Effects of Climate Change Could Cost Billions, E.P.A. Report Says

WASHINGTON — In the absence of global action to curb greenhouse gas emissions, Americans by the end of the century may have to pay as much as $3.1 billion in damages caused by rising sea levels and up to $180 billion in economic losses because of drought and water shortages, according to a report released Monday by the White House and Environmental Protection Agency.

White House officials said that the report, which analyzes the economic costs of a changing climate across 20 sectors of the American economy, is the most comprehensive effort to date to quantify the impacts of global warming.

The report comes as President Obama is trying to build political support both at home and abroad for an ambitious climate change agenda. During the president’s six and a half years in office, the E.P.A. has released a series of regulations and legal decisions aimed at reining in planet-warming greenhouse gases from cars, trucks, power plants and airplanes. Mr. Obama hopes to use those regulations as leverage to broker a United Nations accord in Paris this December that would committ all nations to enacting similar emissions cuts.

“That’s what we’re going to use to push other countries to join in global climate action,” said Brian Deese, Mr. Obama’s senior climate and energy policy adviser.

The report, “Climate Change in the United States: Benefits of Global Action,” uses existing scientific and economic studies on the projected impacts of unchecked global climate change emissions. It compares those to a scenario in which global emissions are reduced enough to prevent a rise in average atmospheric temperatures of 2 degrees Celsius, or 3.6 degrees Fahrenheit, the point at which scientists say the planet will be locked into an irreversible future of rising sea levels, stronger storms, extreme drought, food shortages and other damages.

The report was conducted by the E.P.A.’s Office of Atmospheric Programs along with researchers from the Massachusetts Institute of Technology and national scientific laboratories run by the Energy Department. The results were peer reviewed in scientific literature, and the summary report was independently reviewed by seven external independent experts.

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Matter: Picture This? Some Just Can’t

Certain people, researchers have discovered, can’t summon up mental images — it’s as if their mind’s eye is blind. This month in the journal Cortex, the condition received a name: aphantasia, based on the Greek word phantasia, which Aristotle used to describe the power that presents visual imagery to our minds.

I find research like this irresistible. It coaxes me to think about ways to experience life that are radically different from my own, and it offer clues to how the mind works.

And in this instance, I played a small part in the discovery.

In 2005, a 65-year-old retired building inspector paid a visit to the neurologist Adam Zeman at the University of Exeter Medical School. After a minor surgical procedure, the man — whom Dr. Zeman and his colleagues refer to as MX — suddenly realized he could no longer conjure images in his mind.

Dr. Zeman couldn’t find any description of such a condition in medical literature. But he found MX’s case intriguing. For decades, scientists had debated how the mind’s eye works, and how much we rely on it to store memories and to make plans for the future.

MX agreed to a series of examinations. He proved to have a good memory for a man of his age, and he performed well on problem-solving tests. His only unusual mental feature was an inability to see mental images.

Dr. Zeman and his colleagues then scanned MX’s brain as he performed certain tasks. First, MX looked at faces of famous people and named them. The scientists found that certain regions of his brain became active, the same ones that become active in other people who look at faces.

Then the scientists showed names to MX and asked him to picture their faces. In normal brains, some of those face-recognition regions again become active. In MX’s brain, none of them did.

Paradoxically, though, MX could answer questions that would seem to require a working mind’s eye. He could tell the scientists the color of Tony Blair’s eyes, for example, and name the letters of the alphabet that have low-hanging tails, like g and j. These tests suggested his brain used some alternate strategy to solve visual problems.

After I came across the case study of MX in 2010, I wrote about it. And then something remarkable happened: I discovered that MX was not alone.

“I have spent my entire life explaining to people that I do not think visually,” one reader wrote to me. “I cannot conjure a mental image of a person or of a place to save my life.”

As more emails arrived, I did the only thing I could think to do: I forwarded them to Dr. Zeman. It turned out that he and his colleagues were also hearing from people who thought they had the condition.

The scientists decided to make a formal study of their email correspondents. They replied to emails with a questionnaire designed to probe the mind’s eye. All told, the researchers have received 21 responses.

Among the questions, the scientists asked their subjects to picture things like a sunrise. Try as they might, most of the respondents couldn’t see anything. But some of them did report rare, involuntary flashes of imagery. The mention of a friend’s name, for instance, might briefly summon a face.

When the scientists asked their subjects to mentally count the windows in their house or apartment, 14 succeeded. They seem to share MX’s ability to use alternate strategies to get around the lack of a mind’s eye.

All in all, Dr. Zeman and his colleagues were struck by how similar the results of the survey were.

“These people seemed to be describing something consistent,” Dr. Zeman said. Rather than being a unique case, MX may belong to an unrecognized group of people.

In their new report, the scientists note that many of the survey respondents differed from MX in an important way. While he originally had a mind’s eye, they never did. If aphantasia is real, it is possible that injury causes some cases while others begin at birth.

Thomas Ebeyer, a 25-year-old Canadian student, discovered his condition four years ago while talking with a girlfriend. He was shocked that she could remember what a friend had been wearing a year before.

