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While some diseases, like cystic fibrosis, are caused by a single genetic mutation, the most common ones are not. Instead, mutations to a number of different genes can each raise the risk of getting, say, heart disease or breast cancer. Discovering these mutations can shed light on these diseases and point to potential treatments. But many of them are rare, making it necessary to search large groups of people to find them.

The wealth of data created in Iceland may enable scientists to begin doing that

For example, they found eight people in Iceland who shared a mutation on a gene called MYL4. Medical records showed that they also have early onset atrial fibrillation, a type of irregular heartbeat.

they identified a gene called ABCA7 as a risk factor for Alzheimer’s disease.Previous studies had suggested a gene in the genetic neighborhood of ABCA7 was associated with the disease.But the Icelandic study pinpointed the gene itself — and even the specific mutation involved.

Since Dr. Stefansson and his colleagues submitted their initial results for publication, they have continued gathering DNA from Icelanders.The scientists now have full genomes from about 10,000 Icelanders and partial genetic information on 150,000 more.

Dr. Stefansson said that means that his firm could generate a report for genetic disease on every person in Iceland

Iceland is a particularly fertile country for doing genetics research. It was founded by a small number of settlers from Europe arriving about 1,100 years ago. Between 8,000 and 20,000 people came mainly from Scandinavia, Ireland and Scotland.

The country remained isolated for the next thousand years, and so living Icelanders have a relatively low level of genetic diversity. This makes it easier for scientists to detect genetic variants that raise the risk of disease, because there are fewer of them to examine.

celand also has impressive genealogical records. Through epic poems and historical documents, many Icelanders can trace their ancestry back to the nation’s earliest arrivals. Geneticists use national genealogy databases to look for diseases that are unusually common in relatives — a sign that they share a mutation.

the company is now investigating a gene, found by Decode, with a strong link to cardiovascular disease in Iceland. (He declined to name the gene.)

EU citizens have no means of legal recourse against the misuse of their data in the United States, the court said. A bill is currently winding its way through the U.S. Congress to give Europeans the right to legal redress.

ECJ in its ruling referred to revelations from former National Security Agency contractor Edward Snowden, which included that the Prism program allowed U.S. authorities to harvest private information directly from big tech companies such as Apple (AAPL.O), Facebook (FB.O) and Google.

IBM (IBM.N) said it created commercial uncertainty and jeopardized the flow of data across borders.

Researchers expected the details in the study to dispel doubts about the likelihood that many years of head trauma can lead to C.T.E. The growing connections between head trauma and contact sports, though, have led some nervous parents and coaches to assume that any concussion could lead to long-term impairment. Some doctors say that oversimplifies matters. Rather, the total amount of head trauma, including smaller subconcussive hits, as well as how they were treated, must be considered

Shares of Morgan Stanley (MS.N) slid 6.9 percent in their largest one-day drop since November 2012, while rival Goldman Sachs (GS.N) fell 4.6 percent. Both closed at their lowest since 2013.

Facebook Inc (FB.O), Amazon.com Inc (AMZN.O) and other technology stocks that had lent strength to the market last year extended their decline from Friday. Fund managers said last year's outsized gains among some Internet stocks made them the first choice to sell now.

The Dow Jones industrial average .DJI closed down 177.92 points, or 1.1 percent, at 16,027.05, the S&P 500 .SPX lost 26.61 points, or 1.42 percent, to end at 1,853.44 and the Nasdaq Composite .IXIC dropped 79.39 points, or 1.82 percent, to 4,283.75.

Falling oil prices along with concern over a worsening global growth outlook have caused a sharp selloff in stocks this year. Investors have been searching for a catalyst that might change the market's course.

Adding to recent woes for the tech sector, Cognizant (CTSH.O) dropped 7.7 percent to $54.05 after the IT services provider issued a weak sales forecast. Amazon fell 2.8 percent while Facebook dropped 4.2 percent

Declining issues outnumbered advancing ones on the NYSE by 2,484 to 618; on the Nasdaq, 2,029 issues fell and 804 advanced. The S&P 500 posted 7 new 52-week highs and 97 new lows; the Nasdaq recorded 4 new highs and 495 new lows.

more significant, we are not very good at predicting who is likely to be dangerous in the future.

“Most of these killers are young men who are not floridly psychotic. They tend to be paranoid loners who hold a grudge and are full of rage.”

