U.N. Rejects Claim for Direct Compensation to Victims of Cholera Epidemic in Haiti

There will be no direct financial compensation from the United Nations for the more than 8,000 Haitians who died and the 646,000 sickened by cholera since the disease struck the earthquake-ravaged country in October 2010, Secretary General Ban Ki-moon told the Haitian president this week.

More than 15 months after the United Nations received a legal claim seeking to hold peacekeeping troops responsible for setting off the epidemic, its lawyers declared the claim “not receivable,” citing diplomatic immunity.

At the same time, Partners in Health, the leading nongovernmental health care provider in Haiti, has stepped forward to urge the United Nations to invest more seriously in Mr. Ban’s own largely unfunded anticholera initiative to make amends.

In an Op-Ed article posted Friday night on the Web site of The New York Times, Dr. Louise C. Ivers, the group’s senior health and policy adviser, says the United Nations has “a moral, if not legal, obligation to help solve a crisis it inadvertently helped start.” Evidence, she said, finds the United Nations “largely, though not wholly” culpable for the outbreak of cholera.

To date, Mr. Ban has not acknowledged the reigning scientific theory about the origin of Haiti’s cholera epidemic — that peacekeepers from Nepal imported the cholera and, through a faulty sanitation system at their base, infected a tributary of the country’s largest river.

Dr. Ivers, however, while noting the “causality” of epidemic disease is complex, says that no other reasonable hypothesis for Haiti’s cholera has been put forth.

What makes her comments especially striking is that her organization’s co-founder and chief strategist, Dr. Paul Farmer, served as the United Nations’ deputy special envoy for Haiti for the past three years and was appointed by Mr. Ban in December to lead the very anticholera initiative that she found lacking.

Dr. Farmer declined to comment, but a spokeswoman for Partners in Health said Dr. Ivers’s statements represented the group’s concerns about the 10-year, $2.2 billion anticholera initiative that he was supposed to advise.

The ambitious initiative is intended to upgrade Haiti’s abysmal water and sanitation infrastructure while increasing cholera prevention and treatment efforts, including the expansion of a small cholera vaccination campaign that Partners in Health and a Haitian health care group, Gheskio, undertook last year.

Donors have pledged $215 million. The United Nations said it would contribute $23.5 million — 1 percent of the initiative’s cost, Dr. Ivers said.

In contrast, she said, this year’s budget for the United Nations peacekeeping mission, $648 million, “could more than fund the entire cholera elimination initiative for two years.”

Expressing his “deep sorrow and solidarity with the many Haitian families who lost loved ones in this terrible epidemic,” Nigel Fisher, the new head of the peacekeeping mission, nonetheless said that the United Nations had “mobilized resolutely to combat the disease.” It spent some $118 million on cholera before the initiative was announced, officials have said.

Mr. Ban, through his spokesman, also expressed “his profound sympathy” while announcing on Thursday that the legal claim had been rejected.

Mario Joseph, lead lawyer for the cholera victims, said, “While these sympathies are welcome, they will not stop cholera’s killing or ensure that survivors can go on living after losing breadwinners to cholera.”

The demand, filed in an internal United Nations claims unit, had sought $100,000 for each bereaved family and $50,000 for each cholera survivor.

Mr. Joseph described the United Nations’ terse rejection of a claim filed over a year ago as “disgraceful,” and he and his American colleagues at the Institute for Justice and Democracy in Haiti said they would file a lawsuit in Haiti or abroad.

Though the death rate from cholera has declined significantly since the epidemic initially devastated Haiti, the disease is still coursing through the country. National statistics show a spike of reported cases in December 2012 over that same month in 2011 — 11,220 compared with 8,205.

“The U.N. will not pay,” said a headline Friday on the Web site of Haiti’s Le Nouvelliste newspaper.

“It’s not surprising,” a reader responded.

This article has been revised to reflect the following correction:

Correction: February 23, 2013

An earlier version of this article misrendered a quotation from an Op-Ed article by Dr. Louise C. Ivers. The quotation should have read “largely, though not wholly,” not “largely, if not wholly.”

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Drone Pilots Found to Get Stress Disorders Much as Those in Combat Do

U.S. Air Force/Master Sgt. Steve Horton

Capt. Richard Koll, left, and Airman First Class Mike Eulo monitored a drone aircraft after launching it in Iraq.

