Some States Are Lacking in Health Law Authority

Insurance commissioners in about half the states say they do not have clear authority to enforce consumer protection standards that take effect next month.

Federal and state officials are searching for ways to plug the gap. Otherwise, they say, the ability of consumers to secure the benefits of the new law could vary widely, depending on where they live.

Meanwhile, state governments that have for years allowed insurers to set premiums virtually at will are gearing up to establish procedures to review rate increases.

Under the new federal standards, insurers generally must offer coverage to children under 19 and must allow adult children up to age 26 to stay on their parents’ policies. Insurers cannot charge co-payments for preventive services or impose a lifetime limit on benefits; must allow consumers to appeal a denial of benefits; and cannot rescind coverage, except in cases of fraud or intentional misrepresentation.

States have the primary role in enforcing many of the new standards. If a state fails to enforce a standard, the federal government will step in to do so— as it did in several states after passage of ahealth insurancelaw in 1996.

The federal government recently surveyed states to assess their enforcement capabilities, and the results suggest a patchwork of protections.

California, Florida, Hawaii, Michigan, Nebraska, Oklahoma, Virginia and Wyoming, among other states, said they did not have authority to enforce federal law.

Some state regulators said they would ask state legislators to expand their authority by putting the federal standards into state law next year. Others said they would rely on their powers of persuasion, the good will of insurers or general state laws that ban unfair or deceptive trade practices.

By contrast, Maryland passed a bill in April that explicitly authorizes its insurance commissioner to enforce consumer protections in the new federal law. Similar bills were signed in June by Gov. Bev Perdue of North Carolina and in July by Gov.John Lynchof New Hampshire.

Kathleen Sebelius, the secretary of health and human services, said she realized that“some states may lack the full authority they might need or desire to fully enforce” the new market rules.

The administration said its general approach was to have“states take a lead role in providing consumer protections, with federal enforcement only as a fallback measure.”

Sara Rosenbaum, a professor of health law and policy atGeorge Washington University, said this was an awkward arrangement.“The new law creates detailed federal standards for insurance, but does not give consumers a right to sue if insurers don’t live up to their obligations,” Ms. Rosenbaum said.

Kim Holland, the Oklahoma insurance commissioner, said,“We will have to seek explicit authority from our State Legislature to make sure we can adequately enforce all the new provisions of federal law.”

Ken Ross, the Michigan insurance commissioner, said,“I fully expect insurers to comply,” even though his office“does not currently have clear authority to enforce the consumer protections enacted in federal law.”

Arizona said it was unlikely to pass legislation authorizing any state agency to enforce federal insurance standards, in view of its participation in a lawsuit challenging the federal law. Moreover, it said, Gov.Jan Brewerhas“instituted an indefinite rule-making moratorium, so we have no plans to adopt rules related to enforcement” of the law.

Some states hope to secure compliance by using their power to review insurance policy forms and contracts.

In a recent bulletin, the Texas Insurance Department encouraged insurers to file amendments to standard policy forms that would bring them into compliance with federal law. John Greeley, a spokesman for the department, emphasized the word“encouraged.”

“We don’t have authority right now to require it,” Mr. Greeley said.

Florida said that if insurers did not voluntarily revise their contracts, the state“has no legal authority to force them to do so.”

The Nebraska Insurance Department said it did not have“specific authority to order compliance with federal law in the face of a refusal to comply.”

Wyoming said it did not have the authority, under its insurance code or its Unfair Trade Practices Act, to enforce federal law even if it received consumer complaints.

New Jersey, New York and Ohio said they believed they had the power to enforce federal standards.

Gov.David A. Patersonof New York said his state would require insurers to rewrite their contracts to include the new consumer protections. State officials have developed model language. In addition, Mr. Paterson said, the Legislature will consider amending state insurance laws so they“meet or exceed” federal requirements.

Within days, the Obama administration is expected to announce up to $51 million in grants to states to help them perform one of their new duties: reviewing“unreasonable increases in premiums.”

Thirteen states currently have no authority to review proposed health premium increases for most forms of coverage, according to theNational Association of Insurance Commissioners. About a dozen have limited power to review increases after they take effect, while half the states require some form of state approval.

With insurers proposing heavy rate increases this year, possibly in anticipation of tougher regulation, several states have exerted their rate review authority with new vigor.

Sandy Praeger, the Kansas insurance commissioner and chairwoman of the health committee for the National Association of Insurance Commissioners, said states were eager to toughen their procedures to ward off federal interest in obtaining that authority.“The pressure is on us to prove that what we do is effective, and for states that don’t have the authority to get it done,” Ms. Praeger said. Many states will require legislation to change their rate review systems, she said.

States are also waiting for the federalDepartment of Health and Human Servicesto define unreasonable rate increases.

“That’s the big question,” Ms. Praeger said.“Unreasonable is a rather nebulous term.”

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Judge Revokes U.S.D.A. Approval of Modified Sugar Beets

The decision, by Judge Jeffrey S. White of Federal District Court in San Francisco, appears to effectively ban the planting of the genetically modified sugar beets, which make up about 95 percent of the crop, until the Agriculture Department prepares an environmental impact statement and approves the crop again, a process that might take a couple of years.

The decisioncould cause major problems for sugar beet farmers and sugar processors. In the past the sugar industry has warned there might not be enough non-engineered seeds available. However, the judge ruled that crops currently in the ground can be harvested and made into sugar, so the effects will not be felt until next spring’s planting season.

Beets supply about half the nation’s sugar, with the rest coming from sugar cane. Sugar beet growers sold the 2007-8 crop for about $1.335 billion, according to government data.

The decision came in a lawsuit organized by the Center forFood Safety, a Washington advocacy group that opposes biotech crops.

Judge White ruled last September that the Agriculture Department’s approval of the beets violated the National Environmental Policy Act, but he did not specify a remedy. Earlier this year, he denied a request by the plaintiffs to prohibit the planting of the engineered seeds this year, saying that would be too disruptive. But he warned farmers to move toward using conventional seeds.

In his order Friday, the judge granted the plaintiffs’ request to formally vacate the approval of the beets. That would bar farmers from growing them outside of a field trial.

But Judge White denied the plaintiffs’ request for a permanent injunction that would have also banned the growing of the crops. He said an injunction was not necessary if the crop was no longer approved for commercial planting. .

A decision by theUnited States Supreme Courtearlier this year in a similar case involving genetically engineered alfalfa essentially precluded the granting of an injunction.

In the alfalfa case, theSupreme Courtindicated that the government might grant partial approval of agenetically modified crop. It seems that such an option might be available in the sugar beet case as well, which could reduce any hardship for farmers. It is also possible the Agriculture Department will appeal.

Caleb Weaver, a spokesman for the Agriculture Department, said Friday night that the department was“looking at the decision to figure out what’s appropriate as the next step.”Monsantodeclined to comment, saying it would defer to sugar growers and processors.

Duane Grant, a sugar beet farmer in Rupert, Idaho and chairman of the Snake River Sugar Company, said he had not seen the decision and could not assess its impact.

But Mr. Grant, who had intervened in the case, added,“I’m pleased that the crop that is currently planted would be allowed to be harvested and processed. That’s clearly in the best interest of the public.”

Andrew Kimbrell, executive director of the Center for Food Safety, said the ruling was another sign the Agriculture Department was not doing its job.“This is regulation by litigation,” he said.

The ruling followed a hearing held earlier Friday in Judge White’s courtroom.

The Agriculture Department and its allies had argued that the approval of the crop should not be revoked, saying the department’s mistakes were not that serious and that the crop was going to be eventually approved anyway. At the least, they asked for a nine-month delay in revoking the approval to give the department time to put interim measures into place.

