A Breakthrough Against Leukemia Using Altered T-Cells

PHILIPSBURG, Pa. — Emma Whitehead has been bounding around the house lately, practicing somersaults and rugby-style tumbles that make her parents wince.

It is hard to believe, but last spring Emma, then 6, was near death from leukemia. She had relapsed twice after chemotherapy, and doctors had run out of options.

Desperate to save her, her parents sought an experimental treatment at the Children’s Hospital of Philadelphia, one that had never before been tried in a child, or in anyone with the type of leukemia Emma had. The experiment, in April, used a disabled form of the virus that causes AIDS to reprogram Emma’s immune system genetically to kill cancer cells.

The treatment very nearly killed her. But she emerged from it cancer-free, and about seven months later is still in complete remission. She is the first child and one of the first humans ever in whom new techniques have achieved a long-sought goal — giving a patient’s own immune system the lasting ability to fight cancer.

Emma had been ill with acute lymphoblastic leukemia since 2010, when she was 5, said her parents, Kari and Tom. She is their only child.

She is among just a dozen patients with advanced leukemia to have received the experimental treatment, which was developed at the University of Pennsylvania. Similar approaches are also being tried at other centers, including the National Cancer Institute and Memorial Sloan-Kettering Cancer Center in New York.

“Our goal is to have a cure, but we can’t say that word,” said Dr. Carl June, who leads the research team at the University of Pennsylvania. He hopes the new treatment will eventually replace bone-marrow transplantation, an even more arduous, risky and expensive procedure that is now the last hope when other treatments fail in leukemia and related diseases.

Three adults with chronic leukemia treated at the University of Pennsylvania have also had complete remissions, with no signs of disease; two of them have been well for more than two years, said Dr. David Porter. Four adults improved but did not have full remissions, and one was treated too recently to evaluate. A child improved and then relapsed. In two adults, the treatment did not work at all. The Pennsylvania researchers were presenting their results on Sunday and Monday in Atlanta at a meeting of the American Society of Hematology.

Despite the mixed results, cancer experts not involved with the research say it has tremendous promise, because even in this early phase of testing it has worked in seemingly hopeless cases. “I think this is a major breakthrough,” said Dr. Ivan Borrello, a cancer expert and associate professor of medicine at the Johns Hopkins University School of Medicine.

Dr. John Wagner, the director of pediatric blood and marrow transplantation at the University of Minnesota, called the Pennsylvania results “phenomenal” and said they were “what we’ve all been working and hoping for but not seeing to this extent.”

A major drug company, Novartis, is betting on the Pennsylvania team and has committed $20 million to building a research center on the university’s campus to bring the treatment to market.

Hervé Hoppenot, the president of Novartis Oncology, called the research “fantastic” and said it had the potential — if the early results held up — to revolutionize the treatment of leukemia and related blood cancers. Researchers say the same approach, reprogramming the patient’s immune system, may also eventually be used against tumors like breast and prostate cancer.

To perform the treatment, doctors remove millions of the patient’s T-cells — a type of white blood cell — and insert new genes that enable the T-cells to kill cancer cells. The technique employs a disabled form of H.I.V. because it is very good at carrying genetic material into T-cells. The new genes program the T-cells to attack B-cells, a normal part of the immune system that turn malignant in leukemia.

The altered T-cells — called chimeric antigen receptor cells — are then dripped back into the patient’s veins, and if all goes well they multiply and start destroying the cancer.

The T-cells home in on a protein called CD-19 that is found on the surface of most B-cells, whether they are healthy or malignant.

A sign that the treatment is working is that the patient becomes terribly ill, with raging fevers and chills — a reaction that oncologists call “shake and bake,” Dr. June said. Its medical name is cytokine-release syndrome, or cytokine storm, referring to the natural chemicals that pour out of cells in the immune system as they are being activated, causing fevers and other symptoms. The storm can also flood the lungs and cause perilous drops in blood pressure — effects that nearly killed Emma.

Steroids sometimes ease the reaction, but they did not help Emma. Her temperature hit 105. She wound up on a ventilator, unconscious and swollen almost beyond recognition, surrounded by friends and family who had come to say goodbye.

But at the 11th hour, a battery of blood tests gave the researchers a clue as to what might help save Emma: her level of one of the cytokines, interleukin-6 or IL-6, had shot up a thousandfold. Doctors had never seen such a spike before and thought it might be what was making her so sick.

Dr. June knew that a drug could lower IL-6 — his daughter takes it for rheumatoid arthritis. It had never been used for a crisis like Emma’s, but there was little to lose. Her oncologist, Dr. Stephan A. Grupp, ordered the drug. The response, he said, was “amazing.”

Within hours, Emma began to stabilize. She woke up a week later, on May 2, the day she turned 7; the intensive-care staff sang “Happy Birthday.”

Since then, the research team has used the same drug, tocilizumab, in several other patients.

In patients with lasting remissions after the treatment, the altered T-cells persist in the bloodstream, though in smaller numbers than when they were fighting the disease. Some patients have had the cells for years.

Dr. Michel Sadelain, who conducts similar studies at the Sloan-Kettering Institute, said: “These T-cells are living drugs. With a pill, you take it, it’s eliminated from your body and you have to take it again.” But T-cells, he said, “could potentially be given only once, maybe only once or twice or three times.”

The Pennsylvania researchers said they were surprised to find any big drug company interested in their work, because a new batch of T-cells must be created for each patient — a far cry from the familiar commercial strategy of developing products like Viagra or cholesterol medicines, in which millions of people take the same drug.

