Mark Pine

Tomorrow it’s July, and for me that means Independence Day, Bastille Day and the Tour de France.

The Tour is the world’s most challenging sporting event, in my opinion. Cycling has almost always been my favorite sport, except for childhood, when it was baseball. But though I never played baseball beyond little league, as an adult, I’ve done a number of long touring tours in the Mid-Atlantic States, Italy and France. I commuted by bike to work for 25 years and estimate that I’ve ridden over 100,000 miles.

This year’s great race begins in Holland, passes through Belgium, and then begins a clockwise tour of France of 3,000 km. Three American teams are competing—Garmin-Transitions, HTC-Columbia, and RadioShack, Lance’s team.

Lance, 38, has said this year will be his last in the Tour, according to the AP. Two other Tour champions, Levi Leipheimer and Andreas Kloden, will join him and others on the team. Last week, the incomparable cyclist finished second in the Tour de Suisse, and he says he’s ready for the big one.

Like my erstwhile favorite sport, baseball, cycling has suffered from an epidemic of doping. But both sports in the last few years have put in place substantial testing regimens to reduce drug abuse. Lance especially and perennially has been accused of doping, without proof in my opinion. There’s a report that in 1996, Lance told the doctor who treated his testicular and brain cancer that he had used anabolic steroids, growth hormone and blood growth factors. It’s been speculated that the cyclist might have caused his own disease that way.

While that’s plausible (growth factors and hormones make things grow, after all), what’s likely in my opinion is that having once had cancer, Lance would not again use doping drugs, which could cause a recurrence. Lance’s seven tour victories came after he returned to cycling following the cure of his cancer.

In recent years, drug testing of Tour cyclists has increased, and this year the World Anti-Doping Agency will monitor testing procedures. Famously, American cyclist Floyd Landis was caught using synthetic testosterone in 2006. But last year, with stricter measures in place, Armstrong, then aged 37, nevertheless finished third.

It’s reasonable to wonder how without doping Lance and the other great cyclists achieve the stamina to endure the thousands of kilometers of high-speed racing, with several hours in the saddle each day and dozens of gasping, crushing climbs? The answer may be a different kind of doping—”altitude doping.”

According to a story yesterday in Science magazine online:

It’s the legal version of blood doping. Instead of injecting themselves with blood before competition or taking drugs to stimulate the production of oxygen-carrying red blood cells, many endurance athletes spend time in the thin air of high altitudes. The idea is to get their muscles to use oxygen more efficiently so that when they return to lower elevations, they have a leg up on their competition.

My guess is: Unable to return to doping ways after his life-threatening brush with cancer, Armstrong resolved to dope the legal way: Live at high altitude and train at low altitude, a regimen that the article says is most effective. Hard training brought him the seven Tour victories.

Hard training, also, must have been/must be the recourse of the other champions of the Tour in the past few years and in years to come, now that doping is thankfully curtailed. Hopefully, it is on the way out altogether.

Linda Greenhouse, the former NY Times Supreme Court reporter and current legal columnist for the newspaper, has written “Before Row v. Wade,” a book on the history, events and debate leading up to the Court’s 1973 decision on abortion and the perennial struggle and debate that is its aftermath. Reva Seigel, a professor of law at Yale, is her coauthor.

“The initial impulse came from public health concerns and, to some degree from the elite of the legal profession. … At first, abortion was presented as a public health issue. Back alley, illegal abortions were a significant cause of death and injury. Here was really a medical problem that needed to be fixed,” Greenhouse explained during an interview at the Brennan Center for Justice, discussing the societal background of Roe v. Wade.

That is how I remember it. As a medical intern and resident in Washington, D.C., in the years just before and after the Supreme Court decision, I okayed many requests from women to have abortions. A woman would come to the clinic in the District, where abortion was legal but required a physician’s approval. She would explain her case, and I never refused.

In my view, laws that criminalized abortions and the women and doctors to engaged in them were wrong. It was a matter of public health and medical compassion. Prior to Roe, women who wanted abortions in states where it was illegal would do it themselves with coat hangers. Or they would seek out illicit “back alley” abortionists. The outcome was often permanent injury or even death. At least, that is what poor women would do. Women who could afford it would travel to Europe, where medical abortions were legal and safe.

