Health Care: Who Knows 'Best'?

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By Jerome Groopman

One of the principal aims of the current health care legislation is to improve the quality of care. According to the President and his advisers, this should be done through science. The administration's stimulus package already devoted more than a billion dollars to "comparative effectiveness research," meaning, in the President's words, evaluating "what works and what doesn't" in the diagnosis and treatment of patients.

But comparative research on effectiveness is only part of the strategy to improve care. A second science has captured the imagination of policymakers in the White House: behavioral economics. This field attempts to explain pitfalls in reasoning and judgment that cause people to make apparently wrong decisions; its adherents believe in policies that protect against unsound clinical choices. But there is a schism between presidential advisers in their thinking over whether legislation should be coercive, aggressively pushing doctors and patients to do what the government defines as best, or whether it should be respectful of their own autonomy in making decisions. The President and Congress appear to be of two minds. How this difference is resolved will profoundly shape the culture of health care in America.

The field of behavioral economics is rooted in the seminal work of Amos Tversky and Daniel Kahneman begun some three decades ago. Drawing on data from their experiments on how people process information, particularly numerical data, these psychologists challenged the prevailing notion that the economic decisions we make are rational. We are, they wrote, prone to incorrectly weigh initial numbers, draw conclusions from single cases rather than a wide range of data, and integrate irrelevant information into our analysis. Such biases can lead us astray.

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The infusion of behavioral economics into public policy is championed by Cass Sunstein, a respected professor of law and longtime friend of President Obama; he is now in the White House, overseeing regulatory affairs, and will have an important voice in codifying the details of any bill that is passed. In Nudge: Improving Decisions About Health, Wealth, and Happiness, Sunstein and Richard Thaler, a professor of behavioral science and economics at the University of Chicago, propose that people called "choice architects" should redesign our social structures to protect against the incompetencies of the human mind.^[1] Those who understand thinking better can make life better for us all.

Thaler and Sunstein build on behavioral economic research that reveals inertia to be a powerful element in how we act. Most people, they argue, will choose the "default option"—i.e., they will follow a particular course of action that is presented to them instead of making an effort to find an alternative or opt out. Further, they write,

These behavioral tendencies toward doing nothing will be re- inforced if the default option comes with some implicit or explicit suggestion that it represents the normal or even the recommended course of action.

Sunstein and Thaler propose to use default options as "nudges" in the service of "libertarian paternalism." For example, to promote a healthy diet among teenagers, broccoli and carrots would be presented at eye level in the cafeteria and would be easily available, while it would take considerable effort for students to locate junk food, thereby nudging them into accepting a healthier diet. But all choices should be "libertarian"—people should be free to opt out of "undesirable arrangements if they want to do so." The soft paternalistic nudge Sunstein and Thaler envisage should try "to influence choices in a way that will make choosers better off, as judged by themselves." They are very clear that nudges are not mandates, and that behavior should not be forcefully directed by changing economic incentives. Your doctor should not be paid less if she follows a course of treatment that she can defend as reasonable, even if she deviates from officially issued guidelines. To prevent policy planners from going down the slippery slope of coercion, there should, in Sunstein's view, be safety rails. Whatever the proposal put forward, he has written, people must retain "freedom of choice" and be able to oppose the more objectionable kinds of government intervention.

Such freedom of choice, however, is not supported by a second key Obama adviser, Peter Orszag, director of the Office of Management and Budget. In June 2008, testifying before Max Baucus's Senate Finance Committee, Orszag—at the time director of the Congressional Budget Office—expressed his belief that behavioral economics should seriously guide the delivery of health care. In subsequent testimony, he made it clear that he does not trust doctors and health administrators to do what is "best" if they do no more than consider treatment guidelines as the "default setting," the procedure that would generally be followed, but with freedom to opt out. Rather, he said,

To alter providers' behavior, it is probably necessary to combine comparative effectiveness research with aggressive promulgation of standards and changes in financial and other incentives. [Emphasis added.]

The word "probably" is gone in the Senate health care bill. Doctors and hospitals that follow "best practices," as defined by government-approved standards, are to receive more money and favorable public assessments. Those who deviate from federal standards would suffer financial loss and would be designated as providers of poor care. In contrast, the House bill has explicit language repudiating such coercive measures and protecting the autonomy of the decisions of doctors and patients.^[2]

On June 24, 2009, when President Obama convened a meeting on health care at the White House, Diane Sawyer of ABC News asked him whether federally designated "best practices" would be mandated or simply suggested. That is, would he recommend Orszag's shove or Sunstein's nudge?

Obama: ...Let's study and figure out what works and what doesn't. And let's encourage doctors and patients to get what works. Let's discourage what doesn't. Let's make sure that our payment incentives allow doctors to do the right thing. Because sometimes our payment incentives don't allow them to do the right things. And if we do that, then I'm confident that we can drive down costs significantly.

Sawyer: Will it just be encouragement? Or will there be a board making Solomonic decisions... about best practices?

Obama: What I've suggested is that we have a commission... made up of doctors, made up of experts, that helps set best practices.

Sawyer: By law?

Obama: ...If we know what those best practices are, then I'm confident that doctors are going to want to engage in best practices. But I'm also confident patients are going insist on it.... In some cases, people just don't know what the best practices are. And certain cultures build up. And we can change those cultures, but it's going to require some work.

Sawyer: But a lot of people... say..."I'm very concerned that there's going be a reduction in treatment someplace in all of this." And the question is if there is a board that is recommending, that's one thing. If there is a board that is dictating through cost or through some other instruction, that's another thing. Will it have the weight of law? Will it have the weight of regulations?

Obama: ...I don't think that there's anybody who would argue for us continuing to pay for things that don't make us feel better. That doesn't make any sense. [Yet] that's the reason why, in America, we typically pay 50 percent more for our health care than other advanced countries that actually have better health care outcomes.

Still, the President appears not to be entirely in Orszag's camp. He has repeatedly deflected accusations of a "government takeover of health care" by asserting that no federal bureaucrat will come between the doctor and patient in clinical decision-making. The President has also repeatedly told physicians that reform would sustain them as healers, not make them into bean counters and paper pushers. In an interview on NPR two days before passage of the Senate bill, the President said that changes in how doctors and patients think about health care should come from giving them the "best information possible" and did not invoke the coercive measures favored by Orszag.

How do we reconcile this apparent difference between Sunstein and Orszag? The President contends that sound policies are built on data, but which data? Here the evidence is strongly in favor of Sunstein and his insistence on the need for freedom of choice and retaining the ability to oppose objectionable forms of government intervention. Over the past decade, federal "choice architects"—i.e., doctors and other experts acting for the government and making use of research on comparative effectiveness—have repeatedly identified "best practices," only to have them shown to be ineffective or even deleterious.

For example, Medicare specified that it was a "best practice" to tightly control blood sugar levels in critically ill patients in intensive care. That measure of quality was not only shown to be wrong but resulted in a higher likelihood of death when compared to measures allowing a more flexible treatment and higher blood sugar. Similarly, government officials directed that normal blood sugar levels should be maintained in ambulatory diabetics with cardiovascular disease. Studies in Canada and the United States showed that this "best practice" was misconceived. There were more deaths when doctors obeyed this rule than when patients received what the government had designated as subpar treatment (in which sugar levels were allowed to vary).

There are many other such failures of allegedly "best" practices. An analysis of Medicare's recommendations for hip and knee replacement by orthopedic surgeons revealed that conforming to, or deviating from, the "quality metrics"—i.e., the supposedly superior procedure—had no effect on the rate of complications from the operation or on the clinical outcomes of cases treated. A study of patients with congestive heart failure concluded that most of the measures prescribed by federal authorities for "quality" treatment had no major impact on the disorder. In another example, government standards required that patients with renal failure who were on dialysis had to receive statin drugs to prevent stroke and heart attack; a major study published last year disproved the value of this treatment.

Other "quality measures" recommended by the government were carried out in community health centers to improve the condition of patients with asthma, diabetes, and hypertension. The conclusion of subsequent research was that there was, as a result, no change in outcome for any of these three disorders. Finally, Medicare, following the recommendations of an expert panel, specified that all patients with pneumonia must receive antibiotics within four hours of arrival at the emergency room. Many doctors strongly disagreed with such a rigid rule, pointing out that an accurate diagnosis cannot be made so quickly, and the requirement to treat within four hours was not based on convincing evidence. But the government went ahead, and the behavior of physicians was altered by the new default setting—for the worse. Many cases of heart failure or asthma, where the chest X-ray can resemble a pulmonary infection, were wrongly diagnosed as pneumonia; the misdiagnosed patients were given high doses of antibiotics, resulting in some cases of antibiotic-induced colitis. The "quality measure" was ultimately rescinded.^[3]

What may account for the repeated failures of expert panels to identify and validate "best practices"? In large part, the panels made a conceptual error. They did not distinguish between medical practices that can be standardized and not significantly altered by the condition of the individual patient, and those that must be adapted to a particular person. For instance, inserting an intravenous catheter into a blood vessel involves essentially the same set of procedures for everyone in order to assure that the catheter does not cause infection. Here is an example of how studies of comparative effectiveness can readily prove the value of an approach by which "one size fits all." Moreover, there is no violation of autonomy in adopting "aggressive" measures of this kind to assure patient safety.

But once we depart from such mechanical procedures and impose a single "best practice" on a complex malady, our treatment is too often inadequate. Ironically, the failure of experts to recognize when they overreach can be explained by insights from behavioral economics. I know, because I contributed to a misconceived "best practice."

My early research involved so-called growth factors: proteins that stimulate the bone marrow to produce blood cells. I participated in the development of erythropoietin, the red cell growth factor, as a treatment for anemic cancer patients. Erythropoietin appeared to reduce the anemia, lessening the frequency of transfusion. With other experts, I performed a "meta-analysis," i.e., a study bringing together data from multiple clinical trials. We concluded that erythropoietin significantly improved the health of cancer patients and we recommended it to them as their default option. But our analysis and guidelines were wrong. The benefits ultimately were shown to be minor and the risks of treatment sometimes severe, including stroke and heart attack.^[4]

After this failure, I came to realize that I had suffered from a "Pygmalion complex." I had fallen in love with my own work and analytical skills. In behavioral economics, this is called "overconfidence bias," by which we overestimate our ability to analyze information, make accurate estimates, and project outcomes. Experts become intoxicated with their past success and fail to be sufficiently self-critical.

