Mediterranean Diet Can Cut Heart Disease, Study Finds

About 30 percent of heart attacks, strokes and deaths from heart disease can be prevented in people at high risk if they switch to a Mediterranean diet rich in olive oil, nuts, beans, fish, fruits and vegetables, and even drink wine with meals, a large and rigorous new study found.

The findings, published on the New England Journal of Medicine’s Web site on Monday, were based on the first major clinical trial to measure the diet’s effect on heart risks. The magnitude of the diet’s benefits startled experts. The study ended early, after almost five years, because the results were so clear it was considered unethical to continue.

The diet helped those following it even though they did not lose weight and most of them were already taking statins, or blood pressure or diabetes drugs to lower their heart disease risk.

“Really impressive,” said Rachel Johnson, a professor of nutrition at the University of Vermont and a spokeswoman for the American Heart Association. “And the really important thing — the coolest thing — is that they used very meaningful end points. They did not look at risk factors like cholesterol of hypertension or weight. They looked at heart attacks and strokes and death. At the end of the day, that is what really matters.”

Until now, evidence that the Mediterranean diet reduced the risk of heart disease was weak, based mostly on studies showing that people from Mediterranean countries seemed to have lower rates of heart disease — a pattern that could have been attributed to factors other than diet.

And some experts had been skeptical that the effect of diet could be detected, if it existed at all, because so many people are already taking powerful drugs to reduce heart disease risk, while other experts hesitated to recommend the diet to people who already had weight problems, since oils and nuts have a lot of calories.

Heart disease experts said the study was a triumph because it showed that a diet is powerful in reducing heart disease risk, and it did so using the most rigorous methods. Scientists randomly assigned 7,447 people in Spain who were overweight, were smokers, had diabetes or other risk factors for heart disease to follow the Mediterranean diet or a low-fat one.

Low-fat diets have not been shown in any rigorous way to be helpful, and they are also very hard for patients to maintain — a reality born out in the new study, said Dr. Steven E. Nissen, chairman of the department of cardiovascular medicine at the Cleveland Clinic Foundation.

“Now along comes this group and does a gigantic study in Spain that says you can eat a nicely balanced diet with fruits and vegetables and olive oil and lower heart disease by 30 percent,” he said. “And you can actually enjoy life.”

The study, by Dr. Ramon Estruch, a professor of medicine at the University of Barcelona, and his colleagues, was long in the planning. The investigators traveled the world, seeking advice on how best to answer the question of whether a diet alone could make a big difference in heart disease risk. They visited the Harvard School of Public Health several times to consult Dr. Frank M. Sacks, a professor of cardiovascular disease prevention there.

In the end, they decided to randomly assign subjects at high risk of heart disease to three groups. One would be given a low-fat diet and counseled on how to follow it. The other two groups would be counseled to follow a Mediterranean diet. At first the Mediterranean dieters got more intense support. They met regularly with dietitians while the low-fat group just got an initial visit to train them in how to adhere to the diet followed by a leaflet each year on the diet. Then the researchers decided to add more intensive counseling for them, too, but they still had difficulty staying with the diet.

One group assigned to a Mediterranean diet was given extra virgin olive oil each week and was instructed to use at least 4 tablespoons a day. The other group got a combination of walnuts, almonds and hazelnuts and was instructed to eat about an ounce of them each day. An ounce of walnuts, for example, is about a quarter cup — a generous handful. The mainstays of the diet consisted of at least 3 servings a day of fruits and at least two servings of vegetables. Participants were to eat fish at least three times a week and legumes, which include beans, peas and lentils, at least three times a week. They were to eat white meat instead of red, and, for those accustomed to drinking, to have at least 7 glasses of wine a week with meals.

They were encouraged to avoid commercially made cookies, cakes and pastries and to limit their consumption of dairy products and processed meats.

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BP Trial Opens, With Possible Deal in Background

NEW ORLEANS — The long-awaited civil trial against BP and its contractors stemming from the 2010 explosion of a drilling rig in the Gulf of Mexico that left 11 dead and soiled hundreds of beaches began on Monday, even as settlement talks appeared to intensify between the oil company and federal and state goverments.