The study affirms a growing body of research finding health hazards even for those piloting machines from bases far from actual combat zones.

“Though it might be thousands of miles from the battlefield, this work still involves tough stressors and has tough consequences for those crews,” said Peter W. Singer, a scholar at the Brookings Institution who has written extensively about drones. He was not involved in the new research.

That study, by the Armed Forces Health Surveillance Center, which analyzes health trends among military personnel, did not try to explain the sources of mental health problems among drone pilots.

But Air Force officials and independent experts have suggested several potential causes, among them witnessing combat violence on live video feeds, working in isolation or under inflexible shift hours, juggling the simultaneous demands of home life with combat operations and dealing with intense stress because of crew shortages.

“Remotely piloted aircraft pilots may stare at the same piece of ground for days,” said Jean Lin Otto, an epidemiologist who was a co-author of the study. “They witness the carnage. Manned aircraft pilots don’t do that. They get out of there as soon as possible.”

Dr. Otto said she had begun the study expecting that drone pilots would actually have a higher rate of mental health problems because of the unique pressures of their job.

Since 2008, the number of pilots of remotely piloted aircraft — the Air Force’s preferred term for drones — has grown fourfold, to nearly 1,300. The Air Force is now training more pilots for its drones than for its fighter jets and bombers combined. And by 2015, it expects to have more drone pilots than bomber pilots, although fighter pilots will remain a larger group.

Those figures do not include drones operated by the C.I.A. in counterterrorism operations over Pakistan, Yemen and other countries.

The Pentagon has begun taking steps to keep pace with the rapid expansion of drone operations. It recently created a new medal to honor troops involved in both drone warfare and cyberwarfare. And the Air Force has expanded access to chaplains and therapists for drone operators, said Col. William M. Tart, who commanded remotely piloted aircraft crews at Creech Air Force Base in Nevada.

The Air Force has also conducted research into the health issues of drone crew members. In a 2011 survey of nearly 840 drone operators, it found that 46 percent of Reaper and Predator pilots, and 48 percent of Global Hawk sensor operators, reported “high operational stress.” Those crews cited long hours and frequent shift changes as major causes.

That study found the stress among drone operators to be much higher than that reported by Air Force members in logistics or support jobs. But it did not compare the stress levels of the drone operators with those of traditional pilots.

The new study looked at the electronic health records of 709 drone pilots and 5,256 manned aircraft pilots between October 2003 and December 2011. Those records included information about clinical diagnoses by medical professionals and not just self-reported symptoms.

After analyzing diagnosis and treatment records, the researchers initially found that the drone pilots had higher incidence rates for 12 conditions, including anxiety disorder, depressive disorder, post-traumatic stress disorder, substance abuse and suicidal ideation.

But after the data were adjusted for age, number of deployments, time in service and history of previous mental health problems, the rates were similar, said Dr. Otto, who was scheduled to present her findings in Arizona on Saturday at a conference of the American College of Preventive Medicine.

The study also found that the incidence rates of mental heath problems among drone pilots spiked in 2009. Dr. Otto speculated that the increase might have been the result of intense pressure on pilots during the Iraq surge in the preceding years.

The study found that pilots of both manned and unmanned aircraft had lower rates of mental health problems than other Air Force personnel. But Dr. Otto conceded that her study might underestimate problems among both manned and unmanned aircraft pilots, who may feel pressure not to report mental health symptoms to doctors out of fears that they will be grounded.

She said she planned to conduct two follow-up studies: one that tries to compensate for possible underreporting of mental health problems by pilots and another that analyzes mental health issues among sensor operators, who control drone cameras while sitting next to the pilots.

“The increasing use of remotely piloted aircraft for war fighting as well as humanitarian relief should prompt increased surveillance,” she said.

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Many States Say Cuts Would Burden Fragile Recovery

States are increasingly alarmed that they could become collateral damage in Washington’s latest fiscal battle, fearing that the impasse could saddle them with across-the-board spending cuts that threaten to slow their fragile recoveries or thrust them back into recession.

Some states, like Maryland and Virginia, are vulnerable because their economies are heavily dependent on federal workers, federal contracts and military spending, which will face steep reductions if Congress allows the automatic cuts, known as sequestration, to begin next Friday. Others, including Illinois and South Dakota, are at risk because of their reliance on the types of federal grants that are scheduled to be cut. And many states simply fear that a heavy dose of federal austerity could weaken their economies, costing them jobs and much-needed tax revenue.