The majority of abortions were undergone by women who wanted to avoid the disgrace of unmarried pregnancy, which was condemned in those days, or who were young and unready to have a child. For me, approving those decisions was also a matter of medical compassion. The Supreme Court apparently agreed in Roe:

The detriment that the State would impose upon the pregnant woman by denying this choice altogether is apparent. Specific and direct harm medically diagnosable even in early pregnancy may be involved. Maternity, or additional offspring, may force upon the woman a distressful life and future. Psychological harm may be imminent. Mental and physical health may be taxed by child care. There is also the distress, for all concerned, associated with the unwanted child, and there is the problem of bringing a child into a family already unable, psychologically and otherwise, to care for it. In other cases, as in this one, the additional difficulties and continuing stigma of unwed motherhood may be involved. All these are factors the woman and her responsible physician necessarily will consider in consultation.

In the years since, a protracted war of attrition against the decision has been mounted by the Catholic church and religious fundamentalists. Pro-life partisans “use needlessly incendiary terms like ‘the mass slaughter of unborn children,’” wrote a reviewer for Salon.com.

In my view, there is no such thing as an unborn child, since a child is a creature that comes into the world at birth. For most of gestation, and particularly during the first trimester, when the right to abortion most clearly prevails, a human fetus lacks the capacities that we recognize as children. Indeed during most of human gestation, higher animals, like dogs and cats, have more of those capacities.

One especially nettlesome claim by anti-abortion crusaders is the assertion that that human life begins at conception, and it therefore is sacrosanct from that moment. In my view, human life does not begin at all. The ovum and the sperm of the mothers and fathers are alive, as indeed are the parents themselves. If it were maintained that the gametes are not alive, since they cannot survive and reproduce outside of a complete body, then by the same reasoning, the embryo and fetus are not alive, either.

Human life has no beginning. All human lives exist as links in long chains of life going back to the origin of life in the primordial eons of earth. We humans have insisted that our life is special, different, sacred, and higher by a quantum leap than all other forms of life on earth. But science has shown us over and over that we are not so special. Many other forms of life share our capacities to one degree or another. We are animals, too.

It is right that society enacts laws protecting human life in particular. Society could not exist without such laws. But the laws against murder apply to humans and not to fetuses. Society can exist and permit abortions during the first months of pregnancy, and it should permit them.

A psychologist at Baylor University claims to have identified two fundamental concerns underlying marital conflict: Fear of a spouse’s hostility, criticism, blame and control, and fear of a spouse’s neglect and withdrawal of support.

The psychologist’s research, published this month in the journal Psychological Assessment, describes the results of two surveys of married couples. In the first more than 1200 persons assigned ratings to 57 words based on how well the words described their perceptions of themselves and their partners during an episode of conflict. In the second, more than 2300 persons filled out questionnaires and scales measuring their emotions, perceptions and behaviors during conflict.

Applying factor analysis to the data from the first study, the researcher identified the two core dimensions of the subjects’ views and reactions in conflict, and he used the second study to test and confirm the 2-dimensional structure. He found that the structure remained constant, regardless of the racial or ethnic identity of the participants.

The investigator, Dr. Keith Sanford, explained that during disputes, perceived threats or perceived neglect from the partner may result in “reflexive, emotionally charged behavior that can initially serve to escalate the conflict.” He also suggested that when a conflict involved a perception of neglect, an expression of emotion might ameliorate it. But if a conflict is based on a perception of threats, expressions of emotion might not be helpful.

Sanford’s analysis jives with my own marital experience, which included many, many arguments near the end. I almost always perceived a criticism of me or attempt to control me. My wife, I think, usually perceived neglect by me or insufficient support and cooperation.

Both kinds of perceptions, I think, raise existential concerns, and perhaps that’s why such arguments occur often and escalate much of the time. I usually felt that my wife’s demands threatened my autonomy, my free will. I think she felt her survival in the marriage threatened by insufficient emotional sustenance from me.

Perhaps I would have responded better and our conflicts would have lessened, if my wife had openly expressed her needfulness and told me clearly what she needed. Perhaps in turn, I might have tried not to defend my independence so much and so often and instead volunteered her more support.

New techniques to observe the presence of Alzheimer’s disease (AD) in the central nervous systems of living humans are currently in development and have made news recently. At present, the diagnosis of AD can only be made for certain at autopsy by finding the characteristic plaques in brain tissue. To develop and test potential medicines, however, it is necessary to be able to observe plaques in living people, in order to determine whether drugs can prevent or slow down the process of plaque formation.

