The New Old Age Blog: Who Should Receive Organ Transplants?

Joe Gammalo had been contending with pulmonary fibrosis, a scarring of the lungs, for more than a decade when he came to the Cleveland Clinic in 2008 seeking a lung transplant.

“It had gotten to the point where I was on oxygen all the time and in a wheelchair,” he told me in an interview. “I didn’t expect to live.”

Lung transplants are a dicey proposition, involving a huge surgical procedure, arduous follow-up, the lifelong use of potent immunosuppressive drugs and high rates of serious side effects. “It’s not like taking out an appendix,” said Dr. Marie Budev, the medical director of the clinic’s lung transplant program.

Only 50 to 57 percent of all recipients live for five years, she noted, and they will still die of their disease. But there’s no other treatment for pulmonary fibrosis.

Some medical centers would have turned Mr. Gammalo away. Because survival rates are even lower for older patients, guidelines from the International Society for Heart and Lung Transplantation caution against lung transplants for those over 65, though they set no age limit.

But “we are known as an aggressive, high-risk center,” said Dr. Budev. So Mr. Gammalo was 66 when he received a lung; his newly found buddy, Clyde Conn, who received the other lung from the same donor, was 69.

You can’t mistake the trend: A graying population and revised policies determining who gets priority for donated organs, have led to a rising proportion of older adults receiving transplants.

My colleague Judith Graham has reported on the increase in heart transplants, but the pattern extends to other organs, too.

The number of kidney transplants performed annually on adults over 65 tripled between 1998 and last year, according to data from the Scientific Registry of Transplant Recipients. In 2001, 7.4 percent of liver transplant recipients were over 65; last year, that rose to 13 percent.

The rise in elderly lung transplant candidates is particularly dramatic because, since 2005, a “lung allocation score” puts those at the highest mortality risk, rather than those who’ve waited longest, at the top of the list.

In 2001, about 3 percent of those on the wait list and of those transplanted were over 65; last year, older patients represented almost 18 percent of wait-listed candidates and more than a quarter of transplant recipients. (Medicare pays for the surgery, though patients face co-pays and considerable out-of-pocket costs, including for drugs and travel.)

The debate has grown, too: When the number of adults awaiting transplants keeps growing, but organ donations stay flat, is it desirable or even ethical that an increasing proportion of recipients are elderly?

Dr. Budev, who estimated that a third of her program’s patients are over 65, votes yes. As long as a program selects candidates carefully, “how can you deny them a therapy?” she asked. So the Cleveland Clinic has no age limit. “We feel that everyone should have a chance.”

At the University of Michigan, by contrast, the age limit remains 65, though Dr. Kevin Chan, the transplant program’s medical director, acknowledged that some fit older patients get transplanted.

“You can talk about this all day — it’s a tough one,” Dr. Chan said. Younger recipients have greater physiologic reserve to aid in the arduous recovery; older ones face higher risk of subsequent kidney failure, stroke, diabetes and other diseases, and, of course, their lifespans are shorter to begin with.

Donated lungs, fragile and prone to injury, are a particularly scarce commodity. Last year, surgeons performed 16,055 kidney transplants, 5,805 liver transplants and 1,949 heart transplants. Only1,830 patients received lung transplants.

“What if there’s a 35-year-old on a ventilator who needs the lung just as much?” Dr. Chan said. “Why should a 72-year-old possibly take away a lung from a 35-year-old?” Yet, he acknowledged, “it’s easy to look at the statistics and say, ‘Give the lungs to younger patients.’ At the bedside, when you meet this patient and family, it’s a lot different.”

These questions about who deserves scarce resources — those most likely to die without them? or those most likely to live longer with them? — will persist as the population ages. They’re also likely to arise when the International Society for Heart and Lung Transplantation begins working towards revised guidelines this spring. (I’d also like to hear your take, below.)

Lots of 65- and 75-year-olds are very healthy. Yet transplants themselves can cause harm and there’s no backup, like dialysis. Without the transplant, they die. But when the transplant goes wrong, they also die.

More than four years post-transplant, the Cleveland Clinic’s “lung brothers” are success stories. Mr. Conn, who lives near Dayton, Ohio, can’t walk very far or lift more than 10 pounds, but he works part time as a real-estate appraiser and enjoys cruises with his wife.

Mr. Gammalo, a onetime musician, has developed diabetes, like nearly half of all lung recipients. But he went onstage a few weeks back to sing “Don’t Be Cruel” with his son’s rock band, “a highlight of both our lives,” he said.

Yet when I asked Mr. Conn, now 73, how he felt about having priority over a younger but healthier person, he paused. “It’s a good question,” he said, to which he had no answer.

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

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The New Old Age Blog: Who Should Receive Organ Transplants?

Joe Gammalo had been contending with pulmonary fibrosis, a scarring of the lungs, for more than a decade when he came to the Cleveland Clinic in 2008 seeking a lung transplant.

“It had gotten to the point where I was on oxygen all the time and in a wheelchair,” he told me in an interview. “I didn’t expect to live.”

