Prohibition on Sexual Activity by People Under 16

January 31, 2006

A federal trial opened here Monday over whether a Kansas law prohibiting virtually all sexual activity by people under age 16 means health care professionals and educators must report such behavior to state authorities, which some say would stop many teenagers from seeking contraception or treatment for sexually transmitted diseases.
The class-action lawsuit stems from a 2003 opinion by the Kansas attorney general, Phill Kline, a conservative Republican who has developed a national reputation for fighting abortion and whose pursuit of abortion clinic records is also being challenged in court.
Mr. Kline's interpretation of the law focused mainly on the reporting duty of abortion providers, arguing that any pregnant, unmarried minor had by definition been the victim of rape or abuse. But it included a broad mandate for reporting whenever "compelling evidence of sexual interaction is present."
Bonnie Scott Jones, a lawyer for the Center for Reproductive Rights in New York, which is representing the plaintiffs, said in her opening statement that Mr. Kline's "dragnet approach" to amassing information on under-age sex violated minors' privacy rights and the Constitution's equal protection clause, and that it "seriously endangers the health and well-being of adolescents."
"Sexual abuse is not synonymous with consensual sexual activity," Ms. Jones said to the judge deciding the case, J. Thomas Marten of Federal District Court. "Consensual sexual activity is not inherently injurious. It is a normal part of adolescent development."
Steve Alexander, an assistant attorney general defending the suit, said the Kansas statute meant that those younger than 16 could not consent to sex, and that those violating the law forfeited any privacy rights.
"Illegal sexual activity by minors can lead to S.T.D.'s, unwanted pregnancies, abortion, depression, mental illness," Mr. Alexander said. "To pretend otherwise is foolish." He said the case was in essence a challenge to the law barring consensual sex between young people of a similar age, which he called "a policy argument that plaintiffs would be better served making in the Legislature."
Kansas is one of 12 states where sex under a certain age — 16, 17 or 18 — is illegal regardless of the age difference between partners, according to a 2004 report prepared by the Lewin Group, a consulting firm, for the federal Department of Health and Human Services. Laws on reporting child sexual abuse also vary, but a third of states require reporting only when statutory rape involves a parent or guardian, the report found.
Dr. Robert W. Blum, a Johns Hopkins University professor and an expert in pediatrics and adolescent medicine, who was the plaintiffs' lead witness, testified Monday that only one state, California, had previously tried to require reporting of all under-age sex, and that it reversed course after a year in the early 1990's because the authorities were flooded with "irrelevant and obstructive" reports.
Among the plaintiffs' arguments is that blanket reporting of sexual activity would be futile because the Kansas Department of Social and Rehabilitation Services has a policy against investigating cases of consensual teenage sex.
Pressed on cross-examination, Dr. Blum said he did consider all sex by children 12 or younger to be "problematic" and worthy of reporting, but he said, "That's distinctly different than a 14-, 15- or 16-year-old in a romantic relationship."
Nationally, studies suggest that about 30 percent of teenagers under 16 have had intercourse, and an additional 20 percent have experimented with oral sex or genital fondling.
A federal appeals court on Friday overturned a temporary injunction blocking enactment of Mr. Kline's ruling but provided a two-week window, approximately the expected length of the trial, before the reporting would be required.
Among the issues debated Monday was the very definition of sexual activity. Anal and vaginal intercourse and oral sex are mentioned in the law, as is "lewd fondling or touching" done with "the intent to arouse," which Ms. Jones said could cover even intense French kissing.
Mr. Kline, who is expected to testify Friday, declined to discuss the case. In an e-mail statement, he avoided the central controversy over consensual sex between teenagers of a similar age.
"Plaintiffs are arguing that the constitution does not allow the state to require people to report child rape," the statement said. "We differ. Prosecuting and investigating child rapists depends on such laws, and if the plaintiffs believe that adult-child sex should be legal they need to take that debate to the Legislature rather than initiate litigation."
Similarly, Mr. Kline said last year that prosecuting rapists was his goal in seeking access to the medical files of women and girls who had had late-term abortions, which led to a separate lawsuit awaiting a decision by the State Supreme Court.
Mr. Kline, elected in 2002, also serves as chairman of the Republican Attorneys General Association and has fought against abortion throughout his career. He filed a lawsuit, recently dismissed, to challenge the state's use of Medicaid funds for abortions, and he submitted a brief in a federal case arguing that Roe v. Wade should be overturned.
Last year, Mr. Kline successfully lobbied the Legislature to require that abortion providers collect fetal tissue from patients younger than 14 and turn it over to law enforcement.
"He's certainly on a crusade to limit or eliminate abortion in Kansas," said Peter Brownlie, chief executive of Planned Parenthood of Kansas and Mid-Missouri. "That's been a clear agenda for a long time." Mr. Brownlie said Mr. Kline had helped make Kansas a national battlefront in the abortion debate.
But the doctors, nurses, counselors and educators suing over Mr. Kline's interpretation of the reporting law say it goes far beyond abortion to include every teenager who requests birth control pills or H.I.V. testing, or who in a group therapy session even discusses "heavy petting" with a boyfriend or girlfriend.
"If they know what they tell me is reported, they simply won't talk," said Beth McGilley, a Wichita therapist who is among the plaintiffs, referring to both teenage clients and adults who often consult her about their children's sexual exploration.
"To me, it's violating what, quite essentially, therapy is couched in: confidentiality," Ms. McGilley said. "You have two 15-year-olds mashing in the back seat of the car — who's the criminal here? Do we really need Big Brother to decide whether or not that needs to be judiciously pursued?"

