The New Old Age Blog: For the Elderly, Lists of Tests to Avoid

The Choosing Wisely campaign, an initiative by the American Board of Internal Medicine Foundation in partnership with Consumer Reports, kicked off last spring. It is an attempt to alert both doctors and patients to problematic and commonly overused medical tests, procedures and treatments.

It took an elegantly simple approach: By working through professional organizations representing medical specialties, Choosing Wisely asked doctors to identify “Five Things Physicians and Patients Should Question.”

The idea was that doctors and their patients could agree on tests and treatments that are supported by evidence, that don’t duplicate what others do, that are “truly necessary” and “free from harm” — and avoid the rest.

Among the 18 new lists released last week are recommendations from geriatricians and palliative care specialists, which may be of particular interest to New Old Age readers. I’ve previously written about a number of these warnings, but it’s helpful to have them in single, strongly worded documents.

The winners — or perhaps, losers?

Both the American Geriatrics Society and the American Academy of Hospice and Palliative Medicine agreed on one major “don’t.” Topping both lists was an admonition against feeding tubes for people with advanced dementia.

“This is not news; the data’s been out for at least 15 years,” said Sei Lee, a geriatrician at the University of California, San Francisco, and a member of the working group that narrowed more than 100 recommendations down to five. Feeding tubes don’t prevent aspiration pneumonia or prolong dementia patients’ lives, the research shows, but they do exacerbate bedsores and cause such distress that people often try to pull them out and wind up in restraints. The doctors recommended hand-feeding dementia patients instead.

The geriatricians’ list goes on to warn against the routine prescribing of antipsychotic medications for dementia patients who become aggressive or disruptive. Though drugs like Haldol, Risperdal and Zyprexa remain widely used, “all of these have been shown to increase the risk of stroke and cardiovascular death,” Dr. Lee said. They should be last resorts, after behavioral interventions.

The other questionable tests and treatments:

No. 3: Prescribing medications to achieve “tight glycemic control” (defined as below 7.5 on the A1c test) in elderly diabetics, who need to control their blood sugar, but not as strictly as younger patients.

No. 4: Turning to sleeping pills as the first choice for older people who suffer from agitation, delirium or insomnia. Xanax, Ativan, Valium, Ambien, Lunesta — “they don’t magically disappear from your body when you wake up in the morning,” Dr. Lee said. They continue to slow reaction times, resulting in falls and auto accidents. Other sleep therapies are preferable.

No. 5: Prescribing antibiotics when tests indicate a urinary tract infection, but the patient has no discomfort or other symptoms. Many older people have bacteria in their bladders but don’t suffer ill effects; repeated use of antibiotics just causes drug resistance, leaving them vulnerable to more dangerous infections. “Treat the patient, not the lab test,” Dr. Lee said.

The palliative care doctors’ Five Things list cautions against delaying palliative care, which can relieve pain and control symptoms even as patients pursue treatments for their diseases.

It also urges discussion about deactivating implantable cardioverter-defibrillators, or ICDs, in patients with irreversible diseases. “Being shocked is like being kicked in the chest by a mule,” said Eric Widera, a palliative care specialist at the San Francisco V.A. Medical Center who served on the American Academy of Hospice and Palliative Medicine working group. “As someone gets close to the end of life, these ICDs can’t prolong life and they cause a lot of pain.”

Turning the devices off — an option many patients don’t realize they have — requires simple computer reprogramming or a magnet, not the surgery that installed them in the first place.

The palliative care doctors also pointed out that patients suffering pain as cancer spreads to their bones get as much relief, the evidence shows, from a single dose of radiation than from 10 daily doses that require travel to hospitals or treatment centers.

Finally, their list warned that topical gels widely used by hospice staffs to control nausea do not work because they aren’t absorbed through the skin. “We have lots of other ways to give anti-nausea drugs,” Dr. Widera said.

You can read all the Five Things lists (more are coming later this year), and the Consumer Reports publications that do a good job of translating them, on the Choosing Wisely Web site.

