Surgery Returns to NYU Langone Medical Center

Chang W. Lee/The New York Times

Senator Charles E. Schumer spoke at a news conference Thursday about the reopening of NYU Langone Medical Center.

NYU Langone Medical Center opened its doors to surgical patients on Thursday, almost two months after Hurricane Sandy overflowed the banks of the East River and forced the evacuation of hundreds of patients.

While the medical center had been treating many outpatients, it had farmed out surgery to other hospitals, which created scheduling problems that forced many patients to have their operations on nights and weekends, when staffing is traditionally low. Some patients and doctors had to postpone not just elective but also necessary operations for lack of space at other hospitals.

The medical center’s Tisch Hospital, its major hospital for inpatient services, between 30th and 34th Streets on First Avenue, had been closed since the hurricane knocked out power and forced the evacuation of more than 300 patients, some on sleds brought down darkened flights of stairs.

“I think it’s a little bit of a miracle on 34th Street that this happened so quickly,” Senator Charles E. Schumer of New York said Thursday.

Mr. Schumer credited the medical center’s leadership and esprit de corps, and also a tour of the damaged hospital on Nov. 9 by the administrator of the Federal Emergency Management Agency, W. Craig Fugate, whom he and others escorted through watery basement hallways.

“Every time I talk to Fugate there are a lot of questions, but one is, ‘How are you doing at NYU?’ ” the senator said.

The reopening of Tisch to surgery patients and associated services, like intensive care, some types of radiology and recovery room anesthesia, was part of a phased restoration that will continue. Besides providing an essential service, surgery is among the more lucrative of hospital services.

The hospital’s emergency department is expected to delay its reopening for about 11 months, in part to accommodate an expansion in capacity to 65,000 patient visits a year, from 43,000, said Dr. Andrew W. Brotman, its senior vice president and vice dean for clinical affairs and strategy.

In the meantime, NYU Langone is setting up an urgent care center with 31 bays and an observation unit, which will be able to treat some emergency patients. It will initially not accept ambulances, but might be able to later, Dr. Brotman said. Nearby Bellevue Hospital Center, which was also evacuated, opened its emergency department to noncritical injuries on Monday.

Labor and delivery, the cancer floor, epilepsy treatment and pediatrics and neurology beyond surgery are expected to open in mid-January, Langone officials said. While some radiology equipment, which was in the basement, has been restored, other equipment — including a Gamma Knife, a device using radiation to treat brain tumors — is not back.

The flooded basement is still being worked on, and electrical gear has temporarily been moved upstairs. Mr. Schumer, a Democrat, said that a $60 billion bill to pay for hurricane losses and recovery in New York and New Jersey was nearing a vote, and that he was optimistic it would pass in the Senate with bipartisan support. But the measure’s fate in the Republican-controlled House is far less certain.

The bill includes $1.2 billion for damage and lost revenue at NYU Langone, including some money from the National Institutes of Health to restore research projects. It would also cover Long Beach Medical Center in Nassau County, Bellevue, Coney Island Hospital and the Veterans Affairs hospital in Manhattan.

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Bolivia Makes Inroads Toward Reducing Coca Production

Meri Pintas, 30, center, harvests coca leaves with her children in the Yungas region of Bolivia. Bolivia, the world’s third-largest cocaine producer, has advanced its own unorthodox approach toward controlling the growing of coca, which veers markedly from the wider war on drugs and includes high-tech monitoring of thousands of legal coca patches intended to produce coca leaf for traditional uses.

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Libraries Try to Update the Bookstore Model

Tyler Bissmeyer for The New York Times

Vicki Culler shops for discounted books at The Friends of the Public Library in Cincinnati.

At the bustling public library in Arlington Heights, Ill., requests by three patrons to place any title on hold prompt a savvy computer tracking system to order an additional copy of the coveted item. That policy was intended to eliminate the frustration of long waits to check out best sellers and other popular books. But it has had some unintended consequences, too: the library’s shelves are now stocked with 36 copies of “Fifty Shades of Grey.”

Of course, librarians acknowledge that when patrons’ passion for the sexy series lacking in literary merit cools in a year or two, the majority of volumes in the “Fifty Shades” trilogy will probably be plucked from the shelves and sold at the Friends of the Library’s used-book sales, alongside other poorly circulated, donated and out-of-date materials.

“A library has limited shelf space, so you almost have to think of it as a store, and stock it with the things that people want,” said Jason Kuhl, the executive director of the Arlington Heights Memorial Library. Renovations going on there now will turn a swath of the library’s first floor into an area resembling a bookshop, where patrons will be pampered with cozy seating, a vending cafe and, above all, an abundance of best sellers.