So as state officials begin to draw up their budgets for next year, some say that the biggest risk they see is not the weak housing market or the troubled European economy but the federal government. While the threat of big federal cuts to states has become something of a semiannual occurrence in recent years, state officials said in interviews that they fear that this time the federal government might not be crying wolf — and their hopes are dimming that a deal will be struck in Washington in time to avert the cuts.

The impact would be widespread as the cuts ripple across the nation over the next year.

Texas expects to see its education aid slashed hundreds of millions of dollars, which could force local school districts to fire teachers, if the cuts are not averted. Michigan officials say they are in no position to replace the lost federal dollars with state dollars, but worry about cuts to federal programs like the one that helps people heat their homes. Maryland is bracing not only for a blow to its economy, which depends on federal workers and contractors and the many private businesses that support them, but also for cuts in federal aid for schools, Head Start programs, a nutrition program for pregnant women, mothers and children, and job training programs, among others.

Gov. Bob McDonnell of Virginia, a Republican, warned in a letter to President Obama on Monday that the automatic spending cuts would have a “potentially devastating impact” and could force Virginia and other states into a recession, noting that the planned cuts to military spending would be especially damaging to areas like Hampton Roads that have a big Navy presence. And he noted that the whole idea of the proposed cuts was that they were supposed to be so unpalatable that they would force officials in Washington to come up with a compromise.

“As we all know, the defense, and other, cuts in the sequester were designed to be a hammer, not a real policy,” Mr. McDonnell wrote. “Unfortunately, inaction by you and Congress now leaves states and localities to adjust to the looming threat of this haphazard idea.”

The looming cuts come just as many states feel they are turning the corner after the prolonged slump caused by the recession. Gov. Martin O’Malley of Maryland, a Democrat, said he was moving to increase the state’s cash reserves and rainy day funds as a hedge against federal cuts.

“I’d rather be spending those dollars on things that improve our business climate, that accelerate our recovery, that get more people back to work, or on needed infrastructure — transportation, roads, bridges and the like,” he said, adding that Maryland has eliminated 5,600 positions in recent years and that its government was smaller, on a per capita basis, than it had been in four decades. “But I can’t do that. I can’t responsibly do that as long as I have this hara-kiri Congress threatening to drive a long knife through our recovery.”

Federal spending on salaries, wages and procurement makes up close to 20 percent of the economies of Maryland and Virginia, according to an analysis by the Pew Center on the States.

But states are in a delicate position. While they fear the impact of the automatic cuts, they also fear that any deal to avert them might be even worse for their bottom lines. That is because many of the planned cuts would go to military spending and not just domestic programs, and some of the most important federal programs for states, including Medicaid and federal highway funds, would be exempt from the cuts.

States will see a reduction of $5.8 billion this year in the federal grant programs subject to the automatic cuts, according to an analysis by Federal Funds Information for States, a group created by the National Governors Association and the National Conference of State Legislatures that tracks the impact of federal actions on states. California, New York and Texas stand to lose the most money from the automatic cuts, and Puerto Rico, which is already facing serious fiscal distress, is threatened with the loss of more than $126 million in federal grant money, the analysis found.

Even with the automatic cuts, the analysis found, states are still expected to get more federal aid over all this year than they did last year, because of growth in some of the biggest programs that are exempt from the cuts, including Medicaid.

But the cuts still pose a real risk to states, officials said. State budget officials from around the country held a conference call last week to discuss the threatened cuts. “In almost every case the folks at the state level, the budget offices, are pretty much telling the agencies and departments that they’re not going to backfill — they’re not going to make up for the budget cuts,” said Scott D. Pattison, the executive director of the National Association of State Budget Officers, which arranged the call. “They don’t have enough state funds to make up for federal cuts.”

The cuts would not hit all states equally, the Pew Center on the States found. While the federal grants subject to the cuts make up more than 10 percent of South Dakota’s revenue, it found, they make up less than 5 percent of Delaware’s revenue.

Many state officials find themselves frustrated year after year by the uncertainty of what they can expect from Washington, which provides states with roughly a third of their revenues. There were threats of cuts when Congress balked at raising the debt limit in 2011, when a so-called super-committee tried and failed to reach a budget deal, and late last year when the nation faced the “fiscal cliff.”