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John Silva, Maker of ‘Telecopter’ Camera, Dies at 92

Helicopter news footage is common today. But until myriad problems in sending live pictures from a moving aircraft were solved, television broadcasters could not show an eagle’s-eye view of a forest fire, or contemplate aerial coverage of, say, a famous man fleeing the police in a white Ford Bronco.

John Silva made that now-familiar vantage possible in 1958, when he converted a small helicopter into the first airborne virtual television studio.

The KTLA “Telecopter,” as it was called by the Los Angeles station where Mr. Silva was the chief engineer, became the basic tool of live television traffic reporting, disaster coverage and that most famous glued-to-the-tube moment in the modern era of celebrity-gawking, the 1994 broadcast of O. J. Simpson leading a motorcade of pursuers on Los Angeles freeways after his former wife and a friend of hers were killed.

Mr. Silva, who later earned two Emmy Awards for his pioneering technical work, died in Camarillo, Calif., on Nov. 27. His death was confirmed by a spokesman for KTLA-TV, where he worked from 1946 until leaving to become an electronics design consultant in 1978. He was 92.

Mr. Silva, an electronics engineer trained in radar science during World War II, faced three main roadblocks to transmitting black-and-white images live from helicopters. Rotor vibrations distorted the pictures, and sometimes even cracked the transmitter’s vacuum tubes. Directional antennas went haywire when helicopters changed direction suddenly, as helicopters sometimes do. And the camera equipment weighed a ton.

With help from fellow KTLA engineers, though mainly working alone to keep the project secret from competitors, Mr. Silva stabilized onboard cameras with a system of shock absorbers and cushions, designed aluminum parts to replace heavier metals in his equipment and commissioned an antenna that would extend below the chopper and rotate to maintain uninterrupted contact with KTLA’s mountaintop transmitter. By paring and remachining a basic set of broadcast equipment, he reduced it to 368 pounds from 2,000 pounds and distributed the load with precise symmetry throughout the tiny Bell 47G2 chopper leased for the project to prevent listing.

KTLA, the first commercially licensed television station west of the Rockies, faced growing competition in the late ’50s. New network-affiliated stations were scoring scoops with mobile broadcast units like ones Mr. Silva had pioneered, and everyone was fighting to get through increasingly clogged Los Angeles freeways.

The Telecopter was intended to kill the competition.

“If we could build a news mobile unit in a helicopter,” Mr. Silva recalled in a 2002 interview for the Archive of American Television, “we could get over it all, get there first, avoid the traffic and get to all the stories before anybody in the competition.”

“It’d be a wonderful thing,” he said.

By the time he began work on his airborne live television, Mr. Silva had already achieved a landmark in ground-level television history. In 1949, he was the technical director at KTLA who rigged the electronic connections — using duct-tape ingenuity and a borrowed generator — that carried what historians consider the first live television broadcast of a breaking news event.

The 27-hour rescue operation in San Marino, Calif., to save Kathy Fiscus, a 3-year-old trapped in an abandoned water pipe 94 feet below ground, was unsuccessful; but the station’s coverage was the precursor to every wall-to-wall television event broadcast since.

The Telecopter’s first flight took place at Los Angeles City Hall on July 24, 1958. It re-established KTLA’s dominance (until competitors put their own helicopters up). And for better and worse, it brought a Hollywood-style excitement to television news.

In the archive interview, Mr. Silva was asked what the first live helicopter pictures showed. They were panning shots, he said — zooming in and out of the L.A. landscape between the station’s Sunset Boulevard studio and City Hall.

Most of what they showed, he added, “was the freeway.”

John Daniel Silva was born in San Diego on Feb. 20, 1920, the youngest of three children of a commercial fisherman, Guy Silva, and his wife, Lottie, a homemaker. He attended M.I.T. for two years, and graduated with a bachelor’s degree after two years more at Stanford.

During World War II, he was a Naval officer who positioned radar defenses in the Pacific.

After the war, he worked for Paramount Pictures as an engineer for an experimental television station, W6XYZ, that later became KTLA.

Mr. Silva’s survivors include his wife, Mary Lou Steinkraus-Silva; three daughters, Patricia Vawter, Kathleen Silva and Karen Samaha; and a granddaughter.

The Telecopter had its greatest moments, predictably, at news events of Cecil B. DeMille dimensions: The 1963 dam break at the Baldwin Hills Reservoir in Los Angeles that sent 250 million gallons of water into surrounding neighborhoods, destroying many homes and claiming five lives. The 1965 Watts riots. The 1961 brush fire that swept through Bel Air, sending Hollywood stars scrambling to their roofs with garden hoses.

In his three-hour interview with the television archive, Mr. Silva never mentioned the 1994 O. J. Simpson freeway pursuit footage he made possible. But in answering a question about the future of helicopter reporting, he made clear that he had no regrets about the Telecopter’s role in creating an increasingly graphic television sensibility.

He would just like the lenses to get longer and the close-ups tighter, he said.

“When they’re doing freeway chases, they need to have a system that can come down in front, and be able to get pictures of suspects in the front windshield,” he said, describing one improvement he hoped to see.

Smiling, he added, “To fill the screen with their wonderful faces.”

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Changing of the Guard: Signals in China of a More Open Economy

Carlos Barria/Reuters

In November, Xi Jinping made his official debut as party chief at the 18th party congress, which military officers attended.