As librarians across the nation struggle with the task of redefining their roles and responsibilities in a digital age, many public libraries are seeing an opportunity to fill the void created by the loss of traditional bookstores. Indeed, today’s libraries are increasingly adapting their collections and services based on the demands of library patrons, whom they now call customers. Today’s libraries are reinventing themselves as vibrant town squares, showcasing the latest best sellers, lending Kindles loaded with e-books, and offering grassroots technology training centers. Faced with the need to compete for shrinking municipal finances, libraries are determined to prove they can respond as quickly to the needs of the taxpayers as the police and fire department can.

“I think public libraries used to seem intimidating to many people, but today, they are becoming much more user-friendly, and are no longer these big, impersonal mausoleums,” said Jeannette Woodward, a former librarian and author of “Creating the Customer-Driven Library: Building on the Bookstore Model.”

“Public libraries tread a fine line,” Ms. Woodward said. “They want to make people happy, and get them in the habit of coming into the library for popular best sellers, even if some of it might be considered junk. But libraries also understand the need for providing good information, which often can only be found at the library.”

Cheryl Hurley, the president of the Library of America, a nonprofit publisher in New York “dedicated to preserving America’s best and most significant writing,” said the trend of libraries catering to the public’s demand for best sellers is not surprising, especially given the ravages of the recession on public budgets.

Still, Ms. Hurley remains confident that libraries will never relinquish their responsibility to also provide patrons with the opportunity to discover literary works of merit, be it the classics, or more recent fiction from novelists like Philip Roth, whose work is both critically acclaimed and immensely popular.

“The political ramifications for libraries today can result in driving the collection more and more from what the people want, rather than libraries shaping the tastes of the readers,” Ms. Hurley said. “But one of the joys of visiting the public library is the serendipity of discovering another book, even though you were actually looking for that best seller that you thought you wanted.”

“It’s all about balancing the library’s mission and its marketing, and that is always a tricky dance,” she added.

While print books, both fiction and nonfiction, still make up the bulk of most library collections – e-books remain limited to less than 2 percent of many collections in part because some publishers limit their availability at libraries — building renovation plans these days rarely include expanding shelf space for print products. Instead, many libraries are culling their collections and adapting floor plans to accommodate technology training programs, as well as mini-conference rooms that offer private, quiet spaces frequently requested by self-employed consultants meeting with clients, as well as teenagers needing space to huddle over group projects.

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Home Tech: Devices to Monitor Physical Activity and Food Intake

STEP LIVELY Fitbit One pedometer clips onto your belt or pocket to record activity.

WHEN I received the results of a routine cholesterol test this summer, I was certain there had been some kind of mistake. I’m young, unstressed and healthy, or so I imagined. I work out, too, and most impartial observers — and some partial ones — would describe me as lean. Plus, I eat a nutritious diet, I swear. So why did my LDL levels surpass my I.Q. — or, for that matter, Einstein’s?

The facts were stark: My genes predisposed me to metabolic syndrome, my doctor told me. Like my forebears, I was on a fast path to heart disease and diabetes. My doctor ordered me to reduce my carbs and come up with a more stringent exercise plan. I’ve rarely monitored what I eat and how much exercise I get. I had no idea how to go about the logistics of it. How would I count my carbs? How would I track my fitness routine?

Of course, there are apps for that. I set out to scour the market for devices and programs to help me and any family member who wished to join me in my low-carb adventure improve our health. I found two kinds of technologies: fitness trackers to monitor physical activity, and P.C. and smartphone apps to track diet. I spent weeks testing several of them. And while I found a few to be quite helpful, they were all just short of fantastic.

I tried four high-end fitness gadgets: Nike’s FuelBand ($149), the Fitbit One ($99.95), Jawbone’s Up ($129.99) and the BodyMedia FIT wireless armband ($149). I also threw in a plain-Jane pedometer, the Omron HJ-720ITC, which I found for $31 at many stores online.

All of these devices work in a similar way. You attach them to your person (the FuelBand and Up fit around your wrist, the FIT goes around your upper arm, and the Fitbit and Omron pedometer can be placed in a pocket or clipped to your belt). Then, as you move, the devices measure your activity.

Unfortunately each device had major drawbacks. Even though I had gotten the proper size, I found that the Up and the FuelBand did not fit well around my wrist. They tapped against my desk while I typed, and they slid about uncomfortably when I washed the dishes. (They are both water-resistant.) BodyMedia’s FIT, meanwhile, is about the size of a man’s large wristwatch. Positioned directly against the skin around the upper arm, it is ungainly — I found it distracting when I was in a short-sleeve workout shirt, and strange-looking under a nice button-down shirt.

