Making Sure a Plan for Long-Term Care Adds Up

In fact, he spent about a decade working on it, finally succeeding whenthe Class Act, short for Community Living Assistance Services and Support, became law as part of last year’s landmarkhealth insurancepackage.

The Class Actpromises a lot: eligibility for most people, no matter their health status, as long as they are working at least a little; a benefit of at least $50 or so a day that lasts until death if necessary; and a premium structure that will offer big discounts for lower-income people but still won’t require any federal money.

This all turned out to be a bit too optimistic. In recent months,Kathleen Sebelius, the secretary of health and human services,has said that it will be difficultto make the offering both affordable and actuarially sound without some alterations.

She and her staff are making some changes, and the law gives them a certain amount of leeway. Their ultimate challenge is to make sure that the premium is not so low that there won’t be enough money to pay claims. But it also cannot be so high that it will scare off the young, healthy people who could subsidize all of the infirm people attracted to the plan’s generous eligibility rules (or frighten the employers of younger adults, who might encourage them to sign up).

Plenty of politiciansare furiousabout the fact that something like this became law without the long-term numbers adding up. The far more interesting question, however, is why Senator Kennedy felt this law was necessary in the first place.

Here’s the blunt truth:Medicaregenerally won’t pay for as much nursing home or in-home care as many people think it will. Your cash savings may well be insufficient, especially if you want to leave plenty of money for a spouse who may outlive you. Your family may not be willing or able to take care of you. And if you do spend all of your assets to qualify forMedicaid, there’s no guarantee Medicaid will pay for the quality of care you want and do so close to friends or family.

So we better hope that the Class Act works and helps lots of Americans. Because if it doesn’t, plenty of people will beright back in denial-landagain.

That said, there are some people who have already purchased long-term care insurance from a commercial company. Limra, a market research firm, figures there are about seven million of them.

Some buy it out of an abundance of caution, while others do it because their employers offer subsidized premiums as a benefit. Many others have seen family members spend hundreds of thousands of dollars on care or struggled to provide care themselves when there was no money left.

Even so, the insurance companies can make this a tough product to love, given their unexpected price jumps oroccasional outright abandonmentof the business.

How can the federal government possibly hope to do better? There are at least three ways.

First, it can enlist the help of employers, who could each make the government plan available to many thousands of employees.

According to anAonHewitt survey of over 1,300 large employers, 50 percent already made long-term care insurance available in 2010. But would those employers really want to replace what they have with a government program that would probably offer a lower level of benefits? Or would they offer it alongside their current plans?

As for the half of employers who do not offer any plan now, will their wary human resources executives really be first in line for a new government program?

The second way to potential success here is through automatic enrollment: getting those employers who do sign on to put every employee in the government plan and let individuals opt out later if they so choose.

The Class Act specifically mentions this possibility, though it does not seem to require it. The idea comes straight from the401(k)playbook. According to an estimate from David L. Wray, president of theProfit Sharing/401k Council of America, which represents the interests of employers, about 38 percent of employees who have access to 401(k) plans work for employers who automatically enroll new workers.

Nobody, however, currently makes their employees buy long-term care insurance, according to Guy Bertsch, vice president for long-term care operations atUnum, which claims to sell far more policies through the workplace than any other company.

The authors of the Class Act were clearly worried about what would happen if employers did not sign everyone up automatically, though. Indeed, at employers that do not provide long-term care insurance free to everyone but still make it available for employee purchase, voluntary buy-in tends to be below 10 percent, Mr. Bertsch said.

Finally, there’s the possibility of rebranding the product to make it more relevant to young adults.Connie Garner, a former member of Senator Kennedy’s staff who worked closely with him on the Class Act, says she believes long-term care insurance has an image problem.“People think it’s for the lady with the blue hair in a wheelchair,” she said.

Ms. Garner, who is anurse practitionerand now runs an advocacy group calledAdvanceClass, speaks to groups about the fact that young adults who see themselves as invincible are only one dive into shallow water away from needing in-home care for the rest of their lives. That, she said, often moves parents in the audience to volunteer to pay for any premiums for their children, given that they would be discounted in the Class Act’s plan.

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Florida Medicaid Overhaul Vote Near

The cuts and changes being sought by the Republican-led Legislature and encouraged by the new Republican governor,Rick Scott, a wealthy former hospital company executive, are deeper than those in many other states.

In the past 11 years, the cost of Medicaid in Florida has grown to $21 billion from $9 billion and amounts to a third of the state budget. The federal government pays more than half the tab.

“There is a consensus that the Medicaid system is irretrievably broken,” said State Senator Joe Negron, a Republican who took the lead in writing theSenate bill, which is expected to come to a vote before the legislative session ends a week from Friday. The House approved its bill this month. The changes could go into effect as early as next year.

“I’ve never seen something where we are spending $21 billion and nobody is happy,” Mr. Negron said.“We were not going to kick the can down the road another year.”

Relying loosely on a five-year-old pilot program to shift care to H.M.O.’s, Florida lawmakers are poised to scrap the traditional model in which the state pays doctors for each service they perform. Instead, almost all of Florida’s Medicaid recipients would be funneled into state-authorized, for-profit H.M.O.’s or networks run byhospitalsor doctors. H.M.O.’s or networks would also manage the long-term care of the elderly, shifting them away fromnursing homesand leading to an expansion of in-home care. Lawmakers who support the bill say the state needs this flexibility in curtailing the exploding cost of Medicaid.

The Florida legislation is being closely watched by other states as they tackle the rapid growth of enrollment and the cost of care. Because Florida has three million Medicaid patients and a high number of uninsured people, a swift jump into managed care would be significant. And while many states use managed care for Medicaid users in one form or other, the Florida proposals stand out because they would set possible limits on services, giving the state and H.M.O.’s the right to deny some benefits that are now offered to patients. This would require federal permission.

“If Florida adopts this method of looking at managed care, other states will definitely look at that, and this is a tool we can use,” said Michael W. Garner, the president of theFlorida Association of Health Plans, which lobbies for H.M.O.’s.“The toolbox is pretty empty right now.”

But there is concern across the state that the emerging proposals will not only reduce available health care for millions, but also leave the most vulnerable— the disabled, the elderly and those with serious chronic illnesses— at risk. An Aprilstudyof the pilot program byGeorgetown Universityraised doubts about patient services and cost efficiency, saying there was too little data. For some, the proposals hold a fearful prospect.

Vicki Ahern, 40, a single mother in Davie, Fla., who is her son’s full-time caregiver, spent several years trying to cobble together a network of medical specialists across several counties to help her son, Keith, 16, grapple withmuscular dystrophy, spinal injuries and debilitating pain.

Then, suddenly, the network crumbled. With 10 days’ notice, Ms. Ahern said, Keith was shuttled into the pilot project, which transferred Medicaid patients in five counties to H.M.O.’s and hospital- or doctor-run networks. The counties are Baker, Clay, Duval and Nassau in the northeast and Broward in the south.

