Books: Woe Is Syphilis, and Other Afflictions of Famous Writers





The old Irishman was a swollen, wheezing mess, blood pressure wildly out of control, kidneys failing, heart fibrillating. “What we have here,” said his new Spanish doctor, “is an antique cardiorenal sclerotic of advanced years.”




In fact, what the doctor had there was William Butler Yeats: the poet had a long list of chronic medical problems and experienced one of his regular cardiac crises while wintering in Spain. He still had three poetically productive years ahead of him before he died of heart failure in 1939, at age 73.


What makes antique case histories like Yeats’s so compelling to research, so interesting to read? Admittedly, they have educational value — medicine moves forward by looking back — but their major attraction is undoubtedly the operatic vigor of their emotional punch. As we contemplate the poor health of historic notables, we can sigh gustily at the immense suffering our ancestors considered routine, wince at the lunatic treatments they so innocently underwent, and marvel over and over again that the body, the brain and the mind can take such divergent paths.


These pleasures are present in abundance in the newest addition to the genre of medical biography, “Shakespeare’s Tremor and Orwell’s Cough.” Dr. John J. Ross, a Harvard physician, writes that he stumbled into the field by accident while trying to enliven a lecture on syphilis with a few literary references. The discovery that Shakespeare was apparently obsessed with syphilis (and suspiciously familiar with its symptoms) hooked Dr. Ross.


The resulting collection of 10 medico-literary biographical sketches ranges from the tubercular Brontës, whose every moist cough is familiar to their fans, to figures like Nathaniel Hawthorne, whose medical stories are considerably less familiar.


Dr. Ross’s discussion of Shakespeare is unique in the collection for its paucity of relevant data: so few details are known of the playwright’s life, let alone his health, that all commentary is necessarily supposition. Dr. Ross is not the first to note that references to syphilis are “more abundant, intrusive and clinically exact” in Shakespeare’s works than those of his contemporaries. This observation, along with the apparent deterioration of Shakespeare’s handwriting in his last years, leads to the hypothesis that Shakespeare had syphilis repeatedly as a young man, and wound up suffering more from treatment than disease.


The Elizabethans dosed syphilis with a combination of hot baths (treating the disease by raising body temperature endured into the 20th century), cathartics and lavish quantities of mercury. The drooling that accompanies mercury poisoning was considered a sign of excellent therapeutic progress, Dr. Ross writes: “Savvy physicians adjusted the mercury dose to produce three pints of saliva a day for two weeks.”


And so, when Shakespeare signed his will a month before he died with a shaky hand, was his tremor not possibly a sign of residual nerve damage from the mercury doses of his sybaritic youth? No amount of scholarship is likely to confirm this theory, but details of the argument are gripping and instructive nonetheless.


The story of the blind poet John Milton runs for a while along similar lines. Much is known about the long deterioration of Milton’s vision and other particulars of his delicate health, but Dr. Ross observes that many of his problems seem to have cleared up once he actually became blind. Was he vigorously medicating himself with lead-based nostrums in hopes of forestalling what Dr. Ross argues was probably progressive retinal detachment, then recovering from lead poisoning once his vision was irretrievably gone? Another intriguing if unanswerable question.


Just as the competing injuries of disease and treatment battered the luminaries of English and American literature, so did pervasive mental illness.


Jonathan Swift was a classic obsessive-compulsive long before he succumbed to frontotemporal dementia (Pick’s disease). Poor Hawthorne, so forceful on the page, was in person a tortured shrinking violet, the embodiment of social phobia and depression. Emily Brontë’s behavior was strongly suggestive of Asperger syndrome; Herman Melville was clearly bipolar; Ezra Pound was just nuts.


Yet they all wrote on, despite continual psychic and physical torments. Perhaps the thickest medical chart of all belongs to Jack London, who survived several dramatic episodes of scurvy while prospecting in the Klondike (he was treated with raw potatoes, a can of tomatoes and a single lemon), then accumulated a long list of other medical problems before killing himself (inadvertently, Dr. Ross argues) with an overdose of morphine from his personal and very capacious medicine chest.


Dr. Ross has not written a perfect book. The fictionalized scenes he creates between some of his subjects and their medical providers should all have been excised by a kindly editorial hand, which might also have addressed more than a few grammatical errors. Frequent leaps from descriptive to didactic mode as Dr. Ross updates the reader on various medical conditions can be jarring, like PowerPoint slides suddenly deployed in a poetry reading. True literary scholars might dismiss the book as lit crit lite, a hodgepodge of known facts culled from the usual secondary sources.


But all these caveats fade into the background when Dr. Ross hits his narrative stride, as he does in chapter after chapter. Then the stories of the wounded storytellers unfold smoothly on the page, as mesmerizing as any they themselves might have told, those squinting, wheezing, arthritic, infected, demented, defective yet superlative examples of the human condition.


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The Hard Road Back: Prosthetic Arms a Complex Test for Amputees




A Future Reset:
After losing his arm in an I.E.D. explosion in Afghanistan, Cpl. Sebastian Gallegos has adjusted to his prosthetic limb.







SAN ANTONIO — After the explosion, Cpl. Sebastian Gallegos awoke to see the October sun glinting through the water, an image so lovely he thought he was dreaming. Then something caught his eye, yanking him back to grim awareness: an arm, bobbing near the surface, a black hair tie wrapped around its wrist.