For Surfers

January 29, 2006
For Surfers, All Waves Lead to Hawaii
By JULIA CHAPLIN
SPENDING time on the North Shore of Oahu, just 30 miles from the urban sprawl of Honolulu, provides a crash course in the hang-10 lifestyle. Old surfboards serve as signposts for the driveways of wooden bungalows, the fronts of shops and the turnoff points for restaurants at this fabled surf Mecca. Even the barbecue delivery car has a surfboard strapped sideways on its roof as a makeshift billboard.
There is hardly a waiter, store clerk or bartender around who doesn't have a ripped physique, a sun-burned nose and flip-flops barely encasing scraped-up feet - all signs of the hard-core surfer. Out in the lineup, in the calm water just outside the break where throngs of surfers jockey to catch waves, it is not uncommon to see Hawaiian grandmothers longboarding among teenagers covered in tribal tattoos doing aerial maneuvers.
Pro surfers, especially those who grew up on the North Shore, rule the hierarchy. Local surf stars like Fred Patacchia, Pancho Sullivan, Jamie O'Brien and Megan Abubo, who was the stunt double for Michelle Rodriguez's character in the film "Blue Crush," can be spotted hauling groceries to their trucks at the parking lot at Foodland or at Haleiwa Joe's, the North Shore equivalent of the Ivy in Beverly Hills, where pros and potential sponsors dine, and contest victory celebrations are held. On a recent morning at Cafe Haleiwa, decorated like all restaurants here with old surf photos and paintings of giant barreling waves, Ms. Abubo, tanned and muscular, was fielding calls from producers for television programs and commercials looking for stunt doubles and pro surf specimens.
"The North Shore is a little like going back in time," Ms. Abubo said. "Even though the crowds have tripled in the last few years, people still hitchhike to get around, and there's a tightknit community. It's the best place in the world for a surfer to live."
The North Shore is now in a rather sticky situation of courting fame while trying to preserve an old-school, precrowd vibe. The throngs began to show up, boards under arms, soon after the release of "Blue Crush" four years ago. The Drew Barrymore-Adam Sandler film "50 First Dates," episodes of "Baywatch" and the WB reality series "Boarding House: North Shore" were all recently filmed here.
And the primetime hit "Lost" - its base camp in the tropical vegetation between Haleiwa, the historic town founded by missionaries in the 1800's on the southwest end of the North Shore, and Waimea Bay - has set scenes on dozens of the coconut-strewn sandy beaches and thick jungles here. (An amusing pastime for fans is to ferret out locations like the site of a plane crash scene, which was shot just to the left of a Y.M.C.A. camp on Farrington Highway.)
Yet, its Hollywood connections aside, the feeling at this seven-mile stretch of world-class surf breaks and rolling, grassy fields, is like that of a junior high, where the cool kids are surfers and the nerds are outsiders (especially tourists) who don't possess killer tans and/or deft surfing skills. "Even celebrities who come here, like Owen Wilson or Brian Grazer, get dropped in on in the lineup," said Leah Metz, a surfer and massage therapist, who was standing in a bikini scoping out the action at the Laniakea break with her friend Ms. Abubo on a recent mid-morning.
So far, the local community has succeeded, to a degree, in maintaining its surfing heritage. There are no high-rise condos, only one resort hotel and just a handful of small guesthouses. Residents recently stopped a developer's plan to construct a 55-store shopping mall, and the North Shore Community Land Trust, a collective that includes the pro surfer Kelly Slater and the musician Jack Johnson, has helped to raise $7 million to preserve a 200-acre parcel that overlooks Sunset Beach and Banzai Pipeline.
This is hardly the strip's first brush with fame. Hawaiian royalty braved the swells on impossibly long wooden surfboards hundreds of years ago, but it wasn't until the late 1930's that a few surf pioneers living in Honolulu began trekking over in search of bigger thrills. The area was rugged country sparsely populated by farmers and plantation workers, and the waves, which can charge upward of 20 feet in the winter months and once every few years to a heart-stopping 40 to 50 feet, were considered unridable death wishes. (In fact, one 17-year-old surfer, Dickie Cross, drowned in Waimea Bay's 35-foot surf in 1943, warding surfers off for more than a decade.)
All that changed in the late 1950's, when a group of California daredevils including Pat Curren, Mickey Muñoz and Greg Noll, the founder of Greg Noll Surfboards, known for barreling down giant faces in jailhouse-striped swimming trunks, dared to paddle out. They were youthful counterculture rebels living in rustic shacks on the beach, defying nature just for kicks, all with mischievous smiles and beers in hand. Their images, documented in surf magazines and movies, wowed the Gidget-fueled surf craze that was sweeping the nation, and the lineups have been clogged ever since. "Surfing wasn't about money back then," said Mark Cunningham, a retired North Shore lifeguard and renowned body surfer. "Surfers always lived cheaply and scraped by."
Though the North Shore is a year-round destination for tourists, the surf culture peaks for a month each winter at the ever-popular Vans Triple Crown of Surfing, a series of three surf contests founded in 1983 that is the extreme sport equivalent of the Superbowl. (Last year's contest ran from Nov. 12 to Dec. 20 with Andy Irons winning the title. He dedicated it to his friend Malik Joyeux, a 25-year-old pro from Tahiti who died surfing Pipeline last December.)
Ke-Nui Road, a dirt alley with puddles and tropical overgrowth between Sunset Beach and Banzai Pipeline, the surfer's 90210, is where the action is. During the contests, which draw thousands of surf pilgrims, groupies and fans, surf apparel companies like Volcom, Billabong and Roxy rent out oceanfront homes for their pros and throw frat-like parties - a sort of beach version of street marketing.
The more out of control, the better the branding - such as the rager at Rip Curl's rental during this past year's contest, described on Surfing Magazine's Web site: "Brilliant. Beers and broken bottles on the floors. Condiments everywhere. Holes in the walls. Then someone came up with the awesome idea of throwing eggs into the ceiling fans so the yokes splattered everywhere. Yeah, wreck the place, boys. Sick fun."
A typical day on the North Shore begins early, around 7 a.m., as surfers start trolling the Kamehameha Highway, the busy two-lane main drag, for a swell. (It's easy to judge where the conditions are best by the number of cars and bicycles parked along the side of the road, which has no crosswalks and can take up to 10 minutes to get across.) On a day when the swell is pumping, photographers line the beach, as ambitious up-and-comers and pros such as Kelly Slater or Andy and Bruce Irons show off with tailslides (a cutback maneuver on the top of the wave), 360 turns and green-room tube rides (when the surfer moves through the hollow barrel of the wave).
The crowds tend to thin out in the scorching midday sun, which can be the only time for newbies to paddle out and actually catch a wave. Many of the surfers return just before sunset, when the wind generally dies down, the temperature is cooler and more civilized, and the texture of the water is glassy. Surfers tend to go to bed early, so they can do it all over again the next day, except on Thursday evenings, when the action is at Breakers, a restaurant and bar owned by the family of the pro surfer Benji Weatherly in Haleiwa. Here young men try to impress girls with tattooed navels with tales of surfing prowess. (Women who surf are no longer a novelty.)
"Just don't do anything stupid and its fine," said Garrett McNamara, the current world champion of North Shore Tow-In Surfing Championships, who grew up in the rough North Shore town of Waialua. "But if you don't pay respect, especially in the water, you might get a beat down. Sometimes when locals get drunk, they express how they feel about Howlie." (Howlie is the Hawaiian slang term for white people, or in this case, white tourists.)
One way to blend is to share accommodations with a handful of surfers. The bulletin board outside of Foodland, the main supermarket, is a great resource. (A recent posting read: "Mellow, employed, stable people only. No drugs. $600 per month.") And, of course, there are always the hand-scrawled room-for-rent signs posted outside the occasional home along Kamehameha Highway.
The lack of a tourist infrastructure seems only to have made the place more endearing to surf aficionados and travelers fleeing the overpampered experience at resorts with infinity pools, aromatherapy and Evian spray canisters. Defunct pineapple and sugar plantations turn into rambling pastures lush with palms and tropical flowers, while grazing horses and goats dot the landscape. Famed surf spots line the coast like the stars on Hollywood Boulevard - Waimea Bay, Sunset Beach, Off the Wall and Velzyland, with their awe-inspiring waves. (A well-kept secret is that for much of the year the swell is much smaller and friendly enough for a casual surfer.)
Several of the businesses are also legendary and worth visiting for the time-capsule feel alone. Kammie's Market at Sunset Beach, a family-run convenience store that was one of the first to cater to surfers when it opened in the 1960's with a mural of a big wave painted on the outside (and a surf break across the street named after it, the ultimate pedigree here), still stocks such surf essentials as six-packs of beer, ramen noodles and flip-flops. And Surf-N-Sea, in the same building since the late 1960's in Haleiwa, is like a community center, where locals stand around and trade the latest on the day's swell, surf contests and gossip.
Its other charms aside, the North Shore's full seductive powers are best felt atop a surfboard in the warm blue ocean, when you spy a swell building on the horizon, somehow break away from the pack, position yourself just right and glide sublimely across the face of the perfect wave.
If You Go

Inhaled Insulin

January 28, 2006
U.S. Regulators Approve Insulin in Inhaled Form
By ANDREW POLLACK and ALEX BERENSON
An inhaled form of insulin won federal approval yesterday, offering the first alternative to injections for millions of people with diabetes since the drug was introduced in the 1920's.
The new inhaler could offer more convenience and less pain for many of the roughly five million Americans already using insulin, diabetes experts say.
Analysts predict that the therapy, called Exubera and sold by Pfizer, will be popular, with worldwide sales of as much as $2 billion a year by 2010. Pfizer said it planned to begin selling Exubera this summer.
But some doctors say they are concerned that Exubera's risks to the lungs have not been properly tested, especially because Exubera works no better than injected insulin at controlling blood sugar. In clinical trials, Exubera caused a slight reduction in patients' ability to breathe.
The Food and Drug Administration is recommending that patients have their lung function checked before starting Exubera and every 6 to 12 months afterward.
Assuming Exubera proves safe for long-term use, the therapy could have a big impact on public health by overcoming the reluctance of some Type 2 diabetics to use insulin. Insulin is the most reliable method of controlling blood sugar, the key to reducing the risk of complications of diabetes, which affects about 20 million Americans.
"The thing that people with diabetes who have to take insulin hate the most are shots," said Dr. Robert Goldstein, chief scientist of the Juvenile Diabetes Research Foundation International. "So anything that can replace shots patients are going to be very pleased to have."
Exubera uses a powdered form of insulin and a special inhalation device initially developed by Nektar Therapeutics, a biotechnology company in San Carlos, Calif. The inhaler is about the size of an eyeglass case when not in use and about a foot long when it is used. It combines pressurized air with the insulin powder to create a powdered cloud of insulin that diabetics breathe in over several seconds.
David Kliff, who takes insulin for his Type 2 diabetes and publishes the Diabetic Investor newsletter about diabetes-related companies, said the inhalation device might be too big and cumbersome to attract users.
"I can't see somebody whipping this out in public and using it," Mr. Kliff said. "People with diabetes are sensitive enough as it is."
But Paul Matelis of Miami, who has used the device in clinical trials for seven years, disagreed. "I've used it at the Orange Bowl," he said.
Mr. Matelis, 54, who has Type 1 diabetes, said the inhaler was much more convenient than syringes. "It's much easier to take a puff than to load up a syringe and inject yourself in a moving vehicle," he said.
Nektar licensed the insulin and the device to Pfizer, the world's largest drug company, which will pay Nektar a royalty of 15 percent on sales. Pfizer has not announced a price for Exubera, though analysts project it will cost two or three times as much as injected insulin.
About 90 percent of Americans with diabetes have Type 2, which has been linked to obesity and inactivity. In Type 2 diabetes, the body does not effectively use its insulin, a hormone that is needed to process blood sugar, and can slowly lose the ability to produce it. Most people with Type 2 do not take insulin, although some experts say more patients should because they do not control their blood sugar adequately.
In Type 1 diabetes, which often begins in childhood, the body is unable to produce insulin, and so people depend on injections.
Exubera was approved for adults with either type of diabetes. It is designed to be taken at mealtime, meaning that people with Type 1 and some with Type 2 will still have to take one or two injections a day of longer-acting insulin. They will also still have to prick their fingers to measure their blood sugar levels.
The F.D.A.'s approval yesterday marks the end of a long medical quest, said Dr. Michael Berelowitz, a senior vice president of Pfizer. Scientists have tried to find ways to make insulin inhalable almost since they began to produce it, he said.
"It is not natural to have to inject insulin, and many people find it difficult," Dr. Berelowitz said.
It took Nektar years to develop insulin with particles of a size that could make it into the lungs and be stable without refrigeration. Insulin is a protein, and it cannot be taken orally because it would be destroyed by acids in the stomach.
Pfizer, in consultation with the F.D.A., delayed seeking approval for Exubera for at least two years while conducting more research because of concerns that it might damage the lungs. Since 2004, lawmakers and consumer groups have sharply criticized the F.D.A. for approving potentially unsafe drugs like Vioxx.
But an advisory panel to the agency recommended approval of the product in September, at least for patients without pre-existing lung diseases. The agency itself, after putting off a decision for three months, concurred.
"I think that we and the advisory committees felt that there was very robust data with regard to the safety of the drug in patients without underlying lung disease," said Dr. Robert Meyer, director of the F.D.A. office overseeing diabetes drugs.
But some experts say the risks of using the product day after day for life have not been ascertained.
"We don't have long-term studies on this medication," said Dr. Marc Sandberg, the medical director of the Diabetes Health Center in Flemington, N.J.
Because of the safety questions, Exubera was not tested much in children and is not approved for them. It is also not recommended for people with asthma, bronchitis or emphysema. Also, smokers or those who have quit smoking within six months are not supposed to use the product because their lungs absorb too much of it, posing the risk of an overdose.
Pfizer has committed to conduct additional safety studies and will monitor whether problems arise as Exubera goes into widespread use.
Other companies are now racing to develop their own inhaled insulins, including big manufacturers like Eli Lilly and Novo Nordisk and smaller ones like MannKind and Kos Pharmaceuticals.
But Pfizer is considered two years or more ahead of the competitors. One reason could be that big insulin producers initially were not interested in Nektar's invention, thinking there would not be a big market for it, said John Patton, co-founder and chief scientist of Nektar. But Pfizer was not in the insulin business and saw a new opportunity, he said.
To obtain insulin, Pfizer made a deal with Aventis, now known as Sanofi-Aventis. Pfizer recently agreed to pay $1.3 billion to buy out its partner.
Analysts predict that Exubera will rapidly become a blockbuster drug, a term used in the industry to describe a treatment with more than $1 billion in annual sales. Ian Sanderson, an industry analyst at SG Cowen, predicted that Exubera, which was also approved in Europe this week, will have $1.8 billion in annual sales worldwide by 2010, including $1.1 billion in the United States.
"I've been astounded at the patient response to Exubera," Mr. Sanderson said.
Mr. Sanderson predicted that Exubera would cost between $120 and $150 a month, roughly comparable to the price of pills taken by some people with Type 2 diabetes but about three times the price of injectable insulin.
Dr. Jay Skyler, associate director of the diabetes research center at the University of Miami, said thinner needles and penlike injectors have taken much of the sting out of shots.
He said the benefit of inhaled insulin would be mainly for "people who have never been on an injection, that are really desirous of going onto this instead of injections because they think the injections are going to be difficult for them."

