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PE R S PE C T IV E

scenarios assessing personality


traits such as listening skills,
empathy, and a nonjudgmental
nature can help interviewers predict a candidates likely future
performance.
A 2010 systematic review concluded that many studies evaluating CHW programs have substantial methodologic limitations,
including high attrition rates and
designs that introduce the potential for bias.5 This low-quality
science has led policymakers to
either dismiss CHW programs or
have unrealistic expectations for
their success. But since 2010, the
number of articles on CHWs
published annually (in journals
indexed in PubMed) has nearly
doubled, and the quality of research has improved; nearly 400
randomized, controlled trials have
been published in the past 5 years
suggesting that CHW interventions can be subjected to the
same level of rigorous evaluation
as new drugs. As the evidence
base for specific CHW interventions improves, future questions

From Rhetoric to Reality

will focus on the implementation


and programmatic features required for success in a variety of
settings.
Their long history and the expanding evidence base for CHW
programs suggest that they have
strong potential for improving
health outcomes. Many policymakers believe that the key to
realizing this potential lies in
standardized training and certification of CHWs. But unless we
address program-level implementation barriers, employee-level
standardization is unlikely to be
effective. Program accreditation
based on evidence and on-site
surveys such as those conducted by the Joint Commission
might help to foster the CHW
programs that are most likely to
succeed.
The current policy and financing environment has created a
historic opportunity to improve
U.S. health care delivery through
the effective use of CHWs. As we
move beyond the financing, it
will take hard work at the imple-

mentation level to maximize the


likelihood of success.
Disclosure forms provided by the authors
are available with the full text of this article
at NEJM.org.
From the Division of General Internal Medicine, Perelman School of Medicine (S.K.,
D.G.), and the Penn Center for Community
Health Workers (S.K.), University of Pennsylvania, Philadelphia; and the Department
of Population Health, New York University
School of Medicine, New York (C.T.-S.).
1. Rifkin SB. Paradigms lost: toward a new
understanding of community participation
in health programmes. Acta Trop 1996;61:7992.
2. IMPaCT manuals. Philadelphia: Penn
Center for Community Health Workers, 2013
(http://chw.upenn.edu).
3. Richter RW, Bengen B, Alsup PA, Bruun B,
Kilcoyne MM, Challenor BD. The community
health worker: a resource for improved health
care delivery. Am J Public Health 1974;64:
1056-61.
4. OBrien MJ, Squires AP, Bixby RA, Larson
SC. Role development of community health
workers: an examination of selection and
training processes in the intervention literature. Am J Prev Med 2009;37:Suppl 1:S262S269.
5. Viswanathan M, Kraschnewski JL, Nishikawa B, et al. Outcomes and costs of community health worker interventions: a systematic review. Med Care 2010;48:792-808.
DOI: 10.1056/NEJMp1502569
Copyright 2015 Massachusetts Medical Society.

Post-9/11 Torture at CIA Black Sites Physicians


and Lawyers Working Together
George J. Annas, J.D., M.P.H., and Sondra S. Crosby, M.D.

n December 2014, the U.S. Senate Intelligence Committees report on torture was released to
the public. The 600-page report
(a redacted summary of the stillclassified 6000-page report) documents in disturbing detail the
use by the Central Intelligence
Agency (CIA) of physicians, lawyers, and psychologists in its post9/11 torture program at more
than a dozen black sites, or secret prisons, around the world.1

The United Nations High Commissioner for Human Rights, Zeid


Raad al-Hussein, has called the
report courageous and commendable, while condemning the torture program it details and noting
that torture cannot be amnestied
and should not be permitted to recur.2 To begin to understand the
torture, we believe its necessary
to understand how physicians and
lawyers collaborated to overcome
their professional inhibitions.

