The New Old Age Blog: In the Middle: Why Elderly Couples Fight

George and Gracie (let’s call them that because using their real names would make them even unhappier than they already appear to be) are in their 80s and married for more than 65 years. Until recently they seemed to ride the waves that are inevitable in any marriage that spans nearly seven decades; through good and bad, they were partners and best friends.

But lately — ever since her hospitalization and his fall — they have been arguing more bitterly than usual (“Do you have to make such a mess in the kitchen?”), criticizing each other (“Why haven’t you dealt with the insurance company yet?”), withdrawing from each other, and generally making each other more miserable, more often than ever before.

This kind of degenerative relationship is not uncommon among the elderly in even the happiest marriages, marriage therapists and geriatricians said. But that is small comfort to either the couple in the middle of the maelstrom, or the children who care for them, as evidenced by a number postings on caregiver blogs. As some of the children have wondered there: “Why can’t we all just get along?”

Therapists and others who work with the elderly said the first step to addressing the problem is understanding where it came from.

“A key question is whether the marital bickering is part of a lifelong marital style or a change,” said Dr. Linda Waite, director of the Center on Aging at NORC/University of Chicago. Is it new behavior – or just new to the grown children who are suddenly so deeply enmeshed in their parents’ lives that they are only now noticing that something is amiss?

How much of the problem is really just the marriage style? “Some couples like to fight and argue – it keeps their adrenaline going,” said Dr. Nancy K. Schlossberg, professor emerita of counseling psychology at the University of Maryland and author of “Overwhelmed: Coping with Life’s Ups and Downs.”

Sometimes the best judges of whether there is a problem are outsiders, said Dr. William Dale, chief of geriatrics at the University of Chicago Geriatrics Medicine. Pay attention if someone says, “‘Gee, Mom seems more argumentative or withdrawn than the last time I saw her,’” Dr. Dale advised.

If the tone or severity of the marital tensions seem new, then it is important to find out why. The causes could be mental or physical, doctors say.

On the mental front, increased anger and fighting could be one of the first signs of mild cognitive impairment, a precursor of dementia or Alzheimer’s, in one or both of the spouses, said Dr. Lisa Gwyther, director of the Duke Center for Aging Family Support Program and Associate Professor in the Department of Psychiatry and Behavioral Sciences.

Dr. Dale concurs: “There is good evidence that the earliest signs of cognitive impairment are often emotional changes” — anger, anxiety, depression — “rather than cognitive ones” — memory, abstract thought.

But these early signs of cognitive decline can be so subtle that neither the spouses themselves, or their grown children, recognize them for what they are, Dr. Gwyther said. So husband and wife blame each other for the changes and allow feelings of hurt and resentment to grow.

Withdrawing from activities that used to give them pleasure can be a telltale sign of mild cognitive impairment – and can trigger anger and arguments.

“In one couple, the husband just didn’t want to participate in the holidays — the wife got angry and said he was being lazy and stubborn,” said Dr. Gwyther. But the truth was that his cognitive decline made all the activity overwhelming, and he didn’t want anyone to know that he was anxious about not remembering everyone’s names and embarrassing himself.

Suspicion and paranoia can also accompany mild cognitive decline and precipitate distrust and hurtful accusations. Dr. Gwyther recalled another woman who “called her daughter frantic because she said her husband dropped her at her chemo appointment, went to park the car, and didn’t return to get her.” The woman couldn’t imagine that her husband could possibly have lost his sense of time and direction, Dr. Gwyther added. She took it personally, complaining to her daughter that “your father doesn’t seem to care any more.”

Dr. Dale told of a spouse who accused her mate of infidelity because “she was convinced that when he was out grocery shopping he was really having an affair.”

Hoarding, an early symptom of mild cognitive impairment, can also create tension in a marriage. (For new treatments, see this recent post by my colleague Paula Span.)

When one couple came to a counseling session with Dr. Norman Abeles, emeritus professor of psychology and former director of psychological clinic at Michigan State University, the hoarding spouse finally said, “she did it because she thought that they would run out of money, even though there was enough money to go around.” Dr. Abeles said that incident led to her diagnosis of mild cognitive impairment.

Adding to the confusion, mild cognitive impairment (M.C.I.) comes and goes. “There are good days and bad days, good hours and bad hours,” said Dr. Gwyther. “Alzheimer’s and dementia don’t start on Tuesday — it’s a slow insidious onset.” But the diagnosis is becoming more common: The Institute for Dementia Research and Prevention predicts that 1 in 6 women, and 1 in 10 men, who live past the age of 55 will develop dementia in their lifetime.

“Spouses find it difficult to know when their partner with M.C.I. is acting differently (usually badly) due to the advancing illness or due to ‘willful’ personality issues,” said Dr. Dale, citing a 2007 study in the journal Family Relations exploring the problems this can create for couples.

Blaming is often easier than understanding. Another of Dr. Gwyther’s patients was furious at her husband for not filing their taxes. “He’s a C.P.A.,” she said. “How could we owe back taxes?” It did not occur to her that he might be unable to handle that task — and was too frightened about his deteriorating mental focus to let her know.

But as harmful as mental decline can be for a marriage, it is just part of the equation. Physical ailments – even those that seem completely unrelated to marital relations – “can upset the equilibrium of the marriage,” according to a study in the Canadian Medical Association Journal.

“Most men get angry at what’s happened to them when they get ill, women get angry and scared when he’s not what he used to be — so they fight,” said Dr. Schlossberg.

Chronic illnesses, like diabetes, arthritis and heart disease, can have a strong negative effect on mood, said Dr. Waite, who will soon be publishing a study on the subject. Diabetes is so often accompanied by depression that, Dr. Waite said, “one of my colleagues argues that that it is even part of the disease.”

And ailments can have an effect on a couple’s sex life — which can compound the marital problems, doctors said.

“Diabetes brings on neuropathy,” said Dr. Waite. “That means touching and feeling in sex is not as rewarding.” Without the pleasures of affectionate touching — whether a passing hug at the sink, or more — tensions can build. That’s why, if a couple is having problems with sex, they are more likely to have problems in the relationship — and vice versa, according to a 2007 New England Journal of Medicine study of sex and health among older adults.