The pedometer and the Fitbit were easier to handle; I hardly noticed them crammed with my keys and phone in my pocket. On the other hand, because they are not wearable, I often forgot them on my bedside table, where they did no good.

Still, among these vast offerings, I found the Fitbit and the cheap Omron to be best. The Fitbit is an unobtrusive slab of plastic about the size of a U.S.B. thumb drive. Its software — which is available for Macs and Windows P.C.’s, as well as iOS and Android devices — is simple to learn and offers plenty of graphs and stats to track your progress. The most useful is a graph of your activity over the course of the day: you can see how many calories you burned while at work and alter your behavior accordingly. Maybe go for a brief walk after lunch?

(I was a big fan of Jawbone’s Up software, too, but I ultimately found it too limited: It works only on Apple’s iOS devices; the company has not yet made versions for P.C.’s or Android devices.)

The best thing about the Fitbit is its wireless syncing capability. It comes with a tiny receiver that plugs into your computer’s U.S.B. port; whenever your Fitbit is near your machine, it sends its data over the air, no physical docking required. It also syncs directly to your phone over Bluetooth. (You do have to plug your Fitbit in to charge it, but only rarely — you can go more than a week between charges.)

The Omron, by comparison, does not do wireless syncing, and its optional P.C. software is pretty basic. But paucity is its beauty. No setup is required. Just turn it on and leave it in your pocket. At the end of the day, peek at its screen — in large, readable type, it shows a single stat: how many steps you have walked that day. The Omron does not promise the world, but it delivers enough information to keep you healthy.

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New York’s Mental Health System Thrashed by Services Lost to Storm

Marcus Yam for The New York Times

Dr. Richard Rosenthal, physician in chief of behavioral services for Continuum hospitals, at St. Luke’s-Roosevelt Hospital Center.

When a young woman in the grip of paranoid delusions threatened a neighbor with a meat cleaver one Saturday last month, the police took her by ambulance to the nearest psychiatric emergency room. Or rather, they took her to Beth Israel Medical Center, the only comprehensive psychiatric E.R. functioning in Lower Manhattan since Hurricane Sandy shrank and strained New York’s mental health resources.

The case was one of 9,548 “emotionally disturbed person” calls that the Police Department answered in November, and one of the 2,848 that resulted in transportation to a hospital, a small increase over a year earlier.

But the woman was discharged within hours, to the shock of the mental health professionals who had called the police. It took four more days, and strong protests from her psychiatrist and caseworkers, to get her admitted for two weeks of inpatient treatment, said Tony Lee, who works for Community Access, a nonprofit agency that provides supportive housing to people with mental illness, managing the Lower East Side apartment building where she lives.

Psychiatric hospital admission is always a judgment call. But in the city, according to hospital records and interviews with psychiatrists and veteran advocates of community care, the odds of securing mental health treatment in a crisis have worsened significantly since the hurricane. The storm’s surge knocked out several of the city’s largest psychiatric hospitals, disrupted outpatient services and flooded scores of coastal nursing homes and “adult homes” where many mentally ill people had found housing of last resort.

One of the most affected hospitals, Beth Israel, recorded a 69 percent spike in psychiatric emergency room cases last month, with its inpatient slots overflowing. Instead of admitting more than one out of three such cases, as it did in November 2011, it admitted only one out of four of the 691 emergency arrivals this November, records show. Capacity was so overtaxed that ambulances had to be diverted to other hospitals 15 times in the month, almost double the rate last year, in periods typically lasting for eight hours, officials said.

Dr. Richard Rosenthal, physician in chief of behavioral services for Continuum Health Partners, Beth Israel’s parent organization, said he was proud of how much Continuum’s hospitals had done to handle psychiatric overflow since storm damage shuttered Bellevue Hospital Center, the city’s flagship public hospital; NYU Langone Medical Center; and the Veterans Affairs Hospital. But these days, he said, as he walks on Amsterdam Avenue between Continuum’s Roosevelt hospital on West 59th Street and its St. Luke’s hospital on West 114th Street, he notices more mentally ill people in the streets than he has seen in years.

“When you have the most vulnerable folks, all you need is one chink in the system and you lose them,” Dr. Rosenthal said. “Whether they lost their housing, or the outpatient services they usually go to were closed and they were lost to follow-up, they have become disconnected, with predictable results.”