Lung transplants are a dicey proposition, involving a huge surgical procedure, arduous follow-up, the lifelong use of potent immunosuppressive drugs and high rates of serious side effects. “It’s not like taking out an appendix,” said Dr. Marie Budev, the medical director of the clinic’s lung transplant program.

Only 50 to 57 percent of all recipients live for five years, she noted, and they will still die of their disease. But there’s no other treatment for pulmonary fibrosis.

Some medical centers would have turned Mr. Gammalo away. Because survival rates are even lower for older patients, guidelines from the International Society for Heart and Lung Transplantation caution against lung transplants for those over 65, though they set no age limit.

But “we are known as an aggressive, high-risk center,” said Dr. Budev. So Mr. Gammalo was 66 when he received a lung; his newly found buddy, Clyde Conn, who received the other lung from the same donor, was 69.

You can’t mistake the trend: A graying population and revised policies determining who gets priority for donated organs, have led to a rising proportion of older adults receiving transplants.

My colleague Judith Graham has reported on the increase in heart transplants, but the pattern extends to other organs, too.

The number of kidney transplants performed annually on adults over 65 tripled between 1998 and last year, according to data from the Scientific Registry of Transplant Recipients. In 2001, 7.4 percent of liver transplant recipients were over 65; last year, that rose to 13 percent.

The rise in elderly lung transplant candidates is particularly dramatic because, since 2005, a “lung allocation score” puts those at the highest mortality risk, rather than those who’ve waited longest, at the top of the list.

In 2001, about 3 percent of those on the wait list and of those transplanted were over 65; last year, older patients represented almost 18 percent of wait-listed candidates and more than a quarter of transplant recipients. (Medicare pays for the surgery, though patients face co-pays and considerable out-of-pocket costs, including for drugs and travel.)

The debate has grown, too: When the number of adults awaiting transplants keeps growing, but organ donations stay flat, is it desirable or even ethical that an increasing proportion of recipients are elderly?

Dr. Budev, who estimated that a third of her program’s patients are over 65, votes yes. As long as a program selects candidates carefully, “how can you deny them a therapy?” she asked. So the Cleveland Clinic has no age limit. “We feel that everyone should have a chance.”

At the University of Michigan, by contrast, the age limit remains 65, though Dr. Kevin Chan, the transplant program’s medical director, acknowledged that some fit older patients get transplanted.

“You can talk about this all day — it’s a tough one,” Dr. Chan said. Younger recipients have greater physiologic reserve to aid in the arduous recovery; older ones face higher risk of subsequent kidney failure, stroke, diabetes and other diseases, and, of course, their lifespans are shorter to begin with.

Donated lungs, fragile and prone to injury, are a particularly scarce commodity. Last year, surgeons performed 16,055 kidney transplants, 5,805 liver transplants and 1,949 heart transplants. Only1,830 patients received lung transplants.

“What if there’s a 35-year-old on a ventilator who needs the lung just as much?” Dr. Chan said. “Why should a 72-year-old possibly take away a lung from a 35-year-old?” Yet, he acknowledged, “it’s easy to look at the statistics and say, ‘Give the lungs to younger patients.’ At the bedside, when you meet this patient and family, it’s a lot different.”

These questions about who deserves scarce resources — those most likely to die without them? or those most likely to live longer with them? — will persist as the population ages. They’re also likely to arise when the International Society for Heart and Lung Transplantation begins working towards revised guidelines this spring. (I’d also like to hear your take, below.)

Lots of 65- and 75-year-olds are very healthy. Yet transplants themselves can cause harm and there’s no backup, like dialysis. Without the transplant, they die. But when the transplant goes wrong, they also die.

More than four years post-transplant, the Cleveland Clinic’s “lung brothers” are success stories. Mr. Conn, who lives near Dayton, Ohio, can’t walk very far or lift more than 10 pounds, but he works part time as a real-estate appraiser and enjoys cruises with his wife.

Mr. Gammalo, a onetime musician, has developed diabetes, like nearly half of all lung recipients. But he went onstage a few weeks back to sing “Don’t Be Cruel” with his son’s rock band, “a highlight of both our lives,” he said.

Yet when I asked Mr. Conn, now 73, how he felt about having priority over a younger but healthier person, he paused. “It’s a good question,” he said, to which he had no answer.

---

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

Read More..

Mobile Apps Drive Rapid Changes in Search Technology

SAN FRANCISCO — When the Federal Trade Commission decided last week to close its antitrust investigation of Google without charges, one important factor, though hardly mentioned, was just beneath the surface: the mobile revolution.

Google has repeatedly made the argument — and the commission agreed — that the speed of change in the technology industry made it impossible for regulators to impose restrictions without stalling future innovations.

Exhibit A is the mobile device. Nowhere has technology changed as rapidly and consumer behavior as broadly. As people abandon desktop computers for mobile ones, existing tech companies’ business models are being upended and new companies are blooming.

“Mobile is very much a moving target,” said Herbert Hovenkamp, a professor of antitrust law at the University of Iowa who has been a paid adviser to Google. “This is a market in which new competitors come in a week’s time.”

