Bits Blog: Digital Diary: Are We Suffering From Mobile App Burnout?

At last count, I had 259 applications on my iPhone.

I probably use 16 regularly — including Google Maps, Messages, Twitter for iPhone and Instagram.

When I got my first iPhone in late 2008, I couldn’t wait to peruse the App Store for cool new games, neat productivity tools and quirky new social services. In a way, it felt like what television once was, a new kind of inexpensive, readily available entertainment. During those early days, people rushed to download the next new thing, and Apple’s swiftly rising count of the number of applications available was a hallmark of success. The sheer number of apps gave Apple a significant market appeal and a seemingly unbeatable lead over rivals like Android and Research in Motion, who all scrambled to try to recreate those successes.

But now the App Store just feels daunting. Apple recently said there were 775,000 applications for the iPhone and iPad available on its virtual shelves. Who has the time to sift through that glut to uncover new gems?

Of course, trendy new games and services like Tiny Tower and Draw Something still float up and become all the rage. But they typically fade away, at least for me. Although I download new applications constantly for my job, it is rare that one becomes integral to my daily routine. I just don’t have the time to use more than I’m already using. Does anyone?

I asked a few friends, and their behavior is similar to mine. One friend who lives in Los Angeles said he had 150 applications installed on his phone. He estimates that he uses about 15 on a daily basis. Another friend, this one in New York, told me he had 104 apps on his phone and used around 20 regularly.

This seems to correlate with a larger study by Nielsen, which found that the average number of applications per smartphone was rising, but that the amount of time people spent using apps had not changed much. The most heavily used apps were Facebook, YouTube, the Android Market, Google Search and Gmail.

Onavo, a company that helps people monitor their data use, estimates that only about 1,000 applications have at least 50,000 users in the United States. The rest remain far from the mainstream.

For the typical app, less than half the people who download it use it more than once, said Guy Rosen, the chief executive of Onavo.

Do you suffer from app overload? How many apps do you have in your phone, and how many of those do you actually use? Do you find yourself shutting yourself off to new apps because you simply can’t handle any more?

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Peru Objects to U.S. Embassy’s Warning to Tourists

LIMA, Peru (AP) — A United States Embassy warning to American tourists about a potential kidnapping threat in the Cuzco region of Peru, which includes the Incan citadel Machu Picchu, drew vehement objections from Peruvian officials on Friday.

But a United States Embassy official said credible evidence existed of a threat from a Peruvian terrorist group.

The official confirmed a report in La República, a Peruvian newspaper, that said that leaders of the Shining Path guerrilla group had discussed kidnapping foreigners, particularly Americans, in intercepted communications. Tens of thousands of Americans visit Peru each year.

The official agreed to discuss the report only if not quoted by name because of the political delicacy of the warning.

La República said its sources about the interceptions included members of Peru’s military high command, but the country’s military chief, Adm. José Cueto, said that he had no such information.

“Perhaps it is information that they alone have and have not shared,” Admiral Cueto said of the United States government.

The embassy warning that mentioned Peru’s biggest tourist draw was posted on the embassy’s Facebook page on Thursday. Dated Feb. 13, it was also posted on the embassy’s Web site.

It says a “criminal organization may be planning to kidnap U.S. citizen tourists in the Cuzco and Machu Picchu area.” The warning also says United States Embassy personnel are barred from visiting Machu Picchu and the Cuzco region unless on official business, which is restricted.

“It’s very rare that it would be so pointed to us,” the American official said of the threat.

The mayor of the city of Cuzco, Luis Florez, urged the American ambassador, Rose M. Likins, to retract the warning.

“Tourism is an incredibly sensitive topic, and they would be damaging a big source of earnings at the national level,” Mr. Florez told reporters after a group of mayors met with President Ollanta Humala.

But Ms. Likins said the United States government was obliged by law to inform its citizens of any information regarding their security. “In this case, we received information that we consider reliable,” she told RPP radio.

The Maoist-inspired Shining Path group had been severely disrupted by the time the State Department designated it a foreign terrorist organization in 1997. Its remnants number about 500 and have become an increasingly potent and disciplined fighting force, financing themselves by taxing drug traffickers in Peru’s coca-growing heartland.

Shining Path’s radius of action has in recent years expanded to include the northern jungle province of Convención in Cuzco, where, La República said, the conversations were intercepted and where the Camisea natural gas project is located.

In that region, a rugged 100 miles north of Machu Picchu, Shining Path fighters last April kidnapped and briefly detained 36 construction workers near a Camisea site. All were released unharmed, but the rebels killed eight soldiers and police officers sent to rescue them. The group has killed more than 80 Peruvian soldiers since 2008.

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DealBook: Confidence on Upswing, Mergers Make Comeback

The mega-merger is back.

For the corporate takeover business, the last half-decade was a fallow period. Wall Street deal makers and chief executives, brought low by the global financial crisis, lacked the confidence to strike the audacious multibillion-dollar acquisitions that had defined previous market booms.

Cycles, however, turn, and in the opening weeks of 2013, merger activity has suddenly roared back to life. On Thursday, Berkshire Hathaway, the conglomerate run by Warren E. Buffett, said it had teamed up with Brazilian investors to buy the ketchup maker H. J. Heinz for about $23 billion. And American Airlines and US Airways agreed to merge in a deal valued at $11 billion.

Those transactions come a week after a planned $24 billion buyout of the computer company Dell by its founder, Michael S. Dell, and private equity backers. And Liberty Global, the company controlled by the billionaire media magnate John C. Malone, struck a $16 billion deal to buy the British cable business Virgin Media.

