CARLOS Tiger without Time

On wards and in intensive care units, when doctors, nurses, patients and families find themselves at odds with one another, they inevitably turn to the experts of last resort: the bioethicists.

Regularly called upon to weigh in on issues including life support, human research, patient rights and organ transplantation, bioethicists are known for bringing clarity to situations so overwrought with opinions, values and special interests that consensus appears impossible.

Now, as the search for consensus in health care reform grinds toward the end of its first year, a national leader in bioethics has cast his critical eye on the debate. At issue, however, are not the usual moral suspects: pharmaceutical manufacturers, medical device makers and hospitals. This time it is physicians who have lapsed in their ethical responsibilities.

In an editorial in The New England Journal of Medicine, Dr. Howard Brody, professor of family medicine and director of the Institute for the Medical Humanities at the University of Texas Medical Branch in Galveston, writes that the medical profession, unlike other groups, has made little effort to curtail future medical costs. Physicians, Dr. Brody maintains, are not “innocent bystanders” to spiraling health care costs but have been complicit in their failure to take an active role in curtailing them.
Moreover, Dr. Brody points out, certain doctors’ groups have gone so far as to make their support for reform contingent on promises that their own income would remain unaffected. “If physicians seized the moral high ground,” Dr. Brody writes in his editorial, “we just might astonish enough other people to change the entire reform debate for the better.”

I spoke with Dr. Brody recently about the ethical obligations of doctors in the health care overhaul, the role of organized medicine, his “Top Five” plan to regain medicine’s moral ground, and whether it all comes down to money.

Q. You write that doctors have an ethical responsibility to advocate health care reform. Why?
A. Doctors have two responsibilities. First, they have a moral duty as an individual advocate. A doctor has a responsibility to his or her individual patients to make them healthier and to help them live longer.
But doctors have a second moral duty: they have an obligation to the general public to be prudent stewards of scarce resources. Doctors only get about 10 percent of health care costs in their pockets, but they control about 80 percent. That isn’t our money — it’s someone else’s — and the public has entrusted us to spend it as wisely as possible.

Q. Have doctors failed in that second moral duty?
A. Unlike previous health care reform discussions where doctors were put on a pedestal, people are now turning the searchlight, appropriately I think, on the medical profession and asking if we are the problem. But rather than rising to that challenge and exercising moral leadership in health care reform, we are acting like one more special interest group. Instead of saying we care about patients enough to put our own interests on the back burner, it has been as if we were more concerned about maximizing our income.
We make so much more money than so many people in this society. To say that we are entitled to that income rather than we are privileged and should give back to society does not, and should not, win us a lot of friends.
The reason that the public gave us so much regard, trusted us, was because they saw us as willing to make that moral commitment to put the patient first. If we ever retreat from that commitment, we lose so much. I don’t even want to think what that would be like.

Q. But are you referring to individual doctors or to organized medicine? Some doctors would argue that the opinions of organized medicine are not representative of doctors as a whole. Take the American Medical Association, for example; it counts only about 30 percent of licensed doctors as members.
A. Over the years I’ve met doctors from virtually every specialty who firmly place the good of the patient ahead of their own personal income and who have made personal sacrifices in their own income in order to practice the best medicine. But there are certain things that can only be accomplished by professional medical societies, things that doctors as individuals could never do.
I firmly believe that if a professional medical society came out and said, “This is our prescription for health care reform, even if it costs us money,” that would get attention.

Q. So is it all about the money?
A. No. It’s an unfortunate joining of money with other issues and motives. We have an American public that generally believes more is better. And rather than giving up bad habits, exercising and eating right, they would rather believe that the answer to health is in high technology.
When you combine this love affair with high technology with a reimbursement system that pays so much more for technology — and less for thinking and sitting and talking with patients — you end up with an expensive kind of medicine, which, when practiced by doctors, puts more money into their pockets.
In actual fact, there’s such a low chance that technology will help all these patients.

Q. How does your “Top Five” solution work?
A. The basic idea is that each specialty would decide on the top five procedures or diagnostic studies that are done commonly but only really help a small fraction of patients. These are things like arthroscopy for osteoarthritis of the knee or MRI’s and CAT scans, all of which are massively overused, not because they help but because of our enthusiasm regarding high technology.
Once each specialty has gone through the research evidence and decided on its “Top Five,” the respective professional organizations would take a public stand, issuing guidelines and recommendations against overuse of those “Top Five” procedures or studies.
By taking a public stand and making it harder for individual doctors to say, “Oh, I know better,” we could build real momentum for cost containment. And we would ultimately all benefit because we don’t need all that technology. You can still be as healthy without it.

By PAULINE W. CHEN, M.D. (March 3, 2010-NYT)

AFTER five years of investigation, the Justice Department has released its findings regarding the government lawyers who authorized waterboarding and other forms of torture during the interrogation of suspected terrorists at Guantánamo Bay and elsewhere. The report’s conclusion, that the lawyers exercised poor judgment but were not guilty of professional misconduct, is questionable at best. Still, the review reflects a commitment to a transparent investigation of professional behavior.

In contrast, the government doctors and psychologists who participated in and authorized the torture of detainees have escaped discipline, accountability or even internal investigation.