But Judge White disagreed, writing in his opinion that the Agriculture Department’s errors“are not minor or insignificant” and that it had already had time since his initial ruling in September to put interim measures into place.

The judge said it was not clear legally if he could consider the economic consequences of revoking the approval, but that even if he could, the Agriculture Department had not adequately demonstrated there would be a severe impact.

In his previous ruling, Judge White said the department had not adequately assessed the consequences from the likely spread of the genetically engineered trait to other sugar beets or to the related crops of Swiss chard and red table beets.

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Patient Money - Filling In the Insurance Gap for Adult Children

But not until January. In the meantime, she will renew the student policy she had last year, even though the coverage isn’t as good and the price, $1,745 for the year, is much steeper than rejoining her father’s plan, which she will be able to do free.

“It’s extremely frustrating,” she said.

Finding a health plan for college-age children isn’t something parents have had to think much about. Most decide to keep their children on their employer’s plan, which is typically more comprehensive than coverage offered through the school or in the market for individual policies.

But many health plans limit coverage of college-age children for a variety of reasons, including age, whether they live at home and whether they are financially dependent. For families with those plans, the choices are more difficult. And the health care law has addedwrinklesto an already complicated decision.

Under the new law, employers will be required to offer to cover adult offspring until they are 26, regardless of their student status or whether they are financially dependent on their parents. The provision takes effect on or after Sept. 23, whenever health plans renew coverage.

For many companies, that means January 2011, but for others it could be March or even July. So students like Ms. Zaidenweber face a gap in coverage of several months.

Because of a pre-existing condition, she does not qualify for an individual insurance policy to tide her over until January, when she will rejoin her father’s plan. But Georgetown won’t permit her to buy student coverage for just one semester, so beginning in January she will be doubly insured.

For many such students and their families, finding adequatehealth insuranceremains a challenge. Here are strategies to consider.

EMPLOYER PLANSEmployer plans generally offer more comprehensive coverage than student or individual policies. But don’t assume the company plan is the best choice.

If you haven’t done so, check with your human resources department to make sure your child will be covered in the fall. If there is going to be a gap, find out your health plan renewal date and when the enrollment period will be held to add adult children.

If your plan doesn’t renew until next year, under the federal Consolidated Omnibus Budget Reconciliation Act, Cobra, you can keep your child on your employer plan in the interim. But you will be responsible for paying the premium to cover the child.

Cost is another important question. Once the plan renews its policy, the new health care law prohibits employers from charging a higher rate for adult children who are newly eligible for coverage. Companies can charge more for all dependents, however, and many may do so.

In a recent survey by Mercer, a human resources consulting firm, one third of employers said they would strongly consider increasing the premiums for dependent coverage to offset the higher costs of covering adult offspring. If your company plans to do this, you may want to consider other options, such as individual insurance, especially if your child is healthy.

The new health care law eliminates some barriers for parents who want to keep college students on the family plan, but obstacles remain. One all-too-common difficulty: If your child is going to school out of state, your health plan may not cover most services there.

That’s the situation facing the Davis family of Malibu, Calif. Skyler Davis, 18, is heading to Drexel University this fall, but the family’s health maintenance organization will cover him only for emergency or urgent care, not routine doctor appointments, while he’s in Philadelphia.

So the Davises will probably buy Drexel’s student plan, at $1,140 a year. Elyse Davis concedes she does not like the $50,000 per condition per lifetime cap on benefits.

“You go into the hospital for two days, and that could do it,” she said.

STUDENT POLICIESA majority of colleges offer student health insurance, and some provide solid coverage— but they are the exception.“Most student plans are really bad,” said Stephen Beckley, a health care management consultant for colleges and universities in Fort Collins, Colo.

Student health plans must meet new standards under the health law, but the specific regulations have not been issued. The law is likely to have no effect this fall, since those health plans are already in place.

If you’re considering buying a college plan, look for several important elements, said Mr. Beckley and other experts. They include: catastrophic coverage of at least $1 million in lifetime benefits; no exclusions of coverage for pre-existing conditions if your child was covered immediately before signing up; first-dollarmental healthcoverage, not subject to a deductible; and solid prescription drug coverage.

As more parents see cuts to their generous employer health benefits or lose them entirely, some student health plans, even ones that aren’t particularly robust, are starting to look at least somewhat attractive.

Donna and Brent Funck’s daughter Brenna, 18, will attendTulane Universityin New Orleans this fall. Mr. Funck owns a software business, and the family is insured through an individual policy. Brenna Funck, however, has a congenital heart defect that makes her difficult to insure. The Funcks pay $300 a month for a separate individual policy for her, with a $2,500 deductible.

Tulane’s policy isn’t ideal for someone with a medical condition that may require expensive care. The policy maxes out at $250,000 per condition per lifetime.“One event that requires surgery would wipe that out,” Ms. Funck said.

But the $1,754 annual premium is a lot less than the Funcks pay, and the deductible is just $250. Despite reservations, they said they will sign her up.

INDIVIDUAL PLANSIf the parents’ insurance isn’t an option and the school policy is poor or nonexistent, students who are healthy may be able to get a good deal on an individual policy.

The average rate for an 18- to 24-year-old is $106 a month for a plan with a $2,300 deductible, said Carrie McLean, a consumer specialist witheHealthInsurance.com, which sells policies from 180 insurers through its Web site.

Individual policies are not known for being generous, but they may be a better choice for students than in years past. Under the health care law, new individual plans must meet new standards beginning Sept. 23, including no lifetime limits on coverage and free preventive care.

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Antibiotic-Resistant Bacteria Moving From South Asia to U.S.

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A Heart Pump Ticks Down, and a Stranger Steps In to Help

Mr. Volpe, 67, a slight, gray-haired man, looked in his car for the bag he always keeps nearby with spare batteries. But, no bag. In his mind’s eye he saw exactly where he had left it, to make sure he would not forget it, on a chair near the door back home— an hour and a half away. He thought of the clever little hand pump he had been given to keep his mechanical heart going in an emergency. It, too, was in the missing bag. Standing in the parking lot, he could hear one thing. Beep. Beep. Beep.

“I have to admit, I panic,” he said.

Mr. Volpe is one of thousands of Americans who have had these pumps, called left ventricular assist devices, surgically implanted to help their failing hearts. FormerVice President Dick Cheneyis another. Sometimes the pumps are used to keep people alive until a transplant becomes available, but in other cases they are meant to remain as long as the patient lives.

Mr. Volpe, a retired subway conductor who had had two heart attacks and two bypass operations, had an assist pump implanted in October 2009 by Dr. Yoshifumi Naka at NewYork-Presbyterian/Columbia hospital.

The pump is placed near the patient’s own heart. A power line emerges about waist level and connects to a controller, a mini-computer which plugs into a pair of one-and-a-half-pound, 12-volt batteries. Patients wear a black mesh vest over their clothing that holds the controller and batteries. The pump Mr. Volpe had, a HeartMate XVE, made by Thoratec, could run for about four hours on two batteries. The pumps cost $70,000 to $80,000, usually covered by insurance.

That day in the parking lot in December, in Fishkill, in upstate New York, Mr. Volpe was too far from Columbia to get there in time. But his wife phoned its heart-pump clinic, andnurse practitionerstold her to call 911 for an ambulance to the nearest hospital.

Mr. Volpe knew that if the pump stopped, he was not likely to die immediately; his own heart, though weak, would probably keep him alive. But he was still in real danger, because clots would form in the mechanical heart if it quit, and cause a stroke if they escaped into his bloodstream.