“Since the crisis, one by one, the stars came into alignment, and it was only a matter of time before you had a week like we just had,” said James B. Lee Jr., the vice chairman of JPMorgan Chase.

Still, bankers and lawyers remain circumspect, warning that it is still too early to declare a mergers-and-acquisitions boom like those during the junk bond craze of 1989, the dot-com bubble of 1999 and the leveraged buyout bonanza of 2007. They also say that it is important to pay heed to the excesses that developed during these moments of merger mania, which all ended badly.

A confluence of factors has driven the recent deals. Most visibly, the stock market has been on a tear, with the Standard & Poor’s 500-stock index this week briefly hitting its highest levels since November 2007. Higher share prices have buoyed the confidence of chief executives, who now, instead of retrenching, are looking for ways to expand their businesses.

A number of clouds that hovered over the markets last year have also been removed, eliminating the uncertainty that hampered deal making. Mergers and acquisitions activity in 2012 remained tepid as companies took a wait-and-see approach over the outcome of the presidential election and negotiations over the fiscal cliff. The problems in Europe, which began in earnest in 2011, shut down a lot of potential transactions, but the region has since stabilized.

“When we talk to our corporate clients as well as the bankers, we keep hearing them talk about increased confidence,” said John A. Bick, a partner at the law firm Davis Polk & Wardwell, who advised Heinz on its acquisition by Mr. Buffett and his partners.

Mr. Bick said that mega-mergers had a psychological component, meaning that once transactions start happening, chief executives do not want to be left behind. “In the same way that success breeds success, deals breed more deals,” he said.

A central reason for the return of big transactions is the mountain of cash on corporate balance sheets. After the financial crisis, companies hunkered down, laying off employees and cutting costs. As a result, they generated savings. Today, corporations in the S.& P. 500 are sitting on more than $1 trillion in cash. With interest rates near zero, that money is earning very little in bank accounts, so executives are looking to put it to work by acquiring businesses.

The private equity deal-making machine is also revving up again. The world’s largest buyout firms have hundreds of billions of dollars of “dry powder” — money allotted to deals in Wall Street parlance — and they are on the hunt. The proposed leveraged buyout of Dell, led by Mr. Dell and the investment firm Silver Lake Partners, was the largest private equity transaction since July 2007, when the Blackstone Group acquired the hotel chain Hilton Worldwide for $26 billion just as the credit markets were seizing up.

But perhaps the single biggest factor driving the return of corporate takeovers is the banking system’s renewed health. Corporations often rely on bank loans for financing acquisitions, and the ability of private equity firms to strike multibillion-dollar transactions depends on the willingness of banks to lend them money.

For years, banks, saddled by the toxic mortgage assets weighing on their balance sheets, turned off the lending spigot. But with the housing crisis in the rearview mirror and economic conditions slowly improving, banks are again lining up to provide corporate loans at record-low interest rates to finance acquisitions.

The banks, of course, are major beneficiaries of megadeals, earning big fees from both advising on the transactions and lending money to finance them. Mergers and acquisitions in the United States total $158.7 billion so far this year, according to Thomson Reuters data, more than double the amount in the same period last year. JPMorgan, for example, has benefited from the surge, advising on four big deals in recent weeks, including the Dell bid and Comcast’s $16.7 billion offer for the rest of NBCUniversal that it did not already own.

Mr. Buffett, in a television interview last month, declared that the banks had repaired their businesses and no longer posed a threat to the economy. “The capital ratios are huge, the excesses on the asset aside have been largely cleared out,” said Mr. Buffett, whose acquisition of Heinz will be his second-largest acquisition, behind his $35.9 billion purchase of a majority stake in the railroad company Burlington Northern Santa Fe in 2009.

While Wall Street has an air of giddiness over the year’s start, most deal makers temper their comments about the current environment with warnings about undisciplined behavior like overpaying for deals and borrowing too much to pay for them.

Though private equity firms were battered by the financial crisis, they made it through the downturn on relatively solid ground. Many of their megadeals, like Hilton, looked destined for bankruptcy after the markets collapsed, but they have since recovered. The deals have benefited from an improving economy, as well as robust lending markets that allowed companies to push back the large amounts of debt that were to have come due in the next few years.

But there are still plenty of cautionary tales about the consequences of overpriced, overleveraged takeovers. Consider Energy Future Holdings, the biggest private equity deal in history. Struck at the peak of the merger boom in October 2007, the company has suffered from low natural gas prices and too much debt, and could be forced to restructure this year. Its owners, a group led by Kohlberg Kravis Roberts and TPG, are likely to lose billions.

Even Mr. Buffett made a mistake on Energy Future Holdings, having invested $2 billion in the company’s bonds. He admitted to shareholders last year that the investment was a blunder and would most likely be wiped out.

“In tennis parlance,” Mr. Buffett wrote, “this was a major unforced error.”

Michael J. de la Merced contributed reporting.

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Doctor and Patient: Afraid to Speak Up to Medical Power

The slender, weather-beaten, elderly Polish immigrant had been diagnosed with lung cancer nearly a year earlier and was receiving chemotherapy as part of a clinical trial. I was a surgical consultant, called in to help control the fluid that kept accumulating in his lungs.

During one visit, he motioned for me to come closer. His voice was hoarse from a tumor that spread, and the constant hissing from his humidified oxygen mask meant I had to press my face nearly against his to understand his words.

“This is getting harder, doctor,” he rasped. “I’m not sure I’m up to anymore chemo.”

