The Lede Blog: Aleppo's History Under Threat

As my colleagues Chris Chivers, Tyler Hicks and Ben Solomon report in text, photographs and video, civilians are suffering from shortages of food and medicine, among other hardships, in Aleppo, Syria’s largest city, which is being torn apart in urban warfare between rebels and forces loyal to President Bashar al-Assad.

But the city is also one of the Middle East’s most culturally and historically significant. Aleppo has been designated a World Heritage site since 1986, recognized for its ancient market, citadel and mosques, and the United Nations in recent months has called several times for its protection while emphasizing the tremendous toll the war has taken on civilians.

Many of Aleppo’s historical sites stand damaged by the fighting, perhaps irreparably, including the 17th-century market, or souk, in the Old City, which was engulfed by fire in September.

The contrast between the beauty of the city in more peaceful times and the damage that the fighting has wrought can be seen clearly on YouTube, in video of the souk before and after it became a battlefield.

Video of the Aleppo souk before it was ravaged by fighting.

Video of Aleppo’s souk in flames in late September.

By early October, as my colleague Anne Barnard reported, much of Aleppo’s historic center was in smoking ruins. Ancient stone walls had collapsed. The 12th-century citadel at the heart of the medieval city appeared to be damaged and government soldiers had taken up positions in the Umayyad Mosque, with snipers on the minaret.

After the fire swept through the ancient souk, Irina Bokova, the Unesco director-general, said in a statement:

The human suffering caused by this situation is already extreme. That the fighting is now destroying cultural heritage that bears witness to the country’s millenary history — valued and admired the world over — makes it even more tragic. The Aleppo souks have been a thriving part of Syria’s economic and social life since the city’s beginnings. They stand as testimony to Aleppo’s importance as a cultural crossroads since the second millennium B.C.

She made her remarks in October, deploring the damage to the Citadel, the Umayyad mosque and the “extreme human suffering” caused by the fighting.

Until the peaceful uprising spiraled into violence, Aleppo was a city for tourists, featured in The New York Times’s travel section in 2010. Tourism was up then, and the travel writer Lionel Beehner spoke glowingly about the mosques, the souk and the best reason to visit the Citadel: to take in the view of Aleppo’s minaret-dotted skyline.

Many have tried to capture what it means to a people to see their heritage destroyed. In one such attempt this month, Amal Hanano, a Syrian writer from Aleppo, also used the Citadel as an example, but this time of a city’s lost past, saying it was no longer a stage for impressing visitors but rather it had reclaimed its original purpose as a fortress.

Noting the deaths of more than 40,000 Syrians in less than two years of war, she wrote in a December article in Foreign Policy magazine:

But the death of a city is different. It is slow — each neighborhood’s death is documented bomb by bomb, shell by shell, stone by fallen stone. Witnessing the deaths of your cities is unbearable. Unlike the news of dead people — which arrives too late, always after the fact — the death of a city seems as if it can be halted, that the city can be saved from the clutches of destruction. But it is an illusion: The once-vibrant cities cannot be saved, so you watch, helpless, as they become ruins.

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Career Couch: Home Office Requires a Businesslike Attitude

Q. You have been working from home and find that it’s hard to stay focused and productive. Could it be that you simply don’t work well outside a corporate office?

A. Not necessarily. We often assume that people are more productive when they work in an office rather than at home, but that’s not always the case. We are less productive when we’re distracted, and that can happen anywhere, says Jason Henham, managing director of Slate Consulting, a management consulting firm in Melbourne, Australia.

“In the office, lack of productivity is masked by things like meetings, interruptions and socializing,” Mr. Henham says. The key to productivity — whether it’s in a corporate office or at the kitchen table — is a clear understanding of the results you’re trying to achieve each day, he says.

Q. How should you organize your home work space to encourage efficiency and productivity?

A. Rather than sitting with your laptop at the kitchen table, create a dedicated space for work that isn’t in a high-traffic area and that has easy access to electrical outlets, good lighting, Wi-Fi and, if possible, a door, says Angie Mattson, owner of Your Organized Guide, a time-management and organization firm in Charlotte, N.C. “That gives you a separate space for working and sets a tone that says ‘work happens here,’ ” she says.

She also recommends setting up rules with one’s spouse, children or roommates about when you can and can’t be interrupted.

Keep your work space organized, says Janet Bernstein, owner of Janet Bernstein Organizers in Philadelphia. “If your work space is cluttered, your mind is cluttered,” she says. “Your desk — even if you don’t work full time from home — should only have the essentials you need access to on a daily basis.”

