Ground Zero Volunteers Face Obstacles to Compensation

Todd Heisler/The New York Times

Richard Oliver said he became ill after volunteering at ground zero but had little proof he was there other than a terse thank-you note written on American Red Cross letterhead.

On the day the terrorists flew into the World Trade Center, the Wu-Tang Clan canceled its meeting with a record mixer named Richard Oliver, so Mr. Oliver rushed downtown from his Hell's Kitchen apartment to help out.

He said he spent three sleepless days at ground zero, tossing body bags. "Then I went home, ate, crashed, woke up," he said. He had left his Dr. Martens boots on the landing outside his apartment, where he said they "had rotted away."

"That was kind of frightening," he continued. "I was breathing that stuff."

After the Sept. 11 attacks, nothing symbolized the city's rallying around like many New Yorkers who helped at ground zero for days, weeks, months, without being asked. Now Mr. Oliver, suffering from back pain and a chronic sinus infection, is among scores of volunteers who have begun filing claims for compensation from a $2.8 billion fund that Congress created in 2010.

But proving they were there and eligible for the money is turning out to be its own forbidding task.

The other large classes of people who qualify — firefighters, police officers, contractors, city workers, residents and students — have it relatively simple, since they are more likely to have official work orders, attendance records and leases to back them up. But more than a decade later, many volunteers have only the sketchiest proof that they are eligible for the fund, which is expected to make its first awards early this year. (A separate $1.5 billion treatment fund also was created.)

They are volunteers like Terry Graves, now ill with lung cancer, who kept a few business cards of people she worked with until 2007, then threw them away. Or Jaime Hazan, a former Web designer with gastric reflux, chronically inflamed sinuses and asthma, who managed to dig up a photograph of himself at ground zero — taken from behind.

Or Mr. Oliver, who has a terse two-sentence thank-you note on American Red Cross letterhead, dated 2004, which does not meet the requirement that it be witnessed or sworn.

"For some people, there's great records," said Noah H. Kushlefsky, whose law firm, Kreindler & Kreindler, is representing volunteers and others who expect to make claims. "But in some respects, it was a little bit of a free-for-all. Other people went down there and joined the bucket brigade, talked their way in. It's going to be harder for those people, and we do have clients like that."

As documentation, the fund requires volunteers to have orders, instructions or confirmation of tasks they performed, or medical records created during the time they were in what is being called the exposure zone, including the area south of Canal Street, and areas where debris was being taken.

Failing that, it will be enough to submit two sworn statements — meaning the writer swears to its truth, under penalty of perjury — from witnesses describing when the volunteers were there and what they were doing.

Proving presence at the site might actually be harder than proving the illness is related to Sept. 11, since the rules now allow a host of ailments to be covered, including 50 kinds of cancer, despite an absence of evidence linking cancer to ground zero.

A study by the New York City health department, just published in the Journal of the American Medical Association, found no clear association between cancer and Sept. 11, though the researchers noted that some cancers take many years to develop.

Unlike the original compensation fund, administered by Kenneth Feinberg, which dealt mainly with people who were killed or maimed in the attack, "This one is dealing with injuries that are very common," said Sheila L. Birnbaum, a former mediator and personal injury defense lawyer, who is in charge of the new fund. "So it's sort of a very hard process from the fund's point of view to make the right call, and it requires some evidence that people were actually there."

Asked how closely the fund would scrutinize documents like sworn statements, Ms. Birnbaum said she understood how hard it was to recreate records after a decade, and was going on the basic assumption that people would be honest.

In his career as a record mixer, Mr. Oliver, 56, has been associated with 7 platinum and 11 gold records, and 2 Grammy credits, which now line the walls of his condominium in College Point, Queens. He said he first got wind of the Sept. 11 attacks from a client, the Wu-Tang Clan. "One of the main guys called me: 'Did you see what's on TV? Because our meeting ain't going to happen,' " he recalled.

Having taken a hazmat course after high school, he called the Red Cross and was told they needed people like him. "I left my soon-to-be-ex-wife and 1-year-old son and went down," he said. "I came back three days later," after surviving on his own adrenaline, Little Debbie cakes handed out to volunteers and bottled water. After working for three days setting up a morgue, he was willing to go back, he said, but "they said we have trained people now, thank you very much for your service."

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Scant Proof Is Found to Back Up Claims by Energy Drinks

Energy drinks are the fastest-growing part of the beverage industry, with sales in the United States reaching more than $10 billion in 2012 — more than Americans spent on iced tea or sports beverages like Gatorade.

Their rising popularity represents a generational shift in what people drink, and reflects a successful campaign to convince consumers, particularly teenagers, that the drinks provide a mental and physical edge.

The drinks are now under scrutiny by the Food and Drug Administration after reports of deaths and serious injuries that may be linked to their high caffeine levels. But however that review ends, one thing is clear, interviews with researchers and a review of scientific studies show: the energy drink industry is based on a brew of ingredients that, apart from caffeine, have little, if any benefit for consumers.