Similar patterns are playing out in Brooklyn, where Maimonides Medical Center has been overwhelmed with mental health emergencies from the Coney Island vicinity since Coney Island Hospital, one of the city’s largest acute care psychiatric hospitals, suspended operations, hospital officials said.

“Triage has reached a different level: You have to get sicker to get in,” said Dr. Andrew Kolodny, the chairman of psychiatry at Maimonides, citing a 56 percent increase in psychiatric emergency room visits there from Oct. 26 to Dec. 7, compared with the same period last year, and a 24 percent rise in admissions. The increase in admissions was possible only with emergency permission from the state to exceed licensed limits.

“Not only is there decreased capacity, because Bellevue and Coney Island are off line,” Dr. Kolodny added, “but there’s increased demand because the storm or the loss of their residence has been a stressor for mental illness.”

The storm battered a mental health system that still relies heavily on private nursing homes and substandard adult homes to house people with mental illness. Such institutions have a sordid history of neglect and exploitation, and the courts have repeatedly found that their overuse by the state isolated thousands of people in violation of the Americans With Disabilities Act.

Plans are under way to increase supportive housing — dwellings where mentally ill people can live relatively independently, with support services. But even before Hurricane Sandy, the expansion fell far short of demand.

The storm underscored the fragility of the system. Many disabled evacuees who were sent first to makeshift school shelters lost access to the psychiatric medications that kept their symptoms at bay, Dr. Kolodny said. Even those lucky enough to have the drugs they need are at greater risk of relapse as they experience crowded living conditions. “If they’re now sleeping in a gym with 100 people, that can tip them over the edge and start making them really paranoid,” he said.

On Staten Island, where the chief of psychiatry at Richmond University Medical Center says psychiatric resources have been stretched to the limit, clergy members report that mentally ill people transferred to a large adult home in New Brighton from one that was washed away in Far Rockaway, Queens, are now showing up at church rectories, begging for socks and underwear.

“It’s heartbreaking, because they just found us by chance,” said Margaret Moschetto, a missionary at the Church of Assumption-St. Paul in New Brighton. “They were just walking around the neighborhood. They really didn’t know where they were.”

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Egypt’s Hamdeen Sabahi vs. Islamists and Free Markets

CAIRO — Hamdeen Sabahi was the most popular leader in the fight against Egypt’s new Islamist-backed constitution. Now he is preparing for his next battle: against Islamist leaders’ plans for Western-style free-market reforms.

Do not listen to your allies in the Muslim Brotherhood, Mr. Sabahi said he warned President Mohamed Morsi, of the Brotherhood’s political arm, in a private meeting a few weeks ago. “Because the Brotherhood’s economic and social thought is the same as Mubarak’s: the law of the markets,” Mr. Sabahi said he had told Mr. Morsi, referring to Hosni Mubarak, the former president. “You will just make the poor poorer, and they will be angry with you just as they were with Mubarak.”

Mr. Sabahi, 58, a leftist in the style of another former president, Gamal Abdel Nasser, frightens most economists. He is an outspoken opponent of free-market economic moves in general as well as of a pending $4.5 billion loan from the International Monetary Fund that economists say is urgently needed to avert a catastrophic currency collapse.

But to the dismay of some Western diplomats, Mr. Sabahi is emerging as an increasingly salient voice in Egyptian politics, in part because of the bruising race to ratify the Islamist-backed charter. Both sides now expect the anti-Islamist opposition to reap big gains in the coming parliamentary vote, set to be held in two months against the backdrop of a simultaneous debate over the I.M.F. loan.

Among Egypt’s opposition figures, Mr. Sabahi has the biggest base of support in the streets. After campaigning as a dark horse in the spring’s presidential election, he missed the runoff by fewer than a million votes, finishing the first round almost neck and neck with Mr. Morsi.

Economic overhaul now poses a critical test of Egypt’s fragile democracy. Without enough trust in government, the changes to the systems of taxes or subsidies needed to reduce the deficit could easily stir new unrest in the streets, just as such moves have in the past. But if Mr. Morsi expects his opponents to hold their fire just because economists say the need is dire, Mr. Sabahi said, the president should think again.

“Why support him, for what?” Mr. Sabahi said in an interview in the borrowed offices of an Egyptian film director, decorated with pictures of President Nasser but also of Che Guevara. “Is he a democratic ruler, is he a revolutionary? Is he a model of a president, so I want him to succeed?”

Mr. Sabahi, 58, known for writing poetry and quoting Arab literature and for his blow-dried hair, was one of the few non-Islamist politicians willing to endure imprisonment alongside the members of the Muslim Brotherhood in the struggle against Egypt’s autocracy, giving him a unique credibility among more secular leaders.

