New Attention to First Lady

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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DealBook: Mylan Buys Drug Maker of Generic Injectables

The drug maker Mylan announced on Wednesday that it was acquiring Agila Specialties Private, an Indian manufacturer of generic injectable drugs, for $1.6 billion in cash.

The move would double Mylan's presence in the injectable-drug market, a fast-growing segment of the generic drug industry that has been troubled by major quality and supply problems in recent years.

Mylan's chief executive, Heather Bresch, said in a telephone interview that the acquisition, expected to be completed in the fourth quarter, would help expand the company's presence in emerging overseas markets and establish it as a major player in the injectables market. Mylan expects the injectables market to grow by 13 percent a year through 2017.

Despite this growth, however, most major manufacturers of injectable drugs have suffered from serious supply and quality problems in recent years, leading to recalls and a nationwide shortage of critical products like chemotherapy drugs.

Ms. Bresch said Mylan's recognizable brand — it is one of the world's largest makers of generic drugs — would set it apart from its competitors.

"Our ability to bring real quality leadership in this space is our real opportunity," she said.

In the past, the injectable business was so competitive that companies drove prices too low, said Rajiv Malik, Mylan's president. But now that several large manufacturers — including Hospira, Sandoz and Teva — have invested millions of dollars in upgrading their plants, that picture has changed.

"I think they won't be chasing the floor anymore anytime soon," he said.

Mylan is acquiring Agila from the Indian pharmaceutical company Strides Arcolab.

Agila, which is based in Bangalore, sells more than 300 products worldwide, including 61 drugs in the United States. It has nine manufacturing facilities in India, Poland and Brazil, and Mylan says the company has a strong presence in emerging markets like Brazil.

Mylan, based near Pittsburgh, Pa., said it had received a commitment letter from Morgan Stanley for a $1 billion senior unsecured bridge term loan, which would be used in combination with the company's existing cash and other lines of credit to pay for the acquisition.

Morgan Stanley is serving as financial adviser to Mylan, and Skadden, Arps, Slate, Meagher & Flom is the legal adviser, assisted by Slaughter and May and Platinum Partners.

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Ex-Hostess at Lavo Sues, Claiming Loud Music Damaged Her Hearing

Alexis Clemente knew the music was extraordinarily loud at Lavo, the celebrity playpen in Midtown Manhattan where she worked for two years as a hostess.

She could feel the bass thumping in her throat. Cocktail glasses bounced. Heavy vases shimmied along surfaces to the beat. But it was not until last summer, when the club's owners, prompted by an article in The New York Times about dangerous noise levels, had employees' hearing tested, that Ms. Clemente discovered the damage that she said had been wrought.

Ms. Clemente had significant hearing loss in her right ear, most likely caused by noise exposure, an audiologist found. She was told to immediately stop working in loud environments to prevent it from getting worse.

"I was hysterically crying," Ms. Clemente recalled this week. After the test, she told her supervisors about the results, she said, and asked to be placed at the door, slightly removed from the din. But her employers refused, she said, failed to offer her another position, fired her and canceled her health insurance.

This week, she sued. The suit, filed in State Supreme Court in Manhattan, was reported this week by The New York Post.

"I had tremendous gratitude for this job," Ms. Clemente, who is unemployed, said, sitting alongside her lawyer, Russell Moriarty, in the offices of Levine & Blit, at times choking up as she spoke. "All I cared about was sticking with them and working. They went above and beyond to make sure that that didn't happen."

Lavo opened on East 58th Street in 2010, the counterpart to the wildly successful Lavo restaurant and nightclub in Las Vegas, which is owned by the night-life wunderkinder Noah Tepperberg, Jason Strauss, Marc Packer and Richard Wolf. Together and separately, they had birthed some of the country's hottest nightclubs, among them Tao, Avenue and Marquee, alchemizing an alluring combination of models and bottles: the rich, the powerful, the famous; people willing to shell out several thousand dollars to book a table and drink; as well as regular earthlings along for the ride.

For employees, the lucre trickled down. Ms. Clemente's hourly wage was $42, she said, plus tips. Employees had health care coverage and often spent part of the summers in the South of France. The job allowed her to pursue careers in acting and modeling. "People would cut off their arm to work there," she said.

Ms. Clemente's job involved ushering guests downstairs into the pounding club, which sits beneath Lavo's restaurant, at 39 East 58th Street. To protect her hearing, she wore silicone earplugs. But their efficacy was thwarted by the radio headset she wore in one ear, cranked up over the music, to communicate with other workers and handle logistical issues.

She often complained about the noise, she said, but her employers did not take action until last summer, after The Times recorded and reported volumes averaging 96 decibels, akin to a power mower, in Lavo's restaurant. Legally, workers should not be exposed to that volume for over three and a half hours without ear protection. And Lavo employees said the volumes at the downstairs club were far worse.

Lavo began offering its employees earplugs and hearing tests, said Ms. Clemente, who declined to give her age. It was then that she discovered her hearing loss. Initially, she said, one of the club's executives said she could probably work at the door, but she was later told that would not happen. She was also charged retroactively, she said, for additional tests and treatment related to her hearing damage.

David Jaroslawicz, a lawyer who represents Lavo, though not in this case, said there were numerous meetings between Ms. Clemente and the Lavo executives and that she was offered "numerous" positions. "This unfortunately deteriorated to where she decided she was going to take a shot and buy a lottery ticket in the form of a lawsuit," he said.

Because hearing loss is cumulative, proving that Ms. Clemente's hearing damage was caused by working at Lavo will be difficult, several audiologists said. "If she didn't have a hearing test prior to this episode, it's hard to pinpoint that as the cause," said Kevin O'Flaherty, an audiologist at Manhattan Audiological Services.

Yet Ms. Clemente (who sued under her legal name, Margaret Clemente) said she had never been subjected to such loud volumes before working at Lavo. Although she had worked for several years at other nightclubs, she said, she worked at the door, insulated from loud music.

"The only time I've been exposed to this kind of noise was at Lavo," she said. "My hearing was damaged and I was let go."

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Well: Think Like a Doctor: The Man Who Wobbled

The Challenge: Can you solve the medical mystery of a man who suddenly becomes too dizzy to walk?

Every month, the Diagnosis column of The New York Times Magazine asks Well readers to try their hand at solving a medical mystery. Below you will find the story of a 56-year-old factory worker with dizziness and panic attacks. I have provided records from his two hospital visits that will give you all the information available to the doctor who finally made the diagnosis.

The first reader to offer the correct diagnosis gets a signed copy of my book, "Every Patient Tells a Story," and the satisfaction of solving a case that stumped a roomful of specialists.

The Patient's Story:

The middle-aged man clicked his way through the multiple reruns of late-late-night television. He should have been in bed hours ago, but lately he hadn't been able to get to sleep. Suddenly his legs took on a life of their own. Stretched out halfway to the center of the room, they began to shake and twitch and jump around. The man watched helplessly as his legs disobeyed his mental orders to stop moving. He had no control over them. He felt nauseous, sweaty and out of breath, as if he had been running some kind of race. He called out to his wife. She hurried out of bed, took one look at him and called 911.

The Patient's History:

By the time the man arrived at Huntsville Hospital, in Alabama, the twitching in his legs had subsided and his breathing had returned to normal. Still, he had been discharged from that same hospital for similar symptoms just two weeks earlier. They hadn't figured out what was going on then, so they weren't going to send him home now.