She replied that she could see a picture of it in her mind.

“I had no idea what she was talking about,” he said in an interview. Mr. Ebeyer was surprised to discover that everyone he knew could summon images to their minds. Last year, someone showed him my article about MX.

“I’d been searching forever on Google, but I didn’t know what to look for,” he said. “It was really empowering just to hear a story of someone else who had it.”

Mr. Ebeyer got in touch with Dr. Zeman, who sent him the questionnaire. Like many other subjects, he could count his windows without actually picturing his house.

“It’s weird and hard to explain,” he said. “I know the facts. I know where the windows are.”

The new study has brought Mr. Ebeyer some relief. “There’s something I can call this now,” he said.

Dr. Zeman now wonders just how common aphantasia is. “Moderately rare” is his guess, but to follow up, he has sent the questionnaire to thousands of people in Exeter.

He hopes to find enough people with the condition to begin a bigger scanning study, comparing their brains with those of people who see vivid mental images. Together, they may reveal more than MX could on his own.

Speaking of which — Dr. Zeman said that he was interested in meeting more people with aphantasia. He can be reached at a.zeman@exeter.ac.uk.

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Nina Simone’s Time Is Now, Again

The feminist writer Germaine Greer once declared: “Every generation has to discover Nina Simone. She is evidence that female genius is real.” This year, that just might happen for good.

Nina Simone is striking posthumous gold as the inspiration for three films and a star-studded tribute album, and she was name-dropped in John Legend’s Oscar acceptance speech for best song. This flurry comes on the heels of a decade-long resurgence: two biographies, a poetry collection, several plays, and the sampling of her signature haunting contralto by hip-hop performers including Jay Z, the Roots and, most relentlessly, Kanye West.

Fifty years after her prominence, Nina Simone is now reaching her peak.

The documentary “What Happened, Miss Simone?,” directed by Liz Garbus (“The Farm: Angola, USA”) and due on Wednesday in New York and two days later on Netflix, opens by exploring Simone’s unorthodox blend of dusky, deep voice, classical music, gospel and jazz piano techniques, and civil rights and black-power musical activism.

Not only did she compose the movement staple “Mississippi Goddam,” but she also broadened the parameters of the great American pop artist. “How can you be an artist and not reflect the times?” Simone asks in the film. “That to me is the definition of an artist.” And in “What Happened,” Simone emerges as a singer whose unflinching pursuit of musical and political freedom establishes her appeal for contemporary activism.

Simone’s androgynous voice, genre-breaking musicianship and political consciousness may have concerned ’60s and ’70s marketing executives and concert promoters, but those are a huge draw for today’s gay, lesbian, black and female artists who want to be taken seriously for their talent, their activism or a combination of both.

“Nina has never stopped being relevant because her activism was so right on, unique, strong, said with such passion and directness,” Ms. Garbus said in an interview at a Brooklyn bakery. “But why has she come back now?” she asked, answering her own question by pointing to how little has changed, citing the protests over the police killings of unarmed African-Americans like Michael Brown, Rekia Boyd, Eric Garner and Freddie Gray.

While Simone’s lyrical indictment of racial segregation and her work on behalf of civil rights organizations connects her to our contemporary moment, those closest to her felt more comfortable telling Simone’s story after her death in 2003. As Ms. Garbus said, “From a filmmaking point of view, the answer for her return is also because of the estate, and people being ready to relinquish some control of her story.”

In this case, it was Simone’s daughter, the singer and actress Lisa Simone Kelly, who shared personal diaries, letters, and audio and video footage with Ms. Garbus and has an executive producer credit on the film. Speaking by phone from her mother’s former home in Carry-le-Rouet, France, Ms. Kelly said: “It has been on my watch that this film was made. And I believe that my mother would have been forgotten if the family, my husband and I, had not taken the right steps to find the right team for her to remembered in American culture on her own terms.”

Ms. Kelly is only partly right. Over the last decade, a steady stream of reissued albums and previously unheard interviews and songs, as well as unseen concert footage have flooded the market. But the estate has enabled and impaired Simone’s revival. There has been a dizzying array of lawsuits over the rights to her master recordings in the last 25 years, a tangled situation that includes a recent Sony Music move to rescind a deal with the estate.

The most high-profile controversy about Simone’s legacy, however, involves Cynthia Mort’s biopic, “Nina,” due later this year. Starring Zoe Saldana in the title role, the film was initially beleaguered by public criticism over the casting, an antagonism further fueled by leaked photos of Ms. Saldana with darkened skin and a nose prosthetic. Eventually, the film’s release was set back even more by Ms. Mort’s own 2014 lawsuit against the production company, which she accused of hijacking the film, as The Hollywood Reporter put it.

Though Ms. Saldana told InStyle magazine that “I didn’t think I was right for the part,” the fallout and online petition calling for a boycott of the film nevertheless revealed a deep cultural investment in both Simone’s politics and aesthetics by a new generation.

