In Soldier’s Hearing, Afghans Tell of Horror

JOINT BASE LEWIS-McCHORD, Wash. — Through a live video feed from half a world away in Afghanistan, in an extraordinary night court session, descriptions of chaos and horror poured into a military courtroom here as if from an open spigot.

Lois Silver/FR 170774 Associated Press, via Associated Press

In a courtroom sketch, Staff Sgt. Robert Bales, lower right, is shown during testimony on Friday.

Reuters

Sergeant Bales, left, during a 2011 training exercise in Fort Irwin, California.

“Their brains were still on the pillows,” said Mullah Khamal Adin, 39, staring into the camera with his arms folded on the table, describing the 11 members of his cousin’s family he found dead in the family compound — most of the bodies burned in a pile in one room.

Mr. Adin, in a hearing that started here late Friday, was asked about the smell. Was there an odor of gasoline or kerosene?

Just bodies and burned plastic, he replied through a translator.

The Army’s preliminary hearing in the case against Staff Sgt. Robert Bales, accused of killing 16 Afghan civilians in Kandahar Province this year, unfolded last week mostly in the bustling daylight of a working military base an hour south of Seattle. But to accommodate witnesses in Afghanistan, and the 12-and-a-half-hour time difference, the schedule was shifted at week’s end, with testimony through cameras and uplinks in Afghanistan and here at Lewis-McChord starting at 7:30 p.m. Pacific time on Friday and running until shortly after 2 a.m. Saturday.

The attacks, which occurred on March 11 in a deeply poor rural region while most of the victims were asleep, were the deadliest war crime attributed to a single American soldier in the decade of war that has followed the terrorist attacks of Sept. 11, 2001, and they further frayed the relationship between the American and Afghan governments.

The military says Sergeant Bales, 39, was serving his fourth combat tour overseas when he walked away from his remote outpost in southern Afghanistan and shot and stabbed members of several families in a nighttime ambush on two villages. At least nine of the people he is accused of killing were children, and others were women. After the victims were shot, some of the bodies were dragged into a pile and burned.

“ ‘What are you doing? What are you doing?’ ” one witness, a farmer named Haji Naim, said he had shouted to the American soldier, whom he described as wearing a blindingly bright headlamp in a house that, without electricity, was pitch black. The gunman said nothing, Mr. Naim said, and simply kept firing.

“He shot me right here, right here, and right here,” he said, indicating wounds from which he has apparently recovered.

Most of the testimony, however graphic, was circumstantial, pointing to a lone American gunman but not directly implicating Sergeant Bales. The villagers testified on the fifth day of a military proceeding known as an Article 32 investigation, held to establish whether there is enough evidence to bring Sergeant Bales before a court-martial. If a court-martial is ordered and the Army decides to continue the prosecution as a capital case, the sergeant could face the death penalty.

Sergeant Bales, a decorated veteran of three tours in Iraq before being sent to Afghanistan last December, was deployed from Joint Base Lewis-McChord. He was held at the military prison at Fort Leavenworth in Kansas before being brought here for the hearing.

Witnesses earlier in the week talked about the blood-soaked clothes that Sergeant Bales was seen wearing when he returned to his base in Kandahar and his comments to fellow soldiers about having done “the right thing.” There was also testimony about the test for steroids in his system that came back positive three days after the killings.

The hearing’s night sessions, which were scheduled to continue on Saturday, were all about the violence that unfolded the night of March 11. Mr. Adin, who was summoned to his cousin’s compound by a telephone call early the next morning, told of boot prints that were on some bodies, including the head of a child who had apparently been shot and stomped or kicked. Mr. Adin talked about a small child who he said appeared to have been “grabbed from her bed and thrown on the fire.” But Mr. Adin never saw the gunman, arriving after the fact.

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Yale Graduates Seek a Degree in Hip-Hop

IT started with confusion over a Cam’ron lyric.

In 2009, Tom Lehman, a computer programmer, was puzzled by the line, “80 holes in your shirt: there, your own Jamaican clothes” in the rap song “Family Ties.” What were “Jamaican clothes,” he wondered?

A friend from Yale, Mahbod Moghadam, guessed that the lyric referred to the tattered clothing worn by impoverished Jamaicans. That turned out not to be true, but it was enough to inspire Mr. Lehman to build Rap Genius, a Web site that seeks to decipher every lyric in hip-hop.

While rap lyric sites are not new, Rap Genius distinguished itself by adding a Wikipedia-esque twist, allowing anyone to annotate lyrics with words, photos and videos. More than 250,000 people have submitted explanations to date, with contributions vetted by 500 editors, many of them high school or college students.

The result is a mélange of decoded slang, interpretations of varying plausibility and dorky jokes that has struck a chord. The site draws two million unique visitors a month, according to comScore, an independent analytics firm, and last month Ben Horowitz, a well-known venture capitalist in Silicon Valley with a soft spot for hip-hop, announced he was investing $15 million in the site.

But the project has also been dogged by awkward questions about race and authenticity, including a recent dispute over conversations in a chat room that some call racist. Not helping matters is the sometimes-outlandish behavior of its three founders, Mr. Lehman, Mr. Moghadam and a third buddy from Yale, Ilan Zechory.

Rap Genius is run out of two penthouse apartments in Williamsburg, Brooklyn, where the founders seem to fancy themselves as hip-hop personalities in their own right.

Mr. Lehman, 28, sports an unkempt Afro of sorts, and seems to wear a different pair of sunglasses for every conversation. Friends noted a striking accumulation of skinny jeans in various colors after he received Mr. Horowitz’s check. Mr. Lehman is also a stickler for punctuation, which can be torture for someone who runs a crowd-sourced hip-hop Web site.

Mr. Moghadam, 29, favors shirtlessness to show off a muscular upper body, and speaks in a unique patois that mixes phrases like “we got bottles” and “pop it for pimp” with graduate-school-level discussions of Orientalism and religious texts. He can come off as a star-struck fan, bragging about meeting Gucci Mane or Big Boi one moment, before drifting into hyperbolic claims about Rap Genius’s future the next.

Mr. Zechory, 28, cuts a more modest figure. He says that his two friends are playing roles, and marvels at their ability to keep up the act. “I’ve never seen him break character,” he said of Mr. Moghadam.

Perhaps the site’s biggest claim to fame has been its ability to get several famous rappers, including Nas and 50 Cent, to explain their own lyrics on the site. GZA from the Wu-Tang Clan received a tutorial last month. He came away enthusiastic.

“This is a perfect site for me, because I love talking about hip-hop and lyrics,” he said. “The way I write is like a puzzle, so most of it can be broken down and explained in detail.”

But some critics suspect that Rap Genius’s founders are engaged in a sort of perpetual parody of the music they claim to be rhapsodizing. “There’s a consciousness about what they’re doing — we call it ‘slumming,’ ” said Camille Charles, a sociology professor at the University of Pennsylvania who studies race.

The site has been plagued by other troubles. Many of the song transcripts are identical — typos and all — to those found on the Original Hip-Hop Lyrics Archive, a Web site that has existed in varying forms since 1992. And some explanations are cause for eye-rolling.

“It’s frequently incorrect, just straight up wrong, in the transcription and definitely in the interpretation,” said Adam Mansbach, the author of “Go the ____ to Sleep,” a profane play on the bedtime storybook.

Mr. Moghadam said that he is aware of how a hip-hop site created by three Yale graduates might raise suspicions. But he notes that Rap Genius is designed to weed out wrong answers, using as an example his own faulty explanation of “Jamaican clothes,” which the site now says refers to “mesh tank tops with a lot of little holes in them.”

At the same time, Mr. Moghadam’s own actions have given critics plenty to work with.

When Kool A.D., a rapper from the group Das Racist, referred to Rap Genius as “white devil sophistry” in a song last year, Mr. Moghadam posted a response video, in which he raps about the color of Kool A.D.’s skin with a line that some took as racist. (Mr. Moghadam, who is Persian, insists he was making a reference to how he thought Kool A.D. looks sickly.)

But the racial questions arose again a few weeks ago when Bryan Crawford, a prominent hip-hop blogger, posted screen grabs from a Rap Genius chat room that showed users making jokes about slavery.

In response, the founders denounced the jokes as racist, but added that the site could be not be held accountable for every comment, much like Twitter can’t be blamed for every offensive tweet. On his own, however, Mr. Moghadam went further and physically threatened Mr. Crawford in an online chat and on Twitter.

Mr. Moghadam insists that the beef was largely tongue-in-cheek, and that the bluster is just part of the pugnacious hip-hop world. “Dissing is their vocabulary,” he said. “If they’re dissing you, they’re showing you respect.”

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The New Old Age Blog: The Emotional Aftermath of Hurricane Sandy

Let’s talk about the emotional aftermath of the storm that left tens of thousands of older people on the East Coast without power, bunkered down in their homes, chilled to the bone and out of touch with the outside world.

