'It doesn't seem right' - washingtonpost.com

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A group plagued by service, cost complaints is awarded $4.5 million. How?

By Debbie Cenziper
Monday, October 19, 2009

Alexander Harrington walked into the house "where miracles happen every day" with a single suitcase and $3 to his name, fresh out of prison and determined not to spend another day doped up in dark alleyways.

At 59, he had been living with HIV for more than a decade. Now, he was four years sober with grandchildren he wanted to see. While visiting a local medical clinic, he had heard about a house of second chances, part of a District-funded AIDS nonprofit group called Miracle Hands Community Development Corp., that provided emergency housing, counseling, job training and help with finding a permanent place to live.

Harrington moved into the house in Northeast Washington in April.

In a bedroom with filthy floors that he shared with three other men, he waited for counseling and job training. He waited for a chance to learn where he might go once his limited stay at the house had ended.

After a few weeks, he caught a bus to the D.C. Health Department's HIV/AIDS Administration to seek services there. He was told he'd get a call back and waited some more.

Then, on a Friday afternoon in May, as men lounged around the steamy house and a single supervisor sat in the dining room, Harrington struggled with the news that it was time to go. He said he left Miracle Hands without job training or a lead on permanent housing.

"It doesn't seem right," he said, packing his suitcase for the streets.

In a city fighting to control a devastating AIDS epidemic, Miracle Hands promised to reach into the poorest pockets of the District, offering a lifeline in African American neighborhoods long overlooked by established AIDS groups.

But the nonprofit group, which became one of the most heavily funded AIDS organizations in the city, has been racked by complaints from city monitors, former clients and other AIDS groups about a lack of services and supplies, missing records and questionable expenses, The Washington Post found.

Twice, monitors suggested the city withhold money to the group. But former HIV/AIDS Administration housing chief Debra Rowe continued to provide steady support to Miracle Hands, which over five years was awarded about $4.5 million, much of it from Rowe's department.

Included was $420,000 in housing funds for a highly anticipated job training center that more than three years later has yet to open. Meanwhile, more than 400 people with HIV or AIDS are on a years-long waiting list for supportive housing.

"It was not a wise decision," HIV/AIDS Administration spokesman Michael Kharfen said of funding the renovation.

The story of Miracle Hands shows how start-up nonprofit groups that pledged to help the sick in a city with the nation's highest AIDS rate were able to draw millions from a D.C. agency that time and again failed to ensure its money was well spent. From 2004 to 2008, the HIV/AIDS Administration -- entrusted with spending the city's AIDS dollars -- paid more than $25 million to groups marked by financial problems or questions about the quality of care and services, including Miracle Hands.

Miracle Hands officials defend their programs, saying they are properly staffed and equipped and especially needed in the District's poorest neighborhoods.

From its headquarters in a 14,000-square-foot warehouse on Queens Chapel Road NE and rental houses throughout the city, Miracle Hands said it has provided support groups, housing and a day treatment center offering showers, meals and therapy. Group officials said that they offer support to housing clients but that the services are optional.

Miracle Hands' executive director is 52-year-old Cornell Jones, who once ran a massive cocaine ring on the streets of Northeast. Arrested in the 1980s, he served time in prison and emerged to start Miracle Hands in the late 1990s to help ex-offenders, the homeless and troubled children. He had business ventures as well: Next door to Miracle Hands, Jones opened a popular nightclub called D.C. Tunnel.

"This deadly disease . . . is not a gay, white Dupont Circle disease anymore. . . . The [city] didn't have a clue how to attack that population," Jones said. "We came in with some new ideas . . . and try to give these clients everything that they need."

Jones and Rowe said they have a long-standing professional relationship. Like Jones, Rowe had overcome a drug past, serving time in prison for heroin and cocaine charges before building a career focused on people with AIDS.

One Miracle Hands supervisor said Rowe visited frequently and would help Jones with paperwork.

"She did a lot of work for Miracle Hands," supervisor James Lynch-Bey said.

But Jones said Rowe did not favor his group, noting that Miracle Hands applied for funding through a competitive process. City officials, however, said department heads such as Rowe supervise the selection process, weigh in on how grants are awarded and monitor the money.

Rowe also had a personal connection to Miracle Hands: Three of her family members and a friend were hired by Jones.

Rowe, 50, said she never benefited personally from Miracle Hands and did not provide favored treatment to any group. She said she did the best she could under difficult circumstances, taking over a housing department that funded and monitored many struggling nonprofit groups.

"It was a mess," she said. "Everybody said that Debra Rowe was the one that can fix it."

When asked by The Post about Miracle Hands' performance, Rowe said that the HIV/AIDS Administration's "records speak for themselves" and that if she had found "serious discrepancies" she would have stepped in.

She acknowledged that her 28-year-old son was hired by Jones to work as a Miracle Hands housing staffer and that her father and uncle worked parking lot duty at D.C. Tunnel.

Rowe said she saw no conflict. She said she did not realize her father and uncle worked there until she visited the club. Her son, she said, took the job in 2003, when Rowe was a public health adviser at the HIV/AIDS Administration but a year before she had taken over as housing chief. One Miracle Hands roster showed Rowe's son's salary was $29,120.

Rowe also said she had referred her friend Danette Williams to Miracle Hands when Williams needed a job. Jones hired Williams as the Miracle Hands program director in 2004; she is now the deputy director.

In December 2006, the FBI launched a probe into the District's AIDS funding, Rowe's connections and others involved in funding decisions, seizing files from Miracle Hands and Rowe. Rowe and her attorney said the case was recently closed.

FBI Supervisory Special Agent Darlene G. Hoyns, however, said the case remains active.

Williams said Miracle Hands has recently received praise from the HIV/AIDS Administration, citing high marks on a capacity assessment, which considered such criteria as experience and the completion of invoices.

City officials, however, say the assessment does not measure the quality of services or a program's overall success.

Despite the FBI investigation and complaints about services, the HIV/AIDS Administration continued to provide grant money to Miracle Hands, with more than $700,000 awarded this year. Kharfen said recent site visits for the group have not identified deficiencies, although the city no longer funds the group's long-term housing and day programs.

"It shows you how embedded the culture is here," said Ron Harris, a local AIDS case manager. "It's that Debra Rowe mind-set: Everybody gets paid."

'That's my people'

Rowe said she had met Jones years ago while trying to encourage young people to get tested for HIV. She said she would often recruit at D.C. Tunnel, where she liked to watch go-go guitarist Chuck Brown play.

Rowe and Jones had both come a long way.

Jones was once a drug kingpin with international ties. A police search of his home when he was arrested for drug distribution in 1985 found $870,000 in cash, plus jewelry, furs, 28 airline tickets to Las Vegas, five guns, cocaine, a currency-counting machine and a drug identification kit.

He was paroled in 1995 after serving nine years of a 27-year sentence. Three years later, Jones opened Miracle Hands to take in people from the streets.

"That's my people. That's who I knew all my life," Jones said. "I was a fairly decent criminal. I thought I could be a fairly decent manager . . . for that population as well."

Jones based the operation in the warehouse, part of a complex of buildings in an industrial park in Northeast that was purchased through a limited liability company, managed by Jones, for $1.4 million in 2002.

Rowe had rebuilt her life as well, completing a master's degree in human services after serving 15 months in prison on drug charges. In 1999, seven years out of prison, she took a job at the HIV/AIDS Administration.

Miracle Hands started receiving money shortly before Rowe was promoted to interim housing director in late 2004. The $10 million-a-year program is funded by the U.S. Department of Housing and Urban Development.

Monitors quickly began to note problems, with one writing that Miracle Hands' invoices were "routinely late and lack[ed] requisite documentation." Jones wasn't meeting monitors for site visits at Miracle Hands and had skipped training sessions at the HIV/AIDS Administration, records show.

Williams said Jones opted to skip meetings early on because he worried that his criminal past would taint the organization.

"He realized that due to his history, many would perceive Miracle Hands as being a 'rogue' organization," Williams said.

HIV/AIDS Administration monitors also found that insurance information, spending plans, and employee résumés and contracts were missing.

Still, Jerry Brown, a friend and colleague of Rowe's at the HIV/AIDS Administration, noted improvements and recommended future partnerships with Miracle Hands.

