Promo Umroh VIP 2015 di Jakarta Hubungi 021-9929-2337 atau 0821-2406-5740 Alhijaz Indowisata adalah perusahaan swasta nasional yang bergerak di bidang tour dan travel. Nama Alhijaz terinspirasi dari istilah dua kota suci bagi umat islam pada zaman nabi Muhammad saw. yaitu Makkah dan Madinah. Dua kota yang penuh berkah sehingga diharapkan menular dalam kinerja perusahaan. Sedangkan Indowisata merupakan akronim dari kata indo yang berarti negara Indonesia dan wisata yang menjadi fokus usaha bisnis kami.

Promo Umroh VIP 2015 di Jakarta Alhijaz Indowisata didirikan oleh Bapak H. Abdullah Djakfar Muksen pada tahun 2010. Merangkak dari kecil namun pasti, alhijaz berkembang pesat dari mulai penjualan tiket maskapai penerbangan domestik dan luar negeri, tour domestik hingga mengembangkan ke layanan jasa umrah dan haji khusus. Tak hanya itu, pada tahun 2011 Alhijaz kembali membuka divisi baru yaitu provider visa umrah yang bekerja sama dengan muassasah arab saudi. Sebagai komitmen legalitas perusahaan dalam melayani pelanggan dan jamaah secara aman dan profesional, saat ini perusahaan telah mengantongi izin resmi dari pemerintah melalui kementrian pariwisata, lalu izin haji khusus dan umrah dari kementrian agama. Selain itu perusahaan juga tergabung dalam komunitas organisasi travel nasional seperti Asita, komunitas penyelenggara umrah dan haji khusus yaitu HIMPUH dan organisasi internasional yaitu IATA.

Promo Umroh VIP 2015 di Jakarta

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saco-indonesia.com, Kanker hati primer merupakan penyakit di mana sel kanker yang tumbuh berasal dari organ hati. Beberapa tipe

saco-indonesia.com, Kanker hati primer merupakan penyakit di mana sel kanker yang tumbuh berasal dari organ hati. Beberapa tipe kanker hati primer telah diberi nama sesuai dengan asal tumbuh sel kanker tersebut. Hepatocellular carcinoma (HCC) atau dikenal hepatoma yang tumbuh dari sel utama hati yang disebut hepatocytes dan juga merupakan 85% dari kasus kanker primer. Jenis kanker hati primer yang tidak begitu umum terjadi berasal dari sel berada pada garis saluran empedu yang disebut cholangiocytes, sehingga kanker tipe ini juga lebih dikenal sebagai kanker cholangiocarcinoma atau kanker saluran empedu.

Organ hati juga merupakan tempat dari tumbuhnya satu tipe kanker yang disebut kanker hati sekunder (kanker metastatik). Pada kondisi ini kanker utama sebenarnya berasal dari bagian tubuh yang lain dan telah membentuk deposit sekunder pada hati. Contoh umum dari kasus yang sering terjadi adalah kanker kolorektal yang telah menyebar ke organ hati melalui pembuluh darah.

Umumkah Kanker Hati?

Secara global, kanker hati primer umumnya telah terjadi pada pria dua kali lipat lebih sering dibandingkan pada wanita. Kanker hati juga merupakan kanker paling umum urutan ke-5 dan ke-7 bagi pria dan wanita. Negara-negara Asia juga mempunyai 80% pasien kanker hati primer secara global di mana sekitar 600.000 kasus terdiagnosa setiap tahunnya.

Apa yang menjadi faktor resiko penyebab kanker hati?

Terdapat tiga faktor utama yang dapat menyebabkan tumbuhnya HCC (kanker hati primer paling umum) yaitu infeksi kronis Hepatitis B, infeksi kronis Hepatitis C, dan konsumsi alkohol yang berlebihan. Resiko bagi individual dengan infeksi kronis Hepatitis B untuk terkena HCC adalah 100x dari individu normal.

Faktor lain yang dapat menjadi resiko meliputi aflatoxin (racun yang telah ditemukan pada kacang yang berjamur, gandum, dan kedelai), kondisi yang telah diwariskan (misal haemochromatosis, defisiensi alpha-1 anti-trypsin) dan penyebab cirrhosis (luka sepanjang hati) seperti hepatitis autoimun atau primary biliary cirrhosis. Banyak kanker hati juga dapat dicegah melalui peran masyarakat dalam mengurangi paparan terhadap faktor-faktor resiko yang telah diketahui.

 
Apa saja gejala-gejala kanker hati

Pasien yang terkena HCC biasanya tidak memiliki gejala-gejala yang berbeda dengan penyakit hati kronik lainnya. Dengan gejala yang memburuk dari penyakit hati kronis seperti pembengkakan perut akibat cairan (ascites), encephalopathy (berubahnya kondisi mental), sakit kuning, atau pendarahan pada sistem saluran pencernaan dapat meningkatkan kemungkinan berkembangnya HCC. Disamping itu, beberapa pasien juga mungkin merasakan rasa nyeri pada perut bagian atas, kehilangan berat badan, mudah kenyang, letih lesu, anoreksia, atau benjolan yang dapat dirasakan pada perut bagian atas.

 
Apakah dapat dilakukan skrining untuk kanker hati

Ya, skrining juga dapat membantu dokter untuk dapat menemukan dan mengobati HCC sedini mungkin, saat kanker masih setempat saja dan lebih mudah diangkat melalui proses bedah. Hal ini juga dapat meningkatkan tingkat keselamatan. Mereka yang telah mengidap infeksi Hepatitis B kronis dan luka hati (cirrhosis) karena hepatitis C atau sebab lain memiliki resiko tinggi terkena penyakit ini dan harus melalukan skrining guna untuk mendeteksi kanker hati.

Proses skrining meliputi:

    Tes darah untuk alpha-fetoprotein (AFP) 3-6 bulan sekali.
    Scan ultrasound pada bagian hati 6-12 bulan sekali.

 
Diagnosis dan Penilaian
          

Bagaimana proses diagnosa kanker hati?

