in the ground and many more years to bear fruit.

"Isn't there a gene," Mr. Kress asked Mr. Irey, "to hurry up Mother Nature?"

For a time, the answer seemed to lie with a third scientist, William O. Dawson at the University of Florida, who had managed to alter fully grown trees by attaching a gene to a virus that could be inserted by way of a small incision in the bark. Genes transmitted that way would eventually stop functioning, but Mr. Kress hoped to use it as a stopgap measure to ward off the disease in the 60 million citrus trees already in Florida's groves. Dr. Dawson joked that he hoped at least to save the grapefruit, whose juice he enjoyed, "preferably with a little vodka in it."

But his most promising result that year was doomed from the beginning: of the dozen bacteria-fighting genes he had then tested on his greenhouse trees, the one that appeared effective came from a pig.

One of about 30,000 genes in the animal's genetic code, it was, he ventured, "a pretty small amount of pig."

"There's no safety issue from our standpoint — but there is a certain creep factor," an Environmental Protection Agency official observed to Mr. Kress, who had included it on an early list of possibilities to run by the agency.

"At least something is working," Mr. Kress bristled. "It's a proof of concept."

A similar caution dimmed his hopes for the timely approval of a synthetic gene, designed in the laboratory of a fourth scientist, Jesse Jaynes of Tuskegee University. In a simulation, Dr. Jaynes's gene consistently vanquished the greening bacteria. But the burden of proving a synthetic gene's safety would prolong the process. "You're going to get more questions," Mr. Kress was told, "with a gene not found in nature."

And in the fall of 2010, an onion gene that discouraged psyllids from landing on tomato plants was working in the Cornell laboratory of Mr. Kress's final hope, Herb Aldwinckle. But it would be some time before the gene could be transferred to orange trees.

Only Dr. Mirkov's newly fine-tuned trees with the spinach gene, Mr. Kress and Mr. Irey agreed, could be ready in time to stave off what many believed would soon be a steep decline in the harvest. In the fall of 2010, they were put to the test inside a padlocked greenhouse stocked with infected trees and psyllids.

The Monsanto Effect

Mr. Kress's only direct brush so far with the broader battle raging over genetically modified food came in December 2010, in the reader comments on a Reuters article alluding to Southern Gardens' genetic engineering efforts.

Some readers vowed not to buy such "frankenfood." Another attributed a rise in allergies to genetic engineering. And dozens lambasted Monsanto, the St. Louis-based company that dominates the crop biotechnology business, which was not even mentioned in the article.

"If this trend goes on, one day, there will be only Monsanto engineered foods available," read one letter warning of unintended consequences.

Mr. Kress was unperturbed. Dozens of long-term animal feeding studies had concluded that existing G.M.O.'s were as safe as other crops, and the National Academy of Sciences, the World Health Organization and others had issued statements to the same effect.

But some of his researchers worried that the popular association between G.M.O.'s and Monsanto — and in turn between Monsanto and the criticisms of modern agriculture — could turn consumers against Southern Gardens' transgenic oranges.

"The article doesn't say 'Monsanto' anywhere, but the comments are all about Monsanto," Dr. Mirkov said.

It had not helped win hearts and minds for G.M.O.'s, Mr. Kress knew, that the first such crop widely adopted by farmers was the soybean engineered by Monsanto with a bacteria gene — to tolerate a weed killer Monsanto also made.

Starting in the mid-1990s, soybean farmers in the United States overwhelmingly adopted that variety of the crop, which made it easier for them to control weeds. But the subsequent broader use of the chemical — along with a distaste for Monsanto's aggressive business tactics and a growing suspicion of a food system driven by corporate profits — combined to forge a consumer backlash. Environmental activists vandalized dozens of field trials and protested brands that used Monsanto's soybeans or corn, introduced soon after, which was engineered to prevent pests from attacking it.

In response, companies including McDonald's, Frito-Lay and Heinz pledged not to use G.M.O. ingredients in certain products, and some European countries prohibited their cultivation.

Some of Mr. Kress's scientists were still fuming about what they saw as the lost potential for social good hijacked both by the activists who opposed genetic engineering and the corporations that failed to convince consumers of its benefits. In many developing countries, concerns about safety and ownership of seeds led governments to delay or prohibit cultivation of needed crops: Zambia, for instance, declined shipments of G.M.O. corn even during a 2002 famine.

"It's easy for someone who can go down to the grocery store and buy anything they need to be against G.M.O.'s," said Dr. Jaynes, who faced such barriers with a high-protein sweet potato he had engineered with a synthetic gene.

To Mr. Kress in early 2011, any comparison to Monsanto — whose large blocks of patents he had to work around, and whose thousands of employees worldwide dwarfed the 750 he employed in Florida at peak harvest times — seemed far-fetched. If it was successful, Southern Gardens would hope to recoup its investment by charging a royalty for its trees. But its business strategy was aimed at saving the orange crop, whose total acreage was a tiny fraction of the crops the major biotechnology companies had pursued.