Dr. Donna Mancini, Mr. Volpe’s cardiologist and director of theheart failureand transplant program at NewYork-Presbyterian/Columbia, said the hospital had not encountered a situation like this before.

“But with these devices getting more use, it may arise,” Dr. Mancini said.

Right now, Dr. Mancini said, Columbia has 45 patients with pumps who are waiting for transplants. Just a few years ago, there were only 10.

She said she did not know why, but this year fewer donor hearts have become available than in the past, leaving more patients dependent on the pumps. Usually, the hospital performs 80 to 100 transplants a year.

“This year we’re on a course that will probably yield around 60 transplants,” Dr. Mancini said, adding that there were about 150 patients on Columbia’s waiting list.

Nationwide, 3,138 people are waiting for heart transplants, according to the United Network for Organ Sharing. Last year, 2,211 received new hearts.

Thoratec said that in the past decade or so, a total of 6,000 XVE devices and 5,000 of a newer model, the HeartMate II (the one Mr. Cheney has) had been implanted.

An ambulance took Mr. Volpe to Vassar Brothers Medical Center in Poughkeepsie. But that hospital does not implant assist pumps, and had no batteries or hand pump. Doctors there, advised by Columbia, began dripping in a blood-thinning drug, heparin, to prevent clots.

Meanwhile, Khristine Orlanes, a nurse practitioner at Columbia, began trying to find another patient with an assist pump who was close enough to bring Mr. Volpe a set of batteries in time.

She called Robert Bump, 61, a building contractor who worked near Poughkeepsie. He had six spare batteries in a knapsack.

“I’m on my way,” Mr. Bump said.

An electrician offered to drive, and they tore off in his pickup truck. The electrician called a state trooper friend, told him the story and said,“We’re not stopping.”

A police car met them partway to Poughkeepsie and escorted them. They made the half-hour trip in about 20 minutes.

Mr. Bump strode into the emergency room and spotted Mr. Volpe on a gurney, surrounded by doctors, nurses and his frantic wife. The alarm was still beeping. A doctor, noticing Mr. Bump’s black-mesh vest and the controller, said,“Oh, he’s got one, too.”

Mr. Volpe, who had no idea what plans had been hatched on his behalf, said:“I see this big fellow walk in. I recognized the outfit right away.”

Mr. Bump snapped the batteries in place and said,“O.K., you’re good.”

There was a small round of applause in the emergency room. Mr. Volpe could not stop saying thank you.

His pump, due to run out in 15 minutes, had somehow lasted nearly an hour, but apparently had just minutes left when Mr. Bump arrived.

The two men had different pump models that happened to use the same batteries. If Mr. Bump had been using a newer version of the batteries for his model, they would not have been compatible with Mr. Volpe’s.

“Mr. Volpe’s stars were aligned that day,” Mr. Bump said.“There is some reason that gentleman needs to be here.”

On July 24, after nearly a year on his assist pump, Mr. Bump made it to the top of the waiting list and received a transplant at NewYork-Presbyterian/Columbia. At the hospital, his wife overheard the spouse of another transplant patient say that she, too, was from upstate.

Mr. Bump’s wife mentioned that her husband had helped another patient from the same area who needed batteries for an assist pump.

“That was my husband,” the other woman said.

By coincidence, Mr. Volpe had also just received a transplant.

Last week, the two were up and about, in good spirits. Both said they owed their lives to the assist pumps— but were thrilled to be free of them. Both were desperate for showers, after nearly a year of sponge baths. They would not miss the vests, either. On more than one occasion, Mr. Bump had had to reassure strangers that he was not wearing a bomb.

Leaving a sitting room at the hospital last Thursday, Mr. Bump rose first and offered Mr. Volpe a hand getting up.

“No thanks,” Mr. Volpe said softly, smiling.“You gave me enough help, Robert.”

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Q and A - Water Safety - Question

A.If the water was clean when it went into the containers, if the jugs were perfectly clean and sanitized to begin with, and if you are sure the containers were never opened, it will not have become unsafe to consume.

If you have doubts about any of these factors, the water can still be used if it is purified. The purification methods usually suggested are filtering followed by boiling or adding a few drops (about eight drops per two-liter bottle) of unscented liquid householdbleach.

Authorities like theRed Crossand theFederal Emergency Management Agencyrecommend keeping emergency water supplies on hand in case of a disaster: a gallon a day per household member, enough for at least three days. It should be either commercially bottled water or chlorinated tap water put into clean, food-grade, soft-drink-type plastic containers, not cardboard juice or milk containers.

The authorities also recommend renewing the supply every six months and keeping it away from heat and sunlight, which encourage the growth of any microbes that may be present. Boiled water can be aerated to make it more palatable by pouring water back and forth between two clean containers.C. CLAIBORNE RAY

Readers are invited to submit questions by mail to Question, Science Times, The New York Times, 620 8th Avenue, New York, N.Y. 10018, or by e-mail to question@nytimes.com. Questions of general interest will be answered in this column, but requests for medical advice cannot be honored and unpublished letters cannot be answered individually.

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Recipes For Health - Halibut With Cucumbers and Dill

2 medium cucumbers, peeled if waxed, or 1 European seedless cucumber

3 tablespoons chopped fresh dill

Salt and freshly ground pepper

1 1/2 pounds Pacific halibut fillets or sand dabs

2 large garlic cloves, minced

1 or 2 shallots, minced (optional)

1/4 cup fresh lemon juice

1 tablespoon extra virgin olive oil

1/4 cup dry white wine

1.Preheat the oven to 425 degrees. If using regular cucumbers, cut in half, scoop out the seeds and slice thin. If using a European cucumber, just slice thin. Oil a baking dish large enough to accommodate the fish fillets in one layer. Cut a piece of parchment the size of the baking dish, and set it aside. Line the baking dish with half of the cucumber slices. Sprinkle on 1 tablespoon of the dill and salt and pepper lightly.

2.Rinse the fish fillets, and pat dry. With the tip of a sharp knife, score them on the diagonal a few times (this prevents them from curling when they cook). Lay on top of the cucumbers. Salt and pepper lightly, and sprinkle on the garlic and shallot. Sprinkle with another tablespoon of the dill, and drizzle on half the lemon juice and the olive oil. Top with the remaining cucumbers. Add the remaining lemon juice, and sprinkle the remaining dill over the top layer of cucumbers. Add the white wine, and cover with the parchment. Cover the dish tightly with foil, and place in the oven. Bake 10 to 15 minutes until the fish is opaque and pulls apart when stuck with a fork.

3.Remove from the oven, let sit for a few minutes and then serve from the baking dish, spooning some of the liquid from the baking dish over the top.

Yield:Serves four.

Advance preparation:If you wish, you can assemble the dish ahead of time, but don’t add the lemon juice or wine. Cover with plastic, and refrigerate for one hour or longer. When ready to bake, add the lemon juice and wine.

Nutritional information per serving:245calories; 7 grams fat; 1 gramsaturated fat; 54 milligramscholesterol; 4 gramscarbohydrates; 1 gramdietary fiber; 95 milligrams sodium (does not include salt added during cooking); 36 grams protein

Martha Rose Shulman can be reached atmartha-rose-shulman.com.

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Veterans Sound Alarm Over Burn-Pit Exposure

Every conceivable type of waste was piled high in the pit— plastics, batteries, appliances, medicine, dead animals, even human body parts— and burned, with a dousing of jet fuel. A huge black plume of smoke hung over the pit, nearly blinding Ms. Clifford on her twice-a-month visits, and wafted over the entire base.

By 2005, Ms. Clifford, who had been a serious runner, began tocoughup phlegm, and soon found it difficult to do any physical training. As her breathing got worse and other symptoms became more serious, doctors discovered that her lungs were filling with fluids.