Q. Will you be less productive if you work in your pajamas?

A. Being showered and dressed will often prompt a work mind-set to start your day, just as if you were preparing to go to a corporate office, Ms. Bernstein says. “Don’t work in your pajamas or sweats,” she says. “If you are too comfortable and relaxed in what you’re wearing, your attitude is too comfortable and relaxed.”

Q. Are any time-management strategies especially useful for working from home?

A. It’s helpful to build in the kind of accountability found in traditional offices. Tell your manager — or a friend or a colleague who agrees to act as your accountability partner — what you intend to achieve that day or week. “Couch this in terms of results you will achieve, rather than tasks performed, so you have flexibility around how you get your work completed,” Mr. Henham says. Check in daily or weekly to discuss what you’ve accomplished.

David Smith, managing director of the talent and organization practice at the consulting firm Accenture in Hartford, says that while results are what ultimately count, you still need to set up your tasks: “Create a to-do list for the day and cross each task off as you do it.”

Set realistic, achievable goals for each day and week. You may feel overwhelmed if a task is too big, so break it down into smaller pieces.

It’s also important to know your circadian rhythms, says Karen Southall Watts, a motivational coach in Bellingham, Wash. When possible, “schedule your most demanding tasks during your natural periods of high energy, and do your planning and reflection when you are feeling less perky,” she says. “When your energy is low, that’s not the moment to make 10 sales calls.”

Q. It’s easy to become distracted at home, when there aren’t others around you who are also working. How can you redirect your focus?

A. Eliminate as many distractions as you can — say, by turning off e-mail for long periods. The television, the refrigerator and the unwashed laundry, for example, should be off limits during your workday, Mr. Smith says. Build in breaks for things like snacking, checking Facebook, a walk, a lunch out or coffee, Ms. Bernstein says. Use music to rest, refocus and stay motivated.

But no amount of productivity coaching will help people buckle down if they don’t like the work they do, Ms. Mattson says. When that’s the case, you will look for anything to distract yourself. “If you like what you do and are eager to do it,” she says, “it’s much easier to stay focused.”

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Lawyer Says Ritual Circumcision Is Protected Activity

A lawyer for Orthodox Jewish groups asked a federal judge on Tuesday to throw out a New York City regulation requiring parents to sign a consent form before their infant sons undergo a form of Jewish ritual circumcision in which the circumciser uses his mouth to remove blood from the incision.

The lawyer, Shay Dvoretzky, said the practice, which is prevalent in parts of the ultra-Orthodox community, is a constitutionally protected religious activity. He said that requiring ritual circumcisers, known collectively as mohelim, to be involved in conveying the city’s perspective on the procedure would infringe upon their rights of free speech.

“That lies at the heart of First Amendment protection,” Mr. Dvoretzky said.

But a lawyer for the city argued that the regulation was necessary and that the practice most likely caused 11 herpes infections in infants between 2004 and 2011. Two of the infected babies died; at least two others suffered brain damage.

“The health department is not looking at the religion in determining what to do about this conduct,” said Michelle L. Goldberg-Cahn, a lawyer for the city. “The city is looking at the conduct.”

The Orthodox groups, including Agudath Israel of America and the Central Rabbinical Congress, sued the city in October to block the regulation, which was approved by the New York City Board of Health in September but is suspended until a ruling is issued in this case. The groups say that the procedure is safe and that the city has not definitively linked infections to the practice.

Infectious disease experts, several of whom filed briefs in support of the regulation, widely agree that the oral contact, known in Hebrew as metzitzah b’peh, creates a risk of transmission of herpes that can be deadly to infants because of their underdeveloped immune systems.

On Tuesday, Judge Naomi Reice Buchwald, of Federal District Court in Manhattan, heard oral arguments in the case, one that pits the sanctity of ancient religious rituals against the rigors of both modern medicine and secular government regulation. She said her decision would come within a few weeks.

Her sharpest inquiries were directed at Mr. Dvoretzky, the lawyer for the Orthodox groups.

She raised a hypothetical situation in which a single religious group amputates left pinkie fingers at birth, and asked Mr. Dvoretzky whether the city would have the authority to regulate the activity. He said it would depend upon whether the practice caused immediate, serious harm.

Judge Buchwald also said there was a direct comparison to consent requirements placed on physicians when they perform a circumcision.

Mr. Dvoretzky called that an “apples and oranges” comparison, because a physician would not perform a metzitzah b’peh.

“Wait a second,” Judge Buchwald interrupted. “They can’t perform any circumcision without consent. It’s a surgery.”