When the commission began its investigation 19 months ago, for instance, the iPhone did not have the Siri voice search, Apple did not have its own mapping service and Yelp’s mobile apps had no ads. By the time the inquiry concluded, all of that had changed. Google had new competitors on all sides trying to chip away at its hold on the mobile search and advertising market.

Still, Google is even more dominant on mobile phones than on desktop computers. It has 96 percent of the world’s mobile search market, according to StatCounter, which tracks Web use. It collects 57 percent of mobile ad revenue in the United States, while Facebook, its nearest competitor, gets just 9 percent, according to eMarketer.

But, analysts say, as people change their search habits on mobile devices — bypassing Google to go straight to apps like Yelp’s, for example — that dominance could wane, or a competitor could swoop in and knock Google off its perch.

“It’s important to recognize that many mobile apps are really vertical search engines,” said Rebecca Lieb, a digital media analyst at the Altimeter Group. “It is impossible to really say anyone dominates a section of mobile in a secure way right now.”

On cellphones or tablets, for instance, people increasingly skip Google altogether in favor of apps like Flixster for movie times or Kayak for flights.

Apple is taking on mobile search with Siri on the iPhone, which can answer questions about the weather or search for nearby restaurants. With its new mapping service, Apple has also entered local search.

On Friday, Blekko, a search start-up, introduced an app called Izik for Apple and Android devices. It tries to make searching more tablet-friendly by showing images instead of just links, and making it easier to swipe through many pages of results with a finger.

On mobile devices, said Rich Skrenta, chief executive of Blekko, “the user experience is so different that we think it opens things up. On your desktop, if it doesn’t look like Google, you think that’s not a search engine. On a tablet, it’s just vastly different.”

Jon Leibowitz, chairman of the F.T.C., said at a news conference Thursday that the speed of change in the tech industry meant that “you want to be careful before you apply sanctions.”

The commission also considered Google’s partnerships with cellphone makers like Samsung and HTC that license Google search on phones, so that a search box shows up on the home screen. In the end it decided not to take action against Google.

Some Google critics said that even though the competitive landscape is different on mobile devices, it should not have influenced the government’s analysis of Google’s behavior on the desktop Web.

“There’s no doubt that mobile applications, including Yelp’s, give consumers the ability to bypass the major search engines and go directly to the best provider of the service they’re looking for,” said Vince Sollitto, vice president for government relations at Yelp. Still, he added, “I don’t see how that impacts how someone is acting anticompetitively on the desktop.”

(One of Google’s concessions to the federal agency, that it would allow other Web companies to ask Google not to show their content in its own vertical search products — a chief complaint of Yelp’s — applies to mobile as well.)

But others said antitrust enforcement in the 21st century needs to be more agile.

Nick Wingfield contributed reporting from Seattle.

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Chemical Weapons Showdown With Syria Led to Rare Accord

Muzaffar Salman/Reuters

The violence in Syria continued on Monday. Above, Syrians went to the aid of a man who was wounded when a missile hit the al-Mashhad district of Aleppo.

WASHINGTON — In the last days of November, Israel’s top military commanders called the Pentagon to discuss troubling intelligence that was showing up on satellite imagery: Syrian troops appeared to be mixing chemicals at two storage sites, probably the deadly nerve gas sarin, and filling dozens of 500-pounds bombs that could be loaded on airplanes.

Within hours President Obama was notified, and the alarm grew over the weekend, as the munitions were loaded onto vehicles near Syrian air bases. In briefings, administration officials were told that if Syria’s increasingly desperate president, Bashar al-Assad, ordered the weapons to be used, they could be airborne in less than two hours — too fast for the United States to act, in all likelihood.

What followed next, officials said, was a remarkable show of international cooperation over a civil war in which the United States, Arab states, Russia and China have almost never agreed on a common course of action.

The combination of a public warning by Mr. Obama and more sharply worded private messages sent to the Syrian leader and his military commanders through Russia and others, including Iraq, Turkey and possibly Jordan, stopped the chemical mixing and the bomb preparation. A week later Defense Secretary Leon E. Panetta said the worst fears were over — for the time being.

But concern remains that Mr. Assad could now use the weapons produced that week at any moment. American and European officials say that while a crisis was averted in that week from late November to early December, they are by no means resting easy.

“I think the Russians understood this is the one thing that could get us to intervene in the war,” one senior defense official said last week. “What Assad understood, and whether that understanding changes if he gets cornered in the next few months, that’s anyone’s guess.”

While chemical weapons are technically considered a “weapon of mass destruction” — along with biological and nuclear weapons — in fact they are hard to use and hard to deliver. Whether an attack is effective can depend on the winds and the terrain. Sometimes attacks are hard to detect, even after the fact. Syrian forces could employ them in a village or a neighborhood, some officials say, and it would take time for the outside world to know.

But the scare a month ago has renewed debate about whether the West should help the Syrian opposition destroy Mr. Assad’s air force, which he would need to deliver those 500-pound bombs.

The chemical munitions are still in storage areas that are near or on Syrian air bases, ready for deployment on short notice, officials said.