Let’s name the feelings they may have experienced. Fear. Despair. Hopelessness. Anxiety. Panic.

Linda Leest and her staff at Services Now for Adult Persons in Queens heard this in the voices of the older people they had been calling every day, people who were homebound and at risk because of medical conditions that compromise their physical functioning.

“They’re afraid of being alone,” she said in a telephone interview a few days after the storm. “They’re worried that if anything happens to them, no one is going to know. They feel that they’ve lost their connection with the world.”

What do we know about how older adults fare, emotionally, in a disaster like that devastating storm, which destroyed homes and businesses and isolated older adults in darkened apartment buildings, walk-ups and houses?

Most do well — emotional resilience is an underappreciated characteristic of older age — but those who are dependent on others, with pre-existing physical and mental disabilities, are especially vulnerable.

Most will recover from the disorienting sense that their world has been turned upside down within a few weeks or months. But some will be thrown into a tailspin and will require professional help. The sooner that help is received, the more likely it is to prevent a significant deterioration in their health.

The best overview comes from a November 2008 position paper from the American Association for Geriatric Psychiatry that reviewed the effects of Hurricane Katrina and other disasters. After Katrina, “the elderly had the highest mortality rates, health decline and suicide rates of any subgroup,” that document notes. “High rates of psychosomatic problems were seen, with worsening health problems and increased mortality and disability.”

This is an important point: Emotional trauma in older adults often is hard to detect, and looks different from what occurs in younger people. Instead of acknowledging anxiety or depression, for instance, older people may complain of having a headache, a bad stomachache or some other physical ailment.

“This age group doesn’t generally feel comfortable talking about their feelings; likely, they’ll mask those emotions or minimize what they’re experiencing,” said Dr. Mark Nathanson, a geriatric psychiatrist at Columbia University Medical Center.

Signs that caregivers should watch out for include greater-than-usual confusion in an older relative, a decline in overall functioning and a disregard for “self care such as bathing, eating, dressing properly and taking medication,” Dr. Nathanson said.

As an example, he mentioned an older man who had “been sitting in a cold house for days and decided to stop taking his water pill because he felt it was just too much trouble.” Being distraught or distracted and forgetting or neglecting to take pills for chronic conditions like diabetes or heart disease can have immediate harmful effects.

Especially at risk of emotional disturbances are older adults who are frail and advanced in age, those who have cognitive impairments like Alzheimer’s disease, those with serious mental illnesses like schizophrenia or major depression, and those with chronic medical conditions or otherwise in poor physical health, according to the geriatric psychiatry association’s position paper.

A common thread in all of the above is the depletion of physical and emotional reserves, which impairs an older person’s ability to adapt to adverse circumstances.

“In geriatrics, we have this idea of the ‘geriatric cascade’ that refers to how a seemingly minor thing can set in motion a functional, cognitive and psychological downward spiral” in vulnerable older adults, said Dr. Mark Lachs, chief of the division of geriatrics at Weill Cornell Medical College. “Well, the storm was a major thing — a very large disequilibrating event — and its impact is an enormous concern.”

Of special concern are older people who may be in the early stages of Alzheimer’s disease or other types of dementia who are living alone. For this group, the maintenance of ordinary routines and the sense of a dependable structure in their lives is particularly important, and “a situation like Sandy, which causes so much disruption, can be a tipping point,” Dr. Lachs said.

Also of concern are older people who may have experienced trauma in the past, and who may suffer a reignition of post-traumatic stress symptoms because of the disaster.

Most painful of all, for many older adults, is the sense of profound isolation that can descend on those without working phones, electricity or relatives who can come by to help.

“That isolation, I can’t tell you how disorienting that can be,” said Bobbie Sackman, director of public policy for the Council of Senior Centers and Services of New York City. “They’re scared, but they won’t tell you because they’re too proud and ashamed to ask for help.”

The best remedy, in the short run, is the human touch.

“Now is the time for people to reach out to their neighbors in high-rises or in areas where seniors are clustered, to knock on doors and ask people how they are doing,” said Dr. Gary Kennedy, director of the division of geriatric psychiatry at Montefiore Medical Center in the Bronx.

Don’t make it a one-time thing; let the older person know you’ll call or come by again, and set up a specific time so “there’s something for them to look forward to,” Dr. Kennedy said. So-called naturally occurring retirement communities with large concentrations of older people should be organizing from within to contact residents who may not be connected with social services and find out how they’re doing, he recommended.

In conversations with older adults, offer reassurance and ask open-ended questions like “Are you low on pills?” or “Can I run out and get you something?” rather than trying to get them to open up, experts recommended. Focusing on problem-solving can make people feel that their lives are being put back in order and provide comfort.

Although short-term psychotherapy has positive outcomes for older adults who’ve undergone a disaster, it’s often hard to convince a senior to seek out mental health services because of the perceived stigma associated with psychological conditions. Don’t let that deter you: Keep trying to connect them with services that can be of help.

Be mindful of worrisome signs like unusual listlessness, apathy, unresponsiveness, agitation or confusion. These may signal that an older adult has developed delirium, which can be extremely dangerous if not addressed quickly, Dr. Nathanson said. If you suspect that’s the case, call 911 or make sure you take the person to the nearest hospital emergency room.

This is a safe place to talk about all kinds of issues affecting older adults. Would you be willing to share what kinds of mental health issues you or family members are dealing with since the storm so readers can learn from one another?

Read More..

The New Old Age Blog: The Emotional Aftermath of Hurricane Sandy

Let’s talk about the emotional aftermath of the storm that left tens of thousands of older people on the East Coast without power, bunkered down in their homes, chilled to the bone and out of touch with the outside world.

Let’s name the feelings they may have experienced. Fear. Despair. Hopelessness. Anxiety. Panic.

Linda Leest and her staff at Services Now for Adult Persons in Queens heard this in the voices of the older people they had been calling every day, people who were homebound and at risk because of medical conditions that compromise their physical functioning.

“They’re afraid of being alone,” she said in a telephone interview a few days after the storm. “They’re worried that if anything happens to them, no one is going to know. They feel that they’ve lost their connection with the world.”

What do we know about how older adults fare, emotionally, in a disaster like that devastating storm, which destroyed homes and businesses and isolated older adults in darkened apartment buildings, walk-ups and houses?

Most do well — emotional resilience is an underappreciated characteristic of older age — but those who are dependent on others, with pre-existing physical and mental disabilities, are especially vulnerable.

Most will recover from the disorienting sense that their world has been turned upside down within a few weeks or months. But some will be thrown into a tailspin and will require professional help. The sooner that help is received, the more likely it is to prevent a significant deterioration in their health.

The best overview comes from a November 2008 position paper from the American Association for Geriatric Psychiatry that reviewed the effects of Hurricane Katrina and other disasters. After Katrina, “the elderly had the highest mortality rates, health decline and suicide rates of any subgroup,” that document notes. “High rates of psychosomatic problems were seen, with worsening health problems and increased mortality and disability.”

This is an important point: Emotional trauma in older adults often is hard to detect, and looks different from what occurs in younger people. Instead of acknowledging anxiety or depression, for instance, older people may complain of having a headache, a bad stomachache or some other physical ailment.

“This age group doesn’t generally feel comfortable talking about their feelings; likely, they’ll mask those emotions or minimize what they’re experiencing,” said Dr. Mark Nathanson, a geriatric psychiatrist at Columbia University Medical Center.

Signs that caregivers should watch out for include greater-than-usual confusion in an older relative, a decline in overall functioning and a disregard for “self care such as bathing, eating, dressing properly and taking medication,” Dr. Nathanson said.

As an example, he mentioned an older man who had “been sitting in a cold house for days and decided to stop taking his water pill because he felt it was just too much trouble.” Being distraught or distracted and forgetting or neglecting to take pills for chronic conditions like diabetes or heart disease can have immediate harmful effects.

Especially at risk of emotional disturbances are older adults who are frail and advanced in age, those who have cognitive impairments like Alzheimer’s disease, those with serious mental illnesses like schizophrenia or major depression, and those with chronic medical conditions or otherwise in poor physical health, according to the geriatric psychiatry association’s position paper.

A common thread in all of the above is the depletion of physical and emotional reserves, which impairs an older person’s ability to adapt to adverse circumstances.

“In geriatrics, we have this idea of the ‘geriatric cascade’ that refers to how a seemingly minor thing can set in motion a functional, cognitive and psychological downward spiral” in vulnerable older adults, said Dr. Mark Lachs, chief of the division of geriatrics at Weill Cornell Medical College. “Well, the storm was a major thing — a very large disequilibrating event — and its impact is an enormous concern.”

Of special concern are older people who may be in the early stages of Alzheimer’s disease or other types of dementia who are living alone. For this group, the maintenance of ordinary routines and the sense of a dependable structure in their lives is particularly important, and “a situation like Sandy, which causes so much disruption, can be a tipping point,” Dr. Lachs said.