It is hardly news that medical staff at the C.I.A. and the Pentagon played a critical role in developing and carrying out torture procedures. Psychologists and at least one doctor designed or recommended coercive interrogation methods including sleep deprivation, stress positions, isolation and waterboarding. The military’s Behavioral Science Consultation Teams evaluated detainees, consulted their medical records to ascertain vulnerabilities and advised interrogators when to push harder for intelligence information.

Psychologists designed a program for new arrivals at Guantánamo that kept them in isolation to “enhance and exploit” their “disorientation and disorganization.” Medical officials monitored interrogations and ordered medical interventions so they could continue even when the detainee was in obvious distress. In one case, an interrogation log obtained by Time magazine shows, a medical corpsman ordered intravenous fluids to be administered to a dehydrated detainee even as loud music was played to deprive him of sleep.

When the C.I.A.’s inspector general challenged these “enhanced interrogation” methods, the agency’s Office of Medical Services was brought in to determine, in consultation with the Justice Department, whether the techniques inflicted severe mental pain or suffering, the legal definition of torture. Once again, doctors played a critical role, providing professional opinions that no severe pain or suffering was being inflicted.

According to Justice Department memos released last year, the medical service opined that sleep deprivation up to 180 hours didn’t qualify as torture. It determined that confinement in a dark, small space for 18 hours a day was acceptable. It said detainees could be exposed to cold air or hosed down with cold water for up to two-thirds of the time it takes for hypothermia to set in. And it advised that placing a detainee in handcuffs attached by a chain to a ceiling, then forcing him to stand with his feet shackled to a bolt in the floor, “does not result in significant pain for the subject.”

The service did allow that waterboarding could be dangerous, and that the experience of feeling unable to breathe is extremely frightening. But it noted that the C.I.A. had limited its use to 12 applications over two sessions within 24 hours, and to five days in any 30-day period. As a result, the lawyers noted the office’s “professional judgment that the use of the waterboard on a healthy individual subject to these limitations would be ‘medically acceptable.’”
The medical basis for these opinions was nonexistent. The Office of Medical Services cited no studies of individuals who had been subjected to these techniques. Its sources included a wilderness medical manual, the National Institute of Mental Health Web site and guidelines from the World Health Organization.

The only medical source cited by the service was a book by Dr. James Horne, a sleep expert at Loughborough University in Britain; when Dr. Horne learned that his book had been used as a reference, he said the C.I.A. had distorted his findings and misrepresented his research, and that its conclusions on sleep deprivation were nonsense.

Dr. Horne had used healthy volunteers who were subject to no other stresses and could withdraw at any time, while C.I.A. and Pentagon interrogators used a broad array of stresses in combination on the detainees. Sleep deprivation, he said, mixed with pain-inducing positioning, intimidation and a host of other stresses, would probably exhaust the body’s defense mechanisms, cause physical collapse and worsen existing illness. And that doesn’t begin to acknowledge the dire psychological consequences.

The shabbiness of the medical judgments, though, pales in comparison to the ethical breaches by the doctors and psychologists involved. Health professionals have a responsibility extending well beyond nonparticipation in torture; the historic maxim is, after all, “First do no harm.” These health professionals did the polar opposite.

Nevertheless, no agency — not the Pentagon, the C.I.A., state licensing boards or professional medical societies — has initiated any action to investigate, much less discipline, these individuals. They have ignored the gross and appalling violations by medical personnel. This is an unconscionable disservice to the thousands of ethical doctors and psychologists in the country’s service. It is not too late to begin investigations. They should start now.
Leonard S. Rubenstein is a visiting scholar at the Johns Hopkins Bloomberg School of Public Health. Stephen N. Xenakis is a psychiatrist and a retired Army brigadier general.

Text  By LEONARD S. RUBENSTEIN and STEPHEN N. XENAKIS
March 1, 2010
Op-Ed Contributors-New York Times

Feeling her Toyota Mark X station wagon lurch forward at a busy intersection, Masako Sakai slammed on the brakes. But the pedal “had gone limp,” she said. Downshifting didn’t seem to work either.

“I tried everything I could think of,” Mrs. Sakai, 64, said, as she recently recalled the accident that happened six months ago.
Her car surged forward nearly 3,000 feet before slamming into a Mercedes Benz and a taxi, injuring drivers in both those vehicles and breaking Mrs. Sakai’s collarbone.
As shaken as she was by the accident, Mrs. Sakai says she was even more surprised by what happened after. She says that Toyota — from her dealer to headquarters — has not responded to her inquiries, and Japanese authorities have been indifferent to her concerns as a consumer.

Mrs. Sakai says the Tokyo Metropolitan Police urged her to sign a statement saying that she pressed the accelerator by mistake — something she strongly denies. She says the police told her she could have her damaged car back to get it repaired if she made that admission. She declined.
The police say it was a misunderstanding and that they kept her car to carry out their investigation.
But veterans of Japan’s moribund consumer rights movement say that Mrs. Sakai, like many Japanese, is the victim of a Japanese establishment that values Japanese business over Japanese consumers, and the lack of consumer protections here.