Medical professionals, primarily private contractors, filled four


basic roles at the black sites:
clearing terrorist suspects as
medically fit for torture; monitoring torture to prevent death
and treat injuries; developing
novel torture methods; and actually torturing prisoners. All these
actions were taken only after CIA
and U.S. Department of Justice
attorneys assured the medical
professionals that they had im-

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The New England Journal of Medicine


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PERS PE C T IV E

Post-9/11 Torture at CIA Black Sites

munity from prosecution and


would not be held legally responsible for violating U.S. and international law against torture as
long as they used the techniques
approved in legal memos (since
withdrawn) written to justify their
actions.1 Lawyers agreed to provide immunity assurances that
specific torture techniques were
legal enhanced interrogation
methods only if the physicians
assured them that they would be
present to prevent permanent
harm to prisoners. The CIA
opened more than a dozen black
sites around the world after 9/11,
in which at least 117 prisoners
were held; 39 of these prisoners
were subjected to one or more
torture techniques.1
From the Senate report and
the documents on which it builds,
the physicians involved appear
initially to have had at best mixed
feelings about direct involvement
in torture, but they evolved into
active participants. In August
2002, CIA e-mail messages included lines such as [I] want to
caution [the medical officer] that
this is almost certainly not a place
hes ever been before in his medical career and the comment that
viewing videotapes of the waterboarding of Abu Zubaydah (the
first terrorist turned over to the
CIA) has produced strong feelings of futility (and [il]legality).1
Seven months later, in March
2003, one on-site physician questioned the plan towaterboard the
alleged 9/11 mastermind, Khalid
Sheikh Mohammed (referred to as
KSM), for the fourth time in 24
hours, because the draft guidelines of the CIAs Office of Medical Services (OMS) stated that
three waterboarding sessions in 24
hours was the acceptable maximum. The Counterterrorism Centers attorney assured the site
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personnel that the medical officer was incorrect in thinking that


this limit had been approved. Later the same day, the medical officer wrote to the OMS, saying,
things are slowly evolving from
OMS being viewed as the institutional conscience and the limiting
factor to the ones who are dedicated to maximizing the benefit
in a safe manner and keeping
everyones butt out of trouble.1
The waterboarding of KSM, like
almost all the torture conducted,
was directly overseen by two contract psychologists, former supervisors of the U.S. Air Forces SERE
(survival, evasion, resist, escape)
course, who were hired to develop
an interrogation program by reverse engineering the SERE program, to get the suspected terrorists to talk.1 Instead, they relied
almost exclusively on what they
called learned helplessness, a
technique based on research in
dogs, which was used to try to
break down a prisoners resistance
to the point where he feels helpless enough to confess to whatever
his torturers want. Before KSMs
waterboarding, the two psychologists (their CIA cover names were
Swigert and Dunbar; their real
names are James Mitchell and
Bruce Jessen) had used nudity,
standing sleep deprivation (for up
to 180 hours), the attention grab
and insult slap, the facial grab,
the abdominal slap, the kneeling
stress position, and walling
(pushing into a wall quickly and
firmly).1 The Department of Justice had approved these methods
as long as they were done with a
physician present.
The use of unapproved torture
methods illustrates, we think, the
impossibility of confining torture to legally defined methods.
For example, CIA agents threatened KSMs children, a universal-

ly condemned method that was


nonetheless later declared legal
by the Counterterrorism Center,
so long as the threats were conditional, whatever that means.1
Another unapproved method
called water dousing (a variation on waterboarding) was developed with guidance from CIA
[Counterterrorism Center] attorneys and the CIAs Office of Medical Services working together.1
Physicians and lawyers consistently gave themselves permission to do whatever they agreed
among themselves was important
to do (to save lives). Another
unapproved technique, described
as rectal feeding, consisted of
delivering food rectally to demonstrate dominance over the prisoner (though no nutrition can be
delivered through the rectal mucosa). This torture technique was
used, for example, on Majid
Khan, who was on a hunger
strike. CIA medical officers had
discussed rectal rehydration as
a means of behavior control.
Three weeks into a hunger strike,
nasogastric feeding was replaced
with a more aggressive treatment regimen. Majid Khan was
subjected to involuntary rectal
feeding and rectal hydration,
which included two bottles of
Ensure. Later that same day,
Majid Khans lunch tray, consisting of hummus, pasta with
sauce, nuts, and raisins, was
pureed and rectally infused. Additional sessions of rectal feeding and hydration followed.1
There is, of course, no medical indication for rectal feeding,
and the fact that it was done by
or under the supervision of a
physician cannot convert this torture technique into a medical
procedure. Nonetheless, a medical justification was the cover
story to legitimize its use when it

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The New England Journal of Medicine