BEIJING — In a strong signal of support for greater market-oriented economic policies, Xi Jinping, the new head of the Communist Party, made a visit over the weekend to the special economic zone of Shenzhen in south China, which has stood as a symbol of the nation’s embrace of a state-led form of capitalism since its growth over the last three decades from a fishing enclave to an industrial metropolis.

The trip was Mr. Xi’s first outside Beijing since becoming party chief on Nov. 15. Mr. Xi visited a private Internet company on Friday and went to Lotus Hill Park on Saturday to lay a wreath at a bronze statue of Deng Xiaoping, the leader who opened the era of economic reforms in 1979, when Shenzhen was designated a special economic zone. Mr. Deng famously later visited the city in 1992 to encourage reviving those economic policies after they had stalled following the violent crackdown on pro-democracy protests in 1989.

“Reform and opening up is a guiding policy that the Communist Party must stick to,” Mr. Xi said, according to Phoenix Television, one of several Hong Kong news organizations that covered the trip. “We must keep to this correct path. We must stay unwavering on the road to a prosperous country and people, and there must be new pioneering.”

In the months before the transition, there were widespread calls, including from people close to Mr. Xi, to adopt more liberal economic policies and even to experiment with greater political openness as a way for the party to maintain its rule. Without much success so far, reformers have long been encouraging the leadership to move toward a more sustainable growth model for China, one that relies more on domestic consumption rather than infrastructure investment and exports, and where state enterprises play less of a role.

Mr. Xi, known as a skillful consensus builder, has kept his ideas carefully veiled throughout his career, but his trip to Shenzhen is the strongest sign yet that he may favor more open policies. In a speech in Beijing on Nov. 29, Mr. Xi spoke of the “Chinese dream” of realizing the nation’s “revival,” which, besides being a call for renewal, also signaled strong nationalist leanings.

Mr. Xi’s father, Xi Zhongxun, was a revered senior official handpicked by Mr. Deng to help shape the new economic policies and oversee the creation of the Shenzhen zone. Mr. Xi’s mother lives in Shenzhen, and he visited her on his trip, according to Hong Kong news reports.

“If he indeed went to Shenzhen, that means he intends to make reform a subject of priority,” said Li Weidong, a liberal political analyst. “That would really be a phenomenon.”

Mr. Li cautioned, though, that the so-called reform policies that followed Mr. Deng’s 1992 southern tour, in his view, “ended up being fake” because China’s boom resulted in widespread corruption and the expansion of state enterprises at the expense of private entrepreneurship.

When Mr. Xi’s predecessor, Hu Jintao, became party chief in 2002, he was seen by many as a potential reformer, but his tenure was marked by conservative policies. For his first trip outside Beijing as party chief, Mr. Hu went in December 2002 to Xibaipo, a hallowed site for the revolution, where he reiterated a speech given by Mao Zedong.

Over the weekend, video footage from Phoenix Television showed a line of minibuses and police cars winding its way through Shenzhen. Mr. Xi and other officials walked outdoors in dark suits. The party’s official news organizations did not immediately report on the trip, but some prominent mainland Chinese news Web sites cited the Hong Kong reports.

Mr. Xi’s early moves as party leader seem aimed at emphasizing national “revival,” a theme he highlighted when he appeared on Nov. 29 with the party’s new seven-man Politburo Standing Committee in a history museum at Tiananmen Square. According to People’s Daily, the party mouthpiece, Mr. Xi stood in front of an exhibition called “The Road to Rejuvenation” and said, “After the 170 or more years of constant struggle since the Opium Wars, the great revival of the Chinese nation enjoys glorious prospects.”

He added: “Now everyone is discussing the Chinese dream, and I believe that realizing the great revival of the Chinese nation is the greatest dream of the Chinese nation in modern times.”

The emphasis on a “Chinese dream” is particular to Mr. Xi, and could prove to be a recurring motif throughout his tenure. The notion of a grand revival — “fu xing” in Mandarin — has been popular with Chinese leaders for at least a century, but Mr. Xi appears to be tapping more deeply into that nationalist vein than his recent predecessors, perhaps recognizing that traditional Communist ideology no longer has popular appeal.

Patrick Zuo contributed research.

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Arithmetic on Taxes Shows Top Rate Is Just a Starting Point

WASHINGTON — Despite hints in recent days that President Obama and House Speaker John A. Boehner might compromise on the tax rate to be paid by top earners, a host of other knotty tax questions could still derail a deal to avert a fiscal crisis in January.

The math shows why. Even if Republicans were to agree to Mr. Obama’s core demand — that the top marginal income rates return to the Clinton-era levels of 36 percent and 39.6 percent after Dec. 31, rather than stay at the Bush-era rates of 33 percent and 35 percent — the additional revenue would be only about a quarter of the $1.6 trillion that Mr. Obama wants to collect over 10 years. That would be about half of the $800 billion that Republicans have said they would be willing to raise.

That calculation alone suggests the scope of the other major tax issues to be negotiated beyond tax rates. And that is why many people in both parties remain unsure that a deal will come together before Jan. 1. Without agreement, more than $500 billion in automatic tax increases on all Americans and cuts in domestic and military programs will take hold, which could cause a recession if left in place for months, economists say.

“The question is making sure that we hit a revenue target that’s required for a truly balanced deficit-reduction plan,” said Representative Chris Van Hollen of Maryland, the senior Democrat on the House Budget Committee. “And when the president and all of us say this is a question of math, we mean it. It’s very hard to make the numbers work without the top rates going back to the full Clinton-era levels.”