“In Japan, there is a phrase: if something smells, put a lid on it,” said Shunkichi Takayama, a Tokyo-based lawyer who has handled complaints related to Toyota vehicles.

Toyota has recalled eight million cars outside Japan because of unexpected acceleration and other problems, but has insisted that there are no systemic problems with its cars sold in Japan. The company recalled the Prius for a brake problem earlier this year.

Critics say many companies benefit from Japan’s weak consumer protections. (The country has only one full-time automobile recall investigator, supported by 15 others on limited contracts.)

In a case in the food industry, a meat processor called Meat Hope collapsed in 2008 after revelations that it had mixed pork, mutton and chicken bits into products falsely labeled as pure ground beef, all under the noses of food inspectors.

A 2006 police inquiry into gas water heaters made by the manufacturer Paloma found that a defect had resulted in the deaths of 21 people over 10 years from carbon monoxide poisoning.

Paloma initially insisted that users had tampered with the heaters’ safety device; the company ultimately admitted that the heaters were at fault — and that executives had been aware of a potential problem for more than a decade. Executives are now being charged with professional negligence, and a court verdict is due in May.
When it comes to cars, the rapid growth of the auto industry here and of car ownership in the 1960s and ’70s was accompanied by a spate of fatal accidents. A consumer movement soon emerged among owners of these defective vehicles.

The most active was the Japan Automobile Consumers Union, led by Fumio Matsuda, a former Nissan engineer often referred to as the Ralph Nader of Japan. But the automakers fought back with a campaign discrediting the activists as dangerous agitators. Mr. Matsuda and his lawyer were soon arrested and charged with blackmail. They fought the charges to Japan’s highest court, but lost.

Now, few people are willing to take on the country’s manufacturers at the risk of arrest, Mr. Matsuda said in a recent interview. “The state sided with the automakers, not the consumers,” he said.

It has become difficult for drivers to access even the most elementary data or details on incidents of auto defects, says Hiroko Isomura, an executive at the National Association of Consumer Specialists and a former adviser to the government on auto recalls. “Unfortunately, the Automobile Consumers Union was shut down,” she said. “No groups like that exist any more.”

For the government to order a recall, it must prove that automobiles do not meet national safety standards, which is difficult to do without the automakers’ cooperation. Most recalls are done on a voluntary basis without government supervision.
An examination of transport ministry records by The New York Times found that at least 99 incidents of unintended acceleration or surge in engine rotation had been reported in Toyotas since 2001, of which 31 resulted in some form of collision.

Critics like Mr. Takayama charge that the number of reports of sudden acceleration in Japan would be bigger if not for the way many automakers in Japan, helped by reticent regulators, have kept such cases out of official statistics, and out of the public eye.
In 2008, about 6,600 accidents and 30 deaths were blamed on drivers of all kinds of vehicles mistakenly pushing the accelerator instead of the brakes, according to the Tokyo-based Institute for Traffic Accident Research and Data Analysis.
But Mr. Takayama has long argued that number includes cases of sudden acceleration. “It has become the norm here to blame the driver in almost any circumstance,” he said.
“Regulators have long accepted the automakers’ assertions at face value,” said Yukiko Seko, a retired lawmaker of the Japan Communist Party who pursued the issue in Parliament in 2002.

The police strongly deny pressuring drivers to accept the blame in any automobile accident. “All investigations into auto accidents are conducted in a fair and transparent way,” the Tokyo Metropolitan Police said in response to an inquiry by The Times.
Figuring out who is really to blame can be hard because of Japan’s lack of investigators.
Japan’s leniency has also meant that automakers here have routinely ignored even some of the safety standards for cars sold in the United States. Until the early 1990s, Japanese cars sold domestically lacked the reinforcing bars in car walls required of all vehicles sold in the United States. Critics say skimping on safety was one way automakers generated profits in Japan to finance their export drive abroad.

A handful of industry critics like Mr. Takayama and Ms. Seko have, over the years, voiced concern over cases of sudden acceleration in Toyota and other cars in Japan. Under scrutiny especially after the introduction of automatic transmission cars in the late 1980s, Toyota recalled five models because a broken solder was found in its electronics system, which could cause unintended acceleration.

In 1988 the government ordered a nationwide study and tests, and urged automakers to introduce a fail-safe system to make sure the brakes always overrode the accelerator. This month, more than 20 years later, Toyota promised to install a brake override system in all its new models.
Meanwhile, Toyota maintains a large share on the Japanese market, with about 30 percent. The Prius gas-electric hybrid remained the top-selling car in Japan in February despite the automaker’s global recalls, figures released Thursday showed.

But Japan’s pro-industry postwar order may be changing.
In 2009, in one of the last administrative moves by the outgoing government, a new consumer affairs agency was set up to better police defective products, unsafe foods and mislabeling.

The new government’s transport minister, Seiji Maehara, has been outspoken against Toyota.
He said last week that he would push to revamp the country’s oversight of the auto industry, including adding more safety investigators. The government has also said it was examining 38 complaints of sudden acceleration in Toyotas reported from 2007 through 2009, as well as 96 cases in cars produced by other automakers.

