Asperger's dropped from revised diagnosis manual

CHICAGO (AP) — The now familiar term "Asperger's disorder" is being dropped. And abnormally bad and frequent temper tantrums will be given a scientific-sounding diagnosis called DMDD. But "dyslexia" and other learning disorders remain.

The revisions come in the first major rewrite in nearly 20 years of the diagnostic guide used by the nation's psychiatrists. Changes were approved Saturday.

Full details of all the revisions will come next May when the American Psychiatric Association's new diagnostic manual is published, but the impact will be huge, affecting millions of children and adults worldwide. The manual also is important for the insurance industry in deciding what treatment to pay for, and it helps schools decide how to allot special education.

This diagnostic guide "defines what constellations of symptoms" doctors recognize as mental disorders, said Dr. Mark Olfson, a Columbia University psychiatry professor. More important, he said, it "shapes who will receive what treatment. Even seemingly subtle changes to the criteria can have substantial effects on patterns of care."

Olfson was not involved in the revision process. The changes were approved Saturday in suburban Washington, D.C., by the psychiatric association's board of trustees.

The aim is not to expand the number of people diagnosed with mental illness, but to ensure that affected children and adults are more accurately diagnosed so they can get the most appropriate treatment, said Dr. David Kupfer. He chaired the task force in charge of revising the manual and is a psychiatry professor at the University of Pittsburgh.

One of the most hotly argued changes was how to define the various ranges of autism. Some advocates opposed the idea of dropping the specific diagnosis for Asperger's disorder. People with that disorder often have high intelligence and vast knowledge on narrow subjects but lack social skills. Some who have the condition embrace their quirkiness and vow to continue to use the label.

And some Asperger's families opposed any change, fearing their kids would lose a diagnosis and no longer be eligible for special services.

But the revision will not affect their education services, experts say.

The new manual adds the term "autism spectrum disorder," which already is used by many experts in the field. Asperger's disorder will be dropped and incorporated under that umbrella diagnosis. The new category will include kids with severe autism, who often don't talk or interact, as well as those with milder forms.

Kelli Gibson of Battle Creek, Mich., who has four sons with various forms of autism, said Saturday she welcomes the change. Her boys all had different labels in the old diagnostic manual, including a 14-year-old with Asperger's.

"To give it separate names never made sense to me," Gibson said. "To me, my children all had autism."

Three of her boys receive special education services in public school; the fourth is enrolled in a school for disabled children. The new autism diagnosis won't affect those services, Gibson said. She also has a 3-year-old daughter without autism.

People with dyslexia also were closely watching for the new updated doctors' guide. Many with the reading disorder did not want their diagnosis to be dropped. And it won't be. Instead, the new manual will have a broader learning disorder category to cover several conditions including dyslexia, which causes difficulty understanding letters and recognizing written words.

The trustees on Saturday made the final decision on what proposals made the cut; recommendations came from experts in several work groups assigned to evaluate different mental illnesses.

The revised guidebook "represents a significant step forward for the field. It will improve our ability to accurately diagnose psychiatric disorders," Dr. David Fassler, the group's treasurer and a University of Vermont psychiatry professor, said after the vote.

The shorthand name for the new edition, the organization's fifth revision of the Diagnostic and Statistical Manual, is DSM-5. Group leaders said specifics won't be disclosed until the manual is published but they confirmed some changes. A 2000 edition of the manual made minor changes but the last major edition was published in 1994.

Olfson said the manual "seeks to capture the current state of knowledge of psychiatric disorders. Since 2000 ... there have been important advances in our understanding of the nature of psychiatric disorders."

Catherine Lord, an autism expert at Weill Cornell Medical College in New York who was on the psychiatric group's autism task force, said anyone who met criteria for Asperger's in the old manual would be included in the new diagnosis.

One reason for the change is that some states and school systems don't provide services for children and adults with Asperger's, or provide fewer services than those given an autism diagnosis, she said.

Autism researcher Geraldine Dawson, chief science officer for the advocacy group Autism Speaks, said small studies have suggested the new criteria will be effective. But she said it will be crucial to monitor so that children don't lose services.