The participating H.M.O.’s in Broward County, where the Aherns live, listed none of Keith’s doctors or therapists; they offered few specialists and fewer services. The one rheumatologist who proved helpful dropped out of the program because of low reimbursement rates and frustrations with the bureaucracy.

“I started panicking and considered moving out of state, but we couldn’t,” Ms. Ahern said.“I was very angry because I knew he wasn’t going to get his services. If you have a chronic disability or are medically fragile, then forget it.”

After several months in the pilot program, Ms. Ahern discovered she could opt out, a long bureaucratic process, and she did.

The two bills now in play in Tallahassee are modeled in large part on the pilot program. It allowed the state to provide a set amount of money for managed-care companies to more efficiently serve each Medicaid patient, who include low-income children and pregnant women, the developmentally disabled and others.

The bills vary: the House version would send the developmentally disabled to managed care; the Senate’s would not. The Senate is pushing block grants, which would restrict financing further by creating a cap on the Medicaid budget each year; the House version does not.

The proposed changes worry health care advocates and Medicaid patients, who say that the for-profit nature of H.M.O.’s makes it difficult to care for the neediest.

The pilot program appears to have been far from successful, according to the Georgetown report: H.M.O.’s fled because of low reimbursement rates. Among those leaving was WellCare, which left 55 percent of Duval County’s Medicaid patients in limbo. The company was later accused of cherry-picking Medicaid patients to maximize profits, and five of its former executives were indicted on fraud charges.

Patients were shuffled from H.M.O. to H.M.O. and reported difficulty gaining access to services. In other cases, doctors listed in the network stopped accepting Medicaid patients. Supporters of the bills say that the rates would be adjusted to increase H.M.O. participation and that oversight would be bolstered.

Lawmakers are also planning steep budget cuts in the Medicaid program to tackle the state’s yawning deficits. This would make the shift even more burdensome, Democrats say.

“It can’t work,” said Representative Elaine J. Schwartz, a Democrat, who held community meetings on the program in Broward County.“It undermines the basic purpose of Medicaid, which is to provide services. If the private sector could have made money on Medicaid, they would have. With this plan, we are basically handing them $20 billion. Two groups of people will suffer: the patients because they are bamboozled and the taxpayer who is not getting their money’s worth.”

Joan Alker of theCenter for Children and Families at Georgetown, who co-wrote the April report, said that so far there was no solid evidence of how much the pilot program had saved or whether the savings came from denying services. Florida pays among the lowest rates in the country for each Medicaid patient, ranking 43rd, making Medicaid less expensive than private insurance, Ms. Alker said.

Mr. Negron said he envisioned $1 billion in savings from his proposal in its first year and perhaps $4 billion in subsequent years.

“One of my guiding principles,” he said,“is that our friends and neighbors on Medicaid should not receive fewer benefits than their counterparts, but they shouldn’t have a more generous benefit either.”

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Average Height Falls for Very Poor Women in Africa

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Robert W. Fogel Investigates Human Evolution

Next month Cambridge University Press will publish the capstone of this inquiry,“The Changing Body: Health, Nutrition, and Human Development in the Western World Since 1700,” just a few weeks shy of Mr. Fogel’s 85th birthday. The book, whichsums up the workof dozens of researchers on one of the most ambitious projects undertaken in economic history, is sure to renew debates over Mr. Fogel’s groundbreaking theories about what some regard as the most significant development in humanity’s long history.

Mr. Fogel and his co-authors, Roderick Floud, Bernard Harris and Sok Chul Hong, maintain that“in most if not quite all parts of the world, the size, shape and longevity of the human body have changed more substantially, and much more rapidly, during the past three centuries than over many previous millennia.” What’s more, they write, this alteration has come about within a time frame that is“minutely short by the standards of Darwinian evolution.”

“The rate of technological and human physiological change in the 20th century has been remarkable,” Mr. Fogel said in an telephone interview from Chicago, where he is the director of the Center for Population Economics at the University of Chicago’s business school.“Beyond that, a synergy between the improved technology and physiology is more than the simple addition of the two.”

This“technophysio evolution,” powered by advances in food production and public health, has so outpaced traditional evolution, the authors argue, that people today stand apart not just from every other species, but from all previous generations of Homo sapiens as well.

 “I don’t know that there is a bigger story in human history than the improvements in health, which include height, weight, disability and longevity,” said Samuel H. Preston, one of the world’s leading demographers and a sociologist at the University of Pennsylvania. Without the 20th century’s improvements in nutrition, sanitation and medicine, only half of the current American population would be alive today, he said.

To take just a few examples, the average adult man in 1850 in America stood about 5 feet 7 inches and weighed about 146 pounds; someone born then was expected to live until about 45. In the 1980s the typical man in his early 30s was about 5 feet 10 inches tall, weighed about 174 pounds and was likely to pass his 75th birthday.

Across the Atlantic, at the time of the French Revolution, a 30-something Frenchman weighed about 110 pounds, compared with 170 pounds now. And in Norway an average 22-year-old man was about 5½ inches taller at the end of the 20th century (5 feet 10.7 inches) than in the middle of the 18th century (5 feet 5.2 inches).

Mr. Fogel and his colleagues’ great achievement was to figure out a way to measure some of that gain in body size, Mr. Preston said. Much of the evidence— childhood growth, mortality, adult living standards, labor productivity, food and manufacturing output— was available, but no one had put it all together in this way before. Over the years Mr. Fogel and his colleagues have pored over a monumental amount of raw data to piece together the health records of thousands of people in different countries. When he won the Nobel in economics in 1993, the Swedish committee stated it was“for having renewed research in economic history by applying economic theory and quantitative methods in order to explain economic and institutional change.”

“The Changing Body” is full of statistical tables and graphs that include the heights of girls in Croatia and Germany; the caloric energy derived from potatoes, fish and wine; and the average annual allowance of grains and meat for widows in Middlesex County, Mass., from 1654 to 1799— a testament to both the staggering accumulation of information and the collaborative nature of the enterprise. 

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With Help From a Gene Called Hippo, a Possible Heart Attack Therapy

These are not characters from a Damon Runyon story but a crew of genes that work together to switch other genes on and off. A team of biologists led by James F. Martin and Todd Heallen of theTexas A&MSystem Health Science Center has now found that these genes block the heart from growing new heart muscle cells, at least in mice.

Knock out Hippo, for example, and the mouse’s heart grows two and a half times bigger than usual,they reportin Science.

This and other advances, including the discovery this year thatinfant mice can regenerate their heartsfor the first seven days after birth, is evoking considerable interest among researchers trying to develop new treatments for heart attacks.

The findings“will mark a renaissance of interest in thegeneticsof cardiac muscle growth control because of the potential therapeutic applications,” said Michael D. Schneider, a heart biology expert at Imperial College in London.

The reason that heart attacks are so serious is that when a large number of heart muscle cells die, they are not replaced. Yet the heart does slowly generate new muscle cells during a person’s lifetime, showing that a growth program is in place. It is firmly repressed, however, presumably to avert the danger ofcancer.