Toyota continues to deny there are problems with unintended acceleration in Japan.
“Yes, there have been incidents of unintended acceleration in Japan,” Shinichi Sasaki, Toyota’s quality chief, said at a news conference last week. “But we believe we have checked each incident and determined that there was no problem with the car,” he said.
Mrs. Sakai said she has called and visited her Toyota dealer, as well as Toyota Motor itself, but has not received a response.

A Toyota spokeswoman, Mieko Iwasaki, confirmed that the automaker had been contacted about complaints of a crash caused by sudden acceleration in September. She said, however, that she could not divulge details of how the company handled each case.
“We are investigating the accident alongside the police, and are cooperating fully with investigations,” she said. “Anything we find, we will tell the police.”
Makiko Inoue and Yasuko Kamiizumi contributed from Tokyo.

By HIROKO TABUCHI-NYT (TOKYO —March 5, 2010)

Angered by increases in tuition and cuts in state financing, thousands of students, parents and faculty members protested across California on Thursday at colleges, universities and even elementary schools to plead for help with the state’s education crisis.

Called a “strike and day of action to defend public education” by organizers, the demonstrations were boisterous and occasionally confrontational — campus and building entrances were blocked at several schools — but they were largely peaceful for most of the day.
Late Thursday afternoon, however, more than 150 people were arrested after they stopped traffic along an interstate in Oakland, according to the California Highway Patrol. There was also one injury. Protesters in Davis, outside Sacramento, also tried to block an interstate but were rebuffed by the authorities using pepper spray. One student protester was arrested.
Scattered tuition protests occurred in other states, too, with at least 16 people arrested at the University of Wisconsin, Milwaukee, when protesters tried to force their way into administration offices and threw ice chunks at campus officers, according to a university spokesman.
One of the largest demonstrations in California took place here on the north steps of the Capitol, where more than 1,000 people used drums, bullhorns, and scores of young voices to try to get their message across.

“How are we going to save the future if we can’t even get into our classes?” said Reid E. Milburn, the president of the Student Senate for California Community Colleges, referring to tuition increases and reductions in the number of courses. Her comments drew a large cheer from those in the crowd, many them students avoiding classes in a show of protest.
California’s public education system has been racked by spending cuts because of the state’s financial problems, which include a looming $20 billion budget deficit. Layoffs and furloughs have hit many districts and school systems, along with reductions in course offerings and grants.
On Wednesday, Gov. Arnold Schwarzenegger, a Republican in his last year of office, said the layoffs and reductions in courses carried out by some schools in the state were “terrible.” The bottom line, he said, was that “they need much more money.”
Where that money might come from is unclear. Alberto Torrico, the Democratic majority leader in the State Assembly, has proposed a 12.5 percent tax on the state’s oil producers, which he says could raise $2 billion for higher education. But with any new tax in California requiring a two-thirds majority in the Legislature, its prospects are uncertain.
Educators said the 23-campus California State University system — which has more than 425,000 students and lower fees than the 10-campus University of California system — was being hit particularly hard by cutbacks.
Julie Chisholm, an assistant professor of writing at one Cal State institution, the California Maritime Academy, in Vallejo, was struggling with 1-year-old twins at the Sacramento protest. She said that her $60,000 salary had been cut 10 percent by furloughs, but that she had chosen to take her furloughs on nonteaching days to avoid inconveniencing her students.
“Our students are getting hit, too, with higher tuition,” she said.
In Santa Cruz, the surfing town south of San Francisco, protesters effectively shut down access to the University of California campus there by blocking entrances, according to a message posted on the university’s Web site. Protesters also broke at least one windshield and intimidated visitors, the message said.

Santa Cruz and several other University of California campuses were the sites of demonstrations last fall when the State Board of Regents approved a 32 percent increase in undergraduate fees, the equivalent of tuition.
Several hundred students also protested at Bruin Plaza at the University of California, Los Angeles, where people in one group had painted skulls on their faces. And at the university’s Berkeley campus, Rafael Velazquez, 23, a graduate student in the school of education, who plans to be a public high school teacher, was one of hundreds protesting.
“I plan to be a teacher, but it’s not my job prospects I’m worried about,” said Mr. Velazquez, who has a brother in fifth grade in San Lorenzo. “It’s the whole system.”
The cuts are also being felt in economically depressed areas like Richmond, near San Francisco, where unemployment is 17.6 percent and violent crime and poverty are common.
“Kids come to school hungry; some are homeless,” said Mary Flanagan, 55, a third-grade teacher from Richmond. “How can we deal with problems like that with as many as 38, 40 kids in a class?”
Protesters said they would continue to press their case with more demonstrations, including what was expected to be a well-attended protest on Thursday evening in central San Francisco. But at San Francisco State, where about 150 students, faculty members and administrators had joined to form an “informational picket line,” some were skeptical that anything — other than a sudden influx of money — would be effective in swaying state leaders.
“We’ve had tons of protests here, and it doesn’t do much,” said Maura Geiszler, 22, a senior studying music. “All they’ve got to do is turn off the news.”
Reporting was contributed by Malia Wollan from Berkeley, Calif.; Jennifer Steinhauer and Rebecca Cathcart from Los Angeles; and Gerry Shih from San Francisco.