A second flaw in formulating "best practices" is also explained by behavioral economics—"confirmation bias." This is the tendency to discount contradictory data, staying wed to assumptions despite conflicting evidence. Inconsistent findings are rationalized as being "outliers." There were, indeed, other experts who questioned our anemia analysis, arguing that we had hastily come to a conclusion, neglecting findings that conflicted with our position. Those skeptics were right.^[5]

Yet a third powerful bias identified in behavioral economics can plague expert panels: this is the "focusing illusion," which occurs when, basing our predictions on a single change in the status quo, we mistakenly forecast dramatic effects on an overall condition. "If only I moved from the Midwest to sunny California, I would be so much happier" is a classical statement of a focusing illusion, proven to be such by studies of people who have actually moved across the country. Another such illusion was the prescription of estrogen as the single remedy to restore feminine youth and prevent heart disease, dementia, and other complications of the complex biology of aging.^[6] Such claims turned out to be seriously flawed.

There is a growing awareness among researchers, including advocates of quality measures, that past efforts to standardize and broadly mandate "best practices" were scientifically misconceived. Dr. Carolyn Clancy of the Agency for Healthcare Research and Quality, the federal body that establishes quality measures, acknowledged that clinical trials yield averages that often do not reflect the "real world" of individual patients, particularly those with multiple medical conditions. Nor do current findings on best practices take into account changes in an illness as it evolves over time. Tight control of blood sugar may help some diabetics, but not others. Such control may be prudent at one stage of the malady and not at a later stage. For years, the standards for treatment of the disease were blind to this clinical reality.^[7]

Orszag's mandates not only ignore such conceptual concerns but also raise ethical dilemmas. Should physicians and hospitals receive refunds after they have suffered financial penalties for deviating from mistaken quality measures? Should public apologies be made for incorrect reports from government sources informing the public that certain doctors or hospitals were not providing "quality care" when they actually were? Should a physician who is skeptical about a mandated "best practice" inform the patient of his opinion? To aggressively implement a presumed but still unproven "best practice" is essentially a clinical experiment. Should the patient sign an informed consent document before he receives the treatment? Should every patient who is treated by a questionable "best practice" be told that there are credible experts who disagree with the guideline?

But even when there are no coercive measures, revising or reversing the default option requires a more complicated procedure than the one described by the President at the White House meeting. In November, the United States Preventive Services Task Force, reversing a long-standing guideline, recommended that women between the ages of forty and forty-nine do not need to have routine mammograms. To arrive at this conclusion, researchers made both a meta-analysis and computer models of data from seven clinical trials. The task force found that routine mammograms result in a 15 percent reduction in the relative risk of death from breast cancer for women in the forty to forty-nine age group, a similar level of benefit as in earlier analyses. For women in their forties, this means one life is saved for every 1,904 women screened. For older women in their fifties, one life is saved for every 1,359 women screened.^[8]

If these estimates are correct, then how many lives might be saved in the United States for each age group if every woman received a mammogram? The 2008 US Census estimates the number of women between forty and forty-nine at 22.3 million. So if mammography were available to all these women, nearly 12,000 deaths could be potentially averted during these ten years in their lives. As for the 20.5 million women in their fifties, some 15,000 deaths could potentially be averted.

What are the risks of mammography for women in their forties? The task force estimated a higher rate of false positive findings in mammograms in women in their forties compared to older women. This translates into increased anxiety when women are told that there may be a cancer and there is not. A false positive reading may also result in a woman having a biopsy. For every case of invasive breast cancer in a young woman diagnosed by mammography, five women with benign findings will have biopsies. In addition, there are potential risks of radiation from the mammogram itself, although no one really knows how significant these are. Then there is an unanswered question in the biology of breast cancer: Which tumors are indolent and which are aggressive? We lack the molecular tools to distinguish between slow- and fast-growing cancers. Some slow-growing ones detected in young women might be treated later in life without any disadvantage in the rate of survival. But aggressive breast cancers in young women are notoriously difficult to treat and frequently result in death. And as with essentially all screening tests in a population, the majority of women receiving mammograms do not have any disorder.

These, roughly, are the statistics and state of the science with regard to breast cancer. How do we weigh the evidence and apply it to individuals and to society at large? Setting the default option that doctors will present to patients requires us to make value judgments. Dr. Otis Brawley of the American Cancer Society, an oncologist who worked for decades at the National Cancer Institute, is well versed in preventive care; he disagrees with the new default setting, based on findings that mammograms save lives. (Brawley also happens to be an African-American and has long been concerned about the meager access among minority and poor groups to potentially lifesaving screenings.)

Dr. Diana Petitti, a professor of bioinformatics at Arizona State University and vice-chair of the task force, appeared with Brawley on November 17, 2009, on the PBS NewsHour. She had no disagreement with him about what the studies show, and emphasized that the task force did not say that women in their forties should not get mammograms, only that they were no longer routinely recommended since the benefit to patients did not clearly outweigh the risks. Cost considerations were not part of the task force's deliberations.

Other supporters of the new recommendations took a less temperate view. A statistician who developed computer models for the task force told The New York Times that "this decision is a no-brainer."^[9] It did not appear to be so clear to Melissa Block of NPR when she interviewed an internist who agreed with the task force. The doctor said that stopping routine mammography for young women would spare them anxiety, distress, and unnecessary biopsies. Block replied, "I've heard this before.... When people say, you know, there's unnecessary anxiety and false positives and fear and worry." That, she said, is "a very patronizing approach to take toward women's health.... Women may very well be willing to assume those harms if it means that they may be diagnosed earlier." The internist replied that each woman should talk with her doctor and figure out what is best.^[10] Sunstein's Nudge coauthor, the behavioral economist Richard Thaler, wrote a thoughtful analysis of the pros and cons of mammography in The New York Times and concluded that "one can make a good case that we don't want the government making these choices" for us.^[11]

Two days after the task force recommendations were released, Health and Human Services Secretary Kathleen Sebelius put some distance between the Obama administration and the task force's conclusions, saying:

My message to women is simple. Mammograms have always been an important life-saving tool in the fight against breast cancer and they still are today. Keep doing what you have been doing for years....

Dr. Petitti later appeared before Congress to apologize for any "confusion" caused by the task force report. Petitti was not recanting a scientific truth. She correctly described the new recommendations as "qualitative." That is, they were offered as value judgments that could be modified or revised; and the political process offers one way of doing so. As Sunstein has written, if default options embody standards that many people judge as not better for themselves, those standards can be changed.

Shortly after the new mammography guidelines were announced, an expert panel of obstetricians and gynecologists recommended that teenage girls no longer have routine pap smears for cervical cancer.^[12] The incidence of deadly cervical cancer among teens is at most one in a million and screening does not appear to save that one life. When false positive results from screenings are followed by cervical surgery, the risk may be injury that can predispose a young woman to later premature labor. There was no public uproar following this changed default setting for many women. It was consistent with how most people value the benefit of lives saved versus risks incurred. This is the reality of "comparative effectiveness" research. It is not simply a matter of "what works and what doesn't." Nor will patients always "insist" on being treated according to what experts define as "best practice." They should be aware that there are numerous companies, some of them "not for profit," issuing standards for treatment that are congenial to the insurance industry but are often open to the kinds of counterevidence I have described here.

What of the President's statement that doctors will want to engage in federally approved "best practices"? The American College of Physicians, composed of internists, agreed with the task force conclusions about mammography. The American Society of Clinical Oncology, representing oncologists, did not. I am a member of both professional organizations. What do I do? As a physician who has cared for numerous young women with breast cancer, many dying an untimely death, my bias was that the dangers of mammograms do not outweigh the reduction in mortality. Notably, the oncologists who head the breast cancer programs at Minnesota's Mayo Clinic and Utah's Intermountain Health—described by President Obama as pinnacles of quality care using guidelines—also disagreed with the task force.

Such challenges to "best practice" do not imply that doctors should stand alone against received opinion. Most physicians seek data and views on treatments from peers and, as needed, specialists, and then present information and opinion to patients who ultimately decide.

While costs were not part of the task force calculations, they prominently entered the national debate on them. Dr. Robert Truog of Boston Children's Hospital allowed that mammography saves lives, but asked if it is "cost effective."^[13] That is, should policy planners set a price on saving those young women?

Cost-effectiveness is going to be a hard sell to the American public, not only because of the great value placed on each life in the Judeo-Christian tradition, but because the federal government has devoted many hundreds of billions of dollars to bail out Wall Street. To perform mammograms for all American women in their forties costs some $3 billion a year, a pittance compared to the money put into the bank rescue. The Wall Street debacle also made many Americans suspicious of "quants," the math whizzes who developed computer models that in theory accurately assessed value in complex monetary instruments but in fact nearly brought down the worldwide financial system. When a medical statistician says that imposing a limit on mammography is a "no-brainer," people may recall George Tenet's claim that the case for invading Iraq was a "slam-dunk."

At the White House gathering, the President portrayed comparative effectiveness as equivalent to cost- effectiveness, noting that other countries spend half of what we do by only paying for "what works." This contention is not supported by evidence. Theodore Marmor, a professor of health care policy at Yale, writes in Fads, Fallacies and Foolishness in Medical Care Management and Policy that movements for "quality improvement" in Britain have failed to reduce expenditures.^[14] Marmor, with Jonathan Oberlander, a professor at the University of North Carolina, has written in these pages that the President has offered up rosy scenarios to avoid the harsh truth that there is no "painless cost control."^[15] Lower spending in countries like France and Germany is accounted for not by comparative effectiveness studies but by lower costs of treatment attained through their systems of medical care and by reduced medical budgets. In Europe, prescription drugs cost between 50 and 60 percent of what they do in the US, and doctor's salaries are lower. (Insurance premiums also are tightly constrained.) France and Germany have good records in health care, but in Great Britain, where costs are strictly controlled by the National Health Service, with rationing of expensive treatments, outcomes for many cancers are among the worst in Europe.^[16]

The care of patients is complex, and choices about treatments involve difficult tradeoffs. That the uncertainties can be erased by mandates from experts is a misconceived panacea, a "focusing illusion." If a bill passes, Cass Sunstein will be central in drawing up the regulations that carry out its principles. Let's hope his thinking prevails.