Why Is Everybody going to Cambodia?

January 22, 2006
Why Is Everybody Going to Cambodia?
By MATT GROSS
JUST after Christmas in 1859, the French explorer Henri Mouhot left Bangkok to explore the uncharted regions of Indochina. It took him a year of hacking through brush and fending off leopards, leeches and wild elephants before he arrived at Angkor Wat, the jungle-smothered complex of temples deep inside the kingdom of Cambodia. Less than two years later, he died of malaria.
What took Mouhot a year can now be accomplished in little more than an hour, via Bangkok Airways' seven daily flights from the Thai capital to Siem Reap, home base for Angkor expeditions. Mouhot may have had to trudge three hours down a sandy path through dense forest to reach the ruins, but 21st-century visitors have the luxury of everything from tuk-tuks to Land Cruisers to an AS-350 Squirrel helicopter.
And while Mouhot lamented the temples' abandonment, today they are such popular tourist attractions that the measure of an expert Angkor guide is not his knowledge of Hindu and Buddhist cosmology, nor his mastery of English, French and Japanese, but his ability to show visitors the most popular sites - the Bayon, Phnom Bakheng, Ta Prohm and Angkor Wat itself - and have them wondering, at day's end, "Where was everybody else?"
But not all guides are expert at deftly avoiding the tourist crush, and there are frequently days when it seems everybody is in Cambodia. In 2004, international arrivals topped one million for the first time, a figure reached in 2005 by the end of September, according to the Ministry of Tourism.
In almost every part of the country, you can find a conceptually and architecturally ambitious hotel: In mountainous Ratanakiri, there's the Terres Rouges Lodge, a former provincial governor's lakeside residence that has, Time Asia said last July, "the best bar in the middle of nowhere." On the Sanker River in Battambang, Cambodia's second-largest city, there's La Villa, a 1930 house that in October opened as a six-room hotel filled with Art Deco antiques. And sometime this summer, you should be able to head south to Kep and stay at La Villa de Monsieur Thomas, a 1908 oceanfront mansion that's being transformed into a French restaurant ringed with bungalows.
And then there is Angkor Wat. Foreign visitors are flooding in - 690,987 paid entrance fees last year, up from 451,046 in 2004. And while there are no official figures as to how much each spends in Siem Reap, the town's dizzying array of luxury hotels - at least 10 by my count, ranging from the Raffles Grand Hotel d'Angkor to quirky boutiques like Hôtel de la Paix - testifies to the emergence of a new generation of high-end travelers, who not only demand round-the-clock Khmer massage but are also willing to pay $400 a day to hire a BMW L7 or $1,375 an hour for a helicopter tour.
Cambodia is not alone in its luxury revolution. Since the mid-1990's, the former French colonies of Southeast Asia have made enormous leaps in catering to tourists who prefer plunge pools to bucket showers. From the forests of Laos to the beaches of Vietnam to the ruins of Cambodia, you can find well-conceived, well-outfitted, well-run hotels that will sleep you in style for hundreds of dollars a night.
Change has come at an amazing pace. Take Luang Prabang, in Laos. This tidy hill town feels like a Hollywood set, with painted lamps glowing in French restaurants and brick walkways brightened by a yellow glow emanating from knee-high terra-cotta pots. Even the bare fluorescent tubes draped over lonely late-night streets do their part to make visitors feel as if they've arrived at the end of the world.
But it's not mere atmospherics they've found: Luang Prabang has high-end hotels to house a legion of W-worshipers, with enough bistros and boutiques to keep their credit cards on the verge of meltdown. There are spa treatments to succumb to, and Veuve Clicquot to toast with. This town of just 60,000 people is, almost all of a sudden, a luxury getaway.
Less than a decade ago, there were no hotels with infinity pools, no restaurants serving fricassee of wild boar, no silk merchants who took Visa. (Also, no paved roads.) The foreigners who climbed the 328 steps of Mount Phousi were usually backpackers who sought guidance from Lonely Planet's "Southeast Asia on a Shoestring." Today, the traveler with a Lonely Planet in one hand is likely to have a Mandarina Duck carry-on in the other.
Meanwhile, in Vietnam, well-heeled travelers are making pilgrimages to the Evason Hideaway outside Nha Trang, a coastal town 280 miles northeast of Ho Chi Minh City. The Evason, part of Six Senses, a small Bangkok-based chain of resorts, is without question Vietnam's top resort. The villas are enormous, with private plunge pools and wine cellars (and free Wi-Fi), and rock-star-style privacy is paramount: the mountain-backed resort is accessible only by boat.
The Evason is not Vietnam's sole outpost of escapism. Along its 2,140 miles of coastline, there's La Résidence in Hue, the Life Resort in Hoi An and the Furama in Da Nang. You can tour Ha Long Bay in the Emeraude, a replica of a 1920's steamer, or in the Hai Huong, a reproduction of a classic junk. The Victoria chain has been setting up four-star hotels in unusual inland spots, such as Can Tho, Chau Doc and Sapa. And the Evason is already at work on a second resort, in the southern hill town of Da Lat.
But in a country like Vietnam, still poor despite a vibrant economy, the luxury business is a tricky balancing act: How over the top can you go without seeming to take advantage?
The Evason walks that line with the deftness of a tightrope walker. The 17 villas feel inserted into, not imposed upon, the landscape. Motor vehicles are nowhere to be seen: everyone walks or bikes. Is this eco-tourism? Maybe, but when you're at a wine-tasting in a rock cave, or scraping grilled curried lobster tail from its shell, or spotting parrotfish and sea urchins in the coral-lined bay, it feels like something else entirely.
DESPITE all the changes in Cambodia, the immigration desk at Siem Reap International Airport remains a bastion of indifference. When I passed through in October, 10 officials sat behind the visa counter, wordlessly gazing at a mob of tourists, who were hurriedly filling in application forms, fumbling for passport photos and $20 bills, and in the absence of any signs or personnel to direct them, wondering where to go next.
Outside, however, it was a different story: A guest assistant from Hôtel de la Paix carried my bag through the parking lot - past a new terminal designed to handle 1.5 million passengers a year when it opens this summer - to a Lexus S.U.V. As we drove into town, listening to Morcheeba on the car's iPod Mini, the driver and I discussed development on the airport road: I could remember when it had few hotels and restaurants; he could remember when it had none.
At la Paix, an artfully serene white palace designed by the landscape architect Bill Bensley, another assistant led me into the expansive arts lounge, where I sipped fresh orange juice and split my attention between the movie "Indochine," which was being projected on the wall, and the youthful staff members, who moved about with a surprising sureness of purpose.
Soon, an assistant took me to my room - dark woods, creamy fabrics, functioning Wi-Fi and another iPod - and cheerfully helped me plan my stay: a trip to Angkor Wat (with an "excellence guide," he wrote on his notepad) and, almost as important, a local SIM card for my cellphone ("first thing in the morning"). I wandered to the second-floor pool, which flowed like a river from the spa and down to the courtyard, at whose center grew a knotty ficus. Everywhere: calm. The hotel was aptly named.
This was a Cambodia so far removed from the one I'd encountered when I first visited, in March 1997, that I began to wonder if I was even in the same country. Back then, Cambodia was the Wild West, with Phnom Penh its Deadwood. My hotel was the Morakat, which had two room-service menus, one for food, the other for girls. My spa treatment was an unceremonious ear-cleaning at a Vietnamese-run barber shop. (I still have nightmares.) I dined on streetside fried noodles and went to a pitch-black nightclub, where a friend and I were shown to our table by a tuxedoed midget with an enormous flashlight.
Oh, and the day after I arrived, unidentified assailants threw grenades into a crowd of 200 people demonstrating outside the National Assembly, killing at least 16 and injuring more than 100.
To say that Cambodia has come a long way is to state the obvious. Gone are the Khmer Rouge, the Vietnamese occupation, the United Nations democracy-restoration period and the era of warring prime ministers (the current prime minister, Hun Sen, came out on top in 1997). Angkor Wat has been swept clean of land mines, and it is generally safe to travel city streets at night.
When I visited Siem Reap in December 1999, it was far from bustling, and visitors to the temples could climb atop the rubble of Ta Prohm unbothered by security guards. The Grand, which dates back to 1932, had been renovated and reopened by the Raffles Group only two years before, and Angkor Village was the resort for in-the-know tourists and expatriates who wanted something nicer than a guesthouse.
Now more than 100 hotels serve tourists of all budgets. The Grand has been joined by a Sofitel, Le Meridien and the Sokha Angkor. On the boutique side, Angkor Village must now contend with la Paix, La Résidence d'Angkor, the FCC Angkor, the Shinta Mani and an Aman resort, the Amansara. By the end of this month, the One Hotel plans to open its doors - or, rather, its door: There's just one room, a duplex with flat-screen TV, iBook, Wi-Fi and a whirlpool.
These changes are perhaps hardly surprising, given Angkor Wat's popularity and the increasing adventurousness of luxury travelers.
"People want to take their lifestyle and life standard with them," said Grant Thatcher, the publisher of Luxe City Guides, a series of directories to chic treats in Asia. "People don't want to just sit in a flea-bitten rat hole and get eaten by mosquitoes."
