Buying Sunglasses, UV Rays in Mind

Skiing on fresh snow, skating on reflective ice or hiking at high altitudes can be harder on your eyes than a day at the beach. Snow, as many East Coast readers may have noticed this week, reflects nearly 80 percent of the sun’s rays. Dry beach sand? Just 15 percent.

Most of us already know that ultraviolet (UV) rays can causeskin cancerand other problems. But that’s not all there is to worry about.“Most people don’t appreciate the damage that UV rays can do to their eyes,” said Dr. Rachel J. Bishop, a clinical ophthalmologist at the National Eye Institute in Bethesda, Md.

Winter or summer, hours of bright sunlight can burn the surface of the eye, causing a temporary and painful condition known as photokeratitis. Over time, unprotected exposure can contribute tocataracts, as well ascancerof the eyelids and the skin around the eyes.

UV exposure also may increase the risk ofmacular degeneration, the leading cause ofblindnessin people over age 65. While cataracts can be removed surgically, there is no way to reverse damage to the macula, the area in the center of the retina.

Worried? Consider this article license to buy yourself a new pair of UV-protective shades. But don’t let price and style be your only guides.

“Some cheap sunglasses are great, some expensive ones are not,” said Dr. Lee R. Duffner, an ophthalmologist in Hollywood, Fla., and a clinical correspondent for the American Academy of Ophthalmology. In fact, some knockoff designer frames may do your eyes more harm than if you’d worn no glasses at all.

Below, some advice on how to find sunglasses that will protect your eyes without plundering your wallet.

READ THE FINE PRINTProlonged exposure to UV radiation damages the surface tissues of the eye as well as the retina and the lens. Yet while theFood and Drug Administrationregulates sunglasses as medical devices, the agency does not stipulate that they must provide any particular level of UV protection. The wares at the average sunglasses store therefore can range from protective to wholly ineffective.

Look for labels and tags indicating that a pair of sunglasses provides at least“98 percent UV protection” or that it“blocks 98 percent of UVA and UVB rays.” If you find sunglasses without labels, or they say something vague like“UV absorbing” or“blocks most UV light,” don’t buy them— the sunglasses may not offer much protection.

For the best defense, look for sunglasses that“block all UV radiation up to 400 nanometers,” which is equivalent to blocking 100 percent of UV rays, advised Dr. Duffner.

CHOOSE THE RIGHT STYLEIdeally, your sunglasses should cover the sides of your eyes to prevent stray light from entering. Wraparound lenses are best, but if that’s not an appealing style, look for close-fitting glasses with wide lenses. Avoid models with small lenses, such asJohn Lennon-style sunglasses.

Don’t be seduced by dark tints. UV protection is not related to how dark the lens is. Sunglasses tinted green, amber, red and gray may offer the same protection as dark lenses. For the least color distortion, pick gray lenses, said Dr. Duffner.

If you are frequently distracted by glare while driving, boating or skiing, look for polarized lenses, which block the horizontal light waves that create glare. But remember, polarization in itself will not block UV light. Make sure the lenses also offer 98 percent or 100 percent UV protection.

Though the F.D.A. does not require that sunglasses have UV protection, the agency does insist that they meet impact-resistance standards— which basically means they won’t shatter when struck. Even so, if you wear sunglasses while cycling, sailing or gardening, for instance, consider purchasing a pair with polycarbonate lenses, which are 10 times more durable than regular plastic or glass lenses.

AVOID SIDEWALK VENDORSBuy a pair of chic Chanel knockoffs that offer no UV protection, and you might look swell— but your eyes will suffer. The tinted lenses will relax your pupils, letting more damaging radiation hit your retina than if you were wearing no glasses at all.

To play it safe, buy glasses from well-established drug, chain or department stores, rather than from vendors on the street. Shop around: you should be able to find a pair of drugstore sunglasses for $10 to $20 that provide all the protection you need.

Among the recent offerings atSunglasswarehouse.com, for instance, were wraparound and aviator-style sunglasses that came with full UV protection for just $13.

DON’T FORGET THE CHILDRENUpgrade your children from their Dora and Spider-man toy sunglasses to legitimate shades that offer 98 percent to 100 percent UV protection. Children with light-colored eyes are especially vulnerable to sun damage, said Dr. Duffner. The injury is cumulative, so the earlier children get in the habit of wearing shades, the better off their eyes will be.