The elastic tie was a memento of his wife, a dime-store amulet that he wore on every patrol in Afghanistan. Now, from the depths of his mental fog, he watched it float by like driftwood on a lazy current, attached to an arm that was no longer quite attached to him.


He had been blown up, and was drowning at the bottom of an irrigation ditch.


Two years later, the corporal finds himself tethered to a different kind of limb, a $110,000 robotic device with an electronic motor and sensors able to read signals from his brain. He is in the office of his occupational therapist, lifting and lowering a sponge while monitoring a computer screen as it tracks nerve signals in his shoulder.


Close hand, raise elbow, he says to himself. The mechanical arm rises, but the claw-like hand opens, dropping the sponge. Try again, the therapist instructs. Same result. Again. Tiny gears whir, and his brow wrinkles with the mental effort. The elbow rises, and this time the hand remains closed. He breathes.


Success.


“As a baby, you can hold onto a finger,” the corporal said. “I have to relearn.”


It is no small task. Of the more than 1,570 American service members who have had arms, legs, feet or hands amputated because of injuries in Afghanistan or Iraq, fewer than 280 have lost upper limbs. Their struggles to use prosthetic limbs are in many ways far greater than for their lower-limb brethren.


Among orthopedists, there is a saying: legs may be stronger, but arms and hands are smarter. With myriad bones, joints and ranges of motion, the upper limbs are among the body’s most complex tools. Replicating their actions with robotic arms can be excruciatingly difficult, requiring amputees to understand the distinct muscle contractions involved in movements they once did without thinking.


To bend the elbow, for instance, requires thinking about contracting a biceps, though the muscle no longer exists. But the thought still sends a nerve signal that can tell a prosthetic arm to flex. Every action, from grabbing a cup to turning the pages of a book, requires some such exercise in the brain.


“There are a lot of mental gymnastics with upper limb prostheses,” said Lisa Smurr Walters, an occupational therapist who works with Corporal Gallegos at the Center for the Intrepid at Brooke Army Medical Center in San Antonio.


The complexity of the upper limbs, though, is just part of the problem. While prosthetic leg technology has advanced rapidly in the past decade, prosthetic arms have been slow to catch up. Many amputees still use body-powered hooks. And the most common electronic arms, pioneered by the Soviet Union in the 1950s, have improved with lighter materials and microprocessors but are still difficult to control.


Upper limb amputees must also cope with the critical loss of sensation. Touch — the ability to differentiate baby skin from sandpaper or to calibrate between gripping a hammer and clasping a hand — no longer exists.


For all those reasons, nearly half of upper limb amputees choose not to use prostheses, functioning instead with one good arm. By contrast, almost all lower limb amputees use prosthetic legs.


But Corporal Gallegos, 23, is part of a small vanguard of military amputees who are benefiting from new advances in upper limb technology. Earlier this year, he received a pioneering surgery known as targeted muscle reinnervation that amplifies the tiny nerve signals that control the arm. In effect, the surgery creates additional “sockets” into which electrodes from a prosthetic limb can connect.


More sockets reading stronger signals will make controlling his prosthesis more intuitive, said Dr. Todd Kuiken of the Rehabilitation Institute of Chicago, who developed the procedure. Rather than having to think about contracting both the triceps and biceps just to make a fist, the corporal will be able to simply think, close hand, and the proper nerves should fire automatically.


In the coming years, new technology will allow amputees to feel with their prostheses or use pattern-recognition software to move their devices even more intuitively, Dr. Kuiken said. And a new arm under development by the Pentagon, the DEKA Arm, is far more dexterous than any currently available.


But for Corporal Gallegos, becoming proficient on his prosthesis after reinnervation surgery remains a challenge, likely to take months more of tedious practice. For that reason, only the most motivated amputees — super users, they are called — are allowed to undergo the surgery.


Corporal Gallegos was not always that person.


His father, an Army veteran, did not want him to join the infantry, but it was like him to ignore the advice.


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Paris Journal: In France, Beer Lovers Chafe at Tax Increase Plans


Stephane Remael for The New York Times


Beer drinkers at Chez Prune in Paris. A half-pint of beer may cost 6 cents to 60 cents more if a tax increase is approved.







PARIS — Simon Thillou likes to think of La Cave à Bulles, his shop here devoted only to beer, as a place where beer lovers can gather to taste new brews and, of course, discuss the state of the world. But this was one controversy he never saw coming, and wishes he never had: a proposed 160 percent increase in the tax on beer.




“The increase is brutal; 160 percent is a lot,” said Mr. Thillou, 36, who prides himself on promoting French microbreweries. On a barrel near the entrance, a pile of fliers that say “+160% taxes on beer: Who is going to pay the price?” shows what he thinks of the government’s latest plan for raising revenue.


It is not just the tax increase — which would raise prices by 25 to 40 cents per bottle — that has him upset. “I am shocked that beer is the only target,” he said. “I am shocked that other alcohol producers aren’t affected.”


Winemakers come in for particular criticism. “Wine growers aren’t behind the nation, but the nation is behind them,” he said.


Complaints about the tax increase are coming not just from customers, but from brewers, the food industry generally and politicians, who know that some voters, at least, like French ales. They say the government’s public health arguments are an excuse to single out beer, instead of spreading the pain across all alcoholic drinks.