His guides - to silversmiths in Bali, Dutch colonial antiques in Sri Lanka, orchids in Bangkok - are fast becoming indispensable for their up-to-date intelligence (each is reissued every six months) and cheeky, Daily Candy-in-Hong Kong voice. (On the Metropole, in Hanoi: "This grand old Gertie has finally got off her colonial bum and begun an upgrade.")
Luxe does not yet offer a Cambodia guide, but the entrepreneurs of Siem Reap are doing their best to prepare for it. Want to see Angkor Wat by hot-air balloon? No problem. Is $1 too little to pay for a krama, the traditional Cambodian checked scarf? A crinkly silk boutique version can run more than $50. Want your entire stay videotaped, then edited into a feature-length film? Just ask the One's front desk.
It's in the realm of culture that Siem Reap really excels, and to a degree that would be surprising in any tourist locale, let alone one dominated by one of the greatest and most perplexing artistic achievements of all, Angkor Wat. On weekends there are cello concerts, and in December "Les Nuits d'Angkor," a blend of ballet and traditional Khmer dance, takes place in front of the temple itself. My October stay coincided with the Angkor Photography Festival, a week of exhibitions, workshops and exclusive soirées.
Just add a soothing glass of pastis, and it's easy to imagine you're in a hub of sophistication, shuttling between cocktail parties, fancy restaurants and gallery openings with a crowd of like-minded travelers. Except that everywhere in Siem Reap - and throughout Cambodia - are reminders of the country's wretched history, crushing poverty and political mismanagement. Take two steps outside your hotel, and you'll find people sleeping in the streets, some of them missing limbs. (Still, there are fewer today than in the past.)
Corruption is rampant. Villagers are routinely evicted at gunpoint from their land by the wealthy and well-connected, critics of Hun Sen's policies are liable to find themselves imprisoned, and the leader of the small political opposition, Sam Rainsy, who organized the tragic 1997 demonstration, lost his parliamentary immunity a year ago and fled the country to escape defamation charges; last month, a court convicted him in absentia. The belief among many foreigners living in Cambodia is that this constitutional monarchy is really a totalitarian kleptocracy, its officials enriching themselves at the expense of aid organizations (which heavily subsidize the government's budget), not to mention the long-suffering Cambodian people.
Which makes it all the more stunning and delightful and sad that those Cambodians are, for the most part, some of the sweetest people you'll ever meet. Show kindness to a driver, to a bellhop, to the newly middle-class guy drinking a Heineken next to you at the FCC bar, and you'll have an instant friend. After all the dehumanizing treatment they've put up with over the last 30 years, Cambodians, it seems to me, just want to be considered human beings, equals despite the financial disparity between them and the average foreign tourist.
It's enough to make you feel guilty as you soak in your freestanding terrazzo tub at la Paix, listening to Miles Davis on the iPod. But the high-end hotels are all too aware that their room rates - $200 to as much as $1,900 -can surpass what the average Cambodian earns in a year. La Paix and its sister, the Shinta Mani, a hotel and hospitality training institute, offer a menu of "community-based activities" that lets tourists finance anything from school supplies ($12) to a breeding pair of piglets ($60) to the building of a new house ($980). The One Hotel plans a similar "Good Karma" package.
F OR some people, it may be hard to imagine Cambodia as a luxury traveler's paradise. Are there really tourists willing to shell out hundreds, even thousands, of dollars a night to see Angkor Wat - knowing that their fancy hotels will not be like Jamaican all-inclusives, conveniently keeping the gritty outside world at bay?
I posed the question to Toby Anderson, manager of the Amansara, possibly the nicest - and, at $650 a night and up, definitely the most expensive - resort in town. A former royal residence, the Amansara, with its single-story modernist architecture, still feels like a swinging-60's pad. You can easily imagine Norodom Sihanouk, the former king, standing by the pool with a flute of Champagne in one manicured hand.
I followed Mr. Anderson, a tall, fair-featured Australian, to the library, as he rebuffed my suggestion that his guests might have different expectations of Cambodia.
"They're well read, they know the history and situation," he said. "They're looking for a Cambodian experience.
"I was a backpacker once," he added. "I still like to backpack. I don't know whether the mindset is that different. Does being able to stay in the Amansara change what you experience?"
Indeed, he was probably right. Once you ride the vintage Mercedes limo outside the gates of the Amansara compound, you are unmistakably, unavoidably in Cambodia: crumbling roads, frequent floods, implacable heat and tour guides who coolly unload personal tales of Khmer Rouge horror. It's not as if you can, by dint of a fat wallet, hide from this reality.
And why would you want to? The draw for millions of people is not just plush beds and nimble-fingered masseuses; it's these three countries' uniquely messy histories and the ways all are struggling to move forward.
In the end, what that fat wallet does get you is simply the opportunity to travel - which is, as Henri Mouhot understood, the greatest luxury of all. "Even if destined here to meet my death," he wrote in his journals, "I would not change my lot for all the joys and pleasures of the civilized world."
If You Go
GETTING THERE
You can fly from Newark to Siem Reap on Singapore Air, 800-742-3333, http://www.singaporeair.com/, (with a stop in Singapore, a 22-hour trip). Fares start about $1,760 for executive economy and $6,365 for business, with taxes.
GETTING AROUND
The telephone code for Cambodia is 855.
Since Siem Reap has no formal taxi service, the most common means of transport is the tuk-tuk, or motorized rickshaw, which offers little protection from rain, dust, noise and heat. Still, they're convenient. Most rides around town cost less than $2 (generally, dollars are preferred to riels).
Renting a car is far more relaxing. Your hotel can arrange anything from a four-wheel drive to a vintage limousine. A Toyota Land Cruiser with driver will run $17 an hour at Hôtel de la Paix; the BMW at the Raffles Grand is $400 a day.
To see the temples by helicopter, contact Angkor Scenic Flights, near the Old Market (12-814-500 angkorscenicflights.com). An eight-minute Angkor Wat flyby costs $68 a person (three to five people); a 14-minute flight is $120. Charter flights can get you quickly to temples that might take all day to reach by land, for $1,375 an hour, plus taxes.
WHERE TO STAY
Outside Phnom Penh, Cambodians are not big on addresses. Once I asked a receptionist the name of the street her hotel was on. "I forget," she said after a moment, "because I don't care."
At the 74-year-old Raffles Grand Hotel d'Angkor, the past is on display everywhere you look: the white-gravel driveway, the iron-cage elevator, the colonial-style bathroom fixtures and ceiling fans. The restaurant requires men to wear jackets at dinner. Still, it's far from stuffy, with visitors drinking gin and tonics in the Elephant Bar. The hotel is at 1 Vithei Charles de Gaulle, Khum Svay Dang Kum, 63-963-888, http://www.raffles.com/. Doubles start at $360, but for an extra-special time, book the 3,180-square-foot villa ($1,900 a night).
Though Hôtel de la Paix (Sivatha Boulevard, 63-966-000, hoteldelapaixangkor.com) is new, its roots run back a half-century to the original Paix, an Art Deco hotel that stood on the same spot; its owner was a guerilla fighter -turned-businessman named Dap Chhuon. The $400-a-night duplex suites have rooftop terraces the size of a Manhattan one-bedroom and, of course, every room has an iPod. Standard doubles from $195.
The Amansara, on the road to Angkor (63-760-333, amanresorts.com), may be the anti-Grand: Modern rather than Classical, intimate rather than sprawling, casual rather than formal. The suites, starting at $650, are big enough to have their own courtyards. Twelve new suites have plunge pools ($850). Two meals a day are included, as well as a car and driver for visiting the temples.
WHERE TO EAT AND DRINK
While Cambodian food looks a bit like that of neighboring Thailand and Vietnam - curries and stews, noodle dishes and lots of rice - it's rarely as tasty. Still, the most ambitious restaurants in town like Meric, at Hôtel de la Paix (63-966-000) are trying to resurrect Cambodian fine dining. Paul Hutt, Meric's chef (and a friend of mine) is devoted to digging up unusual ingredients, like dried snake, and glamming up traditional peasant food, like rice flakes and prahok, the ubiquitous and pungent fish paste. The Khmer set menu is usually $35 a person (many restaurants price in dollars).
For classic Cambodian food, Khmer Kitchen, in an alley near the Old Market called the Passage (12-763-468), may be the best in town. It's not fancy, but the menu of simple curries, fried pumpkin and spicy meat salads called larb was good enough for Mick Jagger and, at about $12 for dinner for two, cheap enough for his fans.
Dead Fish Tower (Sivatha Street, 12-630-377, talesofasia.com/cambodia-deadfish.htm) is a bizarre Cambodian take on dinner theater. Upstairs, you can watch traditional dancing and downstairs, you can feed the crocodiles. (They get their fish raw - happily, you get it curried.) Dinner for two is about $15.
In a more modern vein, there's Abacus (Om Khun Street, 12-644-286). Get a table amid the silk lanterns in the garden, and sample entrees like the ostrich in red-wine sauce ($13).
There are a million bars in Siem Reap, many of them on what has come to be known as Pub Street, and most filled with Australian backpackers. But nearby there's also Laundry Bart (276 Group 10, Module 1 Village, east of the Old Market, 16-962-026), a slick, dark lounge that feels like the East Village circa 1995.
Linga, near the Old Market Across from the One Hotel (12-246-912, lingabar.com), is a straight-friendly gay bar with expertly mixed cocktails.
MATT GROSS is working on a novel about 1950's Cambodia.

