Undecided Syrians Could Tip Balance of Rebellion





BEIRUT, Lebanon — At his government office in the Syrian capital, Damascus, the civil servant avoids discussing what Syrians call “the situation.” But he quietly ponders his own private endgame, toying with defecting to the rebels, yet clinging to his post, increasingly sure there are no fighters worth joining.




A multilingual former military officer, he says he is among many friends and colleagues who feel trapped: disenchanted with President Bashar al-Assad, disgusted by the violence engulfing Syria and equally afraid of the government and the rebels, with both sides, as he puts it, ready to sacrifice “the innocents.”


Mr. Assad remains in power in part because two years into the uprising, a critical bloc of Syrians remains on the fence. Among them are business owners who drive the economy, bankers who finance it, and the security officials and government employees who hold the keys to the mundane but crucial business of maintaining an authoritarian state. If they abandoned the government or embraced the rebels en masse, they might change the tide. Instead, their uncertainty contributes to the stalemate.


The Egyptian and Tunisian rebellions that inspired Syria’s initially peaceful uprising reached tipping points within weeks, with far less bloodshed. In those cases, widespread desire for change overwhelmed the fear of the unknown, and toppled governments — or rather, the dictatorial cliques that headed them. But in Syria, each side has bloodied the other while many stay on the sidelines, and a core contingent of supporters feels obligated to stick with the government even as their doubts grow. That is in part because the government’s ruthless crackdown has made protest far more risky than in other uprisings. But it is also because of doubts, among the urban elite and others, about the direction of the revolution and how a rebel-ruled Syria would look.


“Me and my neighbors, we were the first to go down to the street and scream that we want a country, a real country, not a plantation,” said Samar Haddad, who runs a Syrian publishing house. “But this armed revolution, I refuse it as much as I refuse the regime.”


Ms. Haddad, who is in her late 40s and now spends much of her time outside Damascus, said that she and her circle of intellectuals and professionals embrace unarmed Syrian protesters as heroes, but believe that the armed rebellion is creating warlords and cycles of revenge that will be hard to uproot.


The fence sitters include government employees, security forces, intellectuals and wealthy Syrians. Some, including members of Mr. Assad’s minority Alawite sect, say they fear the rule of Islamists, or the calls for vengeance from some factions of the Sunni Muslim-dominated uprising.


Some are former soldiers who say they defected only to be disappointed by rebels who lack discipline or obsess about religious ideology. One young man, Nour, said he gave up on revolution when he tried to join an Islamist brigade, Al Tawhid, but was rejected for wearing skinny jeans.


Others, like the Damascus civil servant, a Sunni, simply fear a post-Assad vacuum and are confused about the safest course for their families and the country.


Fewer and fewer Syrians appear to believe the government can restore order; the fraying of the country has become hard to miss. This has resulted in countless private debates over how to survive — amid growing alarm that without a political settlement or intervention, endless fighting will gut the Syrian state.


For those who support neither Mr. Assad nor his opponents, life has become a fearful wait.


In Damascus, little gets done in offices that tremble with explosions and empty out by dusk. Government salaries are still paid, the civil servant said, but fewer workers show up. Ms. Haddad said her publishing employees still come to work, in what has become an act of defiance to show that life goes on.


Many people express a wish for a political solution — perhaps a transitional government involving moderate government officials — but believe that decisions are being made by armed men on both sides who refuse to compromise.


“Both sides have the same mind,” said Abu Tony, a shopkeeper in central Damascus who favors a compromise and gave only a nickname for safety reasons.


“This is not life,” he said, “to spend half of the day without electricity, without heating oil and without even bread just because the two sides refuse to give up some of their demands.”


Ms. Haddad said she and like-minded friends were trying quietly to build civil society. But she said: “We feel depressed, useless, helpless. We are not the decision makers.”


Even as some Alawites grow frustrated with Mr. Assad — believing he has poisoned their future in Syria — many believe there is no safe place for them on the other side. In part for this reason, there have not been mass defections by senior Alawite military officers.


But even Sunni soldiers under strong pressure to defect sometimes feel that “we can’t offer them much,” said one rebel commander based in the northern province of Idlib.


He said many were in touch with colleagues who defected earlier, who recount months without salaries, and the humiliation of former colonels commanded by junior fighters with swollen egos.


One such disappointed defector is Nour, who said he served in the feared Fourth Division commanded by Mr. Assad’s brother Maher. He said he defected after security forces raped and killed his fiancée and many friends begged him to join the rebels.


But he was let down, first by fighters who drank and took drugs and offered him money for sexual acts; then by Al Tawhid Brigade, whose fighters, he said, taunted him, saying “You want to join us and you’re wearing skinny trousers?” He said he had decided to stay in Turkey and avoid both sides in the conflict.


The Damascus civil servant and would-be defector — who has talked for months about defecting, first to rebels from his hometown and then to a reporter — said he hesitates over many questions about the rebels and their plans: “Are the people aware enough? Can they practice self-control? Can the rebels set up a security zone?”


“Many questions need answers,” he said.


The government, he added, long ago stopped forcing him to attend pro-Assad demonstrations, but rebel supporters call him a traitor for asking questions.


“Why should I join a group where I am obliged to curtsy?”


An employee of The New York Times contributed reporting from Damascus, Syria, and Hania Mourtada from Beirut.



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Europe Likely to Be Harder on Google Over Search





PARIS — By some accounts, the United States let Google off the hook when it found that the technology giant had not abused its dominance in the Internet search market.







Yves Logghe/Associated Press

Joaquín Almunia has vowed to restore competition to the Internet search business in Europe.






Few expect the European antitrust watchdog to be as lenient.


The Federal Trade Commission ruled on Thursday that Google had not broken antitrust laws, after a 19-month inquiry into how it operated its search engine. But the European Commission, which is pursuing claims that the company rigs results to favor its own businesses, operates under a different standard.


The agreement with the American authorities, analysts and competition lawyers say, is unlikely to alter the demands of European regulators, led by the competition commissioner, Joaquín Almunia.


“We have taken note of the F.T.C. decision, but we don’t see that it has any direct implications for our investigation, for our discussions with Google, which are ongoing,” said Michael Jennings, a spokesman for the European Commission in Brussels.


Faced with nearly $4 billion in possible penalties and restrictions on its business in Europe, Google submitted proposals in July to remedy the concerns of the European Commission, which covered four areas. In its deal with the F.T.C., Google made concessions in two of those areas but was not required to do so in the rest.


A Google spokesman, Al Verney, declined to comment on the content of the company’s proposals to Mr. Almunia but said the company would “continue to work cooperatively with the European Commission.”


The Google case underscores a basic difference between the approaches to monopoly power in Europe and the United States. American antitrust regulators tend to focus on whether a company’s dominance harms consumers; the European system seeks to keep competitors in the market. Mr. Almunia has vowed to restore competition to the Internet search business in Europe.


“History shows that competition law is applied to monopoly power more stringently in the E.U. than in the U.S.,” said Jacques Lafitte, head of the competition practice at Avisa Partners, a consultancy in Brussels, who brought one of the original complaints against Google. “Whether the E.U. is right or not is a different question.”


Mr. Lafitte has some expertise in the matter. He is the former head of corporate affairs at Microsoft Europe and watched as that company did battle with regulators over its dominant computer operating system. Microsoft won a lenient settlement with the Justice Department in October 2001, he said, only to be slapped with nearly 1.6 billion euros, or $2.1 billion, in fines and penalties from the European Union from 2004 to 2008.


Google learned from Microsoft’s mistakes. It worked with authorities in both the United States and Europe to reach a deal rather than fight a desperate legal action. That approach appears to have paid off: last month, after a meeting with Eric E. Schmidt, Google’s executive chairman, Mr. Almunia said that the sides had “substantially reduced our differences.”


In its deal with the F.T.C., Google agreed to make concessions in two areas that concerned European regulators. In one, it will allow rivals to opt out of allowing Google to “scrape,” or copy, text from their sites. Google will probably offer the same concession to European authorities.


But in a second area of European concern — whether Google deliberately favors its own content in search results — the F.T.C. did not require changes.


Mr. Almunia has also demanded that Google put fewer restrictions on advertising distribution deals, an area his American counterparts did not explore.


The company will make a detailed set of proposed remedies in January. The European Commission will then allow the complainants to review them in a period of what is known as “market testing.” Antitrust lawyers say a final denouement could arrive by spring, depending on how hostile Google’s rivals are to the proposed remedies.