Other changes include:

—A new diagnosis for severe recurrent temper tantrums — disruptive mood dysregulation disorder. Critics say it will medicalize kids' who have normal tantrums. Supporters say it will address concerns about too many kids being misdiagnosed with bipolar disorder and treated with powerful psychiatric drugs. Bipolar disorder involves sharp mood swings and affected children are sometimes very irritable or have explosive tantrums.

—Eliminating the term "gender identity disorder." It has been used for children or adults who strongly believe that they were born the wrong gender. But many activists believe the condition isn't a disorder and say calling it one is stigmatizing. The term would be replaced with "gender dysphoria," which means emotional distress over one's gender. Supporters equated the change with removing homosexuality as a mental illness in the diagnostic manual, which happened decades ago.

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

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Report: At least three dead after Japan tunnel collapse

TOKYO (Reuters) - A tunnel on a major highway in central Japan collapsed on Sunday, killing at least three people and starting a blaze, Japanese media reported.

Attempts to rescue those still trapped inside the smashed tunnel, which began spewing smoke after concrete ceiling panels fell onto the road, have been interrupted for fear they might trigger another collapse.

Three bodies have been found so far, television networks Fuji and Asahi said.

The fire service earlier said at least seven people were unaccounted for in the 4.7 km (2.8-mile) tunnel in Yamanashi prefecture, about 80 km (50 miles) west of Tokyo on the Chou Expressway, a main road connecting the capital to western Japan.

"Dense smoke was coming out as if it covers the entire mountain," witness Kiyoko Toyomura told Japanese news agency Kyodo.

The fire service said the blaze was extinguished about 11 a.m. - some three hours after the accident occurred.

The operator of the highway, Central Nippon Expressway, said a 50-60 meters (165 feet) long section of ceiling panels fell to the road, and it was looking into the cause of the accident.

Motorists described narrow escapes from falling debris, and a long walk through the darkness after abandoning their cars.

"When I was driving in the tunnel, concrete pieces fell down suddenly from the ceiling," a man in his 30s told public broadcaster NHK. "I saw a crushed car catching fire. I was frightened, left my car and walked for about an hour to get out of the tunnel."

In 1996 a tunnel in Hokkaido, northern Japan, collapsed and falling rocks crushed cars and a bus, killing 20 people.

NHK reporter Yoshio Goto, caught in Sunday's accident, hit the accelerator and managed to drive out.

"But it was a bit too late and pieces of ceiling fell on my car. I kept pressing the pedal and managed to get out," he said. "Then when I looked around, I saw half of the car ceiling was crushed."

(Reporting by Hideyuki Sano; Editing by Daniel Magnowski)

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NKorea says it will launch long-range rocket soon

SEOUL, South Korea (AP) — North Korea announced Saturday that it would attempt to launch a long-range rocket in mid-December, a defiant move just eight months after a failed April bid was widely condemned as a violation of a U.N. ban against developing its nuclear and missile programs.

The launch, set for Dec. 10 to 22, is likely to heighten already strained tensions with Washington and Seoul as the United States prepares for Barack Obama's second term as U.S. president and South Korea holds its own presidential election on Dec. 19.

This would be North Korea's second launch attempt under leader Kim Jong Un, who took power following his father Kim Jong Il's death nearly a year ago. The announcement by North Korea's space agency followed speculation overseas about stepped-up activity at North Korea's west coast launch pad captured in satellite imagery.

A spokesman for North Korea's Korean Committee for Space Technology said scientists have "analyzed the mistakes" made in the failed April launch and improved the precision of its Unha rocket and Kwangmyongsong satellite, according to the official Korean Central News Agency.

KCNA said the launch was a request of late leader Kim Jong Il, whose Dec. 17, 2011, death North Koreans are expected to mark with some fanfare. The space agency said the rocket would be mounted with a polar-orbiting Earth observation satellite, and maintained its right to develop a peaceful space program.

Washington considers North Korea's rocket launches to be veiled covers for tests of technology for long-range missiles designed to strike the United States, and such tests are banned by the United Nations.