The patient considered himself pretty healthy, but the past year or so had been tough. In 2011, at the age of 54, he had had a mild stroke. He had no medical problems that put him at risk for stroke — no high blood pressure, no high cholesterol, no diabetes. A work-up at that time showed that he had a hole in his heart that allowed a tiny clot from somewhere in his body to travel to the brain and cause the stroke. He was discharged on a couple of blood thinners to keep his blood from making more clots. He hadn't really felt completely well, though, ever since. His balance seemed a little off, and he was subject to these weird panic attacks, in which his heart would pound and he would feel short of breath whenever he got too stressed. Mostly he could manage them by just walking away and focusing on his breathing. Still, he never felt as if he was the kind of guy to panic.

And he had always been quick on his feet. The first half of his career he had been in the steel business — building huge metal trusses and supports. He and his team put together 60-plus tons of steel structures every day. For the past decade he had been machining car parts. After his stroke, work seemed to get a lot harder.

The Dizziness:

A few weeks ago, he stood up and wham — suddenly the whole world went off-kilter. He felt as if he was constantly about to fall over in a world that no longer lay down flat. His first thought was that he was having another stroke. He went straight to his doctor's office. The doctor wasn't sure what was going on and sent him to that same emergency room at Huntsville Hospital. After three days of testing and being evaluated by lots of specialists, his doctors still were not sure what was going on. He hadn't had a heart attack; he hadn't had a stroke. There was no sign of infection. All the tests they could think of were normal.

The only abnormal finding was that when he stood up, his blood pressure dropped. Why this happened wasn't clear, but the doctors in the hospital gave him compression stockings and a pill — both could help keep his blood pressure in the normal range. Then they sent him home. He was also started on an antidepressant to help with the panic attacks he continued to have from time to time.

You can read the report from that hospital admission below.

You can also read the consultation and discharge notes from that hospital visit here.

He had been home for nearly two weeks and still he felt no better. He tried to go back to work after a week or so at home, but after driving for less than five miles, he felt he had to turn around. He wasn't sure what was wrong; he just knew he didn't feel right. Then his legs started jumping around, and he ended up back in the hospital.

The Doctor's Exam:

It was nearly dawn by the time Dr. Jeremy Thompson, the first-year resident on duty that night, saw the patient. Awake but tired, the patient told his story one more time. He had been at home, watching TV, when his legs started jumping on their own and he started feeling short of breath. His wife sat at the bedside. She looked just as worried and exhausted as he did. She told the resident that when he spoke that night at home, his speech was slurred. And when the ambulance came, he could barely walk. He has never missed this much work, she told the young doctor. It's not like him. Can't you figure out what's wrong?

The resident had already reviewed the records from the patient's previous hospital admissions. He asked a few more questions: the patient had never smoked and rarely drank; his father died at age 80; his mother was still alive and well. The patient exam was normal, as were the studies done in the E.R.

The first E.R. doctor thought that his symptoms were a result of anxiety, culminating in a full-blown panic attack. The resident thought that was probably right. In any case he would discuss the case with the attending in a couple of hours during rounds on the new patients. Till then, he told the worried couple, they should just try to get a little sleep.

An Important Clue:

Dr. Robert Centor was definitely a morning person. His cheerful enthusiasm about teaching and taking care of patients made him a favorite among residents. At 7:30 that morning, he stood outside the patient's door as Dr. Thompson relayed the somewhat frustrating case of the middle-aged man with worsening dizziness and panic attacks. Then they went into the room to meet the patient. He was a big guy, tall and muscular with the first signs of middle-aged thickening around his middle. His complexion had the look of someone who spent a lot of time outdoors. Dr. Centor introduced himself and pulled up a chair as the rest of the team watched. He asked the patient what brought him to the hospital.

"Every time I get up, I get dizzy," the man replied. Sure, he had had some balance problems ever since his stroke, he explained, but this felt different – somehow worse. He could hardly walk, he told the doctor. He just felt too unstable.

"Can you get up and show us how you walk?" Dr. Centor asked.

"Don't let me fall," the patient responded. He carefully swung his legs over the side of the bed. The resident and intern stood on either side as he slowly rose. He stood with his feet far apart. When asked to close his eyes as he stood there, he wobbled and nearly fell over. When he took a few steps, his heel and toes hit the ground at the same time, making a strange slapping sound.

Seeing that, Dr. Centor knew where the problem lay and ordered a few tests to confirm his diagnosis.

You can see the review report and notes for the patient's second hospital visit below.

Solving the Mystery:

What tests did Dr. Centor order? Do you know what is making this middle-aged man wobble? Enter your guesses below. I'll post the answer tomorrow.

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Rules and Regulations: Post your questions and diagnosis in the Comments section below. The correct answer will appear tomorrow on Well. The winner will be contacted. Reader comments may also appear in a coming issue of The New York Times Magazine.

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Economic Scene: Medicare Needs Fixing, but Not Right Now

What's the rush? For all the white-knuckled wrangling over spending cuts set to start on Friday, the fundamental partisan argument over how to fix the government's finances is not about the immediate future. It is about the much longer term: how will the nation pay for the care of older Americans as the vast baby boom generation retires? Will the government keep Medicare spending in check by asking older Americans to shoulder more costs? Should we raise taxes instead?

It might not be a good idea to try to resolve these questions quite so urgently. Partisan bickering under the threat of automatic budget cuts is unlikely to produce a calm, thoughtful deal.

"We don't have to solve this tomorrow; not even next year," said Jonathan Gruber, an economist at the Massachusetts Institute of Technology who worked on the design of President Obama's health care reform.

More significantly perhaps, some economists point out that the problem may already be on the way toward largely fixing itself. The budget-busting rise in health care costs, it seems, is finally losing speed. While it would be foolhardy to assume that this alone will stabilize government's finances, the slowdown offers hope that the challenge may not be as daunting as the frenzied declarations from Washington make it seem.

The growth of the nation's spending slowed sharply over the last four years. This year, it is expected to increase only 3.8 percent, according to the Centers for Medicare and Medicaid Services, the slowest pace in four decades and slower than the rate of nominal economic growth.

Medicare spending is growing faster — stretched by baby boomers stepping out of the work force and into retirement. But its pace has slowed markedly, too. Earlier this month, the Congressional Budget Office said that by 2020 Medicare spending would be $126 billion less than it predicted three years ago. Spending over the coming decade, it added, would be $143 billion less than it forecast just last August.

While economists acknowledge that the recession accounts for part of the decline, depressing incomes and consumption, something else also seems to be going on: insurers, doctors, hospitals and other providers are experimenting with new, cheaper and more efficient ways to deliver care.

Prodded by President Obama's Affordable Care Act, which offers providers a share of savings reaped by Medicare from any efficiency gains, many doctors are dropping the costly practice of charging a fee for each service regardless of its contribution to patients' health. Doctors are joining hundreds of so-called Accountable Care Organizations, which are paid to maintain patients in good health and are thus encouraged to seek the most effective treatments at the lowest possible cost.

This has kindled hope among some scholars that Medicare could achieve the needed savings just by cleaning out the health care system's waste.

Elliott Fisher, who directs Dartmouth's Atlas of Health Care, which tracks disparities in medical practices and outcomes across the country, pointed out that Medicare spending per person varies widely regardless of quality — from $7,734 a year in Minneapolis to $11,646 in Chicago — even after correcting for the different age, sex and race profiles of their populations.

He noted that if hospital stays by Medicare enrollees across the country fell to the length prevailing in Oregon and Washington, hospital use — one of the biggest drivers of costs — would fall by almost a third.

"Twenty to 30 percent of Medicare spending is pure waste," Dr. Fisher argues. "The challenge of getting those savings is nontrivial. But those kinds of savings are not out of the question."

We could be disappointed, of course. Similar breakthroughs before have quickly fizzled. Just think back to that brief spell in the mid-1990s when health maintenance organizations seemed to beat health care inflation — until patients rebelled against being denied services and doctors dropped out of their networks rather than accept lower fees.

