In Sickness And In Health

Abstract

Doctors at the CIA are checking up on world leaders to take the guesswork out of regime change.

We've all been sick at some point and can appreciate the abject misery that even a common cold can cause. Most often our malaise is limited–causing us to miss, at most, a day or two of work. In those unfortunate cases where more serious debilitating illness grabs hold, the physical and emotional toll can spread beyond the afflicted individual to involve a small circle of family and close friends. But seldom does one person's sickness have the potential to contribute to widespread political upheaval within a country, or to radically alter the course of conduct between two nations.

So, consider the case of a middle-aged man who discovers one day that the left side of his abdomen is swollen. During a medical checkup, the man's physician discovers that his spleen is enlarged. Could this be a flare-up of malaria that he had contracted years earlier, or some new malady? Initial blood tests suggest a low-grade infection. A specialist in blood disorders is consulted, and a bone marrow sample shows that our patient actually suffers from a slowly progressive form of leukemia. He may not even fully realize that he has “cancer” because his doctors have told him that he has “Waldenström's macroglobulinemia.” Compounding his problem, he initially fails to follow the prescribed low-dose chemotherapy regimen.

Maybe he is in denial or doesn't want to worry anyone unduly. In any case, for the first few years, he manages to keep the nature of his illness a secret, even from his wife. But after awhile, he is no longer able to deny the chronic cough, the weight loss, the weakness, and the jaundice. Nor is he able to muster the emotional and political will to adequately handle an emerging crisis in his workplace. Ironically, a close friend had only recently called him an “island of stability.” His illness ultimately forces him to hastily step down from his position of immense responsibility. A little more than a year later, he dies. 1

While similar events could occur in any number of clinics around the world, ours is no ordinary patient. His name was Mohammed Reza Pahlavi–the late shah of Iran–and in February 1979, he fled his country in the face of a surging Islamist revolution. In October of that year, the U.S. government agreed to admit the ailing shah, apparently so he could receive advanced medical treatment. That fateful decision precipitated one of the most serious foreign policy crises in U.S. history–the seizure of the U.S. Embassy in Tehran by student radicals–and continues to adversely affect U.S.-Iranian relations. While the shah was a single leader of a single country, in many cases the physical or mental health of a foreign head of state has the potential to influence the course and conduct of U.S. foreign relations. Consider just two recent events.

On December 18, 2005, Israeli Prime Minister Ariel Sharon suffered what doctors called a “mild stroke” and temporarily lost the ability to speak. Sharon returned to work the next week and began preparing his newly formed centrist Kadima Party for the upcoming March parliamentary elections. However, on January 4, 2006, Sharon suffered a massive cerebral hemorrhage, likely due to blood-thinning medications, and required three emergency operations to relieve pressure on his brain. Within days, it was clear to the Israeli public and the world that, regardless of the outcome, his political career was effectively over. The viability of Sharon's party and his disengagement strategy for Israel's occupied territories remained in doubt. 2

Six months later, on the evening of July 31, 2006, a stunning announcement was made over Cuban airwaves that, due to “an acute intestinal crisis, with sustained bleeding” that required a “complicated surgical operation,” President Fidel Castro would temporarily hand over power to his younger brother, Raul. 3 In Miami's Cuban exile community, there was jubilant dancing in the streets over the prospect of the elder Castro's “imminent” demise. Did Castro have cancer? Was he poisoned? If Castro was indeed terminally ill, how might this affect U.S.-Cuban relations?

Meanwhile, in Washington, a small analytical team within the Central Intelligence Agency's Directorate of Intelligence known as the Medical and Psychological Analysis Center (MPAC)–whose specific function is to provide policy makers with assessments of the physical and mental health of key foreign actors–was undoubtedly hard at work pouring over incoming intelligence information to discern the true nature of Sharon and Castro's respective conditions and the likely impact on their leadership. In both cases, the nature of the disease could be decisive in determining the stability of a foreign government.