North Korea has capable short- and medium-range missiles, but long-range launches in 1998, 2006, 2009 and in April of this year ended in failure. North Korea is not known to have succeeded in mounting an atomic bomb on a missile but is believed to have enough weaponized plutonium for at least half a dozen bombs, according to U.S. experts, and in 2010 revealed a uranium enrichment program that could provide a second source of material for nuclear weapons.

Six-nation negotiations on dismantling North Korea's nuclear program in exchange for aid fell apart in early 2009.

In Seoul, South Korean officials have accused North Korea of trying to influence its presidential election with what they consider provocations meant to put pressure on voters and on the United States as the North seeks concessions. Conservative Park Geun-hye, the daughter of late President Park Chung-hee, is facing liberal Moon Jae-in in the South Korean presidential vote. Polls show the candidates in a close race.

Some analysts, however, question whether North Korean scientists have corrected whatever caused the misfire of its last rocket.

"Preparing for a launch less than a year after a failure calls into question whether the North could have analyzed and fixed whatever went wrong," David Wright, a physicist with the Union of Concerned Scientists, wrote on the organization's website this week.

The United States has criticized North Korea's pursuit of nuclear weapons and ballistic missiles as a threat to Asian and world security. In 2009, North Korea conducted rocket and nuclear tests within months of Obama taking office.

North Korea under its young leader has pledged to bolster its nuclear arsenal unless Washington scraps what the North calls a "hostile" policy. North Korea maintains that it is building bombs to defend itself against what it sees as a U.S. nuclear threat in the region.

Before its last two rocket launches, North Korea notified the International Civil Aviation Organization and the International Maritime Organization about its intentions to launch. The two organizations haven't responded to requests by The Associated Press for details. But South Korean officials and outside analysts say North Korea has not notified international or South Korean authorities.

The announcement comes two days after South Korea canceled what would have been the launch of its first satellite from its own territory. Scientists in Seoul cited technical difficulties. South Korea's Foreign Ministry said in a statement that the North's planned launch is "a grave provocation and a head-on challenge to the international community."

North Korea's missile and nuclear programs will be a challenge for Obama in his second term and for the incoming South Korean leader. Washington's most recent attempt to negotiate a freeze of the North's nuclear program and a test moratorium in exchange for food aid collapsed with the April launch.

The Korean Peninsula remains in a state of war because the 1950-53 Korean conflict ended in a truce, not a peace treaty. Washington stations nearly 30,000 troops in South Korea as a buttress against any North Korean aggression. Tens of thousands more are in nearby Japan.

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Associated Press writers Jean H. Lee and Sam Kim contributed to this report.

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JLo tones down concert in Indonesia

JAKARTA, Indonesia (AP) — Jennifer Lopez wowed thousands of fans in Indonesia, but they didn't see as much of her as concertgoers in other countries — the American pop star toned down both her sexy outfits and her dance moves during her show in the world's most populous Muslim country, promoters said Saturday.

Lopez's "Dance Again World Tour" was performed in the country's capital, Jakarta, on Friday in line with promises Lopez made to make her show more appropriate for the audience, said Chairi Ibrahim from Dyandra Entertainment, the concert promoter.

"JLo was very cooperative ... she respected our culture," Ibrahim said, adding that Lopez's managers also asked whether she could perform her usual sexy dance moves, but were told that "making love" moves were not appropriate for Indonesia.

"Yes, she dressed modestly ... she's still sexy, attractive and tantalizing, though," said Ira Wibowo, an Indonesian actress who was among more than 7,000 fans at the concert.

Another fan, Doddy Adityawarman, was a bit disappointed with the changes.

"She should appear just the way she is," he said, "Many local artists dress even much sexy, much worse."

Lopez changed several times during her 90-minute concert along with several dancers, who also dressed modestly without revealing their chests or cleavage.

Most Muslims in Indonesia, a secular country of 240 million people, are moderate. But a small extremist fringe has become more vocal in recent years.

They have pushed through controversial laws — including an anti-pornography bill — and have been known to attack anything perceived as blasphemous, from transvestites and bars to "deviant" religious sects.

