IHT Rendezvous: Should Common Plastics Be Labeled Toxic?

THE HAGUE — Hoping to reduce one of the most ubiquitous forms of waste, a global group of scientists is proposing that certain types of plastic be labeled hazardous.

The group, lead by two California scientists, wrote in this week’s issue of the scientific journal Nature:

We believe that if countries classified the most harmful plastics as hazardous, their environmental agencies would have the power to restore affected habitats and prevent more dangerous debris from accumulating.

While 280 million tons of plastic were produced globally last year, less than half of that plastic has ended up in landfills or was recycled, according to the scientists’ data. Some of the unaccounted for 150 million tons of plastic is still in use, but much of it litters roadsides, cities, forests, deserts, beaches and oceans. (Just think of the great floating garbage patches at sea).

Unlike other forms of solid waste, such as uneaten food, scrap metal or last year’s clothes, plastics take an especially long time to break down. And when they finally do, they create hazardous, even toxic particles that can harm wildlife, ecosystems and humans.

For now, the group — led by Chelsea M. Rochman of the School of Veterinary Medicine at the University of California, Davis, and Mark Anthony Browne at the National Center for Ecological Analysis and Synthesis in Santa Barbara, California — is calling for the reclassification of plastics that are particularly difficult to recycle and that are most toxic when degrading: PVC, polystyrene, polyurethane and polycarbonate.

The scientists say these types of plastics — used in construction, food containers, electronics and furniture — make up an estimated 30 percent of all plastics produced.

Join our sustainability conversation. Does it make sense to re-classify common plastics as hazardous, or are their better ways to reduce the amount of plastics we throw out?

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Bits Blog: Facebook Says Hackers Breached Its Computers

Facebook admitted that it was breached by sophisticated hackers in recent weeks, two weeks after Twitter made a similar admission. Both Facebook and Twitter were breached through a well-publicized vulnerability in Oracle’s Java software.

In a blog post late Friday afternoon, Facebook said it was attacked when a handful of its employees visited a compromised site for mobile developers. Simply by visiting the site, their computers were infected with malware. The company said that as soon as it discovered the malware, it cleaned up the infected machines and tipped off law enforcement.

“We have found no evidence that Facebook user data was compromised,” Facebook said.

On Feb. 1, Twitter said hackers had breached its systems and potentially accessed the data of 250,000 Twitter users. The company suggested at that time that it was one of several companies and organizations to be have been similarly attacked.

Facebook has known about its own breach for at least a month, according to people close to the investigation, but it was unclear why the company waited this long to announce it. Fred Wolens, a Facebook spokesman, declined to comment.

Like Twitter, Facebook said it believed that it was one of several organizations that were targeted by the same group of attackers.

“Facebook was not alone in this attack,” the company said in its blog post. “It is clear that others were attacked and infiltrated recently as well.”

The attacks add to the mounting evidence that hackers were able to use the security hole in Oracle’s Java software to steal information from a broad range of companies. Java, a widely used programming language, is installed on more than three billion devices. It has long been hounded by security problems.

Last month, after a security researcher exposed a serious vulnerability in the software, the Department of Homeland Security issued a rare alert that warned users to disable Java on their computers. The vulnerability was particularly disconcerting because it let attackers download a malicious program onto its victims’ machines without any prompting. Users did not even have to click on a malicious link for their computers to be infected. The program simply downloaded itself.

After Oracle initially patched the security hole in January, the Department of Homeland Security said that the fix was not sufficient and recommended that, unless “absolutely necessary”, users should disable it on their computers completely. Oracle did not issue another fix until Feb. 1.

Social networks are a prime target for hackers, who look to use people’s personal data and social connections in what are known as “spearphishing” attacks. In this type of attack, a target is sent an e-mail, ostensibly from a connection, containing a malicious link or attachment. Once the link is clicked or attachment opened, attackers take control of a user’s computer. If the infected computer is inside a company’s system, the attackers are able to gain a foothold. In many cases, they then extract passwords and gain access to sensitive data.

Facebook said in its blog post that the updated patch addressed the vulnerability that allowed hackers to access its employees’ computers.

Hackers have been attacking organizations inside the United States at an alarming rate. The number of attacks reported by government agencies last year topped 48,500 — a ninefold jump from the 5,500 attacks reported in 2006, according to the Government Accountability Office.

In the last month alone, The New York Times, The Wall Street Journal and The Washington Post all confirmed that they were targets of sophisticated hackers. But security experts say that these attacks are just the tip of the iceberg.

A common saying among security experts is that there are now only two types of American companies: Those that have been hacked and those that don’t know they’ve been hacked.

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Livestrong Tattoos as Reminder of Personal Connections, Not Tarnished Brand





As Jax Mariash went under the tattoo needle to have “Livestrong” emblazoned on her wrist in bold black letters, she did not think about Lance Armstrong or doping allegations, but rather the 10 people affected by cancer she wanted to commemorate in ink. It was Jan. 22, 2010, exactly a year since the disease had taken the life of her stepfather. After years of wearing yellow Livestrong wristbands, she wanted something permanent.




A lifelong runner, Mariash got the tattoo to mark her 10-10-10 goal to run the Chicago Marathon on Oct. 10, 2010, and fund-raising efforts for Livestrong. Less than three years later, antidoping officials laid out their case against Armstrong — a lengthy account of his practice of doping and bullying. He did not contest the charges and was barred for life from competing in Olympic sports.