China´s wealth

January 14, 2006
Wealth Grows, but Health Care Withers in China
By HOWARD W. FRENCH
FUYANG, China - When Jin Guilian's family took him to a county hospital in this gritty industrial city after a jarring two-day bus ride during which he drifted in and out of consciousness, the doctors took one look at him and said: "How dare you do this to him? This man could die at any moment."
The doctors' next question, though, was about money. How much would the patient's family of peasants and migrant workers be able to pay - up front - to care for Mr. Jin's failing heart and a festering arm that had turned black?
The relatives scraped together enough money for four days in the hospital. But when Mr. Jin, 36, failed to improve, they were forced to move him to an unheated and scantily equipped clinic on the outskirts of Fuyang where stray dogs wandered the grimy, unlighted halls.
China's economic reforms have turned an almost uniformly poor nation into an increasingly prosperous one in the space of a mere generation. But the collapse of socialized medicine and staggering cost increases have opened a yawning gap between health care in the cities and the rural areas, where the former system of free clinics has disintegrated.
In the last several years China has experimented with reforms aimed at improving health care for peasants. The most important is an insurance plan in which participating farmers must make an annual payment of a little more than a dollar to gain eligibility for basic medical treatments.
Many peasants have complained that even the dollar payment is too big a burden and that in any event the coverage the plan theoretically provides is inadequate.
The government, which under President Hu Jintao has made rural living standards a top priority, has recently announced an expansion of this experiment, with increased fees and increased coverage, but it has yet to make an impact on the health crisis.
As a result, according to the government's own estimates, in less than a generation a rural population that once enjoyed universal, if rudimentary, coverage is now 79 percent uninsured.
The near total absence of adequate health care in much of the countryside has sown deep resentment among the peasantry while helping to spread infectious diseases like hepatitis and tuberculosis and making the country - and the world - more vulnerable to epidemics like severe acute respiratory syndrome, or SARS, and possibly bird flu.
The failure of the government to provide decent health care for peasants has reinforced the idea of China as two separate nations: one urban and increasingly comfortable, the other rural and increasingly miserable.
Every year hundreds of millions of rural Chinese, like the Jin family, face the clash between health and poverty, knowing that if they treat their illnesses they will lack the money needed for marriage, education and, sometimes, food.
Even the official Chinese news media are regularly filled with accounts of the desperate choices people are forced to make over health care, of brothers who must draw lots to see whose serious disease will be treated because their family cannot afford to treat both, or of a father who sells a kidney to treat an ill son.
"There's basically no safety net at all for medical care in the village I live in," said Yang Yunbiao, a worker with a Chinese independent organization in Fuyang that aids poor sick people. "Our village has a lot of aged people with disease who are unable to get treatment, just staying at home in bed with barely enough to eat. They are shut in and can't work, and their disease and poverty have taken away their dignity."
In Mr. Jin's case, the best doctors could do was to administer oxygen and an antibiotic drip. But the new locale did have one sure merit: with their savings nearly exhausted, of all the places the Jin family had taken their brother in a 500-mile trek from Guangdong Province, it was the cheapest, costing what for them was still an exorbitant fee of about $15 a day.
"We don't want to go anywhere else," said Jin Guibin, an elder brother who spoke at the patient's bedside in his frigid room. "If he dies, he'll die here. If he recovers, he'll recover here. We don't have any other means."
That China finds itself in this situation today is as remarkable as the country's economic takeoff and, paradoxically, is inseparably related to it. Until the beginning of the reform period in the early 1980's, China's socialized medical system, with "barefoot doctors" at its core, worked public health wonders.
From 1952 to 1982 infant mortality fell from 200 per 1,000 live births to 34, and life expectancy increased from about 35 years to 68, according to a recent study published by The New England Journal of Medicine.
Since then, in one of the great policy reversals of modern times, China has dissolved its rural communes, privatized vast swaths of the economy and shifted public health resources away from rural areas and toward the cities. Public hospitals were urged to charge commercial rates for new drugs and most procedures, and today the salaries of health care workers are typically linked to the amount of income they generate for their hospitals.
More than half of urban residents, by comparison, enjoy some kind of coverage, which is supplied by their employers.
The recent emphasis on profit, meanwhile, has led doctors and other well-trained health care workers to abandon the countryside, with a result that peasants are left at the mercy of unqualified caregivers and outright charlatans who peddle expensive, improperly prescribed drugs and counterfeit medicines.
"From the liberation to the Cultural Revolution, conditions in the rural areas were fairly good," Dr. Wang Weizhong, a physician and member of the National People's Congress from Jilin Province in the northeast, said of the period from 1949 to the 1970's. "There were township clinics in every area, and there was no problem getting at least small illnesses treated everywhere."
Dr. Wang insisted that the government was working hard with its recent health care reforms to address the problems, but agreed that the old public health system that once protected peasants "had dissolved."
Unable to afford proper care, the first recourse of most peasants when they fall ill is to take whatever drugs they can find on the market to relieve their symptoms and hope that their ailment goes away. Often, of course, they merely get worse or, if their illness is communicable, spread it to others. Once a peasant's illness becomes debilitating, his relatives can face a double catastrophe: the serious decline of a breadwinner, and medical bills steep enough to bankrupt the family.
"I've visited many villages that are really very poor, and reading the doctors' records you can see people unable to pay the clinic only two yuan or five yuan," or 25 to 60 cents, said He Congpei, an expert on health care in rural China with the Amity Foundation, a Chinese independent organization that promotes rural health care and development.
"Maybe it is the beginning of something simple that if taken care of in time wouldn't be a problem," Mr. He said. "But these people are too poor to pay even five yuan or two yuan."
The story of Jin Guilian, the migrant worker with heart problems who was taken home to Anhui Province by his family from Guangdong, 500 miles to the south, displays all of those weaknesses in the public health system and more.
Seeking employment, Mr. Jin set out from his village in Anhui, one of eastern China's poorest provinces, when he was in his early 20's. Living with an uncle in Heilongjiang Province in the far northeast, he collapsed one day while hauling wood. He was taken to a hospital but left without treatment for lack of financial means.
That was the first of several incidents pointing to what doctors eventually diagnosed as congenital heart disease, a condition that has gone untreated. Some doctors have urged his brothers to arrange valve surgery, which they say would cost about $10,000, in a big city like Shanghai.
Ever desperate for work, Mr. Jin later made his way to Shantou, a city in Guangdong, not far from Hong Kong. There he got a job working as an orderly in a large hospital for about $6 a day. From those meager earnings, about $30 a month had to be paid to the hospital for the privilege of holding the job.
It was at the Shantou hospital that Mr. Jin recently fell gravely ill. But as "just a migrant laborer," he said from his bed in the Fuyang clinic, he was denied treatment by his employer of 10 years. "Although I worked there, I knew that I'd have to pay a deposit to get treated," he said. Unable to afford that, he left the hospital for a neighborhood clinic, where he was put on a simple saline drip.
He summoned his family, and when they saw him, visibly weak and with his blackened arm, they decided that his chances would be better if he returned home. Asked whether he regretted not having his brother treated earlier, Jin Guixiu, another brother of the patient, grew emotional.
"How can I not regret, but what good would that do?" he said. "For villagers the problem is not enough money. This is my brother, and if I had enough money of course I would treat him."

Brazil´s Pantanal deforestation mirrors Amazon´s plight

Report: World's largest wetland vanishing
Brazil's Pantanal deforestation mirrors Amazon's plight


Brazil

SAO PAULO, Brazil (Reuters) -- The world's largest wetland, Brazil's Pantanal, is being destroyed by increased farming, ranching and mining, according to a report by the environmental watchdog Conservation International.
The threat mirrors the more publicized situation in the Amazon, where ranchers and loggers have cleared vast areas of the rain forest at an alarming rate.
The Pantanal, an area of low-lying forests, marshes and dry plains, covers about 77,230 square miles (200,000 square kilometers) in the western Brazilian states of Mato Grosso and Mato Grosso do Sul near the borders with Bolivia and Paraguay.
It is home to a huge variety of wildlife, including jaguars, anteaters, tapirs and crocodiles, and it floods in the rainy season.
The Conservation International report said deforestation had destroyed 17 percent of the natural vegetation of the Pantanal and if it continued unchecked, all the original forest would disappear within 45 years.
Scientists used satellite images to compare the deforested areas with those that still had natural vegetation.
"They concluded that agriculture, cattle grazing and coal mining are the major threats to the Paraguay River Basin, a significant hydrographical drainage of the South American continent," it said.
Overall in the Paraguay River Basin, which includes the Pantanal, ranching and agriculture has destroyed almost 45 percent of the original vegetation.
The destruction had put wildlife and the ecological system at risk.
"These locations contribute to wildlife populations and serve as refuges for the fauna during unfavorable seasons, sheltering species that migrate to avoid floods and climate extremes," said Sandro Menezes, manager of Conservation's Pantanal program.
It mentioned the hyacinth macaw, which is threatened with extinction because the manduvi tree where it shelters and breeds is being wiped out.
Calling the Pantanal situation critical, the report urged action at local, state and government levels to stop the destruction and to restore damaged areas.