The director Gina Prince-Bythewood said in a phone interview that she used Simone as the muse for her lead character, Noni (Gugu Mbatha-Raw), a biracial British pop sensation, in her 2014 film “Beyond the Lights” because “during her time, Nina was unapologetically black and proud of who she was, and it was reflected in the authenticity of songs like ‘Four Women.’ And this is something that Noni absolutely struggles with because she has been instructed to be a male fantasy.”

But for Ms. Prince-Bythewood, Simone is not simply an alternative to today’s image of an oversexualized or overmanufactured female artist, but the idol most suited for the multilayered identity politics of our social movements. “This moment of ‘Black Lives Matter,’ ” she said, “is a resurgence of racial pride but also a time in which black women are now at the forefront.”

Like the renaissance of interest in Malcolm X in the early 1990s, Simone’s iconography arises in yet another time of national crisis. However, her biography, as an artist who was proudly black but steadfastly rejected the musical, sexual and social conventions expected of African-American and female artists of her time, renders her a complicated pioneer.

Born Eunice Waymon in 1933, Simone grew up in segregated Tryon, N.C. At 3, she was playing her mother’s favorite gospel hymns for their church choir on piano; by 8, her talents garnered her so much attention that her mother’s white employer offered to pay for her classical music lessons for a year. Determined to become a premier classical pianist, Simone trained at Juilliard for a year, then sought and was denied admission to the Curtis Institute of Music in Philadelphia — a heartbreaking rejection that led to a series of reinventions — renaming herself Nina Simone, performing in Atlantic City nightclubs and adopting jazz standards in her repertoire.

She would go on to have her only Top 40 hit with “I Loves You, Porgy” in 1959 off her debut album, “Little Girl Blue.” To further her music career, Simone moved back to New York, where she befriended the activist-writers Lorraine Hansberry, James Baldwin, Langston Hughes and Malcolm X. Influenced by these political friendships and the momentum of the civil rights movement itself, Simone went on to compose “Mississippi Goddam” in 1964 in response to the assassination of the civil rights leader Medgar Evers in Mississippi and the murder of four African-American girls in a church bombing in Birmingham, Ala., a year earlier. The song was Simone at her best — a sly blend of the show tune, searing racial critique and apocalyptic warning.

Oh but this whole country is full of lies

You’re all gonna die and die like flies

I don’t trust you any more

You keep on saying “Go slow!”

“Go slow!”

Simone’s growing political involvement affected both her professional and personal life. Though she was bisexual, her longest romance was her 11-year turbulent marriage to Andy Stroud, a former police officer who managed her career for most of the ’60s. Stroud would use physical and sexual abuse to limit Simone’s activism and friendships, and to control her unpredictable emotional outbursts. Unfortunately, it would take another 20 years for Simone’s “mood swings” to be diagnosed as a bipolar disorder. In the interim, Simone left her marriage and country, becoming an expatriate in Liberia, Switzerland, then France. (In the film, Ms. Kelly says that because her mother became more symptomatic and abusive toward her, she had to move back in with her father.)

She had not only become more militant by aligning songs like “To Be Young, Gifted and Black” with Stokely Carmichael and the black power movement, but also found it increasingly difficult to secure contracts with American record companies. Looking back on this period in her 1991 memoir, “I Put A Spell on You,” Simone recalled, “The protest years were over not just for me but for a whole generation and in music, just like in politics, many of the greatest talents were dead or in exile and their place was filled by third-rate imitators.” She died in 2003 at her home in France.

“Nina Simone, more than anyone else, talked about using her art as a weapon against oppression, and she paid the price of it,” said Ernest Shaw, a visual artist who last year painted a mural featuring Malcolm X, James Baldwin and Simone on the wall of a Baltimore home just two miles from the scene of Freddie Gray’s arrest.

Today Simone’s multitudinous identity captures the mood of young people yearning to bring together our modern movements for racial, gender and sexual equality.

This is a large part of the appeal of the documentary “The Amazing Nina Simone,” by Jeff L. Lieberman, which features more than 50 interviews with Simone’s family, associates and academics (including me), scheduled to be released later this fall.

Mr. Lieberman said he wanted to explore the relationship between Simone and Marie-Christine Dunham Pratt, a former model and the only child of the dancer Katherine Dunham, because “many gay men and lesbians have long connected with Nina Simone because she was this outsider in her many worlds, sometimes sad, sometimes lonely, but always determined, and unrelenting in her fight for freedom.”

Still, the preoccupation with Simone has more to do with her sound than her life story. Those who have covered Simone on recent albums — including Algiers, a Southern gospel and punk band; Xiu Xiu, an experimental post-punk group; and Meshell Ndegeocello, the neo-soul, neo-funk artist — are remarkably different from one another. Their common use of Simone speaks to how her music cuts across race, gender and genre.

But it has been hip-hop, the genre that Simone once said had “ruined music, as far as I’m concerned,” that has kept her musically relevant more than anything else.

