IHT Rendezvous: Drones, Brennan and Obama's Legacy of Secrecy

NEW YORK — John O. Brennan’s testimony before the Senate Intelligence Committee on Thursday was representative of the Obama administration’s approach to counter-terrorism: right-sounding assurances with little transparency.

Mr. Brennan, the president’s choice to be the next head of the Central Intelligence Agency, said the United States should publicly disclose when American drone attacks kill civilians. He called water boarding “reprehensible” and vowed it would never occur under his watch. And he said that countering militancy should be “comprehensive,” not just “kinetic,” and involve diplomatic and development efforts as well.

What any of that means in practice, critics say, remains unknown.

Mr. Brennan failed to clearly answer questions about the administration’s excessive embrace of drone strikes and secrecy.

He flatly defended the quadrupling of drone strikes that has occurred on President Obama’s watch. He gave no clear explanation for why the public has been denied access to Justice Department legal opinions that give the president the power to kill U.S. citizens without judicial review. And his statement that the establishment of a special court to review the targeting of Americans was “worthy of discussion” was noncommittal.

Before the hearing administration officials defended the career CIA officer who has served as the president’s chief counter-terrorism adviser throughout his first term. A senior administration official who asked not be named said that Mr. Brennan has actively worked to reduce drone attacks and increase transparency.

Officials described him as a traditionalist who would move the CIA away from the paramilitary attacks that have come to define its mission since 2001. Instead, the agency would move back to espionage and hand over lethal strikes, including drone attacks, to the military’s Special Operations forces.

Over the last two years, drone strikes in Pakistan have, in fact, decreased by nearly two-thirds from a peak of 122 in 2010 to 48 last year, according to The New American Foundation. At the same time, strikes in Yemen have increased, killing an estimated 400 people including 80 civilians.

From his office in the basement of the White House, Mr. Brennan has been at the center of it all. Daniel Benjamin, who recently stepped down as the State Department’s top counterterrorism official, told the New York Times this week that Mr. Brennan had sweeping authority.

“He’s probably had more power and influence than anyone in a comparable position in the last 20 years,” said Mr. Benjamin. “He’s had enormous sway over the intelligence community. He’s had a profound impact on how the military does counterterrorism.”

Some former military and intelligence officials have warned that the administration’s drone strikes have shifted from an attempt to only target senior militants to a de facto bombing campaign against low-level fighters. They say such a policy creates high levels of public animosity toward the United States with questionable results.

In a recent interview with Reuters, retired Gen. Stanley McChrystal, the former commander of American forces in Afghanistan, said drones were useful tools, but they are “hated on a visceral level” in many countries and contribute to a “perception of American arrogance.”

In Thursday’s hearing, Mr. Brennan showed an awareness of how excessive use of force can be counterproductive. He also aggressively defended the need for the United States to abide by the rule of law, a vital practice if the US is going to ever gain popular support in the region.

In one of his strongest moments, Mr. Brennan flatly rejected suggestions by Senator Marco Rubio of Florida that U.S. officials should have pressured Tunisian officials to improperly detain a suspect in the fatal attack on the U.S. consulate in Benghazi, Libya. Mr. Brennan said Tunisian officials had no evidence linking the man to the incident.

“Senator, this country needs to make sure we are setting an example and a standard for the world,” he said, adding that Washington had to “respect the rights of these governments to enforce their laws independently.”

Mr. Brennan also argued that opponents of the program misunderstood it. He said the United States only used drone strikes as a “last resort,” and the administration goes through “agony” before launching drone strikes in order to avoid civilian casualties.

In truth, the administration’s insistence on keeping the drone program secret fuels public suspicion. Declaring a program “covert” when it is reported on by the global media on a daily basis is increasingly absurd: as Joshua Foust, an analyst and former U.S. intelligence official, has argued, keeping the program secret cedes the debate to critics who say the strikes only kill vast numbers of civilians.

It is easy to see why many analysts say the United States should continue to carry out drone strikes – they are a military necessity – but keep them to a minimum. And details such as why an attack is carried out, who is killed and any civilian casualties should be publicly disclosed.

Mr. Brennan’s statement that drone strikes have decimated al Qaeda’s core leadership in Pakistan’s tribal areas was largely accurate. But despite the increase in strikes under Mr. Obama, the attacks have failed to do the same to the Afghan and Pakistani Taliban operating out of the same area. Drone strikes will never be a silver bullet. They have created a stalemate in Pakistan, weakening militant groups but not eliminating them.

After the hearing, Sen. Dianne Feinstein, the Democratic chair of the Senate Intelligence Committee, said she was considering drafting legislation that would create a special court to review requests by the president to target Americans under certain circumstances. The new body would be similar to the court that currently reviews government requests to wiretap citizens.

Critics point out that the Obama administration has a long record of promising transparency and then embracing secrecy — from drone strikes to legal memos to unprecedented prosecutions of government officials for leaking to the news media.