New York Hotel prices hit all-time High

New York hotel prices hit all-time high
Hospitality industry strong after post-September 11 slowdown


NEW YORK (AP) -- The Days Inn Brooklyn sits on a charmless block in a working-class neighborhood 30 minutes by subway from the nearest tourist spot in Manhattan.
Security glass encloses the front desk. Breakfast is packaged commercial pastry, served from a rack in a closet-sized lobby. The clean but drab rooms overlook train tracks.
Everything about the place says budget travel, except the price. On New Year's Eve, rooms were going for $229 per night.
The hefty bill is no fluke. Hotel prices set wallet-busting records in New York City in 2005 after a long, slow recovery from the 2001 terrorist attacks.
The average daily price of a room in the city hit $292 in November, according to the hospitality industry analysis firm PKF Consulting. Figures for December weren't yet available, but the city is a lock to break its previous record yearlong average of $237 per night, set in 2000.
Prices were high in every corner of town, from the noisy motels jammed into industrial neighborhoods near Kennedy Airport to the palaces near Central Park.
If the cost of a room deterred some people from visiting, it didn't show.
An estimated 22 million nights were sold at city hotels in 2005, according to city tourism officials, surpassing the 21.4 million last year and the 19.9 million in the year before the terrorist attacks.
Even the $14,000-per-night presidential suite at the Mandarin Oriental, New York was occupied about 75 percent of the time in 2005.
"A-list celebrities," explained hotel spokeswoman Tiana Kartadinata. "New York has a lot of premieres."
New York has never been a cheap place to stay, but today's high prices are remarkable, considering where the city has been.
Nationwide recovery
Tourism dipped significantly after the September 11 attacks. Hotels dropped their prices to an average $198 per night in 2002, and still the city drew millions fewer tourists than it had two years earlier.
Yet the crisis also prompted a national outpouring of love for the damaged city that may have helped fuel a comeback.
"I think people, for the first time, saw New Yorkers unfiltered," said Christyne Nicholas, president of NYC & Company, the city's convention and visitors bureau.

At the posh Mandarin Oriental, the base rate for a room will rise to $725 in 2006.
"A lot of the stereotypes went away after September 11 of us being rude and obnoxious and unwelcoming," she said. "For the first time, our police officers and our firefighters were a tourist attraction."
There has also been a nationwide recovery. Hotel prices across the country fell after the terror attacks, but grew 4 percent in 2004 and about 5 percent in 2005, according to Smith Travel Research. The average U.S. hotel room now costs $90.80.
In New York, simple laws of supply and demand may have made a difference too.
In recent years, the city's ultra-hot real estate market has prompted a rash of conversions of old hotels into luxury condominiums -- most notably, the famed 805-room Plaza Hotel near Central Park.
The overall number of hotel rooms in Manhattan has dwindled by about 1,500 in the past two years, officials said.
Some relief may be on the way. About 5,000 new rooms are expected to open in the city in the coming years, mostly at medium-priced chain hotels being constructed slightly off the beaten path.
"I think we need 1,000 to 1,500 extra rooms per year, just to keep up with the expanding economy," said PKF senior vice president John Fox.
For those travelers on a tight budget, now may be the time to visit. Prices will drop significantly in the next few months as winter sets in and holiday visitors clear out.
For those willing to travel in January and February there are some nice rooms to be had at three-star hotels in Manhattan for relatively bargain basement prices: around $160 per night.
But don't expect the discounts to last long.
At the posh Mandarin Oriental, which opened in the new Time Warner building overlooking Central Park two years ago, the base rate for a room will rise to $725 in 2006. On opening night, the same quarters could be had for $595.
For those with smaller wallets, there is always the Days Inn Brooklyn