Since the early 1960s, the U.S. intelligence community has incorporated remote medical and psychological analyses on select foreign political and military leaders into its larger leadership-analysis effort. In the early 1970s, this program evolved into distinct analytical centers involved in remote psychological/psychiatric assessment and remote health assessment. Eventually, the centers were combined into the single MPAC unit within the CIA. This small multidisciplinary analytical team consists of agency physicians, psychiatrists, psychologists, sociologists, anthropologists, and epidemiologists who provide policy makers with timely reports on the medical and psychological factors that affect world leaders' decision making, political behavior, and long-term ability to govern. The unit also conducts assessments of epidemiological and other health issues that are important to national security, such as the global impact of pandemic disease. To enhance its credibility with policy makers, MPAC convenes a semiannual panel of medical and surgical consultants from the academic community to review the unit's methodology, to discuss specific cases, and to ensure a high-quality analytical product. These consultants have all been granted security clearances to view highly classified–top secret and above–material.

Whereas much has been written about the methodology underlying the CIA's psychological profiling effort, virtually nothing has been written about the medical component of these intelligence assessments. 4 Recently, however, a small window has opened onto this highly secretive effort through declassified historical documents, unclassified research papers written by unit members, and a speech delivered by a former MPAC director, Dr. Leslie R. Pyenson. 5

The uses of human frailty

The requirement for medical and psychological assessment of world leaders arose from the realization that nation-states, militia and insurgent groups, and transnational criminal enterprises alike are led by imperfect human beings whose personalities are molded by their peculiar cultural, religious, and educational backgrounds. These same actors, like everyone else, occasionally get sick. With age, they can suffer from chronic hypertension, diabetes, kidney stones, or cancer. Like the late Israeli Prime Minister Menachem Begin, they may battle profound depression or other psychological problems; like the late British Prime Minister Anthony Eden, they may misuse prescription medications; or like former Russian President Boris Yeltsin, they may drink too much alcohol. 6

Human behavior is often profoundly affected by illness, especially terminal illness. While some aspects of one's personality may not change with circumstance, other aspects, such as pessimism or paranoia, may become magnified in the face of severe chronic disease. Some ill leaders, sensing a need to establish their legacy, may drastically alter past behavior to achieve some political goal. Others may psychologically deny their illness and desperately try to hold on to power. Some ailing leaders will not be able to concentrate, process information, or govern their nations effectively. A leader who is ill, or perceived to be ill, may present an alluring target for coup plotters. In 1965, for instance, rumors of Indonesian President Sukarno's declining health led to an unsuccessful coup attempt by communist elements within Indonesia. 7

The failure to adequately assess the potential impact of adverse health could prove disastrous for U.S. interests abroad. The United States was evidently unaware of the extent of the shah's illness early on. Had officials known in 1974 that he was as sick as he was, some might have urged him to seek an accommodation with his opponents earlier. 8 At a minimum, having advance knowledge of a world leader's potentially life-threatening or debilitating illness could help forecast a change in leadership in strategically important nations, such as Pakistan or North Korea, where a rapid shift of government could cause regional instability. Such “medical intelligence” could provide U.S. policy makers with sources of leverage against U.S. adversaries or possible opportunities for diplomacy, such as offering state-of-the-art medical care to an important international actor in exchange for some political concession. 9

Human behavior is often profoundly affected by illness, especially terminal illness. While some aspects of one's personality may not change with circumstance, other aspects, such as pessimism or paranoia, may become magnified in the face of severe chronic disease.

Monitoring the health of foreign leaders may also provide insight into the dynamics of leadership succession. Throughout the 1960s and 1970s, CIA medical analysts closely followed the health of top Soviet leaders such as Leonid Brezhnev and Yuri Andropov. None of the active players were considered to be in “robust health,” and the agency judged that the declining health of the top politburo members could result in a rapid turnover in leadership, which is exactly what happened after Brezhnev died in 1982. 10

MPAC exists because most policy makers lack the medical or psychiatric expertise to fully grasp how an illness in its earliest stages can affect a foreign actor's leadership and decision-making skills, as well as the potential complications of medical treatment, prescription drugs, or substance abuse. Policy makers may adroitly perceive the political or economic nuances of a given situation, but they may completely overlook the human element that underlies all decision making. The primary motivation of many world leaders is to remain in power. When they are sick, there may be strong incentive to manipulate public perception and project an image of strength and vitality. Policy makers may be able to detect denial, deception, and disinformation when matters concern a state-run nuclear weapons program, for example, but they are not always equipped to detect such misleading efforts when they pertain to a leader's health.