Jim Roy, the lead lawyer of private plaintiffs, started the trial with a scathing attack on BP for ignoring multiple signs of problems on the rig and in routine maintenance of safety tests and equipment that led to the Macondo well accident.

“BP made a series of decisions to save time and money that substantially increased risk,” Mr. Roy told a packed courtroom. He said the decisions were typical of “a culture of profit and production over safety.”

In more than an hour of testimony, Mr. Roy noted that BP had decided to employ single-walled drill pipe, which provided inferior barriers to leaks, and it decided that it was not necessary to circulate drilling mud, a method designed to strengthen cement, before installing a seal on the well. He reminded the court that BP opted against conducting a cement bond test, an acoustics test that could have identified the gas that had leached into the piping during the well cementing process.

And finally, he said, using information that has previously been described in numerous government and private reports since the accident, BP ignored the results of a failed pressure test shortly before the well was sealed and blew out.

But Mr. Roy also argued that Transocean, the owner and operator of the Deepwater Horizon rig, had failed to adequately train its employees in emergency operations, and Halliburton was deficient in testing and mixing the cement to seal the well.

The first phase of the trial, which was expected to last three months under Judge Carl J. Barbier of Federal District Court in New Orleans, will determine whether BP or its contractors were “grossly negligent” in causing the accident.

Many of Mr. Roy’s arguments will be repeated in later opening statements by the Justice Department and gulf state attorneys general. BP and its contractors will contest much of the testimony, and they are expected to lay various degrees of blame on each other. The private plaintiffs in the trial, including thousands of businesses and individuals, are suing for damages from all the companies.

At the same time, details of a settlement offer by federal and state officials to the oil company began to emerge over the weekend. The plan, worth a total of $16 billion, would limit the fines paid by BP under the Clean Water Act to $6 billion, a proposal that could help reduce its tax liability, one person briefed on the plan said Sunday, speaking on the condition of anonymity.

BP would also pay $9 billion in penalties to cover damages to natural resources as well as the cost of restoration, that person said. The remaining $1 billion would be set aside in a fund that could be tapped if unanticipated environmental damages related to the spill developed.

No one at BP, the Justice Department or the states involved has commented on any settlement proposal, but several lawyers briefed on the negotiations said that a $16 billion proposal had been made. The affected states are Alabama, Florida, Louisiana, Mississippi and Texas, although only Alabama and Louisiana are participating in the trial.

Even if settlement talks slow or stall, the proposal represents a big breakthrough for several reasons, lawyers briefed on the talks said. For one, it represents the first time that Louisiana, which was hardest hit by the spill and would receive the largest payout of any state from a settlement, has participated in an offer.

In addition, the proposal signals the first agreement among states and the federal government on two other crucial issues: a rough plan for how the states would divide any settlement money, and how the settlement would balance fines and penalties against BP.

BP pleaded guilty last year to 14 criminal charges, including manslaughter; admitted negligence in misreading important tests before the blowout; and agreed to pay $4.5 billion in fines and other penalties. The Justice Department has also filed criminal charges against four BP employees.

Last February, a trial to resolve claims against BP by individuals and businesses affected by the spill was delayed by Judge Barbier on the eve of trial because of settlement talks. BP subsequently agreed to create a fund now valued at $8.5 billion to settle those claims. However, numerous individuals and businesses chose not to participate and are also parties to the trial that started Monday.

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In Last Sunday Address as Pope, Benedict Says He Will Continue to Serve

Andrew Medichini/Associated Press

Pope Benedict XVI delivered his final Sunday address from the window of his apartment overlooking St. Peter's Square.

VATICAN CITY — Pope Benedict spoke from his window for the last time on Sunday, telling the faithful packed into St. Peter’s Square that the first papal abdication in centuries was God’s will and insisting he was not abandoning the Church.

Four days before the 85-year-old Benedict’s often troubled eight-year rule ends, new talk of scandal hit the cardinals who will choose his successor; one of them, a Scottish archbishop, had to deny news media accusations of misconduct with priests in the 1980s.