The Centers for Medicare and Medicaid Services already expects spending to rebound in coming years. Without tougher cost control devices, be it vouchers to limit government spending or direct government rationing, counting on savings of the scale needed to overcome the expected increase in Medicare rolls may be hoping for pie in the sky.

"It makes no sense," said Eugene Steuerle, an economist at the Urban Institute, to expect the government will reap vast Medicare savings without having an impact on the quality of care.

The Affordable Care Act already contemplates fairly big cuts to Medicare. In its latest long-term projections published last year, the Congressional Budget Office estimated that under current law, growth in spending per beneficiary over the coming decade would be about half a percentage point slower than the rate of economic growth per person.

To understand how ambitious this is, consider that Medicare spending per beneficiary since 1985 has exceeded the growth of gross domestic product per person by about 1.5 percentage points per year. Slowing down that spending would require deep cuts in doctor reimbursements that, though written into law, Congress has never allowed to happen — repeatedly voting to cancel or postpone them.

Under a more realistic situation, the Budget Office projected that the growth of Medicare spending per capita over the next 10 years would be in fact 0.6 percentage points higher than under current law and accelerate further after that.

Yet despite the ambition of these targets, they would not be enough to stabilize future Medicare spending as a share of the economy. A report by three health care policy experts, Michael Chernew and Richard Frank of Harvard Medical School, together with Stephen Parente of the University of Minnesota, concluded that to do that would require limiting the growth of spending per beneficiary at 1.25 percentage points less than the growth of our gross domestic product per person.

"The Affordable Care Act places Medicare spending on a trajectory that is historically low," Mr. Chernew said, noting his opinion was not an official statement as vice chairman of Medicare's Payment Advisory Commission, which advises Congress on Medicare. "Could we do better? Of course. Will we? That requires a little more skepticism."

Yet even if it is unrealistic to expect that newfound efficiencies will stabilize Medicare's finances, the slowdown in health care spending suggests that politicians in Washington calm down. It offers, at the very least, more breathing room to carefully consider reforms to the system to raise revenue or trim benefits in the least damaging way.

There are many ideas out there — from changing Medicare's premiums, deductibles and coinsurance to introducing a tax on carbon emissions to raise revenue. Some of them are not as good as others. Until recently, President Obama favored increasing the eligibility age for Medicare. Then research by the Kaiser Family Foundation concluded that raising the age would increase insurance premiums and cost businesses, beneficiaries and states more than the federal government would save. The nation would lose money in the deal.

"As we do this, there are smarter and dumber ways to do it," Mr. Gruber said. "It would be a problem if we were to do things in a panic mode that set us backward."

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N.F.L. Will Use IPads to Expand In-Game Concussion Testing

"Where are we?" "Who did we play in the last game?" "What is the date today?"

Those are some of the questions N.F.L. players are asked after they are hit in the head during a game. Next season, they are coming to an iPad.

The mandatory postinjury sideline concussion assessment tool, instituted for the 2012 season along with a baseline test done during physicals at the start of preseason, will now be used in app form by all 32 teams, a method that was tried by a handful of teams in a pilot program last season. The hope is that being able to compare the results of a baseline test and a postinjury test side by side in real time will speed diagnosis and help doctors and trainers recognize when a player should be removed from a game. The league also plans to have independent neurological consultants on the sideline during each game to assist the team physician in diagnosing and treating players.

The players union, which had pushed strongly for independent doctors to be on the sideline, said it was encouraged by the technological advance the new test represented, but it still had questions about how much power the independent consultants would have to make decisions about players. The union wants the independent sideline concussion experts to have almost exclusive authority in detecting concussions and administering tests, in part because it believes team doctors are often busy attending to other injured players, while the concussion experts are there for one reason.

"If you're busy and didn't see the play, how do you know you need us?" said Dr. Thomas Mayer, the union's medical director. "This is a big enough issue we need an extra set of eyes, an extra judgment."

The postinjury test is quick — it takes about six to eight minutes — and shares many elements with the baseline test to allow a comparison that might indicate a decline in function. Both include a section on the players' concussion history and a 24-symptom checklist; players are asked to score themselves on a scale of 1 to 6 in categories like dizziness, confusion, irritability and sleep problems. Both note any abnormal pupil reaction or neck pain. There is a balance test and a concentration test, in which players, who are usually brought to the locker room to be evaluated, are asked to say the months of the year in reverse order, to recite a string of numbers backward and to remember a collection of words three times. Then they are asked to recall them again, without warning, at least five minutes later. The words and sequence of numbers may be changed from test to test, so players cannot memorize them from a previous test to mask concussion symptoms — a fact that has annoyed players, according to Dr. Margot Putukian, the director of athletic medicine at Princeton University Health Services and a member of the N.F.L.'s Head, Neck and Spine Committee.

On the postinjury tests, there is one different element: a series of five questions designed to test orientation and glean how confused a player might be at that moment. They are: Where are we? What quarter is it right now? Who scored last in the practice or game? Did we win the last game? Those questions, known as Maddocks questions, were developed in the 1990s by an Australian doctor who worked with players in Australian rules football.

"What the application does, when you are evaluating the athlete, you actually see — as they are doing their word recall — his baseline," said Putukian, who added that it was her understanding that team doctors would administer the tests. "He was able to remember 15 out of 15 words, and now he's having trouble giving you five back right away? Maybe he's only able to remember two? It gives you real-time information."

The tests are far from perfect tools for diagnosing concussions. Some doctors are concerned the N.F.L. tests are trying to reduce concussion evaluation to ticking items off a checklist, a problem Putukian acknowledged, emphasizing the importance of having doctors familiar with the players evaluate them. Last season, Jets running back Shonn Greene took a hit to his helmet in a game and walked unsteadily back toward the huddle before quarterback Mark Sanchez sent him off. Greene later returned to the game, and the Jets said he had passed concussion tests given in the locker room. Also last season, San Francisco quarterback Alex Smith took a hit that caused blurred vision, but he remained in the game for several plays and completed a touchdown pass before being removed. He was subsequently found to have a concussion. While he was out, the backup Colin Kaepernick took over, and Smith effectively lost his starting job.

"I think we have to be careful," Putukian said. "The tool, it's not the be-all, end-all. There are going to be athletes who have concussions that this tool does not pick up. It's not a perfect test. Nor is there one. We don't have one that is a perfect test."

She added: "Athletes may take this and perform this test and do fine on it. But you may know the athlete, athletes will stumble through it — 'Yeah, we played the Seawhawks' — you know they are struggling. It's not bang, bang, bang. They'll give you the right answers, but they are struggling. If you know that athlete, you say: 'I know you passed the test, but I know you. You're not O.K.' "

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A Wave of Concussions Hits the N.H.L.

Gene J. Puskar/Associated Press

The Penguins' Evgeni Malkin after sliding into the boards and banging his head.

For the last two seasons, concussions and hits to the head were frequent talking points in the N.H.L., with the Pittsburgh Penguins star Sidney Crosby serving as the catalyst.

As the lockout dragged on for more than four months, though, the conversation shifted from player safety to revenue percentages and competitive balance. The first few weeks of the shortened 48-game season passed without much talk of concussions.

But in the past two weeks, 11 N.H.L. players are believed to have sustained them, among them Crosby's teammate and the reigning most valuable player, Evgeni Malkin, thrusting the issue of head injuries back into the spotlight.

Concussions continue to plague the league, despite its increased emphasis on reducing them. For the second season, the N.H.L. is playing under its broadened version of Rule 48, which penalizes hits that target an opponent's head or make the head the principal point of contact. But many of the recent injuries, including Malkin's, were not caused by hits deemed worthy of fines or suspensions.

