Square Feet: Pier 17 Mall Has Upgrades Planned After Hurricane Sandy

SHoP Architects

A rendering shows plans to transform the Pier 17 shopping mall at South Street Seaport.

Nearly two months after Hurricane Sandy devastated the South Street Seaport on the East River in Lower Manhattan, Dumpsters still line its cobblestone streets and nearly all of the stores west of Franklin D. Roosevelt Drive remain closed.

But the storm surge largely spared Pier 17, the seaport’s long-maligned shopping mall to the east. The operators of the mall, the Howard Hughes Corporation of Dallas, say it escaped damage because it is three feet above the pier, which in turn sits well above the water. And so, the company, which holds the ground lease to the city-owned pier, is moving forward with its plans to transform its dated festival marketplace into an open and airy three-story retail and entertainment center.

The local community board voted last month to support the proposal, despite reservations about the signage and some other design features. Though the plan is still working its way through the city’s land use process, the developer’s agreement with the city Economic Development Corporation requires that construction begin on July 1. David R. Weinreb, the chief executive of Howard Hughes, said in a telephone interview that the company would meet that deadline.

After being blocked off by metal gates and closed until this month because of concerns about the stability of the pier, the mall is now open, though some stores are still closed. Inspectors from Halcrow, an international engineering company hired by Howard Hughes, recently determined that the structure was sound. The pier is south of the Brooklyn Bridge, just beyond Fulton Street.

“The pier got a solid rating,” Christopher J. Curry, a senior executive vice president at Howard Hughes, said in a recent interview at the company’s offices on Fulton Street. City officials confirmed that no problems were found at the pier.

In addition to Pier 17, the company controls 170,000 square feet of space farther inland at the seaport, including stores like Brookstone, Ann Taylor and Coach, which suffered extensive storm damage.

“We’re working diligently to remediate the shops,” Mr. Weinreb said. Asked whether the closed stores would remain at the seaport, he said, “We’re in discussions with our tenants about what is in their best interests. Many of those tenants enjoy very good sales and fully expect and want to be back open.”

From the mid-1980s to the early ’90s, the seaport was a big draw, especially for young people, who crowded its bars and restaurants. But then it fell out of favor with New Yorkers, though it has remained a must-see for visitors taking in other downtown sites, retail specialists said.

The operators of the mall at Pier 17 have long wanted to give it more cachet with city residents. Shortly before the economic crisis, a previous owner, General Growth Properties, a mall developer, introduced a much more ambitious plan for the seaport, including a 42-story tower, which was unpopular with residents.

The Howard Hughes Corporation, which is primarily known for its vast master-planned communities like Summerlin, near Las Vegas, acquired the shopping center in 2010, when it was spun off from General Growth as the mall company was emerging from bankruptcy.

Completed in 1985, the Pier 17 shopping center was developed by the Rouse Company, the creator of marketplaces in Boston and Baltimore. (General Growth bought Rouse in 2004.)

But by the time the mall opened, the marketplace concept may already have been outmoded. The existing mall “has basically been a disappointment to everyone over its life,” Hardy Adasko, a senior vice president for planning at the city Economic Development Corporation, testified last week at a City Planning Commission hearing. His agency sees the redevelopment of the pier as a way of advancing its long-term investment in the waterfront, he said.

In contrast to the marketplace design, which was intended to shield visitors from the grittiness of the port, the new structure will capitalize on its waterfront location, offering abundant views of the bridge. Outdoor space on either side of the pier also will be enhanced.

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Op-Ed Contributor: Our Failed Approach to Schizophrenia

TOO many pendulums have swung in the wrong directions in the United States. I am not referring only to the bizarre all-or-nothing rhetoric around gun control, but to the swing in mental health care over the past 50 years: too little institutionalizing of teenagers and young adults (particularly men, generally more prone to violence) who have had a recent onset of schizophrenia; too little education about the public health impact of untreated mental illness; too few psychiatrists to talk about and treat severe mental disorders — even though the medications available in the past 15 to 20 years can be remarkably effective.

Instead we have too much concern about privacy, labeling and stereotyping, about the civil liberties of people who have horrifically distorted thinking. In our concern for the rights of people with mental illness, we have come to neglect the rights of ordinary Americans to be safe from the fear of being shot — at home and at schools, in movie theaters, houses of worship and shopping malls.

“Psychosis” — a loss of touch with reality — is an umbrella term, not unlike “fever.” As with fevers, there are many causes, from drugs and alcohol to head injuries and dementias. The most common source of severe psychosis in young adults is schizophrenia, a badly named disorder that, in the original Greek, means “split mind.” In fact, schizophrenia has nothing to do with multiple personality, a disorder that is usually caused by major repeated traumas in childhood. Schizophrenia is a physiological disorder caused by changes in the prefrontal cortex, an area of the brain that is essential for language, abstract thinking and appropriate social behavior. This highly evolved brain area is weakened by stress, as often occurs in adolescence.

Psychiatrists and neurobiologists have observed biochemical changes and alterations in brain connections in patients with schizophrenia. For example, miscommunications between the prefrontal cortex and the language area in the temporal cortex may result in auditory hallucinations, as well as disorganized thoughts. When the voices become commands, all bets are off. The commands might insist, for example, that a person jump out of a window, even if he has no intention of dying, or grab a set of guns and kill people, without any sense that he is wreaking havoc. Additional symptoms include other distorted thinking, like the notion that something — even a spaceship, or a comic book character — is controlling one’s thoughts and actions.