Overall, Mr. Brennan impressed those watching yesterday. We will see if he moves the CIA and the administration toward greater transparency. What he and the president plan remains secret.


David Rohde is a columnist for Reuters, former reporter for The New York Times and two-time winner of the Pulitzer Prize. His forthcoming book, “Beyond War: Reimagining American Influence in a New Middle East” will be published in March 2013.

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Wall Street Edges Ahead


Stocks opened slightly higher on Wall Street on Friday after a trio of positive economic data points, but gains were expected to be modest.


The Standard & Poor’s 500-stock index added 0.2 percent in early trading, the Dow Jones industrial average rose 0.2 percent and the Nasdaq composite index jumped 0.4 percent.


Data showed that Chinese exports grew more than expected in January, while imports climbed 28.8 percent, highlighting robust domestic demand. German data showed a 2012 trade surplus that was the nation’s second highest in more than 60 years, an indication of the underlying strength of Europe’s biggest economy.


And U.S. data showed that the trade deficit shrank in December to $38.5 billion, its narrowest in nearly three years, indicating the economy did better in the fourth quarter than initially estimated.


The S.&P. 500 has risen for five straight weeks and is up 5.8 percent for the year. Its advance was helped by legislators in Washington averting a series of automatic spending cuts and tax increases earlier in the year, as well as better-than-expected corporate earnings and data that pointed to modest economic improvement but no immediate change in the Federal Reserve’s stimulus plans.


But the index, hovering near five-year highs, has stalled in recent days as investors await strong trading incentives to drive it further..


“The market has made a big run, a lot of this was anticipated and so now investors are saying, ‘Now what? What do we do for an encore?'” said Terry Morris, senior equity manager for National Penn Investors Trust Company in Reading, Pa. “It has made a big run and it is deserving of rest — in fact, it would probably be healthy if we had a little bit of a pullback.”


McDonald’s said that January sales at established hamburger restaurants around the world fell 1.9 percent, a steeper decline than analysts expected. Shares edged down 0.5 percent.


LinkedIn jumped 10.6 percent after announcing both blow-out quarterly profit and a bullish forecast for the new year that exceeded Wall Street’s already lofty expectations.


According to Thomson Reuters data through Thursday morning, of 317 companies in the S.&P. 500 that have reported earnings, 69 percent have exceeded analysts’ expectations, above a 62 percent average since 1994 and a 65 percent average over the past four quarters.


Fourth-quarter earnings for S.&P. 500 companies grew 5 percent, according to the data, above a 1.9 percent forecast at the start of the earnings season.


On Thursday, comments about the strength of the euro by the European Central Bank president, Mario Draghi, renewed concern about the euro zone economy and sent global equities lower. On Friday, European stock markets were mostly higher in afternoon trading, while the euro traded around $1.3394.


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The New Old Age: The Executor's Assistant

I’m serving as executor for my father’s estate, a role few of us are prepared for until we’re playing it, so I was grateful when the mail brought “The American Bar Association Guide to Wills and Estates” — the fourth edition of a handbook the A.B.A. began publishing in 1995.

This is a legal universe, I’m learning, in which every step — even with a small, simple estate that owes no taxes and includes no real estate or trusts — turns out to be at least 30 percent more complicated than expected.

If my dad had been wealthy or owned a business, or if we faced a challenge to his will, I would have turned the whole matter over to an estate lawyer by now. But even then, it would be helpful to know what the lawyer was talking about. The A.B.A. guide would help.

Written with surprising clarity (hey, they’re lawyers), it maps out all kinds of questions and decisions to consider and explains the many ways to leave property to one’s heirs. Updated from the third edition in 2009, the guide not only talks taxes and trusts, but also offers counsel for same-sex couples and unconventional families.

If you want to permit your second husband to live in the family home until he dies, but then guarantee that the house reverts to the children of your first marriage, the guide tells you how a “life estate” works. It explains what is taxable and what isn’t, and discusses how to choose executors and trustees. It lists lots of resources and concludes with an estate-planning checklist.

In general, the A.B.A. intends its guide for the person trying to put his or her affairs in order, more than for family members trying to figure out how to proceed after someone has died. But many of us will play both these parts at some point (and if you are already an executor, or have been, please tell us how that has gone, and mention your state). We’ll need this information.


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

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The New Old Age: The Executor's Assistant

I’m serving as executor for my father’s estate, a role few of us are prepared for until we’re playing it, so I was grateful when the mail brought “The American Bar Association Guide to Wills and Estates” — the fourth edition of a handbook the A.B.A. began publishing in 1995.

This is a legal universe, I’m learning, in which every step — even with a small, simple estate that owes no taxes and includes no real estate or trusts — turns out to be at least 30 percent more complicated than expected.

If my dad had been wealthy or owned a business, or if we faced a challenge to his will, I would have turned the whole matter over to an estate lawyer by now. But even then, it would be helpful to know what the lawyer was talking about. The A.B.A. guide would help.