Lady Gaga was forced to cancel her sold-out show in Indonesia in May following threats by Islamic hard-liners, who called her a "devil worshipper."

Lopez will also perform in Muslim-majority Malaysia on Sunday.

"Thank you Jakarta for an amazing night," the 43-year-old diva tweeted to her 13 million followers Saturday.

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South Africa makes progress in HIV/AIDS fight

JOHANNESBURG (AP) — In the early 90s when South Africa's Themba Lethu clinic could only treat HIV/AIDS patients for opportunistic diseases, many would come in on wheelchairs and keep coming to the health center until they died.

Two decades later the clinic is the biggest ARV (anti-retroviral) treatment center in the country and sees between 600 to 800 patients a day from all over southern Africa. Those who are brought in on wheelchairs, sometimes on the brink of death, get the crucial drugs and often become healthy and are walking within weeks.

"The ARVs are called the 'Lazarus drug' because people rise up and walk," said Sue Roberts who has been a nurse at the clinic , run by Right to Care in Johannesburg's Helen Joseph Hospital, since it opened its doors in 1992. She said they recently treated a woman who was pushed in a wheelchair for 3 kilometers (1.8 miles) to avoid a taxi fare and who was so sick it was touch and go. Two weeks later, the woman walked to the clinic, Roberts said.

Such stories of hope and progress are readily available on World AIDS Day 2012 in sub-Saharan Africa where deaths from AIDS-related causes have declined by 32 percent from 1.8 million in 2005 to 1.2 million in 2011, according to the latest UNAIDS report.

As people around the world celebrate a reduction in the rate of HIV infections, the growth of the clinic, which was one of only a few to open its doors 20 years ago, reflects how changes in treatment and attitude toward HIV/AIDS have moved South Africa forward. The nation, which has the most people living with HIV in the world at 5.6 million, still faces stigma and high rates of infection.

"You have no idea what a beautiful time we're living in right now," said Dr. Kay Mahomed, a doctor at the clinic who said treatment has improved drastically over the past several years.

President Jacob Zuma's government decided to give the best care, including TB screening and care at the clinic, and not to look at the cost, she said. South Africa has increased the numbers treated for HIV by 75 percent in the last two years, UNAIDS said, and new HIV infections have fallen by more than 50,000 in those two years. South Africa has also increased its domestic expenditure on AIDS to $1.6 billion, the highest by any low-and middle-income country, the group said.

Themba Lethu clinic, with funding from the government, USAID and PEPFAR, is now among some 2,500 ARV facilities in the country that treat approximately 1.9 million people.

"Now, you can't not get better. It's just one of these win-win situations. You test, you treat and you get better, end of story," Mahomed said.

But it hasn't always been that way.

In the 1990s South Africa's problem was compounded by years of misinformation by President Thabo Mbeki, who questioned the link between HIV and AIDS, and his health minister, Manto Tshabalala-Msimang, who promoted a "treatment" of beets and garlic.

Christinah Motsoahae first found out she was HIV positive in 1996, and said she felt nothing could be done about it.

"I didn't understand it at that time because I was only 24, and I said, 'What the hell is that?'" she said.

Sixteen years after her first diagnosis, she is now on ARV drugs and her life has turned around. She says the clinic has been instrumental.

"My status has changed my life, I have learned to accept people the way they are. I have learned not to be judgmental. And I have learned that it is God's purpose that I have this," the 40-year-old said.

She works with a support group of "positive ladies" in her hometown near Krugersdorp. She travels to the clinic as often as needed and her optimism shines through her gold eye shadow and wide smile. "I love the way I'm living now."

Motsoahae credits Nelson Mandela's family for inspiring her to face up to her status. The anti-apartheid icon galvanized the AIDS community in 2005 when he publicly acknowledged his son died of AIDS.

None of Motsoahae's children was born with HIV. The number of children newly infected with HIV has declined significantly. In six countries in sub-Saharan Africa — South Africa, Burundi, Kenya, Namibia, Togo and Zambia —the number of children with HIV declined by 40 to 59 percent between 2009 and 2011, the UNAIDS report said.