But after missing the presidential runoff this year, Mr. Sabahi declined to endorse either Mr. Morsi or his opponent, Ahmed Shafik, a former Mubarak prime minister. It was a choice between “tyranny in the name of the state” and “tyranny in the name of religion,” Mr. Sabahi said at the time in a television interview.

Mr. Sabahi argued in the interview that although Mr. Morsi won election democratically, he has failed to govern as a democrat. “He is kicking away the ladder he climbed,” Mr. Sabahi said, arguing that Mr. Morsi’s decree setting his authority above the courts, if only for a month, ended his credibility as a democrat.

The resulting discord between the Islamists and their opponents has postponed the I.M.F. loan and helped bring Egypt closer than ever to economic collapse. State media on Tuesday described a “dollarization frenzy” gripping the country as people raced to sell Egyptian pounds. The currency is at its lowest level in the past eight years.

Since Mr. Mubarak’s ouster, Egypt’s hard currency reserves have fallen to $15 billion from $43 billion as it has struggled to prop up the pound, and economists say the government now urgently needs a cash infusion of about $14 billion in order to stay afloat. The $4.5 billion I.M.F. loan is expected to act as a seal of approval for others, after the I.M.F. concludes Egypt is at least on a path to greater balance.

If that loan does not come through soon, “the risk is a disaster,” said Heba Handoussa of the Economic Research Forum. “We can’t afford to wait.”

There are other more Western-friendly faces of the opposition, like Mohamed ElBaradei, the former United Nations diplomat, and Amr Moussa, the former foreign minister. But neither has Mr. Sabahi’s following at the grass roots, and he speaks for a segment of the Egyptian public deeply suspicious of free markets and, especially, the I.M.F. A popular singer, El Manawahly, has even recorded a song and music video opposing the loan. “Oh monetary fund / Show me how to industrialize, plant and kneel.”

Mayy El Sheikh contributed reporting.

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The 30-Minute Interview: The 30-Minute Interview With Nick J. Romito

Mr. Romito, 30, is the founder and chief executive of View the Space, a new real estate technology business that creates online video tours, primarily of office space, and provides data-tracking services to commercial real estate companies, among them SL Green Realty, Vornado Realty Trust and Silverstein Properties.

Before starting the business last year, Mr. Romito worked as a commercial broker and tenant and landlord representative.

Q. How has business been so far?

A. Business is good. We launched the beta version of the Web site about a year ago, and this April was when we took the beta logo off and decided that we were at a point where we could start charging for the product. We’ve grown extraordinarily fast, but that’s a good thing.

Q. Are you profitable yet?

A. We had profitability in May, then like most start-up companies we scaled up. We hit profitability again in October.

I put in all my life savings, which was roughly $50,000 to $100,000, with my wife’s help. As we were going into the market and trying to get people to believe in our dream it gets rough. But we actually got really lucky and found some great partners — a syndicate of hedge fund professionals who knew commercial real estate and invest in start-ups — who liked our idea. We raised about $650,000.

Q. Let’s talk about the services you provide.

A. As you probably know, commercial real estate is an antiquated business, more or less reluctant to embrace technology. We thought we were a crazy enough bunch to change that. We decided we could improve the process by taking it online from start to finish. So for us that means video. We’ve created a style of shooting video for office space that’s really never existed. Ours is the closest thing to actually being there, where you fly through the space and you actually feel like you’re in it. You just can’t touch the walls.

On the landlord side, we allow you to track how a person is interacting with the tour. So you get to see 1) the prospect who’s looking at it; 2) how many times they’ve watched it; and 3) how engaged are they with it. You’ll actually be able to tell whether a specific firm has taken the tour 10 times — that’s a very, very high level of engagement — and they’re a serious prospect so I’m going to follow up with them.

Q. What kind of analytics software accomplishes this?

A. We had to build a pretty serious back end of data that’s taken us awhile. You’ve got I.P. addresses all over the place, so we had to build a library of those, which we can identify for the most part which companies are viewing your space.

Q. And how do the clients see this information?

A. They can see it in real time whenever they want — from their dashboard. And if they’re not online we’ll e-mail it to them.

Q. Has this service helped to sell property faster?

A. Yeah. We’re at about 1.5 million square feet leased on View the Space since December 2011.

Q. How many clients do you have right now?

A. Over 50. We’ve got most of the larger commercial real estate institutions both on the public and private side.

It’s funny, when we first started, our thesis was that we would get all of the smaller landlords on board first because we have more access to them. But because we worked so tightly with the brokerage community to build this, SL Green caught wind of what we were doing very quickly and they ended up being our first big client.