“If we want to keep industries and economic sectors, we can’t do any old thing,” said Bernard Gérard, a center-right politician in the National Assembly, Parliament’s lower house. “Increasing excise duties by 160 percent seems completely unreasonable to me.”


Having promised to reduce France’s budget deficit, the new Socialist government has proposed about $30 billion in new taxes. The increase in the beer tax is expected to generate an additional $625 million.


The social security budget, which is in the final stages of the legislative process, also includes heavier taxes on tobacco and new ones on energy drinks.


According to government estimates, the higher tax will increase the price of a half-pint of ordinary beer by approximately 6 cents. (A half-pint of an average beer at a bar costs about 2.60 euros or $3.40.) But brewery and food industry lobbies say the increase will be considerably more because of a multiplier effect as each step of the distribution chain recalculates its profit margins, reaching 25 cents to 60 cents for the final customer.


The lobbyists fear that consumption will drop, pulling down production and threatening jobs and investment, especially for small breweries that do not have the international flexibility of European giants like Heineken or Anheuser-Busch InBev.


The French beer industry represents two billion euros in sales, or about $2.6 billion, and more than 71,000 jobs, according to the Brewers of France, a lobby that represents 80 percent of the industry. It says that 70 percent of the beer consumed in France is brewed domestically.


Laurent Lutse, president of the cafe, bar and nightclub branch of France’s main food and hotel union, said that beer represents 25 percent of sales in 80,000 member companies and worried that a tax increase would accelerate the decline of such establishments. “In France in 1960 there were still 200,000 bistros,” Mr. Lutse said. “There are fewer than 35,000 left, which means there are fewer bistros than there are church towers.”


Despite the complaints, the tax increase is expected to pass in the Socialist-dominated National Assembly.


Many opponents of the bill suggested that wine was exempted because the industry has greater political clout, given that it is one of the country’s top three exporters and employs 250,000 people. Wine is currently taxed around the same rate as beer, per hectoliter, but unlike the rates for beer, its rates do not increase with the degrees of alcohol.


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Oprah Winfrey Seeks a Younger Audience to Bolster a Flagging Empire


Stephanie Diani for The New York Times


Oprah Winfrey spoke last month at a convention held by O, The Oprah Magazine, in Los Angeles.







LOS ANGELES — It’s not easy to find a fresh way to photograph Oprah Winfrey.




That’s why the editors of O, The Oprah Magazine, recently tried to create a shot that recalled the glory days of Ms. Winfrey’s syndicated talk show. They arranged to photograph her for its April 2013 issue as she stepped onstage to speak to 5,000 attendees at the magazine’s annual conference, a New Age slumber party of sorts for women held at the convention center here last month. When Ms. Winfrey confidently strode out dressed in a sea foam green V-neck dress and a pair of perilously tall ruby red stilettos, the audience collectively leapt to its feet and shrieked at the sight of her.


“I love you, Oprah,” some women shouted, while other fans brushed away tears. “I love you back,” she responded in her signature commanding voice. “It’s no small thing to get the dough to come here.”


Ms. Winfrey, who used to receive this kind of applause from fans five days a week, has had fewer such receptions since the talk show she hosted for 25 years ended 18 months ago. The cable network OWN, which she started with Discovery Communications, is emerging from low ratings and management shake-ups. And without a regular presence on daytime network television, she cannot steer traffic to her other products as easily as in the past. Her magazine, in particular, has experienced a decline in advertising revenue and newsstand sales since the talk show finished.


“She’s still Oprah. But she’s still struggling,” said Janice Peck, an associate professor of journalism and mass communication at the University of Colorado who wrote the 2008 book “The Age of Oprah.” “I think she’s scared, even though she’s very, very rich and she’s always going to be very, very rich. The possibility of failure, it’s quite scary.”


Ms. Winfrey, 58, has shown some signs of strain. She arrived at the conference with faint shadows under her eyes and announced to her best friend, Gayle King, and the audience simultaneously that she had a breast cancer scare the week before. (It was ultimately a false alarm.) When Ms. King grew visibly upset, one woman chided Ms. Winfrey for not telling her friend ahead of time and ordered her to apologize to Ms. King — all before an audience. Ms. Winfrey also did not hide her dissatisfaction with the criticism she had faced. She told the audience, “the press tried to cut me off at the knees” in its coverage of OWN, and bristled at questions about the challenges her magazine confronted.


“I don’t care what the form is,” Ms. Winfrey said with the conviction of a preacher. “I care about what the message is.”


With signs of progress at OWN, Ms. Winfrey now has more time to devote to other media platforms — her magazine, her radio channel on XM Satellite Radio, her Facebook page, which has 7.8 million subscribers, her Twitter account, which has nearly 15 million followers, and her latest content channel on The Huffington Post.


“It’s all an opportunity to speak to people,” Ms. Winfrey said as she sat for an interview during the conference, a pair of glittery gold stilettos slung in her hand and a couple of handlers in the corner quietly tapping away at smartphones. She pushed aside a bottle of sparkling water, a glass with a silver straw and a delicate orchid placed before her and spoke frankly about her plans.


“Ultimately, you have to make money because you are a business. I let other people worry about that. I worry about the message. I am always, always, always about holding true to the vision and the message, and when you are true to that, then people respond.”


When it comes to the magazine, Ms. Winfrey said her staff prepared her to expect a 25 percent decline in newsstand sales after the talk show ended. (It has been closer to 22 percent.) And while she acknowledged that she enjoyed “holding the magazine in my hand,” she was pragmatic about print’s future and said she would stop publishing a print magazine if it were not profitable.