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

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The New Old Age Blog: For the Elderly, Lists of Tests to Avoid

The Choosing Wisely campaign, an initiative by the American Board of Internal Medicine Foundation in partnership with Consumer Reports, kicked off last spring. It is an attempt to alert both doctors and patients to problematic and commonly overused medical tests, procedures and treatments.

It took an elegantly simple approach: By working through professional organizations representing medical specialties, Choosing Wisely asked doctors to identify “Five Things Physicians and Patients Should Question.”

The idea was that doctors and their patients could agree on tests and treatments that are supported by evidence, that don’t duplicate what others do, that are “truly necessary” and “free from harm” — and avoid the rest.

Among the 18 new lists released last week are recommendations from geriatricians and palliative care specialists, which may be of particular interest to New Old Age readers. I’ve previously written about a number of these warnings, but it’s helpful to have them in single, strongly worded documents.

The winners — or perhaps, losers?

Both the American Geriatrics Society and the American Academy of Hospice and Palliative Medicine agreed on one major “don’t.” Topping both lists was an admonition against feeding tubes for people with advanced dementia.

“This is not news; the data’s been out for at least 15 years,” said Sei Lee, a geriatrician at the University of California, San Francisco, and a member of the working group that narrowed more than 100 recommendations down to five. Feeding tubes don’t prevent aspiration pneumonia or prolong dementia patients’ lives, the research shows, but they do exacerbate bedsores and cause such distress that people often try to pull them out and wind up in restraints. The doctors recommended hand-feeding dementia patients instead.

The geriatricians’ list goes on to warn against the routine prescribing of antipsychotic medications for dementia patients who become aggressive or disruptive. Though drugs like Haldol, Risperdal and Zyprexa remain widely used, “all of these have been shown to increase the risk of stroke and cardiovascular death,” Dr. Lee said. They should be last resorts, after behavioral interventions.

The other questionable tests and treatments:

No. 3: Prescribing medications to achieve “tight glycemic control” (defined as below 7.5 on the A1c test) in elderly diabetics, who need to control their blood sugar, but not as strictly as younger patients.

No. 4: Turning to sleeping pills as the first choice for older people who suffer from agitation, delirium or insomnia. Xanax, Ativan, Valium, Ambien, Lunesta — “they don’t magically disappear from your body when you wake up in the morning,” Dr. Lee said. They continue to slow reaction times, resulting in falls and auto accidents. Other sleep therapies are preferable.

No. 5: Prescribing antibiotics when tests indicate a urinary tract infection, but the patient has no discomfort or other symptoms. Many older people have bacteria in their bladders but don’t suffer ill effects; repeated use of antibiotics just causes drug resistance, leaving them vulnerable to more dangerous infections. “Treat the patient, not the lab test,” Dr. Lee said.

The palliative care doctors’ Five Things list cautions against delaying palliative care, which can relieve pain and control symptoms even as patients pursue treatments for their diseases.

It also urges discussion about deactivating implantable cardioverter-defibrillators, or ICDs, in patients with irreversible diseases. “Being shocked is like being kicked in the chest by a mule,” said Eric Widera, a palliative care specialist at the San Francisco V.A. Medical Center who served on the American Academy of Hospice and Palliative Medicine working group. “As someone gets close to the end of life, these ICDs can’t prolong life and they cause a lot of pain.”

Turning the devices off — an option many patients don’t realize they have — requires simple computer reprogramming or a magnet, not the surgery that installed them in the first place.

The palliative care doctors also pointed out that patients suffering pain as cancer spreads to their bones get as much relief, the evidence shows, from a single dose of radiation than from 10 daily doses that require travel to hospitals or treatment centers.

Finally, their list warned that topical gels widely used by hospice staffs to control nausea do not work because they aren’t absorbed through the skin. “We have lots of other ways to give anti-nausea drugs,” Dr. Widera said.

You can read all the Five Things lists (more are coming later this year), and the Consumer Reports publications that do a good job of translating them, on the Choosing Wisely Web site.