One new technique involves the use of a radioactive dye that binds to plaques in the brains of AD patients. Yesterday, Gina Kolata, a science reporter for the NY Times, reported the advance, which makes it possible to observe plaques in the brains of AD patients, who are administered the dye and then undergo PET scans. Dr. Daniel Skovronsky, the researcher who developed the dye and has formed a company to market it, will describe his work at the International Conference on Alzheimer’s Disease next month in Honolulu.

Skovronsky’s technique is unique among diagnostic technologies in current development for AD. It has passed a crucial clinical test, that of proving the accuracy of the technique by showing that PET scans of human patients who have received the dye actually do identify AD plaques in their brains. The trial was done in hospice patients who had not long to live and who consented to receive the dye and undergo the scans and then have their brains autopsied after death. By May of this year, 35 patients had been studied, the target number for completing the study. The results showed that the autopsies confirmed the accuracy of the scans.

This month at the Society of Nuclear Medicine’s 57th Annual Meeting, researchers from the University of Leipzig announced the results of a clinical trial of another radioactive dye, florbetaben, in AD patients imaged with PET scans. Like Skovronsky’s imaging agent, the Leipzig researchers’ dye binds to plaques and can be observed with the scans in living patients.

In this case, however, the patients studied were not near to dying, and no autopsies were done as part of the trial. Rather, the accuracy of the technique was assayed by administering the compound to a group of 81 patients with probably AD, diagnosed using clinical signs of dementia, such as memory loss. As a control, florbetaben was also administered to a group of 69 healthy volunteers, and the presence of plaques on the PET scans was compared between the groups. All the subjects were 55 years or older.

The results of the trial were said to demonstrate the accuracy of the scans. However, since the methodology of the trial lacks a definitive diagnosis of the AD patients, which can only be made at autopsy, the results cannot be considered proof.

Researchers at the Cedars-Sinai Medical Center, the Weizmann Institute of Science in Israel and the University of Southern California have described a third technique. In early development, this technology may prove to be the easiest to use and least costly, since it does not rely on administering synthetic dyes and doing PET scans.

The medical scientists used curcumin, a component of the spice, turmeric, which is a fluorescent dye and binds to AD plaques also. They imaged the retinas of deceased patients with AD and those with presumed AD based on clinical findings. Using the curcumin dye and high-resolution optical imaging, they detected plaques in the retinas of patients but not in a group of aged-matched control subjects without the disease [correction per study author 7/2/10].

Although the retina of the eye is not a part of the brain, it is part of the central nervous system, and it is the only part of the CNS that can be visualized directly without surgery. The scientists showed that plaques also form in the retinas of AD patients, as part of the disease process.

The scientists also tested the curcumin technique in mice genetically modified to express a murine equivalent to human AD. Plaques were detected in the retinas and the brains of the mice, and the retinal plaques appeared even before those in the brains did. They scientists will present the results of their work at the international conference in Honolulu next month.

Any trial of a potential therapy to slow the progression of AD in living humans or to arrest or reverse the disease process would have to rely on techniques like these to image plaques in the brains of living patients. In such a trial, groups of patients with AD would be followed for months or years, and the patients treated with the potential therapy would be compared with the patients treated with a placebo. Both groups of patients would undergo serial imaging during the period of the trial, and the number of plaques would be determined and compared between the patients receiving the investigational treatment and those receiving the placebo. If a therapy worked, the patients in the treatment group would show, on average, fewer plaques than the patients in the placebo group.

The Rolling Stone article on Gen. McChrystal paints the picture of a type-A personality—indeed, a self-designated superman of a military commander. Such a man is not constitutionally inclined to subordinate himself to anyone, and those he does choose to talk up to must meet the highest standard—superhuman like himself. A young president without military experience would have a hard time. Most political and diplomatic types, the more tentative people to whom the Constitution gives ultimate military command, would not qualify in the general’s mind. And apparently that is what happened.

Besides the impression of McChrystal’s overpowering personality, the article portrays the commander and his team of close military advisers disdaining the civilians in the chain of command to which they report. The situation is a recipe for disaster, because disrespect between a general in the field and the central command will undermine operations during the most critical times, those of greatest difficulty, as the situation now is in Afghanistan.