Even though we know from large-scale epidemiologic studies like the E.C.A. study that a young psychotic male who is intoxicated with alcohol and has a history of involuntary commitment is at a high risk of violence, most individuals who fit this profile are harmless.

“Can we reliably predict violence?  ‘No’ is the short answer. Psychiatrists, using clinical judgment, are not much better than chance at predicting which individual patients will do something violent and which will not.”

Even if clinicians could predict violence perfectly, keeping guns from people with mental illness is easier said than done. Nearly five years after Congress enacted the National Instant Criminal Background Check System, only about half of the s

All the focus on the small number of people with mental illness who are violent serves to make us feel safer by displacing and limiting the threat of violence to a small, well-defined group

But the sad and frightening truth is that the vast majority of homicides are carried out by outwardly normal people in the grip of all too ordinary human aggression to whom we provide nearly unfettered access to deadly force.

The rate of firearm homicides was 20 times higher in the United States than in the other countries, according to the report, which cited a 2011 study of 23 countries. And though suicide rates were lower in the United States, firearm suicide rates were six times higher.

Panelists were surprised at just how consistently Americans ended up at the bottom of the rankings. The United States had the second-highest death rate from the most common form of heart disease, the kind that causes heart attacks, and the second-highest death rate from lung disease, a legacy of high smoking rates in past decades. American adults also have the highest diabetes rates.

Youths fared no better. The United States has the highest infant mortality rate among these countries, and its young people have the highest rates of sexually transmitted diseases, teen pregnancy and deaths from car crashes. Americans lose more years of life before age 50 to alcohol and drug abuse than people in any of the other countries.

Americans also had the lowest probability over all of surviving to the age of 50. The report’s second chapter details health indicators for youths where the United States ranks near or at the bottom. There are so many that the list takes up four pages.

the U.S. ranked near and at the bottom in almost every heath indicator. That stunned us.”

The panel sought to explain the poor performance. It noted the United States has a highly fragmented health care system, with limited primary care resources and a large uninsured population. It has the highest rates of poverty among the countries studied.

In the other countries, more generous social safety nets buffer families from the health consequences of poverty, the report said.

Could cultural factors like individualism and dislike of government interference play a role? Americans are less likely to wear seat belts and more likely to ride motorcycles without helmets.  

The United States is a bigger, more heterogeneous society with greater levels of economic inequality, and comparing its health outcomes to those in countries like Sweden or France may seem lopsided. B

the panelists point out that this country spends more on health care than any other in the survey. And as recently as the 1950s, Americans scored better in life expectancy and disease than many of the other countries in the current study.

Gloves and soap have vanished from some hospitals. Often, cancer medicines are found only on the black market. There is so little electricity that the government works only two days a week to save what energy is left.

At the University of the Andes Hospital in the mountain city of Mérida, there was not enough water to wash blood from the operating table. Doctors preparing for surgery cleaned their hands with bottles of seltzer water.

The hospital has no fully functioning X-ray or kidney dialysis machines because they broke long ago. And because there are no open beds, some patients lie on the floor in pools of their blood.

This nation has the largest oil reserves in the world, yet the government saved little money for hard times when oil prices were high.

So without water, gloves, soap or antibiotics, a group of surgeons prepared to remove an appendix that was about to burst, even though the operating room was still covered in another patient’s blood.

In April, the authorities arrested its director, Aquiles Martínez, and removed him from his post. Local news reports said he was accused of stealing equipment meant for the hospital, including machines to treat people with respiratory illnesses, as well as intravenous solutions and 127 boxes of medicine.

In a supply room, cockroaches fled as the door swung open.

Ms. Parucho, a diabetic, was unable to receive kidney dialysis because the machines were broken. An infection had spread to her feet, which were black that night. She was going into septic shock.

A holiday had been declared by the government to save electricity, and the blood bank took donations only on workdays.

For the past two and a half months, the hospital has not had a way to print X-rays. So patients must use a smartphone to take a picture of their scans and take them to the proper doctor.

Near him, a handwritten sign read, “We sell antibiotics — negotiable.” A black-market seller’s number was listed.

The ninth floor of the hospital is the maternity ward, where the seven babies had died the day before. A room at the end of the hall was filled with broken incubators.