In mid-2005, a monitor noted that Miracle Hands had billed the city for "questionable" jobs. Among the payments: $9,000 for an unnamed computer specialist and $3,600 for an unnamed mental health professional, with the monitor writing, "Who/Where/Agency?"

Williams told The Post that the issues pointed out by monitors were "small."

For part of its tenure, Miracle Hands also lacked a basic requirement for doing business in the District: a license.

Monitors repeatedly asked Miracle Hands about the license and other required documentation, records show. Monitor Rony Mohram wrote directly to Rowe and others in August 2005: "Since we are precluded from continuing to fund out of compliance vendors, please advise me on what to do in regards with this matter."

Monitor Jonathan Alston responded: "We should withhold payment of any outstanding invoices until they comply. That's my suggestion."

By then, Rowe had risen to interim housing chief at the agency. She defended Miracle Hands, responding in an e-mail that the group had been seeking a license for eight months. Rowe forwarded a letter that she had received from Williams. The two women had met years earlier when they worked with another AIDS group, the Abundant Life Clinic.

Williams appealed to Rowe in a letter about the licensing delay, writing, "Your consideration and understanding in this matter is greatly appreciated."

The matter was dropped, records show. Miracle Hands received a business license in mid-2005, more than two years after the group started receiving grants. Rowe told The Post that licensing in the city can be long and tedious.

"There are other groups that didn't have it," she said.

Years later, Miracle Hands' records continue to show lapses: The nonprofit group has never filed a federal tax return, IRS records show. Williams said the recent returns could not be filed because records had been seized by the FBI.

'Out of proportion'

Some reports have praised Miracle Hands for well-kept houses and a strong management team.

One monitor once wrote, "My recommendation for this provider is to continue to do great work for the community." A quality-assurance consultant noted the group's managers had "compassion, dedication and cultural proficiency."

Time and again, however, Miracle Hands was criticized for inconsistencies in record-keeping, billing and client care.

An independent audit for 2005 by an outside firm found that Miracle Hands had made only one payment to an employee that year and owed nearly $60,000 in outstanding salaries.

Williams said employees weren't always paid on time because of delays in processing invoices at the city.

In 2006, monitors found more problems, noting that Miracle Hands again had not turned in paperwork required to do business with the city, such as proof of liability insurance. Monitors continued to call on Miracle Hands for missing audits, client reports and budgets.

The same year, HIV/AIDS Administration official Gunther Freehill e-mailed Rowe about a Miracle Hands job-readiness program, saying: "They have billed a total of about $6,600 for the first four months of their grant and have reported nothing more than that they are preparing curriculum. The costs are a little out of proportion."

There were other problems at a day program run by Miracle Hands out of a ramshackle house in Southeast. In May 2006, a housing case manager documented dirty and dangerous conditions: peeling wallpaper, soiled carpets, an uneven stairwell and no fire escape. The report was forwarded to Rowe.

Staffers at other AIDS groups also noticed the conditions.

"The house was in terrible shape," said Priscilla Norris, head nurse at the Northwest AIDS hospice Joseph's House, who visited the day program about two years ago. "There was no day treatment. It was just a place to go and watch TV."

One afternoon in the spring, The Post found men sitting side by side in the living room watching TV. The house was hot, with the windows held open by books. The ceilings had holes, and the floor was lopsided. The only place for napping was a closet with a ripped cot. The upstairs meeting room had no books, no pencils, no computers, no paper.

When The Post made an arranged visit last month, a card table was set up in the living room. Seven men were talking to case manager Willie Cheeks.

As Jones and Williams looked on, Cheeks said, "In order to be competitive out there, you have to have a skill."

One of the men responded, "In the institution, I had heard that this program was very instrumental."

Jones said that in the past, the HIV/AIDS Administration provided little money for his group's day program. Still, he said, clients are offered hot meals and therapy. Williams added that computers and supplies are stored to prevent theft and that the cot is offered only if a client is not feeling well. She also said that the house has new carpeting, a new stove and a restored front porch and that other repairs have been made.

Besides its day program, Miracle Hands says it offers job training in its warehouse, a squat, rundown building with worn carpeting and a vast room in the back. One day in the spring, The Post found that the only person there was the group's finance manager, Malik Savage. There was one sheet of drywall, a couple piles of wood on the floor and a single computer in the back, which Savage said was once used to teach telecommunications. Donated computers were piled one on top of the other in a storage room.

Williams said they had not been set up because they were missing hard drives.

A budget from a 2007 grant shows that Miracle Hands proposed charging $60,000 for use of the warehouse for job training. But the budget included only $1,000 for supplies associated with the training courses, such as drywall, metal studs, screw guns, tape and wiring.

Williams said the contractors who teach the classes bring supplies.

Harris, the local AIDS case manager, said he has repeatedly tried to refer clients to the Miracle Hands job-training programs but was never able to reach anyone.

"It was a brick wall," he said. "I never heard of anyone who did job training there."

Williams said the job programs were "comprehensive." Miracle Hands officials said there will always be some disgruntled clients.

"Miracle Hands is a good organization, committed and steadfast to its mission to help those in need," Williams said.

Former Miracle Hands client Michael Tyree also cited a lack of supplies in the group's housing program, where he stayed for two months in 2007. Sick with AIDS and throat cancer, he said he often couldn't find food and slept on beds without sheets or blankets.

"The whole house was completely dirty. They didn't feed you at all," Tyree said. "To me, Miracle Hands was just about the money. They say they were helping people, but they weren't."

Tyree now lives at the nonprofit Joseph's House. He has his own room in the basement with pictures of his nieces on the wall.

Sitting on his bed one spring morning, bundled in a red bathrobe, he said, "This feels like my home."

'The darndest places'

While Jones was operating Miracle Hands, he was struggling to keep his nightclub afloat.

City dispatchers had received 77 calls for service to D.C. Tunnel between 2006 and 2008 after reports of assaults, theft, disorderly conduct and destruction of property. The club was the site of two shootings within 90 days last year.

D.C. Police Chief Cathy L. Lanier requested at the time that the city revoke the club's alcohol license. Jones and his partners agreed to sell the club, pay a $10,000 fine and not apply for a liquor license for four years.

Jones said he saw nothing wrong with running a nightclub next to a program that is supposed to help people with HIV, many of whom are recovering addicts.

"The club was there first," Jones said, adding that it did not open until 10 p.m., after the AIDS program had closed. "The club only opened after the sun goes down. That's when the party comes out."

Said Rowe, "People start [AIDS groups] in the darndest places."

Under Rowe's tenure, the Miracle Hands warehouse next to the nightclub got a big boost from the city:

In 2005, she moved to give Miracle Hands $335,000 to renovate the warehouse, which was supposed to create a state-of-the-art job-training center.

"I had the vision for a job-training center for people living with HIV/AIDS," Rowe told The Post.

Before the grant was approved, however, Health Department supervisor Charles Nichols urged Rowe in an e-mail to justify the money because it was to be given to Miracle Hands without competitive bidding.

"The sole-source justification to allow Miracle Hands to receive these funds must address . . . why we should renovate a building for them. . . . I prefer you issue a competitive [request] so that we can make sure we are getting the best value for our resources," Nichols wrote.

HIV/AIDS Administration officials say Nichols eventually called off the noncompetitive deal.

In 2006, through a competitive process, Miracle Hands was awarded $279,000 for the renovation from Rowe's department. Miracle Hands was the only bidder, Rowe said.

Rowe also signed off on an $84,000 advance on the grant money, records show, in part so Miracle Hands could hire a general contractor for the renovation.

Yet no work was being done. Month after month, monitors noted the lack of progress, with monitor Sheree Avent writing in November 2006, "This issue has been brought to the attention of . . . Debra Rowe." Avent later followed up in an e-mail to Rowe: "Construction has not begun. . . . It is my recommendation that . . . [funding] levels need to be modified."

Grants supervisor Carine Mathurin followed up, e-mailing Rowe: "Shouldn't we de-obligate some of this money?"

Rowe e-mailed back: "No, the funds should not be de-obligated . . . [the Housing program] is well aware of the start-up issues in reference to this grant . . . [the Housing program] is fine with this."

In late 2006, Jones submitted a $494,000 estimate for the renovation work from El Cos. of Chantilly. But the address on the estimate does not exist, according to the U.S. Postal Service. The company has no phone listing in the District or Virginia.

