In Nigeria, Polio Vaccine Workers Are Killed by Gunmen

At least nine polio immunization workers were shot to death in northern Nigeria on Friday by gunmen who attacked two clinics, officials said.

The killings, with eerie echoes of attacks that killed nine female polio workers in Pakistan in December, represented another serious setback for the global effort to eradicate polio.

Most of the victims were women and were shot in the back of the head, local reports said.

A four-day vaccination drive had just ended in Kano State, where the killings took place, and the vaccinators were in a “mop-up” phase, looking for children who had been missed, said Sarah Crowe, a spokeswoman for the United Nations Children’s Fund, one of the agencies running the eradication campaign.

Dr. Mohammad Ali Pate, Nigeria’s minister of state for health, said in a telephone interview that it was not entirely clear whether the gunmen were specifically targeting polio workers or just attacking the health centers where vaccinators happened to be gathering early in the morning. “Health workers are soft targets,” he said.

No one immediately took responsibility, but suspicion fell on Boko Haram, a militant Islamist group that has attacked police stations, government offices and even a religious leader’s convoy.

Polio, which once paralyzed millions of children, is now down to fewer than 1,000 known cases around the world, and is endemic in only three countries: Nigeria, Pakistan and Afghanistan.

Since September — when a new polio operations center was opened in the capital and Nigeria’s president, Goodluck Jonathan, appointed a special adviser for polio — the country had been improving, said Dr. Bruce Aylward, chief of polio eradication for the World Health Organization. There have been no new cases since Dec. 3.

While vaccinators have not previously been killed in the country, there is a long history of Nigerian Muslims shunning the vaccine.

Ten years ago, immunization was suspended for 11 months as local governors waited for local scientists to investigate rumors that it caused AIDS or was a Western plot to sterilize Muslim girls. That hiatus let cases spread across Africa. The Nigerian strain of the virus even reached Saudi Arabia when a Nigerian child living in hills outside Mecca was paralyzed.

Heidi Larson, an anthropologist at the London School of Hygiene and Tropical Medicine who tracks vaccine issues, said the newest killings “are kind of mimicking what’s going on in Pakistan, and I feel it’s very much prompted by that.”

In a roundabout way, the C.I.A. has been blamed for the Pakistan killings. In its effort to track Osama bin Laden, the agency paid a Pakistani doctor to seek entry to Bin Laden’s compound on the pretext of vaccinating the children — presumably to get DNA samples as evidence that it was the right family. That enraged some Taliban factions in Pakistan, which outlawed vaccination in their areas and threatened vaccinators.

Nigerian police officials said the first shootings were of eight workers early in the morning at a clinic in the Tarauni neighborhood of Kano, the state capital; two or three died. A survivor said the two gunmen then set fire to a curtain, locked the doors and left.

“We summoned our courage and broke the door because we realized they wanted to burn us alive,” the survivor said from her bed at Aminu Kano Teaching Hospital.

About an hour later, six men on three-wheeled motorcycles stormed a clinic in the Haye neighborhood, a few miles away. They killed seven women waiting to collect vaccine.

Ten years ago, Dr. Larson said, she joined a door-to-door vaccination drive in northern Nigeria as a Unicef communications officer, “and even then we were trying to calm rumors that the C.I.A. was involved,” she said. The Iraq and Afghanistan wars had convinced poor Muslims in many countries that Americans hated them, and some believed the American-made vaccine was a plot by Western drug companies and intelligence agencies.

Since the vaccine ruse in Pakistan, she said, “Frankly, now, I can’t go to them and say, ‘The C.I.A. isn’t involved.’ ”

Dr. Pate said the attack would not stop the newly reinvigorated eradication drive, adding, “This isn’t going to deter us from getting everyone vaccinated to save the lives of our children.”

Aminu Abubakar contributed reported from Kano, Nigeria.

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The fine line between legitimate businesses and pyramid schemes

Controversy is again casting a shadow over the multilevel marketing industry, as nutritional supplement company Herbalife Inc., which has thousands of distributors in the Chicago region, has been publicly called a pyramid scheme by a prominent investor — an allegation the company vigorously denies.