If your child plays sports regularly, consider also purchasing sport-specific goggles. Eye injuries are the leading cause of blindness in children, and most of those injuries occur when they are playing basketball, baseball, ice hockey or racket sports.

The National Eye Institute says it believes that protective eyewear could prevent 90 percent of sports-related eye injuries in children.

TEST THOSE OLD GLASSESReluctant to pop for a new pair of sunglasses? If you already have a favorite pair but don’t know what kind of protection they offer, ask your local eyewear store if they have a UV meter. This device can measure the UV protection of your glasses and help you determine whether you should buy a new pair.“Most opticians have such a meter and can do this very easily,” said Dr. Duffner.

Even if you wearcontact lensesthat offer UV protection, you’re not in the clear. Contact lenses sit on the cornea in the center of your eyes and so can’t protect the surrounding white area (the conjunctiva) and skin.

“I see many older patients who have growths on the whites of their eyes that were caused by sun damage,” Dr. Bishop said. These yellow bumps, calledpinguecula, often lead to eye irritation and dryness and may eventually disrupt vision. To prevent them, adults with contact lenses still must wear sunglasses outdoors.

Lastly, if you wear prescription glasses, you can avoid buying sunglasses by either purchasing clip-ons that attach to your frames or having a UV coating applied to your lenses. Presto, you’ll have two pairs in one.

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In Tucson Shootings, Legal Strategy May Hinge on Mental Assessment

Even if that is found to be true, the lawyers for Mr. Loughner, the 22-year-old college dropout who has been charged in theTucson shootings, may find it difficult to mount a successful insanity defense.

The rules regarding such a legal strategy were tightened over the years in the wake of the verdict forJohn W. Hinckley Jr., who was found not guilty by reason of insanity in the 1981 assassination attempt on PresidentRonald Reagan. The insanity argument is now seldom successful, legal experts said.

What is more likely, they say, is that Mr. Loughner’s lawyers will use anymental healthproblems they find to stave off the death penalty, if he should go to trial and be convicted.

His lawyer,Judy Clarke, is likely to begin a far-ranging investigation of his life and family history, going back several generations to learn as much as possible about his origins, the environment in which he grew up and how he has functioned in society, said David I. Bruck, who worked with Ms. Clarke in the defense of Susan Smith, the South Carolina woman who drowned her two young sons in 1994 and who received a life sentence.

Ms. Clarke“will present a case which is focused, grounded in the facts, thorough and heartfelt,” said Mr. Bruck, a veteran death-penalty lawyer and a professor at Washington and Lee University in Lexington, Va.“She won’t try to sell what she wouldn’t buy. She’s going to find this man’s story, and once she’s found it, she’s going to be confident about telling it to a jury.”

But just where Ms. Clarke will tell that story— and before how many juries— is unclear.

The defense could ask that Mr. Loughner’s case be moved from Arizona out of concern that potential jurors might be influenced by news accounts.

Mr. Loughner (pronounced LOF-ner) may also have to be defended in separate trials brought by federal and state prosecutors, who are both likely to seek the death penalty.

The federal government has charged Mr. Loughner in the killings of two federal employees— JudgeJohn M. Roll, the chief federal judge for Arizona, andGabriel Zimmerman, an aide to RepresentativeGabrielle Giffords— and the Pima County attorney, Barbara LaWall, has said she will“pursue charges on behalf of the nonfederal victims.”

Her office has been researching the issue of whether it can proceed at the same time as the federal prosecutors, or whether the state’s case will have to wait until the United States attorney’s office has finished its work.

“I think initially there’ll be some confusion as to who’s going to go first, and how fast they are going to go,” said Rory Little, a former Justice Department official in the Clinton administration who teaches at the Hastings College of the Law in San Francisco.

“I would guess that you’re having some pretty intense discussions now between the federal government and the state side, and it wouldn’t surprise me to see the case divided up,” he said.

Either way, federal and state prosecutors would have two opportunities to seek the death penalty against Mr. Loughner if they chose to do so. That occurred in the case stemming from the 1995 bombing of the Alfred P. Murrah Federal Building in Oklahoma City, which killed 168 people, including infants and children in a day care center. One defendant,Timothy J. McVeigh, received the death penalty at his federal trial, but a second,Terry L. Nichols, did not.