Rangkaian tes dan prosedur berikut bisa dilakukan untuk dapat mendiagnosa HCC dan untuk dapat menunjukkan stadium kanker:

    Pemeriksaan fisik untuk kesehatan secara umum. Pemeriksaan bagian perut dilakukan untuk dapat mendeteksi adanya gumpalan keras atau ascites.
    Tes darah untuk kesehatan secara umum, fungsi hati dan jumlah/kadar AFP. Jumlah AFP pada penderita HCC lebih tinggi daripada pada orang normal.
    Scan ultasound pada hati dengan menggunakan gelombang suara untuk dapat menghasilkan citra hati. Prosedur tes ini juga tidak menimbulkan rasa sakit dan hanya perlu beberapa saat untuk dapat dilakukan. Citra yang dihasilkan dapat menunjukkan ada tidaknya tumor pada hati.
    Scan pencitraan Tomografi terkomputasi (CT) atau Magnetic Resonance Imaging (MRI) pada bagian perut juga akan memberikan gambar 3 dimensi dari hati. Gambar tersebut juga dapat menunjukkan ukuran dan posisi tumor, serta penyebarannya.

            
Walau diagnosa HCC dapat dibuat berdasarkan kadar AFP dalam darah dan pada hasil scan CT atau MRI, biopsi hati kadang kala juga perlu dilakukan untuk dapat memastikan hasil diagnosa. Bila kanker belum dapat menyebar dan masih dapat diangkat, maka biopsi tidak perlu dilakukan. Hal ini juga disebabkan oleh adanya resiko kecil penyebaran kanker sebagai akibat dari pengangkatan kanker oleh jarum biopsi. Pada situasi seperti ini, diagnosa dipertegas setelah bedah pengangkatan tumor.

 
Pengobatan dan Perawatan

Bagaimana cara mengobati kanker hati?

Tipe pengobatan untuk pasien kanker hati sangat tergantung pada stadium kanker (yaitu ukuran dan tingkat penyebaran kanker) dan kondisi kesehatan pasien secara umum. Prosedur pengobatan utama yang digunakan adalah bedah, ablasi tumor, kemoterapi, terapi kanker terarah dan radioterapi.
Pembedahan
          
Ablasi tumor

Pembedahan telah memiliki potensi penyembuhan dan juga merupakan prosedur pengobatan pilihan untuk pasien dengan HCC tahap dini. Bila hanya bagian tertentu dari hati yang terkena kanker dan bagian hati lainnya sehat, maka prosedur bedah juga dapat dilakukan untuk bisa mengangkat bagian yang terkena kanker. Prosedur bedah tipe ini juga disebut reseksi hati. Bentuk prosedur lain dari pembedahan adalah cangkok hati. Prosedur ini telah melibatkan pengangkatan seluruh organ hati dan menggantinya dengan organ hati donor yang masih sehat. Prosedur bedah besar seperti ini telah dilakukan bila kanker hanya terdapat pada hati dan donor hati tersedia. Bila prosedur bedah tidak memungkinkan, maka metode pengobatan lain akan diberikan guna untuk mengendalikan pertumbuhan kanker, dengan begitu mengurangi efek/gejala kanker serta meningkatkan kualitas hidup pasien.
          

Ablasi tumor bertujuan untuk dapat menghancurkan sel kanker hati primer dengan menggunakan panas (ablasi frekuensi radio: RFA) atau dengan alkohol (percutaneous ethanol injection; PEI). Prosedur ini umumnya hanya dilakukan di departemen scanning dimana ultrasound atau CT dapat membantu dokter untuk dapat mengarahkan jarum melalui kulit dan masuk ke dalam kanker yang berada di hati. Prosedur ini juga menggunakan anastesi lokal. Pengobatan RFA dengan menggunakan sinar laser atau gelombang radio yang dihantarkan melalui jarum menuju kanker guna untuk menghancurkan sel kanker. Pengobatan PEI dengan mengunakan alkohol yang disuntikkan masuk melalui jarum untuk dapat menghancurkan sel-sel kanker. Ablasi tumor juga dapat dilakukan berulang-ulang apabila tumor kembali tumbuh.
            
Kemoterapi
          
          
Kemoterapi adalah penggunaan obat-obatan anti kanker untuk dapat menghancurkan sel kanker atau menghentikan pertumbuhannya. Prosedur ini juga dapat membantu mengendalikan kanker dengan menyusutkan kanker serta memperlambat pertumbuhannya. Obat-obatan kemoterapi pada umumnya telah diberikan melalui suntikan pada pembuluh darah (secara intravena), walau terkadang dapat pula diberikan dalam bentuk tablet. Kemoterapi juga dapat diberikan sebagai bagian dari pengobatan yang disebut kemo embolisasi. Porses kemo embolisasi juga melibatkan suntikan obat kemoterapi langsung pada kanker dalam hati, bersamaan dengan sebuah jel atau titis plastik kecil untuk dapat menghambat aliran darah menuju kanker (embolisasi). Tidak semua pasien dapat menjalani prosedur kemoterapi ini karena prosedur ini telah memerlukan hati yang masih bisa berfungsi dengan baik.
            
Terapi kanker terarah
          
Radioterapi

Terapi kanker terarah (Targeted Cancer Therapy) dengan menggunakan obat-obatan atau pengobatan lainnya untuk dpat mencegah pertumbuhan serta penyebaran kanker dengan melakukan interfensi pada molekul tertentu yang terlibat dalam pertumbuhan kanker. Satu obat untuk terapi kanker terarah bernama Sorafenib dapat digunakan untuk dapat mengobati pasien dengan HCC tahap lanjut. Sorafenib menyerang kanker dengan cara mencegah kanker mengembangkan pembuluh darahnya sendiri. Sel kanker juga memerlukan asupan darah untuk dapat membawa nutrisi dan oksigen. Sorafenib juga berfungsi untuk dapat membatasi kemampuan kanker untuk berkembang. Sorafenib telah melalui dua uji klinis besar pada pasien dengan HCC tahap lanjut, dibandingkan dengan mereka yang dirawat hanya dengan perawatan pendukung. Sorafenib adalah tablet yang umumnya diberikan 2 kali sehari. Efek samping yang diberikan termasuk diare, cepat letih, mual dan tekanan darah tinggi.
          