“It’s heartbreaking,” Mariash, of Wilson, Wyo., said of the antidoping officials’ report, released in October, and Armstrong’s subsequent confession to Oprah Winfrey. “When I look at the tattoo now, I just think of living strong, and it’s more connected to the cancer fight and optimal health than Lance.”


Mariash is among those dealing with the fallout from Armstrong’s descent. She is not alone in having Livestrong permanently emblazoned on her skin.


Now the tattoos are a complicated, internationally recognized symbol of both an epic crusade against cancer and a cyclist who stood defiant in the face of accusations for years but ultimately admitted to lying.


The Internet abounds with epidermal reminders of the power of the Armstrong and Livestrong brands: the iconic yellow bracelet permanently wrapped around a wrist; block letters stretching along a rib cage; a heart on a foot bearing the word Livestrong; a mural on a back depicting Armstrong with the years of his now-stripped seven Tour de France victories and the phrase “ride with pride.”


While history has provided numerous examples of ill-fated tattoos to commemorate lovers, sports teams, gang membership and bands that break up, the Livestrong image is a complex one, said Michael Atkinson, a sociologist at the University of Toronto who has studied tattoos.


“People often regret the pop culture tattoos, the mass commodified tattoos,” said Atkinson, who has a Guns N’ Roses tattoo as a marker of his younger days. “A lot of people can’t divorce the movement from Lance Armstrong, and the Livestrong movement is a social movement. It’s very real and visceral and embodied in narrative survivorship. But we’re still not at a place where we look at a tattoo on the body and say that it’s a meaningful thing to someone.”


Geoff Livingston, a 40-year-old marketing professional in Washington, D.C., said that since Armstrong’s confession to Winfrey, he has received taunts on Twitter and inquiries at the gym regarding the yellow Livestrong armband tattoo that curls around his right bicep.


“People see it and go, ‘Wow,’ ” he said, “But I’m not going to get rid of it, and I’m not going to stop wearing short sleeves because of it. It’s about my family, not Lance Armstrong.”


Livingston got the tattoo in 2010 to commemorate his brother-in-law, who was told he had cancer and embarked on a fund-raising campaign for the charity. If he could raise $5,000, he agreed to get a tattoo. Within four days, the goal was exceeded, and Livingston went to a tattoo parlor to get his seventh tattoo.


“It’s actually grown in emotional significance for me,” Livingston said of the tattoo. “It brought me closer to my sister. It was a big statement of support.”


For Eddie Bonds, co-owner of Rabbit Bicycle in Hill City, S.D., getting a Livestrong tattoo was also a reflection of the growth of the sport of cycling. His wife, Joey, operates a tattoo parlor in front of their store, and in 2006 she designed a yellow Livestrong band that wraps around his right calf, topped off with a series of small cyclists.


“He kept breaking the Livestrong bands,” Joey Bonds said. “So it made more sense to tattoo it on him.”


“It’s about the cancer, not Lance,” Eddie Bonds said.


That was also the case for Jeremy Nienhouse, a 37-year old in Denver, Colo., who used a Livestrong tattoo to commemorate his own triumph over testicular cancer.


Given the diagnosis in 2004, Nienhouse had three rounds of chemotherapy, which ended on March 15, 2005, the date he had tattooed on his left arm the day after his five-year anniversary of being cancer free in 2010. It reads: “3-15-05” and “LIVESTRONG” on the image of a yellow band.


Nienhouse said he had heard about Livestrong and Armstrong’s own battle with the cancer around the time he learned he had cancer, which alerted him to the fact that even though he was young and healthy, he, too, could have cancer.


“On a personal level,” Nienhouse said, “he sounds like kind of a jerk. But if he hadn’t been in the public eye, I don’t know if I would have been diagnosed when I had been.”


Nienhouse said he had no plans to have the tattoo removed.


As for Mariash, she said she read every page of the antidoping officials’ report. She soon donated her Livestrong shirts, shorts and running gear. She watched Armstrong’s confession to Winfrey and wondered if his apology was an effort to reduce his ban from the sport or a genuine appeal to those who showed their support to him and now wear a visible sign of it.


“People called me ‘Miss Livestrong,’ ” Mariash said. “It was part of my identity.”


She also said she did not plan to have her tattoo removed.


“I wanted to show it’s forever,” she said. “Cancer isn’t something that just goes away from people. I wanted to show this is permanent and keep people remembering the fight.”


Read More..

Livestrong Tattoos as Reminder of Personal Connections, Not Tarnished Brand





As Jax Mariash went under the tattoo needle to have “Livestrong” emblazoned on her wrist in bold black letters, she did not think about Lance Armstrong or doping allegations, but rather the 10 people affected by cancer she wanted to commemorate in ink. It was Jan. 22, 2010, exactly a year since the disease had taken the life of her stepfather. After years of wearing yellow Livestrong wristbands, she wanted something permanent.




A lifelong runner, Mariash got the tattoo to mark her 10-10-10 goal to run the Chicago Marathon on Oct. 10, 2010, and fund-raising efforts for Livestrong. Less than three years later, antidoping officials laid out their case against Armstrong — a lengthy account of his practice of doping and bullying. He did not contest the charges and was barred for life from competing in Olympic sports.


