Amgen Workers Helped U.S. in Aranesp Marketing Inquiry

“I hope no one is taping this,” the Amgen manager remarked at a company sales meeting in 2005.

The manager then boasted of how she had given a $10,000 unrestricted grant to a pet project of a doctor who was an adviser to the local Medicare contractor. In turn, she said, the doctor would help persuade the contractor to provide reimbursement for an unapproved use of Amgen’s anemia drug, Aranesp.

Someone, it turned out, was taping it. Jill Osiecki, a longtime sales representative at Amgen, was wearing a recording device under her clothes, transmitting the proceedings to agents of the Department of Health and Human Services.

The result of Ms. Osiecki’s undercover work, and information provided by other whistle-blowers, led to Amgen’s agreement this week to pay $762 million to settle federal investigations regarding the marketing of some of its top-selling drugs.

Judge Sterling Johnson Jr. of Federal District Court in Brooklyn accepted the settlement on Wednesday, clearing the way for 10 whistle-blower lawsuits to be unsealed.

Amgen, the world’s largest biotechnology company, will pay $150 million in criminal penalties after pleading guilty to one misdemeanor count of marketing Aranesp for unapproved uses and in unapproved doses.

The rest of the money — $612 million — will go to settle civil false claims lawsuits filed by the federal government, states and whistle-blowers. These contain accusations that go well beyond the off-label marketing of Aranesp.

They include off-label marketing of other drugs like Enbrel for psoriasis and Neulasta, which increases the levels of white blood cells. Amgen is also accused of offering kickbacks to doctors and clinics to induce them to use its drugs. These reportedly came as cash, rebates, free samples, educational and research grants, dinners and travel, and other inducements. The government also accused the company of knowingly misreporting the prices of some of its drugs.

Except for those in the criminal count, Amgen denied the other accusations, though it did issue a statement on Wednesday acknowledging the settlement.

“The government raised important concerns in the criminal prosecution,” Cynthia M. Patton, chief compliance officer at Amgen, said in the statement. “Amgen acknowledges that mistakes were made, and we did not live up to our standards.”

Ms. Osiecki, 52, was one of the main whistle-blowers and will be entitled to a share of the settlement. The amount each whistle-blower will receive has not been determined or is being kept confidential, their lawyers said.

Ms. Osiecki worked as a sales representative for Merck for nine years before joining Amgen in 1990, soon after the biotechnology company won regulatory approval for its first product. The company, based outside Los Angeles, had “good science, good products, strong ethics,” Ms. Osiecki said in an interview.

But, she said, the corporate culture changed starting around 2000. That was when new management came in and Aranesp was approved, setting up a fierce marketing battle with Johnson & Johnson and its rival anemia drug, Procrit.

“It was more important to make your numbers than to follow the rules,” said Ms. Osiecki, who was based in Milwaukee and sold Aranesp.

In August 2004, with her concerns mounting, Ms. Osiecki called the Office of Inspector General of the Department of Health and Human Services and left a message. Within days, she was called back, and she went to see an agent, who persuaded her to secretly record meetings. She did that 13 times over about 15 months, mainly sales meetings.

Aranesp is used mainly in a hospital, clinic or physician’s office. It is bought by the medical practice, which can make a profit if the patient and insurers pay more for the use of the drug than the practice paid.

Ms. Osiecki said Amgen “marketed the spread,” trying to make it more profitable for doctors to use Aranesp rather than Procrit.

Such financial inducements could also spur greater overall use of a drug and can violate anti-kickback laws, said Ms. Osiecki’s lawyer, Brian P. Kenney of Kenney & McCafferty in Blue Bell, Pa.

Ms. Osiecki said the first sales meeting at which she wore the recording device, wrapped around her midriff under baggy clothes, was in October 2004 in a Milwaukee hotel. She could look down from the meeting room and see the car parked across the street containing the agent with the receiving device. She said she was not particularly nervous.

The speaker was a pharmacist from an oncology practice going through the numbers on how his practice could make a million dollars more a year using Aranesp rather than Procrit.

Ms. Osiecki said Amgen was careful to cover up such marketing. Spreadsheets showing doctors how much more money they could make using Aranesp were “homemade bread,” meaning they were created by each sales representative, not by the company. And representatives were told not to leave the presentations behind after showing them to doctors.

Her 107-page complaint, filed in late 2004, contains many other accusations.

Other whistle-blowers made other accusations. Kassie Westmoreland, a former sales representative, said Amgen overfilled vials of Aranesp, essentially providing free drugs to doctors. They could then bill Medicare or private insurers for the use of that drug, making an extra profit.

“Amgen was offering a kickback in the form of extra product subsidized by the taxpayers,” said Robert M. Thomas Jr., one of Ms. Westmoreland’s lawyers.

Elena Ferrante and Marc Engelman, both former sales representatives, contended that Amgen promoted Enbrel’s off-label use for mild psoriasis when the drug was approved only for moderate or severe cases of the disease.

Lydia Cotz, one of their lawyers, said the two refused to go along with the off-label marketing. They are now pursuing wrongful termination claims against Amgen in arbitration proceedings that Amgen requires be kept confidential, she said.

“It’s been a very long heroic journey for my clients,” she said.

Ms. Osiecki is now also a former Amgen sales representative. She said that she was fired in December 2005 after she let slip that she had retained a company voice mail message that she thought provided evidence of illegal activity. Leaving the pharmaceutical industry, she moved to Amelia Island, Fla. She now works for a small business.

Mosi Secret and Barry Meier contributed reporting.