“The doctors say they have never seen anyone like me, and they don’t know what to do,” she said.

Ms. Clifford, who retired from the Army with full disability in April, is one of the first veterans to receive an official ruling from the military that exposure to open-air burn pits at American bases in Iraq and Afghanistan have caused medical problems. Hundreds of other veterans have complained of similar illnesses that they believe were caused by exposure to the pits, forcing the Pentagon to restrict their use and theDepartment of Veterans Affairsto begin an investigation.

About 300 victims or their families have joined a class-action lawsuit against KBR, the military contractor that operated some of the burn pits at bases in Iraq. The company is fighting the suit, filed in federal court in Maryland, claiming that it operated some pits at the military’s direction, while most were operated by the Army.

The Defense Department and the Department of Veterans Affairs are proceeding cautiously in linking soldiers’ symptoms to the burn pits. While dealing with disability claims on a case-by-case basis, like Ms. Clifford’s, they have not developed a broad policy on the issue.

“At this point in time, there is no medical data to indicate any specific illness or illnesses have been caused by exposure to burn-pit smoke,” Dr. Michael E. Kilpatrick, the deputy director of the Pentagon’sForce Health Protection and Readiness Programs, said in a statement.

In response to complaints from hundreds of veterans and growing pressure from Congress, the V.A. has provided money for theInstitute of Medicine, part of theNational Academy of Sciences, to conduct a large-scale study, scheduled to be completed next year, of the possible consequences of burn-pit exposure. This year, the V.A. issued new guidelines for its staff to be on the lookout for veterans with illnesses that may have been caused by burn-pit exposure.

Meanwhile, the Pentagon is conducting a separate review of burn pits and their current status in Iraq and Afghanistan, and Congress has passed legislation requiring the military to justify any further use of them. Many of them in Iraq have been shut down as a result.

As of May, 42 were still operating in Iraq, and 184 more in Afghanistan. The burn pits began as a makeshift solution in a war zone, and critics say they remained in place long after alternatives, like incinerators, could be used.

Some veterans complained that the Pentagon has moved slowly and only reluctantly to deal with their medical complaints. Former Sgt. Kimani Grant of Cleveland said that after he served on an American base near Tikrit, Iraq, in 2005, where he lived and worked near a large burn pit, he developed persistentshortness of breath.

“It’s difficult for me to walk or run,” said Mr. Grant, who is 28.“I used to be real active in sports, and now I can’t do any of it. But when I went to the Army doctors, they never told me I had any kind of disease.”

While medical experts caution that it can be difficult to establish causality between environmental exposure and illness, several physicians who have conducted independent studies of the problem said that military medical officials have played down any connection. They pointed to a 2008 study by the military that found no evidence of a significant health risk tied to burn pits in Iraq.

“I’ve been concerned that the military really seems like they are trying not to find much of a link,” said Dr. Robert F. Miller, a pulmonary expert at theVanderbilt University Medical Center, who has conducted extensive studies of veterans returning from Iraq withrespiratory diseases.

He has treated dozens of soldiers from Fort Campbell, Ky., who served in Iraq, and he said he has found a pattern of unusual respiratory and pulmonary disease. He said he saw soldiers from the 101st Airborne Division who had fought a major sulfur mine fire in Iraq in 2003, many of whom had developed constrictivebronchiolitis. He then found other soldiers who had not been involved in fighting that fire but had similar symptoms that he believed might be linked to burn-pit exposure.

“How big a problem is it?” Dr. Miller asked.“I think it’s pretty big. The soldiers know more about it than the physicians. I get calls from soldiers all over the country.”

Dr. Anthony Szema of theStony Brook University Medical Centerpublished a study this week that found that soldiers from Long Island who were deployed to Iraq from 2004 to 2007 had a higher rate ofasthmathan those who remained in the United States. Of 900 soldiers from Long Island who were deployed to Iraq during that time, 6.6 percent came back with new diagnoses of asthma, compared with 4.4 percent of those who stayed in the United States.

In an interview, Dr. Szema said that the study“raises the concern of whether this is really asthma, or lung injuries. All of the soldiers in our study passed through Camp Anaconda, where a burn pit was going full blast. It doesn’t prove causality, but we know that if you burn things slowly in an unregulated manner, it creates more air pollution than if you use an incinerator.”

Officials of theDisabled American Veteranssaid they had been contacted by more than 500 veterans complaining of illnesses they believed were caused by burn-pit exposure. Representative Timothy H. Bishop, a Democrat from Long Island who has taken the lead on the matter in Congress, said he believed that the burn-pit issue could grow as the health effects are more widely recognized.

“To me, this is very evocative of the experience we’ve had with the exposure to toxins at ground zero in New York,” Mr. Bishop said.“Just like with ground zero, we are going to see the numbers of people who contract illnesses grow dramatically as the years pass.”

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News Analysis - In Push to Detect Early Alzheimer’s Markers, Hopes for Prevention

That is the hope behindnew diagnostic guidelinesbeing proposed by the National Institute on Aging and the Alzheimer’s Association.

In July, when the groups first announced theirproposed guidelines, they were met with some skepticism and anger. Why suggest ways of diagnosing the disease before a person even has symptoms? Why tell people they are doomed?

And are those early diagnosis guidelines just a sop to pharmaceutical companies so they can start marketing expensive, and perhaps not very effective, new drugs?

So the Alzheimer’s Association, with participation from the National Institute on Aging, held a conference call on Wednesday to clarify their position.

They wanted, in particular, to explain why they advocated using so-called biomarkers, like scans for amyloid plaque in the brain, a unique feature of Alzheimer’s, and tests of cerebrospinal fluid. Such brain scans are still experimental.

The groups said biomarkers would be used, at this stage, only for research, with some patients in studies having tests to see how well such brain changes predict disease.

A main goal of the proposed guidelines, which are expected to be adopted, is to find signs of the disease much earlier. Now, the diagnosis— based on decliningmemoryand reasoning abilities— requires severe symptoms. But researchers agree that Alzheimer’s smolders in the brain a decade or more beforememory lossor diminished ability to reason. With new criteria for early diagnosis, the stage is set for testing drugs that might prevent the disease from running its course, investigators say.

“Certainly, we are not out there trying to help drug companies,” said Dr. Reisa Sperling ofBrigham and Women’s Hospitalin Boston. But the situation today— nearly all drugs are tested only in people who have severe symptoms— seems a recipe for failure.

“We are trying these drugs way too late,” Dr. Sperling said in a telephone interview on Tuesday.

But, said Dr. Jason Karlawish, an Alzheimer’s researcher at theUniversity of Pennsylvaniawho was not part of the conference call, it is not unreasonable to worry about the role of drug companies.

“They are driven by profits over progress and by trying to move a drug as fast as they can into the clinic without getting all the good evidence they need,” Dr. Karlawish said.

The challenge, he said, is to avoid a rush to approve drugs that are not truly effective and to find a way to keep prices reasonable.

And there is a challenge in making sure diagnostic tests are not misused.

That may not be easy.

Already, some doctors are using biomarkers, like spinal fluid tests that are commercially available, against the advice of researchers. Scientists are still working on standardizing the tests— making sure that, like a test for cholesterol orprostate cancer, an Alzheimer’s biomarker test done in one lab will give the same results as one done elsewhere. The spinal fluid tests can show levels of amyloid and another Alzheimer’s protein, tau. But it is not yet known what levels of amyloid or tau in spinal fluid are abnormal. And measurements of amyloid and tau can vary as much as 30 percent from one research lab to another, said Dr. Marilyn Albert ofJohns Hopkins University.“That’s why we are very concerned about these measurements being used in clinical settings at the current time.”