Also of concern are older people who may have experienced trauma in the past, and who may suffer a reignition of post-traumatic stress symptoms because of the disaster.

Most painful of all, for many older adults, is the sense of profound isolation that can descend on those without working phones, electricity or relatives who can come by to help.

“That isolation, I can’t tell you how disorienting that can be,” said Bobbie Sackman, director of public policy for the Council of Senior Centers and Services of New York City. “They’re scared, but they won’t tell you because they’re too proud and ashamed to ask for help.”

The best remedy, in the short run, is the human touch.

“Now is the time for people to reach out to their neighbors in high-rises or in areas where seniors are clustered, to knock on doors and ask people how they are doing,” said Dr. Gary Kennedy, director of the division of geriatric psychiatry at Montefiore Medical Center in the Bronx.

Don’t make it a one-time thing; let the older person know you’ll call or come by again, and set up a specific time so “there’s something for them to look forward to,” Dr. Kennedy said. So-called naturally occurring retirement communities with large concentrations of older people should be organizing from within to contact residents who may not be connected with social services and find out how they’re doing, he recommended.

In conversations with older adults, offer reassurance and ask open-ended questions like “Are you low on pills?” or “Can I run out and get you something?” rather than trying to get them to open up, experts recommended. Focusing on problem-solving can make people feel that their lives are being put back in order and provide comfort.

Although short-term psychotherapy has positive outcomes for older adults who’ve undergone a disaster, it’s often hard to convince a senior to seek out mental health services because of the perceived stigma associated with psychological conditions. Don’t let that deter you: Keep trying to connect them with services that can be of help.

Be mindful of worrisome signs like unusual listlessness, apathy, unresponsiveness, agitation or confusion. These may signal that an older adult has developed delirium, which can be extremely dangerous if not addressed quickly, Dr. Nathanson said. If you suspect that’s the case, call 911 or make sure you take the person to the nearest hospital emergency room.

This is a safe place to talk about all kinds of issues affecting older adults. Would you be willing to share what kinds of mental health issues you or family members are dealing with since the storm so readers can learn from one another?

Read More..

Hurricane Sandy and the Disaster-Preparedness Economy

Jeffrey Phelps for The New York Times

An assembly line at a Generac Power Systems plant. Generac makes residential generators, coveted items in the wake of Hurricane Sandy.

FOLKS here don’t wish disaster on their fellow Americans. They didn’t pray for Hurricane Sandy to come grinding up the East Coast, tearing lives apart and plunging millions into darkness.

But the fact is, disasters are good business in Waukesha. And, lately, there have been a lot of disasters.

This Milwaukee suburb, once known for its curative spring waters and, more recently, for being a Republican stronghold in a state that President Obama won on Election Day, happens to be the home of one of the largest makers of residential generators in the country. So when the lights go out in New York — or on the storm-savaged Jersey Shore or in tornado-hit Missouri or wherever — the orders come pouring in like a tidal surge.

It’s all part of what you might call the Mad Max Economy, a multibillion-dollar-a-year collection of industries that thrive when things get really, really bad. Weather radios, kerosene heaters, D batteries, candles, industrial fans for drying soggy homes — all are scarce and coveted in the gloomy aftermath of Hurricane Sandy and her ilk.

It didn’t start with the last few hurricanes, either. Modern Mad Max capitalism has been around a while, decades even, growing out of something like old-fashioned self-reliance, political beliefs and post-Apocalyptic visions. The cold war may have been the start, when schoolchildren dove under desks and ordinary citizens dug bomb shelters out back. But economic fears, as well as worries about climate change and an unreliable electronic grid have all fed it.

 Driven of late by freakish storms, this industry is growing fast, well beyond the fringe groups that first embraced it. And by some measures, it’s bigger than ever.

Businesses like Generac Power Systems, one of three companies in Wisconsin turning out generators, are just the start.

The market for gasoline cans, for example, was flat for years. No longer. “Demand for gas cans is phenomenal, to the point where we can’t keep up with demand,” says Phil Monckton, vice president for sales and marketing at Scepter, a manufacturer based in Scarborough, Ontario. “There was inventory built up, but it is long gone.”

Even now, nearly two weeks after the superstorm made landfall in New Jersey, batteries are a hot commodity in the New York area. Win Sakdinan, a spokesman for Duracell, says that when the company gave away D batteries in the Rockaways, a particularly hard-hit area, people “held them in their hands like they were gold.”

Sales of Eton emergency radios and flashlights rose 15 percent in the week before Hurricane Sandy — and 220 percent the week of the storm, says Kiersten Moffatt, a company spokeswoman. “It’s important to note that we not only see lifts in the specific regions affected, we see a lift nationwide,” she wrote in an e-mail. “We’ve seen that mindfulness motivates consumers all over the country to be prepared in the case of a similar event.”

Garo Arabian, director of operations at B-Air, a manufacturer based in Azusa, Calif., says he has sold thousands of industrial fans since the storm. “Our marketing and graphic designer is from Syria, and he says: ‘I don’t understand. In Syria, we open the windows.’ ”

But Mr. Arabian says contractors and many insurers know that mold spores won’t grow if carpeting or drywall can be dried out within 72 hours. “The industry has grown,” he says, “because there is more awareness about this kind of thing.”

Retailers that managed to stay open benefited, too. Steve Rinker, who oversees 11 Lowe’s home improvement stores in New York and New Jersey, says his stores were sometimes among the few open in a sea of retail businesses.

Predictably, emergency supplies like flashlights, lanterns, batteries and sump pumps sold out quickly, even when they were replenished. The one sought-after item that surprised him the most? Holiday candles. “If anyone is looking for holiday candles, they are sold out,” he says. “People bought every holiday candle we have during the storm.”

If the hurricane was a windfall for Lowe’s, its customers didn’t seem to mind. Rather, most appeared exceedingly grateful when Mr. Rinker, working at a store in Paterson, N.J., pointed them toward a space heater, or a gasoline can, that could lessen the misery of another day without power.

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Citing Affair, Petraeus Resigns as C.I.A. Director

The sudden development came just days after President Obama won re-election to a second term. Mr. Petraeus, a highly decorated general who had led the wars in Iraq and Afghanistan, had been expected to remain in the president’s administration.

Instead, Mr. Petraeus said in the statement that the president accepted his resignation on Friday after he had informed him of his indiscretion a day earlier.

“After being married for over 37 years, I showed extremely poor judgment by engaging in an extramarital affair,” Mr. Petraeus wrote. “Such behavior is unacceptable, both as a husband and as the leader of an organization such as ours. This afternoon, the president graciously accepted my resignation.”

Mr. Obama released a statement praising Mr. Petraeus for his “extraordinary service” to the country and saying that Michael J. Morell, the deputy director of the C.I.A., would take over once again as acting director. He served in that position briefly after Leon E. Panetta left the agency last year.

“By any measure, through his lifetime of service, David Petraeus has made our country safer and stronger,” the president said. Without directly addressing the affair, Mr. Obama added: “Going forward, my thoughts and prayers are with Dave and Holly Petraeus, who has done so much to help military families through her own work. I wish them the very best at this difficult time.” Ms. Petraeus is the assistant director of the Office of Servicemember Affairs at the Consumer Financial Protection Bureau.

The development came as a shock to the national security establishment. In a statement, James R. Clapper, the director of national intelligence, called the decision “a loss” to the country.

“Dave’s decision to step down represents the loss of one of our nation’s most respected public servants.” Mr. Clapper wrote. “From his long, illustrious Army career to his leadership at the helm of C.I.A., Dave has redefined what it means to serve and sacrifice for one’s country.”

By acknowleding an extramarital affair, Mr. Petraeus, 60, was confronting a sensitive issue for a spy chief. Intelligence agencies are often concerned about the possibility that agents who engage in such behavior could be blackmailed for information.

In his statement, Mr. Petraeus did not provide any details about his behavior, saying that he asked the president to be allowed “for personal reasons” to resign.

Mr. Petraeus praised his colleagues at the C.I.A.’s headquarters in Langley, Va., calling them “truly exceptional in every regard” and thanking them for their service to the country. He made it clear that his departure was not how he had envisioned ending a storied career in the military and in intelligence.

“Teddy Roosevelt once observed that life’s greatest gift is the opportunity to work hard at work worth doing,” he said. “I will always treasure my opportunity to have done that with you, and I will always regret the circumstances that brought that work with you to an end.”

Over the last several years, Mr. Petraeus had become one of the most recognizable military officials, serving as the public face of the war effort in Congress and on television.

Under President George W. Bush, Mr. Petraeus was credited for helping to develop and put in place the “surge” in troops in Iraq that helped wind down the war in that country. Mr. Petraeus was moved to Afghanistan in 2010 after Mr. Obama fired General Stanley H. McChrystal over comments he made to a magazine reporter.

In Afghanistan, Mr. Petraeus led the push for a similar increase in troops ordered by Mr. Obama, but he was unable to replicate the success he had in the Iraq conflict.