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Amgen Workers Helped U.S. in Aranesp Marketing Inquiry

“I hope no one is taping this,” the Amgen manager remarked at a company sales meeting in 2005.

The manager then boasted of how she had given a $10,000 unrestricted grant to a pet project of a doctor who was an adviser to the local Medicare contractor. In turn, she said, the doctor would help persuade the contractor to provide reimbursement for an unapproved use of Amgen’s anemia drug, Aranesp.

Someone, it turned out, was taping it. Jill Osiecki, a longtime sales representative at Amgen, was wearing a recording device under her clothes, transmitting the proceedings to agents of the Department of Health and Human Services.

The result of Ms. Osiecki’s undercover work, and information provided by other whistle-blowers, led to Amgen’s agreement this week to pay $762 million to settle federal investigations regarding the marketing of some of its top-selling drugs.

Judge Sterling Johnson Jr. of Federal District Court in Brooklyn accepted the settlement on Wednesday, clearing the way for 10 whistle-blower lawsuits to be unsealed.

Amgen, the world’s largest biotechnology company, will pay $150 million in criminal penalties after pleading guilty to one misdemeanor count of marketing Aranesp for unapproved uses and in unapproved doses.

The rest of the money — $612 million — will go to settle civil false claims lawsuits filed by the federal government, states and whistle-blowers. These contain accusations that go well beyond the off-label marketing of Aranesp.

They include off-label marketing of other drugs like Enbrel for psoriasis and Neulasta, which increases the levels of white blood cells. Amgen is also accused of offering kickbacks to doctors and clinics to induce them to use its drugs. These reportedly came as cash, rebates, free samples, educational and research grants, dinners and travel, and other inducements. The government also accused the company of knowingly misreporting the prices of some of its drugs.

Except for those in the criminal count, Amgen denied the other accusations, though it did issue a statement on Wednesday acknowledging the settlement.

“The government raised important concerns in the criminal prosecution,” Cynthia M. Patton, chief compliance officer at Amgen, said in the statement. “Amgen acknowledges that mistakes were made, and we did not live up to our standards.”

Ms. Osiecki, 52, was one of the main whistle-blowers and will be entitled to a share of the settlement. The amount each whistle-blower will receive has not been determined or is being kept confidential, their lawyers said.

Ms. Osiecki worked as a sales representative for Merck for nine years before joining Amgen in 1990, soon after the biotechnology company won regulatory approval for its first product. The company, based outside Los Angeles, had “good science, good products, strong ethics,” Ms. Osiecki said in an interview.

But, she said, the corporate culture changed starting around 2000. That was when new management came in and Aranesp was approved, setting up a fierce marketing battle with Johnson & Johnson and its rival anemia drug, Procrit.

“It was more important to make your numbers than to follow the rules,” said Ms. Osiecki, who was based in Milwaukee and sold Aranesp.

In August 2004, with her concerns mounting, Ms. Osiecki called the Office of Inspector General of the Department of Health and Human Services and left a message. Within days, she was called back, and she went to see an agent, who persuaded her to secretly record meetings. She did that 13 times over about 15 months, mainly sales meetings.

Aranesp is used mainly in a hospital, clinic or physician’s office. It is bought by the medical practice, which can make a profit if the patient and insurers pay more for the use of the drug than the practice paid.

Ms. Osiecki said Amgen “marketed the spread,” trying to make it more profitable for doctors to use Aranesp rather than Procrit.

Such financial inducements could also spur greater overall use of a drug and can violate anti-kickback laws, said Ms. Osiecki’s lawyer, Brian P. Kenney of Kenney & McCafferty in Blue Bell, Pa.

Ms. Osiecki said the first sales meeting at which she wore the recording device, wrapped around her midriff under baggy clothes, was in October 2004 in a Milwaukee hotel. She could look down from the meeting room and see the car parked across the street containing the agent with the receiving device. She said she was not particularly nervous.

The speaker was a pharmacist from an oncology practice going through the numbers on how his practice could make a million dollars more a year using Aranesp rather than Procrit.

Ms. Osiecki said Amgen was careful to cover up such marketing. Spreadsheets showing doctors how much more money they could make using Aranesp were “homemade bread,” meaning they were created by each sales representative, not by the company. And representatives were told not to leave the presentations behind after showing them to doctors.

Her 107-page complaint, filed in late 2004, contains many other accusations.

Other whistle-blowers made other accusations. Kassie Westmoreland, a former sales representative, said Amgen overfilled vials of Aranesp, essentially providing free drugs to doctors. They could then bill Medicare or private insurers for the use of that drug, making an extra profit.

“Amgen was offering a kickback in the form of extra product subsidized by the taxpayers,” said Robert M. Thomas Jr., one of Ms. Westmoreland’s lawyers.

Elena Ferrante and Marc Engelman, both former sales representatives, contended that Amgen promoted Enbrel’s off-label use for mild psoriasis when the drug was approved only for moderate or severe cases of the disease.

Lydia Cotz, one of their lawyers, said the two refused to go along with the off-label marketing. They are now pursuing wrongful termination claims against Amgen in arbitration proceedings that Amgen requires be kept confidential, she said.

“It’s been a very long heroic journey for my clients,” she said.

Ms. Osiecki is now also a former Amgen sales representative. She said that she was fired in December 2005 after she let slip that she had retained a company voice mail message that she thought provided evidence of illegal activity. Leaving the pharmaceutical industry, she moved to Amelia Island, Fla. She now works for a small business.

Mosi Secret and Barry Meier contributed reporting.