So it’s kind of like a domino effect where you get the SL Greens of the world soon enough the Silversteins and all the other players want to find out what you’re doing.

Q. Where do you hope to see your business in, say, the next five to 10 years?

A. We think that technology is here to stay in commercial real estate. And we see us growing, hopefully, in every major market. We’re actively in 10 markets right now.

New York right now is probably 60 percent of the activity that we have.

Q. You don’t have a technology background, do you?

A. I don’t. During the first year of development I was still a broker. I tried to outsource the first part of this to India, which was a very painful process. You’ve got to start your day at 4 a.m., because of the time difference, and the language barrier was very difficult. Not only was I trying to learn Hindi, but also the language of technology.

Q. So when you’re not learning new languages, what do you do for fun?

A. I surf. That was more or less my life growing up on the Jersey Shore. In Toms River.

Q. Were you or your family affected by Hurricane Sandy?

A. My mom lost her house. She got a couple of feet of water, and now they’ll have to demo the house.

But as long as everyone is O.K., it’s just stuff. I think everybody down there is so resilient, and this is like when everybody really comes together.

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Is the Cure for Cancer Inside You?

Claudia Steinman saw her husband’s BlackBerry blinking in the dark. It had gone untouched for several days, in a bowl beside his keys, the last thing on anybody’s mind. But about an hour before sunrise, she got up to get a glass of water and, while padding toward the kitchen, found an e-mail time-stamped early that morning — “Sent: Monday, Oct. 3, 2011, 5:23 a.m. Subject: Nobel Prize. Message: Dear Dr. Steinman, I have good news for you. The Nobel Assembly has today decided to award you the Nobel Prize in Physiology or Medicine for 2011.” Before she finished reading, Claudia was hollering at her daughter to wake up. “Dad got the Nobel!” she cried. Alexis, still half-asleep, told her she was crazy. Her father had been dead for three days.

Steinman: Photograph by Ingbert Grüttner/Rockefeller University. Dendritic cell: Rockefeller University Press.

Ralph Steinman in 1983. He would become his most compelling experiment.

Dendritic cell: Rockefeller University Press.

The cell Steinman hoped would save his life looks something like a sea anemone or a ruffled shrimp dumpling.

The Nobel Foundation doesn’t allow posthumous awards, so when news of Ralph Steinman’s death reached Stockholm a few hours later, a minor intrigue ensued over whether the committee would have to rescind the prize. It would not, in fact; but while newspapers stressed the medal mishap (“Nobel jury left red-faced by death of laureate”), they spent less time on the strange story behind the gaffe. That Steinman’s eligibility was even in question, that he’d been dead for just three days instead of, say, three years, was itself a minor miracle.

In the spring of 2007, Steinman, a 64-year-old senior physician and research immunologist at Rockefeller University in New York, had come home from a ski trip with a bad case of diarrhea, and a few days later he showed up for work with yellow eyes and yellow skin — symptoms of a cancerous mass the size of a kiwi that was growing on the head of his pancreas. Soon he learned that the disease had made its way into nearby lymph nodes. Among patients with his condition, 80 percent are dead within the first year; another 90 percent die the year after that. When he told his children about the tumor over Skype, he said, “Don’t Google it.”

But for a man who had spent his life in the laboratory, who brought copies of The New England Journal of Medicine on hiking trips to Vermont and always made sure that family vacations overlapped with scientific symposia, there was only one way to react to such an awful diagnosis — as a scientist. The outlook for pancreatic cancer is so poor, and the established treatments so useless, that any patient who has the disease might as well shoot the moon with new, untested therapies. For Steinman, the prognosis offered the opportunity to run one last experiment.

In the long struggle that was to come, Steinman would try anything and everything that might extend his life, but he placed his greatest hope in a field he helped create, one based on discoveries for which he would earn his Nobel Prize. He hoped to reprogram his immune cells to defeat his cancer — to concoct a set of treatments from his body’s own ingredients, which could take over from his chemotherapy and form a customized, dynamic treatment for his disease. These would be as far from off-the-shelf as medicines can get: vaccines designed for the tumor in his gut, made from the products of his plasma, that could only ever work for him.