Last season, according to CBC network estimates, about 90 players missed games because of concussions, about 13 percent of N.H.L. players on active rosters on a given night. Crosby missed 60 games while recovering from a concussion he sustained in the 2011 Winter Classic.

Malkin, who has 4 goals and 17 assists in 18 games this season, received a concussion diagnosis Sunday, two days after he fell awkwardly into the end boards following a routine shove from Florida's Erik Gudbranson. Malkin slid back-first into the boards, causing his head to snap sharply backward and strike the boards.

Penguins Coach Dan Bylsma said Malkin initially had short-term memory loss but was improving. The team placed Malkin on injured reserve Monday, retroactive to Sunday. A player on injured reserve is ineligible to play for a minimum of seven days, meaning the soonest Malkin can be reactivated is next Sunday.

"There's not a specific schedule for that right now in terms of physical activity," Bylsma told reporters Tuesday in Sunrise, Fla., where the Penguins played the Panthers again.

"The protocol and resting with a concussion, he's following that right now," Bylsma added.

The Penguins, who lead the Atlantic Division, have a new medical team this season, headed by Dr. Christopher Harner of the University of Pittsburgh Medical Center, where the team is planning to open a training, sports medicine and performance facility. The Penguins announced in the summer that they had ended their association with their longtime team doctor, Charles Burke.

The team and Burke said that their parting was amicable and not related to Crosby's 14-month concussion saga. Penguins President David Morehouse said the team "wanted to have enhanced medical coverage for our players," which included having doctors travel with the team.

Perhaps because of their history with Crosby, the Penguins are among the N.H.L.'s most transparent teams in disclosing concussions, and General Manager Ray Shero is considered a progressive voice in support of tighter rules governing hits to the head and concussion protocol.

A lack of openness about concussions can make it difficult to have an accurate accounting of head injuries. Among the other players with recently announced head injuries are the 20-year-old Carolina forward Jeff Skinner, who missed 16 games last season with a concussion; St. Louis's high-scoring rookie Vladimir Tarasenko; another top rookie, Brendan Gallagher of Montreal; and Devils winger Ryan Carter.

Under N.H.L. regulations, clubs are not required to disclose the specific nature of a player's injury. But they are not permitted to give out false or misleading information about an injury.

The Columbus Blue Jackets' announcement that Artem Anisimov is out with an "upper body injury" is allowed under those guidelines, even though he was taken off the ice in Detroit on a stretcher Thursday after his head was driven into the ice by the elbow of a falling Red Wing, Kyle Quincey.

The Rangers do not always disclose players' concussions. Rick Nash and Ryan McDonagh are believed to be out of the lineup with concussions, but the team has issued no details regarding their conditions. Forward Darroll Powe was sidelined with a confirmed concussion Feb. 17, but returned to play on Tuesday.

Nash, who has missed four games, returned to practice Tuesday and told reporters that his absence was because of a "number of things." He declined to confirm or deny that a concussion was among the injuries.

The Rangers have been reluctant to disclose concussions in the recent past. In January 2011, they revealed that the enforcer Derek Boogaard had sustained a concussion in a fight about a month earlier, and in September 2011 they disclosed that defenseman Marc Staal had played more than two months at the end of the previous season with concussion symptoms. Staal did not return to game action until the 2012 Winter Classic.

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Well: What Housework Has to Do With Waistlines

Phys Ed

Gretchen Reynolds on the science of fitness.

One reason so many American women are overweight may be that we are vacuuming and doing laundry less often, according to a new study that, while scrupulously even-handed, is likely to stir controversy and emotions.

The study, published this month in PLoS One, is a follow-up to an influential 2011 report which used data from the U.S. Bureau of Labor Statistics to determine that, during the past 50 years, most American workers began sitting down on the job. Physical activity at work, such as walking or lifting, almost vanished, according to the data, with workers now spending most of their time seated before a computer or talking on the phone. Consequently, the authors found, the average American worker was burning almost 150 fewer calories daily at work than his or her employed parents had, a change that had materially contributed to the rise in obesity during the same time frame, especially among men, the authors concluded.

But that study, while fascinating, was narrow, focusing only on people with formal jobs. It overlooked a large segment of the population, namely a lot of women.

"Fifty years ago, a majority of women did not work outside of the home," said Edward Archer, a research fellow with the Arnold School of Public Health at the University of South Carolina in Columbia, and lead author of the new study.

So, in collaboration with many of the authors of the earlier study of occupational physical activity, Dr. Archer set out to find data about how women had once spent their hours at home and whether and how their patterns of movement had changed over the years.

He found the information he needed in the American Heritage Time Use Study, a remarkable archive of "time-use diaries" provided by thousands of women beginning in 1965. Because Dr. Archer wished to examine how women in a variety of circumstances spent their time around the house, he gathered diaries from both working and non-employed women, starting with those in 1965 and extending through 2010.

He and his colleagues then pulled data from the diaries about how many hours the women were spending in various activities, how many calories they likely were expending in each of those tasks, and how the activities and associated energy expenditures changed over the years.

As it turned out, their findings broadly echoed those of the occupational time-use study. Women, they found, once had been quite physically active around the house, spending, in 1965, an average of 25.7 hours a week cleaning, cooking and doing laundry. Those activities, whatever their social freight, required the expenditure of considerable energy. (The authors did not include child care time in their calculations, since the women's diary entries related to child care were inconsistent and often overlapped those of other activities.) In general at that time, working women devoted somewhat fewer hours to housework, while those not employed outside the home spent more.

Forty-five years later, in 2010, things had changed dramatically. By then, the time-use diaries showed, women were spending an average of 13.3 hours per week on housework.

More striking, the diary entries showed, women at home were now spending far more hours sitting in front of a screen. In 1965, women typically had spent about eight hours a week sitting and watching television. (Home computers weren't invented yet.)

By 2010, those hours had more than doubled, to 16.5 hours per week. In essence, women had exchanged time spent in active pursuits, like vacuuming, for time spent being sedentary.

In the process, they had also greatly reduced the number of calories that they typically expended during their hours at home. According to the authors' calculations, American women not employed outside the home were burning about 360 fewer calories every day in 2010 than they had in 1965, with working women burning about 132 fewer calories at home each day in 2010 than in 1965.

"Those are large reductions in energy expenditure," Dr. Archer said, and would result, over the years, in significant weight gain without reductions in caloric intake.

What his study suggests, Dr. Archer continued, is that "we need to start finding ways to incorporate movement back into" the hours spent at home.

This does not mean, he said, that women — or men — should be doing more housework. For one thing, the effort involved is such activities today is less than it once was. Using modern, gliding vacuum cleaners is less taxing than struggling with the clunky, heavy machines once available, and thank goodness for that.

Nor is more time spent helping around the house a guarantee of more activity, over all. A telling 2012 study of television viewing habits found that when men increased the number of hours they spent on housework, they also greatly increased the hours they spent sitting in front of the TV, presumably because it was there and beckoning.

Instead, Dr. Archer said, we should start consciously tracking what we do when we are at home and try to reduce the amount of time spent sitting. "Walk to the mailbox," he said. Chop vegetables in the kitchen. Play ball with your, or a neighbor's, dog. Chivvy your spouse into helping you fold sheets. "The data clearly shows," Dr. Archer said, that even at home, we need to be in motion.

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Global Health: After Measles Success, Rwanda to Get Rubella Vaccine

Rwanda has been so successful at fighting measles that next month it will be the first country to get donor support to move to the next stage — fighting rubella too.