Mr. Dvoretzky said the city should undertake a broad education campaign, to prevent all infant herpes infections.

But Judge Buchwald said such a campaign would have little impact, because the risk of infections is medically well-known.

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Lawyer Says Ritual Circumcision Is Protected Activity

A lawyer for Orthodox Jewish groups asked a federal judge on Tuesday to throw out a New York City regulation requiring parents to sign a consent form before their infant sons undergo a form of Jewish ritual circumcision in which the circumciser uses his mouth to remove blood from the incision.

The lawyer, Shay Dvoretzky, said the practice, which is prevalent in parts of the ultra-Orthodox community, is a constitutionally protected religious activity. He said that requiring ritual circumcisers, known collectively as mohelim, to be involved in conveying the city’s perspective on the procedure would infringe upon their rights of free speech.

“That lies at the heart of First Amendment protection,” Mr. Dvoretzky said.

But a lawyer for the city argued that the regulation was necessary and that the practice most likely caused 11 herpes infections in infants between 2004 and 2011. Two of the infected babies died; at least two others suffered brain damage.

“The health department is not looking at the religion in determining what to do about this conduct,” said Michelle L. Goldberg-Cahn, a lawyer for the city. “The city is looking at the conduct.”

The Orthodox groups, including Agudath Israel of America and the Central Rabbinical Congress, sued the city in October to block the regulation, which was approved by the New York City Board of Health in September but is suspended until a ruling is issued in this case. The groups say that the procedure is safe and that the city has not definitively linked infections to the practice.

Infectious disease experts, several of whom filed briefs in support of the regulation, widely agree that the oral contact, known in Hebrew as metzitzah b’peh, creates a risk of transmission of herpes that can be deadly to infants because of their underdeveloped immune systems.

On Tuesday, Judge Naomi Reice Buchwald, of Federal District Court in Manhattan, heard oral arguments in the case, one that pits the sanctity of ancient religious rituals against the rigors of both modern medicine and secular government regulation. She said her decision would come within a few weeks.

Her sharpest inquiries were directed at Mr. Dvoretzky, the lawyer for the Orthodox groups.

She raised a hypothetical situation in which a single religious group amputates left pinkie fingers at birth, and asked Mr. Dvoretzky whether the city would have the authority to regulate the activity. He said it would depend upon whether the practice caused immediate, serious harm.

Judge Buchwald also said there was a direct comparison to consent requirements placed on physicians when they perform a circumcision.

Mr. Dvoretzky called that an “apples and oranges” comparison, because a physician would not perform a metzitzah b’peh.

“Wait a second,” Judge Buchwald interrupted. “They can’t perform any circumcision without consent. It’s a surgery.”

Mr. Dvoretzky said the city should undertake a broad education campaign, to prevent all infant herpes infections.

But Judge Buchwald said such a campaign would have little impact, because the risk of infections is medically well-known.

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F.T.C. Broadens Rules for Online Privacy of Children

In a move intended to give parents greater control over data collected about their children online, federal regulators on Wednesday broadened longstanding privacy safeguards covering children’s apps and Web sites.

Daniel Rosenbaum for The New York Times

Senator John D. Rockefeller of West Virginia, left, and Jon Leibowitz, the chairman of the F.T.C., at a news conference announcing rules to better protect children online.

Members of the Federal Trade Commission said they had updated the provisions to keep pace with the growing use of mobile phones and tablets among children. The regulations also reflect innovations like voice recognition technology, global positioning systems and behavior-based online advertising — that is, ads tailored to an Internet user’s habits.

Regulators had not significantly changed the original rule, based on the Children’s Online Privacy Protection Act of 1998, or Coppa, since its inception. That rule required operators of Web sites directed at children to notify parents and obtain their permission before collecting or sharing personal information — like first and last names, phone numbers, home addresses or e-mail addresses — from children under 13.

Legislators who enacted that law said the intent was to give parents control over entities seeking to collect information about their children so that parents could, among other things, prevent unwanted contact by strangers.

The new rule, unveiled at a news conference in Washington, significantly expands the types of companies required to obtain parental permission before knowingly collecting personal details from children, as well as the types of information that will require parental consent to collect.

Jon D. Leibowitz, the chairman of the F.T.C., described the rule revision as a major advance for children’s privacy.

“Congress enacted Coppa in the desktop era and we live in an era of smartphones and mobile marketing,” Mr. Leibowitz said. “This is a landmark update of a seminal piece of legislation.”

In an era of widespread photo sharing, video chatting and location-based apps, the revised rule makes clear that online operators must obtain parental consent before collecting certain details that could be used to identify, contact or locate a child. These include photos, videos and audio recordings as well as the location of a child’s mobile device.