“It’s heartbreaking,” Mariash, of Wilson, Wyo., said of the antidoping officials’ report, released in October, and Armstrong’s subsequent confession to Oprah Winfrey. “When I look at the tattoo now, I just think of living strong, and it’s more connected to the cancer fight and optimal health than Lance.”


Mariash is among those dealing with the fallout from Armstrong’s descent. She is not alone in having Livestrong permanently emblazoned on her skin.


Now the tattoos are a complicated, internationally recognized symbol of both an epic crusade against cancer and a cyclist who stood defiant in the face of accusations for years but ultimately admitted to lying.


The Internet abounds with epidermal reminders of the power of the Armstrong and Livestrong brands: the iconic yellow bracelet permanently wrapped around a wrist; block letters stretching along a rib cage; a heart on a foot bearing the word Livestrong; a mural on a back depicting Armstrong with the years of his now-stripped seven Tour de France victories and the phrase “ride with pride.”


While history has provided numerous examples of ill-fated tattoos to commemorate lovers, sports teams, gang membership and bands that break up, the Livestrong image is a complex one, said Michael Atkinson, a sociologist at the University of Toronto who has studied tattoos.


“People often regret the pop culture tattoos, the mass commodified tattoos,” said Atkinson, who has a Guns N’ Roses tattoo as a marker of his younger days. “A lot of people can’t divorce the movement from Lance Armstrong, and the Livestrong movement is a social movement. It’s very real and visceral and embodied in narrative survivorship. But we’re still not at a place where we look at a tattoo on the body and say that it’s a meaningful thing to someone.”


Geoff Livingston, a 40-year-old marketing professional in Washington, D.C., said that since Armstrong’s confession to Winfrey, he has received taunts on Twitter and inquiries at the gym regarding the yellow Livestrong armband tattoo that curls around his right bicep.


“People see it and go, ‘Wow,’ ” he said, “But I’m not going to get rid of it, and I’m not going to stop wearing short sleeves because of it. It’s about my family, not Lance Armstrong.”


Livingston got the tattoo in 2010 to commemorate his brother-in-law, who was told he had cancer and embarked on a fund-raising campaign for the charity. If he could raise $5,000, he agreed to get a tattoo. Within four days, the goal was exceeded, and Livingston went to a tattoo parlor to get his seventh tattoo.


“It’s actually grown in emotional significance for me,” Livingston said of the tattoo. “It brought me closer to my sister. It was a big statement of support.”


For Eddie Bonds, co-owner of Rabbit Bicycle in Hill City, S.D., getting a Livestrong tattoo was also a reflection of the growth of the sport of cycling. His wife, Joey, operates a tattoo parlor in front of their store, and in 2006 she designed a yellow Livestrong band that wraps around his right calf, topped off with a series of small cyclists.


“He kept breaking the Livestrong bands,” Joey Bonds said. “So it made more sense to tattoo it on him.”


“It’s about the cancer, not Lance,” Eddie Bonds said.


That was also the case for Jeremy Nienhouse, a 37-year old in Denver, Colo., who used a Livestrong tattoo to commemorate his own triumph over testicular cancer.


Given the diagnosis in 2004, Nienhouse had three rounds of chemotherapy, which ended on March 15, 2005, the date he had tattooed on his left arm the day after his five-year anniversary of being cancer free in 2010. It reads: “3-15-05” and “LIVESTRONG” on the image of a yellow band.


Nienhouse said he had heard about Livestrong and Armstrong’s own battle with the cancer around the time he learned he had cancer, which alerted him to the fact that even though he was young and healthy, he, too, could have cancer.


“On a personal level,” Nienhouse said, “he sounds like kind of a jerk. But if he hadn’t been in the public eye, I don’t know if I would have been diagnosed when I had been.”


Nienhouse said he had no plans to have the tattoo removed.


As for Mariash, she said she read every page of the antidoping officials’ report. She soon donated her Livestrong shirts, shorts and running gear. She watched Armstrong’s confession to Winfrey and wondered if his apology was an effort to reduce his ban from the sport or a genuine appeal to those who showed their support to him and now wear a visible sign of it.


“People called me ‘Miss Livestrong,’ ” Mariash said. “It was part of my identity.”


She also said she did not plan to have her tattoo removed.


“I wanted to show it’s forever,” she said. “Cancer isn’t something that just goes away from people. I wanted to show this is permanent and keep people remembering the fight.”


Read More..

The Lede: Spectacular Video of Meteor Over Siberia

Video posted on YouTube Friday appeared to catch an explosion caused by a meteor streaking over the Russian city of Chelyabinsk.

Last Updated, 11:08 a.m. As our colleagues Ellen Barry and Andrew Kramer report, Russians recorded video of bright objects, apparently debris from a meteor, “streaking through the sky in western Siberia early on Friday, accompanied by a boom that damaged buildings across a vast area of territory.” Hundreds of injuries were reported, mainly from breaking glass.

Video recorded from the dashboard camera of a car in the Russian city of Chelyabinsk on Friday.

Video said to have been recorded on Friday in the Russian city of Chelyabinsk as a meteor passed low overhead. An explosion can be heard clearly at the 7-minute mark of the video.

The video clips, many recorded from cars on the dashboard cameras that are popular in Russia, quickly spread from social networks to Russian news sites. While it was not possible to confirm the authenticity of these clips, they track closely with witness accounts and each other.