I was not the only doctor that he confided to. But what I quickly learned was that none of us was eager to broach the topic of stopping treatment with his primary cancer doctor.

That doctor was a rising superstar in the world of oncology, a brilliant physician-researcher who had helped discover treatments for other cancers and who had been recruited to lead our hospital’s then lackluster cancer center. Within a few months of the doctor’s arrival, the once sleepy department began offering a dazzling array of experimental drugs. Calls came in from outside doctors eager to send their patients in for treatment, and every patient who was seen was promptly enrolled in one of more than a dozen well-documented treatment protocols.

But now, no doctors felt comfortable suggesting anything but the most cutting-edge, aggressive treatments.

Even the No. 2 doctor in the cancer center, Robin to the chief’s cancer-battling Batman, was momentarily taken aback when I suggested we reconsider the patient’s chemotherapy plan. “I don’t want to tell him,” he said, eyes widening. He reeled off his chief’s vast accomplishments. “I mean, who am I to tell him what to do?”

We stood for a moment in silence before he pointed his index finger at me. “You tell him,” he said with a smile. “You tell him to consider stopping treatment.”

Memories of this conversation came flooding back last week when I read an essay on the problems posed by hierarchies within the medical profession.

For several decades, medical educators and sociologists have documented the existence of hierarchies and an intense awareness of rank among doctors. The bulk of studies have focused on medical education, a process often likened to military and religious training, with elder patriarchs imposing the hair shirt of shame on acolytes unable to incorporate a profession’s accepted values and behaviors. Aspiring doctors quickly learn whose opinions, experiences and voices count, and it is rarely their own. Ask a group of interns who’ve been on the wards for but a week, and they will quickly raise their hands up to the level of their heads to indicate their teachers’ status and importance, then lower them toward their feet to demonstrate their own.

It turns out that this keen awareness of ranking is not limited to students and interns. Other research has shown that fully trained physicians are acutely aware of a tacit professional hierarchy based on specialties, like primary care versus neurosurgery, or even on diseases different specialists might treat, like hemorrhoids and constipation versus heart attacks and certain cancers.

But while such professional preoccupation with privilege can make for interesting sociological fodder, the real issue, warns the author of a courageous essay published recently in The New England Journal of Medicine, is that such an overly developed sense of hierarchy comes at an unacceptable price: good patient care.

Dr. Ranjana Srivastava, a medical oncologist at the Monash Medical Centre in Melbourne, Australia, recalls a patient she helped to care for who died after an operation. Before the surgery, Dr. Srivastava had been hesitant to voice her concerns, assuming that the patient’s surgeon must be “unequivocally right, unassailable, or simply not worth antagonizing.” When she confesses her earlier uncertainty to the surgeon after the patient’s death, Dr. Srivastava learns that the surgeon had been just as loath to question her expertise and had assumed that her silence before the surgery meant she agreed with his plan to operate.

“Each of us was trying our best to help a patient, but we were also respecting the boundaries and hierarchy imposed by our professional culture,” Dr. Srivastava said. “The tragedy was that the patient died, when speaking up would have made all the difference.”

Compounding the problem is an increasing sense of self-doubt among many doctors. With rapid advances in treatment, there is often no single correct “answer” for a patient’s problem, and doctors, struggling to stay up-to-date in their own particular specialty niches, are more tentative about making suggestions that cross over to other doctors’ “turf.” Even as some clinicians attempt to compensate by organizing multidisciplinary meetings, inviting doctors from all specialties to discuss a patient’s therapeutic options, “there will inevitably be a hierarchy at those meetings of who is speaking,” Dr. Srivastava noted. “And it won’t always be the ones who know the most about the patient who will be taking the lead.”

It is the potentially disastrous repercussions for patients that make this overly developed awareness of rank and boundaries a critical issue in medicine. Recent efforts to raise safety standards and improve patient care have shown that teams are a critical ingredient for success. But simply organizing multidisciplinary lineups of clinicians isn’t enough. What is required are teams that recognize the importance of all voices and encourage active and open debate.

Since their patient’s death, Dr. Srivastava and the surgeon have worked together to discuss patient cases, articulate questions and describe their own uncertainties to each other and in patients’ notes. “We have tried to remain cognizant of the fact that we are susceptible to thinking about hierarchy,” Dr. Srivastava said. “We have tried to remember that sometimes, despite our best intentions, we do not speak up for our patients because we are fearful of the consequences.”

That was certainly true for my lung cancer patient. Like all the other doctors involved in his care, I hesitated to talk to the chief medical oncologist. I questioned my own credentials, my lack of expertise in this particular area of oncology and even my own clinical judgment. When the patient appeared to fare better, requiring less oxygen and joking and laughing more than I had ever seen in the past, I took his improvement to be yet another sign that my attempt to talk about holding back chemotherapy was surely some surgical folly.

But a couple of days later, the humidified oxygen mask came back on. And not long after that, the patient again asked for me to come close.

This time he said: “I’m tired. I want to stop the chemo.”

Just before he died, a little over a week later, he was off all treatment except for what might make him comfortable. He thanked me and the other doctors for our care, but really, we should have thanked him and apologized. Because he had pushed us out of our comfortable, well-delineated professional zones. He had prodded us to talk to one another. And he showed us how to work as a team in order to do, at last, what we should have done weeks earlier.

Read More..

Doctor and Patient: Afraid to Speak Up to Medical Power

The slender, weather-beaten, elderly Polish immigrant had been diagnosed with lung cancer nearly a year earlier and was receiving chemotherapy as part of a clinical trial. I was a surgical consultant, called in to help control the fluid that kept accumulating in his lungs.