Radioterapi dengan menggunakan sinar energi tinggi untuk dapat menghancurkan sel kanker atau menghentikan pertumbuhannya. Radioterapi eksternal dengan menggunakan mesin yang digunakan secara eksternal dari tubuh untuk dapat menghantarkan radiasi pada kanker. Prosedur pengobatan ini juga jarang digunakan pada penderita kanker HCC karena hati tidak dapat terpapar oleh radiasi tinggi. Namun, prosedur ini juga dapat mengurangi rasa sakit, seperti misalnya pada pasien yang kankernya telah menyebar hingga ke tulang. Sebagai prosedur alternatif, radiasi internal yang menggunakan zat radioaktif dihantarkan secara selektif menuju kanker melalui pembuluh darah arteri yang mengantarkan darah ke hati.

 
Apakah kanker hati dapat dicegah?

Tentu saja. Ada beberapa hal yang dapat kita lakukan untuk dapat mencegah kanker hati:

    Vaksinasi terhadap virus hepatitis B
    Hindari mengkonsumsi bahan-bahan yang mengandung karsinogen hati, khususnya alkohol.
    Hindari daging berlemak dan lemak hewani. Hindari kacang dan gandum berjamur.
    Lakukan skrining secara regular bila Anda termasuk dalam kelompok dengan resiko kanker yang tinggi

 
Dukungan apa yang tersedia?
          

CanHOPE, adalah badan non-profit yang bergerak di bidang layanan konseling dan dukungan terhadap penderita kanker yang diprakarsai oleh Parkway Cancer Centre.

Sebagai bagian dari sebuah pendekatan holistik untuk dapat mengobati kanker, CanHOPE juga bekerjasama dengan tim medis dan ahli-ahli kesehatan professional yang telah menawarkan sumber daya serta informasi yang luas mengenai kanker untuk dapat membantu pasien dan keluarga mereka agar dapat mengambil keputusan yang tepat selama perjalanan mereka menuju kesembuhan.


Editor : dian sukmawati

ate in February, Dr. Ben Carson, the celebrated pediatric neurosurgeon turned political insurrectionist, was trying to check off another box on his presidential-campaign to-do list: hiring a press secretary. The lead prospect, a public-relations specialist named Deana Bass, had come to meet him at the dimly lit Capitol Hill office of Carson’s confidant and business manager, Armstrong Williams. Carson sat back and scrutinized her from behind a small granite table, as life-size cardboard cutouts of more conventional politicians — President Obama, with a tight smile, and Senator John McCain, glowering — loomed behind each of his shoulders. (The mock $3 bill someone had left on a table in Williams’s waiting room undercut any notion that this was a bipartisan zone; it featured Obama wearing a turban.)

Bass seemed momentarily speechless, and not just because no one had warned her that a New York Times reporter would be sitting in on her job interview. Though she knew Williams — a jack-of-all-trades entrepreneur who owns several television stations and a public-affairs business and who hosts a daily talk-radio show — through Washington’s small circle of black conservatives, the two hadn’t spoken in years until he called her two days earlier. He had been struggling to come up with the perfect national spokesperson, he told her. Then, at the gym, her name popped into his head; Williams was fairly certain she was the one. Sitting across from a likely candidate for president, Bass was adjusting to the idea that her life might be about to take a sudden chaotic turn.

“It’s like getting the most random call on a Monday that you simply do not see coming,” she said. “Oftentimes, that is how the Lord works.”

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His life in brain surgery
has prepared him for the
presidency, he maintains,
better than lives in
politics have for his rivals.

Carson concurred: “It’s always how he works in my life.” Carson is soft-spoken and often talks with his eyes half closed, frequently punctuating his sentences with a small laugh, even if the humor of his statement is not readily apparent. Bass told Carson that she had been a Republican staff member on Capitol Hill then worked for the Republican National Committee. In 2007 she started a Christian public-relations firm with her sister. She enjoyed working on the Hill, she said, but the pay wasn’t as high as the hours were long. “We figured that we worked like slaves for other people, and we wanted to work for ourselves.”

Carson stopped her. “You know you can’t mention that word, right?” Carson waited a beat, then laughed, and Williams and Bass joined in. He was getting to the point; he needed a professional who could help him check his penchant for creating uncontrolled controversy just by talking.

The Ben Carson movement began in 2013, when Carson, a neurosurgeon, whose operating-room prowess and up-from-poverty back story had made him the subject of a television movie and a regular on the inspirational-speaking circuit, was invited to address the annual National Prayer Breakfast in Washington. With Barack Obama sitting just two seats away, Carson warned that “moral decay” and “fiscal irresponsibility” could destroy America just as it did ancient Rome. He proposed a substitute for Obamacare — Health Savings Accounts, which, he said, would end any talk of “death panels” — and a flat-tax based on the concept of tithing. His address, combined with the president’s stony reaction, was a smash with Republican activists. Speaking and interview requests flooded in. Carson, then 61, announced his planned retirement a few weeks later, freeing his calendar to accept just about all of them. In the months that followed, his rhetoric became increasingly strident. The claim that drew the most attention, perhaps, was that Obamacare was “the worst thing that has happened in this nation since slavery.”

Bass’s own use of the word prompted Carson to ask her what she thought about that incident. She considered for a moment.

“If you want to reach people and have them even understand what you’re saying, there is a way to do it, without that hyperbole, that might be. . . . ” She paused. “I just think it’s important not to shut people off before they —”

Carson jumped in. “That doesn’t allow them to hear what you’re saying?”

Bass nodded.

Likening Obamacare to slavery — and slavery was incomparably worse, Carson said — had its political advantages for a candidacy like his. It was the kind of statement that stoked the angriest of the Republican voters: conservative stalwarts who can’t hear enough bad things about Obama. This, in turn, led to more talk-radio and Fox News appearances, more book sales, more donations to the super PAC started in his name, more support in the polls. (The day before the meeting, one poll of Republican voters showed Carson statistically tied for first place with Jeb Bush and Scott Walker.)