—January 14, 2010

Notes

^[1]Yale University Press, 2008; See the review in these pages by John Cassidy, "Economics: Which Way for Obama?," June 12, 2008.

^[2]On June 16, 2008, at the Health Reform Summit of the Senate Finance Committee, Orszag explicitly invoked behavioral economics to explain some of the deficiencies in American health care and as the basis for legislative interventions that would remedy rapidly escalating costs and gaps in quality.

On August 7, 2008, addressing the Retirement Research Consortium in Washington, D.C., Orszag presented "Behavioral Economics: Lessons from Retirement Research for Health Care and Beyond." Here, he states the likely need for aggressive measures. The Senate Finance Committee, under Max Baucus, was widely reported to have worked closely with the White House, and many of Orszag's proposals are prominent in the bill that Majority Leader Harry Reid brought to the floor. See Senate Bill HR 3590, Title III—Improving the Quality and Efficiency of Health Care.

The House rejected many of the ideas from the President's advisers in favor of safeguards on patient–physician autonomy, causing Rahm Emanuel, the White House chief of staff, to quip that politics trumps "ideal" plans made in the shade of the "Aspen Institute." See Sheryl Gay Stolberg, "Democrats Raise Alarms over Health Bill Costs," The New York Times, November 9, 2009. Explicit language in the House bill is intended to safeguard patient–physician autonomy. See House Bill HR 3962, Title IV—Quality; Subtitle A—Comparative Effectiveness Research.

^[3]These results, respectively, come from the NICE-SUGAR Study Investigators, "Intensive versus Conventional Glucose Control in Critically Ill Patients," The New England Journal of Medicine, March 26, 2009; Silvio E. Inzucchi and Mark D. Siegel, "Glucose Control in the ICU—How Tight Is Too Tight?," The New England Journal of Medicine, March 26, 2009; the Action to Control Cardiovascular Risk in Diabetes Study Group, "Effects of Intensive Glucose Lowering in Type 2 Diabetes," The New England Journal of Medicine, June 12, 2008; the ADVANCE Collaborative Group, "Intensive Blood Glucose Control and Vascular Outcomes in Patients with Type 2 Diabetes," The New England Journal of Medicine, June 12, 2008; Robert G. Dluhy and Graham T. McMahon, "Intensive Glycemic Control in the ACCORD and ADVANCE Trials," The New England Journal of Medicine, June 12, 2008; Gregg C. Fonarow et al., "Association Between Performance Measures and Clinical Outcomes for Patients Hospitalized with Heart Failure," The Journal of the American Medical Association, January 3, 2007; Bengt C. Fellström et al., for the AURORA Study Group, "Rosuvastatin and Cardiovascular Events in Patients Undergoing Hemodialysis," The New England Journal of Medicine, April 2, 2009; Bruce E. Landon et al., "Improving the Management of Chronic Disease at Community Health Center," The New England Journal of Medicine, March 1, 2007; Rodney A. Hayward, "Performance Measurement in Search of a Path," The New England Journal of Medicine, March 1, 2007; Robert M. Wachter et al., "Public Reporting of Antibiotic Timing in Patients with Pneumonia: Lessons from a Flawed Performance Measures," Annals of Internal Medicine, July 1, 2008.

^[4]The clinical development of other growth factors, like G-CSF for a low white blood cell count, fared better. G-CSF is a valuable treatment for many cancer patients, but, of course, not all.

^[5]Contradictory evidence reverses "best practices" so frequently that within one year 15 percent must be changed, within two years, 23 percent are reversed, and at 5.5 years, half are incorrect. See Kaveh G. Shojania et al., "How Quickly Do Systematic Reviews Go Out of Date? A Survival Analysis," Annals of Internal Medicine, August 21, 2007.

^[6]Focusing illusions are wonderfully illuminated by Daniel Gilbert, Stumbling on Happiness (Knopf, 2006). Also see the role of marketing in fostering the illusion: Natasha Singer and Duff Wilson, "Menopause, as Brought to You by Big Pharma," The New York Times, December 13, 2009. See also David A. Schkade and Daniel Kahneman, "Does Living in California Make People Happy? A Focusing Illusion in Judgments of Life Satisfaction," Psychological Science, September 1998.

^[7]Dr. Clancy seeks new statistical methods to analyze heterogeneous groups of "real world" patients, so treatment guidelines become "personalized," delivering "the right treatment to the right patient at the right time." (See Patrick H. Conway and Carolyn Clancy, "Comparative-Effectiveness Research —Implications of the Federal Coordinating Council's Report," The New England Journal of Medicine, July 23, 2009; Harold C. Sox and Sheldon Greenfield, "Comparative Effectiveness Research: A Report From the Institute of Medicine," Annals of Internal Medicine, August 4, 2009.) This is a laudable goal and deeply attractive. It is more likely to come from basic science that classifies patients based on their genetic characteristics rather than statistics. Past attempts at observing groups of "real world" patients have often generated conclusions that were flawed, mistaking correlation for causation. A valiant attempt to apply research on comparative effectiveness to prostate cancer treatment options came up against similar hurdles. See Jenny Marder, "A User's Guide to Cancer Treatment," Science, November 27, 2009.

^[8]US Preventive Services Task Force, "Screening for Breast Cancer: US Preventive Services Task Force Recommendation Statement," Annals of Internal Medicine, November 17, 2009; Heidi D. Nelson et al., "Screening for Breast Cancer: An Update for the US Preventive Services Task Force," Annals of Internal Medicine, November 17, 2009; Jeanne S. Mandelblatt et al. for the Breast Cancer Working Group of the Cancer Intervention and Surveillance Modeling Network (CISNET), "Effects of Mammography Screening Under Different Screening Schedules: Model Estimates of Potential Benefits and Harms, Annals of Internal Medicine, November 17, 2009.

^[9]Gina Kolata, "In Reversal, Panel Urges Mammograms at 50, not 40," The New York Times, November 17, 2009. A detailed summation of the controversy is found in The Cancer Letter, November 20 and December 4, 2009.

^[10]National Public Radio, All Things Considered, November 16, 2009.

^[11]Richard H. Thaler, "Gauging the Odds (and the Costs) in Health Screening," The New York Times, December 20, 2009.

^[12]acog Practice Bulletin, "Clinical Management Guidelines for Obstetrician-Gynecologists," Number 109, Obstetrics & Gynecology, December 2009; Denise Grady, "Guidelines Push Back Age for Cervical Cancer Tests," The New York Times, November 20, 2009.

^[13]Robert D. Truog, "Screening Mammography and the 'R' Word," The New England Journal of Medicine, December 24, 2009.

^[14]World Scientific, 2007.

^[15]"Health Reform: The Fateful Moment," The New York Review, August 13, 2009.

^[16]Theodore Marmor, Jonathan Oberlander, and Joseph White, "The Obama Administration's Options for Health Care Cost Control: Hope versus Reality," Annals of Internal Medicine, April 7, 2009; Donald M. Berwick, "Measuring Physicians' Quality and Performance, The Journal of the American Medical Association, December 9, 2009. A layman's journey seeking care abroad is described in the lively book by T.R. Reid. The Healing of America: A Global Quest for Better, Cheaper, and Fairer Health Care (Penguin, 2009). Concerning the uproar in Britain about poor cancer outcomes, see Nick Triggle, "NHS Must Get Better at Early Cancer Diagnosis," BBC News, November 30, 2009; Rebecca Smith, "Cancer Care on the NHS Falls Behind the Rest of Europe," The Daily Telegraph, November 30, 2009; NHS Department of Health, "Cancer Reform Strategy: Achieving Local Implementation—Second Annual Report," December 1, 2009.

Witness to Horror

Image by Steve Rhodes via Flickr

By Charles Simic

Stripping Bare the Body: Politics Violence War

by Mark Danner

Nation Books, 626 pp., $28.95

"We got no dog in this fight."

—Secretary of State James Baker after his failed mission to Yugoslavia in 1991

1.

Now that independent war correspondents are nearly an extinct species and we fight wars with fewer and fewer images of destruction and carnage shown on television or in newspapers, it's worth recalling that there was a time when this wasn't so. Before the Pentagon established the policy of embedding reporters with our armed forces—thus restricting their movement and making it harder for images and reports that do not fit the official narrative to appear—war correspondents were more or less on their own in war-torn countries, reporting what they saw and drawing their own conclusions. It was an extremely dangerous line of work. Between 1991 and 2001, forty-three journalists died in the Balkans, which is fewer than in Iraq, where between 2003 and 2009, 145 were killed in crossfire, suicide bombings, and premeditated murders by various participants in the conflict who didn't want reporters poking their noses where they shouldn't.

Beginning with the 1987 election that was supposed to bring democracy to Haiti after the bloody reign of the Duvaliers, and which resulted in another bloodbath, Mark Danner chronicles the even more violent conflicts in Bosnia and Croatia in the early 1990s, the post-invasion violence in Iraq, the torture in our secret prisons around the world, and the various policy decisions in Washington that had either a dire or beneficial impact on the people of those countries. These lengthy, well-researched, and well-written pieces, many of which appeared in these pages, combine political analysis, historical background, and Danner's eyewitness reporting to convey the vast human suffering behind events that can often seem remote.

