IHT Rendezvous: Drones, Brennan and Obama's Legacy of Secrecy

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NEW YORK — John O. Brennan’s testimony before the Senate Intelligence Committee on Thursday was representative of the Obama administration’s approach to counter-terrorism: right-sounding assurances with little transparency.

Mr. Brennan, the president’s choice to be the next head of the Central Intelligence Agency, said the United States should publicly disclose when American drone attacks kill civilians. He called water boarding “reprehensible” and vowed it would never occur under his watch. And he said that countering militancy should be “comprehensive,” not just “kinetic,” and involve diplomatic and development efforts as well.

What any of that means in practice, critics say, remains unknown.

Mr. Brennan failed to clearly answer questions about the administration’s excessive embrace of drone strikes and secrecy.

He flatly defended the quadrupling of drone strikes that has occurred on President Obama’s watch. He gave no clear explanation for why the public has been denied access to Justice Department legal opinions that give the president the power to kill U.S. citizens without judicial review. And his statement that the establishment of a special court to review the targeting of Americans was “worthy of discussion” was noncommittal.

Before the hearing administration officials defended the career CIA officer who has served as the president’s chief counter-terrorism adviser throughout his first term. A senior administration official who asked not be named said that Mr. Brennan has actively worked to reduce drone attacks and increase transparency.

Officials described him as a traditionalist who would move the CIA away from the paramilitary attacks that have come to define its mission since 2001. Instead, the agency would move back to espionage and hand over lethal strikes, including drone attacks, to the military’s Special Operations forces.

Over the last two years, drone strikes in Pakistan have, in fact, decreased by nearly two-thirds from a peak of 122 in 2010 to 48 last year, according to The New American Foundation. At the same time, strikes in Yemen have increased, killing an estimated 400 people including 80 civilians.

From his office in the basement of the White House, Mr. Brennan has been at the center of it all. Daniel Benjamin, who recently stepped down as the State Department’s top counterterrorism official, told the New York Times this week that Mr. Brennan had sweeping authority.

“He’s probably had more power and influence than anyone in a comparable position in the last 20 years,” said Mr. Benjamin. “He’s had enormous sway over the intelligence community. He’s had a profound impact on how the military does counterterrorism.”

Some former military and intelligence officials have warned that the administration’s drone strikes have shifted from an attempt to only target senior militants to a de facto bombing campaign against low-level fighters. They say such a policy creates high levels of public animosity toward the United States with questionable results.

In a recent interview with Reuters, retired Gen. Stanley McChrystal, the former commander of American forces in Afghanistan, said drones were useful tools, but they are “hated on a visceral level” in many countries and contribute to a “perception of American arrogance.”

In Thursday’s hearing, Mr. Brennan showed an awareness of how excessive use of force can be counterproductive. He also aggressively defended the need for the United States to abide by the rule of law, a vital practice if the US is going to ever gain popular support in the region.

In one of his strongest moments, Mr. Brennan flatly rejected suggestions by Senator Marco Rubio of Florida that U.S. officials should have pressured Tunisian officials to improperly detain a suspect in the fatal attack on the U.S. consulate in Benghazi, Libya. Mr. Brennan said Tunisian officials had no evidence linking the man to the incident.

“Senator, this country needs to make sure we are setting an example and a standard for the world,” he said, adding that Washington had to “respect the rights of these governments to enforce their laws independently.”

Mr. Brennan also argued that opponents of the program misunderstood it. He said the United States only used drone strikes as a “last resort,” and the administration goes through “agony” before launching drone strikes in order to avoid civilian casualties.

In truth, the administration’s insistence on keeping the drone program secret fuels public suspicion. Declaring a program “covert” when it is reported on by the global media on a daily basis is increasingly absurd: as Joshua Foust, an analyst and former U.S. intelligence official, has argued, keeping the program secret cedes the debate to critics who say the strikes only kill vast numbers of civilians.

It is easy to see why many analysts say the United States should continue to carry out drone strikes – they are a military necessity – but keep them to a minimum. And details such as why an attack is carried out, who is killed and any civilian casualties should be publicly disclosed.

Mr. Brennan’s statement that drone strikes have decimated al Qaeda’s core leadership in Pakistan’s tribal areas was largely accurate. But despite the increase in strikes under Mr. Obama, the attacks have failed to do the same to the Afghan and Pakistani Taliban operating out of the same area. Drone strikes will never be a silver bullet. They have created a stalemate in Pakistan, weakening militant groups but not eliminating them.

After the hearing, Sen. Dianne Feinstein, the Democratic chair of the Senate Intelligence Committee, said she was considering drafting legislation that would create a special court to review requests by the president to target Americans under certain circumstances. The new body would be similar to the court that currently reviews government requests to wiretap citizens.

Critics point out that the Obama administration has a long record of promising transparency and then embracing secrecy — from drone strikes to legal memos to unprecedented prosecutions of government officials for leaking to the news media.

Overall, Mr. Brennan impressed those watching yesterday. We will see if he moves the CIA and the administration toward greater transparency. What he and the president plan remains secret.

David Rohde is a columnist for Reuters, former reporter for The New York Times and two-time winner of the Pulitzer Prize. His forthcoming book, “Beyond War: Reimagining American Influence in a New Middle East” will be published in March 2013.

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John E. Karlin, 1918-2013: John E. Karlin, Who Led the Way to All-Digit Dialing, Dies at 94

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Courtesy of Alcatel-Lucent USA


John E. Karlin, a researcher at Bell Labs, studied ways to make the telephone easier to use.







A generation ago, when the poetry of PEnnsylvania and BUtterfield was about to give way to telephone numbers in unpoetic strings, a critical question arose: Would people be able to remember all seven digits long enough to dial them?




And when, not long afterward, the dial gave way to push buttons, new questions arose: round buttons, or square? How big should they be? Most crucially, how should they be arrayed? In a circle? A rectangle? An arc?


For decades after World War II, these questions were studied by a group of social scientists and engineers in New Jersey led by one man, a Bell Labs industrial psychologist named John E. Karlin.


By all accounts a modest man despite his variegated accomplishments (he had a doctorate in mathematical psychology, was trained in electrical engineering and had been a professional violinist), Mr. Karlin, who died on Jan. 28, at 94, was virtually unknown to the general public.


But his research, along with that of his subordinates, quietly yet emphatically defined the experience of using the telephone in the mid-20th century and afterward, from ushering in all-digit dialing to casting the shape of the keypad on touch-tone phones. And that keypad, in turn, would inform the design of a spate of other everyday objects.


It is not so much that Mr. Karlin trained midcentury Americans how to use the telephone. It is, rather, that by studying the psychological capabilities and limitations of ordinary people, he trained the telephone, then a rapidly proliferating but still fairly novel technology, to assume optimal form for use by midcentury Americans.


“He was the one who introduced the notion that behavioral sciences could answer some questions about telephone design,” Ed Israelski, an engineer who worked under Mr. Karlin at Bell Labs in the 1970s, said in a telephone interview on Wednesday.


In 2013, the 50th anniversary of the introduction of the touch-tone phone, the answers to those questions remain palpable at the press of a button. The rectangular design of the keypad, the shape of its buttons and the position of the numbers — with “1-2-3” on the top row instead of the bottom, as on a calculator — all sprang from empirical research conducted or overseen by Mr. Karlin.


The legacy of that research now extends far beyond the telephone: the keypad design Mr. Karlin shepherded into being has become the international standard on objects as diverse as A.T.M.’s, gas pumps, door locks, vending machines and medical equipment.


Mr. Karlin, associated from 1945 until his retirement in 1977 with Bell Labs, headquartered in Murray Hill, N.J., was widely considered the father of human-factors engineering in American industry.


A branch of industrial psychology that combines experimentation, engineering and product design, human-factors engineering is concerned with easing the awkward, often ill-considered marriage between man and machine. In seeking to design and improve technology based on what its users are mentally capable of, the discipline is the cognitive counterpart of ergonomics.


“Human-factors studies are different from market research and other kinds of studies in that we observe people’s behavior and record it, systematically and without bias,” Mr. Israelski said. “The hallmark of human-factors studies is they involve the actual observation of people doing things.”


Among the issues Mr. Karlin examined as the head of Bell Labs’ Human Factors Engineering department — the first department of its kind at an American company — were the optimal length for a phone cord (a study that involved gentle, successful sabotage) and the means by which rotary calls could be made efficiently after the numbers were moved from inside the finger holes, where they had nestled companionably for years, to the rim outside the dial.


John Elias Karlin was born in Johannesburg on Feb. 28, 1918, and reared nearby in Germiston, where his parents owned a grocery store and tearoom.


He earned a bachelor’s degree in philosophy, psychology and music, and a master’s degree in psychology, both from the University of Cape Town. Throughout his studies he was a violinist in the Cape Town Symphony Orchestra and the Cape Town String Quartet.