"If you had a cup of coffee you are going to affect metabolism in the same way," said Dr. Robert W. Pettitt, an associate professor at Minnesota State University in Mankato, who has studied the drinks.

Energy drink companies have promoted their products not as caffeine-fueled concoctions but as specially engineered blends that provide something more. For example, producers claim that "Red Bull gives you wings," that Rockstar Energy is "scientifically formulated" and Monster Energy is a "killer energy brew." Representative Edward J. Markey of Massachusetts, a Democrat, has asked the government to investigate the industry's marketing claims.

Promoting a message beyond caffeine has enabled the beverage makers to charge premium prices. A 16-ounce energy drink that sells for $2.99 a can contains about the same amount of caffeine as a tablet of NoDoz that costs 30 cents. Even Starbucks coffee is cheap by comparison; a 12-ounce cup that costs $1.85 has even more caffeine.

As with earlier elixirs, a dearth of evidence underlies such claims. Only a few human studies of energy drinks or the ingredients in them have been performed and they point to a similar conclusion, researchers say — that the beverages are mainly about caffeine.

Caffeine is called the world's most widely used drug. A stimulant, it increases alertness, awareness and, if taken at the right time, improves athletic performance, studies show. Energy drink users feel its kick faster because the beverages are typically swallowed quickly or are sold as concentrates.

"These are caffeine delivery systems," said Dr. Roland Griffiths, a researcher at Johns Hopkins University who has studied energy drinks. "They don't want to say this is equivalent to a NoDoz because that is not a very sexy sales message."

A scientist at the University of Wisconsin became puzzled as he researched an ingredient used in energy drinks like Red Bull, 5-Hour Energy and Monster Energy. The researcher, Dr. Craig A. Goodman, could not find any trials in humans of the additive, a substance with the tongue-twisting name of glucuronolactone that is related to glucose, a sugar. But Dr. Goodman, who had studied other energy drink ingredients, eventually found two 40-year-old studies from Japan that had examined it.

In the experiments, scientists injected large doses of the substance into laboratory rats. Afterward, the rats swam better. "I have no idea what it does in energy drinks," Dr. Goodman said.

Energy drink manufacturers say it is their proprietary formulas, rather than specific ingredients, that provide users with physical and mental benefits. But that has not prevented them from implying otherwise.

Consider the case of taurine, an additive used in most energy products.

On its Web site, the producer of Red Bull, for example, states that "more than 2,500 reports have been published about taurine and its physiological effects," including acting as a "detoxifying agent." In addition, that company, Red Bull of Austria, points to a 2009 safety study by a European regulatory group that gave it a clean bill of health.

But Red Bull's Web site does not mention reports by that same group, the European Food Safety Authority, which concluded that claims about the benefits in energy drinks lacked scientific support. Based on those findings, the European Commission has refused to approve claims that taurine helps maintain mental function and heart health and reduces muscle fatigue.

Taurine, an amino acidlike substance that got its name because it was first found in the bile of bulls, does play a role in bodily functions, and recent research suggests it might help prevent heart attacks in women with high cholesterol. However, most people get more than adequate amounts from foods like meat, experts said. And researchers added that those with heart problems who may need supplements would find far better sources than energy drinks.

Hiroko Tabuchi contributed reporting from Tokyo and Poypiti Amatatham from Bangkok.

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Safed Journal: New Insights on Marijuana in Israel, Where It’s Illegal

Baz Ratner/Reuters

Tikkun Olam, a medical marijuana farm in Israel, blends the high-tech and the spiritual.

SAFED, Israel — Among the rows of plants growing at a government-approved medical marijuana farm in the Galilee hills in northern Israel, one strain is said to have the strongest psychoactive effect of any cannabis in the world. Another, rich in anti-inflammatory properties, will not get you high at all.

Marijuana is illegal in Israel, but farms like this one, at a secret location near the city of Safed, are at the cutting edge of the debate on the legality, benefits and risks of medicinal cannabis. Its staff members wear white lab coats, its growing facilities are fitted with state-of-the-art equipment for controlling light and humidity, and its grounds are protected by security cameras and guards.

But in addition to the high-tech atmosphere, there is a spiritual one. The plantation, Israel's largest and most established medical marijuana farm — and now a thriving commercial enterprise — is imbued with a higher sense of purpose, reflected by the aura of Safed, an age-old center of Jewish mysticism, as well as by its name, Tikkun Olam, a reference to the Jewish concept of repairing or healing the world.

There is an on-site synagogue in a trailer, a sweet aroma of freshly harvested cannabis that infuses the atmosphere and, halfway up a wooded hillside overlooking the farm, a blue-domed tomb of a rabbinic sage and his wife.