Written with surprising clarity (hey, they’re lawyers), it maps out all kinds of questions and decisions to consider and explains the many ways to leave property to one’s heirs. Updated from the third edition in 2009, the guide not only talks taxes and trusts, but also offers counsel for same-sex couples and unconventional families.

If you want to permit your second husband to live in the family home until he dies, but then guarantee that the house reverts to the children of your first marriage, the guide tells you how a “life estate” works. It explains what is taxable and what isn’t, and discusses how to choose executors and trustees. It lists lots of resources and concludes with an estate-planning checklist.

In general, the A.B.A. intends its guide for the person trying to put his or her affairs in order, more than for family members trying to figure out how to proceed after someone has died. But many of us will play both these parts at some point (and if you are already an executor, or have been, please tell us how that has gone, and mention your state). We’ll need this information.


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

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DealBook: Einhorn Sues Apple Over Plan to Discard Preferred Stock

9:02 p.m. | Updated

Wall Street has had a long romance with Apple. Now one of the company’s best-known investors is saying: I love you, but you need to change.

The surprising declaration by the billionaire hedge fund manager David Einhorn adds to the growing dissatisfaction with Apple and its once soaring stock.

On Thursday, Mr. Einhorn urged his fellow shareholders to block a plan by Apple to scrap a certain class of stock. He says that the move limits the company’s ability to use its enormous war chest — some $137 billion in cash — to reward investors.

The campaign is an unusually aggressive one for Mr. Einhorn, who came to fame betting against Lehman Brothers. To thwart the proposal, Mr. Einhorn is suing Apple in Federal District Court in Manhattan, claiming that it violated securities rules by tying the plan with two other initiatives that he sees as good corporate governance.

The standoff sets up an unusual clash between two sides who can each claim a huge following on Wall Street. In one corner is Apple, whose stock’s almost unearthly growth has bewitched investors across the globe — at least until recently. In the other is Mr. Einhorn, widely regarded as an intelligent investor whose moves inspire legions of copycats. His merely asking a few questions on an earnings call for Herbalife, a nutritional supplement company, last May prompted a plunge in its shares.

So far, each side has remained cordial. Mr. Einhorn called Apple “phenomenal” and contended that his campaign had nothing to do with its recent stock decline. His firm, Greenlight Capital, currently holds 1.3 million shares, now worth nearly $609 million.

“We own more Apple today than we ever have before,” he said in a telephone interview. “We’re optimistic about the company’s prospects, and think too much bad news has been priced in.”

In a response, Apple said that it “welcomes” Mr. Einhorn’s views and added that its management and its board were actively discussing how to return more cash to shareholders.

But the spat underlines recent hand-wringing over Apple, whose stock has proved vulnerable in recent weeks. Over the decade that ended in late September, its share price soared an astounding 18,749 percent, to more than $700. Scores of hedge funds bought into the stock, riding its coat tails to bolster their own returns.

Since about Sept. 21, however, Apple’s stock price has tumbled almost 33 percent, closing on Thursday at $468.22. (Even so, its market capitalization stands at $439.7 billion, making Apple the most valuable public company in the world.)

As the shares have fallen, the volume of criticism has risen.

“Because the stock has sold off from its high, and because Apple’s earnings have declined for the first time in a decade, you’ll hear people become more vocal,” said Walter Piecyk Jr., an analyst at BTIG Research.

Since at least 2005, no shareholder has conducted a formal campaign against an Apple management proposal, according to the data provider FactSet.

Mr. Einhorn’s main concern is Apple’s cash hoard, which is bigger than Intel’s entire market value. Shareholders have long complained that the cash, invested in the likes of Treasury bonds, is increasingly a drag on the stock price and should either be invested in new opportunities for growth or returned to them.

Last spring, the company announced a plan to return $45 billion to shareholders over three years, in the form of share buybacks and a dividend for its common stock. But that will hardly make a dent in a cash pile that swelled by $117 million a day during its most recent quarter.

Mr. Einhorn on Thursday compared Apple to his grandmother, whose experience surviving the Great Depression molded her into an extreme saver who did not leave voice mail messages for fear of using extra cellphone minutes. The company’s own near-death experience in 1997, he said, left a similarly profound scar on its corporate psyche.

As an alternative, he has been proposing since last May what he calls a “win-win” for Apple and its investors. The company, he says, could issue $50 billion in preferred shares to existing shareholders, which would carry a roughly 4 percent annual dividend. Over time, Apple could issue more preferred stock and increase its overall payouts.

The idea, which Mr. Einhorn said had been discussed within his firm for some time, would reward shareholders while ensuring that Apple would spend that additional cash over time. He raised the idea with company executives, including Apple’s chief financial officer, Peter Oppenheimer, over several months, but was rebuffed.

Mr. Einhorn became more aggressive after seeing Apple’s proposal to eliminate so-called blank check preferred stock from its corporate charter. The move would prohibit it from issuing preferred stock without shareholder approval. To Mr. Einhorn, that would sharply limit options for “unlocking value.”

