Software Programs Help Doctors Diagnose, but Can’t Replace Them





SAN FRANCISCO — The man on stage had his audience of 600 mesmerized. Over the course of 45 minutes, the tension grew. Finally, the moment of truth arrived, and the room was silent with anticipation.




At last he spoke. “Lymphoma with secondary hemophagocytic syndrome,” he said. The crowd erupted in applause.


Professionals in every field revere their superstars, and in medicine the best diagnosticians are held in particularly high esteem. Dr. Gurpreet Dhaliwal, 39, a self-effacing associate professor of clinical medicine at the University of California, San Francisco, is considered one of the most skillful clinical diagnosticians in practice today.


The case Dr. Dhaliwal was presented, at a medical  conference last year, began with information that could have described hundreds of diseases: the patient had intermittent fevers, joint pain, and weight and appetite loss.


To observe him at work is like watching Steven Spielberg tackle a script or Rory McIlroy a golf course. He was given new information bit by bit — lab, imaging and biopsy results. Over the course of the session, he drew on an encyclopedic familiarity with thousands of syndromes. He deftly dismissed red herrings while picking up on clues that others might ignore, gradually homing in on the accurate diagnosis.


Just how special is Dr. Dhaliwal’s talent? More to the point, what can he do that a computer cannot? Will a computer ever successfully stand in for a skill that is based not simply on a vast fund of knowledge but also on more intangible factors like intuition?


The history of computer-assisted diagnostics is long and rich. In the 1970s, researchers at the University of Pittsburgh developed software to diagnose complex problems in general internal medicine; the project eventually resulted in a commercial program called Quick Medical Reference. Since the 1980s, Massachusetts General Hospital has been developing and refining DXplain, a program that provides a ranked list of clinical diagnoses from a set of symptoms and laboratory data.


And I.B.M., on the heels of its triumph last year with Watson, the Jeopardy-playing computer, is working on Watson for Healthcare.


In some ways, Dr. Dhaliwal’s diagnostic method is similar to that of another I.B.M. project: the Deep Blue chess program, which in 1996 trounced Garry Kasparov, the world’s best player at the time, to claim an unambiguous victory in the computer’s relentless march into the human domain.


Although lacking consciousness and a human’s intuition, Deep Blue had millions of moves memorized and could analyze as many each second. Dr. Dhaliwal does the diagnostic equivalent, though at human speed.


Since medical school, he has been an insatiable reader of case reports in medical journals, and case conferences from other hospitals. At work he occasionally uses a diagnostic checklist program called Isabel, just to make certain he hasn’t forgotten something. But the program has yet to offer a diagnosis that Dr. Dhaliwal missed.


Dr. Dhaliwal regularly receives cases from physicians who are stumped by a set of symptoms. At medical conferences, he is presented with one vexingly difficult case and is given 45 minutes to solve it. It is a medical high-wire act; doctors in the audience squirm as the set of facts gets more obscure and all the diagnoses they were considering are ruled out. After absorbing and processing scores of details, Dr. Dhaliwal must commit to a diagnosis. More often than not, he is right.


When working on a difficult case in front of an audience, Dr. Dhaliwal puts his entire thought process on display, with the goal of “elevating the stature of thinking,” he said. He believes this is becoming more important because physicians are being assessed on whether they gave the right medicine to a patient, or remembered to order a certain test.


Without such emphasis, physicians and training programs might forget the importance of having smart, thoughtful doctors. “Because in medicine,” Dr. Dhaliwal said, “thinking is our most important procedure.”


He added: “Getting better at diagnosis isn’t about figuring out if someone has one rare disease versus another. Getting better at diagnosis is as important to patient quality and safety as reducing medication errors, or eliminating wrong site surgery.”


Clinical Precision


Dr. Dhaliwal does half his clinical work on the wards of the San Francisco V. A. Medical Center, and the other half in its emergency department, where he often puzzles through multiple mysteries at a time.


One recent afternoon in the E.R., he was treating a 66-year-old man who was mentally unstable and uncooperative. He complained of hip pain, but routine lab work revealed that his kidneys weren’t working and his potassium was rising to a dangerous level, putting him in danger of an arrhythmia that could kill him — perhaps within hours. An ultrasound showed that his bladder was blocked.


There was work to be done: drain the bladder, correct the potassium level. It would have been easy to dismiss the hip pain as a distraction; it didn’t easily fit the picture. But Dr. Dhaliwal’s instinct is to hew to the ancient rule that physicians should try to come to a unifying diagnosis. In the end, everything — including the hip pain — was traced to metastatic prostate cancer.


“Things can shift very quickly in the emergency room,” Dr. Dhaliwal said. “One challenge of this, whether you use a computer or your brain, is deciding what’s signal and what’s noise.” Much of the time, it is his intuition that helps figure out which is which.


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Michigan Movie Studio Gets Tax Breaks, but Results in Few Jobs





PONTIAC, Mich. — Even the great and powerful Oz could not save the film studio that was supposed to save this town.




The studio, a state-of-the-art facility fit for Hollywood blockbusters, had risen from the ruins of a General Motors complex here. It was the brainchild of a small group of investors with big plans: the studio would attract prestigious filmmakers, and the movie productions would create jobs and pump money into the local economy. A glamorous sheen would rub off on this down-on-its-luck town.


But in Pontiac, happy endings do not usually come Hollywood-style. The tale behind the studio, though, was cinematic in its own right, filled with colorful characters, calls from the White House and a starring role for Michigan’s taxpayers. Rounding out the cast was a big-budget Disney movie, “Oz: The Great and Powerful.”