“Obviously, the show was helping in ways that you know I hadn’t accounted for,” Ms. Winfrey said. “I’m not interested, you know, in bleeding money.”


Ms. Winfrey, who spoke in a conference room over the roars of an expectant crowd in the convention space below, said she knew that her brand’s strength stemmed from how she resonated with a breadth of viewers.


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Agency Investigates Deaths and Injuries Associated With Bed Rails


Thomas Patterson for The New York Times


Gloria Black’s mother died in her bed at a care facility.







In November 2006, when Clara Marshall began suffering from the effects of dementia, her family moved her into the Waterford at Fairway Village, an assisted living home in Vancouver, Wash. The facility offered round-the-clock care for Ms. Marshall, who had wandered away from home several times. Her husband Dan, 80 years old at the time, felt he could no longer care for her alone.








Thomas Patterson for The New York Times

Gloria Black, visiting her mother’s grave in Portland, Ore. She has documented hundreds of deaths associated with bed rails and said families should be informed of their possible risks.






But just five months into her stay, Ms. Marshall, 81, was found dead in her room apparently strangled after getting her neck caught in side rails used to prevent her from rolling out of bed.


After Ms. Marshall’s death, her daughter Gloria Black, who lives in Portland, Ore., began writing to the Consumer Product Safety Commission and the Food and Drug Administration. What she discovered was that both agencies had known for more than a decade about deaths from bed rails but had done little to crack down on the companies that make them. Ms. Black conducted her own research and exchanged letters with local and state officials. Finally, a letter she wrote in 2010 to the federal consumer safety commission helped prompt a review of bed rail deaths.


Ms. Black applauds the decision to study the issue. “But I wish it was done years ago,” she said. “Maybe my mother would still be alive.” Now the government is studying a problem it has known about for years.


Data compiled by the consumer agency from death certificates and hospital emergency room visits from 2003 through May 2012 shows that 150 mostly older adults died after they became trapped in bed rails. Over nearly the same time period, 36,000 mostly older adults — about 4,000 a year — were treated in emergency rooms with bed rail injuries. Officials at the F.D.A. and the commission said the data probably understated the problem since bed rails are not always listed as a cause of death by nursing homes and coroners, or as a cause of injury by emergency room doctors.


Experts who have studied the deaths say they are avoidable. While the F.D.A. issued safety warnings about the devices in 1995, it shied away from requiring manufacturers to put safety labels on them because of industry resistance and because the mood in Congress then was for less regulation. Instead only “voluntary guidelines” were adopted in 2006.


More warnings are needed, experts say, but there is a technical question over which regulator is responsible for some bed rails. Are they medical devices under the purview of the F.D.A., or are they consumer products regulated by the commission?


“This is an entirely preventable problem,” said Dr. Steven Miles, a professor at the Center for Bioethics at the University of Minnesota, who first alerted federal regulators to deaths involving bed rails in 1995. The government at the time declined to recall any bed rails and opted instead for a safety alert to nursing homes and home health care agencies.


Forcing the industry to improve designs and replace older models could have potentially cost bed rail makers and health care facilities hundreds of million of dollars, said Larry Kessler, a former F.D.A. official who headed its medical device office. “Quite frankly, none of the bed rails in use at that time would have passed the suggested design standards in the guidelines if we had made them mandatory,” he said. No analysis has been done to determine how much it would cost the manufacturers to reduce the hazards.


Bed rails are metal bars used on hospital beds and in home care to assist patients in pulling themselves up or helping them out of bed. They can also prevent people from rolling out of bed. But sometimes patients — particularly those suffering from Alzheimer’s — can get confused and trapped between a bed rail and a mattress, which can lead to serious injury or even death.


While the use of the devices by hospitals and nursing homes has declined as professional caregivers have grown aware of the dangers, experts say dozens of older adults continue to die each year as more rails are used in home care and many health care facilities continue to use older rail models.


Since those first warnings in 1995, about 550 bed rail-related deaths have occurred, a review by The New York Times of F.D.A. data, lawsuits, state nursing home inspection reports and interviews, found. Last year alone, the F.D.A. data shows, 27 people died.


As deaths continued after the F.D.A. warning, a working group put together in 1999 and made up of medical device makers, researchers, patient advocates and F.D.A. officials considered requiring bed rail makers to add warning labels.


But the F.D.A. decided against it after manufacturers resisted, citing legal issues. The agency said added cost to small manufacturers and difficulties of getting regulations through layers of government approval, were factors against tougher standards, according to a meeting log of the group in 2000 and interviews.


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Agency Investigates Deaths and Injuries Associated With Bed Rails


Thomas Patterson for The New York Times


Gloria Black’s mother died in her bed at a care facility.







In November 2006, when Clara Marshall began suffering from the effects of dementia, her family moved her into the Waterford at Fairway Village, an assisted living home in Vancouver, Wash. The facility offered round-the-clock care for Ms. Marshall, who had wandered away from home several times. Her husband Dan, 80 years old at the time, felt he could no longer care for her alone.








Thomas Patterson for The New York Times

Gloria Black, visiting her mother’s grave in Portland, Ore. She has documented hundreds of deaths associated with bed rails and said families should be informed of their possible risks.






