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.”

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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.

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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.”

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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.

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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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