While the new rule strengthens such safeguards, it could also disrupt online advertising. Web sites and online advertising networks often use persistent identification systems — like a customer code number in a cookie in a person’s browser — to collect information about a user’s online activities and tailor ads for that person.

But the new rule expands the definition of personal information to include persistent IDs — such as a customer code number, the unique serial number on a mobile phone, or the I.P. address of a browser — if they are used to show a child behavior-based ads. It also requires third parties like ad networks and social networks that know they are operating on children’s sites or apps to notify and obtain consent from parents before collecting such personal information. And it makes children’s sites or apps responsible for notifying parents about data collection by third parties integrated into their services.

Collecting data to show children contextual ads based on the content of a site or app, however, will not require parental consent.

“The only limit we place is on behavioral advertising,” Mr. Leibowitz said. “Until and unless you get parental consent, you may not track children to create massive profiles” for behavior-based ads.

Stuart P. Ingis, a lawyer representing several marketing associations, said that reputable online marketers did not knowingly profile children to show them behavior-based ads. He added that industry guidelines prohibited the practice.

He agreed with regulators that privacy protections for children online needed to keep pace with new technologies. But he said he was concerned that the restrictions on cookie-based identifiers might cause some children’s sites to reduce their use of outside services to avoid notifying parents about data collection by those services.

“The F.T.C. is saying that it is the obligation of first parties not to allow third-party ad networks or social network plug-ins on their site,” said Mr. Ingis, who represents the Direct Marketing Association and the Association of National Advertisers. “There might be overreaction that would limit just general third-party collection of data, which is very useful to businesses and consumers.”

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Sasol Betting Big on Gas-to-Liquid Plant in U.S.

Oryx

The Oryx natural gas processing plant in Qatar, where Sasol is converting natural gas to diesel fuel.

RAS LAFFAN INDUSTRIAL CITY, Qatar — The compact assembly of towers, tubes and tanks that make up the Oryx natural gas processing plant is almost lost in a vast petrochemical complex that rises here like a hazy mirage from a vast ocean of sand.

A blog about energy and the environment.

ORYX GTL

The Sasol plant in Qatar makes 32,000 barrels of liquid fuels daily. Experts say the economics of the process are challenged.

But what is occurring at Oryx is a particular kind of alchemy that has tantalized scientists for nearly a century with prospects of transforming the energy landscape. Sasol, a chemical and synthetic fuels company based in South Africa, is converting natural gas to diesel fuel using a variation of a technology developed by German scientists in the 1920s.

Performing such chemical wizardry is exceedingly costly. But executives at Sasol and a partner, Qatar’s state-owned oil company, are betting that natural gas, which is abundant here, will become the dominant global fuel source over the next 50 years, oil will become scarcer and more expensive and global demand for transport fuels will grow.

Sasol executives say the company believes so strongly in the promise of this technology that this month, it announced plans to spend up to $14 billion to build the first gas-to-liquids plant in the United States, in Louisiana, supported by more than $2 billion in state incentives. A shale drilling boom in that region in the last five years has produced a glut of cheap gas, and the executives say Sasol can tap that supply to make diesel and other refined products at competitive prices.

Marjo Louw, president of Sasol Qatar, says that his company can produce diesel fuel that burns cleaner, costs less and creates less greenhouse gas pollution than fuel derived from crude oil.

“We believe the planets are aligned for G.T.L.,” Mr. Louw said during a recent tour of the Oryx plant. “Other players — much bigger players — will follow.”

Perhaps. So far, however, the record for converting gas to liquids is spotty.

The newest and largest plant in operation, Royal Dutch Shell’s giant Pearl plant, also in Qatar, cost the leviathan sum of $19 billion, more than three times its original projected cost, and has been plagued with unexpected maintenance problems. BP and ConocoPhillips built and briefly operated demonstration plants in Alaska and Oklahoma, but stopped short of full development of the technology. Exxon Mobil and ConocoPhillips announced plans to build giant plants in Qatar, but backed out, putting their capital instead into terminals to export liquefied natural gas.

Today only a handful of gas-to-liquids plants operate commercially, in Malaysia, South Africa and Qatar. Together they produce only a bit more than 200,000 barrels of fuels and lubricants a day — equivalent to less than 1 percent of global diesel demand.

“The reason you see so few G.T.L. plants is the economics are challenged at best,” said William M. Colton, Exxon Mobil’s vice president of corporate strategic planning. “We do not see it being a relevant source of fuels over the next 20 years.”

