Departing Secretary of State Clinton's Legacy of Firsts













After 31 years of public service, Secretary of State Hillary Clinton leaves the limelight behind.


On Friday, President Obama nominated Sen. John Kerry, D-Mass., to take her place as secretary of state, leaving Clinton to help him move in and then bow out.


Over the past three decades, Clinton has served her country in one way or another, a tenure that was full of firsts.


She was the only first lady to refuse the traditional cookie bake off and the first secretary of state to visit more than 100 countries. She served under the first black president and was the first first lady to have an office in the West Wing of the White House. Clinton was the first secretary of state to visit East Timor, and the first first lady to later win elective office. And long before she ever appeared on a ballot, Clinton was the first child born to Hugh and Dorothy Rodham.


Hillary Clinton Through the Years


Her departure from the State Department does not come as a surprise. For the past year, she has made clear her intentions to step down and said her goodbyes at outposts all over the world.


"It's important for me to step off this incredibly high wire I've been on," Clinton said after casting her ballot in November's presidential election, "to take stock of the rest of my life."






Laurent Gillieron/AFP/Getty Images











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Recently, she told ABC's Barbara Walters she's looking forward to taking a step back, "maybe do some reading and writing and speaking and teaching."


In October, she took the blame for State Department security failures that led to the death of four Americans, including Ambassador Christopher Stevens, in Benghazi, Libya. It was a move that signaled a willingness to put politics aside and embrace responsibility.


I take responsibility," Clinton said a month after the attack in an interview in Lima, Peru. "I'm in charge of the State Department's 60,000-plus people all over the world, 275 posts.


"The president and the vice president wouldn't be knowledgeable about specific decisions that are made by security professionals," Clinton said, a clear attempt to absolve a president who was up for re-election of blame with little regard for her own popularity.


At the end of November, Clinton reflected on her accomplishments as secretary of state over the past four years in two wide-ranging speeches on foreign policy.


Her four years of work focused on advancing rights for women and religious minorities across the globe, helping to maintain the tenuous peace between Israelis and Palestinians, discouraging Iran from obtaining nuclear weapons and, in her own words, "advancing a new approach to development that puts human dignity and self-sufficiency at the heart of our efforts."


Clinton reflected on her travels to more than 112 countries, calling it "shoe-leather diplomacy," and emphasizing the importance of being on the ground.


"I have found it highly ironic that, in today's world, when we can be anywhere virtually, more than ever people want us to show up, actually," she said at the Newseum in Washington, D.C. "Somebody said to me the other day, 'I look at your travel schedule.  Why Togo?  Why the Cook Islands?'  No secretary of state had ever been to Togo before.  Togo happens to be on the U.N. Security Council.  Going there, making the personal investment, has a real strategic purpose."


Though Clinton took political heat this year for her role in the Benghazi attack, her global colleagues joked and prodded her about a second presidential run at each increment of her long-term farewell. The popular Democrat continues to deny she'll run.






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Egyptians back new constitution in referendum


CAIRO (Reuters) - An Islamist-backed Egyptian constitution won approval in a referendum, rival camps said on Sunday, after a vote the opposition said would sow deep social divisions in the Arab world's most populous nation.


The Islamist Muslim Brotherhood, which propelled President Mohamed Mursi to power in a June election, said an unofficial tally showed 64 percent of voters backed the charter after two rounds of voting that ended with a final ballot on Saturday.


An opposition official also told Reuters their unofficial count showed the result was a "yes" vote, while party spokesmen said there had been a series of abuses during the voting.


The main opposition coalition, the National Salvation Front, responded to the defeat by saying it was moving towards forming a single political party to challenge the Islamists who have dominated the ballot box since strongman Hosni Mubarak was overthrown two years ago.


Members of the opposition, taking heart from a low turnout of about 30 percent of voters, pledged to keep up pressure on Mursi through peaceful protests and other democratic means.


"The referendum is not the end of the road," said Khaled Dawoud, a spokesman for the National Salvation Front. "It is only the beginning of a long struggle for Egypt's future."


The referendum committee may not declare official results for the two rounds until Monday, after hearing appeals. If the outcome is confirmed, a parliamentary election will follow in about two months.


Mursi's Islamist backers say the constitution is vital for the transition to democracy, nearly two years after Mubarak was ousted in a popular uprising. It will provide the stability needed to help a fragile economy, they say.


The constitution was "a historic opportunity to unite all national powers on the basis of mutual respect and honest dialogue for the sake of stabilizing the nation," the Brotherhood said in a statement.


RECIPE FOR UNREST


The opposition accuses Mursi of pushing through a text that favors Islamists and ignores the rights of Christians, who make up about 10 percent of the population, as well as women. They say it is a recipe for further unrest.


The opposition said voting in both rounds was marred by abuses. However, an official said the overall vote favored the charter.


"The majority is not big and the minority is not small," liberal politician Amr Hamzawy said, adding that the National Salvation Front would use "all peaceful, democratic means" such as protests to challenge the constitution.


The vote was split over two days as many judges had refused to supervise the ballot, making a single day of voting impossible.


During the build-up to the vote there were deadly protests, sparked by Mursi's decision to award himself extra powers in a November 22 decree and then to fast-track the constitutional vote.


The new basic law sets a limit of two four-year presidential terms. It says the principles of sharia, Islamic law, remain the main source of legislation but adds an article to explain this. It also says Islamic authorities will be consulted on sharia - a source of concern to Christians and others.


ABUSES


Rights groups reported what they said were illegalities in voting procedures. They said some polling stations opened late, that Islamists illegally campaigned at some polling places, and complained of irregularities in voter registration.


But the committee overseeing the two-stage vote said its investigations showed no major irregularities in voting on December 15, which covered about half of Egypt's 51 million voters. About 25 million were eligible to vote in the second round.


The Brotherhood said turnout was about a third of voters.


The opposition says the constitution will stir up more trouble on the streets since it has not received sufficiently broad backing for a document that should be agreed by consensus, and raised questions about the fairness of the vote.


In the first round, the district covering most of Cairo voted "no," which opponents said showed the depth of division.


"I see more unrest," said Ahmed Said, head of the liberal Free Egyptians Party and a member of the opposition Front.