Meanwhile, a different multilevel marketer, Fortune Hi-Tech Marketing, was shut down in recent weeks after a lawsuit was brought by regulators and several states, including Illinois, alleging the company scammed consumers out of $169 million. The scheme affected an estimated 100,000 Americans, including some in Chicago, where it targeted Spanish-speaking consumers, the Federal Trade Commission alleged.

Most people outside the industry might have only a vague notion about multilevel marketing, also called network marketing and direct selling. It often involves personal sales of cosmetics, wellness products or home decor items — or as critics flippantly call it, "pills, potions and lotions" — usually sold through product parties hosted by friends or relatives.

For sellers, the companies offer the appeal of starting a business on the cheap with little training, working from home and being their own boss, if only for part-time money. Some might recruit friends and family to become sellers, which augments their own commissions and gives them a shot at the six-figure compensation many such marketing companies tout but few distributors attain.

The largest multilevel marketing companies, often known as MLMs, are household names: Avon, Mary Kay, Pampered Chef and Amway. MLMs have annual sales of about $30 billion, with about 16 million people in the United States selling their products, according to the industry group Direct Selling Association, which represents these firms and others.

The recent controversies might raise the question: What's the difference between a legitimate multilevel marketing company and an illegal pyramid scheme, in which only people who get in first — at the top of the pyramid-like structure — make money and everyone else is a dupe?

The harshest critics maintain there is no difference, that there's no such thing as a legitimate MLM and that the industry's secrets stay safe because of a cultlike mentality and a blind eye of regulators.

Jon M. Taylor, who was once a seller for an MLM company, said he has studied the industry for 18 years and analyzed more than 500 MLM companies. He maintains the website MLM-thetruth.com and offers a free e-book there.

"I have not yet found a good MLM — a good MLM is an oxymoron," Taylor said.

He said all MLM companies have the same flaw: They depend on endless chains of recruiting new members.  "There is no more unfair and deceptive practice than multilevel marketing," Taylor said.

Tracy Coenen, a forensic accountant and fraud investigator with Sequence Inc. in Chicago and Milwaukee, is author of the Fraud Files Blog. She is also a critic.

"Multilevel marketing companies are pyramid schemes that the government allows to operate," said Coenen. "The only difference is that Herbalife, or any multilevel marketing company, has a tangible product that they use to make their pyramid appear legitimate."

The Direct Selling Association says MLMs are legitimate businesses, and that the group has about 200 members carefully screened by the organization to ensure they are not pyramid schemes and don't use deceptive practices.

The Federal Trade Commission agrees there are legitimate MLMs. The difference between a legitimate business and pyramid scheme comes down to products.

If the company and its distributors make money primarily from the sale of products to end-users (and not boxes of product accumulating in a distributor's garage), it's OK.

By contrast, a pyramid scheme compensates those at the top of the pyramid with participation fees paid by those recruited at the bottom. It eventually collapses when the scheme can't recruit more people.

But identifying a pyramid scheme can be difficult because MLMs typically have product sales, along with recruitment fees and recruitment incentives.

"It gets cloudy when you have a situation where you have fees being paid for both," said Monica Vaca, assistant director of the FTC's division of marketing practices. "It's very nuanced."

While prosecuting an MLM can seem somewhat of a judgment call, cases have a common factor: deceptive promises about how much money distributors will earn, Vaca said.

In the Fortune Hi-Tech Marketing case filed last month, C. Steven Baker, director of the FTC's Midwest region, said, "These defendants were promising people that if they worked hard they could make lots of money. But it was a rigged game, and the vast majority of people lost money."

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Community says goodbye to slain teen

CAPTIONS

Hadiya Pendleton wake
Tanique Parker, 16, cries as she leaves the wake for friend and classmate Hadiya Pendleton at Calahan Funeral Home on Chicago's South Side. (Chris Sweda, Chicago Tribune /February 8, 2013)

By Bridget Doyle




Tribune reporter

7:41 p.m. CST, February 8, 2013

Friends and family gathered at Calahan Funeral Home on the South Side this afternoon for the wake of Hadiya Pendleton, the 15-year-old girl whose slaying last week became a national symbol of the gun violence in Chicago.