Rhetorical excess was good for business, but Carson now wants to be seen as more than a novelty candidate. He has come to learn that such extreme analogies, while true to his views, aren’t especially presidential. They alienate more moderate voters and, perhaps even more damaging, reinforce the impression that he is not “serious” — that he is another Herman Cain, the black former Godfather’s Pizza chief executive who rose to the top of the early presidential polls in 2011 but then bowed out before the Iowa caucuses, largely because of leaked allegations of sexual misconduct, which he denied but from which he never recovered. Cain lingers as a cautionary tale for the party as much as for a right-leaning candidate like Carson. The fact that Cain, with his folksy sayings (“shucky ducky”) and misnomers (“Ubeki-beki-beki-beki-stan-stan”), reached the top of the national polls — much less that he was eventually followed there by the likes of Michele Bachmann, Newt Gingrich and Rick Santorum, who all topped one or another poll in the 2012 primary season — wound up being a considerable embarrassment for the eventual nominee, Mitt Romney, and for the longtime party regulars who were trying to fast-track his way to the nomination.

Carson liked Bass and, without directly saying so, made it clear the job was hers for the taking. Carson’s campaign chairman, Terry Giles — a white lawyer whose clients have included the comedian Richard Pryor and the stepson of the model Anna Nicole Smith and who helped reconcile the business interests of the descendants of the Rev. Martin Luther King Jr. — had assembled a mostly white campaign team, including many from the 2012 Gingrich effort, and Carson wanted a person of color to speak for him. Bass said she would have to mull it over, pray about it. Carson nodded approvingly. “Pray about it,” he said. “See what you think.”

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Williams knew the party was intent on protecting the eventual 2016 nominee from the same embarrassment Romney suffered. Already, suspiciously tough articles about Carson were showing up in conservative magazines and on right-wing websites. “They’re protecting these establishment candidates,” Williams said. “This is coming from within the house. This is family.” At the very least, he wanted to make sure that Carson didn’t do their work for them. (Carson would commit another unforced error a week later, when he told CNN that homosexuality was clearly a choice, because a lot of people go in prison straight and “when they come out, they’re gay”; he later apologized.)

“We need somebody to protect him, sometimes, from himself,” he told Bass — laughing, but only half kidding.

A candidacy like Carson’s presents a new kind of problem to the establishment wing of the G.O.P., which, at least since 1980, has selected its presidential nominees with a routine efficiency that Democrats could only envy. The establishment candidate has usually been a current or former governor or senator, blandly Protestant, hailing from the moderate, big-business wing of the party (or at least friendly with it) and almost always a second-, third- or fourth-time national contender — someone who had waited “his turn.” These candidates would tack predictably to the right during the primaries to satisfy the evangelicals, deficit hawks, libertarian leaners and other inconvenient but vital constituents who made up the “base” of the party. In return, the base would, after a brief flirtation with some fantasy candidate like Steve Forbes or Pat Buchanan, “hold their noses” and deliver their votes come November. This bargain was always tenuous, of course, and when some of the furthest-right activists turned against George W. Bush, citing (among other apostasies) his expansion of Medicare’s prescription drug benefit, it began to fall apart. After Barack Obama defeated McCain in 2008, the party’s once dependable base started to reconsider the wisdom of holding their noses at all.

Photo
 
Republican candidates at a pre-straw-poll debate, held at Iowa State University in 2011. Credit Chip Somodevilla/Getty Images

This insurgent attitude was helped along by changes in the nomination rules. In 2010, the Republican National Committee, hoping to capture the excitement of the coast-to-coast Democratic primary competition between Obama and Hillary Clinton, introduced new voting rules that required many of the early voting states to award some delegates to losing candidates, based on their shares of the vote. The proportional voting rules would encourage struggling candidates to stay in the primaries even after successive losses, as Clinton did, because they might be able to pull together enough delegates to take the nomination in a convention-floor fight or at least use them to bargain for a prime speaking slot or cabinet post.

This shift in incentives did not go unnoticed by potential 2012 candidates, nor did changes in election law that allowed billionaire donors to form super PACs in support of pet candidacies. At the same time, increasingly widespread broadband Internet access allowed candidates to reach supporters directly with video and email appeals and supporters to send money with the tap of a smartphone, making it easier than ever for individual candidates to ignore the wishes of the party.

Into this newly chaotic Republican landscape strode Mitt Romney. There could be no doubt that it was his turn, and yet his journey to the nomination was interrupted by one against-the-odds challenger after another — Cain, Michele Bachmann, Newt Gingrich, Rick Santorum, Ron Paul; always Ron Paul. It was easy to dismiss the 2012 primaries as a meaningless circus, but the onslaught did much more than tarnish the overall Republican brand. It also forced Romney to spend money he could have used against Obama and defend his right flank with embarrassing pandering that shadowed him through the general election. It was while trying to block a surge from Gingrich, for instance, that Romney told a debate audience that he was for the “self-deportation” of undocumented immigrants.

At the 2012 convention in Tampa, a group of longtime party hands, including Romney’s lawyer, Ben Ginsberg, gathered to discuss how to prevent a repeat of what had become known inside and outside the party as the “clown show.” Their aim was not just to protect the party but also to protect a potential President Romney from a primary challenge in 2016. They forced through new rules that would give future presumptive nominees more control over delegates in the event of a convention fight. They did away with the mandatory proportional delegate awards that encouraged long-shot candidacies. And, in a noticeably targeted effort, they raised the threshold that candidates needed to meet to enter their names into nomination, just as Ron Paul’s supporters were working to reach it. When John A. Boehner gaveled the rules in on a voice vote — a vote that many listeners heard as a tie, if not an outright loss — the hall erupted and a line of Ron Paul supporters walked off the floor in protest, along with many Tea Party members.

At a party meeting last winter, Reince Priebus, who as party chairman is charged with maintaining the support of all his constituencies, did restore some proportional primary and caucus voting, but only in states that held voting within a shortened two-week window. And he also condensed the nominating schedule to four and a half months from six months, and, for the first time required candidates to participate in a shortened debate schedule, determined by the party, not by the whims of the networks. (The panel that recommended those changes included names closely identified with the establishment — the former Bush White House spokesman Ari Fleischer, the Mississippi committeeman Haley Barbour and, notably, Jeb Bush’s closest adviser, Sally Bradshaw.)