Last year, Mr. Obama persuaded Mr. Petraeus to leave the Army after 37 years to lead the C.I.A., succeeding Mr. Panetta, who moved to the Defense Department.

This article has been revised to reflect the following correction:

Correction: November 9, 2012

An earlier version of this article incorrectly stated that David H. Petraeus was expected to remain in President Obama’s cabinet. The C.I.A. director is not a cabinet member in the Obama administration.

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Groupon Earnings Miss Expectations on Weakness in Europe

SAN FRANCISCO (Reuters) — Groupon reported financial results late Thursday that fell short of Wall Street’s already cautious expectations, as the daily-deal company failed to turn around its struggling European business.

Groupon also confirmed that it had laid off about 80 employees, mainly in sales, as part of an effort to automate the way it handles its deals.

The company’s shares fell as low as $3.21 in after-hours trading, down as much as 18 percent from their closing price of $3.92. Groupon was the darling of investors during last year’s consumer dot-com boom in initial public offerings, but now it has shed more than 80 percent of its value since making its public debut at $20 a share.

Wall Street has grown uneasy about Groupon’s prospects as daily-deals fever wanes among consumers and merchants, and as growth rates sputter. Adding to the difficulties, the S.E.C. has been looking into Groupon’s accounting and disclosures, an area of controversy during its initial public offering.

Groupon reported third-quarter revenue of $568.6 million, compared with $430.2 million a year earlier. Analysts had expected revenue of $590 million, according to Thomson Reuters.

The company posted a quarterly net loss of $3 million, or break-even on a per-share basis, compared with a net loss of $54.2 million, or 18 cents a share, in the third quarter of 2011.

Andrew Mason, chief executive of Groupon, said a “solid performance” in North America was offset by weakness in Europe. International revenue, including Europe, grew 3 percent to $277 million; North American revenue surged 80 percent to $292 million.

Europe has been a particular problem for Groupon, partly because the sovereign debt crisis there has hurt demand for higher-price deals. Groupon was also offering steeper discounts, disappointing some merchants.

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Advertising: Help Remedies Tries to Cure Ailments in Small Doses

DISAPPOINTED voters, runners with blisters and headache sufferers alike are getting some unexpected relief from a pop-up pharmacy that opened this week in the nation’s capital.

The “help shop,” which offers low-dose drugs for everyday woes, is the idea of Help Remedies, a start-up company that sells minimalist white packets directed at single medical issues like nausea, headache or insomnia.

The company, the collaboration of two marketers, is creating quirky scenes including a high-heel wearing model walking on a treadmill to market its “Help, I have a blister” packet of bandages, or a performer sleeping in a store window to drum up interest for its “Help, I can’t sleep” caplets.

This week, shoppers and passers-by attracted by the napper, for example, could go inside the temporary pharmacy to investigate its 10 over-the-counter remedies for conditions like body aches and allergies.

The store’s team fanned out to polling stations on Tuesday to hand out its headache packets, and then on Wednesday to the nearby Republican National Committee to share nausea relief. Their marketing may be seen as fun and zany, but the company founders, Richard Fine and Nathan Frank, say they have a serious message.

“We want people to see that there are simple solutions,” said Mr. Fine, who said his straightforward approach was influenced by his parents, who are medical professors specializing in epidemiology.

“Most people shop by brand or product, and it’s difficult to know what you should be buying and taking,” he said. “It is a confusing space for people who are not experts.”

Mr. Fine and Mr. Frank, who met while working in branding and advertising, decided to try to streamline what they see as an antiquated and cluttered pharmaceutical market.

“We wanted to take what’s basic and works, and make it human,” Mr. Fine said. Their strategy of providing single ingredients in low dosages is aimed at basic medical conditions that do not require hospitalization.

After starting the company in 2008, they consulted pharmaceutical sources to zero in on the drugs and dosages to use. Their “Help, I have a headache” formulation, for example, contains 325 milligrams of acetaminophen per caplet.

“That is less than the amount in an extra strength caplet,” said Mr. Fine. “If you need more, you can take more. But this is what pharmacists recommend.”

By that summer, Help Remedies was distributing its packets in some high-end hotel chains and business conferences. In 2009, the two men quit their jobs and started the company Web site, helpineedhelp.com, which includes a link to drug facts for each product.

To carve a niche in the crowded pharmaceutical market, Mr. Frank, who handles the company’s creative efforts, said he focused on offbeat marketing, including tactile packaging and performance windows, and viral videos that mixed up the serious, the absurd and even the goofy.

For the packaging, Mr. Frank settled on a flat, white, textured box that opens like a tin. Taking a page from product designers like Apple, he settled on a simple font called century schoolbook, in various colors.

The graphic work was originally done by ChappsMalina and Little Fury, design firms in New York, and was since updated by another firm, Pearlfisher.

Help Remedies, a privately held company, did not disclose its advertising spending, which was $400 in 2010 and $12,500 last year, according to figures from Kantar Media, a WPP unit.

With a small budget, the company has focused on spinning out lighthearted solutions to situations — like countering boredom by focusing on a bouncing ball or hangovers by staring at a rag — on its Web site, videos, bus shelters and other advertising and in the store windows of Ricky’s, a New York beauty supply company.

Help Remedies set up “living windows” like “Help, I’ve never been kissed,” with models on hand to give hugs and kisses in Ricky’s storefronts. There were also serious problems like “Help, I want to save a life,” that provided registration kits from the bone marrow donor center DKMS.

To expand, the company is adapting the living window approach to its first pop-up pharmacy, in Washington, which was delayed by Hurricane Sandy and got under way as the election results were unfolding.

In addition to giving “Help, I have a headache” packets to anyone who asked, the store manager, Melinda Welch, and her staff distributed 2,000 packets — for blisters and for body aches — to participants in the annual High Heel Race.

The company’s products are found in major pharmacy outlets like Duane Reade and CVS, as well as Target and Walgreens. Last year, the company reached $4 million in sales and is set to expand after Washington to San Francisco; Seattle; Portland, Ore.; Austin, Tex.; Chicago; and Miami.

As part of its expansion, the Washington store plans to hold a “Help, I am Insecure” event on Saturday with a life coach to provide support and advice, and a manicurist for those insecure about their nails, Ms. Welch said.

Other events at later dates include “Help, I am Lonely,” with an online dating site consultation, and “Help, I’m in an Argument with my Spouse,” with a relationship judge to settle differences.

William G. Daddi, the president of Daddi Brand Communications, said Help Remedies’s distinct packaging was well suited to compete in the crowded health and beauty market.

But he warned that tying so many products to whimsical marketing carried risks because “there will be consumer confusion and the remedies will be seen as novelty products.”

“To build a true brand, the consumer needs to see that the product is effective,” Mr. Daddi said. “There needs to be a link to tangible outcomes so people see that the product works.”

Read More..

Advertising: Help Remedies Tries to Cure Ailments in Small Doses

DISAPPOINTED voters, runners with blisters and headache sufferers alike are getting some unexpected relief from a pop-up pharmacy that opened this week in the nation’s capital.

The “help shop,” which offers low-dose drugs for everyday woes, is the idea of Help Remedies, a start-up company that sells minimalist white packets directed at single medical issues like nausea, headache or insomnia.

The company, the collaboration of two marketers, is creating quirky scenes including a high-heel wearing model walking on a treadmill to market its “Help, I have a blister” packet of bandages, or a performer sleeping in a store window to drum up interest for its “Help, I can’t sleep” caplets.

This week, shoppers and passers-by attracted by the napper, for example, could go inside the temporary pharmacy to investigate its 10 over-the-counter remedies for conditions like body aches and allergies.

The store’s team fanned out to polling stations on Tuesday to hand out its headache packets, and then on Wednesday to the nearby Republican National Committee to share nausea relief. Their marketing may be seen as fun and zany, but the company founders, Richard Fine and Nathan Frank, say they have a serious message.

“We want people to see that there are simple solutions,” said Mr. Fine, who said his straightforward approach was influenced by his parents, who are medical professors specializing in epidemiology.

“Most people shop by brand or product, and it’s difficult to know what you should be buying and taking,” he said. “It is a confusing space for people who are not experts.”

Mr. Fine and Mr. Frank, who met while working in branding and advertising, decided to try to streamline what they see as an antiquated and cluttered pharmaceutical market.

“We wanted to take what’s basic and works, and make it human,” Mr. Fine said. Their strategy of providing single ingredients in low dosages is aimed at basic medical conditions that do not require hospitalization.

After starting the company in 2008, they consulted pharmaceutical sources to zero in on the drugs and dosages to use. Their “Help, I have a headache” formulation, for example, contains 325 milligrams of acetaminophen per caplet.

“That is less than the amount in an extra strength caplet,” said Mr. Fine. “If you need more, you can take more. But this is what pharmacists recommend.”

