The New Old Age Blog: The Reluctant Caregiver

Now and then, I refer to the people that caregivers tend to as “loved ones.” And whenever I do, a woman in Southern California tells me, I set her teeth on edge.

She visits her mother-in-law, runs errands, helps with the paperwork — all tasks she has shouldered with a grim sense of duty.  She doesn’t have much affection for this increasingly frail 90something or enjoy her company; her efforts bring no emotional reward. Her husband, an only child, feels nearly as detached. His mother wasn’t abusive, a completely different scenario, but they were never very close.

Ms. A., as I’ll call her because her mother-in-law reads The Times on her computer, feels miserable about this. “She says she appreciates us, she’s counting on us. She thanks us,” Ms. A. said of her non-loved one. “It makes me feel worse, because I feel guilty.”

She has performed many services for her mother-in-law, who lives in a retirement community, “but I really didn’t want to. I know how grudging it was.”

Call her the Reluctant Caregiver. She and her husband didn’t invite his parents to follow them to the small city where they settled to take jobs. The elders did anyway, and as long as they stayed healthy and active, both couples maintained their own lives. Now that her mother-in-law is widowed and needy, Ms. A feels trapped.

Ashamed, too. She knows lots of adult children work much harder at caregiving yet see it as a privilege. For her, it is mere drudgery. “I don’t feel there’s anybody I can say that to,” she told me — except a friend in Phoenix and, anonymously, to us.

The friend, therapist Randy Weiss, has served as both a reluctant caregiver to her mother, who died very recently at 86, and a willing caregiver to her childless aunt, living in an assisted living dementia unit at 82. Spending time with each of them made Ms. Weiss conscious of the distinction.

Her visits involved many of the same activities, “but it feels very different,” she said. “I feel the appreciation from my aunt, even if she’s much less able to verbalize it.” A cherished confidante since adolescence, her aunt breaks into smiles when Ms. Weiss arrives and exclaims over every small gift, even a doughnut. She worked in the music industry for decades and, despite her memory loss, happily sings along with the jazz CDs Ms. Weiss brings.

Because she had no such connection with her mother, whom Ms. Weiss described as distant and critical, “it’s harder to do what I have to do,” she said. (We spoke before her mother’s death.) “One is an obligation I fulfill out of duty. One is done with love.”

Unlike her friend Ms. A, “I don’t feel guilty that I don’t feel warmly towards my mother,” Ms. Weiss said. “I’ve made my peace.”

Let’s acknowledge that at times almost every caregiver knows exhaustion, anger and resentment.  But to me, reluctant caregivers probably deserve more credit than most. They are not getting any of the good stuff back, no warmth or laughter, little tenderness, sometimes not even gratitude.

Yet they are doing this tough work anyway, usually because no one else can or will. Maybe an early death or a divorce means that the person who would ordinarily have provided care can’t. Or maybe the reluctant caregiver is simply the one who can’t walk away.

“It’s important to acknowledge that every relationship doesn’t come from ‘The Cosby Show,’” said Barbara Moscowitz when I called to ask her about reluctance. Ms. Moscowitz, a senior geriatric social worker at Massachusetts General Hospital, has heard many such tales from caregivers in her clinical practice and support groups.

“We need to allow people to be reluctant,” she said. “It means they’re dutiful; they’re responsible. Those are admirable qualities.”

Yet, she recognizes, “they feel oppressed by the platitudes. ‘Your mother is so lucky to have you!’” Such praise just makes people like Ms. A. squirm.

Ms. Moscowitz also worries about reluctant caregivers, and urges them to find support groups where they can say the supposedly unsay-able, and to sign up early for community services — hotlines, senior centers, day programs, meals on wheels — that can help lighten the load.

“Caregiving only goes one way – it gets harder, more complex,” she said. “Support groups and community resources are like having a first aid kit. It’s going to feel like even more of a burden, and you need to be armed.”

I wonder, too, if reluctant caregivers have a romanticized view of what the task is like for everyone else. Elder care can be a wonderful experience, satisfying and meaningful, but guilt and resentment are also standard parts of the job description, at least occasionally.

For a reluctant caregiver, “the satisfaction is, you haven’t turned your back,” Ms. Moscowitz said. “You can take pride in that.”

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

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DealBook: Court Gives Investor an Edge in a Lawsuit Against Apple

7:47 p.m. | Updated

In the battle between Apple and the hedge fund manager David Einhorn, score a point for the billionaire who is taking up the mantle of shareholder advocate.

A federal judge said on Tuesday that he was leaning toward Mr. Einhorn’s contention that Apple had violated securities regulations by bundling several shareholder proposals into one matter.