Mr. Nichols was tried again, on state charges, in McAlester, Okla. He was again spared execution.

Beth A. Wilkinson, a member of the federal prosecution team in the Oklahoma City case, said of the Tucson shootings:“In a crime like this, it’s also very important to recognize the state’s interest in prosecuting murder and attempted murder of their citizens. The vast majority of murder cases are prosecuted by state authorities.”

Neither the Justice Department nor the Pima County attorney’s office have said if it would pursue the death penalty against Mr. Loughner.

One of Ms. Clarke’s critical early steps will be to argue against any federal death-penalty case through a written submission and in meetings with federal prosecutors in Arizona and with the Justice Department’s Capital Case Committee in Washington. Attorney GeneralEric H. Holder Jr.will have the final say.

Aitan D. Goelman, who also was involved in the federal prosecution of the Oklahoma City case, said he doubted that an effort to block a death-penalty prosecution would prevail.“These kinds of cases are essentially the reason we have the federal death penalty,” he said.

The federal complaint against Mr. Loughner charges him with the murders of Judge Roll and Mr. Zimmerman, along with the attempted murders of Ms. Giffords, who was struck in the head but survived, and of two of her staff members, Pamela Simon and Ronald Barber, who were both wounded and were expected to recover.

One complication is that Mr. Loughner’s lawyers can only pursue the insanity defense if the defendant approves, said Stephen J. Morse, a professor of law and psychiatry at the University of Pennsylvania.

“It cannot be imposed on a defendant over his objection,” Professor Morse said.

He said that lawyers in federal court tend to regard the insanity plea as“a defense of last resort, because juries are skeptical of claims that a defendant was not responsible for his actions.”

Still, he said, given early accounts of the evidence that has surfaced in the Tucson case— that Mr. Loughner appears to have carefully planned his attack on Ms. Giffords— his only chance might be to invoke such a defense.

“Based on the early information,” Professor Morse said,“I would be surprised if he didn’t, because he seems to have no other defense as far as I can tell.”

Marc Lacey contributed reporting from Tucson.

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Swallowed Objects That Went Straight Into History

A laryngologist who worked in the late 19th and early 20th centuries, he preserved more than 2,000 objects that people had swallowed or inhaled: nails and bolts, miniature binoculars, a radiator key, a child’s perfect-attendance pin, a medallion that says“Carry me for good luck.”

Jackson retrieved these objects from people’s upper torsos, generally with little or noanesthesia. He was so intent on assembling his collection that he once refused to return a swallowed quarter, even when its owner threatened his life.

“He was a fetishist, no question,” said Mary Cappello, the author of“Swallow” (New Press), a new book about Jackson and his bizarre collection.“But his obsession had the effect of saving lives. That’s kind of amazing, and lucky for us that his madness made possible forms of rescue.”

Jackson was an artisan and a mechanical prodigy, a humanist and an ascetic whom colleagues sometimes described as aloof or cold. He spent hundreds of hours crushing peanuts with forceps to learn exactly how much pressure to exert. He experimented extensively on mannequins and dogs.

In those days surgery was associated with high mortality, and few physicians were willing or able to peer into the air and food passages, let alone remove objects like open safety pins. Yet Ms. Cappello writes that the survival rate among patients from whom he removed objects was better than 95 percent.

“If Jackson could tell us how he wished to be remembered, I’m certain he would do so by assemblage, or meaningful collage,” said Ms. Cappello, an English professor at theUniversity of Rhode Island. For him, collecting was a form of self-portraiture as well as a clinical and scientific pursuit.

Jackson viewed the world as a precarious place. Small and bookish as a child, he endured intense torment and bullying; at one point other children blindfolded him and threw him into a coal pit, and he was rescued only after a dog happened to find him unconscious.

So in a sense, Ms. Cappello said, when Jackson became a physician— first in Pittsburgh, then Philadelphia— he“was saving lives, yes, but he was also saving himself.” He grew to be a pioneer of the upper body, developing new endoscopic techniques for peering into dark recesses.

He attached a tiny light called a mignon lamp to the end of a rod that he inserted into his scopes. (Previously, physicians who used endoscopes had worked mainly with light held outside the body.)

And he was an early and outspoken safety advocate, particularly when it came to children. As one of his assistants put it, his quest was to make the public and the medical profession“foreign-body-conscious” about swallowing.