Surgeons have tried injectingstem cellsof all kinds into stricken hearts, but despite many clinical trials, there is little evidence that the cells do much good. This setback has led to renewed interest in trying to unlock the heart cells’ inherent growth program.

Dr. Martin started with the Hippo gene because it is known to regulate the size of a fruit fly’s organs. Fruit fly biologists are often the first to recognize new genes and to work out what they do. The names they confer on genes are colorful and often grotesque because they are inspired by what happens to the fly when you knock out a specific gene from its genome.

If you delete the Hippo gene, the fruit fly grows an enormous head with folded skin around the neck. Hence Hippo.

By engineering a mouse in which Hippo was deleted just in the heart, Dr. Martin’s team showed that the chain of genes in which Hippo acts serves as at least one of the natural restraints on the proliferation of heart muscle cells.

Zebra fish can regenerate the tip of the heart when it is cut off. Researchers have recently found the fish can even replace thescartissue that forms when muscle cells die, which is often a problem for failing human hearts. The finding that infant mice can also regenerate the heart means that mammals, perhaps including people, may also have this ability, even though it is lost in adults.

If the mouse and zebra fish have some natural way of escaping the Hippo gene’s clamp on heart cell growth, it is possible that some drug could be developed that would close down the Hippo pathway in people for a few days after a heart attack, allowing the heart muscle cells to enjoy a much-needed spurt of proliferation.

Dr. Martin said his next step would be to grow adult mice with a disabled Hippo gene and see if they recover faster after a heart attack. He also plans to see if human heart muscle cells grown in a laboratory dish proliferate better if the Hippo pathway is disrupted.

In fruit flies, an organ can produce more cells only if two gene promoters, called Yorkie and Armadillo, get to penetrate the cell’s nucleus and switch on the suites of genes required for the cells to grow and divide. But when Hippo is active neither Yorkie nor Armadillo can do its work. The signal that activates Hippo in the fly is called Dachsous, which must first trigger a receptor protein called Fat in the cell’s surface. But receptors like Fat can respond to many different signals. So it is not yet clear that the mouse or human counterparts to Dachsous and Fat are the triggers for the effect Dr. Martin’s team has seen, Dr. Schneider said.

If the human counterparts are identified, then a drug that blocked them, switching off Hippo, might let heart muscle cells regenerate themselves, leading to a novel and fundamental treatment for heart attacks.

But Hippo, Warts, Merlin and crew would not be part of the story. When mouse researchers look for the counterparts of fruit fly genes in mice, they give them new and duller names. Human geneticists are even more fearful that colorful gene names will create an aura of frivolity that discourages serious grant money.“They ruin it,” Dr. Martin said. The gene that fly biologists call Ménage-à-trois 1 is called MAT 1 by human geneticists. The poetically named Son-of-Sevenless in flies is the prosaic SOS 1 in people. As for Hippo, mouse researchers have already decolorized it to MST 1.

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Battling the Wheat-Threatening‘Yellow Rust’ Fungi

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A Family Doctor Looks to Retire, but Finds No One to Take Over

Dr. Ronald Sroka held his hands about three feet apart, andJohn Mayer— fishing buddy and patient— smiled from the examination table. Dr. Sroka shook his head, glanced at a wall clock and quickly put his stethoscope to his ears.

“All right, deep breaths,” Dr. Sroka said. It was only 10 a.m., but Dr. Sroka was already behind schedule, with patients backed up in the waiting room like planes waiting to take off atLa Guardia Airport. Too many stories; too little time.

“Talking too much is the kind of thing that gets me behind,” Dr. Sroka said with a shrug.“But it’s the only part of the job I like.”

A former president of theMaryland State Medical Society, Dr. Sroka has practiced family medicine for 32 years in a small, red-brick building just six miles from his childhood home, treating fishing buddies, neighbors and even his elementary school principal much the way doctors have practiced medicine for centuries. He likes to chat, but with costs going up and reimbursements down, that extra time has hurt his income. So Dr. Sroka, 62, thought about retiring.

He tried to sell his once highly profitable practice. No luck. He tried giving it away. No luck.

Dr. Sroka’s fate is emblematic of a transformation in American medicine. He once provided for nearly all of his patients’ medical needs— stitching up the injured, directing care for the hospitalized and keeping vigil for the dying. But doctors like him are increasingly being replaced by teams of rotating doctors and nurses who do not know their patients nearly as well. A centuries-old intimacy between doctor and patient is being lost, and patients who visit the doctor are often kept guessing about who will appear in the white coat.

The share of solo practices among members of theAmerican Academy of Family Physiciansfell to 18 percent by 2008 from 44 percent in 1986. Andcensus figuresshow that in 2007, just 28 percent of doctors described themselves as self-employed, compared with 58 percent in 1970. Many of the provisions of the new health care law are likely to accelerate these trends.

“There’s not going to be any of us left,” Dr. Sroka said.

Indeed, younger doctors— half of whom are now women— are refusing to take over these small practices.They want better lifestyles, shorter work days, and weekends free of the beepers, cellphones and patient emergencies that have long defined doctors’ lives.Weighed down with debt, they want regular paychecks instead of shopkeeper risks. And even if they wanted such practices, banks— attuned to the growing uncertainties— are far less likely to lend the money needed.

For patients, the transition away from small private practices is not all bad. While larger practices tend to be less intimate, the care offered tends to be better— with more preventive services, better cardiac advice and fewer unnecessary tests. And the new policies that may finally put Dr. Sroka out of business are almost universally embraced— including wholesale adoption of electronic medical records and bundled payments from the federalMedicareprogram that encourage coordinated care.

“Those of us who think about medical errors and cost have no nostalgia— in fact, we have outright disdain— for the single practitioner like Marcus Welby,” David J. Rothman, president of the Institute on Medicine as a Profession atColumbia University, said of the 1970s TV doctor.

Dr. Sroka has not taken a sick day in 32 years. After his latest partner left in September, he was unable for five months to schedule any time off until another local doctor volunteered to cover for him. His income and patients depend upon his daily presence. This resiliency is part of a tough-minded medical culture— forged in round-the-clock residency shifts, constant on-call schedules, and workplaces in which revered doctors made decisions and staff members followed orders— that is fast disappearing.

Had he left a decade ago, Dr. Sroka might have been able to persuade a doctor to pay $500,000 or more for his roster of 4,000 patients. That he cannot give his practice away results not only from the unattractiveness of its inflexible schedule but also because large group practices can negotiate higher fees from insurers, which translates into more money for doctors.

Building Relationships

Handsome, silver-haired and likable, Dr. Sroka is indeed a modern-day Marcus Welby, his idol. He holds ailing patients’ hands, pats their thickening bellies, and has a talent for diagnosing and explaining complex health problems.

Many of his patients adore him.