But just five months into her stay, Ms. Marshall, 81, was found dead in her room apparently strangled after getting her neck caught in side rails used to prevent her from rolling out of bed.


After Ms. Marshall’s death, her daughter Gloria Black, who lives in Portland, Ore., began writing to the Consumer Product Safety Commission and the Food and Drug Administration. What she discovered was that both agencies had known for more than a decade about deaths from bed rails but had done little to crack down on the companies that make them. Ms. Black conducted her own research and exchanged letters with local and state officials. Finally, a letter she wrote in 2010 to the federal consumer safety commission helped prompt a review of bed rail deaths.


Ms. Black applauds the decision to study the issue. “But I wish it was done years ago,” she said. “Maybe my mother would still be alive.” Now the government is studying a problem it has known about for years.


Data compiled by the consumer agency from death certificates and hospital emergency room visits from 2003 through May 2012 shows that 150 mostly older adults died after they became trapped in bed rails. Over nearly the same time period, 36,000 mostly older adults — about 4,000 a year — were treated in emergency rooms with bed rail injuries. Officials at the F.D.A. and the commission said the data probably understated the problem since bed rails are not always listed as a cause of death by nursing homes and coroners, or as a cause of injury by emergency room doctors.


Experts who have studied the deaths say they are avoidable. While the F.D.A. issued safety warnings about the devices in 1995, it shied away from requiring manufacturers to put safety labels on them because of industry resistance and because the mood in Congress then was for less regulation. Instead only “voluntary guidelines” were adopted in 2006.


More warnings are needed, experts say, but there is a technical question over which regulator is responsible for some bed rails. Are they medical devices under the purview of the F.D.A., or are they consumer products regulated by the commission?


“This is an entirely preventable problem,” said Dr. Steven Miles, a professor at the Center for Bioethics at the University of Minnesota, who first alerted federal regulators to deaths involving bed rails in 1995. The government at the time declined to recall any bed rails and opted instead for a safety alert to nursing homes and home health care agencies.


Forcing the industry to improve designs and replace older models could have potentially cost bed rail makers and health care facilities hundreds of million of dollars, said Larry Kessler, a former F.D.A. official who headed its medical device office. “Quite frankly, none of the bed rails in use at that time would have passed the suggested design standards in the guidelines if we had made them mandatory,” he said. No analysis has been done to determine how much it would cost the manufacturers to reduce the hazards.


Bed rails are metal bars used on hospital beds and in home care to assist patients in pulling themselves up or helping them out of bed. They can also prevent people from rolling out of bed. But sometimes patients — particularly those suffering from Alzheimer’s — can get confused and trapped between a bed rail and a mattress, which can lead to serious injury or even death.


While the use of the devices by hospitals and nursing homes has declined as professional caregivers have grown aware of the dangers, experts say dozens of older adults continue to die each year as more rails are used in home care and many health care facilities continue to use older rail models.


Since those first warnings in 1995, about 550 bed rail-related deaths have occurred, a review by The New York Times of F.D.A. data, lawsuits, state nursing home inspection reports and interviews, found. Last year alone, the F.D.A. data shows, 27 people died.


As deaths continued after the F.D.A. warning, a working group put together in 1999 and made up of medical device makers, researchers, patient advocates and F.D.A. officials considered requiring bed rail makers to add warning labels.


But the F.D.A. decided against it after manufacturers resisted, citing legal issues. The agency said added cost to small manufacturers and difficulties of getting regulations through layers of government approval, were factors against tougher standards, according to a meeting log of the group in 2000 and interviews.


Read More..

Building Start-Ups Using Stars’ Social Media Ties to Fans


You might have heard Jessica Alba on daytime TV talking about her new e-commerce company, which sells diapers and other baby supplies, or seen Kim Kardashian pitching her online shoe store in the tabloids.


The man behind the companies, Brian Lee, is far from a household name. Yet in the world of tech start-ups, he is an emerging force.


Mr. Lee, a lawyer turned entrepreneur, has a simple formula: partner with a celebrity that fans associate with a certain product, whether stilettos or baby supplies. He first did it in 1999, when he cold-called Robert Shapiro, O.J. Simpson’s lawyer, and persuaded him to join him at his first start-up, LegalZoom, for creating your own legal documents.


Hiring a famous face to represent your brand is the oldest marketing trick in the book. But Mr. Lee is doing it with an Internet twist. He uses celebrities’ social media connections with fans, coupled with recent innovations in e-commerce, to sell things in ways that were not possible just a few years ago.


The Honest Company, Ms. Alba’s start-up selling eco-friendly baby supplies, has raised $27 million from investors, including Lightspeed Venture Partners. ShoeDazzle, Ms. Kardashian’s shoe company, has raised $66 million from Andreessen Horowitz, Lightspeed and others. But despite this investment, it has recently struggled, replacing its chief executive, laying off employees and raising bigger questions about the new breed of subscription e-commerce companies.


E-commerce is going through a shift, as retailers move beyond publishing print catalogs online to creating new business models for the Web. According to the National Venture Capital Association, venture capitalists invested $2.2 billion in e-commerce start-ups last year, almost three times as much as the year before and more than they have invested since the first Internet boom, which created Amazon.com and eBay.


Mr. Lee’s companies tap the latest e-commerce trends, including selling monthly subscriptions, using software algorithms to determine personal style suggestions and eliminating middlemen by designing products in-house and selling them directly to consumers.