FairSearch, an alliance of Google rivals, accused the F.T.C. of rushing its decision. It said in a statement that closing the F.T.C. investigation “with only voluntary commitments from Google is disappointing and premature.”


The outcome in Europe may also be affected by Google’s dominance there. Google’s share of the United States search market was 67 percent in November, according to comScore, a digital analytics company, while its share in Europe was 83 percent that month.


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Scare Amplifies Fears That Clinton’s Work Has Taken Heavy Toll


Pool photo by Brendan Smialowski


Hillary Rodham Clinton with Field Marshal Mohamed Hussein Tantawi in Cairo in July.







WASHINGTON — When Secretary of State Hillary Rodham Clinton fractured her right elbow after slipping in a State Department garage in June 2009, she returned to work in just a few days. Her arm in a sling, she juggled speeches and a trip to India and Thailand with physical therapy, rebuilding a joint held together with wire and pins.




It was vivid evidence of Mrs. Clinton’s indomitable stamina and work ethic — as a first lady, senator, presidential candidate and, for the past four years, the most widely traveled secretary of state in American history.


But after a fall at home in December that caused a concussion, and a subsequent diagnosis of a blood clot in her head, it has taken much longer for Mrs. Clinton to bounce back. She was released from a hospital in New York on Wednesday, accompanied by her daughter, Chelsea, and her husband, former President Bill Clinton. On Thursday, she told colleagues that she hoped to be in the office next week.


Her health scare, though, has reinforced the concerns of friends and colleagues that the years of punishing work and travel have taken a heavy toll. Even among her peers at the highest levels of government, Mrs. Clinton, 65, is renowned for her grueling schedule. Over the past four years, she was on the road for 401 days and spent the equivalent of 87 full days on a plane, according to the State Department’s Web site.


In one 48-hour marathon in 2009 that her aides still talk about, she traveled from talks with Palestinian leaders in Abu Dhabi to a midnight meeting with Prime Minister Benjamin Netanyahu in Jerusalem, then boarded a plane for Morocco, staying up all night to work on other issues, before going straight to a meeting of Arab leaders the next morning.


“So many people who know her have urged me to tell her not to work so hard,” said Melanne S. Verveer, who was Mrs. Clinton’s chief of staff when she was first lady and is now the State Department’s ambassador at large for women’s issues. “Well, that’s not easy to do when you’re Hillary Clinton. She doesn’t spare herself.”


It is not just a matter of duty, Ms. Verveer and others said. Mrs. Clinton genuinely relishes the work, pursuing a brand of personal diplomacy that, she argues, requires her to travel to more places than her predecessors.


While there is no medical evidence that Mrs. Clinton’s clot was caused by her herculean work habits, her cascade of recent health problems, beginning with a stomach virus, has prompted those who know her best to say that she desperately needs a long rest. Her first order of business after leaving the State Department in the coming weeks, they say, should be to take care of herself.


Some even wonder whether this setback will — or should — temper the feverish speculation that she will make another run for the White House in 2016.


“I am amazed at the number of women who come up to me and tell me she must run for president,” said Ellen Chesler, a New York author and a friend of Mrs. Clinton’s. “But perhaps this episode will alter things a bit.”


Given Mrs. Clinton’s enduring status as a role model, Ms. Chesler said women would be watching which path she decides to take, as they plan their own transitions out of the working world.


“Do remember that women of our generation are really the first to have worked through the life cycle in large numbers,” she added. “Many seem to be approaching retirement with dread.”


For now, aides say, Mrs. Clinton’s focus is on wrapping up her work at the State Department. She would like to take part in a town hall-style meeting, thank her staff and sit for some interviews. But first she has to get clearance from her doctors, who are watching her to make sure that the blood thinners they have prescribed for her clot are working.


Speaking to a meeting of a foreign policy advisory board from her home in Chappaqua, N.Y., on Thursday, Mrs. Clinton said she was crossing her fingers and encouraging her doctors to let her return next week. “I’m trying to be a compliant patient,” she said, according to a person who was in the room. “But that does require a certain level of patience, which I’ve had to cultivate over the last three and a half weeks.”


While convalescing, Mrs. Clinton has spoken with President Obama and has held a 30-minute call with Senator John Kerry, Democrat of Massachusetts, whom Mr. Obama nominated as her successor.


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Scare Amplifies Fears That Clinton’s Work Has Taken Heavy Toll


Pool photo by Brendan Smialowski


Hillary Rodham Clinton with Field Marshal Mohamed Hussein Tantawi in Cairo in July.







WASHINGTON — When Secretary of State Hillary Rodham Clinton fractured her right elbow after slipping in a State Department garage in June 2009, she returned to work in just a few days. Her arm in a sling, she juggled speeches and a trip to India and Thailand with physical therapy, rebuilding a joint held together with wire and pins.




It was vivid evidence of Mrs. Clinton’s indomitable stamina and work ethic — as a first lady, senator, presidential candidate and, for the past four years, the most widely traveled secretary of state in American history.


But after a fall at home in December that caused a concussion, and a subsequent diagnosis of a blood clot in her head, it has taken much longer for Mrs. Clinton to bounce back. She was released from a hospital in New York on Wednesday, accompanied by her daughter, Chelsea, and her husband, former President Bill Clinton. On Thursday, she told colleagues that she hoped to be in the office next week.


Her health scare, though, has reinforced the concerns of friends and colleagues that the years of punishing work and travel have taken a heavy toll. Even among her peers at the highest levels of government, Mrs. Clinton, 65, is renowned for her grueling schedule. Over the past four years, she was on the road for 401 days and spent the equivalent of 87 full days on a plane, according to the State Department’s Web site.


In one 48-hour marathon in 2009 that her aides still talk about, she traveled from talks with Palestinian leaders in Abu Dhabi to a midnight meeting with Prime Minister Benjamin Netanyahu in Jerusalem, then boarded a plane for Morocco, staying up all night to work on other issues, before going straight to a meeting of Arab leaders the next morning.


“So many people who know her have urged me to tell her not to work so hard,” said Melanne S. Verveer, who was Mrs. Clinton’s chief of staff when she was first lady and is now the State Department’s ambassador at large for women’s issues. “Well, that’s not easy to do when you’re Hillary Clinton. She doesn’t spare herself.”


It is not just a matter of duty, Ms. Verveer and others said. Mrs. Clinton genuinely relishes the work, pursuing a brand of personal diplomacy that, she argues, requires her to travel to more places than her predecessors.


While there is no medical evidence that Mrs. Clinton’s clot was caused by her herculean work habits, her cascade of recent health problems, beginning with a stomach virus, has prompted those who know her best to say that she desperately needs a long rest. Her first order of business after leaving the State Department in the coming weeks, they say, should be to take care of herself.


Some even wonder whether this setback will — or should — temper the feverish speculation that she will make another run for the White House in 2016.


“I am amazed at the number of women who come up to me and tell me she must run for president,” said Ellen Chesler, a New York author and a friend of Mrs. Clinton’s. “But perhaps this episode will alter things a bit.”


Given Mrs. Clinton’s enduring status as a role model, Ms. Chesler said women would be watching which path she decides to take, as they plan their own transitions out of the working world.


“Do remember that women of our generation are really the first to have worked through the life cycle in large numbers,” she added. “Many seem to be approaching retirement with dread.”


For now, aides say, Mrs. Clinton’s focus is on wrapping up her work at the State Department. She would like to take part in a town hall-style meeting, thank her staff and sit for some interviews. But first she has to get clearance from her doctors, who are watching her to make sure that the blood thinners they have prescribed for her clot are working.


Speaking to a meeting of a foreign policy advisory board from her home in Chappaqua, N.Y., on Thursday, Mrs. Clinton said she was crossing her fingers and encouraging her doctors to let her return next week. “I’m trying to be a compliant patient,” she said, according to a person who was in the room. “But that does require a certain level of patience, which I’ve had to cultivate over the last three and a half weeks.”


While convalescing, Mrs. Clinton has spoken with President Obama and has held a 30-minute call with Senator John Kerry, Democrat of Massachusetts, whom Mr. Obama nominated as her successor.


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After Fiscal Deal, Tax Code May Be Most Progressive Since 1979





WASHINGTON — With 2013 bringing tax increases on the incomes of a small sliver of the richest Americans, the country’s top earners now face a heavier tax burden than at any time since Jimmy Carter was president.