Schizophrenia generally rears its head between the ages of 15 and 24, with a slightly later age for females. Early signs may include being a quirky loner — often mistaken for Asperger’s syndrome — but acute signs and symptoms do not appear until adolescence or young adulthood.

People with schizophrenia are unaware of how strange their thinking is and do not seek out treatment. At Virginia Tech, where Seung-Hui Cho killed 32 people in a rampage shooting in 2007, professors knew something was terribly wrong, but he was not hospitalized for long enough to get well. The parents and community-college classmates of Jared L. Loughner, who killed 6 people and shot and injured 13 others (including a member of Congress) in 2011, did not know where to turn. We may never know with certainty what demons tormented Adam Lanza, who slaughtered 26 people at an elementary school in Newtown, Conn., on Dec. 14, though his acts strongly suggest undiagnosed schizophrenia.

I write this despite the so-called Goldwater Rule, an ethical standard the American Psychiatric Association adopted in the 1970s that directs psychiatrists not to comment on someone’s mental state if they have not examined him and gotten permission to discuss his case. It has had a chilling effect. After mass murders, our airwaves are filled with unfounded speculations about video games, our culture of hedonism and our loss of religious faith, while psychiatrists, the ones who know the most about severe mental illness, are largely marginalized.

Severely ill people like Mr. Lanza fall through the cracks, in part because school counselors are more familiar with anxiety and depression than with psychosis. Hospitalizations for acute onset of schizophrenia have been shortened to the point of absurdity. Insurance companies and families try to get patients out of hospitals as quickly as possible because of the prohibitively high cost of care.

As documented by writers like the law professor Elyn R. Saks, author of the memoir “The Center Cannot Hold: My Journey Through Madness,” medication and treatment work. The vast majority of people with schizophrenia, treated or untreated, are not violent, though they are more likely than others to commit violent crimes. When treated with medication after a rampage, many perpetrators who have shown signs of schizophrenia — including John Lennon’s killer and Ronald Reagan’s would-be assassin — have recognized the heinousness of their actions and expressed deep remorse.

It takes a village to stop a rampage. We need reasonable controls on semiautomatic weapons; criminal penalties for those who sell weapons to people with clear signs of psychosis; greater insurance coverage and capacity at private and public hospitals for lengthier care for patients with schizophrenia; intense public education about how to deal with schizophrenia; greater willingness to seek involuntary commitment of those who pose a threat to themselves or others; and greater incentives for psychiatrists (and other mental health professionals) to treat the disorder, rather than less dangerous conditions.

Too many people with acute schizophrenia have gone untreated. There have been too many Glocks, too many kids and adults cut down in their prime. Enough already.

Paul Steinberg is a psychiatrist in private practice.

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Op-Ed Contributor: Our Failed Approach to Schizophrenia

TOO many pendulums have swung in the wrong directions in the United States. I am not referring only to the bizarre all-or-nothing rhetoric around gun control, but to the swing in mental health care over the past 50 years: too little institutionalizing of teenagers and young adults (particularly men, generally more prone to violence) who have had a recent onset of schizophrenia; too little education about the public health impact of untreated mental illness; too few psychiatrists to talk about and treat severe mental disorders — even though the medications available in the past 15 to 20 years can be remarkably effective.

Instead we have too much concern about privacy, labeling and stereotyping, about the civil liberties of people who have horrifically distorted thinking. In our concern for the rights of people with mental illness, we have come to neglect the rights of ordinary Americans to be safe from the fear of being shot — at home and at schools, in movie theaters, houses of worship and shopping malls.

“Psychosis” — a loss of touch with reality — is an umbrella term, not unlike “fever.” As with fevers, there are many causes, from drugs and alcohol to head injuries and dementias. The most common source of severe psychosis in young adults is schizophrenia, a badly named disorder that, in the original Greek, means “split mind.” In fact, schizophrenia has nothing to do with multiple personality, a disorder that is usually caused by major repeated traumas in childhood. Schizophrenia is a physiological disorder caused by changes in the prefrontal cortex, an area of the brain that is essential for language, abstract thinking and appropriate social behavior. This highly evolved brain area is weakened by stress, as often occurs in adolescence.

Psychiatrists and neurobiologists have observed biochemical changes and alterations in brain connections in patients with schizophrenia. For example, miscommunications between the prefrontal cortex and the language area in the temporal cortex may result in auditory hallucinations, as well as disorganized thoughts. When the voices become commands, all bets are off. The commands might insist, for example, that a person jump out of a window, even if he has no intention of dying, or grab a set of guns and kill people, without any sense that he is wreaking havoc. Additional symptoms include other distorted thinking, like the notion that something — even a spaceship, or a comic book character — is controlling one’s thoughts and actions.

Schizophrenia generally rears its head between the ages of 15 and 24, with a slightly later age for females. Early signs may include being a quirky loner — often mistaken for Asperger’s syndrome — but acute signs and symptoms do not appear until adolescence or young adulthood.

People with schizophrenia are unaware of how strange their thinking is and do not seek out treatment. At Virginia Tech, where Seung-Hui Cho killed 32 people in a rampage shooting in 2007, professors knew something was terribly wrong, but he was not hospitalized for long enough to get well. The parents and community-college classmates of Jared L. Loughner, who killed 6 people and shot and injured 13 others (including a member of Congress) in 2011, did not know where to turn. We may never know with certainty what demons tormented Adam Lanza, who slaughtered 26 people at an elementary school in Newtown, Conn., on Dec. 14, though his acts strongly suggest undiagnosed schizophrenia.