One of them, Alicia Beall, 53, came in for a consultation after a pain in her foot grew worrisome. She has been seeing Dr. Sroka for 30 years, and he quickly guessed that she was suffering plantar fasciitis, a painful inflammation.

“So take off your shoe,” Dr. Sroka said. She did, and Dr. Sroka lifted her foot.

“If it’s plantar fasciitis, it’s usually right there,” Dr. Sroka said and pressed his thumb into her heel.

“Ow! Don’t do that,” Ms. Beall said and smacked him with a magazine. They both laughed.

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In Online Games, a Path to Young Consumers

Lesly likes this online game so much that she plays twice a week, often e-mailing her creations to friends.“I always send them to my cousin in Los Angeles,” she said.

But this is not just a game— it is also advertising.Create a Comic, as it is called, was created byGeneral Millsto help it sell Honey Nut Cheerios to children.

Like many marketers, General Mills and other food companies are rewriting the rules for reaching children in the Internet age. These companies, often selling sugar cereals and junk food, are using multimedia games, online quizzes and cellphone apps to build deep ties with young consumers. And children like Lesly are sharing their messages through e-mail and social networks, effectively acting as marketers.

When these tactics revolve around food, and blur the line between advertising and entertainment, they are a source of intensifying concern for nutrition experts and children’s advocates— and are attracting scrutiny from regulators. The Federal Trade Commission has undertaken a study of food marketing to children, due out this summer, while the White House Task Force on Childhood Obesity has said one reason so many children are overweight is the way junk food is marketed.

Critics say the ads, from major companies likeUnileverand Post Foods, let marketers engage children in a way they cannot on television, where rules limit commercial time during children’s programming. With hundreds of thousands of visits monthly to many of these sites, the ads are becoming part of children’s daily digital journeys, often flying under the radar of parents and policy makers, the critics argue.

“Food marketers have tried to reach children since the age of the carnival barker, but they’ve never had so much access to them and never been able to bypass parents so successfully,” said Susan Linn, a psychiatry instructor at Harvard Medical School and director of theCampaign for a Commercial-Free Childhood, an advocacy coalition. Ms. Linn and others point to many studies that show the link between junk-food marketing and poor diets, which are implicated in childhood obesity.

Food industry representatives call the criticism unfair and say they have become less aggressive in marketing to children in the Internet era, not more so.

Since 2006, 17 major corporations— including General Mills,McDonald’s,Pepsi,Coca-Colaand Burger King—have taken a voluntary pledgeto reduce marketing of their least nutritious brands to children, an effort they updated last year to include marketing on mobile devices.

The pledge says the companies, if they choose to market to children, will only advertise food choices that are“better for you,” said Elaine D. Kolish, director of theChildren’s Food and Beverage Advertising Initiative, an arm of the Better Business Bureau that oversees the pledge.

“Compliance is excellent,” she said of the pledge. She noted that in recent months, companies had shut down several child-centric sites, including General Mills’spopular virtual world Millsberry, while other sites have been changed to focus on adults, like those of Kellogg’s Pop Tarts and Pepsi’s Cap’n Crunch. And she said General Mills and Post Foods had cut or pledged to cut the amount of sugar in some cereals.

Only rarely do these major companies violate their pledges, she said:“It’s pretty darn infrequent and it’s not willful.”

Nutrition experts say that the voluntary pledges are fraught with loopholes, and that“better for you” is a relative term that allows companies to keep marketing unhealthful options.

Whatever criticism they may invite, the companies have good financial reason to pitch to children. James McNeal, a former marketing professor atTexas A&M University, estimates conservatively that children influence more than $100 billion in food and beverage purchases each year, and well over half of all cold cereal purchases.

Children“have power over spending in the household, they have power over the grandparents, they have power over the babysitters, and on and on and on,” said Professor McNeal, who has researched family behavior for decades and consulted for major companies on marketing to children.“All of that is finally being recognized and acknowledged.”

Some parents, like Lesly Lopez’s mother, Toribia Huerta, 26, say the online marketing is subverting their efforts to improve their children’s diets. Ms. Huerta said Lesly and her younger siblings pester her for sugary cereals they see in the games and for snacks like Baby Bottle Pops, a candy with a game site that the girl also visits often.

“They ask me for it constantly. They’re hard to resist when they whine,” Ms. Huerta said, speaking in Spanish through a translator. She blames her daughter’s love of sugar for her dental problems, including many cavities.

But Ms. Huerta also said the food sites seemed fun and safe:“They look like good games for her age.”

Games for Goods

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Joshua Brustein contributed reporting from New York.

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Calorie Burn Continues After Workout, Researchers Find

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Answers for Deprivation of Smell and Taste

After weeks passed without improvement, he consulted experts at theUniversity of PennsylvaniaSmell and Taste Center, one of 11 such clinics now scattered around the country. Tests there showed that as a result of his illness, he’d lost 70 percent of his ability to smell.

In the years since, Dr. DeVere has recovered much of his ability to smell and taste. But the experience inspired him to open his own clinic for smell and taste disorders and, most recently, to write a book,“Navigating Smell and Taste Disorders” (Demos Health), about this poorly understood and often unrecognized problem.

In an interview, Dr. DeVere said he hoped the book would help not only patients with smell and taste disorders but also their physicians, most of whom know little about these problems, he said, and often tell sufferers that“nothing can be done— you’ll have to live with it.”

The book was written with his sister-in-law, Marjorie Calvert, an accomplished cook who provided a food preparation guide and dozens of recipes— some contributed by patients— that can help restore dining pleasure to those affected. Taste is mostly a result of odor detection, so the recipes emphasize spice, texture and temperature, sensations that remain unimpaired even when smell malfunctions.

You’ve no doubt experienced a temporary disruption in smell and taste while suffering from a cold orsinus infection. Try to imagine your life if the problem lasted indefinitely and you could no longer enjoy the flavor of an orange or chocolate or taste the difference between chicken and steak.

But smell and taste disorders can affect more than the ability to“smell the roses” in life and toenjoy food. Also affected is the ability to detect and correct unpleasant smells, like body odor or a dirty diaper in need of changing. For people like professional cooks and firefighters, the problem can force an occupational switch.

Most important, smell disorders can be downright dangerous for those who cannot detect the odor of smoke, burning or spoiled food,natural gasor other noxious aromas.

An Underrecognized Problem

While reliable statistics are hard to come by, several million Americans are thought to suffer from the major smell disorders: hyposmia, a reduced ability to detect certain odors;anosmia, an inability to detect any odors at all; or dysosmia, in which pleasant odors can smell foul or vice versa.

Most people who think they have a taste disorder, usually because food has lost its flavor, turn out to have a smell problem, according to Richard M. Costanzo, a neurophysiologist atVirginia Commonwealth University. The smell disorders clinic there receives regular inquiries from distressed patients; one of them said his inability to taste food flavors was“a very life-altering experience, and most normal people cannot understand the impact it has on one’s life.”