“Given the choice between shopping at a boutique or warehouse, if the styles were right, which would my wife choose?” Mr. Lee said, describing the strategy behind ShoeDazzle and Honest. “A large group of women would choose that kind of curated boutique.”


At Honest, customers sign up for monthly deliveries of diapers festooned with anchors or hearts as well as items like shampoo and detergent, each formulated in-house to reduce chemicals. Ms. Alba conceived the idea, along with Christopher Gavigan, former chief of the nonprofit Healthy Child Healthy World, and turned to Mr. Lee for a business model.


When ShoeDazzle was founded in 2009, it was the first of a flurry of subscription e-commerce start-ups. The shoes, generally $39.95, are suggested based on the results of a style quiz the customer takes. They are designed by ShoeDazzle and manufactured at the same factories that big shoe brands use.


But ShoeDazzle has been struggling with that model, and analysts say that could foreshadow problems for its many imitators, which, in addition to Honest, include Birchbox for cosmetics, Wittlebee for children’s clothing, JustFab for shoes and handbags, and BeachMint, which has sites for jewelry, T-shirts, skin care, shoes, home décor and lingerie. Earlier this month, Walmart joined the trend, introducing a monthly subscription box of food called The Goodies Company.


“Subscriptions were the hot trend in the last year, but I think some of that energy has really flattened,” said Sucharita Mulpuru, an e-commerce analyst at Forrester.


While subscriptions have worked well at companies like Amazon.com and Diapers.com for necessities like toilet paper and diapers, shoppers might find it harder to justify a recurring credit-card charge for colorful suede booties.


ShoeDazzle switched to a nonsubscription model this year, so shoppers log on whenever they are in the mood to shop instead of receiving monthly boxes. In September, the company replaced its chief executive, Bill Strauss, with Mr. Lee. He laid off 20 of its 220 employees and cut expenses like corporate apartments. Both Honest and ShoeDazzle are capital-intensive because they design, store and ship their own inventory.


“We lost our way,” said Jeremy Liew, managing director of Lightspeed Venture Partners. “But there’s real value in this company and customers love the product.”


Mr. Lee said ShoeDazzle would approach $100 million in revenue this year and become profitable next year. Honest is not yet a year old, but its founders say it has proved popular with shoppers. Mr. Lee is the right person for the job, Mr. Liew said, because he has a Hollywood sensibility that Bay Area executives lack.


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As Rebels Gain, Congo Again Slips Into Chaos





GOMA, Democratic Republic of Congo — The lights are out in most of Goma. There is little water. The prison is an empty, garbage-strewn wasteland with its rusty front gate swinging wide open and a three-foot hole punched through the back wall, letting loose 1,200 killers, rapists, rogue soldiers and other criminals.




Now, rebel fighters are going house to house arresting people, many of whom have not been seen again by their families.


“You say the littlest thing and they disappear you,” said an unemployed man named Luke.


In the past week, the rebels have been unstoppable, steamrolling through one town after another, seizing this provincial capital, and eviscerating a chaotic Congolese Army whose drunken soldiers stumble around with rocket-propelled grenades and whose chief of staff was suspended for selling crates of ammunition to elephant poachers.


Riots are exploding across the country — in Bukavu, Butembo, Bunia, Kisangani and Kinshasa, the capital, a thousand miles away. Mobs are pouring into streets, burning down government buildings and demanding the ouster of Congo’s weak and widely despised president, Joseph Kabila.


Once again, chaos is courting Congo. And one pressing question is, why — after all the billions of dollars spent on peacekeepers, the recent legislation passed on Capitol Hill to cut the link between the illicit mineral trade and insurrection, and all the aid money and diplomatic capital — is this vast nation in the heart of Africa descending to where it was more than 10 years ago when foreign armies and marauding rebels carved it into fiefs?


“We haven’t really touched the root cause,” said Aloys Tegera, a director for the Pole Institute, a research institute in Goma.


He said Congo’s chronic instability is rooted in very local tensions over land, power and identity, especially along the Rwandan and Ugandan borders. “But no one wants to touch this because it’s too complicated,” he added.


The most realistic solution, said another Congo analyst, is not a formal peace process driven by diplomats but “a peace among all the dons, like Don Corleone imposed in New York.”


Congo’s problems have been festering for years, wounds that never quite scabbed over.


But last week there was new urgency after hundreds of rebel fighters, wearing rubber swamp boots and with belt-fed machine guns slung across their backs, marched into Goma, the capital of North Kivu Province and one of the country’s most important cities.


The rebels, called the M23, are a heavily armed paradox. On one hand, they are ruthless. Human rights groups have documented how they have slaughtered civilians, pulling confused villagers out of their huts in the middle of the night and shooting them in the head.


On the other hand, the M23 are able administrators — seemingly far better than the Congolese government, evidenced by a visit in recent days to their stronghold, Rutshuru, a small town about 45 miles from Goma.


In Rutshuru, there are none of those ubiquitous plastic bags twisted in the trees, like in so many other parts of Congo. The gravel roads have been swept clean and the government offices are spotless. Hand-painted signs read: “M23 Stop Corruption.” The rebels even have green thumbs, planting thousands of trees in recent months to fight soil erosion.


“We are not a rebellion,” said Benjamin Mbonimpa, an electrical engineer, a bush fighter and now a top rebel administrator. “We are a revolution.”