He was further irked by Apple’s tying the plan with two others that he said he would ordinarily support.

In its statement, Apple said that its proposal was actually aimed at making itself more responsive to investors. It added that the plan would not prevent the introduction of precisely the kind of initiative that Mr. Einhorn had discussed.

At least one major investor has sided with Apple. Calpers, the giant California public employee pension fund that is the company’s 43rd-biggest shareholder, said in a statement that the proposal “significantly strengthens share owner rights and deserves full support.”

For his part, Mr. Einhorn said he planned on trying to persuade other shareholders. And he has reconciled himself to Apple’s days of meteoric growth now lying in the past.

“It’s not going to grow 80 percent a year,” he said of the company, “but that doesn’t mean it’s going to go bankrupt.”

David Einhorn's Lawsuit Against Apple by

A version of this article appeared in print on 02/08/2013, on page B1 of the NewYork edition with the headline: Investor Sues Apple Over Plan For Stocks.
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India Ink: Calls Grow Louder for Politician Accused of Rape to Resign

KOCHI— Demands for a fresh investigation of an Indian politician accused of raping a teenager in 1996 gained momentum after the young woman’s mother urged the Congress Party’s leader to dismiss the lawmaker.

As a teenager, a woman from a small town called Suryanelli in Kerala was allegedly abducted and raped by 42 men over a period of 40 days in January and February of 1996. Among the suspects the girl identified was P.J. Kurien, then a member of Parliament and now the deputy chairman of the upper house of Parliament.

In an emotionally charged letter to Sonia Gandhi, the president of Congress Party, the woman’s mother called for Mr. Kurien, a Congress member, to be dismissed from his position in the Rajya Sabha.

“We believe that Mr. P.J. Kurien has exerted undue influence over the investigating officials in order to escape from the clutches of law, and he had succeeded in that,” she said in the letter, dated Thursday.

She also asked Mrs. Gandhi how Mr. Kurien could be allowed to preside over the legislative debate on criminal law amendments for tougher rape laws.

In a country outraged by the gang-rape of a 23-year-old physiotherapy student in Delhi and by the authorities’ failure to prevent and punish crimes against women, this latest rape case is being seen as yet another example of India’s slow justice system, where cases languish in courts for years. It has also focused attention on official corruption, which allows the wealthy and politically connected to influence police investigations.

For the last 17 years, the Kerala rape case has been winding its way through India’s judicial system. On Jan. 31, the Supreme Court ordered a retrial, overturning the acquittal of a majority of the 42 suspects in 2005 by the Kerala High Court, which said that the girl had not tried to escape.

The girl alleged that Mr. Kurien had raped her at a government guest house in the southern town of Kumily. But police failed to include him on the list of men she had accused, so she filed a private complaint before a magistrate in 1999, said Sureshbabu Thomas, a special prosecutor for the case against the rest of the men.

Mr. Kurien filed a petition to dismiss the case in the lower court, which rejected his request. He then filed his appeal with the Kerala High Court, which said there was insufficient evidence against Mr. Kurien. The state government of Kerala appealed to the Supreme Court, which sided with Mr. Kurien.

“All the others who were named by the victim had to appear in the court, but P.J. Kurien did not,” K.V. Bhadra Kumari, a women’s rights activist and a lawyer, said in a phone interview. “Let him also be tried and let the law take its course.”

The Kerala government has refused to investigate Mr. Kurien, saying that his case has been cleared by the Supreme Court, but that has only enraged those who want Mr. Kurien to stand trial.

Opposition leaders in Kerala, Mr. Kurien’s home state, disrupted state legislative assembly proceedings Friday, demanding that Mr. Kurien resign. Angry protests were also held in Kerala’s capital city of Thiruvananthapuram.

Mr. Kurien has refused to step down. “I have already offered myself for judicial scrutiny in 1990s. Why should I do so again?” Mr. Kurien told an Indian television channel NDTV. “Then the High Court and Supreme Court had exonerated me. A fresh investigation will be contempt of court.”

Kerala, one of the few states in India where women outnumber men, is considered one of India’s most progressive states because of its high literacy rates: 93.91 percent overall, and a female literacy rate of 91.98 percent. It also has a much higher rate of reported rapes than the national average and has one of the highest rates of reported crimes against women among India’s 26 states.

K. Ajitha, a former member of the Naxal movement who now serves as a director of Anweshi, a woman’s organization that fights gender-based violence, said that one of the crucial problems is that there is a well-connected criminal network in the state, which protects political leaders and influential people when they are accused of rape.

“The organized mafia traps young adolescent girls by spreading its tentacles to all fields — the political leadership, the police, the judiciary,” she said. “So a rape victim rarely receives justice.”

Two of Kerala’s most publicized cases of sexual assault, known in the media as the “Suryanelli” and the “Vithura” after the hometowns of the victims, have been pending for years.