The contact on the estimate was Edward Hunter, who is the stepbrother of Savage, the Miracle Hands finance manager, records and interviews show.

Williams said Miracle Hands solicited quotes from other contractors. She could not provide any of the proposals, saying the paperwork was seized by the FBI.

She said Hunter has construction experience and noted that the company has a trade name registration in the District. His estimate, Williams said, was far below those provided by other companies.

Edward Hunter said his business is a sole proprietorship and has not done any work in the District or Virginia. He said he does not recall how he heard that Miracle Hands was looking for a contractor.

"I was trying to get my business off the ground. . . . I figured I'd get lucky and get an opportunity," Hunter said.

As for the problems with his company's address on the estimate, he said that his wife rented space at a real estate office on the street he had listed and that it is possible numbers were transposed.

In March 2007, Rowe's department issued a second grant for the renovation, this time for $140,000, bringing the city's total investment over two years to $420,000.

Two months later, Avent, the monitor, wrote that the location for the project had changed.

Instead of renovating the Miracle Hands warehouse, work would be done at another warehouse owned by Jones two doors down, on the far side of the nightclub. Avent said she had requested a new work plan and time frame for completion of the project.

She also noted renovations at the new location were lagging, writing, "The rehabilitation work was a few weeks behind schedule and should be completed by August."

Through last year, however, monitors continued to document delays at the new site. A report issued by Miracle Hands last October said the project was scheduled to be completed within two months.

The facility has still not opened -- more than three years after the renovation money was first awarded. Williams said Miracle Hands ran out of money and needs $300,000 more. She added that much of the project has been done, including architectural plans and work on windows, walls and plumbing.

"What we have to do is nickel-and-dime it," she said.

Neither Miracle Hands nor the city could provide invoices or receipts to account for the $420,000. Kharfen, the HIV/AIDS Administration spokesman, said the agency has no plans to provide more money for the project, adding that the city's housing dollars must be invested in housing.

Rowe said Miracle Hands continues to work to complete the project.

"It was a lot of people's dreams," she said.

In April 2008, Rowe was removed from her $97,000-a-year job as the AIDS housing chief and subsequently left city government.

She is now an administrator with a new nonprofit group for ex-offenders, Returning Citizens United.

Jones is a founding member.

"Where else would I turn except to still work on behalf of that marginalized population?" Rowe said.

Staff researcher Meg Smith contributed to this report.

War and politics in Afghanistan : The New Yorker

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bySteve Coll

Over the summer, the Afghan Taliban’s military committee distributed “A Book of Rules,” in Pashto, to its fighters. The book’s eleven chapters seem to draw from the population-centric principles of F.M. 3-24, the U.S. Army’s much publicized counter-insurgency field manual, released in 2006. Henceforth, the Taliban guide declares, suicide bombers must take “the utmost steps . . . to avoid civilian human loss.” Commanders should generally insure the “safety and security of the civilian’s life and property.” Also, lest anxious Afghan parents get the wrong idea, Taliban guerrillas should avoid hanging around with beardless young boys and should particularly refrain from “keeping them in camps.”

The manual might be risible if the Taliban’s coercive insurgency were not so effective. Afghanistan’s self-absorbed President, Hamid Karzai, might even consider leafing through it; if he could account for his citizenry’s appetite for justice and security half as adaptively as his enemies do, Barack Obama would not be struggling so hard to locate the “good war” he pledged to win during his campaign for the White House.

Afghanistan’s deterioration cannot be blamed on one man, and certainly not on Karzai. After the Taliban’s fall, he was a symbol of national unity in a broken land—for several years, he was perhaps the only Afghan leader able to attract the simultaneous confidence of northern Tajik militias, southern Pashtun tribes, and international aid donors. The landslide he won in the 2004 election truly reflected his standing.

Gradually, however, Karzai seemed to succumb to palace fever and corruption. An unfortunate blend of ego and passivity hobbled him; he could neither manage the American presence in his country nor turn its failures to his advantage by remaking himself as a convincing nationalist. For years, the Bush Administration accepted Karzai’s limitations, and did nothing to create conditions from which a plausible alternative might emerge. In 2008, as another election approached, President Bush’s advisers at last sensed trouble; some of them considered trying to dump Karzai. In the end, however, Bush chose a policy of neutrality, which the incoming Obama Administration endorsed.

There is no sugarcoating how Karzai played his hand: he or his backers tried to rig the election on August 20th, a day on which several million of his countrymen defied Taliban threats of violence to attend the polls. Recently, after weeks of equivocating, the head of the United Nations mission in Kabul, Kai Eide, of Norway, admitted that the vote had been marred by “widespread fraud.” (The U.N. had earlier fired Eide’s American deputy, Peter Galbraith, for chasing this conclusion too vigorously.) U.N. voter-turnout estimates show that most of the fraud occurred in Karzai’s strongholds and lifted his tally far more than any other candidate’s. In southern Helmand Province, for example, the U.N. estimates suggest that Karzai’s campaign may have manufactured more than seventy thousand fake votes; in Kandahar, a hundred and twenty thousand; in Paktika, a hundred and sixty thousand. From June through August, nearly two hundred coalition soldiers died in military operations designed in part to create security for the election.

Karzai’s apparent betrayal has the capacity to shock, but it would be a mistake to overemphasize his failings, just as it was an error to overemphasize his early successes. American interests in Afghanistan—namely, the disablement of Al Qaeda along the Pakistan-Afghanistan border, and the pursuit of a region free from the threat of Taliban revolution—should not be wholly confused with the quest for an honest President in Kabul, where rulers have not often been trustworthy.

A second round of voting now looks probable; it could help calm the country, or it could make things worse. In any event, the election is not yet an utter catastrophe. Two years ago, in Kenya, Mwai Kibaki allegedly stole his reëlection to the Presidency, and the country erupted in mass riots and militia killings. In June, Iran’s fraud-riddled vote ignited a protest movement with revolutionary ambitions. In Afghanistan, despite possibly decisive fraud, the opposition has barely thrown a rock. Abdullah Abdullah, the aggrieved second-place finisher, just holds press conferences in his garden.

It goes without saying that Afghans have had enough of violence. Abdullah’s restraint signals a broader, resilient desire among many political and tribal leaders to avoid having their country descend into chaos again. This is the opening that American policy has repeatedly failed to grasp since the Taliban’s fall in late 2001: an opportunity to reject the false expediency of warlords and indispensable men, in favor of deepening participatory, Afghan-led political reform and national reconciliation.

In tandem with a decision about troop levels, the Obama Administration requires an ambitious political strategy for Afghanistan, one that will seize upon the willingness of opposition leaders to negotiate even with a tainted President Karzai about an array of national questions. These include how electoral fraud might be prevented in the future; whether provincial governors should be elected rather than appointed at the President’s whim; how ethnic balance can be assured as the country’s Army and police force grow; whether political parties should be encouraged; whether the 2004 constitution should be revised to strengthen parliament; how local government can be improved; how corrupt or drug-dealing government officials should be brought to account; and how Taliban foot soldiers and leaders might be encouraged to forswear violent revolution for constitutional politics.

It is not the specifics of these talks that matter most; it is the prospective project of continuous Afghan-led negotiations, formal and informal, amply resourced with money, international attention, and supportive expertise. Some of these projects, such as the establishment of local rehabilitation centers for defecting low-level Taliban fighters, demand urgent investments, within months.

Such political work will be no more certain to succeed than anything else in Afghanistan. Karzai will resist encroachments upon his authority; efforts to satisfy northern groups such as those aligned with Abdullah will conflict with efforts to pacify the Taliban, who are rooted in the south and the east. It is essential work, nonetheless—counter-insurgency campaigns rarely prevail unless military deployments are intimately connected with political negotiations.

Since the Soviet Union invaded Afghanistan, in 1979, attempts by foreign powers to shape events there have repeatedly been thwarted by what intelligence analysts call “mirror imaging,” which is the tendency of decision-makers in one country to judge counterparts in another through the prism of their own language and politics. The Politburo, for example, engaged in energetic debates about the extent to which Afghanistan might conform to the stages of revolutionary development contemplated in Marxist-Leninist theory.