On Tuesday evening Keith Olbermann argued on his MSNBC-TV news program that the president should refuse McChrystal’s resignation. Doing that would help with the politics and at the same time reinforce Obama’s authority over the general, he said. It was a cogent line of reasoning. But Obama decided otherwise and quickly, as reported in the NY Times.

Obama had no choice. He had to maintain his own Constitutional authority and ensure the functional capacity of the members of his war council, its civilian as well as military members. In the face of McChrystal’s contempt, the president had no other option but to dismiss him.

Follow-Up On Yesterday’s Post On Comparative Effectiveness Research

Yesterday, I posted on the challenges of putting into practice the results of comparative effectiveness research (CER) on the effectiveness, safety and costs of alternative treatments for the same condition. A remarkable example of such research has just recently appeared.

The results of a clinical trial comparing four leading medications for type 2 diabetes (the most common kind of diabetes), have been reported. More than 800 diabetic patients were divided into four groups, and each was assigned to receive one of four diabetes medicines for 26 weeks. At the end, the outcome was primarily determined by each group’s average A1c level, the standard measure of diabetes control. Other outcomes were followed also, particularly the group’s average weight lost or gained.

The winner was an old standby drug, metformin, the least expensive medication by a factor of 3 or 4. Metformin lowered A1c just about as much or more than all the other medications, and in addition it promoted the most weight loss, which is helpful in diabetes.

There are two noteworthy aspects to the research. First, it’s an excellent example of just the kind of research that needs to be done: Head-to-head comparisons of treatment options in well-designed prospective clinical trials. It showed that the newer, much more expensive diabetes treatments are no better than a cheap old standard. In this case the trial showed that the less expensive alternative, which costs about $55 for a 30-day supply, is as good or better than the newest drugs, which cost from $130 to $230 for 30 days.

Secondly, the trial was done as a drug-approval study for one of the medications, Byetta, which was being tested in a new dosage form. Studies for the approval of new drugs or dosage forms are required by government regulations and are supervised by the FDA. In the past, such studies have rarely, if ever, served the purpose of CER. Rather, they have most often matched a new active drug against a placebo. In other cases, the new drug is usually compared against only one other active drug a time. The way this study was done suggests that the FDA may be asking companies to use drug approval trials for the additional purpose of doing CER. If so, then in the future much CER might be funded by pharmaceutical companies seeking new drug approvals. A lot of CER could get done that way.

America’s healthcare system must change, and one of the most consequential and necessary changes will be implementing the findings of comparative effectiveness research (CER). Doing so is supported by most healthcare experts and the government. Perhaps no other alteration would do more to improve the health of Americans at the same time as it reduces the cost of health care. But the transformation will not come easily.

CER evaluates medical drugs, devices and procedures in well-designed clinical trials and epidemiologic studies. Treatments for the same indication are matched on effectiveness, safety and cost. In February 2009, President Obama approved a law providing a billion dollars for such research. Despite the support, implementation will likely face obstacles from healthcare providers that may have to modify their decisions and their systems, insurers that may have to revise their coverage, corporations that may face loss of revenue, and patients who may have to get their treatments adjusted.

The following are two examples of how implementing CER recommendations could encounter obstacles. In the first case, massive opposition actually did arise, and the case shows when might happen when the members of the public feel threatened. The second case is intended to show how powerful financial interests of corporations could undermine it.

In an upcoming article in Academy Health Reports, which was reported yesterday in ScienceDaily, Michael Gusmano, a researcher at The Hasting Center, and Bradford Gray, a senior fellow at the Urban Institute, gave the example of the controversy over mammography guidelines that erupted last fall. Medical and statistical experts at the U.S. Preventive Task Force had determined on the basis of epidemiologic studies that routine screening of women aged 40-49 might do more harm than good. In that age group, a large number of false positive results might subject too many women to unnecessary treatment and anxiety.

The task force probably expected its recommendation to gain acceptance as the considered judgment of experts endeavoring to determine the best practice. But a huge public outcry ensued, with protests from prominent women, women’s groups, and medical associations. The U.S. Senate even passed an amendment directing the government to continue paying for such screenings.