Grass-roots activists have complained that the condensed schedule robs nonestablishment candidates — “movement candidates” like Carson — of the extra time they need to build momentum, money and organizations. But Priebus, who says the nomination could be close to settled by April, said it helped all the party’s constituencies when the nominee was decided quickly. “We don’t need a six-month slice-and-dice festival,” Priebus said when we spoke in mid-March. “While I can’t always control everyone’s mouth, I can control how long we can kill each other.”

All the rules changes were built to sidestep the problems of 2012. But the 2016 field is shaping up to be vastly different and far larger. A new Republican hints that he or she is considering a run seemingly every week. There are moderates like Gov. John Kasich of Ohio and former Gov. George Pataki of New York; no-compromise conservatives like Senator Ted Cruz of Texas and former Senator Rick Santorum of Pennsylvania; business-wingers like the former Hewlett-Packard chief executive Carly Fiorina; one-of-a-kinds like Donald Trump — some 20 in all, a dozen or so who seem fairly serious about it. That opens the possibility of multiple candidates vying for all the major Republican constituencies, some of them possibly goaded along by super-PAC-funding billionaires, all of them trading wins and collecting delegates well into spring.

Giles says his candidate can capitalize on all that chaos. Rivals may laugh, but Giles argues that if Carson can make a respectable showing in Iowa, then win in South Carolina — or at least come in second should a home-state senator, Lindsey Graham, run — and come in second behind Bush or Senator Marco Rubio in their home state of Florida, he could be positioned to make a real run. But that would depend on avoiding pitfalls like Carson’s ill-considered comments on homosexuality. Rather than capitalizing on the chaos, Carson may only contribute to it.

Ben Carson is, in many ways, the ideal Republican presidential candidate. With a not-too-selective reading of his life story, conservative voters can — and do — see in him an inspiring, up-from-nowhere African-American who shares their beliefs, a right-wing answer to Barack Obama. Before he was born, his parents moved to Detroit from rural Tennessee as part of the second great migration. His father, Robert Solomon Carson, worked at a Cadillac factory. His mother, Sonya — who herself had grown up as one of 24 children and left school at third grade — cleaned houses. When Carson was 8, Sonya discovered that Robert was keeping a second family. She moved, with her two sons, into a rundown group house. It was in a part of town that Carson described to me as crawling with “big rats and roaches and all kinds of horrible things.” Sonya worked several jobs at a time and made up the shortfall with food stamps. (Carson has called for paring back the social safety net but not doing away with it.)

Carson recounts this story in his best-selling 1990 memoir, “Gifted Hands,” which also became the basis for a 2009 movie on TNT, starring Cuba Gooding Jr. as Carson. Raised as a Seventh Day Adventist, Carson realized that he wanted to become a physician during a church sermon about a missionary doctor who, while serving overseas, was almost attacked by thieves but found safety by putting his faith in God. When Carson, then 8, told his mother his new dream, “She said, ‘Absolutely, you could do it, you could do anything,’ ” he told me. Forced by his mother to read two extra books a week, he made it to Yale, then to medical school at the University of Michigan, where he decided to specialize in neurosurgery. He was selected for residency at Johns Hopkins Children’s Center, where he was named director of pediatric neurosurgery at 33, becoming the youngest person, and the first black person, to hold the title. He drew national attention by conducting a succession of operations that had never been performed successfully, most famously planning and managing the first separation of conjoined twins connected through major blood vessels in the brain.

Carson, a two-time Jimmy Carter voter, traces his conservative political awakening to a patient he met during the Reagan years. During a routine obstetrics rotation, he found himself treating an unwed pregnant teenager who had run away from her well-to-do parents. When Carson asked her how she was getting by, she informed him she was on public assistance; this led him to ponder the fact that the government was paying for the result of what he did not view as a “wise decision.” The incident, he says, fed his growing sense that the welfare system too often saps motivation and rewards irresponsible behavior. (When we spoke, he suggested that the government should cut off assistance to would-be unwed mothers, but only after warning them that it would do so within a certain amount of time, say five years. “I bet you’d see a dramatic decrease in unwed motherhood.”)

Carson’s friends at Hopkins say they do not remember him being particularly outspoken about his conservatism. He devoted most of his public engagement to urging poor kids in bad neighborhoods to use “these fancy brains God gave us,” through weekly school visits, student hospital tours and, ultimately, a multimillion-dollar scholarship program. “His issues were always medical care for the poor, education for the poor, equal opportunity — helping the less fortunate and really inspiring them as an example,” a mentor who named him to the chief pediatrics-neurosurgery post at Hopkins, Dr. Donlin Long, told me.

Even when Carson got the chance, in 1997, to speak in front of President Bill Clinton, at the national prayer breakfast, he mostly discussed the lack of role models for black children who were not sports stars or rappers. (There was possibly an oblique reference to Clinton’s sex scandals, when he told the audience that, if they are always honest, they won’t have to worry later about “skeletons in the closet.”)

Photo
 
Ben Carson at CPAC on Feb. 26 in Oxon Hill, Md. Credit Dolly Faibyshev for The New York Times

In 2011, Carson’s politics took a strident turn, mirroring that of many in his party during the Obama years. “America the Beautiful,” his sixth book, which he wrote with Candy Carson, his wife of 39 years, included a get-tough-on-illegal-immigration message and offered anti-establishment praise for the Tea Party. It suggested that blacks who voted for Obama only because he was black were themselves practicing a form of racism. (Earlier this year he admitted to Buzzfeed that portions of the book were lifted directly from several sources without proper attribution.) His prayer-breakfast performance in 2013, and the extremity of his remarks in the months afterward (Obamacare is the worst thing since slavery; the United States is “very much like Nazi Germany”; allowing same-sex marriage could lead to allowing bestiality), left some of his old friends bewildered. Students at Johns Hopkins University School of Medicine protested his planned convocation address there in 2013, and he eventually backed out. When I asked Carson about the view at Hopkins that he had changed, he said his themes are still the same: “hard work, self-reliance, helping other people.” If he had become more overtly political, he said, it was only because the Obama years had led him to believe that “we’re really moving in a direction that is very, very destructive.”