Other changes in circumstances — retirement, shifting roles, the loss of autonomy, disparities in health and abilities — can wreak havoc. Losing independence can feel like losing oneself — and if you don’t know who you are any more, how can you know how to relate to your spouse?

“Fighting may come from a misguided notion that you can regain power by asserting it over your spouse,” said Dr. Schlossberg, whose observations are echoed in a 1984 study in the Canadian Journal of Medicine. “It doesn’t work, it’s false power – but they’ll try anything.”

The sheer exhaustion that can come from being the caregiving spouse is also bound to “make them stressed and angry,” said Dr. Waite. Not to mention guilty and resentful — never a prescription for happy marital relations.

“Part of the trap for the caregiver is the idea that you have to do it all, and the guilt you feel when you cannot live up to it,” said Dr. Gordon Herz, a psychologist in private practice in Madison, Wisc. Not surprisingly, resentment can soon follow, Dr. Herz added, because it’s hard to admit to anyone that, “‘this is too much for me.’”

What can outside caregivers — children or other loved ones — do about these golden marriages on the rocks? Should they intervene — or butt out? And can marital therapy help — or is it too late to change?

Share your thoughts and experiences — and tomorrow we’ll try to provide some advice from experts.

Read More..

The New Old Age Blog: In the Middle: Why Elderly Couples Fight

George and Gracie (let’s call them that because using their real names would make them even unhappier than they already appear to be) are in their 80s and married for more than 65 years. Until recently they seemed to ride the waves that are inevitable in any marriage that spans nearly seven decades; through good and bad, they were partners and best friends.

But lately — ever since her hospitalization and his fall — they have been arguing more bitterly than usual (“Do you have to make such a mess in the kitchen?”), criticizing each other (“Why haven’t you dealt with the insurance company yet?”), withdrawing from each other, and generally making each other more miserable, more often than ever before.

This kind of degenerative relationship is not uncommon among the elderly in even the happiest marriages, marriage therapists and geriatricians said. But that is small comfort to either the couple in the middle of the maelstrom, or the children who care for them, as evidenced by a number postings on caregiver blogs. As some of the children have wondered there: “Why can’t we all just get along?”

Therapists and others who work with the elderly said the first step to addressing the problem is understanding where it came from.

“A key question is whether the marital bickering is part of a lifelong marital style or a change,” said Dr. Linda Waite, director of the Center on Aging at NORC/University of Chicago. Is it new behavior – or just new to the grown children who are suddenly so deeply enmeshed in their parents’ lives that they are only now noticing that something is amiss?

How much of the problem is really just the marriage style? “Some couples like to fight and argue – it keeps their adrenaline going,” said Dr. Nancy K. Schlossberg, professor emerita of counseling psychology at the University of Maryland and author of “Overwhelmed: Coping with Life’s Ups and Downs.”

Sometimes the best judges of whether there is a problem are outsiders, said Dr. William Dale, chief of geriatrics at the University of Chicago Geriatrics Medicine. Pay attention if someone says, “‘Gee, Mom seems more argumentative or withdrawn than the last time I saw her,’” Dr. Dale advised.

If the tone or severity of the marital tensions seem new, then it is important to find out why. The causes could be mental or physical, doctors say.

On the mental front, increased anger and fighting could be one of the first signs of mild cognitive impairment, a precursor of dementia or Alzheimer’s, in one or both of the spouses, said Dr. Lisa Gwyther, director of the Duke Center for Aging Family Support Program and Associate Professor in the Department of Psychiatry and Behavioral Sciences.

Dr. Dale concurs: “There is good evidence that the earliest signs of cognitive impairment are often emotional changes” — anger, anxiety, depression — “rather than cognitive ones” — memory, abstract thought.

But these early signs of cognitive decline can be so subtle that neither the spouses themselves, or their grown children, recognize them for what they are, Dr. Gwyther said. So husband and wife blame each other for the changes and allow feelings of hurt and resentment to grow.

Withdrawing from activities that used to give them pleasure can be a telltale sign of mild cognitive impairment – and can trigger anger and arguments.

“In one couple, the husband just didn’t want to participate in the holidays — the wife got angry and said he was being lazy and stubborn,” said Dr. Gwyther. But the truth was that his cognitive decline made all the activity overwhelming, and he didn’t want anyone to know that he was anxious about not remembering everyone’s names and embarrassing himself.

Suspicion and paranoia can also accompany mild cognitive decline and precipitate distrust and hurtful accusations. Dr. Gwyther recalled another woman who “called her daughter frantic because she said her husband dropped her at her chemo appointment, went to park the car, and didn’t return to get her.” The woman couldn’t imagine that her husband could possibly have lost his sense of time and direction, Dr. Gwyther added. She took it personally, complaining to her daughter that “your father doesn’t seem to care any more.”

Dr. Dale told of a spouse who accused her mate of infidelity because “she was convinced that when he was out grocery shopping he was really having an affair.”

Hoarding, an early symptom of mild cognitive impairment, can also create tension in a marriage. (For new treatments, see this recent post by my colleague Paula Span.)

When one couple came to a counseling session with Dr. Norman Abeles, emeritus professor of psychology and former director of psychological clinic at Michigan State University, the hoarding spouse finally said, “she did it because she thought that they would run out of money, even though there was enough money to go around.” Dr. Abeles said that incident led to her diagnosis of mild cognitive impairment.

Adding to the confusion, mild cognitive impairment (M.C.I.) comes and goes. “There are good days and bad days, good hours and bad hours,” said Dr. Gwyther. “Alzheimer’s and dementia don’t start on Tuesday — it’s a slow insidious onset.” But the diagnosis is becoming more common: The Institute for Dementia Research and Prevention predicts that 1 in 6 women, and 1 in 10 men, who live past the age of 55 will develop dementia in their lifetime.

“Spouses find it difficult to know when their partner with M.C.I. is acting differently (usually badly) due to the advancing illness or due to ‘willful’ personality issues,” said Dr. Dale, citing a 2007 study in the journal Family Relations exploring the problems this can create for couples.