If it had been up to him, Ms. Cappello said,“parents who fed peanuts to children without molars would be drawn and quartered.” Chew everything thoroughly, he exhorted the public:“Chew your milk!”

And he lobbied for passage of the Federal Caustic Poison Act of 1927, which required manufacturers to place warning labels on poisonous substances like lye, which burns the esophagus and causes severe scarring that can make it impossible to swallow.

Children often ingested lye because it was present in many households (where it was used to make soap) and because it looked like sugar. A 7-year-old girl who could not swallow even a drop of water was taken to Dr. Jackson, who fed an endoscope into her esophagus and removed a grayish mass— perhaps food, perhaps dead tissue— with a forceps. Afterward, one of his assistants gave the child a glass of water.

“She took a small sip expecting it to choke her and come back up,” Jackson recalled in his 1938 autobiography.“It went slowly down; she took another sip, and it went down. Then she gently moved aside the glass of water in the nurse’s hand, took hold of my hand and kissed it.”

Jackson also developed a technique for dilating the esophagus in children with scarring. He taught them to swallow a long tube and to do so regularly for an extended period. He suggested they might think of themselves as sword swallowers and imagine that the feat“inspires awe in other children.” This eventually helped many of them to eat and drink again normally.

To remove objects like keys and coins and pins, Jackson would insert a long, rigid tube into his patients— usually children, and usually awake, though his assistants did help to hold them still.“He must have had an exquisite gentleness and ability to calm people,” Ms. Cappello said. He also treated many poor children without pay.

Still, his eccentricities marked him.“Some people might have painted him as a socially phobic, friendless loner,” she added.“He was not a warm and fuzzy doctor.”

Nor would he compromise when it came to his collection. In the case of that swallowed quarter, he told the patient’s infuriated father that“all foreign bodies removed from the air and food passages were put into a scientific collection where they would be available to physicians working on the problems of relieving little children.”

The father had beaten the boy as punishment, and when he didn’t get the coin back he apparently beat him again, so viciously he broke his son’s arm.

At that point Jackson gave the family a half dollar. But he did not return the swallowed coin.

The Jackson collection is now owned by theMütter Museum of the College of Physicians of Philadelphia, which is refurbishing it for an exhibition that is to open Feb. 18. Ms. Cappello will help curate the exhibition; Anna Dhody, the museum’s curator, called her work a substantial contribution that“we’re very lucky to have.”

Dr. V. Alin Botoman, a gastroenterologist at theUniversity of Miamiwho has also done scholarly work on Jackson, called him“truly a renaissance man who made so many contributions to medicine and has been all but forgotten.” Until now. In October, Ms. Cappello gave a lecture on Jackson atthe Observatory, an art and events space in Brooklyn. She also presented black-and-white films from Jackson’s family that had never been seen in public.

In a series of clips, Jackson is shown on a small boat, looking out at the sky. He is riding in the back of a pickup truck, writing intently.

His granddaughter, then a toddler, wobbles across a lawn holding a stuffed animal and a flower. She looks at the camera, shakes the flower and puts it in her mouth.

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The Claim - Drinking Extra Fluids Helps Beat a Cold

The advice for conquering a cold is time-honored: Get plenty of rest and drink lots of fluids.

While it’s hard to argue against getting proper rest, some scientists suspect that loading up on liquid— that is, beyond the normal amount required in a day— may not do much good.

Theoretically, taking in extra beverages like water and juice helps replace fluids lost fromfeverand respiratory tract evaporation, and it helps loosen mucus. But when a team of scientists at the University of Queensland in Australia set out to determine whether this was indeed the case, they found a surprising dearth of data in the medical literature.

Fortheir report, published in the journal BMJ in 2004,“we examined references of relevant papers and contacted experts in the subject,” they wrote, yet were unable to find even a single clinical trial in the last four decades that specifically studied whether increased fluid intake reduced the severity of an infection.

They did find some evidence that in some children with moderate to severepneumonia, consuming extra fluids might contribute tohyponatremia, a blood-sodium deficiency. Butother scientists pointed out in responsethat those findings should not be extrapolated to any respiratory infections besides pneumonia.

Ultimately, the Australians did not argue against maintaining proper hydration during a cold or otherupper respiratory infection, but they said the advice to drink more fluids than usual should be rigorously studied because it is so widespread.