Video uploaded to YouTube on Friday was said to have been recorded over the Russian city of Chelyabinsk (although the camera’s time stamp displays an earlier date).

Several clips showed a flaming object streaking through the sky and a burst of blinding light followed by a smoke trail. One, shot by a driver named Alexander Mezentsev, showed a bright light over a city street in Chelyabinsk, a city of 1 million about 900 miles east of Moscow.

One clip, recorded on a street in Chelyabinsk, appeared to capture the chaotic aftermath of the event, as glass shattered following the shock wave and people shouted and tried to make sense of what was happening.

Video said to have been recorded in the Russian city of Chelyabinsk on Friday after a meteor passed overhead.

A very loud explosion could be heard about 25 seconds into another video, apparently recorded on a phone in the same city by a blogger named Sergey Hametov.

Video said to have been recorded on Friday in Chelyabinsk appeared to capture a loud explosion.

“There was panic. People had no idea what was happening,” Mr. Hametov told The Associated Press. “We saw a big burst of light, then went outside to see what it was and we heard a really loud, thundering sound.”

Another video, shot from the window of a building, seemed to capture the long trail of smoke after the object passed through the sky.

Video posted on YouTube Friday appeared to show the trail of a meteorite fragment in the sky.

Several clips also showed what bloggers said was the damage caused by the sonic boom.

Damage to a school in the Chelyabinsk region of Russia, said to have been caused by the sonic boom from a meteor.

Video of what was described as damage caused by the sonic boom after a meteor passed over Russia on Friday.

Some of the numerous videos that quickly emerged of the incident highlighted a distinctly Russian phenomenon: the dashboard cam. As the blogger Marina Galperina explained last year, they are commonplace in Russia partly because of the dangerous driving conditions that lead to so many accidents, and with an unreliable police force such cameras can provide valuable evidence following a crash.

The conditions of Russian roads are perilous, with insane gridlock in cities and gigantic ditches, endless swamps and severe wintry emptiness on the backroads and highways. Then there are large, lawless areas you don’t just ride into, the police with a penchant for extortion and deeply frustrated drivers who want to smash your face.

Psychopaths are abundant on Russian roads. You best not cut anyone off or undertake some other type of maneuver that might inconvenience the 200-pound, six-foot-five brawling children you see on YouTube hopping out of their SUVs with their dukes up. They will go ballistic in a snap, drive in front of you, brake suddenly, block you off, jump out and run towards your vehicle. Next thing you start getting punches in your face because your didn’t roll up your windows, or getting pulled out of the car and beaten because you didn’t lock the doors.

These fights happen all the time and you can’t really press charges. Point to your broken nose or smashed windows all you want. The Russian courts don’t like verbal claims. They do, however, like to send people to jail for battery and property destruction if there’s definite video proof.


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Gadgetwise Blog: App Smart Extra: Apps to Improve Your Singing

This week in my App Smart column, I talked about a few karaoke apps that can replicate many of the features of a full-fledged karaoke machine. I also mentioned one app that can help you train your singing voice.

There are, of course, numerous apps that try to help you improve your singing or let you groove to your own rendition of a popular hit.

One interesting app that can help teach you the subtleties of singing in harmonies is the $3 iOS app Sing Harmonies. This app is all about prerecorded adult voices singing harmony parts to well-known songs. The idea is that you can turn the backing music off at will, and also turn off each of the parts separately. In this way, you can learn the harmony parts by copying them individually, and perhaps teach yourself to listen to other singer’s voices when you’re performing. It’s fun and pleasingly simple to use, but $3 only gets you a very short list of songs.

For an app that’s got an element of karaoke, check out the free iOS app StarMaker: Karaoke + Auto Tune. Like other apps of this sort, you have to spend in-app “credits” to access tracks. To add credits, you have to sing songs, perform actions like uploading and sharing your experiences or watch video advertisements. You can also pay, with unlimited access for $3 a week. When you are singing each track from this app’s impressively up-to-date archive, it scores how well you’ve performed by analyzing your voice. Thus, the Starmaker may help you be a better singer — or at least a better karaoke performer. That is, if you don’t turn on the auto-tune system, which automatically fixes the notes you sing!

For a bit of musical fun, singers may enjoy the free Android app Pitch Lab Pro–Chromatic Tuner. In part, this is an app aimed at helping you tune an instrument like a guitar. But its core function of listening to an input sound and reporting what musical note that sound matches may also be good for training your singing. To do this, it has an array of different graphical visualizations that show the note you are singing — including how accurately you’re hitting the right frequency.

Remember that for many singing apps, the microphone built into your smartphone or tablet might not be the best option; plugging in a dedicated microphone or your hands-free set could yield better results.

Quick call

Runkeeper is one of the better apps for helping runners, cyclists and walkers keep track of their exercise regimes. It’s just been upgraded to version 3.0 for Android devices, complete with a more highly polished new look and extra features like in-activity splits.

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Doctor and Patient: Afraid to Speak Up to Medical Power

The slender, weather-beaten, elderly Polish immigrant had been diagnosed with lung cancer nearly a year earlier and was receiving chemotherapy as part of a clinical trial. I was a surgical consultant, called in to help control the fluid that kept accumulating in his lungs.