The top tax rates are taking center stage right now because Mr. Obama believes he won a mandate after campaigning relentlessly on the idea of extending Mr. Bush’s tax cuts only for households with annual income below $250,000. But the two parties also have ideological differences on taxes affecting savings, investment and inheritance, which have flared in battles going back to the Reagan years. To get a deal in the coming weeks, those differences must be addressed at least in broad terms, even if the details are left to a battle over revamping the tax code next year.

The argument over rates is far from settled. Although the two sides seem close enough on the percentages for easy compromise, principle and politics loom large: Republicans oppose raising rates as a matter of ideology, saying that it kills jobs, and the president insists that he will not keep the Bush-era rates on income above roughly $250,000 after two campaigns in which he vowed to return them to the levels of the Clinton years.

“Just to be clear, I’m not going to sign any package that somehow prevents the top rate from going up for folks at the top 2 percent,” he said Thursday.

In recent days, comments from some Republicans, including Mr. Boehner, their chief negotiator, have hinted that the party — recognizing its weak hand — might be moving toward a concession on tax rates. Seldom mentioned is that Mr. Obama’s revenue total also reflects four other changes from Bush-era tax cuts: higher tax rates on investment income from capital gains and dividends, and the restoration of two other Clinton-era provisions limiting deductions and tax exemptions for affluent individuals.

Together those changes would raise $407.4 billion over a decade — nearly as much as the president’s proposal on higher rates, which would raise $441.6 billion by 2023, for a total of $849 billion. Another $119 billion would come from higher estate taxes, opposed by Republicans and some Democrats.

And both the president and Republicans are committed to raising hundreds of billions of dollars by overhauling the tax code to further limit or end the tax breaks that high-income taxpayers can claim, though they differ in how to do that.

Republicans want to raise all $800 billion from overhauling the tax code, erasing tax breaks for high-income households and using the new revenues both to reduce deficits and to lower everyone’s tax rates. But they have not proposed how to do that, and the president insists it cannot be done without hitting middle-income taxpayers.

Mr. Obama has proposed to keep existing tax breaks but to limit the rate of those breaks for people in higher tax brackets to 28 percent, which would raise $584 billion in a decade. He has proposed variations of that proposal for four years, only to be ignored by both parties because of opposition from charitable groups, the housing industry, insurers and others to curbing deductions for charitable giving, mortgage insurance and other purposes.

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New Taxes to Take Effect to Fund Health Care Law

WASHINGTON — For more than a year, politicians have been fighting over whether to raise taxes on high-income people. They rarely mention that affluent Americans will soon be hit with new taxes adopted as part of the 2010 health care law.

The new levies, which take effect in January, include an increase in the payroll tax on wages and a tax on investment income, including interest, dividends and capital gains. The Obama administration proposed rules to enforce both last week.

Affluent people are much more likely than low-income people to have health insurance, and now they will, in effect, help pay for coverage for many lower-income families. Among the most affluent fifth of households, those affected will see tax increases averaging $6,000 next year, economists estimate.

To help finance Medicare, employees and employers each now pay a hospital insurance tax equal to 1.45 percent on all wages. Starting in January, the health care law will require workers to pay an additional tax equal to 0.9 percent of any wages over $200,000 for single taxpayers and $250,000 for married couples filing jointly.

The new taxes on wages and investment income are expected to raise $318 billion over 10 years, or about half of all the new revenue collected under the health care law.

Ruth M. Wimer, a tax lawyer at McDermott Will & Emery, said the taxes came with “a shockingly inequitable marriage penalty.” If a single man and a single woman each earn $200,000, she said, neither would owe any additional Medicare payroll tax. But, she said, if they are married, they would owe $1,350. The extra tax is 0.9 percent of their earnings over the $250,000 threshold.

Since the creation of Social Security in the 1930s, payroll taxes have been levied on the wages of each worker as an individual. The new Medicare payroll is different. It will be imposed on the combined earnings of a married couple.

Employers are required to withhold Social Security and Medicare payroll taxes from wages paid to employees. But employers do not necessarily know how much a worker’s spouse earns and may not withhold enough to cover a couple’s Medicare tax liability. Indeed, the new rules say employers may disregard a spouse’s earnings in calculating how much to withhold.

Workers may thus owe more than the amounts withheld by their employers and may have to make up the difference when they file tax returns in April 2014. If they expect to owe additional tax, the government says, they should make estimated tax payments, starting in April 2013, or ask their employers to increase the amount withheld from each paycheck.

In the Affordable Care Act, the new tax on investment income is called an “unearned income Medicare contribution.” However, the law does not provide for the money to be deposited in a specific trust fund. It is added to the government’s general tax revenues and can be used for education, law enforcement, farm subsidies or other purposes.

Donald B. Marron Jr., the director of the Tax Policy Center, a joint venture of the Urban Institute and the Brookings Institution, said the burden of this tax would be borne by the most affluent taxpayers, with about 85 percent of the revenue coming from 1 percent of taxpayers. By contrast, the biggest potential beneficiaries of the law include people with modest incomes who will receive Medicaid coverage or federal subsidies to buy private insurance.

Wealthy people and their tax advisers are already looking for ways to minimize the impact of the investment tax — for example, by selling stocks and bonds this year to avoid the higher tax rates in 2013.