The two hip-hop artists most responsible for Simone’s current ubiquity are Kanye West and Lauryn Hill. Mr. West has rendered Simone hip-hop- and pop-friendly by sampling her in songs like “Bad News,” “New Day” and “Blood on the Leaves.” While he declined to comment on Simone, like her, he fashions himself as a controversial if not misunderstood rebel — a figure who wants to be appreciated as much for his refusal of artistic genres as for his musical virtuosity.

Ms. Hill was one of the first rappers to mention Simone in song — on the Fugees’ “Ready or Not” in 1996 — and she recorded several songs for “Nina Revisited: A Tribute to Nina Simone,” an album (due July 10) tied to “What Happened, Miss Simone?”

Jayson Jackson, Ms. Hill’s former manager and a producer of Ms. Garbus’s film, conceived “Nina Revisited,” and said that while working on the album, Ms. Hill told him, “I grew up listening to Nina Simone, so I believed everyone spoke as freely as she did.”

Paradoxically, Simone’s comeback also reveals an absence. A majority of pop artists — with the exception of a few like D’Angelo, J. Cole and Killer Mike — have largely been musically silent about police violence in Ferguson, Mo.; New York; and Baltimore.

John Legend, who covered Simone on his own 2010 protest album with the Roots, “Wake Up!,” and recently started Free America, a campaign to end mass incarceration in the United States, attributes this absence to artists unwilling or unable to take positions outside the mainstream. “I don’t think it is career suicide to take on these positions, but I think there is actually a limited number of artists who really want to say something cogent about social issues, so most do not even dive in,” he said in an interview.

He added, “To follow in her footsteps, I think it takes a degree of savvy, consciousness, communication skills, and a vibrant intellectual community that most artists aren’t encouraged to cultivate.”

Today, Simone’s sound and style have made her a compelling example of racial, sexual and gender freedom. As Angela Davis explained in the liner notes for the album, “In representing all of the women who had been silenced, in sharing her incomparable artistic genius, she was the embodiment of the revolutionary democracy we had not yet learned how to imagine.”

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Croatia’s Dalmatian Coast: From Sevid to Split

It’s a flawless day. My car winds along lanes edged with dry stone walls. It’s early season, the Mediterranean flora is still verdant and has yet to take on the bleached hues of late summer. I drive past the church and the road takes a sharp curve to the left. A black car is waiting. The platinum blonde within gestures for me to follow.

Another five minutes and I round a corner on to a delicious view. The Dalmatian coast is spotty. Inlets, islands, small bays, large bays reach out to sea and double back on themselves – a patchwork of land and water. In the distance a low-rise straggle of whitewashed villas with terracotta roofs follows the curve of Sevid’s bay out to a headland – an "almost island" in the shape of a cloven hoof. The water is sparkling, shading from turquoise near the shore to deeper aquamarines further out. All is tranquil. Too tranquil. Something doesn’t add up.

We turn on to a track that’s little more than a stream of poured concrete running down the hillside. It’s a bumpy ride. After a few more twists and turns, we pull up by the iron gate of a villa. My pathfinder ushers me in and hands over the keys. I have questions. We are less than half an hour from Split and its international airport – why is this idyllic spot so sleepy? Where are the holidaymaking hordes? But before I have a chance to gather my wits, she’s gone.

Primosten harbour (Getty) I should confess that the sinister voice on the phone belonged not to one of Ernst Stavro Blofeld’s sons but to Nikola – the owner of the villa. And the blonde is his wife, Daniela. But I am still left struggling with the Mystery of Sevid.

The villa itself occupies a grandstand position overlooking the bay. The terraces on both the first and ground floors make the most of the views. The interior is comfortable without being ostentatious – more of a weekend family home than a magnate’s palace.

The pool (one of only two in the locality I later learn) occupies pride of place in front of the house, leading the eye on to the greater expanse of the sea beyond. The steps and platforms around the pool have no handrails or safety gates, which brings out the health and safety inspector in me.

There is something wonderfully unfinished about Sevid. The absence of resort clutter is striking. The "beach" a few yards in front of the villa consists of a series of concrete platforms – their stark severity marginally mitigated by a scattering of sun loungers. Further up the causeway there is a sandy stretch but no promenade. The beach ends abruptly at the garden walls of holiday homes. There are no waterfront bars, no souvenir kiosks, not even a café. Eventually I find a small grocery store and a rather lumpen pizza parlour in a back street. And that’s the bright lights of Sevid done.

Luckily, the roadside gostionica (barbecue restaurants) are a fast-food feature of the area. The Tivoli, on the main highway from Marina to Sibenik, is a short drive away. It’s blazingly hot as we park and make our way to the terrace. Tivoli is evidently popular, with local families up to their elbows in promising greasy cuts.

We wait for our takeaway lamb on the terrace. There is thunder in the air and the distant roar gets steadily louder until the air is throbbing. It turns out to be a touring Harley-Davidson club. No sooner have they passed than a real storm brews. Thunder and lighting appear from nowhere and the sky goes black. Within seconds the deluge is upon us. The gutters are overflowing and huge salvos of water slam out of the sky like shrapnel. Safe under the rattling tin roof I enjoy a moment of schadenfreude, picturing the leather knights on their Harleys getting battered sideways down the road.