In the United States, medical marijuana programs exist in 18 states but remain illegal under federal law. In Israel, the law defines marijuana as an illegal and dangerous drug, and there is still no legislation regulating its use for medicinal purposes.

Yet Israel's Ministry of Health issues special licenses that allow thousands of patients to receive medical marijuana, and some government officials are now promoting the country's advances in the field as an example of its pioneering and innovation.

"I hope we will overcome the legal obstacles for Tikkun Olam and other companies," Yuli Edelstein, the minister of public diplomacy and diaspora affairs, told journalists during a recent government-sponsored tour of the farm, part of Israel's effort to brand itself as something beyond a conflict zone. In addition to helping the sick, he said, the effort "could be helpful for explaining what we are about in this country."

Israelis have been at the vanguard of research into the medicinal properties of cannabis for decades.

In the 1960s, Prof. Raphael Mechoulam and his colleague Yechiel Gaoni at the Weizmann Institute of Science isolated, analyzed and synthesized the main psychoactive ingredient in the cannabis plant, tetrahydrocannabinol, or THC. Later, Professor Mechoulam deciphered the cannabinoids native to the brain. Ruth Gallily, a professor emerita of immunology at the Hebrew University of Jerusalem, has studied another main constituent of cannabis — cannabidiol, or CBD — considered a powerful anti-inflammatory and anti-anxiety agent.

When Zach Klein, a former filmmaker, made a documentary on medical marijuana that was broadcast on Israeli television in 2009, about 400 Israelis were licensed to receive the substance. Today, the number has risen to about 11,000.

Mr. Klein became devoted to the subject and went to work for Tikkun Olam in research and development. "Cannabis was used as medicine for centuries," he said. "Now science is telling us how it works."

Israeli researchers say cannabis can be beneficial for a variety of illnesses and conditions, from helping cancer patients relieve pain and ease loss of appetite to improving the quality of life for people with post-traumatic stress disorder and neuropsychological conditions. The natural ingredients in the plant, they say, can help with digestive function, infections and recovery after a heart attack.

The marijuana harvest, from plants that can grow over six feet tall, is processed into bags of flowers and ready-rolled cigarettes. There are also cannabis-laced cakes, cookies, candy, gum, honey, ointments and oil drops. The strain known as Eran Almog, which has the highest concentration of THC, is recommended for severe pain. Avidekel, a strain rich in CBD and with hardly any psychoactive ingredient, allows patients to benefit from the drug while being able to drive and to function at work.

Working with Hebrew University researchers, the farm has also developed a version in capsule form, which would make exporting the drug more practical, should the law allow it.

Professor Mechoulam, now 82, said in an interview that he had been urging producers over the years to grow cannabis with less THC and more CBD, something in which nonmedical marijuana growers had little interest. He said what Tikkun Olam had done was not great science but "a very practical development."

In Israel, he said, research in the field is "definitely a work in progress," and he cautioned, "Science is not a 100-meters Olympic race; it is not who is first on the line that is important."

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Study Suggests Lower Mortality Risk for Overweight People

A century ago, Elsie Scheel was the perfect woman. So said a 1912 article in The New York Times about how Miss Scheel, 24, was chosen by the "medical examiner of the 400 'co-eds' " at Cornell University as a woman "whose very presence bespeaks perfect health."

Miss Scheel, however, was hardly model-thin. At 5-foot-7 and 171 pounds, she would, by today's medical standards, be clearly overweight. (Her body mass index was 27; 25 to 29.9 is overweight.)

But a new report suggests that Miss Scheel may have been onto something. The report on nearly three million people found that those whose B.M.I. ranked them as overweight had less risk of dying than people of normal weight. And while obese people had a greater mortality risk over all, those at the lowest obesity level (B.M.I. of 30 to 34.9) were not more likely to die than normal-weight people.

The report, although not the first to suggest this relationship between B.M.I. and mortality, is by far the largest and most carefully done, analyzing nearly 100 studies, experts said.

But don't scrap those New Year's weight-loss resolutions and start gorging on fried Belgian waffles or triple cheeseburgers.

Experts not involved in the research said it suggested that overweight people need not panic unless they have other indicators of poor health and that depending on where fat is in the body, it might be protective or even nutritional for older or sicker people. But over all, piling on pounds and becoming more than slightly obese remains dangerous.

"We wouldn't want people to think, 'Well, I can take a pass and gain more weight,' " said Dr. George Blackburn, associate director of Harvard Medical School's nutrition division.

Rather, he and others said, the report, in The Journal of the American Medical Association, suggests that B.M.I., a ratio of height to weight, should not be the only indicator of healthy weight.

"Body mass index is an imperfect measure of the risk of mortality," and factors like blood pressure, cholesterol and blood sugar must be considered, said Dr. Samuel Klein, director of the Center for Human Nutrition at Washington University School of Medicine in St. Louis.