The trial of the 45 men accused in the Vithura case, where a girl was allegedly gang raped in 1995, is still under way 18 years after the crime was first reported. The victim, now in her early 30s, has requested the courts to discontinue the trial, saying it was traumatic to relive the incidents over and over again. The Kerala High Court, however, has rejected the request.

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DealBook: Einhorn to Sue Apple Over Plan to Discard Preferred Stock

The hedge fund magnate David Einhorn has long been known as a fervent fan of Apple. But he is making an unusually public stand to oppose a move by the company: a lawsuit.

His hedge fund, Greenlight Capital, said on Thursday that it was suing Apple in an effort to block a move that would eliminate preferred shares. In a letter to fellow stockholders, Mr. Einhorn said the move to amend the company’s charter would unnecessarily limit the technology giant’s ability to create value for shareholders and called on them for support.

“This is an unprecedented action to curtail the company’s options,” he wrote in the letter. “We are not aware of any other company that has ever voluntarily taken this step.”

The stated goal of the legal action is technical, based on an accusation that Apple is violating securities rules by bundling several shareholder initiatives in one proposal. But underneath it lies deeper dissatisfaction with the company.

Activists have taken on increasingly bigger targets in recent years, including the likes of Hess and Procter & Gamble. But no one has dared to take on the onetime darling of the hedge fund community.

The opposition by Mr. Einhorn is the latest sign of investor ire with a company whose stock price in recent years had been almost unearthly in its gains. That growth attracted Greenlight, which now holds 1.3 million shares – a stake of more than $590 million – and a wide array of hedge funds that hitched their investment performance to Apple’s rising star.

Over the last several months, however, shares in Apple have tumbled, leaving many with a sour taste in their mouths. In a letter to Greenlight investors last month, Mr. Einhorn joked that some of his fund’s stumbles were because “our apple was bruised.”

On Thursday, however, he took a more adversarial tone.

Mr. Einhorn praised Apple as “a phenomenal company filled with talented people creating iconic products that consumers around the world love.” But he expressed deep dissatisfaction over how Apple was managing its finances, complaining that the company’s enormous $137 billion cash hoard was shortchanging shareholders.

It appears that the move by Apple to eliminate preferred shares in its charter is the final straw. Mr. Einhorn said he had called upon the company to issue existing shareholders a perpetual preferred stock that would pay out a dividend. In one suggested outcome, the company would initially distribute $50 billion carrying a 4 percent annual dividend, and then issue more over time.

Mr. Einhorn said he had raised the issue with Apple executives several times, only to be rejected.

As Apple’s share price has fallen – it is down more than 26 percent over the last six months – Mr. Einhorn has said shareholders are owed more.

“The recent, severe underperformance of Apple’s shares, which are down approximately 35 percent from their peak valuation, underscores the need for the company to apply the same level of creativity used to develop revolutionary technology for its consumers to unlock the value of its strong balance sheet for its shareholders,” he wrote in the letter.

On CNBC, Mr. Einhorn likened Apple, whose near-collapse in 1997 profoundly scarred the company, to his his grandmother, who survived the Great Depression. Both have adopted tendencies to amass far more cash than they need, instead of putting it to more productive investments.

Apple is like “someone who’s gone through traumas,” the hedge fund magnate said. “They sometimes feel they can never have cash.”

Mr. Einhorn also protested that Apple was tying the preferred stock proposal to two other initiatives he supported: allowing for simple majority voting for directors and establishing a par value for common stock.

Shares in Apple were up slightly in early-morning trading on Thursday, at $457.57. That remains well below its 52-week high of $705.07.

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Well: Think Like a Doctor: A Confused and Terrified Patient

The Challenge: Can you solve the mystery of a middle-aged man recovering from a serious illness who suddenly becomes frightened and confused?

Every month the Diagnosis column of The New York Times Magazine asks Well readers to sift through a difficult case and solve a diagnostic riddle. Below you will find a summary of a case involving a 55-year-old man well on his way to recovering from a series of illnesses when he suddenly becomes confused and paranoid. I will provide you with the main medical notes, labs and imaging results available to the doctor who made the diagnosis.

The first reader to figure out this case will get a signed copy of my book, “Every Patient Tells a Story,” along with the satisfaction of knowing you solved a case of Sherlockian complexity. Good luck.

The Presenting Problem:

A 55-year-old man who is recovering from a devastating injury in a rehabilitation facility suddenly becomes confused, frightened and paranoid.

The Patient’s Story:

The patient, who was recovering from a terrible injury and was too weak to walk, had been found on the floor of his room at the extended care facility, raving that there were people out to get him. He was taken to the emergency room at the Waterbury Hospital in Connecticut, where he was diagnosed with a urinary tract infection and admitted to the hospital for treatment. Doctors thought his delirium was caused by the infection, but after 24 hours, despite receiving the appropriate antibiotics, the patient remained disoriented and frightened.

A Sister’s Visit:

The man’s sister came to visit him on his second day in the hospital. As she walked into the room she was immediately struck by her brother’s distress.