By JESSE McKINLEY-NYT (SACRAMENTO —March 4, 2010)

It has been three years since the Supreme Court’s conservative majority abruptly departed from precedent to uphold a federal ban on a particular method of abortion. Emboldened, foes of reproductive freedom are pressing new attacks on women’s rights and health.

In Utah, Gov. Gary Herbert, a Republican, has signed a bill that would criminalize certain behavior by women that results in miscarriage. It was prompted by a sad and strange case last year in which a teenager who was seven months pregnant sought to induce a miscarriage by hiring a man to beat her. The measure exempts lawful abortions, and particularly worrisome language about “reckless” acts has been removed. But the law still raises concern about zealous prosecutors using a woman’s difficult choices to open an investigation.

In Oklahoma, the Center for Reproductive Rights succeeded last week in blocking a burdensome measure designed to discourage abortions by requiring preprocedure sonograms and exempting physicians from liability for failing to disclose fetal abnormalities. But the ruling turned on a technical flaw in the law, and its supporters are expected to try again.

An even more ominous assault on reproductive freedom is looming in Nebraska. A blatantly unconstitutional measure moving through the State Legislature would ban abortions at 20 weeks’ gestation — before viability and earlier than constitutionally allowed. Its narrow health exception excludes mental health. Indeed, the bill prohibits doctors from performing an abortion to avoid a serious risk that the woman may commit suicide.

The obvious goal here is to present the Supreme Court with a new vehicle for further watering down Roe v. Wade. That is troubling enough, but lately another tactic is being deployed to demonize abortion and abortion providers and further polarize the nation.

Citing the disproportionately high number of African-American women who undergo abortions, for example, abortion foes are hurling baseless charges of genocide and racial discrimination. Since last year, a staff member of Georgia Right to Life has been traveling to black churches and colleges, spreading the lie that abortion is the key to conspiracy to kill off blacks. Recently, the group posted dozens of billboards around Atlanta that proclaim, “Black children are an endangered species.”

In fact, of course, there is no conspiracy. The real reason so many black women have abortions can be explained in four words: too many unwanted pregnancies.
Even in this charged debate, phony accusations of genocide should be out of bounds, but political forces that oppose abortion are pursuing a focused, often successful campaign. Americans who support women’s reproductive rights need to make their voices heard.

Editorial-NYT (March 10, 2010)

Tim Westergren recently sat in a Las Vegas penthouse suite, a glass of red wine in one hand and a truffle-infused Kobe beef burger in the other, courtesy of the investment bankers who were throwing a party to court him.

It was a surreal moment for Mr. Westergren, who founded Pandora, the Internet radio station. For most of its 10 years, it has been on the verge of death, struggling to find investors and battling record labels over royalties.

Had Pandora died, it would have joined myriad music start-ups in the tech company graveyard, like SpiralFrog and the original Napster. Instead, with a successful iPhone app fueling interest, Pandora is attracting attention from investment bankers who think it could go public, the pinnacle of success for a start-up.
Pandora’s 48 million users tune in an average 11.6 hours a month. That could increase as Pandora strikes deals with the makers of cars, televisions and stereos that could one day, Pandora hopes, make it as ubiquitous as AM/FM radio.
“We were in a pretty deep dark hole for a long time,” said Mr. Westergren, who is now the company’s chief strategy officer.. “But now it’s a pretty out-of-body experience.”

At the end of 2009, Pandora reported its first profitable quarter and $50 million in annual revenue — mostly from ads and the rest from subscriptions and payments from iTunes and Amazon.com when people buy music. Revenue will probably be $100 million this year, said Ralph Schackart, a digital media analyst at William Blair.
Pandora’s success can be credited to old-fashioned perseverance, its ability to harness intense loyalty from users and a willingness to shift directions — from business to consumer, from subscription to free, from computer to mobile — when its fortunes flagged.
Its library now has 700,000 songs, each categorized by an employee based on 400 musical attributes, like whether the voice is breathy, like Charlotte Gainsbourg, or gravelly like Tom Waits. Listeners pick a song or musician they like, and Pandora serves up songs with similar qualities — Charlotte Gainsbourg to Feist to Viva Voce to Belle and Sebastian. Unlike other music services like MySpace Music or Spotify, now available in parts of Europe, listeners cannot request specific songs.
Though Pandora’s executives say it is focusing on growth, not a public offering, the company is taking steps to make it possible. Last month, it hired a chief financial officer, Steve Cakebread, who had that job at Salesforce.com when it went public.

It is all a long way from January 2000, when Mr. Westergren founded the company. Trained as a jazz pianist, he spent a decade playing in rock bands before taking a job as a film composer. While analyzing the construction of music to figure out what film directors would like, he came up with an idea to create a music genome.
This being 1999, he turned the idea into a Web start-up and raised $1.5 million from angel investors. It was originally called Savage Beast Technologies and sold music recommendation services to businesses like Best Buy.

By the end of 2001, he had 50 employees and no money. Every two weeks, he held all-hands meetings to beg people to work, unpaid, for another two weeks. That went on for two years.