As the Obama war cabinet now debates its choices, American discourse barely refers to Afghan leaders by name or to the particular equations of the country’s diverse provinces. Instead, historical analogies and abstract concepts from political-theory texts abound—arguments about “legitimacy” and “governance,” as if the Taliban were motivated primarily by the “Rights of Man.” Obama and his advisers might profitably consult the Democratic Party’s own book of rules, specifically an entry composed by a peaceable boss from Massachusetts: All politics is local. In the case of Afghanistan, there is a corollary: All local progress, or failure, will be political.

Who's in Big Brother's Database? - The New York Review of Books

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By James Bamford

The Secret Sentry: The Untold History of the National Security Agency

by Matthew M. Aid

Bloomsbury, 423 pp., $30.00

On a remote edge of Utah's dry and arid high desert, where temperatures often zoom past 100 degrees, hard-hatted construction workers with top-secret clearances are preparing to build what may become America's equivalent of Jorge Luis Borges's "Library of Babel," a place where the collection of information is both infinite and at the same time monstrous, where the entire world's knowledge is stored, but not a single word is understood. At a million square feet, the mammoth $2 billion structure will be one-third larger than the US Capitol and will use the same amount of energy as every house in Salt Lake City combined.

Unlike Borges's "labyrinth of letters," this library expects few visitors. It's being built by the ultra-secret National Security Agency—which is primarily responsible for "signals intelligence," the collection and analysis of various forms of communication—to house trillions of phone calls, e-mail messages, and data trails: Web searches, parking receipts, bookstore visits, and other digital "pocket litter." Lacking adequate space and power at its city-sized Fort Meade, Maryland, headquarters, the NSA is also completing work on another data archive, this one in San Antonio, Texas, which will be nearly the size of the Alamodome.

Just how much information will be stored in these windowless cybertemples? A clue comes from a recent report prepared by the MITRE Corporation, a Pentagon think tank. "As the sensors associated with the various surveillance missions improve," says the report, referring to a variety of technical collection methods, "the data volumes are increasing with a projection that sensor data volume could potentially increase to the level of Yottabytes (10²⁴ Bytes) by 2015."^[1] Roughly equal to about a septillion (1,000,000,000,000,000,000,000,000) pages of text, numbers beyond Yottabytes haven't yet been named. Once vacuumed up and stored in these near-infinite "libraries," the data are then analyzed by powerful infoweapons, supercomputers running complex algorithmic programs, to determine who among us may be—or may one day become—a terrorist. In the NSA's world of automated surveillance on steroids, every bit has a history and every keystroke tells a story.

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In the near decade since September 11, the tectonic plates beneath the American intelligence community have undergone a seismic shift, knocking the director of the CIA from the top of the organizational chart and replacing him with the new director of national intelligence, a desk-bound espiocrat with a large staff but little else. Not only surviving the earthquake but emerging as the most powerful chief the spy world has ever known was the director of the NSA. He is in charge of an organization three times the size of the CIA and empowered in 2008 by Congress to spy on Americans to an unprecedented degree, despite public criticism of the Bush administration's use of the agency to conduct warrantless domestic surveillance as part of the "war on terror." The legislation also largely freed him of the nettlesome Foreign Intelligence Surveillance Court (FISA). And in another significant move, he was recently named to head the new Cyber Command, which also places him in charge of the nation's growing force of cyber warriors.

Wasting no time, the agency has launched a building boom, doubling the size of its headquarters, expanding its listening posts, and constructing enormous data factories. One clue to the possible purpose of the highly secret megacenters comes from the agency's British partner, Government Communications Headquarters. Last year, the British government proposed the creation of an enormous government-run central database to store details on every phone call, e-mail, and Internet search made in the United Kingdom. Click a "send" key or push an "answer" button and the details of the communication end up, perhaps forever, in the government's data warehouse to be scrutinized and analyzed.

But when the plans were released by the UK government, there was an immediate outcry from both the press and the public, leading to the scrapping of the "big brother database," as it was called. In its place, however, the government came up with a new plan. Instead of one vast, centralized database, the telecom companies and Internet service providers would be required to maintain records of all details about people's phone, e-mail, and Web-browsing habits for a year and to permit the government access to them when asked. That has led again to public anger and to a protest by the London Internet Exchange, which represents more than 330 telecommunications firms. "We view...the volume of data the government now proposes [we] should collect and retain will be unprecedented, as is the overall level of intrusion into the privacy of citizenry," the group said in August.^[2]

Unlike the British government, which, to its great credit, allowed public debate on the idea of a central data bank, the NSA obtained the full cooperation of much of the American telecom industry in utmost secrecy after September 11. For example, the agency built secret rooms in AT&T's major switching facilities where duplicate copies of all data are diverted, screened for key names and words by computers, and then transmitted on to the agency for analysis. Thus, these new centers in Utah, Texas, and possibly elsewhere will likely become the centralized repositories for the data intercepted by the NSA in America's version of the "big brother database" rejected by the British.

Matthew M. Aid has been after the NSA's secrets for a very long time. As a sergeant and Russian linguist in the NSA's Air Force branch, he was arrested and convicted in a court-martial, thrown into prison, and slapped with a bad conduct discharge for impersonating an officer and making off with a stash of NSA documents stamped Top Secret Codeword. He now prefers to obtain the NSA's secrets legally, through the front door of the National Archives. The result is The Secret Sentry: The Untold History of the National Security Agency , a footnote-heavy history told largely through declassified but heavily redacted NSA reports that have been slowly trickling out of the agency over the years. They are most informative in the World War II period but quickly taper off in substance during the cold war.

Aid begins his study on the eve of Pearl Harbor, a time when the entire American cryptologic force could fit into a small, half-empty community theater. But by war's end, it would take a football stadium to seat the 37,000 military and civilian "crippies." On August 14, 1945, as the ink dried on Japan's instruments of surrender, the linguists and codebreakers manning the thirty-seven key listening posts around the world were reading more than three hundred diplomatic code and cipher systems belonging to sixty countries. "The American signals intelligence empire stood at the zenith of its power and prestige," notes Aid. But within days, the cryptanalysts put away their well-sharpened pencils and the intercept operators hung up their earphones. By the end of December 1945, America's crypto world had shrunk to 7,500 men and women.

Despite the drastic layoffs, the small cadre of US and British codebreakers excelled against the new "main enemy," as Russia became known. The joint US-British effort deciphered tens of thousands of Russian army and navy messages during the mid-to-late 1940s. But on October 29, 1948, as President Truman was about to deliver a campaign speech in New York, the party was over. In what became known within the crypto world as "Black Friday," the Russian government and military flipped a switch and instantly converted to new, virtually unbreakable encryption systems and from vulnerable radio signals to buried cables. In the war between spies and machines, the spies won. The Soviets had managed to recruit William Weisband, a forty-year-old Russian linguist working for the US Army, who informed them of key cryptologic weaknesses the Americans were successfully exploiting. It was a blow from which the codebreakers would never recover. NSA historians called it "perhaps the most significant intelligence loss in US history."

In the 1970s, when some modest gains were made in penetrating the Russian systems, history would repeat itself and another American turncoat, this time Ronald Pelton, would again give away the US secrets. Since then, it has largely been a codemaker's market not only with regard to high-level Russian ciphers, but also those of other key countries, such as China and North Korea. On the other hand, the NSA has made significant progress against less cryptologically sophisticated countries and, from them, gained insight into plans and intentions of countries about which the US has greater concerns. Thus, when a Chinese diplomat at the United Nations discusses some new African venture with a colleague from Sudan, the eavesdroppers at the NSA may be deaf to the Chinese communications links but they may be able to get that same information by exploiting weaknesses in Sudan's communications and cipher systems when the diplomat reports the meeting to Khartoum. But even third-world cryptography can be daunting. During the entire war in Vietnam, writes Aid, the agency was never able to break the high-level encryption systems of either the North Vietnamese or the Vietcong. It is a revelation that leads him to conclude "that everything we thought we knew about the role of NSA in the Vietnam War needs to be reconsidered."