The last-minute deal struck by the departing 112th Congress raised taxes on a handful of the highest-earning Americans, with about 99.3 percent of households experiencing no change in their income taxes. But the Tax Policy Center estimates that the average family in the top 1 percent will pay a federal tax rate of more than 36 percent this year, up from 28 percent in 2008. That is the highest rate since 1979, at least.


By some measures, the tax code might now be the most progressive in a generation, tax economists said, while noting that every American is paying a lower burden currently than they did then. In fact, the total federal tax rate is still vastly lower for the very rich than it was at any point in the 1940s through 1970s. It has risen from historical lows, but is still closer to those lows than where it was in the postwar decades.


“We made the system more progressive by raising rates at the top and leaving them for everyone else,” said Roberton Williams of the Tax Policy Center, a research group based in Washington. “The offsetting issue is that the rich have gotten a lot richer.”


Indeed, over the last three decades the bulk of pretax income gains have gone to the wealthy — and the higher up on the income scale, the bigger the gains, with billionaires outpacing millionaires who outpaced the merely rich. Economists doubted that the tax increases would do much to reverse that trend.


With the recovery failing to improve incomes for millions of average Americans and the country running trillion-dollar deficits, President Obama made “tax fairness” a centerpiece of his re-election campaign. In the heated negotiations with House Speaker John A. Boehner, that translated into the White House’s insistence on tax increases for the top 2 percent of households and a continuation of tax breaks and cuts for a vast number of taxpayers.


Republicans resisted increasing tax rates and aimed for lower revenue targets, arguing that spending was the budget’s primary problem and that no American should see his or her taxes go up too much in such a sluggish economy. But ultimately they relented, and Congress cut a last-minute deal.


“A central promise of my campaign for president was to change the tax code that was too skewed towards the wealthy at the expense of working middle-class Americans,” Mr. Obama said after Congress reached an agreement.


That deal includes a host of tax increases on the rich. It raises the tax rate to 39.6 percent from 35 percent on income above $400,000 for individuals, and $450,000 for couples. The rate on dividends and capital gains for those same taxpayers was bumped up 5 percentage points, to 20 percent. Congress also reinstated limits on the amount households with more than $300,000 in income can deduct. On top of that, two new surcharges — a 3.8 percent tax on investment income and a 0.9 percent tax on regular income — hit those same wealthy households.


As a result of the taxes added in both the deal and the 2010 health care law, which came into effect this year, taxpayers with $1 million in income and up will pay on average $168,000 more in taxes. Millionaires’ share of the overall federal tax burden will climb to 23 percent from 20 percent.


The result is a tax code that squeezes hundreds of billions of dollars more from the very well off — about $600 billion more over 10 years — while leaving the tax burden on everyone else mostly as it was. And the changes come after 30 years of both Republican and Democratic administrations doing the converse: zeroing out federal income taxes for many poor working families while also reducing the tax burden for households on the higher end of the income scale.


“Back at the end of the Carter and beginning of the Reagan administrations, we had a pretty severe income-tax burden for people at a low level of income. It was actually kind of appalling,” said Alan D. Viard, a tax expert at the American Enterprise Institute, a right-of-center research group in Washington. “Policy makers in both parties realized that was bad policy and started whittling away at it” by expanding credits and tinkering with tax rates.


After those changes and the new law, comparing average tax rates for poor households and wealthy households, 2013 might be the most progressive tax code since 1979. But economists cautioned that measuring progressivity is tricky. “It’s not like there is some scientific measure of progressivity all economists agreed upon,” said Leonard E. Burman, a professor of public affairs at Syracuse University. “People look at different numerical measures and they’ve changed in different ways at different income levels.”


Mr. Viard said that over time the code had become markedly more progressive for the poor compared with the middle class. But it arguably did not become much more progressive for the rich compared with the middle class, or the very rich compared with the rich, in part because of the George W. Bush-era tax cuts on investment income.


An anesthesiologist who earns a $500,000 salary subject to payroll and income taxes might pay a higher tax rate than a hedge fund manager making $1 billion subject mostly to capital-gains taxes, for instance.


Economists are also divided on the ultimate effect of those tax increases on the wealthy to income growth and income inequality in the United States. The recession hit the incomes of the rich hard, but they have snapped back much more strongly than those for middle or low-income workers.


“I’d still rather be really rich, even if I’m getting taxed much more than a low-income person” would be, Mr. Williams of the Tax Policy Center added.


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Letter from Europe: A Struggle With Identity and Racism







PARIS — What do bananas have to do with national identity?




A lot, if you consider the bananas hurled at black soccer players in different parts of Europe, igniting outrage among international players and feeble calls for tolerance by coaches.


When racist behavior is exhibited by individuals, it can be written off — not excused — as random, individual acts of hooliganism. In northern Italy this past week, the Milan soccer team walked off the field after fans of the opposing team yelled abuse at black teammates. But when the verbal equivalent appears in a manifesto published by a powerful fan club, the crude clash between “them” and “us” falls squarely in the middle of a recurring debate about national identity that makes Europe feel like a continent under siege.


In fact, it came as no surprise when Landscrona, the biggest fan club of the Zenit soccer team in St. Petersburg, recently published an open letter saying it would not accept dark-skinned players being “all but forced down Zenit’s throat.” St. Petersburg fans have long been accused of preventing club managers from signing up black players, a fact that the letter confirmed in writing: “For us, the absence of black Zenit players is an important tradition that underlines the team’s identity and nothing more,” it said.


There it is, “identity,” a word that gets flashed like a red card as people struggle to determine what it means to be French, Belgian, British or Russian in an era of large-scale immigration, and economic globalization.


The problem is that this debate typically turns defensive, with identity defined in narrow, exclusive terms. The issue may be a reflection of a popular uneasiness over waves of new arrivals from abroad, but the terms of the discussion are rarely about integration, or tolerance.


In France, then-President Nicolas Sarkozy started a febrile — and largely futile — debate on the state of the nation’s identity in 2009. It was a flop right from the start as critics questioned the usefulness of any discussion set in motion by a presidential decree.


Soon afterward, and not coincidentally, the government started another national debate, this one about the role of Islam in France. The main result was a law banning face coverings — including Muslim veils like the niqab and the burqa — in public places. Whatever the merits of the law, it was hardly a rallying call for the country’s largely Muslim immigrant population, which was ostensibly the target of the double-barreled exercise.


Similar attempts to define and affirm the Russian national identity have slid either toward irrelevance, or toward a dangerous kind of ethnic-center nationalism, with slogans like “Russia for Russians. ”


In 2005, Russia resurrected an old holiday on Nov. 4, called Day of National Unity, which falls on the anniversary of the expulsion of the Poles from Moscow in 1612. The day is marked by a hodgepodge of demonstrations, brandishing a variety of symbols from Orthodox icons to the Soviet hammer and sickle.


It is hard to see how these demonstrations speak to a country made up of more than 100 ethnic groups, including Muslim Tatars and Chechens, as well as Buddhist Buryats.


Both the French debate and the Russian holiday make no attempt to appeal to recent immigrants who need help in identifying with their adopted nation. The instinct to hit history’s “replay” button — revisiting the glories of Alexander Nevsky, or Napoleon — may help educate the new arrivals about the past, but it doesn’t give them the tools they need to become modern citizens.


Immigration has changed the face of many European countries over the past half-century. In France, the new arrivals — mostly from former colonies — have put a strain on the old model of integration that worked so well with immigrants from Italy, Spain and Eastern Europe. Since the collapse of the Soviet Union, Russia, too, has seen waves of workers coming from Central Asia, whose presence, legal and illegal, has stirred latent strains of xenophobia.


These tensions give a backdrop to the racist screed of soccer fans in St. Petersburg. It is all the more jarring in a city that was founded as Russia’s “window on Europe,” where leaders of the French Enlightenment were invited to the court of Catherine the Great and that was home to Russia’s most beloved national poet, Alexander Pushkin, whose grandfather was a black man from Africa.


Landscrona fans don’t seem to care about passports, just race. Of the two dark-skinned players whose arrival seems to have incited the manifesto, one, Axel Witsel, is Belgian with a French father who comes from the Caribbean island of Martinique.


Their demands are weirdly specific, directly contradicting the explicit denial of racism. “We only want players from other brotherly Slav nations such as Ukraine and Belarus, as well as from the Baltic states and Scandinavia,” the manifesto read, which blithely ignored the origins of Dick Advocaat, the Dutchman who coached the team to victory in Russian championships in 2007, and Luciano Spalletti, an Italian who is now the Zenit coach.


In his response to the fans, published on the team’s Web site, Spalletti ignored the implicit insult. “Being tolerant means that you fight against any kind of stupidity,” he wrote.