Meanwhile, he appealed to venture capitalists, charged up 11 credit cards and considered a company trip to Reno to gamble for more money. The dot-com bubble had burst, and shell-shocked investors were not interested in a company that relied on people, who required salaries and health insurance, instead of computers.
In March 2004, he made his 348th pitch seeking backers. Larry Marcus, a venture capitalist at Walden Venture Capital and a musician, decided to lead a $9 million investment.
“The pitch that he gave wasn’t that interesting,” Mr. Marcus said. “But what was incredibly interesting was Tim himself. We could tell he was an entrepreneur who wasn’t going to fail.”

Mr. Westergren took $2 million of it and called another all-hands meeting to pay everyone back. The next order of business: focus the service on consumers instead of businesses, change the name and replace Mr. Westergren as chief executive with Joe Kennedy, who had experience building consumer products at E-Loan and Saturn. Pandora’s listenership climbed, and in December 2005, it sold its first ad.
But in 2007, Pandora got news that threatened most of its revenue. A federal royalty board had raised the fee that online radio stations had to pay to record labels for each song. “Overnight our business was broken,” Mr. Westergren said. “We contemplated pulling the plug.”
Instead, Pandora hired a lobbyist in Washington and recruited its listeners to write to their representatives. “A lot of these users think they’re customers of the cause rather than users per se,” said Willy C. Shih, a professor at Harvard Business School who has written a case study on Pandora. “It’s a different spin on marketing.” The board agreed to negotiations and after two years settled on a lower rate.
Some music lovers dislike Pandora’s approach to choosing music based on its characteristics rather than cultural associations. Slacker Radio, a competitor with three times as many songs but less than a third of Pandora’s listeners, takes a different approach. A ’90s alternative station should be informed by Seattle grunge, said Jonathan Sasse, senior vice president for marketing at Slacker. “It’s not just that this has an 80-beat-a-minute guitar riff,” he said. “It’s that this band toured with Eddie Vedder.”

Yet in 2008, Pandora built an iPhone app that let people stream music. Almost immediately, 35,000 new users a day joined Pandora from their cellphones, doubling the number of daily signups.
For Pandora and its listeners, it was a revelation. Internet radio was not just for the computer. People could listen to their phone on the treadmill or plug it into their car or living room speakers.

In January, Pandora announced a deal with Ford to include Pandora in its voice-activated Sync system, so drivers will be able to say, “Launch my Lady Gaga station” to play their personalized station based on the music of that performer. Consumer electronics companies like Samsung, Vizio and Sonos are also integrating Pandora into their Blu-ray players, TVs and music systems.

“Think about what made AM/FM radio so accessible,” said Mr. Kennedy, Pandora’s chief. “You get into the car or buy a clock for your nightstand and push a button and radio comes out,” he said. “That’s what we’re hoping to match.”

By CLAIRE CAIN MILLER-NYT (OAKLAND, California—March 7, 2010)

When the great orchestras of Europe glide through the United States on tour, they stay at elegant hotels like Le Parker Meridien near Carnegie Hall, play in grand spaces like Symphony Hall in Boston and can receive more than $100 a day in meal money.

Then there is the Moscow State Radio Symphony Orchestra.

On their nine-week tour, these Muscovites are slogging to Ashland, Ky.; Quincy, Ill.; and Zanesville, Ohio, often riding buses for up to seven hours, moving from highway to budget hotel to concert hall, and then all over again the next morning. They have a day off every two weeks, on average.
The pay? About $40 a concert in most cases, the musicians said. Per diems? Zero, making “breakfast included” the sweetest of words. The bus drivers often stop at malls to let them shop for food at a Wal-Mart. Many of them double up in hotel rooms.
“Musicians are human beings too, and they should be treated like humans,” one disgusted musician wrote in an e-mail message. Like most of the orchestra members who were contacted, this one spoke on condition of anonymity, fearing being blacklisted from future jobs.
The conditions are tough — akin to the grinding travel of low-level minor league baseball teams or striving rock bands or the barnstorming jazz orchestras of yore — and a little unexpected for a group of highly trained classical musicians. Yet they are not uncommon.
Performing arts centers and concert halls in smaller cities and towns around the country are hungry for classical music programming. The Royal Philharmonic Orchestra or Berlin Symphony is well beyond their means. So lesser known, and lower priced, foreign orchestras provide a solution.
Presenters on the Moscow orchestra’s tour said it cost from $50,000 to $75,000 to engage it, compared to $100,000 and up for a well known orchestra, or twice that for one of the elite, like the Berlin or Vienna Philharmonic.
Foreign orchestras, no matter the level, provide a lure of the exotic.

“There’s a cachet there,” said Wesley O. Brustad, the president and chief executive of the State Theater in New Brunswick, N.J. “American orchestras are tough to sell,” he said. They are also more expensive because of union rules. As a bonus, presenters of foreign groups benefit from a built-in audience: ethnic groups that live in the area. Russians are especially enthusiastic concertgoers.
The State Theater played host to the Muscovites on Feb. 14, a day after they performed at George Mason University in Fairfax, Va., where the musicians plowed through a preconcert buffet.