The takeaway duly appears and the storm passes as quickly as it arrived. There are rivers running down the road. However, as we make our way back to the coast it seems a miracle has occurred. Within a mile, over the hills, the roads are baking dry. The biblical storm was so pinpoint that a few hundred yards away there’s not even a wisp of cloud to disturb the Mediterranean idyll.

About 30 minutes up the coast, Primosten offers a teasing contrast to the soporific pace of Sevid. Both resorts are perched on slight hillocks connected to the mainland by a narrow causeway, but there the similarity ends. Primosten spills down the hill untidily from the bell tower of the 1485 St George’s church. On the sunset-facing west side is an elegant paved promenade offering sublime views along the Dalmatian coast and islands. There are cafés, souvenir emporia and beach bars. There is even a Butlin’s-style, Tito-era, workers’ fun palace on the other side of the lovely horseshoe bay, thumping out Euro house anthems, thankfully at a discreet volume. The quayside is buzzing with diners, chattering in the many tongues of Europe. In short – here is life.

Roman ruins and cathedral in Split (Getty) Back at the villa there is no noise of human origin. But there is entertainment. A thrilling aerial ballet arcs through the air as swifts, house martins and swallows line up to skim the surface of the pool picking off stranded insects. After sunset, there is a change of shift: the birds are replaced by bats, silent and barely discernible against the night. Moonbeams glitter on the sea, interrupted by the island of Arkandel, which forms a natural breakwater across the mouth of the south-facing bay. The darkness thickens around the silhouette of the headland – as does the plot. Why is Sevid snoozing while, just up the coast, Primosten parties?

Not just Primosten. Split, in the opposite direction, is also just 30 minutes away – the bright-lights, big city of the region. Its primary attraction is the extraordinary Diocletian’s Palace. Sprawling across 30,000 square metres, the citadel is a living museum (3,000 people do in fact live here) following the grid outlines of the Roman emperor’s original palace. Now it’s a mash-up of old stone from every period – Roman ruins, Romanesque towers, gothic this and baroque that. It’s the kind of place where you find yourself casually leaning on a 3,500-year-old Egyptian sphinx – one of three left lying around in the streets.

If it’s history you want, there’s an embarrassment of riches. Trogir is another gem. The island town is separated from the mainland by a narrow canal and is itself a stepping stone to the much larger island of Ciovo. A long, messy Mediterranean history of conquest and destruction is attached – but the cute lanes, civic buildings, piazzas and churches all scream of Venice, which ruled from 1420 for nearly 400 years. Unsurprisingly, the Unesco World Heritage site has served as a body double for the Venetian Republic in Doctor Who and as a generic medieval cityscape for Game of Thrones among its many screen credits.

But the movie that keeps replaying in my head is the Mystery of Sevid. The more I discover of the area, with its world heritage sites and outstanding coastal beauty, the more improbable Sevid seems – preternaturally immune to the encroachment of tourism.

I get my break when I go looking for the Lanterna restaurant. We’ve been led to believe the establishment exists but attempts to find it have led to a number of dead ends. Misdirections from well-meaning locals and an almost contemptuous lack of signage are to blame. One final push in the mini-maze of coastal tracks leads us down an impossible gradient to a secluded bay – and there it is.

Lanterna gets it business from the water, which explains why the owner, Jere Silber, is so relaxed about the signposting on land. A breeze is blowing in from the sea, ruffling the sun shades at the tables on the terraces. A couple of small yachts bob about on the swell a few metres off shore, and a few kids are splashing around the restaurant’s concrete jetty. It’s a soothing snapshot of the Mediterranean as it used to be.

In the distance on the left, the headland of Sevid is visible – the low‑key development, with the occasional three-storey holiday apartment block, draws a disapproving look from Jere. "I don’t mind if people build apartments – people need to make money. But there should be some rules," he says.

Jere explains that during the 1990s planning control was non-existent, and wealthy families from Split bought up plots in the area and built holiday homes as they saw fit. With so many properties, built in effect guerrilla style, the municipality eventually cut a deal. "They had an amnesty on illegal development last year," he says. "Ninety per cent of the houses here were built illegally. But the government couldn’t find a way to stop them. So – anything built before 1 July 2013 was allowed to stay."

He then reveals the answer to my question. "There is no water here – that is the biggest problem. There’s no garbage collection either." The secret is out. Water explains everything. With its ambiguous planning status, and lacking basic utilities, the resort could not grow. Even now water is trucked in at great expense. Surrounded by water as far the eye can see, it is the lack of running water that explains why time appears to have stood still in Sevid.

"It’s undeveloped," concludes Jere. "I hope it stays like this. If we had water, although it would be better for my business it would destroy the area." Mystery solved, I nod in mute agreement.