The day of the power blackout, Dr. Rodríguez said, the hospital staff tried turning on the generator, but it did not work.

At the meeting, my colleague Dr. Benard P. Dreyer, professor of pediatrics at New York University and a past president of the Academic Pediatric Association, called on pediatricians to take on poverty as a serious underlying threat to children’s health. He was prompted, he told me later, by the widening disparities between rich and poor, and the gathering weight of evidence about the importance of early childhood, and the ways that deprivation and stress in the early years of life can reduce the chances of educational and life success.

When Tony Blair became prime minister of Britain, amid growing socioeconomic disparities, he made it a national goal to cut child poverty in half in 10 years. It took a coalition of political support and a combination of measures that increased income, especially in families with young children (minimum wage, paid maternity and paternity leaves, tax credits), and better services — especially universal preschool programs. By 2010, reducing child poverty had become a goal across the British political spectrum, and child poverty had fallen to 10.6 percent of children below the absolute poverty line (similar to the measure used in the United States), down from 26.1 percent in 1999.

Dr. Dreyer said: “Income matters. You get people above the poverty level, and they actually are better parents. It’s critical to get people out of poverty, but in addition our focus has to be on also giving families supports for other aspects of their lives — parenting, interventions in primary care, universal preschool.”

Robert H. Dugger, managing partner of Hanover Investment Group, who made the economic case for investing in young children. “History shows that productivity increases when people are able to access their rights to life, liberty and the pursuit of happiness,” Mr. Dugger told me. “There is no economic recovery strategy stronger than committing to early childhood and K-through-12 investment.”

Comparing genomes, scientists concluded that today’s humans outside Africa carry an average of 2.5 percent Neanderthal DNA, and that people from parts of Oceania also carry about 5 percent Denisovan DNA. A study published in November found that Southeast Asians carry about 1 percent Denisovan DNA in addition to their Neanderthal genes.

as few as six couplings all those tens of thousands of years ago might have led to the current level of ancient immune alleles.

This means that our modern era, since H. floresiensis died out, is the only time in the four-million-year human history that just one type of human has been alive,

Were they romantic couplings? More likely they were aggressive acts between competing human groups, Dr. Stringer said. For a model, he pointed to modern hunter-gatherer groups that display aggressive behavior among tribes.

The value of the interbreeding shows up in the immune system, Dr. Parham’s analysis suggests. The Neanderthals and Denisovans had lived in Europe and Asia for many thousands of years before modern humans showed up and had developed ways to fight the diseases there

When modern humans mated with them, they got an injection of helpful genetic immune material, so useful that it remains in the genome today. This suggests that modern humans needed the archaic DNA to survive. The downside of archaic immune material is that it may be responsible for autoimmune diseases like diabetes, arthritis and multiple sclerosis, Dr. Parham said, stressing that these are preliminary results.

little is known about the Denisovans — the only remains so far are the pinky bone and the tooth, and there are no artifacts like tools. Dr. Reich and others suggest that they were once scattered widely across Asia, from the cold northern cave to the tropical south. The evidence is that modern populations in Oceania, including aboriginal Australians, carry Denisovan genes.

Such information would allow detection of so-called Mendelian disorders, like cystic fibrosis, Tay-Sachs disease and Marfan syndrome, which are caused by mutations in a single gene.

“It’s throughout all the private schools here,” said DeAnsin Parker, a New York psychologist who treats many adolescents from affluent neighborhoods like the Upper East Side. “It’s not as if there is one school where this is the culture. This is the culture.”

The D.E.A. lists prescription stimulants like Adderall and Vyvanse (amphetamines) and Ritalin and Focalin (methylphenidates) as Class 2 controlled substances — the same as cocaine and morphine — because they rank among the most addictive substances that have a medical use.

merely giving a friend an Adderall or Vyvanse pill is the same as selling it and can be prosecuted as a felony.

While these medicines tend to calm people with A.D.H.D., those without the disorder find that just one pill can jolt them with the energy and focus to push through all-night homework binges and stay awake during exams afterward. “It’s like it does your work for you,”

But abuse of prescription stimulants can lead to depression and mood swings (from sleep deprivation), heart irregularities and acute exhaustion or psychosis during withdrawal, doctors say. Little is known about the long-term effects of abuse of stimulants among the young

the pills eventually become an entry to the abuse of painkillers and sleep aids.