A lawsuit by Mr. Einhorn’s Greenlight Capital, filed this month in Federal District Court in Manhattan, argues that Apple improperly grouped a vote to eliminate the company’s ability to issue preferred stock at will with other initiatives that Mr. Einhorn supports.

While the judge overseeing the case, Richard J. Sullivan, did not immediately grant Mr. Einhorn’s request for a halt to the vote, he said that the facts of the case favored the investor’s interpretation.

“I think success on the merits lies with Greenlight,” Judge Sullivan said at the end of a nearly two-hour hearing. Earlier in the hearing, he implied that he believed Securities and Exchange Commission rules prohibited the bundling of disparate shareholder initiatives.

Spokesmen for Greenlight and Apple declined to comment after the hearing.

Though a small point in the skirmish between Apple and Mr. Einhorn, the judge’s comments may provide some ballast to the hedge fund manager’s call to other investors. Mr. Einhorn’s bigger goal is to persuade Apple to return some of its $137 billion cash trove to shareholders.

He has asked Apple to issue preferred shares, which would pay out billions of dollars in dividends over time. His lawsuit revolves around the technology giant’s proposal to eliminate “blank check” preferred shares that the company can issue without a shareholder vote. He argues that the company improperly bundled the plan with two other corporate governance changes that he supports.

Apple has said that it will consider Mr. Einhorn’s request, but that it has no plans to amend the shareholder proposal.

Judge Sullivan is expected to decide within days whether to grant a preliminary injunction, given the Feb. 27 cutoff for voting on Apple’s shareholder proposals.

A lawyer for Mr. Einhorn, Mitchell P. Hurley of the firm Akin Gump, argued during Tuesday’s hearing that his client would suffer “irreparable harm” if the vote were allowed to proceed, because he would be forced to vote against two matters he would ordinarily support.

During questioning, however, Judge Sullivan expressed skepticism about the need to take immediate action.

A lawyer for Apple, George Riley of O’Melveny & Myers, said in court that if shareholders approved the disputed initiative, the company would wait for the judge to rule before adopting the new measures in its corporate charter.

Judge Sullivan also questioned why Mr. Einhorn had waited so long to act. He filed suit on Feb. 6, over a month after Apple first disclosed its shareholder proxy.

A version of this article appeared in print on 02/20/2013, on page B2 of the NewYork edition with the headline: Court Gives Investor an Edge In a Lawsuit Against Apple.

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Activists Say Syrian Missile Strike Kills 8

BEIRUT (AP) — A Syrian missile strike leveled a stretch of buildings and killed at least eight people in the city of Aleppo, anti-regime activists said Tuesday.

Videos posted online showed scores of men searching the destroyed buildings in the Jabal Badro neighborhood for the dead and wounded. One man swung a sledgehammer to break through concrete while a bulldozer hauled off rubble. In another video, a man covered in grey dust struggled under pile of concrete.

The Britain-based activist group Syrian Observatory for Human Rights and the Aleppo Media Center reported at least eight dead in the attack late Monday night, saying the strike appeared to be from a ground-to-ground missile.

Aleppo activist Mohammed al-Khatib said via Skype that the death toll could rise further as residents search the site for more bodies.

"There are still many martyrs under the rubble. ... There are still lots of people missing from the area," he said.

He said the strike appeared to be from a large ground-to-ground missile because of the scale of the destruction and because residents did not report hearing a fighter jet, as they usually do during airstrikes.

Although President Bashar Assad's forces regularly shell and launch airstrikes on areas held by anti-government rebels, their use of large missiles has been limited.

In December, U.S. and NATO officials confirmed rebel reports that Syrian forces had fired Scud missiles at rebel areas in northern Syria. That was the last confirmed use of such weapons.

Also Wednesday, rebels clashed with government forces near Aleppo's international airport and the Kweiras military airport nearby, the Observatory said. Clashes have halted air traffic to the two airports for weeks, since rebels launched their offensive to try to capture them.

The Observatory also reported government shelling and airstrikes and clashes between government forces and rebels east and south of the capital, Damascus.

The Syrian state news agency said the army had carried out "successful operations against terrorists" in Aleppo, mentioning a number of neighborhoods that did not include Jabal Badro.

Syria refers to rebels seeking to topple Assad as "terrorists" and blames the conflict on an international conspiracy to weaken the country.

The U.N. says some 70,000 have been killed since Syria's uprising against Assad's rule began in March 2011.

On Monday, U.N. investigators called on the Security Council to refer Syria to the International Criminal Court, after issuing a report that accused elements on both sides of committing atrocities.