Moving to the United States, Mr. Karlin earned a Ph.D. from the University of Chicago in 1942. Afterward, he became a research associate at Harvard; he also studied electrical engineering there and at the Massachusetts Institute of Technology.


At Harvard, Mr. Karlin did research for the United States military on problems in psychoacoustics that were vital to the war effort — studying the ways, for instance, in which a bomber’s engine noise might distract its crew from their duties.


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In Nigeria, Polio Vaccine Workers Are Killed by Gunmen

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At least nine polio immunization workers were shot to death in northern Nigeria on Friday by gunmen who attacked two clinics, officials said.




The killings, with eerie echoes of attacks that killed nine female polio workers in Pakistan in December, represented another serious setback for the global effort to eradicate polio.


Most of the victims were women and were shot in the back of the head, local reports said.


A four-day vaccination drive had just ended in Kano State, where the killings took place, and the vaccinators were in a “mop-up” phase, looking for children who had been missed, said Sarah Crowe, a spokeswoman for the United Nations Children’s Fund, one of the agencies running the eradication campaign.


Dr. Mohammad Ali Pate, Nigeria’s minister of state for health, said in a telephone interview that it was not entirely clear whether the gunmen were specifically targeting polio workers or just attacking the health centers where vaccinators happened to be gathering early in the morning. “Health workers are soft targets,” he said.


No one immediately took responsibility, but suspicion fell on Boko Haram, a militant Islamist group that has attacked police stations, government offices and even a religious leader’s convoy.


Polio, which once paralyzed millions of children, is now down to fewer than 1,000 known cases around the world, and is endemic in only three countries: Nigeria, Pakistan and Afghanistan.


Since September — when a new polio operations center was opened in the capital and Nigeria’s president, Goodluck Jonathan, appointed a special adviser for polio — the country had been improving, said Dr. Bruce Aylward, chief of polio eradication for the World Health Organization. There have been no new cases since Dec. 3.


While vaccinators have not previously been killed in the country, there is a long history of Nigerian Muslims shunning the vaccine.


Ten years ago, immunization was suspended for 11 months as local governors waited for local scientists to investigate rumors that it caused AIDS or was a Western plot to sterilize Muslim girls. That hiatus let cases spread across Africa. The Nigerian strain of the virus even reached Saudi Arabia when a Nigerian child living in hills outside Mecca was paralyzed.


Heidi Larson, an anthropologist at the London School of Hygiene and Tropical Medicine who tracks vaccine issues, said the newest killings “are kind of mimicking what’s going on in Pakistan, and I feel it’s very much prompted by that.”


In a roundabout way, the C.I.A. has been blamed for the Pakistan killings. In its effort to track Osama bin Laden, the agency paid a Pakistani doctor to seek entry to Bin Laden’s compound on the pretext of vaccinating the children — presumably to get DNA samples as evidence that it was the right family. That enraged some Taliban factions in Pakistan, which outlawed vaccination in their areas and threatened vaccinators.


Nigerian police officials said the first shootings were of eight workers early in the morning at a clinic in the Tarauni neighborhood of Kano, the state capital; two or three died. A survivor said the two gunmen then set fire to a curtain, locked the doors and left.


“We summoned our courage and broke the door because we realized they wanted to burn us alive,” the survivor said from her bed at Aminu Kano Teaching Hospital.


About an hour later, six men on three-wheeled motorcycles stormed a clinic in the Haye neighborhood, a few miles away. They killed seven women waiting to collect vaccine.


Ten years ago, Dr. Larson said, she joined a door-to-door vaccination drive in northern Nigeria as a Unicef communications officer, “and even then we were trying to calm rumors that the C.I.A. was involved,” she said. The Iraq and Afghanistan wars had convinced poor Muslims in many countries that Americans hated them, and some believed the American-made vaccine was a plot by Western drug companies and intelligence agencies.


Since the vaccine ruse in Pakistan, she said, “Frankly, now, I can’t go to them and say, ‘The C.I.A. isn’t involved.’ ”


Dr. Pate said the attack would not stop the newly reinvigorated eradication drive, adding, “This isn’t going to deter us from getting everyone vaccinated to save the lives of our children.”


Aminu Abubakar contributed reported from Kano, Nigeria.



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In Nigeria, Polio Vaccine Workers Are Killed by Gunmen

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At least nine polio immunization workers were shot to death in northern Nigeria on Friday by gunmen who attacked two clinics, officials said.




The killings, with eerie echoes of attacks that killed nine female polio workers in Pakistan in December, represented another serious setback for the global effort to eradicate polio.


Most of the victims were women and were shot in the back of the head, local reports said.


A four-day vaccination drive had just ended in Kano State, where the killings took place, and the vaccinators were in a “mop-up” phase, looking for children who had been missed, said Sarah Crowe, a spokeswoman for the United Nations Children’s Fund, one of the agencies running the eradication campaign.


Dr. Mohammad Ali Pate, Nigeria’s minister of state for health, said in a telephone interview that it was not entirely clear whether the gunmen were specifically targeting polio workers or just attacking the health centers where vaccinators happened to be gathering early in the morning. “Health workers are soft targets,” he said.


No one immediately took responsibility, but suspicion fell on Boko Haram, a militant Islamist group that has attacked police stations, government offices and even a religious leader’s convoy.


Polio, which once paralyzed millions of children, is now down to fewer than 1,000 known cases around the world, and is endemic in only three countries: Nigeria, Pakistan and Afghanistan.


Since September — when a new polio operations center was opened in the capital and Nigeria’s president, Goodluck Jonathan, appointed a special adviser for polio — the country had been improving, said Dr. Bruce Aylward, chief of polio eradication for the World Health Organization. There have been no new cases since Dec. 3.


While vaccinators have not previously been killed in the country, there is a long history of Nigerian Muslims shunning the vaccine.


Ten years ago, immunization was suspended for 11 months as local governors waited for local scientists to investigate rumors that it caused AIDS or was a Western plot to sterilize Muslim girls. That hiatus let cases spread across Africa. The Nigerian strain of the virus even reached Saudi Arabia when a Nigerian child living in hills outside Mecca was paralyzed.


Heidi Larson, an anthropologist at the London School of Hygiene and Tropical Medicine who tracks vaccine issues, said the newest killings “are kind of mimicking what’s going on in Pakistan, and I feel it’s very much prompted by that.”


In a roundabout way, the C.I.A. has been blamed for the Pakistan killings. In its effort to track Osama bin Laden, the agency paid a Pakistani doctor to seek entry to Bin Laden’s compound on the pretext of vaccinating the children — presumably to get DNA samples as evidence that it was the right family. That enraged some Taliban factions in Pakistan, which outlawed vaccination in their areas and threatened vaccinators.


Nigerian police officials said the first shootings were of eight workers early in the morning at a clinic in the Tarauni neighborhood of Kano, the state capital; two or three died. A survivor said the two gunmen then set fire to a curtain, locked the doors and left.


“We summoned our courage and broke the door because we realized they wanted to burn us alive,” the survivor said from her bed at Aminu Kano Teaching Hospital.


About an hour later, six men on three-wheeled motorcycles stormed a clinic in the Haye neighborhood, a few miles away. They killed seven women waiting to collect vaccine.


Ten years ago, Dr. Larson said, she joined a door-to-door vaccination drive in northern Nigeria as a Unicef communications officer, “and even then we were trying to calm rumors that the C.I.A. was involved,” she said. The Iraq and Afghanistan wars had convinced poor Muslims in many countries that Americans hated them, and some believed the American-made vaccine was a plot by Western drug companies and intelligence agencies.


Since the vaccine ruse in Pakistan, she said, “Frankly, now, I can’t go to them and say, ‘The C.I.A. isn’t involved.’ ”


Dr. Pate said the attack would not stop the newly reinvigorated eradication drive, adding, “This isn’t going to deter us from getting everyone vaccinated to save the lives of our children.”


Aminu Abubakar contributed reported from Kano, Nigeria.



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U.S. Use of Mexican Battery Recyclers Is Faulted

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United States companies are sending spent lead batteries to recycling plants in Mexico that do not meet American environmental standards, according to an environmental agency created under the North American Free Trade Agreement, putting Mexican communities at risk.




In a blistering report submitted this week, the agency, the Commission for Environmental Cooperation, notes that the United States does not fully follow procedures common among developed nations that treat international battery shipments as hazardous waste. It faults environmental agencies on both sides of the border for lapses in regulation and enforcement. Cross-border trade in lead batteries increased by up to 525 percent from 2004 to 2011, the report said.


The report, which has been circulating in draft form, has been forwarded to the governments of the United States, Canada and Mexico, which have 60 days to object to its publication. An estimated 20 percent of lead acid batteries from the United States now go to Mexico for recycling, according to trade statistics.