With an American cardinal urged not to go to the electoral conclave because of his role in handling sexual abuse cases in the United States, and the Vatican accusing media of running smears to influence the vote, the Church faces a stormy succession.

Benedict, however, defended his shock decision to resign as dictated by his failing health; his address to tens of thousands of well-wishers was met with calls of “Viva il Papa!”

“The Lord is calling me to climb the mountain, to dedicate myself even more to prayer and meditation,” the German-born pontiff said in Italian, his voice strong and clear.

“But this does not mean abandoning the Church. Actually, if God asks this of me, it is precisely because I can continue to serve her with the same dedication and the same love I have shown so far,” he said, adding that he would be serving the Church “in a way more in keeping with my age and my strengths”.

As he spoke, two of the some 117 cardinals who will enter the conclave next month to choose his successor as leader of the 1.2 billion Roman Catholics were mired in controversy.

Britain’s top Catholic cleric, Cardinal Keith O’Brien of Edinburgh, rejected claims in The Observer newspaper that he had been involved in unspecified inappropriate behavior with other priests.

The paper said Cardinal O’Brien, 74, known for his outspoken views against homosexuality, had been reported to the Vatican by three priests and a former priest, who said they had come forward to demand he resign and not take part in the conclave.

“Cardinal O’Brien contests these claims and is taking legal advice,” a spokesman for the cardinal said.

He was the second cardinal to be caught up in controversy over his attendance ahead of the conclave. On Saturday, Catholic activists petitioned Cardinal Roger Mahony to recuse himself from the conclave so as not to insult survivors of sexual abuse by priests committed while he was archbishop of Los Angeles..

In that post from 1985 until 2011, Cardinal Mahony worked to send priests known to be abusers out of state to shield them from law enforcement scrutiny in the 1980s, according to church files unsealed under a federal district. court order last month.

The minds of those in the crowd in St Peter’s Square on Sunday, some holding banners reading “Thank you Holy Father,” were not on scandals, real or potential, but on the Church history unfolding around them.

“It’s bittersweet,” said Sarah Ennis, 21, a student from Minnesota who studies in Rome. “Bitter because we love our Pope Benedict and hate to see him go, but sweet because he is going for a good reason and we are excited to see the next pope.”

Others, however, saw it as a possible harbinger for the Church.

“This is an ill wind blowing,” said Marina Tacconi, a midwife. “It feels like something ugly could happen. I’m 58 years old, I have seen popes come and go. But never one resign.”

The Sunday address was one of Benedict’s last appearances as pontiff before the curtain comes down on a problem-ridden pontificate.

On Wednesday, he will hold his last general audience in St. Peter’s Square and on Thursday he will meet with cardinals and then fly to the papal summer retreat south of Rome.

The papacy will become vacant on Thursday night.

Cardinals will begin meetings the next day to prepare for a secret conclave in the Sistine Chapel.

They have already begun informal consultations by phone and e-mail in the last two weeks since Benedict announced his abdication in order to build a profile of the man they think would be best suited to lead the Church.

On Monday, the pope is expected to issue slight changes to Church rules governing the conclave so that it could start before March 15, the earliest it can be held under a detailed constitution by his predecessor John Paul.

Some cardinals believe a conclave should start sooner than March 15 in order to reduce the time in which the Church will be without a leader. But some in the Church believe that an early conclave would give an unfair advantage to cardinals already in Rome and working in the Curia, the Vatican’s central administration, which has been at the center of accusations of ineptitude that some say led Benedict to step down.

The Vatican appears to be aiming to have a new pope elected by mid-March and then installed before Palm Sunday on March 24 so he can preside at Holy Week services leading to Easter.

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Daytona ready for race, willing to relocate fans

DAYTONA BEACH, Fla. (AP) — Fans feeling unsafe after the horrific crash at Daytona International Speedway can change seats for NASCAR's biggest race.

Track President Joie Chitwood says workers successfully repaired a section of fence — 54 feet wide and 22 feet high — that was shredded Saturday when Kyle Larson's car went airborne on the final lap of a second-tier race and crashed through the barrier that separates cars from fans. Large pieces of debris, including a tire, sprayed into the upper and lower section of the stands.