The 131-page report by the U.N.-appointed Commission of Inquiry on Syria detailed deepening radicalization by both sides, who increasingly see the war in sectarian terms and rely on brutal tactics to advance their cause, spreading fear and hardship among civilians.

The report accused both sides of atrocities, but said those committed by rebel fighters have not reached the "intensity and scale" of the government's violations.

The report also accused both sides of using child soldiers, citing the presence of fighters younger than 18 on the government side and under 15 among the rebels.

The commission said it will submit a new, confidential list of Syrians suspected of committing crimes against humanity to the U.N. high commissioner for human rights, Navi Pillay, next month.

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TV special shows glory, trauma of military dogs

LOS ANGELES (AP) — It's been almost seven months since a bomb exploded on a strip of dirt in Kandahar Province, Afghanistan. Air Force Tech. Sgt. Leonard Anderson can only remember a reassuring voice.

He has seen the ambush and its aftermath on film, though: The man behind the voice putting a tourniquet on Anderson's leg as a medic tended to the other, listening to his own cries for help and his dog's whines of worry.

The blast that severely wounded the military dog handler was captured on film by one of four camera crews that were embedded with front line troops last year. The voice that reassured him belonged to Craig Constant, a cameraman for Animal Planet's "Glory Hounds" TV special, which airs Thursday.

It took the network a year to get permission to film the two-hour special, which followed the animals into combat zones where insurgents and buried explosives could be around any bend or under any pile of dirt.

Military dogs are prized targets for Taliban insurgents, Anderson said. They sniff out bombs, making safe passage for troops to follow and saving countless lives. The U.S. Department of Defense calls each dog a piece of equipment, but Constant says they're much more than that.

"They call them tools, and they are not. They are soldiers. They just have four paws instead of two feet. They walk in front of the platoons. It's a deadly game, and they die all the time. But they save lives by finding IEDs that technology can't find," said Constant, referring to the military terminology for improvised explosive devices.

Anderson became the handler for an 8-year-old Belgian Malinois named Azza when he asked for the job as kennel master at the base in Sperwan Ghar, said the 29-year-old who loves animals.

The breed is among four — including Dutch shepherd, German shepherd and Labrador retriever — that is commonly used by the military because they are of similar size and temperament, easy to train and enjoy working, said Ron Aiello, president of the U.S. War Dogs Association.

Azza became a military dog when she was 3 and detecting explosives was her specialty, said Anderson.

On the day of the blast, early morning on July 28, Azza and Anderson were about a mile from the base camp. They didn't need to go into the field — Anderson's job was to assess daily needs, plot routes and assign teams. But the self-described adrenaline junkie said he couldn't do his job if he didn't know where his men and dogs were headed and what they were facing.

Constant and his sound technician were about 10 feet behind them when the bomb went off. Military experts who examined the blast site said it was activated by remote control, not set off by touch.

But the dog bore the guilt: Constant remembers most vividly the anguished look on her face and her whines.

"Azza just looked at him. She had a human face. She was helpless. She was concerned. She was fixated on him," Constant said.

The explosion knocked the camera out of Constant's hands. He picked it up, planning to film, but dropped it when he saw Anderson.

"I don't know how he survived. There was a 6-foot-by-5-foot crater, and he was right on top of it," said Constant, who suffered ear drum damage and shrapnel wounds. The sound technician was wounded in the leg.

Anderson slipped in and out of consciousness while a medic and Constant, who is a former Marine, worked on his legs. Azza watched and whined.

"The only thing I remember from that day is Craig's voice talking to me telling me to 'calm down,' 'be easy,' 'it's going to be all right,'" Anderson said. "I woke up in Texas and that's when I asked, 'Where is my dog?' and 'What's going on?'"

Anderson doesn't know how many surgeries he had in Afghanistan, Germany and San Antonio, Texas, but he estimates around 20 based on what doctors and relatives have told him. He lost his left forearm and four fingers on his right hand, suffered upper body injuries and lost the skin on both legs.

Azza has been retired and was adopted by Anderson, his wife and their sons, ages 1 and 2. Memories of combat still haunt her, he said.

"She has some pretty bad nightmares, moving, breathing real heavy. I will slowly wake her up. She will get up and pace the house," he said.

Constant believes "Glory Hounds" shows the importance of dogs and their combat work.

"They really showed the truth and consequences of what these guys do. It's sad to watch because the story is told as much as you can tell it in two hours," he said.

His only regret from filming the show was that he didn't have his camera trained on Azza while they were helping Anderson.

"I wish to God I could have shot that. I wish I could have gotten that on film," Constant said. "It would have changed people's ideas about dogs" being viewed as merely equipment or property, he added.