“There needs to be better coordination between government agencies and better cross-border tracking,” said Evan Lloyd, who was the agency’s executive director until late last year and oversaw the yearlong study.


The report highlighted a number of shortcomings: Customs data on the number of batteries crossing the border did not mesh with counts by the United States Environmental Protection Agency. Though the E.P.A. requires notice of batteries leaving the United States, there was no effort to make sure that they had arrived at qualified recyclers in Mexico. The data that battery companies sent to the E.P.A. about exports consisted of “piles of paper,” Mr. Lloyd said, and it was never amassed into an electronic database that would be “useful to regulators.”


Almost all lead acid batteries used in the United States are recycled to extract the lead for reuse because lead is a dangerous pollutant and because it is a valuable commodity. Lead batteries are used in vehicles, cellphone towers and wind turbines.


Since 2008, new United States limits on lead pollution have made domestic recycling complicated and costly. That has helped propel the recycling trade to Mexico, both legally and illegally, environmental groups say, because that country has less stringent limits for lead pollution, and far less vigorous enforcement.


“There’s a pretty consistent pattern suggesting that exports are the direct result of U.S. emissions standards,” said Perry Gottesfeld, executive director of Occupational Knowledge International, which has led the campaign against lead poisoning internationally. Mr. Gottesfeld noted that a Mexican plant owned by a major American recycler, Johnson Controls Inc., puts out more than 30 times as much lead emissions as its newest plant in the United States.


“What Mexico needs to do is to get its recycling up to U.S. standards, and the U.S. needs to do a much better job of tracking batteries overseas,” he said. In an e-mail, Johnson Controls, based in Milwaukee, said it was “modernizing and reinvesting” in the Mexican facility, acquired in 2005, “to reduce its environmental footprint.”


The report was initiated in response to a report by Occupational Knowledge International and Fronteras Comunes, a Mexican environmental group, as well as to an investigative article in The New York Times, Mr. Lloyd said. Soil collected by The Times in a school playground near a recycling plant outside Mexico City was found to have lead levels five times those allowed in the United States.


Lead poisoning causes high blood pressure, kidney damage and abdominal pain in adults, and serious developmental delays and behavioral problems in young children. When batteries are broken for recycling, the lead is released as dust and, during melting, as lead-laced emissions.


In the United States, recyclers operate in highly mechanized, tightly sealed plants, with smokestack scrubbers and extensive monitors to detect lead release. Plants in Mexico vary greatly in safety standards, and in some, the recycling process is little more than men with hammers smashing batteries and melting down their contents in furnaces.


In recent months, there have been new efforts to curb the flow of batteries south of the border, though many battery makers have fought that. In response to a draft of the report released late last year, Battery Council International, an industry group, said it opposed “the creation of additional burdensome certification programs.”


Last year, the United States General Services Administration, which is responsible for federal vehicles, asked ASTM International, an independent standards agency, to explore a voluntary standard for battery recycling.


But that effort came to naught after the proposal was voted down at an open meeting attended by representatives from industry, government and environmental groups in December. Of the 103 people at the meeting, 49 worked for Johnson Controls.


This article has been revised to reflect the following correction:

Correction: February 9, 2013

An earlier version of this article misstated part of the name of an American recycler cited by Perry Gottesfeld, executive director of Occupational Knowledge International, as the owner of a Mexican plant that puts out more than 30 times as much lead emissions as the company’s newest plant in the United States. The American recycling company is Johnson Controls Inc., not Johnson Controls International.



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Fire Destroys Offices of Israeli Soccer Team That Recruited Muslims

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Integrating Israeli Soccer:
The Times’s Jodi Rudoren looks at lingering racism in the stands of the last Israeli soccer team to field Muslim players.







JERUSALEM — Prime Minister Benjamin Netanyahu of Israel on Friday condemned as “shameful” the recent protests by soccer fans here of their team’s recent recruitment of two Muslim players, hours after the offices of the team were burned in what the police suspect was an arson set by some of those fans.




“We cannot accept such racist behavior,” Mr. Netanyahu said. “The Jewish people, who suffered excommunications and expulsions, need to represent a light unto the nations.”


The team, Beitar Jerusalem, has long been linked to Mr. Netanyahu’s Likud Party, and for 15 years has been notorious for racism and violence, including an incident last spring in which fans stormed a local mall chanting “Death to Arabs” and beat up several Arab employees. Founded in 1936, it is the only one of Israel’s professional soccer teams never to have recruited an Arab player.


The current controversy concerns the team’s addition of two Muslim players from Chechnya. Although one is injured, the other is expected to play for the first time in a match on Sunday against a team from Sakhnin, an Arab-Israeli town.


In anticipation of the Muslim players’ arrival, some fans unfurled a banner at the team’s Jan. 26 game saying “Beitar Pure Forever.” Some critics said the banner was reminiscent of Nazi Germany’s expulsion of Jews from sport, and it led to nationwide soul-searching.


Four fans were indicted on Thursday for incitement. Beitar headquarters were set on fire at 5 a.m. Friday, according to the police, destroying the team’s trophies, commemorative jerseys of former stars, championship flags, photographs and books. “All the history of Beitar Jerusalem,” said the team spokesman, Asaf Shaked. “It’s not damage by money, it’s damage by emotion.”


The mayor of Jerusalem, Nir Barkat, also condemned the violence on Friday, likening the perpetrators to the mafia. Limor Livnat, Israel’s minister of culture and sport, said she would attend Sunday’s game to show support for the team’s management.


Micky Rosenfeld, a police spokesman, said a special investigative team was looking into the arson, which he said “gushed through the offices,” and that the police would not only send hundreds of extra officers to Sunday’s game, but seek to arrest troublemakers beforehand.


Eli Abarbanel, a senior state prosecutor and Beitar fan, said on Israel Radio Friday that the soccer struggle reflected “a broad phenomenon of racism in all of Israeli society,” citing expressions of “joy” on social media after a recent bus accident that killed 20 Palestinian children.


Itzik Kornfein, Beitar’s manager, also said that the dispute had “gone beyond sports” and had “ramifications for Israeli society and for how we look to the world.” Speaking to Israel Radio, Mr. Kornfein vowed not to back down from his decision to integrate the team, saying, “I don’t compromise on the matter of racism” and predicting that “after violence of this kind, people will come to their senses.”


Mr. Shaked, the Beitar spokesman, said management would “continue to fight against this part of the fans” and “continue to hug the two players” in order “to show all the world” that the club is not defined by the slogans shouted from the stands.


“I hope that from this Sunday we’re going to start a new way for the club,” he said. “We call that ‘The New Beitar.’ This is the slogan of the club now: a different Beitar, a new Beitar.”


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DealBook: Helping Start-Ups With Local Support and National Networks

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When Will Fuentes planned an extended business trip to Seattle last year, he tapped into the local chapter of a national networking group there. Within hours, Mr. Fuentes, who founded the Arlington, Va., software company Lemur Retail, had secured a work space, introductions and even restaurant recommendations via the group, the Startup America Partnership.“Before I flew out there, I already had five or six meetings set up with potential clients and other key contacts, as well as one potential acquirer,” Mr. Fuentes said.

A couple of years ago, entrepreneurs would have needed several trips to make similar connections outside their own cities. Even in this era of social networks and venture conferences, start-ups are still surprisingly disconnected on a national level.

“Each region has its ties, but in many cases, entrepreneurs are operating in silos,” said Carolynn Duncan, the chief executive of Portland Ten, a mentoring program for early-stage companies, mainly in Oregon. “An entrepreneur in Oregon doesn’t have an easy way to network with entrepreneurs in Washington D.C.”

Startup America, a nonprofit organization with an all-star cast of deep-pocketed backers, is trying to bridge the gap. The organization, which was started in January 2011 as the brainchild of AOL’s co-founder, Steve Case, and the Ewing Marion Kauffman Foundation, wanted to bring a private-sector support to start-ups — without financial strings attached.

“Supporting start-ups throughout the country is the only way to make sure the American economy is firing on all cylinders,” said Mr. Case, who is the chairman of the partnership.

Start-ups are a crucial driver for job creation in the United States. From March 1994 to March 2010, businesses less than one year old created 3.9 million jobs a year on average, according to the Bureau of Labor Statistics, though that number has declined during the recent economic weakness.

The Small Business Administration and United States Chamber of Commerce have long been a resource for start-ups, but these government agencies have a broad mandate. There is a “growing recognition,” said Mr. Case, that high-growth start-ups — those with the potential to be national or international companies — have different needs and requirements than traditional small businesses.

Startup America’s initial focus was to provide support to start-ups through deals on goods and services, like 40 percent off FedEx shipping and free flights on American Airlines. But the group quickly realized that start-ups needed more practical help, like sharing best practices and networking.