By that summer, Help Remedies was distributing its packets in some high-end hotel chains and business conferences. In 2009, the two men quit their jobs and started the company Web site, helpineedhelp.com, which includes a link to drug facts for each product.

To carve a niche in the crowded pharmaceutical market, Mr. Frank, who handles the company’s creative efforts, said he focused on offbeat marketing, including tactile packaging and performance windows, and viral videos that mixed up the serious, the absurd and even the goofy.

For the packaging, Mr. Frank settled on a flat, white, textured box that opens like a tin. Taking a page from product designers like Apple, he settled on a simple font called century schoolbook, in various colors.

The graphic work was originally done by ChappsMalina and Little Fury, design firms in New York, and was since updated by another firm, Pearlfisher.

Help Remedies, a privately held company, did not disclose its advertising spending, which was $400 in 2010 and $12,500 last year, according to figures from Kantar Media, a WPP unit.

With a small budget, the company has focused on spinning out lighthearted solutions to situations — like countering boredom by focusing on a bouncing ball or hangovers by staring at a rag — on its Web site, videos, bus shelters and other advertising and in the store windows of Ricky’s, a New York beauty supply company.

Help Remedies set up “living windows” like “Help, I’ve never been kissed,” with models on hand to give hugs and kisses in Ricky’s storefronts. There were also serious problems like “Help, I want to save a life,” that provided registration kits from the bone marrow donor center DKMS.

To expand, the company is adapting the living window approach to its first pop-up pharmacy, in Washington, which was delayed by Hurricane Sandy and got under way as the election results were unfolding.

In addition to giving “Help, I have a headache” packets to anyone who asked, the store manager, Melinda Welch, and her staff distributed 2,000 packets — for blisters and for body aches — to participants in the annual High Heel Race.

The company’s products are found in major pharmacy outlets like Duane Reade and CVS, as well as Target and Walgreens. Last year, the company reached $4 million in sales and is set to expand after Washington to San Francisco; Seattle; Portland, Ore.; Austin, Tex.; Chicago; and Miami.

As part of its expansion, the Washington store plans to hold a “Help, I am Insecure” event on Saturday with a life coach to provide support and advice, and a manicurist for those insecure about their nails, Ms. Welch said.

Other events at later dates include “Help, I am Lonely,” with an online dating site consultation, and “Help, I’m in an Argument with my Spouse,” with a relationship judge to settle differences.

William G. Daddi, the president of Daddi Brand Communications, said Help Remedies’s distinct packaging was well suited to compete in the crowded health and beauty market.

But he warned that tying so many products to whimsical marketing carried risks because “there will be consumer confusion and the remedies will be seen as novelty products.”

“To build a true brand, the consumer needs to see that the product is effective,” Mr. Daddi said. “There needs to be a link to tangible outcomes so people see that the product works.”

Read More..

Your Money: After the Storm: Managing Your Homeowner’s Claim

Tom Mihalek/Reuters

Mark Baronowski shoveled sand from the living room of a beach front property in Bay Head, N.J., last week. Many victims of Hurricane Sandy are novices when it comes to catastrophic insurance claims.

There is a sort of honeymoon period that occurs after a big storm like Hurricane Sandy, when insurance executives appear on the local news offering reassuring words. Their brightly painted vans pull into residential neighborhoods amid the standing water and debris. Everyone is hopeful. Handshakes and back-patting all around.

That period is about to end. Prices for roofers and construction materials will rise, disadvantageous parsing of policy language will commence and gangs of class-action lawyers will round up aggrieved clients who still have months of homelessness ahead of them. Many claims will take years to settle.

It happens every time, and so it will with this storm. That’s not to say that a majority of people with insurance claims won’t be satisfied with the check they receive or won’t get one quickly.

But when this many people have extensive damage to their most significant asset, billions of dollars are at stake for the companies that have the power to make them whole. So there is no reason for policyholders to be anything but wary until their own big check clears.

Many victims of Hurricane Sandy are novices when it comes to catastrophic insurance claims. So to see what sort of resistance they should expect shortly, I turned to the lawyers and adjusters-for-hire who do nothing but negotiate with insurance companies all day long. Some of them used to work for the companies, in fact.

Here are the things they warn people to watch out for:

THAT INDEPENDENT ADJUSTER Many people with damaged homes have started to meet with representatives who assessed their damaged homes to estimate repair costs. They may have introduced themselves as “independent adjusters,” but this is a misnomer. They represent the insurance company and are not neutral.

In storms like this, large numbers of these freelance claims adjusters parachute in from out of town. In the industry, they are known as storm troopers. They work 18-hour days for a while since no insurance company has enough of its own full-time staff to deploy after a storm like this one. Often, they make enough money not to work for months afterward.

“These guys have a lot of work to do, and it’s a thankless job,” said Matthew Tennenbaum, who used to be an independent adjuster but switched sides and now works for policyholders as a “public” adjuster in Cherry Hill, N.J.

Mr. Tennenbaum worries about the storm troopers’ thoroughness. “They’re going to see 10 properties a day and they’re quickly writing estimates,” he said. “If they spend an extra three or four hours properly writing one estimate, they could have written three more and made more money.”

Though many of them are former builders or contractors, they may not, if time is of the essence, always pull up every floor, explore every inch of the attic or look behind every wall. And they may not know much about your insurance company’s policy.

“The insurance companies hand them a manual, and they may not really understand the manual,” said J. Robert Hunter, the director of insurance for the Consumer Federation of America, who has worked for insurance companies and once ran the federal flood insurance program.  “It’s a crash course at that point.”

  The good news here is that these are not the people who make the final call on your claim. But many policyholders assume that their word is the final word.

WIND VERSUS FLOOD Back at headquarters, other adjusters have their eye on an exclusion that will be crucial for this storm, with its horrific storm surges but relatively mild winds: homeowner’s insurance generally does not cover floods.

Unfortunately, many people do not know this and many more have not purchased or renewed policies with the federal flood insurance program that covers up to $250,000 of flood damage. Researchers from the Wharton Risk Management and Decision Processes Center, working with colleagues at Florida State, the University of Miami and Columbia University, surveyed people in the storm’s path by telephone three days before it hit.

Among people within a block of a body of water, 46 percent had no flood insurance. In areas that had been evacuated in past storms or where the authorities advised people to leave, 58 percent did not have it. Moreover, 39 percent of all the people who thought they did have flood coverage mistakenly believed that their homeowner’s insurance covered it.

People without coverage but lots of damage from the storm surge might do one of a couple of things. A few stubborn ones will sue, arguing that if the wind drove the surge then it’s not really a flood. Judges haven’t taken kindly to this line of reasoning over the years, but that probably won’t keep people from trying again. The Federal Emergency Management Agency may also offer some assistance.

Read More..

A Transfer of Power Begins in China

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DealBook: Priceline.com Agrees to Buy Kayak for $1.8 Billion

Just months after going public, Kayak Software has been snapped up by a rival.

On Thursday,Priceline.com, a travel company from an earlier Internet age, announced that it would buy Kayak, its younger competitor, for $1.8 billion.

Under the terms of the cash-and-stock deal, Priceline agreed to pay $40 a share. The price represents a 29 percent premium over Kayak’s closing price of $31 a share on Thursday.

“We’re excited to join the world’s premier online travel company,” Steve Hafner, Kayak’s chief executive, said in a statement.

Kayak announced the deal as it reported earnings on Thursday.

The company said it generated revenue of $78.6 million in the third quarter, an increase of 29 percent from the period a year earlier. Its net income rose 14 percent to $8 million.

Kayak’s stock has risen since its I.P.O. in July, in which its shares were priced at $26 apiece. The company had a long journey to the public markets, after initially filing to go public in 2010.

“Kayak has built a strong brand in online travel research and their track record of profitable growth is demonstrative of their popularity with consumers and value to advertisers,” Jeffery H. Boyd, Priceline’s chief executive, said in a statement. “We believe we can be helpful with Kayak’s plans to build a global online travel brand.”

Read More..

Doctor and Patient: Comparative Effectiveness Studies Lack Impact

“Comparative effectiveness” studies, which compare one treatment for a particular illness against another to determine which works better, have received a lot of attention and billions of dollars in federal support in the last few years. But when I mentioned comparative effectiveness research recently to a colleague who I know is particularly interested in treatments and the clinical trials behind them, he let out a loud snort and guffaw before I even finished saying the words.

“It’s a great idea, but it’s not real life,” he said, regaining his composure. “Or at least not the real life of a lot of doctors and patients.”

To explain, he described a newly published study on treating children who are thought to have swallowed a small foreign object, like a coin or a toy. He reeled off a long list of laboratory tests, scans, scopes and X-rays that the researchers recommended for such cases, adding, “Those experts assume that everyone lives near big medical centers like theirs, but not all of my patients do. And what are we going to do if the insurance company doesn’t approve of all the tests we order?”

It took only a cursory review of comparative effectiveness research over the last decade for me to realize that my colleague was right. Despite many useful and even potentially cost-saving findings, many of them failed to change doctors’ practice and patient care.