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The title of the book comes from the former Haitian president Leslie Manigat, who took power from Duvalierist officers after they brutally aborted the 1987 election. He told Danner that political violence "strips bare the social body," allowing us to see beneath the surface to the real workings of a society. That is what makes this collection so fascinating to read. At the same time as we are being educated about these countries beset by violence, we are witnessing Danner's own education, his deepening understanding of the limits and unintended consequences of our military interventions.

Haiti was Danner's initiation. He arrived to cover the country's "transition to democracy" for The New Yorker in 1986, just after François "Papa Doc" Duvalier's son was flown to luxurious exile in France in an American military jet, courtesy of the Reagan administration. Danner naively expected, as he himself admits, that a freely held election and the popular government it would produce could break the cycle of military coups and dictators, in which a shy country doctor becomes a homicidal monster, a general with a stutter a drunken Caligula. He came to realize that

Violence is the motor of Haiti's politics, the means of regime change, the method of succession. The struggle for power is ongoing and endless, permeating all aspects of life and implicating any Haitian of wealth and reputation. "If a man does not go into politics," says the former president who gave me this book's title, "then politics itself comes to him." A professor, intellectual, and writer from an illustrious political family, he attained power thanks to the military after a bloody, aborted election, and lost it a few months later in a tumultuous coup d'etat.

History repeats itself in unhappy countries. The absence of respected institutions and well-established laws that a person can count on to protect him condemns these societies to reenact the same conflicts, make the same mistakes more than once, and bear the same horrific consequences of these acts. In Haiti, as a former finance minister told Danner, "The whole bloody business of repression, torture, and killing was developed to stay in office, in order to make money."

There are plenty of other places where this has been true and continues to be true, but such corruption is usually better concealed behind the veneer of law and order. In impoverished Haiti, with its sharp split between a small, educated ruling class that speaks French and the rest of the population who are illiterate and speak Creole (so they often do not understand what their president says to them), these harsh realities are, indeed, laid bare. The elder Duvalier, who ruled between 1957 and his death in 1971, believed there should be no boundaries in administering terror. One ought to kill not only one's enemies but also their friends, and in as spectacular and brutal a fashion as possible.

On Sunday, November 29, 1987, the day the election was aborted by General Henri Namphy, the head of the military junta that had ruled the country since the departure of the younger Duvalier, another stunning daylight massacre took place. Without a word of warning, soldiers opened fire on people waiting in line at polling places. The streets of Port-au-Prince were strewn with corpses of men, women, and children lying in pools of blood. In the countryside, it was the same. As a well-to-do woman told Danner over the phone, "'All this brings back Duvalier, the father.... You see,' she said after a pause, ' you think it was a massacre, but this was just a normal day under Duvalier.'"

American attempts to reshape politics in Haiti go back to 1915 when Marines were sent to put an end to the chaos of internal conflict. They stayed for nineteen years, declaring that the Haitian people were unfit to rule themselves. Americans seized land and created an army and police force that were supposed to prevent revolt and protect American capital. That was not the end. Papa Doc Duvalier received US military assistance during his first, bloodiest years. He got $40 million from Washington and the help of Marines to protect his regime from any popular movement that might threaten his rule.

In 1994, President Clinton ordered American forces to intervene to restore the elected president, Jean-Bertrand Aristide, to power after he was overthrown, protect American interests, and stop the atrocities. "Even sending twenty thousand US troops," as Danner writes, "failed to alter the fundamental dynamic." US soldiers did not confront the militiamen who kept their weapons since they did not want to risk American casualties. As for Aristide, he was flown by US helicopter back to the Presidential Palace, from which he ruled erratically, only to be flown a decade later into exile again.

2.

The pros and cons of American intervention were to become a pressing issue once more during the wars in the former Yugoslavia, which Danner reported on a few years after his visit to Haiti. The Dayton agreement brought peace to Bosnia and Herzegovina in November 1995, and almost four years later the NATO intervention in Kosovo and the bombing of Serbia took place. Danner, who spent time in Bosnia during the war, was pondering not just his own experience there, but looking back at the events that led to the secession and recognition of various republics as independent nations, the wars that ensued, and the dissolution of a country that had been known as Yugoslavia since 1918.

What concerns him, as it does almost everyone who has written about these wars, is how it was possible for the international community, and in particular the United States, to do nothing in the face of the shelling of Sarajevo and the murder of unarmed people by the Serbian forces, which the whole world saw on TV. Why wasn't there a military intervention to counter Serbian ethnic cleansing? Why wasn't air cover provided to escort the surrounded and defenseless Bosnians in Srebrenica to safety? Some of the dithering by the United States and the European Union about what to do can be understood and even forgiven in retrospect, but not this atrocity for which there was plenty of advanced warning given to people who could do something about it and who then procrastinated until it was too late.

Danner chronicles the involvement of the United States, beginning with the first President Bush and the failed visit of Secretary Baker to Belgrade in June 1991. Baker tried to hold Yugoslavia together despite a recent CIA National Intelligence Estimate that, according to an unnamed source quoted in The New York Times, said prophetically that the old Yugoslav experiment had failed, that the country would break up, and that this likely would be accompanied by ethnic violence and unrest leading to civil war. "No one can prove that 'concrete threats' or even 'actions' (and one can conceive of many, short of all-out war) could have prevented the conflicts to come," Danner writes. Military intervention, however, was not considered, since the United States was busy elsewhere with the turmoil in the Soviet Union and the Middle East, and with the approaching presidential election.

Danner claims that with Slovenia and Croatia about to secede, Baker's warnings against a unilateral declaration of independence and against the use of force to hold the federation together seemed to sanction force by the Serbs. Still, it wasn't the Serbs but the Yugoslav army and the Yugoslav government—still in place—that naturally would have had some interest in preserving the union.

The situation, at least before the hostilities started, was not as clear-cut as Danner leads us to believe. Yugoslavia was a country that, despite what the ethnic nationalists trumpeted, was not an awful place to live for most of its population and especially for the people who were intermarried or lived as minorities in republics where another ethnic group dominated. They and many other Yugoslavs hoped for reason to prevail and some sort of looser confederation between the republics to emerge gradually. The European Community, however, put a stop to that by going on record to declare in March 1991 that the Yugoslav republics had the right to freely determine their own future. Germany pushed for Slovenia and Croatia to secede immediately, as did the United States a few months later with Bosnia and Herzegovina.

Without a thought for the consequences, they encouraged nationalist leaders and ethnic groups they found congenial to break up a multiethnic country at the expense of those who had no clear ethnic loyalties and those like the Serbs who, although the largest ethnic group in Yugoslavia, found themselves a large minority in Croatia and almost half the population in Bosnia-Herzegovina. None of the nationalist parties favored by the US, including the Slovenes, had any use for multicultural identity. The openly fascist features of Croatia's ruling HDZ party, with its anti-Serb rhetoric, were passed over as a matter of little importance. So was the Muslim triumphalism in Bosnia. Slobodan Milo evic would not have had such a free rein if Yugoslavia and its last government, including its multiethnic army, were not so precipitously forced out of existence.

In view of all that, it was understandable that Serbs would feel threatened when the entire international community not only sided with the secessionists, but instantly rewrote the history of Yugoslavia, making them the oppressors and everyone else victims despite the fact that the absolute ruler of Yugoslavia from 1945 till his death in 1980, Marshal Tito, was partly a Croat and that Slovenia and Croatia were the two most prosperous republics in the federation. The European Community also declared that the borders of republics could not be changed, so that, for instance, Croatia could secede, but not the Serbs in the region called Krajina who wanted to separate from Croatia, or, for that matter, the Albanians in Kosovo who wanted to secede from Serbia.

Of course, when in the autumn of 1991 Serb artillery and infantry encircled the Croatian city of Vukovar and Milo evic first revealed to the world his plan for defending Serbian national interests by destroying cities and shooting unarmed civilians, nobody cared to remember what led to the war or had any sympathy for the already demonized Serbs. Danner thinks force should have been used immediately, quoting with approval a US Army military planner who felt that a concentrated air attack on Serbian forces surrounding Vukovar would have halted the siege; but Danner also grudgingly admits the unlikelihood of any nation using its military at a moment's notice to break up a foreign conflict.

I'm surprised that Danner doesn't mention several early attempts to broker peace between the warring sides. In particular José Cutileiro, a Portuguese diplomat, in February and March 1992 tried to preclude civil war by bringing the leaders of the three ethnic groups to Lisbon to reach a constitutional agreement well before the republics declared independence. The arrangement he proposed would have divided Bosnia into three separate regions with a high level of autonomy and a weak central government, with Muslims getting 45 percent of the land, the Serbs 42.5 percent, and the Croats 12.5 percent.

In his memoirs, the former US ambassador Walter Zimmerman, who encouraged the Bosnian Muslim leader Alija Izetbegovic to reject the plan at the time, states that Cutileiro's proposal would have probably worked out better for the Muslims than any subsequent plan, including the Dayton formula that ended the fighting in 1995. So why did the United States sabotage the Lisbon accord and then go on to recognize Bosnia and Herzegovina the very next day, when its intelligence agencies were unanimous in saying that after such recognition the place would blow up?

David N. Gibbs, in his excellent book about the destruction of Yugoslavia, First Do No Harm,^[1] offers a credible explanation. The US was worried about European efforts to create an independent European foreign policy. In recognizing Bosnia, the US reaffirmed its leadership position and corrected its early lack of clear policy. In other words, considerations of realpolitik were behind the US decision.

Whatever the full story of that decision may be, what happened next was hell on earth. Approximately 100,000 people died in the next three years, both soldiers and civilians, with twice as many Muslims killed as Serbs. Danner's detailed account of the atrocities that culminated with Srebrenica makes a powerful indictment of the indecision of the international community and the savagery of the Serbs, who set out to slaughter and ethnically cleanse Muslims in a manner nearly identical to that used by Croatian fascists in eliminating Serbs fifty years earlier. Not that the Muslim and Croats were entirely blameless. John Deutch, then a Defense Department official, said, "One of the reasons it was so hard to have a good policy is how terrible all the sides were." In any case, the Bush White House and the generals were against intervention. Of the two tragedies going on in the world, they chose to intervene in Somalia over Bosnia, regarding the former as a low-risk, high-payoff operation.