Getting there

Split is served from a range of UK airports by easyJet (0843 104 5000; easyJet.com), Jet2 (0800 408 1350; jet2.com), Croatia Airlines (020 8745 4683; croatiaairlines.com), British Airways (0344 493 0787; ba.com), Norwegian (0843 3780 888; norwegian.com/uk) and Wizzair (0906 959 0002; wizzair.com).

Staying there

Sankha Guha was a guest of Croatian Villas (020 8888 6655; croatianvillas.com), which offers rental of a four-bedroom villa with a pool in Sevid from £1,554 per week. It also offers car hire from around £80 per week.

More information

croatia.hr

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Mending Hearts: Putting Stents to the Test

Millions of Americans have had stents — small wire cages — inserted in their coronary arteries to prop them open. And many are convinced the devices are protecting them from heart attacks. After all, a partly blocked artery is now cleared, and the pain in a heart muscle starved of blood often vanishes once the artery is open again.

But while stents unquestionably save lives of patients in the throes of a heart attack or a threatened heart attack, there is no convincing evidence that stents reduce heart attack risk for people suffering from the chest pains known as stable angina. These are people who feel tightness or discomfort walking up a hill, for example, because a partly blocked coronary artery is depriving their heart of blood. But the pain or tightness goes away if they stop and rest or just stay still. And there is a reasonable argument that drugs — cholesterol-lowering statins in particular — might be just as good at reducing such pain.

“It is kind of amazing that we don’t have the evidence,” said Dr. David J. Maron, the director of preventive cardiology at Stanford.

Now, the National Heart, Lung and Blood Institute is trying to find out whether stents do in fact prevent heart attacks. The answer could change the standard of care for the more than half a million Americans annually who receive a new diagnosis of heart disease after they see a doctor for angina. Heart disease remains the biggest killer of Americans despite significant treatment advances in the past decade.

The typical treatment for angina is to thread a narrow catheter up from a blood vessel in the groin to the heart, squirt in a dye that allows a cardiologist to see blockages in arteries on X-rays, and then insert a stent in the blocked areas. Stents are safe but expensive. Medicare payments vary depending on what kind of stent is used and how many, but are generally above $10,000 and can be more than $17,000.

And stents are not always a permanent solution to chest pain, as Albert Nassar of Brooklyn discovered. When he had angina four years ago, the reason seemed clear and the solution straightforward. An angiogram — the test in which dye is injected into the coronary arteries — showed one was 90 percent blocked. When a doctor inserted a stent to open that artery, the pain vanished.

But three years later, Mr. Nassar, 59, again felt tightness in his chest as he rode a recumbent bike at the gym. He said he expected another stent, but his cardiologist surprised him. He told Mr. Nassar that the medical profession does not actually know if stents help people like him with moderate to severely blocked coronary arteries.

Then he asked Mr. Nassar if he would be part of the National Heart, Lung and Blood Institute clinical trial, known as Ischemia, and have his treatment decided randomly between two options. If he was assigned to one group, his doctors would look at his blocked artery with X-rays and open it mechanically with a stent or, if the X-rays showed he was among the minority whose blockage could not be opened with a stent, with bypass surgery. He would also be asked to take drugs and change his lifestyle to protect his heart. In the other, his treatment would consist solely of drugs and the lifestyle changes. There would be no peeking at his blockage.

Mr. Nassar leapt at the chance and when he was assigned to take the drugs — a statin, blood pressure drugs and an aspirin — he was delighted.

“I didn’t feel the urge to have another surgical procedure,” he said. “I’ve had enough of those.”

The idea that opening blocked arteries saves lives dates to the 1970s and ’80s. In those decades, neither stents nor statins were used. The only treatment for blocked arteries was bypass surgery, a major operation in which the ribs are split open and a patient is put on a heart-lung machine while the heart is stopped. A surgeon bypasses the blockage with a blood vessel taken from elsewhere in the body.

Studies at the time had found that surgery was better for patients with severe blockages of major coronary arteries than not having surgery.

Stents were introduced in the 1990s, and because they relieved pain and were far less invasive than bypass surgery, they became the treatment of choice. Doctors and patients started to believe they also saved lives in stable patients, though there was no solid evidence of that.

“The thought was better to go in and open it up,” said Dr. Harmony R. Reynolds, a cardiologist at NYU Langone Medical Center and a principal investigator in the study that Mr. Nassar joined. “But now meds have gotten so good that it is not clear surgery adds anything for stable patients.”

Researchers tried to get an answer with a big federal study, called Courage, that was published in 2007. But many cardiologists said the study was flawed and they did not believe its conclusion that stents failed to prevent heart attacks and deaths.

In Courage, as in the new study, participants were given stents and intensive drug therapy —– a statin, blood pressure drugs and aspirin — or just the medicines. The criticism, though, was that doctors may have cherry-picked patients for the study, excluding the sickest. Because angiograms revealed blockages in arteries before patients were invited to enroll in the trial, doctors who believed stents were lifesaving may never have asked patients with the most severe disease to join the study.

The result, skeptics said, was that most patients in the study were at such low risk that it did not matter which treatment they received. They were certain to do well, so the study proved nothing about whether stents worked.