But the situation remains dire for those over the age of 15, who make up the 5.3 million infected in South Africa. Fear and denial lend to the high prevalence of HIV for that age group in South Africa, said the clinic's Kay Mahomed.

About 3.5 million South Africans still are not getting therapy, and many wait too long to come in to clinics or don't stay on the drugs, said Dr. Dave Spencer, who works at the clinic .

"People are still afraid of a stigma related to HIV," he said, adding that education and communication are key to controlling the disease.

Themba Lethu clinic reaches out to the younger generation with a teen program.

Tshepo Hoato, 21, who helps run the program found out he was HIV positive after his mother died in 2000. He said he has been helped by the program in which teens meet one day a month.

"What I've seen is a lot people around our ages, some commit suicide as soon as they find out they are HIV. That's a very hard stage for them so we came up with this program to help one another," he said. "We tell them our stories so they can understand and progress and see that no, man, it's not the end of the world."

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Why Obama is pushing for stimulus in 'fiscal cliff' deal

How about a little government economic stimulus?

That may sound incongruous considering the budget deficit and the push from Republicans to cut government spending.

But President Obama’s first offer to avoid going over the "fiscal cliff" holds out the hope of at least some stimulus. This would include extending the 2 percentage point Social Security payroll tax cut, boosting a tax incentive to businesses, establishing a $50 billion bank for long-term infrastructure projects, and extending unemployment benefits.

RECOMMENDED: 'Fiscal cliff' 101: 5 basic questions answered

The total bill: about $255 billion out of the federal government's pocket – an amount the GOP would likely say needs to be offset by spending cuts elsewhere.

The argument in favor of such stimulus? The tax measures, at least, could minimize the drag on the economy from Mr. Obama's proposed tax increases on the wealthy.

“The increases in the top two income tax brackets would put a drag on consumption, so I think, from the Obama point of view, the spending or tax cuts are designed to offset that drag to consumption,” says Michael Brown, an economist at Wells Fargo Securities in Charlotte, N.C.

But to some budget experts, Obama’s list seems more like an opening round of negotiations, where he has asked for a lot more than he will get.

“It looks to me like these are bargaining chips,” says Pete Davis of Davis Capital Ideas, which advises Wall Street firms. “Even most Democrats had given up on the prospect of getting the payroll tax cut extended.”

Mr. Davis considers the odds of most of the stimulus proposals passing Congress “very low.”

What's needed most, say others, is just buckling down and negotiating an end to the fiscal cliff. “Cancelling the fiscal cliff is economic stimulus,” says Stan Collender, a budget expert and partner at Qorvis Communications in Washington.

If Obama's stimulus were passed, however, here is a look at the impact the four elements might have.

SOCIAL SECURITY PAYROLL TAX CUT

The largest chunk of the Obama plan is the extension of the payroll tax cut. This is the money that comes out of an individual’s paycheck as a contribution to Social Security. Two years ago, in an effort to stimulate the economy, Congress decreased the individual contribution from 6.2 percent to 4.2 percent. The employer’s contribution of 6.2 percent remained unchanged.

The Obama administration estimates extending the cuts would cost the government as much as $115 billion in revenue.

The argument for extending the tax cut is that it helps lower-income workers who live paycheck to paycheck. “The difference in the paycheck might be the ability to pay the electric bill for someone or the chance to go to a sit-down restaurant once a month,” says Chris Christopher, an economist at IHS in Lexington, Mass.

The argument against continuing the cut is that it is weakening the Social Security Trust Fund. In order to make up for the loss of contributions, the government taps the general tax revenues, says Pamela Tainter-Causey, a spokeswoman for the National Committee to Preserve Social Security and Medicare.

“It sets up Social Security to compete for funding from the general fund,” she says. “It’s a perfect set up for people who are gunning for the program and claim we can’t afford it now.”

BUSINESS TAX INCENTIVE

The second largest program proposed by Obama would be the extension of accelerated depreciation for business, which would cost the US Treasury about $65 billion in fiscal year 2013, according to the Congressional Budget Office.

Two years ago, business was allowed to accelerate the write-off of 100 percent of its spending on certain capital equipment. Capital spending on equipment and computer software soared by 18.3 percent in 2011.