Dr. Steven Heymsfield, executive director of the Pennington Biomedical Research Center in Louisiana, who wrote an editorial accompanying the study, said that for overweight people, if indicators like cholesterol "are in the abnormal range, then that weight is affecting you," but that if indicators are normal, there's no reason to "go on a crash diet."

Experts also said the data suggested that the definition of "normal" B.M.I., 18.5 to 24.9, should be revised, excluding its lowest weights, which might be too thin.

The study did show that the two highest obesity categories (B.M.I. of 35 and up) are at high risk. "Once you have higher obesity, the fat's in the fire," Dr. Blackburn said.

But experts also suggested that concepts of fat be refined.

"Fat per se is not as bad as we thought," said Dr. Kamyar Kalantar-Zadeh, professor of medicine and public health at the University of California, Irvine.

"What is bad is a type of fat that is inside your belly," he said. "Non-belly fat, underneath your skin in your thigh and your butt area — these are not necessarily bad."

He added that, to a point, extra fat is accompanied by extra muscle, which can be healthy.

Still, it is possible that overweight or somewhat obese people are less likely to die because they, or their doctors, have identified other conditions associated with weight gain, like high cholesterol or diabetes.

"You're more likely to be in your doctor's office and more likely to be treated," said Dr. Robert Eckel, a past president of the American Heart Association and a professor at University of Colorado.

Some experts said fat could be protective in some cases, although that is unproven and debated. The study did find that people 65 and over had no greater mortality risk even at high obesity.

"There's something about extra body fat when you're older that is providing some reserve," Dr. Eckel said.

And studies on specific illnesses, like heart and kidney disease, have found an "obesity paradox," that heavier patients are less likely to die.

Still, death is not everything. Even if "being overweight doesn't increase your risk of dying," Dr. Klein said, it "does increase your risk of having diabetes" or other conditions.

Ultimately, said the study's lead author, Katherine Flegal, a senior scientist at the Centers for Disease Control and Prevention, "the best weight might depend on the situation you're in."

Take the perfect woman, Elsie Scheel, in whose "physical makeup there is not a single defect," the Times article said.

This woman who "has never been ill and doesn't know what fear is" loved sports and didn't consume candy, coffee or tea. But she also ate only three meals every two days, and loved beefsteak.

Maybe such seeming contradictions made sense against the societal inconsistencies of that time. After all, her post-college plans involved tilling her father's farm, but "if she were a man, she would study mechanical engineering."

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Letters: Recovery After Trauma

To the Editor:

Re "A New Focus on the 'Post' in Post-Traumatic Stress" (Mind, Dec. 25): Social contexts are well-established predictors of adjustment following trauma. Sexual abuse survivors who are believed and supported following an abuse disclosure fare better than those who are not, and returning veterans' social support predicts P.T.S.D. over and above the extent of military trauma exposure. Interpersonal traumas cause greater psychological scars than do noninterpersonal traumas like accidents or disasters, with the worst outcomes linked to trauma perpetrated by someone to whom the victim was close.

Rachel Goldsmith

New York

The writer is a clinical psychologist.

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F.D.A. Approves Sirturo, a New Tuberculosis Drug

The Food and Drug Administration announced on Monday that it had approved a new treatment for multidrug-resistant tuberculosis that can be used as an alternative when other drugs fail.

The drug, to be called Sirturo, was discovered by scientists at Janssen, the pharmaceuticals unit of Johnson & Johnson, and is the first in a new class of drugs that aims to treat the drug-resistant strain of the disease.

Tuberculosis is a highly infectious disease that is transmitted through the air and usually affects the lungs but can also affect other parts of the body, including the brain and kidneys. It is considered one of the world's most serious public health threats. Although rare in the United States, multidrug-resistant tuberculosis is a growing problem elsewhere in the world, especially in poorer countries. About 12 million people worldwide had tuberculosis in 2011, according to Johnson & Johnson, and about 630,000 had multidrug-resistant TB.

A study in September in The Lancet found that almost 44 percent of patients with tuberculosis in countries like Russia, Peru and Thailand showed resistance to at least one second-line drug, or a medicine used after another drug had already failed.

Treating drug-resistant tuberculosis can take years and can cost 200 times as much as treating the ordinary form of the disease

"This is quite a milestone in the story of therapy for TB," Dr. Paul Stoffels, the chief scientific officer at Johnson & Johnson, said in an interview. He said the approval was the first time in 40 years that the agency had approved a drug that attacked tuberculosis in a different way from the current treatments on the market. Sirturo works by inhibiting an enzyme needed by the tuberculosis bacteria to replicate and spread throughout the body.

Sirturo, also known as bedaquiline, would be used on top of the standard treatment, which is a combination of several drugs. Patients with drug-resistant tuberculosis often must be treated for 18 to 24 months.

Even as it announced the approval, however, the F.D.A. also issued some words of caution.