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Adding to Rules for Online Privacy

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 mobile apps and Web sites. Members of the Federal Trade Commission said they updated the rules to keep pace with the growing use of mobile phones and tablets by children.

The regulations also reflect innovations like voice recognition technology, global positioning systems and behavior-based online advertising, or ads tailored to an individual Internet user.

Regulators had not significantly changed the original rule, based on the Children’s Online Privacy Protection Act of 1998, or Coppa. That rule required operators of Web sites directed at children under 13 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.

The intent of that 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 trade commission, 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.”

The agency’s expanded privacy protections for children also represent the first step in a larger effort by a few regulators and legislators to give adult consumers some rights to control data collected about them.

“The Coppa rule revisions which we are announcing today are a critical piece in our overall approach to how we deal with consumer privacy in this technological age,” said Julie Brill, a member of the commission.

Industry analysts said the new rule represented a partial victory for Web site operators, app developers and advertising networks because regulators watered down some of their original proposals to which companies like Apple, Facebook, Google and Twitter had objected. Apple and Google, for example, opposed proposals that suggested they would be responsible for the data collected by children’s apps sold in their app stores. Regulators have now clarified that general-interest app stores would not be held liable for that.

Yet, few companies lent any support to the commission at its news conference; Viacom and Disney sent representatives, but other companies were absent.

“What we’ve got here is an expansion of Coppa that some in the industry would say has gone too far,” said Alan Friel, a lawyer who leads the media and technology practice at the firm of Edwards Wildman Palmer. “But the F.T.C. has provided exceptions that continue to allow internal use of a child’s data, including one-time use of contact information for facilitating promotions and send-a-friend e-mails.”

In an era of widespread photo sharing, video chatting and location-based apps, the revised children’s privacy rule makes clear that companies must obtain parental consent before collecting certain details that could be used to identify, contact or locate a child. These include photos, video and audio 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 cookie in a person’s browser, the unique serial number on a mobile phone, or the I.P. address of a computer — to collect information about a user’s online activities and tailor ads for that person.

The new rule expands the definition of personal information to include persistent IDs 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 to notify and obtain consent from parents before collecting such personal information. And it makes children’s sites 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 ad networks to avoid having to notify parents about data collection by those services.

“There might be overreaction that would limit just general third-party collection of data, which is very useful to businesses and consumers,” said Mr. Ingis, who represents the Direct Marketing Association and the Association of National Advertisers.

The revised rule also clarifies requirements for sites that are not primarily directed at young children but whose audience may include them, like a Disney family site, for example. Those sites can now screen visitors by age, but they will be required to obtain permission from a parent to collect personal data about children under 13.

Children’s advocates generally welcomed the strengthened protections.

“Clearly, this is a major step forward, but the devil is in the details,” said Jeffrey Chester, the executive director of the Center for Digital Democracy, an advocacy group in Washington.

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Three State Department Officials Resign After Benghazi Report

WASHINGTON — Three State Department officials resigned on Wednesday after an independent panel criticized the “grossly inadequate” security at a diplomatic compound in Benghazi, Libya, that was attacked on Sept. 11, leading to the deaths of Ambassador J. Christopher Stevens and three other Americans.

The officials were Eric J. Boswell, the assistant secretary of state for diplomatic security; Charlene R. Lamb, the deputy assistant secretary responsible for embassy security; and Raymond Maxwell, a deputy assistant secretary who had responsibility for North Africa, an administration official said.

The panel’s classified report identified officials in the State Department’s Bureau for Diplomatic Security whose performance reflected a “lack of proactive leadership,” and complained that the Bureau of Near Eastern Affairs had displayed a “lack of ownership of Benghazi’s security issues.”

The report did not criticize any other senior officials, including Patrick F. Kennedy, the under secretary for management, who has vigorously defended the State Department’s decision-making on Benghazi to Congress, or Secretary of State Hillary Rodham Clinton.

At a news conference at the State Department on Wednesday, Thomas R. Pickering, a former ambassador who led the independent review, said that most of the blame should fall on officials in the two bureaus.

“We fixed it at the assistant secretary level, which is, in our view, the appropriate place to look, where the decision-making in fact takes place, where, if you like, the rubber hits the road,” said Mr. Pickering, who did not identify the officials.

At the same time, the report that Mr. Pickering oversaw suggested that there was a culture of “husbanding resources” at senior levels of the State Department that contributed to the security deficiencies in Benghazi. Without identifying Mr. Kennedy or other senior officials, the report said that attitude “had the effect of conditioning a few State Department managers to favor restricting the use of resources as a general orientation.”

Two deputy secretaries of state, William J. Burns and Thomas R. Nides, are scheduled to testify to Congressional committees on Thursday. The question of whether senior officials at the State Department should be held accountable is likely to be raised by lawmakers at the hearing.

“The board severely critiques a handful of individuals, and they have been held accountable,” said Representative Ed Royce, Republican of California, who is the incoming chairman of the House Foreign Affairs Committee. “The degree that others bear responsibility warrants Congressional review, given the report’s rather sweeping indictment. And the Foreign Affairs Committee must hear from Secretary Clinton concerning her role, which this report didn’t address.”

Mrs. Clinton, in a letter to Congress, outlined a number of steps the department is taking to improve security, including hiring hundreds of additional Marine guards for high-risk embassies and consulates around the world.

Another issue, which might be raised and which was largely skirted by the independent panel, concerns what role the American military should play in protecting diplomats abroad.