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Google’s Lawyers Work Behind the Scenes to Carry the Day





SAN FRANCISCO — For 19 months, Google pressed its case with antitrust regulators investigating the company. Working relentlessly behind the scenes, executives made frequent flights to Washington, laying out their legal arguments and shrewdly applying lessons learned from Microsoft’s bruising antitrust battle in the 1990s.




After regulators had pored over nine million documents, listened to complaints from disgruntled competitors and took sworn testimony from Google executives, the government concluded that the law was on Google’s side. At the end of the day, they said, consumers had been largely unharmed.


That is why one of the biggest antitrust investigations of an American company in years ended with a slap on the wrist Thursday, when the Federal Trade Commission closed its investigation of Google’s search practices without bringing a complaint. Google voluntarily made two minor concessions.


“The way they managed to escape it is through a barrage of not only political officials but also academics aligned against doing very much in this particular case,” said Herbert Hovenkamp, a professor of antitrust law at the University of Iowa who has worked as a paid adviser to Google in the past. “The first sign of a bad antitrust case is lack of consumer harm, and there just was not any consumer harm emerging in this very long investigation.”


The F.T.C. had put serious effort into its investigation of Google. Jon Leibowitz, the agency’s chairman, has long advocated for the commission to flex its muscle as an enforcer of antitrust laws, and the commission had hired high-powered consultants, including Beth A. Wilkinson, an experienced litigator, and Richard J. Gilbert, a well-known economist.


Still, Mr. Leibowitz said during a news conference announcing the result of the inquiry, the evidence showed that Google “doesn’t violate American antitrust laws.”


“The conclusion is clear: Google’s services are good for users and good for competition,” David Drummond, Google’s chief legal officer, wrote in a company blog post.


The main thrust of the investigation was into how Google’s search results had changed since it expanded into new search verticals, like local business listings and comparison shopping. A search for pizza or jeans, for instance, now shows results with photos and maps from Google’s own local business service and its shopping product more prominently than links to other Web sites, which has enraged competing sites.


But while the F.T.C. said that Google’s actions might have hurt individual competitors, over all it found that the search engine helped consumers, as evidenced by Google users’ clicking on the products that Google highlighted and competing search engines’ adopting similar approaches.


Google outlined these kinds of arguments to regulators in many meetings over the last two years, as it has intensified its courtship of Washington, with Google executives at the highest levels, as well as lawyers, lobbyists and engineers appearing in the capital.


One of the arguments they made, according to people briefed on the discussions, was that technology is such a fast-moving industry that regulatory burdens would hinder its evolution. Google makes about 500 changes to its search algorithm each year, so results look different now than they did even six months ago.


The definition of competition in the tech industry is also different and constantly changing, Google argued.


For instance, just recently Amazon and Apple, which used to be in different businesses than Google, have become its competitors. Google’s share of the search market has stayed at about two-thirds even though competing search engines are “just a click away,” as the company repeatedly argued. That would become the company’s mantra to demonstrate that it was not abusing its market power.


Claire Cain Miller reported from San Francisco, and Nick Wingfield from Seattle.



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Scant Proof Is Found to Back Up Claims by Energy Drinks





Energy drinks are the fastest-growing part of the beverage industry, with sales in the United States reaching more than $10 billion in 2012 — more than Americans spent on iced tea or sports beverages like Gatorade.




Their rising popularity represents a generational shift in what people drink, and reflects a successful campaign to convince consumers, particularly teenagers, that the drinks provide a mental and physical edge.


The drinks are now under scrutiny by the Food and Drug Administration after reports of deaths and serious injuries that may be linked to their high caffeine levels. But however that review ends, one thing is clear, interviews with researchers and a review of scientific studies show: the energy drink industry is based on a brew of ingredients that, apart from caffeine, have little, if any benefit for consumers.


“If you had a cup of coffee you are going to affect metabolism in the same way,” said Dr. Robert W. Pettitt, an associate professor at Minnesota State University in Mankato, who has studied the drinks.


Energy drink companies have promoted their products not as caffeine-fueled concoctions but as specially engineered blends that provide something more. For example, producers claim that “Red Bull gives you wings,” that Rockstar Energy is “scientifically formulated” and Monster Energy is a “killer energy brew.” Representative Edward J. Markey of Massachusetts, a Democrat, has asked the government to investigate the industry’s marketing claims.


Promoting a message beyond caffeine has enabled the beverage makers to charge premium prices. A 16-ounce energy drink that sells for $2.99 a can contains about the same amount of caffeine as a tablet of NoDoz that costs 30 cents. Even Starbucks coffee is cheap by comparison; a 12-ounce cup that costs $1.85 has even more caffeine.


As with earlier elixirs, a dearth of evidence underlies such claims. Only a few human studies of energy drinks or the ingredients in them have been performed and they point to a similar conclusion, researchers say — that the beverages are mainly about caffeine.


Caffeine is called the world’s most widely used drug. A stimulant, it increases alertness, awareness and, if taken at the right time, improves athletic performance, studies show. Energy drink users feel its kick faster because the beverages are typically swallowed quickly or are sold as concentrates.


“These are caffeine delivery systems,” said Dr. Roland Griffiths, a researcher at Johns Hopkins University who has studied energy drinks. “They don’t want to say this is equivalent to a NoDoz because that is not a very sexy sales message.”


A scientist at the University of Wisconsin became puzzled as he researched an ingredient used in energy drinks like Red Bull, 5-Hour Energy and Monster Energy. The researcher, Dr. Craig A. Goodman, could not find any trials in humans of the additive, a substance with the tongue-twisting name of glucuronolactone that is related to glucose, a sugar. But Dr. Goodman, who had studied other energy drink ingredients, eventually found two 40-year-old studies from Japan that had examined it.


In the experiments, scientists injected large doses of the substance into laboratory rats. Afterward, the rats swam better. “I have no idea what it does in energy drinks,” Dr. Goodman said.


Energy drink manufacturers say it is their proprietary formulas, rather than specific ingredients, that provide users with physical and mental benefits. But that has not prevented them from implying otherwise.


Consider the case of taurine, an additive used in most energy products.


On its Web site, the producer of Red Bull, for example, states that “more than 2,500 reports have been published about taurine and its physiological effects,” including acting as a “detoxifying agent.” In addition, that company, Red Bull of Austria, points to a 2009 safety study by a European regulatory group that gave it a clean bill of health.


But Red Bull’s Web site does not mention reports by that same group, the European Food Safety Authority, which concluded that claims about the benefits in energy drinks lacked scientific support. Based on those findings, the European Commission has refused to approve claims that taurine helps maintain mental function and heart health and reduces muscle fatigue.


Taurine, an amino acidlike substance that got its name because it was first found in the bile of bulls, does play a role in bodily functions, and recent research suggests it might help prevent heart attacks in women with high cholesterol. However, most people get more than adequate amounts from foods like meat, experts said. And researchers added that those with heart problems who may need supplements would find far better sources than energy drinks.


Hiroko Tabuchi contributed reporting from Tokyo and Poypiti Amatatham from Bangkok.



Read More..

Scant Proof Is Found to Back Up Claims by Energy Drinks





Energy drinks are the fastest-growing part of the beverage industry, with sales in the United States reaching more than $10 billion in 2012 — more than Americans spent on iced tea or sports beverages like Gatorade.




Their rising popularity represents a generational shift in what people drink, and reflects a successful campaign to convince consumers, particularly teenagers, that the drinks provide a mental and physical edge.


The drinks are now under scrutiny by the Food and Drug Administration after reports of deaths and serious injuries that may be linked to their high caffeine levels. But however that review ends, one thing is clear, interviews with researchers and a review of scientific studies show: the energy drink industry is based on a brew of ingredients that, apart from caffeine, have little, if any benefit for consumers.


“If you had a cup of coffee you are going to affect metabolism in the same way,” said Dr. Robert W. Pettitt, an associate professor at Minnesota State University in Mankato, who has studied the drinks.


Energy drink companies have promoted their products not as caffeine-fueled concoctions but as specially engineered blends that provide something more. For example, producers claim that “Red Bull gives you wings,” that Rockstar Energy is “scientifically formulated” and Monster Energy is a “killer energy brew.” Representative Edward J. Markey of Massachusetts, a Democrat, has asked the government to investigate the industry’s marketing claims.