He cited "serious violations" on the first day of voting, and said anger against Mursi was growing. "People are not going to accept the way they are dealing with the situation."


At least eight people were killed in protests outside the presidential palace in Cairo this month. Islamists and rivals clashed in Alexandria, the second-biggest city, on the eves of both voting days.


(Writing by Edmund Blair and Giles Elgood; editing by Philippa Fletcher)



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Antony nod for commissioning of paralyzed IAF cadet‬‪

NEW DELHI: The defence ministry in an unprecedented humanitarian decision has given the green signal to the commissioning of a 22-year-old flight cadet, who got paralysed from waist downwards after his trainer aircraft crashed last year, as a full-fledged officer in the IAF.

Defence minister A K Antony on Friday approved the proposal of Air Chief Marshal N A K Browne for retention in service and commissioning'' of flight cadet R K Herojit Singh as a ground duty officer in the accounts branch of IAF as a special case''.

Hailing from a large middle-class family in Manipur, cadet Singh sustained spinal cord injuries after the Kiran aircraft he was flying crashed at the Air Force Station in Hakimpet on August 28, 2011, just two months before he was to be commissioned into the IAF as a fighter pilot.

Wheelchair-bound as a paraplegic, cadet Singh is recuperating at the military hospital in Kirkee (Pune). Mobile on his wheelchair, his intellectual and other motor capabilities are fully intact. He had completed over 80% of his training and bagged several awards at the National Defence Academy and Air Force Academy during his four years of training, including 'the most accomplished flight cadet' of his course,'' said an officer.

With ACM Browne being a firm believer'' in People first, mission always'', along with the force's credo of not being the one to leave its people or equipment behind'', the IAF chief approached Antony for special approval'' in the case.

Cadet Singh will now begin a further six months of training in the accounts branch at the Air Force Academy at Dundigal (Hyderabad) from January 9. The case is special since he did not meet the medical norms for getting commissioned after his injury. He is highly-motivated and eager to serve the IAF,'' he added.

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Predicting who's at risk for violence isn't easy


CHICAGO (AP) — It happened after Columbine, Virginia Tech, Aurora, Colo., and now Sandy Hook: People figure there surely were signs of impending violence. But experts say predicting who will be the next mass shooter is virtually impossible — partly because as commonplace as these calamities seem, they are relatively rare crimes.


Still, a combination of risk factors in troubled kids or adults including drug use and easy access to guns can increase the likelihood of violence, experts say.


But warning signs "only become crystal clear in the aftermath, said James Alan Fox, a Northeastern University criminology professor who has studied and written about mass killings.


"They're yellow flags. They only become red flags once the blood is spilled," he said.


Whether 20-year-old Adam Lanza, who used his mother's guns to kill her and then 20 children and six adults at their Connecticut school, made any hints about his plans isn't publicly known.


Fox said that sometimes, in the days, weeks or months preceding their crimes, mass murderers voice threats, or hints, either verbally or in writing, things like "'don't come to school tomorrow,'" or "'they're going to be sorry for mistreating me.'" Some prepare by target practicing, and plan their clothing "as well as their arsenal." (Police said Lanza went to shooting ranges with his mother in the past but not in the last six months.)


Although words might indicate a grudge, they don't necessarily mean violence will follow. And, of course, most who threaten never act, Fox said.


Even so, experts say threats of violence from troubled teens and young adults should be taken seriously and parents should attempt to get them a mental health evaluation and treatment if needed.


"In general, the police are unlikely to be able to do anything unless and until a crime has been committed," said Dr. Paul Appelbaum, a Columbia University professor of psychiatry, medicine and law. "Calling the police to confront a troubled teen has often led to tragedy."


The American Academy of Child & Adolescent Psychiatry says violent behavior should not be dismissed as "just a phase they're going through."


In a guidelines for families, the academy lists several risk factors for violence, including:


—Previous violent or aggressive behavior


—Being a victim of physical or sexual abuse


—Guns in the home


—Use of drugs or alcohol


—Brain damage from a head injury


Those with several of these risk factors should be evaluated by a mental health expert if they also show certain behaviors, including intense anger, frequent temper outbursts, extreme irritability or impulsiveness, the academy says. They may be more likely than others to become violent, although that doesn't mean they're at risk for the kind of violence that happened in Newtown, Conn.


Lanza, the Connecticut shooter, was socially withdrawn and awkward, and has been said to have had Asperger's disorder, a mild form of autism that has no clear connection with violence.


Autism experts and advocacy groups have complained that Asperger's is being unfairly blamed for the shootings, and say people with the disorder are much more likely to be victims of bullying and violence by others.


According to a research review published this year in Annals of General Psychiatry, most people with Asperger's who commit violent crimes have serious, often undiagnosed mental problems. That includes bipolar disorder, depression and personality disorders. It's not publicly known if Lanza had any of these, which in severe cases can include delusions and other psychotic symptoms.


Young adulthood is when psychotic illnesses typically emerge, and Appelbaum said there are several signs that a troubled teen or young adult might be heading in that direction: isolating themselves from friends and peers, spending long periods alone in their rooms, plummeting grades if they're still in school and expressing disturbing thoughts or fears that others are trying to hurt them.


Appelbaum said the most agonizing calls he gets are from parents whose children are descending into severe mental illness but who deny they are sick and refuse to go for treatment.


And in the case of adults, forcing them into treatment is difficult and dependent on laws that vary by state.


All states have laws that allow some form of court-ordered treatment, typically in a hospital for people considered a danger to themselves or others. Connecticut is among a handful with no option for court-ordered treatment in a less restrictive community setting, said Kristina Ragosta, an attorney with the Treatment Advocacy Center, a national group that advocates better access to mental health treatment.


Lanza's medical records haven't been publicly disclosed and authorities haven't said if it is known what type of treatment his family may have sought for him. Lanza killed himself at the school.


Jennifer Hoff of Mission Viejo, Calif. has a 19-year-old bipolar son who has had hallucinations, delusions and violent behavior for years. When he was younger and threatened to harm himself, she'd call 911 and leave the door unlocked for paramedics, who'd take him to a hospital for inpatient mental care.