On March 11, it will hold a nationwide three-day vaccination campaign with a combined measles-rubella vaccine, hoping to reach nearly five million children up to age 14. It will then integrate the dual vaccine into its national health service.

Rwanda can do so "because they've done such a good job on measles," said Christine McNab, a spokeswoman for the Measles and Rubella Initiative, which will provide the vaccine and help pay for the campaign.

Rubella, also called German measles, causes a rash that is very similar to the measles rash, making it hard for health workers to tell the difference.

Rubella is generally mild, even in children, but in pregnant women, it can kill the fetus or cause serious birth defects, including blindness, deafness, mental retardation and chronic heart damage.

Ms. McNab said that Rwanda had proved that it can suppress measles and identify rubella, and it would benefit from the newer, more expensive vaccine.

The dual vaccine costs twice as much — 52 cents a dose at Unicef prices, compared with 24 cents for measles alone. (The MMR vaccine that American children get, which also contains a vaccine against mumps, costs Unicef $1.)

More than 90 percent of Rwandan children now are vaccinated twice against measles, and cases have been near zero since 2007.

The tiny country, which was convulsed by Hutu-Tutsi genocide in 1994, is now leading the way in Africa in delivering medical care to its citizens, Ms. McNab said. Three years ago, it was the first African country to introduce shots against human papilloma virus, or HPV, which causes cervical cancer.

In wealthy countries, measles kills a small number of children — usually those whose parents decline vaccination. But in poor countries, measles is a major killer of malnourished infants. Around the world, the initiative estimates, about 158,000 children die of it each year, or about 430 a day.

Every year, an estimated 112,000 children, mostly in Africa, South Asia and the Pacific islands, are born with handicaps caused by their mothers' rubella infection.

Thanks in part to the initiative — which until last year was known just as the Measles Initiative — measles deaths among children have declined 71 percent since 2000. The initiative is a partnership of many health agencies, vaccine companies, donors and others, but is led by the American Red Cross, the United Nations Foundation, the Centers for Disease Control and Prevention, Unicef and the World Health Organization.

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News Analysis: Proposed Brain Mapping Project Faces Significant Hurdles

In more than a century of scientific inquiry into the interwoven cells known as neurons that make up the brain, researchers acknowledge they are only beginning to scratch the surface of a scientific challenge that is certain to prove vastly more complicated than sequencing the human genome.

The Obama administration is hoping to announce as soon as next month its intention to assemble the pieces — and, even more challenging, the financing — for a decade-long research project that will have the goal of building a comprehensive map of the brain's activity.

At present, scientists are a long way from doing so. Before they can even begin the process, they have to develop the tools to examine the brain. And before they develop tools that will work on humans, they must succeed in doing so in a number of simpler species — assuming that what they learn can even be applied to humans.

Besides the technological and scientific challenges, there are a host of issues involving storing the information researchers gather, and ethical concerns about what can be done with the data. Also highly uncertain is whether the science will advance quickly enough to meet the time frames being considered for what is being called the Brain Activity Map project.

Many neuroscientists are skeptical that a multiyear, multibillion dollar effort to unlock the brain's mysteries will succeed."I believe the scientific paradigm underlying this mapping project is, at best, out of date and at worst, simply wrong," said Donald G. Stein, a neurologist at the Emory University School of Medicine in Atlanta. "The search for a road map of stable, neural pathways that can represent brain functions is futile."

The state of the art in animal research is to sample from roughly a thousand neurons simultaneously. The human brain has between 85 and 100 billion neurons. "For a human we must develop new techniques, and some of them from scratch," said Dr. Rafael Yuste, a neuroscientist at Columbia who has pioneered the use of lasers to measure the activity of neurons in the cortex of mice.

An article last year in the journal Neuron described a possible path toward mapping the active human brain. The article, signed by six prominent scientists, proposes that the project begin with species that have brains with very small numbers of neurons and then work toward increasingly complex animals.

The scientists cited the worm C. elegans, which to date is the only animal for which there is a complete static map, or "connectome." That worm has just 302 neurons with 7,000 connections. The authors propose moving on to the Drosophila fly, which has 135,000 neurons; the zebra-fish, with roughly one million neurons; the mouse; and then the Etruscan shrew, the smallest known mammal, whose cortex is composed of roughly a million neurons.

But the leap to the human brain is so enormous that one of the scientists who has participated in planning sessions, the neuroscientist Terry Sejnowski from the Salk Institute, has called the challenge "the million neuron march."

While the researchers have proposed a wide range of technologies that might be applied to the problems, many of them are still prototypes or speculative. Some of them, like nano-robots being designed at places like the Wyss Institute laboratory at Harvard, seem like they are straight from "Fantastic Voyage," the 1966 movie that imagined the ability to shrink submarines and humans — specifically, Raquel Welch — for journeys through the human body.

Moreover, many technologies now used to sample human brain activity at high resolution require opening the skull, dramatically restricting what is possible. Progress is being made using those available techniques, but only at a basic level.

Still, last week in the journal Nature a group of neurosurgeons at the University of California, San Francisco, reported significant new insights into mechanisms of the language function of the human brain. That research, which was conducted with permission from three people who had severe epileptic seizures, involved installing a dense sensor mesh of electrodes on the surface of their brains. The 264 electrodes each sampled from an area that might encompass as many as millions of neurons, according to Dr. Edward F. Chang, a neurosurgeon who led the team.

Although the sensor's resolution was crude, it was four times more powerful than what has been used until now. It revealed how the speech centers in the human cortex control the larynx, tongue, jaw, lips and face, all of which are involved in making the sounds that constitute human speech.

"I don't think this was a major technological innovation," Dr. Chang said. "But it demonstrates the power of even incremental advances, and shows how they can have a major impact on what we can understand."

The goal of the University of California group is ultimately to gain enough understanding of the speech mechanism in the brain to be able to develop sophisticated prosthetics, making it possible for victims of paralysis or stroke to speak.

It is that potential — and more — that has excited scientists, and generated pressure for a multibillion dollar effort to develop a human brain activity map, backed by the United States government, in partnership with research foundations and institutions.

The project's roots lie in a small scientific conference in London in September 2011.

The meeting had been organized by Miyoung Chun, a molecular biologist who is vice president of scientific programs at the Kavli Foundation. Its goal was to gather some of the world's best neuroscientists and nano-scientists and figure out how they might work together, according to Ralph J. Greenspan, a molecular biologist at the University of California, San Diego, who attended the conference.

For two days the scientists mostly "talked at each other," he recalled. Then George M. Church, a Harvard molecular geneticist who helped start the original Human Genome Project in 1984, said, "All right I've heard all of you say what you can do, but I haven't heard anyone say what you really want to do."

"I want to be able to record from every neuron in the brain at the same time," Dr. Yuste replied.

In the next year, two white papers calling for a concerted and heavily funded national effort were published. Cristof Koch and R. Clay Reid, of the Allen Institute of Brain Science in Seattle, proposed mapping the mouse brain completely. And in June, six scientists, including Dr. Yuste, Dr. Church, Dr. Greenspan and Dr. Chun, wrote the Neuron paper.

Last fall when Thomas A. Kalil, the deputy director of the White House Office of Science and Technology Policy, encountered a group of neuroscientists at a conference, the idea of a broad multiagency government project took hold.

The scientists acknowledge that, beyond the scientific hurdles, the Brain Activity Map project faces significant technical challenges.

At a meeting in Pasadena, Calif., on Jan. 17 to explore the data storage needs of the proposed mapping project, computer scientists, neuroscientists and nanoscientists concluded that it would require three petabytes of storage capacity to capture the amount of information generated by just one million neurons in a year.