None of this went unnoticed by campaign professionals. In August 2013, John Philip Sousa IV and Vernon Robinson, each of whom professes to be a virtual stranger to Carson, and who had previously been active in the anti-illegal-immigration movement, started the National Draft Ben Carson for President Committee. Sousa was just coming off a campaign to defend the sheriff of Maricopa County, Arizona, Joe Arpaio, from a recall effort, and he told me that he found Carson’s lack of political experience refreshing. “We have 500 guys and gals with probably a collective 5,000 years experience, and look at the mess we’re in,” he said.

Many others in the party feel the same way. Carson’s PAC finished 2014 with more than $13 million in donations, more than Ready for Hillary. Much of its money has gone toward further fund-raising, but Sousa — the great-grandson of the famous composer — points out that their effort has already built far more than just a war chest, organizing leaders in all 99 of Iowa’s counties. Regardless, Carson credits the fund-raising success of Sousa and Robinson with persuading him to enter the race.

Very early the morning after the job interview, Carson was in a black S.U.V., heading from Washington to the Gaylord National Resort and Convention Center in Oxon Hill, Md., where he was to give the opening candidate speech of the Conservative Political Action Conference. The event, which functions as an early tryout for Republican presidential contenders, tends to skew rightward in its audience, drawing many of the same sorts of people who shouted at Boehner in Tampa. As such, it tends to favor anti-establishment candidates, but the news leading up to this year’s event was that Jeb Bush hoped to make inroads there.

It was still dark when we set out, and I joked with Carson about the hour, telling him he’d better get used to it. He retorted that his career in pediatric brain surgery made him no stranger to early mornings. This is a big theme of Carson’s presidential pitch: that neither the rigors of the campaign nor those of the White House can faze a man who held children’s lives in his hands. His life in brain surgery has prepared him for the presidency, he maintains, better than lives in politics have for his rivals. At the very least, he says, it conditioned him against getting too worked up about any problem that isn’t life threatening. “I mean, it’s grueling, but interestingly enough, I don’t feel the pressure,” he said.

At the convention hall, we were quickly surrounded by admirers. Two women were already waiting to meet him — white, middle-aged volunteers for Carson’s super PAC, who had traveled from South Carolina. One of them, Chris Horne, was holding a dog-eared and taped Bible. A founding member of the Charleston Tea Party who went on to work for Gingrich’s successful South Carolina primary campaign in 2012, Horne lamented over the attacks that Carson was sure to face. “You served us, you served the Lord, just don’t let them steal that from you,” she said. Her friend told him, “You’ve got God behind you!” Such religious evocations trailed Carson constantly while I walked the CPAC floor with him. Evangelicals are impressed not only with his devotion to their politics but also with his career path; as one of them told me, what’s more pro-life than saving babies?

During our ride to the conference, Carson told me his speech was not looking to “feed the beast.” When his appointed time came, he kept his remarks as tame as promised. “Real compassion” meant “using our intellect” to help people “climb out of dependency and realize the American dream,” he said. The national debt is going to “destroy us,” Obamacare was about “redistribution and control,” but Republicans better come forward with their own alternative before they repeal it, he said.

Because his speech was first, and it started several minutes early, the auditorium was slow to fill. Still, the first day saw a crush of people seeking autographs and pictures as he roamed the hall. The Draft Carson committee’s 150 volunteers swarmed the auditorium, collecting emails and handing out “Run Ben Run” stickers. After a quick interview with Sean Hannity, the conservative-radio and Fox News host — his second in two days — Carson was off to Tampa.

In the hours that followed his talk, the hall offered a view in miniature of what the next 12 to 14 months might hold for the party. Chris Christie, sitting across from the tough-minded talk-radio host Laura Ingraham, boasted about his multiple vetoes of Planned Parenthood funding, his refusal to raise income taxes and his belief that “sometimes people need to be told to sit down and shut up.” Cruz, an audience favorite, warning his fellow Republicans against falling for a “squishy moderate,” declared, “Take all 125,000 I.R.S. agents and put ’em on our Southern border!” Gov. Scott Walker of Wisconsin, surging in polls, boasted that if he could face down the 100,000 union supporters who protested his legislation limiting collective bargaining for public employees, he could certainly handle ISIS. The next day, the traditional CPAC favorite Rand Paul spoke, packing the hall with his supporters who chanted “President Paul.” He warned, counter to the overall hawkish tenor of the event, that “we should not succumb to the notion that a government inept at home will somehow become successful abroad.” But he also vowed to end foreign aid to countries whose citizens are seen burning American flags. “Not one penny more to these haters of America.”

Perhaps the defining moment came near the end of the conference, when Jeb Bush spoke. In a neat trick of political gamesmanship — and a show of establishment muscle — his team had bused in an ample cheering section for the dozens of cameras on hand for his appearance. But a small contingent of Tea Party activists and Rand Paul supporters staged a walk out. When Bush began a question-and-answer session, they turned and left the auditorium to chant “U.S.A., U.S.A.” in the hallway, led by a man in colonial garb waving a huge “Don’t Tread on Me” banner. Plenty of other detractors stayed in the hall and peppered Bush’s remarks with booing as he stood by positions unpopular with the conservative grass roots: support for the Common Core standards and an immigration overhaul that provides a “path to legal status” for undocumented immigrants. Bush took it all in good humor, but finally seemed to give up.

“For those who made an ‘oo’ sound — is that what it was? — I’m marking you down as neutral,” he said. “And I want to be your second choice.”

Bush strategists told me they would not repeat Romney’s mistakes. Of course they would love to glide to an early nomination, they said, but they are prepared for a long contest and won’t be wasting any energy bending under pressure from a Paul or a Cruz or a Carson.

No one doubts that the pressure will increase, though. Despite the best wishes of the party’s leaders, GOP primary voters have given little indication that they will narrow the field quickly.