I write this despite the so-called Goldwater Rule, an ethical standard the American Psychiatric Association adopted in the 1970s that directs psychiatrists not to comment on someone’s mental state if they have not examined him and gotten permission to discuss his case. It has had a chilling effect. After mass murders, our airwaves are filled with unfounded speculations about video games, our culture of hedonism and our loss of religious faith, while psychiatrists, the ones who know the most about severe mental illness, are largely marginalized.

Severely ill people like Mr. Lanza fall through the cracks, in part because school counselors are more familiar with anxiety and depression than with psychosis. Hospitalizations for acute onset of schizophrenia have been shortened to the point of absurdity. Insurance companies and families try to get patients out of hospitals as quickly as possible because of the prohibitively high cost of care.

As documented by writers like the law professor Elyn R. Saks, author of the memoir “The Center Cannot Hold: My Journey Through Madness,” medication and treatment work. The vast majority of people with schizophrenia, treated or untreated, are not violent, though they are more likely than others to commit violent crimes. When treated with medication after a rampage, many perpetrators who have shown signs of schizophrenia — including John Lennon’s killer and Ronald Reagan’s would-be assassin — have recognized the heinousness of their actions and expressed deep remorse.

It takes a village to stop a rampage. We need reasonable controls on semiautomatic weapons; criminal penalties for those who sell weapons to people with clear signs of psychosis; greater insurance coverage and capacity at private and public hospitals for lengthier care for patients with schizophrenia; intense public education about how to deal with schizophrenia; greater willingness to seek involuntary commitment of those who pose a threat to themselves or others; and greater incentives for psychiatrists (and other mental health professionals) to treat the disorder, rather than less dangerous conditions.

Too many people with acute schizophrenia have gone untreated. There have been too many Glocks, too many kids and adults cut down in their prime. Enough already.

Paul Steinberg is a psychiatrist in private practice.

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Google Apps Moving Onto Microsoft’s Business Turf

SAN FRANCISCO — It has taken years, but Google seems to be cutting into Microsoft’s stronghold — businesses.

Google’s software for businesses, Google Apps, consists of applications for document writing, collaboration, and text and video communications — all cloud-based, so that none of the software is on an office worker’s computer. Google has been promoting the idea for more than six years, and it seemed that it was going to appeal mostly to small businesses and tech start-ups.

But the notion is catching on with larger enterprises. In the last year Google has scored an impressive string of wins, including at the Swiss drug maker Hoffmann-La Roche, where over 80,000 employees use the package, and at the Interior Department, where 90,000 use it.

One big reason is price. Google charges $50 a year for each person using its product, a price that has not changed since it made its commercial debut, even though Google has added features. In 2012, for example, Google added the ability to work on a computer not connected to the Internet, as well as security and data management that comply with more stringent European standards. That made it much easier to sell the product to multinationals and companies in Europe.

Many companies that sell software over the cloud add features without raising prices, but also break from traditional industry practice by rarely offering discounts from the list price.

Microsoft’s Office suite of software, which does not include e-mail, is installed on a desktop PC or laptop. In 2013, the list price for businesses will be $400 per computer, but many companies pay half that after negotiating a volume deal.

At the same time, Microsoft has built its business on raising prices for extra features and services. The 2013 version of Office, for example, costs up to $50 more than its predecessor.

“Google is getting traction” on Microsoft, said Melissa Webster, an analyst with IDC. “Its ‘good enough’ product has become pretty good. It looks like 2013 is going to be the year for content and collaboration in the cloud.”

Microsoft has also jumped on the office-in-the-cloud trend. In June 2011, it released Office 365, and now offers its software in both a cloud version and a hybrid version that uses cloud computing and conventional servers. Office 365 starts at a list price of $72 a year, per person, and can cost as much as $240 a person annually, in versions that offer many more features and software development capabilities. Microsoft says it offers more than Google for the money, but the product has not won many converts from Google.

In a recent report, Gartner, the information technology research company, called Google “the only strong competitor” to Microsoft in cloud-based business productivity software, though it warned that “enterprise concerns may not be of paramount importance to the search giant.”

Google is tight-lipped about how many people use Google Apps, saying only that in June more than five million businesses were using it, up from four million in late 2011. Almost all these companies are tiny, but in early December Google announced that even companies with fewer than 10 employees, which used to get Google Apps free, would have to pay.

Google’s revenue from Apps, according to a former executive who asked not to be named in order to maintain good relations with Google, amounted to perhaps $1 billion of the $37.9 billion Google earned in 2011.

Shaw Industries, a carpet maker in Dalton, Ga., with about 30,000 employees, switched to Google Apps this year for communication tools like e-mail and videoconferencing. Jim Nielsen, the company’s manager of enterprise technology, calculated that using Google instead of similar Microsoft products would cost, over seven years, about one-thirteenth Microsoft’s price.

Shaw is a subsidiary of Berkshire Hathaway, run by Warren E. Buffett, but the close friendship of Mr. Buffett and Microsoft’s founder, Bill Gates, did not sway Mr. Nielsen. “When you add it up, the numbers are pretty compelling,” he said.

In addition to the lower price, Google has simplicity in pricing. Mr. Nielsen said he had to sort through 11 pricing models to figure out what he would pay Microsoft.