The new 3.8 percent tax applies to the net investment income of certain high-income taxpayers, those with modified adjusted gross incomes above $200,000 for single taxpayers and $250,000 for couples filing jointly.

David J. Kautter, the director of the Kogod Tax Center at American University, offered this example. In 2013, John earns $160,000, and his wife, Jane, earns $200,000. They have some investments, earn $5,000 in dividends and sell some long-held stock for a gain of $40,000, so their investment income is $45,000. They owe 3.8 percent of that amount, or $1,710, in the new investment tax. And they owe $990 in additional payroll tax.

The new tax on unearned income would come on top of other tax increases that might occur automatically next year if President Obama and Congress cannot reach an agreement in talks on the federal deficit and debt. If Congress does nothing, the tax rate on long-term capital gains, now 15 percent, will rise to 20 percent in January. Dividends will be treated as ordinary income and taxed at a maximum rate of 39.6 percent, up from the current 15 percent rate for most dividends.

Under another provision of the health care law, consumers may find it more difficult to obtain a tax break for medical expenses.

Taxpayers now can take an itemized deduction for unreimbursed medical expenses, to the extent that they exceed 7.5 percent of adjusted gross income. The health care law will increase the threshold for most taxpayers to 10 percent next year. The increase is delayed to 2017 for people 65 and older.

In addition, workers face a new $2,500 limit on the amount they can contribute to flexible spending accounts used to pay medical expenses. Such accounts can benefit workers by allowing them to pay out-of-pocket expenses with pretax money.

Taken together, this provision and the change in the medical expense deduction are expected to raise more than $40 billion of revenue over 10 years.

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Stalled Adoption Program in Guatemala Leaves Families in Limbo

Rodrigo Cruz for The New York Times

Amy and Rob Carr in Guatemala with Geovany Archilla Rodas, whom they have been trying to adopt since 2007. More Photos »

GUATEMALA CITY — The little boy flies like an airplane through the hotel, his arms outstretched. Then he leaps like a superhero, beaming as the red lights on his new sneakers flash and flicker, while the American couple he is with dissolve in laughter.

He calls them Mamá and Papi. They call him Hijo — Son. He corrects their fledgling Spanish. They teach him English. “Awe-some,” he repeats carefully, eyeing his new shoes.

To outsiders, they look like a family. But Geovany Archilla Rodas, an impish 6-year-old boy with spiky black hair, lives in an orphanage on the outskirts of this capital city. The Americans — Amy and Rob Carr of Reno, Nev. — live a world away. They are the only parents he has ever known.

They have been visiting him every year, usually twice a year, since he was a toddler, flying into this Central American city for a few days at a time to buy him clothes and to read him stories, to wipe his tears and to tickle him until he collapses in giggles at their hotel or in the orphanage.

Yet half a decade after agreeing to adopt him, the Carrs still have no idea when — or if — they will ever take Geovany home.

“There’s this hope in you that doesn’t want to die,” said Mrs. Carr, who arrived here last month with her husband, more determined than ever to cut through the bureaucracy. “In my heart, he’s my son.”

The Carrs are among the 4,000 Americans who found themselves stuck in limbo when Guatemala shut down its international adoption program in January 2008 amid mounting evidence of corruption and child trafficking. Officials here and in Washington promised at the time to process the remaining cases expeditiously.

But officials and prospective parents say that bureaucratic delays, lengthy investigations and casework hobbled by shortages of staff and resources have left hundreds of children stranded in institutions for years. Today, 150 children — including Geovany — are still waiting in orphanages and foster homes here while the Guatemalan authorities weigh whether to approve their adoptions to families in the United States.

Stalled adoptions are not unique to Guatemala. Concerns about fraud, including allegations of kidnappings and baby selling, have held up American adoptions for months, and sometimes years, from Ethiopia, Kyrgyzstan, Vietnam and Haiti. The State Department currently refuses to approve adoptions from Cambodia and Vietnam to pressure those countries to install safeguards so that children with biological relatives who can care for them are not shipped overseas, officials say.

But the problem of delayed adoptions is particularly acute in Guatemala, a country of about 14 million people, which in 2007 ranked second only to China in the number of children sent to the United States.

As officials here have spent months, and then years, trying to distinguish legitimate adoptions from fraudulent ones, many hopeful couples who had painted nurseries, hosted baby showers and bought brand new cribs began to despair as the infants they had hoped to adopt took their first steps and spoke their first words without them.

Faced with a seemingly endless process, scores of prospective parents quietly abandoned their efforts to adopt the children they once considered their own, officials say.

Guatemalan officials said they never intended for the children to remain institutionalized for so long. They say they have had to thoroughly investigate the cases, some of which are complicated by inconsistencies, false documents and questionable stories, to ensure that the children were not bought or stolen from impoverished rural women.

“These are very vulnerable people, who can be easily taken advantage of,” said Elizabeth Orrego de Llerena, president of the board of directors of the National Adoption Council, which is processing the adoption cases once they have been cleared by the child welfare investigative branch. “At times, they have not had the opportunity to make a complaint or to seek solutions.”

Ms. Orrego de Llerena said that the investigations, which typically include searches for biological relatives, were necessary to ensure that children were given up voluntarily.

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India Ink: Newswallah: Bharat Edition

Jammu and Kashmir: In the legislative council elections held this week for four seats under the quota for panchayats, or village councils — the first such polls in 38 years — the governing coalition of National Conference and Indian National Congress won, Kashmir Live reported. The voters comprised 33,540 elected village council members and heads from the Jammu region and Kashmir Valley, according to an IANS report on the IBNLive Web site.