The crash injured more than 30 people, raising more questions about fan safety at race tracks. NASCAR President Mike Helton said "most everybody" had been released from local hospitals, but there are a "few still being treated."

Chitwood says if any fans are uncomfortable with their up-close seating for Sunday's Daytona 500, officials will work to move them.

"If fans are unhappy with their seating location or if they have any incidents, we would relocate them," Chitwood said Sunday. "So we'll treat that area like we do every other area of the grandstand. If a fan is not comfortable where they're sitting, we make every accommodation we can."

Track workers finished repairs about 2 a.m. Sunday, having installed a new fence post, new metal meshing and part of the concrete wall.

Officials decided not to rebuild the collapsed cross-over gate, which allows fans to travel between the stands and the infield before races.

Daytona has a grandstand remodel planned. Chitwood said the injuries could prompt a redesign that might include sturdier fences or stands further away from the on-track action.

"It's tough to connect the two right now in terms of a potential redevelopment and what occurred," Chitwood said. "We were prepared yesterday, had emergency medical respond. As we learn from this, you bet: If there are things that we can incorporate into the future, whether it's the current property now or any other redevelopment, we will.

"The key is sitting down with NASCAR, finding out the things that happened and how we deal with them."

Daytona reexamined its fencing and ended up replacing the entire thing following Carl Edwards' scary crash at Talladega Superspeedway in Alabama in 2009. Edwards' car sailed into the fence and spewed debris into the stands.

"We've made improvements since then," Chitwood said. "I think that's the key: that we learn from this and figure out what else we need to do."

NASCAR plans to take what remained of Larson's sheared car along with debris back to its research and development center in Charlotte, N.C., for testing.

"We'll bring in the best and brightest," said Steve O'Donnell, NASCAR's senior vice president for racing operations. "Anything we can learn will be put in place. ... Fans are our first priority. Obviously we want everybody to be safe at an event. We've talked to the speedway. We're confident in what's in place at today's event. Certainly still thinking about those affected, but we're confident to move forward for this race."

The 12-car crash began as the front-runners approached the checkered flag. Leader Regan Smith attempted to block Brad Keselowski for the win, triggering a pileup that could have been much worse.

Larson's burning engine wedged through a gaping hole in the fence. Parts and pieces of his car sprayed into the stands, including a tire that cleared the top of the fence and landed midway up the spectator section closest to the track.

The 20-year-old Larson stood in shock a few feet from his car as fans in the stands waved frantically for help. Smoke from the burning engine briefly clouded the area, and emergency vehicles descended on the scene.

Ambulance sirens could be heard wailing behind the grandstands at a time the race winner would typically be doing celebratory burnouts.

"It was freaky. When I looked to my right, the accident happened," Rick Harpster of Orange Park said. "I looked over and I saw a tire fly straight over the fence into the stands, but after that I didn't see anything else. That was the worst thing I have seen, seeing that tire fly into the stands. I knew it was going to be severe."

In 1987, Bobby Allison's car lifted off the track at Talladega while running over 200 mph, careening into the steel-cable fence and scattering debris into the crowd. That crash led to the use of horsepower-sapping restrictor plates at Talladega and its sister track in Daytona, NASCAR's fastest layouts.

As a result, the cars all run nearly the same speed, and the field is typically bunched tightly together — which plenty of drivers have warned is actually a more dangerous scenario than higher speeds.

"That's one of the things that really does scare you," Allison said Sunday. "But it's always a possibility because of the speeds, where they are."

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The Texas Tribune: Advocates Seek Mental Health Changes, Including Power to Detain

Matt Rainwaters for Texas Monthly

The Sherman grave of Andre Thomas’s victims.

SHERMAN — A worried call from his daughter’s boyfriend sent Paul Boren rushing to her apartment on the morning of March 27, 2004. He drove the eight blocks to her apartment, peering into his neighbors’ yards, searching for Andre Thomas, Laura Boren’s estranged husband.

Expanded coverage of Texas is produced by The Texas Tribune, a nonprofit news organization. To join the conversation about this article, go to texastribune.org.