Hadiya’s body lay in an open casket, dressed in a purple dress embellished with sparkles. The inside of the casket was lined in a soft purple.

Visitors signed in a registry and wrote personal messages to Hadiya on a dedication board. Family gathered in the back of the room, some talking with visitors, others sitting in chairs.

Dozens of bouquets of flowers lined the room and a large photo of Hadiya was hung on display. A small TV played a picture slideshow of Hadiya smiling with family and friends.

John Burdette, a Hyde Park resident, said although he didn't know the Pendleton family, he wanted to pay his condolences.

“It helped put me at ease,” said Burdette, 64. "This poor young lady. Things are nuts out there and it's terrible. I don't leave my house after 4 p.m.”

Media trucks and police cars lined Halsted Street outside the funeral home, as Hadiya's death has garnered much attention on both a local and national scale.

The wake is scheduled from 2 to 9 p.m. Friday with the funeral to follow Saturday morning. First lady Michelle Obama is scheduled to attend.bdoyle@tribune.com

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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.

Friday Feb. 8 4:13 p.m. | Updated Thanks for all your responses. You can read about the winner at “Think Like a Doctor: A Confused and Terrified Patient Solved.”

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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.

Correction: The patient’s eyes were brown, not blue.

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S&C relay at center of Super Bowl outage

An electrical relay device supplied by Rogers Park's S&C Electric Co. was found to be at the center of the Super Bowl power outage in New Orleans, the company said Friday.

S&C Electric Co. said the outage, which lasted for more than 30 minutes at Sunday's game, happened when the demand for Superdome power exceeding a "trip setting" for its electrical relay.

But the device didn't malfunction, S&C said. Instead, it said it found in testing that system operators didn't account for the amount of power needed at the Superdome. S&C doesn't control the power settings on its equipment.

S&C wouldn't go into more details, but the power provider for Sunday's game was Entergy New Orleans, a unit of Entergy Corp.

In a statement, Entergy said the relay device had functioned properly at other high-profile sporting events, including the Sugar Bowl.

The relay was designed to prevent an outage if a cable connection to the stadium failed.

"S&C continues to work with all those involved to get the system back online, and our customers can continue to rely on the quality and performance of our products," Spokesman Michael Edmonds said in a statement.

S&C equipment is commonly used where high reliability is critical, he said, including data centers for United Parcel Service Inc., drug manufacturing centers and hospitals. The company also works with other stadiums throughout the U.S. and Canada.

Entergy said in a statement that the Superdome relay has been removed and replacement equipment is being examined.

That statement came before a special meeting of the New Orleans City Council's Utility Committee Friday morning to discuss the root cause of the outage.

Immediately after the game, Entergy indicated its equipment was functional and the problem must have come from the Superdome, but later said it was launching an investigation to determine the source of the problem.

"While some further analysis remains, we believe we have identified and remedied the cause of the power outage and regret the interruption that occurred during what was a showcase event for the city and state," Entergy New Orleans President and CEO Charles Rice said.

sbomkamp@tribune.com | Twitter: @SamWillTravel

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Attorney: Poisoned lottery winner changed finances to benefit wife

Weeks before he died mysteriously from cyanide poisoning after winning a $1 million lottery jackpot, a North Side businessman inked a deal with his business partner to ensure that his share of several dry cleaning stores went to his wife in the event of his death.

The unusual agreement is sure to fuel the fight among heirs of Urooj Khan over his estate, once estimated at about $2 million.

The agreement means that Khan’s widow, Shabana Ansari, owns half of the dry cleaning business and its real estate, instead of those assets being divided among heirs in probate court, according to Ansari’s lawyer, Al-Haroon Husain.

Those business assets are worth more than $1 million, leaving only about $680,000 – including the $425,000 in lottery winnings -- to be split among Khan’s heirs, Husain contends.