Arunachal Pradesh: Three years after the central government released three million rupees to the state to implement the national health insurance plan known as the Rashtriya Swastha Bima Yojana, potential  beneficiaries are still waiting, according to a PTI report in The Hindu Business Line. State officials said a memorandum of agreement between the state and Royal Sundaram, the insurance company chosen to implement the program, had yet to be signed, according to the report.

Manipur: The Supreme Court of India said Thursday that a special investigating team should be established to look into so-called encounter killings in the state, according to a PTI report carried by IBNLive. The court was responding to litigation filed by a group representing the families of alleged victims of “fake encounters” carried out by security forces.  

Rajasthan: A program to improve broadband connectivity in rural areas has begun in Arain town in Ajmer district, The Times of India reported. The goal is to give 250,000 elected village councils across the country broadband Internet connections within a year. The Universal Service Obligation Fund of India, funded by a percentage of all telecom companies’ revenue, is financing the project.  

Maharashtra: In a recent report, India’s comptroller and auditor general chastised the armed forces authorities in Pune for failing to prevent the unauthorised use of defense assets, Daily News & Analysis reported. According to the report, the Army Public School, which is run by the Army Welfare Education Society, was using eight military-owned buildings in violation of Ministry of Defense guidelines.

Andhra Pradesh: At the urging of Congress lawmakers pushing to establish Telangana as a separate state, the governing United Progressive Alliance on Wednesday agreed to hold an all-party meeting to discuss the controversial bid, according to a report in The New Indian Express.  Legislators from Telangana, which is a region in Andhra Pradesh, said the meeting would be held on Dec. 28.

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Economix Blog: Uwe E. Reinhardt: How Medicare Is Misrepresented

Uwe E. Reinhardt is an economics professor at Princeton. He has some financial interests in the health care field.

A common phrase in the current debate over the so-called fiscal cliff is “Medicare needs to be restructured.” The term serves as code for policies unlikely to be appealing to voters, a term that can mean everything and, thus, nothing.

The question is what problem restructuring is to solve in traditional Medicare, which remains one of the most popular health insurance programs in this country. People who use this vague term should always be challenged to explain exactly why and how Medicare should be changed.

Critics of traditional Medicare – even those who should know better – often accuse it of being “fee for service.” It is a strange accusation. After all, fee-for-service remains the dominant method of paying the providers of health care under private insurance, including Medicare Advantage, the option of private coverage open to all Medicare beneficiaries.

Describing Medicare as fee-for-service insurance is about as thoughtful as describing a horse as “an animal that has four legs,” a characteristic shared by many other animals. The practice is particularly odd, given that traditional Medicare as early as the 1970s was the first program to develop so-called “bundled payments” for hospital inpatient care – the diagnostically related groupings, known as D.R.G. – in place of fee-for-service payment of hospitals, an innovation that has since been copied around the globe.

A more descriptive term for traditional Medicare would be “free choice of providers” or “unmanaged care” insurance. These features, of course, would hardly be viewed as shortcomings among people covered by traditional Medicare or their families. Neither term would be a good marketing tool among voters for proposals to abandon traditional Medicare.

In this regard, it may be helpful to list the various contractual relationships that can exist between the insured and insurers, on the one hand, and the various methods of paying the providers of care, on the other:

Indemnity Insurance: This is the oldest form of health insurance. It offers the insured free choice of health care provider and of treatment, which is why such policies tend to be expensive.

Under indemnity insurance, providers of care are typically paid on a fee-for-service basis. Insurers usually pay a stipulated fraction (say 80 percent) of the providers’ bills for covered services. Patients absorb the rest in the form of deductibles and coinsurance (e.g., 20 percent of the providers’ bill). Under some policies, insurers ask patients to pay providers first and then seek reimbursement from the insurer.

Managed-Care Contracts: The other three insurance contracts shown in the display – H.M.O., P.P.O. and P.O.S. contracts – are generally lumped together under the generic term “managed care.” It is another ill-defined term that can mean a host of specific limitations on the insured’s freedom of choice.

Doctors may assert that it is they who manage the medical treatments. But in health-policy circles, the term managed care means that the doctor’s medical treatments are subject to external constraints imposed by a private regulator — the patient’s health insurer — although, in principle, public insurers could “manage” care as well, if legislators permitted it.

These externally imposed constraints may take the form of formularies for prescription drugs or prior authorization by the insurer for specific procedures – e.g., expensive imaging or elective surgery – before the insurer agrees to pay for the procedures. They may mean exclusion from coverage of procedures deemed by the insurer to have a low expected benefit-cost ratio. While Congress forbids Medicare to let cost-benefit analysis guide its coverage decisions, private insurers are not subject to that constraint.

Finally, managed care techniques might include the external coordination of medical treatments that involved multiple providers of health care, especially the treatment of chronic disease, often by subcontracted companies specializing in care coordination.

These are the major forms of managed care insurance contracts.

Health Maintenance Organizations (H.M.O.): These contracts represent the most restrictive form of managed care. The insurer provides covered health care benefits through a network of health care providers under contract to the insurer, with zero or very modest cost-sharing at point of service on the part of the insured.

In a staff model H.M.O., the insurer actually owns the health care facilities and health professionals are the insurer’s salaried employees. More commonly, the H.M.O. merely contracts with a set of otherwise independent providers that are paid negotiated fees or, for primary care, sometimes annual capitation payments per patient on the doctor’s list.