“It’s not the best orchestra in the world,” Mr. Brustad said. “The winds were a little weak.” But the musicians played with emotion, he said. (When told the Moscow players generally made $40 for the concert, Mr. Brustad said: “Oh, my goodness. No kidding. Wow. I had no idea.”)
The Moscow State Radio Symphony’s biography says it was founded in 1978 to give broadcast performances. It toured the United States once before, in 2004, and has made recent trips to China and Italy. It has made several dozen recordings, including a number for the Naxos label.
Anatoli Nemudrov, the orchestra’s artistic director, declined to discuss financial arrangements, saying they were confidential. But, he noted, touring “is hard work for all musicians, Russians and Americans.” He said the tour had been going well, adding, “We have good concerts.”
The producer of the tour, Andrew S. Grossman of Columbia Artists Management, did not respond to phone messages left at his office, on his cellphone and with his assistant, and did not respond to an e-mail query.

The Columbia Artists chairman, Ronald A. Wilford, said he was not familiar with the details of the contract. But he said that typically Columbia Artists, as a producer, receives fees from the presenters, who keep the box office receipts. Columbia Artists arranges travel inside the country and lodging, and guarantees the orchestra a set fee. “We have no idea what they’re paying their orchestra,” Mr. Wilford said of Moscow State Radio Symphony’s management.
The orchestra began its latest American tour on Jan. 13, when it arrived in Atlanta, and is due in St. Louis on Wednesday. After an original itinerary of 53 concerts in 67 days, it leaves from Los Angeles on March 22. The trip began in the deep South, worked its way north, swung through southern New England, is now in the Midwest and heads out to Arizona, Nevada and California.
On Feb. 17 the tour brought the group to Worcester, Mass. This season’s schedule of the presenter there, Music Worcester, also includes the Odessa Philharmonic, the Orquestra de São Paulo, the Shanghai Symphony and I Musici de Montréal.

“It was an all-Tchaikovsky program, which is a win-win to begin with,” Stasia Hovenesian, the executive director of Worcester Music, said of the Moscow group’s appearance. “No one but no one plays Tchaikovsky as well as the Russians do.”
And Russians they are, including conductor and soloists (except for several last-minute American substitutes). Whether they were actually members of the Moscow State Radio Symphony Orchestra is another question. A half-dozen players interviewed said they were students or freelancers hired for the tour. One musician who did allow his name to be used, Vladimir Prikhodko, a double bassist, estimated that only about 20 to 30 players in the 90-piece group were full-time members.
Mr. Nemudrov, the artistic director, said that only about a half-dozen were not regulars.
On Feb. 21 the orchestra played a concert at the Lehman Center for the Performing Arts in the Bronx. Eva Bornstein, the center’s executive director, introduced it as “one of the finest orchestras of Europe.”

A few days before the Lehman concert a Russian mechanical engineer living in Manhattan, Sergei Levitan, contacted The New York Times to denounce what he said was mistreatment of the players. He said he knew several through mutual friends. “It’s demeaning,” he said of the conditions. “I got upset.”
After the Lehman concert a player said he grew dizzy and tumbled over a railing into a stairwell, cracking his skull. The player was interviewed by telephone at St. Barnabas Hospital in the Bronx, where he was admitted with a head injury.
The conditions are “very bad,” said another member. “I wouldn’t do this trip again. They should pay us at least twice as much,” the player said. Others lamented that they had come to see the United States but had little opportunity. Several said that a kindly bus driver had taken them into New York on a day off while they were staying in New Jersey.

Rehearsals are relentless even though they are not paid for, some musicians said, but pride in their craft pushed them to attend anyway.
Others welcomed the chance to gain concert experience, and said that the money was not bad by Russian standards. Mr. Prikhodko, 31, the double bass player, called the tour a “difficult experience, but a very useful one.” Besides, he added, “I like traveling.”
The e-mailing orchestra member, in a separate interview at Lehman, acknowledged that the performance level was not the highest. “There’s a direct relationship between how we play and how much we get paid,” he said. As for the rigors of the tour, he shrugged them off.
“I am strong man, and I am Russian,” he said. “So I can do this.”

By DANIEL J. WAKIN -NYT (March 4, 2010)

NOT long ago, Yelena S. Chizhova was engaged in what has become a standard winter pastime for Russia’s middle class: taking the sun at a giant resort hotel in Egypt. She and a girlfriend, who also grew up in St. Petersburg, joined the river of people flowing into the warehouse-size dining hall, its tables heaped with steaming meat and pastries.

And then something passed over them like a shadow. The women felt so uneasy that they had to step away for a moment, and Ms. Chizhova asked her friend what she was thinking about. But she did not need to ask. What the two women had in common was relatives who starved in the 872-day siege of Leningrad, as St. Petersburg was then known, when army engineers set off explosives in the fields and shoveled corpses into the craters.
For a moment, Ms. Chizhova had the strange feeling that she was seeing the piles of food through the eyes of her dying relatives. Born in 1958, she learned the official version of the siege from Soviet textbooks, which cast it as a patriotic triumph. The truly terrible facts sifted down to her when she eavesdropped on her mother and great-grandmother, who lost most of their family in the siege, as they talked quietly over cups of tea.
These snatches of conversation are at the core of her novel, “Time of Women,” which won last year’s Russian Booker Prize, the country’s most prestigious literary award. Ms. Chizhova tells the story of three elderly women raising a small girl in a communal apartment in the early 1960s, where the ordinary business of dishes and laundry is interrupted by memories of purges and famine.