It all started back in August 2007, when Gov. Jennifer M. Granholm met with Mike Binder, a Michigan-born actor and director who was lamenting the state’s lackluster program to award financial aid — otherwise known as film credits — to the movie industry. Ms. Granholm, an aspiring actress when she was in her early 20s, became determined to make Michigan competitive, she recalled.


Eight months later, the capital of the flailing auto industry became the capital of film tax credits. For every dollar spent locally, filmmakers would receive almost half back from Michigan. That sort of money turns heads at even the richest film studios, and word spreads fast. Janet Lockwood, the director of the state’s film office, said that a week after the enhanced credits were announced, she was besieged at a movie conference in Santa Monica, Calif., by “the baby studios to the big guys.”


Hollywood may make movies about the evils of capitalism, but it rarely works without incentives, which are paid for by taxpayers. Nationwide, about $1.5 billion in tax breaks is awarded to the film industry each year, according to a state-by-state survey by The New York Times.


Within two months, 24 movies had signed up to film in Michigan — up from two the entire year before. The productions estimated that they would spend $195 million filming there, and in return they would be refunded about $70 million in cash.


Before long, residents were rushing out on their lunch breaks to catch a glimpse of celebrities like Drew Barrymore, who was filming her movie “Whip It” in Ann Arbor, and Clint Eastwood, who was shooting “Gran Torino” in the Detroit area. Even Michael Moore, who was filming a movie about corporate welfare called “Capitalism: A Love Story,” sought and received incentives.


A ‘No-Brainer’ for Michigan


It was a time when most financial news was bad. Housing prices plunged, and thousands of automobiles went unsold. Michigan was facing growing budget shortfalls, and some lawmakers who voted for the film credits soon began questioning whether the state could actually afford them.


In Pontiac, tax revenue plummeted as General Motors pulled out and workers left. Half of downtown was boarded up, and landlords accepted rent checks through slits in doors locked for safety. For some, Hollywood provided distraction and hope.


By 2008, a plan was being hatched for what would become the movie studio in Pontiac. The man behind it, Linden Nelson, was a well-connected local entrepreneur with a charismatic personality. He had made a name for himself by creating the removable key chain for valet parkers in the 1980s. His company later manufactured promotional trinkets for brands like AT&T and Harley-Davidson. In the late 1990s, Mr. Nelson found himself in the headlines when a fire broke out at his office in Beverly Hills, Mich. It was ruled accidental.


Mr. Nelson got the idea for the studio, he said, from his college-age son, who had heard that the Michigan tax credits were the talk of the Cannes Film Festival in France that year. Mr. Nelson soon met an old friend, Ari Emanuel, over coffee in Aspen, Colo., to discuss the idea. Mr. Emanuel was the force behind what would become William Morris Endeavor Entertainment, and his fast-talking, take-no-prisoners style had been immortalized in HBO’s “Entourage.” His brother Rahm would soon be named the chief of staff to President Obama.


Intrigued, Mr. Emanuel did not take long to sign on. “I’m, like, blown away by it,” he told a gathering of the Detroit Regional Chamber of Commerce. “Not to use an L.A. phrase — I think this is a no-brainer for the state of Michigan.”


Motown Motion Pictures LLC was incorporated in May 2008, and two more partners came on board. One, John Rakolta Jr., had building expertise as the head of a commercial construction company. The other, A. Alfred Taubman, was a longtime friend of Mr. Nelson and a prominent investor who made billions building shopping malls nationwide.


Mr. Taubman is among the most generous donors to universities and institutions in Michigan and elsewhere. He went to prison for nearly 10 months in 2002 over price-fixing accusations related to Sotheby’s auction house, which his company owned. He has maintained that he was innocent.


When Mr. Taubman first visited the vacated General Motors site in Pontiac, he was brought to tears. “What happened to all the people?” he said, according to Mr. Nelson, who was at his side. “Where are the cars? What happened to their families?”


In early 2009, the four investors bought the property from G.M. for “virtually nothing,” said Mr. Rakolta. General Motors, which had just received a hefty federal bailout, “spent more on the carpet than we spent on this building,” he said.


The investors agreed that they would put in a total of $10 million to $12 million of their own money, according to the studio’s chief financial officer. They would pay for the rest — $70 million or so — using borrowed money and state and federal incentives. “Michigan’s current tax incentive program appears to be the largest competitive advantage for the company,” one studio document said.


Ms. Lockwood, the film commissioner at the time, said she visited Mr. Taubman’s office in early 2009. Over lunch served by a butler, Mr. Taubman filled her in on the plan. “He believed that there was money to be made,” she recalled.


A Town on the Ropes


In public, the investors extolled the studio as an altruistic effort on behalf of Pontiac. “I go into things to make money, but on this, I don’t really care,” Mr. Taubman told The Detroit Free Press. “I just want to help create jobs, and this can create 3,600 jobs.”


Pontiac desperately needed them. In March of that year, roughly one of every two residents was without work, according to federal data. Food pantries had record requests. Pontiac was consistently listed among the top 10 most dangerous cities by the F.B.I. The city had made national news when a group of teenagers approached homeless people on the street and beat them to death.


Ms. Granholm declared the city in a financial crisis in February 2009 and appointed an emergency manager, Fred Leeb. The city’s budget was $54 million a year, but it was overspending by an estimated $7 million to $12 million. Pontiac was also still weighted down by old incentives it had given to businesses like G.M.


The movie studio was an added challenge, since it was seeking financial incentives from the city — not to mention from other branches of the government. It won redevelopment tax credits from the federal government and separate aid from the state that included incentives for technology companies that hire residents.