The Obama administration and other governments have said little in public about the chemical weapons movements, in part because of concern about compromising sources of intelligence about the activities of Mr. Assad’s forces. This account is based on interviews with more than half a dozen military, intelligence and diplomatic officials, all of whom spoke on the condition of anonymity because of the intelligence matters involved.

The head of Germany’s foreign intelligence service, the BND, warned in a confidential assessment last month that the weapons could now be deployed four to six hours after orders were issued, and that Mr. Assad had a special adviser at his side who oversaw control of the weapons, the German newsmagazine Der Spiegel reported. Some American and other allied officials, however, said in interviews that the sarin-laden bombs could be loaded on planes and airborne in less than two hours.

“Let’s just say right now, it would be a relatively easy thing to load this quickly onto aircraft,” said one Western diplomat.

How the United States and Israel, along with Arab states, would respond remains a mystery. American and allied officials have talked vaguely of having developed “contingency plans” in case they decided to intervene in an effort to neutralize the chemical weapons, a task that the Pentagon estimates would require upward of 75,000 troops. But there have been no evident signs of preparations for any such effort.

The United States military has quietly sent a task force of more than 150 planners and other specialists to Jordan to help the armed forces there, among other things, prepare for the possibility that Syria will lose control of its chemical weapons.

Israel’s prime minister, Benjamin Netanyahu, was reported to have traveled to Jordan in recent weeks, and the Israeli news media have said the topic of discussion was how to deal with Syrian weapons if it appeared that they could be transferred to Lebanon, where Hezbollah could lob them over the border to Israel. But the plans, to the extent they exist, remain secret.

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DealBook: After Madoff, Financial Fraud Defies Policing

LOS ANGELES — To Philip Horn, the Braemar Country Club was not just a golf course, it was an extension of his office. Most weeks, Mr. Horn, a financial adviser at Wells Fargo, chatted up potential clients between holes at the upscale club set against the backdrop of the Santa Monica Mountains.

“I always thought, ‘This is a great guy and a straight shooter,’ ” said Barry Zelner, one of several country club members who invested with Mr. Horn.

Now, those same clients are wondering what went wrong.

After Wells Fargo alerted him to account discrepancies, Mr. Zelner, a corporate lawyer, said he stormed onto the club’s rolling greens in April, accusing the broker of theft. “Tell them what you did, Phil,” the lawyer bellowed among a crowd of members.

A few months later, Mr. Horn pleaded guilty to defrauding more than a dozen clients and Wells Fargo.

While Mr. Horn is a relatively minor player in the pantheon of financial fraud, his actions highlight the persistent problems with policing the industry, even after the wave of rules enacted since the collapse of Bernard L. Madoff’s giant Ponzi scheme in 2008.

And the challenge of oversight is not becoming any easier, with the ranks of financial advisers swelling. As new regulations crimp profits, big banks like Wells Fargo are ramping up their brokerage businesses in an effort to make up for lost revenue.

Amid the renewed focus, banks have spent millions of dollars to beef up their compliance systems and improve their oversight. Regulators, too, have bolstered their efforts, increasing enforcement and adopting new measures.

Every month, the Financial Industry Regulatory Authority, a Wall Street watchdog, penalizes more than 100 brokers for various actions, including unauthorized trading and fraudulent activities, as well as smaller violations.

“Theft, Ponzi schemes and other financial scams continue to happen at an alarming rate,” said Thomas Ajamie, a plaintiff’s lawyer who represents two of Mr. Horn’s clients.

For more than two years, Mr. Horn systematically executed and canceled trades in clients’ portfolios, pocketing the profits. To avoid detection, he limited his paper trail and made it appear that the trades originated in his own account, according to court documents.

“It’s simply unbelievable to me that this kind of fraud could happen for so long without Wells Fargo doing anything about it,” Mr. Zelner said. After meeting Mr. Horn on the golf course, Derek Brown invested more than $10 million with him in 2006, assured by the Wells Fargo name on his business card. “This wasn’t just Schlepper & Schlepper,” Mr. Brown, a retired pharmaceutical executive, said.

A Wells Fargo spokeswoman, Raschelle Burton, said the bank discovered the problems with Mr. Horn in October 2011 and immediately alerted law enforcement agencies. Wells Fargo also fired Mr. Horn. Mr. Horn is set to be sentenced on Monday. Prosecutors have recommended an 18-month sentence. A lawyer for Mr. Horn declined to comment.

Some of Mr. Horn’s clients are struggling to understand the extent of their losses. Mr. Brown and Mr. Zelner say that Wells Fargo has not let them review the trading records. Instead, they have had to rely on the bank’s analysis. “The firm believes it has provided appropriate information,” Ms. Burton said.

Prosecutors estimate the scheme’s damages at $732,000. But there are indications the losses could be higher. Last year, Wells Fargo, without explanation, transferred roughly $500,000 to an account that Mr. Brown has at Merrill Lynch. Mr. Brown said he planned to file a lawsuit seeking additional compensation.

While some clients still have concerns, Wells Fargo said the matter had been resolved and declined to provide further details. “In cases where his actions harmed the clients, the firm has either credited those accounts or reached another resolution with those clients,” Ms. Burton said.