Their aims, he said, were to overthrow the government and set up a more equitable, decentralized political system. This is why the rebels have balked at negotiating with Mr. Kabila, though this weekend several rebels said that the pressure was increasing on them to compromise, especially coming from Western countries.


On Sunday, rebel forces and government troops were still squared off, just a few miles apart, down the road from Goma.


The M23 rebels are widely believed to be covertly supported by Rwanda, which has a long history of meddling in Congo, its neighbor blessed with gold, diamonds and other glittering mineral riches. The Rwandan government strenuously denies supplying weapons to the M23 or trying to annex eastern Congo. Rwanda has often denied any clandestine involvement in this country, only to have the denials later exposed as lies.


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Lobbying, a Windfall and a Leader’s Family


Gilles Sabrie for The New York Times


Ping An, one of China’s largest financial services companies, is building a 115-story office tower in Shenzhen. The company is a $50 billion powerhouse now worth more than A.I.G., MetLife or Prudential.







SHENZHEN, China — The head of a financially troubled insurer was pushing Chinese officials to relax rules that required breaking up the company in the aftermath of the Asian financial crisis.




The survival of Ping An Insurance was at stake, officials were told in the fall of 1999. Direct appeals were made to the vice premier at the time, Wen Jiabao, as well as the then-head of China’s central bank — two powerful officials with oversight of the industry.


“I humbly request that the vice premier lead and coordinate the matter from a higher level,” Ma Mingzhe, chairman of Ping An, implored in a letter to Mr. Wen that was reviewed by The New York Times.


Ping An was not broken up.


The successful outcome of the lobbying effort would prove monumental.


Ping An went on to become one of China’s largest financial services companies, a $50 billion powerhouse now worth more than A.I.G., MetLife or Prudential. And behind the scenes, shares in Ping An that would be worth billions of dollars once the company rebounded were acquired by relatives of Mr. Wen.


The Times reported last month that the relatives of Mr. Wen, who became prime minister in 2003, had grown extraordinarily wealthy during his leadership, acquiring stakes in tourist resorts, banks, jewelers, telecommunications companies and other business ventures.


The greatest source of wealth, by far, The Times investigation has found, came from the shares in Ping An bought about eight months after the insurer was granted a waiver to the requirement that big financial companies be broken up.


Long before most investors could buy Ping An stock, Taihong, a company that would soon be controlled by Mr. Wen’s relatives, acquired a large stake in Ping An from state-owned entities that held shares in the insurer, regulatory and corporate records show. And by all appearances, Taihong got a sweet deal. The shares were bought in December 2002 for one-quarter of the price that another big investor — the British bank HSBC Holdings — paid for its shares just two months earlier, according to interviews and public filings.


By June 2004, the shares held by the Wen relatives had already quadrupled in value, even before the company was listed on the Hong Kong Stock Exchange. And by 2007, the initial $65 million investment made by Taihong would be worth $3.7 billion.


Corporate records show that the relatives’ stake of that investment most likely peaked at $2.2 billion in late 2007, the last year in which Taihong’s shareholder records were publicly available. Because the company is no longer listed in Ping An’s public filings, it is unclear if the relatives continue to hold shares.


It is also not known whether Mr. Wen or the central bank chief at the time, Dai Xianglong, personally intervened on behalf of Ping An’s request for a waiver, or if Mr. Wen was even aware of the stakes held by his relatives.


But internal Ping An documents, government filings and interviews with bankers and former senior executives at Ping An indicate that both the vice premier’s office and the central bank were among the regulators involved in the Ping An waiver meetings and who had the authority to sign off on the waiver.


Only two large state-run financial institutions were granted similar waivers, filings show, while three of China’s big state-run insurance companies were forced to break up. Many of the country’s big banks complied with the breakup requirement — enforced after the financial crisis because of concerns about the stability of the financial system — by selling their assets in other institutions.


Ping An issued a statement to The Times saying the company strictly complies with rules and regulations, but does not know the backgrounds of all entities behind shareholders. The company also said “it is the legitimate right of shareholders to buy and sell shares between themselves.”


In Beijing, China’s foreign ministry did not return calls seeking comment for this article. Earlier, a Foreign Ministry spokesman sharply criticized the investigation by The Times into the finances of Mr. Wen’s relatives, saying it “smears China and has ulterior motives.”


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White House Presses for Drone Rule Book





WASHINGTON — Facing the possibility that President Obama might not win a second term, his administration accelerated work in the weeks before the election to develop explicit rules for the targeted killing of terrorists by unmanned drones, so that a new president would inherit clear standards and procedures, according to two administration officials.




The matter may have lost some urgency after Nov. 6. But with more than 300 drone strikes and some 2,500 people killed by the Central Intelligence Agency and the military since Mr. Obama first took office, the administration is still pushing to make the rules formal and resolve internal uncertainty and disagreement about exactly when lethal action is justified.


Mr. Obama and his advisers are still debating whether remote-control killing should be a measure of last resort against imminent threats to the United States, or a more flexible tool, available to help allied governments attack their enemies or to prevent militants from controlling territory.


Though publicly the administration presents a united front on the use of drones, behind the scenes there is longstanding tension. The Defense Department and the C.I.A. continue to press for greater latitude to carry out strikes; Justice Department and State Department officials, and the president’s counterterrorism adviser, John O. Brennan, have argued for restraint, officials involved in the discussions say.