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"Glory Hounds" airs Thursday at 8 p.m. ET/PT and repeats on Feb. 24 at 9 a.m. ET/PT.

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Online:

http://www.animalplanet.com

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National Briefing | South: Abortion Curbs Clear Senate in Arkansas

The State Senate voted 25 to 7 on Monday to ban most abortions 20 weeks into a pregnancy. The measure goes back to the House to consider an amendment that added exceptions for rape and incest. The legislation is based on the belief that fetuses can feel pain 20 weeks into a pregnancy, and is similar to bans in several other states. Opponents say it would require mothers to deliver babies with fatal conditions. Gov. Mike Beebe has said he has constitutional concerns about the proposal but has not said whether he will veto it.

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European Parliament Approves Plan to Bolster Carbon Trading

LONDON — In a move to bolster the floundering European market for carbon offsets, the environmental committee of the European Parliament voted Tuesday to allow the European Commission to reduce the numbers of carbon permits that it auctions in the next three years.

Prices of carbon allowances, which permit companies to emit greenhouse gases, plunged below €3, or about $4, per ton last month, compared to around €30 per ton in 2008 and about €9 per ton a year ago.

Many analysts think that setting a hefty price on carbon will prove the most efficient way to reduce emissions. The European system is the world’s flagship program and its struggles could have negative implications for other countries that are considering similar efforts, including the United States.

The vote Tuesday, by an unexpectedly decisive 38 to 25 with two abstentions, is “a lifeline for the carbon market and for emissions trading as a policy tool for curbing emissions,” said Stig Schjoelset, head of carbon analysis at Reuters Point Carbon, a market research firm in Oslo. Mr. Schoelset added that if the vote had gone the other way, the system would have been “more or less dead.”

Although this vote is only a first step, politicians and analysts said it might allow the European Union program to begin recovering credibility with markets as a means to curb emissions.

“It is important that we get this right, and the sooner we get it right the better,” the E.U. climate action commissioner, Connie Hedegaard, said during an interview Monday.

Prices for carbon allowances on the Emissions Trading System, the world’s premier cap and trade program, fell to as low as €2.8 per metric ton last month. After the vote Tuesday prices were about €4.5 per ton, after closing at €5.13 per ton on Monday.

The proposal approved Tuesday would take 900 million carbon credits that were scheduled to be auctioned over 2013 to 2015 and “backload” them to 2019 and 2020 in order to put a floor under prices. It is estimated that there is now a surplus of 2 billion credits, so this move will not soak up all of the carbon allowance glut.

The changes will need to be approved later by the full Parliament and member states.

“It is really the first step in a long, long process,” said Kass Burchett, an analyst at IHS, an energy research firm.

The European Trading System was set up by the European Union to provide a signal to polluters like utilities and heavy manufacturers that they needed to reduce carbon emissions. Companies are either allocated or required to buy at auction enough credits to offset their annual emissions. The trouble is that with Europe’s dismal economy dampening industrial activity and energy use, there is now a huge surplus of allowances, or credits, depressing their price.

Industrialists and analysts say that single-digit prices do not provide the intended incentive for companies to switch to cleaner fuels and energy-efficient technology. Mr. Schoelset said that to encourage switching from coal to natural gas, a price of €30 to €40 per ton is needed, while an even higher level of perhaps €60 to €150 per ton is required for utilities to invest in expensive carbon–reducing technologies like carbon capture and storage.

“The vote signals the intention of the European Parliament to begin the process of restoring the most cost-effective approach to meeting Europe’s energy needs and reducing emissions over time,” David Hone, chief climate change adviser to the oil giant Royal Dutch Shell, said in a statement. “It will not immediately restore the system to good health, but it is a start.”

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Chávez Returns to Venezuela After Cancer Surgery in Cuba

Jorge Silva/Reuters

Supporters of Venezuela's president, Hugo Chavez, outside a military hospital where he was taken following his return to Caracas on Monday.

CARACAS, Venezuela — President Hugo Chávez made a surprise return to Venezuela on Monday, 10 weeks after leaving for cancer surgery in Cuba, sparking celebration among his supporters.

VTV, the government television station, said that he arrived at 2:30 a.m. He was taken to a military hospital in Caracas.

"We have arrived again in Venezuela," said a post at 3:42 a.m. on Mr. Chávez’s long-dormant Twitter account. "Thank you, my God!! Thank you, beloved people!! We will continue treatment here."

Mr. Chávez, 58, has been out of sight and silent since his Dec. 11 surgery, plunging the country into increasing uncertainty.

Unlike returns from Cuba, the government did not televise his arrival or release video or photographs nor did he address the country.