On paper, Mr. Horn seemed like a model broker. After a short stint at Lehman Brothers in New York, he spent a decade at Citigroup in Los Angeles, moving to Wells Fargo in 2006. For much of his career, his regulatory record was clean, with few customer complaints.

At Wells Fargo, Mr. Horn, who worked in a team of brokers, seemed to land clients without an aggressive approach. He wooed clients slowly, often over many years. Between golf holes, he would casually mention winning trades, almost as an aside.

He nurtured friendships with clients. Norman Strang, an 80-year-old retired aerospace executive, said his wife regularly cooked dinner for Mr. Horn at the couple’s home in Pacific Palisades, Calif. “Here he was being this friendly guy, and yet he stole several thousands of dollars from our account.” Mr. Horn went to the weddings of both Mr. Brown’s children and planned to join him on a charitable trip to Israel and Morocco in the fall of 2011.

In 2011, Mr. Horn invited clients to his 50th birthday party inspired by the movie “Saturday Night Fever.” The tall and lanky Mr. Horn wore a white disco suit and handed out CDs with a cover that superimposed his head onto John Travolta’s body.

Given Mr. Horn’s gregarious nature, clients say they dismissed what should have been red flags. According to Mr. Zelner, Mr. Horn avoided meeting at his office, preferring the golf course. Between games, they would meet in the country club’s parking lot, where the broker would pull trading documents from his trunk.

“Phil would present his investments as if he was giving you something that would protect you,” said Mr. Zelner, adding that “he was also just a guy you wanted to drink with.”

Many clients trusted him. Each month, they received thick booklets detailing trading activity, but few pored over the trades. “If I had time to do that, I wouldn’t need a broker,” Mr. Brown said.

Amid hundreds of legitimate transactions, a dubious trade was also hard to spot. In one instance, Mr. Horn bought 1,000 shares of an exchange-traded fund for $77.93 apiece on Feb. 15, 2011, according to Mr. Brown’s bank statements. A month later, Mr. Horn canceled the trade. By then, the price had surged to $86. But the transaction was buried within more than 50 double-sided pages. It appeared as a canceled trade, which by itself was not alarming.

Mr. Brown and his wife did not know anything was amiss until they received a startling call from an executive at Wells Fargo. While the couple were celebrating the Jewish holidays in Toronto in October 2011, the bank executive told them about the problems with their account. Mr. Brown added, “He said we had a ‘six-figure problem.’ ”

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Alarm in Albuquerque Over Plan to End Methadone for Inmates

Mark Holm for The New York Times

Officials at New Mexico’s largest jail want to end its methadone program. Addicts like Penny Strayer hope otherwise.

ALBUQUERQUE — It has been almost four decades since Betty Jo Lopez started using heroin.

Her face gray and wizened well beyond her 59 years, Ms. Lopez would almost certainly still be addicted, if not for the fact that she is locked away in jail, not to mention the cup of pinkish liquid she downs every morning.

“It’s the only thing that allows me to live a normal life,” Ms. Lopez said of the concoction, which contains methadone, a drug used to treat opiate dependence. “These nurses that give it to me, they’re like my guardian angels.”

For the last six years, the Metropolitan Detention Center, New Mexico’s largest jail, has been administering methadone to inmates with drug addictions, one of a small number of jails and prisons around the country that do so.

At this vast complex, sprawled out among the mesas west of downtown Albuquerque, any inmate who was enrolled at a methadone clinic just before being arrested can get the drug behind bars. Pregnant inmates addicted to heroin are also eligible.

Here in New Mexico, which has long been plagued by one of the nation’s worst heroin scourges, there is no shortage of participants — hundreds each year — who have gone through the program.

In November, however, the jail’s warden, Ramon Rustin, said he wanted to stop treating inmates with methadone. Mr. Rustin said the program, which had been costing Bernalillo County about $10,000 a month, was too expensive.

Moreover, Mr. Rustin, a former warden of the Allegheny County Jail in Pennsylvania and a 32-year veteran of corrections work, said he did not believe that the program truly worked.

Of the hundred or so inmates receiving daily methadone doses, he said, there was little evidence of a reduction in recidivism, one of the program’s main selling points.

“My concern is that the courts and other authorities think that jail has become a treatment program, that it has become the community provider,” he said. “But jail is not the answer. Methadone programs belong in the community, not here.”

Mr. Rustin’s public stance has angered many in Albuquerque, where drug addiction has been passed down through generations in impoverished pockets of the city, as it has elsewhere across New Mexico.

Recovery advocates and community members argue that cutting people off from methadone is too dangerous, akin to taking insulin from a diabetic.

The New Mexico office of the Drug Policy Alliance, which promotes an overhaul to drug policy, has implored Mr. Rustin to reconsider his stance, saying in a letter that he did not have the medical expertise to make such a decision.

Last month, the Bernalillo County Commission ordered Mr. Rustin to extend the program, which also relies on about $200,000 in state financing annually, for two months until its results could be studied further.

“Addiction needs to be treated like any other health issue,” said Maggie Hart Stebbins, a county commissioner who supports the program.