More broadly, the administration’s legal reasoning has not persuaded many other countries that the strikes are acceptable under international law. For years before the Sept. 11, 2001, attacks, the United States routinely condemned targeted killings of suspected terrorists by Israel, and most countries still object to such measures.


But since the first targeted killing by the United States in 2002, two administrations have taken the position that the United States is at war with Al Qaeda and its allies and can legally defend itself by striking its enemies wherever they are found.


Partly because United Nations officials know that the United States is setting a legal and ethical precedent for other countries developing armed drones, the U.N. plans to open a unit in Geneva early next year to investigate American drone strikes.


The attempt to write a formal rule book for targeted killing began last summer after news reports on the drone program, started under President George W. Bush and expanded by Mr. Obama, revealed some details of the president’s role in the shifting procedures for compiling “kill lists” and approving strikes. Though national security officials insist that the process is meticulous and lawful, the president and top aides believe it should be institutionalized, a course of action that seemed particularly urgent when it appeared that Mitt Romney might win the presidency.


“There was concern that the levers might no longer be in our hands,” said one official, speaking on condition of anonymity. With a continuing debate about the proper limits of drone strikes, Mr. Obama did not want to leave an “amorphous” program to his successor, the official said. The effort, which would have been rushed to completion by January had Mr. Romney won, will now be finished at a more leisurely pace, the official said.


Mr. Obama himself, in little-noticed remarks, has acknowledged that the legal governance of drone strikes is still a work in progress.


“One of the things we’ve got to do is put a legal architecture in place, and we need Congressional help in order to do that, to make sure that not only am I reined in but any president’s reined in terms of some of the decisions that we’re making,” Mr. Obama told Jon Stewart in an appearance on “The Daily Show” on Oct. 18.


In an interview with Mark Bowden for a new book on the killing of Osama bin Laden, “The Finish,” Mr. Obama said that “creating a legal structure, processes, with oversight checks on how we use unmanned weapons, is going to be a challenge for me and my successors for some time to come.”


The president expressed wariness of the powerful temptation drones pose to policy makers. “There’s a remoteness to it that makes it tempting to think that somehow we can, without any mess on our hands, solve vexing security problems,” he said.


Despite public remarks by Mr. Obama and his aides on the legal basis for targeted killing, the program remains officially classified. In court, fighting lawsuits filed by the American Civil Liberties Union and The New York Times seeking secret legal opinions on targeted killings, the government has refused even to acknowledge the existence of the drone program in Pakistan.


But by many accounts, there has been a significant shift in the nature of the targets. In the early years, most strikes were aimed at ranking leaders of Al Qaeda thought to be plotting to attack the United States. That is the purpose Mr. Obama has emphasized, saying in a CNN interview in September that drones were used to prevent “an operational plot against the United States” and counter “terrorist networks that target the United States.”


But for at least two years in Pakistan, partly because of the C.I.A.’s success in decimating Al Qaeda’s top ranks, most strikes have been directed at militants whose main battle is with the Pakistani authorities or who fight with the Taliban against American troops in Afghanistan.


In Yemen, some strikes apparently launched by the United States killed militants who were preparing to attack Yemeni military forces. Some of those killed were wearing suicide vests, according to Yemeni news reports.


“Unless they were about to get on a flight to New York to conduct an attack, they were not an imminent threat to the United States,” said Micah Zenko, a fellow at the Council on Foreign Relations who is a critic of the strikes. “We don’t say that we’re the counterinsurgency air force of Pakistan, Yemen and Somalia, but we are.”


Then there is the matter of strikes against people whose identities are unknown. In an online video chat in January, Mr. Obama spoke of the strikes in Pakistan as “a targeted, focused effort at people who are on a list of active terrorists.” But for several years, first in Pakistan and later in Yemen, in addition to “personality strikes” against named terrorists, the C.I.A. and the military have carried out “signature strikes” against groups of suspected, unknown militants.


Originally that term was used to suggest the specific “signature” of a known high-level terrorist, such as his vehicle parked at a meeting place. But the word evolved to mean the “signature” of militants in general — for instance, young men toting arms in an area controlled by extremist groups. Such strikes have prompted the greatest conflict inside the Obama administration, with some officials questioning whether killing unidentified fighters is legally justified or worth the local backlash.


Many people inside and outside the government have argued for far greater candor about all of the strikes, saying excessive secrecy has prevented public debate in Congress or a full explanation of their rationale. Experts say the strikes are deeply unpopular both in Pakistan and Yemen, in part because of allegations of large numbers of civilian casualties, which American officials say are exaggerated.


Gregory D. Johnsen, author of “The Last Refuge: Yemen, Al Qaeda and America’s War in Arabia,” argues that the strike strategy is backfiring in Yemen. “In Yemen, Al Qaeda is actually expanding,” Mr. Johnsen said in a recent talk at the Brookings Institution, in part because of the backlash against the strikes.


Shuja Nawaz, a Pakistan-born analyst now at the Atlantic Council in Washington, said the United States should start making public a detailed account of the results of each strike, including any collateral deaths, in part to counter propaganda from jihadist groups. “This is a grand opportunity for the Obama administration to take the drones out of the shadows and to be open about their objectives,” he said.


But the administration appears to be a long way from embracing such openness. The draft rule book for drone strikes that has been passed among agencies over the last several months is so highly classified, officials said, that it is hand-carried from office to office rather than sent by e-mail.


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