“Once you break the seal on using pills, or any of that stuff, it’s not scary anymore — especially when you’re getting A’s,” said the boy who snorted Adderall in the parking lot. He spoke from the couch of his drug counselor, detailing how he later became addicted to the painkiller Percocet and eventually heroin.

“Children have prefrontal cortexes that are not fully developed, and we’re changing the chemistry of the brain. That’s what these drugs do

The number of prescriptions for A.D.H.D. medications dispensed for young people ages 10 to 19 has risen 26 percent since 2007, to almost 21 million yearly, according to IMS Health, a health care information company — a number that experts estimate corresponds to more than two million individuals.

Doctors and teenagers from more than 15 schools across the nation with high academic standards estimated that the portion of students who do so ranges from 15 percent to 40 percent.

“They’re the A students, sometimes the B students, who are trying to get good grades,”

“They’re the quote-unquote good kids, basically.”

After 30 minutes, the buzz began, she said: laser focus, instant recall and the fortitude to crush any test in her path.

“It wasn’t that hard of a decision. Do I want only four hours of sleep and be a mess, and then underperform on the test and then in field hockey? Or make the teachers happy and the coach happy and get good grades, get into a good college and make my parents happy?”

Madeleine estimated that one-third of her classmates at her small school, most of whom she knew well, used stimulants without a prescription to boost their scholastic performance. Many students across the United States made similar estimates for their schools, all of them emphasizing that the drugs were used not to get high, but mostly by conscientious students to work harder and meet ever-rising academic expectations.

Every school identified in this article was contacted regarding statements by its students and stimulant abuse in general. Those that responded generally said that they were concerned about some teenagers turning to these drugs, but that their numbers were far smaller than the students said.

This is one of the more vexing problems with stimulants in high schools, experts said — the drugs enter the schools via students who get them legally, if not legitimately.

Newer long-lasting versions like Adderall XR and Vyvanse allow parents to give children a single dose in the morning, often unaware that the pills can go down a pants pocket as easily as the throat. Some students said they took their pills only during the week and gave their weekend pills to friends.

She said many parents could push as hard for prescriptions as their children did, telling her: “My child is not doing well in school. I understand there are meds he can take to make him smarter.”

“These are academic steroids. But usually, parents don’t get the steroids for you.”

Asked if the improper use of stimulants was cheating, students were split. Some considered that the extra studying hours and the heightened focus during exams amounted to an unfair advantage. Many countered that the drugs “don’t give you the answers” and defended their use as a personal choice for test preparation, akin to tutoring.

One consensus was clear: users were becoming more common, they said, and some students who would rather not take the drugs would be compelled to join them because of the competition over class rank and colleges’ interest.

“Junior and senior year is a whole new ballgame,” the boy said. “I promised myself I wouldn’t take it, but that can easily, easily change. I can be convinced.”

In 2009, prosecutors kicked off a string of cases, first taking aim at Lloyds and then Credit Suisse. Barclays settled in 2010, laying the groundwork for ING, Standard Chartered and HSBC to strike their own deals in 2012.

As the deals were being negotiated, a whistle-blower approached a rank-and-file prosecutor at the Manhattan district attorney’s office about BNP’s ties to Iran. BNP was also doing business with Sudan at a time that the nation was operating a genocidal regime.

. The volume of transactions reached tens of billions of dollars. And the $8.9 billion penalty is more than triple the amount that the six other banks collectively paid to resolve sanctions cases.

El Salvador’s Health Ministry is particularly concerned about the rise of cases of Guillain-Barré syndrome, which leads to paralysis, usually temporary; researchers are exploring a possible link between Guillain-Barré and Zika. Forty-six suspected cases of the syndrome had been reported as of last week, Violeta Menjívar, the health minister, said in a radio interview.

virus has appeared in only three Mexican states. The mosquitoes that carry the virus, he said, could not survive in the high altitudes of the central plateau, including Mexico City.“I think it’s good to have these warnings,” he said, “but these things should be explained to people.”

Their model for Zika’s possible spread, using worldwide temperature profiles and air travel routes, also determined that more than 60 percent of the population in the United States lives in areas conducive to seasonal Zika transmission. And about 23 million people in the United States live in places with climates like Florida and parts of Texas where Zika can be transmitted by mosquitoes year-round, the researchers said.The authorities in Brazil insist that they are taking steps to fight Zika, including vaccine research.