Blaming is often easier than understanding. Another of Dr. Gwyther’s patients was furious at her husband for not filing their taxes. “He’s a C.P.A.,” she said. “How could we owe back taxes?” It did not occur to her that he might be unable to handle that task — and was too frightened about his deteriorating mental focus to let her know.

But as harmful as mental decline can be for a marriage, it is just part of the equation. Physical ailments – even those that seem completely unrelated to marital relations – “can upset the equilibrium of the marriage,” according to a study in the Canadian Medical Association Journal.

“Most men get angry at what’s happened to them when they get ill, women get angry and scared when he’s not what he used to be — so they fight,” said Dr. Schlossberg.

Chronic illnesses, like diabetes, arthritis and heart disease, can have a strong negative effect on mood, said Dr. Waite, who will soon be publishing a study on the subject. Diabetes is so often accompanied by depression that, Dr. Waite said, “one of my colleagues argues that that it is even part of the disease.”

And ailments can have an effect on a couple’s sex life — which can compound the marital problems, doctors said.

“Diabetes brings on neuropathy,” said Dr. Waite. “That means touching and feeling in sex is not as rewarding.” Without the pleasures of affectionate touching — whether a passing hug at the sink, or more — tensions can build. That’s why, if a couple is having problems with sex, they are more likely to have problems in the relationship — and vice versa, according to a 2007 New England Journal of Medicine study of sex and health among older adults.

Other changes in circumstances — retirement, shifting roles, the loss of autonomy, disparities in health and abilities — can wreak havoc. Losing independence can feel like losing oneself — and if you don’t know who you are any more, how can you know how to relate to your spouse?

“Fighting may come from a misguided notion that you can regain power by asserting it over your spouse,” said Dr. Schlossberg, whose observations are echoed in a 1984 study in the Canadian Journal of Medicine. “It doesn’t work, it’s false power – but they’ll try anything.”

The sheer exhaustion that can come from being the caregiving spouse is also bound to “make them stressed and angry,” said Dr. Waite. Not to mention guilty and resentful — never a prescription for happy marital relations.

“Part of the trap for the caregiver is the idea that you have to do it all, and the guilt you feel when you cannot live up to it,” said Dr. Gordon Herz, a psychologist in private practice in Madison, Wisc. Not surprisingly, resentment can soon follow, Dr. Herz added, because it’s hard to admit to anyone that, “‘this is too much for me.’”

What can outside caregivers — children or other loved ones — do about these golden marriages on the rocks? Should they intervene — or butt out? And can marital therapy help — or is it too late to change?

Share your thoughts and experiences — and tomorrow we’ll try to provide some advice from experts.

Read More..

In Europe, a Push for Higher Phone Fees

BERLIN — When the authorities have tinkered with European telecommunications rules, it has usually been to lower prices for consumers, whether through retail price controls on mobile roaming fees or mandatory cuts in regulated interconnection charges.

But this year, to encourage more investment in high-speed broadband networks, regulators are considering helping the biggest operators increase a main source of income: the rent they receive from rivals that lease their landline grids.

The architect of the plan, Neelie Kroes, the European Union’s digital agenda commissioner, has pitched the increases as part of a broader package to stimulate spending while preserving competition and consumer choice.

The plan, however, has alarmed operators that would have to pay the higher charges, like the British mobile operator Vodafone. Vittorio Colao, chief executive of Vodafone, said that the plan to increase the fees collected by former monopolies, including BT, Deutsche Telekom, France Télécom, KPN, Telecom Italia and Telefónica, could lead to a “re-monopolization” of the business.

Mr. Colao said he was worried that landline operators would use the additional revenue to lower their own prices and try to squeeze competitors like Vodafone.

“Increasing the incentive to invest is a good thing,” Mr. Colao said. But now Ms. Kroes must “demonstrate that these new criteria won’t contaminate the competitive arena in Europe,” he said.

Under the plan, the European Commission, the executive arm of the European Union, would begin regulating the fees that mobile operators routinely pay to lease the grids of landline operators.

In much of the world, running telecommunications lines to homes and businesses has traditionally been the domain of a local monopoly, or sometimes a duopoly in the case of telephones and cable television in the United States. Until 1998, countries in the European Union were allowed to maintain national monopolies for this “local loop” to the consumer.

With deregulation, however, the former monopolies were required to unbundle the cost of the local loop and offer it to competitors, thus allowing companies like Vodafone to enter the market.

Despite 14 years of deregulation, and the addition of more than 100 mobile operators in Europe, the former monopolies still supply the majority of fixed-line services in their home countries. In Spain, Telefónica has more than 70 percent of this business.

Until now, these unbundling rates have been set by national regulators, and the average monthly cost per customer in the European Union stands at €8.62, or $11.35. The fee typically makes up a third or more of monthly landline phone bills in Europe and also influences wireless prices because it affects mobile operator costs. The fee ranges from €4.20 in Slovakia to €12.41 in Ireland.

Mrs. Kroes proposed to lower, not raise, unbundling fees in September 2011, to make the old landline networks less profitable for big operators and to encourage them to invest in new networks. But the former monopolies protested, and after personal appeals from executives at big operators, in some cases accompanied by their investors, she reversed course.

Ms. Kroes is proposing that each country within the European Union be required to set its fee within the range of €8 to €10 per month, according to a copy of her proposal obtained by the International Herald Tribune. The new range would most likely require 10 E.U. countries where the fee is currently below this range to raise it, in some cases only slightly, and in others, sharply.

The increases would in all likelihood be passed on to consumers. The rise in fees could be greatest in Eastern Europe, where regulators have been most aggressive in setting low leasing rates to encourage competition. The level of leasing charges could double in Estonia, Latvia, Poland and Slovakia.

Mr. Colao, the Vodafone chief executive, said Ms. Kroes needed to tighten the legal safeguards in her plan to prevent big operators from exploiting access to landline networks.

Read More..

Darjeeling Journal: Darjeeling Tea Growers Get Protection From E.U.