The Pentagon had no forces that could be readily sent to Benghazi when the crisis unfolded. The closest AC-130 gunship was in Afghanistan. There are no armed drones thought to be within range of Libya. There was no Marine expeditionary unit — a large seaborne force with its own helicopters — in the Mediterranean Sea. The Africa Command, whose area of operation includes North Africa, also did not have on hand its own force able to respond rapidly to emergencies — a Commanders’ In-Extremis Force, or C.I.F. Every other regional combatant command had one at the time.

The Defense Department has repeatedly declined to say whether the Africa Command requested that any of these forces be on hand during the anniversary of the Sept. 11, 2001, terrorist attacks. Nor has it said whether Defense Secretary Leon E. Panetta or Gen. Martin E. Dempsey, the chairman of the Joint Chiefs of Staff, gave any thought to moving forces in the region as a precaution.

The unclassified version of the Benghazi report concluded that “there simply was not enough time given the speed of the attacks for armed U.S. military assets to have made a difference.” But the report did not address whether it would have been prudent to station quick-reaction forces in the region or whether the United States would have been in a position to quickly respond militarily had Ambassador Stevens been kidnapped and the crisis dragged on, as was initially feared.

The United States military’s best-trained team to extract diplomats under fire — Delta Force commandos — was half a world away, in Fort Bragg, N.C., and by the estimates of both military officials and some members of the investigation panel, it would have taken at least 18 hours, and perhaps considerably longer, for those commandos to get into the city. By that time, Mr. Stevens and three others were dead.

“What this report shows is that we need a fundamental rethink of the problem,” said one senior Pentagon official who has spent considerable time examining the issue of protecting American diplomats since the attack in September. “It’s not the military’s job to protect diplomats; it’s the host government’s. But in the absence of a real government, we never asked the question, ‘So how do we do this?’ ”

Gen. Carter F. Ham, the head of the Africa Command, indicated in a recent appearance at George Washington University that the question of whether the military should adjust its deployments to respond to diplomatic compounds under threat was being discussed.

But as the military budget declines, some ranking officers are wary about taking on new commitments, even ones that involve protecting Americans.

“It is not reasonable nor feasible to tether U.S. forces at the ready to respond to protect every high-risk post in the world,” Mike Mullen, the retired admiral and former chairman of the Joint Chiefs of Staff, who served as vice chairman of the independent review, said Wednesday.

David E. Sanger contributed reporting.

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State of the Art: Android Cameras From Nikon and Samsung Go Beyond Cellphones - Review

60 Seconds With Pogue: Android Cameras:
David Pogue reviews the Nikon Coolpix S800C and the Samsung Galaxy Camera.

“Android camera.” Wow, that has a weird ring, doesn’t it? You just don’t think of a camera as having an operating system. It’s like saying “Windows toaster” or “Unix jump rope.”

But yes, that’s what it has come to. Ever since cellphone cameras got good enough for everyday snapshots, camera sales have been dropping. For millions of people, the ability to share a fresh photo wirelessly — Facebook, Twitter, e-mail, text message — is so tempting, they’re willing to sacrifice a lot of real-camera goodness.

That’s an awfully big convenience/photo-quality swap. A real camera teems with compelling features that most phones lack: optical zoom, big sensor, image stabilization, removable memory cards, removable batteries and decent ergonomics. (A four-inch, featureless glass slab is not exactly optimally shaped for a hand-held photographic instrument.)

But the camera makers aren’t taking the cellphone invasion lying down. New models from Nikon and Samsung are obvious graduates of the “if you can’t beat ’em, join ’em” school. The Nikon Coolpix S800C ($300) and Samsung’s Galaxy Camera ($500 from AT&T, $550 from Verizon) are fascinating hybrids. They merge elements of the cellphone and the camera into something entirely new and — if these flawed 1.0 versions are any indication — very promising.

From the back, you could mistake both of these cameras for Android phones. The big black multitouch screen is filled with app icons. Yes, app icons. These cameras can run Angry Birds, Flipboard, Instapaper, Pandora, Firefox, The New York Times, GPS navigation programs and so on. You download and run them exactly the same way. (That’s right, a GPS function. “What’s the address, honey? I’ll plug it into my camera.”)

But the real reason you’d want an Android camera is wirelessness. Now you can take a real photo with a real camera — and post it or send it online instantly. You eliminate the whole “get home and transfer it to the computer” step.

And as long as your camera can get online, why stop there? These cameras also do a fine job of handling Web surfing, e-mail, YouTube videos, Facebook feeds and other online tasks. Well, as fine a job as a phone could do, anyway.

You can even make Skype video calls, although you won’t be able to see your conversation partner; the lens has to be pointing toward you.

Both cameras get online using Wi-Fi hot spots. The Samsung model can also get online over the cellular networks, just like a phone, so you can upload almost anywhere.

Of course, there’s a price for that luxury. Verizon charges at least $30 a month if you don’t have a Verizon plan, or $5 if you have a Verizon Share Everything plan. AT&T charges $50 a month or more for the camera alone, or $10 more if you already have a Mobile Share plan.

If you have a choice, Verizon is the way to go. Not only is $5 a month much more realistic than $10 a month, but Verizon’s 4G LTE network is far faster than AT&T’s 4G network. That’s an important consideration, since what you’ll mostly be doing with your 4G cellular camera is uploading big photo files. (Wow. Did I just write “4G cellular camera?”)

These cameras offer a second big attraction, though: freedom of photo software. The Android store overflows with photography apps. Mix and match. Take a shot with one app, crop, degrade and post it with Instagram.