Job creation became a point of contention with beleaguered Pontiac, which was being asked to waive virtually all property taxes for the studio. The investors claimed that thousands of people would be employed, but Mr. Leeb said that when he asked for job numbers to be written into the contract, the investors refused. “We started seeing some backpedaling,” said Mr. Leeb, who added that the negotiations featured “knock-down, drag-out fights.”


Mr. Nelson said he did not recall that request, but added that his company could not have guaranteed jobs anyway, since they were mainly supposed to be created by filmmakers renting out the studio.


Under pressure from the governor’s office, Mr. Leeb said he had little choice but to approve the investors’ requests.


Ms. Granholm announced the project in her 2009 State of the State address, saying she thought the industry would create a flood of new jobs. “It was very exciting,” recalled Ms. Granholm, a Democrat. “A classic transformation, the phoenix rising from the ashes. This plant in Pontiac — it was a really great moment for a community that really wanted and needed hope.”


That summer, as the studio moved forward, Mr. Nelson was in local headlines for a second fire, this one at his 23,000-square-foot lakefront home in Bloomfield Hills. The fire extensively damaged the home, and its cause was not determined. Mr. Nelson declined to discuss it.


Not long after, he and the other studio investors hit a major hurdle. They would be borrowing around $18 million in municipal bonds, but they needed someone to back them.


Over the objections of some local officials, the state agreed to use the state workers’ pension funds to guarantee the bonds. If the investors failed to pay, the retirees would be on the hook.


At the time of the deal, the governor was speaking regularly with Mr. Obama, who was negotiating the General Motors bailout. Edward B. Montgomery, who was leading the White House’s efforts on communities and workers affected by the automaker’s bankruptcy, was engaged on the studio plans.


Mr. Montgomery said in an interview that he had expressed support for the studio and other projects that he believed would help diversify Michigan’s economy. He said the studio’s investors received assistance from the Treasury Department to qualify for a federal tax credit program. Mr. Montgomery said he was unaware of the bond guarantee involving the state pension fund.


On July 27, 2010, the governor and other officials gathered for the studio’s groundbreaking. Also on hand were Hollywood players like Mr. Binder, a creator of HBO’s “The Mind of the Married Man,” who had been instrumental in persuading the governor to expand the film subsidies.


Mr. Nelson, the studio’s main impresario, talked up the job numbers on local radio that day and said the incentives were necessary. “It’s a very competitive landscape out there,” he said. “There are very, very competitive rebates going on with other states. People don’t realize this, but 40 states have some kind of rebate or another in this industry. It’s an industry that’s fought after.”


Even as Michigan celebrated the studio, the Motion Picture Association of America was facing criticism of the use of film credits in a report by a Washington tax research group. The film association estimated that the industry employs just over two million people and supports 115,000 businesses. The report, conducted by the nonprofit Tax Foundation, which opposes film incentives, said that states justified them using “fanciful estimates of economic activity.”


The Pontiac studio was complete by the summer of 2011. Its first big production moved in after being awarded about $40 million from the state — the largest single movie payout yet. The Disney “Oz” film was being directed by Sam Raimi, a Michigan native who made the recent “Spider-Man” movies.


Over the coming months, the studio’s seven stages were filled with a yellow brick road and a haunted forest. The designers planted live grass and built a huge waterfall and pond where James Franco, the star of the film, could land in a hot-air balloon. Perhaps the most elaborate set was the courtyard around the good witch Glinda’s castle, which took 75,000 hours of work to build and used $9 million worth of wood, according to Mr. Nelson.


Sahir Rashid, a 35-year-old production assistant and Detroit resident, said that walking into the studio had been overwhelming. It was his first time on a soundstage, and he was thankful that the state’s movie boom allowed him to give up construction work. “For me, the films saved my life,” he said. “It’s not a dead-end job. It’s actually a career.”


As for the crew and actors, “the majority of them I think were from L.A.,” said London Moore, a local actress. Ms. Moore was the body double for Michelle Williams, who was playing Glinda. “I went into this thinking these people were probably going to be stuck up, but they welcomed me with open arms. They are like a family to me.”


Film Jobs Prove Scarce


The studio had created only 200 positions by the summer of 2011, according to correspondence between the company and local officials. And when temporary construction workers were excluded from the tally, Pontiac’s records show, the studio reported only two employees in 2010 and 12 the next year. The studio’s chief financial officer said it had not been able to cash in on $110 million in tax credits that were contingent on creating jobs. But the studio did cash in on other credits, including $14 million for a “Film and Digital Media Infrastructure Investment Tax Credit,” he said.


As the “Oz” shoot was under way, Pontiac moved on to its third emergency manager, Louis Schimmel, and he was not a fan of incentives. A former municipal bond analyst, Mr. Schimmel spent decades warning Michigan towns against trading tax revenues for jobs. “I’m just about the biggest critic of these programs, because giving away the taxes of the city is so detrimental,” he said. “The money is needed for police, fire and trash pickup.”


Mr. Schimmel said Disney had offered to prepay its workers’ personal income tax to the city, but Pontiac declined. The city later had problems collecting some of the taxes because Disney operated through a separate business entity that was difficult to track down, he said.


“This is a glamorous industry if you want to talk about Hollywood, but it’s not very glamorous for the municipality that wants to collect something,” Mr. Schimmel said. Pontiac, he said, was outgunned.


Disney declined to comment. Mr. Nelson said the studio and Disney were responsive to the city.


Mr. Schimmel was not alone in his opposition to incentives. Michigan elected a new governor in 2010, Rick Snyder, a Republican who believed that it made better sense to lower taxes for all businesses. The governor’s budget director, John Nixon, said in an interview, “States harm themselves by competing on tax credits.” The governor quickly began reining in the program.