---

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

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Gadgetwise Blog: Tip of the Week: Clean Your Phone and Its Camera

Smartphones spend a lot of time in hand, where they can pick up germs and dirt. Wiping down the phone regularly with an antibacterial cloth intended for use with touch screens can help keep it clean. Many office supply stores like Staples or Office Depot carry disposable wipes for use on phone and tablet screens.

If your phone has a camera and your photos have been looking blurry, you can clean its lens with a microfiber cloth or other wipe for use with camera lenses; a cotton swab moistened with distilled water can also take off stubborn grime. Whatever you do, though, do not spray the phone with industrial cleansers or use cleaning wipes designed for household chores, because these can damage the screen and other parts of the handset.

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Thailand to Hold Peace Talks With Rebel Group

The Thai government agreed on Thursday to hold peace talks with a major rebel group in what analysts said was a hopeful but tentative sign that tensions may ease in an insurgency in southern Thailand that has left 5,000 people dead.

The agreement between a representative of the rebel group, the Barisan Revolusi Nasional, and Paradorn Pattanathabutr, secretary general of Thailand’s National Security Council, was signed in Kuala Lumpur, Malaysia. Thai news media reported that the actual talks would begin in two weeks.

“This was just talks to have talks,” said Sunai Phasuk, an expert on the southern insurgency with Human Rights Watch in Thailand. “But it’s a very important public commitment. It’s a courageous decision.”

Numerous attempts at negotiations with rebels by Thai security agencies have foundered in recent years but analysts said this time they were encouraged by the presence of a senior figure from the rebel group, Hassan Taib, at the ceremony in Kuala Lumpur.

The talks appear to have the backing of the Malaysian government, which has sought to project the image of regional peacemaker in recent years by helping broker separate deals between rebel groups and the Philippines and Indonesian governments.

Thursday’s agreement comes after a spate of bombings by insurgents in southern Thailand and the failed attack on a Thai military base in February that left 16 insurgents dead.

In some ways southern Thailand appears ripe for a de-escalation of violence. The killing of teachers by insurgents  — more than 150 have been killed since 2004  —  has angered villagers and lead to public criticism by Muslim groups.

But one potential stumbling block in the negotiations will be knowing who to negotiate with. There are at least four major rebel groups and many factions and cells within them.

“The big trouble is to identify those who are in control,” said Panitan Wattanayagorn, a professor at Bangkok’s Chulalongkorn University and a specialist on southern Thailand.

Rungrawee Chalermsripinyorat, an expert on southern Thailand, called the agreement a “major milestone” but warned that the negotiation process, even if it succeeds could take years. The peace process between the Philippine government and the Moro National Liberation Front in the southern Philippines began in 1996 and only reached agreement last year, she said. “There are still remaining sticking points,” she said.

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DealBook: Regulators Block Ryanair’s Latest Attempt to Buy Aer Lingus

BRUSSELS – The European Commission on Wednesday blocked the third attempt by Ryanair to acquire Aer Lingus, saying a union of the two Irish airlines would damage competition and raise prices on air routes to Ireland.

The decision was widely expected after Ryanair — the largest budget carrier in Europe — said earlier that the commission would prohibit the deal, worth about 700 million euros ($900 million).

“The Commission’s decision protects more than 11 million Irish and European passengers who travel each year to and from Dublin, Cork, Knock and Shannon,” the European Union competition commissioner, Joaquín Almunia, said in a statement before a news conference.

Proposals made by Ryanair “were simply inadequate to solve the very serious competition problems which this acquisition would have created on no less than 46 routes,” Mr. Almunia said.

Shares of Ryanair were down 6 euro cents, at 5.60 euros, in afternoon trading in Dublin; Aer Lingus stock was up 1 cent, at 1.25 euros.

Aer Lingus, which had rejected Ryanair’s offers, said on Wednesday that it welcomed the commission decision. Ryanair, which owns about 30 percent of Aer Lingus, reiterated that it would appeal the decision to the European Court of Justice.

Ryanair accused Mr. Almunia of protecting Aer Lingus, the Irish flag carrier, against a takeover by an upstart. The company also contends that the regulator applied a double standard because he approved the takeover by British Airways and Iberia of British Midland International last year under a simplified procedure.