“It’s a bit unusual,” Husain said of the agreement following a hearing Thursday in the Daley Center courthouse. “I just think he wanted to make sure his wife had a business and had attachment to the commercial property if something happened to him.”

Khan and his partner, Shakir Mohammed, a childhood friend from their native India, signed the agreement early last May, according to court documents. Khan, 46, won the lottery prize later in May and died suddenly in mid-July before he collected the check.

Husain said he didn’t believe Khan “thought he’d be passing away so soon thereafter.”

In addition to the business agreement, Khan had signed a real estate contract with his wife that entitles her to sole ownership of their Rogers Park home, which is valued at almost half a million dollars, Husain said.

Based on those changes, Husain filed amended papers Thursday in court, drastically lowering the value of Khan’s estate to the $680,000 figure, down from about $2 million a few weeks ago.

Khan's family has been fighting in probate court over his estate since his unexpected death at 46. His brother, Imtiaz, raised concerns that since Khan left no will, his 17-year-old daughter from a previous marriage would not get "her fair share" of the inheritance. Khan and Ansari did not have children together.

As the Tribune first revealed last month, the Cook County medical examiner's office initially ruled that Khan died from hardening of the arteries after no signs of trauma were found on his body and a preliminary blood test did not raise any questions.

But the investigation was reopened about a week later after a relative raised concerns that Khan may have been poisoned.
 
Chicago police became involved in September after further testing found cyanide in Khan's blood. By late November, more comprehensive testing showed lethal levels of the toxic chemical, leading the medical examiner's office to declare his death a homicide.
 
Last month authorities exhumed Khan's body in order to perform an autopsy and gather additional evidence for the homicide investigation. No results have been made public yet.
 
While a motive for Khan’s homicide has not been determined, police have not ruled out that he was killed because of his lottery win, a law enforcement source has told the Tribune.

Ansari has been questioned by Chicago police detectives in her husband’s death, but she has denied any wrongdoing.

jmeisner@tribune.com
jgorner@tribune.com

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Martial arts drama kicks off Berlin film festival

BERLIN (Reuters) – The 2013 Berlin film festival kicks off on Thursday with the red carpet premiere of “The Grandmaster”, Hong Kong director Wong Kar Wai‘s martial arts period drama set in China at the time of the Japanese invasion in the 1930s.

Starring regular collaborator Tony Leung Chiu Wai as kung fu master Ip Man and Zhang Ziyi as his rival and friend Gong Er, the heavily stylized picture is a story of honor, principle, betrayal and forbidden love all set in a time of turmoil.

Wong, also president of the jury at the cinema showcase this year, said he was determined to get beneath the surface of martial arts in a way most films in the genre had not.

“‘Grandmaster’ is a film about kung fu. It tells you more than the skill,” he told reporters after a press screening and ahead of the opening night gala.

“It tells you more about these people, martial artists, the world of martial arts. What is their code of honor? What is their value? What is their philosophy?

“I hope this film can bring the audience a new perspective about martial arts, kung fu and also Chinese,” he added, wearing his trademark dark glasses and speaking in English.

The idea for “The Grandmaster” was first announced more than a decade ago and it took the notoriously slow filmmaker four years to make, involving rigorous training for both Leung and Zhang which both actors said changed them profoundly.

Leung’s character, which dominates the first part of the film, is based on a real-life master of the same name who developed the Wing Chun school of martial arts and counted Bruce Lee among his students.

Gong Er’s character gradually takes a central role, and her repressed longing for Ip Man brings to the fore Wong’s mastery of melancholy, which he showed so memorably in his best known film to date “In the Mood for Love” also starring Leung.

IRANIAN FILM DEFIES BAN

Leung, 50, said he started training for the part four years ago, and reportedly broke his arm early in the process.

“There is a spiritual side of kung fu and that side cannot be learned from books or by fact-finding,” he said. “It grows spontaneously. So that’s why I had to practice four years. You can only achieve that thing through practice.”

“The Grandmaster” marks the official start of 11 days of screenings, photocalls, interviews and parties across Berlin where hundreds of movies will be screened, reviewed and traded at a film market that accompanies the Berlinale.