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The TV Watch: Indian Soap Operas, Ruled by Mothers-in-Law

Kuni Takahashi for The New York Times

The Bhats, of Mumbai, watch soap operas together.

MUMBAI, India — Mothers-in-law are not a joke on Indian TV.

They are the law.

Soap operas dominate prime time here and the mother-in-law reigns in almost all of them. However plucky the heroine or serpentine the plot, every love story seems to circle back to marriage and the many relatives who come with the words “I do.”

The extended family is still the bedrock of Indian society, where modernization meets its match. Soap operas here are outlandish — some so stylized and wildly melodramatic they verge on camp. But they are also oddly prosaic; expressions of duty, deference and parental obligation that inform everyday lives.

Television isn’t an insurrectionist force in India. It’s a relatively young medium struggling to adapt to a vast viewing audience that respects tradition and suspects change. Like many an Indian bride, television here occasionally tests the boundaries but mostly finds its way by following the rules and not making too many waves.

The rules can seem confounding to outsiders: India is a country where female infanticide can be a soap opera plot point in prime time but scenes of casual dating are taboo. In this realm it is the mother-in-law who is the metronome of Indian family values, issuing orders, giving advice and setting the rhythm of acceptable change.

Speed-clicking the remote after 8 p.m. is like watching a PowerPoint display of passion in hot pink, glimmering tears and the occasional stinging slap across the face. Sweet, noble Sandhya dreams of entering the Civil Service on “The Light and the Lamp Are We,” one of the top-rated shows in India, and her handsome husband, a humble candy shop owner, is all for it. But there’s an obstacle that drives the narrative: Her mother-in-law is adamantly opposed.

The basic plot of “Child Bride” is evident from its title, and this soap about an under-age wife is also a top-rated show — under-age marriage is still prevalent enough to wedge its way into the family hour. More shocking, perhaps, is that in more recent episodes the in-laws accept the young heroine as their own and — brace for it — encourage her to leave her husband (he’s a philanderer) and find a better match.

That may be a fantasy, but matriarchal interference (call it guidance) is marriage Indian-style. When Indian women discuss the need to “adjust” to matrimony, they don’t just mean adapting to a new husband. They mean moving in with his parents, grandparents and siblings, a custom that is still the norm, even in prosperous families. In a country with 1.2 billion people, about 148 million households have television and that amounts to as many as 600 million viewers. In the slums of Mumbai even sections without running water sport satellite dishes on corrugated roofs. Almost everywhere, Indians gather in front of the family television and the mother-in-law controls the remote.

“Women like to see their favorite characters express their own feelings, so the mother-in-law identifies with the mother-in-law, the daughter-in-law with the daughter-in-law,” is how Ekta Kapoor explains soap opera transference. Ms. Kapoor, a 37-year-old television and film producer who currently has five shows on the air, became queen of the Indian soap world with her breakthrough series, “The Mother-in-Law Was Once a Daughter-in-Law, Too,”one of the all-time hits of Indian television that ran from 2000 to 2008.

Male children are favored in Indian society, and wives join the husband’s family at the low end of the pecking order, often relegated to kitchen drudge work while the mother-in-law rules over the grandchildren. “We live with our parents until we are married, then we live with someone else’s parents,” Ms. Kapoor said. “There is pressure to give everything to the son. It’s a source of conflict in so many homes.” (Ms. Kapoor, the daughter of well-known actors, is single and owns her own house but lives with her parents in their home anyway.)

Alessandra Stanley, chief television critic of The New York Times, has gone abroad to watch foreign TV this year.

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Books: From Bang to Whimper: A Heart Drug’s Story

On June 23, 2005, American medicine managed to take a small step forward and a giant step backward at precisely the same time, with government approval of the first medication to be earmarked for a specific racial group. It was BiDil, a drug designed to treat heart failure in blacks.

Enthusiasts hailed BiDil’s approval by the Food and Drug Administration as a landmark event in the nascent field of pharmacogenomics, which aims to create drugs tailored to fit an individual’s genetic makeup as precisely as a bespoke suit drapes its owner’s shoulders. Critics just winced and clocked one more misstep in medicine’s long history of race-related disasters.

You would think that the elucidation of the human genome would have cleared up most of the hoary untruths surrounding race and health. But as Jonathan Kahn makes clear in his worthy if convoluted review of the events surrounding the birth of BiDil, the genome has in many respects only made things worse.

It has been clear for decades that race has minimal relevance to the body’s inner workings. Research has repeatedly shown that the biologic variations among individuals of the same race are reliably great enough for race to retain little utility as a biologic predictor. You might as well sort people by height. Or, in the words of an editorial writer for Nature Biotechnology in 2005, “Pooling people in race silos is akin to zoologists grouping raccoons, tigers and okapis on the basis that they are all stripy.”

But old misconceptions die hard, particularly for entrepreneurs eagerly awaiting cash bonanzas from the genomic revolution.

Race may be irrelevant; it may be, as Dr. Francis Collins, the director of the National Institutes of Health, put it, “a weak and imperfect proxy” for genetic differences. But it is also a familiar concept — and asking people what race they are is substantially cheaper than genotyping them.

So in a peculiar paradox, race has come to serve in some circles as a crude surrogate for genetic analysis until actual genomic medicine comes along — a temporary bridge from now to later, known to be flawed but still a quasi-legitimate stand-in for the real thing.