For Berlin, loosening its energy dependence on Russia is not simply about hitting Moscow’s main revenue stream. It’s a threat to roll back “Ostpolitik,” a totemic post-World War II policy of rapprochement with the Soviet Union, and by extension later Russia, that involved economic and political engagement, notably through oil and gas links.

Yet as customers desert Russia, its partnership with the oil titans of the Middle East, with which it jointly leads the OPEC+ coalition, has so far stayed intact. Russia and Saudi Arabia are the world’s top oil exporters, accounting for 29% of the global total. 

“The U.S. can try to make Saudi Arabia increase production, but why would they accept a break in the alliance, which is key for them?”

Riyadh’s OPEC+ partnership with Moscow calmed years of distrust between the two oil rivals, and saved the kingdom from relying exclusively on Washington.

“Saudi Arabia doesn’t want to switch horses mid-race when they do not know if the other horse is actually going to show up,”

Gulf Arab nations accused the U.S. of a lack of support in the face of repeated attacks by Iranian-backed militia on Saudi oil facilities and Gulf tanker traffic, and on Abu Dhabi this year. In a measure of the discord, the United Arab Emirates abstained in a U.S.-led United Nations Security Council vote to condemn Russia’s invasion.

“Now that we are in a crisis moment, we’re reaping the effect of that lack of trust that’s been building over the years,” said Karen Young, senior fellow at the Middle East Institute in Washington. 

Another source of friction lies in U.S. efforts to reinstate the nuclear agreement with Iran, Saudi Arabia’s regional rival.

Demonstrating just how exceptional the times are, a U.S. delegation traveled to Russian ally Venezuela last weekend in an overture to a country that holds the largest known crude reserves in the world.

Venezuela has been subject to international sanctions since the Trump era that have crippled its ability to sell oil. While there is not yet talk of allowing exports to resume, President Nicolas Maduro responded by offering to turn on the taps anyway, saying that state oil company PDVSA is prepared to raise output to as many three million barrels a day “for the world.”

the U.S. visit was “unexpected, surprising, a complete change in policy orientation,” with energy as the strategic catalyst.

“But I think there is a more important geopolitical move that is redefining the West,” he added. The U.S. is looking to confine the spheres of influence enjoyed by Russia and especially China, and for Venezuela that means a gradual process “to reincorporate with the West, through energy.” 

China will continue to carry on “normal trade cooperation” with Russia, including in oil and gas, said Zhao Lijian, a foreign ministry spokesperson. China is considering buying or increasing stakes in Russian companies such as Gazprom PJSC,

Even assuming a discount on the price per barrel, state-owned importers would weigh very carefully the impact on their global business of large purchases from a country that’s subject to so many sanctions, according to Qin Yan, an analyst with research house Refinitiv.

Neither would buying energy from Moscow be an easy solution, even if it meant less pollution, said Li Shuo, a climate analyst at Greenpeace East Asia. “To change China’s current energy structure, to replace a lot of coal it uses now with Russia’s oil and gas, would be a huge project for China, and it would take time,”

In Europe, the EU is refusing to budge on its climate commitments as it seeks to slash imports from its biggest supplier this year and replace flows from Russia completely by 2027. Those efforts were given a jolt by a suggestion that Moscow might shut off gas supplies through the Nord Stream 1 pipeline to Europe.

“We simply cannot rely on a supplier who explicitly threatens us,” EU Commission President Ursula von der Leyen said as she unveiled the bloc’s plans this week. 

as Scholz told the Bundestag, Russia’s attack on Ukraine means “we are in a new era.” The world today “is no longer the same world that it was before.”

lower costs are going to be about finding ways to get people to take more responsibility for their health — for losing weight, for example, or bringing their blood pressure down.

there are other concerns, such as whether an all-encompassing system like Kaiser’s can really be replicated and whether the limits it places on where patients can seek care will be accepted by enough people to make a difference.

Or whether, as the nation’s flirtation with health maintenance organizations, or H.M.O.’s, in the 1990s showed — people will balk at the concept of not being able to go to any doctor or hospital of their choice.

its integrated model is in favor again. Hospitals across the country are buying physician practices or partnering with doctors and health insurers to form accountable care organizations, or A. C.O.’s, as a way of controlling more aspects of patient care. Doctors are also creating so-called medical homes, where patient care is better coordinated.