Steinman would be the only patient in this makeshift trial, but the personalized approach for which he would serve as both visionary and guinea pig has implications for the rest of us. It is known as cancer immunotherapy, and its offshoots have just now begun to make their way into the clinic, and treatments have been approved for tumors of the skin and of the prostate. For his last experiment, conducted with no control group, Steinman would try to make his life into a useful anecdote — a test of how the treatments he assembled might be put to work. “Once he got diagnosed with cancer, he really started talking about changing the paradigm of cancer treatment,” his daughter Alexis says. “That’s all he knew how to do. He knew how to be a scientist.”

First, Steinman needed to see his tumor. Not an M.R.I. or CT scan, but the material itself. The trouble was that most people with his cancer never have surgery. If there’s cause to think the tumor has spread — and there usually is — it may not be worth the risk of having it removed, along with the bile duct, the gallbladder, large portions of the stomach and the duodenum. Luckily for Steinman, early scans showed that his tumor was a candidate for resection. On the morning of April 3, 2007, less than two weeks after his diagnosis, he went in for the four-hour procedure at Memorial Sloan-Kettering Cancer Center, just across the avenue from his office at Rockefeller University.

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Is the Cure for Cancer Inside You?

Claudia Steinman saw her husband’s BlackBerry blinking in the dark. It had gone untouched for several days, in a bowl beside his keys, the last thing on anybody’s mind. But about an hour before sunrise, she got up to get a glass of water and, while padding toward the kitchen, found an e-mail time-stamped early that morning — “Sent: Monday, Oct. 3, 2011, 5:23 a.m. Subject: Nobel Prize. Message: Dear Dr. Steinman, I have good news for you. The Nobel Assembly has today decided to award you the Nobel Prize in Physiology or Medicine for 2011.” Before she finished reading, Claudia was hollering at her daughter to wake up. “Dad got the Nobel!” she cried. Alexis, still half-asleep, told her she was crazy. Her father had been dead for three days.

Steinman: Photograph by Ingbert Grüttner/Rockefeller University. Dendritic cell: Rockefeller University Press.

Ralph Steinman in 1983. He would become his most compelling experiment.

Dendritic cell: Rockefeller University Press.

The cell Steinman hoped would save his life looks something like a sea anemone or a ruffled shrimp dumpling.

The Nobel Foundation doesn’t allow posthumous awards, so when news of Ralph Steinman’s death reached Stockholm a few hours later, a minor intrigue ensued over whether the committee would have to rescind the prize. It would not, in fact; but while newspapers stressed the medal mishap (“Nobel jury left red-faced by death of laureate”), they spent less time on the strange story behind the gaffe. That Steinman’s eligibility was even in question, that he’d been dead for just three days instead of, say, three years, was itself a minor miracle.

In the spring of 2007, Steinman, a 64-year-old senior physician and research immunologist at Rockefeller University in New York, had come home from a ski trip with a bad case of diarrhea, and a few days later he showed up for work with yellow eyes and yellow skin — symptoms of a cancerous mass the size of a kiwi that was growing on the head of his pancreas. Soon he learned that the disease had made its way into nearby lymph nodes. Among patients with his condition, 80 percent are dead within the first year; another 90 percent die the year after that. When he told his children about the tumor over Skype, he said, “Don’t Google it.”

But for a man who had spent his life in the laboratory, who brought copies of The New England Journal of Medicine on hiking trips to Vermont and always made sure that family vacations overlapped with scientific symposia, there was only one way to react to such an awful diagnosis — as a scientist. The outlook for pancreatic cancer is so poor, and the established treatments so useless, that any patient who has the disease might as well shoot the moon with new, untested therapies. For Steinman, the prognosis offered the opportunity to run one last experiment.

In the long struggle that was to come, Steinman would try anything and everything that might extend his life, but he placed his greatest hope in a field he helped create, one based on discoveries for which he would earn his Nobel Prize. He hoped to reprogram his immune cells to defeat his cancer — to concoct a set of treatments from his body’s own ingredients, which could take over from his chemotherapy and form a customized, dynamic treatment for his disease. These would be as far from off-the-shelf as medicines can get: vaccines designed for the tumor in his gut, made from the products of his plasma, that could only ever work for him.

Steinman would be the only patient in this makeshift trial, but the personalized approach for which he would serve as both visionary and guinea pig has implications for the rest of us. It is known as cancer immunotherapy, and its offshoots have just now begun to make their way into the clinic, and treatments have been approved for tumors of the skin and of the prostate. For his last experiment, conducted with no control group, Steinman would try to make his life into a useful anecdote — a test of how the treatments he assembled might be put to work. “Once he got diagnosed with cancer, he really started talking about changing the paradigm of cancer treatment,” his daughter Alexis says. “That’s all he knew how to do. He knew how to be a scientist.”