There are one million gigabytes in a petabyte. The Large Hadron Collider in Geneva generates about 10 petabytes of data annually. If the brain contains between 85 and 100 billion neurons, that means that the complete brain generates about 300,000 petabytes of data each year.

One facet of the project certain to create controversy is that the scientists are also developing technologies that manipulate neurons, raising the specter not just of mind reading, but mind control. The scientists argue that it is in controlling neurons that they can gain valuable information on brain function.

This article has been revised to reflect the following correction:

Correction: February 25, 2013

An earlier version of this article misspelled the given name of a scientist at the Allen Institute of Brain Science in Seattle. He is Christof Koch, not Kristof.

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C. Everett Koop, Forceful Surgeon General, Dies at 96

Paul Hosefros/The New York Times

Dr. C. Everett Koop, in his office, was 66 when President Ronald Reagan appointed him surgeon general in 1981.

Dr. C. Everett Koop, who was widely regarded as the most influential surgeon general in American history and played a crucial role in changing public attitudes about smoking, died on Monday at his home in Hanover, N.H. He was 96.

His death was confirmed by Susan A. Wills, an assistant at the Geisel School of Medicine at Dartmouth College, which has an institute named after Dr. Koop. In 1981, Dr. Koop had never served in public office when President Ronald Reagan appointed him surgeon general of the United States. By the time he stepped down in 1989, he had become a household name, a rare distinction for a public health administrator.

Dr. Koop issued emphatic warnings about the dangers of smoking, and he almost single-handedly pushed the government into taking a more aggressive stand against AIDS. And despite his steadfast moral opposition to abortion, he refused to use his office as a pulpit from which to preach against it.

These stands led many liberals who had bitterly opposed his nomination to praise him, and many conservatives who had supported his appointment to vilify him. Conservative politicians representing tobacco-growing states were among his harshest critics, and many Americans, for moral or religious reasons, were upset by his public programs to fight AIDS and felt betrayed by his relative silence on abortion.

As much as anyone, it was Dr. Koop who took the lead in trying to wean Americans off smoking, and he did so in imposing fashion. At a sturdy 6-foot-1, with his bushy gray biblical beard, Dr. Koop would appear before television cameras in the gold-braided dark-blue uniform of a vice admiral — the surgeon general's official uniform, which he revived — and sternly warn of the terrible consequences of smoking.

"Smoking kills 300,000 Americans a year," he said in one talk. "Smokers are 10 times more likely to develop lung cancer than nonsmokers, two times more likely to develop heart disease. Smoking a pack a day takes six years off a person's life."

When Dr. Koop took office, 33 percent of Americans smoked; when he left, the percentage had dropped to 26. By 1987, 40 states had restricted smoking in public places, 33 had prohibited it on public conveyances and 17 had banned it in offices and other work sites. More than 800 local antismoking ordinances had been passed, and the federal government had restricted smoking in 6,800 federal buildings. Antismoking campaigns by private groups like the American Lung Association and the American Heart Association had accelerated.

Dr. Koop also played a major role in educating Americans about AIDS. Though he believed that the nation had been slow in facing the crisis, he extolled its efforts once it did, particularly in identifying H.I.V., the virus that causes the disease, and developing a blood test to detect it.

Where he failed, in his own view, was to interest either Reagan or his successor as president, George Bush, in making health care available to more Americans.

Dr. Koop was completing a successful career as a pioneer in pediatric surgery when he was nominated for surgeon general, having caught the attention of conservatives with a series of seminars, films and books in collaboration with the theologian Francis Schaeffer that expressed anti-abortion views.

At his confirmation hearings, Senate liberals mounted a fierce fight against him. Senator Edward M. Kennedy, Democrat of Massachusetts, said Dr. Koop, in denying a right to abortion, adhered to a "cruel, outdated and patronizing stereotype of women." Women's rights organizations, public health groups, medical associations and others lobbied against his appointment. An editorial in The New York Times called him "Dr. Unqualified."

But after months of testimony and delay, he was confirmed by a vote of 68 to 24, garnering more support than many had expected. Some senators who had been hesitant to support him said he had convinced them of his integrity.

Dr. Koop himself said he had taken a principled approach to the nomination. As he and his wife, Elizabeth, had driven to Washington for the confirmation hearings, he recalled telling her, "If I ever have to say anything I don't believe or feel shouldn't be said, we'll go home."

An Only Child in Brooklyn

Charles Everett Koop was born on Oct. 14, 1916, in Brooklyn, and grew up in a three-story brick house in South Brooklyn surrounded by relatives; his paternal grandparents lived on the third floor, and his maternal grandparents as well as uncles, aunts and cousins lived on the same street. He was the only child of John Everett Koop, a banker and descendant of 17th-century Dutch settlers of New York, and the former Helen Apel.

Dr. Koop traced his interest in medicine to watching his family's doctors at work as a child. To develop the manual dexterity of a surgeon, he practiced tying knots and cutting pictures out of magazines with each hand. At 14 he sneaked into an operating theater at Columbia University's medical college, and he operated on rabbits, rats and stray cats in his basement after his mother had administered anesthesia. By his account, not one of the animals died.

Daniel E. Slotnik contributed reporting.

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Horse Meat in European Beef Raises Questions on U.S. Exposure

The alarm in Europe over the discovery of horse meat in beef products escalated again Monday, when the Swedish furniture giant Ikea withdrew an estimated 1,670 pounds of meatballs from sale in 14 European countries.

Ikea acted after authorities in the Czech Republic detected horse meat in its meatballs. The company said it had made the decision even though its tests two weeks ago did not detect horse DNA.

Horse meat mixed with beef was first found last month in Ireland, then Britain, and has now expanded steadily across the Continent. The situation in Europe has created unease among American consumers over whether horse meat might also find its way into the food supply in the United States. Here are answers to commonly asked questions on the subject.

Has horse meat been found in any meatballs sold in Ikea stores in the United States?

Ikea says there is no horse meat in the meatballs it sells in the United States. The company issued a statement on Monday saying meatballs sold in its 38 stores in the United States were bought from an American supplier and contained beef and pork from animals raised in the United States and Canada.

"We do not tolerate any other ingredients than the ones stipulated in our recipes or specifications, secured through set standards, certifications and product analysis by accredited laboratories," Ikea said in its statement.

Mona Liss, a spokeswoman for Ikea, said by e-mail that all of the businesses that supply meat to its meatball maker  issue letters guaranteeing that they will not misbrand or adulterate their products. "Additionally, as an abundance of caution, we are in the process of DNA-testing our meatballs," Ms. Liss wrote. "Results should be concluded in 30 days."

Does the United States import any beef from countries where horse meat has been found?

No. According to the Department of Agriculture, the United States imports no beef from any of the European countries involved in the scandal. Brian K. Mabry, a spokesman for the department's Food Safety and Inspection Service, said: "Following a decision by Congress in November 2011 to lift the ban on horse slaughter, two establishments, one located in New Mexico and one in Missouri, have applied for a grant of inspection exclusively for equine slaughter. The Food Safety and Inspection Service (F.S.I.S.) is currently reviewing those applications."

Has horse meat been found in ground meat products sold in the United States?

No. Meat products sold in the United States must pass Department of Agriculture inspections, whether produced domestically or imported. No government financing has been available for inspection of horse meat for human consumption in the United States since 2005, when the Humane Society of the United States got a rider forbidding financing for inspection of horse meat inserted in the annual appropriations bill for the Agriculture Department. Without inspection, such plants may not operate legally.

The rider was attached to every subsequent agriculture appropriations bill until 2011, when it was left out of an omnibus spending bill signed by President Obama on Nov. 18. The U.S.D.A.  has not committed any money for the inspection of horse meat.