Then, this year, the benefit to business was cut in half to 50 percent. Capital spending sank in the third quarter by 2.7 percent compared with the same quarter the prior year. With business interest in using the tax break diminishing, economist Gregory Daco of IHS says “it’s a goner.”

INFRASTRUCTURE BANK

Obama has also proposed a $50 billion infrastructure bank. The idea is to fund roads, bridges, tunnels and other large projects that last for a long period of time. “At the moment the funding is done on a cash basis – you have to pay for it as you build it,” says Mr. Collender.

Democrats have been trying to get Congress to fund the bank for the past 10 years, he says. “It does not have a chance of getting through the House," which is controlled by the Republicans, says Mr. Collender.

UNEMPLOYMENT BENEFITS

And, finally, Obama wants to extend unemployment benefits, which would cost about $30 billion.

Under current law, if Congress does nothing, the maximum number of weeks in which an individual could receive jobless will drop to 26 from the current 73 weeks for states with unemployment over 9 percent and 63 weeks for states with unemployment over 7 percent.

If Congress does nothing about the program during the lame-duck session, some 2.1 million jobless will lose their benefits in the first week of January, says Judy Conti, a federal advocacy coordinator at the National Employment Law Project (NELP) in Washington. By the end of the March, she says, another 900,000 people will lose their benefits.

“Forty percent of the unemployed are long term unemployed,” she says. “They have been out of the workforce for over six months.”

RECOMMENDED: 'Fiscal cliff' 101: 5 basic questions answered

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Shoppers' habits not changed by garment plant fire

NEW YORK (AP) — Before purchasing a shirt, shoppers will run their hands over the fabric, look at the price tag and wonder how it will hold up in the washing machine. Some might even ask if it makes them look fat.

The one detail, however, that is rarely considered: What are the conditions like for the workers making the shirt?

A horrific fire that raced through a Bangladesh garment factory Saturday, killing 112 people, has put the spotlight — at least temporarily — back on those workers and their sometimes treacherous work environment.

The factory, owned by Tazreen Fashions Ltd., made clothing for several retailers around the globe including Wal-Mart, Sears and The Walt Disney Co. All three companies have distanced themselves from responsibility for the incident, saying they didn't know that their subcontractors were using the factory.

Holiday shoppers have also maintained their distance from the tragedy.

"Truthfully, I hadn't even thought about it," said Megan Miller of Philadelphia as she walked out of the Disney Store in Times Square. "I had Christmas on my mind and getting my kids something from New York."

Shoppers from Cincinnati to Paris to Singapore all said the same thing: They were aware of the fatal factory fire, but they weren't thinking about it while browsing stores in the days since. Brand name, fit and — above all — prices were on their minds.

"Either our pockets get lighter or we have to live with more blood on our hands," said Amy Hong, a college student who was at a store in Singapore. "I try not to think about it."

Experts who survey shoppers say the out of sight, out of mind attitude is nothing new.

"When you talk to them about their biggest concerns, where something is made, or the abuses in some country, almost never show up," said C. Britt Beemer, chairman of America's Research Group, which interviews 10,000 to 15,000 consumers a week, mostly on behalf of retailers. "The numbers are so small, I quit asking the question."

Convenience is much more important to shoppers.

Take Tammy Johnson who was at a Walmart in Bloomington, Minn. this week. She lives nearby and appreciates that the store has a large grocery section in addition to clothing and other goods.

"It's easier and it's cheaper," she said of her decision to shop there. "I hate that, but it is true."

Even those who want to make socially responsible purchases a priority have little information available to work with.

There's no widespread system in place to say where all the materials in a shirt come from let alone whether it was made in a sweatshop or not.

A label saying "Made in USA of imported fabrics" doesn't provide as much information to shoppers as they might think. Maybe tailors assembled it under good working conditions, but what about the people who wove the fabrics? Another label saying that a shirt is made from 100 percent organic cotton fails to say anything about the conditions of the factory in which it was made.