Against this background unfolds the story of BiDil, a drama of greed and good intentions.

Several observations prompted the drug’s development. Among them was the common assertion from the last century that blacks with heart failure were more likely to die than whites. (Mr. Kahn does an impressive job of researching and debunking this statistic.) Then there was the belief that blacks often reacted badly to some of the newer drugs used for treating heart failure, and the results of a study dating from the 1980s suggesting that many black patients did well with two old standby drugs.

Those two drugs were (and are) on sale as generics, costing pennies a pill. But just suppose they were combined into a single pill that could be then specifically marketed to patients who just happened to be thought in particular need of effective medication? Now there was a pharmacologic and marketing plan that would extend a lucrative new patent for decades.

And so it came to pass that a collection of eager investors and some of the nation’s foremost cardiologists smiled on the results of an industry-sponsored trial performed on self-identified black subjects with heart failure: The two cheap drugs combined into the not-so-cheap BiDil reduced mortality by 40 percent compared with placebo. This figure was impressive enough to end the trial early and speed BiDil to market.

How did whites do on BiDil? Nobody bothered to check.

Mr. Kahn deserves credit for teasing out all the daunting complexities behind these events, including the details of genetic analysis, the perils of racial determinations and the minutiae of patent law. Unfortunately, though, he suffocates his powerful subject in a dry, repetitive, ponderous read.

A law professor with a doctorate in history and longstanding interest in race issues, Mr. Kahn trudges a partisan path through the drama in which he himself was a player. (He testified before an F.D.A. advisory committee that BiDil should be approved without racial qualifications.)

He heads bravely into many statistical thickets, but omits relevant clinical data; he repeatedly refers to the trial that led to BiDil’s approval, for instance, but I could find its numerical findings nowhere in the book and had to look them up. In a story that fairly drips with potential human interest, he offers the reader not one sip.

The issues raised on every page are so important and so thought-provoking that it would be irresponsible to warn interested readers away. Still, it would be almost as irresponsible to misrepresent the difficulty of the journey.

As it happens, BiDil itself has had a remarkably inglorious career. Despite its much-trumpeted release, patients did not request the medication, and practicing doctors did not prescribe it.

NitroMed, the company that developed it, sponsored no further studies and failed in 2009.

The drug still lingers on the market; Mr. Kahn writes that BiDil may be resurrected in sustained-release form — that other time-honored technique for wringing a few more years from a drug’s patent.

For a parable of early 21st-century medicine, as it treads water between past and future and never hesitates to reach for a buck, it doesn’t get much better than BiDil.

Read More..

Books: From Bang to Whimper: A Heart Drug’s Story

On June 23, 2005, American medicine managed to take a small step forward and a giant step backward at precisely the same time, with government approval of the first medication to be earmarked for a specific racial group. It was BiDil, a drug designed to treat heart failure in blacks.

Enthusiasts hailed BiDil’s approval by the Food and Drug Administration as a landmark event in the nascent field of pharmacogenomics, which aims to create drugs tailored to fit an individual’s genetic makeup as precisely as a bespoke suit drapes its owner’s shoulders. Critics just winced and clocked one more misstep in medicine’s long history of race-related disasters.

You would think that the elucidation of the human genome would have cleared up most of the hoary untruths surrounding race and health. But as Jonathan Kahn makes clear in his worthy if convoluted review of the events surrounding the birth of BiDil, the genome has in many respects only made things worse.

It has been clear for decades that race has minimal relevance to the body’s inner workings. Research has repeatedly shown that the biologic variations among individuals of the same race are reliably great enough for race to retain little utility as a biologic predictor. You might as well sort people by height. Or, in the words of an editorial writer for Nature Biotechnology in 2005, “Pooling people in race silos is akin to zoologists grouping raccoons, tigers and okapis on the basis that they are all stripy.”

But old misconceptions die hard, particularly for entrepreneurs eagerly awaiting cash bonanzas from the genomic revolution.

Race may be irrelevant; it may be, as Dr. Francis Collins, the director of the National Institutes of Health, put it, “a weak and imperfect proxy” for genetic differences. But it is also a familiar concept — and asking people what race they are is substantially cheaper than genotyping them.

So in a peculiar paradox, race has come to serve in some circles as a crude surrogate for genetic analysis until actual genomic medicine comes along — a temporary bridge from now to later, known to be flawed but still a quasi-legitimate stand-in for the real thing.

Against this background unfolds the story of BiDil, a drama of greed and good intentions.

Several observations prompted the drug’s development. Among them was the common assertion from the last century that blacks with heart failure were more likely to die than whites. (Mr. Kahn does an impressive job of researching and debunking this statistic.) Then there was the belief that blacks often reacted badly to some of the newer drugs used for treating heart failure, and the results of a study dating from the 1980s suggesting that many black patients did well with two old standby drugs.

Those two drugs were (and are) on sale as generics, costing pennies a pill. But just suppose they were combined into a single pill that could be then specifically marketed to patients who just happened to be thought in particular need of effective medication? Now there was a pharmacologic and marketing plan that would extend a lucrative new patent for decades.

And so it came to pass that a collection of eager investors and some of the nation’s foremost cardiologists smiled on the results of an industry-sponsored trial performed on self-identified black subjects with heart failure: The two cheap drugs combined into the not-so-cheap BiDil reduced mortality by 40 percent compared with placebo. This figure was impressive enough to end the trial early and speed BiDil to market.