The days when doctors, hospitals and other providers are paid separately for each procedure will disappear eventually, health experts say. Instead, providers will have financial incentives to encourage them to keep people healthy, including lump sums to care for patients or provide comprehensive care for a specific condition. “All of care is going to move down this path, and it has to,” Mr. Halvorson said. “Medical homes are doing it; the very best A. C.O’s are going to figure out how to do it.”

there are downsides to the creation of large health care systems that may be motivated by the desire to increase their clout in the market, making it easier to fill beds and charge the insurers more for care. “They become these huge local monopolies,”

“We have all the pieces,” said Philip Fasano, Kaiser’s chief information officer. “Anything a patient needs you get in the four walls of our offices,

its plans are typically at least 10 percent less expensive than others, especially where they control all the providers

Kaiser has also been using the information to identify those doctors or clinics that excel in certain areas, as well as those in need of improvement. The organization has also used the records to change how it delivers care, identifying patients at risk for developing bed sores in the hospital and then sending electronic alerts every two hours to remind the nurses to turn the patients. The percentage of patients with serious pressure ulcers, or bed sores, dropped to well under 1 percent from 3.5 percent.

The announcement may increase pressure on Congress to allocate more than $1.8 billion in emergency funding that President Obama requested for prevention and treatment of the outbreak

About 700 people in the United States have been infected with the Zika virus as of last week, including 69 pregnant women, Dr. Anne Schucat, the deputy director of the C.D.C., said on Monday at a White House briefing. About half of the cases are in Puerto Rico, where the virus is circulating locally.

C.D.C. officials said they were not ready to confirm that Zika can cause neurological conditions in adults, including Guillain-Barre syndrome, cases of which have increased in some countries in the Zika outbreak.

Beyond microcephaly, Dr. Rasmussen said, the authors concluded that Zika causes some other fetal brain problems, such as calcifications inside the skull.

Unfortunately, epinephrine is inherently unstable. Research shows that it degrades pretty quickly over time, and it’s recommended that EpiPens be replaced every year.

Mylan stopped selling individual EpiPens and began to sell only twin-packs.It also raised the price.

Kids need them in many places. They need them at home. They need them at school. They need them at camp. They may even want to stash one at Grandma’s house. So people often need to buy quite a few.More revenue for Mylan. And it raised the price.

Then in 2010, federal guidelines changed to recommend that two EpiPens be sold in a package instead of one

People in anaphylaxis need a full dose every time. They therefore need to replace all their EpiPens every year, again and again.

In 2013, the government went further. It passed a law that gave funding preferences for asthma treatment grants to states that maintained an emergency supply of EpiPens. As the near sole supplier of the devices, Mylan stood to make even more money. Advertisement Continue reading the main story That year, Mylan raised the price again.

Of course, competition would bring the price down. But it’s very hard to bring such a device to market.

setbacks, all in the last year, have once again left Mylan with a veritable run of the market. It raised the price of EpiPens again. As of this May, they cost more than $600 a pack. Since 2004, after adjusting for inflation, the price of EpiPens has risen more than 450 percent.

An alternative still exists. The Adrenaclick, while still not cheap, is back and less expensive than the EpiPen. Some think it’s harder to use, though. It’s not on the accepted list for many health insurance plans. More important, few physicians think of it. Because of that, they write prescriptions for EpiPens. Since the Adrenaclick is not a generic version of the EpiPen, pharmacists can’t substitute one for the other. A prescription for an EpiPen must be filled with an EpiPen, regardless of what consumers might want.

you could argue that they’re an alternative when the “Cadillac” EpiPens are financially out of reach. Write A Comment But those are unsatisfactory arguments. Epinephrine isn’t an elective medication. It doesn’t last, so people need to purchase the drug repeatedly. There’s little competition, but there are huge hurdles to enter the market, so a company can raise the price again and again with little pushback. The government encourages the product’s use, but makes no effort to control its cost. Insurance coverage shields some from the expense, allowing higher prices, but leaves those most at-risk most exposed to extreme out-of-pocket outlays. The poor are the most likely to consider going without because they can’t afford it.

EpiPens are a perfect example of a health care nightmare. They’re also just a typical example of the dysfunction of the American health care system.