"Multidrug-resistant tuberculosis poses a serious health threat throughout the world, and Sirturo provides much-needed treatment for patients who have don't have other therapeutic options available," Edward Cox, director of the office of antimicrobial products in the F.D.A.'s center for drug evaluation and research, said in a statement. "However, because the drug also carries some significant risks, doctors should make sure they use it appropriately and only in patients who don't have other treatment options."

The consumer advocacy group Public Citizen opposed approval in a letter to the F.D.A. in mid-December, saying that the results of a limited clinical trial showed that patients using bedaquiline were five times as likely to die than those on the standard drug regimen to treat the disease.

"Given that bedaquiline belongs to an entirely new class of drugs, it is entirely feasible that death in some cases was due to some unmeasured toxicity of the drug," the letter said.

Sirturo carries a so-called black box warning for patients and health care professionals that the drug can affect the heart's electrical activity, which could lead to an abnormal and potentially fatal heart rhythm. The warning also notes deaths in patients treated with Sirturo. Nine patients who received Sirturo died compared with two patients who received a placebo. Five of the deaths in the Sirturo group and all of the deaths in the placebo arm seemed to be related to tuberculosis, but no consistent reason for the deaths in the remaining Sirturo-treated patients could be identified.

Doctors Without Borders and the Bill and Melinda Gates Foundation, both active in the fight against tuberculosis and other global diseases, applauded the F.D.A.'s decision.

Jan Gheuens, interim director of the TB Program for the Gates Foundation, called it a "long-awaited event" and said the fight against TB had not benefited from new drugs in the way H.I.V. had. Beyond the benefits of the drug itself, he said the quick approval process could be a model for other drugs sorely needed in the developing world.

He also suggested, however, that more trials should be conducted to get a better understanding of the side effects that led to the black box warning.

The F.D.A. approved bedaquiline under an accelerated program that allows the agency to conditionally approve drugs that are viewed as filling unmet medical needs with less than the usual evidence that they work. The drug's approval was based on studies that showed it killed bacteria more quickly than a control group taking the standard regimen, but it did not measure whether in the end patients actually fared better on bedaquiline. Johnson & Johnson will conduct larger clinical trials to investigate whether the drug performs as predicted.

In a statement responding to Public Citizen's letter, a spokeswoman for Johnson & Johnson said the company was committed to supporting appropriate use of Sirturo and would "work to ensure Sirturo is used only where treatment alternatives are not available."

Dr. Stoffels said the hope was that other new tuberculosis drugs would also be approved that, when used in combination with bedaquiline, could shorten and simplify the current standard of treatment. "That is still a long time away," he acknowledged, but "this is a first step in a new regimen for TB."

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U.S. Birthrate Dips, Especially for Hispanics

ORLANDO, Fla. — Hispanic women in the United States, who have generally had the highest fertility rates in the country, are choosing to have fewer children. Both immigrant and native-born Latinas had steeper birthrate declines from 2007 to 2010 than other groups, including non-Hispanic whites, blacks and Asians, a drop some demographers and sociologists attribute to changes in the views of many Hispanic women about motherhood.

As a result, in 2011, the American birthrate hit a record low, with 63 births per 1,000 women ages 15 to 44, led by the decline in births to immigrant women. The national birthrate is now about half what it was during the baby boom years, when it peaked in 1957 at 122.7 births per 1,000 women of childbearing age.

The decline in birthrates was steepest among Mexican-American women and women who immigrated from Mexico, at 25.7 percent. This has reversed a trend in which immigrant mothers accounted for a rising share of births in the United States, according to a recent report by the Pew Research Center. In 2010, birthrates among all Hispanics reached their lowest level in 20 years, the center found.

The sudden drop-off, which coincided with the onset of the recession, suggests that attitudes have changed since the days when older generations of Latinos prized large families and more closely followed Roman Catholic teachings, which forbid artificial contraception.

Interviews with young Latinas, as well as reproductive health experts, show that the reasons for deciding to have fewer children are many, involving greater access to information about contraceptives and women's health, as well as higher education.

When Marucci Guzman decided to marry Tom Beard here seven years ago, the idea of having a large family — a Guzman tradition back in Puerto Rico — was out of the question.

"We thought one, maybe two," said Ms. Guzman Beard, who gave birth to a daughter, Attalai, four years ago.

Asked whether Attalai might ever get her wish for a little brother or sister, Ms. Guzman Beard, 29, a vice president at a public service organization, said: "I want to go to law school. I'm married. I work. When do I have time?"

The decisions were not made in a vacuum but amid a sputtering economy, which, interviewees said, weighed heavily on their minds.

Latinos suffered larger percentage declines in household wealth than white, black or Asian households from 2005 to 2009, and, according to the Pew report, their rates of poverty and unemployment also grew more sharply after the recession began.

Prolonged recessions do produce dips in the birthrate, but a drop as large as Latinos have experienced is atypical, said William H. Frey, a sociologist and demographer at the Brookings Institution. "It is surprising," Mr. Frey said. "When you hear about a decrease in the birthrate, you don't expect Latinos to be at the forefront of the trend."