Promoting a message beyond caffeine has enabled the beverage makers to charge premium prices. A 16-ounce energy drink that sells for $2.99 a can contains about the same amount of caffeine as a tablet of NoDoz that costs 30 cents. Even Starbucks coffee is cheap by comparison; a 12-ounce cup that costs $1.85 has even more caffeine.


As with earlier elixirs, a dearth of evidence underlies such claims. Only a few human studies of energy drinks or the ingredients in them have been performed and they point to a similar conclusion, researchers say — that the beverages are mainly about caffeine.


Caffeine is called the world’s most widely used drug. A stimulant, it increases alertness, awareness and, if taken at the right time, improves athletic performance, studies show. Energy drink users feel its kick faster because the beverages are typically swallowed quickly or are sold as concentrates.


“These are caffeine delivery systems,” said Dr. Roland Griffiths, a researcher at Johns Hopkins University who has studied energy drinks. “They don’t want to say this is equivalent to a NoDoz because that is not a very sexy sales message.”


A scientist at the University of Wisconsin became puzzled as he researched an ingredient used in energy drinks like Red Bull, 5-Hour Energy and Monster Energy. The researcher, Dr. Craig A. Goodman, could not find any trials in humans of the additive, a substance with the tongue-twisting name of glucuronolactone that is related to glucose, a sugar. But Dr. Goodman, who had studied other energy drink ingredients, eventually found two 40-year-old studies from Japan that had examined it.


In the experiments, scientists injected large doses of the substance into laboratory rats. Afterward, the rats swam better. “I have no idea what it does in energy drinks,” Dr. Goodman said.


Energy drink manufacturers say it is their proprietary formulas, rather than specific ingredients, that provide users with physical and mental benefits. But that has not prevented them from implying otherwise.


Consider the case of taurine, an additive used in most energy products.


On its Web site, the producer of Red Bull, for example, states that “more than 2,500 reports have been published about taurine and its physiological effects,” including acting as a “detoxifying agent.” In addition, that company, Red Bull of Austria, points to a 2009 safety study by a European regulatory group that gave it a clean bill of health.


But Red Bull’s Web site does not mention reports by that same group, the European Food Safety Authority, which concluded that claims about the benefits in energy drinks lacked scientific support. Based on those findings, the European Commission has refused to approve claims that taurine helps maintain mental function and heart health and reduces muscle fatigue.


Taurine, an amino acidlike substance that got its name because it was first found in the bile of bulls, does play a role in bodily functions, and recent research suggests it might help prevent heart attacks in women with high cholesterol. However, most people get more than adequate amounts from foods like meat, experts said. And researchers added that those with heart problems who may need supplements would find far better sources than energy drinks.


Hiroko Tabuchi contributed reporting from Tokyo and Poypiti Amatatham from Bangkok.



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Google’s Lawyers Work Behind the Scenes to Carry the Day





SAN FRANCISCO — For 19 months, Google pressed its case with antitrust regulators investigating the company. Working relentlessly behind the scenes, executives made frequent flights to Washington, laying out their legal arguments and shrewdly applying lessons learned from Microsoft’s bruising antitrust battle in the 1990s.




After regulators had pored over nine million documents, listened to complaints from disgruntled competitors and took sworn testimony from Google executives, the government concluded that the law was on Google’s side. At the end of the day, they said, consumers had been largely unharmed.


That is why one of the biggest antitrust investigations of an American company in years ended with a slap on the wrist Thursday, when the Federal Trade Commission closed its investigation of Google’s search practices without bringing a complaint. Google voluntarily made two minor concessions.


“The way they managed to escape it is through a barrage of not only political officials but also academics aligned against doing very much in this particular case,” said Herbert Hovenkamp, a professor of antitrust law at the University of Iowa who has worked as a paid adviser to Google in the past. “The first sign of a bad antitrust case is lack of consumer harm, and there just was not any consumer harm emerging in this very long investigation.”


The F.T.C. had put serious effort into its investigation of Google. Jon Leibowitz, the agency’s chairman, has long advocated for the commission to flex its muscle as an enforcer of antitrust laws, and the commission had hired high-powered consultants, including Beth A. Wilkinson, an experienced litigator, and Richard J. Gilbert, a well-known economist.


Still, Mr. Leibowitz said during a news conference announcing the result of the inquiry, the evidence showed that Google “doesn’t violate American antitrust laws.”


“The conclusion is clear: Google’s services are good for users and good for competition,” David Drummond, Google’s chief legal officer, wrote in a company blog post.


The main thrust of the investigation was into how Google’s search results had changed since it expanded into new search verticals, like local business listings and comparison shopping. A search for pizza or jeans, for instance, now shows results with photos and maps from Google’s own local business service and its shopping product more prominently than links to other Web sites, which has enraged competing sites.


But while the F.T.C. said that Google’s actions might have hurt individual competitors, over all it found that the search engine helped consumers, as evidenced by Google users’ clicking on the products that Google highlighted and competing search engines’ adopting similar approaches.


Google outlined these kinds of arguments to regulators in many meetings over the last two years, as it has intensified its courtship of Washington, with Google executives at the highest levels, as well as lawyers, lobbyists and engineers appearing in the capital.


One of the arguments they made, according to people briefed on the discussions, was that technology is such a fast-moving industry that regulatory burdens would hinder its evolution. Google makes about 500 changes to its search algorithm each year, so results look different now than they did even six months ago.


The definition of competition in the tech industry is also different and constantly changing, Google argued.


For instance, just recently Amazon and Apple, which used to be in different businesses than Google, have become its competitors. Google’s share of the search market has stayed at about two-thirds even though competing search engines are “just a click away,” as the company repeatedly argued. That would become the company’s mantra to demonstrate that it was not abusing its market power.


Claire Cain Miller reported from San Francisco, and Nick Wingfield from Seattle.



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Murder Charges Expected Against 5 Men in New Delhi Gang Rape





NEW DELHI – Rape, murder and other charges were filed on Thursday against five men suspected of carrying out the brutal gang rape and murder of a 23-year-old physiotherapy student in a case that has sparked outrage and protests across India.







Sajjad Hussain/Agence France-Presse — Getty Images

Indian lawyers protested on Thursday outside a court in New Delhi where charges were filed in a gang rape case.







The police submitted the accusations against the five men to a magistrate in the South Delhi neighborhood where the crime took place on Dec. 16. In addition to rape and murder, the charges were expected to include kidnapping, robbery and assault, a list of crimes that could result in the rare imposition of the death penalty. The official submission of the charges was expected to be kept secret because of confidential details, the police said. A sixth person accused in the case is a juvenile, and his case will be handled in a separate proceeding. The magistrate was expected to refer the case to a fast-track court set up in recent days to handle cases involving crimes against women. That court is expected to hold a trial soon in stark contrast to the apathy and years of delay that Indian rape victims often face when seeking justice.


The five are accused of luring the 23-year-old and her boyfriend onto a bus in South Delhi, beating them and abusing her so brutally with a metal rod during the rape that she sustained fatal internal injuries. The woman clung to life for two weeks but died on Saturday in a Singapore hospital, where she had been transferred for special care.


Gang rapes have become almost routine in India, a country that some surveys suggest has one of the highest rates of sexual violence in the world. Rape complaints increased 25 percent between 2006 and 2011, although it is impossible to know whether this represents a real increase in crime or simply an increased willingness by victims to file charges and by the police to accept them.


But something about the recent crime caught the public’s attention. Among the reasons could be the randomness of the crime (most rape victims know their abusers), its brutality and the sympathetic profile of the victim.


The outpouring of anger at the crime caught the government by surprise and there has been widespread criticism of its aggressive response to protesters which included tear gas, water cannons and beatings by truncheon-wielding riot police officers. The government invoked a terrorism law that prohibits even small gatherings and it closed a huge portion of the capital to vehicular and pedestrian traffic, which represented a punishing loss to businesses in the area.


The government’s reaction fed longtime criticism that India’s police are too often used to guard the powerful from the people rather than to protect the people from predators. India’s police are generally poorly trained, deeply corrupt and often viewed by women as predators rather than protectors – one reason that laws forbid officers from arresting a woman or even bringing her to a police station for questioning during nighttime hours.


The case has also led to an ongoing discussion about the conflict between the aspirations of India’s rising middle class and a deeply conservative and patriarchal culture that views the recent educational and economic successes of Indian women with unease and even alarm. An estimated 25,000 women are murdered each year by families who view their choice of mate as inappropriate, and Indian newspapers and television news programs now feature almost daily stories about new rape cases.