Now that he's an adult, she said he has refused medication, left home, and authorities have indicated he can't be forced into treatment unless he harms himself — or commits a violent crime and is imprisoned. Hoff thinks prison is where he's headed — he's in jail, charged in an unarmed bank robbery.


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Online:


American Academy of Child & Adolescent Psychiatry: http://www.aacap.org


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AP Medical Writer Lindsey Tanner can be reached at http://www.twitter.com/LindseyTanner


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'Fiscal Cliff' Leaves Boehner a Wounded Speaker












John Boehner is a bloodied House speaker following the startling setback that his own fractious Republican troops dealt him in their "fiscal cliff" struggle against President Barack Obama.



There's plenty of internal grumbling about the Ohio Republican, especially among conservatives, and lots of buzzing about whether his leadership post is in jeopardy. But it's uncertain whether any other House Republican has the broad appeal to seize the job from Boehner or whether his embarrassing inability to pass his own bill preventing tax increases on everyone but millionaires is enough to topple him.



"No one will be challenging John Boehner as speaker," predicted John Feehery, a consultant and former aide to House GOP leaders. "No one else can right now do the job of bringing everyone together" and unifying House Republicans.



The morning after he yanked the tax-cutting bill from the House floor to prevent certain defeat, Boehner told reporters he wasn't worried about losing his job when the new Congress convenes Jan. 3.



"They weren't taking that out on me," he said Friday of rank-and-file GOP lawmakers, who despite pleading from Boehner and his lieutenants were shy of providing the 217 votes needed for passage. "They were dealing with the perception that somebody might accuse them of raising taxes."






Jacquelyn Martin/AP Photo








That "somebody" was a number of outside conservative groups such as the Club for Growth and Heritage Action for America, which openly pressured lawmakers to reject Boehner's bill. Such organizations often oppose GOP lawmakers they consider too moderate and have been headaches for Boehner in the past.



This time, his retreat on the tax measure was an unmistakable blow to the clout of the 22-year House veteran known for an amiable style, a willingness to make deals and a perpetual tan.



Congressional leaders amass power partly by their ability to command votes, especially in showdowns. His failure to do so Thursday stands to weaken his muscle with Obama and among House Republicans.



"It's very hard for him to negotiate now," said Sarah Binder, a George Washington University political scientist, adding that it's premature to judge if Boehner's hold on the speakership is in peril. "No one can trust him because it's very hard for him to produce votes."



She said the loss weakens his ability to summon support in the future because "you know the last time he came to you like this, others didn't step in line."



Boehner, 63, faces unvarnished hostility from some conservatives.



"We clearly can't have a speaker operate well outside" what Republicans want to do, said freshman Rep. Tim Huelskamp, R-Kan.



Huelskamp is one of four GOP lawmakers who lost prized committee assignments following previous clashes with party leaders. That punishment was an anomaly for Boehner, who is known more for friendly persuasion than arm-twisting.



He said Boehner's job would depend on whether the speaker is "willing to sit and listen to Republicans first, or march off" and negotiate with Obama.



Conservative Rep. Steve King, R-Iowa, said one of the tea party's lasting impacts would be if Boehner struggled to retain his speakership due to the fight over the fiscal cliff, which is the combination of deep tax increases and spending cuts that start in early January without a bipartisan deal to avert them.



"If there's a major defeat delivered here, it could make it tough on him," King said. "He's in a tough spot."





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Egypt extends voting on Islamist-drafted charter


CAIRO (Reuters) - Egypt extended voting by four hours on Saturday in the second and decisive round of a referendum that was expected to approve the country's new Islamist-drafted constitution after weeks of protests and violence.


Islamist supporters of President Mohamed Mursi, who was elected in June, say the charter is vital to move Egypt towards democracy, nearly two years after an Arab Spring revolution overthrew authoritarian ruler Hosni Mubarak.


It will help restore the stability needed to fix an economy that is on the ropes, they say.


But the opposition says the document is divisive and has accused Mursi of pushing through a text that favors his Islamist allies while ignoring the rights of Christians, who make up about 10 percent of the population, as well as women.


"I'm voting 'no' because Egypt can't be ruled by one faction," said Karim Nahas, 35, a stockbroker, heading to a polling station in Giza, a province included in this round of voting which covers parts of greater Cairo.


At another polling station, some voters said they were more interested in ending Egypt's long period of political instability than in the Islamist aspects of the charter.


"We have to extend our hands to Mursi to help fix the country," said Hisham Kamal, an accountant.


Queues formed at some polling stations around the country and voting was extended by four hours to 11 p.m. (2100 GMT).


Unofficial tallies are likely to emerge within hours of the close, but the referendum committee may not declare an official result for the two rounds until Monday, after hearing appeals.


CHEATING ALLEGED


As polling opened on Saturday, a coalition of Egyptian rights groups reported a number of alleged irregularities.


They said some polling stations had opened late, that Islamists urging a "yes" vote had illegally campaigned at some stations, and complained of irregularities in voter registration irregularities, including the listing of one dead person.


The first round of voting last week resulted in a 57 percent vote in favor of the constitution, according to unofficial figures.


Analysts expect another "yes" on Saturday because the vote covers rural and other areas seen as having more Islamist sympathizers. Islamists may also be able to count on many Egyptians who are simply exhausted by two years of upheaval.


Among the provisions of the new basic law are a limit of two four-year presidential terms. It says the principles of sharia law remain the main source of legislation but adds an article to explain this further. It also says Islamic authorities will be consulted on sharia - a source of concern to Christians and other non-Muslims.


If the constitution is passed, a parliamentary election will be held in about two months. If not, an assembly will have to be set up to draft a new one.


After the first round of voting, the opposition said a litany of alleged abuses meant the first stage of the referendum should be re-run.


But the committee overseeing the two-stage vote said its investigations showed no major irregularities in voting on December 15, which covered about half of Egypt's 51 million voters.


There was no indication on Saturday that the alleged abuses were any worse than those claimed during the first round.


MORE UNREST


Even if the charter is approved, the opposition say it is a recipe for trouble since it has not received broad consensus backing from the population. They say the result may go in Mursi's favor but it will not be the result of a fair vote.