“If we can treat addiction at the jail to the point where they stay clean and don’t reoffend, that saves us the cost of reincarcerating that person,” she said.

Hard data, though, is difficult to come by — hence the county’s coming review.

Darren Webb, the director of Recovery Services of New Mexico, a private contractor that runs the methadone program, said inmates were tracked after their release to ensure that they remained enrolled at outside methadone clinics.

While the outcome was never certain, Mr. Webb said, he maintained that providing methadone to inmates would give them a better chance of staying out of jail once they were released. “When they get out, they won’t be committing the same crimes they would if they were using,” he said. “They are functioning adults.”

In a study published in 2009 in The Journal of Substance Abuse Treatment, researchers found that male inmates in Baltimore who were treated with methadone were far more likely to continue their treatment in the community than inmates who received only counseling.

Those who received methadone behind bars were also more likely to be free of opioids and cocaine than those who received only counseling or started methadone treatment after their release.

Read More..

Alarm in Albuquerque Over Plan to End Methadone for Inmates

Mark Holm for The New York Times

Officials at New Mexico’s largest jail want to end its methadone program. Addicts like Penny Strayer hope otherwise.

ALBUQUERQUE — It has been almost four decades since Betty Jo Lopez started using heroin.

Her face gray and wizened well beyond her 59 years, Ms. Lopez would almost certainly still be addicted, if not for the fact that she is locked away in jail, not to mention the cup of pinkish liquid she downs every morning.

“It’s the only thing that allows me to live a normal life,” Ms. Lopez said of the concoction, which contains methadone, a drug used to treat opiate dependence. “These nurses that give it to me, they’re like my guardian angels.”

For the last six years, the Metropolitan Detention Center, New Mexico’s largest jail, has been administering methadone to inmates with drug addictions, one of a small number of jails and prisons around the country that do so.

At this vast complex, sprawled out among the mesas west of downtown Albuquerque, any inmate who was enrolled at a methadone clinic just before being arrested can get the drug behind bars. Pregnant inmates addicted to heroin are also eligible.

Here in New Mexico, which has long been plagued by one of the nation’s worst heroin scourges, there is no shortage of participants — hundreds each year — who have gone through the program.

In November, however, the jail’s warden, Ramon Rustin, said he wanted to stop treating inmates with methadone. Mr. Rustin said the program, which had been costing Bernalillo County about $10,000 a month, was too expensive.

Moreover, Mr. Rustin, a former warden of the Allegheny County Jail in Pennsylvania and a 32-year veteran of corrections work, said he did not believe that the program truly worked.

Of the hundred or so inmates receiving daily methadone doses, he said, there was little evidence of a reduction in recidivism, one of the program’s main selling points.

“My concern is that the courts and other authorities think that jail has become a treatment program, that it has become the community provider,” he said. “But jail is not the answer. Methadone programs belong in the community, not here.”

Mr. Rustin’s public stance has angered many in Albuquerque, where drug addiction has been passed down through generations in impoverished pockets of the city, as it has elsewhere across New Mexico.

Recovery advocates and community members argue that cutting people off from methadone is too dangerous, akin to taking insulin from a diabetic.

The New Mexico office of the Drug Policy Alliance, which promotes an overhaul to drug policy, has implored Mr. Rustin to reconsider his stance, saying in a letter that he did not have the medical expertise to make such a decision.

Last month, the Bernalillo County Commission ordered Mr. Rustin to extend the program, which also relies on about $200,000 in state financing annually, for two months until its results could be studied further.

“Addiction needs to be treated like any other health issue,” said Maggie Hart Stebbins, a county commissioner who supports the program.

“If we can treat addiction at the jail to the point where they stay clean and don’t reoffend, that saves us the cost of reincarcerating that person,” she said.

Hard data, though, is difficult to come by — hence the county’s coming review.

Darren Webb, the director of Recovery Services of New Mexico, a private contractor that runs the methadone program, said inmates were tracked after their release to ensure that they remained enrolled at outside methadone clinics.

While the outcome was never certain, Mr. Webb said, he maintained that providing methadone to inmates would give them a better chance of staying out of jail once they were released. “When they get out, they won’t be committing the same crimes they would if they were using,” he said. “They are functioning adults.”

In a study published in 2009 in The Journal of Substance Abuse Treatment, researchers found that male inmates in Baltimore who were treated with methadone were far more likely to continue their treatment in the community than inmates who received only counseling.

Those who received methadone behind bars were also more likely to be free of opioids and cocaine than those who received only counseling or started methadone treatment after their release.

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Virtual U.: Massive Open Online Courses Prove Popular, if Not Lucrative Yet

Ramin Rahimian for The New York Times

Coursera has 35 employees in Mountain View, Calif. An employee works on a laptop near a new reception area.

MOUNTAIN VIEW, Calif. — In August, four months after Daphne Koller and Andrew Ng started the online education company Coursera, its free college courses had drawn in a million users, a faster launching than either Facebook or Twitter.

The co-founders, computer science professors at Stanford University, watched with amazement as enrollment passed two million last month, with 70,000 new students a week signing up for over 200 courses, including Human-Computer Interaction, Songwriting and Gamification, taught by faculty members at the company’s partners, 33 elite universities.