There are many common causes. In addition to viral infections likecoldsandflu, they include disorders of the nose (for example, polyps) or sinuses; injuries to the nose or head; medications likeblood pressuredrugs,antibiotics,cholesterol-lowering drugs,antidepressantsandcancerchemotherapy; radiation therapy of the head and neck; exposure to toxins like formaldehyde andpesticides;smokingandalcohol abuse; diseases of the thyroid, kidneys, liver or pancreas; and neurological disorders likeParkinson’s disease, Lewy body disease,multiple sclerosisand various kinds ofdementia.

Half of all people withdiabeteshave a diminished sense of smell and taste, and 90 percent of those withAlzheimer’s diseasehave impaired smell capacity, Dr. DeVere said.

By far the leading cause— and the one least often recognized— is advancing age. Whereas only 1 percent to 2 percent of young people are affected, a quarter of those over 55 and nearly two-thirds of those over 80 have a diminished sense of smell.

But unlike vision orhearing loss, which is often apparent to others, if not to the afflicted person, a loss of smell sensitivity with age is often undetected because it occurs gradually. The result can be a diminished interest in food and gradual weight loss, or a tendency to over-season foods with salt or sugar, which may impair control ofhigh blood pressureor diabetes, common problems in the elderly.

Limited Treatments

Depending on the cause of a smell disorder, therapeutic possibilities include treatment with nasal decongestants, antihistamines, or antibiotics; surgery to removenasal polyps; use of a nasal saline solution; correction of hormonal or nutrient deficiencies; and stopping smoking.

Dr. DeVere said that over time smell disorders may gradually diminish in intensity, as his did. Nonetheless, Dr. Costanzo said:“We have to be fair to patients. There’s no magic bullet. Some smell problems are treatable, most are not.”

Especially challenging are those that result from head injuries, whether minor or severe, that disrupt the function of the body’s smell receptors— olfactory nerve cells that lie outside the brain. These cells pick up odor molecules high in the nose and transmit scent messages to the brain’s olfactory bulb, he explained.

A head blow can injure or tear olfactory nerves. Damaged olfactory nerve cells can regenerate, but don’t always reconnect properly in the brain. Dr. Costanzo and colleagues are working on grafts and transplants that may one day overcome current treatment limitations.

Staying Safe

While everyone should have working smoke detectors in their homes, a person with a smell disorder should also have a detector for natural gas orpropane, lest a leak go undetected and result in an explosion.

Perishable foods should be dated and kept refrigerated, and discarded when they expire. It may be wise for a person with normal olfactory function to check these foods before someone with an impaired sense of smell eats them.

Make sure all cleaning and garden products are properly labeled and stored separately from foods.

When cooking or baking, check periodically to make sure nothing is burning, and set a timer to ring when the food will be done.

Since you can’t rely on a“sniff test,” be sure to bathe and launder clothes regularly. Use underarm deodorant, and go easy with cologne. Regularly check diapers for visual signs that a change is needed.

For more information, consult the Web site of the National Institute on Deafness and Other Communication Disorders atwww.nidcd.nih.gov/health/smelltaste.

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Apple-Spice Breakfast Soup - Recipes for Health

1 1/2 quarts water

4 large tart apples, like Pink Lady, unpeeled, cored and diced (about 2 1/2 pounds)

2/3 cup dark or golden raisins

1 teaspoon freshly grated nutmeg

1 1/2 teaspoons ground cinnamon

1/4 teaspoon ground cloves

1/2 teaspoon ground allspice

Pinch of salt

1/4 cup honey

4 slices whole-wheat or multigrain bread (about 6 ounces), diced (3 cups tightly packed)

2 tablespoons fresh lemon juice

1/2 to 1 cup plain yogurt, to taste, plus additional for garnish

Thin lemon slices for garnish

1.Combine the water, apples, raisins, spices, salt and honey in a large soup pot. Bring to a boil, reduce the heat and stir in the bread. Cover and simmer one hour. The bread will fall apart and thicken the soup.

2.Remove from the heat, and stir in the lemon juice and yogurt. Serve hot or warm, or chill and serve cold. Garnish each serving with a dollop of yogurt and a thin slice of lemon.

Yield:Serves six to eight.

Advance preparation:This soup will keep for a few days in the refrigerator.

Nutritional information per serving (six servings):251calories; 0 gramssaturated fat; 0 grams polyunsaturated fat; 0 grams monounsaturated fat; 0 milligramscholesterol; 62 gramscarbohydrates; 7 gramsdietary fiber; 161 milligrams sodium (does not include salt to taste); 4 grams protein

Nutritional information per serving (eight servings):189 calories; 0 grams saturated fat; 0 grams polyunsaturated fat; 0 grams monounsaturated fat; 0 milligrams cholesterol; 47 grams carbohydrates; 5 grams dietary fiber; 121 milligrams sodium (does not include salt to taste); 3 grams protein

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

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Font Size May Not Aid Learning, but Its Style Can, Researchers Find

The answer is neither. Font size has no effect onmemory, even though most people assume that bigger is better. But font style does.

New research finds that people retain significantly more material— whether science, history or language— when they study it in a font that is not only unfamiliar but also hard to read.

Psychologists have long known that people’s instincts about how well they’ve learned a subject are often way off. The feel of a study session can be a poor reflection of its nutritional value: Concepts that seem perfectly clear become fuzzy at exam time, and those that are hard to grasp somehow click into place when it counts.

In recent years, researchers have begun to clarify why this is so, and in some cases how to correct for it. The findings are especially relevant nowadays, experts say.

“So much of the learning that we do now is unsupervised, on our own,” said Robert A. Bjork, a psychologist at theUniversity of California, Los Angeles,“that it’s crucial to be able to monitor that learning accurately; that is, to know how well we know what we know, so that we avoid fooling ourselves.”

Mistakes in judging what we know— in metacognition, as it’s known— are partly rooted in simple biases. For instance, most people assume when studying that newly learned facts will long be remembered and that further practice won’t make much difference. These beliefs are subconscious and automatic, studies find, even though people know better when they stop to think about it.

Yet overconfidence also develops as a result of the brain’s natural tendency to find shortcuts— and to quickly forget that it used them.In a recent reportin the journal PNAS, researchers atHarvardand Duke had college students take what they thought was an I.Q. test. Some got an answer key with the test“to check their answers afterward,” and others did not.

To no one’s surprise, those who got the key peeked at it and did better on the test, on average, than those without it. But after grading their tests, both groups of students predicted how well they would do on a hypothetical longer test without the answer key. Those who had seen the key expected a far higher score on the future test than did those who hadn’t.

“The finding was that people who use an answer key when taking a test see their score as a sign of their innate ability, selectively forgetting that the key helped them achieve the score,” said the lead author, Zoe Chance, a doctoral student in marketing at Harvard Business School.

Without the answers handy, those confident students did no better on an actual second test than the others.

Anyone who has ever peeked at the answers at the back of the physics or chemistry textbook already suspects this. It’s one thing to study a solution when the problem itself is totally unfamiliar, requiring techniques that haven’t yet been learned. It is another to scan the answers when problems are familiar but difficult. Those problem sets go more smoothly, confidence goes up, the temptation to take a study break grows stronger.