First, Steinman needed to see his tumor. Not an M.R.I. or CT scan, but the material itself. The trouble was that most people with his cancer never have surgery. If there’s cause to think the tumor has spread — and there usually is — it may not be worth the risk of having it removed, along with the bile duct, the gallbladder, large portions of the stomach and the duodenum. Luckily for Steinman, early scans showed that his tumor was a candidate for resection. On the morning of April 3, 2007, less than two weeks after his diagnosis, he went in for the four-hour procedure at Memorial Sloan-Kettering Cancer Center, just across the avenue from his office at Rockefeller University.

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No Easy Route If Assad Opts to Go, or Stay

BEIRUT, Lebanon — President Bashar al-Assad of Syria sits in his mountaintop palace as the tide of war licks at the cliffs below.

Explosions bloom over the Damascus suburbs. His country is plunging deeper into chaos. The United Nations’ top envoy for the Syrian crisis, Lakhdar Brahimi, met with Mr. Assad in the palace on Monday in an urgent effort to resolve the nearly two-year-old conflict.

How Mr. Assad might respond to Mr. Brahimi’s entreaty depends on his psychology, shaped by a strong sense of mission inherited from his iron-fisted father and predecessor, Hafez al-Assad; his closest advisers, whom supporters describe as a hard-line politburo of his father’s gray-haired security men; and Mr. Assad’s assessment, known only to himself, about what awaits him if he stays — victory, or death at the hands of his people.

From his hilltop, Mr. Assad can gaze toward several possible futures.

East of the palace lies the airport and a possible dash to exile, a route that some say Mr. Assad’s mother and wife may have already taken. But the way is blocked, not just by bands of rebels, but by a belief that supporters say Mr. Assad shares with his advisers that fleeing would betray both his country and his father’s legacy.

He can stay in Damascus and cling to — even die for — his father’s aspirations, to impose a secular Syrian order and act as a pan-Arab leader on a regional and global stage.

Or he can head north to the coastal mountain heartland of his minority Alawite sect, ceding the rest of the country to the uprising led by the Sunni Muslim majority. That would mean a dramatic comedown: reverting to the smaller stature of his grandfather, a tribal leader of a marginalized minority concerned mainly with its own survival.

Mr. Brahimi was closemouthed about the details of his meeting, but has warned in recent weeks that without a political solution, Syria faces the collapse of the state and years of civil war that could dwarf the destruction already caused by the conflict that has taken more than 40,000 lives.

A Damascus-based diplomat said Monday that Mr. Assad, despite official denials, was “totally aware” that he must leave and was “looking for a way out,” though the timetable is unclear.

“More importantly,” said the diplomat, who is currently outside Syria but whose responsibilities include the country, “powerful people in the upper circle of the ruling elite in Damascus are feeling that an exit must be found.”

Yet others close to Mr. Assad and his circle say any retreat would clash with his deep-seated sense of himself, and with the wishes of increasingly empowered security officials, whom one friend of the president’s has come to see as “hotheads.”

Mr. Assad believes he is “defending his country, his people, and his regime and himself” against Islamic extremism and Western interference, said Joseph Abu Fadel, a Lebanese political analyst who supports Mr. Assad and met with government officials last week in Damascus.

Analysts in Russia, one of Syria’s staunchest allies, say that as rebels try to encircle Damascus and cut off escape routes to the coast, the mood in the palace is one of panic, evinced by the erratic use of weapons: Scud missiles better used against an army than an insurgency, naval mines dropped from the air instead of laid at sea.

But even if Mr. Assad wanted to flee, it is unclear if the top generals would let him out alive, Russian analysts say, since they believe that if they lay down arms they — and their disproportionately Alawite families — will die in vengeance killings, and need him to rally troops.

“If he can fly out of Damascus,” Semyon A. Bagdasarov, a Middle East expert in Moscow, said — at this, he laughed dryly — “there is also the understanding of responsibility before the people. A person who has betrayed several million of those closest to him.”

Many Syrians still share Mr. Assad’s belief that he is protecting the Syrian state, which helps explain how he has held on this long. At a lavish lunch hosted by a Lebanese politician outside Beirut in September, prominent Syrian backers of Mr. Assad — Alawites, Sunnis and Christians — spoke of the president, over copious glasses of Johnnie Walker scotch, as the bulwark of a multicultural, modern Syria.

Reporting was contributed by Kareem Fahim and David D. Kirkpatrick from Beirut, Ellen Barry from Moscow, Sebnem Arsu from Istanbul, Rick Gladstone from New York, and an employee of The New York Times from Tartus, Syria.

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