"We're real close to getting some processing plants up and running, but there are no inspectors because the U.S.D.A. is working on protocols," said Dave Duquette, a horse trader in Oregon and president of United Horsemen, a small group that works to retrain and rehabilitate unwanted horses and advocates the slaughter of horses for meat. "We believe very strongly that the U.S.D.A. is going to bring inspectors online directly."

Are horses slaughtered for meat for human consumption in the United States?

Not currently, although live horses from the United States are exported to slaughterhouses in Canada and Mexico. The lack of inspection effectively ended the slaughter of horse meat for human consumption in the United States; 2007 was the last year horses were slaughtered in the United States. At the time financing of inspections was banned, a Belgian company operated three horse meat processing plants — in Fort Worth and Kaufman, Tex., and DeKalb, Ill. — but exported the meat it produced in them.

Since 2011, efforts have been made to re-establish the processing of horse meat for human consumption in the United States. A small plant in Roswell, N.M., which used to process beef cattle into meat has been retooled to slaughter 20 to 25 horses a day. But legal challenges have prevented it from opening, Mr. Duquette said. Gov. Susana Martinez of New Mexico opposes opening the plant and has asked the U.S.D.A. to block it.

Last month, the two houses of the Oklahoma Legislature passed separate bills to override a law against the slaughter of horses for meat but kept the law's ban on consumption of such meat by state residents. California, Illinois, New Jersey, Tennessee and Texas prohibit horse slaughter for human consumption.

Is there a market for horse meat in the United States?

Mr. Duquette said horse meat was popular among several growing demographic groups in the United States, including Tongans, Mongolians and various Hispanic populations. He said he knew of at least 10 restaurants that wanted to buy horse meat. "People are very polarized on this issue," he said. Wayne Pacelle, chief executive of the Humane Society of the United States, disagreed, saying demand in the United States was limited. Italy is the largest consumer of horse meat, he said, followed by France and Belgium.

Is horse meat safe to eat?

That is a matter of much debate between proponents and opponents of horse meat consumption. Mr. Duquette said that horse meat, some derived from American animals processed abroad, was eaten widely around the world without health problems. "It's high in protein, low in fat and has a whole lot of omega 3s," he said.

The Humane Society says that because horse meat is not consumed in the United States, the animals' flesh is likely to contain residues of many drugs that are unsafe for humans to eat. The organization's list of drugs given to horses runs to 29 pages.

"We've been warning the Europeans about this for years," Mr. Pacelle said. "You have all these food safety standards in Europe — they do not import chicken carcasses from the U.S. because they are bathed in chlorine, and won't take pork because of the use of ractopamine in our industry — but you've thrown out the book when it comes to importing horse meat from North America."

The society has filed petitions with the Department of Agriculture and Food and Drug Administration, arguing that they should test horse meat before allowing it to be marketed in the United States for humans to eat.

This article has been revised to reflect the following correction:

Correction: February 25, 2013

An earlier version of this article misstated how many pounds of meatballs Ikea was withdrawing from sale in 14 European countries. It is 1,670 pounds, not 1.67 billion pounds.

This article has been revised to reflect the following correction:

Correction: February 25, 2013

An earlier version of this article misstated the last year that horses were slaughtered in the United States. It is 2007, not 2006.

 

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Health Care Panel, Lacking Budget, Is Left Waiting

WASHINGTON — One of the biggest threats to the success of President Obama's health care law comes from shortages of doctors, nurses and other health care professionals. But a 15-member commission created to investigate the problem has never met in two and a half years because it has no money from Congress or the administration.

"It's like 'Waiting for Godot,' " said Dr. Richard D. Krugman, the dean of the University of Colorado Medical School and a member of the commission. "We are sitting on a park bench, waiting for Godot. We'll see if he shows up."

With an aging population and 30 million people expected to gain coverage under Mr. Obama's health care law, the demand for medical care is expected to increase. But Dr. Sheldon M. Retchin, the vice chairman of the panel, the National Health Care Workforce Commission, said, "We are prohibited from meeting and discussing these issues."

Members of the independent nonpartisan panel said they wanted to address these questions: How many more doctors are needed? What is the right mix of primary care physicians and specialists? Who will care for the millions of people gaining Medicaid coverage next year?

Should states rewrite their laws to allow nurse practitioners and physician assistants to do more of the work done by doctors? Could pharmacists play a larger role in coordinating care and managing the use of medications?

The commission was created by the 2010 health care law, the Affordable Care Act. Mr. Obama has requested $3 million for the panel in each of the last two years, and some Democrats, like Senator Tom Harkin of Iowa, chairman of the Appropriations subcommittee on health, have supported the request.

But Republicans in Congress have been reluctant to provide money for anything connected with the law, which they opposed. "Anything authorized in the Affordable Care Act has a tough road with the Republicans," said Dr. Atul Grover, the chief lobbyist for the Association of American Medical Colleges.

The chairman of the commission, Peter I. Buerhaus, a professor of nursing at Vanderbilt University, said: "It's a disappointing situation. The nation's health care work force has many problems that are not being attended to. These problems were apparent before health care reform, and they will be even more pressing after health care reform."

Dr. Krugman said the commission was "caught in a broader political struggle, and in the gridlock between Congress and the administration."

Dr. Retchin, who is the senior vice president for health sciences at Virginia Commonwealth University in Richmond, said "the government needs to analyze the scope, caliber and composition of the health care work force" because labor costs accounted for a large share of the nation's health care bill.

Members of the panel, appointed in September 2010 by the comptroller general of the United States, have no staff, no budget and no agenda.

Kim J. Gillan, the director of the work force training program at Montana State University Billings, said federal officials had made clear to her and other panel members that "we were not to function as a group or have contact with one another."

Ms. Gillan said some people apparently feared that the commission might recommend the national licensing of health care professionals or other steps that could interfere with state prerogatives.

Another panel member, Prof. Thomas C. Ricketts of the University of North Carolina at Chapel Hill, said the Government Accountability Office, an investigative arm of Congress, had advised the panel that "we were not to work or be seen to be working."

Dr. Krugman said, "We were told that we were to have no conversations until we were funded because that would be a violation of some federal law or rule."

Chuck Young, a spokesman for the accountability office, said, "Agencies generally cannot conduct business without an appropriation."

In a summary of research, the Department of Health and Human Services said, "The United States faces shortages of primary care physicians, dentists, nurses and other health professionals."

Roger J. Moncarz, an economist at the Bureau of Labor Statistics, said that employment in health care occupations was expected to grow by 29 percent, with the addition of 3.5 million new jobs from 2010 to 2020. Federal officials expect 712,000 new jobs for registered nurses — more than for any other occupation in the country — and a total of 1.3 million new jobs for home health and personal care aides, he said.

Edward S. Salsberg, the director of the National Center for Health Workforce Analysis at the Health and Human Services Department, said 57 million people were living in areas with shortages of primary care practitioners.

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Off the Dribble: Salley Offers a Healthy Assist

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

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

Anthony admitted that his body felt "depleted out there."

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

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

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

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

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

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

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

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

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

Salley was striving for similar health and success.

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

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

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

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

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

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

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

But it was worth it.

"I was playing so well it was crazy," he said.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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Anemia Drug Recalled After Allergic Reactions; 3 Patients Died

The suppliers of a new drug to treat anemia in patients undergoing kidney dialysis have recalled all lots of the product after reports that it had caused severe allergic reactions, including some that were fatal.

Affymax and Takeda Pharmaceutical, which jointly market the drug, Omontys, or peginesatide, announced the recall late on Saturday, and the notice was also posted by the Food and Drug Administration.