John E. Nixon, the director of Michigan’s budget office, said that all the uncertainty made the state’s planning more difficult. “If it’s going to happen,” he said, “at some point we need to rip off the Band-Aid.”

Fernanda Santos contributed reporting.

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India Ink: Image of the Day: Feb. 22

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Pistorius granted bail pending murder trial

PRETORIA, South Africa (AP) — In an agonizingly slow announcement, a magistrate allowed Oscar Pistorius to go free on bail Friday, nine days after the Paralympian was arrested in the Valentine's Day killing of his girlfriend.

Pistorius' family members and supporters shouted "Yes!" when Chief Magistrate Desmond Nair made his decision after a more than 1 hour and 45 minute explanation of his ruling to a packed courtroom.

Radio stations and a TV news network in South Africa broadcast the audio of the decision live, and even international channels like the BBC and CNN went live with it, underscoring the huge global interest in the case.

Nair banned cameras from Friday's dramatic bail hearing and complained about cameras constantly "flashing" in Pistorius' face the previous three days of hearings, saying the spectacle made the athlete look like "some kind of species the world has never seen before."

Nair set the bail at 1 million rand ($113,000), with $11,300 in cash up front and proof that the rest is available. The magistrate said Pistorius must hand over his passports and also turn in any other guns that he owns. Pistorius also cannot leave the district of Pretoria, South Africa's capital, without the permission of his probation officer, Nair said, nor can he take drugs or drink alcohol.

The double-amputee Olympian's next court appearance was set for June 4. He left the courthouse in a silver Land Rover, sitting in the rear, just over an hour after the magistrate imposed the bail conditions.

The magistrate ruled that Pistorius could not return to his upscale home in a gated community in the eastern suburbs of Pretoria, where the killing of Reeva Steenkamp took place.

Pistorius' uncle, Arnold Pistorius said: "We are relieved at the fact that Oscar got bail today but at the same time we are in mourning for the death of Reeva with her family. As a family, we know Oscar's version of what happened on that tragic night and we know that that is the truth and that will prevail in the coming court case."

Pistorius' senior defense lawyer, Barry Roux, told reporters the defense is satisfied with the bail.

Nair made the ruling after four days of arguments from prosecution and defense in Pistorius' bail hearing. During Friday's long session in Pretoria Magistrate's Court, Pistorius alternately wept and appeared solemn and more composed, especially toward the end as Nair criticized police procedures in the case and as a judgment in Pistorius' favor appeared imminent.

Nair said Pistorius' sworn statement, in which he gave his version of the events of the shooting during the predawn hours of Feb. 14 in a sworn statement, had helped his application for bail.

"I come to the conclusion that the accused has made a case to be released on bail," Nair said.

Pistorius said in the sworn statement that he shot his girlfriend — a model and budding reality TV contestant — accidentally, believing she was an intruder in his house.

Prosecutors say he intended to kill Steenkamp and charged him with premeditated murder, saying the shooting followed a loud argument between the two.

Sharon Steenkamp, Reeva's cousin, had said earlier that the family wouldn't be watching the bail decision and hadn't been following the hearing in Pretoria.

"It doesn't make any difference to the fact that we are without Reeva," she told The Associated Press.

Despite the bail decision, prosecution spokesman Medupe Simasiku said: "We're still confident in our case," outside court.

Pistorius faced the sternest bail requirements in South Africa because of the seriousness of the charge, and his defense lawyers had to prove that he would not flee the country, would not interfere with witnesses or the case, and his release would not cause public unrest.

Nair questioned whether Pistorius would be a flight risk and be prepared to go "ducking and diving" around the world when he stood to lose a fortune in cash, cars, property and other assets. Nair also said that while it had been shown that Pistorius had aggressive tendencies, he did not have a prior record of offenses for violent acts.

He criticized Hilton Botha, the previous lead investigator in the case, for not doing more to uncover evidence that the Olympian had violent tendencies.

"There is ample room and ample time to do that by looking at the background of the accused," he said.

But while Nair leveled harsh criticism at former lead investigator Botha for "errors" and "blunders," he said one man does not represent the state's case and that the state could not be expected to put all the pieces of its puzzle together in such a short time.