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PE R S PE C T IV E

became public. For example, responding to the Senate report,


Vice President Dick Cheney said
rectal feeding was not approved
but that he believed it was done
for medical reasons. It seems
more accurate to describe rectal
feeding as a technique of sexual
assault. Seen in the context of the
constant state of nudity of most
black-site prisoners, it seems reasonable to conclude that the
goal of rectal feeding is dominance and punishment that it
is about vengeance, not medicine.
In U.S. prisons, medicine (and
public health) have also been
used to justify demonstrating
dominance by forced nudity of
prisoners, in the form of routine
mandatory strip searches.3
The Senate committees Republican minority (now the majority) published a rebuttal to the
report, arguing that it was incomplete because it relied exclusively on documents and did not
involve interviewing participants.
The minority also disagreed that
no useful information was obtained by torture, correctly noting that there is no way to recreate a nontorture scenario to see
what information could have been
discovered without torture. On
the other hand, whether torture

Post-9/11 Torture at CIA Black Sites

works like whether slavery


works is simply the wrong
question.4 Both are international
ly recognized as crimes against humanity that have no justification.
In 2004, Robert Lifton wrote
in the Journal that it is possible to
get physicians to become torturers by putting them in atrocityproducing situations.5 One such
situation is certainly a CIA black
site, a site with no official existence that is created for the primary purpose of extracting information from suspected terrorists.
The Senate report supports Liftons conclusion and suggests
that one way to try to prevent a
repetition of the torture program
is, as President Barack Obama
has said, to eliminate black sites
altogether. The report adds to
our knowledge of how lawyers
and physicians can collaborate
with each other to rationalize
torture a dynamic that has
also played out in military prisons, including Abu Ghraib and
Guantanamo, and even in some
U.S. prisons, especially supermax
prisons and others that rely heavily on solitary confinement.
Beyond the elimination of black
sites, attorneys will have to stand
with physicians who want to
maintain their ethics (and follow,

among other legal standards, the


Geneva Conventions), support
health professionals in their refusals to torture, and refuse to
give CIA agents and contractors
prospective legal immunity for
violating human rights laws. And
in all contexts, physicians should
act only in ways consistent with
good and accepted medical practice, with the consent of their patients.
Disclosure forms provided by the authors
are available with the full text of this article
at NEJM.org.
From the Department of Health Law, Bioethics, and Human Rights, Boston University School of Public Health (G.J.A., S.S.C.),
and the Department of Medicine, Boston
University School of Medicine (S.S.C.)
both in Boston.
1. Senate Select Committee on Intelligence.
Committee study of the Central Intelligence
Agencys detention and interrogation program.
December 3, 2014 (http://www.intelligence
.senate.gov/study2014/sscistudy1.pdf).
2. Cumming-Bruce N. U.N. rights chief criticizes world powers. New York Times. March 6,
2015:A8.
3. Annas GJ. Strip searches in the Supreme
Court prisons and public health. N Engl J
Med 2012;367:1653-7.
4. Cole D. Did the torture report give the
C.I.A. a bum rap? New York Times. February
22, 2015:SR6.
5. Lifton RJ. Doctors and torture. N Engl J
Med 2004;351:415-6.
DOI: 10.1056/NEJMp1503428
Copyright 2015 Massachusetts Medical Society.

Behavioral Economics and Physician Compensation


Promise and Challenges
Dhruv Khullar, M.D., M.P.P., Dave A. Chokshi, M.D., Robert Kocher, M.D., Ashok Reddy, M.D., Karna Basu, Ph.D.,
Patrick H. Conway, M.D., and Rahul Rajkumar, M.D., J.D.

edicare aims to apply alternative payment models to


50% of its fee-for-service payments by the end of 2018 an
important shift toward valuebased health care.1 The success
of national payment reform, how-

ever, will depend on engaging


clinicians in making better decisions in managing individual and
population health. Many physician behaviors are well explained
by rational economic models
(e.g., fee-for-service reimburse-

ment tends to promote well-compensated procedures), and revising incentives may drive changes
in decision making, shifting our
focus from volume to value. Provider organizations embracing
alternative payment models may

n engl j med 372;24nejm.orgjune 11, 2015

The New England Journal of Medicine


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