“Get me out of here!” the man shouted from his hospital bed. “They are coming to get me. I gotta get out of here!”

His brown eyes darted from side to side as if searching for his would-be attackers. His arms and legs shook with fear. He looked terrified.

For the past few months, the man had been in and out of the hospital, but he had been getting better — at least he had been improving the last time his sister saw him, the week before. She hurried into the bustling hallway and found a nurse. “What the hell is going on with my brother?” she demanded.

A Long Series of Illnesses:

Three months earlier, the patient had been admitted to that same hospital with delirium tremens. After years of alcohol abuse, he had suddenly stopped drinking a couple of days before, and his body was wracked by the sudden loss of the chemical he had become addicted to. He’d spent an entire week in the hospital but finally recovered. He was sent home, but he didn’t stay there for long.

The following week, when his sister hadn’t heard from him for a couple of days, she forced her way into his home. There she found him, unconscious, in the basement, at the bottom of his staircase. He had fallen, and it looked as if he may have been there for two, possibly three, days. He was close to death. Indeed, in the ambulance on the way to the hospital, his heart had stopped. Rapid action by the E.M.T.’s brought his heart back to life, and he made it to the hospital.

There the extent of the damage became clear. The man’s kidneys had stopped working, and his body chemistry was completely out of whack. He had a severe concussion. And he’d had a heart attack.

He remained in the intensive care unit for nearly three weeks, and in the hospital another two weeks. Even after these weeks of care and recovery, the toll of his injury was terrible. His kidneys were not working, so he required dialysis three times a week. He had needed a machine to help him breathe for so long that he now had to get oxygen through a hole that had been cut into his throat. His arms and legs were so weak that he could not even lift them, and because he was unable even to swallow, he had to be fed through a tube that went directly into his stomach.

Finally, after five weeks in the hospital, he was well enough to be moved to a short-term rehabilitation hospital to complete the long road to recovery. But he was still far from healthy. The laughing, swaggering, Harley-riding man his sister had known until that terrible fall seemed a distant memory, though she saw that he was slowly getting better. He had even started to smile and make jokes. He was confident, he had told her, that with a lot of hard work he could get back to normal. So was she; she knew he was tough.

Back to the Hospital:

The patient had been at the rehab facility for just over two weeks when the staff noticed a sudden change in him. He had stopped smiling and was no longer making jokes. Instead, he talked about people that no one else could see. And he was worried that they wanted to harm him. When he remained confused for a second day, they sent him to the emergency room.

You can see the records from that E.R. visit here.

The man told the E.R. doctor that he knew he was having hallucinations. He thought they had started when he had begun taking a pill to help him sleep a couple of days earlier. It seemed a reasonable explanation, since the medication was known to cause delirium in some people. The hospital psychiatrist took him off that medication and sent him back to rehab that evening with a different sleeping pill.

Back to the Hospital, Again:

Two days later, the patient was back in the emergency room. He was still seeing things that weren’t there, but now he was quite confused as well. He knew his name but couldn’t remember what day or month it was, or even what year. And he had no idea where he was, or where he had just come from.

When the medical team saw the patient after he had been admitted, he was unable to provide any useful medical history. His medical records outlined his earlier hospitalizations, and records from the nursing home filled in additional details. The patient had a history of high blood pressure, depression and alcoholism. He was on a long list of medications. And he had been confused for the past several days.

On examination, he had no fever, although a couple of hours earlier his temperature had been 100.0 degrees. His heart was racing, and his blood pressure was sky high. His arms and legs were weak and swollen. His legs were shaking, and his reflexes were very brisk. Indeed, when his ankle was flexed suddenly, it continued to jerk back and forth on its own three or four times before stopping, a phenomenon known as clonus.

His labs were unchanged from the previous visit except for his urine, which showed signs of a serious infection. A CT scan of the brain was unremarkable, as was a chest X-ray. He was started on an intravenous antibiotic to treat the infection. The thinking was that perhaps the infection was causing the patient’s confusion.

You can see the notes from that second hospital visit here.

His sister had come to visit him the next day, when he was as confused as he had ever been. He was now trembling all over and looked scared to death, terrified. He was certain he was being pursued.

That is when she confronted the nurse, demanding to know what was going on with her brother. The nurse didn’t know. No one did. His urinary tract infection was being treated with antibiotics, but he continued to have a rapid heart rate and elevated blood pressure, along with terrifying hallucinations.

Solving the Mystery:

Can you figure out why this man was so confused and tremulous? I have provided you with all the data available to the doctor who made the diagnosis. The case is not easy — that is why it is here. I’ll post the answer on Friday.


Rules and Regulations: Post your questions and diagnosis in the comments section below.. The correct answer will appear Friday on Well. The winner will be contacted. Reader comments may also appear in a coming issue of The New York Times Magazine.

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Well: Think Like a Doctor: A Confused and Terrified Patient

The Challenge: Can you solve the mystery of a middle-aged man recovering from a serious illness who suddenly becomes frightened and confused?