Enrico Fabian for The New York Times

A woman on the Sungma Tea Estate in Darjeeling, India, where growers have followed the example of Scottish whisky distillers and French wineries in limiting the use of certain geographic names to products from those places. More Photos »

DARJEELING, India — Among connoisseurs, few teas surpass a good Darjeeling. The smooth and mellow taste commands a premium price, and the name itself evokes a bygone era when the British first introduced Chinese tea plants here in the Indian foothills of the Himalayas.

To Anil K. Jha, the superintendent of the Sungma Tea Estate, all this would be extremely good for business, except that much of the tea sold globally as Darjeeling is not actually grown here. Foreign wholesalers often put the name on a blend of the real stuff and lesser teas. And in some cases, growers elsewhere simply slap a Darjeeling label on their tea.

So Mr. Jha and other Darjeeling growers have followed the example of Scottish whisky distillers and French wineries, winning legal protection for the Darjeeling label under laws that limit the use of certain geographic names to products that come from those places.

In a decision this year, the European Union agreed to phase out the use of “Darjeeling” on blended teas. Now, just as a bottle of Cognac must come from the region around the French town of Cognac, a cup of Darjeeling tea will have to be made only from tea grown around Darjeeling.

“That flavor, that uniqueness that comes from here — it is nowhere else,” Mr. Jha said as he stood among manicured tea bushes on a hillside about 5,000 feet above sea level, near the border with Nepal. “People have tried to replicate it, but have failed,” he said.

The uniqueness of Darjeeling as a place certainly seems beyond dispute. On clear days, the white peaks of Kanchenjunga, the world’s third-highest mountain after Everest and K2, floats over the hilltop city like an ethereal fortress. Beyond the clamor of the city, many of the steep surrounding foothills are carpeted with tea estates, some planted more than 160 years ago when a British surgeon found that tea bushes thrived in the region’s alpine setting.

The mountainous terrain also limits production. India produces almost two billion pounds of tea annually, more than any other country, but Darjeeling accounts for only about 1 percent of that output. The Darjeeling district has 87 certified tea gardens, as they are locally known, producing about 20 million pounds of tea every year, and the potential for expansion is almost nil.

That is why local tea growers grew annoyed that as much as 88 million pounds of tea were being sold as Darjeeling on the global market each year.

“Darjeeling tea has always been more expensive,” said Ranen Datta, a longtime adviser to local tea growers, noting that the wholesale price is about five times that of ordinary teas. “And we found that sellers all over the world were selling tea under the name Darjeeling.”

And not only tea: A French company that makes lingerie has fought legal battles with the Tea Board of India to keep using the name.

“This brand name, Darjeeling, was being misused,” Mr. Jha said. “The basic interest of Darjeeling was being killed.”

Local tea growers had already fought to save their product from the vagaries of cold war politics. During the era of British rule, Darjeeling tea was shipped mainly to Europe, which remained the primary market after Indian independence in 1947, when Darjeeling’s tea gardens shifted from British to Indian ownership.

But as India drew politically closer to the Soviet Union, a deal to sell tea to Moscow ushered in a dark period for Darjeeling. The Soviets ordered in bulk and mixed Darjeeling with pedestrian teas from Soviet satellite countries so it could be marketed more widely.

“Russians were not particular about the quality of Darjeeling,” Mr. Datta said. “They took it if it was clear and black.”

Growers saturated their tea gardens with chemicals and pesticides to maximize output, and annual production rose to about 29 million pounds. But when the Soviet Union dissolved in 1991, so did the export deal, leaving Darjeeling with a crop it had trouble selling in Europe, where many customers, especially in Germany, were aghast at the chemical use.

“There were no buyers,” Mr. Jha recalled. “It took a long time to revive the image of Darjeeling.”

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As Gold Is Spirited Out of Afghanistan, Officials Wonder Why

Zalmai for The New York Times

A Kabul jewelry shop. Officials are concerned about gold being flown out of Afghanistan.

KABUL, Afghanistan — Packed into hand luggage and tucked into jacket pockets, roughly hewed bars of gold are being flown out of Kabul with increasing regularity, confounding Afghan and American officials who fear money launderers have found a new way to spirit funds from the country.

Most of the gold is being carried on commercial flights destined for Dubai, according to airport security reports and officials. The amounts carried by single couriers are often heavy enough that passengers flying from Kabul to the Persian Gulf emirate would be well advised to heed warnings about the danger of bags falling from overhead compartments. One courier, for instance, carried nearly 60 pounds of gold bars, each about the size of an iPhone, aboard an early morning flight in mid-October, according to an airport security report. The load was worth more than $1.5 million.

The gold is fully declared and legal to fly. Some, if not most, is legitimately being sent by gold dealers seeking to have old and damaged jewelry refashioned into new pieces by skilled craftsmen in the Persian Gulf, said Afghan officials and gold dealers.

But gold dealers in Kabul and current and former Kabul airport officials say there has been a surge in shipments since early summer. The talk of a growing exodus of gold from Afghanistan has been spreading among the business community here, and in recent weeks has caught the attention of Afghan and American officials. The officials are now puzzling over the origin of the gold — very little is mined in Afghanistan, although larger mines are planned — and why so much appears to be heading for Dubai.

“We are investigating it, and if we find this is a way of laundering money, we will intervene,” said Noorullah Delawari, the governor of Afghanistan’s central bank. Yet he acknowledged that there were more questions than answers at this point. “I don’t know where so much gold would come from, unless you can tell me something about it,” he said in an interview. Or, as a European official who tracks the Afghan economy put it, “new mysteries abound” as the war appears to be drawing to a close.

Figuring out what precisely is happening in the Afghan economy remains as confounding as ever. Nearly 90 percent of the financial activity takes place outside formal banks. Written contracts are the exception, receipts are rare and statistics are often unreliable. Money laundering is commonplace, say Western and Afghan officials.

As a result, with the gold, “right now you’re stuck in that situation we usually are: is there something bad going on here or is this just the Afghan way of commerce?” said a senior American official who tracks illicit financial networks.