Matt Damon, Anne Hathaway and Nicolas Cage are expected on the red carpet, as are European heavyweights Catherine Deneuve and Jude Law and Asian stars including Leung and Zhang.

In the main competition of 19 movies eligible for awards is “Promised Land”, about the controversial drilling technique for extracting gas known as “fracking” and starring Matt Damon directed by his “Good Will Hunting” collaborator Gus Van Sant.

Steven Soderbergh‘s “Side Effects” is in part a critique of the pharmaceutical industry and boasts Law, Channing Tatum and Catherine Zeta-Jones in the cast.

Soderbergh, an Oscar winner for his 2000 narcotics drama “Traffic”, has announced it will be his final big screen feature film, at least for the foreseeable future.

One of the most eagerly awaited pictures at the festival is “Closed Curtain”, co-directed by acclaimed Iranian director Jafar Panahi who made it in defiance of a 20-year ban on film making imposed by authorities at home.

Out of competition is 3D prehistoric animation comedy “The Croods”, featuring the voices of Cage and Ryan Reynolds, and “Dark Blood”, which River Phoenix was filming when he died aged 23 in 1993.

(Reporting by Mike Collett-White, editing by Paul Casciato)

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Well: The 'Monday Morning' Medical Screaming Match

I did not think I would ever see another “morbidity and mortality” conference in which senior doctors publicly attacked their younger colleagues for making medical errors. These types of heated meetings were commonplace when I was a medical student but have largely been abandoned.

Yet here they were again on “Monday Mornings,” a new medical drama on the TNT network, based on a novel by Dr. Sanjay Gupta, CNN’s chief medical correspondent and one of the executive producers of the show. Such screaming matches may make for good television, but it is useful to review why new strategies have emerged for dealing with medical mistakes.

So-called M&M conferences emerged in the early 20th century as a way for physicians to review cases that had either surprising outcomes or had somehow gone wrong. Although the format varied among institutions and departments, surgery M&Ms were especially known for their confrontations, as more experienced surgeons often browbeat younger doctors into admitting their errors and promising to never make them again.

Such conferences were generally closed door — that is, attended only by physicians. Errors were a private matter not to be shared with other hospital staff, let alone patients and families.

But in the late 1970s, a sociology graduate student named Charles L. Bosk gained access to the surgery department at the University of Chicago. His resultant 1979 book, “Forgive and Remember,” was one of the earliest public discussions of how the medical profession addressed its mistakes.

Dr. Bosk developed a helpful terminology. Technical and judgment errors by surgeons could be forgiven, but only if they were remembered and subsequently prevented by those who committed them. Normative errors, which called into question the moral character of the culprit, were unacceptable and potentially jeopardized careers.

Although Dr. Bosk’s book was more observational than proscriptive, his depiction of M&M conferences was disturbing. I remember attending a urology M&M as a medical student in which several senior physicians berated a very well-meaning and competent intern for a perceived mistake. The intern seemed to take it very well, but my fellow students and I were shaken by the event, asking how such hostility could be conducive to learning.

There were lots of angry accusations in the surgical M&Ms in the pilot episode of “Monday Mornings.” In one case, a senior doctor excoriated a colleague who had given Tylenol to a woman with hip pain who turned out to have cancer. “You allowed metastatic cancer to run amok for four months!” he screamed.

If this was what Dr. Bosk would have called a judgment error, the next case raised moral issues. A neurosurgeon had operated on a boy’s brain tumor without doing a complete family history, which would have revealed a disorder of blood clotting. The boy bled to death on the operating table. “The boy died,” announced the head surgeon, “because of a doctor’s arrogance.”

In one respect, it is good to see that the doctors in charge were so concerned. But as the study of medical errors expanded in the 1990s, researchers found that the likelihood of being blamed led physicians to conceal their errors. Meanwhile, although doctors who attended such conferences might indeed not make the exact same mistakes that had been discussed, it was far from clear that M&Ms were the best way to address the larger problem of medical errors, which, according to a 1999 study, killed close to 100,000 Americans annually.