Before I left, I spotted Newt Gingrich, himself a fleeting presidential front-runner during those strange primary days of 2012. I asked him whether he thought all the party maneuvering — all the attempts to change the rules and fast-track the process — would preclude someone from presenting the sort of outside primary challenge he had carried out in the last election.

“No,” he told me, as if it was the most obvious thing in the world. “Look at where Ben Carson is right now.”

Jim Rutenberg is the chief political correspondent for the magazine. His most recent feature was about Megyn Kelly.

WASHINGTON — A decade after emergency trailers meant to shelter Hurricane Katrina victims instead caused burning eyes, sore throats and other more serious ailments, the Environmental Protection Agency is on the verge of regulating the culprit: formaldehyde, a chemical that can be found in commonplace things like clothes and furniture.

But an unusual assortment of players, including furniture makers, the Chinese government, Republicans from states with a large base of furniture manufacturing and even some Democrats who championed early regulatory efforts, have questioned the E.P.A. proposal. The sustained opposition has held sway, as the agency is now preparing to ease key testing requirements before it releases the landmark federal health standard.

The E.P.A.’s five-year effort to adopt this rule offers another example of how industry opposition can delay and hamper attempts by the federal government to issue regulations, even to control substances known to be harmful to human health.

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Document: The Formaldehyde Fight

Formaldehyde is a known carcinogen that can also cause respiratory ailments like asthma, but the potential of long-term exposure to cause cancers like myeloid leukemia is less well understood.

The E.P.A.’s decision would be the first time that the federal government has regulated formaldehyde inside most American homes.

“The stakes are high for public health,” said Tom Neltner, senior adviser for regulatory affairs at the National Center for Healthy Housing, who has closely monitored the debate over the rules. “What we can’t have here is an outcome that fails to confront the health threat we all know exists.”

The proposal would not ban formaldehyde — commonly used as an ingredient in wood glue in furniture and flooring — but it would impose rules that prevent dangerous levels of the chemical’s vapors from those products, and would set testing standards to ensure that products sold in the United States comply with those limits. The debate has sharpened in the face of growing concern about the safety of formaldehyde-treated flooring imported from Asia, especially China.

What is certain is that a lot of money is at stake: American companies sell billions of dollars’ worth of wood products each year that contain formaldehyde, and some argue that the proposed regulation would impose unfair costs and restrictions.

Determined to block the agency’s rule as proposed, these industry players have turned to the White House, members of Congress and top E.P.A. officials, pressing them to roll back the testing requirements in particular, calling them redundant and too expensive.

“There are potentially over a million manufacturing jobs that will be impacted if the proposed rule is finalized without changes,” wrote Bill Perdue, the chief lobbyist at the American Home Furnishings Alliance, a leading critic of the testing requirements in the proposed regulation, in one letter to the E.P.A.

Industry opposition helped create an odd alignment of forces working to thwart the rule. The White House moved to strike out key aspects of the proposal. Subsequent appeals for more changes were voiced by players as varied as Senator Barbara Boxer, Democrat of California, and Senator Roger Wicker, Republican of Mississippi, as well as furniture industry lobbyists.

Hurricane Katrina in 2005 helped ignite the public debate over formaldehyde, after the deadly storm destroyed or damaged hundreds of thousands of homes along the Gulf of Mexico, forcing families into temporary trailers provided by the Federal Emergency Management Agency.

The displaced storm victims quickly began reporting respiratory problems, burning eyes and other issues, and tests then confirmed high levels of formaldehyde fumes leaking into the air inside the trailers, which in many cases had been hastily constructed.

Public health advocates petitioned the E.P.A. to issue limits on formaldehyde in building materials and furniture used in homes, given that limits already existed for exposure in workplaces. But three years after the storm, only California had issued such limits.

Industry groups like the American Chemistry Council have repeatedly challenged the science linking formaldehyde to cancer, a position championed by David Vitter, the Republican senator from Louisiana, who is a major recipient of chemical industry campaign contributions, and whom environmental groups have mockingly nicknamed “Senator Formaldehyde.”

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Formaldehyde in Laminate Flooring

In laminate flooring, formaldehyde is used as a bonding agent in the fiberboard (or other composite wood) core layer and may also be used in glues that bind layers together. Concerns were raised in March when certain laminate flooring imported from China was reported to contain levels of formaldehyde far exceeding the limit permitted by California.

Typical

laminate

flooring

CLEAR FINISH LAYER

Often made of melamine resin

PATTERN LAYER

Paper printed to resemble wood,

or a thin wood veneer

GLUE

Layers may be bound using

formaldehyde-based glues

CORE LAYER

Fiberboard or other

composite, formed using

formaldehyde-based adhesives

BASE LAYER

Moisture-resistant vapor barrier

What is formaldehyde?

Formaldehyde is a common chemical used in many industrial and household products as an adhesive, bonding agent or preservative. It is classified as a volatile organic compound. The term volatile means that, at room temperature, formaldehyde will vaporize, or become a gas. Products made with formaldehyde tend to release this gas into the air. If breathed in large quantities, it may cause health problems.

WHERE IT IS COMMONLY FOUND

POTENTIAL HEALTH RISKS

Pressed-wood and composite wood products

Wallpaper and paints

Spray foam insulation used in construction

Commercial wood floor finishes

Crease-resistant fabrics

In cigarette smoke, or in the fumes from combustion of other materials, including wood, oil and gasoline.

Exposure to formaldehyde in sufficient amounts may cause eye, throat or skin irritation, allergic reactions, and respiratory problems like coughing, wheezing or asthma.

Long-term exposure to high levels has been associated with cancer in humans and laboratory animals.

Exposure to formaldehyde may affect some people more severely than others.

By 2010, public health advocates and some industry groups secured bipartisan support in Congress for legislation that ordered the E.P.A. to issue federal rules that largely mirrored California’s restrictions. At the time, concerns were rising over the growing number of lower-priced furniture imports from Asia that might include contaminated products, while also hurting sales of American-made products.

Maneuvering began almost immediately after the E.P.A. prepared draft rules to formally enact the new standards.