Officials said on Friday that because of a breathing tube in Mr. Chávez’s throat he had difficulty speaking. Also on Friday, officials released photographs of Mr. Chávez for the first time since his surgery. The photographs showed him lying in a hospital bed flanked by two of his daughters.

"We are very happy," Vice President Nicolás Maduro said in an early morning telephone call to the government television station.

"He is an example of permanent battle and here we have him in Caracas, in our Caracas, in our Venezuela, here he is, our commander."

However, when he was asked by a television announcer for information on Mr. Chávez’s condition, Mr. Maduro declined to provide details.

A short time later, Information Minister Ernesto Villegas led a celebration in response, calling members of the station staff onto a set and chanting "He returned! He returned!"

Another post on the president’s Twitter account thanked the Cuban leaders Fidel and Raúl Castro and added, "Thanks to Venezuela for so much love!!!"

"I am holding tight to Christ and confident in my doctors and nurses," a third post said. "We will live and we will win!!!"

Monday’s posts were the first on Mr. Chávez’s Twitter account since Nov. 1.

He was re-elected Oct. 7 but on Dec. 8 he shocked the nation by announcing that his cancer had returned and he would have to go to Cuba for emergency surgery. He left on Dec. 10 and had the operation the next day.

His long absence has left the country in the grips of uncertainty. He was unable to return to be sworn in for the start of his new term on Jan. 10. The country has been run since his departure by Vice President Nicolás Maduro, National Assembly President Diosdado Cabello and a group of government ministers.

The opposition has protested vehemently, charging that the arrangement is unconstitutional and asking for more detailed information about the president’s health. In recent days, a group of 21 students had chained themselves together in protest in front of the Cuban embassy in Caracas.

The government has never said what type of cancer Mr. Chávez has or where exactly in his body it occurred, although they have said that his recent surgery, his fourth since June 2011, was followed by complications, including bleeding and a severe lung infection.

On Friday Science and Technology Minister Jorge Arreaza, who is married to one of Mr. Chávez’s daughters, said the president was undergoing palliative treatment. He did not elaborate.

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Singer Mindy McCready dies in apparent suicide

HEBER SPRINGS, Ark. (AP) — Perhaps there was one heartbreak too many for Mindy McCready.

The former country star apparently took her own life Sunday afternoon in Heber Springs, Ark. Authorities say McCready died of a suspected self-inflicted gunshot to the head and an autopsy is planned. She was 37, the mother of two young sons.

If confirmed, it was at least her fourth suicide attempt since 2005, ending a series of tumultuous public events that marked much of the singer's adult life.

Speaking to The Associated Press in 2010, McCready smiled wryly while talking about the string of issues she'd dealt with over the last half-decade.

"It is a giant whirlwind of chaos all the time," she said of her life. "I call my life a beautiful mess and organized chaos. It's just always been like that. My entire life things have been attracted to me and vice versa that turn into chaotic nightmares or I create the chaos myself. I think that's really the life of a celebrity, of a big, huge, giant personality."

This time it seems the whirlwind overwhelmed McCready.

Her death comes a month after that of David Wilson, her longtime boyfriend and the father of her youngest son. He is believed to have shot himself on the same porch of the home they shared in the small wooded community of large lakefront houses about 65 miles north of Little Rock, Ark., and his death also was investigated as a suicide.

It was the most difficult moment in a life full of them. McCready issued a statement last month lamenting his death. And she called him her soul mate and a caregiver to her sons in an interview with NBC's "Today" show.

"I just keep telling myself that the more suffering that I go through, the greater character I'll have," she said, according to a transcript of the interview.

Like so many times before, McCready showed a little toughness in the midst of a personal storm, again endearing herself to her fans. But as usual, the brave face for the camera hid a much more complicated internal struggle that surfaced publicly time and again over the last 10 years.

This time, along with her remembrances of finding Wilson as he lay dying, she also answered questions about whether they'd argued earlier that evening about an affair and if she'd shot him.

"Oh, my God," the "Today" transcript reads. "No. Oh, my God. No. He was my life. We were each other's life."

It's unclear what circumstances led to McCready taking her own life, but it appears she was struggling again with twin issues that have persisted for years — substance abuse and the custody of her children. She checked into court-ordered rehab and gave her children up to foster care earlier this month after her father asked a judge to intervene, saying she'd stopped taking care of herself and her sons and was abusing alcohol and prescription drugs.

It's not clear where her sons, 6-year-old Zander and infant Zayne, were Sunday.

A deputy stationed outside McCready's home Sunday night referred questions to the Cleburne County sheriff, who was unavailable. Yellow crime-scene tape cordoned off the front yard and a dark-colored pickup truck sat in the driveway.