Because of the doubts about that study and ingrained habits, medical practice was largely unchanged by its findings. A recent study, which analyzed recorded conversations between cardiologists and patients with stable angina, found that 75 percent of the cardiologists recommended stents and when they did, their patients almost always complied. And, the study found, on the rare occasions when the cardiologists presented both stents and medical treatment as options, none of the patients chose stenting.

The new study aims to avoid the methodological flaw in the 2007 Courage study. Patients who agree to participate are not given angiograms before being assigned a treatment. Instead, they are accepted into the trial on the basis of noninvasive tests that indicate blocked arteries and high risk of a heart attack. Their doctors know only that an artery is blocked — not which one or how much — so they are not able to pluck out patients they believe need stents and prevent them from entering the trial.

Underlying the debate about the utility of stents is an uncertainty about how and why heart attacks occur.

For years, the common notion was they were caused by a plumbing problem. In this view, plaque — pimplelike lumps — partly blocked a coronary artery and grew until no blood could get through, and a stent was needed to open an artery before it closed completely.

But a leading hypothesis says there is no predicting where a heart attack will originate. It could start anywhere there is plaque, even if the plaque is not obstructing the flow of blood in an artery. Unpredictably, a piece of plaque can burst open. Blood starts to clot on the injured area. Soon, the blood clot clogs blocks the artery. The result is a heart attack.

It is known that certain plaques, with thin walls and bursting with fat-filled white blood cells, are prone to rupture. A study published in 2011 found that only a third of heart attacks originated in plaques that were blocking at least half of an artery, as seen on an angiogram. The rest began with the rupture of plaques that appeared to be causing no problems.

According to this view of how and why heart attacks happen, stenting would not be protective because people with atherosclerosis have arteries studded with plaque. The partly blocked area visible in an angiogram is no more likely to be the site of a heart attack than any other with plaque. But statins could work because they change the nature of plaques, making them less likely to rupture.

Although stents relieve chest pain, today’s medical therapy can, too, though it may take weeks or months.

But proving whether stents make a difference is turning out to be harder than expected. Many doctors and patients have such strong opinions about the value of stenting that recruitment for the new study has been difficult. Stents have become part of the fabric of heart disease care. Former President George W. Bush, for example, had a treadmill stress test in the summer of 2013 as part of a physical examination. When the test indicated he might have a blocked artery, he had an angiogram. It showed a partial blockage that a cardiologist opened with a stent.

The challenge now is to get Ischemia done and get some answers that might not be disputed. In the past two years, researchers randomized nearly 2,000 patients for the trial at the 300 participating medical centers. The plan is to randomize 8,000 patients over four years. Columbia has randomized one patient; NYU Langone has randomized 24.

“Cardiologists think this is a very important study intellectually,” said Dr. Maron, who is one of the study’s authors. “But when it comes to their own patients, some cardiologists balk, even though they know we don’t have the answer.”

The issue potentially affects many heart patients.

“Half the people over 65 have blockages,” Dr. Gregg W. Stone, an interventional cardiologist at Columbia, said. “If you have some degree of atherosclerosis, you have blockages.”

And once a stress test or an angiogram reveals a blockage, it can be hard to ignore a partly blocked artery, hard to avoid thinking a stent has to help.

“People believe that if they have a blockage, they have to fix it mechanically,” said Dr. Judith S. Hochman, the study chairwoman for the Ischemia trial and a cardiologist at NYU Langone. “It seems logical, but in medicine, many things that seem logical are not true.”

Not only do cardiologists find it hard to fight their own feelings that stenting makes sense, they also find it hard to persuade patients to try medical therapy, said Dr. Brahmajee Nallamothu, an interventional cardiologist at the University of Michigan.

The concept that stenting helps, he said, “is a paradigm so deeply set on the part of the public and a lot of doctors that it is tough to overcome.”

Mr. Nassar was one of the rare patients who did not hesitate to enter the trial. Though stents had relieved his pain in the past, they were no panacea. Like most heart patients, he had never taken the most important drug for those with his condition: a statin.

So far, he says he is happy with his drug treatment. His angina is gone.

“I feel no pain,” he said.

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Q&A: The Inevitability of Yellow Teeth

Q. Why do teeth turn yellow with age? Is there any way to prevent it?

A. Besides the cumulative effect of the many external causes of tooth discoloration over a lifetime, there are at least two structural changes that make teeth more likely to appear yellow as someone grows older. These are the gradual thinning of the enamel, the outer coating of the tooth, and the thickening of the layer under that, called the dentin.

As the enamel thins because of wear and tear and things like acidic foods, the natural yellow-to-brown color of the dentin it covers shows through more and more, according to a review of the literature on tooth discoloration published in The British Dental Journal in 2001.

The yellowing may be more or less obvious, depending on the genetically determined natural color of the dentin and the thickness of the enamel. A further complication is that once the dentin is exposed, other coloring agents are more easily absorbed by teeth.