Almost immediately, filmmakers pulled out of Michigan. The change hit hard at “Hollywood-land in Pontiac,” as Mr. Nelson sometimes refers to his studio, now called Michigan Motion Picture Studios. He said the makers of “Iron Man 3” had been considering filming there but opted for North Carolina after Mr. Snyder slashed incentives.


When the bill for the studio’s bond interest came due in February this year, it paid only a portion, $210,000. The state pension fund had to pick up the remaining $420,000. Mr. Nelson said he and his partners would have made the payment if the state had not changed the tax credit program. “No one would have missed a bond payment,” he said. “No one would have missed anything.”


The situation is galling to even longtime government officials, who over the years have seen plenty of economic development deals fail. “Taubman could write the whole check for that himself,” said Doug Smith, an official at the state’s economic development agency. The state pension fund may “end up owning these studios,” he said.


One of the development agency’s board members is Mr. Rakolta, the construction executive who invested in the Pontiac studio. He and Mr. Nelson said in separate interviews that they had never considered personally paying for the bond interest. A deal is a deal, they said, and the state agreed to cover the bond. The studio’s chief financial officer said the investors already stood to lose twice as much as they originally intended to invest.


A spokesman for Mr. Emanuel said he was not willing to discuss the situation on the record. A spokesman for Mr. Taubman said he was unavailable.


In August, the studio defaulted on the entire $630,000 payment on the bond, despite a decision by Mr. Snyder to temporarily allocate some film incentives.


The investors are lobbying state lawmakers to put more money into the tax credits and have formed a political action committee. Donating to the PAC are the four investors; Mr. Emanuel’s agency, William Morris Endeavor; and the Teamsters union. To rally public support, the studio offers public tours. “Please don’t hesitate to contact your state representative,” Mr. Nelson tells visitors. “Tell them you’ve been here, you believe in it, so please appropriate enough money so it will work.”


Mr. Nelson said that if the state did not improve the incentives, the Pontiac studio would probably shut down. For now, the soundstages are empty. Filming wrapped up last month on a Warner Brothers movie called “Black Sky.” It is about a town ravaged by deadly tornadoes.

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Clinton Warns Syria Against Using Chemical Weapons





PRAGUE — Secretary of State Hillary Rodham Clinton on Monday warned Syrian President Bashar al-Assad not to use chemical weapons and said that the United States was prepared to act if he ignored the warning.




“This is a red line for the United States,” Mrs. Clinton said. “I am not going to telegraph in any specifics what we would do in the event of credible evidence that the Assad regime has resorted to using chemical weapons against their own people. But suffice it to say we are certainly planning to take action if that eventuality were to occur.”


There have been signs in recent days of heightened activity at some of Syria’s chemical weapons sites, according to American and Israeli officials familiar with intelligence reports. Mrs. Clinton did not confirm the intelligence reports or say what sort of activity was occurring.


The Syrian Foreign Ministry, in a swift response, said Damascus "would not use chemical weapons, if it had them, against its own people under any circumstances." The statement was reported on Syrian state television and the Lebanese channel LBC.


Mrs. Clinton, who made her comments after meeting with Karel Schwarzenberg, the foreign minister of the Czech Republic, indicated that the two sides had discussed the situation in Syria, including the potential chemical weapons threat.


Mr. Schwarzenberg described the situation in Syria as “rather chaotic” and “highly dangerous.” He said that Czech troops who specialize in the detection of chemical weapons and decontamination if they are used are in Jordan training with Jordanian forces.


An American task force has been deployed to Jordan and has been helping the Jordanians deal with the escalating humanitarian crisis, including an exodus of more than 200,000 refugees from Syria to Jordan. The force is also planning on how to respond, if necessary, to a chemical weapons threat.


Although Mrs. Clinton’s reference to a “red line” echoed a warning issued by President Obama in August, it was the most explicit warning from a ranking American official since reports of renewed chemical weapons activity began to surface in recent days.


Mrs. Clinton stopped in Prague on her way to Brussels for a meeting of NATO foreign ministers. A major topic of the NATO meeting is a Turkish request that the alliance deploy Patriot antimissile batteries in Turkey. The Turkish government is concerned about Syria’s ballistic missiles, which could carry chemical weapons, and wants NATO to guard as many as 10 sites inside Turkey.


What exactly is happening at Syria’s chemical sites is unclear.  One American official said Sunday that “the activity we are seeing suggests some potential chemical weapon preparation,” which goes beyond the mere movement of stockpiles among Syria’s several dozen known sites. But the official declined to offer more specifics.


Over the weekend, the activity in Syria prompted a series of urgent consultations among the Western nations, which have long been developing contingency plans to neutralize the chemical weapons, a task that the Pentagon estimates would require more than 75,000 troops. But there were no signs that any American action was imminent.


So far, President Obama has been very cautious about intervening in Syria, declining to arm the opposition groups directly.


Anne Barnard contributed reporting from Beirut, Lebanon.



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Gadgetwise Blog: Q&A: Opening a New Page in a Browser Tab

Is there a way to make Internet Explorer open a link in a new browser tab, instead of in a whole new window?

Right-clicking the link you want to open on the current page and choosing “Open in New Tab” from the drop-down menu is one way to avoid having a whole new browser window appear. If you want to make the process a little more automatic, though, you can adjust Internet Explorer’s settings.

In Internet Explorer 7 and later, go to the Tools menu (or click the gear icon in later versions of the program) in the browser toolbar and select Internet Options; hold down the ALT key if you do not see a menu bar in the browser window. In the Internet Options box, click the General tab and then click the Settings button; in Internet Explorer 10, click the Tabs button here instead.