The investigators said people worried about their memory should consider entering clinical trials studying the natural history of the disease and testing new drugs. It might be a decade or more before any drugs are found to work and approved for marketing. So there is not much people can do if they go to a private doctor, have a spinal fluid test and are told they might be in the early stages of Alzheimer’s. The test might not be valid, and no drugs now on the market can slow the disease.

The biggest questions are what it means when tests find that people have amyloid in their brain yet have no symptoms. Are those people certain to develop Alzheimer’s if they live long enough? Or is brain plaque like the very different plaque that forms in arteries? Many people have plaque in their arteries yet never have aheart attack.

If amyloid plaque is analogous to artery plaque, some who take drugs would be protected from Alzheimer’s. But many others who would never get Alzheimer’s might end up taking drugs for decades. That means the drugs must be very safe and not prohibitively expensive.

Even so, said Dr. Steven DeKosky, the dean of theUniversity of Virginiamedical school, the future now looks brighter than it ever has.

He and others are convinced the field is at a turning point, resembling the early days of cholesterol testing for heart disease.

“This is where we’re going in Alzheimer’s disease,” Dr. DeKosky said.

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Two New Paths to the Dream - Regeneration

Animals like newts and zebra fish can regenerate limbs, fins, even part of the heart. If only people could do the same, amputees might grow new limbs and stricken hearts be coaxed to repair themselves.

But humans have very little regenerative capacity, probably because of an evolutionary trade-off: suppressing cell growth reduced the risk ofcancer, enabling humans to live longer. A person can renew his liver to some extent, and regrow a fingertip while very young, but not much more.

In the first of the two new approaches,a research group at Stanford Universityled by Helen M. Blau, Jason H. Pomerantz and Kostandin V. Pajcini has taken a possible first step toward unlocking the human ability to regenerate. By inactivating two genes that work to suppresstumors, they got mouse muscle cells to revert to a younger state, start dividing and help repair tissue.

What is true of mice is often true of humans, and although scientists are a long way from being able to cause limbs to regenerate, the research is attracting attention. Jeremy Brockes, a leading expert on regeneration at University College London, said the report was“an excellent paper.” Though there is a lot still to learn about the process,“it is hard to imagine that it will not be informative for regenerative medicine in the future,” he said.

In recent years, most research in the field of regenerative medicine has focused on the hope thatstem cells, immature cells that give rise to any specific type of cell needed in the body, can somehow be trained to behave as normal adult cells do. Nature’s method of regeneration is quite different in that it starts with the adult cells at the site of a wound and converts the cells to a stemlike state in which they can grow and divide.

The Stanford team has taken a step toward mimicking the natural process.“What I like is that it’s built on what’s happening in nature,” Dr. Blau said.“We mammals lost this regenerative capacity in order to have bettertumorsuppression, but if we reawaken it in a careful way we could make use of it in a clinical setting.”

Dr. Pomerantz, a clinician, hopes the technique can be applied to people, though many more animal experiments need to be done first.“We have shown we can recapitulate in mammalian cells behavior of lower vertebrate cells that is required for regeneration,” he said.“We would propose using it in amputations of a limb or part of a limb or in cardiac muscle.” After aheart attack, the muscle cells do not regenerate, so any method of making them do so would be a possible treatment.

Interfering with tumor suppressor genes is a dangerous game, but Dr. Pomerantz said the genes could be inhibited for just a short period by applying the right dose of drug. When the drug has dissipated, the antitumor function of the gene would be restored.

Finding the right combination of genes to suppress was a critical step in the new research. One of the two tumor suppressor genes is an ancient gene, known as Rb, which is naturally inactivated in newts and fish when they start regenerating tissue. Mammals possess both the Rb gene and a backup, called the Arf gene, which will close down a cancer-prone cell if Rb fails to do so.

The Stanford team found that newts did not have the Arf backup gene, which mammals must have acquired after their lineage diverged from that of amphibians. This suggests that the backup system“evolved at the expense of regeneration,” theStanford researchers sayin Friday’s issue ofCell Stem Cell.

The Stanford team shut off both Rb and Arf with a chemical called silencing-RNA and found the mouse muscle cells started dividing. When injected into a mouse’s leg, the cells fused into the existing muscle fibers, just as they are meant to.

The Stanford researchers have learned how to block two genes thought to inhibit the natural regenerative capacity of cells, but it is somewhat surprising that the regenerative mechanism should still exist at all if mammals have been unable to use it for 200 million years.“One school of thought is that regeneration is a default mechanism and doesn’t require its own program,” Dr. Pomerantz said.

Dr. Brockes believes that this is true in part. Regeneration“depends on a largely conserved cellular machinery,” he said, meaning that it is present in all animals. The machinery comes into play in wound healing and tissue maintenance. But specific instances of regeneration, like regrowing a whole limb, are invoked by genes specific to various species. He has found a protein specific to salamanders that coordinates regrowth of a salamander limb.

If the regeneration of a whole limb is a special ability that salamanders have evolved, then humans would not have any inherent ability to do the same.“I would beware of suggesting that this sort of manipulation is capable of unlocking‘the newt within,’ ” Dr. Brockes said.

A second, quite different approach to regenerating a tissue is reported inFriday’s issue of Cellby Deepak Srivastava and colleagues at theUniversity of California, San Francisco. Working also in the mouse, they have developed a way of reprogramming the ordinary tissue cells of the heart into heart muscle cells, the type that is irretrievably lost in a heart attack.

The Japanese scientist Shinya Yamanaka showed three years ago that skin cells could be converted to embryonic stem cells simply by adding four proteins known to regulate genes. Inspired by Dr. Yamanaka’s method, Dr. Srivastava and his colleagues selected 14 such proteins and eventually found that with only three of them they could convert heart fibroblast cells into heart muscle cells.

To make clinical use of the discovery, Dr. Srivastava said he would need first to duplicate the process with human cells, and then develop three drugs that could substitute for the three proteins used in the conversion process. The drugs could be loaded into astent, a small tube used in coronary bypass operations. With the stent inserted into a heart artery, the drugs would convert some of the heart’s tissue cells into heart muscle cells.

Some researchers hope that with Dr. Yamanaka’s method of turning skin cells into embryonic stem cells, those stem cells can be converted into usable heart muscle cells. One problem with this approach is that any unconverted embryonic stem cells may form tumors. Dr. Srivastava’s method sidesteps this problem by avoiding the stem cell stage.

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Recipes for Health - Spinach Omelet With Parmesan

4 ounces baby spinach, or 1/2 pound bunch spinach, stemmed and cleaned in two rinses of water

Salt and freshly ground pepper

2 large or extra-large eggs

2 teaspoons low-fat milk

1 tablespoon chopped chives (optional)

1 teaspoon extra virgin olive oil

1 tablespoon freshly grated Parmesan

1.Wash the spinach but don’t dry. Heat a large frying pan over high heat, and wilt the spinach in the water left on the leaves after washing. Remove from the heat, rinse briefly with cold water and squeeze dry. Chop medium-fine, season with salt and pepper, and set aside.

2.Break two eggs into a bowl, and beat with a fork or a whisk until frothy. Whisk in the milk, chives (if using), and salt and pepper to taste.

3.Heat an 8-inch nonstick omelet pan over medium-high heat. Add the olive oil. When the oil feels hot as you hold your hand above it, pour in the eggs, scraping every last bit into the pan. Swirl the pan to distribute the eggs evenly over the surface. Shake the pan gently, tilting it with one hand while lifting up the edges of the omelet with a spatula in your other hand. Let the eggs run underneath and set in several thin layers during the first few minutes of cooking. As soon as the eggs are set on the bottom and barely runny on top, sprinkle the Parmesan and then the spinach down the middle of the eggs. Jerk the pan quickly away from you then back toward you so that the omelet folds over onto itself.