White House records show at least five meetings in mid-2012 with industry executives — kitchen cabinet makers, chemical manufacturers, furniture trade associations and their lobbyists, like Brock R. Landry, of the Venable law firm. These parties, along with Senator Vitter’s office, appealed to top administration officials, asking them to intervene to roll back the E.P.A. proposal.

The White House Office of Management and Budget, which reviews major federal regulations before they are adopted, apparently agreed. After the White House review, the E.P.A. “redlined” many of the estimates of the monetary benefits that would be gained by reductions in related health ailments, like asthma and fertility issues, documents reviewed by The New York Times show.

As a result, the estimated benefit of the proposed rule dropped to $48 million a year, from as much as $278 million a year. The much-reduced amount deeply weakened the agency’s justification for the sometimes costly new testing that would be required under the new rules, a federal official involved in the effort said.

“It’s a redlining blood bath,” said Lisa Heinzerling, a Georgetown University Law School professor and a former E.P.A. official, using the Washington phrase to describe when language is stricken from a proposed rule. “Almost the entire discussion of these potential benefits was excised.”

Senator Vitter’s staff was pleased.

“That’s a huge difference,” said Luke Bolar, a spokesman for Mr. Vitter, of the reduced estimated financial benefits, saying the change was “clearly highlighting more mismanagement” at the E.P.A.

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The review’s outcome galvanized opponents in the furniture industry. They then targeted a provision that mandated new testing of laminated wood, a cheaper alternative to hardwood. (The California standard on which the law was based did not require such testing.)

But E.P.A. scientists had concluded that these laminate products — millions of which are sold annually in the United States — posed a particular risk. They said that when thin layers of wood, also known as laminate or veneer, are added to furniture or flooring in the final stages of manufacturing, the resulting product can generate dangerous levels of fumes from often-used formaldehyde-based glues.

Industry executives, outraged by what they considered an unnecessary and financially burdensome level of testing, turned every lever within reach to get the requirement removed. It would be particularly onerous, they argued, for small manufacturers that would have to repeatedly interrupt their work to do expensive new testing. The E.P.A. estimated that the expanded requirements for laminate products would cost the furniture industry tens of millions of dollars annually, while the industry said that the proposed rule over all would cost its 7,000 American manufacturing facilities over $200 million each year.

“A lot of people don’t seem to appreciate what a lot of these requirements do to a small operation,” said Dick Titus, executive vice president of the Kitchen Cabinet Manufacturers Association, whose members are predominantly small businesses. “A 10-person shop, for example, just really isn’t equipped to handle that type of thing.”

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Becky Gillette wants strong regulation of formaldehyde. Credit Beth Hall for The New York Times

Big industry players also weighed in. Executives from companies including La-Z-Boy, Hooker Furniture and Ashley Furniture all flew to Washington for a series of meetings with the offices of lawmakers including House Speaker John Boehner, Republican of Ohio, and about a dozen other lawmakers, asking several of them to sign a letter prepared by the industry to press the E.P.A. to back down, according to an industry report describing the lobbying visit.

Within a matter of weeks, two letters — using nearly identical language — were sent by House and Senate lawmakers to the E.P.A. — with the industry group forwarding copies of the letters to the agency as well, and then posting them on its website.

The industry lobbyists also held their own meeting at E.P.A. headquarters, and they urged Jim Jones, who oversaw the rule-making process as the assistant administrator for the agency’s Office of Chemical Safety and Pollution Prevention, to visit a North Carolina furniture manufacturing plant. According to the trade group, Mr. Jones told them that the visit had “helped the agency shift its thinking” about the rules and how laminated products should be treated.

The resistance was particularly intense from lawmakers like Mr. Wicker of Mississippi, whose state is home to major manufacturing plants owned by Ashley Furniture Industries, the world’s largest furniture maker, and who is one of the biggest recipients in Congress of donations from the industry’s trade association. Asked if the political support played a role, a spokesman for Mr. Wicker replied: “Thousands of Mississippians depend on the furniture manufacturing industry for their livelihoods. Senator Wicker is committed to defending all Mississippians from government overreach.”

Individual companies like Ikea also intervened, as did the Chinese government, which claimed that the new rule would create a “great barrier” to the import of Chinese products because of higher costs.

Perhaps the most surprising objection came from Senator Boxer, of California, a longtime environmental advocate, whose office questioned why the E.P.A.’s rule went further than her home state’s in seeking testing on laminated products. “We did not advocate an outcome, other than safety,” her office said in a statement about why the senator raised concerns. “We said ‘Take a look to see if you have it right.’ ”

Safety advocates say that tighter restrictions — like the ones Ms. Boxer and Mr. Wicker, along with Representative Doris Matsui, a California Democrat, have questioned — are necessary, particularly for products coming from China, where items as varied as toys and Christmas lights have been found to violate American safety standards.

While Mr. Neltner, the environmental advocate who has been most involved in the review process, has been open to compromise, he has pressed the E.P.A. not to back down entirely, and to maintain a requirement that laminators verify that their products are safe.

An episode of CBS’s “60 Minutes” in March brought attention to the issue when it accused Lumber Liquidators, the discount flooring retailer, of selling laminate products with dangerous levels of formaldehyde. The company has disputed the show’s findings and test methods, maintaining that its products are safe.

“People think that just because Congress passed the legislation five years ago, the problem has been fixed,” said Becky Gillette, who then lived in coastal Mississippi, in the area hit by Hurricane Katrina, and was among the first to notice a pattern of complaints from people living in the trailers. “Real people’s faces and names come up in front of me when I think of the thousands of people who could get sick if this rule is not done right.”

An aide to Ms. Matsui rejected any suggestion that she was bending to industry pressure.

“From the beginning the public health has been our No. 1 concern,” said Kyle J. Victor, an aide to Ms. Matsui.

But further changes to the rule are likely, agency officials concede, as they say they are searching for a way to reduce the cost of complying with any final rule while maintaining public health goals. The question is just how radically the agency will revamp the testing requirement for laminated products — if it keeps it at all.

“It’s not a secret to anybody that is the most challenging issue,” said Mr. Jones, the E.P.A. official overseeing the process, adding that the health consequences from formaldehyde are real. “We have to reduce those exposures so that people can live healthy lives and not have to worry about being in their homes.”

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