"I see more unrest," said Ahmed Said, head of the liberal Free Egyptians Party and a member of the National Salvation Front, an opposition coalition formed after Mursi expanded his powers on November 22 and then pushed the constitution to a vote.


Protesters accused the president of acting like a pharaoh, and he was forced to issue a second decree two weeks ago that amended a provision putting all his decisions above legal challenge.


Said cited "serious violations" on the first day of voting, and said anger against Mursi and his Islamist allies was growing. "People are not going to accept the way they are dealing with the situation."


At least eight people were killed in protests outside the presidential palace in Cairo this month. Islamists and rivals clashed on Friday in the second biggest city of Alexandria, hurling stones at each other. Two buses were torched.


The head of the Muslim Brotherhood, an Islamist group that represents Mursi's power base, said the vote was an opportunity for Egypt to move on.


"After the constitution is settled by the people, the wheels in all areas will turn, even if there are differences here and there," the Brotherhood's supreme guide, Mohamed Badie, said as he went to vote in Beni Suef, south of Cairo.


"After choosing a constitution, all Egyptians will be moving in the same direction," he said.


The vote was staggered after many judges refused to supervise the ballot, meaning there were not enough to hold the referendum on a single day nationwide.


The first round was won by a slim enough margin to buttress opposition arguments that the text was divisive. Opponents who include liberals, leftists, Christians and more moderate-minded Muslims accuse Islamists of using religion to sway voters.


Islamists, who have won successive ballots since Mubarak's overthrow, albeit by narrowing margins, dismiss charges that they are exploiting religion and say the document reflects the will of a majority in the country where most people are Muslim.


(Additional reporting by Tamim Elyan; Writing by Edmund Blair and Giles Elgood; Editing by Mark Trevelyan)



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Will continue to oppose promotion quota bill: Mulayam Singh Yadav

LUCKNOW: Justifying the ruckus created by the Samajwadi Party (SP) MPs when constitutional amendment bill providing scheduled castes and scheduled tribes (SC/ST) reservation in promotions in government jobs was tabled in the Lok Sabha, SP chief Mulayam Singh Yadav on Friday said that his party will not allow passage of the bill, even if its MPs are disqualified or it leads to fall of the government. The SP, he said, will go to any extent to prevent the 'unconstitutional' bill from being enacted. Mulayam, however, did not specify when and under what conditions, the SP will withdraw support to the Central government on the issue.

Addressing a gathering at Safai mahotsav in his how town Etawah, Mulayam said that SP had only eight members in the Rajya Sabha but the opposed the bill with all its might. Similarly, he added, the strength of the SP MPs in Lok Sabha is small in comparison to national parties but party will continue to protest against the bill which not violates the spirit of equality enshrined in the constitution but will affect over 80% of the people in India. It will make a senior junior to his/her subordinate staff. He said that because of SP's opposition, the Lok Sabha could not pass the bill. He also said that SP is getting huge support of the people on the issue from across the country. "It could be gauged from the fact that wherever I go, including places (upper caste dominated) where people earlier used to raise slogan Mulayam Singh 'murdabad' (condemnation), now chant Mulayam Singh 'zindabad' (long live)," the SP chief said amid thunderous applause.

On December 19, the SP MPs had snatched the papers from union personnel minister V Narayanasamy's hands when the Congress led UPA government decided to initiate the discussion on quota bill in Lok Sabha. It led to unruly scenes with the SP and the Congress members coming to blows, following which the Lok Sabha was adjourned. Again, on December 20, the House was adjourned due to ruckus created by the SP members. Since it was the last day of the winter session, the bill will now be taken up in budget session. The Rajya Sabha has passed the bill. It will come into effect after being passed by the Lok Sabha. The bill is being opposed by government employees, barring SC/ST, in some states. The bill has been brought under the pressure of the Bahujan Samaj Party (BSP) which wants to consolidate its position among dalits, whereas the SP is opposing the bill eying votes of upper castes, backward classes and minorities.

On Saturday last, Mulayam had warned the Congress led UPA government not to take him for granted. Describing the bill as anti-national, the Yadav satrap had then also said that his party would review its stand of 'outside support' to the UPA 2, if bill is pushed in the parliament, overlooking SP's opposition. On Thursday, he said that the proposed legislation will create a permanent rift in the society and divide the country. For just 22% people, rest of the population including upper castes, backwards and minorities will suffer immensely, he warned. Mulayam also pointed out the reservation in promotions will demotivate other classes, who will also lose the charm of government services, leading to long term irreversible adverse impact. He also said that even if the quota bill is passed, final verdict on the issue will be given by the people of the country in the next Lok Sabha elections. The bill is being supported by most of the political parties.

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AP IMPACT: Big Pharma cashes in on HGH abuse


A federal crackdown on illicit foreign supplies of human growth hormone has failed to stop rampant misuse, and instead has driven record sales of the drug by some of the world's biggest pharmaceutical companies, an Associated Press investigation shows.


The crackdown, which began in 2006, reduced the illegal flow of unregulated supplies from China, India and Mexico.


But since then, Big Pharma has been satisfying the steady desires of U.S. users and abusers, including many who take the drug in the false hope of delaying the effects of aging.


From 2005 to 2011, inflation-adjusted sales of HGH were up 69 percent, according to an AP analysis of pharmaceutical company data collected by the research firm IMS Health. Sales of the average prescription drug rose just 12 percent in that same period.


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EDITOR'S NOTE — Whether for athletics or age, Americans from teenagers to baby boomers are trying to get an edge by illegally using anabolic steroids and human growth hormone, despite well-documented risks. This is the second of a two-part series.


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Unlike other prescription drugs, HGH may be prescribed only for specific uses. U.S. sales are limited by law to treat a rare growth defect in children and a handful of uncommon conditions like short bowel syndrome or Prader-Willi syndrome, a congenital disease that causes reduced muscle tone and a lack of hormones in sex glands.


The AP analysis, supplemented by interviews with experts, shows too many sales and too many prescriptions for the number of people known to be suffering from those ailments. At least half of last year's sales likely went to patients not legally allowed to get the drug. And U.S. pharmacies processed nearly double the expected number of prescriptions.


Peddled as an elixir of life capable of turning middle-aged bodies into lean machines, HGH — a synthesized form of the growth hormone made naturally by the human pituitary gland — winds up in the eager hands of affluent, aging users who hope to slow or even reverse the aging process.