News of McCready's death spread quickly Sunday night on Twitter, with major country stars paying their respects to the onetime Nashville darling.

"Too much tragedy to overcome. R.I.P Mindy McCready," wrote Natalie Maines of The Dixie Chicks.

And Carrie Underwood added: "I grew up listening to Mindy McCready...so sad for her family tonight. Many prayers are going out to them..."

Melinda Gayle McCready arrived in Nashville in 1994 still in her teens with tapes of her karaoke vocals and earned a recording contract with BNA Records. She had a few memorable moments professionally, scoring her first No. 1 hit almost immediately.

"Guys Do It All the Time," a self-assured dig at male chauvinism, endeared her to female fans in 1996. She also scored a hit with "Ten Thousand Angels," and her album of that title sold 2 million copies.

Beyond that, though, she's mostly remembered for a string of dramatic moments as she spent the next 15 years chasing another huge hit. Her problems included a custody battle with her mother over one of her sons, arrests, overdoses and discord in her love life.

She made headlines in April 2008 when she claimed a longtime relationship with baseball great Roger Clemens. Published reports at the time said she met the pitcher at a Florida karaoke bar when she was 15 and he was 28 and married. Clemens denied the relationship. A decade earlier she was engaged to actor Dean Cain, but the two never married.

She also had a turbulent relationship with Billy McKnight, a country singer who is the father of her oldest son. McKnight was arrested in 2005 on charges of attempted murder after authorities say he beat and choked her.

During this period she also pleaded guilty to obtaining the painkiller OxyContin fraudulently at a pharmacy and got probation. She violated the probation with a drunken driving arrest in May 2005, a few days before McKnight was arrested. And in July 2007, she was arrested in her hometown of Fort Myers, Fla., on misdemeanor charges of scratching her mother, Gayle Inge, on the face during a scuffle and resisting sheriff's deputies.

Less than a year later, McCready was arrested and charged with violating her probation by falsifying her community service records relating to the 2004 drug charge. A month later, she entered an extended care facility for undisclosed treatment, and followed that with a 60-day jail sentence. Inge took custody of Zander.

There were at least three suicide attempts between July 2005 and December 2008.

She tried to get help in an unusual way, joining the cast of "Celebrity Rehab 3" with Dr. Drew Pinsky. McCready came off as a sympathetic figure during the show's run. Pinsky called her an "angel" and in an interview in 2010 said it appeared McCready was doing "rather well."

Pinsky helped treat McCready for love addiction on the show and said he'd referred her to professionals who could continue to help her afterward.

"A love addict basically is somebody that really didn't have a good model for intimacy in their childhood, often times traumatized in one way or another, thereby intimacy becomes a risk place, becomes an intolerable place," Pinsky said. "And so what they tend to do is attach themselves to idealized, bigger than life, unavailable others, specifically go after some public figure that's married or go after some rock star who is himself a sex addict and not interested in a relationship, and then idealize that person and actively pursue them to the point of obsession."

McCready suffered a seizure in one of the show's scarier moments. Tests showed she has suffered brain damage, something she attributed to her abusive relationship with McKnight.

McCready is the fifth celebrity to pass away since appearing on Pinsky's show and the third from Season 3. Alice in Chains bassist Mike Starr and "Real World" participant Joey Kovar both died of overdoses.

In the months after her stint, McCready said she found some peace, telling The Associated Press in early 2010 that she hoped to get her career restarted, write a book about her experiences and begin production on a reality show with her brothers. She'd just met Wilson and talked openly about their relationship, although the producer and musician declined to speak on the record.

With a publicist, reporters, cameras, makeup artists and musicians swirling around her during a press day for her last album, "I'm Still Here," McCready fended off questions about a sex tape and said she and Wilson started out as friends.

"And I've never had a relationship like that before where we started completely as friends," she said. "It turned into friends really caring about each other and then it turned into love and I've never had that happen before."

At the time, Pinsky thought the relationship was on the right track: "She's an easy person to like and to care about and we hope she does well," Pinsky said. "So far so good as far as I can tell."

McCready said her main goal in 2010 was to pull her family back together: "I would like my son back with me and for my brothers and I and he to be able to go and do this (TV reality show), and I think after that I will be a pretty happy girl."

The new album debuted at No. 71 and failed to gain radio airplay. McCready's plans never materialized and she soon was in legal trouble again, this time fighting for custody.

McCready took her older son from her mother, the boy's legal guardian, in late 2011. She fled to Arkansas without permission over what she called child abuse fears. Authorities eventually found McCready hiding in a home without permission and took the boy into custody.