Anticipating the shape of the state's case at trial, he said he had serious questions about Pistorius' account: Why he didn't try to locate his girlfriend on fearing an intruder was in the house, why he didn't try to determine who was in the toilet and why he would venture into perceived "danger" - the bathroom area - when he could have taken other steps to ensure his safety.

"There are improbabilities which need to be explored," Nair said, adding that Pistorius could clarify these matters by testifying under oath at trial.

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AP Sports Writer Gerald Imray and AP writer Carley Petesch contributed to this report from Johannesburg.

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Well: Depression May Stifle Shingles Vaccine Response

Depression may lower the effectiveness of the shingles vaccine, a new study found.

The research showed that adults with untreated depression who received the vaccine mounted a relatively weak immune response. But those who were taking antidepressants showed a normal response to the vaccine, even when symptoms of depression persist.

Shingles, an acute and painful rash, strikes a million Americans each year, mostly older adults. Health officials recommend that those over 60 get vaccinated against the condition, which is caused by reactivation of the same virus that causes chickenpox, varicella-zoster.

In the new study, published in the journal Clinical Infectious Diseases, researchers followed a group of 92 older men and women for two years. Forty of the subjects had a major depressive disorder; they were matched with 52 control subjects of similar age. The researchers measured their immune responses to the shingles vaccine and a placebo shot.

Compared with the control patients, those with depression were poorly protected by the vaccine. But the patients who were being treated for their depression showed a boost in immunity — what the researchers called a “normalization” of the immune response. It is unclear why that was the case.

The authors of the study speculated that treatment of older people with depression might increase the effectiveness of the flu shot and other vaccines as well.

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Room for Debate: Should Companies Tell Us When They Get Hacked?

A National Priority and a Business Priority

Lauren Gelman, BlurryEdge Strategies

Like pollution, an insecure infrastructure is bad for everyone. Disclosing security breaches reintroduces the public's collective interest.

Disclosure Plays Into Hackers’ Hands

Alexander Tabb, partner, research and consulting firm

By requiring companies to disclose security breaches, we would be requiring them to telegraph their weaknesses to the world.

Investors Need to Know

Jacob Olcott, Good Harbor Security Risk Management

It’s not that the events aren’t happening. It’s that you're not being told about them -- despite the S.E.C.'s instructions.

We Need Better Notification Laws

Lee Tien, Electronic Frontier Foundation

Existing laws focus mainly on whether a breach exposed information, not why it happened. Yet the reason can be critical.

More Disclosure Is Not Always Better

Baruch Fischhoff, decision sciences, Carnegie Mellon

People may exaggerate the risk of hacking if they suddenly start hearing about a lot of it. Or they may get used to frequent reports and underestimate the risks.

Improve Digital Hygiene

Joseph Lorenzo Hall, Center for Democracy and Technology

As a nation we devote few resources to creating a common social understanding of how to keep people and computer systems safe.

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India Ink: Image of the Day: Feb. 21

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Top detective appointed new Pistorius investigator

PRETORIA, South Africa (AP) — South Africa's top detective was appointed lead investigator in the Oscar Pistorius case Thursday, replacing a veteran policeman who was charged with attempted murder in the latest shock development to hit a case being watched closely by the nation.

National Police Commissioner Riah Phiyega promised that a team of "highly skilled and experienced" officers would investigate the killing of Pistorius' 29-year-old girlfriend. Pistorius, 26, has been charged with premeditated murder in the case.

The decision to put police Lt. Gen. Vinesh Moonoo in charge came soon after word emerged that the initial chief investigator, Hilton Botha, is facing attempted murder charges, and a day after he offered testimony damaging to the prosecution in Pistorius' bail hearing.

Pistorius, an Olympic runner whose lower legs were amputated when he was less than a year old, killed his girlfriend Reeva Steenkamp in the predawn hours of Valentine's Day. He claims he mistook her for an intruder when he shot her through a locked door in a bathroom in his home. Prosecutors say the shooting happened after the couple got into an argument and allege the killing was deliberate, carried out with no mercy.

Botha acknowledged Wednesday in court that nothing in Pistorius' version of the fatal shooting of Steenkamp contradicted what police had discovered, even though there have been some discrepancies. Botha also said that police had left a 9 mm slug in the toilet and had lost track of allegedly illegal ammunition found in Pistorius' home.