Soon after the partnership’s start, entrepreneurs around the country starting contacting Startup America, asking how they could create their own networks and reach out to counterparts in other states. “Most of these regions were already coming up with their own initiatives or thinking about them,” said the organization’s chief executive, Scott Case, a founder and former chief technology officer of Priceline.com (and no relation to Steve Case). “We’re helping to stitch together all these parts.”

Taking cues from the entrepreneurs, Startup America has turned its attention to building such a network. Nearly 12,000 members are now affiliated with local Startup America initiatives in 30 states. The partnership expects to add another 10 states this year.

Each Startup America region is spearheaded by local “champions” who come together several times a year at national conferences, communicate via Google groups and have access to an online “idea center” where they can brainstorm about, say, bringing in outside capital or hosting a start-up conference. These envoys are all “founder types” at different stages of their careers, Scott Case said. “Some have exited companies and are looking to continue to feed that creative drive. Others understand that if they can strengthen their community, they can strengthen their own company.”

Brooks Bell, founder of an eponymous 22-employee digital consulting business based in Raleigh, N.C., became involved with the partnership in 2011 after realizing that many potential clients considered her area a backwater. “I realized that was impacting my company’s brand, too,” she said.

Mrs. Bell pointed out that other national groups, like Entrepreneurs’ Organizations, offer resources for high-growth companies. Yet, their emphasis is typically on supporting individuals rather than elevating the region and networking nationally. “They also tend to focus on early-stage companies,” she said. Until Startup America, she added, “there weren’t a lot of opportunities for early-stage companies to interact with funded companies.”

Though Startup America regions work off the same blueprint, each takes a slightly different approach. In Maryland, the staff and champions volunteer virtually. Startup Tennessee partnered with the Entrepreneur Center in Nashville, which runs a nonprofit incubator program. Startup Colorado works out of Silicon Flatirons, a center for law, technology and entrepreneurship at the University of Colorado Law School, and finds partners to finance specific projects.

Although the regional chapters operate independently, they benefit from the credibility of a national organization. “It’s helping elevate our start-ups nationally and get them in front of audiences we never would have,” said Andy Stoll, an entrepreneur in the Iowa City, Iowa, area, where rebuilding from the floods in 2008 has helped generate a boom in start-up activity.

“To have the opportunity to sit in a room with their board and have Steve Case ask me, ‘What are the three things that those of us at this table can do to really help support the Indiana community?’ is amazing and a humbling experience,” said Michael Coffey, a partner at DeveloperTown, an Indianapolis design and development firm that works with companies of all sizes.

In the end, it’s all about business.

Aaron Schwartz, a co-founder of the San Francisco-based Modify Watches, initially joined Startup America for the discounts. Now, he’s also tapping into the partnership to network, including finding corporate clients who order custom watches and vendors. “I now have a contact in Tennessee who has offered to look into manufacturing our watches there,” he said

Mr. Fuentes of Lemur Retail found two potential clients, both national chains, through his connections in Seattle last year; he’s currently in talks with those companies. He’s also helping his Northwest counterparts make inroads in the Washington area. He likens the experience to a fraternity or alumni organization of entrepreneurs.

“When people contact me from my high school or college, I pick up the phone,” he said. “This is no different.”

A version of this article appeared in print on 02/08/2013, on page B5 of the NewYork edition with the headline: Helping Start-Ups With Local Support and National Networks.
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The New Old Age: The Executor's Assistant

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I’m serving as executor for my father’s estate, a role few of us are prepared for until we’re playing it, so I was grateful when the mail brought “The American Bar Association Guide to Wills and Estates” — the fourth edition of a handbook the A.B.A. began publishing in 1995.

This is a legal universe, I’m learning, in which every step — even with a small, simple estate that owes no taxes and includes no real estate or trusts — turns out to be at least 30 percent more complicated than expected.

If my dad had been wealthy or owned a business, or if we faced a challenge to his will, I would have turned the whole matter over to an estate lawyer by now. But even then, it would be helpful to know what the lawyer was talking about. The A.B.A. guide would help.

Written with surprising clarity (hey, they’re lawyers), it maps out all kinds of questions and decisions to consider and explains the many ways to leave property to one’s heirs. Updated from the third edition in 2009, the guide not only talks taxes and trusts, but also offers counsel for same-sex couples and unconventional families.

If you want to permit your second husband to live in the family home until he dies, but then guarantee that the house reverts to the children of your first marriage, the guide tells you how a “life estate” works. It explains what is taxable and what isn’t, and discusses how to choose executors and trustees. It lists lots of resources and concludes with an estate-planning checklist.

In general, the A.B.A. intends its guide for the person trying to put his or her affairs in order, more than for family members trying to figure out how to proceed after someone has died. But many of us will play both these parts at some point (and if you are already an executor, or have been, please tell us how that has gone, and mention your state). We’ll need this information.

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

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The New Old Age: The Executor's Assistant

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I’m serving as executor for my father’s estate, a role few of us are prepared for until we’re playing it, so I was grateful when the mail brought “The American Bar Association Guide to Wills and Estates” — the fourth edition of a handbook the A.B.A. began publishing in 1995.

This is a legal universe, I’m learning, in which every step — even with a small, simple estate that owes no taxes and includes no real estate or trusts — turns out to be at least 30 percent more complicated than expected.

If my dad had been wealthy or owned a business, or if we faced a challenge to his will, I would have turned the whole matter over to an estate lawyer by now. But even then, it would be helpful to know what the lawyer was talking about. The A.B.A. guide would help.

Written with surprising clarity (hey, they’re lawyers), it maps out all kinds of questions and decisions to consider and explains the many ways to leave property to one’s heirs. Updated from the third edition in 2009, the guide not only talks taxes and trusts, but also offers counsel for same-sex couples and unconventional families.

If you want to permit your second husband to live in the family home until he dies, but then guarantee that the house reverts to the children of your first marriage, the guide tells you how a “life estate” works. It explains what is taxable and what isn’t, and discusses how to choose executors and trustees. It lists lots of resources and concludes with an estate-planning checklist.

In general, the A.B.A. intends its guide for the person trying to put his or her affairs in order, more than for family members trying to figure out how to proceed after someone has died. But many of us will play both these parts at some point (and if you are already an executor, or have been, please tell us how that has gone, and mention your state). We’ll need this information.

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

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DealBook: Helping Start-Ups With Local Support and National Networks

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When Will Fuentes planned an extended business trip to Seattle last year, he tapped into the local chapter of a national networking group there. Within hours, Mr. Fuentes, who founded the Arlington, Va., software company Lemur Retail, had secured a work space, introductions and even restaurant recommendations via the group, the Startup America Partnership.“Before I flew out there, I already had five or six meetings set up with potential clients and other key contacts, as well as one potential acquirer,” Mr. Fuentes said.

A couple of years ago, entrepreneurs would have needed several trips to make similar connections outside their own cities. Even in this era of social networks and venture conferences, start-ups are still surprisingly disconnected on a national level.

“Each region has its ties, but in many cases, entrepreneurs are operating in silos,” said Carolynn Duncan, the chief executive of Portland Ten, a mentoring program for early-stage companies, mainly in Oregon. “An entrepreneur in Oregon doesn’t have an easy way to network with entrepreneurs in Washington D.C.”

Startup America, a nonprofit organization with an all-star cast of deep-pocketed backers, is trying to bridge the gap. The organization, which was started in January 2011 as the brainchild of AOL’s co-founder, Steve Case, and the Ewing Marion Kauffman Foundation, wanted to bring a private-sector support to start-ups — without financial strings attached.

“Supporting start-ups throughout the country is the only way to make sure the American economy is firing on all cylinders,” said Mr. Case, who is the chairman of the partnership.

Start-ups are a crucial driver for job creation in the United States. From March 1994 to March 2010, businesses less than one year old created 3.9 million jobs a year on average, according to the Bureau of Labor Statistics, though that number has declined during the recent economic weakness.

The Small Business Administration and United States Chamber of Commerce have long been a resource for start-ups, but these government agencies have a broad mandate. There is a “growing recognition,” said Mr. Case, that high-growth start-ups — those with the potential to be national or international companies — have different needs and requirements than traditional small businesses.

Startup America’s initial focus was to provide support to start-ups through deals on goods and services, like 40 percent off FedEx shipping and free flights on American Airlines. But the group quickly realized that start-ups needed more practical help, like sharing best practices and networking.

Soon after the partnership’s start, entrepreneurs around the country starting contacting Startup America, asking how they could create their own networks and reach out to counterparts in other states. “Most of these regions were already coming up with their own initiatives or thinking about them,” said the organization’s chief executive, Scott Case, a founder and former chief technology officer of Priceline.com (and no relation to Steve Case). “We’re helping to stitch together all these parts.”