“We regret that this prohibition is manifestly motivated by narrow political interests rather than competition concerns, and we believe that we have strong grounds for appealing and overturning this politically inspired prohibition,” said Robin Kiely, a spokesman for Ryanair.

Prolonged litigation could have wider ramifications, making it more difficult for the Irish government to sell its 25 percent stake in Aer Lingus. Ireland agreed to sell that stake under the terms of an international bailout finalized in November 2010, although that agreement did not set a deadline for the sale.

The deal is the fourth Mr. Almunia has blocked since he took over as the region’s antitrust chief in February 2010. Last month, the commission thwarted the attempt by U.P.S. to buy TNT Express.

The decision on Wednesday is the latest chapter in years of acrimony between the commission and Ryanair’s pugnacious chief executive, Michael K. O’Leary, who has repeatedly criticized commission officials for decisions that curtailed his ambitions.

The enmity between Mr. O’Leary and the commission developed last decade when the two sides began a running battle over whether Ryanair received illegal state subsidies that enabled the airline to open up routes to regional airports. Those airports were often some distance from major transport hubs, but still close enough to lure passengers away from more established carriers.

Last year, the commission announced new investigations into the effect of discounts Ryanair had received at Lübeck-Blankensee Airport in Germany and the Klagenfurt regional airport in Austria.

Mr. O’Leary has sharply criticized the commission for failing to do more to save money by booking its officials on low-cost airlines like his own. Ryanair also has said its arrangements with all European Union airports comply with the bloc’s competition rules.

The competition authority blocked Ryanair’s first bid for Aer Lingus in 2007 on the grounds that the combined airline would have had a monopoly on too many routes. At the time, Mr. O’Leary accused the commission of bowing to political pressure from the Irish government, which opposed the deal. The airline abandoned a second attempt in 2009 because of opposition from the Irish government.

On Wednesday, Ryanair accused the commission of holding it to a higher standard than other airlines seeking mergers after it had offered “historic and unprecedented” concessions.

Among other items, Ryanair had offered to allow two competitor airlines to serve Dublin, Cork and Shannon; give those airlines more than half of the short-distance business currently belonging to Aer Lingus; agree to transfer airport slots in Britain to allow British Airways to serve Ireland from both Gatwick and Heathrow. Ryanair also had offered Flybe, a competitor, 100 million euros in financing to make it “a commercially profitable and viable entity” in Ireland.

On Wednesday, the commission outlined the reasons behind its decision.

It said that both Ryanair and Aer Lingus had strengthened their positions in the Irish market since the commission refused the previous deal in 2007, and that the merger would have created an “outright monopoly” on 28 short-distance routes serving Ireland. The commission also said there were such high barriers to entry to the Irish market that any new competitors would face too many challenges.

The commission’s “market investigation showed that there was no prospect that any new carrier would enter the Irish market after the merger, in particular by the creation of a base at the relevant Irish airports, and challenge the new entity on a sufficient scale,” it said in a statement. “Higher prices for passengers would have been the likely outcome.”

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Global Health: After Measles Success, Rwanda to Get Rubella Vaccine

Rwanda has been so successful at fighting measles that next month it will be the first country to get donor support to move to the next stage — fighting rubella too.

On March 11, it will hold a nationwide three-day vaccination campaign with a combined measles-rubella vaccine, hoping to reach nearly five million children up to age 14. It will then integrate the dual vaccine into its national health service.

Rwanda can do so “because they’ve done such a good job on measles,” said Christine McNab, a spokeswoman for the Measles and Rubella Initiative. M.R.I. helped pay for previous vaccination campaigns in the country and the GAVI Alliance is helping financing the upcoming one.

Rubella, also called German measles, causes a rash that is very similar to the measles rash, making it hard for health workers to tell the difference.

Rubella is generally mild, even in children, but in pregnant women, it can kill the fetus or cause serious birth defects, including blindness, deafness, mental retardation and chronic heart damage.