The second example involves the two drugs, Prilosec and Nexium, both for the same indication, gastric reflux or heartburn. AstraZeneca, which markets both drugs, came out with Prilosec years earlier. A blockbuster that reaped billions for the company, it was one of the most widely prescribed drugs. About the year 2000, just as the drug was going of patent and would be subject to low-price competition, AstraZeneca came out with Nexium. The company advertised and marketed its new purple pill heavily and succeeded in gaining market share. The twist is that Prilosec and Nexium contain the same drug, except for the rotational configuration. (Two spirals can rotate in opposite directions. Prilosec contains both forms, Nexium only one.)

In effect, AstraZeneca had extended the patent and the profitability of the hugely successful product. Comparing the two drugs on efficacy and safety there is no difference, except for the dose. But The Medical Letter gives the cost for one treatment’s supply of Nexium as $166 and that of Prilosec OTC as about $20. CER in this case would favor the lower priced drug, but doing might run up against protests from the company and from doctors and patients influenced its marketing.

Implementing CER successfully will require more than doing the research and publishing the results. The government will have to plan its own marketing campaigns to pave the way. In part, that will require educating the public on the medical benefits and cost effectiveness of proposed changes. And just as important, perhaps, will be advertisements in the media, in which attractive actors speak clever words about how much good the changes would do.

It’s the great mystery of obesity: Why do people continue to gobble after eating more than enough food, often the high-fat kind, to satisfy hunger and calorie needs? New research on humans points to the hormone ghrelin as the culprit.

At a scientific meeting this week in San Diego, endocrinologists from Imperial College, London, presented the results of a study of men and women who were shown pictures of food—either high calorie food like chocolate cake or pizza or low-calorie food like salad or fish—after receiving injections of ghrelin or a salt water placebo. On one morning, the volunteers saw the pictures after skipping breakfast, and on two other mornings, they saw them after eating. They each received the injections on the two mornings they ate, one time ghrelin and the other time the placebo. Both the subjects and the researchers were blind to the content of the injection.

The investigators asked the subjects to rate the appeal of the food on a scale, and they simultaneously obtained MRI images of their brains. They found that the volunteers rated the high-calorie food higher than the low-calorie food after not eating breakfast and also after eating and receiving ghrelin, but not after eating and receiving the placebo. Also, after ghrelin but not after skipping the meal, the subjects rated sweet food higher than other high-calorie food. The researchers plan to analyze the MRIs in the future to determine which brain regions are involved in the appeal of the food.

Ghrelin is a stomach hormone that acts to increase food intake and fat storage in the body. In 2009, scientists at the University of Cincinnati reported that ghrelin, which has been called the “hunger hormone,” may stimulate fatty food consumption in particular. Experimenting on mice, they investigated the effect of an enzyme in the stomach called “GOAT,” which turns ghrelin into an acylated form, which the researchers believe activates it. (A fatty acid, a kind of fat, gets attached to the hormone.) They found that normal mice accumulated more body fat when fed a diet high in fat-like substances. But when fed the same diet, mice genetically modified to lack GOAT gained less fat than normal mice, and mice modified to have excess GOAT gained more fat than normal mice.

The investigators also reported finding that the fatty substances that get attached to ghrelin come directly from the diet of the animals and not from their own bodies. The results suggested that the ghrelin-GOAT system in the stomach acts as a sensor for fatty food in the diet by turning on appetite when fatty high-calorie food is available.

Matthias Tschöp, the lead scientist, said that the while the results of the study cannot yet be applied to people, human studies have shown that during fasting the non-acylated form of ghrelin increases in the blood, but after meals containing fat the acylated form of ghrelin rises to a peak. He explained:

Our GOAT studies in mice offer an explanation of what could have been happening during the longer fasting periods in these human studies. Without dietary fats, ghrelin peaks remain inactive and don’t affect storage of fat.

He also said the results could explain why gastric bypass surgery is so effective in reducing appetite and losing weight.

This powerful obesity therapy frequently reduces appetite and improves metabolism before substantial weight loss occurs. Intriguingly, this procedure causes food to bypass the stomach and gut sections that contain GOAT/ghrelin cells, which, based on this newly described model, would prevent ghrelin activation.

Research last year on mice at the University of Texas also provides evidence that ghrelin acts to enhance the appeal of fatty food. They took mice sated from eating enough and observed how long they would continue to poke their snouts into a hole through which they had previously been given high-fat food. Mice that had been dosed with ghrelin continued to poke much longer than those that hadn’t received the hormone.