Experts say these folks don't need the drug, and may be harmed by it. The supposed fountain-of-youth medicine can cause enlargement of breast tissue, carpal tunnel syndrome and swelling of hands and feet. Ironically, it also can contribute to aging ailments like heart disease and Type 2 diabetes.


Others in the medical establishment also are taking a fat piece of the profits — doctors who fudge prescriptions, as well as pharmacists and distributors who are content to look the other way. HGH also is sold directly without prescriptions, as new-age snake oil, to patients at anti-aging clinics that operate more like automated drug mills.


Years of raids, sports scandals and media attention haven't stopped major drugmakers from selling a whopping $1.4 billion worth of HGH in the U.S. last year. That's more than industry-wide annual gross sales for penicillin or prescription allergy medicine. Anti-aging HGH regimens vary greatly, with a yearly cost typically ranging from $6,000 to $12,000 for three to six self-injections per week.


Across the U.S., the medication is often dispensed through prescriptions based on improper diagnoses, carefully crafted to exploit wiggle room in the law restricting use of HGH, the AP found.


HGH is often promoted on the Internet with the same kind of before-and-after photos found in miracle diet ads, along with wildly hyped claims of rapid muscle growth, loss of fat, greater vigor, and other exaggerated benefits to adults far beyond their physical prime. Sales also are driven by the personal endorsement of celebrities such as actress Suzanne Somers.


Pharmacies that once risked prosecution for using unauthorized, foreign HGH — improperly labeled as raw pharmaceutical ingredients and smuggled across the border — now simply dispense name brands, often for the same banned uses. And usually with impunity.


Eight companies have been granted permission to market HGH by the U.S. Food and Drug Administration, which reviews the benefits and risks of new drug products. By contrast, three companies are approved for the diabetes drug insulin.


The No. 1 maker, Roche subsidiary Genentech, had nearly $400 million in HGH sales in the U.S. last year, up an inflation-adjusted two-thirds from 2005. Pfizer and Eli Lilly were second and third with $300 million and $220 million in sales, respectively, according to IMS Health. Pfizer now gets more revenue from its HGH brand, Genotropin, than from Zoloft, its well-known depression medicine that lost patent protection.


On their face, the numbers make no sense to the recognized hormone doctors known as endocrinologists who provide legitimate HGH treatment to a small number of patients.


Endocrinologists estimate there are fewer than 45,000 U.S. patients who might legitimately take HGH. They would be expected to use roughly 180,000 prescriptions or refills each year, given that typical patients get three months' worth of HGH at a time, according to doctors and distributors.


Yet U.S. pharmacies last year supplied almost twice that much HGH — 340,000 orders — according to AP's analysis of IMS Health data.


While doctors say more than 90 percent of legitimate patients are children with stunted growth, 40 percent of 442 U.S. side-effect cases tied to HGH over the last year involved people age 18 or older, according to an AP analysis of FDA data. The average adult's age in those cases was 53, far beyond the prime age for sports. The oldest patients were in their 80s.


Some of these medical records even give explicit hints of use to combat aging, justifying treatment with reasons like fatigue, bone thinning and "off-label," which means treatment of an unapproved condition. In other cases, the drug was used "for an unknown indication," meaning that the reason for treatment wasn't clear.


Even Medicare, the government health program for older Americans, allowed 22,169 HGH prescriptions in 2010, a five-year increase of 78 percent, according to data released by the Centers for Medicare and Medicaid Services in response to an AP public records request. And nearly half the increase came in one year: 2007.


"There's no question: a lot gets out," said hormone specialist Dr. Mark Molitch of Northwestern University, who helped write medical standards meant to limit HGH treatment to legitimate patients.


And those figures don't include HGH sold directly by doctors without prescriptions at scores of anti-aging medical practices and clinics around the country. Those numbers could only be tallied by drug makers, who have declined to say how many patients they supply and for what conditions.


The AP approached every U.S.-authorized manufacturer to ask what efforts they make to market responsibly and prevent abuse. Only one HGH supplier, Novo Nordisk, agreed to an interview.


"We're doing our level best to make sure that the right patients are getting the right medicine at the right time," said company spokesman Ken Inchausti.


He said the company is aware of the abuse issue. He said if patients apply for assistance from the company's patient-support hub, prescriptions will be flagged for review if they are missing the most rigorous test or an endocrinologist's signature. He said the company won't sell HGH directly to doctors accused of bad practices and does not deal with anti-aging clinics.


Representatives of other FDA-approved HGH makers insist they do not encourage use by bodybuilders or athletes or wealthy baby boomers trying to recapture their youth. But some said they are largely powerless to control who uses their medications or why.


"Lilly cannot restrict the actions of distributors, pharmacies or doctors," Eli Lilly spokeswoman Kelley Murphy said in a written statement.


That argument doesn't fly for critics like Dr. Peter Rost, a retired Pfizer executive who filed a whistleblower lawsuit over the HGH marketing practices of Pharmacia, which later merged with Pfizer. He said drug companies are simply looking the other way and betting that their profits will eclipse the cost of any fines.


They view it as "good business," he said.


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PEDDLED ON INTERNET


Type "human growth hormone" into any Internet search engine, and it will spit back countless websites with overblown promises of smoother skin, better sex, weight loss and even renewed body organs.


Any doctor who actually prescribes the drug for those purposes is taking a legal risk.


FDA regulations ban the sale of HGH as an anti-aging drug. In fact, since 1990, prescribing it for things like weight loss and strength conditioning has been punishable by 5 to 10 years in prison.


Such marketing claims are routinely made at hormone clinics like Palm Beach Life Extension, whose owners are among 13 people now awaiting trial on federal charges in Florida in a steroids and HGH distribution case brought last year.


"Grow YOUNG with Us!" screamed a banner on the company's now-defunct website, which advertised that HGH can reduce body fat, improve vision, strengthen the immune system, aid kidney function, lower blood pressure and enhance memory and mood.


The clinic arranged to have its clients' prescriptions filled at Treasure Coast Pharmacy, in Jensen Beach, Fla.