In the Settings box, make sure the box to enable tabbed browsing is checked. In the area under “When a popup is encountered,” select “Always open pop-ups in a new tab.” Click the O.K. button until you have closed all the settings and options boxes. Now, when you click on a link that is coded to open in its own new window, the page should open in a new tab within your existing browser window.

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Call That Kept Nursing Home Patients in Sandy’s Path


Chang W. Lee/The New York Times


Workers were shocked that nursing and adult homes in areas like Rockaway Park, Queens, weren’t evacuated.







Hurricane Sandy was swirling northward, four days before landfall, and at the Sea Crest Health Care Center, a nursing home overlooking the Coney Island Boardwalk in Brooklyn, workers were gathering medicines and other supplies as they prepared to evacuate.




Then the call came from health officials: Mayor Michael R. Bloomberg, acting on the advice of his aides and those of Gov. Andrew M. Cuomo, recommended that nursing homes and adult homes stay put. The 305 residents would ride out the storm.


The same advisory also took administrators by surprise at the Ocean Promenade nursing home, which faces the Atlantic Ocean in Queens. They canceled plans to move 105 residents to safety.


“No one gets why we weren’t evacuated,” said a worker there, Yisroel Tabi. “We wouldn’t have exposed ourselves to dealing with that situation.”


The recommendation that thousands of elderly, disabled and mentally ill residents remain in more than 40 nursing homes and adult homes in flood-prone areas of New York City had calamitous consequences.


At least 29 facilities in Queens and Brooklyn were severely flooded. Generators failed or were absent. Buildings were plunged into a cold, wet darkness, with no access to power, water, heat and food.


While no immediate deaths were reported, it took at least three days for the Fire Department, the National Guard and ambulance crews from around the country to rescue over 4,000 nursing home and 1,500 adult home residents. Without working elevators, many had to be carried down slippery stairwells.


“I was shocked,” said Greg Levow, who works for an ambulance service and helped rescue residents at Queens. “I couldn’t understand why they were there in the first place.”


Many sat for hours in ambulances and buses before being transported to safety through sand drifts and debris-filled floodwaters. They went to crowded shelters and nursing homes as far away as Albany, where for days, they often lacked medical charts and medications. Families struggled to locate relatives.


The decision not to empty the nursing homes and adult homes in the mandatory evacuation area was one of the most questionable by the authorities during Hurricane Sandy. And an investigation by The New York Times found that the impact was worsened by missteps that officials made in not ensuring that these facilities could protect residents.


They did not require that nursing homes maintain backup generators that could withstand flooding. They did not ensure that health care administrators could adequately communicate with government agencies during and after a storm. And they discounted the more severe of the early predictions about Hurricane Sandy’s surge.


The Times’s investigation was based on interviews with officials, health care administrators, doctors, nurses, ambulance medics, residents, family members and disaster experts. It included a review of internal State Health Department status reports. The findings revealed the striking vulnerability of the city’s nursing and adult homes.


On Sunday, Oct. 28, the day before Hurricane Sandy arrived, Mr. Bloomberg ordered a mandatory evacuation in Zone A, the low-lying neighborhoods of the city. But by that point, Mr. Bloomberg, relying on the advice of the city and state health commissioners, had already determined that people in nursing homes and adult homes should not leave, officials said.


The mayor’s recommendations that health care facilities not evacuate startled residents of Surf Manor adult home in Coney Island, said one of them, Norman Bloomfield. He recalled that another resident exclaimed, “What about us! Why’s he telling us to stay?”


The commissioners made the recommendation to Mr. Bloomberg and Mr. Cuomo because they said they believed that the inherent risks of transporting the residents outweighed the potential dangers from the storm.


In interviews, senior Bloomberg and Cuomo aides did not express regret for keeping the residents in place.


“I would defend all the decisions and the actions” by the health authorities involving the storm, said Linda I. Gibbs, a deputy mayor. “I feel like I’m describing something that was a remarkable, lifesaving event.”


Dr. Nirav R. Shah, the state health commissioner, who regulates nursing homes, said: “I’m not even thinking of second-guessing the decisions.”


Still, officials in New Jersey and in Nassau County adopted a different policy, evacuating nursing homes in coastal areas well before the storm.


Contradictory Forecasts


The city’s experience with Tropical Storm Irene last year weighed heavily on state and city health officials and contributed to their underestimating the impact of Hurricane Sandy, according to records and interviews.


Before Tropical Storm Irene, the officials ordered nursing homes and adult homes to evacuate. The storm caused relatively minor damage, but the evacuation led to millions of dollars in health care, transportation, housing and other costs, and took a toll on residents.


As a result, when Hurricane Sandy loomed, the officials were acutely aware that they could come under criticism if they ordered another evacuation that proved unnecessary.


Read More..

Call That Kept Nursing Home Patients in Sandy’s Path


Chang W. Lee/The New York Times


Workers were shocked that nursing and adult homes in areas like Rockaway Park, Queens, weren’t evacuated.







Hurricane Sandy was swirling northward, four days before landfall, and at the Sea Crest Health Care Center, a nursing home overlooking the Coney Island Boardwalk in Brooklyn, workers were gathering medicines and other supplies as they prepared to evacuate.




Then the call came from health officials: Mayor Michael R. Bloomberg, acting on the advice of his aides and those of Gov. Andrew M. Cuomo, recommended that nursing homes and adult homes stay put. The 305 residents would ride out the storm.


The same advisory also took administrators by surprise at the Ocean Promenade nursing home, which faces the Atlantic Ocean in Queens. They canceled plans to move 105 residents to safety.