It is an earthbound and frankly emotional novel, especially in a literary scene long dominated by the cerebral trickery of postmodernism. Ms. Chizhova is hoping that Russian artists are ready — finally — to address the good and evil of the Soviet past. Under Brezhnev, people averted their eyes from that past out of fear; under Vladimir V. Putin, she said, it was replaced by apathy. “For the vast majority of people, it simply is not interesting,” said Ms. Chizhova, 52, who smokes and talks with the energy of a coiled spring. “They do not have the feeling that history continues. It seems to them that in the 1990s, we just started over. As if we were all born then.”

But St. Petersburg is a city where blotting out history is difficult. Ms. Chizhova’s mother watched two brothers die of hunger while profiteers were taking fistfuls of gold jewelry in exchange for bread. Her father was forced into a detachment of irregular fighters who were sent against German tanks in groups of five, provided with only one rifle. Neither would have dreamed of explaining this to their daughter. But Ms. Chizhova’s great-grandmother was different; she turned over the memories absently, almost as if she was talking to herself. When Ms. Chizhova, then 5, recited a poem about cannibals in Africa, her great-grandmother explained matter-of-factly how the starving residents of Leningrad resorted to eating bodies.
“I would ask, ‘Where did they get it?’ ” Ms. Chizhova said. “For me it was like a fairy tale. She said some of them bought it in the market, thinking it was just meat. And then she would explain that when she worked in the hospital, they would store the bodies near the hospital gates, and by the time they went home in the evening, some of the soft parts were cut off.
“She would talk about that calmly,” she said. “And I heard it calmly.”

THOUGH the conversations stopped abruptly when Ms. Chizhova turned 6, they had already engraved something on her. When her teachers told her, “All Leningrad, like one person, stood in defense of the city,” her private thought was: It was a crime not to evacuate the children. And 40 years later, the insistent voices of old women began to declaim in Ms. Chizhova’s head, and she sat down to write a novel.
A slender 95 pages, told in a sometimes cryptic stream of conversation, “Time of Women” was not favored to win the Booker Prize, and some critics dripped contempt. Summing up the books of the year for the magazine Literaturnaya Rossiya, Kirill Ankudinov sneered at “literature sitting on grandmother’s trunk and becoming drunk on memories of how well people behaved under Brezhnev,” and Yevgeny Yermolin bemoaned the popularity of “cemetery erotica.”
There is no question that the past is exerting a pull on Russian art. All the novels short-listed for the prize vibrated with the feel of the 20th century, noted Elena Dyakova, a critic at the newspaper Novaya Gazeta.

“AFTER the period of post-modernism, people are searching for some moral bearings, and it’s easiest to find that in the lives of your own grandmothers,” she said. “Theoretically, we consider that there are no decent people in Russia, but empirically, we can show that they used to exist, in any case.”
So it is with Ms. Chizhova’s fictional grandmothers, hardly dissident types, who find themselves at war with the Soviet system as they struggle to keep the girl, Sonia, who is mute, out of a state home for the handicapped. At a moment of despair, knowing too well the bleak life that awaits Sonia in state custody, one of them tries to prepare her.
“You may be locked up and we may not be allowed to see you,” the grandmother whispers fiercely to the girl. “You will have to manage alone. But you should know — wherever you are locked up — I am with you. Any day I am outside the fence. I will keep walking as long as God gives me life. You may not see me, but you should remember — my granny is there.”

Last month, Ms. Chizhova was still adjusting to her victory, raising her eyebrows when a stranger called to invite her to join his literary circle. (“Now that I have won a prize,” she remarked dryly, “it seems I have changed a great deal.”) As the Soviet Union began to fall, she bounced from an economics department — her thesis was on regulated costs in machine-tool building enterprises — to English instruction to the wobbly business world of the 1990s. The last bounce took place on a burning cruise ship off the coast of Turkey, when she spent six hours shut in her cabin, waiting to see if help would come.
“I sat by myself and tried to answer the question of what would be better — to explode or to throw myself into the sea,” said Ms. Chizhova, who is married and has two grown daughters. “I understood that I had done a lot in my life, but none of it was right. And when we were saved, I decided to throw it all away and sit and write.”

That was 1996. Since then she has written for six hours a day without weekends or vacations, producing five novels, three of them finalists for the Booker Prize. It is not surprising, given this, that she speaks about her work with moral urgency. History repeats itself in Russia, she said, the same evils appear in new guises, and failing to study it means repeating terrible mistakes. But her tone softens and blurs when she is asked whether her novel is political.
“If I am honest, I wrote it for those who died,” she said. “I wrote it for them. I was speaking with them. I always had the feeling that they were listening to me.”

By ELLEN BARRY-NYT (ST. PETERSBURG, Russia, March 5, 2010)