During one visit, he motioned for me to come closer. His voice was hoarse from a tumor that spread, and the constant hissing from his humidified oxygen mask meant I had to press my face nearly against his to understand his words.

“This is getting harder, doctor,” he rasped. “I’m not sure I’m up to anymore chemo.”

I was not the only doctor that he confided to. But what I quickly learned was that none of us was eager to broach the topic of stopping treatment with his primary cancer doctor.

That doctor was a rising superstar in the world of oncology, a brilliant physician-researcher who had helped discover treatments for other cancers and who had been recruited to lead our hospital’s then lackluster cancer center. Within a few months of the doctor’s arrival, the once sleepy department began offering a dazzling array of experimental drugs. Calls came in from outside doctors eager to send their patients in for treatment, and every patient who was seen was promptly enrolled in one of more than a dozen well-documented treatment protocols.

But now, no doctors felt comfortable suggesting anything but the most cutting-edge, aggressive treatments.

Even the No. 2 doctor in the cancer center, Robin to the chief’s cancer-battling Batman, was momentarily taken aback when I suggested we reconsider the patient’s chemotherapy plan. “I don’t want to tell him,” he said, eyes widening. He reeled off his chief’s vast accomplishments. “I mean, who am I to tell him what to do?”

We stood for a moment in silence before he pointed his index finger at me. “You tell him,” he said with a smile. “You tell him to consider stopping treatment.”

Memories of this conversation came flooding back last week when I read an essay on the problems posed by hierarchies within the medical profession.

For several decades, medical educators and sociologists have documented the existence of hierarchies and an intense awareness of rank among doctors. The bulk of studies have focused on medical education, a process often likened to military and religious training, with elder patriarchs imposing the hair shirt of shame on acolytes unable to incorporate a profession’s accepted values and behaviors. Aspiring doctors quickly learn whose opinions, experiences and voices count, and it is rarely their own. Ask a group of interns who’ve been on the wards for but a week, and they will quickly raise their hands up to the level of their heads to indicate their teachers’ status and importance, then lower them toward their feet to demonstrate their own.

It turns out that this keen awareness of ranking is not limited to students and interns. Other research has shown that fully trained physicians are acutely aware of a tacit professional hierarchy based on specialties, like primary care versus neurosurgery, or even on diseases different specialists might treat, like hemorrhoids and constipation versus heart attacks and certain cancers.

But while such professional preoccupation with privilege can make for interesting sociological fodder, the real issue, warns the author of a courageous essay published recently in The New England Journal of Medicine, is that such an overly developed sense of hierarchy comes at an unacceptable price: good patient care.

Dr. Ranjana Srivastava, a medical oncologist at the Monash Medical Centre in Melbourne, Australia, recalls a patient she helped to care for who died after an operation. Before the surgery, Dr. Srivastava had been hesitant to voice her concerns, assuming that the patient’s surgeon must be “unequivocally right, unassailable, or simply not worth antagonizing.” When she confesses her earlier uncertainty to the surgeon after the patient’s death, Dr. Srivastava learns that the surgeon had been just as loath to question her expertise and had assumed that her silence before the surgery meant she agreed with his plan to operate.

“Each of us was trying our best to help a patient, but we were also respecting the boundaries and hierarchy imposed by our professional culture,” Dr. Srivastava said. “The tragedy was that the patient died, when speaking up would have made all the difference.”

Compounding the problem is an increasing sense of self-doubt among many doctors. With rapid advances in treatment, there is often no single correct “answer” for a patient’s problem, and doctors, struggling to stay up-to-date in their own particular specialty niches, are more tentative about making suggestions that cross over to other doctors’ “turf.” Even as some clinicians attempt to compensate by organizing multidisciplinary meetings, inviting doctors from all specialties to discuss a patient’s therapeutic options, “there will inevitably be a hierarchy at those meetings of who is speaking,” Dr. Srivastava noted. “And it won’t always be the ones who know the most about the patient who will be taking the lead.”

It is the potentially disastrous repercussions for patients that make this overly developed awareness of rank and boundaries a critical issue in medicine. Recent efforts to raise safety standards and improve patient care have shown that teams are a critical ingredient for success. But simply organizing multidisciplinary lineups of clinicians isn’t enough. What is required are teams that recognize the importance of all voices and encourage active and open debate.

Since their patient’s death, Dr. Srivastava and the surgeon have worked together to discuss patient cases, articulate questions and describe their own uncertainties to each other and in patients’ notes. “We have tried to remain cognizant of the fact that we are susceptible to thinking about hierarchy,” Dr. Srivastava said. “We have tried to remember that sometimes, despite our best intentions, we do not speak up for our patients because we are fearful of the consequences.”

That was certainly true for my lung cancer patient. Like all the other doctors involved in his care, I hesitated to talk to the chief medical oncologist. I questioned my own credentials, my lack of expertise in this particular area of oncology and even my own clinical judgment. When the patient appeared to fare better, requiring less oxygen and joking and laughing more than I had ever seen in the past, I took his improvement to be yet another sign that my attempt to talk about holding back chemotherapy was surely some surgical folly.

But a couple of days later, the humidified oxygen mask came back on. And not long after that, the patient again asked for me to come close.

This time he said: “I’m tired. I want to stop the chemo.”

Just before he died, a little over a week later, he was off all treatment except for what might make him comfortable. He thanked me and the other doctors for our care, but really, we should have thanked him and apologized. Because he had pushed us out of our comfortable, well-delineated professional zones. He had prodded us to talk to one another. And he showed us how to work as a team in order to do, at last, what we should have done weeks earlier.