Ms. McNab said that Rwanda had proved that it can suppress measles and identify rubella, and it would benefit from the newer, more expensive vaccine.

The dual vaccine costs twice as much — 52 cents a dose at Unicef prices, compared with 24 cents for measles alone. (The MMR vaccine that American children get, which also contains a vaccine against mumps, costs Unicef $1.)

More than 90 percent of Rwandan children now are vaccinated twice against measles, and cases have been near zero since 2007.

The tiny country, which was convulsed by Hutu-Tutsi genocide in 1994, is now leading the way in Africa in delivering medical care to its citizens, Ms. McNab said. Three years ago, it was the first African country to introduce shots against human papilloma virus, or HPV, which causes cervical cancer.

In wealthy countries, measles kills a small number of children — usually those whose parents decline vaccination. But in poor countries, measles is a major killer of malnourished infants. Around the world, the initiative estimates, about 158,000 children die of it each year, or about 430 a day.

Every year, an estimated 112,000 children, mostly in Africa, South Asia and the Pacific islands, are born with handicaps caused by their mothers’ rubella infection.

Thanks in part to the initiative — which until last year was known just as the Measles Initiative — measles deaths among children have declined 71 percent since 2000. The initiative is a partnership of many health agencies, vaccine companies, donors and others, but is led by the American Red Cross, the United Nations Foundation, the Centers for Disease Control and Prevention, Unicef and the World Health Organization.

This article has been revised to reflect the following correction:

Correction: February 27, 2013

An earlier version of this article misstated the source of the financing for the upcoming vaccination campaign in Rwanda. It is being financed by the GAVI Alliance, not the Measles and Rubella Initiative.

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Global Health: After Measles Success, Rwanda to Get Rubella Vaccine

Rwanda has been so successful at fighting measles that next month it will be the first country to get donor support to move to the next stage — fighting rubella too.

On March 11, it will hold a nationwide three-day vaccination campaign with a combined measles-rubella vaccine, hoping to reach nearly five million children up to age 14. It will then integrate the dual vaccine into its national health service.

Rwanda can do so “because they’ve done such a good job on measles,” said Christine McNab, a spokeswoman for the Measles and Rubella Initiative. M.R.I. helped pay for previous vaccination campaigns in the country and the GAVI Alliance is helping financing the upcoming one.

Rubella, also called German measles, causes a rash that is very similar to the measles rash, making it hard for health workers to tell the difference.

Rubella is generally mild, even in children, but in pregnant women, it can kill the fetus or cause serious birth defects, including blindness, deafness, mental retardation and chronic heart damage.

Ms. McNab said that Rwanda had proved that it can suppress measles and identify rubella, and it would benefit from the newer, more expensive vaccine.

The dual vaccine costs twice as much — 52 cents a dose at Unicef prices, compared with 24 cents for measles alone. (The MMR vaccine that American children get, which also contains a vaccine against mumps, costs Unicef $1.)

More than 90 percent of Rwandan children now are vaccinated twice against measles, and cases have been near zero since 2007.

The tiny country, which was convulsed by Hutu-Tutsi genocide in 1994, is now leading the way in Africa in delivering medical care to its citizens, Ms. McNab said. Three years ago, it was the first African country to introduce shots against human papilloma virus, or HPV, which causes cervical cancer.

In wealthy countries, measles kills a small number of children — usually those whose parents decline vaccination. But in poor countries, measles is a major killer of malnourished infants. Around the world, the initiative estimates, about 158,000 children die of it each year, or about 430 a day.

Every year, an estimated 112,000 children, mostly in Africa, South Asia and the Pacific islands, are born with handicaps caused by their mothers’ rubella infection.

Thanks in part to the initiative — which until last year was known just as the Measles Initiative — measles deaths among children have declined 71 percent since 2000. The initiative is a partnership of many health agencies, vaccine companies, donors and others, but is led by the American Red Cross, the United Nations Foundation, the Centers for Disease Control and Prevention, Unicef and the World Health Organization.