MPAC strives to make timely medical assessments that are accurate, objective, and relevant for policy makers. While a third-year medical student can make a reliable medical diagnosis based on observation alone, a simple diagnosis on a world leader will not suffice for national-security decision makers. Indeed, arriving at a diagnosis and prognosis are only part of the analytical problem. What if a world leader suffers from chronic hypertension? Remote medical analysis should not only contain a judgment on the current condition but, most important, an estimate of the impact of health, personality, and medical treatment on decision making, negotiating style, and capacity to govern. MPAC also considers cultural factors that may play particularly important roles in a leader's medical course. For instance, Sukarno refused to have surgery for a large kidney stone because a soothsayer had told him that he would “die by steel.” 11 MPAC's analyses must also address other key issues, such as the possibility of denial and deception and the political dynamics involved in VIP medical care. 12

Post-mortem: President Ronald Reagan signs the condolences book at the Soviet Embassy following the death of General Secretary Yuri Andropov in 1984.

The doctor cannot see you

Medical diagnosis is a form of the scientific method that combines deductive and inductive reasoning, the art of interpreting physical signs, and prudent judgment. 13 Physical diagnosis–the hands-on examination by a doctor that most of us are familiar with–is the traditional means by which practitioners gather information about a patient to formulate a diagnosis. It provides physicians with a conceptual framework for collecting and collating medical information, analyzing data, and disseminating reports on medical status. The physician must determine the exact health problem that made the patient seek medical attention; characterize the “history of present illness” (symptom onset, associated symptoms, ameliorating and exacerbating factors); review the medical, surgical, and family health history; and, finally, perform a direct physical exam–feeling for swollen glands, listening to the heart and lungs, palpating the abdomen. While gathering facts, the physician often subconsciously draws tentative conclusions about the nature of illness before the exam is even completed.

MPAC physicians do not have intimate, unfettered access to their patients and therefore do not actively diagnose medical problems in world leaders in the traditional sense. They reach conclusions about the likely medical condition and attempt to predict the effect on subsequent behavior. Since they lack the ability to routinely examine their subjects, it may not be possible for MPAC analysts to make a specific diagnosis with certainty. But by gathering data and medical facts (not medical opinion) and confirming them over time, it may be possible for analysts to narrow the diagnostic possibilities and make a realistic prognosis.

For these reasons, MPAC seeks to hire expert diagnosticians–seasoned physicians who are willing to take analytical risks, and who are able to weave sparse medical data into a coherent story. 14 Even under the optimal conditions with access to state-of-theart diagnostic equipment, some diseases, such as lymphoma, may present a confusing clinical picture early on. Other conditions, like coronary atherosclerosis, may not manifest themselves until very late in the disease process, so analysts may not recognize a serious health condition in a world leader. Some leaders, like Sukarno, who had moderate hypertension and a nonfunctioning left kidney, may suffer from multiple medical problems, any of which could be life-threatening. The intelligence analyst confronted with equivocal data will need to follow an individual leader's health for some time, reassessing facts, challenging assumptions, and comparing analysis with outcome.

MPAC analysts rely on traditional intelligence sources and methods of human intelligence, communications intercepts, special electronic intelligence, photographic analysis, and open-source media to formulate their remote health assessments.