If you don’t like your omelet runny in the middle, jerk the pan again so that the omelet folds over once more. Cook for about a minute longer until heated through, shaking the pan gently.

Tilt the pan and roll out onto a plate. Serve hot.

Yield:Serves one.

Advance preparation:The wilted spinach will keep for about four days in the refrigerator in a covered bowl.

Nutritional information per serving:235calories; 16 grams fat; 5 gramssaturated fat; 428 milligramscholesterol; 6 gramscarbohydrates; 2 gramsdietary fiber; 312 milligrams sodium (does not include salt added during preparation); 18 grams protein

Martha Rose Shulman can be reached atmartha-rose-shulman.com.

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Recipes for Health - Spinach Salad With Tomatoes, Cucumber and Feta

1/2 small red onion, sliced (optional)

6 ounces baby spinach

1 pound tomatoes, cut in wedges or diced

1 small cucumber, cut in half lengthwise, then sliced

8 calamata olives, pitted and cut in half lengthwise

1 green or red pepper, thinly sliced

2 teaspoons chopped fresh dill

1 tablespoon chopped fresh mint

2 tablespoons fresh lemon juice

Salt to taste

5 tablespoons extra virgin olive oil

2 ounces feta cheese, cut in small dice or crumbled

1.Place the onion in a bowl, cover with cold water and let sit for five minutes. Drain, rinse and dry on paper towels. (The reason for soaking the onion is to wash away some of the compounds that cause the onion flavor to linger in your mouth.) Combine with the tomatoes, cucumber, olives, pepper, dill and mint in a large bowl.

2.Mix together the lemon juice, salt and olive oil. Toss half of the dressing with the tomato mixture and half with the spinach. Combine everything in one bowl, add the feta, toss together thoroughly and serve.

Yield:Serves six.

Advance preparation:You can prepare the ingredients and dressing several hours before you toss the salad. Keep them in the refrigerator.

Nutritional information per serving:167calories; 15 grams fat; 3 gramssaturated fat; 8 milligramscholesterol; 7 gramscarbohydrates; 2 gramsdietary fiber; 215 milligrams sodium (does not include salt added during preparation); 3 grams protein

Martha Rose Shulman can be reached atmartha-rose-shulman.com.

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Global Update - Africa - In a Meningitis Hotbed, a New Vaccine at a Price Governments Can Afford

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Patient Money - For Most, Implants Beat Dentures, but at a Price

“They fell out when I talked,” Mr. Panko, 56, a small-business owner in Woodridge, Ill., recalled.“I couldn’t taste my food— in fact, I could hardly chew. It was the most miserable time of my entire life.”

Mr. Panko, who lost his teeth in his early 50s because of a hereditary form of periodontal disease, eventually replaced his dentures with something better: dental implants. While many people wear dentures without discomfort, implants are now considered the preferred treatment for replacing lost teeth, saidDr. Robert Pick, an associate professor of surgery at the Feinberg School of Medicine atNorthwestern University.

The procedure is straightforward. A surgeon places a titanium screw in the jaw bone, and prosthetic teeth are secured to the implant. They don’t wiggle or slip, as dentures can, and are healthier for the gums and bone. Most patients find implants easier to maintain than dentures.

“Best decision I ever made,” Mr. Panko said of his implants.“I could chew beer cans now.”

If only paying for them were so easy. For all their advantages, implants are expensive.Insurancecoverage is usually minimal, and patients often are surprised by high out-of-pocket costs.

An implant to replace a single tooth can cost $3,000 to $4,500, depending on where you live. Implants to replace a full or partial set of teeth can run from $20,000 to as much as $45,000.

Why so much? Implants typically involve the work of both a surgeon and a dentist. Several office visits may be needed to put in the screws and to add the prosthetic teeth.

More dental insurance plans are covering the costs, but the annual reimbursement limit is typically $1,500, an amount that hasn’t changed in four decades. That may be enough to cover half the cost of a single implant; you will end up paying the rest.

Still, many patients may find it a worthwhileinvestment. Implants typically last a lifetime, with a failure rate of less than 5 percent.

Let’s say you lose one tooth. If you opt for a bridge, which costs almost as much as an implant but is more often covered by insurance, the dentist will grind down the two adjacent teeth to create a structure that secures the replacement tooth.

The ground teeth become more vulnerable to decay and nerve damage, and there’s a good chance you will require a root canal in the future, saidDr. Karl Gruendl, a dentist in Fenton, Mo., who advises insurance plans.

A study done for Washington Dental Service, the largest insurance carrier in Washington State, found that over a five-year period the maintenance costs for people with bridges were higher than for those who had implants.

“For a single tooth replacement, over the long run we think it’s more beneficial to get the implant,” saidDr. Ron Inge, dental director for Washington Dental Service. And that’s an insurance executive talking.

If you need to replace most or all of your teeth, dentures are clearly the cheaper alternative, costing around $2,500 for a set (upper and lower jaws). But the implants won’t move around, nor interfere with your sense of taste, as a denture might.

Implants also will help protect your bones over time.“The screw in your jawbone will trick the body into thinking you still have teeth,” said Dr. Ira Cheifetz, president of theAmerican Association of Oral and Maxillofacial Surgeons.“The bone continues to grow and thrive.”

Implants aren’t appropriate for every patient, particularly those who smoke or already have substantial bone loss. If you are a candidate for the procedure, consider these cost-saving strategies.

YOUR PLAN BENEFITSIf your dental insurance covers implants, bravo. If it does not, ask the carrier to give you an allowance toward what a bridge or conventional denture would have cost, Dr. Gruendl suggested.

See a dentist who belongs to your insurance network. Dental plans negotiate discounted rates with their network providers, which means the overall cost of the implant will be substantially less than the“retail” charge, said Evelyn Ireland, executive director of theNational Association of Dental Plans.

How much less? Depending on the carrier, it might be as little as 5 percent of the standard price, or as high as 40 percent.

FINANCING OPTIONSMost dentists are willing to offer some kind of discount to patients who expect to have large bills. If you don’t have insurance or your plan doesn’t cover implants, ask your dentist for the rate provided to in-network insured patients.

Some dentists may let you pay them directly in installments. Mr. Panko, for example, is still paying off the $45,000 bill for the implants he got four years ago from Dr. Pick. Mr. Panko is pleased it worked out that way:“I have a longstanding relationship with my periodontist, and we worked out a payment plan.”

Many dentists also participate in financing programs, such asCareCreditandWells Fargo Health Advantage, that let patients pay bills over time with no, or minimal, interest. With CareCredit, for instance, you pay no interest if you pay off your balance in full within two years. Ask your dentist about financing plans if you’re worried about paying your bills all at once.

AN ALTERNATIVE PROVIDERDental schools sometimes have clinics where advanced students do implant procedures at reduced rates. Check the Web site of Oral Health America for help finding a clinic near you:oralhealthamerica.org.

START AN F.S.A.If you know you need one or more implants, but it’s not an emergency, fully fund your flexible spending account for next year. F.S.A.’s, offered by many employers, allow you to use pretax dollars to pay health care expenses. Depending on your tax bracket, pretax dollars can amount to an extra 20 percent to spend on the dental bill, compared to using taxed income.