This article has been revised to reflect the following correction:

Correction: February 27, 2013

An earlier version of this article misstated the source of the financing for the upcoming vaccination campaign in Rwanda. It is being financed by the GAVI Alliance, not the Measles and Rubella Initiative.

Read More..

Gadgetwise Blog: Q&A: Moving iTunes Libraries

How do I transfer my iTunes library from a desktop PC to a laptop, neither of which are Apple computers?

All the items in your iTunes library, like music, TV shows and podcasts, are stored in folders on the computer. The iTunes software itself, which is basically a big database program crossed with a media player, displays the items in your library in lists and makes it relatively easy to manage your collection.

To move your library to a new computer, you just need to move your iTunes library folder from the old machine to the new one with a copy of the iTunes software installed. You can do this in several ways depending on how you use iTunes — including transferring all the files over your network with the Home Sharing feature, copying your iTunes folder to an external hard drive or set of DVDs for transport between computers, or transferring content from the iTunes Store with an iPod, iPad or iPhone.

Apple has step-by-step, illustrated instructions for all these moving methods (and others) on its site. If you plan to get rid of the old computer, be sure to deauthorize it for use with your iTunes purchases, as explained here.

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India Ink: Revisiting the Horror in Sri Lanka

NEW DELHI — In the series of photographs shot in 2009, the bare-chested boy is first shown seated on a bench watching something outside the frame. Then he is seen having a snack. In the third image he is lying on the ground with bullet holes in his chest. The photographs, which were released last week by the British broadcaster Channel 4, appear to document the final moments in the life of 12-year-old Balachandran Prabhakaran, the youngest son of the slain founder of the Liberation Tigers of Tamil Eelam, Velupillai Prabhakaran.

The images are from the documentary film “No Fire Zone,” which tells the story of Sri Lanka’s violent suppression of Mr. Prabhakaran’s equally violent revolution, which had come very close to securing a separate state for the Tamil minority of Sri Lanka. After 26 years of civil war between the Tamils, who are chiefly Hindus, and the Sinhalese majority, who are chiefly Buddhists, the Sri Lankan state won decisively in 2009. Human rights activists say that hundreds of Tamil fighters, political leaders and their families, including Mr. Prabhakaran and his family, did not die in action but were executed. They estimate that more than 40,000 Tamil civilians died in the final months of the war.

Within its borders, the Sri Lankan government appears to wink at its Sinhalese population to accept their congratulations for ending the war, but it maintains a righteous indignation when the world accuses its army of planned genocide.

“No Fire Zone” includes video footage and photographs shot on mobile phones by Tamil survivors and Sinhalese soldiers that were somehow leaked. The film’s director, Callum Macrae, told me that it will be screened at the 22nd session of the U.N. Human Rights Council, now under way in Geneva, where the United States plans to introduce a resolution asking Sri Lanka to investigate the allegations of war crimes by its army.

It is not clear what such a resolution will achieve because Sri Lanka’s powerful president, Mahinda Rajapaksa, who has a rustic swagger about him and a manly black mustache, is the triumphant face of Sri Lanka’s victory in the war. The Sri Lankan Army is unambiguously under his control. Whatever the worth of the resolution, India is expected to support it more enthusiastically than it did a similar resolution last March.

Over the years, the shape and location of Sri Lanka have inspired several Indian cartoonists to portray the island nation as a tear drop beneath India’s peninsular chin. This is an illogical depiction of Sri Lanka’s trauma because a tear drop is not sorrowful; it is a consequence of someone’s sorrow. Some caricatures that appeared in the late 1980s and early 1990s, however, showed the Indian peninsula weeping and Sri Lanka as the consequent tear drop. This imagery had a stronger logic. India’s history with Sri Lanka is, in a way, about a bumbling giant being hurt by a cunning dwarf.