Danner asks the hard question: What accounts for the extraordinary cruelty of the Serbs? He attributes it to the ideology connected with a belief in Greater Serbia (of which, by the way, I never heard a word before the fall of Yugoslavia), the near-hysterical sense of historical grievance, and the heightened rhetoric and paranoia about a coming genocide of Serbs (forgetting that the bloodbath carried out by Croatian fascists in World War II was still fresh in many minds).

Danner is closer to the truth when he lays the blame on ambitious and ruthless politicians; nevertheless, his portrait of Milo evic, whom he calls a dictator despite his having to deal with opposition parties and frequent demonstrators in the streets, is unconvincing. As is often the case with men who bring disaster to their own people, Milo evic was an opportunist and a manipulator without an ounce of common sense. His nationalist policy was not meant to solve any problems for his fellow Serbs, but existed solely to increase his personal power and to enrich his associates. Instead of protecting legitimate national interests, he behaved like a thug and managed to squander whatever international sympathy Serbs might have had.

As for his followers—80,000 of whom came out in Belgrade in 2006 to pay him their last respects, many of them ethnically cleansed from Croatia, Bosnia, and Kosovo—they clearly made no connection between his policies and their plight. What they remembered about him and what they still admired was his pigheadedness. He kept saying no to everybody even when it was against his own interests. Danner gives the impression that he was a kind of evil genius who had everything planned ahead. I don't see it that way. It was the Croatian leader General Franjo Tudjman who knew how to plan. He knew you needed to have powerful allies if you wanted to get away with ethnic cleansing.

In both Croatia and Bosnia a lot of what happened was about revenge. As Danner documents in his articles, the massacre in Srebrenica was revenge for the killings of Serbs by the Muslims who used the "safe area" to make nightly raids on the surrounding villages. In General Ratko Mladic's unforgiving, brutal mind, this gave him the right to massacre two to three times as many Muslims regardless of their individual responsibility for what happened to the Serbs. It's no wonder it took the international community almost four years to fully grasp what kind of demons Milo evic had let loose.

I share Danner's outrage that something was not done to halt the siege of Sarajevo and to prevent the mass killing in Srebrenica, but Europe and the United States were caught between two morally and practically contradictory policies: either deploy peacekeeping forces to stop the killing—which would have favored the Serbs, who by mid-1995 held almost 70 percent of Bosnian territory—or seek to reverse ethnic cleansing by bombing Serbs and letting Muslims and Croats, who were regarded as victims, ethnically cleanse them in turn.

Danner acknowledges that the latter course would have meant hundreds of thousands of additional Serb refugees. But he thinks it would have been preferable: instead of ethnic partition, it might have led, if the US had been willing to take on "the task and responsibility of building a new state," to "the reconstruction of some sort of integral Bosnia." This, he says, "might have brought to Bosnia a very different future from the grim 'cold peace'" of the Dayton accord, however idealistic and unlikely, in my view, that may have been. Also, I don't think he grasps the full implication of what he is suggesting. In order to restore justice we would have committed another monstrous injustice by treating all Bosnian Serbs as guilty. In the end, neither the United States nor the European Union could bring themselves to do that.

3.

Danner's pieces on Iraq, published in these pages between September 2003 and April 2009, and written after visits to witness key political events in the country, which I read and admired as they came out, seem even stronger now that they are collected together. With all the disadvantages of making political analysis and predictions on the spot, this is reporting at its best. His pictures of Baghdad torn by ethnic strife and hundreds of suicide bombings, its streets lined with twelve- or fifteen-foot-high blast barriers, and of Fallujah with its buildings reduced to near rubble by Marine artillery are terrifyingly vivid. As an opponent of the war, Danner is more skeptical of US government claims and more appreciative of the immense complexity of the situation on the ground than he was in Yugoslavia. He is good at showing the distance between a bleak reality—a country devastated by our occupation, civil war, huge political problems, and terrorism—and Bush administration officials with their confident view that truth is subservient to power and that they had the ability to make reality appear to be whatever they wanted it to be. The toppling of Saddam Hussein's statue, the waving of purple fingers after the first election, and other such carefully managed images are what they wanted us to see, and not the rest, which they believed ought to remain hidden from the eyes of Americans.

Both Danner and Ron Suskind, whose book The One Percent Doctrine he quotes from at length,^[2] believe the invasion of Iraq was meant to make an example of Hussein in order to demonstrate what anyone with the temerity to acquire weapons of mass destruction—which in fact they did not possess—or in any way to flout the authority of the United States could expect from us. Henry Kissinger concurred; he supported the war, Danner quotes him as saying, "'Because Afghanistan was not enough.' The radical Islamists, he said, want to humiliate us. 'And we need to humiliate them.'" For the sake of American prestige and the credibility of American power, Danner writes, the image of "the burning, smoking towers collapsing into rubble" had to be supplanted by the scenes of "American tanks rumbling proudly down the streets of a vanquished Arab capital." This was to be a grand display of "shock and awe" unrestrained by the so-called weapons of the weak: the United Nations, the international laws and courts that the rest of the world uses to hobble American power.

In actual practice, what Danner describes in Iraq resembles what Barbara W. Tuchman called "the march of folly" far more than a demonstration of invincibility. In her famous book,^[3] she studied historical figures who made catastrophic decisions contrary to the self-interest of their countries, decisions that were perceived as counter-productive even in their time and for which an alternative course of action was readily available.

To reread Danner's pieces today is to realize that there was nothing remotely resembling sober reflection prior to our invasion of Iraq. Our leaders were sure of themselves and refused to allow UN inspections to continue; they believed that weighing and calculating the risk would only inhibit action. What could careful deliberation, based on cause and effect, matter when one has the most powerful military, spending more on defense than the rest of the world combined? When, following the invasion of Iraq, looting broke out in government ministries in Baghdad, universities, hospitals, power stations, and factories, virtually destroying the country's infrastructure and with it whatever respect Iraqis might have had for our competence, the 140,000 American troops did nothing but watch the growing anarchy.

Similarly, when L. Paul Bremer, the US administrator of Iraq charged with overseeing the reconstruction of the country, made the decision to fire all Baathists from the government and disband the army—thus making 350,000 humiliated and suddenly unemployed people into enemies, and transforming what had been the Pentagon's plan for a quick victory and quick departure into a long-running occupation—no one on the National Security Council or in the State Department was warned beforehand. The systematic failure in Iraq, Danner makes clear in his book, resulted in large part from an almost willful determination of those who made decisions to cut themselves off from those in government who knew anything. As a historian remarked regarding the extraordinarily imprudent Philip II of Spain, "No experience of the failure of his policy could shake his belief in its essential excellence."

The two most disturbing pieces in the book deal with torture and were published last April after Danner got hold of a secret report by the officials of the International Committee of the Red Cross (ICRC). In order to monitor compliance with the Geneva Conventions and to supervise the treatment of prisoners, they traveled to Guantánamo and interviewed in private a number of inmates who divulged what kind of interrogations they'd been subjected to both at Guantánamo and in our secret global network of prisons where they had been held. They describe in detail, and independently of each other, what President Bush called the "alternative set of procedures" that indisputably, despite his vehement denials, are torture.

Borrowed from Soviet and Chinese Communists and other repressive regimes, both ancient and modern, these "techniques" were fine-tuned with the assistance of lawyers in the Department of Justice working with CIA officials, doctors, and psychologists. They not only revived the long-outlawed practices of inflicting pain and terror on human beings from the most shameful chapters of human history, but did so with the active participation of senior officials in government who insisted on being informed on an hourly basis about the progress of these "interrogations," and who micromanaged the application of waterboarding, sleep and sensory deprivation, and other barbaric methods on some of the more well-known prisoners.

Since international law (to which the United States is a signatory) prohibits cruel, inhuman, or degrading treatment, our practice of torture was obfuscated, excused, and pretty much dismissed, not only by the Bush administration and its apologists, but equally by Congress and now even by many Americans, more than half of whom support it according to the latest polls. What makes reading Danner's pieces on the ICRC report even more chilling is that they were written when we still had a reasonable hope that there would be some type of serious investigation and possibly eventual prosecution by the new administration.

That is not likely to happen. The Obama administration has taken steps to end torture and released documents showing official complicity in carrying it out, but it appears to have no interest in any kind of truth commission that would fully investigate what crimes our past leaders and high officials have committed. This is where Danner's book becomes so valuable. It ought to be read by those who still see our wars as moral crusades. They may learn from its pages why so many ungrateful beneficiaries of our largesse are willing to blow themselves up in order to do us harm, and why wars based on delusions only lead to more delusions and more wars.

Notes

^[1]First Do No Harm: Humanitarian Intervention and the Destruction of Yugoslavia (Vanderbilt University Press, 2009).

^[2]The One Percent Doctrine: Deep Inside America's Pursuit of Its Enemies Since 9/11 (Simon and Schuster, 2006).

^[3]The March of Folly: From Troy to Vietnam (Knopf, 1984).

Burma hints of Aung San Suu Kyi release in November

Aung San Suu Kyi has been detained for 14 of the past 20 years

Burma's military government may be planning to release pro-democracy leader Aung San Suu Kyi later this year, say reports from the country.

Burma's home minister reportedly said Ms Suu Kyi would be freed when her current period of house arrest expires, which is scheduled for November.

Ms Suu Kyi's detention was extended last year, after a US man visited her house uninvited.

Critics say the junta intends to detain her until after elections this year.

Home Minister Maung Oo is reported to have made the comments about Ms Suu Kyi at a provincial town meeting four days ago.

The BBC's South East Asia correspondent Rachel Harvey says it is a measure of how tightly information is controlled in Burma that it has taken this long for the reports to filter out.

Burmese officials have hinted many times that Aung San Suu Kyi may be released, our correspondent adds, but this is the first time in recent months that a putative date has been attached to the idea.

Aung San Suu Kyi's own lawyer told the BBC he had heard the rumour but could not confirm it.