People who’ve had problems with weight—including this writer—have often complained how even high-calorie, high fat food can seem not to satisfy. Indeed, fatty desserts often stimulate a desire for more. The traditional explanation has been that it tastes so good you just want to keep eating. This research, however, suggests another explanation, one that may be physiologically based and therefore more persuasive.

Eating fat may provide substrate for the ghrelin-GOAT sensor system in the stomach that signals that high-calorie food is plentiful, so eat as much as you can. Such a sensory system and response may have arisen during evolutionary history, during eras when fat was scarce and starvation was common. If the hypothesis is correct, it may be possible to invent an effective obesity drug that acts by blocking that action of GOAT.

The oil gushing into the Gulf of Mexico horrifies Americans with the prospect of this vast ecosystem holding toxic waters for years and even decades. But for those of us who don’t depend on the gulf for home, livelihood or recreation, the most immediate concern may be for the seafood we eat. Crude oil contains toxic substances, metals like mercury and lead and carcinogenic hydrocarbons like benzene and toluene. Fish and shellfish in contaminated regions of the gulf inevitably ingest these toxins and incorporate them. This is particularly true for shellfish, which do not move around and filter the water in their immediate environment.

Although most seafood consumed by Americans is supermarket-purchased and 83% of it is imported, a substantial quantity comes from the gulf, including 7% of the shrimp and half the nation’s shellfish http. Unless it is identified by origin, seafood lovers have reason to be cautious about the shrimp, oysters, clams, crabs and finfish they consume. I will be especially vigilant, since the only animal protein that I choose to eat comes from the sea.

The federal government is taking steps to ensure seafood safety. NOAA and FDA issued a joint press announcement last week. NOAA banned seafood harvesting in gulf waters that have been contaminated and is using tracking systems or onboard observers to verify that fishing vessels stay clear of contaminated regions. The agency is also checking seafood harvested in uncontaminated waters by sampling at the dock.

“The FDA will first target oysters, crab, and shrimp, which due to their biology retain contaminants longer than finfish, for additional sampling,” the announcement states. In contrast, it says, “finfish rapidly metabolize the oil so the risk of exposure is far less than the other seafood species previously mentioned.”

Testing will be done in two steps. First, experts will smell and taste the raw seafood and compare it to a standard of water laced with oil and chemical dispersant that mimics the contaminated gulf water. Then chemical analysis will definitively determine whether oil contaminants are present. The agency has deployed a mobile chemical laboratory to the region. It has also sent a letter to food processors requiring them to document plans to ensure that the clams and oysters they process come only from growing waters approved for harvest.

But if chemical contamination of gulf seafood were not enough cause for concern, the spill may also have created a microbial danger. It turns out that one species of Vibrio, a kind of bacteria found in shellfish, feasts on oil and may multiply hugely as a result of the spill. A different species of Vibrio that contaminates oysters can cause severe disease and death to people eating them raw. The Vibrio species that loves oil is not the same as the one that can kill. But the scientists aware of this possible problem, including those at the FDA, aren’t sure whether the numbers of the dangerous kind might also multiply due to the oil in the waters.

For now, I will check the origin of all the seafood I buy and for some time refrain from eating seafood from the gulf. If the product is not clearly identified as to origin, I won’t eat it. Unfortunately, since it’s the season for dining near the shore, that may mean not ordering seafood in many restaurants.

A medical home is a clinic staffed by a multidisciplinary medical team, at which a roster of patients receive health care. The clinic staff see patients on a flexible schedule and use up-to-date health IT and the best evidence-based preventive and therapeutic techniques. In the June 2 issue of JAMA, the journal of the AMA, two Canadian physicians described the outcome of a real-world application of the medical home system to meeting the health care needs of the people of Ontario.

In the U.S., the health care reform has been a top priority. Our current system is extremely costly, currently exceeding 16% of national GDP but delivering only mediocre results, as reflected in life expectancy and mortality rates, on which the U.S. lags other first-world nations. In order to improve our system, the authors of the JAMA article wrote, “the Ontario experience with medical homes could be a blueprint for reform in US primary care.”