Meanwhile, “the natural laying down of secondary dentin affects the light-transmitting properties of teeth, resulting in a gradual darkening of teeth with age,” the review continues.

That process cannot be stopped, but care can be taken to minimize enamel loss. Many of its causes are avoidable or treatable, like dry mouth; excessive consumption of sugars, acids and alcohol; bulimia; teeth grinding; and acid reflux disease.

There are many other causes of discoloration, among them inherited and metabolic disorders that affect tooth structure even before old age. Discoloration can also result from certain drugs, like tetracycline taken by children when their teeth are developing, or absorbed while they are in the womb. Beverages like tea, coffee and red wine and foods like blackberries are also well known to discolor the teeth, as is tobacco in any form.question@nytimes.com

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The seven US states still living under Confederacy flags

Defenders of the flag say it’s a symbol of Southern heritage. Detractors maintain that hatred and racism are an inextricable part of that heritage. With all the focus on South Carolina, it’s easy to forget that Confederate symbolism still adorns many official state flags in the South. Some states, like Georgia and Mississippi, have seen fierce political battles over explicit Confederate imagery in their flags. In other states, the references are subtler.

As of the 2010 Census, these state were home to about 60 million Americans — including 12 million African-Americans, meaning roughly one third of the nation’s black population lives under a state flag that evokes, at least in the eyes of many, the Confederacy. Take a look below.

Alabama

The red cross of the Alabama flag, adopted in 1895, was designed to evoke the battle flag of the Alabama infantry in the Civil War. That’s according to a written account of the flag’s history given by the attorney general of Alabama in 1987.

Arkansas

The Arkansas state flag was officially adopted in 1913, according to the Arkansas Secretary of State. There were initially three blue stars "representing that Arkansas belonged to three countries (France, Spain, and the United States) before attaining statehood." The secretary of state noted "1803 was the year of the Louisiana Purchase when the land that is now Arkansas was acquired by the United States; and Arkansas was the third state created from the purchase by the United States, after Louisiana and Missouri."

But 10 years later, trouble brewed when legislators realized that "there was no indication on the flag the Arkansas had been a member of the Confederate States of America from 1861 to 1865." So a fourth star was added, above the word Arkansas.

"The lone star above the word is to commemorate Arkansas’s membership in the Confederacy," wrote the Secretary of State.

Florida

Florida’s flag is similar to Alabama’s, consisting of a state seal over a red cross. The cross was added to the flag a few years after Alabama adopted its flag, at the suggestion of Governor Francis P. Fleming. Fleming had enlisted in the Confederate army in his youth, and some historians see his choice of the cross as an attempt to memorialize the confederacy.

Georgia

Georgia’s flag has a long and complicated history. The Confederate battle flag was incorporated in to the state flag’s design in 1956, a symbol of the state’s opposition to racial integration, according to a report by the state Senate in 2000. The design was changed by the legislature in 2001, over the stiff opposition of the Sons of Confederate Veterans and other groups.

In 2002, Sonny Perdue was elected Governor of Georgia, partly by promising voters a referendum on the new flag. In the end, the legislature changed it to a new design: it consists of the first national flag of the Confederacy (the "Stars and Bars") with the addition of the Georgia seal.

Mississippi

Mississippi remains the only state incorporating the Confederate battle flag into its state flag design. It was adopted in 1894.

In 2001, a voter referendum was held to determine whether to keep the existing flag, or to adopt a new flag design removing Confederate elements. Voters opted to keep the existing flag by nearly a two-to-one margin.

North Carolina

The current North Carolina state flag was adopted in 1885. It closely resembles the flag adopted in 1861, shortly after North Carolina seceded from the Union. The first date on the flag, May 20, 1775, is the date of the so-called Mecklenburg Declaration, a purported statement of independence from Great Britain that happened in North Carolina, although the exact nature of the declaration is disputed.

But during the Civil War, Southern secessionist leaders evoked the Mecklenburg Declaration as a parallel to the South’s declaration of independence from the North. Addressing a crowd in Charlotte, N.C., Jefferson Davis is reported to have said "people of this section were the first to defy British authority and declare themselves free."

In the original flag, the second date was May 20th, 1861 — the date of North Carolina’s withdrawal from the Union. In 1885, that date was changed April 12, 1776 — the date of the Halifax resolves, when North Carolina officially called for independence from Great Britain.

Tennessee

The Tennessee Legislature adopted the current flag in 1905. In a 2013 article, vexillologist Steven A Knowlton argues that "the Tennessee flag has pragmatic unity with the Confederate flag: both share the element of white stars inside a fimbriated blue charge, and the element of that blue charge on a red field." He also notes a resemblance between the flag’s vertical bars and the vertical bar of the third national flag of the Confederacy.

But he concludes that one interesting aspect of the Tennessee flag is plausible deniability: "it is reasonable to say a logo is only expressing Tennessee pride, even if deeper symbolic recognition does link it to Confederate imagery."

Copyright: Washington Post

Read more: Confederate flag fight reaches US Supreme Court
What John Oliver thinks should happen to the Confederate Flag

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