How did whites do on BiDil? Nobody bothered to check.

Mr. Kahn deserves credit for teasing out all the daunting complexities behind these events, including the details of genetic analysis, the perils of racial determinations and the minutiae of patent law. Unfortunately, though, he suffocates his powerful subject in a dry, repetitive, ponderous read.

A law professor with a doctorate in history and longstanding interest in race issues, Mr. Kahn trudges a partisan path through the drama in which he himself was a player. (He testified before an F.D.A. advisory committee that BiDil should be approved without racial qualifications.)

He heads bravely into many statistical thickets, but omits relevant clinical data; he repeatedly refers to the trial that led to BiDil’s approval, for instance, but I could find its numerical findings nowhere in the book and had to look them up. In a story that fairly drips with potential human interest, he offers the reader not one sip.

The issues raised on every page are so important and so thought-provoking that it would be irresponsible to warn interested readers away. Still, it would be almost as irresponsible to misrepresent the difficulty of the journey.

As it happens, BiDil itself has had a remarkably inglorious career. Despite its much-trumpeted release, patients did not request the medication, and practicing doctors did not prescribe it.

NitroMed, the company that developed it, sponsored no further studies and failed in 2009.

The drug still lingers on the market; Mr. Kahn writes that BiDil may be resurrected in sustained-release form — that other time-honored technique for wringing a few more years from a drug’s patent.

For a parable of early 21st-century medicine, as it treads water between past and future and never hesitates to reach for a buck, it doesn’t get much better than BiDil.

Read More..

Russian Prosecutor Seeks Acquittal in Magnitsky’s Death

MOSCOW — A prosecutor unexpectedly pressed Monday for the acquittal of the only official to be tried in the case of Sergei L. Magnitsky, a lawyer whose death in prison three years ago generated an international furor over Russian human rights abuses.

The prosecutor’s turnabout, made in his closing argument, came as the Russian government has been moving aggressively to retaliate against the United States for adopting a law named for Mr. Magnitsky that will deny travel and investment access to Russian citizens accused of violating human rights.

Mr. Magnitsky was representing a London investment firm, Hermitage Capital, when he was arrested in November 2008 as he tried to expose a huge government tax fraud. He died, still in detention, nearly a year later. His supporters — including the firm’s founder, William F. Browder, once among the most prominent foreign investors in Russia and now a sharp critic of the Russian government — blamed the authorities for his death, saying he was denied proper medical care.

An investigation yielded charges against two people, both doctors: Larisa Litvinova, who oversaw Mr. Magnitsky’s treatment during his last weeks, and Dmitri Kratov, formerly the chief medical official of the prison where he was held for the last four months of his life, Butyrskaya. This year, prosecutors dropped a charge of professional negligence against Dr. Litvinova, saying the statute of limitations had run out.

On Monday, the prosecutor, Konstantin Bokov, urged the court to acquit Dr. Kratov. “There is no cause-and-effect relationship between Kratov’s actions and Magnitsky’s death,” Mr. Bokov said, according to Russian news services. “I request his acquittal.” A verdict is expected by the end of the week.

A lawyer for Mr. Magnitsky’s family, however, told the court that Dr. Kratov signed prison records declaring Mr. Magnitsky fit to remain imprisoned despite his repeated complaints about needing medical care, and that Dr. Kratov knew that Mr. Magnitsky was suffering from acute pancreatitis and gallstones in the days before his death.

The lawyer, Nikolay Gorokhov, blamed President Vladmir V. Putin for the prosecution’s move, noting that Mr. Putin at his annual news conference last week angrily brushed off a question about why Russian officials had not thoroughly investigated Mr. Magnitsky’s death. Mr. Gorokhov accused the authorities of failing to carry out a thorough investigation or a fair trial, and said important evidence and witnesses were suppressed.

After President Obama signed the Magnitsky Act this month, Russian officials proposed blocking American adoptions of Russian orphans and imposing sanctions on American judges and others who fail to halt or punish abuse of Russian adoptees.

Mr. Putin was pressed about the adoption ban eight times at his news conference. He would not say if he would sign the ban, but he said that Russia had to retaliate and that it was hypocritical of the United States, accused of abuses around the world, to criticize Russia on human rights.

“I don’t know the details, but I know anyway that Mr. Magnitsky died not from torture — nobody tortured him — but from a heart attack,” Mr. Putin said, adding that the only question was if he was given help in time.

But he quickly moved on to attacking the United States. “Do you think people don’t die in American prisons?” he asked. “Come on. And so what? Shall we play it up?”

Mr. Putin also pointed a finger at Mr. Browder, of Hermitage Capital, who was barred from Russia without warning in 2005, for making a mission of seeking justice in Mr. Magnitsky’s case.

“Besides, this Mr. Magnitsky, as is known, was not some human rights champion; he did not struggle for human rights,” Mr. Putin said. “He was the lawyer of Mr. Browder, who is suspected by our law enforcement of committing economic crimes.”

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E-Book Price War Has Yet to Arrive

Thor Swift for The New York Times

A Google e-reader is displayed at a bookstore. Sales of e-books for the devices have slowed this year.

Right about now, just as millions of e-readers and tablets are being slipped under Christmas trees, there was supposed to be a ferocious price war over e-books.

Last spring, the Justice Department sued five major publishers and Apple on e-book price-fixing charges. The case was a major victory for Amazon, and afterward there were widespread expectations — fueled by Amazon — that the price of e-books would plunge.