Read More..

Bits Blog: How Lightning Tightens Apple's Control Over Accessories

When the iPhone 5 was released in September with the new Lightning connection port, all those docks and accessories that longtime Apple customers had been collecting for years were suddenly obsolete. But Lightning-compatible accessories have been trickling in more slowly than the typical flood of Apple accessories that comes after a new iPhone release. Why?

One challenge, according to a person briefed on Apple’s plans who was not approved to discuss them publicly, is that the iPhone 5 is more fundamentally different from previous versions of the device than new models usually are  — introducing a different overall size and shape as well as an engineering change. At the same time, with Lightning, Apple has made it harder for companies to avoid working with its own licensing program. Both of these factors have slowed the production of accessories.

Mophie, an accessory maker, shared some insight into Lightning and the overall process of making an Apple accessory. (This week it introduced the Helium, its first iPhone 5 case with a backup battery.) When a hardware maker signs up with Apple’s MFi Program, for companies that make accessories for Apple products, it orders a Lightning connector component from Apple to use in designing the accessory. The connectors have serial numbers for each accessory maker, and they contain authentication chips that communicate with the phones. When the company submits its accessory to Apple for testing, Apple can recognize the serial number.

“If you took this apart and put it in another product and Apple got a hold of it, they’d be able to see it’s from Mophie’s batch of Lightning connectors,” said Ross Howe, vice president of marketing for Mophie.

The chip inside the Lightning connector can be reverse engineered — copied by another company — but it probably would not work as well as one that came from Apple, Mr. Howe said. Apple could also theoretically issue software updates that would disable Lightning products that did not use its chips, he said.

What’s the benefit for Apple? The proprietary chip makes it more difficult for accessory makers to produce cheap knockoff products that are compatible with Lightning, which could potentially tarnish the iPhone brand. Also, it pushes accessory makers to pay Apple the licensing fees to be part of the MFi program.

“That’s one thing Apple is good at: controlling the user experience from end to end,” Mr. Howe said. “If you’re buying something in an Apple store, it’s gone through all this rigorous testing.”

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Loi Journal: In Vietnam, Some Chose to Be Single Mothers

Justin Mott for the International Herald Tribune

Nguyen Thi Nhan at home with her grandson, Thao, 2. Abandoned by her husband after the war, she asked another man to impregnate her. More Photos »

LOI, Vietnam — They had no plan to break barriers or cause trouble. But 30 years ago in this bucolic village in northern Vietnam, the fierce determination of one group of women to become mothers upended centuries-old gender rules and may have helped open the door for a nation to redefine parenthood.

One recent morning in Loi, as farmers in conical straw hats waded quietly through rice paddies, a small group of women played with their grandchildren near a stream. Their husbands were nowhere to be found, not because they perished in the war, but because the women decided to have children without husbands.

The women’s story began during the American War, as it is called here, when many put the revolution before their families. As peace settled more than a decade later, it became clear that they — like so many of their generation — had sacrificed their marriageable years to the war.

At that time Vietnamese women traditionally married around 16, and those still single at 20 would often be considered “qua lua,” or “past the marriageable age.” When single men who survived the war returned home, they often preferred younger brides, exacerbating the effects of a sex ratio already skewed by male mortality in the war. According to the Vietnam Population and Housing Census of 2009, after reunification in 1979 there were on average only about 88 men for every 100 women between 20 and 44.

Unlike previous generations of unwanted Vietnamese women who dutifully accepted the “so,” or “destiny,” of living a solitary life, a group of women in Loi decided to take motherhood into their own hands. They had endured the war, developed a new strength and were determined not to die alone.

One by one they asked men — whom they would never interact with afterward — to help them conceive a child. The practice became known as “xin con,” or “asking for a child,” and it meant breaking with tradition, facing discrimination and enduring the hardships of raising a child alone.

“It was unusual, and quite remarkable,” said Harriet Phinney, an assistant professor of anthropology at Seattle University who is writing a book on the practice of xin con in Vietnam. Purposely conceiving a child out of wedlock, she said, “was unheard-of” before the revolutionary era.

It was a product of the mothers’ bravery, said Ms. Phinney, but also of a postwar society that acknowledged the unique situation of women across Vietnam, including thousands of widows, who were raising children alone.

Some of the women in Loi were willing to share their stories, though they always kept the names of the fathers a tightly held secret. One of the first women in Loi to ask for a child was Nguyen Thi Nhan, now 58.

Ms. Nhan had led a platoon of women during the war, and though she never saw battle, was awarded a medal for her exemplary leadership. Her husband, with whom she had a daughter, abandoned her after the war. Ms. Nhan moved to the cheapest land she could find, a field near the stream on the outskirts of Loi, where a few refugees from bombing nearby still lived. She then asked for a second child, ending up with the son she wished for.

Her first several years were hard. Despite her best efforts, food and money were scarce. The villagers eventually set aside prejudices and accepted her choice, offering to share the little food they could spare. Eventually, Ms. Nhan was joined by more than a dozen other women. Among them was Nguyen Thi Luu, 63. She had fallen in love with a soldier who was killed in battle in 1972.

“I was 26 when the war ended,” Ms. Luu said. “That was considered too old for marriage, in those times. I did not want to marry a bad, older man, and no single men came to me.”

But Ms. Luu wanted to become a mother, not least so she would have support in her old age. In Vietnam, nursing homes are scarce, and care for the elderly is considered a filial duty.