Taking cues from the entrepreneurs, Startup America has turned its attention to building such a network. Nearly 12,000 members are now affiliated with local Startup America initiatives in 30 states. The partnership expects to add another 10 states this year.

Each Startup America region is spearheaded by local “champions” who come together several times a year at national conferences, communicate via Google groups and have access to an online “idea center” where they can brainstorm about, say, bringing in outside capital or hosting a start-up conference. These envoys are all “founder types” at different stages of their careers, Scott Case said. “Some have exited companies and are looking to continue to feed that creative drive. Others understand that if they can strengthen their community, they can strengthen their own company.”

Brooks Bell, founder of an eponymous 22-employee digital consulting business based in Raleigh, N.C., became involved with the partnership in 2011 after realizing that many potential clients considered her area a backwater. “I realized that was impacting my company’s brand, too,” she said.

Mrs. Bell pointed out that other national groups, like Entrepreneurs’ Organizations, offer resources for high-growth companies. Yet, their emphasis is typically on supporting individuals rather than elevating the region and networking nationally. “They also tend to focus on early-stage companies,” she said. Until Startup America, she added, “there weren’t a lot of opportunities for early-stage companies to interact with funded companies.”

Though Startup America regions work off the same blueprint, each takes a slightly different approach. In Maryland, the staff and champions volunteer virtually. Startup Tennessee partnered with the Entrepreneur Center in Nashville, which runs a nonprofit incubator program. Startup Colorado works out of Silicon Flatirons, a center for law, technology and entrepreneurship at the University of Colorado Law School, and finds partners to finance specific projects.

Although the regional chapters operate independently, they benefit from the credibility of a national organization. “It’s helping elevate our start-ups nationally and get them in front of audiences we never would have,” said Andy Stoll, an entrepreneur in the Iowa City, Iowa, area, where rebuilding from the floods in 2008 has helped generate a boom in start-up activity.

“To have the opportunity to sit in a room with their board and have Steve Case ask me, ‘What are the three things that those of us at this table can do to really help support the Indiana community?’ is amazing and a humbling experience,” said Michael Coffey, a partner at DeveloperTown, an Indianapolis design and development firm that works with companies of all sizes.

In the end, it’s all about business.

Aaron Schwartz, a co-founder of the San Francisco-based Modify Watches, initially joined Startup America for the discounts. Now, he’s also tapping into the partnership to network, including finding corporate clients who order custom watches and vendors. “I now have a contact in Tennessee who has offered to look into manufacturing our watches there,” he said

Mr. Fuentes of Lemur Retail found two potential clients, both national chains, through his connections in Seattle last year; he’s currently in talks with those companies. He’s also helping his Northwest counterparts make inroads in the Washington area. He likens the experience to a fraternity or alumni organization of entrepreneurs.

“When people contact me from my high school or college, I pick up the phone,” he said. “This is no different.”

A version of this article appeared in print on 02/08/2013, on page B5 of the NewYork edition with the headline: Helping Start-Ups With Local Support and National Networks.
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Way of the World: Theorizing About Taxing High Earners

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NEW YORK — Academics can be dismissive of the concerns of the popular media. But when it comes to the growth of the superrich, the tabloids may have gotten it right.




The numbers tell the story. According to a study by John Van Reenen of the London School of Economics and Brian Bell of Oxford University, the share of national income earned by the top 1 percent in the United States surged to 18.3 percent in 2007, from 8 percent in 1979. In Britain, the trend was almost identical: The top 1 percent received 15.4 percent of the national income in 2007 compared with 5.9 percent in 1979. And these figures exclude capital gains.


“A lot of the action has been at the very top end of the distribution, the top 1 percent or the top 0.1 percent,” Mr. Van Reenen, director of the Center for Economic Performance at the L.S.E., told me. “It shows you that the media’s focus on the very rich and on bankers’ bonuses wasn’t misplaced.”


But while much of the shift in income distribution has been at the apex of the pyramid, that is not where most academic research on rising income inequality has been focused.


If anything, Mr. Van Reenen said, academics “have tended to focus on the bottom of the distribution, much more than the top.”


Mr. Van Reenen and some like-minded colleagues have been working to fill that gap. Their efforts made it to the economic major leagues in January, when Mr. Van Reenen convened a panel discussion on extreme wage inequality at the prestigious annual get-together of the American Economic Association.


One of the most striking findings will probably give comfort to the plutocrats: In contrast to previous generations, the superrich today tend to have earned their fortunes rather than inherited them.


Steven Kaplan of the University of Chicago and Joshua Rauh of Stanford University in California studied Forbes magazine’s annual list of the 400 richest Americans. They found that in 1982, just 40 percent of these plutocrats had built their own businesses. By 2011, the superrich had gotten much richer — the combined wealth of the Forbes 400 was $92 billion in 1982 and had surged to $1.53 trillion by 2011 — and many more of them had, as the meme of the 2012 U.S. presidential election campaign had it, built it themselves: 69 percent.


“This isn’t the Downton Abbey rentier class,” explained Mr. Van Reenen, who has found a similar trend in Britain. “These incomes come from the labor market. You can say it is a triumph of the human capitalists over the physical capitalists.”


Among economists who study the surge in pay at the top, it is pretty much a truth universally acknowledged that taxes should rise at the summit, too. “Economics would suggest that when you have big increases in inequality, the top tax rate should rise,” Mr. Van Reenen said. “That seems very right and very reasonable.”


The impact and the structure of higher taxes for the rich are a more complicated and controversial issue. Timothy Besley and Maitreesh Ghatak, both of the London School of Economics, make a robust case for higher taxes on bankers’ bonuses. Their work is theoretical, but beyond the campus green, what may be particularly interesting is the way they frame the wider debate.


“Little undermines the case for a market economy more than the perception that there is injustice in the rewards that it generates,” they argue in a recent paper. “The greatest clamor for reform should come from those who support the market system.”


“We have shown that some form of bonus taxation in the financial sector is optimal above and beyond standard progressive income taxation,” they conclude. “We have identified a form of taxation that we believe makes the market system both fairer and more efficient.”


This robustly pro-market rationale for higher taxes on bankers, who like to think of themselves as the very embodiment of capitalism, is eye-catching, particularly for anyone who spends much time in the United States, where higher taxes and more efficient markets are usually portrayed as being anathema to one another.


Emmanuel Saez, an economist at the University of California, Berkeley, who is one of the pioneering students of incomes at the very top, has offered an even more provocative suggestion. At the American Economic Association meeting, he argued that when tax rates at the top are low, “top earners extract more pay at the expense of the 99 percent.” Higher tax rates for the rich, he suggested, “reduce the pretax income gap without hurting economic growth.”


This is a truly radical idea: that higher taxes at the top can reduce pretax inequality and not weaken the economy as a whole.


Outside the seminar room, however, these elegant ideas may run into political opposition intensified by the trends within the 1 percent that these same economists have documented.


“It may have a political effect,” Mr. Van Reenen said of the shift from inherited fortunes to self-made ones. “You feel you’ve earned it. This does make people more strongly inclined to resist taxation.”


Chrystia Freeland is editor of Thomson Reuters Digital.


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I.H.T. Special: Social Media Firms Move to Capitalize on Popularity in Middle East

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Suhaib Salem/Reuters


Egyptian protesters look at Facebook during a demonstration in Cairo on January 14.









DUBAI — For its most recent advertising push, the Saudi Arabian telecommunications giant Mobily did not turn to the street or television to engage with customers. Mobily paid to promote itself on Twitter.




The use of social media exploded during the Arab Spring as people turned to cyberspace to express themselves. On the back of that, social media networks, including Twitter, Facebook and LinkedIn, have moved into the region commercially, setting up offices to sell advertising products to companies like Mobily, which has over 200,000 Twitter followers, to capitalize on the growing audience.


“In Saudi, social media gets everyone talking to everyone, which is something we just don’t have in the streets here,” said Muna AbuSulayman, a Saudi development consultant and formerly a popular television talk show host, who has over 100,000 followers on Twitter.


“It’s a unique opportunity that lets people have conversations in a boundary-less way that wasn’t possible before,” Ms. AbuSulayman said. “In addition to promoting social and political discussion, it carries a powerful economic incentive for businesses, too.”


The rise of social media in the Arab world is changing the game for regional advertisers, pushing growth in digital advertising in a part of the world where traditional methods like television and print advertising have so far remained dominant.


Digital advertising in the Middle East and North Africa accounts for only about 4 percent of the region’s total advertising spending, at a value of $200 million, according to the most recent available estimate, but it has become the fastest-growing media platform in the region, said a study by the business services firm Deloitte Touche Tohmatsu, published in 2011. Deloitte’s Arab Media Outlook projected growth in digital advertising spending in the region of 35 percent a year over the next three years, generating about $580 million across the region by 2015.