Every month the Diagnosis column of The New York Times Magazine asks Well readers to sift through a difficult case and solve a diagnostic riddle. Below you will find a summary of a case involving a 55-year-old man well on his way to recovering from a series of illnesses when he suddenly becomes confused and paranoid. I will provide you with the main medical notes, labs and imaging results available to the doctor who made the diagnosis.

The first reader to figure out this case will get a signed copy of my book, “Every Patient Tells a Story,” along with the satisfaction of knowing you solved a case of Sherlockian complexity. Good luck.

The Presenting Problem:

A 55-year-old man who is recovering from a devastating injury in a rehabilitation facility suddenly becomes confused, frightened and paranoid.

The Patient’s Story:

The patient, who was recovering from a terrible injury and was too weak to walk, had been found on the floor of his room at the extended care facility, raving that there were people out to get him. He was taken to the emergency room at the Waterbury Hospital in Connecticut, where he was diagnosed with a urinary tract infection and admitted to the hospital for treatment. Doctors thought his delirium was caused by the infection, but after 24 hours, despite receiving the appropriate antibiotics, the patient remained disoriented and frightened.

A Sister’s Visit:

The man’s sister came to visit him on his second day in the hospital. As she walked into the room she was immediately struck by her brother’s distress.

“Get me out of here!” the man shouted from his hospital bed. “They are coming to get me. I gotta get out of here!”

His brown eyes darted from side to side as if searching for his would-be attackers. His arms and legs shook with fear. He looked terrified.

For the past few months, the man had been in and out of the hospital, but he had been getting better — at least he had been improving the last time his sister saw him, the week before. She hurried into the bustling hallway and found a nurse. “What the hell is going on with my brother?” she demanded.

A Long Series of Illnesses:

Three months earlier, the patient had been admitted to that same hospital with delirium tremens. After years of alcohol abuse, he had suddenly stopped drinking a couple of days before, and his body was wracked by the sudden loss of the chemical he had become addicted to. He’d spent an entire week in the hospital but finally recovered. He was sent home, but he didn’t stay there for long.

The following week, when his sister hadn’t heard from him for a couple of days, she forced her way into his home. There she found him, unconscious, in the basement, at the bottom of his staircase. He had fallen, and it looked as if he may have been there for two, possibly three, days. He was close to death. Indeed, in the ambulance on the way to the hospital, his heart had stopped. Rapid action by the E.M.T.’s brought his heart back to life, and he made it to the hospital.

There the extent of the damage became clear. The man’s kidneys had stopped working, and his body chemistry was completely out of whack. He had a severe concussion. And he’d had a heart attack.

He remained in the intensive care unit for nearly three weeks, and in the hospital another two weeks. Even after these weeks of care and recovery, the toll of his injury was terrible. His kidneys were not working, so he required dialysis three times a week. He had needed a machine to help him breathe for so long that he now had to get oxygen through a hole that had been cut into his throat. His arms and legs were so weak that he could not even lift them, and because he was unable even to swallow, he had to be fed through a tube that went directly into his stomach.

Finally, after five weeks in the hospital, he was well enough to be moved to a short-term rehabilitation hospital to complete the long road to recovery. But he was still far from healthy. The laughing, swaggering, Harley-riding man his sister had known until that terrible fall seemed a distant memory, though she saw that he was slowly getting better. He had even started to smile and make jokes. He was confident, he had told her, that with a lot of hard work he could get back to normal. So was she; she knew he was tough.

Back to the Hospital:

The patient had been at the rehab facility for just over two weeks when the staff noticed a sudden change in him. He had stopped smiling and was no longer making jokes. Instead, he talked about people that no one else could see. And he was worried that they wanted to harm him. When he remained confused for a second day, they sent him to the emergency room.

You can see the records from that E.R. visit here.

The man told the E.R. doctor that he knew he was having hallucinations. He thought they had started when he had begun taking a pill to help him sleep a couple of days earlier. It seemed a reasonable explanation, since the medication was known to cause delirium in some people. The hospital psychiatrist took him off that medication and sent him back to rehab that evening with a different sleeping pill.

Back to the Hospital, Again:

Two days later, the patient was back in the emergency room. He was still seeing things that weren’t there, but now he was quite confused as well. He knew his name but couldn’t remember what day or month it was, or even what year. And he had no idea where he was, or where he had just come from.

When the medical team saw the patient after he had been admitted, he was unable to provide any useful medical history. His medical records outlined his earlier hospitalizations, and records from the nursing home filled in additional details. The patient had a history of high blood pressure, depression and alcoholism. He was on a long list of medications. And he had been confused for the past several days.

On examination, he had no fever, although a couple of hours earlier his temperature had been 100.0 degrees. His heart was racing, and his blood pressure was sky high. His arms and legs were weak and swollen. His legs were shaking, and his reflexes were very brisk. Indeed, when his ankle was flexed suddenly, it continued to jerk back and forth on its own three or four times before stopping, a phenomenon known as clonus.