In 2009, the FBI recorded a phone call between the pharmacy's owner, Peter Del Toro, and a doctor in Elkton, Md., who was cooperating with agents after being implicated in a related steroid-distribution case.


Their talk, documented in a court filing, illustrates how things often work in the networks of pharmacies and clinics that drive HGH sales.


Patients submitted a medical history form by mail and took a blood test. But in most instances, the indictment said, the evaluation was a sham: One doctor was charged with giving a clinic a pad of blank, signed prescriptions to save him the chore of signing off on each diagnosis. He got $50 for every drug order bearing his name, the indictment said.


Dr. Rodney Baltazar, the Maryland physician cooperating with the FBI, sometimes consulted briefly with patients via webcam. But he made it clear in the call that those evaluations were perfunctory at best.


Baltazar was a gynecologist, not an endocrinologist. He said he knew "a little bit" about HGH and testosterone, which are often prescribed in tandem, but he relied largely on clinic salespeople to set doses.


The pharmacist coached the doctor: Keep detailed medical charts documenting that patients are taking the drug for at least some kind of health problem, just in case the U.S. Drug Enforcement Administration ever came calling.


"Because somebody questions you, you want to be able to say, 'Here, look at his chart. You know, he's got fatigue. He's got, you know, a decreased sex drive. He's got increased body fat. He has some -- some slight depression, probably.' Whatever his signs and symptoms are."


None of these conditions is a legal reason to prescribe HGH. But the pharmacist said that most investigators will be satisfied and move on "because there's guys that are just selling stuff basically like a boiler room."


Del Toro was arrested along with 12 other people in September 2011 on charges that they distributed steroids and human growth hormone to people who had no legitimate medical need. He is awaiting trial. His lawyer declined to comment. Baltazar was sentenced to six months in prison for involvement in steroid distribution schemes.


At the height of the crackdown in 2007, the federal government went after Pfizer in a case involving anti-aging clinics. The company paid $34.7 million in fines to settle the case — 11 percent of the company's annual revenue from the drug.


___


TROUBLED HISTORY


Blockbuster U.S. sales of HGH represent the latest frustration in 25 years of government efforts to control abuse of the growth drug made infamous by sports scandals.


First marketed in 1985 for children with stunted growth, HGH was soon misappropriated by adults intent on exploiting its modest muscle- and bone-building qualities. Congress limited HGH distribution to the handful of rare conditions in an extraordinary 1990 law, overriding the generally unrestricted right of doctors to prescribe medicines as they see fit.


Despite the law, illicit HGH spread around the sports world in the 1990s, making deep inroads into bodybuilding, college athletics, and professional leagues from baseball to cycling. The even larger banned market among older adults has flourished more recently.


For years, cheaper supplies from unauthorized foreign factories, particularly in China, fed the market via direct and Internet sales that sidestepped the medical establishment.


Though such shipments were banned under other law, the imports initially attracted little attention because they were usually labeled as raw pharmaceutical ingredients, which compounding pharmacies are allowed to bring into the country.


That flow began to be curtailed in 2006, when U.S. drug authorities stepped up efforts to block shipments at the border.


A handful of pharmacies across the country were hit with criminal charges over their handling of HGH. Federal prosecutors charged China's biggest HGH maker, GeneScience Pharmaceutical, with illegally distributing its Jintropin brand in the U.S. The company's CEO pleaded guilty in 2010.


With illicit supplies crimped, many pharmacies stopped selling unauthorized HGH. But tens of thousands of adult abusers began buying pricey U.S.-approved HGH that remained available in abundant supply, the AP found in its analysis of sales data.


Thus, pushed by a powerful demand, sales of U.S.-approved brands have swelled far beyond expected levels for a drug approved in just a handful of rare conditions.


Dr. Robert Marcus, a retired hormone specialist who left HGH manufacturer Eli Lilly and Co. in 2008, said that company was bent on stopping foreign counterfeits, not on cutting off abusers. "That's where their major level of frustration was — pharmaceutical fraud — rather than focusing on people who were using growth hormone illegitimately," he said.


Dr. Jim Meehan, of Tulsa, Okla., who has used HGH to treat aging problems and sports injuries, said the federal clampdown "never seemed to affect my patients and their ability to get Omnitrope, Tev-Tropin" and other government-approved brands.


The big drug companies have applauded the foreign crackdown and urged the government to do even more to combat sales of fake or fraudulently labeled HGH. In 2004, Bruce Kuhlik, speaking for the Pharmaceutical Research and Manufacturers of America, told a federal task force that unauthorized drug importation "is inherently unsafe" and industry representatives used Chinese HGH imports as their poster child.


In 2007, as the HGH embargo gained momentum, authorized makers picked up 41 percent more HGH orders, raising their annual total from 245,000 to 345,000, according to the analysis of the IMS Health data. Similarly, most of the drug's sales boom happened in the first two years of the crackdown, with 46 percent inflation-adjusted growth in yearly sales to $1.1 billion.


Steve Kleppe, of Scottsdale, Ariz., a restaurant entrepreneur who has taken HGH for almost 15 years to keep feeling young, said he noticed a price jump of about 25 percent after the block on imports. He now buys HGH directly from a doctor at an annual cost of about $8,000 for himself and the same amount for his wife.


Despite higher prices, the business has expanded in recent years largely on the strength of sales to healthy adults who can afford to indulge their hope of retaining youthful vigor.


___


GROWING OLD


Many older patients go for HGH treatment to scores of anti-aging practices and clinics heavily concentrated in retirement states like Florida, Nevada, Arizona and California.


These sites are affiliated with hundreds of doctors who are rarely endocrinologists. Instead, many tout certification by the American Board of Anti-Aging and Regenerative Medicine, though the medical establishment does not recognize the group's bona fides.


The clinics offer personalized programs of "age management" to business executives, affluent retirees, and other patients of means, sometimes coupled with the amenities of a vacation resort.


The clinics insist there are few, if any, side effects from HGH. Mainstream medical authorities say otherwise.


A 2007 review of 31 medical studies showed swelling in half of HGH patients, with joint pain or diabetes in more than a fifth. A French study of about 7,000 people who took HGH as children found a 30 percent higher risk of death from causes like bone tumors and stroke, stirring a health advisory from U.S. authorities.