The most extreme outcome went like this: Digital versions of big books selling for $9.99 or less would give Amazon complete domination over the e-book market. As sales zoomed upward, even greater numbers of consumers would abandon physical books. The major publishers and traditional bookstores were contemplating a future that would pass them by.

But doomsday has not arrived, at least not yet. As four of the publishers have entered into settlements with regulators and revised the way they sell e-books, prices have selectively fallen but not as broadly or drastically as anticipated.

The $10 floor that publishers fought so hard to maintain for popular new novels is largely intact. Amazon, for instance, is selling Michael Connelly’s new mystery, “The Black Box,” for $12.74. New best sellers by David Baldacci and James Patterson cost just over $11.

One big reason for the lack of fireworks is that the triumph of e-books over their physical brethren is not happening quite as fast as forecast.

“The e-book market isn’t growing at the caffeinated level it was,” said Michael Norris, a Simba Information analyst who follows the publishing industry. “Even retailers like Amazon have to be wondering, how far can we go — or should we go — to make our prices lower than the other guys if it’s not helping us with market share?”

Adult e-book sales through August were up 34 percent from 2011, an impressive rate of growth if you forget that sales have doubled every year for the last four years. And there have been more recent signs of a market pausing for breath.

Macmillan, the only publisher that has not settled with the Justice Department, said last week as part of a statement from John Sargent, its chief executive, that “our e-book business has been softer of late, particularly for the last few weeks, even as the number of reading devices continues to grow.” His laconic conclusion: “Interesting.”

Mr. Norris said Simba, which regularly surveys e-book buyers, has been noticing what it calls “commitment to content” issues.

“A lot of these e-book consumers aren’t behaving like lab rats at a feeder bar,” the analyst said. “We have found that at any given time about a third of e-book users haven’t bought a single title in the last 12 months. I have a feeling it is the digital equivalent of the ‘overloaded night stand’ effect; someone isn’t going to buy any more books until they make a dent in reading the ones they have already acquired.”

Another, more counterintuitive possibility is that the 2011 demise of Borders, the second-biggest chain, dealt a surprising blow to the e-book industry. Readers could no longer see what they wanted to go home and order. “The print industry has been aiding and assisting the e-book industry since the beginning,” Mr. Norris said.

It is possible that Amazon, which controls about 60 percent of the e-book market, is merely holding back with price cuts for the right moment.

The next few weeks are when e-book sales traditionally take a big jump, as all those newly received devices are loaded up with content.

Amazon declined to comment beyond saying, “We have lowered prices for customers from the prices publishers set on a broad assortment of Kindle books.” Barnes & Noble declined to comment on its pricing strategy.

The question of the proper price for e-books has shadowed the industry ever since Amazon introduced the Kindle in late 2007 and created the first truly popular portable reading device. Amazon had a natural impulse to build a market and was an aggressive retailer in any case, so it took best sellers that cost $25 in independent bookstores and sold them for $9.99 as e-books. Consumers liked that. E-book adoption soared.

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Well: With Help Here and There, Preserving Independence in Old Age

My 92-year-old aunt, who is cognitively impaired and requires a walker or wheelchair to get around, still lives in her own apartment, where round-the-clock home health aides help her get to and from the bathroom, bathe, dress and undress, and go outside each day for some fresh air. The aides shop, prepare and serve meals, do light housekeeping and make sure she takes her medications on time.

But last month, my aunt’s long-term care insurance ran out, and her meager savings will soon do the same. Then what?

Her daughters, both of whom work to support their families, cannot afford the $150 a day for 24-hour care by a certified home health aide, and my aunt has nothing to sell that could bring in the needed cash. Nor does she yet qualify for Medicaid or have a terminal illness that would justify hospice care, which would be covered by Medicare.

Complicating matters, her daughters long ago promised that they would not put her in a nursing home.

Such dilemmas are increasingly common as people live longer. The number of Americans 65 and older is expected to double to 80 million in the next three decades. People 85 and older are the fastest-growing age group; by 2020, there will be 6.6 million people in that age bracket, when rates of debilitating ailments soar.

Most Americans over 65 will eventually need help with the so-called tasks of daily living — eating, dressing, bathing, shopping and the like. But with family members spread all over the map or unable to be full-time caregivers for other reasons, the need for new and better options will only increase.

When asked, 80 to 90 percent of older people say they want to remain in their own homes as long as possible. Yet remaining in one’s home indefinitely is not always the best choice, even if it is financially feasible. As life draws near a close, many older adults need more care than can be provided safely at home. Simply finding reputable home health aides can be a nightmare, and family members often are forced to fill gaps in even the best caregiving plans.

The challenge is all the more difficult when no one has thought through the options before a serious illness or injury makes it impossible for elders to return home without full-time help.

Many elders living independently need outside help long before they require round-the-clock care. A range of assistance and housing alternatives has rapidly sprung up to meet this demand. Many focus on improving accessibility in the home and access to neighborhood conveniences.

An older person living in the suburbs who can no longer drive may become isolated, lonely and at risk of malnutrition if there is no person or community service to shop for her and take her places. Even stairs are a major obstacle.

Elinor Ginzler, director of the Cahnmann Center for Supportive Services at the Jewish Council for the Aging in Rockville, Md., writes that “the ability to age in place is greatly determined by the physical design and accessibility of a home, as well as community features like the availability of nearby services and amenities, affordable housing and transportation options.”