For more articles on mental health and criminal justice in Texas, as well as a timeline of the Andre Thomas case: texastribune.org

Matt Rainwaters for Texas Monthly

Laura Boren

He drove past the brightly colored slides, swings and bouncy plastic animals in Fairview Park across the street from the apartment where Ms. Boren, 20, and her two children lived. He pulled into a parking spot below and immediately saw that her door was broken. As his heart raced, Mr. Boren, a white-haired giant of a man, bounded up the stairwell, calling out for his daughter.

He found her on the white carpet, smeared with blood, a gaping hole in her chest. Beside her left leg, a one-dollar bill was folded lengthwise, the radiating eye of the pyramid facing up. Mr. Boren knew she was gone.

In a panic, he rushed past the stuffed animals, dolls and plastic toys strewn along the hallway to the bedroom shared by his two grandchildren. The body of 13-month-old Leyha Hughes lay on the floor next to a blood-spattered doll nearly as big as she was.

Andre Boren, 4, lay on his back in his white children’s bed just above Leyha. He looked as if he could have been sleeping — a moment away from revealing the toothy grin that typically spread from one of his round cheeks to the other — except for the massive chest wound that matched the ones his father, Andre Thomas (the boy was also known as Andre Jr.), had inflicted on his mother and his half-sister as he tried to remove their hearts.

“You just can’t believe that it’s real,” said Sherry Boren, Laura Boren’s mother. “You’re hoping that it’s not, that it’s a dream or something, that you’re going to wake up at any minute.”

Mr. Thomas, who confessed to the murders of his wife, their son and her daughter by another man, was convicted in 2005 and sentenced to death at age 21. While awaiting trial in 2004, he gouged out one of his eyes, and in 2008 on death row, he removed the other and ate it.

At least twice in the three weeks before the crime, Mr. Thomas had sought mental health treatment, babbling illogically and threatening to commit suicide. On two occasions, staff members at the medical facilities were so worried that his psychosis made him a threat to himself or others that they sought emergency detention warrants for him.

Despite talk of suicide and bizarre biblical delusions, he was not detained for treatment. Mr. Thomas later told the police that he was convinced that Ms. Boren was the wicked Jezebel from the Bible, that his own son was the Antichrist and that Leyha was involved in an evil conspiracy with them.

He was on a mission from God, he said, to free their hearts of demons.

Hospitals do not have legal authority to detain people who voluntarily enter their facilities in search of mental health care but then decide to leave. It is one of many holes in the state’s nearly 30-year-old mental health code that advocates, police officers and judges say lawmakers need to fix. In a report last year, Texas Appleseed, a nonprofit advocacy organization, called on lawmakers to replace the existing code with one that reflects contemporary mental health needs.

“It was last fully revised in 1985, and clearly the mental health system has changed drastically since then,” said Susan Stone, a lawyer and psychiatrist who led the two-year Texas Appleseed project to study and recommend reforms to the code. Lawmakers have said that although the code may need to be revamped, it will not happen in this year’s legislative session. Such an undertaking requires legislative studies that have not been conducted. But advocates are urging legislators to make a few critical changes that they say could prevent tragedies, including giving hospitals the right to detain someone who is having a mental health crisis.

From the time Mr. Thomas was 10, he had told friends he heard demons in his head instructing him to do bad things. The cacophony drove him to attempt suicide repeatedly as an adolescent, according to court records. He drank and abused drugs to try to quiet the noise.

bgrissom@texastribune.org

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Major Banks Aid in Payday Loans Banned by States

Major banks have quickly become behind-the-scenes allies of Internet-based payday lenders that offer short-term loans with interest rates sometimes exceeding 500 percent.

With 15 states banning payday loans, a growing number of the lenders have set up online operations in more hospitable states or far-flung locales like Belize, Malta and the West Indies to more easily evade statewide caps on interest rates.

While the banks, which include giants like JPMorgan Chase, Bank of America and Wells Fargo, do not make the loans, they are a critical link for the lenders, enabling the lenders to withdraw payments automatically from borrowers’ bank accounts, even in states where the loans are banned entirely. In some cases, the banks allow lenders to tap checking accounts even after the customers have begged them to stop the withdrawals.