“The fact is that consumers are online, so brands need to be online,” said Reda Raad, chief operating officer of TBWA\Raad, the Middle East arm of the global advertising agency TBWA. “The use of digital channels has continued to increase dramatically after the Arab Spring and advertising on social media has become a highly targeted, cost-efficient way of communicating with consumers.”


Major brands, including Pepsi Arabia, are taking note. Saudi Arabia has the highest number of Twitter users in the Arab world, holding 38 percent of the region’s two million users, according to a report by the Dubai School of Government’s Arab Social Media Report released in June. In the past year alone, the number of Twitter users in the Arab world tripled, according to Shailesh Rao, Twitter’s vice president for international operations.


Thanks to the platform’s popularity in Saudi Arabia, Egypt, Kuwait and the United Arab Emirates, Arabic is now the fastest-growing language on the Twitter platform.


“We prioritized a list of regions where we wanted to have a business presence, and the Mideast rises toward the top because the region’s user base is one of the fastest-growing in the world,” Mr. Rao said during an interview. “This represents a huge opportunity for brands looking for a large audience that is rapidly growing.”


Twitter has formed a partnership with the Egyptian digital advertising company Connect Ads to market and sell advertising services across the Middle East and North Africa region. Connect Ads will offer brand managers and marketers Twitter’s products, which include promoted tweets, promoted accounts and promoted trends.


Through these, a brand can reach broad Twitter audiences or more narrowly defined geographic or demographic segments. They can even target users of specific smartphone brands, like iPhones. Brands that have signed up so far include Mobily, Pepsi Arabia, the resort company Atlantis The Palm, and the events portal Dubai Calendar.


“Companies can learn a few things about their customers by optimizing for country and targeting those with specific interests,” said Mohamed El Mehairy, managing director of Connect Ads.


“They can probably uncover this type of information through market research,” he added, but it would come “at a higher expense and with more time and effort.”


This article has been revised to reflect the following correction:

Correction: February 7, 2013

A previous version of this article misspelled the name of the advertising agency TBWA. It is TBWA, not TWBA.



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Well: Think Like a Doctor: A Confused and Terrified Patient

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The Challenge: Can you solve the mystery of a middle-aged man recovering from a serious illness who suddenly becomes frightened and confused?

Every month the Diagnosis column of The New York Times Magazine asks Well readers to sift through a difficult case and solve a diagnostic riddle. Below you will find a summary of a case involving a 55-year-old man well on his way to recovering from a series of illnesses when he suddenly becomes confused and paranoid. I will provide you with the main medical notes, labs and imaging results available to the doctor who made the diagnosis.

The first reader to figure out this case will get a signed copy of my book, “Every Patient Tells a Story,” along with the satisfaction of knowing you solved a case of Sherlockian complexity. Good luck.

The Presenting Problem:

A 55-year-old man who is recovering from a devastating injury in a rehabilitation facility suddenly becomes confused, frightened and paranoid.

The Patient’s Story:

The patient, who was recovering from a terrible injury and was too weak to walk, had been found on the floor of his room at the extended care facility, raving that there were people out to get him. He was taken to the emergency room at the Waterbury Hospital in Connecticut, where he was diagnosed with a urinary tract infection and admitted to the hospital for treatment. Doctors thought his delirium was caused by the infection, but after 24 hours, despite receiving the appropriate antibiotics, the patient remained disoriented and frightened.

A Sister’s Visit:

The man’s sister came to visit him on his second day in the hospital. As she walked into the room she was immediately struck by her brother’s distress.

“Get me out of here!” the man shouted from his hospital bed. “They are coming to get me. I gotta get out of here!”

His brown eyes darted from side to side as if searching for his would-be attackers. His arms and legs shook with fear. He looked terrified.

For the past few months, the man had been in and out of the hospital, but he had been getting better — at least he had been improving the last time his sister saw him, the week before. She hurried into the bustling hallway and found a nurse. “What the hell is going on with my brother?” she demanded.

A Long Series of Illnesses:

Three months earlier, the patient had been admitted to that same hospital with delirium tremens. After years of alcohol abuse, he had suddenly stopped drinking a couple of days before, and his body was wracked by the sudden loss of the chemical he had become addicted to. He’d spent an entire week in the hospital but finally recovered. He was sent home, but he didn’t stay there for long.

The following week, when his sister hadn’t heard from him for a couple of days, she forced her way into his home. There she found him, unconscious, in the basement, at the bottom of his staircase. He had fallen, and it looked as if he may have been there for two, possibly three, days. He was close to death. Indeed, in the ambulance on the way to the hospital, his heart had stopped. Rapid action by the E.M.T.’s brought his heart back to life, and he made it to the hospital.

There the extent of the damage became clear. The man’s kidneys had stopped working, and his body chemistry was completely out of whack. He had a severe concussion. And he’d had a heart attack.

He remained in the intensive care unit for nearly three weeks, and in the hospital another two weeks. Even after these weeks of care and recovery, the toll of his injury was terrible. His kidneys were not working, so he required dialysis three times a week. He had needed a machine to help him breathe for so long that he now had to get oxygen through a hole that had been cut into his throat. His arms and legs were so weak that he could not even lift them, and because he was unable even to swallow, he had to be fed through a tube that went directly into his stomach.

Finally, after five weeks in the hospital, he was well enough to be moved to a short-term rehabilitation hospital to complete the long road to recovery. But he was still far from healthy. The laughing, swaggering, Harley-riding man his sister had known until that terrible fall seemed a distant memory, though she saw that he was slowly getting better. He had even started to smile and make jokes. He was confident, he had told her, that with a lot of hard work he could get back to normal. So was she; she knew he was tough.

Back to the Hospital:

The patient had been at the rehab facility for just over two weeks when the staff noticed a sudden change in him. He had stopped smiling and was no longer making jokes. Instead, he talked about people that no one else could see. And he was worried that they wanted to harm him. When he remained confused for a second day, they sent him to the emergency room.

You can see the records from that E.R. visit here.

The man told the E.R. doctor that he knew he was having hallucinations. He thought they had started when he had begun taking a pill to help him sleep a couple of days earlier. It seemed a reasonable explanation, since the medication was known to cause delirium in some people. The hospital psychiatrist took him off that medication and sent him back to rehab that evening with a different sleeping pill.

Back to the Hospital, Again:

Two days later, the patient was back in the emergency room. He was still seeing things that weren’t there, but now he was quite confused as well. He knew his name but couldn’t remember what day or month it was, or even what year. And he had no idea where he was, or where he had just come from.

When the medical team saw the patient after he had been admitted, he was unable to provide any useful medical history. His medical records outlined his earlier hospitalizations, and records from the nursing home filled in additional details. The patient had a history of high blood pressure, depression and alcoholism. He was on a long list of medications. And he had been confused for the past several days.

On examination, he had no fever, although a couple of hours earlier his temperature had been 100.0 degrees. His heart was racing, and his blood pressure was sky high. His arms and legs were weak and swollen. His legs were shaking, and his reflexes were very brisk. Indeed, when his ankle was flexed suddenly, it continued to jerk back and forth on its own three or four times before stopping, a phenomenon known as clonus.

His labs were unchanged from the previous visit except for his urine, which showed signs of a serious infection. A CT scan of the brain was unremarkable, as was a chest X-ray. He was started on an intravenous antibiotic to treat the infection. The thinking was that perhaps the infection was causing the patient’s confusion.

You can see the notes from that second hospital visit here.

His sister had come to visit him the next day, when he was as confused as he had ever been. He was now trembling all over and looked scared to death, terrified. He was certain he was being pursued.

That is when she confronted the nurse, demanding to know what was going on with her brother. The nurse didn’t know. No one did. His urinary tract infection was being treated with antibiotics, but he continued to have a rapid heart rate and elevated blood pressure, along with terrifying hallucinations.

Solving the Mystery:

Can you figure out why this man was so confused and tremulous? I have provided you with all the data available to the doctor who made the diagnosis. The case is not easy — that is why it is here. I’ll post the answer on Friday.

Rules and Regulations: Post your questions and diagnosis in the comments section below.. The correct answer will appear Friday on Well. The winner will be contacted. Reader comments may also appear in a coming issue of The New York Times Magazine.

Correction: The patient’s eyes were brown, not blue.

Read More..

Well: Think Like a Doctor: A Confused and Terrified Patient

Labels:

The Challenge: Can you solve the mystery of a middle-aged man recovering from a serious illness who suddenly becomes frightened and confused?

Every month the Diagnosis column of The New York Times Magazine asks Well readers to sift through a difficult case and solve a diagnostic riddle. Below you will find a summary of a case involving a 55-year-old man well on his way to recovering from a series of illnesses when he suddenly becomes confused and paranoid. I will provide you with the main medical notes, labs and imaging results available to the doctor who made the diagnosis.