The F.D.A. said in a news release on Sunday that it had received 19 reports of anaphylaxis, a severe allergic reaction, and that three of the patients had died, while others required prompt medical intervention or hospitalization.

Approved last March, Omontys broke the lucrative monopoly Amgen had since 1989 on treating anemia in dialysis clinics. While it is not clear yet what the recall means for the future of Omontys, it could help sales of Amgen's drug, Epogen.

Affymax and Takeda said that hypersensitivity reactions have been fatal in 0.02 percent of the roughly 25,000 patients treated with Omontys since its approval. That would suggest there have been five deaths, a slight discrepancy from the F.D.A. figures that was not explained. Over all, the companies said, about 2 of every 1,000 patients had a hypersensitivity reaction.

The companies and the F.D.A. said the reactions occurred within 30 minutes of patients receiving their first dose by intravenous administration. No problems have been reported with subsequent doses, which are given once a month. Still, the companies and the F.D.A. advised that Omontys use be discontinued even by patients who have already had more than one dose.

The big question is whether this will cause the drug to be withdrawn from the market. It is possible that doctors can act to avert or lessen allergic reactions on the first dose. It is also possible the problems are confined to certain dialysis centers.

A spokeswoman for Affymax said executives would not comment further until a conference call for securities analysts on Monday morning. Omontys is the only marketed product for Affymax, which is based in Palo Alto, Calif., and licensed commercialization rights to Takeda, Japan's largest pharmaceutical company.

Reports of severe allergic reactions have been accumulating, and the Omontys label warns of them, as does the Epogen label.

This month, Fresenius Medical Care North America, the nation's largest dialysis provider, halted a pilot program testing Omontys, in part because of these allergic reactions. The company said in a memorandum that it had treated 18,000 patients with the drug and would now analyze the data.

"To date, we have seen infrequent allergic reactions in our patient population receiving their first dose of Omontys," said the Feb. 13 memo by Fresenius's chief medical officer and its associate chief medical officer. They recommended that patients already taking Omontys continue and said dialysis centers could also put new patients on it.

The memo was made public in a regulatory filing by Affymax.

Sales of Omontys for the nine months it was on the market were $34.6 million, compared with $1.5 billion for Epogen. Still, Affymax executives have said Omontys was gaining momentum because of its less-frequent dosing, lower cost and the desire of some dialysis center owners for an alternative to Amgen.

Dr. Daniel W. Coyne, a kidney specialist at Washington University in St. Louis, said that unless the problem was because of contamination, "this could easily lead to withdrawal of drug approval." He said that "two in 10,000 deaths on first exposure is unacceptable, compared to nothing like this" with Epogen.

Dr. Ajay K. Singh, a kidney specialist at Brigham and Women's Hospital in Boston, said that the recall should result in "minimal disruption" because centers could use Epogen or another Amgen drug, Aranesp. But he said it might be hard for Affymax and Takeda, which is based in Osaka, to show the safety of their drug without a huge study.

Amgen's Epogen is a synthetic version of the human protein erythropoietin, or EPO, which stimulates the body to produce oxygen-carrying red blood cells. Omontys is not EPO, but binds to the same receptor in the body.

Sales of Amgen's Epogen have been declining because of changing financial incentives for dialysis clinics and because of safety concerns, particularly those related to blood clots and heart attacks. EPO has also become known for secretly being used by athletes like Lance Armstrong.

The next competition to Epogen could come from Roche's Mircera, a form of EPO, in mid-2014. Biosimilars, or near-generic forms of Epogen, could reach the market after Amgen's last patent expires in 2015.

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‘Bloodless’ Lung Transplants for Jehovah’s Witnesses

Eric Kayne for The New York Times

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Cutting Risks, and Costs

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

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

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

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

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Drone Pilots Found to Get Stress Disorders Much as Those in Combat Do

U.S. Air Force/Master Sgt. Steve Horton

Capt. Richard Koll, left, and Airman First Class Mike Eulo monitored a drone aircraft after launching it in Iraq.

The study affirms a growing body of research finding health hazards even for those piloting machines from bases far from actual combat zones.

"Though it might be thousands of miles from the battlefield, this work still involves tough stressors and has tough consequences for those crews," said Peter W. Singer, a scholar at the Brookings Institution who has written extensively about drones. He was not involved in the new research.

That study, by the Armed Forces Health Surveillance Center, which analyzes health trends among military personnel, did not try to explain the sources of mental health problems among drone pilots.

But Air Force officials and independent experts have suggested several potential causes, among them witnessing combat violence on live video feeds, working in isolation or under inflexible shift hours, juggling the simultaneous demands of home life with combat operations and dealing with intense stress because of crew shortages.

"Remotely piloted aircraft pilots may stare at the same piece of ground for days," said Jean Lin Otto, an epidemiologist who was a co-author of the study. "They witness the carnage. Manned aircraft pilots don't do that. They get out of there as soon as possible."

Dr. Otto said she had begun the study expecting that drone pilots would actually have a higher rate of mental health problems because of the unique pressures of their job.

Since 2008, the number of pilots of remotely piloted aircraft — the Air Force's preferred term for drones — has grown fourfold, to nearly 1,300. The Air Force is now training more pilots for its drones than for its fighter jets and bombers combined. And by 2015, it expects to have more drone pilots than bomber pilots, although fighter pilots will remain a larger group.

Those figures do not include drones operated by the C.I.A. in counterterrorism operations over Pakistan, Yemen and other countries.

The Pentagon has begun taking steps to keep pace with the rapid expansion of drone operations. It recently created a new medal to honor troops involved in both drone warfare and cyberwarfare. And the Air Force has expanded access to chaplains and therapists for drone operators, said Col. William M. Tart, who commanded remotely piloted aircraft crews at Creech Air Force Base in Nevada.

The Air Force has also conducted research into the health issues of drone crew members. In a 2011 survey of nearly 840 drone operators, it found that 46 percent of Reaper and Predator pilots, and 48 percent of Global Hawk sensor operators, reported "high operational stress." Those crews cited long hours and frequent shift changes as major causes.

That study found the stress among drone operators to be much higher than that reported by Air Force members in logistics or support jobs. But it did not compare the stress levels of the drone operators with those of traditional pilots.

The new study looked at the electronic health records of 709 drone pilots and 5,256 manned aircraft pilots between October 2003 and December 2011. Those records included information about clinical diagnoses by medical professionals and not just self-reported symptoms.

After analyzing diagnosis and treatment records, the researchers initially found that the drone pilots had higher incidence rates for 12 conditions, including anxiety disorder, depressive disorder, post-traumatic stress disorder, substance abuse and suicidal ideation.

But after the data were adjusted for age, number of deployments, time in service and history of previous mental health problems, the rates were similar, said Dr. Otto, who was scheduled to present her findings in Arizona on Saturday at a conference of the American College of Preventive Medicine.

The study also found that the incidence rates of mental heath problems among drone pilots spiked in 2009. Dr. Otto speculated that the increase might have been the result of intense pressure on pilots during the Iraq surge in the preceding years.

The study found that pilots of both manned and unmanned aircraft had lower rates of mental health problems than other Air Force personnel. But Dr. Otto conceded that her study might underestimate problems among both manned and unmanned aircraft pilots, who may feel pressure not to report mental health symptoms to doctors out of fears that they will be grounded.

She said she planned to conduct two follow-up studies: one that tries to compensate for possible underreporting of mental health problems by pilots and another that analyzes mental health issues among sensor operators, who control drone cameras while sitting next to the pilots.

"The increasing use of remotely piloted aircraft for war fighting as well as humanitarian relief should prompt increased surveillance," she said.

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