Many analysts and industry insiders say the technology makes sense only when oil and gas supplies and prices are far out of balance, as they are today in Qatar and the United States. When oil and gas come into alignment, gas-to-liquids ventures will become white elephants, these skeptics say. Environmentalists also say that the huge energy inputs required to transform natural gas into diesel or other fuels negate any greenhouse gas benefits.

Until recently, the method used to convert natural gas or coal to liquid fuel — known as the Fischer-Tropsch process after the Germans who invented it — had been used only by pariah nations desperate for transportation fuels when they had little or no oil available. For decades, South Africa defended its system of apartheid from international oil embargoes by producing synthetic oil from its rich coal resources. Nazi Germany did the same to fuel its military machine in World War II.

But with North Africa and the Middle East chronically unstable and natural gas cheap and plentiful in the United States, some say the technology is now an enticing option to produce various fuels without importing a drop of oil.

Shell may soon announce a tentative site for a gas-to-liquids plant on the Gulf Coast of the United States. Given what the company learned from its Qatar plant, executives say it would reduce costs in any new one by using different types of valves and alloys.

But Ken Lawrence, Shell’s vice president for investor relations in North America, said the company was still two years away from a final decision on an American plant.

That leaves Sasol in the forefront of the gas-to-liquids effort.

John M. Broder reported from Ras Laffan Industrial City, Qatar, and Clifford Krauss from Houston.

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As Europe Presses Google on Antitrust, U.S. Backs Away

BRUSSELS — Google seems on its way to coming through a major antitrust investigation in the United States essentially unscathed. But the outlook is not as bright for Google here, as the European Union’s top antitrust regulator prepares to meet on Tuesday with Eric E. Schmidt, Google’s executive chairman.

In the United States, the Federal Trade Commission appears to be ready to back off what had been the centerpiece of its antitrust pursuit of Google: the complaint that the company’s dominant search engine favors the company’s commerce and other services in search queries, thwarting competition.

Yet in a statement last spring, Joaquín Almunia, the competition commissioner of the European Union, placed the contentions about search bias at the top of his list of concerns about Google. And in a private meeting this month, Mr. Almunia told Jon Leibowitz, chairman of the F.T.C., that European antitrust officials remain focused on that issue, according to two people told of the meeting, who asked not to be identified because they were not authorized to speak about it.

Mr. Almunia’s tougher bargaining stance, antitrust experts say, is not merely a personal preference.

European antitrust doctrine, they say, applies a somewhat different standard than United States law does. In America, dominant companies are given great leeway, if their conduct can be justified in the name of efficiency, thus consumer benefit. Google has consistently maintained that it offers a neutral, best-for-the-customer result.

In Europe, antitrust experts say, the law prohibits the “abuse of a dominant position,” with the victims of the supposed abuse often being competitors. “The Europeans tend to use competition law to level the playing field more than is the case in the United States,” said Herbert Hovenkamp, an antitrust expert and law professor at the University of Iowa. (Mr. Hovenkamp advised Google on one project, but no longer has any financial connection to the company.)

The European rationale, legal experts say, is that shielding competitors to some degree preserves competition and enhances consumer welfare in the long run.

“Europe has a stronger hand to play with Google because of its standards,” said Keith N. Hylton, a professor at the Boston University School of Law.

The European antitrust regulators, like their American counterparts, have been in negotiations with Google for several months. The F.T.C. is expected to announce its decision within days, while the European timetable seems not as tight and is likely to go into next year.

The investigations in the United States and Europe really started with accusations of search bias. Rivals complain that the search giant gives more prominent placement and display for its online shopping and travel services, for example, than to competitors. The potential antitrust concern is that such specialized, or “vertical,” search services — like Yelp or Nextag — are partial substitutes for Google’s search engine because they also allow people to find information.

In his public statement in May, Mr. Almunia identified four areas of concern in Europe’s antitrust investigation of Google. The first concern he cited was search bias.

“Google displays links to its own vertical search services differently than it does for links to competitors,” Mr. Almunia said in a statement then. “We are concerned that this may result in preferential treatment compared to those of competing services, which may be hurt as a consequence.”

His other three concerns are ones that Google is preparing to address with a set of voluntary commitments in the United States, according to two people briefed on Google’s talks with the F.T.C., who declined to give their names because they were not authorized to speak about them.

Google, according to the people, has agreed to refrain from copying summaries of product and restaurant reviews from other Web sites and including them in Google search results, a practice known as screen scraping.

James Kanter reported from Brussels and Steve Lohr from New York. Claire Cain Miller contributed reporting from San Francisco.