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Book Review - Long for This World - The Strange Science of Immortality - By Jonathan Weiner

In his new book,“Long for This World,” Weiner makes similar use of another brilliant theoretical scientist, the English gerontologist Aubrey de Grey, a tireless proselytizer for radical life extension. But unlike the Grants, de Grey emerges on the page as someone who can be taken only in small doses.“Medievally thin and pale,” as Weiner puts it, with a luxuriant beard that recalls“Father Time before his hair turned gray” or“Timothy Leary unbound,” he is given to provocative statements that can turn into sermons. Nevertheless, with de Grey as his main character, Weiner explores the fractured, fuzzy science and pseudoscience of immortality.

“This is a good time to be a mortal,” Weiner writes, noting that life expectancy in the developed world is about 80 years, and improving. Yet evolution has equipped us with bodies and instincts designed only to get us to a reproductive age and not beyond.“We get old because our ancestors died young,” Weiner writes.“We get old because old age had so little weight in the scales of evolution; because there were never enough Old Ones around to count for much in the scales.” The first half of life is orderly, a miracle of“detailed harmonious unfolding” beginning with the embryo. What comes after our reproductive years is“more like the random crumpling of what had been neatly folded origami, or the erosion of stone. The withering of the roses in the bowl is as drunken and disorderly as their blossoming was regular and precise.”

De Grey, in the vernacular of science, is a“skin out” person, someone who studies life whole. Naturalists, ecologists, field biologists and evolutionary biologists are in this category, whereas“skin in” people pursue cellular phenomena,“gadgets and widgets that are too small to see through a microscope,” Weiner writes. The dichotomy is captured inFrancis Crick’s scolding ofStephen Jay Gould:“The trouble with you evolutionary biologists is that you are always asking‘why’ before you understand‘how.’” As Weiner describes it, the inspiration for de Grey’s scientific quest for immortality came in a flash one sleepless night:“The evolutionary theory of aging predicts chaos. And chaos is just what you see at the cellular and molecular level, and what you will always see. But what these troubles all have in common is that they fill the aging body with junk. Maybe we can just clean up all the scree and rubble that gathers in our aging bodies.” The beauty of this view is that“curing” aging requires no special knowledge of design, or any understanding of just how the cellular junk got there in the first place. It only requires that we get rid of it.

As de Grey sees it, there are seven types of cellular junk, the gerontological equivalent of the seven deadly sins. They include“cross links” that gum up the machinery and glue cells to one another and mitochondria that fail with age. Then there is junk within cells and junk in the spaces between cells, along with cells that no longer work but hang around and cells that die and poison cells around them. And then there are old cells that acquire dangerous mutations and give rise tocancer. Weiner’s strength as a writer is his ability to flesh out these complex theories without losing the reader. De Grey’s dream of conquering death may seem far-fetched and unreal, but Big Pharma is already at work on some of these ideas— the first cream that overcomes cross-links, which cause our skin to stiffen and wrinkle, will be a blockbuster.

Fortunately,“Long for This World” is not all about Aubrey de Grey. Weiner writes engagingly about other researchers and their work in the field: on so-called Methuselah mutants, creatures that live much longer than the rest of their species; genes like Sir2 (Silent Information Regulator 2), which may be responsible for some of the life-extending effects of extremely calorie-restricted diets; and related proteins, known as sirtuins. That work led to the discovery ofresveratrol, a compound in the skin of grapes that can activate sirtuins and prolong a lab animal’s life.

But as Weiner points out, there is a big problem with immortality. Traditionally, we have viewed our lives as unfolding in stages: Shakespeare’s seven ages of man capture our progression from infant to schoolboy to lover to soldier to justice to clown, ending finally in“second childishness and mere oblivion; sans teeth, sans eyes, sans taste, sans everything.” Immortality could wind up being a terrible stasis.“A huge part of the action and the drama in the seven ages comes from the sense of an ending, the knowledge that all these ages must have an end,” Weiner writes. We might live forever in a state of unending boredom. And the technology might benefit the wrong people:“If biologists could have done for the dictators of the 20th century what they can now do for roundworms and flies— double their life span— thenMao Zedongmight still be alive.”

As a young physician caught up in the early years of theH.I.V.epidemic, I was struck by my patients’ will to live, even as their quality of life became miserable and when loved ones and caregivers would urge the patient to let go. I thought it remarkable that patients never asked me to help end their lives (and found it strange that Dr. Kevorkian managed to encounter so many who did). My patients were dying young and felt cheated out of their best years. They did not want immortality, just the chance to live the life span that their peers could expect. What de Grey and other immortalists seem to have lost sight of is that simply living a full life span is a laudable goal. Partial success in extending life might simply extend the years of infirmity and suffering— something that to some degree is already happening in the West.

Weiner brings his insightful book to a close with this thought:“The trouble with immortality is endless. The thought of it brings us into contact with problems of time itself— with shapeless problems we have never grasped and may never put into words. Our ability to exist in time may require our being mortal, although we can’t understand that any more than the fish can understand water. What we call the stream of consciousness may depend upon mortality in ways that we can hardly glimpse.”

Even if writers become immortal, books must end, and it is by reaching the end that the reader can sit back and find meaning in the journey.“Long for This World” is a great trip.

Abraham Verghese is a professor and senior associate chairman in the department of internal medicine at Stanford University. His most recent book is the novel“Cutting for Stone.”

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Turn 70. Act Your Grandchild’s Age.

Joining Mr. Starr in his 70s next year will be the still-performingBob Dylan(“May you stay forever young”)andPaul Simon(“How terribly strange to be 70”). Following soon after will be Roger Daltrey(“Hope I die before I get old”)andMick Jagger, who is reported to have said, several grandchildren ago,“I’d rather be dead than singing‘Satisfaction’ at 45.”

A rock’n’ roll septuagenarian was someone the gerontologist Robert Butler could have only dreamed of in 1968, when he coined the term“ageism” to describe the way society discriminates against the old.

Dr. Butler, a psychiatrist, died, at age 83, a few days before Ringo’s big bash. No one, his colleagues said, had done more to improve the image of aging in America. His work established that the old did not inevitably become senile, and that they could be productive, intellectually engaged, and active— sexually and otherwise. His life provided a good example: He worked until three days before his death from acute leukemia.

But as much as Dr. Butler would have cheered an aging Beatle onstage, his colleagues said he would have also cautioned against embracing the opposite stereotype— the idea that“aging successfully,” in his phrase, means that you have to be banging on drums in front of thousands— or still be acting like you did at 22 or 42.

That stereotype is almost as enduring as ageism itself.

“The stories that we hear tend to pull us toward the extreme,” said Anne Basting, the director of theCenter on Age and Communityat theUniversity of Wisconsinat Milwaukee.“It’s either the stories of young-onsetAlzheimer’s, or it’s the sky-diving grandmas. We don’t hear enough about the huge middle, which is the vast majority of folks.”

In fact, for most people, the 70s represents the end, not a beginning. Life expectancy in this country is still 78— higher for white women, lower for men and blacks. It is rising, but not as fast, perhaps, as our expectations. AsGloria Steinemsaid of her 70th birthday in 2004,“This one has the ring of mortality.”

Yet withClint Eastwooddirecting films at 80 and Betty White starring in a new sitcom at 88, the pressure for 70-year-olds is not to face mortality, but to kick up those slightly arthritic heels ever higher.

The eighth decade, said Dr. Basting, is“now seen as an active time of life: you’re just past retirement, that’s your time to explore and play mentally.” But while many will be healthy, others will not.“There will be an increase in frailty and disability because people are living longer,” said S. Jay Olshansky, a demographer at theUniversity of Illinoisat Chicago who studies aging. For some people, an increased risk of stroke and Alzheimer’s“is going to be the price they pay for extended longevity,” he said.

The risk, gerontologists say, is that in celebrating the remarkable stories, we make those not playing Radio City, and certainly those suffering the diseases that often accompany old age, feel inadequate.