In less than a year, Coursera has attracted $22 million in venture capital and has created so much buzz that some universities sound a bit defensive about not leaping onto the bandwagon.

Other approaches to online courses are emerging as well. Universities nationwide are increasing their online offerings, hoping to attract students around the world. New ventures like Udemy help individual professors put their courses online. Harvard and the Massachusetts Institute of Technology have each provided $30 million to create edX. Another Stanford spinoff, Udacity, has attracted more than a million students to its menu of massive open online courses, or MOOCs, along with $15 million in financing.

All of this could well add up to the future of higher education — if anyone can figure out how to make money.

Coursera has grown at warp speed to emerge as the current leader of the pack, striving to support its business by creating revenue streams through licensing, certification fees and recruitment data provided to employers, among other efforts. But there is no guarantee that it will keep its position in the exploding education technology marketplace.

“No one’s got the model that’s going to work yet,” said James Grimmelmann, a New York Law School professor who specializes in computer and Internet law. “I expect all the current ventures to fail, because the expectations are too high. People think something will catch on like wildfire. But more likely, it’s maybe a decade later that somebody figures out how to do it and make money.”

For their part, Ms. Koller and Mr. Ng proclaim a desire to keep courses freely available to poor students worldwide. Education, they have said repeatedly, should be a right, not a privilege. And even their venture backers say profits can wait.

“Monetization is not the most important objective for this business at this point,” said Scott Sandell, a Coursera financier who is a general partner at New Enterprise Associates. “What is important is that Coursera is rapidly accumulating a body of high-quality content that could be very attractive to universities that want to license it for their own use. We invest with a very long mind-set, and the gestation period of the very best companies is at least 10 years.”

But with the first trickles of revenue now coming in, Coursera’s university partners expect to see some revenue sooner.

“We’ll make money when Coursera makes money,” said Peter Lange, the provost of Duke University, one of Coursera’s partners. “I don’t think it will be too long down the road. We don’t want to make the mistake the newspaper industry did, of giving our product away free online for too long.”

Right now, the most promising source of revenue for Coursera is the payment of licensing fees from other educational institutions that want to use the Coursera classes, either as a ready-made “course in a box” or as video lectures students can watch before going to class to work with a faculty member.

Ms. Koller has plenty of other ideas, as well. She is planning to charge $20, or maybe $50, for certificates of completion. And her company, like Udacity, has begun to charge corporate employers, including Facebook and Twitter, for access to high-performing students, starting with those studying software engineering.

This fall, Ms. Koller was excited about news she was about to announce: Antioch University’s Los Angeles campus had agreed to offer its students credit for successfully completing two Coursera courses, Modern and Contemporary American Poetry and Greek and Roman Mythology, both taught by professors from the University of Pennsylvania. Antioch would be the first college to pay a licensing fee — Ms. Koller would not say how much — to offer the courses to its students at a tuition lower than any four-year public campus in the state.

“We think this model will spread, helping academic institutions offer their students a better education at a lower price,” she said.

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IHT Rendezvous: Will 2013 Be the Year of the Electric Car?

The Hague —Last year was a good one for electric and plug-in hybrid cars, according to 2012 sales figures and experts.

For example, sales of the Chevrolet Volt, one of North America’s most popular plug-in hybrid cars, tripled in the United States, according to year-end figures.

The 23,461 Volts sold last year represented only about a third of a percent of all new passenger cars sold in the United States, but such sales might be the harbingers of an automobile market shift toward green vehicles.

A new market study estimates annual global sales of 3.8 million electric or plug-in hybrid cars by 2020. The study, released by Pike Research last week, estimates that sales of plug-in cars will grow by 40 percent annually. During that same period, general car sales will grow by 2 percent, according to the research firm. In a press statement, Dave Hurst, the author of the study wrote:

“Sales of EVs have not lived up to automakers’ expectations and politicians’ proclamations, but the market is expanding steadily as fuel prices remain high and consumers increasingly seek alternatives to internal combustion engines.”

Plug-in cars, be they hybrids like the Chevrolet Volt, or all-electric cars like the Nissan Leaf (both of whose successes in the United States in 2012 were reviewed in this story by my colleague Bradley Berman), will contribute most of the growth, while non-plug in hybrids — now the most dominant force on the low-emission front — are expected to grow at 6 percent.

By 2020, there could be as many as 4.4 million all-electric vehicles on the world’s roads and another 3.4 million plug-in hybrid cars, predicts the report’s author.

Currently, all-electric vehicles make up only a sliver of the market, while substantially more drivers invest in hybrid cars. (Our report on fuel efficient vehicles last year explains the difference and the advantages of the competing technologies).

In the United States pure electric vehicles made up roughly 0.3 percent of cars sold in 2012, while hybrids or plug-in hybrids accounted for 3 percent, according to another market study. Here in Europe, electric cars are mostly seen as part of corporate fleets or city car sharing programs, like the Parisian “autolib” program.