Because the book is structured chronologically, it is somewhat difficult to decipher the agency's overall record. But one sees troubling trends. One weakness that seems to recur is that the agency, set up in the wake of World War II to prevent another surprise attack, is itself frequently surprised by attacks and other serious threats. In the 1950s, as over 100,000 heavily armed North Korean troops surged across the 38th parallel into South Korea, the codebreakers were among the last to know. "The North Korean target was ignored," says a declassified NSA report quoted by Aid. "North Korea got lost in the shuffle and nobody told us that they were interested in what was going on north of the 38th parallel," exclaimed one intelligence officer. At the time, astonishingly, the Armed Forces Security Agency (AFSA), the NSA's predecessor, didn't even have a Korean-language dictionary.

Unfortunately for General Douglas MacArthur, the codebreakers were able to read the communications of Spain's ambassador to Tokyo and other diplomats, who noted that in their discussions with the general, he made clear his secret hope for all-out war with China and Russia, including the use of nuclear weapons if necessary. In a rare instance of secret NSA intercepts playing a major part in US politics, once the messages were shown to President Truman, MacArthur's career abruptly ended.

Another major surprise came in the 1960s when the Soviet Union was able to move large numbers of personnel, large amounts of equipment, and many ballistic missiles to Cuba without the NSA hearing a peep. Still unable to break into the high-level Soviet cipher systems, the agency was unaware that the 51st Rocket Division had packed up and was encamped in Cuba. Nor did it detect the move of five complete medium-range and intermediate-range missile regiments from their Russian bases to Cuba. And it had no knowledge that Russian ballistic missiles were on Cuban soil, being positioned in launchers. "Soviet communications security was almost perfect," according to an NSA historian.

The first clues that something unusual was happening had come in mid-July 1962, when NSA analysts noticed record numbers of Soviet cargo and passenger ships heading for Cuba. Analysis of their unencrypted shipping manifests led the NSA to suspect that the ships were delivering weapons. But the nuclear-armed ballistic missiles were not detected until mid-October, a month after their arrival, and not by the NSA; it was the CIA, acting on information from its sources in Cuba and Florida, that ordered the U-2 reconnaisance flight that photographed them at launch sites on the island. "The crisis," Aid concludes, "was in fact anything but an intelligence success story." This is a view shared by the agency itself in a candid internal history, which noted that the harrowing events "marked the most significant failure of SIGINT [signals intelligence] to warn national leaders since World War II."

More recently, the NSA was unaware of India's impending nuclear test in 1998, the 1993 attack on the World Trade Center, the attack on the USS Cole in 2000, and the 1998 bombing of two of America's East African embassies. The agency first learned of the September 11 attacks on $300 television sets tuned to CNN, not its billion-dollar eavesdropping satellites tuned to al-Qaeda.

Then there is the pattern by which the NSA was actually right about a warning, but those in power chose to ignore it. During the Korean War, the AFSA picked up numerous indications from low-level unencrypted Chinese intercepts that the Chinese were shifting hundreds of thousands of combat troops to Manchuria by rail, an obvious signal that China might enter the war. But those in charge of Army intelligence simply refused to believe it; it didn't fit in with their plans.

Then, by reading the dispatches between India's well-connected ambassador to Beijing and his Foreign Office, it became clear that China would intervene if UN forces crossed the 38th parallel into North Korea. But again, says Aid, the warning "was either discounted or ignored completely by policymakers in Washington," and as the UN troops began crossing the divide, Chinese troops crossed the Yalu River into North Korea. Even when intercepts indicated that the Chinese were well entrenched in the North, officials in Washington and Seoul remained in a state of disbelief, until both South Korean and US forces there were attacked by the Chinese forces.

The pattern was repeated in Vietnam when NSA reporting warned on January 25, 1968, that a major coordinated attack would occur "in the near future in several areas of South Vietnam." But neither the White House, the CIA, nor General William Westmoreland at US military headquarters in Saigon believed it, until over 100,000 North Vietnamese and Vietcong troops launched their Tet offensive in the South five days later on January 30. "The [NSA] reports failed to shake the commands in Washington and Saigon from their perception," says an NSA history. Tragically, Aid notes, at the end of the war, all of the heroic Vietnamese cryptologic personnel who greatly helped the NSA were left behind. "Many," the NSA report reveals, "undoubtedly perished." It added, "Their story is yet untold." Then again in 1973, as in Korea and Vietnam, the NSA warned that Egypt and Syria were planning "a major offensive" against Israel. But, as Aid quotes an official NSA history, the CIA refused to believe that an attack was imminent "because [they thought] the Arabs wouldn't be 'stupid enough' to attack Israel." They were, they did, and they won.

Everything seemed to go right for the NSA during the Soviet invasion of Afghanistan, which the agency had accurately forecast. "NSA predicted on December 22 [1979], three full days before the first Soviet troops crossed the Soviet–Afghan border, that the Russians would invade Afghanistan within the next seventy-two hours," writes Aid, adding, "Afghanistan may have been the 'high water mark' for NSA."

The agency also recorded the words of the Russian fighter pilot and his ground controllers as he shot down Korean Airlines Flight 007 in 1983. Although the agency knew that the Russians had accidently mistaken the plane for a potentially hostile US military aircraft, the Reagan administration nevertheless deliberately spun the intercepts to make it seem that the fighter pilot knew all along that it was a passenger jet, infuriating NSA officials. "The White House's selective release of the most salacious of the NSA material concerning the shootdown set off a firestorm of criticism inside NSA," writes Aid. It was not the first time, nor would it be the last, that the NSA's product was used for political purposes.

The most troubling pattern, however, is that the NSA, through gross incompetence, bad intelligence, or deliberate deception through the selective release of information, has helped to push the US into tragic wars. A prime example took place in 1964 when the Johnson administration claimed that two US Navy destroyers in the Gulf of Tonkin, one on an eavesdropping mission for the NSA, were twice attacked by North Vietnamese torpedo boats. Those attacks were then used to justify the escalation of American involvement in the Vietnam War. But Aid cites a top-secret NSA analysis of the incident, completed in 2000, which concluded that the second attack, the one used to justify the war, never took place. Instead, NSA officials deliberately withheld 90 percent of the intelligence on the attacks and told the White House only what it wanted to hear. According to the analysis, only intelligence "that supported the claim that the communists had attacked the two destroyers was given to administration officials."

Not having learned its lesson, in the lead-up to the war in Iraq the NSA again told the administration only what it wanted to hear, despite the clearly ambiguous nature of the evidence. For years beforehand, the agency's coverage of Iraq was disastrous. In the late 1990s, the Iraqis began shifting much of their high-level military communications from radio to buried fiber optic networks, and at the same time, Saddam Hussein banned the use of cell phones. That left only occasional low-level troop communications. According to a later review, Aid writes, NSA had "virtually no useful signals intelligence on a target that was one of the United States' top intelligence priorities." And the little intelligence it did have pointed away from Iraq possessing weapons of mass destruction. "We looked long and hard for any signs," said one retired NSA official. "We just never found a 'smoking gun' that Saddam was trying to build nukes or anything else." That, however, did not prevent the NSA director, Lieutenant Gen. Michael V. Hayden, from stamping his approval on the CIA's 2002 National Intelligence Estimate arguing that Iraq's WMDs posed a grave danger, which helped prepare the way for the devastating war.

While much of the terrain Aid covers has been explored before, the most original areas in The Secret Sentry deal with the ground wars in Afghanistan and Iraq, where the NSA was forced to marry, largely unsuccessfully, its super-high-tech strategic capabilities in space with its tactical forces on the ground. Before the September 11 attacks, the agency's coverage of Afghanistan was even worse than that of Iraq. At the start of the war, the NSA's principal listening post for the region did not have a single linguist proficient in Pashto or Dari, Afghanistan's two principal languages. Agency recruiters descended on Fremont, California, home of the country's largest population of Afghan expatriates, to build up a cadre of translators—only to have most candidates rejected by the agency's overparanoid security experts. On the plus side, because of the collapse of the Taliban regime's rudimentary communications system, its leaders were forced to communicate only by satellite phones, which were very susceptible to NSA monitoring.

Other NSA tactical teams, Aid explains, collaborated on the ground with Special Forces units, including in the mountains of Tora Bora. But it was a new type of war, one the NSA was not prepared for, and both Osama bin Laden and Taliban leader Mullah Omar easily slipped through its electronic net. Eight years later, despite billions of dollars spent by the agency and dozens of tapes released by bin Laden, the NSA is no closer to capturing him or Mullah Omar than it was at Tora Bora in 2001.