For proof that the drug works, marketers turn to images like the memorable one of pot-bellied septuagenarian Dr. Jeffry Life, supposedly transformed into a ripped hulk of himself by his own program available at the upscale Las Vegas-based Cenegenics Elite Health. (He declined to be interviewed.)


These promoters of HGH say there is a connection between the drop-off in growth hormone levels through adulthood and the physical decline that begins in late middle age. Replace the hormone, they say, and the aging process slows.


"It's an easy ruse. People equate hormones with youth," said Dr. Tom Perls, a leading industry critic who does aging research at Boston University. "It's a marketing dream come true."


Some scientific studies of HGH have found modest benefits: some muscle and bone building, as well as limited fat loss, but nothing like the claims of the anti-aging industry. And some of the value credited to HGH may instead come from testosterone, which is routinely provided with HGH by anti-aging doctors and sports suppliers.


Endocrinologists say it's natural for the body to produce less growth hormone as people age beyond their early 20s, because they aren't growing anymore. Only a tiny number of adults with extraordinarily low HGH levels — perhaps several thousand of them — are believed to suffer real deficiencies that can properly be treated with the hormone.


Still, anti-aging doctors routinely diagnose otherwise healthy middle-aged people with an HGH deficiency, simply because their levels are lower than in young adults. "Basically anyone going through midlife," can benefit from the drug, declared one prescriber, Dr. Howard Elkin, of Whittier, Calif., who has himself competed as a bodybuilder.


Dr. Kenneth Knott, of Marietta, Ga., said HGH helps his older patients feel "more vibrant" and look "more alive."


Like many anti-aging doctors, he diagnoses patients by testing for a blood component called insulin growth factor, which is indirectly tied to HGH. Endocrinologists use a more authoritative test that stimulates the pituitary gland to make HGH itself. Nearly all insurers insist on this stimulation testing, and that's why clinic patients almost always pay for HGH out of their own pockets.


Bob Vitols, a 50-year-old lab assistant at a veterinary medicine company in Lincoln, Neb., is a rare exception. His unusually generous health plan isn't allowed to challenge a doctor's prescription.


Four years ago, Vitols began feeling run down. So he Googled his symptoms on the Internet, decided he had a hormone deficiency, and sought out a clinic.


One doctor put him on testosterone replacement therapy. A second clinic added HGH after diagnosing him with osteopenia, a mild bone thinning common in aging adults. It is not, however, a condition that can properly be treated with HGH.


Despite the diagnosis, the treatments — which can cost $10,000 per year — have been covered by his health insurance, he said. He takes Genotropin, the HGH made by Pfizer. His prescriptions are filled via mail order by CVS Caremark Corp., one of the largest dispensers of prescription drugs in the U.S.


Vitols said the drug changed his life: his mood is better, and he isn't burning out every day at 2 p.m. "I feel like I could walk outside and just walk through a fence — and come out fine on the other side," he said.


His experiences with the drug haven't all been positive, though. Vitols said he initially developed elevated liver enzymes and went to a specialist, who told him to stop taking hormones immediately.


Instead, Vitols said, he adjusted his dosage, and the problem disappeared.


He also dumped the specialist:


"I could tell he was against hormones right at the start," Vitols said.


___


Associated Press Writer David Caruso reported from New York and AP National Writer Jeff Donn reported from Plymouth, Mass. AP Writer Troy Thibodeaux provided data analysis assistance from New Orleans.


___


AP's interactive on the HGH investigation: http://hosted.ap.org/interactives/2012/hgh


___


The AP National Investigative Team can be reached at investigate(at)ap.org


EDITOR'S NOTE _ Whether for athletics or age, Americans from teenagers to baby boomers are trying to get an edge by illegally using anabolic steroids and human growth hormone, despite well-documented risks. This is the second of a two-part series.


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1 Week Later: Moment of Silence at Sandy Hook













Incessant rain and a dreary morning failed to keep onlookers away from a moment-of-silence memorial in Newtown, Conn., to pay their respects to the 26 people who were killed at Sandy Hook Elementary School.


Officials scheduled the event to recognize victims of the massacre that began at 9:30 a.m. Dec. 14, when gunman Adam Lanza shot his way into Sandy Hook elementary and launched a shooting spree at the school, taking 26 lives, including 20 children, and then his own.


FULL COVERAGE: Newtown, Conn., Elementary School Shooting


Tents and plastic were used to protect the stuffed animals, candles, notes and pictures that mourners have set up in the town. Flags in Newtown, Conn., which encompasses the village of Sandy Hook, are flying at half-staff.


Gov. Dannel P. Malloy, Lt. Gov. Nancy Wyman and Newtown First Selectman Patricia Llodra, together with other local elected officials, convened on the steps of Edmond Town Hall in Newtown for the moment of silence.








Sandy Hook Victims to Be Remembered in Moment of Silence Watch Video









Newtown Buries First School Shooting Victims Watch Video







They congregated on the steps at 9:28 a.m., with the moment of silence beginning at 9:30 a.m.


President Obama also took part in the moment of silence at the White House. The White House tweeted this morning, "20 beautiful children & 6 remarkable adults. Together, we will carry on & make our country worthy of their memory. -bo #MomentForSandyHook." The "-bo" signature means the tweet was sent by the President himself.


Bells from nearby Trinity Episcopal Church rang 26 times this morning in memory of each life lost at Sandy Hook Elementary School, as did the bells at the National Cathedral in Washington.


No formal remarks were made during the memorial.


Interested in How to Help Newtown Families?


Malloy has proclaimed today a "day of mourning" in Connecticut, asking residents statewide to participate in the moment of silence. He also wrote the nation's governors, inviting each state in the country to participate in the reflection on this day.


On the Web, a movement sprung up to make sites automatically "go silent" at 9:30. Easy-to-install javascript code was included so those who wanted their site to go silent could easily do so.


Lanza, 20, fatally shot his mother last Friday and then entered Sandy Hook elementary by shooting his way through a window to gain entry. From there, he gunned down and killed 26 people, including 20 children.



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Syrian rebels fight for strategic town in Hama province


BEIRUT (Reuters) - Rebels began to push into a strategic town in Syria's central Hama province on Thursday and laid siege to at least one town dominated by President Bashar al-Assad's minority sect, activists said.