The Ontario doctors reported that medical homes in the province have shifted a large fraction of the population (4 million patients) out of the traditional fee-for-service health care system. The fee-for-service system drives up costs by rewarding physicians for doing more treatment, which can often be duplicative and unnecessary. Instead, the medical home system uses a capitation form of payment, in which the homes receive a fixed yearly reimbursement fee for the care of each patient.

The medical homes also improve care through better communication with patients and coordination of the services they provide, enhancements made possible by the team approach. Patients are tracked, receive preventive services and reminders about care, and have their chronic diseases managed.

However, the doctors wrote that the Ontario system, as currently organized, has excluded many of the poorest and sickest patients, who often seek care outside the homes, frequently at hospital emergency departments. Under the system, the capitation payments are geared only to the patients’ sex and age and are not raised for patients with for poor economic or health status. Because medical homes are allowed under the system to drop patients seeking outside care, the homes have tended to retain mostly the wealthier, healthier patients.

For most of my adult life, I received my health care at medical home type of clinic in the U.S. In our country, such facilities have been often been called managed care organizations or group-health cooperatives or associations. As a federal worker, I enrolled in Kaiser-Permanente’s mid-Atlantic healthcare network in the 1980s. As a federal retiree, I remain a Kaiser patient. They government pays Kaiser a yearly capitation fee to take care of me.

The members of my family also received care from Kaiser. When my children were born, my wife received care from their obstetricians and the children from their pediatricians. She currently remains a Kaiser member, as did my children until they aged out of parental coverage at 24.

The Kaiser system works phenomenally well, in my opinion. I have almost always felt completely satisfied by the care my family and I received. If anything, the Kaiser organization and the care they render has improved with time. At present, the cost is quite low in comparison to that of most health insurers, amounting around $200 per month for me. That sum includes both the Kaiser premium and the premium for the Medicare part B, which will pay for much of my outpatient care.

I chose my present doctor from a list of Kaiser physicians, and I’ve been with him for about five years. I find it easy to make appointments to see him, but most often consult with him via email. I get reminders from him and from Kaiser about appointments, tests, and procedures. I get the results of all my tests online.

Best of all, to my mind, is that I never have to worry about finding doctors. Kaiser maintains a large staff of specialists, and I often see one of them for evaluation and treatment. I also know that Kaiser—a large, technically savvy organization—keeps up-to-date on the latest information on best treatment practices.

We should not be surprised that our ability to make quantitative judgments is inborn and operational from the beginning of life. Number and size are fundamental aspects of our world. Still, it causes us to wonder and marvel when psychological experiments show that infants can make quantitative comparisons even before they can use language.

Researchers at Emory University in Atlanta tested nine-month-old infants using a technique that followed their gaze. The methodology assumes that the longer babies fixate on an object or scene, the more information processing is going on in their brains. For example, when babies see something novel or unexpected, they tend to gaze at it longer so that they can assimilate the new information. The research was reported Tuesday in ScienceDaily.

In the experiments, the babies watched computer screens, on which various objects appeared colored with black and white stripes or black dots on white background. The scientists trained their young subjects to expect more objects or larger objects with one of the patterns than the other, and then they would violate the “rule” that they had taught the babies to expect. When the number or size of the images on the computer failed to correspond to the expected pattern, the babies would look longer, indicating that they were surprised and were taking in the new information. That indicated, in turn, that the infants had formed mental rules about the relationships of size and number to color pattern.

We often assume that the higher cognitive abilities, including quantitative judgment, are human traits that depend on our acquisition of language. But much research suggests this may not be so. At nine months of age, the babies in the Emory University study were too young to understand words or speak. But evidently they already had the ability to compare numbers and sizes.

Moreover, other research has shown that many animals without human speech can also make quantitative judgments. In an article last fall in Scientific American, it was reported that monkeys and birds (even newly-hatched chickens) demonstrated quantitative abilities in experimental situations. In 2008, scientists in Italy showed that fish of a certain species could count to 4.

Human cognitive abilities are clearly special and unique, but it appears to be true that our aptitudes are not singular in kind but rather in extent. Our abilities apparently evolved with the evolution of animals, and many animals demonstrate human-like cognitive abilities at much more rudimentary levels of functioning. More information on scientific work on animal cognitive abilities, particularly language capacities, may be found at the website of the Max Planck Institute for Evolutionary Anthropology.