The first reader to figure out this case will get a signed copy of my book, “Every Patient Tells a Story,” along with the satisfaction of knowing you solved a case of Sherlockian complexity. Good luck.

The Presenting Problem:

A 55-year-old man who is recovering from a devastating injury in a rehabilitation facility suddenly becomes confused, frightened and paranoid.

The Patient’s Story:

The patient, who was recovering from a terrible injury and was too weak to walk, had been found on the floor of his room at the extended care facility, raving that there were people out to get him. He was taken to the emergency room at the Waterbury Hospital in Connecticut, where he was diagnosed with a urinary tract infection and admitted to the hospital for treatment. Doctors thought his delirium was caused by the infection, but after 24 hours, despite receiving the appropriate antibiotics, the patient remained disoriented and frightened.

A Sister’s Visit:

The man’s sister came to visit him on his second day in the hospital. As she walked into the room she was immediately struck by her brother’s distress.

“Get me out of here!” the man shouted from his hospital bed. “They are coming to get me. I gotta get out of here!”

His brown eyes darted from side to side as if searching for his would-be attackers. His arms and legs shook with fear. He looked terrified.

For the past few months, the man had been in and out of the hospital, but he had been getting better — at least he had been improving the last time his sister saw him, the week before. She hurried into the bustling hallway and found a nurse. “What the hell is going on with my brother?” she demanded.

A Long Series of Illnesses:

Three months earlier, the patient had been admitted to that same hospital with delirium tremens. After years of alcohol abuse, he had suddenly stopped drinking a couple of days before, and his body was wracked by the sudden loss of the chemical he had become addicted to. He’d spent an entire week in the hospital but finally recovered. He was sent home, but he didn’t stay there for long.

The following week, when his sister hadn’t heard from him for a couple of days, she forced her way into his home. There she found him, unconscious, in the basement, at the bottom of his staircase. He had fallen, and it looked as if he may have been there for two, possibly three, days. He was close to death. Indeed, in the ambulance on the way to the hospital, his heart had stopped. Rapid action by the E.M.T.’s brought his heart back to life, and he made it to the hospital.

There the extent of the damage became clear. The man’s kidneys had stopped working, and his body chemistry was completely out of whack. He had a severe concussion. And he’d had a heart attack.

He remained in the intensive care unit for nearly three weeks, and in the hospital another two weeks. Even after these weeks of care and recovery, the toll of his injury was terrible. His kidneys were not working, so he required dialysis three times a week. He had needed a machine to help him breathe for so long that he now had to get oxygen through a hole that had been cut into his throat. His arms and legs were so weak that he could not even lift them, and because he was unable even to swallow, he had to be fed through a tube that went directly into his stomach.

Finally, after five weeks in the hospital, he was well enough to be moved to a short-term rehabilitation hospital to complete the long road to recovery. But he was still far from healthy. The laughing, swaggering, Harley-riding man his sister had known until that terrible fall seemed a distant memory, though she saw that he was slowly getting better. He had even started to smile and make jokes. He was confident, he had told her, that with a lot of hard work he could get back to normal. So was she; she knew he was tough.

Back to the Hospital:

The patient had been at the rehab facility for just over two weeks when the staff noticed a sudden change in him. He had stopped smiling and was no longer making jokes. Instead, he talked about people that no one else could see. And he was worried that they wanted to harm him. When he remained confused for a second day, they sent him to the emergency room.

You can see the records from that E.R. visit here.

The man told the E.R. doctor that he knew he was having hallucinations. He thought they had started when he had begun taking a pill to help him sleep a couple of days earlier. It seemed a reasonable explanation, since the medication was known to cause delirium in some people. The hospital psychiatrist took him off that medication and sent him back to rehab that evening with a different sleeping pill.

Back to the Hospital, Again:

Two days later, the patient was back in the emergency room. He was still seeing things that weren’t there, but now he was quite confused as well. He knew his name but couldn’t remember what day or month it was, or even what year. And he had no idea where he was, or where he had just come from.

When the medical team saw the patient after he had been admitted, he was unable to provide any useful medical history. His medical records outlined his earlier hospitalizations, and records from the nursing home filled in additional details. The patient had a history of high blood pressure, depression and alcoholism. He was on a long list of medications. And he had been confused for the past several days.

On examination, he had no fever, although a couple of hours earlier his temperature had been 100.0 degrees. His heart was racing, and his blood pressure was sky high. His arms and legs were weak and swollen. His legs were shaking, and his reflexes were very brisk. Indeed, when his ankle was flexed suddenly, it continued to jerk back and forth on its own three or four times before stopping, a phenomenon known as clonus.

His labs were unchanged from the previous visit except for his urine, which showed signs of a serious infection. A CT scan of the brain was unremarkable, as was a chest X-ray. He was started on an intravenous antibiotic to treat the infection. The thinking was that perhaps the infection was causing the patient’s confusion.

You can see the notes from that second hospital visit here.

His sister had come to visit him the next day, when he was as confused as he had ever been. He was now trembling all over and looked scared to death, terrified. He was certain he was being pursued.

That is when she confronted the nurse, demanding to know what was going on with her brother. The nurse didn’t know. No one did. His urinary tract infection was being treated with antibiotics, but he continued to have a rapid heart rate and elevated blood pressure, along with terrifying hallucinations.

Solving the Mystery:

Can you figure out why this man was so confused and tremulous? I have provided you with all the data available to the doctor who made the diagnosis. The case is not easy — that is why it is here. I’ll post the answer on Friday.

Rules and Regulations: Post your questions and diagnosis in the comments section below.. The correct answer will appear Friday on Well. The winner will be contacted. Reader comments may also appear in a coming issue of The New York Times Magazine.

Correction: The patient’s eyes were brown, not blue.

Read More..

DealBook: K.K.R.'s Earnings Rise 22% on Investment Gains

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Improving markets lifted the fortunes of Kohlberg Kravis Roberts in the fourth quarter, as the investment firm reported a 22 percent rise in profit.

K.K.R. said on Thursday that it earned $347.7 million for the quarter, as all of its businesses showed strong gains. For the year, the firm reported earning $2.1 billion.

The fourth-quarter profit, reported as economic net income and which includes unrealized gains from investments, comes out to 48 cents a share. That is more than double the 20-cents-a-share average of analyst estimates compiled by Capital IQ.

Private equity firms have benefited from an improvement in the markets, which have bolstered the value of their own holdings. Last week, the Blackstone Group reported a 43 percent increase in fourth-quarter earnings.

K.K.R. said the value of its investments rose 4 percent for the quarter and 24 percent for the year.

The strongest performers among the firm’s investments included Alliance Boots, a British pharmacy chain; HCA, the giant hospital operator that went public last year; and the Nielsen Company, the media measurement company.

The improved market conditions also make selling portfolio companies a more attractive prospect, letting the firms harvest tangible returns from their investments. That was reflected in K.K.R.’s results, as it reported a nearly fourfold increase in distributable earnings for the quarter, to $546.3 million. That metric tracks how much a firm actually pays to its limited partners.

And K.K.R.’s assets under management rose 13.9 percent from the third quarter, to $75.5 billion.

The firm’s co-founders and co-chairmen, Henry R. Kravis and George R. Roberts, said in a statement that the growth of their private equity portfolio outpaced the Standard & Poor’s 500-stock index by about 7 percent last year.

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IHT Rendezvous: The Best Asian Art? You Can Vote on It

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HONG KONG — Heading into its 10th year, the Sovereign Asian Art Prize has grown far beyond its Hong Kong base to span the very edges of the continent, including former Soviet republics and the Middle East.

Its list of 30 finalists, announced last week, was light on the usual contemporary art superpowers — there was only one name from mainland China — and heavy on Muslim-majority states that may not get as much attention in the art world. Saudi Arabia, Kazakhstan, Oman and the Palestinian territories produced finalists for the first time.

Sovereign focuses on developing talents from developing nations. The $30,000 award goes to a mid-career artist — someone who may be acclaimed in his or her home country, but who has not made it big internationally. (Its sponsor, the Hong Kong-based Sovereign Group, also has an award in Africa).

The majority of the Asian finalists are in their 30s and working in photography, prints or mixed media. While politics is nothing new in contemporary Asian art — those ironic Chairman Mao heads have become a stereotype in Chinese painting — these works also offer views on faith, culture and sexuality. (You can vote for your favorite here.)

Saudi Arabia is represented by Shadia Alem, whose photographic work “Supreme Ka’ba of God” represents her birthplace, Mecca.

“Wedding Memory” by Hassan Meer of Oman depicts a bride and groom, her face partly veiled, his entirely covered.  The catalog notes describe the backdrop as the “room that accommodates the consummation of the marriage,”  though the black-and-white image shows the exterior of a home half-destroyed and marked by graffiti.