Just beware that most of them are intended for cellphones, so they don’t recognize these actual cameras’ optical zoom controls. Some of the photo-editing apps can’t handle these cameras’ big 16-megapixel files, either. Unfortunately, you won’t really know until you pay the $1.50 or $4 to download these apps.

E-mail: pogue@nytimes.com

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Attackers in Pakistan Kill Anti-Polio Workers

Rizwan Tabassum/Agence France-Presse — Getty Images

A Pakistani mother mourned her daughter, who was killed on Tuesday in an attack on health workers participating in a drive to eradicate polio from Pakistan.

ISLAMABAD, Pakistan — Gunmen shot dead five female health workers who were immunizing children against polio on Tuesday, causing the Pakistani government to suspend vaccinations in two cities and dealing a fresh setback to an eradication campaign dogged by Taliban resistance in a country that is one of the disease’s last global strongholds.

“It is a blow, no doubt,” said Shahnaz Wazir Ali, an adviser on polio to Prime Minister Raja Pervez Ashraf. “Never before have female health workers been targeted like this in Pakistan. Clearly there will have to be more and better arrangements for security.”

No group claimed responsibility for the attacks, but most suspicion focused on the Pakistani Taliban, which has previously blocked polio vaccinators and complained that the United States is using the program as a cover for espionage.

The killings were a serious reversal for the multibillion-dollar global polio immunization effort, which over the past quarter century has reduced the number of endemic countries from 120 to just three: Pakistan, Afghanistan and Nigeria.

Nonetheless, United Nations officials insisted that the drive would be revived after a period for investigation and regrouping, as it had been after previous attacks on vaccinators here, in Afghanistan and elsewhere.

Pakistan has made solid gains against polio, with 56 new recorded cases of the diseases in 2012, compared with 192 at the same point last year, according to the government. Worldwide, cases of death and paralysis from polio have been reduced to less than 1,000 last year, from 350,000 worldwide in 1988.

But the campaign here has been deeply shaken by Taliban threats and intimidation, though several officials said Tuesday that they had never seen such a focused and deadly attack before.

Insurgents have long been suspicious of polio vaccinators, seeing them as potential spies. But that greatly intensified after the C.I.A. used a vaccination team headed by a local doctor, Shakil Afridi, to visit Osama bin Laden’s compound in Abbottabad, reportedly in an attempt to obtain DNA proof that the Bin Laden family was there before an American commando raid attacked it in May 2011.

In North Waziristan, one prominent warlord has banned polio vaccinations until the United States ceases drone strikes in the area.

Most new infections in Pakistan occur in the tribal belt and adjoining Khyber-Pakhtunkhwa Province — some of the most remote areas of the country, and also those with the strongest militant presence. People fleeing fighting in those areas have also spread the disease to Karachi, the country’s largest city, where the disease has been making a worrisome comeback in recent years.

After Tuesday’s attacks, witnesses described violence that was both disciplined and well coordinated. Five attacks occurred within an hour in different Karachi neighborhoods. In several cases, the killers traveled in pairs on motorcycle, opening fire on female health workers as they administered polio drops or moved between houses in crowded neighborhoods.

Of the five victims, three were teenagers, and some had been shot in the head, a senior government official said. Two male health workers were also wounded by gunfire; early reports incorrectly stated that one of them had died, the official said.

In Peshawar, the capital of Khyber-Pakhtunkhwa Province, gunmen opened fire on two sisters participating in the polio vaccination program, killing one of them. It was unclear whether that shooting was directly linked to the Karachi attacks.

In remote parts of the northwest, the Taliban threat is exacerbated by the government’s crumbling writ. In Bannu, on the edge of the tribal belt, one polio worker, Noor Khan, said he quit work on Tuesday once news of the attacks in Karachi and Peshawar filtered in. “We were told to stop immediately,” he said by phone.

Still, the Pakistani government has engaged considerable political and financial capital in fighting polio. President Asif Ali Zardari and his daughter Aseefa have been at the forefront of immunization drives. With the help of international donors, including the Bill and Melinda Gates Foundation, they have mounted a huge vaccination campaign aimed at up to 35 million children younger than 5, usually in three-day bursts that can involve 225,000 health workers.

The plan seeks to have every child in Pakistan immunized at least four times per year, although in the hardest-hit areas one child could be reached as many as 12 times in a year.

Declan Walsh reported from Islamabad, and Donald G. McNeil Jr. from New York. Salman Masood contributed reporting from Islamabad, and Zia ur-Rehman from Karachi, Pakistan.

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Attackers in Pakistan Kill Anti-Polio Workers

Rizwan Tabassum/Agence France-Presse — Getty Images

A Pakistani mother mourned her daughter, who was killed on Tuesday in an attack on health workers participating in a drive to eradicate polio from Pakistan.

ISLAMABAD, Pakistan — Gunmen shot dead five female health workers who were immunizing children against polio on Tuesday, causing the Pakistani government to suspend vaccinations in two cities and dealing a fresh setback to an eradication campaign dogged by Taliban resistance in a country that is one of the disease’s last global strongholds.

“It is a blow, no doubt,” said Shahnaz Wazir Ali, an adviser on polio to Prime Minister Raja Pervez Ashraf. “Never before have female health workers been targeted like this in Pakistan. Clearly there will have to be more and better arrangements for security.”

No group claimed responsibility for the attacks, but most suspicion focused on the Pakistani Taliban, which has previously blocked polio vaccinators and complained that the United States is using the program as a cover for espionage.