“I was afraid to die alone,” Ms. Luu said. “I wanted someone to lean on in my old age. I wanted a child of my own.”

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Well: Straining to Hear and Fend Off Dementia

At a party the other night, a fund-raiser for a literary magazine, I found myself in conversation with a well-known author whose work I greatly admire. I use the term “conversation” loosely. I couldn’t hear a word he said. But worse, the effort I was making to hear was using up so much brain power that I completely forgot the titles of his books.

A senior moment? Maybe. (I’m 65.) But for me, it’s complicated by the fact that I have severe hearing loss, only somewhat eased by a hearing aid and cochlear implant.

Dr. Frank Lin, an otolaryngologist and epidemiologist at Johns Hopkins School of Medicine, describes this phenomenon as “cognitive load.” Cognitive overload is the way it feels. Essentially, the brain is so preoccupied with translating the sounds into words that it seems to have no processing power left to search through the storerooms of memory for a response.

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Katherine Bouton speaks about her own experience with hearing loss.

A transcript of this interview can be found here.

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Over the past few years, Dr. Lin has delivered unwelcome news to those of us with hearing loss. His work looks “at the interface of hearing loss, gerontology and public health,” as he writes on his Web site. The most significant issue is the relation between hearing loss and dementia.

In a 2011 paper in The Archives of Neurology, Dr. Lin and colleagues found a strong association between the two. The researchers looked at 639 subjects, ranging in age at the beginning of the study from 36 to 90 (with the majority between 60 and 80). The subjects were part of the Baltimore Longitudinal Study of Aging. None had cognitive impairment at the beginning of the study, which followed subjects for 18 years; some had hearing loss.

“Compared to individuals with normal hearing, those individuals with a mild, moderate, and severe hearing loss, respectively, had a 2-, 3- and 5-fold increased risk of developing dementia over the course of the study,” Dr. Lin wrote in an e-mail summarizing the results. The worse the hearing loss, the greater the risk of developing dementia. The correlation remained true even when age, diabetes and hypertension — other conditions associated with dementia — were ruled out.

In an interview, Dr. Lin discussed some possible explanations for the association. The first is social isolation, which may come with hearing loss, a known risk factor for dementia. Another possibility is cognitive load, and a third is some pathological process that causes both hearing loss and dementia.

In a study last month, Dr. Lin and colleagues looked at 1,984 older adults beginning in 1997-8, again using a well-established database. Their findings reinforced those of the 2011 study, but also found that those with hearing loss had a “30 to 40 percent faster rate of loss of thinking and memory abilities” over a six-year period compared with people with normal hearing. Again, the worse the hearing loss, the worse the rate of cognitive decline.

Both studies also found, somewhat surprisingly, that hearing aids were “not significantly associated with lower risk” for cognitive impairment. But self-reporting of hearing-aid use is unreliable, and Dr. Lin’s next study will focus specifically on the way hearing aids are used: for how long, how frequently, how well they have been fitted, what kind of counseling the user received, what other technologies they used to supplement hearing-aid use.

What about the notion of a common pathological process? In a recent paper in the journal Neurology, John Gallacher and colleagues at Cardiff University suggested the possibility of a genetic or environmental factor that could be causing both hearing loss and dementia — and perhaps not in that order. In a phenomenon called reverse causation, a degenerative pathology that leads to early dementia might prove to be a cause of hearing loss.

The work of John T. Cacioppo, director of the Social Neuroscience Laboratory at the University of Chicago, also offers a clue to a pathological link. His multidisciplinary studies on isolation have shown that perceived isolation, or loneliness, is “a more important predictor of a variety of adverse health outcomes than is objective social isolation.” Those with hearing loss, who may sit through a dinner party and not hear a word, frequently experience perceived isolation.

Other research, including the Framingham Heart Study, has found an association between hearing loss and another unexpected condition: cardiovascular disease. Again, the evidence suggests a common pathological cause. Dr. David R. Friedland, a professor of otolaryngology at the Medical College of Wisconsin in Milwaukee, hypothesized in a 2009 paper delivered at a conference that low-frequency loss could be an early indication that a patient has vascular problems: the inner ear is “so sensitive to blood flow” that any vascular abnormalities “could be noted earlier here than in other parts of the body.”

A common pathological cause might help explain why hearing aids do not seem to reduce the risk of dementia. But those of us with hearing loss hope that is not the case; common sense suggests that if you don’t have to work so hard to hear, you have greater cognitive power to listen and understand — and remember. And the sense of perceived isolation, another risk for dementia, is reduced.

A critical factor may be the way hearing aids are used. A user must practice to maximize their effectiveness and they may need reprogramming by an audiologist. Additional assistive technologies like looping and FM systems may also be required. And people with progressive hearing loss may need new aids every few years.

Increasingly, people buy hearing aids online or from big-box stores like Costco, making it hard for the user to follow up. In the first year I had hearing aids, I saw my audiologist initially every two weeks for reprocessing and then every three months.

In one study, Dr. Lin and his colleague Wade Chien found that only one in seven adults who could benefit from hearing aids used them. One deterrent is cost ($2,000 to $6,000 per ear), seldom covered by insurance. Another is the stigma of old age.

Hearing loss is a natural part of aging. But for most people with hearing loss, according to the National Institute on Deafness and Other Communication Disorders, the condition begins long before they get old. Almost two-thirds of men with hearing loss began to lose their hearing before age 44. My hearing loss began when I was 30.

Forty-eight million Americans suffer from some degree of hearing loss. If it can be proved in a clinical trial that hearing aids help delay or offset dementia, the benefits would be immeasurable.