D'Vera Cohn, a senior writer at the Pew Research Center and an author of the report, said that in past recessions, when overall fertility dipped, "it bounced back over time when the economy got better."

"If history repeats itself, that will happen again," she said.

But to Mr. Frey, the decrease has signaled much about the aspirations of young Latinos to become full and permanent members of the upwardly mobile middle class, despite the challenges posed by the struggling economy.

Jersey Garcia, a 37-year-old public health worker in Miami, is in the first generation of her family to live permanently outside of the Dominican Republic, where her maternal and paternal grandmothers had a total of 27 children.

"I have two right now," Ms. Garcia said. "It's just a good number that I can handle."

"Before, I probably would have been pressured to have more," she added. "I think living in the United States, I don't have family members close by to help me, and it takes a village to raise a child. So the feeling is, keep what you have right now."

But that has not been easy. Even with health insurance, Ms. Garcia's preferred method of long-term birth control, an IUD, has been unaffordable. Birth control pills, too, with a $50 co-payment a month, were too costly for her budget. "I couldn't afford it," she said. "So what I've been doing is condoms."

According to research by the National Latina Institute for Reproductive Health, the overwhelming majority of Latinas have used contraception at some point in their lives, but they face economic barriers to consistent use. As a consequence, Latinas still experience unintended pregnancy at a rate higher than non-Hispanic whites, according to the institute.

And while the share of births to teenage mothers has dropped over the past two decades for all women, the highest share of births to teenage mothers is among native-born Hispanics.

"There are still a lot of barriers to information and access to contraception that exist," said Jessica Gonzáles-Rojas, 36, the executive director of the institute, who has one son. "We still need to do a lot of work."

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Employers Must Offer Family Health Care, Affordable or Not, Administration Says

WASHINGTON — In a long-awaited interpretation of the new health care law, the Obama administration said Monday that employers must offer health insurance to employees and their children, but will not be subject to any penalties if family coverage is unaffordable to workers.

The requirement for employers to provide health benefits to employees is a cornerstone of the new law, but the new rules proposed by the Internal Revenue Service said that employers' obligation was to provide affordable insurance to cover their full-time employees. The rules offer no guarantee of affordable insurance for a worker's children or spouse. To avoid a possible tax penalty, the government said, employers with 50 or more full-time employees must offer affordable coverage to those employees. But, it said, the meaning of "affordable" depends entirely on the cost of individual coverage for the employee, what the worker would pay for "self-only coverage."

The new rules, to be published in the Federal Register, create a strong incentive for employers to put money into insurance for their employees rather than dependents. It is unclear whether the spouse and children of an employee will be able to obtain federal subsidies to help them buy coverage — separate from the employee — through insurance exchanges being established in every state. The administration explicitly reserved judgment on that question, which could affect millions of people in families with low and moderate incomes.

Many employers provide family coverage to full-time employees, but many do not. Family coverage is much more expensive, and the employee's share of the premium is typically much larger.

In 2012, according to an annual survey by the Kaiser Family Foundation, premiums for employer-sponsored health insurance averaged $5,615 a year for single coverage and $15,745 for family coverage. The employee's share of the premium averaged $951 for individual coverage and more than four times as much, $4,316, for family coverage.

Starting in 2014, most Americans will be required to have health insurance. Low- and middle-income people can get tax credits to help pay their premiums, unless they have access to affordable coverage from an employer.

In its proposal, the Internal Revenue Service said, "Coverage for an employee under an employer-sponsored plan is affordable if the employee's required contribution for self-only coverage does not exceed 9.5 percent of the employee's household income."

The rules, though labeled a proposal, are more significant than most proposed regulations. The Internal Revenue Service said employers could rely on them in making plans for 2014.

In writing the law, members of Congress often conjured up a picture of employees working year-round at full-time jobs. But in drafting the rules, the I.R.S. wrestled with the complex reality of part-time, seasonal and temporary workers.

In addition, the administration expressed concern that some employers might try to evade the new requirements by firing and rehiring employees, manipulating their work hours or using temporary staffing agencies. The rules include several provisions to prevent such abuse.

The law says an employer with 50 or more full-time employees may be subject to a tax penalty if it fails to offer coverage to "its full-time employees (and their dependents)."

Employers asked for guidance, and the Obama administration provided it, saying that a dependent is an employee's child under the age of 26.

"Dependent does not include the spouse of an employee," the proposed rules say.

Thus, employers must offer coverage to children of an employee, but do not have to make it affordable. And they do not have to offer coverage at all to the spouse of an employee.

The administration said that the rules — which apply to private businesses, nonprofit organizations and state and local government agencies — would require changes at many work sites.

"A number of employers currently offer coverage only to their employees, and not to dependents," the I.R.S. said. "For these employers, expanding their health plans to add dependent coverage will require substantial revisions to their plans."