The killings were a serious reversal for the multibillion-dollar global polio immunization effort, which over the past quarter century has reduced the number of endemic countries from 120 to just three: Pakistan, Afghanistan and Nigeria.

Nonetheless, United Nations officials insisted that the drive would be revived after a period for investigation and regrouping, as it had been after previous attacks on vaccinators here, in Afghanistan and elsewhere.

Pakistan has made solid gains against polio, with 56 new recorded cases of the diseases in 2012, compared with 192 at the same point last year, according to the government. Worldwide, cases of death and paralysis from polio have been reduced to less than 1,000 last year, from 350,000 worldwide in 1988.

But the campaign here has been deeply shaken by Taliban threats and intimidation, though several officials said Tuesday that they had never seen such a focused and deadly attack before.

Insurgents have long been suspicious of polio vaccinators, seeing them as potential spies. But that greatly intensified after the C.I.A. used a vaccination team headed by a local doctor, Shakil Afridi, to visit Osama bin Laden’s compound in Abbottabad, reportedly in an attempt to obtain DNA proof that the Bin Laden family was there before an American commando raid attacked it in May 2011.

In North Waziristan, one prominent warlord has banned polio vaccinations until the United States ceases drone strikes in the area.

Most new infections in Pakistan occur in the tribal belt and adjoining Khyber-Pakhtunkhwa Province — some of the most remote areas of the country, and also those with the strongest militant presence. People fleeing fighting in those areas have also spread the disease to Karachi, the country’s largest city, where the disease has been making a worrisome comeback in recent years.

After Tuesday’s attacks, witnesses described violence that was both disciplined and well coordinated. Five attacks occurred within an hour in different Karachi neighborhoods. In several cases, the killers traveled in pairs on motorcycle, opening fire on female health workers as they administered polio drops or moved between houses in crowded neighborhoods.

Of the five victims, three were teenagers, and some had been shot in the head, a senior government official said. Two male health workers were also wounded by gunfire; early reports incorrectly stated that one of them had died, the official said.

In Peshawar, the capital of Khyber-Pakhtunkhwa Province, gunmen opened fire on two sisters participating in the polio vaccination program, killing one of them. It was unclear whether that shooting was directly linked to the Karachi attacks.

In remote parts of the northwest, the Taliban threat is exacerbated by the government’s crumbling writ. In Bannu, on the edge of the tribal belt, one polio worker, Noor Khan, said he quit work on Tuesday once news of the attacks in Karachi and Peshawar filtered in. “We were told to stop immediately,” he said by phone.

Still, the Pakistani government has engaged considerable political and financial capital in fighting polio. President Asif Ali Zardari and his daughter Aseefa have been at the forefront of immunization drives. With the help of international donors, including the Bill and Melinda Gates Foundation, they have mounted a huge vaccination campaign aimed at up to 35 million children younger than 5, usually in three-day bursts that can involve 225,000 health workers.

The plan seeks to have every child in Pakistan immunized at least four times per year, although in the hardest-hit areas one child could be reached as many as 12 times in a year.

Declan Walsh reported from Islamabad, and Donald G. McNeil Jr. from New York. Salman Masood contributed reporting from Islamabad, and Zia ur-Rehman from Karachi, Pakistan.

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Facebook Responds to Anger Over Proposed Instagram Changes

Jeremy Pinnix, an app developer in Spring Hill, Tenn., has been a regular user of the photo-sharing service Instagram since it was introduced in 2010, posting pictures of his family, local scenery and favorite moments.

But when Mr. Pinnix, 40, learned this week about changes to the company’s terms of service that would apparently allow his photos to be used as advertisements, he did not hesitate. He deleted his account and has not looked back.

“Many of the photos I take are of my wife and kids,” he said. “The idea that those could be used in ads without my consent is disconcerting.”

Concerns like those have been mounting on social networks this week as Instagram users reacted to the coming changes, part of a push by Facebook, which bought Instagram this year, to make money from the service.

On Tuesday evening, the complaints, which included angry Twitter posts and images on Instagram protesting the changes, prompted action. Kevin Systrom, a co-founder of Instagram, wrote a blog post saying the company would change the new terms of service to make clearer what would happen to users’ pictures.

“We’ve heard loud and clear that many users are confused and upset about what the changes mean,” he wrote. “I’m writing this today to let you know we’re listening and to commit to you that we will be doing more to answer your questions, fix any mistakes and eliminate the confusion.”

Eric Goldman, an associate professor at the Santa Clara University School of Law, said the latest skirmish between Facebook and its users was part of the sometimes uncomfortable dynamic between companies offering free online services and their eventual need to turn a profit from them.

“The interest of the site is never 100 percent aligned with the users, and the divergence inevitably leads to friction,” Mr. Goldman said. “It’s unavoidable.”

When Facebook announced the changes on Monday, it provided few details about how it would integrate advertisements and photos, other than to say that when the changes took effect on Jan. 16 they would not affect any photographs uploaded to the service before then.

That did not prevent unhappy users from threatening to take their portfolios of photographs to rival services, such as EyeEm, another social photo-sharing application. Many, including Mr. Pinnix, considered returning to Flickr, the former king of photo-sharing services, which is owned by Yahoo. In a stroke of lucky timing, Flickr had just released a new application for the iPhone that has drawn considerable praise from users.

The operators of services like Instaport.Me and Instabackup, which let people create copies of their Instagram photos, said they were seeing higher-than-average volume.

Linus Ekenstam, who helped found a service called Copygram that lets people back up their Instagram accounts and order physical prints of their favorite photos, said demand for the company’s free exporting tool had skyrocketed.