Despite the fact that Europe is lagging behind the United States in plug-in cars on the road, the company predicts that by 2018 Germany will come in at third place for plug-in hybrid cars, after the United States and China. Japan, meanwhile, will dominate the non plug-in hybrid market, with almost half of all plug-in cars sold in that country.

In the United Kingdom the number of all-electric cars is expected to double in the coming year, according to one industry expert.

Ben Lane, the managing editor of nextgreencar.com, told the Guardian newspaper:

“The pricing is not yet quite right and the range is still not long enough. Very few people in 2012 were willing to pay a significant sum more for a car that still cannot do everything.”

There are other issues, too. A recent University of Indiana survey of 2,300 adult drivers in the United States, found that most were ignorant and apathetic about plug-in electric cars, as Bradley Burman reported for the Wheels blog some weeks ago.

Quoting John Graham, who designed the latest study, Bradley wrote:

“We found substantial factual misunderstandings of electric cars in our sample of 2,000,” Dr. Graham said. “In some cases, the misunderstandings would cause one to be more pessimistic about the vehicle than they should be. And in other cases, it would cause people to be more optimistic than they should be.”

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Despite New Health Law, Some See Sharp Rise in Premiums

Health insurance companies across the country are seeking and winning double-digit increases in premiums for some customers, even though one of the biggest objectives of the Obama administration’s health care law was to stem the rapid rise in insurance costs for consumers.

Bob Chamberlin/Los Angeles Times

Dave Jones, the California insurance commissioner, said some insurance companies could raise rates as much as they did before the law was enacted.

Particularly vulnerable to the high rates are small businesses and people who do not have employer-provided insurance and must buy it on their own.

In California, Aetna is proposing rate increases of as much as 22 percent, Anthem Blue Cross 26 percent and Blue Shield of California 20 percent for some of those policy holders, according to the insurers’ filings with the state for 2013. These rate requests are all the more striking after a 39 percent rise sought by Anthem Blue Cross in 2010 helped give impetus to the law, known as the Affordable Care Act, which was passed the same year and will not be fully in effect until 2014.

 In other states, like Florida and Ohio, insurers have been able to raise rates by at least 20 percent for some policy holders. The rate increases can amount to several hundred dollars a month.

The proposed increases compare with about 4 percent for families with employer-based policies.

Under the health care law, regulators are now required to review any request for a rate increase of 10 percent or more; the requests are posted on a federal Web site, healthcare.gov, along with regulators’ evaluations.

The review process not only reveals the sharp disparity in the rates themselves, it also demonstrates the striking difference between places like New York, one of the 37 states where legislatures have given regulators some authority to deny or roll back rates deemed excessive, and California, which is among the states that do not have that ability.

New York, for example, recently used its sweeping powers to hold rate increases for 2013 in the individual and small group markets to under 10 percent. California can review rate requests for technical errors but cannot deny rate increases.

The double-digit requests in some states are being made despite evidence that overall health care costs appear to have slowed in recent years, increasing in the single digits annually as many people put off treatment because of the weak economy. PricewaterhouseCoopers estimates that costs may increase just 7.5 percent next year, well below the rate increases being sought by some insurers. But the companies counter that medical costs for some policy holders are rising much faster than the average, suggesting they are in a sicker population. Federal regulators contend that premiums would be higher still without the law, which also sets limits on profits and administrative costs and provides for rebates if insurers exceed those limits.

Critics, like Dave Jones, the California insurance commissioner and one of two health plan regulators in that state, said that without a federal provision giving all regulators the ability to deny excessive rate increases, some insurance companies can raise rates as much as they did before the law was enacted.

“This is business as usual,” Mr. Jones said. “It’s a huge loophole in the Affordable Care Act,” he said.

While Mr. Jones has not yet weighed in on the insurers’ most recent requests, he is pushing for a state law that will give him that authority. Without legislative action, the state can only question the basis for the high rates, sometimes resulting in the insurer withdrawing or modifying the proposed rate increase.

The California insurers say they have no choice but to raise premiums if their underlying medical costs have increased. “We need these rates to even come reasonably close to covering the expenses of this population,” said Tom Epstein, a spokesman for Blue Shield of California. The insurer is requesting a range of increases, which average about 12 percent for 2013.

Although rates paid by employers are more closely tracked than rates for individuals and small businesses, policy experts say the law has probably kept at least some rates lower than they otherwise would have been.

“There’s no question that review of rates makes a difference, that it results in lower rates paid by consumers and small businesses,” said Larry Levitt, an executive at the Kaiser Family Foundation, which estimated in an October report that rate review was responsible for lowering premiums for one out of every five filings.

Federal officials say the law has resulted in significant savings. “The health care law includes new tools to hold insurers accountable for premium hikes and give rebates to consumers,” said Brian Cook, a spokesman for Medicare, which is helping to oversee the insurance reforms.

“Insurers have already paid $1.1 billion in rebates, and rate review programs have helped save consumers an additional $1 billion in lower premiums,” he said. If insurers collect premiums and do not spend at least 80 cents out of every dollar on care for their customers, the law requires them to refund the excess.

As a result of the review process, federal officials say, rates were reduced, on average, by nearly three percentage points, according to a report issued last September.

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