She and Wilson had their son in April 2012.

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Music Writer Chris Talbott reported from Nashville, Tenn. Associated Press writer Tamara Lush contributed to this report from Tampa, Fla.

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Well: Health Effects of Smoking for Women

The title of a recent report on smoking and health might well have paraphrased the popular ad campaign for Virginia Slims, introduced in 1968 by Philip Morris and aimed at young professional women: “You’ve come a long way, baby.”

Today that slogan should include: “…toward a shorter life.” Ten years shorter, in fact.

The new report is one of two rather shocking analyses of the hazards of smoking and the benefits of quitting published last month in The New England Journal of Medicine. The data show that “women who smoke like men die like men who smoke,” Dr. Steven A. Schroeder, a professor of health and health care at the University of California, San Francisco, wrote in an accompanying editorial.

That was not always the case. Half a century ago, the risk of death from lung cancer among men who smoked was five times higher than that among women smokers. But by the first decade of this century, that risk had equalized: for both men and women who smoked, the risk of death from lung cancer was 25 times greater than for nonsmokers, Dr. Michael J. Thun of the American Cancer Society and his colleagues reported.

Today, women who smoke are even more likely than men who smoke to die of lung cancer. According to a second study in the same journal, women smokers face a 17.8 times greater risk of dying of lung cancer than women who do not smoke; men who smoke are at 14.6 times greater risk to die of lung cancer than men who don’t. Women who smoke now face a risk of death from lung cancer that is 50 percent higher than the estimates reported in the 1980s, according to Dr. Prabhat Jha of the Center for Global Health Research in Toronto and his colleagues.

After controlling for age, body weight, education level and alcohol use, the new analysis found something else: men and women who continue to smoke die on average 10 years sooner than those who never smoked.

Dramatic progress has been made in reducing the prevalence of smoking, which has fallen from 42 percent of adults in 1965 (the year after the first surgeon general’s report on smoking and health) to 19 percent in 2010. Yet smoking still results in nearly 200,000 deaths a year among people 35 to 69 years old in the United States. A quarter of all deaths in this age group would not occur if smokers had the same risk of death as nonsmokers.

The risks are even greater among men 55 to 74 and women 60 to 74. More than two-thirds of all deaths among current smokers in these age groups are related to smoking. Over all, the death rate from all causes combined in these age groups “is now at least three times as high among current smokers as among those who have never smoked,” Dr. Thun’s team found.

While lung cancer is the most infamous hazard linked to smoking, the habit also raises the risk of death from heart disease, stroke, pulmonary disease and other cancers, including breast cancer.

Furthermore, changes in how cigarettes are manufactured may have increased the dangers of smoking. The use of perforated filters, tobacco blends that are less irritating, and paper that is more porous made it easier to inhale smoke and encouraged deeper inhalation to achieve satisfying blood levels of nicotine.

The result of deeper inhalation, Dr. Thun’s report suggests, has been an increased risk of chronic obstructive pulmonary disease, or C.O.P.D., and a shift in the kind of lung cancer linked to smoking. Among nonsmokers, the risk of death from C.O.P.D. has declined by 45 percent in men and has remained stable in women, but the death rate has more than doubled among smokers.

But there is good news, too: it’s never too late to reap the benefits of quitting. The younger you are when you stop smoking, the greater your chances of living a long and healthy life, according to the findings of Dr. Jha’s international team.

The team analyzed smoking and smoking-cessation histories of 113,752 women and 88,496 men 25 and older and linked them to causes of deaths in these groups through 2006.

Those who quit smoking by age 34 lived 10 years longer on average than those who continued to smoke, giving them a life expectancy comparable to people who never smoked. Smokers who quit between ages 35 and 44 lived nine years longer, and those who quit between 45 and 54 lived six years longer. Even quitting smoking between ages 55 and 64 resulted in a four-year gain in life expectancy.

The researchers emphasized, however, that the numbers do not mean it is safe to smoke until age 40 and then stop. Former smokers who quit by 40 still experienced a 20 percent greater risk of death than nonsmokers. About one in six former smokers who died before the age of 80 would not have died if he or she had never smoked, they reported.

Dr. Schroeder believes we can do a lot better to reduce the prevalence of smoking with the tools currently in hand if government agencies, medical insurers and the public cooperate.

Unlike the races, ribbons and fund-raisers for breast cancer, “there’s no public face for lung cancer, even though it kills more women than breast cancer does,” Dr. Schroeder said in an interview. Lung cancer is stigmatized as a disease people bring on themselves, even though many older victims were hooked on nicotine in the 1940s and 1950s, when little was known about the hazards of smoking and doctors appeared in ads assuring the public it was safe to smoke.