In view of this challenge, the agency said it would grant a one-time reprieve to employers who fail to offer coverage to dependents of full-time employees, provided they take steps in 2014 to come into compliance. Under the rules, employers must offer coverage to employees in 2014 and must offer coverage to dependents as well, starting in 2015.

The new rules apply to employers that have at least 50 full-time employees or an equivalent combination of full-time and part-time employees. A full-time employee is a person employed on average at least 30 hours a week. And 100 half-time employees are considered equivalent to 50 full-time employees.

Thus, the government said, an employer will be subject to the new requirement if it has 40 full-time employees working 30 hours a week and 20 half-time employees working 15 hours a week.

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F.D.A. Approves Eliquis From Bristol and Pfizer

The Food and Drug Administration on Friday approved Eliquis, an anticlotting drug that has been highly anticipated by cardiologists and is expected to be a blockbuster for Bristol-Myers Squibb, which will make the drug, and Pfizer, which will help market it.

The agency approved Eliquis for reducing the risk of stroke and dangerous blood clots in people with atrial fibrillation, a common heart arrhythmia that afflicts millions of people in the United States.

The drug, also known as apixaban, is the third anticlotting medicine to be approved in recent years and the companies are expected to aggressively compete to pitch their products as a replacement for warfarin, an older treatment that requires more careful monitoring. Warfarin is also known by the brand name Coumadin.

"The marketing games will now begin," said Dr. Sanjay Kaul, a cardiologist at the Cedars-Sinai Medical Center in Los Angeles, who was not involved in the development of any of the drugs.

He said that cardiologists would now have to sort out the differences among Eliquis and its competitors already on the market: Pradaxa, sold by Boehringer Ingelheim, and Xarelto, sold by Johnson & Johnson and Bayer.

While some experts have argued that Eliquis offers the best balance between the drug's benefits and risks, Dr. Kaul said since there have been no clinical trials comparing the three new drugs, "it is impossible to adjudicate which of these new agents is the preferred one."

Bristol-Myers and Pfizer issued a brief statement Friday saying they were pleased with the approval. In a news release in November announcing the drug's approval in Europe, Bristol-Myers noted that Eliquis was the only drug in the group that has shown an advantage over warfarin in reducing the risk of stroke and dangerous blood clots, major bleeding and death.

The agency also warned that patients with prosthetic heart valves should not take Eliquis, nor should patients with atrial fibrillation that is caused by a heart valve problem.

Despite the promise of Eliquis and the other new drugs, some cautioned against prescribing them too enthusiastically.

Dr. Garret FitzGerald, a cardiologist and chairman of pharmacology at the University of Pennsylvania, said the trial results for Eliquis were impressive. But he added in an e-mail on Friday: "What matters to a patient is the individual effect in them."

He noted that patients taking Eliquis also suffered major bleeding episodes and said all drugs that prevent clotting carried a risk of bleeding. "Thus the F.D.A.'s warning to be on the lookout for bleeding seems just as appropriate as approval of Eliquis," he said.

Dr. Kaul says he tends to wait to prescribe new drugs until he learns more from the experience of colleagues, and Eliquis will be no exception. "I'm going to sit back by the sidelines and see how it pans out," he said, adding that he had begun to prescribe Pradaxa and Xarelto to patients.

Eliquis's entry into the United States market has been eagerly anticipated by Bristol-Myers and Pfizer after a succession of delays this year. Bristol-Myers, in particular, has been struggling since its best-selling blood-thinner drug, Plavix, lost its patent protection in May. Sales of Plavix, which Bristol-Myers sells in partnership with Sanofi, fell 96 percent in the third quarter of this year after cheaper generic alternatives flooded the market and the company has struggled to replace the lost sales.

Eliquis is "very important for Bristol because it's one of the legs of their investment case, that they can leapfrog over the Plavix expiration," said Les Funtleyder, the fund manager of Poliwogg, a private equity and hedge fund. He said he expected Eliquis to eventually earn more than $1 billion for its sellers.

In such a crowded field of competitors, Mr. Funtleyder said, consumers and doctors should brace themselves for a marketing onslaught. "I wonder if we'll see our first Eliquis commercial before the new year," he said.

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Well: Food Myths

Let's start the new year on scientifically sound footing by addressing some nutritional falsehoods that circulate widely in cyberspace, locker rooms, supermarkets and health food stores. As a result, millions of people are squandering hard-earned dollars on questionable, even hazardous foods and supplements.

For starters, when did "chemical" become a dirty word? That's a question raised by one of Canada's brightest scientific minds: Joe Schwarcz, director of the Office for Science and Society at McGill University in Montreal. Dr. Schwarcz, who has received high honors from Canadian and American scientific societies, is the author of several best-selling books that attempt to set the record straight on a host of issues that commonly concern health-conscious people.