Eventually, experts recommended a “systems approach” to medical errors, similar to what had been developed by the airline industry. The idea was to look at the root causes of errors and to devise systems to prevent them. Was there a way, for example, to ensure that the woman with the hip problem would return to medical care when the Tylenol did not help? Or could operations not be allowed to occur until a complete family history was in the chart? Increasingly, hospitals have put in systems, such as preoperative checklists and computer warnings, that successfully prevent medical errors.

Another key component of the systems approach is to reduce the emphasis on blame. Even the best doctors make mistakes. Impugning them publicly — or even privately — can make them clam up. But if errors are seen as resulting from inadequate systems, physicians and other health professionals should be more willing to speak up.

Of course, the systems approach is not perfect. Studies continue to show that physicians conceal their mistakes. And elaborate systems for preventing errors can at times interfere with getting things done in the hospital.

Finally, it is important not to entirely remove the issue of responsibility. Sad to say, there still are physicians who are careless and others who are arrogant. Even if today’s M&M conferences rarely involve screaming, supervising physicians need to let such colleagues know that these types of behaviors are unacceptable.

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Barron H. Lerner, M.D., professor of medicine at New York University Langone Medical Center, is the author, most recently, of “One for the Road: Drunk Driving Since 1900.”

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Justice weighs action against Moody's

(Reuters) - The Justice Department and multiple states are discussing also suing Moody's Corp for defrauding investors, according to people familiar with the matter, but any such move will likely wait until a similar lawsuit against rival Standard and Poor's is tested in the courts.

Inquiries into Moody's are in the early stages, largely because state and federal authorities have dedicated more resources to the S&P lawsuit, said the sources, who were not authorized to speak publicly about enforcement discussions.

Moody's spokesman Michael Adler and Justice Department spokeswoman Adora Andy declined to comment for this story.

Moody's in the past has defended itself against similar allegations, including a 2011 congressional report that concluded the major ratings agencies manipulated ratings to drive business.

The firm previously said Moody's takes the quality of its ratings and the integrity of the ratings process very seriously. It also said the firm has protections in place to separate the commercial and analytical aspects of its business.

The U.S. Justice Department filed a $5 billion lawsuit against S&P late on Monday and accused it of an egregious scheme to defraud investors in the run-up to the financial crisis, fueled by a desire to gain more business.

Shares of McGraw Hill Cos Inc , which owns S&P, have fallen more than 25 percent since news of the lawsuits. Moody's shares have fallen about 15 percent, even though it was not named in any of this week's actions.

"Don't think Moody's is off the hook," said one law enforcement official.

Another rival, Fimalac SA's Fitch Ratings, is unlikely to face similar action, the sources said, since it is a much smaller player in the U.S. ratings industry. The firm also escaped the brunt of scrutiny from congressional investigators.

In a sign of just how high-stakes the battle is, S&P hired prominent defense attorney John Keker, who has represented everyone from cyclist Lance Armstrong to Enron's Andrew Fastow.

S&P said in a statement on Tuesday that the lawsuit is meritless and said it will vigorously defend itself.

A similar coordinated federal-state action against Moody's would follow lawsuits two states have already filed against the ratings firm. Connecticut, which led the states in this week's actions, sued Moody's and S&P in March 2010.

In January a state court in Hartford denied the last of the preliminary motions Moody's had filed to have the case thrown out. That case and the one against S&P are proceeding to trial in the second half of 2014.

Democratic Senator Richard Blumenthal of Connecticut, who as then-attorney general brought the cases against S&P and Moody's in 2010, said he found rampant abuse across the credit rating industry.

"The difference is one of degree and scale rather than essential modus operandi," Blumenthal said in an interview. "S&P is the largest and they did the most sizeable amount of ratings with the largest profits."

CASE THEORY

Those earlier cases and the more recent ones against S&P are based on a theory that the firms misled investors by stating that their ratings on mortgage products were objective and not influenced by conflicts of interest.

Instead, the lawsuits contend, the firms inflated ratings and understated risks as the housing bubble started to burst, driven by a desire to gain more business from the investment banks that issued mortgage securities.