These sensations reflect more than simple self-deception.

Even hints or answers that are not consciously remembered alter how the brain processes a problem or question, making the experience very different from an unaided exam question.In a 1996 study, researchers at Macalester College andNew York Universityhad subjects solve 60 anagrams and rate how difficult each one would be for others to solve. One group of participants had already seen the answers to half of the puzzles in an earlier phase of the study, scattered like so many detective-novel clues in a long list of random words. As a result, they solved those anagrams faster and rated them as significantly easier to solve than the other half— without consciously remembering having seen the answers.

“Studying something in the presence of an answer, whether it’s conscious or not, influences how you interpret the question,” Dr. Bjork said.“You don’t appreciate all of the other things that would have come to mind if the answer weren’t there.

“Let’s say you’re studying capitals and you see that Australia’s is Canberra. O.K., that seems easy enough. But when the exam question appears, you think:‘Uh oh, was it Sydney? Melbourne? Adelaide?’ ”

That’s why some experts are leery of students’ increasing use of online sites likeCramster,Course Hero,Koofersand others that offer summaries, step-by-step problem solving and copies of previous exams. The extra help may provide a valuable supplement to a difficult or crowded course, but it could also leave students with a false sense of mastery.

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How Little Sleep Can You Get Away With?

Enter David Dinges, the head of the Sleep and Chronobiology Laboratory at the Hospital atUniversity of Pennsylvania, who has the distinction of depriving more people of sleep than perhaps anyone in the world.

In what was the longest sleep-restriction study of its kind, Dinges and his lead author, Hans Van Dongen, assigned dozens of subjects to three different groups for their 2003 study: some slept four hours, others six hours and others, for the lucky control group, eight hours— for two weeks in the lab.

Every two hours during the day, the researchers tested the subjects’ ability to sustain attention with what’s known as the psychomotor vigilance task, or P.V.T., considered a gold standard of sleepiness measures. During the P.V.T., the men and women sat in front of computer screens for 10-minute periods, pressing the space bar as soon as they saw a flash of numbers at random intervals. Even a half-second response delay suggests a lapse into sleepiness, known as a microsleep.

The P.V.T. is tedious but simple if you’ve been sleeping well. It measures the sustained attention that is vital for pilots, truck drivers, astronauts. Attention is also key for focusing during long meetings; for reading a paragraph just once, instead of five times; for driving a car. It takes the equivalent of only a two-second lapse for a driver to veer into oncoming traffic.

Not surprisingly, those who had eight hours of sleep hardly had any attention lapses and no cognitive declines over the 14 days of the study. What was interesting was that those in the four- and six-hour groups had P.V.T. results that declined steadily with almost each passing day. Though the four-hour subjects performed far worse, the six-hour group also consistently fell off-task. By the sixth day, 25 percent of the six-hour group was falling asleep at the computer. And at the end of the study, they were lapsing fives times as much as they did the first day.

The six-hour subjects fared no better— steadily declining over the two weeks— on a test of working memory in which they had to remember numbers and symbols and substitute one for the other. The same was true for an addition-subtraction task that measures speed and accuracy. All told, by the end of two weeks, the six-hour sleepers were as impaired as those who, in another Dinges study, had been sleep-deprived for 24 hours straight— the cognitive equivalent of being legally drunk.

So, for most of us, eight hours of sleep is excellent and six hours is no good, but what about if we split the difference? What is the threshold below which cognitive function begins to flag? While Dinges’s study was under way, his colleague Gregory Belenky, then director of the division of neuroscience at the Walter Reed Army Institute of Research in Silver Spring, Md., was running a similar study. He purposely restricted his subjects to odd numbers of sleep hours— three, five, seven and nine hours— so that together the studies would offer a fuller picture of sleep-restriction. Belenky’s nine-hour subjects performed much like Dinges’s eight-hour ones. But in the seven-hour group, their response time on the P.V.T. slowed and continued to do so for three days, before stabilizing at lower levels than when they started. Americans average 6.9 hours on weeknights, according to the National Sleep Foundation. Which means that, whether we like it or not, we are not thinking as clearly as we could be.

Of course our lives are more stimulating than a sleep lab: we have coffee, bright lights, the social buzz of the office, all of which work as“countermeasures” to sleepiness. They can do the job for only so long, however. As Belenky, who now heads up the Sleep and Performance Research Center atWashington State University, Spokane, where Van Dongen is also a professor, told me about cognitive deficits:“You don’t see it the first day. But you do in five to seven days. Unless you’re doing work that doesn’t require much thought, you are trading time awake at the expense of performance.”

And it’s not clear that we can rely on weekends to make up for sleep deprivation. Dinges is now running a long-term sleep restriction and recovery study to see how many nights we need to erase our sleep debt. But past studies suggest that, at least in many cases, one night alone won’t do it.

Not every sleeper is the same, of course: Dinges has found that some people who need eight hours will immediately feel the wallop of one four-hour night, while other eight-hour sleepers can handle several four-hour nights before their performance deteriorates. (But deteriorate it will.) There is a small portion of the population— he estimates it at around 5 percent or even less— who, for what researchers think may be genetic reasons, can maintain their performance with five or fewer hours of sleep. (There is also a small percentage who require 9 or 10 hours.)

Still, while it’s tempting to believe we can train ourselves to be among the five-hour group— we can’t, Dinges says— or that we are naturally those five-hour sleepers, consider a key finding from Van Dongen and Dinges’s study: after just a few days, the four- and six-hour group reported that, yes, they were slightly sleepy. But they insisted they had adjusted to their new state. Even 14 days into the study, they said sleepiness was not affecting them. In fact, their performance had tanked. In other words, the sleep-deprived among us are lousy judges of our own sleep needs. We are not nearly as sharp as we think we are.

Maggie Jones (margueritepjones@gmail.com) is a contributing writer for the magazine. Editor: Tony Gervino (t.gervino-MagGroup@nytimes.com).

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Michael C. Latham, Nutrition Expert, Dies at 82

The cause waspneumonia, his son Mark said.

Dr. Latham, who directed theProgram in International NutritionatCornell Universityfor 25 years, first encountered the problems of nutrition in the developing world while practicing medicine as a young doctor for the British colonial service in Tanganyika (now Tanzania).

After the country had gained its independence, he stayed on and was appointed the director of the nutrition unit of the public health ministry. He became alarmed at efforts by Western companies to expand their marketing of infant formula to underdeveloped countries, where high birth rates promised a growing consumer base, and he became one of the first and most forceful public health scientists to sound a warning.

In many poor countries, he pointed out, mothers mixed powdered baby formula with contaminated water, leading to diarrheal diseases. To make the formula last longer, they often used too little of the powder, depriving their babies of vital nutrients.