“It’s a thousand percent more activity than we’re used to,” he said. “Today is crazy.”

He estimated that 15 people per minute were using the exporting tool, and half a million photographs had been backed up.

Of course, that is a sliver of the expanding Instagram universe. The company has said that more than 100 million users have contributed more than five billion photographs to the service. But should that momentum slow, it could damage the plan for producing advertising revenue on the scale Facebook was counting on after spending $735 million in cash and stock to buy Instagram. The company also risks scaring off skittish brands and advertisers who would not want to anger Facebook or Instagram users who disagree with how their images are used.

The history of the social Web is full of cautionary tales of companies, including Digg and Myspace, whose users eventually got so fed up with how the companies meddled that they fled, leaving the companies in ruin.

In Tuesday’s blog post, Mr. Systrom sought to quell the mounting unrest and reassure users that the company would not be peddling photographs of children playing on the beach or friends partying in nightclubs to the highest bidder.

“To be clear, it is not our intention to sell your photos,” he said.

He said that the company also did not intend to put its members in advertisements.

“We do not have plans for anything like this, and because of that we’re going to remove the language that raised the question,” he said. “Our main goal is to avoid things likes advertising banners you see in other apps that would hurt the Instagram user experience.”

He did concede that the company might do something like promote a brand like Topshop and show Facebook visitors which of their friends already follow Topshop, blurbs that could include their user name and avatar.

Mr. Systrom also reassured Instagram users that they still “own their content and Instagram does not claim any ownership rights over your photos.”

“Nothing about this has changed,” he said.

Of course, Mark Zuckerberg, Facebook’s chief executive, said nearly the same thing in April: “We need to be mindful about keeping and building on Instagram’s strengths and features rather than just trying to integrate everything into Facebook. That’s why we’re committed to building and growing Instagram independently.” Since then, the company has cut off Instagram’s easy integration with Facebook’s rival Twitter and bound the photo service more tightly into Facebook.

Rebecca Lieb, an analyst with the Altimeter Group, said worries about Facebook changing for the worse had become common almost any time Facebook altered its site, whether in the design or in its privacy policies. It underscores the importance and omnipotence of the service in its users’ lives as much as it signals a distrust of Facebook.

“There’s always a reaction when Facebook does anything because the user base is so unbelievably large,” Ms. Lieb said. “But while what its users say can be very loud and very viral, what they do can be two very disparate things.”

“There are always Facebook users who say ‘This is the last straw,’ ” she said. But in the end, she said, “There’s not a lot of portability. Where would you go?”

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Aleppo Residents, Battered by War, Struggle to Survive

The Fight for Aleppo:
In Syria’s largest city, a sustained and pitched battle between rebels and the Syrian army has left the city in ruins.

ALEPPO, Syria — Inside the classrooms where they once studied, the boys darted like a pack. Their banging and clanking could be heard for a city block.

The playground outside had been hit by a Syrian Air Force airstrike, which fractured the school’s walls. Now the children were smashing the furniture, prying off wooden desktops and bench seats, rushing away with what they could.

The Isam al-Nadri School for Boys was being dismantled for the firewood it contained. One sixth grader, Ahmed, clutching the kindling he had made by ransacking a room, offered an irreducible argument for looting his own school. “I want heat,” he said.

Winter is descending on Aleppo, Syria’s largest city and the bloodied stage for an urban battle, now running into its sixth month, between rebels and the military of President Bashar al-Assad.

As temperatures drop and the weakened government’s artillery thunders on, Aleppo is administered by no one and slipping into disaster. Front-line neighborhoods are rubble. Most of the city’s districts have had no electricity and little water for weeks. All of Aleppo suffers from shortages of oil, food, medicine, doctors and gas.

Diseases are spreading. Parks and courtyards are being defoliated for firewood, turning streets once lined with trees into avenues bordered by stumps. Months’ worth of trash is piled high, often beside bread lines where hundreds of people wait for a meager stack of loaves.

One of the Middle East’s beautiful and historic cities is being forced by scarcity and violence into a bitter new shape. Overlaying it all is a mix of fatigue and distrust, the sentiments of a population divided in multiple ways.

Aleppo’s citizens scavenge and seethe. And along with the sectarian passions of civil war, some residents express yearnings for starkly opposite visions of the future: either for a return of the relative stability of the Assad government or for the promises of Islamic rule.

Others see a grim hope, calling the tearing apart of their society a period that one day will be remembered as this ancient city’s ultimate test.

“We left high salaries, we left our jobs, we left our rank in society,” said Dr. Ammar Diar Bakerly, who directs medical care in the city’s rebel-held east. “We left everything to get our dignity. This is the price we have to pay, and it is a cheap price to get our freedom from the tyrant.”

Not everyone shares these revolutionary views. “We come every morning to the clinic asking for medicine, but they don’t offer any,” said Johair Iman Mustafa, a house painter and taxi driver with no work, who spotted a visitor and approached in a rage. “We go to the bakery for hours, but there is no bread and they kick us.”

“Before the revolution,” said Mr. Mustafa, a Sunni who had been no supporter of Mr. Assad’s Alawite-led government, “it was much better.”

Supplies Dwindle, Prices Rise

For most of Syria’s 21-month uprising, Aleppo, a commercial and government center built around its historic Old City, was spared the battles engulfing the country.

That changed in July when the Free Syrian Army, or F.S.A., as many rebels call themselves, entered Aleppo and opened urban fronts.