THE BOTTOM LINE

Studies have not validated the age-old advice to drink extra fluids to help beat a cold.ANAHAD O’CONNORscitimes@nytimes.com

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Lifting a Veil of Fear to See the Benefits of Child Fever

As a pediatrician, I know fever is a signal that the immune system is working well. And as a parent, I know there is something primal and frightening about a feverish child in the night.

So those middle-of-the-night calls from worried parents, so frequent in every pediatric practice, can be less than straightforward. A recent paper in The Journal of the American Medical Association pointed out one reason, and a longstanding discussion about parental perceptions reminds us of the emotional context.

The JAMA studylooked at over-the-counter medications for children, including those marketed for treating pain and fever: how they are labeled, and whether the droppers and cups and marked spoons in the packages properly reflect the doses recommended on the labels.

The article concluded that many medications are not labeled clearly, that some provide no dosing instrument, and that the instruments, if included, are not marked consistently. (A dosing chart might recommend 1.5 milliliters, but the dropper has no“1.5 ml” mark.)

“Basically, the main message of the paper is that the instructions on the boxes and bottles of over-the-counter medications are really confusing,” said the lead author, Dr. H. Shonna Yin ofNew York University Medical Center, who is a colleague of mine and an assistant professor ofpediatrics.

Too small a dose of an antipyretic (fever medicine) may be ineffective; too much can be toxic. But the dose depends on the child’s weight, which of course changes over time, and on the concentration of the medicine, which depends on whether it is acetaminophen or ibuprofen, children’s liquid or infant drops.

“We always make them get the bottle,” said Kathleen Martinez, a pediatricnurse practitionerwho is clinical coordinator of the After Hours Telephone Care Program at the Children’s Hospital in Aurora, Colo.“What do you have at home? Is it the ibuprofen infant drops or the children’s? Have the bottle in hand and verify the concentration.

“And then we have to verify the instrument, and then we give the right dose based on weight. It’s time-consuming, and then of course it changes with the weight, so the poor parents have to call back.”

Concerns about fever— how worried should I be, and how much medicine should I give?— account for many of the calls that parents make at night to their children’s doctors. For me, these tricky measurement questions evoke memories of many conversations, often from a crowded, noisy place (my own child’s Little League game, the supermarket), trying to answer a question about a small child with fever.

One recent night, I talked to the mother of a toddler with fever andabdominal pain. I was more worried about the pain, and about whether he was drinking enough to stay hydrated; she was more worried about the fever, and no matter what I asked she kept coming back to that number on the thermometer.

Finally, I got so worried the child was dehydrated that I told her to go to the emergency room. And when she got there, she told them she was scared because the child had a high fever.

Fever can indeed be scary, and any fever in an infant younger than 3 months is cause for major concern because of the risk of serious bacterial infections. But in general, in older children who do not look very distressed, fever is positive evidence of an active immune system, revved up and helping an array of immunological processes work more effectively.

Of course, that may not be reassuring to a parent whose child’s temperature is spiking at midnight. (Fevers tend to go up in the late afternoon and evening, as do normal body temperatures.)

In 1980, Dr. Barton D. Schmitt, a professor of pediatrics at theUniversity of ColoradoSchool of Medicine, publisheda now classic articleabout what he termed“feverphobia.” Many parents, he wrote, believed that untreated fevers might rise to critical levels and that even moderate and low-grade fevers could have serious neurological effects (that is, as parents we tend to suspect that our children’s brains may melt).

A group at Johns Hopkins revisited Dr. Schmitt’s work in 2001, publishing a paper in the journal Pediatrics,“Fever Phobia Revisited: Have Parental Misconceptions About Fever Changed in 20 Years?”Their conclusion was that the fears and misconceptions persisted.

In fact, fever does not harm the brain or the body, though it does increase the need for fluids. And even untreated, fevers rarely rise higher than 104 or 105 degrees.

As many as 5 percent of children are at risk forseizures with fever. Theseseizurescan be terrifying to watch but are not harmful and do not causeepilepsy. Still, a child who has a firstfebrile seizureshould be checked by a physician. (These seizures tend to run in families, and children who have had one may well have another.)