Bad Blood

January 9, 2006
Bad Blood
Diabetes and Its Awful Toll Quietly Emerge as a Crisis
By N. R. KLEINFIELD
Begin on the sixth floor, third room from the end, swathed in fluorescence: a 60-year-old woman was having two toes sawed off. One floor up, corner room: a middle-aged man sprawled, recuperating from a kidney transplant. Next door: nerve damage. Eighth floor, first room to the left: stroke. Two doors down: more toes being removed. Next room: a flawed heart.
As always, the beds at Montefiore Medical Center in the Bronx were filled with a universe of afflictions. In truth, these assorted burdens were all the work of a single illness: diabetes. Room after room, floor after floor, diabetes. On any given day, hospital officials say, nearly half the patients are there for some trouble precipitated by the disease.
An estimated 800,000 adult New Yorkers - more than one in every eight - now have diabetes, and city health officials describe the problem as a bona fide epidemic. Diabetes is the only major disease in the city that is growing, both in the number of new cases and the number of people it kills. And it is growing quickly, even as other scourges like heart disease and cancers are stable or in decline.
Already, diabetes has swept through families, entire neighborhoods in the Bronx and broad slices of Brooklyn, where it is such a fact of life that people describe it casually, almost comfortably, as "getting the sugar" or having "the sweet blood."
But as alarmed as health officials are about the present, they worry more about what is to come.
Within a generation or so, doctors fear, a huge wave of new cases could overwhelm the public health system and engulf growing numbers of the young, creating a city where hospitals are swamped by the disease's handiwork, schools scramble for resources as they accommodate diabetic children, and the work force abounds with the blind and the halt.
The prospect is frightening, but it has gone largely unnoticed outside public health circles. As epidemics go, diabetes has been a quiet one, provoking little of the fear or the prevention efforts inspired by AIDS or lung cancer.
In its most common form, diabetes, which allows excess sugar to build up in the blood and exact ferocious damage throughout the body, retains an outdated reputation as a relatively benign sickness of the old. Those who get it do not usually suffer any symptoms for years, and many have a hard time believing that they are truly ill.
Yet a close look at its surge in New York offers a disturbing glimpse of where the city, and the rest of the world, may be headed if diabetes remains unchecked.
The percentage of diabetics in the city is nearly a third higher than in the nation. New cases have been cropping up close to twice as fast as cases nationally. And of adults believed to have the illness, health officials estimate, nearly one-third do not know it.
One in three children born in the United States five years ago are expected to become diabetic in their lifetimes, according to a projection by the Centers for Disease Control and Prevention. The forecast is even bleaker for Latinos: one in every two.
New York, perhaps more than any other big city, harbors all the ingredients for a continued epidemic. It has large numbers of the poor and obese, who are at higher risk. It has a growing population of Latinos, who get the disease in disproportionate numbers, and of Asians, who can develop it at much lower weights than people of other races.
It is a city of immigrants, where newcomers eating American diets for the first time are especially vulnerable. It is also yielding to the same forces that have driven diabetes nationally: an aging population, a food supply spiked with sugars and fats, and a culture that promotes overeating and discourages exercise.
Diabetes has no cure. It is progressive and often fatal, and while the patient lives, the welter of medical complications it sets off can attack every major organ. As many war veterans lost lower limbs last year to the disease as American soldiers did to combat injuries in the entire Vietnam War. Diabetes is the principal reason adults go blind.
So-called Type 2 diabetes, the predominant form and the focus of this series, is creeping into children, something almost unheard of two decades ago. The American Diabetes Association says the disease could actually lower the average life expectancy of Americans for the first time in more than a century.
Even those who do not get diabetes will eventually feel it, experts say - in time spent caring for relatives, in higher taxes and insurance premiums, and in public spending diverted to this single illness.
"Either we fall apart or we stop this," said Dr. Thomas R. Frieden, commissioner of the New York City Department of Health and Mental Hygiene.
Yet he and other public health officials acknowledge that their ability to slow the disease is limited. Type 2 can often be postponed and possibly prevented by eating less and exercising more. But getting millions of people to change their behavior, he said, will require some kind of national crusade.
The disease can be controlled through careful monitoring, lifestyle changes and medication that is constantly improving, and plenty of people live with diabetes for years without serious symptoms. But managing it takes enormous effort. Even among Americans who know they have the disease, about two-thirds are not doing enough to treat it.
Nearly 21 million Americans are believed to be diabetic, according to the Centers for Disease Control, and 41 million more are prediabetic; their blood sugar is high, and could reach the diabetic level if they do not alter their living habits.
In this sedentary nation, New York is often seen as an island of thin people who walk everywhere. But as the ranks of American diabetics have swelled by a distressing 80 percent in the last decade, New York has seen an explosion of cases: 140 percent more, according to the city's health department. The proportion of diabetics in its adult population is higher than that of Los Angeles or Chicago, and more than double that of Boston.
There was a pronounced increase in diagnosed cases nationwide in 1997, part of which was undoubtedly due to changes in the definition of diabetes and in the way data was collected, though there has continued to be a marked rise ever since.
Yet for years, public health authorities around the country have all but ignored chronic illnesses like diabetes, focusing instead on communicable diseases, which kill far fewer people. New York, with its ambitious and highly praised public health system, has just three people and a $950,000 budget to outwit diabetes, a disease soon expected to afflict more than a million people in the city.
Tuberculosis, which infected about 1,000 New Yorkers last year, gets $27 million and a staff of almost 400.
Diabetes is "the Rodney Dangerfield of diseases," said Dr. James L. Rosenzweig, the director of disease management at the Joslin Diabetes Center in Boston. As fresh cases and their medical complications pile up, the health care system tinkers with new models of dispensing care and then forsakes them, unable to wring out profits. Insurers shun diabetics as too expensive. In Albany, bills aimed at the problem go nowhere.
"I will go out on a limb," said Dr. Frieden, the health commissioner, "and say, 20 years from now people will look back and say: 'What were they thinking? They're in the middle of an epidemic and kids are watching 20,000 hours of commercials for junk food.' "
Of course, revolutionary new treatments or a cure could change everything. Otherwise, the price will be steep. Nationwide, the disease's cost just for 2002 - from medical bills to disability payments and lost workdays - was conservatively put by the American Diabetes Association at $132 billion. All cancers, taken together, cost the country an estimated $171 billion a year.
"How bad is the diabetes epidemic?" asked Frank Vinicor, associate director for public health practice at the Centers for Disease Control. "There are several ways of telling. One might be how many different occurrences in a 24-hour period of time, between when you wake up in the morning and when you go to sleep. So, 4,100 people diagnosed with diabetes, 230 amputations in people with diabetes, 120 people who enter end-stage kidney disease programs and 55 people who go blind.
"That's going to happen every day, on the weekends and on the Fourth of July," he said. "That's diabetes."
One Day in the Trenches
The rounds began on the seventh floor with Iris Robles. She was 26, young for this, supine in bed. She wore a pink "Chicks Rule" T-shirt; an IV line protruded from her arm. For more than a year, she had had a recurrent skin infection. The pain overwhelmed her. Then came extreme thirst and the loss of 50 pounds in six weeks. In the emergency room, she found out she had diabetes.
She was out of work, wanted to be an R & B singer, had no insurance. It was her fourth day in Montefiore Medical Center. Her grandmother, aunt and two cousins have diabetes.
"I'm scared," she said. "I'm still adjusting to it."
Next came Richard Dul, watching news chatter on a compact TV. Now 64, he has had diabetes since he was 22. A month before, he had a blockage in his heart and needed open-heart surgery. He was home a few days, but an infection arose and he was back. Postoperative infections are more common with diabetes. This was his 21st straight day in the hospital.
Here, then, was the price of diabetes, not just the dollars and cents but the high cost in quality of life.
Simply put, diabetes is a condition in which the body has trouble turning food into energy. All bodies break down digested food into a sugar called glucose, their main source of fuel. In a healthy person, the hormone insulin helps glucose enter the cells. But in a diabetic, the pancreas fails to produce enough insulin, or the body does not properly use it. Cells starve while glucose builds up in the blood.
There are two predominant types of diabetes. In Type 1, the immune system destroys the cells in the pancreas that make insulin. In Type 2, which accounts for an estimated 90 percent to 95 percent of all cases, the body's cells are not sufficiently receptive to insulin, or the pancreas makes too little of it, or both.
Type 1 used to be called "juvenile diabetes" and Type 2 "adult-onset diabetes." By 1997, so many children had developed Type 2 that the Diabetes Association changed the names.
What is especially disturbing about the rise of Type 2 is that it can be delayed and perhaps prevented with changes in diet and exercise. For although both types are believed to stem in part from genetic factors, Type 2 is also spurred by obesity and inactivity. This is particularly true in those prone to the illness. Plenty of fat, slothful people do not get diabetes. And some thin, vigorous people do.
The health care system is good at dispensing pills and opening up bodies, and with diabetes it had better be, because it has proved ineffectual at stopping the disease. People typically have it for 7 to 10 years before it is even diagnosed, and by that time it will often have begun to set off grievous consequences. Thus, most treatment is simply triage, doctors coping with the poisonous complications of patients who return again and again.
Diabetics are two to four times more likely than others to develop heart disease or have a stroke, and three times more likely to die of complications from flu or pneumonia, according to the Centers for Disease Control. Most diabetics suffer nervous-system damage and poor circulation, which can lead to amputations of toes, feet and entire legs; even a tiny cut on the foot can lead to gangrene because it will not be seen or felt.
Women with diabetes are at higher risk for complications in pregnancy, including miscarriages and birth defects. Men run a higher risk of impotence. Young adults have twice the chance of getting gum disease and losing teeth.
And people with Type 2 are often hounded by parallel problems - high blood pressure and high cholesterol, among others - brought on not by the diabetes, but by the behavior that led to it, or by genetics.
Dr. Monica Sweeney, medical director of the Bedford-Stuyvesant Family Health Center, offered an analogy: "It's like bad kids. If you have one bad kid, not so bad. Two bad kids, it's worse. Put five bad kids together and it's unmanageable. Diabetes is like five bad kids together. You want to scream."
The Caro Research Institute, a consulting firm that evaluates the burden of diseases, estimates that a diabetic without complications will incur medical costs of $1,600 a year - unpleasant, but not especially punishing. But the price tag ratchets up quickly as related ailments set in: an average $30,400 for a heart attack or amputation, $40,200 for a stroke, $37,000 for end-stage kidney disease.
One of the most horrific consequences is losing a leg. According to the federal Agency for Healthcare Research and Quality, some 70 percent of lower-limb amputations in 2003 were performed on diabetics. Sometimes, the subtraction is cumulative. One toe goes. Two more. The ankle. Everything to the knee. The other leg. Studies suggest that as many as 70 percent of amputees die within five years.
Yet medical experts believe that most diabetes-related amputations are preventable with scrupulous care, and that is why the offices of conscientious doctors post signs like this: "All patients with diabetes: Don't forget to bare your feet each visit."
To witness the pitiless course that diabetes can take, simply continue on the hospital tour. This one day will do. Dr. Rita Louard, an endocrinologist, and Anne Levine, a nurse diabetes educator, were making their way through the rooms at Montefiore.
Here was Julius Rivers, 58, on the sixth floor. Three years with diabetes. He had been at home in bed when he saw a light like a starburst and told his wife to take him to the emergency room. His blood sugar was 1,400, beyond the pale. (A fasting level of 126 milligrams per deciliter is the demarcation point of diabetes.)
This was his third trip to the hospital in seven months. At the moment, he had a blood clot in his left leg. He had a heart attack a few years ago. He was on dialysis. "Tuesday, Thursday and Saturday," he said.
On the sixth floor was Mauri Stein, 58, a guidance counselor, a diabetic for 20 years. She had been at a party recently and "zoned out." Her words slurred. Foam appeared on her mouth. She had had a mild stroke.
Now she tried to control her emotions, tried not to cry. She had had repeated laser surgery on her eyes, and was effectively blind in one. She had recovered from the stroke, but doctors had also found a tumor on her heart and said it would need surgery.
"My feet burn," she said. "My toes burn all the time. My days of wearing my pumps are over. I've gotten more cortisone shots in my feet than I'm sure are legal."
She mentioned her brother, who lived in California. Diabetes had ransacked his body - an amputation, kidney dialysis, heart disease, blindness in one eye. He now resided in an assisted-living center. He was 53.
Ms. Stein's husband walked in and sat on the bed. Six months ago, he found out the same truth: he had diabetes.
This was one day in one hospital.
Inside the Incubator