Under the late Prime Minister Indira Gandhi, the type of strategists who imagine they are great Machiavellian characters, and love to add the prefix “geo” to “politics” to feel good about their advisory jobs, ensured that India armed and financed the Tamil rebels. In 1984, when she was assassinated and her son Rajiv Gandhi took over as prime minister, Sri Lanka was engaged in a full-fledged civil war. Now, India wanted to play gracious giant in the region and bring peace to Sri Lanka. In 1987, it sent troops to achieve that end. It was a disastrous move, and resulted in the deaths of nearly 1,200 Indian soldiers and thousands of Tamil fighters. In an act of vengeance, Mr. Prabhakaran made his greatest strategic blunder: ordering the assassination of Rajiv Gandhi.

On the early morning of May 22, 1991, as the news spread through Madras (now Chennai) by phone and radio, I saw people run out of their homes in some kind of delirium to pick up the newspapers from their porches. The city had just woken up to the improbable fact that a suicide bomber had killed Mr. Gandhi the previous night in a small town not far from Chennai. Until then, the southern state of Tamil Nadu, whose capital is Chennai, was a haven for the Tamil Tigers. Bound by a common language, the masses of Tamil Nadu felt a deep compassion for the struggle of Sri Lankan Tamils. But Mr. Gandhi’s assassination was seen by them as an act of war against India. The chief minister of Tamil Nadu at the time, Muthuvel Karunanidhi, who was accused of being a friend of the Tigers, went around Chennai in an open-roof van, standing with his palms joined in apology. That was not good enough. In the 1991 Tamil Nadu assembly elections, his party won only two seats.

But now, the plight of the Sri Lankan Tamils has returned as a passionate political issue in Tamil Nadu. Mr. Karunanidhi is too old to stand anymore but even as a patriarch who uses a wheelchair, he is a useful ally of the Indian National Congress party, which heads the national government. He has often demanded that the accomplices of Mr. Gandhi’s assassin now on death row in India be pardoned, and that President Rajapaksa be tried on war crimes charges. Last year, when the United States introduced a resolution against Sri Lanka, India was reluctant to back it for strategic reasons, including that it has commercial interests in Sri Lanka, which China is fast grabbing. But Mr. Karunanidhi and public sentiment in Tamil Nadu finally persuaded the Indian government to support it.

In a few days, when the United States introduces its new resolution against Sri Lanka, the brute forces of politics and practicality will ensure that the Indian government led by the Congress party, whose leader is Sonia Gandhi, will join other nations in asking Sri Lanka to explain how exactly it eliminated the organization that made her a widow.

Manu Joseph is editor of the Indian newsweekly Open and author of the novel “The Illicit Happiness of Other People.”

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DealBook: Banks Fear Court Ruling in Argentina Bond Debt

A fierce battle between the government of Argentina and hedge funds and other investors led by a group of hedge funds has already led to the seizure of a naval ship and dragged in the United States Treasury. Now a federal appeals court is hearing the dispute, and how it rules could have a major impact on world debt markets.

The investors — including the hedge fund tycoon Paul E. Singer — sued Argentina seeking payment for $1.3 billion relating to bonds that the country defaulted on in 2001. On Wednesday, the case comes before the United States Court of Appeals for the Second Circuit, which has already sided with the hedge funds on their main arguments.

But the issue that the appeals court is still undecided about is perhaps the most important. It involves devising a method to pressure Argentina to pay up on the disputed bonds. And that has left the investors who hold a majority of Argentina’s foreign debt vulnerable, as well as the banks that process the payments to those investors.

While the hedge funds have grabbed the headlines — winning a temporary court order to seize an Argentine naval ship docked in Ghana, for example — most of the other holders of Argentina’s nearly $100 billion in defaulted debt agreed over the last decade to accept new bonds, taking big losses in the process. The country has since faithfully paid on the exchange bonds.

At the same time, Argentina has vehemently repeated that it will not pay the hedge funds and other holders of its old debt and has passed laws forbidding the government from paying anything to the bondholders who didn’t participate in the exchanges.

But last year, Judge Thomas P. Griesa of the Federal District Court in Manhattan ruled that if Argentina wanted to pay the holders of the restructured debt, it would have to pay the hedge funds and other holders of the defaulted debt, too. The judge included third-party banks in his injunction, and prohibited them from processing payments to holders of the exchange bonds unless all debt holders were paid.