“Parents are telling us that they’re worried that fever can cause brain damage or even death in their children,” said Dr. Michael Crocetti, an assistant professor of pediatrics at Johns Hopkins and lead author of the 2001 study.“I’ve been doing this for a long time, and it seems to me that even though I do a tremendous amount of education about fever, its role in illness, its benefit in illness, it doesn’t seem to be something they keep hold of from visit to visit.”

Dr. Janet Serwint, another author of the study and a professor of pediatrics at Johns Hopkins, agreed.“I personally think there should be much more education about this at well visits,” she told me, adding that parents need to understand“the helpfulness of fever— how fever actually is a well-orchestrated healthy response of our body.”

Other studies have looked at attitudes among medical personnel, who can be just as worried about fever as parents.

“Doctors are part of the problem,” Dr. Schmitt said. Some of the phobia“comes from doctors and nurses,” he added—“doctors and nurses who weren’t taught about fever and all the wondrous things fever does in the animal kingdom.”

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The Movement to Restore Children’s Play Gains Momentum

Ms. Wilson lives in Stroudsburg, Pa., a small town in the Poconos. Many days, her home is strewn with dress-up clothes, art supplies and other artifacts from playtime with her two small children, Benjamin, 6, and Laura, 3.“I let them get it messy because that’s what it’s here for,” she said.

Ms. Wilson has embraced a growing movement to restore the sometimes-untidy business of play to the lives of children. Her interest was piqued when she toured her local elementary school last year, a few months before Benjamin was to enroll in kindergarten. She still remembered her own kindergarten classroom from 1985: it had a sandbox, blocks and toys. But this one had a wall of computers and little desks.

“There’s no imaginative play anymore, no pretend,” Ms. Wilson said with a sigh.

For several years, studies and statistics have been mounting that suggest the culture of play in the United States is vanishing. Children spend far too much time in front of a screen, educators and parents lament— 7 hours 38 minutes a day on average, according to a survey by the Kaiser Family Foundation last year. And only one in five children live within walking distance (a half-mile) of a park or playground, according to a 2010 report by the federalCenters for Disease Control, making them even less inclined to frolic outdoors.

Behind the numbers is adult behavior as well as children’s: Parents furiously tapping on their BlackBerrys in the living room, too stressed by work demands to tolerate noisy games in the background. Weekends consumed by soccer, lacrosse and other sports leagues, all organized and directed by parents. The full slate of lessons (chess, tae kwon do, Chinese, you name it) and homework beginning in the earliest grades. Add to that parental safety concerns that hinder even true believers like Ms. Wilson.

“People are scared to let their kids outside, even where I live,” she said.“If I want my kids to go outside, I have to be with them.”

Kathy Hirsh-Pasek, a developmental psychologist atTemple Universityin Philadelphia, concluded,“Play is just a natural thing that animals do and humans do, but somehow we’ve driven it out of kids.”

Too little playtime may seem to rank far down on the list of society’s worries, but the scientists,psychologists, educators and others who are part of the play movement say that most of the social and intellectual skills one needs to succeed in life and work are first developed through childhood play. Children learn to control their impulses through games like Simon Says, play advocates believe, and they learn to solve problems, negotiate, think creatively and work as a team when they dig together in a sandbox or build a fort with sofa cushions. (The experts define play as a game or activity initiated and directed by children. So video games don’t count, they say, except perhaps ones that involve creating something, and neither, really, do the many educational toys that do things like sing the A B C’s with the push of a button.)

Much of the movement has focused on the educational value of play, and efforts to restore recess and unstructured playtime to early childhood and elementary school curriculums. But advocates are now starting to reach out to parents, recognizing that for the movement to succeed, parental attitudes must evolve as well— starting with a willingness to tolerate a little more unpredictability in children’s schedules and a little less structure at home. Building that fort, for example, probably involves disassembling the sofa and emptying the linen closet. (A sheet makes an excellent roof.)

“I think more than anything, adults are a little fearful of children’s play,” said Joan Almon, executive director of the Alliance for Childhood, a nonprofit pro-play group.“Some people have a greater tolerance for chaos and have developed a hand for gently bringing it back into order. Others get really nervous about it.” Megan Rosker, a mother of three (ages 6, 3 and 2) in Redington Shores, Fla., has learned to embrace the disorder. She set aside the large sunroom in her home for the children and filled it with blocks, games, crayons, magazines to cut up and draw in, as well as toys and dress-up clothes.“I think a big part of free play is having space to do it in, a space that isn’t ruled over by adults,” she said.