Little about diabetes is straightforward, and to comprehend why New York is such an incubator for the disease, it is necessary to grasp that diabetes is as much a sociological and anthropological story as a medical one. While it assaults all classes, ages and ethnic groups, it is inextricably bound up with race and money.
Diabetes bears an inverse relationship to income, for poverty usually means less access to fresh food, exercise and health care. New York's poverty rate, 20.3 percent, is much higher than the nation's, 12.7 percent.
African-Americans and Latinos, particularly Mexican-Americans and Puerto Ricans, incur diabetes at close to twice the rate of whites. More than half of all New Yorkers are black or Hispanic, and the Hispanic population is growing rapidly, as it is around the nation.
Some Asian-Americans and Pacific Islanders also appear more prone, and they can develop the disease at much lower weights. Asians constitute one-tenth of New York's population, more than twice their proportion nationwide.
The nature of these groups' susceptibility remains under study, but researchers generally blame an interplay of genetic and socioeconomic forces. Many researchers believe that higher proportions of these groups have a "thrifty gene" that enabled ancestors who farmed and hunted to stockpile fat during times of plenty so they would not starve during periods of want. In modern America, with food beckoning on every corner, the gene works perversely, causing them to accumulate unhealthy quantities of fat.
But the velocity of new cases among all races has accelerated significantly from just a few decades ago. Genetics cannot explain this surge, because the human gene pool does not change that fast. Instead, the culprit is thought to be behavior: faulty diet and inactivity. Dr. Vinicor, of the Centers for Disease Control, likes to use this expression: "Genetics may load the cannon, but human behavior pulls the trigger."
Of the country's spike in diabetes cases over the last two decades, C.D.C. studies suggest that about 60 percent stem from demographic changes: a population increasingly comprising older people and ethnic groups with a higher risk.
The studies ascribe the other 40 percent to lifestyle changes: the fundamental shift that has people eating jumbo meals and shunning exercise as if it were illegal. At every turn, technology has made physical activity unnecessary or unappealing. Gym class has largely been deleted from schools. Fewer than a third of junior high schools require physical education at all, the C.D.C. says.
On the whole, New York's corpulence is below the national average, with 20 percent of adults qualifying as obese, compared with 30 percent for the country, the C.D.C. says. But the figure is much higher in poor areas like the South Bronx and East Harlem.
When the health department studied diabetes in the city's 34 major neighborhoods, the distribution echoed demographic patterns: Diabetes left only a light imprint on more affluent, white areas like the Upper West Side and Brooklyn Heights. The prevalence was about average in working-class Ridgewood, Queens, and almost nil on the Upper East Side.
But that apparent immunity is weakening. Of those 34 neighborhoods, 22 already have diabetes rates above the national average, and the numbers are rising all over as the city continually remakes itself.
"New York is switching from a mom-and-pop type of environment to a chain-store type of environment, a proliferation of fast food, even in high-rent neighborhoods they haven't had access to before, like the East Village and Lower Manhattan," said Peter Muennig, an assistant professor of health policy and management at Columbia.
If changes in daily living can bring on diabetes, they can also delay it, though it is uncertain for how long.
A federal program studied people around the country at high risk of getting diabetes, and concluded that 58 percent of new cases could be postponed by shifts in behavior - most notably, shedding pounds.
But Dr. Frieden, New York's health commissioner, says meaningful prevention cannot be achieved at the city level. "I can urge people until I'm blue in the face to walk and take the stairs and eat less, and it won't make much difference," he said.
His emphasis is on trying to better treat those who already have diabetes, an ambitious goal in its own right. Most primary care doctors treat too many patients to provide the attention that diabetics need, or to check for the disease, he said. Specialists are scarce. And compliance among patients is notoriously poor.
Even the most basic step in controlling the disease - watching one's blood sugar - is too much for many diabetics. Doctors recommend that two to four times a year, patients take a so-called A1c test, which gauges the average sugar level over the prior 90 days and is more revealing than daily at-home measurements.
But in 2002 , the health department found that 89 percent of diabetics did not know their A1c levels. Of those who did, presumably the most conscientious, four out of five had readings over the level the American Diabetes Association says separates well-controlled from poorly controlled diabetes.
The patients in the survey were not much better at knowing their blood pressure and cholesterol, which are also crucial for diabetics to control.
"Diabetes is an interesting beast," said Dr. Diana K. Berger, who heads the diabetes division at the health department. "It's probably one of the easier conditions to diagnose but one of the hardest to manage."
Shortages and Shipwrecks
There is an underappreciated truth about disease: it will harm you even if you never get it. Disease reverberates outward, and if the illness gets big enough, it brushes everyone. Diabetes is big enough.
Predicting the path of a disease is always speculative, but without bold intervention diabetes threatens to hamper some of society's most basic functions.
For instance, no one with diabetes can join the military, though service members whose disease is diagnosed after enlisting can sometimes stay. No insulin-dependent diabetic can become a commercial pilot.
Shereen Arent, director of legal advocacy for the American Diabetes Association, says she already fields 150 calls a month from diabetics who complain that they are being discriminated against in the workplace, double the number just a couple of years ago. She mentioned a typical case, a man rejected for a job at a baked-bean factory in Texas as a safety risk. "If this continues," she said, "we're in big trouble."
Dr. Daniel Lorber is an endocrinologist in Queens who thinks a lot about the disease's present and future. "The work force 50 years from now is going to look fat, one-legged, blind, a diminution of able-bodied workers at every level," he said, presuming that current trends persist.
As more women contract diabetes in their reproductive years, Dr. Lorber said, more babies will be born with birth defects. Those needy babies will be raised by parents increasingly crippled by their diabetes.
"At a time when we are trying to shift health care out of hospitals, with diabetics you don't have a choice," he said. "Nursing homes are going to be crammed to the gills with amputees in rehab. Kidney dialysis centers will multiply like rabbits. We will have a tremendous amount of people not blind but with low vision. And we have lousy facilities in this country for low-vision problems. These people will not be able to function in society without significant aid."
Cost pressures have been slashing the number of hospital beds, and some exasperated doctors are known to denigrate advanced diabetics as "shipwrecks," because they have so many health problems and virtually live in the hospital.
Not only will the future mean too few beds and unsupportable drains on Medicaid and Medicare, Mr. Muennig said, but if an emergency strikes - a terrorist attack, an earthquake - the city health system's ability to respond may be compromised because all the beds will be full of diabetics.
Most schools do not have full-time nurses. Some public schools, Ms. Arent said, try to turn away children with diabetes, even though that is illegal. Others ban them from field trips and sports teams. And this is now, when diabetes is still relatively rare among children.
If trends continue, people will live through years blighted by disability, then die too young. Diabetes is thought to shave 5 to 10 years off a life.
"Life expectancy usually decreases because there's a plague or there's a massive economic trauma," Mr. Muennig said. "In this case, we will see a decline in life expectancy due to a chronic condition."
In 2003, diabetes vaulted past stroke and AIDS from the sixth-leading cause of death in New York to the fourth. It was fifth, slightly behind stroke, in 2004. But the health department says it believes the actual toll is much worse because doctors who fill out death certificates may ascribe the death to a complication rather than to the diabetes at its root. Lorna Thorpe, deputy health commissioner, combed through medical charts and concluded that diabetes should be third, trailing cardiovascular disease and cancer.
Laurie Raps is a claims representative for Social Security on Staten Island, 31 years on the job. From her perspective, interviewing people embarking on full-time disability, she has seen the disease's long tentacles. When she started, she saw people in their 50's and 60's, hobbled by the usual problems of age: arthritis, herniated discs, heart conditions. Now, every week, she gets diabetic after diabetic, people as young as 30.
In fact, a 2004 study by UnumProvident, a major provider of disability insurance, found that the number of workers filing claims for Type 2 diabetes doubled between 2001 and 2003.
"It's a double whammy," Ms. Raps said. "You don't have these people working and paying into the system, and then you have these people collecting from the system."
Ten years ago, Ms. Raps developed diabetes. Her husband has it. Both her parents have it, their lives being washed away.
"When I look at the people who sit before me with disability claims, I have to check the birth date in their records," she said. "They look 10 or 20 years older. Diabetes does that. It wears you down and wears you down. We're looking at a future of people 10 or 20 years older in sickness than they are. What kind of future is that?"
'A 15-Year-Old Is Immortal'
"I'm Linda and I've had diabetes for 13 years."
"I'm Dominique and I've had diabetes for seven years."
"I'm Joseph and I've had diabetes for two months."
The brisk introductions went on, the ritual start to the monthly meeting of a support group called Sugar Babes Place. All the members had diabetes. All were children.
Sugar Babes is the idea of Dr. Yolaine St. Louis, chief of pediatric endocrinology at Bronx-Lebanon Hospital Center. When she started practicing medicine 16 years ago, the only children she saw with diabetes had Type 1.
Now, of Sugar Babes' 90 official members, roughly 40 percent have Type 2. One is 8. Another is 7.
It scares Dr. St. Louis. It scares many doctors who see the same thing, because they know it does not have to be. Type 2 was supposed to be an old person's disease. Diabetes still increases with age in an almost linear fashion - today, one in five New Yorkers age 65 and older have it - but the starting point used to be mostly in their 50's.
Dr. Alan Shapiro, a pediatrician with the Children's Health Fund and Montefiore Medical Center who has spent 13 years ministering to children in the South Bronx, said there was an easy way to illustrate the change. When he began, there was a "failure-to-thrive" clinic, meant to address the undernourished, because so many children were dangerously thin and small.
"Now I don't think we hardly ever see a failure-to-thrive case," he said.
In the clinic's place is an obesity program. Dr. Shapiro never saw children with Type 2 diabetes in his early years in medicine. Now, the program has about 10 cases.
One concern he and fellow doctors have is the surge in children who take antipsychotic drugs for anxiety and conditions like autism. Some newer drugs can promote weight gain and thus elevate the risk of diabetes. Dr. Shapiro has an autistic patient who he feels needs the new medication. But since taking it, the young man has markedly put on weight and, at 18, developed diabetes.
This extension of the disease to the young is where health care professionals feel society and public policy have most glaringly failed. Diabetes, they say, should never have gotten there.
There has been little research into the long-term impact of Type 2 diabetes on children. But doctors have a rough idea. The harsh consequences that can accompany diabetes tend to arrive 10 to 15 years after onset.
If people contract diabetes when they are 15, 10 or even 5, they may well start developing complications, not on the cusp of retirement but in the prime of their lives.
There is a big difference between losing a limb at 21 and at 70. There is a big difference between going on dialysis at 30 and at 65.
"I heard a horror story a few weeks ago," Dr. Lorber said, "of a girl who was born deaf, got diabetes at 11 or 12 and went blind from diabetes at 30."
The C.D.C. has projected that a child found to have Type 2 diabetes at age 10 will see his life shortened by 19 years.
"Imagine if kids were showing up at emergency rooms in cardiac arrest," said Dr. David L. Katz, director of the Prevention Research Center at the Yale University School of Medicine. "Frankly, I think that's the next big thing. It's that dramatic. If diabetes doesn't respect age, why should coronary disease? Lord knows, I hope this never happens. But this is what keeps me up at night."
Yet children can be the most reluctant to accept the truths of their condition.
"A lot of them are in denial," Dr. St. Louis said. "They have blood sugars of 300, 400, and they tell me right to my face they don't have diabetes. 'You're wrong,' they say. 'I don't feel anything.' I tell them what can happen down the road, and they shrug. A 15-year-old doesn't care what's going to happen at 35 or 45. A 15-year-old is immortal."
The doctor was telling the Sugar Babes that everyone should have two compact blood-sugar meters, one for home and one for school. Then she warned them, "If your sugar is bad and you don't do anything, you're going to be dropping down all over the Bronx."
Interest was tepid. Some children couldn't keep their eyes off the waiting dinner arranged at a buffet table by the wall. No rapt attention from Joseph, 12, who had begged not to come, until his mother put her foot down. He moaned that he had schoolwork.
"Look at that," said Dorothy Morris-Swaby, a diabetes nurse educator who worked with Dr. St. Louis, nodding at a girl who was talking on her phone. "We're educating about diabetes, and she's on her cellphone. Typical teenager."
As time ran out, hula hoops were brought out. Dr. St. Louis was trying to identify activities other than video games and TV that the children might try. Last meeting, they held a jump-rope contest.
"They have 10,000 excuses why they can't do something," the doctor said. "So you have to give them ideas and then hope."
The meeting wound up. The hoops were stashed away. Some of the children stepped toward the buffet table and began to eat.