During one visit, he motioned for me to come closer. His voice was hoarse from a tumor that spread, and the constant hissing from his humidified oxygen mask meant I had to press my face nearly against his to understand his words.

“This is getting harder, doctor,” he rasped. “I’m not sure I’m up to anymore chemo.”

I was not the only doctor that he confided to. But what I quickly learned was that none of us was eager to broach the topic of stopping treatment with his primary cancer doctor.

That doctor was a rising superstar in the world of oncology, a brilliant physician-researcher who had helped discover treatments for other cancers and who had been recruited to lead our hospital’s then lackluster cancer center. Within a few months of the doctor’s arrival, the once sleepy department began offering a dazzling array of experimental drugs. Calls came in from outside doctors eager to send their patients in for treatment, and every patient who was seen was promptly enrolled in one of more than a dozen well-documented treatment protocols.

But now, no doctors felt comfortable suggesting anything but the most cutting-edge, aggressive treatments.

Even the No. 2 doctor in the cancer center, Robin to the chief’s cancer-battling Batman, was momentarily taken aback when I suggested we reconsider the patient’s chemotherapy plan. “I don’t want to tell him,” he said, eyes widening. He reeled off his chief’s vast accomplishments. “I mean, who am I to tell him what to do?”

We stood for a moment in silence before he pointed his index finger at me. “You tell him,” he said with a smile. “You tell him to consider stopping treatment.”

Memories of this conversation came flooding back last week when I read an essay on the problems posed by hierarchies within the medical profession.

For several decades, medical educators and sociologists have documented the existence of hierarchies and an intense awareness of rank among doctors. The bulk of studies have focused on medical education, a process often likened to military and religious training, with elder patriarchs imposing the hair shirt of shame on acolytes unable to incorporate a profession’s accepted values and behaviors. Aspiring doctors quickly learn whose opinions, experiences and voices count, and it is rarely their own. Ask a group of interns who’ve been on the wards for but a week, and they will quickly raise their hands up to the level of their heads to indicate their teachers’ status and importance, then lower them toward their feet to demonstrate their own.

It turns out that this keen awareness of ranking is not limited to students and interns. Other research has shown that fully trained physicians are acutely aware of a tacit professional hierarchy based on specialties, like primary care versus neurosurgery, or even on diseases different specialists might treat, like hemorrhoids and constipation versus heart attacks and certain cancers.

But while such professional preoccupation with privilege can make for interesting sociological fodder, the real issue, warns the author of a courageous essay published recently in The New England Journal of Medicine, is that such an overly developed sense of hierarchy comes at an unacceptable price: good patient care.

Dr. Ranjana Srivastava, a medical oncologist at the Monash Medical Centre in Melbourne, Australia, recalls a patient she helped to care for who died after an operation. Before the surgery, Dr. Srivastava had been hesitant to voice her concerns, assuming that the patient’s surgeon must be “unequivocally right, unassailable, or simply not worth antagonizing.” When she confesses her earlier uncertainty to the surgeon after the patient’s death, Dr. Srivastava learns that the surgeon had been just as loath to question her expertise and had assumed that her silence before the surgery meant she agreed with his plan to operate.

“Each of us was trying our best to help a patient, but we were also respecting the boundaries and hierarchy imposed by our professional culture,” Dr. Srivastava said. “The tragedy was that the patient died, when speaking up would have made all the difference.”

Compounding the problem is an increasing sense of self-doubt among many doctors. With rapid advances in treatment, there is often no single correct “answer” for a patient’s problem, and doctors, struggling to stay up-to-date in their own particular specialty niches, are more tentative about making suggestions that cross over to other doctors’ “turf.” Even as some clinicians attempt to compensate by organizing multidisciplinary meetings, inviting doctors from all specialties to discuss a patient’s therapeutic options, “there will inevitably be a hierarchy at those meetings of who is speaking,” Dr. Srivastava noted. “And it won’t always be the ones who know the most about the patient who will be taking the lead.”

It is the potentially disastrous repercussions for patients that make this overly developed awareness of rank and boundaries a critical issue in medicine. Recent efforts to raise safety standards and improve patient care have shown that teams are a critical ingredient for success. But simply organizing multidisciplinary lineups of clinicians isn’t enough. What is required are teams that recognize the importance of all voices and encourage active and open debate.

Since their patient’s death, Dr. Srivastava and the surgeon have worked together to discuss patient cases, articulate questions and describe their own uncertainties to each other and in patients’ notes. “We have tried to remain cognizant of the fact that we are susceptible to thinking about hierarchy,” Dr. Srivastava said. “We have tried to remember that sometimes, despite our best intentions, we do not speak up for our patients because we are fearful of the consequences.”

That was certainly true for my lung cancer patient. Like all the other doctors involved in his care, I hesitated to talk to the chief medical oncologist. I questioned my own credentials, my lack of expertise in this particular area of oncology and even my own clinical judgment. When the patient appeared to fare better, requiring less oxygen and joking and laughing more than I had ever seen in the past, I took his improvement to be yet another sign that my attempt to talk about holding back chemotherapy was surely some surgical folly.

But a couple of days later, the humidified oxygen mask came back on. And not long after that, the patient again asked for me to come close.

This time he said: “I’m tired. I want to stop the chemo.”