The operation risks inflaming already raw sectarian tensions as the 21-month-old revolt against four decades of Assad family rule - during which the president's Alawite sect has dominated leadership of the Sunni Muslim majority - rumbles on.


Opposition sources said rebels had won some territory in the strategic southern town of Morek and were surrounding the Alawite town of al-Tleisia.


They were also planning to take the town of Maan, arguing that the army was present there and in al-Tleisia and was hindering their advance on nearby Morek, a town on the highway that runs from Damascus north to Aleppo, Syria's largest city and another battleground in the conflict.


"The rockets are being fired from there, they are being fired from Maan and al-Tleisia, we have taken two checkpoints in the southern town of Morek. If we want to control it then we need to take Maan," said a rebel captain in Hama rural area, who asked not to be named.


Activists said heavy army shelling had targeted the town of Halfaya, captured by rebels two days earlier. Seven people were killed, 30 were wounded, and dozens of homes were destroyed, said activist Safi al-Hamawi.


Hama is home to dozens of Alawite and Christian villages among Sunni towns, and activists said it may be necessary to lay siege to many minority areas to seize Morek. Rebels want to capture Morek to cut off army supply lines into northern Idlib, a province on the northern border with Turkey where rebels hold swathes of territory.


From an offshoot of Shi'ite Islam, Alawites have largely stood behind Assad, many out of fear of revenge attacks. Christians and some other minorities have claimed neutrality, with a few joining the rebels and a more sizeable portion of them supporting the government out of fear of hardline Islamism that has taken root in some rebel groups.


Activists in Hama said rebels were also surrounding the Christian town of al-Suqeilabiya and might enter the city to take out army positions as well as those of "shabbiha" - pro-Assad militias, the bulk of whom are usually Alawite but can also include Christians and even Sunnis.


"We have been in touch with Christian opposition activists in al-Suqeilabiya and we have told them to stay downstairs or on the lowest floor of their building as possible, and not to go outside. The rebels have promised not to hurt anyone who stays at home," said activist Mousab al-Hamdee, speaking by Skype.


He said he was optimistic that potential sectarian tensions with Christians could be resolved but that Sunni-Alawite strife may be harder to suppress.


SECTARIAN FEARS


U.N. human rights investigators said on Thursday that Syria's conflict was becoming more "overtly sectarian", with more civilians seeking to arm themselves and foreign fighters - mostly Sunnis - flocking in from 29 countries.


"They come from all over, Europe and America, and especially the neighboring countries," said Karen Abuzayd, one of the U.N. investigators, told a news conference in Brussels.


Deeper sectarian divisions may diminish prospects for post-conflict reconciliation even if Assad is ousted, and the influx of foreigners raises the risk of fighting spilling into neighboring countries riven by similar communal fault lines.


Some activists privately voiced concerns of sectarian violence, but the rebel commander in Hama said fighters had been told "violations" would not be tolerated and argued that the move to attack the towns was purely strategic.


"If we are fired at from a Sunni village that is loyal to the regime we go in and we liberate it and clean it," he said. "So should we not do the same when it comes to an Alawite village just because there is a fear of an all-out sectarian war? We respond to the source of fire."


President Vladimir Putin of Russia, Assad's main ally and arms supplier, warned that any solution to the conflict must ensure government and rebel forces do not merely swap roles and fight on forever. It appeared to be his first direct comment on the possibility of a post-Assad Syria.


The West and some Arab states accuse Russia of shielding Assad after Moscow blocked three U.N. Security Council resolutions intended to increase pressure on Damascus to end the violence, which has killed more than 40,000 people. Putin said the Syrian people would ultimately decide their own fate.


Assad's forces have been hitting back at rebel advances with heavy shelling, particularly along the eastern ring of suburbs outside Damascus, where rebels are dominant.


A Syrian security source said the army was planning heavy offensives in northern and central Syria to stem rebel advances, but there was no clear sign of such operations yet.


Rebels seized the Palestinian refugee district of Yarmouk earlier this week, which put them within 3 km (2 miles) of downtown Damascus. Heavy shelling and fighting forced thousands of Palestinian and Syrian residents to flee the Yarmouk area.


Rebels said on Thursday they had negotiated to put the camp - actually a densely packed urban district - back into the hands of pro-opposition Palestinian fighters. There are some 500,000 Palestinian refugees and their descendants living in Syria, and they have been divided by the uprising.


Palestinian factions, some backed by the government and others by the rebels, had begun fighting last week, a development that allowed Syrian insurgents to take the camp.


A resident in Damascus said dozens of families were returning to the camp but that the army had erected checkpoints. Many families were still hesitant to return.


LEBANON BORDER POST TAKEN


Elsewhere, Syrian insurgents took over an isolated border post on the western frontier with Lebanon earlier this week, local residents told Reuters on Thursday.


The rebels already hold much of the terrain along Syria's northern and eastern borders with Turkey and Iraq respectively.


They said around 20 rebels from the Qadissiyah Brigade overran the post at Rankus, which is linked by road to the remote Lebanese village of Tufail.


Video footage downloaded on the Internet on Thursday, dated December 16, showed a handful of fighters dressed in khaki fatigues and wielding rifles as they kicked down a stone barricade around a small, single-storey army checkpoint.


Syrian Interior Minister Ibrahim al-Shaar arrived in Lebanon on Wednesday for treatment of wounds sustained in a bomb attack on his ministry in Damascus a week ago.


Lebanese medical sources said Shaar had shrapnel wounds in his shoulder, stomach and legs but they were not critical.


The Syrian opposition has tried to peel off defectors from the government as well as from the army, though only a handful of high-ranking officials have abandoned Assad.


The conflict has divided many Syrian families. Security forces on Thursday arrested an opposition activist who is also the relative of Vice President Farouq al-Sharaa, the Syrian Observatory said. The man was arrested along with five other activists who are considered pacifists, it said.


Sharaa, a Sunni Muslim who has few powers in Assad's Alawite-dominated power structure, said earlier this week that neither side could win the war in Syria. He called for the formation of a national unity government.


(Reporting by Erika Solomon; Editing by Andrew Osborn)



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