Large banks, investors and the United States Treasury Department have objected to the judge’s order. In short, they say, using the sanction could cause financial losses for innocent bystanders and lead to unnecessary disruption in the bond markets.

“They are trying to block the payments system,” said Vladimir Werning, executive director for Latin American research at JPMorgan Chase. “This is unprecedented in the New York jurisdiction.”

In an e-mail, Kevin Heine, a spokesman for Bank of New York Mellon, which handles bond payments, said the ruling, “will create unrest in the credit markets and result in cascades of litigation, which is precisely the opposite effect that an injunction should have.”

A ruling in favor of the hedge funds would also have ripple effects throughout the debt markets.

“Any time you have something that can change of balance of power, it can matter beyond Argentina,” said Robert Kahn, a fellow at the Council on Foreign Relations.

Despite the legal worries, investors have so far been keen to hold higher-yielding emerging markets debt, given that interest rates are so low. Apart from Argentine bonds, debt issued by developing countries has performed strongly.

Unlike Argentina, some countries have held their noses and cut deals with holdouts in the past to get on with important economic overhauls, most recently Greece on certain smaller foreign-law bonds.

And in the years since Argentina’s default, most sovereign bonds have special clauses in them that make it much harder for holdouts to succeed. These are called collective action clauses, which state that if a certain majority of bondholders agree to take losses in a bond restructuring, those losses would be forced on all bondholders, even would-be holdouts who don’t agree.

But large amounts of bonds, those issued more than 10 years ago, do not have collective action clauses. And those that do have the clauses may not act as intended if the holdouts win their Argentina case, said Mr. Werning of JPMorgan.

Right now, a bond with a collective action clause might get restructured if 75 percent of the holders agree to it. If Judge Griesa’s ruling is upheld, more bondholders might be reluctant to enter a restructuring and the required majority might not be achieved. Bondholders might not enter the restructuring because they fear holdout litigation depriving them of payments later on.

“This could adversely affect the level of participation in a swap,” Mr. Werning said.

Still, others contend that the market for sovereign debt may be improved if the judge’s ruling is upheld, with the sanction on payments banks mostly intact. Countries like Argentina, they say, have taken advantage of the fact that there is no bankruptcy regime in the sovereign debt market to allow creditors to recoup money in a default. Indeed, Judge Griesa has said the Argentina case is partly about creating safeguards for creditors in the absence of bankruptcy regime.

But Anna Gelpern, a professor at the Washington College of Law at the American University, said that if the federal court’s rulings are upheld, it might just end up underscoring the limitations of the American courts’ power.

“What if Argentina still doesn’t settle? How does the court look then?” she said. “It can only isolate Argentina and Argentina seems content to be isolated.”

While there is a chance that the appellate court’s decision could be appealed to the United States Supreme Court, it is more likely that its ruling will be the final word on the lower court order.

According to that order, if a bank chose to channel payments from Argentina to the owners of the restructured debt, the bank would not be in compliance with his order. A payments bank, Bank of New York Mellon in the case of Argentine exchange bonds, would then decline to process the exchange bond payments, and the bonds could fall into default, inflicting big losses on their holders.

Some market specialists have raised the prospect that Argentina could keep paying the exchange bondholders by avoiding payments banks that operate in the United States. It could, for instance, swap the exchange bonds for new instruments registered under Argentine law that make payments through an Argentine entity.

But the court may decide that, in such a situation, the exchange bondholders themselves would be breaking its injunction. One of the things the appeals court is looking into is how to determine which third parties should sit outside the reach of the district court’s ruling.

It is not just hedge funds who are hoping to gain from an affirmation of the lower court ruling. This group also includes many individual investors, who are now feeling more optimistic about getting their money back as the case comes before the appeals court.

“We are hopeful the ruling will stay as issued,” said Horacio Vázquez, who helps lead a group in Buenos Aires that represents bondholders.

A version of this article appeared in print on 02/26/2013, on page B1 of the NewYork edition with the headline: Banks Fear Court Ruling In Argentina Bond Debt.

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