Social policy may only contribute to that pressure. TheEuropean Commission recommended last week that European workers not be allowed to retire before 70, to keep state pension funds solvent. In this country, RepresentativeJohn Boehnerof Ohio, the Republicans’ leader in the House, suggested raising the retirement age forSocial Securitybenefits to 70 to keep the program afloat.

Thomas R. Cole, director of theMcGovern Center for Health, Humanities and the Human Spiritat theUniversity of TexasHealth Science Center in Houston and the author of a cultural history of aging, said he hailed anyone who, borrowing a phrase from his mother, age 85,“is playing above the grass.”

At the same time, he said,“if we don’t pay attention to the dark side of our 70s and 80s, we’re not going to pay enough attention to the people who need help.”

“We’re going to make it look like if you’re sick, it’s your own fault; if you’re not having orgasms or running marathons, there’s something wrong with you. We need to think carefully about how to take care of people who are frail. We need to allow people to not feel like failures when they can’t do the things they used to do.”

He traces the origins of this“splitting apart” of the reality of old age— good and bad— to the mid-1800s, when people in the United States first experienced what he calls“the legitimization of longevity.”

Life expectancy was only 40, but people began to believe that humans could live to be old— which they defined as 80 or more.

“People first began to say,‘I’m here to live a long life, and if I work hard and am a good person and am middle class, I will die a good death,’” Dr. Cole said,“‘and if I don’t do these things, I deserve a short life and a painful death.’”

That split persists, he said, in our obsession with health and longevity, visible to anyone glancing across a magazine stand.

“It assumes you can control these things through willpower,” he said.

Gerontologists tend to think of successful aging as taking advantage of what potential there is, staying as socially and intellectually engaged as possible. Our culture tends to measure it more in terms of how active people are.

“It wouldn’t do us a whole boatload of harm to reinstate some values to contemplation,” said Dr. Basting.“Part of the pressure on older people to be successful and give back and volunteer and be active and play tennis is that we are a culture of doing. We don’t really know how tobe. That’s something that late life gives us, is time to be. But that’s stigmatized.”

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Columbia Scientists Prepare for a Dirty Bomb

Some 70 years later, physicists from the center, now part ofColumbia University Medical Center, are once again racing against time. But their work today centers on containing the damage from a much smaller and less sophisticated weapon: the dirty bomb, a crude explosive rigged to spray radioactive material.

In a cramped room off Broadway on West 120th Street, in Columbia’s mechanical engineering department, sits a prototype of a large robotic apparatus that could, after a dirty bomb detonated, test tens of thousands of New Yorkers a day for radiation exposure using a simple finger prick. Currently, such tests must be done manually, with blood removed from the arm and the sample shipped to a laboratory.

“In the best of circumstances, you could do only a few hundred people a day, even with many labs involved,” said David J. Brenner, the center’s director and a professor of radiation biophysics, who has been collaborating on the project with mechanical engineers and biologists from Columbia.

A dirty bomb attack has never occurred, but there have been scares: In 1998 authorities in Chechnya defused a container filled with radioactive materials attached to an explosive. The work at Columbia has taken on new urgency after a car bomb was left on a bustling street in Times Square in May but failed to detonate.

“The concern is that it’s not that hard to manufacture a dirty bomb,” Dr. Brenner said.“Basically you just need to get some radioactive materials.”

The development of a fully automated testing system, with the potential to process up to 30,000 blood samples in a single day, is important because the type of treatment forradiation sicknessdepends on the dose received.

And there is another reason government officials and scientists are pushing to bring the device to market: allaying fears after a bombing.

“The last thing you want is somebody like me going on TV and saying,‘Don’t panic,’ because everyone will panic,” Dr. Brenner said.“The idea is to have some physical test that you can give individuals whereby you can demonstrate what their radiation exposure really is. Most people will get almost no dose.

“The bad guys want to create disruption and panic. If you can fight that by reassuring people, then you have defeated the goals of the terrorists.”

TheNew York Police Departmenthas long been on alert for a radiological attack, particularly since 9/11, said Paul J. Browne, the department’s chief spokesman.“Our focus in counterterrorism is on intelligence-gathering that would learn of any plot before a device could be deployed,” Mr. Browne said.“But we do have some robust detection programs up and running now.”

Nearly 2,000 police officers carry devices the size of a BlackBerry that clip to their belts and detect the gamma radiation that a dirty bomb would emit. More advanced searches are done by officers wearing special backpacks with equipment that can also register the neutron radiation that a fission or fusion bomb would unleash. And larger pieces of detection equipment are deployed in police trucks and helicopters to pick up“any radiological signature” emanating from other vehicles, Mr. Browne said.

Still, those efforts are meant to find a bomb before it explodes. The task of measuring the harm afterward would fall to city health officials, who say they are tracking the progress of Dr. Brenner’s team.

“The development of a validated system to rapidly and accurately assess public radiation exposure is important,” the health department said in a statement, adding that the city would“weigh in on public applications” when the system was ready.

One company, Northrop Grumman, plans to manufacture a compact version of the machine. But the federalFood and Drug Administrationmust approve the device first, a process that could take three years or more.

Dr. Brenner said a medium-size dirty bomb might result in significant doses of radiation“only within only a few hundred yards of an actual event, and possibly less.” A large bomb, however, could affect people miles away, depending on the winds.

While some people may envision widespread illness from a dirty bomb, Dr. Brenner said the reality would probably be quite different. In 1987 in Goiania, a city of 1.3 million people in Brazil, thieves stole and broke open sources of radioactivecesiumfrom an abandoned medical center. The dispersal of radiation was equivalent to what scientists would classify as a medium-size dirty bomb.

About 130,000 people overwhelmed hospital emergency rooms. Of those, 250 people, some with radioactive residue still on their skin, were found to be contaminated through the use of Geiger counters. (The counters can detect radioactive material, but if the material is no longer present, they cannot necessarily tell whether an individual was exposed.)

Eventually, only 20 people showed signs of radiation sickness and required treatment.

“So the lesson from that is you need triage,” Dr. Brenner said.“You need to be able to figure out who actually needs treatment, and those are the sort of numbers from a dirty bomb that you might expect— one in 10,000 might need treatment.” While people with lower doses would not need immediate care, he added, they could be at risk forcancerlater in life.

The Columbia center is one of several institutions that have won grants and contracts since 9/11 to develop products and therapies for use in a radiological attack. Dr. Brenner and the scientists have received $25 million since 2005 from theNational Institute of Allergy and Infectious Diseasesto develop new, faster ways to measure radiation exposure. Additional financing has come from theBiomedical Advanced Research and Development Authority, part of the United StatesDepartment of Health and Human Services.

“Some of our scenarios are based on tens of thousand of people being exposed,” said Gary L. Disbrow, deputy director of the authority’s Division of Chemical, Biological, Radiological and Nuclear Countermeasures.“But in addition to that, we expect 10 times that number of‘worried well,’ and they will want access to those countermeasures.”

The Columbia project is focused on three means of measuring exposure levels, two based on blood and one on urine. The one closest to fruition, the Rapid Automated Biodosimetry Tool, or Rabit for short, looks for chromosome damage in a single drop of blood from a finger prick.

In the Columbia lab, a robotic arm whirls rapidly, taking dozens of such samples and moving them through several steps.

One day, there could be several machines inhospitalsaround the city. There they would bide their time— and be kept in good working condition— by performing other tasks, like analyzing amniotic fluid for genetic abnormalities.

“You can perfectly imagine that these machines would be sitting in a dusty basement, and no one could remember what they were for,” Dr. Brenner said.“It’s a strange situation to build a machine that may be used decades down the line.”

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