“No one gets why we weren’t evacuated,” said a worker there, Yisroel Tabi. “We wouldn’t have exposed ourselves to dealing with that situation.”


The recommendation that thousands of elderly, disabled and mentally ill residents remain in more than 40 nursing homes and adult homes in flood-prone areas of New York City had calamitous consequences.


At least 29 facilities in Queens and Brooklyn were severely flooded. Generators failed or were absent. Buildings were plunged into a cold, wet darkness, with no access to power, water, heat and food.


While no immediate deaths were reported, it took at least three days for the Fire Department, the National Guard and ambulance crews from around the country to rescue over 4,000 nursing home and 1,500 adult home residents. Without working elevators, many had to be carried down slippery stairwells.


“I was shocked,” said Greg Levow, who works for an ambulance service and helped rescue residents at Queens. “I couldn’t understand why they were there in the first place.”


Many sat for hours in ambulances and buses before being transported to safety through sand drifts and debris-filled floodwaters. They went to crowded shelters and nursing homes as far away as Albany, where for days, they often lacked medical charts and medications. Families struggled to locate relatives.


The decision not to empty the nursing homes and adult homes in the mandatory evacuation area was one of the most questionable by the authorities during Hurricane Sandy. And an investigation by The New York Times found that the impact was worsened by missteps that officials made in not ensuring that these facilities could protect residents.


They did not require that nursing homes maintain backup generators that could withstand flooding. They did not ensure that health care administrators could adequately communicate with government agencies during and after a storm. And they discounted the more severe of the early predictions about Hurricane Sandy’s surge.


The Times’s investigation was based on interviews with officials, health care administrators, doctors, nurses, ambulance medics, residents, family members and disaster experts. It included a review of internal State Health Department status reports. The findings revealed the striking vulnerability of the city’s nursing and adult homes.


On Sunday, Oct. 28, the day before Hurricane Sandy arrived, Mr. Bloomberg ordered a mandatory evacuation in Zone A, the low-lying neighborhoods of the city. But by that point, Mr. Bloomberg, relying on the advice of the city and state health commissioners, had already determined that people in nursing homes and adult homes should not leave, officials said.


The mayor’s recommendations that health care facilities not evacuate startled residents of Surf Manor adult home in Coney Island, said one of them, Norman Bloomfield. He recalled that another resident exclaimed, “What about us! Why’s he telling us to stay?”


The commissioners made the recommendation to Mr. Bloomberg and Mr. Cuomo because they said they believed that the inherent risks of transporting the residents outweighed the potential dangers from the storm.


In interviews, senior Bloomberg and Cuomo aides did not express regret for keeping the residents in place.


“I would defend all the decisions and the actions” by the health authorities involving the storm, said Linda I. Gibbs, a deputy mayor. “I feel like I’m describing something that was a remarkable, lifesaving event.”


Dr. Nirav R. Shah, the state health commissioner, who regulates nursing homes, said: “I’m not even thinking of second-guessing the decisions.”


Still, officials in New Jersey and in Nassau County adopted a different policy, evacuating nursing homes in coastal areas well before the storm.


Contradictory Forecasts


The city’s experience with Tropical Storm Irene last year weighed heavily on state and city health officials and contributed to their underestimating the impact of Hurricane Sandy, according to records and interviews.


Before Tropical Storm Irene, the officials ordered nursing homes and adult homes to evacuate. The storm caused relatively minor damage, but the evacuation led to millions of dollars in health care, transportation, housing and other costs, and took a toll on residents.


As a result, when Hurricane Sandy loomed, the officials were acutely aware that they could come under criticism if they ordered another evacuation that proved unnecessary.


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DealBook: Delta Air Lines Ponders Stake in Virgin Atlantic Airways

Delta Air Lines is in talks to buy Singapore Airlines’ 49 percent stake in Virgin Atlantic Airways, in an effort to bolster its international operations, particularly flights between New York and London, a person briefed on the matter said on Sunday.

Talks are continuing but a deal will not be announced soon, this person said. Singapore Airlines confirmed that it was in discussions about a potential sale of its Virgin stake, but provided no further details.

A transaction would be the latest in a round of mergers that has reshaped the airline industry, as companies in the United States and Europe have looked to consolidation to restore profitability.

With oil prices remaining stubbornly high and the economic outlook uncertain, many airlines have continued to struggle. That may precipitate even more takeovers, analysts say.

A deal would also be Delta’s most significant strategic move since its 2008 merger with Northwest Airlines, which made it the biggest American carrier until the union of United Airlines and Continental Airlines last year.

It would provide more access to London’s Heathrow Airport, one of the world’s busiest, and expand Delta’s North Atlantic business.

It would also bolster its partnership with Air France KLM, Europe’s biggest airline. Both companies are part of the Sky Team global alliance, and also run a joint business in the North Atlantic market, sharing flights, revenues and costs.

“Delta has shown time and time again that it is extremely opportunistic,” said Brett Snyder, an airline expert. “If it sees a good opportunity, nothing is off the table.”

If it proceeded, a transaction would directly challenge the Oneworld global alliance, whose biggest members are American Airlines and British Airways. The two airlines have an international joint venture. Virgin does not belong to any of the three major airline alliances — Star, Oneworld and Sky Team — depriving it of the ability to coordinate flights and cut costs, which has helped many of its competitors. Star’s major carriers are United, US Airways and Lufthansa. The deal would also give Virgin a strong partner as it struggles to compete against rivals with deeper pockets. Founded by Richard Branson in 1984, the company has long embraced an image of fun travel and cheaper fares.