"What do they know at the point of sale about where it comes from, other than the tag?" said Paco Underhill, founder of Envirosell, which studies consumer behavior. "Our hearts are generally are in the right places. It's the question of making sure we have the knowledge and pocketbook to follow."

And it's not just clothing. It is hard to tell where televisions or laptop components are made.

Companies selling products say they even struggle to tell. Work is often given to subcontractors who themselves use subcontractors. While many major companies stipulate ethics and standards that their subcontractors must follow, policing them is a costly, time-consuming process that sounds easier than it is.

In the case of the Bangladesh factory, Wal-Mart said it had received a safety audit showing the factory was "high-risk" and had decided months before the blaze to stop doing business with Tazreen. But it said a supplier had continued to use Tazreen without authorization.

In recent years, consumers have become much more aware about the food they eat, and where it comes from.

Supermarkets are full of eggs laid by free-range chickens, organically-grown apples and beef from grass-fed, hormone-free cows. Some upscale restaurants now name the farm that provided them with pork chops. And customers pay a premium for these foods.

The difference: They perceive a direct benefit, since the food is going into their bodies.

Ethical choices when buying clothing — or the latest version of Apple's iPhone — are much more blurred.

Jean MacLeod, who was shopping at a Walmart on the south side of Indianapolis, is willing to pay more for goods if they are made in an ethically responsible manner and does it all the time when she buys food.

Walmart wants the best prices for its customers, she said, but the company also has power as a buyer to make sure factories have decent working conditions.

"They should be able to say, 'Look it, we don't want to buy from you unless you do things a little more our way,'" MacLeod said. "If they don't want to buy from them, then that means that factory will go out of business."

Arguments have been made that producing items with cheap labor isn't necessarily a bad thing.

Factories in the Third World can provide jobs with wages well above a region's average. They can help lift families out of severe poverty. The catch is that there are fewer safeguards to protect workers from being exploited from unscrupulous employers.

At the Bangladesh factory, locked exits prevented many workers from escaping after fire broke out.

It draws eerie parallels to New York's Triangle Shirtwaist Fire of 1911, where 146 people died within 18 minutes of a fire starting in a factory with locked exits.

That fire was the catalyst for widespread changes in labor laws in U.S. But in the 100 years since, the desire for cheap clothing hasn't abated and costly labor has just shifted to factories overseas.

"To put it maybe too frankly, profit and efficiency and competition always trump safety and health," said James A. Gross, a labor relations professor at Cornell University.

Not every company sees things that way.

Los Angeles-based American Apparel promotes itself as a line of "sweatshop free" clothing. Its founder and CEO, Dov Charney, said that companies can control working conditions — they just need to bring production closer to home. American Apparel knits, dyes, cuts and sews all of its products in-house.

"When the company knows the face of its worker, that's important," Charney said. "You can control working conditions and quality."

Yes, American Apparel spends more on labor, but it isn't as much as you would expect. Charney estimates that an imported T-shirt selling for $6 at Walmart would cost about $6.30 if produced domestically thanks to the company's massive scale.

"The consumer can care. They can buy from companies that are committed to fair trade and try to seek out those companies," he said.

Take Nike.

In the mid-1990s, the sneaker giant came under pressure to change its ways after numerous reports of child labor, low wages and poor working conditions. Eventually wages climbed, minimum age requirements were put in place and Nike increased monitoring at its factories.

But such change only comes after persistent public pressure.

"Clothes makers will always do what they want, but the buyer should educate himself," said Paris shopper Pierre Lefebvre.

Not all buyers have that luxury. Family budgets are tight.

"Especially with this economy, we like our money to go as far as it can," said Lesley Schuldt, who left a Cincinnati Macy's this week with five shopping bags worth of jewelry, cookware and gifts. "I have no idea where half the stuff I bought was made, but I imagine it was not in the U.S."

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Associated Press reporters Amanda Lee Myers in Cincinnati, Josh Freed in Bloomington, Minn., Tom Murphy in Indianapolis, Meghan Barr in New York, Heather Tan in Singapore and Thomas Adamson in Paris contributed to this report.

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Scott Mayerowitz can be reached at http://twitter.com/GlobeTrotScott.