Organizations like Staying in Place, a nonprofit group of volunteers, helps people age 50 and older in Woodstock, N.Y., and surrounding communities “maintain active, independent, fulfilling lives in their own homes.” For $125 a year (plus $50 for each additional household member over 50), the organization assists with paperwork and technology; free or low-cost transportation; referrals to discounted service workers; information about, and transport to, local classes and cultural and social activities; and recommendations for home health care agencies and personnel.

Other services that are free or low-cost include Meals on Wheels; friendly visiting; shopping services accessed by phone or computer; activities at senior centers; and adult day care centers.

There are also more costly commercial organizations like Home Instead Senior Care, an international network of more than 900 independently owned franchises that provide in-home nonmedical care for elders and support for their caregivers.

The organization sponsored a yearlong online study of 1,631 caregivers, 697 of whom were assisted by paid in-home nonmedical care. The study found that people receiving the additional paid care required 25 percent fewer doctor visits and were more likely to participate in adult day care.

Sadly, many aides are seriously underpaid. Home Instead, for instance, has lobbied to keep home health care aides exempt from minimum wage standards.

Henry Cisneros, former secretary of the United States Department of Housing and Urban Development and editor of the book “Independent for Life: Homes and Neighborhoods for an Aging America,” points out that “Americans are aging in traditional homes, neighborhoods and communities that were designed for yesterday’s demographic realities, not those of today or the future.”

Mr. Cisneros advocates changing our communities so that the elderly can remain in them. “Homes can be retrofitted, new age-appropriate homes built, existing neighborhoods reconnected, and new communities planned,” he wrote. For example, to accommodate declining eyesight, homes can be fitted with brighter bulbs, better lighting locations, easily accessed controls and nighttime guide lights.

Mr. Cisneros sees a pressing need for affordable packages of home modifications and maintenance to make residences more suitable for older people.

“A certified renovation package for aging in place could include roll-under kitchen and bathroom sinks, grab bars, curbless showers, lever faucets and door handles, a zero-step entrance, and wider doors and hallways,” he wrote.

While such changes have a price tag, they may cost a lot less than current care alternatives for the elderly.

Needed changes at the community level include affordable small-scale housing and cluster housing situated in walkable communities with nearby amenities, businesses, health facilities and public transportation.

Borrowing from the design of assisted living facilities, individual dwelling units might be located around a common space that includes dining areas and social rooms.

For elders who want to be near family members yet maintain their independence, so-called accessory dwelling units with their own kitchens and bathrooms are being built near or attached to family homes.

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How to Know When Home Alone Is No Longer a Good Idea

Paula Spencer Scott, senior editor at Caring.com, recently compiled a guide to help families determine when the time has come to move older relatives from their homes and into a more supportive environment or, alternatively, to bring in a home health aide who can provide assistance. These signs to look for and questions to ask are adapted from Ms. Scott’s recommendations.

¶ Recent accidents or close calls, like a fall, medical scare or minor car accident.

¶ A slow recovery. How well was a recent illness weathered? Did it develop into something serious? Was medical help sought when needed?

¶ Worsening of a chronic health condition. As problems like chronic obstructive pulmonary disease, dementia or congestive heart failure progress, more help will be needed.

¶ Greater difficulty managing the so-called activities of daily living, like dressing, bathing and cooking.

¶ Bodily changes, like obvious weight loss or gain, increased frailty or unpleasant body odor.

¶ A loss of active friendships, including outings with friends, visits with neighbors or participation in religious or other group activities.

¶ Days spent without leaving the house, perhaps because of difficulty driving or a fear of using public transportation.

¶ Is someone checking in regularly? If not, is there a home-safety alarm system, a personal alarm system or a daily calling service in place?

¶ Is someone nearby to assist if there’s a fire, earthquake, flood or other disaster, and does the older resident understand plans for a catastrophe?

¶ Mail in a chaotic state, scattered about and unopened. Are there unpaid overdue bills, surprising thank-you notes from charities, piles of unread magazines?

¶ If an older relative is still driving, go along for a ride and look for failure to fasten the seat belt or heed dashboard warning lights; signs of tension, preoccupation or distraction while driving; damage to the vehicle that may indicate carelessness.

¶ In the kitchen, signs of excess or forgetfulness, like perishables well past their expiration dates.

¶ Favorite appliances are broken but not scheduled for repair.

¶ Signs of fires. Look for charred stove knobs or pot bottoms, potholders with burned edges, a discharged fire extinguisher. Do smoke and carbon monoxide detectors have live batteries?

¶ A once-neat home now cluttered, spills that were not cleaned up, grime coating bathroom and kitchen appliances or an overflowing laundry basket.

¶ Neglected plants or pets.

¶ Signs of neglect outside the home, like broken windows, debris-filled gutters and drains, uncollected rubbish and an overstuffed mailbox.

¶ Ask friends and neighbors whether your family member’s behavior has changed lately.

¶ Ask the person’s doctor whether you should be concerned about the person’s health or safety and whether a home assessment by a social worker or geriatric care manager may be advisable. If you expect resistance from the person, ask the doctor to “prescribe” a professional evaluation.

¶ If you are the primary caregiver, how are you doing? Are you increasingly exhausted, depressed or becoming resentful of the sacrifices you have to make to care for the person?

¶ Consider your older relative’s emotional state. If she is riddled with anxieties or increasingly lonely, then it may be time to make a move for reasons other than health and safety.

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