But that has not helped the airline’s financial condition of late. Virgin lost £80 million, or $128 million, in the year that ended in February, compared with a profit of £18.5 million in the previous year.

The company has been under pressure from the likes of British Airways, whose corporate parent, IAG, bought BMI British Midlands earlier this year. Virgin fought against that deal, arguing that it would give British Airways too much of a presence at Heathrow. But the takeover was completed, after IAG complied with a European Commission order to give back 14 slots at the airport.

The deal may also pave the way for an eventual change of control of Virgin. The company’s chief executive, Steve Ridgway, told The Financial Times in an interview in January that Mr. Branson was prepared to sell some of his 51 percent controlling stake in the airline.

“For Virgin, it’s an exit strategy in an environment where they are being marginalized by alliances on the Atlantic,” said Robert W. Mann, an airline analyst based in Port Washington, N.Y.

A Delta spokeswoman declined to comment. A representative for Virgin was not immediately available for comment.


This post has been revised to reflect the following correction:

Correction: December 3, 2012

An earlier version of this article misstated the date of Delta's merger with Northwest Airlines. It was 2008, not 2010.

A version of this article appeared in print on 12/03/2012, on page B2 of the NewYork edition with the headline: Delta, Seeking London Access, Ponders Stake in Virgin.
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Tunnel Collapse Outside Tokyo Traps Motorists





TOKYO — At least seven people were feared dead after part of a highway tunnel collapsed Sunday in eastern Japan, trapping them in their vehicles and starting a fire that filled the tunnel with thick, black smoke. Government officials said fear of an additional collapse had prevented rescuers from reaching the two trapped vehicles.




The vehicles were crushed under concrete that fell from the ceiling of the three-mile Sasago Tunnel near the city of Otsuki in Yamanashi Prefecture, about 50 miles west of Tokyo, the national government’s disaster management agency said. The agency said it remained unclear why the 150-200-foot section of 8-inch-thick concrete suddenly fell.


A burning vehicle emitted heavy smoke that initially prevented firefighters from entering the tunnel. But even after putting out the blaze, rescuers suspended efforts to reach the trapped vehicles because of the danger of further collapse, the agency said.


The agency said a woman in her 20s managed to flee one of the crushed vehicles. She told firefighters that six other people remained trapped in her vehicle. It was unknown how many people were in the other vehicle besides the driver, who was apparently also still trapped inside.


The accident closed a section of the Chuo Expressway, a vital transportation artery connecting Tokyo to western Japan. Such long tunnels — usually lined with smooth, white concrete — are a common sight on highways in this mountainous island nation.


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John McAfee Plays Hide-and-Seek in Belize


Photo Illustration by The New York Times


John McAfee, right, a pioneer in computer security who lives in Belize, is a “person of interest” in the murder of his neighbor. More Photos »





DANIEL GUERRERO promised during his campaign for mayor here to clean up San Pedro, the only town on this island, a 20-minute puddle jump from the mainland. But if he ever runs for re-election, don’t expect him to mention that vow.


“I meant clean up the trash, the traffic, that sort of thing,” he says. “I didn’t mean this.”


“This” is a full-blown international media frenzy and the kind of mess that no politician could have seen coming. It started on Nov. 11, the morning that Gregory Faull, a 52-year-old American, was found dead, lying face up in a pool of blood in his home. He had been shot in the head. His laptop and iPhone were missing. A 9-millimeter shell was found nearby.


What happened next turned this from a local crime story to worldwide news: The police announced that a “person of interest” in the investigation was a neighbor, John McAfee, a Silicon Valley legend who years ago earned millions from the computer virus-fighting software company that still bears his name.


A priapic 67-year-old, with an improbable mop of blond-highlighted hair and a rotating group of young girlfriends, Mr. McAfee quickly melted into the island’s lush green forest. Then, for Belizean authorities, the real embarrassment began.


Asserting his innocence, Mr. McAfee became a multiplatform cyberdissident, with a Twitter account, and a blog at whoismcafee.com with audio links, a comments section, photographs and a stream of invective against the government and the police of Belize. He has done interviews on podcasts, like the “Joe Rogan Experience,” and offered a $25,000 reward for information leading to the arrest of “the person or persons” who killed Mr. Faull. He has turned lamming it into a kind of high-tech performance art.


“I am asking all people of conscience to read this blog, especially the links in the ‘Background’ section,’ and see the ugly truth unfolding here,” he posted on Nov. 18. “Speak out. Write your congressmen. Write the prime minister. Do what you can.”


Before he went underground, Mr. McAfee led a noisy, opulent and increasingly stressful life here. He was known for the retinue of prostitutes who he says moved in and out of his house, and for employing armed guards, some of whom stood watch on the beach abutting his house. He also kept a pack of untethered dogs on his property who barked at and sometimes bit passers-by.


Two days before the murder, someone had poisoned a handful of those dogs. As it happens, Mr. Faull had complained about the animals, as well as the guards and the constant late-night inflow and outflow of taxis on the dirt path that runs behind his and Mr. McAfee’s homes — a path so tiny that it’s supposed to be off-limits to cars.


Mr. Faull had shown up at the town council office a few weeks ago with a letter decrying the din and the dogs, as well as Mr. McAfee’s guns and behavior. Nothing came of it.


“We were planning to meet with John McAfee and hand him the letter,” Mr. Guerrero said. “But it never happened. We were busy doing other work.”


In hindsight, that looks like a blunder. Mr. McAfee has since said on his blog that he had no choice but to flee because police and politicians in Belize are corrupt and eager to kill him. As proof, he has written at length about a late April raid that the country’s Gang Suppression Unit conducted at a property of his on the mainland, in a district called Orange Walk.