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Hospitals Fear They’ll Bear Brunt of Medicare Cuts

Ángel Franco/The New York Times

A hospital technician tends to a patient in the emergency room at Montefiore Medical Center, a large nonprofit hospital system in the Bronx.

WASHINGTON — As President Obama and Congress try to thrash out a budget deal, the question is not whether they will squeeze money out of Medicare, but how much and who will bear the brunt of the cuts.

Angel Franco/The New York Times

Dr. Steven M. Safyer, the chief executive of Montefiore Medical Center, said his hospital has made changes that would result in lower spending in the long run.

Republicans say that some of the savings should come from beneficiaries, and they are pushing proposals like raising the eligibility age or increasing premiums for people with high incomes, who already pay more than the standard premium. Even President Obama has proposed higher premiums, increasing the likelihood that the idea could be adopted. But any significant tinkering with the benefits for older Americans comes with significant political risks, and most Democrats in Congress strenuously oppose raising the age when Medicare coverage begins.

With growing pressure to reach an agreement on deficit reduction by the end of the year, some consensus is building around the idea that the largest Medicare savings should come from hospitals and other institutional providers of care.

“Hospitals will be in the cross hairs for more cuts,” said Lisa Goldstein, an analyst with Moody’s Investors Service, which follows nonprofit hospitals that issue bonds. While hospital executives fiercely defend the payments their own institutions receive, many acknowledge that Medicare is spending too much and growing too fast.

Those executives point out, however, that they have already agreed to $155 billion in cuts over a decade as part of the Affordable Care Act and they face billions more in additional cuts as part of the current negotiations. They argue that such large cuts to hospitals will ultimately affect beneficiaries.

“There is no such thing as a cut to a provider that isn’t a cut to a beneficiary,” said Dr. Steven M. Safyer, the chief executive of Montefiore Medical Center, a large nonprofit hospital system in the Bronx.

Mr. Obama and Speaker John A. Boehner continued trying on Tuesday to reach an overall budget agreement, which would call for significant savings in Medicare and would avert a deep cut in Medicare payments to doctors, scheduled to occur next month.

Mr. Boehner said that an increase in the eligibility age for Medicare, favored by many Republicans, could wait until next year.

“I don’t believe it’s an issue that has to be dealt with between now and the end of the year,” Mr. Boehner said Tuesday when asked about a possible change in the Medicare eligibility age. “It is an issue, I think, if Congress were to do entitlement reform next year and tax reform, as we envision, if there is an agreement, that issue will certainly be open to debate in that context.”

The starting point for the current negotiations is President Obama’s most recent budget request, which proposed legislation that would save $300 billion, or 4 percent of projected Medicare spending, over 10 years.

By contrast, Republicans in Congress are seeking savings of $400 billion to $600 billion, at least some of which should come from beneficiaries, they say.

Members of the Medicare Payment Advisory Commission, an influential panel that advises Congress, see many opportunities to rein in costs, and they say that financial pressure on providers could make them more efficient without harming the quality of care. At a meeting of the panel earlier this month, one commission member, Scott Armstrong, president of Group Health Cooperative, a nonprofit health system in Seattle, said Medicare spent “too much” on inpatient hospital care — $117 billion last year. “In an efficient system,” he said, “we wouldn’t be spending that kind of money on hospital services.”

Although Congress may leave the details of Medicare savings to be worked out next year, there is already discussion of cutting special payments to teaching hospitals and small rural hospitals. Lawmakers are also considering reducing payments to hospitals for certain outpatient services that can be performed at lower cost in doctors’ offices. Medicare pays substantially higher rates for the same services when they are provided in a hospital outpatient department rather than a doctor’s office. The differential added $1.5 billion to Medicare costs last year, and as hospitals buy physician practices around the country, the costs are likely to grow, the Medicare commission says.

The savings contemplated by Mr. Obama and Mr. Boehner are substantially larger than the Medicare savings that would be produced by automatic across-the-board cutbacks scheduled to start next month if Congress does not intervene. Those Medicare savings have been estimated at $123 billion from 2013 to 2021. Some hospital executives favor the automatic cuts as more equitable — and less painful — than some of the specific reductions being contemplated.

Hospital administrators and others warn of potential hospital closings, shutting down of unprofitable services like hospitalization for psychiatric care and less access to medical care for the most vulnerable if the cuts are too deep. Nancy M. Schlichting, the chief executive of the Henry Ford Health System in Detroit, says severe cuts might make it harder for hospitals like hers to treat patients without insurance. “It’s a big question whether we can continue to do that,” she said. “We would have to make tough decisions.”