Just before he died, a little over a week later, he was off all treatment except for what might make him comfortable. He thanked me and the other doctors for our care, but really, we should have thanked him and apologized. Because he had pushed us out of our comfortable, well-delineated professional zones. He had prodded us to talk to one another. And he showed us how to work as a team in order to do, at last, what we should have done weeks earlier.

Read More..

Doctor and Patient: Afraid to Speak Up to Medical Power

The slender, weather-beaten, elderly Polish immigrant had been diagnosed with lung cancer nearly a year earlier and was receiving chemotherapy as part of a clinical trial. I was a surgical consultant, called in to help control the fluid that kept accumulating in his lungs.

During one visit, he motioned for me to come closer. His voice was hoarse from a tumor that spread, and the constant hissing from his humidified oxygen mask meant I had to press my face nearly against his to understand his words.

“This is getting harder, doctor,” he rasped. “I’m not sure I’m up to anymore chemo.”

I was not the only doctor that he confided to. But what I quickly learned was that none of us was eager to broach the topic of stopping treatment with his primary cancer doctor.

That doctor was a rising superstar in the world of oncology, a brilliant physician-researcher who had helped discover treatments for other cancers and who had been recruited to lead our hospital’s then lackluster cancer center. Within a few months of the doctor’s arrival, the once sleepy department began offering a dazzling array of experimental drugs. Calls came in from outside doctors eager to send their patients in for treatment, and every patient who was seen was promptly enrolled in one of more than a dozen well-documented treatment protocols.

But now, no doctors felt comfortable suggesting anything but the most cutting-edge, aggressive treatments.

Even the No. 2 doctor in the cancer center, Robin to the chief’s cancer-battling Batman, was momentarily taken aback when I suggested we reconsider the patient’s chemotherapy plan. “I don’t want to tell him,” he said, eyes widening. He reeled off his chief’s vast accomplishments. “I mean, who am I to tell him what to do?”

We stood for a moment in silence before he pointed his index finger at me. “You tell him,” he said with a smile. “You tell him to consider stopping treatment.”

Memories of this conversation came flooding back last week when I read an essay on the problems posed by hierarchies within the medical profession.

For several decades, medical educators and sociologists have documented the existence of hierarchies and an intense awareness of rank among doctors. The bulk of studies have focused on medical education, a process often likened to military and religious training, with elder patriarchs imposing the hair shirt of shame on acolytes unable to incorporate a profession’s accepted values and behaviors. Aspiring doctors quickly learn whose opinions, experiences and voices count, and it is rarely their own. Ask a group of interns who’ve been on the wards for but a week, and they will quickly raise their hands up to the level of their heads to indicate their teachers’ status and importance, then lower them toward their feet to demonstrate their own.

It turns out that this keen awareness of ranking is not limited to students and interns. Other research has shown that fully trained physicians are acutely aware of a tacit professional hierarchy based on specialties, like primary care versus neurosurgery, or even on diseases different specialists might treat, like hemorrhoids and constipation versus heart attacks and certain cancers.

But while such professional preoccupation with privilege can make for interesting sociological fodder, the real issue, warns the author of a courageous essay published recently in The New England Journal of Medicine, is that such an overly developed sense of hierarchy comes at an unacceptable price: good patient care.

Dr. Ranjana Srivastava, a medical oncologist at the Monash Medical Centre in Melbourne, Australia, recalls a patient she helped to care for who died after an operation. Before the surgery, Dr. Srivastava had been hesitant to voice her concerns, assuming that the patient’s surgeon must be “unequivocally right, unassailable, or simply not worth antagonizing.” When she confesses her earlier uncertainty to the surgeon after the patient’s death, Dr. Srivastava learns that the surgeon had been just as loath to question her expertise and had assumed that her silence before the surgery meant she agreed with his plan to operate.

“Each of us was trying our best to help a patient, but we were also respecting the boundaries and hierarchy imposed by our professional culture,” Dr. Srivastava said. “The tragedy was that the patient died, when speaking up would have made all the difference.”

Compounding the problem is an increasing sense of self-doubt among many doctors. With rapid advances in treatment, there is often no single correct “answer” for a patient’s problem, and doctors, struggling to stay up-to-date in their own particular specialty niches, are more tentative about making suggestions that cross over to other doctors’ “turf.” Even as some clinicians attempt to compensate by organizing multidisciplinary meetings, inviting doctors from all specialties to discuss a patient’s therapeutic options, “there will inevitably be a hierarchy at those meetings of who is speaking,” Dr. Srivastava noted. “And it won’t always be the ones who know the most about the patient who will be taking the lead.”

It is the potentially disastrous repercussions for patients that make this overly developed awareness of rank and boundaries a critical issue in medicine. Recent efforts to raise safety standards and improve patient care have shown that teams are a critical ingredient for success. But simply organizing multidisciplinary lineups of clinicians isn’t enough. What is required are teams that recognize the importance of all voices and encourage active and open debate.

Since their patient’s death, Dr. Srivastava and the surgeon have worked together to discuss patient cases, articulate questions and describe their own uncertainties to each other and in patients’ notes. “We have tried to remain cognizant of the fact that we are susceptible to thinking about hierarchy,” Dr. Srivastava said. “We have tried to remember that sometimes, despite our best intentions, we do not speak up for our patients because we are fearful of the consequences.”