Bottle feedingwas“incredibly difficult and extremely bad,” Dr. Latham wrote in a 1976 report with Ted Greiner, but“the media onslaught is terrific, the messages are powerful and the profits are high.”

“High also is the resultant human suffering,” they wrote.

Dr. Latham’s cause, taken up by several health groups, led theWorld Health Organizationin 1981 to develop a set of guidelines, theInternational Code of Marketing of Breast-milk Substitutes, which was intended to govern the behavior of private companies. He was a prominent figure in theboycott of Nestlé,a leading manufacturer of infant formula, which agreed in 1984 to abide by the marketing code.

The ideal food for infants, Dr. Latham argued, wasbreast milk. Its benefits, he wrote, were not limited to improved physical and mental development. It could also potentially curb population growth, he argued, since parents who were confident that their children would thrive would be more likely to have smaller families. In 1991, he helped found theWorld Alliance for Breastfeeding Actionto explain and promote the benefits of breastfeeding around the world.

Michael Charles Latham was born on May 6, 1928, in Kilosa, Tanganyika, where his father was a doctor in the British colonial service. After earning a medical degree from Trinity College, Dublin, in 1952, he worked inhospitalsin Britain and the United States before returning to Tanganyika to practice medicine in rural areas. During intermittent leaves, he earned a diploma in tropical public health from the London School of Hygiene and Tropical Medicine in 1958.

After leaving Tanzania in 1964, he taught nutrition at Harvard, where he received a degree in public health in 1965. In 1968 he was recruited by Cornell as a professor of international nutrition. He turned the university’s small Program in International Nutrition into one of the world’s largest training centers for nutritionists, many of whom went on to work in international agencies and public health departments around the world.

His research led to improved programs on infant nutrition, the control of parasitic diseases in humans, and the supply of micronutrients to poor populations.

Dr. Latham often did consulting work in Africa, Asia and South America for organizations like the World Health Organization, theUnited NationsFood and Agriculture Organization,Unicefand theWorld Bank.

In addition to his son Mark, of Somerville, Mass., he is survived by his second wife, Dr. Lani Stephenson, and another son, Miles, of Trumansburg, N.Y.

He was the author of two important books on international nutrition,“Human Nutrition in Tropical Africa” (1965) and“Human Nutrition in the Developing World” (1997), as well as a family memoir,“Kilimanjaro Tales: The Saga of a Medical Family in Africa” (1995), which drew on the journals kept by his mother, Gwynneth Latham.

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Do Cellphones Cause Brain Cancer?

“Thetumorwas exactly in the pattern of the antenna,” Reynard told King. In 1989, Susan Elen Reynard, then 31, was told she had a malignant astrocytoma, a braincancerthat occurs in about 6,000 adults in America each year. To David Reynard, the shape and size of Susan’s tumor— a hazy line swerving from the left side of her midbrain to the hindbrain— uncannily resembled a malignant shadow of the phone (buttumors, like clouds, can assume the shapes of our imaginations). Suzy, as she was known, held her phone at precisely that angle against her left ear, her husband said. Reynard underwent surgery for her cancer but to little effect. She died in 1992, just short of her 34th birthday. David was convinced that high doses of radiation from the cellphone was the cause.

Reynard v. NEC— the first tort suit in the United States to claim a link between phone radiation and brain cancer— illustrated one of the most complex conceptual problems in cancer epidemiology. In principle, a risk factor and cancer can intersect in three ways. The first is arguably the simplest. When a rare form of cancer is associated with a rare exposure, the link between the risk and the cancer stands out starkly. The juxtaposition of the rare on the rare is like a statistical lunar eclipse, and the association can often be discerned accurately by observation alone. The discipline of cancer epidemiology originated in one such a confluence: in 1775, a London surgeon, Sir Percivall Pott, discovered that scrotal cancer was much more common in chimney sweeps than in the general population. The link between an unusual malignancy and an uncommon profession was so striking that Pott did not even need statistics to prove the association. Pott thus discovered one of the first clear links between an environmental substance— a“carcinogen”— and a particular subtype of cancer.

The opposite phenomenon occurs when a common exposure is associated with a common form of cancer: the association, rather than popping out, disappears into the background, like white noise. This peculiar form of a statistical vanishing act occurred famously with tobaccosmokingand lung cancer. In the mid-1930s, smoking was becoming so common and lung cancer so prevalent that it was often impossible to definitively discern a statistical link between the two. Researchers wondered whether the intersection of the two phenomena was causal or accidental. Asked about the strikingly concomitant increases in lung cancer and smoking rates in the 1930s, Evarts Graham, a surgeon, countered dismissively that“the sale of nylon stockings” had also increased. Tobacco thus became the nylon stockings of cancer epidemiology— invisible as a carcinogen to many researchers, until it was later identified as a major cause of cancer through careful clinical studies in the 1950s and 1960s.

But the most complex and most publicly contentious intersection between a risk factor and cancer often occurs in the third instance, when a common exposure is associated with a rare form of cancer. This is cancer epidemiology’s toughest conundrum. The rarity of the cancer provokes a desperate and often corrosive search for a cause (“why, of all people, did I get an astrocytoma?” Susan Reynard must have asked herself). And when patients with brain tumors happen to share a common exposure— in this case, cellphones— the line between cause and coincidence begins to blur. The association does not stand out nor does it disappear into statistical white noise. Instead, it remains suspended, like some sort of peculiar optical illusion that is blurry to some and all too clear to others. (A similarly corrosive intersection of a rare illness, a common exposure and the desperate search for a cause occurred recently in the saga ofautismand vaccination. Vaccines are nearly universal, and autism is relatively rare— and many parents, searching to explain why their children became autistic, lunged toward a common culprit: childhood vaccination. An avalanche of panic ensued. It took years of carefully performed clinical trials to finally disprove the link.)

The Florida Circuit Court that heard Reynard v. NEC was quick to discern these complexities. It empathized with David Reynard’s search for a tangible cause for his wife’s cancer. But it acknowledged that too little was known about such cases;“the uncertainty of the evidence . . . the speculative scientific hypotheses and {incomplete} epidemiological studies” made it impossible to untangle cause from coincidence. David Reynard’s claim was rejected in the spring of 1995, three years after it was originally filed. What was needed, the court said, was much deeper and more comprehensive knowledge about cellphones, brain cancer and of the possible intersection of the two.

Allow, then, a thought experiment: what if Susan Reynard was given a diagnosis of astrocytoma in 2011— but this time, we armed her with the most omniscient of lawyers, the most cutting-­edge epidemiological information, the most powerful scientific evidence? Nineteen years and several billion cellphone users later, if Reynard were to reappear in court, what would we now know about a possible link between cellphones and her cancer?

To answer these questions, we need to begin with a more fundamental question: How do we know that anything causes cancer?

The crudest method to capture a carcinogen’s imprint in a real human population is a large-scale population survey. If a cancer-causing agent increases the incidence of a particular cancer in a population, say tobacco smoking and lung cancer, then the overall incidence of that cancer will rise. That statement sounds simple enough— to find a carcinogen’s shadow, follow the trend in cancer incidence— but there are some fundamental factors that make the task complicated.