"This matter shall receive attention at the national level," Phiyega told reporters soon after the end of proceedings in the third day of Pistorius' bail hearing. The case has riveted South Africa and much of the world and has placed the country's judicial system under close scrutiny.

Bulewa Makeke, spokeswoman for South Africa's National Prosecuting Authority, said the attempted murder charges had been reinstated against Botha on Feb. 4. Police say they found out about it after Botha testified in Pistorius' bail hearing Wednesday.

Botha and two other police officers had seven counts of attempted murder reinstated against them in relation to a 2011 shooting incident. Botha and his two colleagues allegedly fired shots at a minibus they were trying to stop.

Asked about Botha's court performance and handling of the investigation, Phiyega said South Africa's police force "can stand on its own" compared to others around the world.

Makeke, the spokeswoman for the national prosecution office, had said before Botha was dismissed from the Pistorius case that he should be taken off, but added that it was up to the police force to make that decision.

Makeke indicated the charges were reinstated against Botha because more evidence had been gathered. She said the charge against Botha was initially dropped "because there was not enough evidence at the time."

Pistorius' main sponsor Nike, meanwhile, suspended its contract with the multiple Paralympic champion, following eyewear manufacturer Oakley's decision to suspend its sponsorship. Nike said in a brief statement on its website: "We believe Oscar Pistorius should be afforded due process and we will continue to monitor the situation closely."

The judge is still trying to decide whether to grant Pistorius bail, and under what conditions.

During Thursday's bail hearing, Chief Magistrate Desmond Nair asked the defense of Pistorius' bail application: "Do you think there will be some level of shock if the accused is released?"

Defense lawyer Barry Roux responded: "I think there will be a level of shock in this country if he is not released."

Opposing bail, prosecutor Gerrie Nel painted a picture of a man "willing and ready to fire and kill," and said signs of remorse from Pistorius do not mean that the athlete didn't intend to kill his girlfriend.

"Even if you plan a murder, you plan a murder and shoot. If you fire the shot, you have remorse. Remorse might kick in immediately," Nel said.

As Nel summed up the prosecution's case opposing bail, Pistorius began to weep in the crowded courtroom, leading his brother, Carl Pistorius, to reach out and touch his back.

"He (Pistorius) wants to continue with his life like this never happened," Nel went on, prompting Pistorius, who was crying softly, to shake his head. "The reason you fire four shots is to kill," Nel persisted.

Earlier Thursday, Nair questioned Botha over delays in processing records from phones found in Pistorius' house following the killing of Steenkamp, a 29-year-old model and budding reality TV contestant.

"It seems to me like there was a lack of urgency," Nair said as the efficiency of the police investigation was questioned.

Botha is himself to appear in court in May to face seven counts of attempted murder. Botha was dropped from the case but not suspended from the police force, Phiyega said, and could still be called by defense lawyers at trial.

Pisatorius' behavior Thursday reflected the change of mood in the courtroom as his defense lawyers attacked police procedures and maintained his innocence.

Pistorius, in the same gray suit, blue shirt and gray tie combination he has worn throughout the bail hearing, stood ramrod straight in the dock, then sat calmly looking at his hands. On Tuesday and Wednesday, the athlete had been slumped over and sobbing uncontrollably at times as detail was read out of how Steenkamp died in his house.

"The poor quality of the evidence offered by investigative officer Botha exposed the disastrous shortcomings of the state's case," Roux said Thursday. "We cannot sit back and take comfort that he is telling the truth."

Roux also raised issue of intent, saying the killing was not "pre-planned" and referred to a "loving relationship" between the two.

He said an autopsy showed that Steenkamp's bladder was empty, suggesting she had gone to use the toilet as Pistorius had claimed. Prosecutors claim Steenkamp had fled to the toilet to avoid an enraged Pistorius.

"The known forensics is consistent" with Pistorius' statement, Roux said, asking that bail restrictions be eased for Pistorius.

But the prosecutor said Pistorius hadn't given guarantees to the court that he wouldn't leave the country if he was facing a life sentence. Nel also stressed that Pistorius shouldn't be given special treatment.

"I am Oscar Pistorius. I am a world-renowned athlete. Is that a special circumstance? No." Nel said. "His version (of the killing) is improbable."

Nel said the court should focus on the "murder of the defenseless woman."