There is reason to be suspicious: the gold shipments track with the far larger problem of cash smuggling. For years, flights have left Kabul almost every day carrying thick wads of bank notes — dollars, euros, Norwegian kroner, Saudi Arabian riyals and other currencies — stuffed into suitcases, packed into boxes and shrink-wrapped onto pallets. At one point, cash was even being hidden in food trays aboard now-defunct Pamir Airways flights to Dubai.

Last year alone, Afghanistan’s central bank says, roughly $4.5 billion in cash was spirited out through the airport. Efforts to stanch the flow have had limited impact, and concerns about money laundering persist, according to a report released last week by the United States Special Inspector General for Afghanistan Reconstruction.

The unimpeded “bulk cash flows raise the risk of money laundering and bulk cash smuggling — tools often used to finance terrorist, narcotics and other illicit operations,” the report said. The cash, and now the gold, is most often taken to Dubai, where officials are known for asking few questions. Many wealthy Afghans park their money and families in the emirate, and gold dealers say more middle-class Afghans are sending money and gold — seen as a safeguard against economic ruin — to Dubai as talk of a postwar economic collapse grows louder.

But given Dubai’s reputation as a haven for laundered money, an Afghan official said that the “obvious suspicion” is that at least some of the apparent growth in gold shipments to Dubai is tied to the myriad illicit activities — opium smuggling, corruption, Taliban taxation schemes — that have come to define Afghanistan’s economy.

There are also indications that Iran could be dipping into the Afghan gold trade. It is already buying up dollars and euros here to circumvent American and European sanctions, and it may be using gold for the same purpose.

Yahya, a dealer in Kabul, said other gold traders were helping Iran buy the precious metal here. Payment was being made in oil or with Iranian rials, which readily circulate in western Afghanistan. The Afghan dealers are then taking it to Dubai, where the gold is sold for dollars. The money is then moved to China, where it was used to buy needed goods or simply funneled back to Iran, said Yahya, who like many Afghans uses a single name.

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Dr. William F. House, Inventor of Cochlear Implant, Dies

Dr. William F. House, a medical researcher who braved skepticism to invent the cochlear implant, an electronic device considered to be the first to restore a human sense, died on Dec. 7 at his home in Aurora, Ore. He was 89.

The cause was metastatic melanoma, his daughter, Karen House, said.

Dr. House pushed against conventional thinking throughout his career. Over the objections of some, he introduced the surgical microscope to ear surgery. Tackling a form of vertigo that doctors had believed was psychosomatic, he developed a surgical procedure that enabled the first American in space to travel to the moon. Peering at the bones of the inner ear, he found enrapturing beauty.

Even after his ear-implant device had largely been supplanted by more sophisticated, and more expensive, devices, Dr. House remained convinced of his own version’s utility and advocated that it be used to help the world’s poor.

Today, more than 200,000 people in the world have inner-ear implants, a third of them in the United States. A majority of young deaf children receive them, and most people with the implants learn to understand speech with no visual help.

Hearing aids amplify sound to help the hearing-impaired. But many deaf people cannot hear at all because sound cannot be transmitted to their brains, however much it is amplified. This is because the delicate hair cells that line the cochlea, the liquid-filled spiral cavity of the inner ear, are damaged. When healthy, these hairs — more than 15,000 altogether — translate mechanical vibrations produced by sound into electrical signals and deliver them to the auditory nerve.

Dr. House’s cochlear implant electronically translated sound into mechanical vibrations. His initial device, implanted in 1961, was eventually rejected by the body. But after refining its materials, he created a long-lasting version and implanted it in 1969.

More than a decade would pass before the Food and Drug Administration approved the cochlear implant, but when it did, in 1984, Mark Novitch, the agency’s deputy commissioner, said, “For the first time a device can, to a degree, replace an organ of the human senses.”

One of Dr. House’s early implant patients, from an experimental trial, wrote to him in 1981 saying, “I no longer live in a world of soundless movement and voiceless faces.”

But for 27 years, Dr. House had faced stern opposition while he was developing the device. Doctors and scientists said it would not work, or not work very well, calling it a cruel hoax on people desperate to hear. Some said he was motivated by the prospect of financial gain. Some criticized him for experimenting on human subjects. Some advocates for the deaf said the device deprived its users of the dignity of their deafness without fully integrating them into the hearing world.

Even when the American Academy of Ophthalmology and Otolaryngology endorsed implants in 1977, it specifically denounced Dr. House’s version. It recommended more complicated versions, which were then under development and later became the standard.

But his work is broadly viewed as having sped the development of implants and enlarged understanding of the inner ear. Jack Urban, an aerospace engineer, helped develop the surgical microscope as well as mechanical and electronic aspects of the House implant.

Karl White, founding director of the National Center for Hearing Assessment and Management, said in an interview that it would have taken a decade longer to invent the cochlear implant without Dr. House’s contributions. He called him “a giant in the field.”

After embracing the use of the microscope in ear surgery, Dr. House developed procedures — radical for their time — for removing tumors from the back portion of the brain without causing facial paralysis; they cut the death rate from the surgery to less than 1 percent from 40 percent.

He also developed the first surgical treatment for Meniere’s disease, which involves debilitating vertigo and had been viewed as a psychosomatic condition. His procedure cured the astronaut Alan B. Shepard Jr. of the disease, clearing him to command the Apollo 14 mission to the moon in 1971. In 1961, Shepard had become the first American launched into space.

In presenting Dr. House with an award in 1995, the American Academy of Otolaryngology-Head and Neck Surgery Foundation said, “He has developed more new concepts in otology than almost any other single person in history.”

William Fouts House was born in Kansas City, Mo., on Dec. 1, 1923. When he was 3 his family moved to Whittier, Calif., where he grew up on a ranch. He did pre-dental studies at Whittier College and the University of Southern California, and earned a doctorate in dentistry at the University of California, Berkeley. After serving his required two years in the Navy — and filling the requisite 300 cavities a month — he went back to U.S.C. to pursue an interest in oral surgery. He earned his medical degree in 1953. After a residency at Los Angeles County Hospital, he joined the Los Angeles Foundation of Otology, a nonprofit research institution founded by his brother, Howard. Today it is called the House Research Institute.