Some McAfee watchers have a different theory — namely, that he grew paranoid and perhaps psychotic after months of experimenting with and consuming MDPV, a psychoactive drug. These experiments were described in detail by Mr. McAfee himself, under the pseudonym “Stuffmonger” in a forum on Bluelight, a Web site popular with drug hobbyists.


So, here’s one hypothesis: Rich man doses himself to madness while seeking sexual bliss through pharmacology. Then shoots neighbor in a rage. Case closed, right? Ah, but those Bluelight posts were a ruse, Mr. McAfee would later blog, just one of the many pranks he has perpetrated over the years — part of a bet with a friend to see if he could create Bluelight’s largest-ever thread.


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Opinion: A Health Insurance Detective Story





I’VE had a long career as a business journalist, beginning at Forbes and including eight years as the editor of Money, a personal finance magazine. But I’ve never faced a more confounding reporting challenge than the one I’m engaged in now: What will I pay next year for the pill that controls my blood cancer?




After making more than 70 phone calls to 16 organizations over the past few weeks, I’m still not totally sure what I will owe for my Revlimid, a derivative of thalidomide that is keeping my multiple myeloma in check. The drug is extremely expensive — about $11,000 retail for a four-week supply, $132,000 a year, $524 a pill. Time Warner, my former employer, has covered me for years under its Supplementary Medicare Program, a plan for retirees that included a special Writers Guild benefit capping my out-of-pocket prescription costs at $1,000 a year. That out-of-pocket limit is scheduled to expire on Jan. 1. So what will my Revlimid cost me next year?


The answers I got ranged from $20 a month to $17,000 a year. One of the first people I phoned said that no matter what I heard, I wouldn’t know the cost until I filed a claim in January. Seventy phone calls later, that may still be the most reliable thing anyone has told me.


Like around 47 million other Medicare beneficiaries, I have until this Friday, Dec. 7, when open enrollment ends, to choose my 2013 Medicare coverage, either through traditional Medicare or a private insurer, as well as my drug coverage — or I will risk all sorts of complications and potential late penalties.


But if a seasoned personal-finance journalist can’t get a straight answer to a simple question, what chance do most people have of picking the right health insurance option?


A study published in the journal Health Affairs in October estimated that a mere 5.2 percent of Medicare Part D beneficiaries chose the cheapest coverage that met their needs. All in all, consumers appear to be wasting roughly $11 billion a year on their Part D coverage, partly, I think, because they don’t get reliable answers to straightforward questions.


Here’s a snapshot of my surreal experience:


NOV. 7 A packet from Time Warner informs me that the company’s new 2013 Retiree Health Care Plan has “no out-of-pocket limit on your expenses.” But Erin, the person who answers at the company’s Benefits Service Center, tells me that the new plan will have “no practical effect” on me. What about the $1,000-a-year cap on drug costs? Is that really being eliminated? “Yes,” she says, “there’s no limit on out-of-pocket expenses in 2013.” I tell her I think that could have a major effect on me.


Next I talk to David at CVS/Caremark, Time Warner’s new drug insurance provider. He thinks my out-of-pocket cost for Revlimid next year will be $6,900. He says, “I know I’m scaring you.”


I call back Erin at Time Warner. She mentions something about $10,000 and says she’ll get an estimate for me in two business days.


NOV. 8 I phone Medicare. Jay says that if I switch to Medicare’s Part D prescription coverage, with a new provider, Revlimid’s cost will drive me into Medicare’s “catastrophic coverage.” I’d pay $2,819 the first month, and 5 percent of the cost of the drug thereafter — $563 a month or maybe $561. Anyway, roughly $9,000 for the year. Jay says AARP’s Part D plan may be a good option.


NOV. 9 Erin at Time Warner tells me that the company’s policy bundles United Healthcare medical coverage with CVS/Caremark’s drug coverage. I can’t accept the medical plan and cherry-pick prescription coverage elsewhere. It’s take it or leave it. Then she puts CVS’s Michele on the line to get me a Revlimid quote. Michele says Time Warner hasn’t transferred my insurance information. She can’t give me a quote without it. Erin says she will not call me with an update. I’ll have to call her.


My oncologist’s assistant steers me to Celgene, Revlimid’s manufacturer. Jennifer in “patient support” says premium assistance grants can cut the cost of Revlimid to $20 or $30 a month. She says, “You’re going to be O.K.” If my income is low enough to qualify for assistance.


NOV. 12 I try CVS again. Christine says my insurance records still have not been transferred, but she thinks my Revlimid might cost $17,000 a year.


Adriana at Medicare warns me that AARP and other Part D providers will require “prior authorization” to cover my Revlimid, so it’s probably best to stick with Time Warner no matter what the cost.


But Brooke at AARP insists that I don’t need prior authorization for my Revlimid, and so does her supervisor Brian — until he spots a footnote. Then he assures me that it will be easy to get prior authorization. All I need is a doctor’s note. My out-of-pocket cost for 2013: roughly $7,000.


NOV. 13 Linda at CVS says her company still doesn’t have my file, but from what she can see about Time Warner’s insurance plans my cost will be $60 a month — $720 for the year.


CVS assigns my case to Rebecca. She says she’s “sure all will be fine.” Well, “pretty sure.” She’s excited. She’s been with the company only a few months. This will be her first quote.


NOV. 14 Giddens at Time Warner puts in an “emergency update request” to get my files transferred to CVS.


Frank Lalli is an editorial consultant on retirement issues and a former senior executive editor at Time Warner’s Time Inc.



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