Framing the cases in that manner steers clear of attacking individual ratings, which have largely been shielded under free speech protections. Instead, the focus is on proving false just one statement S&P made - that its ratings were objective.

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Quinn minimum wage hike could be tough sell

Chicago Tribune Springfield correspondent Ray Long analyzes Illinois Gov. Pat Quinn's State of the State speech, saying it was ambitious and much like one heard during a re-election campaign. (Posted on: Feb. 6, 2013.)

It won’t be easy for Democrat Gov. Pat Quinn to find enough lawmakers to vote for the minimum wage increase, what with business groups pronouncing it a “job killer.”

But the best news for Quinn is that key Democratic lawmakers already are lined up behind an idea that’s popular with a large number of low-income workers. Senate President John Cullerton and House Majority Leader Barbara Flynn Currie quickly embraced it. Cullerton flatly predicted, “We’ll be able to pass a minimum wage bill.”

“I support it. It’s very, very popular in Illinois,” Cullerton said. “There is overwhelming support in the electorate.”

The electorate is the target audience in Quinn’s State of the State speech as he ramps up for a 2014 re-election campaign. His office estimated 500,000 Illinoisans could benefit from the wage hike. That’s a huge number of potential supporters who might be easily persuaded to cast a vote for a politician that helped them put more money into their pockets, particularly one like Quinn whose margin of victory in both the 2010 primary and general elections were far from overwhelming.

Republicans, including potential rivals in 2014, refused to get behind the minimum wage hike. House Republican leader Tom Cross of Oswego charged Quinn’s priorities are askew when the “elephant in the room” is the state’s $96.8 billion pension debt — a worst-in-the-nation status that has sent the state’s credit rating into a tailspin.

The pension battle has Quinn locked in a protracted war with union workers who are fighting against any rollbacks in retirement benefits at the same time they are unable to come to terms with the administration on a labor contract.

But as Quinn revealed his minimum wage push to a joint session of the House and Senate, he sought to wrap his arms around the working class, saying Illinois must “honor the productivity of our workers.”

“Our businesses are only as good as the employees who drive their success,” Quinn said. “Nobody in Illinois should work 40 hours a week and live in poverty. That’s a principle as old as the Bible.”

Quinn said the state minimum wage — currently $8.25 an hour — should be bumped up over four years to “at least $10 an hour.”

But beyond the finances, Quinn may hope a populist pocketbook issue can boost his own low approval ratings as he prepares to fight potentially big-name Democratic challengers like Attorney General Lisa Madigan and Bill Daley, the former white House chief of staff and a high-profile heir to the Daley family legacy.

Quinn called for a minimum-wage hike during the 2010 governor’s race, while Republican challenger Sen. Bill Brady opposed it.

Following Quinn’s speech on Wednesday, Brady said he wanted to review Quinn’s plan when there details are rolled out.

Hinsdale Republican Sen. Kirk Dillard, who like Brady is eyeing Quinn’s job, said he does not support the minimum wage hike. “We need to create better jobs, not minimum wage jobs, for those who are trying to raise a family,” Dillard said.

The chief sponsor of the minimum wage increase is Sen. Kimberly Lightford, the Maywood Democrat on Cullerton’s leadership team. She has sought to negotiate with foes and backers of the legislation for eight months. She said she wants to roll out a bill in the next few weeks.

One controversial provision Lightford is working through is her desire to raise the minimum wage for restaurant waiters and waitresses, who get a fraction of $8.25 regular minimum wage and get subsidized by tips.

“Businesses should be able to pay them the full $8.25,” Lightford said. But with smaller restaurants in particular balking, Lightford said, finding a happy medium is “not an easy task.”

Still, she said the chance of passage in the Senate “looks good” because she has been priming colleagues about the issue over the last two years.

“It’s not new today, which is very helpful,” Lightford said.

In a town where a raised eyebrow or a snarl can result in major political ramifications, Lightford said she saw House Speaker Michael Madigan, D-Chicago, clapping when Quinn talked about raising the minimum wage.

“That was a good sign,” Lightford said.

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