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Siddhartha Mukherjee (smukherj2011@gmail.com) is an assistant professor of medicine in the division of medical oncology at Columbia University. He is the author of“Emperor of All Maladies: A Biography of Cancer.” Editor: Ilena Silverman (i.silverman-MagGroup@nytimes.com).

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Resistance to Jaitapur Nuclear Plant Grows in India

They stood to lose mango orchards, cashew trees and rice fields, as the government forcibly acquired 2,300 acres to build six nuclear reactors— the biggest nuclear power plant ever proposed anywhere.

But now, as a nuclear disaster unfolds in distant Japan, the lonely group of farmers has seen support for their protest swell to include a growing number of Indian scientists, academics and former government officials.“We are getting ready for bigger protests,” Mr. Gawanker said.

While the government vows to push ahead— citingIndia’s energy needs— Indian newspapers recently reported that the environment minister wrote Prime MinisterManmohan Singhto question the wisdom of large nuclear installations. And a group of 50 Indian scientists, academics and activists has called for a moratorium on new projects.“The Japanese nuclear crisis is a wake-up call for India,” they wrote in an open letter.

Opponents note that the area was hit by 95 earthquakes from 1985 to 2005, although Indian officials counter that most were minor and that the plant’s location on a high cliff would offer protection against tsunamis.

The heated debate shows how the politics ofnuclear energymay be changing, not only in the United States and Europe but in developing countries whose economies desperately need cheap power to continue growing rapidly.

For Indian officials intent on promoting nuclear energy, the partial meltdowns and radiation leaks at the Fukushima Daiichi power plant in Japan could not have come at a worse time. Currently, India gets about 3 percent of its electricity from the 20 relatively small nuclear reactors in the country. But it is building five new reactors and has proposed 39 more, including the ones here in Madban, to help meet the voracious energy needs of India’s fast-growing economy.

Only China, the other emerging-economy giant with a ravenous energy appetite, is planning a more rapid expansion of nuclear power. Beijing has indicated that it, too, plans to proceed cautiously with its nuclear rollout.

By 2050, the Indian government says a quarter of the nation’s electricity should come from nuclear reactors. And the project here would be the biggest step yet toward that ambitious goal. The planned six reactors would produce a total of 9,900 megawatts of electricity— more than three times the power now used by India’s financial capital, Mumbai, about 260 miles up the coast.

So far, workers on the site are simply digging trenches, as a dozen police officers provide round-the-clock watch. Protesters, including Mr. Gawankar, have been arrested at various times, and state police officials have banned gatherings of more than five people in the villages near the site.

Prime Minister Singh has been so committed to atomic power that he staked his government’s survival in 2008 on a controversial civil nuclear deal with the United States. That agreement, completed last year, opened the door for India to buy nuclear technology and uranium fuel from Western nations that previously would not sell to it because of India’s refusal to sign the Nuclear Nonproliferation Treaty.

Most of India’s reactors have been indigenously developed, but it is now building two reactors with Russian help. The proposed nuclear plant in Madban will use a new generation of reactors from the French company Areva. Projects using technology from the United States, and from Japan, are also planned.

Government officials have said that India will conduct more safety reviews to make sure its existing reactors and new proposals are safe. But they reiterated their commitment to nuclear projects, including the one in Madban, which has been named the Jaitapur Nuclear Power Plant, after a nearby village.

Many Indian scientists, though, remain distrustful of India’s nuclear establishment. And they criticize the decision to use Areva’s new reactors, saying they are unproved.

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Heather Timmons contributed reporting from New Delhi.

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Is Sugar Toxic?

Lustig is a specialist on pediatric hormone disorders and the leading expert in childhood obesity at the University of California, San Francisco, School of Medicine, which is one of the best medical schools in the country. He published his first paper on childhood obesity a dozen years ago, and he has been treating patients and doing research on the disorder ever since.

The viral success of his lecture, though, has little to do with Lustig’s impressive credentials and far more with the persuasive case he makes that sugar is a“toxin” or a“poison,” terms he uses together 13 times through the course of the lecture, in addition to the five references to sugar as merely“evil.” And by“sugar,” Lustig means not only the white granulated stuff that we put in coffee and sprinkle on cereal— technically known as sucrose— but also high-fructose corn syrup, which has already become without Lustig’s help what he calls“the most demonized additive known to man.”

It doesn’t hurt Lustig’s cause that he is a compelling public speaker. His critics argue that what makes him compelling is his practice of taking suggestive evidence and insisting that it’s incontrovertible. Lustig certainly doesn’t dabble in shades of gray. Sugar is not just an empty calorie, he says; its effect on us is much more insidious.“It’s not about the calories,” he says.“It has nothing to do with the calories. It’s a poison by itself.”

If Lustig is right, then our excessive consumption of sugar is the primary reason that the numbers of obese and diabetic Americans have skyrocketed in the past 30 years. But his argument implies more than that. If Lustig is right, it would mean that sugar is also the likely dietary cause of several other chronic ailments widely considered to be diseases of Western lifestyles— heart disease, hypertension and many common cancers among them.

The number of viewers Lustig has attracted suggests that people are paying attention to his argument. When I set out to interview public health authorities and researchers for this article, they would often initiate the interview with some variation of the comment“surely you’ve spoken to Robert Lustig,” not because Lustig has done any of the key research on sugar himself, which he hasn’t, but because he’s willing to insist publicly and unambiguously, when most researchers are not, that sugar is a toxic substance that people abuse. In Lustig’s view, sugar should be thought of, like cigarettes and alcohol, as something that’s killing us.

This brings us to the salient question: Can sugar possibly be as bad as Lustig says it is?

It’s one thing to suggest, as most nutritionists will, that a healthful diet includes more fruits and vegetables, and maybe less fat, red meat and salt, or less of everything. It’s entirely different to claim that one particularly cherished aspect of our diet might not just be an unhealthful indulgence but actually be toxic, that when you bake your children a birthday cake or give them lemonade on a hot summer day, you may be doing them more harm than good, despite all the love that goes with it. Suggesting that sugar might kill us is what zealots do. But Lustig, who has genuine expertise, has accumulated and synthesized a mass of evidence, which he finds compelling enough to convict sugar. His critics consider that evidence insufficient, but there’s no way to know who might be right, or what must be done to find out, without discussing it.

If I didn’t buy this argument myself, I wouldn’t be writing about it here. And I also have a disclaimer to acknowledge. I’ve spent much of the last decade doing journalistic research on diet and chronic disease— some of the more contrarian findings,on dietary fat, appeared in this magazine—– and I have come to conclusions similar to Lustig’s.

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Gary Taubes (gataubes@gmail.com) is a Robert Wood Johnson Foundation independent investigator in health policy and the author of“Why We Get Fat.” Editor: Vera Titunik (v.titunik-MagGroup@nytimes.com).

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