Now a group of researchers has offered a cogent analysis in the journal Health Affairs to explain this failure. And they have done so using methods about as different from comparative effectiveness as research can be.

The researchers talked to more than 50 doctors, patient advocates and other health care experts, each of whom had created, conducted or evaluated comparative effectiveness research or helped introduce the findings into clinical practice. During the interviews, they referred to trials of blood pressure medications, spine surgery, antipsychotic drugs, a heart rhythm device, heart catheterizations and bone marrow transplantation, and then asked why some of these studies seemed to inspire enduring changes while others did not.

A handful of factors came up again and again. Those interviewed frequently referred to the fact that many of these studies did not address the actual needs of practicing clinicians and patients. For instance, one study of medications for treating psychosis focused on the differences in efficacy among the drugs, but mental health care providers really wanted to know about differences in safety.

Sometimes, too, a study’s conclusions required such a significant shift in thinking that doctors and patients had difficulty adjusting to the change, like the recent recommendations against using measures of the prostate-specific antigen, or PSA, as a screening test for cancer. Other times, the findings were so nuanced or ambiguous, with such complicated restrictions on what worked best when, that they simply were not incorporated into professional guidelines or recommendations.

But perhaps the most common reason for these studies’ failures came down to dollars. In the current health care system, clinicians are rewarded for doing and ordering more. Pharmaceutical and medical device firms reap fortunes from physicians’ orders, and a single change could cost them billions. Studies that endorse anything less than another expensive procedure or a newer and more expensive medication or the latest device are often destined for failure or a protracted struggle against drug and device companies that are willing to put up a costly fight.

“The incentives are all out of whack,” said Justin W. Timbie, the lead author and a health policy researcher at the RAND Corporation in Arlington, Va. “The current system favors treatments that are well paid, not necessarily those that are most effective.”

For example, one study found that generic diuretic pills that cost pennies a day worked better for patients with high blood pressure than newer drugs that could be as much as 20 times as expensive. Because hypertension affects tens of millions of Americans, this finding had the potential to save the health care system billions of dollars.

But the finding never really took hold; the percentage of patients taking the cheaper diuretics barely increased. Physicians had a difficult time changing their prescribing habits; limited funding prevented researchers from widely disseminating the results; and pharmaceutical companies waged an aggressive marketing campaign that included paying health care experts to speak about the study in a way that made their expensive drugs seem better.

Based on their findings from these interviews, Dr. Timbie and his fellow investigators offer several suggestions that may improve the impact of these studies. These include realigning financial incentives to support recommended changes in practice; incorporating a broad range of perspectives, like those of practicing doctors and patients, in the design, goals and interpretation of such studies; and, above all, proceeding with a clear strategy for all future comparative effectiveness research.

Despite the challenges, the researchers remain optimistic about the future. And for good reason. Their study was initiated by policy makers and financed by the federal office responsible for health care policy coordination and planning. And representatives from the new national organization, the Patient-Centered Outcomes Research Institute, whose mission is to develop and oversee such studies, have reviewed and discussed the suggestions with Dr. Timbie and the other authors of the study.

“The track record to now has not been great, but for the first time, comparative effectiveness research is a priority for the country,” Dr. Timbie said. “The whole process of generating new evidence has a degree of governance that has never existed before.”

“It’s all about impact now,” he added.

Read More..

Doctor and Patient: Comparative Effectiveness Studies Lack Impact

“Comparative effectiveness” studies, which compare one treatment for a particular illness against another to determine which works better, have received a lot of attention and billions of dollars in federal support in the last few years. But when I mentioned comparative effectiveness research recently to a colleague who I know is particularly interested in treatments and the clinical trials behind them, he let out a loud snort and guffaw before I even finished saying the words.

“It’s a great idea, but it’s not real life,” he said, regaining his composure. “Or at least not the real life of a lot of doctors and patients.”

To explain, he described a newly published study on treating children who are thought to have swallowed a small foreign object, like a coin or a toy. He reeled off a long list of laboratory tests, scans, scopes and X-rays that the researchers recommended for such cases, adding, “Those experts assume that everyone lives near big medical centers like theirs, but not all of my patients do. And what are we going to do if the insurance company doesn’t approve of all the tests we order?”

It took only a cursory review of comparative effectiveness research over the last decade for me to realize that my colleague was right. Despite many useful and even potentially cost-saving findings, many of them failed to change doctors’ practice and patient care.

Now a group of researchers has offered a cogent analysis in the journal Health Affairs to explain this failure. And they have done so using methods about as different from comparative effectiveness as research can be.

The researchers talked to more than 50 doctors, patient advocates and other health care experts, each of whom had created, conducted or evaluated comparative effectiveness research or helped introduce the findings into clinical practice. During the interviews, they referred to trials of blood pressure medications, spine surgery, antipsychotic drugs, a heart rhythm device, heart catheterizations and bone marrow transplantation, and then asked why some of these studies seemed to inspire enduring changes while others did not.

A handful of factors came up again and again. Those interviewed frequently referred to the fact that many of these studies did not address the actual needs of practicing clinicians and patients. For instance, one study of medications for treating psychosis focused on the differences in efficacy among the drugs, but mental health care providers really wanted to know about differences in safety.

Sometimes, too, a study’s conclusions required such a significant shift in thinking that doctors and patients had difficulty adjusting to the change, like the recent recommendations against using measures of the prostate-specific antigen, or PSA, as a screening test for cancer. Other times, the findings were so nuanced or ambiguous, with such complicated restrictions on what worked best when, that they simply were not incorporated into professional guidelines or recommendations.

But perhaps the most common reason for these studies’ failures came down to dollars. In the current health care system, clinicians are rewarded for doing and ordering more. Pharmaceutical and medical device firms reap fortunes from physicians’ orders, and a single change could cost them billions. Studies that endorse anything less than another expensive procedure or a newer and more expensive medication or the latest device are often destined for failure or a protracted struggle against drug and device companies that are willing to put up a costly fight.

“The incentives are all out of whack,” said Justin W. Timbie, the lead author and a health policy researcher at the RAND Corporation in Arlington, Va. “The current system favors treatments that are well paid, not necessarily those that are most effective.”

For example, one study found that generic diuretic pills that cost pennies a day worked better for patients with high blood pressure than newer drugs that could be as much as 20 times as expensive. Because hypertension affects tens of millions of Americans, this finding had the potential to save the health care system billions of dollars.

But the finding never really took hold; the percentage of patients taking the cheaper diuretics barely increased. Physicians had a difficult time changing their prescribing habits; limited funding prevented researchers from widely disseminating the results; and pharmaceutical companies waged an aggressive marketing campaign that included paying health care experts to speak about the study in a way that made their expensive drugs seem better.

Based on their findings from these interviews, Dr. Timbie and his fellow investigators offer several suggestions that may improve the impact of these studies. These include realigning financial incentives to support recommended changes in practice; incorporating a broad range of perspectives, like those of practicing doctors and patients, in the design, goals and interpretation of such studies; and, above all, proceeding with a clear strategy for all future comparative effectiveness research.

Despite the challenges, the researchers remain optimistic about the future. And for good reason. Their study was initiated by policy makers and financed by the federal office responsible for health care policy coordination and planning. And representatives from the new national organization, the Patient-Centered Outcomes Research Institute, whose mission is to develop and oversee such studies, have reviewed and discussed the suggestions with Dr. Timbie and the other authors of the study.

“The track record to now has not been great, but for the first time, comparative effectiveness research is a priority for the country,” Dr. Timbie said. “The whole process of generating new evidence has a degree of governance that has never existed before.”

“It’s all about impact now,” he added.

Read More..

News Analysis: For Obama, Housing Policy Presents Second-Term Headaches

A second-term president may be just the person to tackle America’s housing problems.

When President Obama first came into office, home prices were crashing, foreclosures were soaring and the previous Bush administration had just initiated the bailout of Fannie Mae and Freddie Mac, the government-backed entities that agree to repay mortgages if the original borrower defaults.

With the market in shambles in 2009, the Obama administration pursued a tentative housing policy, for the most part avoiding big moves that might have further weakened the housing market or banks. Eventually, there were some bolder initiatives, like the national mortgage settlement with big banks as well as the Treasury Department’s aid programs for homeowners.

But as President Obama’s first administration comes to an end, the government is still deeply embedded in the mortgage market. In the third quarter, various government entities backstopped 92 percent of all new residential mortgages, according to Inside Mortgage Finance, a publication that focuses on the home loan industry.

Mr. Obama’s economic team has consistently said it wants the housing market to work without significant government support. But it has taken few actual steps to advance that idea.

“I think Obama is absolutely committed to reducing the government’s role,” said Thomas Lawler, a former chief economist at Fannie Mae and founder of Lawler Economic and Housing Consulting, an industry analysis firm. “But no one’s yet found a format to do that.”