That was certainly true for my lung cancer patient. Like all the other doctors involved in his care, I hesitated to talk to the chief medical oncologist. I questioned my own credentials, my lack of expertise in this particular area of oncology and even my own clinical judgment. When the patient appeared to fare better, requiring less oxygen and joking and laughing more than I had ever seen in the past, I took his improvement to be yet another sign that my attempt to talk about holding back chemotherapy was surely some surgical folly.

But a couple of days later, the humidified oxygen mask came back on. And not long after that, the patient again asked for me to come close.

This time he said: “I’m tired. I want to stop the chemo.”

Just before he died, a little over a week later, he was off all treatment except for what might make him comfortable. He thanked me and the other doctors for our care, but really, we should have thanked him and apologized. Because he had pushed us out of our comfortable, well-delineated professional zones. He had prodded us to talk to one another. And he showed us how to work as a team in order to do, at last, what we should have done weeks earlier.

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DealBook: Confidence on Upswing, Mergers Make Comeback

The mega-merger is back.

For the corporate takeover business, the last half-decade was a fallow period. Wall Street deal makers and chief executives, brought low by the global financial crisis, lacked the confidence to strike the audacious multibillion-dollar acquisitions that had defined previous market booms.

Cycles, however, turn, and in the opening weeks of 2013, merger activity has suddenly roared back to life. On Thursday, Berkshire Hathaway, the conglomerate run by Warren E. Buffett, said it had teamed up with Brazilian investors to buy the ketchup maker H. J. Heinz for about $23 billion. And American Airlines and US Airways agreed to merge in a deal valued at $11 billion.

Those transactions come a week after a planned $24 billion buyout of the computer company Dell by its founder, Michael S. Dell, and private equity backers. And Liberty Global, the company controlled by the billionaire media magnate John C. Malone, struck a $16 billion deal to buy the British cable business Virgin Media.

“Since the crisis, one by one, the stars came into alignment, and it was only a matter of time before you had a week like we just had,” said James B. Lee Jr., the vice chairman of JPMorgan Chase.

Still, bankers and lawyers remain circumspect, warning that it is still too early to declare a mergers-and-acquisitions boom like those during the junk bond craze of 1989, the dot-com bubble of 1999 and the leveraged buyout bonanza of 2007. They also say that it is important to pay heed to the excesses that developed during these moments of merger mania, which all ended badly.

A confluence of factors has driven the recent deals. Most visibly, the stock market has been on a tear, with the Standard & Poor’s 500-stock index this week briefly hitting its highest levels since November 2007. Higher share prices have buoyed the confidence of chief executives, who now, instead of retrenching, are looking for ways to expand their businesses.

A number of clouds that hovered over the markets last year have also been removed, eliminating the uncertainty that hampered deal making. Mergers and acquisitions activity in 2012 remained tepid as companies took a wait-and-see approach over the outcome of the presidential election and negotiations over the fiscal cliff. The problems in Europe, which began in earnest in 2011, shut down a lot of potential transactions, but the region has since stabilized.

“When we talk to our corporate clients as well as the bankers, we keep hearing them talk about increased confidence,” said John A. Bick, a partner at the law firm Davis Polk & Wardwell, who advised Heinz on its acquisition by Mr. Buffett and his partners.

Mr. Bick said that mega-mergers had a psychological component, meaning that once transactions start happening, chief executives do not want to be left behind. “In the same way that success breeds success, deals breed more deals,” he said.

A central reason for the return of big transactions is the mountain of cash on corporate balance sheets. After the financial crisis, companies hunkered down, laying off employees and cutting costs. As a result, they generated savings. Today, corporations in the S.& P. 500 are sitting on more than $1 trillion in cash. With interest rates near zero, that money is earning very little in bank accounts, so executives are looking to put it to work by acquiring businesses.

The private equity deal-making machine is also revving up again. The world’s largest buyout firms have hundreds of billions of dollars of “dry powder” — money allotted to deals in Wall Street parlance — and they are on the hunt. The proposed leveraged buyout of Dell, led by Mr. Dell and the investment firm Silver Lake Partners, was the largest private equity transaction since July 2007, when the Blackstone Group acquired the hotel chain Hilton Worldwide for $26 billion just as the credit markets were seizing up.

But perhaps the single biggest factor driving the return of corporate takeovers is the banking system’s renewed health. Corporations often rely on bank loans for financing acquisitions, and the ability of private equity firms to strike multibillion-dollar transactions depends on the willingness of banks to lend them money.

For years, banks, saddled by the toxic mortgage assets weighing on their balance sheets, turned off the lending spigot. But with the housing crisis in the rearview mirror and economic conditions slowly improving, banks are again lining up to provide corporate loans at record-low interest rates to finance acquisitions.

The banks, of course, are major beneficiaries of megadeals, earning big fees from both advising on the transactions and lending money to finance them. Mergers and acquisitions in the United States total $158.7 billion so far this year, according to Thomson Reuters data, more than double the amount in the same period last year. JPMorgan, for example, has benefited from the surge, advising on four big deals in recent weeks, including the Dell bid and Comcast’s $16.7 billion offer for the rest of NBCUniversal that it did not already own.