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When Insurers Put Profits Before People

Nataline’s case was not all that different from the more than 200 liver patients I had seen successfully transplanted every year at that institution. She was critically ill, as close to death as one could possibly be while technically still alive, and her fate was inextricably linked to another’s. Somewhere, someone with a compatible organ had to die in time for Nataline to live.

But even when the perfect liver became available a few days after she was put on the list, doctors could not operate. What made Nataline different from most transplant patients, and what eventuallybrought her case to the attention of much of the country, was that her survival did not depend on the availability of an organ or her clinicians or even the quality of care she received. It rested on herhealth insurancecompany.

Cigna had denied the initial request to cover the costs of the liver transplant. Andthe insurer persisted in its refusal, claiming thatthe treatment was“experimental” and unproven, and despite numerous pleas from Nataline’s physicians to the contrary.

But as relatives and friends organized campaigns to draw public attention to Nataline’s plight, the insurance conglomerate found itself embroiled in a public relations nightmare, one that could jeopardize its very existence. The company reversed its decision. But the change came too late. Nataline died just a few hours after Cigna authorized the transplant.

Not long afterward, I spoke with a former nursing colleague who had cared for Nataline. The anger in her voice was still palpable as she recounted the protests in which she had been involved.“This was a 17-year-old girl,” she said.“How could anyone with a conscience— anyone who is human— do this to another person?”

While the public fury over Nataline’s death has abated, that question of conscience in a health care system dependent on for-profit insurers has lurked behind nearly every debate over health care reform. While few politicians have dared to openly address this inherent conflict of interest, one unlikely individual has consistently spoken up over the last year and a half to remind us of this moral dilemma.

Inarticles,interviews,op-edsandtestimonyon Capitol Hill, Wendell Potter has described the dark underbelly of the health care insurance industry— unkept promises of care, canceled coverage of those who get sick and fearmongering campaigns designed to quash any change that might adversely affect profits.

He should know what he is talking about. For 20 years, Mr. Potter was the head of corporate communications at two major insurers, first at Humana and then at Cigna.

Now Mr. Potter has written a fascinating book that details the methods he and his colleagues used to manipulate public opinion and describes his transformation from the idealistic son of working-class parents in eastern Tennessee to top insurance company executive, to vocal critic and industry watchdog. Using little of the fiery rhetoric or lurid prose that usually marks corporate exposés or memoirs of redemption, the book,“Deadly Spin” (Bloomsbury, 2010), is an evenhanded yet riveting account of the inner workings of the health care insurance industry, a cautionary tale that doctors and patients would be wise not to miss.

For a man who has spent his professional life tinkering with impressions, Mr. Potter has astartlingly straightforward narrative voice; he wastes no time cutting to the chase:“It was my job to enhance those firms’ reputations. But as one of the industry’s top public relations executives and media spokesmen, I also helped create and perpetuate myth that had no other purpose but to sustain those companies’ extraordinarily high profitability.”

Mr. Potter goes on to describe the myth-making he did, interspersing descriptions of front groups, paid spies and jiggered studies with a deft retelling of the convoluted (and usually eye-glazing) history of health care insurance policies.

The most moving section is devoted to Nataline Sarkisyan. We learn that executives at Cigna worried that Nataline’s situation would only add fire to the growing public discontent with a health care system anchored by private insurance. As the case drew more national attention, the threat of a legislative overhaul that would ban for-profit insurers became real, and Mr. Potter found himself working on the biggest P.R. campaign of his career.

As busy as they might have felt in the days leading up to Nataline’s death, he and his staff were inundated with calls from the news media immediately afterward. To bolster what was seen as a fight for its survival, Cigna hired a large international law firm and a P.R. firm already well known to them from previous work aimed at discreditingMichael Mooreand his film“Sicko.” Together with Cigna, these outside firms waged a campaign that would eventually include the aggressive placement of articles with friendly“third party” reporters, editors and producers who would“disabuse the media, politicians and the public of the notion that Nataline would have gotten the transplant if she had lived in Canada or France or England or any other developed country.” A“spy” was dispatched to Nataline’s funeral; and when the Sarkisyan family filed a lawsuit against the insurer, a team of lawyers was assigned to keep track of actions and comments by the family’s lawyer.

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