He urged his worried researchers to look at the early success of Flavr Savr tomatoes. Introduced in 1994 and engineered to stay fresh longer than traditional varieties, they proved popular enough that some stores rationed them, before business missteps by their developer ended their production.

And he was no longer alone in the pursuit of a genetically modified orange. Citrus growers were collectively financing research into a greening-resistant tree, and the Agriculture Department had also assigned a team of scientists to it. Any solution would have satisfied Mr. Kress. Almost daily, he could smell the burning of infected trees, which mingled with orange-blossom sweetness in the grove just beyond Southern Gardens' headquarters.

A Growing Urgency

In an infection-filled greenhouse where every nontransgenic tree had showed symptoms of disease, Dr. Mirkov's trees with the spinach gene had survived unscathed for more than a year. Mr. Kress would soon have 300 of them planted in a field trial. But in the spring of 2012, he asked the Environmental Protection Agency, the first of three federal agencies that would evaluate his trees, for guidance. The next step was safety testing. And he felt that it could not be started fast enough.

Dr. Mirkov assured him that the agency's requirements for animal tests to assess the safety of the protein produced by his gene, which bore no resemblance to anything on the list of known allergens and toxins, would be minimal.

"It's spinach," he insisted. "It's been eaten for centuries."

Other concerns weighed on Mr. Kress that spring: growers in Florida did not like to talk about it, but the industry's tripling of pesticide applications to kill the bacteria-carrying psyllid was, while within legal limits, becoming expensive and worrisome. One widely used pesticide had stopped working as the psyllid evolved resistance, and Florida's citrus growers' association was petitioning one company to lift the twice-a-season restrictions on spraying young trees — increasingly its only hope for an uninfected harvest.

Others in the industry who knew of Mr. Kress's project were turning to him. He agreed to speak at the fall meeting of citrus growers in California, where the greening disease had just been detected. "We need to hear about the transgenic solution," said Ted Batkin, the association's director. But Mr. Kress worried that he had nothing to calm their fears.

And an increasingly vocal movement to require any food with genetically engineered ingredients to carry a "G.M.O." label had made him uneasy.

Supporters of one hotly contested California ballot initiative argued for labeling as a matter of consumer rights and transparency — but their advertisements often implied the crops were a hazard: one pictured a child about to take a joyful bite of a pest-resistant cob of corn, on which was emblazoned a question mark and the caption "Corn, engineered to grow its own pesticide."

Yet the gene that makes corn insect-resistant, he knew, came from the same soil bacterium long used by organic food growers as a natural insecticide.

Arguing that the Food and Drug Administration should require labels on food containing G.M.O.'s, one leader of the Environmental Working Group, an advocacy group, cited "pink slime, deadly melons, tainted turkeys and BPA in our soup."

Mr. Kress attributed the labeling campaigns to the kind of tactic any industry might use to gain a competitive edge: they were financed largely by companies that sell organic products, which stood to gain if packaging implying a hazard drove customers to their own non-G.M.O. alternatives. He did not aim to hide anything from consumers, but he would want them to understand how and why his oranges were genetically engineered. What bothered him was that a label seemed to lump all G.M.O.'s into one stigmatized category.

And when the E.P.A. informed him in June 2012 that it would need to see test results for how large quantities of spinach protein affected honeybees and mice, he gladly wrote out the $300,000 check to have the protein made.

It was the largest single expense yet in a project that had so far cost more than $5 million. If these tests raised no red flags, he would need to test the protein as it appears in the pollen of transgenic orange blossoms. Then the agency would want to test the juice.

"Seems excessive," Dr. Mirkov said.

But Mr. Kress and Mr. Irey shared a sense of celebration. The path ahead was starting to clear.

Rather than wait for Dr. Mirkov's 300 trees to flower, which could take several years, they agreed to try to graft his spinach gene shoots to mature trees to hasten the production of pollen — and, finally, their first fruit, for testing.

Wall of Opposition

Early one morning a year ago, Mr. Kress checked the Agriculture Department's Web site from home. The agency had opened its 60-day public comment period on the trees modified to produce "Arctic apples" that did not brown.

His own application, he imagined, would take a similar form.

He skimmed through the company's 163-page petition, showing how the apples are equivalent in nutritional content to normal apples, how remote was the likelihood of cross-pollination with other apple varieties and the potentially bigger market for a healthful fruit.

Then he turned to the comments. There were hundreds. And they were almost universally negative. Some were from parents, voicing concerns that the nonbrowning trait would disguise a rotten apple — though transgenic apples rotten from infection would still turn brown. Many wrote as part of a petition drive by the Center for Food Safety, a group that opposes biotechnology.