Undermined

Ms Suu Kyi's detention was extended by 18 months last August, over an incident in which an American man swam, uninvited, to her lakeside home.

Burma extended Ms Suu Kyi's arrest after an intruder visited her home

If she is released in November, key questions remain about the terms of her possible freedom.

Those include whether there would be conditions attached, whether her activities would be restricted and - crucially - whether the release would come before or after planned elections.

The Supreme Court is also due to deliver its verdict on a legal appeal against her current detention in the next couple of weeks.

But if the military government says she will continue to be detained until at least November, the court's decision has already been somewhat undermined, says our correspondent.

Maung Oo is also reported to have said the vice chairman of Ms Suu Kyi's political party, the National League for Democracy (NLD), will be released in February.

Tin Oo, 82, has been in prison or under house arrest for more than a decade.

Analysts say if he is released, he could have a key role in deciding whether or not the NLD participates in the elections due later this year.

No date for the poll has yet been set.

But if Tin Oo is released in February, and Aung San Suu Kyi remains in detention until November, it could indicate that the elections are pencilled in for a date sometime between the two, says our correspondent.

US commander signals peace talks with Taliban

Gen McChrystal said Taliban figures might participate in government

Nato's top commander in Afghanistan has said increased troop levels could bring a negotiated peace with the Taliban.

US Gen Stanley McChrystal told the UK's Financial Times newspaper that there had been "enough fighting".

He said a political solution in all conflicts was "inevitable". His remarks came as the top UN envoy in Kabul said it was time to talk to the militants.

Afghan and Pakistani leaders are in Turkey to discuss tackling the Taliban-led insurgency in their countries.

This is the fourth such meeting initiated by Turkey, which has offered to broker talks between the Afghan government and the Taliban.

Both Afghan President Hamid Karzai and his Pakistani counterpart, Asif Ali Zardari, will attend an international conference on Afghanistan in London on Thursday.

'Focus on the future'

"I'd like everybody to walk out of London with a renewed commitment, and that commitment is to the right outcome for the Afghan people," Gen McChrystal told the Financial Times.

It's impossible to paint the Taliban all with one brush... [the rank and file] don't want to pay the price for al-Qaeda's extremism for ever Gen Stanley McChrystal, Nato commander in Afghanistan

He said the arrival of the extra 30,000 US troops pledged by President Obama and the additional 7,000 troops promised by other Nato countries should deliver "very demonstrably positive" progress in 2010.

But he warned that the level of Taliban violence could increase sharply this year.

The Taliban wanted to create the perception that Afghanistan was on fire, and that President Karzai and his Western allies could not cope, Gen McChrystal said.

However, if the new US-led strategy was successful, the militants "could look desperate" in a year's time, he said.

"I think they will look like an entity that will be struggling for its own legitimacy... I think they will be on the defensive militarily, not wiped out."

On the issue of reconciliation, Gen McChrystal said: "I believe that a political solution to all conflicts is the inevitable outcome. And it's the right outcome."

Afghan President Karzai told the BBC last week of his desire for reconciliation

Asked if he thought senior Taliban could have a role in a future Afghan government, he said: "I think any Afghans can play a role if they focus on the future, and not the past.

"As a soldier, my personal feeling is that there's been enough fighting," Gen McChrystal added.

'Time has come'

In an interview with the New York Times, United Nations special representative Kai Eide called for some senior Taliban leaders to be removed from a UN list of terrorists, as a prelude to direct talks.

"If you want relevant results, then you have to talk to the relevant person in authority," Mr Eide said. "I think the time has come to do it."

President Karzai recently told the BBC that he planned to introduce a scheme to attract Taliban fighters back to normal life by offering money and jobs.

He said he would offer to pay and resettle Taliban fighters to come over to his side.

Mr Karzai said he hoped to win backing for his plan from the US and UK at the London conference.

U.N. Seeks to Drop Some Taliban From Terror List

Image by Getty Images via Daylife

By DEXTER FILKINS

KABUL, Afghanistan — The leader of the United Nations mission here called on Afghan officials to seek the removal of at least some senior Taliban leaders from the United Nations’ list of terrorists, as a first step toward opening direct negotiations with the insurgent group.

In an interview, Kai Eide, the United Nations special representative, also implored the American military to speed its review of the roughly 750 detainees held in its military prisons here — another principal grievance of Taliban leaders. Until late last year, the Americans were holding those prisoners at a makeshift detention center at Bagram Air Base and refusing to release their names.

Together, Mr. Eide said he hoped that the two steps would eventually open the way to face-to-face talks between Afghan officials and Taliban leaders, many of whom are hiding in Pakistan. The two sides have been at an impasse for years over almost every fundamental issue, including the issue of talking itself.

“If you want relevant results, then you have to talk to the relevant person in authority,” Mr. Eide said. “I think the time has come to do it.”

In recent days, Afghan and American officials have signaled their willingness to take some steps that might ultimately lead to direct negotiations, including striking the names of some Taliban leaders from the terrorist list, as Mr. Eide is suggesting.

The remarks by Mr. Eide, who will leave his post here in March, were the latest in a series of Afghan and Western efforts to engage the Taliban movement with diplomatic and political means, even as a new American-led military effort was under way here.

American, Afghan and NATO leaders are also preparing to start an ambitious program to convince rank-and-file Taliban fighters to give up in exchange for schooling and jobs. That plan, expected to cost hundreds of millions of dollars, will be the focus of an international conference later this week in London.

The plan aims at the bottom of the Taliban hierarchy — the foot soldiers who are widely perceived as mostly poor, illiterate, and susceptible to promises of money and jobs. In 2007 and 2008, a similar effort unfolded in Iraq, where some 30,000 members of the country’s Sunni minority — many of them former insurgents — were put on the American payroll. Partly as a result, violence there plummeted.

Mr. Eide said that in Afghanistan, such efforts at reintegration, while useful, would not be enough. While some rank-and-file Taliban soldiers might be fighting for economic reasons, he said, the motives of most were more complex. The Taliban’s leaders exert more control over the foot soldiers than they are given credit for, he said.

“I don’t believe it’s as simple as saying that these are people who are unemployed, and if we find them employment they will go our way,” Mr. Eide said. “Reintegration by itself is not enough.”

In the past, talks between the Afghan government and the insurgents have foundered on a few core issues. Afghan leaders have demanded that the Taliban forswear violence and their association with Al Qaeda before talks can begin. For their part, the Taliban have demanded that the Americans and other foreign forces leave the country first.

But some Taliban leaders have indicated that they might be willing to engage in some sort of discussions if their names were stricken from the United Nations’ so-called “black list.” The list contains the names of 144 Taliban leaders, including Mullah Mohammed Omar, the movement’s leader, as well as 257 from Al Qaeda. Under United Nations Resolution 1267, governments are obliged to freeze the bank accounts of those on the list and to prevent them from traveling.

Some Taliban leaders say the black list prevents them from entering into negotiations — if they show their face, they say, they would be arrested.

“This would allow the Taliban to appear in public,” said Arsalan Rahmani, a former deputy minister with the Taliban who now lives in the Afghan capital, Kabul. “It would allow the possibility of starting negotiations in a third country.”

Mr. Eide said he does not believe that senior Taliban leaders like Mullah Omar should be removed from the list. It was Mr. Omar, after all, who provided sanctuary to Osama bin Laden and thousands of fighters from Al Qaeda, which launched the Sept. 11 attacks.

But some second-tier Taliban should be taken from the list, he said. Those leaders are not necessarily associated with terrorist acts but might be able to speak for the movement, he said, and might be willing to reciprocate a good-will gesture.

The request to strike any Taliban names from the United Nations list would have to made by Afghan government. In the past, Afghan officials have indicated that they might be willing to take some names off — even that of Mr. Omar. But they have kept details and their ultimate intentions under wraps.

Last week, the American envoy to the region signaled some willingness to allow some Taliban names to be taken off the list as long as they are not senior commanders responsible for atrocities or associated with Al Qaeda.

“A lot of the names don’t mean much to me,” Richard Holbrooke, the Obama administration’s special envoy to Afghanistan and Pakistan, said last week in Kabul. “Some of the people on the list are dead, some shouldn’t be on the list and some are among the most dangerous people in the world.

“I would be all in favor of looking at the list on a case-by-case basis to see if there are people on the list who are on the list by mistake and should be removed, or in fact are dead,” he said.

Mr. Holbrooke showed no willingness to ease up on the leaders of the insurgency, including Mr. Omar and Gulbuddin Hekmatyar, the leader of the Islamic Party, an insurgent group fighting the government and the Americans here. “I can’t imagine what would justify such an action at this time,” he said, “and I don’t know anyone who is suggesting that.”

As for the Taliban prisoners, American officials say they imposed a more rigorous review process several months ago, and that they are examining the cases of each detainee. This month, after years of keeping the names of detainees secret, the American military released the names of 645 detainees being held in the main detention center outside of Kabul.

Since September, when the new review process was imposed, the Americans have reviewed the cases of 576 detainees, and 66 of those have been released, Col. Stephen Clutter said. A review of all 645 detainees will be completed by the end of March, he added. Mr. Eide said he hoped it would go further.

“There needs to be a more comprehensive review of the list that has now been published,” Mr. Eide said.

Still, for all of that, it wasn’t clear Sunday just how the Taliban would respond — or if it would at all.

“I don’t know what they will do,” Mr. Rahmani said.

Sangar Rahmi contributed reporting.

Okinawa voters pick anti-base mayor

Image via Wikipedia

By Blaine Harden
Washington Post Staff Writer
Sunday, January 24, 2010; 2:14 PM

TOKYO -- In a small town election that may have a big impact on U.S. ties with Japan, voters in Nago on Okinawa island chose a new mayor Sunday who opposes the relocation of a noisy U.S. military air base to his town.

Susumu Inamine, who said during his campaign that he did not want the air station constructed in Nago, defeated incumbent Mayor Yoshikazu Shimabukuro, who has long supported hosting the base as a way of increasing jobs and investment.