Botha testified Thursday that he had investigated a 2009 complaint against Pistorius by a woman who claimed the athlete had assaulted her. He said that Pistorius had not hurt her and that the woman had actually injured herself when she kicked a door at Pistorius' home.

The hearing is to continue Friday morning.

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AP Sports Writer Gerald Imray contributed to this report from Johannesburg.

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Well: Getting Patients to Think About Costs

A colleague and I recently got into a heated discussion over health care spending. It wasn’t that he disagreed with me about the need to rein in costs; but he said he was frustrated every time he tried to do so.

Earlier that week, for example, he had tried to avoid ordering a costly M.R.I. scan for a patient who had been suffering from headaches. After a thorough examination, my colleague was convinced the headaches were the result of stress.

But the patient was not.

“She wouldn’t leave until she got that M.R.I.,” my colleague said. Even after he had explained his conclusions several times, proposed a return visit in a month to reassess the situation and ran so far overtime that his office nurse knocked on the door to make sure nothing had gone awry, the patient continued to insist on getting the expensive study.

When my colleague finally evoked cost – telling the woman that while an M.R.I. might ferret out rare causes, it didn’t make sense to spend the enormous fee on something of such marginal benefit – the woman became belligerent. “She yelled that this was her head we were talking about,” he recalled. “And expensive tests like this were the reason she had health insurance.”

Face flushed, he paused to take a deep breath. “Yeah, I may be all for controlling costs,” he finally said. “But are our patients?”

According to a new study in the journal Health Affairs, his concern about patients may not be far off the mark.

A growing number of initiatives aimed at controlling spiraling health care costs have been championed in recent years, aiming to replace the current model in which doctors are reimbursed for every office visit, test or procedure performed. These programs range from pay-for-performance, where doctors can earn more money by meeting predetermined quality “goals” like controlling patients’ blood sugar or high blood pressure, to accountable care organizations, where clinicians and hospitals in partnership are paid a lump sum to cover all care.

Their uninspired monikers aside, all of these plans share one defining feature: doctors are to be the key agents of change. Whether linked with quality measures, bundled payments or satisfaction scores, it is the doctors’ behavior and choice of treatments that result in savings, goes the thinking.

But as the new study reveals, doctors need to take into account more than just symptoms and diseases when deciding what to prescribe and offer. They must also consider their patients’ opinions and willingness to be cost conscious when it comes to their own care.

The researchers conducted more than 20 patient focus groups and asked the participants to imagine themselves with various symptoms and a choice of diagnostic and treatment options that varied only slightly in effectiveness but significantly in cost. They were asked, for example, to choose between an M.R.I. or a CT scan for a severe long-standing headache, with the M.R.I. being much more expensive but also more likely to catch some extremely rare problems.

When it came to their own treatment, “patients for the most part did not want cost to play any role in decision-making,” said Dr. Susan Dorr Goold, one of the study authors and a professor of internal medicine and health management and policy at the University of Michigan in Ann Arbor. Most did not want their doctors to take expenditures into account, and many made it clear that they would ask for the significantly more expensive medications, procedures or diagnostic studies, even if those options were only slightly better than the cheaper alternatives. “That puts doctors, whose primary responsibility is to their individual patients, in a very difficult position.”

A majority of the participants refused to consider the expenses borne by insurers or by society as a whole when making their choices. Some doubted that one individual’s efforts would have any real overall impact and so gave up considering cost-savings altogether. Others said they would go out of their way to choose the more expensive options, viewing such decisions as acts of defiance and a kind of well-deserved “payback” after years of paying insurance premiums.

Underlying all of these comments was the belief that cost was synonymous with quality. Even when the focus group leaders reminded participants that the differences between proposed options were nearly negligible, participants continued to choose the more expensive options as if it were beyond question that they must be more efficacious or foolproof.

The study’s findings are disheartening. But Dr. Goold and her co-investigators believe that public beliefs and attitudes about cost and quality can be changed. They cite the dramatic transformation in attitudes about end-of-life care as an example of how initiatives to improve understanding can lead people to make higher quality and more cost-effective decisions, like choosing hospices over hospitals.

“We need to begin to talk about these issues in a way that doesn’t turn it into a discussion pitting money against life, and we need to find ways of getting people to think about not spending money on things that offer marginal benefit” Dr. Goold said. “Because it’s going to be tough otherwise trying to implement any cost-saving measures, if patients don’t accept them.”

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