Kishwar Desai, an author, wrote an opinion article in The Indian Express on Thursday that said the gang rape illustrated to some that “a certain class of men is deeply uncomfortable with women displaying their independence, receiving education and joining the work force. The gang rape becomes a form of subduing the women, collectively, and establishing their male superiority.”


Because of the intense interest sparked by the case, a vast scrum of television cameras and reporters jostled outside of the courthouse for much of the day. And with officials refusing to provide routine information about whether the suspects in the case would arrive at the courthouse, rumors about the day’s events ricocheted around the media like a drop of water on a hot frying pan.


Niharika Mandhana contributed reporting.



This article has been revised to reflect the following correction:

Correction: January 3, 2013

Because of an editing error, an earlier version of this article erroneously reported that the charges had been filed earlier on Thursday.



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Gadgetwise Blog: Protect Your iPhone With a Vision From Australia

Cygnett, an Australian maker of gadget accessories and cases, is strengthening its brand in the United States with a new line of slim-fit cases for the iPhone 5.

Cygnett joined with some visionary artists for the line, called the Icon Art Series, to create some striking looks, including bright graffiti designs by Tats Cru, the Bronx-based muralists, and hypnotic birds by the Australian illustrator Nathan Jurevicius. I was partial to the bold designs by the Australian indigenous artist Ronnie Tjampitjinpa, which gave the cases an out-on-the-edge feel.

The minimalist cases of the Icon line, which cost $30 apiece, snap on an iPhone 5 easily. The hard shell is durable with a soft finish that makes it easy to hold, but it’s slim enough to slide in and out of pockets. The cases do not have much padding, but they offer enough protection to safeguard a phone when it’s dropped, as I did twice with mine.

As with most cases from Cygnett, the Icon cases come with a screen shield kit, which includes a clear screen protector, a microfiber cloth and an installation card. But after several attempts to apply the adhesive screen protector and smooth out the air bubbles with the card, I gave up. Fortunately, the cases also have a slight bezel that protects the screen.

The cases have a small opening for the volume buttons, so small in fact that I had trouble reaching the button with my thumb (a thumbnail works better). The top and bottom are open for easy access to the power button, charging port and speaker.

Cygnett makes other cases that offer better protection, including the WorkMate series, which has a similar heavy-duty polycarbonate shell but adds a shock-absorbing, rubberized silicone lining. The WorkMate cases are indeed rugged, but the Icon cases are more eye-catching.

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The New Old Age Blog: On the Way to Hospice, Surprising Hurdles

I’ve often wondered why more families don’t call hospice when a loved one has a terminal disease — and why people who do call wait so long, often until death is just days away.

Even though more than 40 percent of American deaths now involve hospice care, many families still are trying to shoulder the burden on their own rather than turning to a proven source of help and knowledge. I’ve surmised that the reason is families’ or patients’ unwillingness to acknowledge the prospect of death, or physicians’ inability to say the h-word and refer dying patients to hospice care.

But maybe there’s another reason. A study in the journal Health Affairs recently pointed out that hospices themselves may be turning away patients because of certain restrictive enrollment policies. It’s possible, too, that physicians who know of these policies aren’t referring patients whom the doctors fear wouldn’t qualify.

Surprisingly, this randomized national survey of almost 600 hospice programs represents the first broad inquiry into enrollment practices, though it’s been nearly 30 years since hospice became a Medicare benefit.

Nearly 80 percent of hospice programs, the study found, reported having at least one policy that could restrict access. “It represents a barrier to people who want hospice care but can’t receive it,” said lead author Melissa Aldridge Carlson, a geriatrics and palliative care researcher at the Mount Sinai School of Medicine.

What kind of barriers are we talking about? More than 60 percent of hospices won’t accept a patient on chemotherapy, and more than half won’t take someone relying on intravenous nutrition. Many won’t enroll patients receiving palliative radiation or blood transfusions; a few say no to tube feeding.

This made more sense a couple of decades ago, when Medicare developed the regulations requiring patients to forgo curative treatments when they entered hospice. Hospice patients must have a terminal disease, likely to cause death within six months, so such treatments were presumed futile.

But medicine evolves. Now, Dr. Aldridge Carlson pointed out, the distinction between curative and palliative treatments has grown blurry. “It’s increasingly an artificial dichotomy,” she said. “That’s not the reality for most patients today with end-stage disease.”

Chemotherapy, for instance, is often used to shrink tumors that cause pain; radiation can prevent nausea and vomiting for patients with bowel obstructions. Though neither will cure a terminal cancer, as palliative treatments they can improve quality of life. Blood transfusions can help anemic cancer patients feel better, too, at least for a while.

Why, then, would hospices not accept dying people using these treatments? First, these are expensive to provide. The national average Medicare reimbursement for hospice care is just $140 a day, the study notes, and it’s not adjusted to reflect the cost of more complicated regimens. Besides, hospices worry about running afoul of Medicare regulations and being denied even that inadequate reimbursement.

This probably explains why the researchers found that smaller hospices were more likely than large ones to say no to patients receiving such treatments. “If you’re a small hospice caring for someone with many medical issues and the reimbursement doesn’t even cover the care – and then Medicare comes to take it back – that’s a big hit,” Dr. Aldridge Carlson said. Larger organizations with more patients and bigger budgets can better absorb the costs.

One bright note, though, is that almost 30 percent of the hospices studied offer some kind of open access enrollment without insisting on those prohibitions. Much more common in nonprofit hospices (a pity, because the real growth is in for-profit ones), open access usually means enrolling people who don’t yet meet the Medicare criteria, then converting them to Medicare patients as they become eligible.

At Gilchrist Hospice Care in Baltimore, for instance, patients still using chemotherapy, radiation, transfusions and several other treatments can enter what it calls “expanded care,” sometimes also known as “concurrent care.” (At Gilchrist, however, such patients still must meet the six-month hospice eligibility requirement.)

“If you say, ‘You can’t get blood transfusions any more,’ people say, ‘Why would I go with your program?’” said Regina Bodnar, Gilchrist’s clinical director. The hospice’s concurrent program “is not so either/or.”

People who enter hospice care with palliative treatments usually decide to forgo them anyway when they become less effective or more burdensome, Ms. Bodnar said, but “this allows people to make the transition over time.” As the largest hospice program in Maryland, a nonprofit with generous donors, Gilchrist can afford this more flexible, but expensive, approach.

Could it be the future of hospice? That would require Medicare to make some changes in eligibility and reimbursement practices — a shift that might bolster Medicare’s solvency, too.

“Hospice saves money because it keeps people out of the hospital,” Dr. Aldridge Carlson said. Even more expensive outpatient treatments, like palliative radiation, are less costly than days spent in intensive care. Adjusting policies to allow more patients into hospice might bring costs down.

But as important, it could make the call to hospice a slightly less terrifying prospect and provide more families with the help they need at the end of life. “We need to take down the barriers to hospice care,” Ms. Bodnar said, “and this is one way to do it.”


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

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The New Old Age Blog: On the Way to Hospice, Surprising Hurdles

I’ve often wondered why more families don’t call hospice when a loved one has a terminal disease — and why people who do call wait so long, often until death is just days away.

Even though more than 40 percent of American deaths now involve hospice care, many families still are trying to shoulder the burden on their own rather than turning to a proven source of help and knowledge. I’ve surmised that the reason is families’ or patients’ unwillingness to acknowledge the prospect of death, or physicians’ inability to say the h-word and refer dying patients to hospice care.

But maybe there’s another reason. A study in the journal Health Affairs recently pointed out that hospices themselves may be turning away patients because of certain restrictive enrollment policies. It’s possible, too, that physicians who know of these policies aren’t referring patients whom the doctors fear wouldn’t qualify.

Surprisingly, this randomized national survey of almost 600 hospice programs represents the first broad inquiry into enrollment practices, though it’s been nearly 30 years since hospice became a Medicare benefit.

Nearly 80 percent of hospice programs, the study found, reported having at least one policy that could restrict access. “It represents a barrier to people who want hospice care but can’t receive it,” said lead author Melissa Aldridge Carlson, a geriatrics and palliative care researcher at the Mount Sinai School of Medicine.

What kind of barriers are we talking about? More than 60 percent of hospices won’t accept a patient on chemotherapy, and more than half won’t take someone relying on intravenous nutrition. Many won’t enroll patients receiving palliative radiation or blood transfusions; a few say no to tube feeding.

This made more sense a couple of decades ago, when Medicare developed the regulations requiring patients to forgo curative treatments when they entered hospice. Hospice patients must have a terminal disease, likely to cause death within six months, so such treatments were presumed futile.