The United States and Japan agreed four years ago to move the U.S. Marine Corps Air Station Futenma, now located in a dense urban area in the center of Okinawa, to Nago, a town of 60,000 in the thinly populated northern part of the tropical island. It was to have been built on landfill along a pristine coast on the edge of the town.

But to the exasperation of the Obama administration, that deal was put on hold last fall after the election of a new government led by Prime Minister Yukio Hatoyama, who says Japan has been too passive in its dealings with the United States. Hatoyama has suggested that the base should be moved off Okinawa or out of Japan altogether -- and has also said that the outcome of the mayoral vote in Nago would be a factor in his government's final decision, which he has promised to make by May.

Inamine's anti-base campaign attracted support from environmentalists and from local members of Hatoyama's Democratic Party of Japan and its coalition partners, as well as from the Japanese Communist Party.

Nago's mayor avoided mention of the airbase in his campaign, saying its relocation was not a matter that could or should be decided by him or residents of his city.

That view is shared by U.S. Marine Corps commanders, who view the Futenma air station as a linchpin in the continuous training and on-call mobility of the Third Marine Expeditionary Force, which is based on Okinawa and is the only such U.S. force in the Far East.

"National security policy cannot be made in towns and villages," Lt. Gen. Keith J. Stalder, commander of Marine forces in the Pacific, said in an interview last week.

Relocating the Marine air station to Nago is a key part of a $26 billion deal between Japan and the United States to transfer 8,000 Marines from Okinawa to Guam and turn over valuable tracts of land to people on the island. Defense Secretary Robert M. Gates said last fall that the deal would probably collapse if the air station does not move to Nago.

Several U.S. officials said last week that they believe that senior leaders in the Hatoyama government have begun to realize that there is no workable alternative to relocating the air station as previously agreed . They also said that such an important decision should be made in Tokyo and not in a local election.

Construction of the air station in Nago would require a massive landfill in a picturesque stretch of waters now used by fishermen and snorkelers. It is opposed by environmentalists who have filed a law suit saying it would destroy habitat of the rare dugong, a manatee-like sea mammal. A Japanese government environmental assessment has said that dugongs have not been seen in the proposed construction area for many years.

For many Okinawans, the Futenma air station has become a symbol of the noise, pollution and risk of accidents that they associate with the large U.S. military presence on the island.

Surrounded by 92,000 people in Ginowan city, Futenma torments its neighbors with the comings and going of combat helicopters and transport aircraft.

In 2004, a helicopter based at the airfield crashed into the administration building of a nearby college. There were no deaths, but the incident angered local residents and led to the 2006 agreement to move the air base to Nago.

The vote in Nago does not necessarily kill the relocation of the air station. The final decision is up to the governor of Okinawa, who has shown qualified support for the base relocation plan, and the central government in Tokyo.

David Plouffe - November doesn't need to be a nightmare for Democrats

Image by Getty Images via Daylife

By David Plouffe
Sunday, January 24, 2010; A17

The Democratic Party got a resounding wake-up call from the voters of Massachusetts on Tuesday. But it's long been clear that 2010 would be a challenging election year for our party.

With few exceptions, the first off-year election in a new president's term has led to big gains for the minority party -- this was true for Harry Truman, Dwight Eisenhower, Ronald Reagan and Bill Clinton. After two election cycles in which Democrats won most of the close races and almost all of the big ones, Democrats have much more fragile turf to defend this year than usual. Add to that a historic economic crisis, stubborn unemployment and the pain that both have inflicted on millions of Americans, and you have a recipe for a white-knuckled ride for many of our candidates.

But not if Democrats do what the American people sent them to Washington to do.

In 2006 and 2008, voters sent an unmistakable message: We want decisive change. This was not just a change of political parties. Instead of a government that works for the entitled and special interests, a government that looks out for Wall Street, they wanted a government that works better for them, a government that plays the role it should to help foster the security of the middle class.

Many of last year's accomplishments are down payments on those principles.

We still have much to do before November, and time is running short. Every race has unique characteristics, but there are a few general things that Democrats can do to strengthen our hand.

-- Pass a meaningful health insurance reform package without delay. Americans' health and our nation's long-term fiscal health depend on it. I know that the short-term politics are bad. It's a good plan that's become a demonized caricature. But politically speaking, if we do not pass it, the GOP will continue attacking the plan as if we did anyway, and voters will have no ability to measure its upside. If we do pass it, dozens of protections and benefits take effect this year. Parents won't have to worry their children will be denied coverage just because they have a preexisting condition. Workers won't have to worry that their coverage will be dropped because they get sick. Seniors will feel relief from prescription costs. Only if the plan becomes law will the American people see that all the scary things Sarah Palin and others have predicted -- such as the so-called death panels -- were baseless. We own the bill and the health-care votes. We need to get some of the upside. (P.S.: Health care is a jobs creator.)

-- We need to show that we not just are focused on jobs but also create them. Even without a difficult fiscal situation, the government can have only so much direct impact on job creation, on top of the millions of jobs created by the president's early efforts to restart the economy. There are some terrific ideas that we can implement, from tax credits for small businesses to more incentives for green jobs, but full recovery will happen only when the private sector begins hiring in earnest. That's why Democrats must create a strong foundation for long-term growth by addressing health care, energy and education reform. We must also show real leadership by passing some politically difficult measures to help stabilize the economy in the short term. Voters are always smarter than they are given credit for. We need to make our case on the economy and jobs -- and yes, we can remind voters where Republican policies led us -- and if we do, without apology and with force, it will have impact.

-- Make sure voters understand what the American Recovery and Reinvestment Act did for the economy. Rarely does a congressional vote or issue lend itself to this kind of powerful localization. If GOP challengers want to run ads criticizing the recovery act as wasteful, Democratic candidates should lift up the police officers, teachers and construction workers in their state or district, those who are protecting our communities, teaching our children and repairing our roads thanks to the Democrats' leadership. Highlight the small-business owners who have kept their doors open through projects funded by the act.

The recovery act has been stigmatized. We need to paint the real picture, in human terms, of what it meant in 2010. In future elections, it will be clear to all that instead of another Great Depression, Democrats broke the back of the recession with not a single Republican vote in the House. In the long run, this will haunt Republicans, especially since they made the mess.

-- Don't accept any lectures on spending. The GOP took us from a $236 billion surplus when President Bush took office to a $1.3 trillion deficit, with unpaid-for tax cuts for the wealthy, two wars and the Medicare prescription drug program. Republicans' fiscal irresponsibility has never been matched in our country's history. We have potent talking points on health care, honest budgeting and cuts in previously sacrosanct programs. Republicans will try to win disingenuously by running as outsiders. We must make them own their record of disastrous economic policies, exploding deficits, and a failure to even attempt to solve our health care and energy challenges.

During the campaign, who will be whispering in Republican ears? Watching GOP leaders talking about health care the past few days, it was easy to imagine lobbyists and big health insurance executives leaning over their shoulders, urging death to health insurance reform. When it comes to cracking down on the banks and passing tough financial regulatory reform, GOP leaders will be dancing to the tune of Wall Street lobbyists and opposing tougher oversight, as if the financial crisis never happened. We need to lay it out plainly: If you put the GOP back in charge, lobbyists and huge corporate special interests will be back in the driver's seat. Workers and families will get run over, just like they did in the past decade.

-- "Change" is not just about policies. In 2006, Democrats promised to drain the swamp and won back Congress largely because the American people soured on corrupt Republican leadership. Many ethics reforms were put in place by the Democrats. But a recent Gallup poll showed that a record 55 percent of Americans think members of Congress have low ethics, up from only 21 percent in 2000. In particular, we have to make sure the freshman and sophomore members of the House who won in part on transparency and reform issues can show they are delivering. The Republicans will suggest they have changed their spots, but the GOP cannot hold a candle to us on reform issues. Let's make sure we own this space.

-- Run great campaigns. Many Democrats won congressional and statewide races in 2006 and 2008 with ideal conditions. Some races could have been won with mediocre campaigns. Not this year. Our campaigns can leave no stone unturned, from believing in the power of grass-roots volunteers and voter registration, to using technology and data innovatively, to raising money -- especially with big corporate interests now freed up to dump hundreds of millions of dollars to elect those who will do their bidding. Democratic candidates must do everything well. Each one must make sure that the first-time voters from 2008 living in your state or district -- more than 15 million nationwide -- are in their sights. Build a relationship with those voters, organize them and educate them. On Nov. 3, many races are sure to be decided by just a few thousand if not a few hundred votes. These voters can make the difference. We have to show them that their 2008 votes mattered, and passing health insurance reform is one way to start.

-- No bed-wetting. This will be a tough election for our party and for many Republican incumbents as well. Instead of fearing what may happen, let's prove that we have more than just the brains to govern -- that we have the guts to govern. Let's fight like hell, not because we want to preserve our status, but because we sincerely believe too many everyday Americans will continue to lose if Republicans and special interests win.

This country is at a crossroads. We are trying to boost the economy in the short term while also doing the long-term work on health care, energy, education and financial reform that will lay a strong foundation for decades to come. Let's remember why we won in 2008 and deliver on what we promised. If Democrats will show the country we can lead when it's hard, we may not have perfect election results, but November will be nothing like the nightmare that talking heads have forecast.

David Plouffe, campaign manager of Obama for America and Obama-Biden 2008, is the author of "Audacity to Win."

Sending money home to Haiti from the U.S. proves difficult

Image by psd via Flickr

By Peter Whoriskey
Sunday, January 24, 2010; A11

MIAMI -- Even in normal times, the dingy money transfer storefronts in this city's Little Haiti provide a critical lifeline for the island nation. Here, and in other immigrant hubs in the United States, money passed to tellers behind plastic glass and then relayed back home is part of a flow that amounts to as much as a quarter of Haiti's economy.

But since the Jan. 12 earthquake, just as Haitians in the United States and elsewhere rallied to send money back home, the critical economic conduit stopped working, and is still far from restored.