His labs were unchanged from the previous visit except for his urine, which showed signs of a serious infection. A CT scan of the brain was unremarkable, as was a chest X-ray. He was started on an intravenous antibiotic to treat the infection. The thinking was that perhaps the infection was causing the patient’s confusion.

You can see the notes from that second hospital visit here.

His sister had come to visit him the next day, when he was as confused as he had ever been. He was now trembling all over and looked scared to death, terrified. He was certain he was being pursued.

That is when she confronted the nurse, demanding to know what was going on with her brother. The nurse didn’t know. No one did. His urinary tract infection was being treated with antibiotics, but he continued to have a rapid heart rate and elevated blood pressure, along with terrifying hallucinations.

Solving the Mystery:

Can you figure out why this man was so confused and tremulous? I have provided you with all the data available to the doctor who made the diagnosis. The case is not easy — that is why it is here. I’ll post the answer on Friday.


Rules and Regulations: Post your questions and diagnosis in the comments section below.. The correct answer will appear Friday on Well. The winner will be contacted. Reader comments may also appear in a coming issue of The New York Times Magazine.

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I.H.T. Special: Social Media Firms Move to Capitalize on Popularity in Middle East


Suhaib Salem/Reuters


Egyptian protesters look at Facebook during a demonstration in Cairo on January 14.









DUBAI — For its most recent advertising push, the Saudi Arabian telecommunications giant Mobily did not turn to the street or television to engage with customers. Mobily paid to promote itself on Twitter.




The use of social media exploded during the Arab Spring as people turned to cyberspace to express themselves. On the back of that, social media networks, including Twitter, Facebook and LinkedIn, have moved into the region commercially, setting up offices to sell advertising products to companies like Mobily, which has over 200,000 Twitter followers, to capitalize on the growing audience.


“In Saudi, social media gets everyone talking to everyone, which is something we just don’t have in the streets here,” said Muna AbuSulayman, a Saudi development consultant and formerly a popular television talk show host, who has over 100,000 followers on Twitter.


“It’s a unique opportunity that lets people have conversations in a boundary-less way that wasn’t possible before,” Ms. AbuSulayman said. “In addition to promoting social and political discussion, it carries a powerful economic incentive for businesses, too.”


The rise of social media in the Arab world is changing the game for regional advertisers, pushing growth in digital advertising in a part of the world where traditional methods like television and print advertising have so far remained dominant.


Digital advertising in the Middle East and North Africa accounts for only about 4 percent of the region’s total advertising spending, at a value of $200 million, according to the most recent available estimate, but it has become the fastest-growing media platform in the region, said a study by the business services firm Deloitte Touche Tohmatsu, published in 2011. Deloitte’s Arab Media Outlook projected growth in digital advertising spending in the region of 35 percent a year over the next three years, generating about $580 million across the region by 2015.


“The fact is that consumers are online, so brands need to be online,” said Reda Raad, chief operating officer of TBWA\Raad, the Middle East arm of the global advertising agency TBWA. “The use of digital channels has continued to increase dramatically after the Arab Spring and advertising on social media has become a highly targeted, cost-efficient way of communicating with consumers.”


Major brands, including Pepsi Arabia, are taking note. Saudi Arabia has the highest number of Twitter users in the Arab world, holding 38 percent of the region’s two million users, according to a report by the Dubai School of Government’s Arab Social Media Report released in June. In the past year alone, the number of Twitter users in the Arab world tripled, according to Shailesh Rao, Twitter’s vice president for international operations.


Thanks to the platform’s popularity in Saudi Arabia, Egypt, Kuwait and the United Arab Emirates, Arabic is now the fastest-growing language on the Twitter platform.


“We prioritized a list of regions where we wanted to have a business presence, and the Mideast rises toward the top because the region’s user base is one of the fastest-growing in the world,” Mr. Rao said during an interview. “This represents a huge opportunity for brands looking for a large audience that is rapidly growing.”


Twitter has formed a partnership with the Egyptian digital advertising company Connect Ads to market and sell advertising services across the Middle East and North Africa region. Connect Ads will offer brand managers and marketers Twitter’s products, which include promoted tweets, promoted accounts and promoted trends.


Through these, a brand can reach broad Twitter audiences or more narrowly defined geographic or demographic segments. They can even target users of specific smartphone brands, like iPhones. Brands that have signed up so far include Mobily, Pepsi Arabia, the resort company Atlantis The Palm, and the events portal Dubai Calendar.


“Companies can learn a few things about their customers by optimizing for country and targeting those with specific interests,” said Mohamed El Mehairy, managing director of Connect Ads.


“They can probably uncover this type of information through market research,” he added, but it would come “at a higher expense and with more time and effort.”


This article has been revised to reflect the following correction:

Correction: February 7, 2013

A previous version of this article misspelled the name of the advertising agency TBWA. It is TBWA, not TWBA.



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