Usually, in an H.M.O., the insured is asked to select one from a roster of primary-care doctors who regulates referrals to specialists. In principle, under an H.M.O. contract the insured is confined to the H.M.O.’s network of providers for covered services and pays in full out-of-pocket for health care procured outside that network.

Preferred Provider Organizations (P.P.O.): A popular alternative to the strictly limited choice under H.M.O.’s is a Preferred Provider Organization. Under that contract, the insurer negotiates prices with a network of “preferred” providers of care and the insured can contact specialists without a required referral by a primary-care doctor.

For the most part these providers in the network are paid on a fee-for-service basis as well, often X times the Medicare fee schedule, where X could be smaller than 1 but usually exceeds 1, where X is negotiated between the insurer and providers. The insured usually faces an annual deductible and relatively modest copays (dollar amounts, not fractions of the fees) if they obtain care from a provider in the network.

If the insured obtains care from a provider outside the P.P.O.’s network, the insurer will reimburse the insured only at what the insurer considers a reasonable fee, leaving the insured to pay any billed fee above that reimbursement. According to a report by the American Health Insurance Plans, these out-of-network fees can be exorbitantly high, which serves as a natural constraint on the free choice of provider under P.P.O.’s.

Point of Service (P.O.S.) Contracts: These contracts are combinations of H.M.O. and P.P.O. contracts. The insured still must select a primary-care doctor who coordinates the insured’s overall medical care, but patients can procure covered care from providers outside the H.M.O.’s network, albeit at high rates of cost-sharing. In that regard the arrangement resembles a P.P.O.

High-Deductible Health Plans (H.D.H.P.): These contracts couple indemnity- or preferred-provider (P.P.O.) insurance with very high annual deductibles, sometimes exceeding $10,000 for a family. The theory is that by putting the insured’s skin in the game, these plans will give patients an incentive to shop around for cost-effective health care. Some call them “Consumer-Directed Health Plans” (C.D.H.P.’s), because in theory they elevate “consumers” (formerly “patients”) to act as the chief managers of their own health care. However, the requisite information for shopping around has not generally been available to patients, forcing them to function in health care as would blindfolded shoppers in a department store.

What the critics of traditional, government-run Medicare actually find wanting in traditional Medicare is that it basically is classic indemnity insurance. It offers its enrollees free choice of doctor, hospital and other providers, and doctors relatively free choice of treatments, while most private insurers typically no longer do.

In other words, the complaint is that health care rendered under traditional Medicare is unmanaged care. These features, of course, are precisely the reason why in the eyes of the public traditional Medicare is still one of the most popular insurance products.

A case can be made, on theoretical and sometimes empirical grounds, that properly managed or coordinated care can on average yield superior medical treatments, at lower cost, than completely unmanaged care under classical indemnity insurance.

The problem has been and continues to be that this is not the folklore among patients or doctors. The latter, as noted, generally believe they can manage their patients’ care properly without outside interference into their clinical decisions. Among patients and doctors, the term managed care is still not quite respectable.

This can explain why critics of traditional Medicare delicately but nonsensically prefer to decry it as being fee for service rather than as free-choice-of-providers insurance or unmanaged-care insurance.

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McAfee Antivirus Software Pioneer Arrested in Guatemala City

MEXICO CITY — The antivirus software pioneer John McAfee was arrested in Guatemala City on Wednesday after he slipped over the border from his home in Belize where police want to question him in their investigation of the murder of his neighbor.

Jorge Dan Lopez/Reuters

John McAfee spoke during an interview in Guatemala City on Wednesday.

The interior minister, Mauricio Lopez Bonilla, told The Associated Press that Mr. McAfee, 67, had been arrested on charges of entering Guatemala illegally. He said that Mr. McAfee had been arrested at a hotel in the capital and taken to a detention center for migrants who are in the nation illegally.

Mr. McAfee had been on the run for almost a month since his neighbor, Gregory Faull, on the Belizean island of Ambergris Caye was found dead at his home on Nov. 11. Police there cited Mr. McAfee as a “person of interest” in their investigation, but Mr. McAfee disapppeared.

But he did not disappear from the Internet. He kept up a continuous stream of comment on his blog and on Twitter, accusing the Belizean authorities of persecuting him.

On Tuesday, he resurfaced in Guatemala, dressed in a suit, his blond curls dyed dark brown.

Accompanied by his 20-year-old Belizean girlfriend, Samantha Venagas, and his Guatemalan lawyer, Telésforo Guerra, Mr. McAfee said that he would seek political asylum in Guatemala. Mr. Guerra, a former Guatemalan attorney general, told reporters at a chaotic news conference outside the Supreme Court that his client was being persecuted because he refused to pay Belizean authorities off any longer.

Mr. McAfee has not been associated with the software company that bears his name since 1994, when he sold it and began to pursue his other interests. He ran a yoga retreat and then built a complex in New Mexico to indulge his hobby of flying motorized ultralight airplanes.

He moved to Belize about four years ago, buying properties on the mainland and on Ambergris Caye. It was there that he clashed with Mr. Faull, who complained about the unleashed dogs that Mr. McAfee kept on his property.

On Nov. 9, several of the dogs were found dead. They had been poisoned.

During his time in Belize, Mr. McAfee had apparently become interested in developing a designer drug called MDPV. He posted extensively about his experiments on a Web site.