Mr. Buffett, in a television interview last month, declared that the banks had repaired their businesses and no longer posed a threat to the economy. “The capital ratios are huge, the excesses on the asset aside have been largely cleared out,” said Mr. Buffett, whose acquisition of Heinz will be his second-largest acquisition, behind his $35.9 billion purchase of a majority stake in the railroad company Burlington Northern Santa Fe in 2009.

While Wall Street has an air of giddiness over the year’s start, most deal makers temper their comments about the current environment with warnings about undisciplined behavior like overpaying for deals and borrowing too much to pay for them.

Though private equity firms were battered by the financial crisis, they made it through the downturn on relatively solid ground. Many of their megadeals, like Hilton, looked destined for bankruptcy after the markets collapsed, but they have since recovered. The deals have benefited from an improving economy, as well as robust lending markets that allowed companies to push back the large amounts of debt that were to have come due in the next few years.

But there are still plenty of cautionary tales about the consequences of overpriced, overleveraged takeovers. Consider Energy Future Holdings, the biggest private equity deal in history. Struck at the peak of the merger boom in October 2007, the company has suffered from low natural gas prices and too much debt, and could be forced to restructure this year. Its owners, a group led by Kohlberg Kravis Roberts and TPG, are likely to lose billions.

Even Mr. Buffett made a mistake on Energy Future Holdings, having invested $2 billion in the company’s bonds. He admitted to shareholders last year that the investment was a blunder and would most likely be wiped out.

“In tennis parlance,” Mr. Buffett wrote, “this was a major unforced error.”

Michael J. de la Merced contributed reporting.

A version of this article appeared in print on 02/15/2013, on page A1 of the NewYork edition with the headline: Confidence on Upswing, Mergers Make Comeback.
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Pope Says He Will Be ‘Hidden To The World’ In Retirement





VATICAN CITY — Saying he would soon be “hidden to the world,” Pope Benedict XVI took his leave of parish priests and clergy of the Diocese of Rome on Thursday in a moving encounter during which he gave a personal, and incisive, recollection of the Second Vatican Council, the gathering of bishops 50 years ago that set the Roman Catholic Church’s course for the future.




Benedict, who announced his resignation four days ago — the first pope to step down willingly in nearly 600 years — also indicated that he would not hold a public role once his resignation becomes official on Feb. 28.


“Though I am now retiring to a life of prayer, I will always be close to all of you and I am sure all of you will be close to me, even though I remain hidden to the world,” he told the assembly of hundreds of priests, who had greeted him with a long, standing ovation and some tears.


The pope will live in a convent inside Vatican City.


At a news briefing Thursday, the Rev. Federico Lombardi, the Vatican spokesman, said Benedict’s longtime personal secretary, Archbishop Georg Gänswein, who was also named prefect of the papal household two months ago, would continue to work for him.


Father Lombardi said he saw no conflict of interest if Archbishop Gänswein served the current pope and his successor.


The prefect is responsible for logistical duties, and “in this sense it is not a profound problem, I think,” Father Lombardi said.


The nuns who currently tend to the pope will also live with the pontiff once he is no longer pope.


Father Lombardi also confirmed news reports that the pope had had an accident during a trip to Mexico last March, hitting his head in the middle of the night, but he denied that the episode had influenced the pontiff’s decision to retire.


Since his surprise announcement on Monday, which stunned the Roman Catholic world, there has been much closer public scrutiny of the pope’s health.


The 85-year-old pope — who has appeared increasingly frail in recent public appearances — said he felt he did not have the strength to continue in his ministry.


On Tuesday, the Vatican confirmed for the first time that the pope had had a pacemaker since his time as a cardinal and had its batteries changed three months ago.


“It didn’t impact on the trip or on his decision,” Father Lombardi said, pointing out that the pope had kept his appointments as scheduled.


The priests from the Rome diocese who attended Benedict’s audience said they felt they had witnessed a powerful moment in church history, one that also humanized a pope who has often seemed remote. “It moved me to see the pope smile,” said Don Mario Filippa, a priest in Rome. “He has found peace within himself.”


“It was a part of history,” said Father Martin Astudillo, 37, an Argentine priest who is studying in Rome. “This is a man of God who at the end of his public role transmits his vision of the church and relationship with the church,” he added. “We saw in a few words a real synthesis of his vision of the church and what he expects from whomever takes over.”


In his remarks, which touched on some of the thorniest issues of his papacy, Benedict also spoke about how the Second Vatican Council had explored ideas of “continuity” between Old and New Testaments, and of the relationship between the Catholic and Jewish faiths.


“Even if it’s clear that the church isn’t responsible for the Shoah, it’s for the most part Christians who did this crime,” Benedict said of the Holocaust, adding that this called for a need to “deepen and renovate the Christian conscience,” even if it’s true that “real believers only fought against” Nazi barbarism.


During the 45-minute reflection — or “chat” in his words — on the council, he also recalled the “incredible” expectations of bishops going into the gathering.


“We were full of hope, enthusiasm and also of good will,” he said.


But while the council made landmark decisions that would propel the church into the future, much got lost in the media’s interpretation of what transpired, he said, which led to the “calamities” that have marred recent church history.


The media reduced the proceedings “into a political power struggle between different currents of the church,” and they chose sides that suited their individual vision of the world, the pope said.


These messages, not that of the council, entered into the public sphere and that led in the years to “so many calamities, so many problems, seminaries closed, convents that closed, the liturgy trivialized,” the pope said.


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