"Apples are supposed to be a natural, healthy snack," it warned. "Genetically engineered apples are neither."

Others voiced a general distrust of scientists' guarantees: "Too many things were presented to us as innocuous and years later we discovered it was untrue," wrote one woman. "After two cancers I don't feel like taking any more unnecessary risks."

Many insisted that should the fruit be approved, it ought to be labeled.

That morning, Mr. Kress drove to work late. He should not be surprised by the hostility, he told himself.

Mr. Irey tried to console him with good news: the data on the honeybees and mice had come back. The highest dose of the protein the E.P.A. wanted tested had produced no ill effect.

But the magnitude of the opposition had never hit Mr. Kress so hard. "Will they believe us?" he asked himself for the first time. "Will they believe we're doing this to eliminate chemicals and we're making sure it's safe? Or will they look at us and say, 'That's what they all say?' "

The major brands were rumored to be looking beyond Florida for their orange juice — perhaps to Brazil, where growers had taken to abandoning infected groves to plant elsewhere. Other experiments that Mr. Kress viewed as similar to his own had foundered. Pigs engineered to produce less-polluting waste had been euthanized after their developer at a Canadian university had failed to find investors. A salmon modified to grow faster was still awaiting F.D.A. approval. A study pointing to health risks from G.M.O.'s had been discredited by scientists, but was contributing to a sense among some consumers that the technology is dangerous.

And while the California labeling measure had been defeated, it had spawned a ballot initiative in Washington State and legislative proposals in Connecticut, Vermont, New Mexico, Missouri and many other states.

In the heat of last summer, Mr. Kress gardened more savagely than his wife had ever seen.

Driving through the Central Valley of California last October to speak at the California Citrus Growers meeting, Mr. Kress considered how to answer critics. Maybe even a blanket "G.M.O." label would be O.K., he thought, if it would help consumers understand that he had nothing to hide. He could never prove that there were no risks to genetically modifying a crop. But he could try to explain the risks of not doing so.

Southern Gardens had lost 700,000 trees trying to control the disease, more than a quarter of its total. The forecast for the coming spring harvest was dismal. The approval to use more pesticide on young trees had come through that day. At his hotel that night, he slipped a new slide into his standard talk.

On the podium the next morning, he talked about the growing use of pesticides: "We're using a lot of chemicals, pure and simple," he said. "We're using more than we've ever used before."

Then he stopped at the new slide. Unadorned, it read "Consumer Acceptance." He looked out at the audience.

What these growers wanted most, he knew, was reassurance that he could help them should the disease spread. But he had to warn them: "If we don't have consumer confidence, it doesn't matter what we come up with."

Planting

One recent sunny morning, Mr. Kress drove to a fenced field, some distance from his office and far from any other citrus tree. He unlocked the gate and signed in, as required by Agriculture Department regulations for a field trial of a genetically modified crop.

Just in the previous few months, Whole Foods had said that because of customer demand it would avoid stocking most G.M.O. foods and require labels on them by 2018. Hundreds of thousands of protesters around the world had joined in a "March Against Monsanto" — and the Agriculture Department had issued its final report for this year's orange harvest showing a 9 percent decline from last year, attributable to citrus greening.

But visiting the field gave him some peace. In some rows were the trees with no new gene in them, sick with greening. In others were the 300 juvenile trees with spinach genes, all healthy. In the middle were the trees that carried his immediate hopes: 15 mature Hamlins and Valencias, seven feet tall, onto which had been grafted shoots of Dr. Mirkov's spinach gene trees.

There was good reason to believe that the trees would pass the E.P.A.'s tests when they bloom next spring. And he was gathering the data the Agriculture Department would need to ensure that the trees posed no risk to other plants. When he had fruit, the Food and Drug Administration would compare its safety and nutritional content to conventional oranges.

In his office is a list of groups to contact when the first G.M.O. fruit in Florida are ready to pick: environmental organizations, consumer advocates and others. Exactly what he would say when he finally contacted them, he did not know. Whether anyone would drink the juice from his genetically modified oranges, he did not know.

But he had decided to move ahead.

Late this summer he will plant several hundred more young trees with the spinach gene, in a new greenhouse. In two years, if he wins regulatory approval, they will be ready to go into the ground. The trees could be the first to produce juice for sale in five years or so.

Whether it is his transgenic tree, or someone else's, he believed, Florida growers will soon have trees that could produce juice without fear of its being sour, or in short supply.

For a moment, alone in the field, he let his mind wander.

"Maybe we can use the technology to improve orange juice," he could not help thinking. "Maybe we can find a way to have oranges grow year-round, or get two for every one we get now on a tree."

Then he reined in those thoughts.

He took the clipboard down, signed out and locked the gate.


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