Disappointingly, the weakest section of the book, mostly summaries of old news clips, deals with what may be the most important subject: the NSA's warrantless eavesdropping and its targeting of American communications. There is no discussion, for example, of the agency's huge data-mining centers, mentioned above, currently being built in Utah and Texas, or to what extent the agency, which has long been confined to foreign and international communications, is now engaged in domestic eavesdropping.

It is a key question and we have no precise answer. By installing its intercept rooms in such locations as AT&T's main switching station in downtown San Francisco, the agency has physical access to domestic as well as international communications. Thus it is possible that the agency scans all the e-mail of both and it may also eavesdrop on the telephone calls of both for targets on its ever-growing watch lists. According to a recent Justice Department report, "As of December 31, 2008, the consolidated terrorist watchlist contained more than 1.1 million known or suspected terrorist identities."^[3]

Aid's history becomes thin as it gets closer to the present day and the archival documents dwindle, especially since he has no substantial first-person, on-the-record interviews. Beyond a brief mention, he also leaves other important aspects of the NSA's history unaddressed, including the tumultuous years in the mid-1970s when it was investigated by the Senate's Church Committee for decades of illegal spying; Trailblazer, the nearly decade-long failure to modernize the agency; and the NSA's increasingly important role in cyberwarfare and its implications in future wars.

Where does all this leave us? Aid concludes that the biggest problem facing the agency is not the fact that it's drowning in untranslated, indecipherable, and mostly unusable data, problems that the troubled new modernization plan, Turbulence, is supposed to eventually fix. "These problems may, in fact, be the tip of the iceberg," he writes. Instead, what the agency needs most, Aid says, is more power. But the type of power to which he is referring is the kind that comes from electrical substations, not statutes. "As strange as it may sound," he writes, "one of the most urgent problems facing NSA is a severe shortage of electrical power." With supercomputers measured by the acre and estimated $70 million annual electricity bills for its headquarters, the agency has begun browning out, which is the reason for locating its new data centers in Utah and Texas. And as it pleads for more money to construct newer and bigger power generators, Aid notes, Congress is balking.

The issue is critical because at the NSA, electrical power is political power. In its top-secret world, the coin of the realm is the kilowatt. More electrical power ensures bigger data centers. Bigger data centers, in turn, generate a need for more access to phone calls and e-mail and, conversely, less privacy. The more data that comes in, the more reports flow out. And the more reports that flow out, the more political power for the agency.

Rather than give the NSA more money for more power—electrical and political—some have instead suggested just pulling the plug. "NSA can point to things they have obtained that have been useful," Aid quotes former senior State Department official Herbert Levin, a longtime customer of the agency, "but whether they're worth the billions that are spent, is a genuine question in my mind."

Based on the NSA's history of often being on the wrong end of a surprise and a tendency to mistakenly get the country into, rather than out of, wars, it seems to have a rather disastrous cost-benefit ratio. Were it a corporation, it would likely have gone belly-up years ago. The September 11 attacks are a case in point. For more than a year and a half the NSA was eavesdropping on two of the lead hijackers, knowing they had been sent by bin Laden, while they were in the US preparing for the attacks. The terrorists even chose as their command center a motel in Laurel, Maryland, almost within eyesight of the director's office. Yet the agency never once sought an easy-to-obtain FISA warrant to pinpoint their locations, or even informed the CIA or FBI of their presence.

But pulling the plug, or even allowing the lights to dim, seems unlikely given President Obama's hawkish policies in Afghanistan. However, if the war there turns out to be the train wreck many predict, then Obama may decide to take a much closer look at the spy world's most lavish spender. It is a prospect that has some in the Library of Babel very nervous. "It was a great ride while it lasted," said one.

Notes

^[1]The MITRE Corporation, "Data Analysis Challenges" (December 2008), p. 13.

^[2]David Leppard, "Internet Firms Resist Ministers' Plan to Spy on Every E-mail," The Sunday Times , August 2, 2009.

^[3]"The Federal Bureau of Investigation's Terrorist Watchlist Nomination Practices," US Department of Justice, Office of the Inspector General, Audit Division, Audit Report 09-25, May 2009.

Diagnosis: What Doctors Are Missing - The New York Review of Books

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By Jerome E. Groopman

Carrying the Heart: Exploring the Worlds Within Us

by F. González-Crussi

Kaplan, 291 pp., $26.95

The Deadly Dinner Party and Other Medical Detective Stories

by Jonathan A. Edlow, M.D.

Yale University Press, 245 pp., $27.50

Several months ago, I led a clinical conference for interns and residents at the Massachusetts General Hospital. It was thirty-three years since I had trained there, and beyond discussing the topic of the gathering, I was keen to learn from these young doctors how they viewed recent changes in the culture of medicine.

The subject of the conference centered on how physicians arrive at a diagnosis and recommend a treatment—questions that are central in the two books under review. We began by discussing not clinical successes but failures. Some 10 to 15 percent of all patients either suffer from a delay in making the correct diagnosis or die before the correct diagnosis is made. Misdiagnosis, it turns out, is rarely related to the doctor being misled by technical errors, like a laboratory worker mixing up a blood sample and reporting a result on the wrong patient; rather, the failure to diagnose reflects the unsuspected errors made while trying to understand a patient's condition.^[1]

These cognitive pitfalls are part of human thinking, biases that cloud logic when we make judgments under conditions of uncertainty and time pressure. Indeed, the cognitive errors common in clinical medicine were initially elucidated by the psychologists Amos Tversky and Daniel Kahneman in their seminal work in the early 1970s.^[2] At the conference, I reviewed with the residents three principal biases these researchers studied: "anchoring," where a person overvalues the first data he encounters and so is skewed in his thinking; "availability," where recent or dramatic cases quickly come to mind and color judgment about the situation at hand; and "attribution," where stereotypes can prejudice thinking so conclusions arise not from data but from such preconceptions.

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A physician works with imperfect information. Patients typically describe their problem in a fragmented and tangential fashion—they tell the doctor when they began to feel different, what parts of the body bother them, what factors in the environment like food or a pet may have exacerbated their symptoms, and what they did to try to relieve their condition. There are usually gaps in the patient's story: parts of his narrative are only hazily recalled and facts are distorted by his memory, making the data he offers incomplete and uncertain. The physician's physical examination, where he should use all of his senses to try to ascertain changes in bodily functions—assessing the tension of the skin, the breadth of the liver, the pace of the heart—yields soundings that are, at best, approximations. More information may come from blood tests, X-rays, and scans. But no test result, from even the most sophisticated technology, is consistently reliable in revealing the hidden pathology.

So a doctor learns to question the quality and significance of the data he extracts from the medical history of the patient, physical examination, and diagnostic testing. Rigorous questioning requires considerable effort to stop and look back with a discerning eye and try to rearrange the pieces of the puzzle to form a different picture that provides the diagnosis. The most instructive moments are when you are proven wrong, and realize that you believed you knew more than you did, wrongly dismissing a key bit of information that contradicted your presumed diagnosis as an "outlier," or failing to consider in your parsimonious logic that the patient had more than one malady causing his symptoms.

At the clinical conference, I recounted this reality to the interns and residents, and emphasized that like every doctor I knew, I had made serious errors in diagnosis, errors that were detrimental to patients. And I worried aloud about how changes in the delivery of health care, particularly the increasing time pressure to see more and more patients in fewer and fewer minutes in the name of "efficiency," could worsen the pitfalls physicians face in their thinking, because clear thinking cannot be done in haste.

When the discussion moved to formulating ways of improving diagnosis, I raised the issue of the growing reliance on "clinical guidelines," the algorithms crafted by expert committees that are intended to implement uniform "best practices." Like all doctors educated over the past decade, the residents had been immersed in what is called "evidence-based medicine." This is a movement to put medical care on a sound scientific footing using data from clinical trials of treatment rather than on anecdotal results. To be sure, this shift to science is welcome, but the "evidence" from clinical trials is often limited in its application to a particular patient's case. Subjects in clinical trials are typically "cherry-picked," meaning that they are included only if they have a single disease and excluded if they have multiple conditions, or are receiving other medications or treatments that might mar the purity of the population under study. People are also excluded who are too young or too old to fit into the rigid criteria set by the researchers.