I've read two of his books, "Science, Sense and Nonsense" (published in 2009) and "The Right Chemistry" (2012), and recently attended a symposium on the science of food that Dr. Schwarcz organized at McGill.

What follows are tips from his books and the symposium that can help you make wiser choices about what does, and does not, pass your lips in 2013.

CURED MEATS Many health-conscious people avoid cured meats like hot dogs and bacon because the nitrites with which they are preserved can react with naturally occurring amines to form nitrosamines. Nitrosamines have produced mutations in cells cultured in the laboratory and cancer in animals treated with very high doses.

As an alternative, sandwich lovers often buy organic versions of processed meats or products without added nitrites. Without preservatives, these foods may not be protected from bacterial contamination. And despite their labels, they may contain nitrites. According to Dr. Schwarcz, organic processed meats labeled "uncured" may be preserved with highly concentrated, nitrate-rich celery juice treated with a bacterial culture that produces nitrites.

If you're really concerned about your health, you'd be wise to steer clear of processed meats — organic, nitrite-free or otherwise. High saturated fat and salt content place them low on the nutritional totem pole.

MEAT GLUE Never heard of it? You may have eaten it, especially if you dine out often. At WD-50 in New York, the chef, Wylie Dufresne, makes his famous shrimp noodles with the enzyme transglutaminase, a k a meat glue. It binds protein molecules, gluing together small pieces of fish, meat or poultry.

The Japanese use meat glue to create artificial crab meat from pollock. Others use it to combine lamb and scallops, or to make sausages that hold together without casings.

Sound frightening? It shouldn't. The enzyme is classified by the Food and Drug Administration as "generally recognized as safe," and there is no reason to think otherwise. Our bodies produce it to help blood clot, Dr. Schwarcz points out. When consumed, it breaks down like any protein into its component amino acids in our digestive tracts.

There is, however, one possible indirect hazard: If glued-together animal protein is not thoroughly cooked, dangerous bacteria that originally contaminated the meat could remain viable within the fused product.

TRANS FATS The removal of heart-damaging trans fats from processed foods is a much-ballyhooed boon to health. But "not all trans fats are fiends," Dr. Schwarcz notes. Certain ones can legally, and healthfully, be added to dairy products, meal-replacement bars, soy milk and fruit juice.

The word "trans" refers to the arrangement of hydrogen and carbon atoms in a fatty acid. The trans formation linked to heart disease is formed when vegetable oils are hardened to prolong shelf life in a manufacturing process called hydrogenation. Natural trans fats, like those in meat and dairy products, take a slightly different form, resulting in an entirely different effect on health.

The most widely consumed "good" trans fat is conjugated linoleic acid, which research has shown can help weight-conscious people lose fat and gain muscle. Various studies have suggested that C.L.A., now widely sold as a supplement, also can enhance immune function and reduce atherosclerosis, high blood pressure and inflammation.

ORGANIC OR NOT? Wherever I shop for food these days, I find an ever-widening array of food products labeled "organic" and "natural." But are consumers getting the health benefits they pay a premium for?

Until the 20th century, Dr. Schwarcz wrote, all farming was "organic," with manure and compost used as fertilizer and "natural" compounds of arsenic, mercury and lead used as pesticides.

Might manure used today on organic farms contain disease-causing micro-organisms? Might organic produce unprotected by insecticides harbor cancer-causing molds? It's a possibility, Dr. Schwarcz said. But consumers aren't looking beyond the organic sales pitch.

Also questionable is whether organic foods, which are certainly kinder to the environment, are more nutritious. Though some may contain slightly higher levels of essential micronutrients, like vitamin C, the difference between them and conventionally grown crops may depend more on where they are produced than how.

A further concern: Organic producers disavow genetic modification, which can be used to improve a crop's nutritional content, enhance resistance to pests and diminish its need for water. A genetically modified tomato developed at the University of Exeter, for example, contains nearly 80 times the antioxidants of conventional tomatoes. Healthier, yes — but it can't be called organic.

FARMED SALMON Most of the salmon consumed nowadays is farmed. Even if we all could afford the wild variety, there's simply not enough of it to satisfy the current demand for this heart-healthy fish.

There may be legitimate concerns about possible pollutants in farmed salmon, but one concern that is a nonissue involves that "salmon" color, produced by adding astaxanthin to fish feed. This commercially made pigment is an antioxidant found naturally in algae, and it is carried up the food chain to give wild salmon its color, too.

NUTS Growing up, I was often warned to avoid nuts because they're "fattening." Now I know better. Although about three-fourths of the calories in peanuts, for example, come from fat, people who regularly eat nuts and nut butters in normal amounts weigh less, on average, than nut avoiders.

The fat in nuts is unsaturated and heart-healthy. Nuts are also good sources of protein, antioxidants, vitamins, minerals and fiber, and can help keep between-meal hunger at bay. The same is true of avocados — just don't go overboard.

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