Human-source intelligence has been particularly important for MPAC analyses. Surreptitiously acquired medical records, X-rays, and laboratory data have provided supplementary details. Nonphysicians have, on occasion, provided crucial confirmatory details about an individual's health. Bits of information obtained at diplomatic receptions can provide information, such as when Fidel Castro was reportedly overheard complaining about his arthritis to Pope John Paul II in 1998. Diplomats and military attachés are briefed on medical-intelligence requirements and given specific health clues to look for during their meetings with important foreign officials. In 1959, U.S. Ambassador W. Averill Harriman helped intelligence analysts determine that Soviet Premier Nikita Khrushchev had not suffered a stroke, despite rumors to that effect.

When you need to determine what is medically wrong with someone, nothing can replace a direct physical examination by a skilled clinician. Although CIA physicians have sought direct contact with their subjects when possible, this is an unusual luxury. 15 Fortunately, as baseball legend Yogi Berra once said, “You can observe a lot by watching.” Physicians, by nature of their training, are excellent observers and are taught to look from head to toe for physical signs of illness. Over the centuries, physicians have described innumerable physical manifestations of disease–such as thyroid goiter, deep earlobe creases in the setting of advanced coronary artery disease, and bulbous fingertips in chronic obstructive pulmonary disease. As such, the CIA's physician-intelligence analysts have relied heavily on careful serial evaluation of photographs and hours of television video outtakes of world leaders to look for such signs. Video can demonstrate an individual's demeanor, stance, and manner of walking, which may unmask any disability present. Comparison of photos over time may reveal, for instance, unexplained weight loss that can be a sign of serious illness such as cancer, or a new facial asymmetry due to a stroke.

Video can demonstrate an individual's demeanor, stance, and manner of walking, which may unmask any disability present. Comparison of photos over time may reveal, for instance, unexplained weight loss that can be a sign of serious illness such as cancer, or a new facial asymmetry due to stroke.

In the early 1980s, CIA analysts reportedly used this comparative technique to follow a potentially cancerous skin lesion seen on the face of then-North Korean leader Kim Il Sung. 16 A fundamental problem with observing physical signs is that they may be misinterpreted when viewed out of context. Although many signs are well known to most experienced clinicians, very few have been subjected to rigorous scientific scrutiny. In a December 2001 video broadcast, Al Qaeda leader Osama bin Laden seemed to preferentially use his right arm. Depending on one's interpretation, bin Laden could have suffered a stroke; shrapnel could have injured him during the battle for Tora Bora; or he may simply have a pinched nerve from slugging around a heavy rifle. 17 There may be little evidence to convince policy makers of the validity of remote medical assessments that rely too heavily on such signs.

One of the principal impediments to accurate remote medical assessment is the lack of reliable firsthand health information. In most countries, including democracies, the number of individuals with direct, intimate access to a national leader is exceedingly small. This lack of access would apply even more so to highly compartmentalized and decentralized terrorist groups such as Al Qaeda. Thus, human-intelligence collection directed toward a leader's medical team might prove fruitful because it may give clues to the nature of the health problems, the type of medical treatment they might receive, potential complications, and outcome. Surely the fact that two of France's most prominent hematologists were secretly flown to Tehran to examine the shah in 1974 should have raised alarms within the intelligence community that he was suffering from a serious blood disorder. Recent reports suggest that bin Laden's physician, Dr. Amer Aziz, is in the custody of the Pakistani Intelligence Service and has provided the FBI with details about the Al Qaeda leader's health. 18 Bin Laden reportedly suffers from kidney stones but is not thought to require dialysis.

MPAC analysts have used signals intelligence, communications intercepts, and other special electronic intelligence sources to obtain essential health information about world leaders. In the early 1970s, the National Security Agency intercepted communications between Soviet politburo members that yielded intelligence on the health of top Soviet leaders. 19 Practicing physicians now routinely view diagnostic medical images such as chest X-rays, computerized tomography scans, and magnetic resonance imaging on semisecure digital networks known as “picture archiving and communications systems,” or PACS. Intelligence analysts may seek to exploit these vast networks to covertly glean medical data on a person of interest.