The government rushed in much-needed army units from elsewhere, turning to heavier weapons in a bid to retain control of a city that, if lost, would change Mr. Assad’s self-assured narrative. The war’s largest battle yet was joined.

Five months on, the government’s gambit has failed. Even with air support and artillery batteries firing relentlessly, Mr. Assad’s military has yielded ground. In roughly half the city, rebels move about openly.

From the outset, Aleppo’s population, its loyalties split, was stuck between forces. Disorganized rebel groups had started a battle they had little prospect to win swiftly. The army fought back in part with a collective-punishment model. Foreign fighters began to trickle in, stalking the front and talking of jihad.

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Facebook Responds to Anger Over Proposed Instagram Changes

Jeremy Pinnix, a 40-year-old app developer in Spring Hill, Tenn., has been a regular user of the photo-sharing service Instagram since it was introduced in 2010, posting pictures of his family, local scenery and favorite moments.

But when he learned this week about changes to the company’s terms of service that would apparently allow his photos to be used as advertisements, he didn’t hesitate. Mr. Pinnix deleted his account and has not looked back.

“Many of the photos I take are of my wife and kids,” he said. “The idea that those could be used in ads without my consent is disconcerting.”

The anxiety has been a mounting theme on social networks this week as Instagram users react to the coming changes, part of a push by Facebook, which now owns Instagram, to make money from the service.

On Tuesday evening, the complaints, which included angry tweets and images on Instagram protesting the changes, prompted some action. Kevin Systrom, a co-founder of Instagram, wrote a blog post saying the company would change the new terms of service to make clearer what would happen to users’ pictures.

“We’ve heard loud and clear that many users are confused and upset about what the changes mean,” he wrote. “I’m writing this today to let you know we’re listening and to commit to you that we will be doing more to answer your questions, fix any mistakes, and eliminate the confusion.”

Eric Goldman, an associate professor at the Santa Clara University School of Law, said the latest skirmish between Facebook and its users was part of the sometimes uncomfortable dynamic between companies offering free online services and their eventual need to turn a profit from them.

“The interest of the site is never 100 percent aligned with the users, and the divergence inevitably leads to friction,” said Mr. Goldman. “It’s unavoidable.”

When it announced the changes on Monday, Facebook provided few details on how it would integrate ads and photos, other than to say that when the changes went into effect on Jan. 16, they would not affect any photographs uploaded to the service before then.

That did not prevent unhappy users from threatening to take their portfolios of photographs over to rival services, such as EyeEm, another social photo-sharing application. Many, including Mr. Pinnix, eyed a return to Flickr, the former king of photo-sharing services, which is owned by Yahoo. In a stroke of lucky timing, Flickr had just released a new application for the iPhone that has drawn considerable praise from users.

The operators of services like Instaport.me and Instabackup, which let people create copies of their Instagram photos, said they were seeing higher than average volume.

Linus Ekenstam, who helped found a service called Copygram that lets people back up their Instagram accounts and order physical prints of their favorite shots, said demand for the company’s free exporting tool had skyrocketed.

“It’s a thousand percent more activity than we’re used to,” he said. “Today is crazy.”

He estimated that roughly 15 people per minute were using the exporting tool, and around half a million photographs had been backed up.

Of course, that’s a sliver of the still-expanding Instagram universe. The company has said more than 100 million users have contributed upward of five billion photographs to the service to date. But should that momentum slow, it could very well damage the plan for producing advertising revenue on the scale Facebook was counting on after spending $735 million in cash and stock to buy Instagram. The company also risks scaring off skittish brands and advertisers that would not want to anger Facebook or Instagram users who disagree with how their images are used.

The history of the social Web is full of cautionary tales of companies, from Digg to Myspace, whose users eventually got so fed up with how the companies meddled that they fled to greener digital pastures, leaving the companies in ruin.

In Tuesday’s blog post, Mr. Systrom sought to quell the mounting unrest and reassure users that the company would not be peddling photographs of kids playing on the beach or friends partying in nightclubs to the highest bidder. “To be clear, it is not our intention to sell your photos,” he said.

He said that the company also did not intend to put its members in advertisements. “We do not have plans for anything like this and because of that we’re going to remove the language that raised the question,” he said. “Our main goal is to avoid things likes advertising banners you see in other apps that would hurt the Instagram user experience.”

He did concede that the company might do something like promote a brand like Topshop and show Facebook visitors which of their friends already follow Topshop, tiny blurbs that could include their username and avatar.

Mr. Systrom also insisted that Instagram users still “own their content” and that “Instagram does not claim any ownership rights over your photos,” adding, “Nothing about this has changed.”

Of course, Mark Zuckerberg, Facebook’s chief executive, said nearly the same thing in April: “We need to be mindful about keeping and building on Instagram’s strengths and features rather than just trying to integrate everything into Facebook. That’s why we’re committed to building and growing Instagram independently.” Since then, the company has cut off Facebook’s easy integration with rival Twitter and bound the photo service more tightly into Facebook.

Rebecca Lieb, an analyst with the Altimeter Group, said worries about Facebook changing for the worse has become par for the course almost any time Facebook alters its site, whether in the design or in its privacy policies. It underscores the importance and omnipotence of the service in its users lives as much as it signals a distrust of Facebook itself.

“There’s always a reaction when Facebook does anything because the user base is so unbelievably large,” said Ms. Lieb. “But while what its users say can be very loud and very viral, what they do can be two very disparate things.”

“There are always Facebook users who say ‘This is the last straw,’ ” she said. But in the end, she said, “there’s not a lot of portability. Where would you go?”

Read More..