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Ancient Bones That Tell a Story of Compassion

Lorna Tilley

DISABLED Almost all the other skeletons at the Man Bac site, south of Hanoi, are straight. But the man now called Burial 9 was laid to rest curled in a fetal position that suggests lifelong paralysis.

While it is a painful truism that brutality and violence are at least as old as humanity, so, it seems, is caring for the sick and disabled.

And some archaeologists are suggesting a closer, more systematic look at how prehistoric people — who may have left only their bones — treated illness, injury and incapacitation. Call it the archaeology of health care.

The case that led Lorna Tilley and Marc Oxenham of Australian National University in Canberra to this idea is that of a profoundly ill young man who lived 4,000 years ago in what is now northern Vietnam and was buried, as were others in his culture, at a site known as Man Bac.

Almost all the other skeletons at the site, south of Hanoi and about 15 miles from the coast, lie straight. Burial 9, as both the remains and the once living person are known, was laid to rest curled in the fetal position. When Ms. Tilley, a graduate student in archaeology, and Dr. Oxenham, a professor, excavated and examined the skeleton in 2007 it became clear why. His fused vertebrae, weak bones and other evidence suggested that he lies in death as he did in life, bent and crippled by disease.

They gathered that he became paralyzed from the waist down before adolescence, the result of a congenital disease known as Klippel-Feil syndrome. He had little, if any, use of his arms and could not have fed himself or kept himself clean. But he lived another 10 years or so.

They concluded that the people around him who had no metal and lived by fishing, hunting and raising barely domesticated pigs, took the time and care to tend to his every need.

“There’s an emotional experience in excavating any human being, a feeling of awe,” Ms. Tilley said, and a responsibility “to tell the story with as much accuracy and humanity as we can.”

This case, and other similar, if less extreme examples of illness and disability, have prompted Ms. Tilley and Dr. Oxenham to ask what the dimensions of such a story are, what care for the sick and injured says about the culture that provided it.

The archaeologists described the extent of Burial 9’s disability in a paper in Anthropological Science in 2009. Two years later, they returned to the case to address the issue of health care head on. “The provision and receipt of health care may therefore reflect some of the most fundamental aspects of a culture,” the two archaeologists wrote in The International Journal of Paleopathology.

And earlier this year, in proposing what she calls a “bioarchaeology of care,” Ms. Tilley wrote that this field of study “has the potential to provide important — and possibly unique — insights into the lives of those under study.” In the case of Burial 9, she says, not only does his care indicate tolerance and cooperation in his culture, but suggests that he himself had a sense of his own worth and a strong will to live. Without that, she says, he could not have stayed alive.

“I’m obviously not the first archaeologist” to notice evidence of people who needed help to survive in stone age or other early cultures, she said. Nor does her method “come out of the blue.” It is based on and extends previous work.

Among archaeological finds, she said, she knows “about 30 cases in which the disease or pathology was so severe, they must have had care in order to survive.” And she said there are certainly more such cases to be described. “I am totally confident that there are almost any number of case studies where direct support or accommodation was necessary.”

Such cases include at least one Neanderthal, Shanidar 1, from a site in Iraq, dating to 45,000 years ago, who died around age 50 with one arm amputated, loss of vision in one eye and other injuries. Another is Windover boy from about 7,500 years ago, found in Florida, who had a severe congenital spinal malformation known as spina bifida, and lived to around age 15. D. N. Dickel and G. H. Doran, from Florida State University wrote the original paper on the case in 1989, and they concluded that contrary to popular stereotypes of prehistoric people, “under some conditions life 7,500 years ago included an ability and willingness to help and sustain the chronically ill and handicapped.”

In another well-known case, the skeleton of a teenage boy, Romito 2, found at a site in Italy in the 1980s, and dating to 10,000 years ago, showed a form of severe dwarfism that left the boy with very short arms. His people were nomadic and they lived by hunting and gathering. He didn’t need nursing care, but the group would have had to accept that he couldn’t run at the same pace or participate in hunting in the same way others did.

Ms. Tilley gained her undergraduate degree in psychology in 1982 and worked in the health care industry studying treatment outcomes before coming to the study of archaeology. She said her experience influenced her interest in ancient health care.

What she proposes, in papers with Dr. Oxenham and in a dissertation in progress, is a standard four-stage method for studying ancient remains of disabled or ill individuals with an eye to understanding their societies. She sets up several stages of investigation: first, establishing what was wrong with a person; second, describing the impact of the illness or disability given the way of life followed in that culture; and third, concluding what level of care would have needed.