“Could we do something to reduce cognitive decline and delay the onset of dementia?” he asked. “It’s hugely important, because by 2050, 1 in 30 Americans will have dementia.

“If we could delay the onset by even one year, the prevalence of dementia drops by 15 percent down the road. You’re talking about billions of dollars in health care savings.”

Should studies establish definitively that correcting hearing loss decreases the potential for early-onset dementia, we might finally overcome the stigma of hearing loss. Get your hearing tested, get it corrected, and enjoy a longer cognitively active life. Establishing the dangers of uncorrected hearing might even convince private insurers and Medicare that covering the cost of hearing aids is a small price to pay to offset the cost of dementia.

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Katherine Bouton is the author of the new book, “Shouting Won’t Help: Why I — and 50 Million Other Americans — Can’t Hear You,” from which this essay is adapted.

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This post has been revised to reflect the following correction:

Correction: February 14, 2013

An article on Tuesday about hearing loss and dementia misidentified the city in which the Medical College of Wisconsin is located. It is in Milwaukee, not in Madison.

Read More..

Well: Straining to Hear and Fend Off Dementia

At a party the other night, a fund-raiser for a literary magazine, I found myself in conversation with a well-known author whose work I greatly admire. I use the term “conversation” loosely. I couldn’t hear a word he said. But worse, the effort I was making to hear was using up so much brain power that I completely forgot the titles of his books.

A senior moment? Maybe. (I’m 65.) But for me, it’s complicated by the fact that I have severe hearing loss, only somewhat eased by a hearing aid and cochlear implant.

Dr. Frank Lin, an otolaryngologist and epidemiologist at Johns Hopkins School of Medicine, describes this phenomenon as “cognitive load.” Cognitive overload is the way it feels. Essentially, the brain is so preoccupied with translating the sounds into words that it seems to have no processing power left to search through the storerooms of memory for a response.

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Katherine Bouton speaks about her own experience with hearing loss.

A transcript of this interview can be found here.

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Over the past few years, Dr. Lin has delivered unwelcome news to those of us with hearing loss. His work looks “at the interface of hearing loss, gerontology and public health,” as he writes on his Web site. The most significant issue is the relation between hearing loss and dementia.

In a 2011 paper in The Archives of Neurology, Dr. Lin and colleagues found a strong association between the two. The researchers looked at 639 subjects, ranging in age at the beginning of the study from 36 to 90 (with the majority between 60 and 80). The subjects were part of the Baltimore Longitudinal Study of Aging. None had cognitive impairment at the beginning of the study, which followed subjects for 18 years; some had hearing loss.

“Compared to individuals with normal hearing, those individuals with a mild, moderate, and severe hearing loss, respectively, had a 2-, 3- and 5-fold increased risk of developing dementia over the course of the study,” Dr. Lin wrote in an e-mail summarizing the results. The worse the hearing loss, the greater the risk of developing dementia. The correlation remained true even when age, diabetes and hypertension — other conditions associated with dementia — were ruled out.

In an interview, Dr. Lin discussed some possible explanations for the association. The first is social isolation, which may come with hearing loss, a known risk factor for dementia. Another possibility is cognitive load, and a third is some pathological process that causes both hearing loss and dementia.

In a study last month, Dr. Lin and colleagues looked at 1,984 older adults beginning in 1997-8, again using a well-established database. Their findings reinforced those of the 2011 study, but also found that those with hearing loss had a “30 to 40 percent faster rate of loss of thinking and memory abilities” over a six-year period compared with people with normal hearing. Again, the worse the hearing loss, the worse the rate of cognitive decline.

Both studies also found, somewhat surprisingly, that hearing aids were “not significantly associated with lower risk” for cognitive impairment. But self-reporting of hearing-aid use is unreliable, and Dr. Lin’s next study will focus specifically on the way hearing aids are used: for how long, how frequently, how well they have been fitted, what kind of counseling the user received, what other technologies they used to supplement hearing-aid use.

What about the notion of a common pathological process? In a recent paper in the journal Neurology, John Gallacher and colleagues at Cardiff University suggested the possibility of a genetic or environmental factor that could be causing both hearing loss and dementia — and perhaps not in that order. In a phenomenon called reverse causation, a degenerative pathology that leads to early dementia might prove to be a cause of hearing loss.

The work of John T. Cacioppo, director of the Social Neuroscience Laboratory at the University of Chicago, also offers a clue to a pathological link. His multidisciplinary studies on isolation have shown that perceived isolation, or loneliness, is “a more important predictor of a variety of adverse health outcomes than is objective social isolation.” Those with hearing loss, who may sit through a dinner party and not hear a word, frequently experience perceived isolation.

Other research, including the Framingham Heart Study, has found an association between hearing loss and another unexpected condition: cardiovascular disease. Again, the evidence suggests a common pathological cause. Dr. David R. Friedland, a professor of otolaryngology at the Medical College of Wisconsin in Milwaukee, hypothesized in a 2009 paper delivered at a conference that low-frequency loss could be an early indication that a patient has vascular problems: the inner ear is “so sensitive to blood flow” that any vascular abnormalities “could be noted earlier here than in other parts of the body.”

A common pathological cause might help explain why hearing aids do not seem to reduce the risk of dementia. But those of us with hearing loss hope that is not the case; common sense suggests that if you don’t have to work so hard to hear, you have greater cognitive power to listen and understand — and remember. And the sense of perceived isolation, another risk for dementia, is reduced.