But medicine evolves. Now, Dr. Aldridge Carlson pointed out, the distinction between curative and palliative treatments has grown blurry. “It’s increasingly an artificial dichotomy,” she said. “That’s not the reality for most patients today with end-stage disease.”

Chemotherapy, for instance, is often used to shrink tumors that cause pain; radiation can prevent nausea and vomiting for patients with bowel obstructions. Though neither will cure a terminal cancer, as palliative treatments they can improve quality of life. Blood transfusions can help anemic cancer patients feel better, too, at least for a while.

Why, then, would hospices not accept dying people using these treatments? First, these are expensive to provide. The national average Medicare reimbursement for hospice care is just $140 a day, the study notes, and it’s not adjusted to reflect the cost of more complicated regimens. Besides, hospices worry about running afoul of Medicare regulations and being denied even that inadequate reimbursement.

This probably explains why the researchers found that smaller hospices were more likely than large ones to say no to patients receiving such treatments. “If you’re a small hospice caring for someone with many medical issues and the reimbursement doesn’t even cover the care – and then Medicare comes to take it back – that’s a big hit,” Dr. Aldridge Carlson said. Larger organizations with more patients and bigger budgets can better absorb the costs.

One bright note, though, is that almost 30 percent of the hospices studied offer some kind of open access enrollment without insisting on those prohibitions. Much more common in nonprofit hospices (a pity, because the real growth is in for-profit ones), open access usually means enrolling people who don’t yet meet the Medicare criteria, then converting them to Medicare patients as they become eligible.

At Gilchrist Hospice Care in Baltimore, for instance, patients still using chemotherapy, radiation, transfusions and several other treatments can enter what it calls “expanded care,” sometimes also known as “concurrent care.” (At Gilchrist, however, such patients still must meet the six-month hospice eligibility requirement.)

“If you say, ‘You can’t get blood transfusions any more,’ people say, ‘Why would I go with your program?’” said Regina Bodnar, Gilchrist’s clinical director. The hospice’s concurrent program “is not so either/or.”

People who enter hospice care with palliative treatments usually decide to forgo them anyway when they become less effective or more burdensome, Ms. Bodnar said, but “this allows people to make the transition over time.” As the largest hospice program in Maryland, a nonprofit with generous donors, Gilchrist can afford this more flexible, but expensive, approach.

Could it be the future of hospice? That would require Medicare to make some changes in eligibility and reimbursement practices — a shift that might bolster Medicare’s solvency, too.

“Hospice saves money because it keeps people out of the hospital,” Dr. Aldridge Carlson said. Even more expensive outpatient treatments, like palliative radiation, are less costly than days spent in intensive care. Adjusting policies to allow more patients into hospice might bring costs down.

But as important, it could make the call to hospice a slightly less terrifying prospect and provide more families with the help they need at the end of life. “We need to take down the barriers to hospice care,” Ms. Bodnar said, “and this is one way to do it.”


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

Read More..

Used to Hardship, Latvia Accepts Austerity, and Its Pain Eases





RIGA, Latvia — When a credit-fueled economic boom turned to bust in this tiny Baltic nation in 2008, Didzis Krumins, who ran a small architectural company, fired his staff one by one and then shut down the business. He watched in dismay as Latvia’s misery deepened under a harsh austerity drive that scythed wages, jobs and state financing for schools and hospitals.




But instead of taking to the streets to protest the cuts, Mr. Krumins, whose newborn child, in the meantime, needed major surgery, bought a tractor and began hauling wood to heating plants that needed fuel. Then, as Latvia’s economy began to pull out of its nose-dive, he returned to architecture and today employs 15 people — five more than he had before. “We have a different mentality here,” he said.


Latvia, feted by fans of austerity as the country-that-can and an example for countries like Greece that can’t, has provided a rare boost to champions of the proposition that pain pays.


Hardship has long been common here — and still is. But in just four years, the country has gone from the European Union’s worst economic disaster zone to a model of what the International Monetary Fund hails as the healing properties of deep budget cuts. Latvia’s economy, after shriveling by more than 20 percent from its peak, grew by about 5 percent last year, making it the best performer in the 27-nation European Union. Its budget deficit is down sharply and exports are soaring.


“We are here to celebrate your achievements,” Christine Lagarde, the chief of the International Monetary Fund, told a conference in Riga, the capital, this past summer. The fund, which along with the European Union financed a bailout of 7.5 billion euros for the country at the end of 2008, is “proud to have been part of Latvia’s success story,” she said.


When Latvia’s economy first crumbled, it wrestled with many of the same problems faced since by other troubled European nations: a growing hole in government finances, a banking crisis, falling competitiveness and big debts — though most of these were private rather than public as in Greece.


Now its abrupt turn for the better has put a spotlight on a ticklish question for those who look to orthodox economics for a solution to Europe’s wider economic woes: Instead of obeying any universal laws of economic gravity, do different people respond differently to the same forces?


Latvian businessmen applaud the government’s approach but doubt it would work elsewhere.


“Economics is not a science. Most of it is in people’s heads,” said Normunds Bergs, chief executive of SAF Tehnika, a manufacturer that cut management salaries by 30 percent. “Science says that water starts to boil at 100 degrees Celsius; there is no such predictability in economics.”


In Greece and Spain, cuts in salaries, jobs and state services have pushed tempers beyond the boiling point, with angry citizens staging frequent protests and strikes. Britain, Portugal, Italy and also Latvia’s neighbor Lithuania, meanwhile, have bubbled with discontent over austerity.


But in Latvia, where the government laid off a third of its civil servants, slashed wages for the rest and sharply reduced support for hospitals, people mostly accepted the bitter medicine. Prime Minister Valdis Dombrovskis, who presided over the austerity, was re-elected, not thrown out of office, as many of his counterparts elsewhere have been.


The cuts calmed fears on financial markets that the country was about to go bankrupt, and this meant that the government and private companies could again get the loans they needed to stay afloat. At the same time, private businesses followed the government in slashing wages, which made the country’s labor force more competitive by reducing the prices of its goods. As exports grew, companies began to rehire workers.


Economic gains have still left 30.9 percent of Latvia’s population “severely materially deprived,” according to 2011 data released in December by Eurostat, the European Union’s statistics agency, second only to Bulgaria. Unemployment has fallen from more than 20 percent in early 2010, but was still 14.2 percent in the third quarter of 2012, according to Eurostat, and closer to 17 percent if “discouraged workers” are included. This is far below the more than 25 percent jobless rate in Greece and Spain but a serious problem nonetheless.


This article has been revised to reflect the following correction:

Correction: January 2, 2013

An earlier version of this article misstated the amount of a bailout given to Latvia in 2008. It was 7.5 billion euros, not $7.5 billion.



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Gadgetwise Blog: Paper For The Paperless Revolution

It may appear that apps like Evernote are intended to cut down on your use of paper. After all, they let you jot notes, store webpages and contact information, while making all of that data electronically searchable on computers, phones and tablets.

But you wouldn’t recognize them as part of the paperless revolution from the posh notebooks that are being manufactured specifically with such apps in mind.

For one, there is the Evernote Smart Notebook by Moleskine. Ranging in price from $25 to $30, depending on size, these 192- or 240-page books are ruled with subtle dotted lines. The lines are supposed to help Evernote’s “page camera” straighten your notes or drawings. My test notes, when photographed, didn’t seem any straighter than those made on regular paper.

The Moleskines also come with sets of stickers that Evernote recognizes and uses to categorize your notes. For instance, put an airplane sticker on notes about travel, and you can find them under the app’s travel tags. You can also change the headings that go with each sticker to anything you’d like.

The Smart Notebooks entitle users to three months of Evernote’s premium service, which is normally $5 a month.

Evernote isn’t the only digital organizer that recommends a paper product as an accessory. Springpad, a service similar to Evernote, had a promotion in October with Whitelines notepads. Whitelines pads are especially camera friendly because they have a slightly gray background ruled with white lines that are supposed to disappear when scanned. Whitelines has its own app, Whitelines Link, for capturing notes and drawings, but users have not rated the app very highly. You may be better just using the notepaper with Springpad.

To make it all a bit more confusing, Whitelines is also allied with Evernote. When you save your notes in Whitelines Link, a button gives you the option of saving them to Evernote or Dropbox.

The Whitelines notebooks come in a variety of sizes and layouts ranging from a 48-page pocket-size notebook for $4 to an 80-page 8-by-12-inch hardbound book for $35. There is also a $12 shipping charge, because the books are coming from Sweden.