Former senior CIA medical analyst Dr. Myles Maxfield has noted that his unit used stereoscopic photography, holography, infrared photography, thermal imaging, and “other regions of the electromagnetic spectrum.” 20 The U.S. intelligence community and Defense Department have conducted research and development on “non-contact polygraphy.” In other words, they have sought methods of remotely performing a lie detector test without the subject's knowledge. Since a polygraph is nothing more than a battery of physiological measurements, such as heart rate and respiratory rate, these techniques are directly applicable to remote medical assessment.

Open-source media, such as foreign newspapers, periodicals, radio and television broadcasts, and published biographies can provide a wealth of information but must be used with caution because they may lack specific details or may give equivocal health information. In some instances, information released by a foreign government may be deliberately vague or misleading, or patently false, to guard the truth about a leader's health. The fact that Castro suffered from “serious intestinal bleeding” was significant but quite nonspecific information for the medical analyst. Many things can cause this in an 80-year-old man–bleeding ulcers, stomach cancer, or diverticulitis–and each has a different treatment and prognosis and, thus, implications for the future leadership of Cuba.

Nevertheless, open sources can provide important details about a world leader, such as alcohol or tobacco use and medical and surgical history, which are integral components of any health assessment. Since there may be a strong familial or genetic predisposition to disease, information about illness and cause of death of siblings or parents may help stratify a leader's future health risk.

Finally, CIA medical analysts may occasionally obtain either highly specific lab results–such as blood glucose level or a complete blood count (CBC)–or actual biological material–such as feces, urine, hair, or even DNA–from an important world leader. In 1978, analysts had near real-time access to information from the blood biochemistry tests done on Algerian President Houari Boumediene, who was suffering from a life-threatening blood-clotting disorder known as disseminated intravascular coagulation. 21 The CIA is said to have surreptitiously obtained stool samples from at least two heads of state: Khrushchev and Egyptian King Farouk. 22 In April 2003, Gen. Tommy Franks, then commander of U.S. Central Command, announced that the United States possessed a sample of Saddam Hussein's DNA and was using it to confirm the identity of the captured Iraqi dictator. 23 CIA medical analysts might use DNA samples covertly obtained from world leaders to assess health and genetic predisposition to disease.

The inherent limitations of indirect medical assessment have compelled MPAC to develop rigorous analytical methods to improve the overall accuracy of their work. The CIA has sponsored various research and development projects to assist in the medical assessment, including computerized predictive algorithms and statistical models based on actuarial data. In openly published research, MPAC analysts showed retrospectively that of 261 world leaders who died between 1965 and 1996, nearly one-third died violently; the remainder died from natural causes, including heart diseases, stroke, and cancer. The natural causes of death mirrored that of the U.S. adult male population and could have been predicted from simple actuarial tables.

Most important, MPAC analysis showed a fundamental distinction between the outcome of leaders who suffered a heart attack and those who suffered a stroke. Most leaders who survived an adverse cardiac event while in office were able to return to work and remain functional. But of those leaders, like Sharon, who suffered a stroke while in office, nearly half were out of power within a year. Those who returned to work had significant long-term cognitive and neuropsychological disability, as well as emotional instability. For U.S. policy makers, this should indicate that world leaders who suffer a nonfatal heart attack will likely remain in office. A leader suffering a stroke will in all likelihood result in a change in leadership. 24

Remote medical assessment is likely to remain a highly specialized area of intelligence analysis. But as long as nations, insurgent groups, and drug cartels are led by human beings, the actions of these groups will be influenced by the peculiar psychological and physiological constitution of its members. Monitoring the health of world leaders may provide policy makers with a measure of political stability in nations of strategic importance, a fuller understanding of the motivations of allies and adversaries, and a range of possible options when dealing with them. Medical analysis of important state and non-state actors is constrained mainly by the lack of reliable firsthand health information about those individuals. As such, analysts must rigorously verify facts over time, challenge assumptions, and remain vigilant against disinformation. Determining a reasonable medical diagnosis is only half the battle; determining how those medical phenomena might influence future political behavior is paramount.