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Hospitals Fear They’ll Bear Brunt of Medicare Cuts

Ángel Franco/The New York Times

A hospital technician tends to a patient in the emergency room at Montefiore Medical Center, a large nonprofit hospital system in the Bronx.

WASHINGTON — As President Obama and Congress try to thrash out a budget deal, the question is not whether they will squeeze money out of Medicare, but how much and who will bear the brunt of the cuts.

Angel Franco/The New York Times

Dr. Steven M. Safyer, the chief executive of Montefiore Medical Center, said his hospital has made changes that would result in lower spending in the long run.

Republicans say that some of the savings should come from beneficiaries, and they are pushing proposals like raising the eligibility age or increasing premiums for people with high incomes, who already pay more than the standard premium. Even President Obama has proposed higher premiums, increasing the likelihood that the idea could be adopted. But any significant tinkering with the benefits for older Americans comes with significant political risks, and most Democrats in Congress strenuously oppose raising the age when Medicare coverage begins.

With growing pressure to reach an agreement on deficit reduction by the end of the year, some consensus is building around the idea that the largest Medicare savings should come from hospitals and other institutional providers of care.

“Hospitals will be in the cross hairs for more cuts,” said Lisa Goldstein, an analyst with Moody’s Investors Service, which follows nonprofit hospitals that issue bonds. While hospital executives fiercely defend the payments their own institutions receive, many acknowledge that Medicare is spending too much and growing too fast.

Those executives point out, however, that they have already agreed to $155 billion in cuts over a decade as part of the Affordable Care Act and they face billions more in additional cuts as part of the current negotiations. They argue that such large cuts to hospitals will ultimately affect beneficiaries.

“There is no such thing as a cut to a provider that isn’t a cut to a beneficiary,” said Dr. Steven M. Safyer, the chief executive of Montefiore Medical Center, a large nonprofit hospital system in the Bronx.

Mr. Obama and Speaker John A. Boehner continued trying on Tuesday to reach an overall budget agreement, which would call for significant savings in Medicare and would avert a deep cut in Medicare payments to doctors, scheduled to occur next month.

Mr. Boehner said that an increase in the eligibility age for Medicare, favored by many Republicans, could wait until next year.

“I don’t believe it’s an issue that has to be dealt with between now and the end of the year,” Mr. Boehner said Tuesday when asked about a possible change in the Medicare eligibility age. “It is an issue, I think, if Congress were to do entitlement reform next year and tax reform, as we envision, if there is an agreement, that issue will certainly be open to debate in that context.”

The starting point for the current negotiations is President Obama’s most recent budget request, which proposed legislation that would save $300 billion, or 4 percent of projected Medicare spending, over 10 years.

By contrast, Republicans in Congress are seeking savings of $400 billion to $600 billion, at least some of which should come from beneficiaries, they say.

Members of the Medicare Payment Advisory Commission, an influential panel that advises Congress, see many opportunities to rein in costs, and they say that financial pressure on providers could make them more efficient without harming the quality of care. At a meeting of the panel earlier this month, one commission member, Scott Armstrong, president of Group Health Cooperative, a nonprofit health system in Seattle, said Medicare spent “too much” on inpatient hospital care — $117 billion last year. “In an efficient system,” he said, “we wouldn’t be spending that kind of money on hospital services.”

Although Congress may leave the details of Medicare savings to be worked out next year, there is already discussion of cutting special payments to teaching hospitals and small rural hospitals. Lawmakers are also considering reducing payments to hospitals for certain outpatient services that can be performed at lower cost in doctors’ offices. Medicare pays substantially higher rates for the same services when they are provided in a hospital outpatient department rather than a doctor’s office. The differential added $1.5 billion to Medicare costs last year, and as hospitals buy physician practices around the country, the costs are likely to grow, the Medicare commission says.

The savings contemplated by Mr. Obama and Mr. Boehner are substantially larger than the Medicare savings that would be produced by automatic across-the-board cutbacks scheduled to start next month if Congress does not intervene. Those Medicare savings have been estimated at $123 billion from 2013 to 2021. Some hospital executives favor the automatic cuts as more equitable — and less painful — than some of the specific reductions being contemplated.

Hospital administrators and others warn of potential hospital closings, shutting down of unprofitable services like hospitalization for psychiatric care and less access to medical care for the most vulnerable if the cuts are too deep. Nancy M. Schlichting, the chief executive of the Henry Ford Health System in Detroit, says severe cuts might make it harder for hospitals like hers to treat patients without insurance. “It’s a big question whether we can continue to do that,” she said. “We would have to make tough decisions.”

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