"It's chaos," said Miami cabdriver Windel Pierre, 41, who was in Little Haiti this week to send money. "A very sad chaos."

Many here, with their relatives suddenly homeless, have been desperately trying to send funds for food and water. But while the companies can perform the electronic transfer, many of the transfer offices in Haiti's capital are closed, and many of those open elsewhere in the country are short of cash because the banks have yet to operate.

Image by Emily Webber via Flickr

Ginette Clark, 38, a hotel server, said that she transferred money on Friday but that her sister hasn't yet been able to get the cash. "There's so much trouble over there," she said. "Nothing is working."

Similarly, Pierre spent an entire day this week trying to send funds so a friend could buy gas for a bus to drive people from Port-au-Prince back to their village in the provinces.

Pulling the receipts from the back of his cab, Pierre said he first paid for a $1,000 transfer with one company. His friend could not get it. Then he tried a $400 transfer with another. No luck. Then, running low on cash, he sent $330 via Western Union. He thinks that worked. "The people desperately need the help, and I can't stop thinking about that," Pierre said. "But it's very difficult to get it to them."

Even the cityscape here reflects money transfers' critical role in the immigrant economy. There aren't many stores in Little Haiti, but amid a couple of botanicas and mini-markets, there are three money transfer offices: Unitransfer, CAM and, in the Isaiah Check Cashing Store, Western Union. More than one-third of Haitians receive cash from overseas, with a typical transfer of $150, according to a recent survey for the Inter-American Development Bank.

In 2008, "remittances" to Haiti totaled nearly $1.9 billion, equal to more than a quarter of the country's gross domestic product. Most of that is spent on food and other necessities, according to the survey.

Remittances are a "life force for Haiti," said Jean-Marc Piquion, vice president for sales and marketing at Unitransfer Florida. "The transfer services must reopen."

The main trouble for now is the lack of currency in Haiti.

Image via Wikipedia

"The big issue is liquidity and getting cash to the recipients," said Greg Watson, remittance program coordinator for the Inter-American Development Bank. "What we have been hearing is that all of the services are having problems in getting their money dispersed -- and in a time like this people want to have cash."

"We have emergency ways to get cash, but not enough for the demand," said Katleen Felix of Fonkoze, a major microfinance operation in Haiti, noting that the banks have yet to open. "We are hoping the central bank will open its vault soon."

Security has also posed a problem at money transfer offices in Haiti. Jean-Claude Saliba, a general manager at CAM, said about 5,000 people turned up at one of the offices in Carrefour. The company asked the government for backup security, and when no help arrived, officials decided to shut down.

Similarly, some residents are hesitant to collect the cash. "My dad is afraid to go to pick up the money -- he's afraid someone will rob him," said Stephanie Laurent, 29, a customer service worker for a phone card company.

Restoration of the flow of remittances is considered a key to the country's recovery. Last week, in deciding to give undocumented Haitians in the United States temporary amnesty, federal officials noted that the measure would allow the immigrants to work, and that, in turn, would mean an increase in private aid to Haiti.

At Notre Dame d'Haiti Church here last week, hundreds of undocumented Haitians turned up seeking assistance in filing for the new federal program, known as temporary protected status. Several said that one of the main purposes of their work will be to return money to relatives in Haiti.

One woman turned out at the church in prim professional clothes hoping she could get the documents that would allow her to get a job. "Nobody is going to hire me without papers," a relative interpreted for her. "I just want any job because I need to help my family. My mom and dad are sleeping on the streets."

More teens are choosing to wait to get driver's licenses

Image via Wikipedia

By Donna St. George
Washington Post Staff Writer
Sunday, January 24, 2010; A01

The quest to get a driver's license at 16 -- long an American rite of passage -- is on the wane among the digital generation, which no longer sees the family car as the end-all of social life.

The holdouts include Kat Velkoff, who turned 17 in Chantilly without a license. Focused on tough classes, the debate team, dance and color guard, she turned 18 without taking the wheel. Then 19.

"It just wasn't a priority," said Velkoff, who got her license last year at 20. "It was just never the next thing that needed to get done in my life."

Federal data released Friday underscore a striking national shift: 30.7 percent of 16-year-olds got their licenses in 2008, compared with 44.7 percent in 1988. The difference is even sharper in Virginia and Maryland, state figures show. Numbers from the District, which go back to 2003, show a decline in the past two years.

"Driving is real important to a lot of the kids in the culture, but it is not the central focus like it was 25 years ago," said Tom Pecoraro, owner of I Drive Smart, a Washington area drivers' education program, who added that plenty of his students are older teens. "They have so many other things to do now," he said, and, with years of being shuttled to sports, lessons and play dates, "kids are used to being driven."

A generation consumed by Facebook and text-messaging, by Xbox Live and smartphones, no longer needs to climb into a car to connect with friends. And although many teens are still eager to drive, new laws make getting a license far more time-consuming, requiring as many as 60 supervised driving practice hours with an adult.

Rob Foss, director of the Center for the Study of Young Drivers at the University of North Carolina, and others suggest that these "graduated" state licensing systems -- which have created new requirements for learner's permits, supervised practice hours, night driving and passengers in the car -- are responsible for much of the decline in the number of licensed 16-year-olds. At the same time, drivers' education has been cut back in some public schools, so families must scrounge up money -- often $300 to $600 -- for private driving schools.

Then there is car insurance and gas, expenses that make driving too costly for some families and a stretch for others.

"In this economy, if my daughter were to drive, just the insurance would be $1,200 a year or more, and that's a lot of money," said Elizabeth Walker, the mother of a reluctant driver in Rockville.

Leaving it to parents

There have always been differences between the city and suburban mind-set when it comes to driving, because cities have more public transportation. In suburban and rural areas, it can be trickier to be a later-teen driver.

Not that this has stopped Wylie Conlon, 17.

The senior at Montgomery Blair High School in Silver Spring has a learner's permit, but the required 60 hours of practice driving toward a driver's license have taken a back seat to his Advanced Placement classes, the rowing team, the literary magazine and Web design projects. "It's hard to spend all that time on driving when I can get places without it," he said.

Conlon said this as his mother, Eva Sullivan Conlon, was driving him to the store to buy supplies for a school project; she ends up taking him places a few times a week. But he also finds his own way, boarding two buses and a train to see his girlfriend in Rockville, for example. In his circle, he adds, "most of my friends don't have driver's licenses, and the few who do end up giving rides to the rest of us."

Natalie Perez-Duel, a 16-year-old junior at Albert Einstein High School in Kensington, has yet to take driving classes and does not know when she will. "It's one more thing to study for, and it's just a hassle," said Perez-Duel, who is already squeezing in AP and International Baccalaureate classes, dance, poms and a school play.

She does not mind rides from her parents. "They have always driven me, and they still do, so it's not that weird," she said.

For parents, the license lag brings mixed reaction. Some are relieved; some mystified.

Barry Johnson, 52, who grew up in Silver Spring, remembers the glory of turning 16 and heading to the Department of Motor Vehicles "on the day you were eligible."

"Not only did all of my friends have licenses," he said, "but most of us worked and had cars by the time we graduated high school." He and his friends worked on their cars in the evening, and on weekends they went out driving -- a mark of "freedom, independence, adulthood," he said.

Now a father of two, Johnson notes that his college-age children still don't have licenses. "Neither one has risen to the occasion," he said. "Both have decided that Washington, D.C., is a great place to use their 'BMW' -- bus, Metro, walk."

Susan Apter, 48, of Rockville said her eldest daughter delayed so long that Apter finally insisted that she get licensed when she was a senior. "I took the initiative to schedule the test, helicopter parent that I am," she joked. By contrast, Apter's 15-year-old son knows the precise day in May when he can get his permit.

Plenty of parents don't want their children driving at 16, given the congestion and peril of the Washington area's roads and the fact that car crashes are the leading cause of teen deaths.

Cindy Wei, 55, of Herndon was thankful that her daughter was in no hurry to get her license. "I wanted her safe as long as possible," Wei said. "If it means I have to give up watching TV for 15 minutes so she can get a ride across town, I'm happy to do it."

A rite of passage

But waiting too long also has its drawbacks. Teens might get the best chance at supervised practice, some parents and experts say, before they head off to college, the military or a job.

"Learning to drive is a fundamental part of adolescence," said psychologist Joseph Allen of the University of Virginia. "It gives teens a major responsibility they have to handle, and it also gives them the chance to move about on their own, to function independently of their families."

It has become harder for teens to grow up, Allen says in a recent book, "Escaping the Endless Adolescence," because parents too often try to eliminate risks and obstacles rather than teaching teens to manage them safely. "Parents are scared to death about their teens driving," he said. "But they won't grow up if we just lock them in a room to keep them safe."

Jack Gibala, 60, a father of three in Rockville, said he and his wife tackled the driving question one child at a time. Their daughter drove at 16. But their two sons had to wait until 18 or 19 because they were less mature. "We just felt it was crazy to put them behind the wheel of a two-ton killing machine," he said.

The downside: "It's a pain . . . hauling these kids around when they are 17 and 18 years old." But he said he is glad he did.

Jeanne Kahn, 49, a mother of two, did some extra driving, too, until her eldest son got his license at 18. But many days, he was content at home in North Potomac, using the computer, playing video games or watching sports on TV. "It may be they feel more entertained at home than my generation did," Kahn said.

Technology has clearly altered the social world for 16-year-olds.

Michelle Wei, 19, who got her license as a senior, was happy to walk to school and carpool to soccer games. Most of her friends lived within a few blocks. "If I couldn't get a ride to see my friend who lives a town over, I could talk on IM," she said. "Or Skype." The digital world, she said, "made it very easy not to drive."

And not driving can be a good thing in some families.

As for Kat Velkoff, who got her license at 20, she and her mother spent 30 minutes together every school day in the family Prius, as they went from their Chantilly home to Velkoff's IB high school program in Reston. "We could talk about everything, and we got to share music with each other," she said. "My mom and I became really close."

Database editor Dan Keating contributed to this report.