Raeda Saadeh, from the Palestinian territories, was born in Umm al-Fahm, an Arab city in the Haifa district of Israel. Her photograph “Penelope” depicts the mythical Greek figure calmly knitting and waiting on a pile of rubble and wire in East Jerusalem, where Israeli forces had destroyed homes.

Evgeny Boikov — representing Kyrgyzstan, but originally from Azerbaijan — depicts a protester who is said to represent the 2005 and 2010 uprisings in Kyrgyzstan, the former Soviet state. Mr. Boikov uses industrial-sized printers (the kind usually used for billboa rds) to print on small canvases. The result is the indigo imprint of a man bent over, though it’s not clear whether from pain, exertion or something else.

From neighboring Kazakhstan, Said Atabekov photographs a girl holding a korpeshe, a traditional textile used as bedding, made here in the likeness of an American flag.

Also using textiles, Risham Syed, who teaches art in her native Pakistan, used acrylic, lace and army coat buttons on a square of Pakistani printed cotton to  riff on Thomas Cole’s 19th-century painting “Indians Viewing the Landscape.”

Pakistan and Hong Kong had the best showings, with four finalists.

Faiza Butt printed a poem on a light box, in Urdu on one side and English on the other. It’s a pretty, almost floral-looking work at first glance. On a closer look, you can see that she has used debris, garbage and half-eaten food as decoration.

Muhammad Ali, 24, fashioned a sepia-toned homoerotic portrait of two scantily clad men, an image that might not be risqué in the West but which could be controversial in a country where homosexuality is illegal.

Waseem Ahmed’s “Fusion” is also sexually charged. A  female nude, rendered in the type of Mughal classical art, is overlaid with details from a Western painting of Adam and Eve, just their groins showing, covered by fig leaves.

When the Man Asian Literary Prize was announced last month,  it called into question two issues concerning arts prizes in Asia. First, where, exactly, does Asia begin and end? (The Man Asia included Orhan Pamuk on its short list, although Mr. Pamuk, the Turkish Nobel laureate, has written about his desire for Turkey to join the European Union). The second is whether Asia’s budding cultural scene still needs Western corporate support. The Man Group, the hedge fund management firm, has said it would no longer underwrite the literary prize. The Sovereign Art Prize has the Swiss bank Julius Bär behind it.

An exhibition of the finalists runs through Friday at Exchange Square in Hong Kong and will later travel to Seoul and Singapore. The winner will be announced, and the works will be auctioned by Christie’s, at the Four Seasons in Hong Kong on Feb. 21.

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Bits Blog: Most Facebook Users Have Taken a Break From the Site, Survey Finds

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Facebook is the most popular social network in America — roughly two-thirds of adults in the country use it on a regular basis.

But that doesn’t mean they don’t get sick of it.

A new survey by the Pew Research Center‘s Internet and American Life Project, conducted in December, found that 61 percent of current Facebook users admitted that they had voluntarily taken breaks from the site, for as many as several weeks at a time.

The main reasons for their social media sabbaticals were not having enough time to dedicate to pruning their profiles, an overall decrease in their interest in the site, and the general sentiment that Facebook was a major waste of time.

About 4 percent cited privacy and security concerns as contributing to their departure. Although those users eventually resumed their regular activity, another 20 percent of Facebook users admitted to deleting their accounts.

Of course, even as some Facebook users pull back on their daily consumption of the service, the vast majority — 92 percent — of all social network users still maintain a profile on the site. But while more than half said that the site was just as important to them as it was a year ago, only 12 percent said the site’s significance increased over the last year — indicating the makings of a much larger social media burnout across the site.

The survey teases out other interesting insights, including the finding that young users are spending less time overall on the site. The report found that 42 percent of Facebook users from the ages of 18 to 29 said that the average time they spent on the site in a typical day had decreased in the last year. A much smaller portion, 23 percent, of older Facebook users, those over 50, reported a drop in Facebook usage over the same period.

Facebook’s biggest challenge revolves around figuring out how to continue to profit from its rich reservoir of one billion users — and a large part of that involves keeping them entertained and returning to the site on a regular basis. Most recently, the company introduced a tool called Graph Search, a research tool that promises to help its users find answers on everything from travel recommendations to potential jobs and even love connections.

Lee Rainie, the director of the Pew Research Center’s Internet & American Life Project, which conducted the survey, described the results as a kind of “social reckoning.”

“These data show that people are trying to make new calibrations in their life to accommodate new social tools,” said Mr. Rainie, in an e-mail. Facebook users are beginning to ask themselves, ” ‘What are my friends doing and thinking and how much does that matter to me?,’ ” he said. “They are adding up the pluses and minuses on a kind of networking balance sheet and they are trying to figure out how much they get out of connectivity vs. how much they put into it.”

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Ipswich Journal: Paul Mason Is One-Third the Man He Used to Be

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Paul Nixon Photography


Paul Mason in 2012, two years after gastric bypass surgery stripped him of the unofficial title of “the world’s fattest man.”







IPSWICH, England — Who knows what the worst moment was for Paul Mason — there were so many awful milestones, as he grew fatter and fatter — but a good bet might be when he became too vast to leave his room. To get him to the hospital for a hernia operation, the local fire department had to knock down a wall and extricate him with a forklift.




That was nearly a decade ago, when Mr. Mason weighed about 980 pounds, and the spectacle made him the object of fascinated horror, a freak-show exhibit. The British news media, which like a superlative, appointed him “the world’s fattest man.”


Now the narrative has shifted to one of redemption and second chances. Since a gastric bypass operation in 2010, Mr. Mason, 52 years old and 6 foot 4, has lost nearly two-thirds of his body weight, putting him at about 336 pounds — still obese, but within the realm of plausibility. He is talking about starting a jewelry business.


“My meals are a lot different now than they used to be,” Mr. Mason said during a recent interview in his one-story apartment in a cheerful public housing complex here. For one thing, he no longer eats around the clock. “Food is a necessity, but now I don’t let it control my life anymore,” he said.


But the road to a new life is uphill and paved with sharp objects. When he answered the door, Mr. Mason did not walk; he glided in an electric wheelchair.


And though Mr. Mason looks perfectly normal from the chest up, horrible vestiges of his past stick to him, literally, in the form of a huge mass of loose skin choking him like a straitjacket. Folds and folds of it encircle his torso and sit on his lap, like an unwanted package someone has set there; more folds encase his legs. All told, he reckons, the excess weighs more than 100 pounds.


As he waits to see if anyone will agree to perform the complex operation to remove the skin, Mr. Mason has plenty of time to ponder how he got to where he is. He was born in Ipswich and had a childhood marked by two things, he says: the verbal and physical abuse of his father, a military policeman turned security guard; and three years of sexual abuse, starting when he was 6, by a relative in her 20s who lived in the house and shared his bed. He told no one until decades later.


After he left school, Mr. Mason took a job as a postal worker and became engaged to a woman more than 20 years older than him. “I thought it would be for life, but she just turned around one day and said, ‘No, I don’t want to see you anymore — goodbye,’ ” he said.


His father died, and he returned home to care for his arthritic mother, who was in a wheelchair. “I still had all these things going around in my head from my childhood,” he said. “Food replaced the love I didn’t get from my parents.” When he left the Royal Mail in 1986, he said, he weighed 364 pounds.


Then things spun out of control. Mr. Mason tried to eat himself into oblivion. He spent every available penny of his and his mother’s social security checks on food. He stopped paying the mortgage. The bank repossessed their house, and the council found them a smaller place to live. All the while, he ate the way a locust eats — indiscriminately, voraciously, ingesting perhaps 20,000 calories a day. First he could no longer manage the stairs; then he could no longer get out of his room. He stayed in bed, on and off, for most of the last decade.


Social service workers did everything for him, including changing his incontinence pads. A network of local convenience stores and fast-food restaurants kept the food coming nonstop — burgers, french fries, fish and chips, even about $22 worth of chocolate bars a day.


“They didn’t deliver bags of crisps,” he said of potato chips. “They delivered cartons.”


His life became a cycle: eat, doze, eat, eat, eat. “You didn’t sleep a normal sleep,” he said. “You’d be awake most of the night eating and snacking. You totally forgot about everything else. You lose all your dignity, all your self-respect. It all goes, and all you focus on is getting your next fix.”


He added, “It was quite a lonely time, really.”


He frequently got infections and was transported to the hospital — first in a laundry van, then on the back of a truck and finally on the forklift. For 18 months after a hernia operation in 2003, he lived in the hospital and in an old people’s home — where he was not allowed to leave his room — while the local government found him a house that could accommodate all the special equipment he needed.


This article has been revised to reflect the following correction:

Correction: February 6, 2013

The headline on an earlier version of this article misstated Paul Mason’s current weight relative to what he weighed nearly a decade ago. He is now about one-third of the weight he was then, not two-thirds.



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