Housing policy is hard to tackle because so many people have benefited from the status quo. The entire real estate system — the banks, the agents, the home buyers — all depend on a market that provides fixed-rate, 30-year mortgages that can be easily refinanced when interest rates drop. That sort of loan is rare outside of the United States. And any effort to overhaul housing and the mortgage market could eventually reduce the amount of such mortgages in the country, angering many and creating a political firestorm.

In other words, the best person to fundamentally change how housing works may be a president who won’t be running for office again.

Most immediately, the housing market has to be strong enough to deal with a government pullback. Some analysts think it’s ready. “I think the housing recovery is far enough along that they can start winding down Fannie and Freddie,” said Phillip L. Swagel at the University of Maryland’s School of Public Policy, who served as assistant secretary for economic policy under Treasury Secretary Henry M. Paulson Jr.

The administration can take smaller steps first. Mr. Lawler, the housing economist, thinks the government could start to reduce the maximum amount that it will guarantee for Fannie and Freddie loans. In some areas, like parts of the Northeast and California, it is as high as $625,000. Before the financial crisis, it was essentially capped at $417,000.

The big question is whether the private sector — banks and investors that buy bonds backed with mortgages — will pick up the slack when the government eases out of the market. If they don’t, the supply of mortgages could fall and house prices could weaken.

Banks say their appetite depends on how new rules for mortgages turn out. In setting such regulations, some tough choices have to be made.

The new rules will effectively map the riskiness of various types of mortgages. In determining that, regulators will look at the features of the loans and the borrowers’ income. Banks say they are unlikely to hold loans deemed risky, and their lobbyists are pressing for legal protection on the safer ones, called qualified mortgages.

The temptation will be to make the definition of what constitutes a qualified mortgage as broad as possible, to ensure that the banks lend to a wide range of borrowers. But regulators concerned with the health of the banks won’t want a system that incentivizes institutions to make potentially risky loans.

One set of qualified mortgage regulations, being written by the Consumer Financial Protection Bureau, could be completed as early as January. Other regulators, like the Federal Reserve, are expected to take longer in finishing their mortgage rules.

Resolving the conflict between mortgage availability and bank strength may depend on the person who replaces Timothy F. Geithner as Treasury secretary. Mr. Geithner is stepping down at the end of Mr. Obama’s first term.

The Obama administration faces other daunting decisions.

One is how to deal with the considerable number of troubled mortgages still in the financial system. Banks might be reluctant to make new loans until they have a better idea of the losses on the old loans. “If you don’t ever deal with these problems, you may never get to where you want to go,” said Mr. Lawler, the housing economist.

To help tackle that issue, the new administration might decide to make its mortgage relief programs more aggressive. It might even aim for more loan modifications, writing down the value of the mortgages to make them easier to pay. The Federal Housing Finance Agency, the regulator that oversees Fannie Mae and Freddie Mac, has effectively blocked such write-downs on the vast amount of loans those entities have guaranteed.

A new Obama administration may move to change the agency’s stance on write-downs, perhaps by replacing its acting director, Edward DeMarco. If that happened, it would be a sign that the White House had a taste for more radical housing actions. The agency declined to comment.

Then there’s what to do with the Federal Housing Administration, another government entity that has backstopped a huge amount of mortgages since the financial crisis. The housing administration was set up to focus on lower-income borrowers, and it backs loans that have very low down payments. Its share of the market has grown since the crisis. The F.H.A. accounted for 13 percent of the market in the third quarter, according to Inside Mortgage Finance.

The new administration has to decide whether it wants the F.H.A. to continue doing as much business. The risk is that a big pullback by the F.H.A. could reduce the availability of mortgages to lower-income borrowers. Banks almost certainly won’t want to write loans with minuscule down payments since they are considered riskier.

Ultimately, housing policy comes down to one question: Which borrowers should get the most subsidies?

Right now, the government largess encompasses a wide swath of borrowers. But most analysts believe government support should be focused on lower-income borrowers.

“We will know that the Obama administration is serious about housing finance reform when it comes up with a proposal for affordable housing,” said Mr. Swagel, the University of Maryland professor.

Read More..

Obama’s Other ‘Cliff’ Is in Foreign Policy

For all the talk of a “fiscal cliff” threatening the nation’s finances, President Obama also faces a foreign policy cliff of sorts, with a welter of national security issues that he put on the back burner during the campaign now clamoring for his attention.

Atop that list, administration officials and foreign policy experts say, is the bloody civil war in Syria and the standoff with Iran over its nuclear program. The United States is likely to engage the Iranian government in direct negotiations over the next few months, in perhaps a last-ditch diplomatic effort to head off a military strike on its nuclear facilities.

Administration officials said that they had not set a date for talks and that they did not know if Iran’s supreme leader, Ayatollah Ali Khamenei, would give his blessing. But with Iran’s uranium centrifuges spinning and Israel threatening its own military action, the need to avoid a war may make this high-risk diplomatic effort Mr. Obama’s No. 1 priority.

Syria, too, will demand a pressing response, given the high human toll of the violence and the danger of a spreading regional conflict. Mr. Obama, however, remains leery of being dragged into the conflict, rejecting calls to supply weapons to rebel groups. His reluctance has been partly political, experts say, but he also has strategic qualms.

“At a time when he was running on a platform of ending wars in the Middle East, he did not want to be seen as starting one,” said Martin S. Indyk, a former American ambassador to Israel.

“But if he doesn’t try to intervene in a way that gives him a way to shape a post-Assad regime on the ground,” Mr. Indyk continued, referring to the Syrian president, Bashar al-Assad, “there’s a high risk of descent into chaos in Syria, and a sectarian war that spreads to Lebanon, Bahrain and eventually Saudi Arabia.”

Beyond those flash points, the president will have to grapple with Pakistan, an unstable nuclear state whose relationship with Washington has eroded during his presidency. And he will have to oversee an orderly exit from Afghanistan, where the waning American role threatens to throw the country back into chaos and Islamic militancy.

As he does so, some question whether he will rethink his administration’s heavy reliance on drone strikes to kill people suspected of being extremists, a policy that has proved lethally efficient but has sown deep resentment in Pakistan and Afghanistan.

More broadly, Mr. Obama will face Russia under the aggressive leadership of President Vladimir V. Putin and China with the opposite problem — negotiating a tumultuous change in power after a scandal that tainted the top ranks of its Communist leadership.

None of these problems are new, but many were effectively shelved over the past year as the president waged a bitter re-election battle dominated by his stewardship of the economy. Foreign policy played such a bit part in the election that even in the debate ostensibly devoted to it, Mr. Obama and Mitt Romney detoured into a discussion of high school test scores in Massachusetts.

For reasons of history and political reality, a re-elected Mr. Obama is likely to devote more time to foreign affairs. From Richard M. Nixon to Bill Clinton, presidents have tended to make their bid for statesman status in their second terms. The prospect of continuing gridlock — with the Republicans still controlling the House — gives Mr. Obama all the more reason to favor diplomacy over domestic legislation.

There is also some unfinished business from the past four years, not least Mr. Obama’s frustrated efforts to broker a peace agreement between Israel and the Palestinians. But several experts cast doubt on whether the president would throw himself into the role of Middle East peacemaker, as Mr. Clinton did in his second term.

The Israeli prime minister, Benjamin Netanyahu, who has had a fraught relationship with Mr. Obama, faces his own voters early next year, but he seems likely to stay in power with a right-wing government. Such an arrangement could make peacemaking difficult.

“Because he got his fingers burned and was outmaneuvered by Netanyahu, he will wait to see the outcome in the Israeli election,” said Mr. Indyk, who wrote a book about Mr. Obama’s foreign policy, “Bending History.” He added that the president is “going to think long and hard about trying again.”

The added wrinkle for the United States: the Palestinian Authority is likely to petition for nonstate membership in the United Nations next month, a step it had put off until after the election. If the United Nations were to grant it, that would trigger Congress to cut off aid not only to the Palestinian Authority but also to the United Nations itself.

The mere fact of Mr. Obama’s victory does not ease these problems. But as the president himself famously said to Russia’s former president, Dmitri A. Medvedev, at a nuclear conference in South Korea, he may have more room to maneuver in dealing with them.

Ask foreign policy experts for wild cards in a second Obama term and two countries come up: India and Cuba. Little progress was made in opening the door to Havana during the past four years, but hope springs eternal for those who advocate an end to the half-century-old trade embargo. Mr. Obama also is likely to build on his ties to India.

India figures into the biggest geopolitical bet of Mr. Obama’s presidency: the American pivot from the Middle East to China and Asia. With four more years, experts said, Mr. Obama can put meat on the bones of an ambitious, but incomplete, policy.

Here, however, is where the fiscal cliff meets foreign policy. To be credible in reasserting an American presence in Asia, experts said, will require a robust military presence from the Yellow Sea to the South China Sea. But unless the White House and Congress can strike some kind of fiscal deal, the Pentagon will face deep automatic cuts in its budget, depriving it of the ability to project power as it once did.