“Without the assistance of the banks in processing and sending electronic funds, these lenders simply couldn’t operate,” said Josh Zinner, co-director of the Neighborhood Economic Development Advocacy Project, which works with community groups in New York.

The banking industry says it is simply serving customers who have authorized the lenders to withdraw money from their accounts. “The industry is not in a position to monitor customer accounts to see where their payments are going,” said Virginia O’Neill, senior counsel with the American Bankers Association.

But state and federal officials are taking aim at the banks’ role at a time when authorities are increasing their efforts to clamp down on payday lending and its practice of providing quick money to borrowers who need cash.

The Federal Deposit Insurance Corporation and the Consumer Financial Protection Bureau are examining banks’ roles in the online loans, according to several people with direct knowledge of the matter. Benjamin M. Lawsky, who heads New York State’s Department of Financial Services, is investigating how banks enable the online lenders to skirt New York law and make loans to residents of the state, where interest rates are capped at 25 percent.

For the banks, it can be a lucrative partnership. At first blush, processing automatic withdrawals hardly seems like a source of profit. But many customers are already on shaky financial footing. The withdrawals often set off a cascade of fees from problems like overdrafts. Roughly 27 percent of payday loan borrowers say that the loans caused them to overdraw their accounts, according to a report released this month by the Pew Charitable Trusts. That fee income is coveted, given that financial regulations limiting fees on debit and credit cards have cost banks billions of dollars.

Some state and federal authorities say the banks’ role in enabling the lenders has frustrated government efforts to shield people from predatory loans — an issue that gained urgency after reckless mortgage lending helped precipitate the 2008 financial crisis.

Lawmakers, led by Senator Jeff Merkley, Democrat of Oregon, introduced a bill in July aimed at reining in the lenders, in part, by forcing them to abide by the laws of the state where the borrower lives, rather than where the lender is. The legislation, pending in Congress, would also allow borrowers to cancel automatic withdrawals more easily. “Technology has taken a lot of these scams online, and it’s time to crack down,” Mr. Merkley said in a statement when the bill was introduced.

While the loans are simple to obtain — some online lenders promise approval in minutes with no credit check — they are tough to get rid of. Customers who want to repay their loan in full typically must contact the online lender at least three days before the next withdrawal. Otherwise, the lender automatically renews the loans at least monthly and withdraws only the interest owed. Under federal law, customers are allowed to stop authorized withdrawals from their account. Still, some borrowers say their banks do not heed requests to stop the loans.

Ivy Brodsky, 37, thought she had figured out a way to stop six payday lenders from taking money from her account when she visited her Chase branch in Brighton Beach in Brooklyn in March to close it. But Chase kept the account open and between April and May, the six Internet lenders tried to withdraw money from Ms. Brodsky’s account 55 times, according to bank records reviewed by The New York Times. Chase charged her $1,523 in fees — a combination of 44 insufficient fund fees, extended overdraft fees and service fees.

For Subrina Baptiste, 33, an educational assistant in Brooklyn, the overdraft fees levied by Chase cannibalized her child support income. She said she applied for a $400 loan from Loanshoponline.com and a $700 loan from Advancemetoday.com in 2011. The loans, with annual interest rates of 730 percent and 584 percent respectively, skirt New York law.

Ms. Baptiste said she asked Chase to revoke the automatic withdrawals in October 2011, but was told that she had to ask the lenders instead. In one month, her bank records show, the lenders tried to take money from her account at least six times. Chase charged her $812 in fees and deducted over $600 from her child-support payments to cover them.

“I don’t understand why my own bank just wouldn’t listen to me,” Ms. Baptiste said, adding that Chase ultimately closed her account last January, three months after she asked.

A spokeswoman for Bank of America said the bank always honored requests to stop automatic withdrawals. Wells Fargo declined to comment. Kristin Lemkau, a spokeswoman for Chase, said: “We are working with the customers to resolve these cases.” Online lenders say they work to abide by state laws.

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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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