Yet these excluded patients are the very people who heavily populate doctors' clinics and seek their care. It is these many patients that a physician must think about deeply, taking on the difficult task of devising an empirical approach, melding statistics from clinical trials with personal experience and even anecdotal results. Yes, prudent physicians consult scientific data, the so-called "best evidence," but they recognize that such evidence is an approximation of reality. And importantly, clinical guidelines do not incorporate the sick person's preferences and values into the doctor's choice of treatment; guidelines are generic, not customized to the individual's sensibilities.^[3]

At the conference, an animated discussion followed, and I heard how changes in the culture of medicine were altering the ways that the young doctors interacted with their patients. One woman said that she spent less and less time conversing with her patients. Instead, she felt glued to a computer screen, checking off boxes on an electronic medical record to document a voluminous set of required "quality of care" measures, many of them not clearly relevant to her patient's problems. Another resident talked about how so-called "work rounds" were frequently conducted in a closed conference room with a computer rather than at the patient's bedside.

During my training three decades ago, the team of interns and residents would move from bedside to bedside, engaging the sick person in discussion, looking for new symptoms; the medical chart was available to review the progress to date and new tests were often ordered in search of the diagnosis. By contrast, each patient now had his or her relevant data on the screen, and the team sat around clicking the computer keyboard. It took concerted effort for the group to leave the conference room and visit the actual people in need.

Still another trainee talked about the work schedule. Because chronic sleep deprivation can lead to medical mistakes, strict regulations have been implemented across the country to limit the amount of time any one resident can attend to patient care. While well intentioned and clearly addressing an important problem with patient safety, the unintended consequence was that care became more fragmented; patients now were "handed off" in shifts, and with such handoffs the trainee often failed to learn how an illness evolved over time, and important information was sometimes lost in the transition.

After the clinical conference, I chatted with my hosts, the two chief residents. I saw what had not changed over the years: the eagerness and excitement about human biology; the mix of tension and pride in taking responsibility for another person's life; the desire, while acknowledging its impossibility, for perfection in practice and performance; and a growing awareness that deciding with the patient on the "best treatment" is a complex process that cannot simply be reduced to formulas using probabilities of risks and benefits.

The two chief residents showed a level of insight about the limits of medical science that I had not had at their age. In the 1970s, clinical medicine was encountering molecular biology for the first time, and I was dazzled by the cascade of findings about genes and proteins. Recombinant DNA technology with gene cloning promised to revolutionize the profession, and indeed it has. Now, diseases are unraveled based on mutations in the genome, and drugs are more rationally designed to target such underlying molecular aberrations.

As an intern and resident, my focus was firmly fixed on this marvelous and awesome science.^[4] Although I prided myself on probing deeply into the patient's history in search of clues that would point to a diagnosis, I too often missed the deeper narrative—the tale of the meaning of the illness to the person. My fellow trainees and I spent scant time pondering how the sufferer experienced his plight, or what values and preferences were relevant to the clinical choices he faced. The two chief residents seemed deeply engaged by their patients' lives and struggles, yet deeply frustrated, because that dimension of medicine, what is termed "medical humanism," was, despite much lip service, given short shrift as a consequence of the enormous change in how medical care is being restructured.

What I heard from the residents at the Massachusetts General Hospital was not confined to that noon meeting or to young physicians. A close friend in New York City told me how his wife with metastatic ovarian cancer had spent six days in the hospital without a single doctor engaging her in a genuine conversation. Yes, she had undergone blood tests and been sent for CT scans. But no one attending to her had sat down in a chair at her bedside and conversed at eye level, asking questions and probing her thoughts and feelings about what was being done to combat her cancer and how much more treatment she was willing to undergo. The doctors had hardly touched her, only briefly placing their hands on her swollen abdomen to gauge its tension. The interactions with the clinical staff were remote, impersonal, and essentially mediated through machines.

Nor were these perceptions of the change in the nature of care restricted to reports from patients and their families. They were also made by senior physicians. My wife and frequent co-writer, Dr. Pamela Hartzband, an endocrinologist, reported conversations among the clinical faculty about how a price tag was being fixed to every hour of the doctor's day. There were monetary metrics to be met, so-called "relative value units," which assessed your productivity as a physician strictly by measuring how much money you, as a salaried staff member, generated for the larger department. There is a compassionate, altruistic core of medical practice—sitting with a grieving family after a loved one is lost; lending your experience to a younger colleague struggling to manage a complex case; telephoning a patient and listening to how she is faring after surgery and chemotherapy for her breast cancer; extending yourself beyond the usual working day to help others because that is much of what it means to be a doctor. But not one minute of such time may be accountable for reimbursement on a bean counter's balance sheet.^[5]

Still, I wondered whether my diagnosis of the ills of modern medicine was accurate. Perhaps I was weighed down by nostalgia, my perspective a product of selective hindsight. Certainly, coldly mercenary physicians were familiar in classical narratives of illness. Tolstoy satirized "celebrity doctors" who were well paid for offering Ivan Ilych ridiculous remedies for his undiagnosed malady while ignoring his suffering. Turgenev in "The Country Doctor" depicted an unctuous provincial physician whose degree of engagement with the sick was tied to the size of their pocketbook. Molière repeatedly lampooned the folly of pompous and greedy physicians.

Such doctors have been members of the profession since its founding. And it would be naive to believe that money is not one part of the exchange between physician and patient. But only recently has medical care been recast in our society as if it took place in a factory, with doctors and nurses as shift workers, laboring on an assembly line of the ill. The new people in charge, many with degrees in management economics, believe that care should be configured as a commodity, its contents reduced to equations, all of its dimensions measured and priced, all patient choices formulated as retail purchases. The experience of illness is being stripped of its symbolism and meaning, emptied of feeling and conflict. The new era rightly embraces science but wrongly relinquishes the soul.

In his book Carrying the Heart, Dr. Frank González-Crussi, a professor of pathology at Northwestern University, has made a sharp departure from medicine as a cold world of clinical facts and figures. Rather, he asks us to return to a view of the body not as a machine but as a wondrous work of creation, where both the corporeal and the spiritual coexist. His aim, he writes, is

to increase the public's awareness of the body's insides. By this, I do not mean the objective facts of anatomy, for most educated people today have a general, if limited, understanding of the body's parts and functions. I mean the history, the symbolism, the reflections, the many ideas, serious or fanciful, and even the romance and lore with which the inner organs have been surrounded historically.

This précis captures the beauty and charm of his book. I learned from González-Crussi that for centuries the stomach was considered the most noble of organs, directing all important physiological functions. The ancients, González-Crussi tells us, called the stomach "the king of viscera," "the senate or the patrician class; the bodily parts were the rebellious plebeians." Shakespeare repeats this fable in Coriolanus, where the stomach lectures the rest of the body's organs about the importance of its function.

Our gastric elements were seen as having a leading part in joy and adversity, and were the seat of the soul—predating the belief that the spirit was housed in the heart or the brain. This regal position was ultimately relinquished through the observations of Dr. William Beaumont in 1822. Beaumont studied a young French-Canadian named Alexis St. Martin, who suffered an accidental musket shot to the belly. He was left with a perforation some two and a half inches in circumference, through which the doctor could look into the living stomach and perform experiments on its workings. Via this "stomach window," the physiology of the organ was gradually deciphered, and its fabled status faded.

No part of our anatomy, González-Crussi recounts, has failed to fascinate poets, priests, and philosophers—including the working of the colon. In the chapter on feces, we learn that the Chinese had a divinity of the toilet. "This was Zi-gu, 'the violet lady.' She was not entirely fictional," González-Crussi writes,

but took her origin from a flesh-and-blood woman who lived about AD 689. To her misfortune, she was made the concubine of a high government official, Li-Jing. The man's legitimate wife, overcome by jealousy, killed Zi-gu in cold blood while she was visiting the toilet. Since then, her ghost has haunted the latrines, "a most inconvenient circumstance for anyone in a hurry."

The colon and its product also were part of the theology of the Aztecs. They believed that excrement

was capable of bringing ills and misfortune, and associated with sin, but also powerful and beneficent, able to ward off disease, to subdue the enemy, and to transform sexual transgressions into something useful and healthy.

Gold was termed "the sun's excrement" and the sun god Tonatiuh deposited his own feces in the form of this precious element in the earth while he passed through to the underworld.