There are also the unallied Dot Grid notebooks from Creative’s Outfitter. Their pages are a field of light gray dots that can be used as a guide like graph paper. A two-pack of 64-page 4-by-6-inch notebooks costs $7 and a 200-page 6-by-8-inch hard cover notebook sells for $17.50.

Of course, no special notebook is required to use any of these apps. A $1.50 spiral-bound from an office supply store will do just fine. You can always preserve your hipster cachet by writing with a fountain pen.

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Scant Proof Is Found to Back Up Claims by Energy Drinks





Energy drinks are the fastest-growing part of the beverage industry, with sales in the United States reaching more than $10 billion in 2012 — more than Americans spent on iced tea or sports beverages like Gatorade.




Their rising popularity represents a generational shift in what people drink, and reflects a successful campaign to convince consumers, particularly teenagers, that the drinks provide a mental and physical edge.


The drinks are now under scrutiny by the Food and Drug Administration after reports of deaths and serious injuries that may be linked to their high caffeine levels. But however that review ends, one thing is clear, interviews with researchers and a review of scientific studies show: the energy drink industry is based on a brew of ingredients that, apart from caffeine, have little, if any benefit for consumers.


“If you had a cup of coffee you are going to affect metabolism in the same way,” said Dr. Robert W. Pettitt, an associate professor at Minnesota State University in Mankato, who has studied the drinks.


Energy drink companies have promoted their products not as caffeine-fueled concoctions but as specially engineered blends that provide something more. For example, producers claim that “Red Bull gives you wings,” that Rockstar Energy is “scientifically formulated” and Monster Energy is a “killer energy brew.” Representative Edward J. Markey of Massachusetts, a Democrat, has asked the government to investigate the industry’s marketing claims.


Promoting a message beyond caffeine has enabled the beverage makers to charge premium prices. A 16-ounce energy drink that sells for $2.99 a can contains about the same amount of caffeine as a tablet of NoDoz that costs 30 cents. Even Starbucks coffee is cheap by comparison; a 12-ounce cup that costs $1.85 has even more caffeine.


As with earlier elixirs, a dearth of evidence underlies such claims. Only a few human studies of energy drinks or the ingredients in them have been performed and they point to a similar conclusion, researchers say — that the beverages are mainly about caffeine.


Caffeine is called the world’s most widely used drug. A stimulant, it increases alertness, awareness and, if taken at the right time, improves athletic performance, studies show. Energy drink users feel its kick faster because the beverages are typically swallowed quickly or are sold as concentrates.


“These are caffeine delivery systems,” said Dr. Roland Griffiths, a researcher at Johns Hopkins University who has studied energy drinks. “They don’t want to say this is equivalent to a NoDoz because that is not a very sexy sales message.”


A scientist at the University of Wisconsin became puzzled as he researched an ingredient used in energy drinks like Red Bull, 5-Hour Energy and Monster Energy. The researcher, Dr. Craig A. Goodman, could not find any trials in humans of the additive, a substance with the tongue-twisting name of glucuronolactone that is related to glucose, a sugar. But Dr. Goodman, who had studied other energy drink ingredients, eventually found two 40-year-old studies from Japan that had examined it.


In the experiments, scientists injected large doses of the substance into laboratory rats. Afterward, the rats swam better. “I have no idea what it does in energy drinks,” Dr. Goodman said.


Energy drink manufacturers say it is their proprietary formulas, rather than specific ingredients, that provide users with physical and mental benefits. But that has not prevented them from implying otherwise.


Consider the case of taurine, an additive used in most energy products.


On its Web site, the producer of Red Bull, for example, states that “more than 2,500 reports have been published about taurine and its physiological effects,” including acting as a “detoxifying agent.” In addition, that company, Red Bull of Austria, points to a 2009 safety study by a European regulatory group that gave it a clean bill of health.


But Red Bull’s Web site does not mention reports by that same group, the European Food Safety Authority, which concluded that claims about the benefits in energy drinks lacked scientific support. Based on those findings, the European Commission has refused to approve claims that taurine helps maintain mental function and heart health and reduces muscle fatigue.


Taurine, an amino acidlike substance that got its name because it was first found in the bile of bulls, does play a role in bodily functions, and recent research suggests it might help prevent heart attacks in women with high cholesterol. However, most people get more than adequate amounts from foods like meat, experts said. And researchers added that those with heart problems who may need supplements would find far better sources than energy drinks.


Hiroko Tabuchi contributed reporting from Tokyo and Poypiti Amatatham from Bangkok.



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Scant Proof Is Found to Back Up Claims by Energy Drinks





Energy drinks are the fastest-growing part of the beverage industry, with sales in the United States reaching more than $10 billion in 2012 — more than Americans spent on iced tea or sports beverages like Gatorade.




Their rising popularity represents a generational shift in what people drink, and reflects a successful campaign to convince consumers, particularly teenagers, that the drinks provide a mental and physical edge.


The drinks are now under scrutiny by the Food and Drug Administration after reports of deaths and serious injuries that may be linked to their high caffeine levels. But however that review ends, one thing is clear, interviews with researchers and a review of scientific studies show: the energy drink industry is based on a brew of ingredients that, apart from caffeine, have little, if any benefit for consumers.


“If you had a cup of coffee you are going to affect metabolism in the same way,” said Dr. Robert W. Pettitt, an associate professor at Minnesota State University in Mankato, who has studied the drinks.


Energy drink companies have promoted their products not as caffeine-fueled concoctions but as specially engineered blends that provide something more. For example, producers claim that “Red Bull gives you wings,” that Rockstar Energy is “scientifically formulated” and Monster Energy is a “killer energy brew.” Representative Edward J. Markey of Massachusetts, a Democrat, has asked the government to investigate the industry’s marketing claims.


Promoting a message beyond caffeine has enabled the beverage makers to charge premium prices. A 16-ounce energy drink that sells for $2.99 a can contains about the same amount of caffeine as a tablet of NoDoz that costs 30 cents. Even Starbucks coffee is cheap by comparison; a 12-ounce cup that costs $1.85 has even more caffeine.


As with earlier elixirs, a dearth of evidence underlies such claims. Only a few human studies of energy drinks or the ingredients in them have been performed and they point to a similar conclusion, researchers say — that the beverages are mainly about caffeine.


Caffeine is called the world’s most widely used drug. A stimulant, it increases alertness, awareness and, if taken at the right time, improves athletic performance, studies show. Energy drink users feel its kick faster because the beverages are typically swallowed quickly or are sold as concentrates.


“These are caffeine delivery systems,” said Dr. Roland Griffiths, a researcher at Johns Hopkins University who has studied energy drinks. “They don’t want to say this is equivalent to a NoDoz because that is not a very sexy sales message.”


A scientist at the University of Wisconsin became puzzled as he researched an ingredient used in energy drinks like Red Bull, 5-Hour Energy and Monster Energy. The researcher, Dr. Craig A. Goodman, could not find any trials in humans of the additive, a substance with the tongue-twisting name of glucuronolactone that is related to glucose, a sugar. But Dr. Goodman, who had studied other energy drink ingredients, eventually found two 40-year-old studies from Japan that had examined it.


In the experiments, scientists injected large doses of the substance into laboratory rats. Afterward, the rats swam better. “I have no idea what it does in energy drinks,” Dr. Goodman said.


Energy drink manufacturers say it is their proprietary formulas, rather than specific ingredients, that provide users with physical and mental benefits. But that has not prevented them from implying otherwise.


Consider the case of taurine, an additive used in most energy products.


On its Web site, the producer of Red Bull, for example, states that “more than 2,500 reports have been published about taurine and its physiological effects,” including acting as a “detoxifying agent.” In addition, that company, Red Bull of Austria, points to a 2009 safety study by a European regulatory group that gave it a clean bill of health.


But Red Bull’s Web site does not mention reports by that same group, the European Food Safety Authority, which concluded that claims about the benefits in energy drinks lacked scientific support. Based on those findings, the European Commission has refused to approve claims that taurine helps maintain mental function and heart health and reduces muscle fatigue.


Taurine, an amino acidlike substance that got its name because it was first found in the bile of bulls, does play a role in bodily functions, and recent research suggests it might help prevent heart attacks in women with high cholesterol. However, most people get more than adequate amounts from foods like meat, experts said. And researchers added that those with heart problems who may need supplements would find far better sources than energy drinks.


Hiroko Tabuchi contributed reporting from Tokyo and Poypiti Amatatham from Bangkok.



Read More..