For Mr. Obama to realize his grandest visions abroad, then, he will still have to work with the same House Republicans who thwarted him on the home front in his first term.

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Massive Open Online Courses Are Multiplying at a Rapid Pace

Clockwise, from top left: an online course in circuits and electronics with an M.I.T. professor (edX); statistics, Stanford (Udacity); machine learning, Stanford (Coursera); organic chemistry, University of Illinois, Urbana (Coursera).

IN late September, as workers applied joint compound to new office walls, hoodie-clad colleagues who had just met were working together on deadline. Film editors, code-writing interns and “edX fellows” — grad students and postdocs versed in online education — were translating videotaped lectures into MOOCs, or massive open online courses. As if anyone needed reminding, a row of aqua Post-its gave the dates the courses would “go live.”

The paint is barely dry, yet edX, the nonprofit start-up from Harvard and the Massachusetts Institute of Technology, has 370,000 students this fall in its first official courses. That’s nothing. Coursera, founded just last January, has reached more than 1.7 million — growing “faster than Facebook,” boasts Andrew Ng, on leave from Stanford to run his for-profit MOOC provider.

“This has caught all of us by surprise,” says David Stavens, who formed a company called Udacity with Sebastian Thrun and Michael Sokolsky after more than 150,000 signed up for Dr. Thrun’s “Introduction to Artificial Intelligence” last fall, starting the revolution that has higher education gasping. A year ago, he marvels, “we were three guys in Sebastian’s living room and now we have 40 employees full time.”

“I like to call this the year of disruption,” says Anant Agarwal, president of edX, “and the year is not over yet.”

MOOCs have been around for a few years as collaborative techie learning events, but this is the year everyone wants in. Elite universities are partnering with Coursera at a furious pace. It now offers courses from 33 of the biggest names in postsecondary education, including Princeton, Brown, Columbia and Duke. In September, Google unleashed a MOOC-building online tool, and Stanford unveiled Class2Go with two courses.

Nick McKeown is teaching one of them, on computer networking, with Philip Levis (the one with a shock of magenta hair in the introductory video). Dr. McKeown sums up the energy of this grand experiment when he gushes, “We’re both very excited.” Casually draped over auditorium seats, the professors also acknowledge that they are not exactly sure how this MOOC stuff works.

“We are just going to see how this goes over the next few weeks,” says Dr. McKeown.

WHAT IS A MOOC ANYWAY?

Traditional online courses charge tuition, carry credit and limit enrollment to a few dozen to ensure interaction with instructors. The MOOC, on the other hand, is usually free, credit-less and, well, massive.

Because anyone with an Internet connection can enroll, faculty can’t possibly respond to students individually. So the course design — how material is presented and the interactivity — counts for a lot. As do fellow students. Classmates may lean on one another in study groups organized in their towns, in online forums or, the prickly part, for grading work.

The evolving form knits together education, entertainment (think gaming) and social networking. Unlike its antecedent, open courseware — usually written materials or videotapes of lectures that make you feel as if you’re spying on a class from the back of the room — the MOOC is a full course made with you in mind.

The medium is still the lecture. Thanks to Khan Academy’s free archive of snappy instructional videos, MOOC makers have gotten the memo on the benefit of brevity: 8 to 12 minutes is typical. Then — this is key — videos pause perhaps twice for a quiz to make sure you understand the material or, in computer programming, to let you write code. Feedback is electronic. Teaching assistants may monitor discussion boards. There may be homework and a final exam.

The MOOC certainly presents challenges. Can learning be scaled up this much? Grading is imperfect, especially for nontechnical subjects. Cheating is a reality. “We found groups of 20 people in a course submitting identical homework,” says David Patterson, a professor at the University of California, Berkeley, who teaches software engineering, in a tone of disbelief at such blatant copying; Udacity and edX now offer proctored exams.

Some students are also ill prepared for the university-level work. And few stick with it. “Signing up for a class is a lightweight process,” says Dr. Ng. It might take just five minutes, assuming you spend two devising a stylish user name. Only 46,000 attempted the first assignment in Dr. Ng’s course on machine learning last fall. In the end, he says, 13,000 completed the class and earned a certificate — from him, not Stanford.

Laura Pappano is author of “Inside School Turnarounds” and writer in residence at the Wellesley Centers for Women.

This article has been revised to reflect the following correction:

Correction: November 4, 2012

An earlier version of this article, using information from Coursera, misidentified the source of a study of peer grading in a Princeton sociology MOOC. The study is by Mitchell Duneier, the course’s teacher, not Coursera. Also, the student work was regraded by Professor Duneier and his assistants, not by Princeton instructors. Results have not been released. Also, the article misspelled the surname of a Udacity co-founder. He is Michael Sokolsky, not Sokolosky.

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A Collective Effort to Save Decades of Research at N.Y.U.

The calls started coming in late on Tuesday and early Wednesday: offers of dry ice, freezer space, coolers. By the end of Thursday there were dozens more: A researcher at Weill Cornell Medical College would clear 1,000 tanks to save threatened zebra fish; another, at Cold Spring Harbor Laboratory, promised to replace some genetically altered mice that were lost; and a doctor at the Children’s Hospital of Philadelphia even offered take over entire experiments, to keep them going.

As hurricane-driven waters surged into New York University research buildings in Kips Bay, on the East Side of Manhattan, investigators in New York and around the world jumped on the phone to offer assistance — executing a reverse Noah’s ark operation, to rescue lab animals and other assets from a flooding vessel.

“I’ve had 43 people who have offered to help so far, and some of them are direct competitors,” said Gordon Fishell, associate director of the N.Y.U. Neuroscience Institute, who lost more than 5,000 genetically altered mice when storm waters surged the night of Oct. 30, cutting off power. “It’s just been unbelievable,” he said. “It really buoys my spirits and my lab’s.”

Staff members at N.Y.U. worked around the clock to preserve research materials, running in and out of darkened buildings without elevator service, hauling dry ice and other supplies up anywhere from 2 to more than 15 floors.

The university’s medical center also got instant help, from almost every major research institution in the area.

The response reflects large shifts in the way that science is conducted over the past generation or so. Individual labs always compete to be first, but researchers increasingly share materials that are enormously expensive and time-consuming to reproduce. The loss of a single cell line or genetically altered animal can slow progress for years in some areas of biomedical research.

“We are totally dependent on each other in the life sciences now, for a very large number of cell lines and extracts, research animals and unique chemical tools and antibodies that might not have backup copies anywhere in the world, or in very few places,” said Dr. Steven Hyman, director of the Stanley Center for Psychiatric Research at the Broad Institute of M.I.T. and Harvard. “Losing any of these tools tears a significant hole in the entire field.”

Danny Reinberg, a professor of biochemistry at N.Y.U.’s medical school, has studied genetics for 30 years, accumulating valuable mice strains and stocks of extracts from cell nuclei that would be extremely difficult to replace. The extracts must be stored at minus 112 degrees Fahrenheit.

Dr. Reinberg said he lost all of his mice: nine strains, including more than 1,000 animals that died in the storm surge. But he managed to save all of the cell extracts by moving some containers into freezers at N.Y.U. labs that weren’t affected and others to the Rockefeller, Columbia and Cornell medical centers, each of which cleared space, he said.

“We were able to save many things; it was just phenomenal to get that kind of help,” said Dr. Reinberg, whose house in New Jersey has had no power.

“Later in the week, at a Starbucks, I could finally download all my e-mail, and there were messages from people at the University of Pennsylvania and the Howard Hughes Medical Institute, asking how they could help us re-establish the mouse lines we lost,” he said.

Some scientists have become interdependent because their students, who develop a specialty in specific tissues or animals, often move among labs. Research projects sometimes draw on experiments or analyses the students worked on at more than one place.

One researcher working in Dr. Fishell’s lab was formerly a student of Dr. Stewart Anderson of the Children’s Hospital of Philadelphia, who sent Dr. Fishell a text message on Wednesday to offer help. “I told him that even if it costs money, we’re happy to keep experiments rolling, if we’re able to,” Dr. Anderson said.

By late Thursday, freezer space in minus-112-degree units was extremely tight in the city. So was dry ice.

Susan Zolla-Pazner, director of AIDS research at the Manhattan Veterans Affairs Medical Center, had lost power in her 18th-floor lab in the department’s building at 23rd Street and First Avenue. She finally hired a company to haul her 20 freezers-full of specimens, for safekeeping.

“We spent all of Tuesday and Wednesday hauling 1,300 pounds of dry ice up to the 18th floor, using the stairs, to stabilize the freezers first,” said Dr. Zolla-Pazner, who is also a professor of pathology at N.Y.U. School of Medicine. “And the dry ice people would only take cash. I have about 25 to 30 people working for me, and everyone was out there on 23rd Street, reaching into their pockets to get what we needed. It was a herculean and heroic effort on the part of everyone here, and that is the story that needs to be told.”

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