But he attracted the attention of Belizean authorities, who raided one of his properties in April. He spent a night in jail, but law enforcement officials found no evidence that he was producing methamphetamine and dropped the charges.

After that experience, though, Mr. McAfee appeared to become increasingly convinced that he was being persecuted by the Belizean government. Officials deny that they are persecuting him.

Mr. Guerra told Guatemalan reporters late Wednesday that since there was no warrant for Mr. McAfee’s arrest and since his client was not a fugitive, he would seek to have his client released and returned to the hotel where he would remain under guard.

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The New Old Age Blog: How the 'Death With Dignity' Law Failed in Massachusetts

On election night, Jim Carberry and others who had worked to put a “Death With Dignity” law on the Massachusetts ballot gathered in the back room of a Waltham restaurant and watched their effort go down to narrow defeat.

“We were disheartened,” Mr. Carberry recalled. “For a lot of us, it was personal.”

His wife Margie, diagnosed with a rare brain tumor in 1995, had sought aggressive treatment for years – many surgeries and procedures, lots of radiation – hoping to see her younger daughter graduate from high school in 2011. She survived long enough to attend the ceremony. Then, with no medical options remaining, she asked to have her feeding tube removed. It took her five weeks to die. She was 51.

“I made her a promise that I would do whatever I could to keep other people from going through what we did,” said Mr. Carberry, who is 56. He gave endless media interviews and appeared in a TV ad with his mother-in-law, urging a yes vote on Question 2.

Question 2, which would have allowed doctors to prescribe drugs with which terminally ill patients could end their lives, drew less national attention than Elizabeth Warren’s Senate victory. But for those concerned with end-of-life decisions, Massachusetts was a major battle in an ongoing campaign.

Heading into election season, the volunteers and staffers who had collected signatures to put the law on the ballot could point to solid public approval. In August and September, polls by the Boston Globe, Suffolk University and others found 60 percent support or more.

By late October, however, Question 2 could no longer claim a majority. It lost by about 68,000 votes, a 51 to 49 percent defeat.

This was a fight its opponents felt they couldn’t afford to lose. “If the proponents could pass this in 40-percent-Catholic Massachusetts, they’d be running through the other states within five years,” said Joe Baerlein, whose public relations and lobbying firm Rasky Baerlein marshaled the opposition.

Its early research showed that Massachusetts residents believed in individual choice, and respect for others’ choices, about death and dying, Mr. Baerlein said. So the anti-Question 2 forces didn’t attack on direct moral or ethical grounds; instead, its ads took aim at certain provisions and how they were worded.

For instance, the proposed law — which included multiple safeguards and waiting periods to prevent impulsive requests, coercion or abuse — required a physician to “recommend” that a terminally ill patient notify his next of kin of his intent.

But it didn’t “require” family notification. “How would you feel if you came home and your mother had decided to take her life?” Mr. Baerlein said. “Voters couldn’t get their arms around that.”

The law also required a prescribing physician to refer a patient to a psychiatrist or psychologist “if the physician believes the patient may have a disorder causing impaired judgment,” like depression. But opposition ads criticized it for not mandating that a psychiatrist be one of the two physicians a patient had to consult.

Opponents also pointed out that medical prognoses — the law required that a patient be within six months of death — can be wrong. One ad, almost a counter to Dignity 2012’s spot featuring Mr. Carberry, showed a young widow whose husband lived a year and a half longer than expected. She was grateful he hadn’t “made a terrible decision based upon a doctor’s guess.”

“In the end, even if you believed you should control your end of life decision-making, there are too many flaws in the language,” Mr. Baerlein said.

To supporters, however, none of this parsing mattered nearly as much as money. They were vastly outspent.

The two groups pushing for Question 2 spent a little over $1 million this year, state finance records show, the bulk of which came from national groups like the Compassion and Choices Action Network and the Death With Dignity National Center.

The two major opposition groups spent close to $5 million, mostly on TV and radio ads in the campaign’s final weeks. “It’s a tactic they’ve used in other states, to blitz the airwaves with commercials,” said Peg Sandeen, who heads the Death With Dignity National Center.

Though some opposition money came from anti-abortion groups and the conservative American Principles Project (it gave $175,000, and its board chairman personally contributed $523,000), most came from Catholic organizations and archdioceses around the country, including $450,000 from the Knights of Columbus and $250,000 from the Archdiocese of Boston.

Supporters of Question 2 couldn’t counter that onslaught. “It’s so easy to scare people on this issue; that’s what happened in Massachusetts,” Ms. Sandeen said. “Fear-based arguments work.”

Data from the two states where physician-assisted suicide is legal shows that “slippery-slope” fears are probably overblown. Very few patients take advantage of death with dignity laws: Last year, just 114 people received lethal prescriptions in Oregon and 103 in Washington. In both states, about a third of those patients ultimately didn’t use the drugs.

It seems unlikely that any change in language could make an assisted-suicide law acceptable to the Catholic leadership.

But the campaign continues and so, undoubtedly, will the opposition. In neighboring Vermont, Gov. Peter Shumlin said last week he believes the legislature will pass a death with dignity law this session. In Massachusetts, Ms. Sandeen said, since supporters must wait until after 2016 to put the law on the ballot again, they will take their case to the legislature.

Mr. Carberry was ready to re-enlist. “I’d like to think that it’s not over,” he said.

Paula Span is the author of “When the Time Comes: Families With Aging Parents Share Their Struggles and Solutions.”

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