Many at the time thought ear surgery was a declining field because of the effectiveness of antibiotics in dealing with ear maladies. But Dr. House saw antibiotics as enabling more sophisticated surgery by diminishing the threat of infection.

When his brother returned from West Germany with a surgical microscope, Dr. House saw its potential and adopted it for ear surgery; he is credited with introducing the device to the field. But again there was resistance. As Dr. House wrote in his memoir, “The Struggles of a Medical Innovator: Cochlear Implants and Other Ear Surgeries” (2011), some eye doctors initially criticized his use of a microscope in surgery as reckless and unnecessary for a surgeon with good eyesight.

Dr. House also used the microscope as a research tool. One night a week he would take one to a morgue for use in dissecting ears to gain insights that might lead to new surgical procedures. His initial reaction, he said, was how beautiful the bones seemed; he compared the experience to one’s first view of the Grand Canyon. His wife, the former June Stendhal, a nurse, often helped.

She died in 2008 after 64 years of marriage. In addition to his daughter, Dr. House is survived by a son, David; three grandchildren; and two great-grandchildren.

The implant Dr. House invented used a single channel to deliver information to the hearing system, as opposed to the multiple channels of competing models. The 3M Company, the original licensee of the House implant, sold its rights to another company, the Cochlear Corporation, in 1989. Cochlear later abandoned his design in favor of the multichannel version.

But Dr. House continued to fight for his single-electrode approach, saying it was far cheaper, and offered voluminous material as evidence of its efficacy. He had hoped to resume production of it and make it available to the poor around the world.

Neither the institute nor Dr. House made any money on the implant. He never sought a patent on any of his inventions, he said, because he did not want to restrict other researchers. A nephew, Dr. John House, the current president of the House institute, said his uncle had made the deal to license it to the 3M Company not for profit but simply to get it built by a reputable manufacturer.

Reflecting on his business decisions in his memoir, Dr. House acknowledged, “I might be a little richer today.”

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Egypt Votes on Constitution; Muslim Brotherhood Expects Approval

Lynsey Addario for The New York Times

A polling site in Cairo on Saturday. Lines were long as a referendum on an Islamist-backed charter got off to an orderly start. More Photos »

CAIRO — Millions of Egyptians voted peacefully on Saturday in a referendum on an Islamist-backed draft constitution, hoping that the results would end three weeks of violence, division and distrust between the Islamists and their opponents over the ground rules of Egypt’s promised democracy.

The Muslim Brotherhood, the main Islamist group aligned with President Mohamed Morsi, predicted a big win for ratification. In the districts that voted Saturday, including the opposition strongholds of Cairo and Alexandria, about 57 percent approved the new constitution, according to preliminary tallies by state media early Sunday morning.

Half of the country will vote next Saturday, but in predominantly rural areas that are expected to heavily favor the charter. The emergence on Sunday of the relatively narrow margin of victory for the charter so far, combined with low turnout — 33 percent, according to the unofficial tallies, down from 41 percent in a referendum on a temporary constitution last year — seemed likely to embolden the non-Islamist opposition that has called for Mr. Morsi to scrap the charter and convene a new constitutional assembly.

A spokesman for the main coalition opposing the charter said that it had found widespread irregularities and that its leaders would speak later on Sunday. In Cairo, the biggest city, about 56 percent voted no, according to an unofficial tally by the Muslim Brotherhood.

Regardless of the results, the orderly balloting and long lines marked yet another turning point for Egypt’s nearly two-year-old revolution. After three weeks of violence and threats of a boycott, millions of voters appeared for the moment to pull back from the brink of civil discord and reaffirm their trust in the ballot box, spending hours in long lines to vote in the sixth national election since the ouster of Hosni Mubarak 22 months ago.

It remained to be seen if the losing side would accept the results, or how long the peace might last. Many who voted yes said they were doing so to end the chaos of the transition rather than to endorse the text of the charter. Despite opposition warnings of chaos, the streets of the capital were free of major protests for the first time in weeks.

And if the constitution is approved by the margins his supporters predict, the smooth vote could fortify Mr. Morsi’s power and legitimacy.

Military officers guarded polling places, and there were few reports of violence. Egyptian state media reported nine injuries in clashes around the Nile Delta town of Dakahleya, and that unknown assailants threw Molotov cocktails near the headquarters of a liberal party that had been part of the opposition under Mr. Mubarak.

As they waited in line to vote, neighbors continued to spar over the contentious process that produced the charter. Some said that it had been unfairly steamrolled by Egypt’s new Islamist leaders over the objections of other parties and the Coptic Christian Church, and that as a result the new charter failed to protect fundamental rights.

Others blamed the Islamists’ opponents for refusing to negotiate, in an effort to undermine democracy because they could not win at the ballot box. Many expressed discontent with political leaders on both sides.

“Neither group can accept its opposition,” said Ahmed Ibrahim, 40, a government clerk waiting to vote in a middle-class neighborhood in the Nasr City area of Cairo. Whatever the outcome, he said, “one group in their hearts will feel wronged, and the other group will gloat over their victory, and so the wounds will remain.”

The referendum once promised to be a day when Egyptians realized the visions of democracy, pluralism and national unity that defined the 18-day revolt against Mr. Mubarak. But then came nearly two years of chaotic political transition in which Islamists, liberals, leftists, the military and the courts all jockeyed for power over an ever-shifting timetable.

The document that Egyptians voted on was a rushed revision of the old Mubarak charter, pushed through an Islamist-dominated assembly in an all-night session, after Christian and secular representatives quit in protest. Many international experts faulted the charter as a missed opportunity, stuffed with broad statements about Egyptian identity but riddled with loopholes regarding the protection of rights.

Mayy El Sheikh and Mai Ayyad contributed reporting.

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Microsoft Battles Google by Hiring Political Brawler Mark Penn

SEATTLE — Mark Penn made a name for himself in Washington by bulldozing enemies of the Clintons. Now he spends his days trying to do the same to Google, on behalf of its archrival Microsoft.