Raising taxes on cigarettes can help. The states with the highest prevalence of smoking have the lowest tax rates on cigarettes, Dr. Schroeder said. Also helpful would be prohibiting smoking in more public places like parks and beaches. Some states have criminalized smoking in cars when children are present.

More “countermarketing” of cigarettes is needed, he said, including antismoking public service ads on television and dramatic health warnings on cigarette packs, as is now done in Australia. But two American courts have ruled that the proposed label warnings infringed on the tobacco industry’s right to free speech.

Health insurers, both private and government, could broaden their coverage of stop-smoking aids and better publicize telephone quit lines, and doctors “should do more to stimulate quit attempts,” Dr. Schroeder said.

As Nicola Roxon, a former Australian health minister, put it, “We are killing people by not acting.”

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Today's Economist: Nancy Folbre: Preschool Economics

Nancy Folbre is an economics professor at the University of Massachusetts, Amherst. She recently edited and contributed to “For Love and Money: Care Provision in the United States.“

Even a 4-year-old can understand the case for early-childhood education. It’s fun, you learn things, you make it easier for Mom and Dad to earn a decent living, and when you grow up you will be better able to earn a decent living yourself. At that point, you will start paying taxes that return the favor, helping finance the retirement and health care of the generation that invested in your education.

President Obama’s proposal to help states develop and expand high-quality early-education programs has won verbal support from across the political spectrum, including David Brooks. More tangible evidence of political viability comes from Oklahoma and Georgia, two traditionally red states that now provide universal voluntary preschool for 4-year-olds.

Still, conservative opposition remains fierce. The loudest complaint is that public programs have not been shown to be cost-effective. But a wealth of research by highly respected economists shows that well-designed, high-quality early-childhood education programs offer a positive payback. At National Public Radio you can listen to the University of Chicago economist James Heckman reiterate this point – as he has been doing for many years.

Timothy Bartik of the Upjohn Institute offers great running commentary on debates over technical issues (such as whether small, demonstrably successful programs can be effectively scaled up) at his Investing in Kids blog.

Academics aren’t the only ones on board. The U.S. Chamber of Commerce published a report last year explaining “Why Business Should Support Early-Childhood Education.”

But the case for a public commitment to early-childhood education extends well beyond any cost-benefit analysis of child outcomes. It would help parents meet their child-care needs and reconcile the conflicting demands of wage employment and family care.

As a report published by the Center for American Progress emphasizes, preschool enrollment rates are already high among 4-year-olds in particular. But high costs mean that participation is highest among the poor, who qualify for Head Start, and the affluent, who can afford to pay out of pocket.

Even parents who currently rely on informal child-care arrangements would benefit from more dependable public provision. Many are just one family member, friend or neighbor away from a child-care crisis that could endanger their jobs. At Forbes, Bryce Covert makes a case for emphasizing the positive employment impact of the proposed policy.

Women’s labor-force participation rates in the United States were once relatively high by international standards. In 1990, we ranked sixth among 22 countries of the Organization for Economic Cooperation and Development. By 2010, our rank had fallen to 17th. Francine Blau and Lawrence Kahn of Cornell University estimate that about 29 percent of the decrease in women’s labor-force participation relative to other countries is attributable to those countries’ adoption of more “family friendly” public policies than those in the United States.

Improvements in children’s future productivity and greater opportunities for productive employment for everyone will shape the future of the United States economy. Conservatives enjoy their strongest support among older white voters, many of whom have already raised their children.

Both young parents and young children are far more ethnically diverse than the population over age 65.

But as the journalist Ronald Brownstein points out in an article memorably titled “The Gray and the Brown,” the very structure of our social programs makes the generations dependent on one another:

Today’s minority students will represent an increasing share of tomorrow’s workforce and thus pay more of the payroll taxes that will be required to fund Social Security and Medicare benefits for the mostly white Baby Boomers. Many analysts warn that if the U.S. doesn’t improve educational performance among African-American and Hispanic children, who now lag badly behind whites in both high school and college graduation rates, the nation will have difficulty producing enough high-paying jobs to generate the tax revenue to maintain a robust retirement safety net.

These are linkages that voters sorely need to understand. In coming months both Social Security and Medicare are likely to withstand the budgetary pressures imposed by the threat of sequestration. On the other hand, programs directed at children – including support for early-childhood education – are likely to come under the deficit-cutting knife.

In the long run, that knife will cut both ways, bleeding our system of intergenerational transfers.

Which is one more reason why it’s important for President Obama and his supporters to wrestle it out of conservative hands.

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