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Adkins explains Confederate flag earpiece

NEW YORK (AP) — Trace Adkins wore an earpiece decorated like the Confederate flag when he performed for the Rockefeller Center Christmas Tree Lighting but says he meant no offense by it.

Adkins appeared with the earpiece on a nationally televised special for the lighting on Wednesday. Some regard the flag as a racist symbol and criticized Adkins in Twitter postings.

But in a statement released Thursday, the Louisiana native called himself a proud American who objects to any oppression and says the flag represents his Southern heritage.

He noted he's a descendant of Confederate soldiers and says he did not intend offense by wearing it.

Adkins — on a USO tour in Japan — also called for the preservation of America's battlefields and an "honest conversation about the country's history."

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Online:

http://www.traceadkins.com

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Clinton releases road map for AIDS-free generation

WASHINGTON (AP) — In an ambitious road map for slashing the global spread of AIDS, the Obama administration says treating people sooner and more rapid expansion of other proven tools could help even the hardest-hit countries begin turning the tide of the epidemic over the next three to five years.

"An AIDS-free generation is not just a rallying cry — it is a goal that is within our reach," Secretary of State Hillary Rodham Clinton, who ordered the blueprint, said in the report.

"Make no mistake about it, HIV may well be with us into the future but the disease that it causes need not be," she said at the State Department Thursday.

President Barack Obama echoed that promise.

"We stand at a tipping point in the fight against HIV/AIDS, and working together, we can realize our historic opportunity to bring that fight to an end," Obama said in a proclamation to mark World AIDS Day on Saturday.

Some 34 million people worldwide are living with HIV, and despite a decline in new infections over the last decade, 2.5 million people were infected last year.

Given those staggering figures, what does an AIDS-free generation mean? That virtually no babies are born infected, young people have a much lower risk than today of becoming infected, and that people who already have HIV would receive life-saving treatment.

That last step is key: Treating people early in their infection, before they get sick, not only helps them survive but also dramatically cuts the chances that they'll infect others. Yet only about 8 million HIV patients in developing countries are getting treatment. The United Nations aims to have 15 million treated by 2015.

Other important steps include: Treating more pregnant women, and keeping them on treatment after their babies are born; increasing male circumcision to lower men's risk of heterosexual infection; increasing access to both male and female condoms; and more HIV testing.

The world spent $16.8 billion fighting AIDS in poor countries last year. The U.S. government is the leading donor, spending about $5.6 billion.

Thursday's report from PEPFAR, the President's Emergency Plan for AIDS Relief, outlines how progress could continue at current spending levels — something far from certain as Congress and Obama struggle to avert looming budget cuts at year's end — or how faster progress is possible with stepped-up commitments from hard-hit countries themselves.

Clinton warned Thursday that the U.S. must continue doing its share: "In the fight against HIV/AIDS, failure to live up to our commitments isn't just disappointing, it's deadly."

The report highlighted Zambia, which already is seeing some declines in new cases of HIV. It will have to treat only about 145,000 more patients over the next four years to meet its share of the U.N. goal, a move that could prevent more than 126,000 new infections in that same time period. But if Zambia could go further and treat nearly 198,000 more people, the benefit would be even greater — 179,000 new infections prevented, the report estimates.

In contrast, if Zambia had to stick with 2011 levels of HIV prevention, new infections could level off or even rise again over the next four years, the report found.

Advocacy groups said the blueprint offers a much-needed set of practical steps to achieve an AIDS-free generation — and makes clear that maintaining momentum is crucial despite economic difficulties here and abroad.

"The blueprint lays out the stark choices we have: To stick with the baseline and see an epidemic flatline or grow, or ramp up" to continue progress, said Chris Collins of amFAR, the Foundation for AIDS Research.

His group has estimated that more than 276,000 people would miss out on HIV treatment if U.S. dollars for the global AIDS fight are part of across-the-board spending cuts set to begin in January.

Thursday's report also urges targeting the populations at highest risk, including gay men, injecting drug users and sex workers, especially in countries where stigma and discrimination has denied them access to HIV prevention services.

"We have to go where the virus is," Clinton said.

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