González-Crussi also reminds us that there was an inordinate fixation on one's bowels during the Victorian age, which honored values of order, temperance, respect for tradition, and sexual repression. Personal self-control, the mark of British culture, was at odds with that urgent process of expelling air and waste:

Perhaps no greater ambivalence has ever existed toward the bowel than in Victorian England, where this organ was viewed with simultaneous skittish embarrassment and fascination, shame and fixed interest, shy modesty and hypnotic engrossment.

A shocking consequence of this cultural tension is that one of the most proficient surgeons of the era, William Arbuthnot Lane, who devised procedures to successfully set compound fractures, concluded that without a colon, man would free himself from inner toxins and extend his health and longevity. A natural physiological function became a pseudodisease. Initially, Lane devised operations to bypass the large bowel, and he then moved on to perform total colectomies. Patients flocked to him from all over Great Britain and abroad, certain that their lives would be more salubrious and fulfilling without their large intestine.

González-Crussi treats with similar scholarship and playful insight the uterus, the penis, the lungs, and the heart. He melds history with literature, religion with science, high humor with serious concerns. The sum of his narrative shows that medicine does not exist as some absolute ideal, but is very much a product of the prevailing culture, affected by the prejudices and passions of the time. This truth is far from the sterile conception of care as a commodity and the body as a jumble of molecules, disconnected from the experience of illness shared between patient and physician. But our culture, with its worship of technology and its deference to the technocrat, risks imposing an approach to medical care that ignores the deeply felt symbolism of our body parts and our desperate search for meaning when we suffer from illness. Patients—their problems, perceptions, and preferences—cannot be reduced to lifeless numbers. Ironically, the emerging quantitative view of medicine is as misleading as are the past conceptions González-Crussi presents.

Jonathan Edlow is concerned with the doctor not as poet or philosopher or priest but as detective. An emergency room physician at the Beth Israel Deaconess Medical Center, a Harvard teaching hospital in Boston where I also work, Edlow recounts how as a teenager with no interest in a medical career, he received a copy of Berton Roueché's The Medical Detectives. This anthology of articles from The New Yorker proved for him to be a companion to the Complete Stories of Sherlock Holmes. Arthur Conan Doyle, of course, was trained as a physician, and the skills of Holmes are precisely those a thinking physician needs. Both detective and doctor not only assemble evidence but must judiciously weigh what they have found, seeking the underlying value of each clue. The successful doctor-detective must be alert to biases that can lead him astray. This was the message of the clinical conference those months ago; and in Edlow's tales of difficult diagnoses, we can observe detours that are due to "anchoring," "availability," and "attribution."

Notably, the collection of cases in Edlow's book The Deadly Dinner Party takes us out of the clinic and into the field, as epidemiologists and infectious disease experts from the Centers for Disease Control and academic medical centers comb for clues in cooking pots that served a communal dinner and in the caverns of office buildings where workers fell ill. In his chapter "An Airtight Case," Edlow implicitly shows why so many of the standard formulas that policymakers promulgate fall short when answers are not obvious. He describes how an office worker (whom he calls Philip Bradford) thought he had developed "the flu—the usual cough, fevers, chest pain, just feeling lousy...." What appeared to be the symptoms of a typical viral illness did not spontaneously disappear. A chest X-ray showed pneumonia, but treatment with antibiotics proved ineffective. The presumptive diagnosis changed from infection to cancer, and Bradford was told by his doctor that he needed his chest opened to resect a piece of lung and identify the tumor.

Fortunately, the patient sought a second opinion, from a senior thoracic surgeon, and the diagnosis was again thrown into doubt—the specialist believed that the problem was neither infection nor an abnormal growth. Over the ensuing months, the mysterious pneumonia spontaneously cleared up, but after a year Bradford again started coughing and running a fever. "His chest X-ray blossomed with ominous nodules," Edlow writes, "then, as with the previous episode, after a few weeks his symptoms mysteriously vanished."

It was the good fortune of this ill office worker with the mysterious lung problem to see Dr. Robert H. Rubin, an infectious disease specialist at the Massachusetts General Hospital, at the time the director of the hospital's clinical investigation program. As Rubin recounts his deciphering of the ultimate diagnosis, what is striking is his "low-tech" thinking: "I was immediately impressed by three aspects of the case," Rubin recalled.

First was that Bradford appeared healthy and athletic, not the picture of someone with a chronic disease. Second, between episodes, he continued to jog over five miles with no apparent problem. And third, his physical examination was normal.

With such comments, we are a universe away from sophisticated blood tests and CT scans, and deeply rooted in the world of the physician's five senses. The most seasoned clinicians teach that the patient tells you his diagnosis if only you know how to listen. The clinical history, beyond all other aspects of information gathering, holds the most clues. And it is this part of medicine—the patient's narrative, the onset and tempo of the illness, the factors that exacerbated the symptoms and those that ameliorated them, the foods the patient ate, the clothing he wore, the people he worked with, the trips he took, the myriad of other events that occurred before, during, and after the malady—that are as vital as any DNA analysis or MRI investigation.

Rubin concentrated that kind of questioning and listening on Bradford. He did not quickly dispatch him for more tests, but instead sharply shifted his focus to investigate clues in Bradford's environment that could reveal what was causing inflammation in his lungs. Edlow goes on to write in clear and fluid prose about how Rubin systematically pursued what could be the agent provocateur in the case. The lengths to which Rubin went are extraordinary, his skill in eliciting and interpreting the patient's narrative exemplary, and certainly not part of the rushed practice of today's clinic. I won't spoil the end of the story; what is important is that the solution came about only by dogged thinking that required the kind of time and inquiry that is absent in much of modern medical care.

The other detective stories in Edlow's compilation transmit the same message: we most need a discerning doctor when a diagnosis is not obvious, when the clues are confusing, when initial tests are inconclusive. No simple technology can serve as a surrogate for the probing human mind. Edlow's book is a welcome complement to González-Crussi's. Both show us that medicine is truly an art and a science that requires doctors both to decipher the mystery and illuminate the meaning of the body in health and disease.

Notes

^[1]There has been a national focus on medical mistakes since the release of a report from the Institute of Medicine of the National Academy of Sciences, "To Err Is Human: Building a Safer Health System" (National Academies Press, 1999). Important measures have been implemented to improve patient safety in hospitals and clinics. But this report did not address the issue of misdiagnosis. See also Jerome Groopman, How Doctors Think. Houghton Mifflin, 2007); Pat Croskerry, "The Cognitive Imperative: Thinking About How We Think," Academic Emergency Medicine, Vol. 7, No. 11 (2000); Donald A. Redelmeier et al., "Problems for Clinical Judgement: Introducing Cognitive Psychology as One More Basic Science," Canadian Medical Association Journal, Vol. 164, No. 3 (2001).

^[2]Amos Tversky and Daniel Kahneman, "Judgment Under Uncertainty: Heuristics and Biases: Bias in Judgments Reveals Some Heuristics of Thinking Under Uncertainty," Science, Vol. 185, No. 4157 (1974).

^[3]In addition, there is serious concern about the influence of the pharmaceutical and device industry in the formulation of clinical guidelines. There is no one process to craft such guidelines, nor is there agreement about limits on conflict of interest and types of funding to support the expert committees reviewing clinical trials and selecting what constitutes "best evidence." The Institute of Medicine recently released a report on this issue that recommends strict measures to avoid financial conflicts in crafting clinical guidelines: "Conflicts of Interest in Medical Research, Education, and Practice" (National Academies Press, 2009). See also David Aron and Leonard Pogach, "Transparency Standards for Diabetes Performance Measures," JAMA, Vol. 301, No. 2 (2009); and Barry Meier, "Diabetes Case Shows Pitfalls of Treatment Rules," The New York Times, August 17, 2009.

^[4]Dr. Stanley Joel Reiser, in his recent book Technological Medicine: The Changing World of Doctors and Patients. Cambridge University Press, 2009), documents how the introduction of each new technology in the clinic, beginning with the stethoscope and extending to our era with MRI scans and electronic medical records, is initially enthusiastically greeted by both physicians and the public, but can impair the doctor in his relationship with the patient by forming a barrier to direct communication.

^[5]Pamela Hartzband and Jerome Groopman, "Money and the Changing Culture of Medicine," The New England Journal of Medicine, Vol. 360, No. 2 (2009).