A critical factor may be the way hearing aids are used. A user must practice to maximize their effectiveness and they may need reprogramming by an audiologist. Additional assistive technologies like looping and FM systems may also be required. And people with progressive hearing loss may need new aids every few years.

Increasingly, people buy hearing aids online or from big-box stores like Costco, making it hard for the user to follow up. In the first year I had hearing aids, I saw my audiologist initially every two weeks for reprocessing and then every three months.

In one study, Dr. Lin and his colleague Wade Chien found that only one in seven adults who could benefit from hearing aids used them. One deterrent is cost ($2,000 to $6,000 per ear), seldom covered by insurance. Another is the stigma of old age.

Hearing loss is a natural part of aging. But for most people with hearing loss, according to the National Institute on Deafness and Other Communication Disorders, the condition begins long before they get old. Almost two-thirds of men with hearing loss began to lose their hearing before age 44. My hearing loss began when I was 30.

Forty-eight million Americans suffer from some degree of hearing loss. If it can be proved in a clinical trial that hearing aids help delay or offset dementia, the benefits would be immeasurable.

“Could we do something to reduce cognitive decline and delay the onset of dementia?” he asked. “It’s hugely important, because by 2050, 1 in 30 Americans will have dementia.

“If we could delay the onset by even one year, the prevalence of dementia drops by 15 percent down the road. You’re talking about billions of dollars in health care savings.”

Should studies establish definitively that correcting hearing loss decreases the potential for early-onset dementia, we might finally overcome the stigma of hearing loss. Get your hearing tested, get it corrected, and enjoy a longer cognitively active life. Establishing the dangers of uncorrected hearing might even convince private insurers and Medicare that covering the cost of hearing aids is a small price to pay to offset the cost of dementia.

---

Katherine Bouton is the author of the new book, “Shouting Won’t Help: Why I — and 50 Million Other Americans — Can’t Hear You,” from which this essay is adapted.

---

This post has been revised to reflect the following correction:

Correction: February 14, 2013

An article on Tuesday about hearing loss and dementia misidentified the city in which the Medical College of Wisconsin is located. It is in Milwaukee, not in Madison.

Read More..

In Japan, the Fax Machine Is Anything but a Relic

Kosuke Okahara for The New York Times

Yuichiro Sugahara, whose company delivers bento lunchboxes, mostly through fax orders.

TOKYO — Japan is renowned for its robots and bullet trains, and has some of the world’s fastest broadband networks. But it also remains firmly wedded to a pre-Internet technology — the fax machine — that in most other developed nations has joined answering machines, eight-tracks and cassette tapes in the dustbin of outmoded technologies.

Last year alone, Japanese households bought 1.7 million of the old-style fax machines, which print documents on slick, glossy paper spooled in the back. In the United States, the device has become such an artifact that the Smithsonian is adding two machines to its collection, technology historians said.

“The fax was such a success here that it has proven hard to replace,” said Kenichi Shibata, a manager at NTT Communications, which led development of the technology in the 1970s. “It has grown unusually deep roots into Japanese society.”

The Japanese government’s Cabinet Office said that almost 100 percent of business offices and 45 percent of private homes had a fax machine as of 2011.

Yuichiro Sugahara learned the hard way about his country’s deep attachment to the fax machine, which the nation popularized in the 1980s. A decade ago, he tried to modernize his family-run company, which delivers traditional bento lunchboxes, by taking orders online. Sales quickly plummeted.

Today, his company, Tamagoya, is thriving with the hiss and beep of thousands of orders pouring in every morning, most by fax, many with minutely detailed handwritten requests like “go light on the batter in the fried chicken” or “add an extra hard-boiled egg.”

“There is still something in Japanese culture that demands the warm, personal feelings that you get with a handwritten fax,” said Mr. Sugahara, 43.

Japan’s reluctance to give up its fax machines offers a revealing glimpse into an aging nation that can often seem quietly determined to stick to its tried-and-true ways, even if the rest of the world seems to be passing it rapidly by. The fax addiction helps explain why Japan, which once revolutionized consumer electronics with its hand-held calculators, Walkmans and, yes, fax machines, has become a latecomer in the digital age, and has allowed itself to fall behind nimbler competitors like South Korea and China.

“Japan has this Galápagos effect of holding on to some things they’re comfortable with,” said Jonathan Coopersmith, a technology historian who is writing a book on the machine’s rise and fall. “Elsewhere, the fax has gone the way of the dodo.”

In Japan, with the exception of the savviest Internet start-ups or internationally minded manufacturers, the fax remains an essential tool for doing business. Experts say government offices prefer faxes because they generate paperwork onto which bureaucrats can affix their stamps of approval, called hanko. Many companies say they still rely on faxes to create a paper trail of orders and shipments not left by ephemeral e-mail. Banks rely on faxes because, they say, customers are worried about the safety of their personal information on the Internet.

Even Japan’s largest yakuza crime syndicate, the Kobe-based Yamaguchi-gumi, has used faxes to send notifications of expulsion to members, the police say.

After the deadly earthquake and tsunami in northeastern Japan in 2011, there was a small boom in fax sales to replace machines that had been washed away. One of the hottest sellers is a model that is powered by batteries so it will keep working during power failures caused by natural disasters.

At Tamagoya, Mr. Sugahara has turned his company’s reliance on the fax and standard telephones into an art form. Every morning, orders for about 62,000 lunches pour in, about half by fax. Most of those lunches are cooked and put onto trucks even before the last order is taken. A small army of 100 fax and telephone operators carefully coordinate deliveries, and fewer than 60 lunches — or 0.1 percent — are wasted.

Hisako Ueno contributed reporting.

Read More..