Since Mr. Penn was put in charge of “strategic and special projects” at Microsoft in August, much of his job has involved efforts to trip up Google, which Microsoft has failed to dislodge from its perch atop the lucrative Internet search market.

Drawing on his background in polling, data crunching and campaigning, Mr. Penn created a holiday commercial that has been running during Monday Night Football and other shows, in which Microsoft criticizes Google for polluting the quality of its shopping search results with advertisements. “Don’t get scroogled,” it warns. His other projects include a blind taste test, Coke-versus-Pepsi style, of search results from Google and Microsoft’s Bing.

The campaigns by Mr. Penn, 58, a longtime political operative known for his brusque personality and scorched-earth tactics, are part of a broader effort at Microsoft to give its marketing the nimbleness of a political campaign, where a candidate can turn an opponent’s gaffe into a damaging commercial within hours. They are also a sign of the company’s mounting frustration with Google after losing billions of dollars a year on its search efforts, while losing ground to Google in the browser and smartphones markets and other areas.

Microsoft has long attacked Google from the shadows, whispering to regulators, journalists and anyone else who would listen that Google was a privacy-violating, anticompetitive bully. The fruits of its recent work in this area could come next week, when the Federal Trade Commission is expected to announce the results of its antitrust investigation of Google, a case that echoes Microsoft’s own antitrust suit in the 1990s. A similar investigation by the European Union is also wrapping up. A bad outcome for Google in either one would be a victory for Microsoft.

But Microsoft, based in Redmond, Wash., has realized that it cannot rely only on regulators to scrutinize Google — which is where Mr. Penn comes in. He is increasing the urgency of Microsoft’s efforts and focusing on their more public side.

In an interview, Mr. Penn said companies underestimated the importance of policy issues like privacy to consumers, as opposed to politicians and regulators. “It’s not about whether they can get them through Washington,” he said. “It’s whether they can get them through Main Street.”

Jill Hazelbaker, a Google spokeswoman, declined to comment on Microsoft’s actions specifically, but said that while Google also employed lobbyists and marketers, “our focus is on Google and the positive impact our industry has on society, not the competition.”

In Washington, Mr. Penn is a lightning rod. He developed a relationship with the Clintons as a pollster during President Bill Clinton’s 1996 re-election campaign, when he helped identify the value of “soccer moms” and other niche voter groups.

As chief strategist for Hillary Clinton’s unsuccessful 2008 campaign for president, he conceived the “3 a.m.” commercial that raised doubts about whether Barack Obama, then a senator, was ready for the Oval Office. Mr. Penn argued in an essay he wrote for Time magazine in May that “negative ads are, by and large, good for our democracy.”

But his approach has ended up souring many of his professional relationships. He left Mrs. Clinton’s campaign after an uproar about his consulting work for the government of Colombia, which was seeking the passage of a trade treaty with the United States that Mrs. Clinton, then a senator, opposed.

“Google should be prepared for everything but the kitchen sink thrown at them,” said a former colleague who worked closely with Mr. Penn in politics and spoke on condition of anonymity. “Actually, they should be prepared for the kitchen sink to be thrown at them, too.”

Hiring Mr. Penn demonstrates how seriously Microsoft is taking this fight, said Michael A. Cusumano, a business professor at M.I.T. who co-wrote a book about Microsoft’s browser war.

“They’re pulling out all the stops to do whatever they can to halt Google’s advance, just as their competition did to them,” Professor Cusumano said. “I suppose that if Microsoft can actually put a doubt in people’s mind that Google isn’t unbiased and has become some kind of evil empire, they might very well get results.”

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

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The Neediest Cases: Disabled Young Man and His Protective Mother Deal With Life’s Challenges

Though he would prefer to put his socks on without his mother’s help, Zaquan West, 25, does not have a choice.

Michelle V. Agins/The New York Times

Joann West is a constant caretaker for her son, Zaquan. Though Ms. West works as a receptionist, the family fell behind on rent.

For the past 100 years, The New York Times Neediest Cases Fund has provided direct assistance to children, families and the elderly in New York. To celebrate the 101st campaign, an article will appear daily through Jan. 25. Each profile will illustrate the difference that even a modest amount of money can make in easing the struggles of the poor.

Last year donors contributed $7,003,854, which was distributed to those in need through seven New York charities.

2012-13 Campaign

Previously recorded:

$3,104,694

Recorded Thursday:

$137,451

*Total:

$3,242,145

Last year to date:

$2,862,836

*Includes $596,609 contributed to the Hurricane Sandy relief efforts.

The Youngest Donors

If your child or family is using creative techniques to raise money for this year’s campaign, we want to hear from you. Drop us a line on Facebook or talk to us on Twitter.

A genetic disorder has encumbered Mr. West all his life, but he has needed assistance with this particular task since only last year. In November 2011, he had surgery to remove a cancerous tumor on his left thigh that was as big as a football, but he was left less flexible.

“He doesn’t do well with disability, with the label,” his mother, Joann West, 55, said. “He doesn’t tell people that he has a disability. If they can’t see it, they just can’t see it.”

When her son was 13 months old, Ms. West learned he had neurofibromatosis, a disorder that causes tumors to grow on the nerves and, in some cases, to infringe on vital organs, or as was the case last year, to become malignant. It also creates large bumps on the skin known as nodules.

At ages 5 and 8, Zaquan had operations to remove neurofibromatosis clusters that were eating away at his left hip bone. The disease has left his left leg a few inches shorter than his right. After each operation, he had to relearn how to walk.

Because of his physical disability, he was placed in a special-education class at school and given the same homework every night, his mother said.

“I advocated for him,” Ms. West said. “I kept fighting, because he was no dummy. He was physically impaired, not mentally. I went out of my way to try to give him a better life. The system would have failed him more than it did if I hadn’t stepped in.” Her efforts led to his being moved from a special-education classroom to a regular one in second grade.

Ms. West, a single mother, acknowledges that her protective instincts made her a very controlling parent, and she did not allow Zaquan out of the house much, which limited his friendships.

“I was afraid for him,” she said. “The streets, they don’t care about your disability.”

When Mr. West entered high school, it was the first time he had truly been away from his mother’s watchful eyes. He began skipping class, often going to the park or wandering their Bedford-Stuyvesant, Brooklyn, neighborhood with truant friends. He eventually dropped out of school.

“It was just me being out on my own and making my own choices,” Mr. West recalled.

Though she did not agree with her son’s decisions, Ms. West said that his need to explore was in some ways a result of her actions. “At a point, I stepped back,” she said, “to allow him to do certain things on his own and do what he wanted to do.”

In 2007, a couple of years after he dropped out, Mr. West joined the Door, an organization focused on empowering young people to reach their potential. There, he obtained his high school equivalency diploma.

Today, Mr. West is job hunting so that he can help pay his and his mother’s expenses.

But paying the monthly bills has become a struggle, Ms. West said, in part because of a recent change in her budget. In August, after an increase in income, they stopped receiving $324 a month in food stamps. The additional income did not cover all their expenses, however, and Ms. West eventually fell behind in the rent on their apartment.

Ms. West, who has been employed in various administrative jobs, currently works as a receptionist for Howie the Harp Advocacy Center, an agency that provides employment help to people with psychiatric disabilities. Her annual salary is about $25,000 before taxes. Her son receives $646 in Social Security disability benefits. After the family’s food stamps were cut off, Mr. West applied individually, and he now receives $200 in food stamps each month.

With the addition of Mr. West’s disability benefits and food stamps, their net monthly income is $2,213. Their contribution for the Section 8-subsidized apartment Ms. West has lived in for the past 30 years is $969.

Knowing she was in need of help, Ms. West’s boss told her about the Community Service Society, one of the organizations supported by The New York Times Neediest Cases Fund. And the society drew $1,598 from the fund to cover her debt.

Ms. West remains a constant caretaker for her independent-minded son, who, she says, has come to accept her help grudgingly. She says that even if they are not on speaking terms after a disagreement, she is there to lend him a hand.

Both are continuing to deal with the inevitable challenges: Mr. West is awaiting word from doctors on whether a new growth in his lungs is cancerous. But one of his greatest assets, given all that he has overcome, is that he is comfortable in his own skin.

“I’m just always going to be me,” he said, “so why deal with somebody else?”

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Microsoft Battles Google by Hiring Political Brawler Mark Penn

SEATTLE — Mark Penn made a name for himself in Washington by bulldozing enemies of the Clintons. Now he spends his days trying to do the same to Google, on behalf of its archrival Microsoft.

Since Mr. Penn was put in charge of “strategic and special projects” at Microsoft in August, much of his job has involved efforts to trip up Google, which Microsoft has failed to dislodge from its perch atop the lucrative Internet search market.

Drawing on his background in polling, data crunching and campaigning, Mr. Penn created a holiday commercial that has been running during Monday Night Football and other shows, in which Microsoft criticizes Google for polluting the quality of its shopping search results with advertisements. “Don’t get scroogled,” it warns. His other projects include a blind taste test, Coke-versus-Pepsi style, of search results from Google and Microsoft’s Bing.

The campaigns by Mr. Penn, 58, a longtime political operative known for his brusque personality and scorched-earth tactics, are part of a broader effort at Microsoft to give its marketing the nimbleness of a political campaign, where a candidate can turn an opponent’s gaffe into a damaging commercial within hours. They are also a sign of the company’s mounting frustration with Google after losing billions of dollars a year on its search efforts, while losing ground to Google in the browser and smartphones markets and other areas.

Microsoft has long attacked Google from the shadows, whispering to regulators, journalists and anyone else who would listen that Google was a privacy-violating, anticompetitive bully. The fruits of its recent work in this area could come next week, when the Federal Trade Commission is expected to announce the results of its antitrust investigation of Google, a case that echoes Microsoft’s own antitrust suit in the 1990s. A similar investigation by the European Union is also wrapping up. A bad outcome for Google in either one would be a victory for Microsoft.

But Microsoft, based in Redmond, Wash., has realized that it cannot rely only on regulators to scrutinize Google — which is where Mr. Penn comes in. He is increasing the urgency of Microsoft’s efforts and focusing on their more public side.

In an interview, Mr. Penn said companies underestimated the importance of policy issues like privacy to consumers, as opposed to politicians and regulators. “It’s not about whether they can get them through Washington,” he said. “It’s whether they can get them through Main Street.”

Jill Hazelbaker, a Google spokeswoman, declined to comment on Microsoft’s actions specifically, but said that while Google also employed lobbyists and marketers, “our focus is on Google and the positive impact our industry has on society, not the competition.”

In Washington, Mr. Penn is a lightning rod. He developed a relationship with the Clintons as a pollster during President Bill Clinton’s 1996 re-election campaign, when he helped identify the value of “soccer moms” and other niche voter groups.

As chief strategist for Hillary Clinton’s unsuccessful 2008 campaign for president, he conceived the “3 a.m.” commercial that raised doubts about whether Barack Obama, then a senator, was ready for the Oval Office. Mr. Penn argued in an essay he wrote for Time magazine in May that “negative ads are, by and large, good for our democracy.”

But his approach has ended up souring many of his professional relationships. He left Mrs. Clinton’s campaign after an uproar about his consulting work for the government of Colombia, which was seeking the passage of a trade treaty with the United States that Mrs. Clinton, then a senator, opposed.

“Google should be prepared for everything but the kitchen sink thrown at them,” said a former colleague who worked closely with Mr. Penn in politics and spoke on condition of anonymity. “Actually, they should be prepared for the kitchen sink to be thrown at them, too.”

Hiring Mr. Penn demonstrates how seriously Microsoft is taking this fight, said Michael A. Cusumano, a business professor at M.I.T. who co-wrote a book about Microsoft’s browser war.

“They’re pulling out all the stops to do whatever they can to halt Google’s advance, just as their competition did to them,” Professor Cusumano said. “I suppose that if Microsoft can actually put a doubt in people’s mind that Google isn’t unbiased and has become some kind of evil empire, they might very well get results.”

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

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