Help wanted ad: The Central Intelligence Agency (CIA) is looking for primary care specialists and psychiatrists “to keep our Nation safe,” a CIA online job ad says.

The recent death of famed CIA profiler Jerrold M. Post, MD, psychiatrist, triggered renewed discussion of physician involvement in medical intelligence work, including controversy over its ethics and medical and psychiatric validity.

For the CIA job noted above, applicants must be willing to serve multi-year assignments in foreign countries. They will use their clinical expertise to “advance the CIA mission where it intersects with medical issues.” A “variety of medical and nonmedical training” will be provided.

Sound vague? Of course. It’s the CIA. How many physicians apply and are hired? We don’t know. It’s the CIA.

The starting base salary is $166,494, plus a 25% hiring bonus and a “progressive physician comparability allowance” of up to $30,000 a year.

“This is one of the most sensitive intelligence programs that the CIA runs,” said Jonathan Clemente, MD, a physician in Charlotte, North Carolina, who has written extensively about the history of medical intelligence and interviewed physicians who have worked in US medical intelligence.

But Charles Morgan, MD, a psychiatrist who worked for the CIA for 7 years, said many physicians working for the agency provide routine medical and psychiatric care to other agency employees, though some do what’s essentially forensic consulting.

“People try to make it super special because it’s the CIA, but physicians aren’t case officers or spies, they’re physicians,” said Morgan, who teaches intelligence analysis at the University of New Haven, Connecticut.

But there’s one big difference: physicians working in the intelligence agencies must learn to operate in a highly secret world. “You receive training in how to go about being a doctor without screwing up the system, like making sure you’re not being followed,” he said.

In addition, they have to decide their comfort level with working for agencies that engage in practices that hurt and kill people. While he was at the CIA during the 2000s, Morgan said many physicians there strongly objected to the Bush administration’s use of torture in interrogating detainees, but they were ignored.

Morgan said that when he was in the CIA, he worked with male and female physicians ranging from their 30s through their 50s, including all different personality types. One appealing part of working for the CIA was freedom from the hassles of traditional medical practice. “I didn’t have to deal with health insurers,” he said. “I could do evaluations, write reports, and deliver care and not have to argue about whether I could hold a patient for more than 2 days because their insurance ran out.”

For decades, US military and intelligence agencies have recruited physicians in psychiatry, internal medicine, cardiology, neurology, epidemiology, and other specialties to evaluate foreign leaders and key nonstate actors like Al Qaeda leader Osama bin Laden. Their role is to help policymakers understand them and predict what they’re likely to do. This is sometimes called medical intelligence, leadership analysis, remote medical diagnosis, or even medical spying.

Their highly classified work is done through the CIA’s Medical, Psychological and Health Security Center (MPHSC). Some physicians deploy with CIA paramilitary teams in dangerous locations, though these may be military doctors, Clemente said.

In a separate arm of medical intelligence work, physicians help military and civilian leaders evaluate a wide range of medical-related threats to US security in foreign countries, including pandemics, disease threats to troops, environmental hazards, and biochemical weapons capability. That’s done through the Defense Intelligence Agency’s National Center for Medical Intelligence.

For instance, physicians and other specialists at NCMI might analyze how Chinese military forces were affected by the COVID-19 pandemic, and whether Russia is developing a vaccine against a deadly virus that they could use as a bioweapon.

Physicians invited into the Medical, Psychological and Health Security Center are mainly recruited from within the CIA ranks, Clemente said. All have at least 15 years of direct patient care experience. Some receive operational spy tradecraft training.

There are no specific personality traits that draw physicians into this line of work, CIA psychologists have found. But Clemente said a common denominator is a desire to live and work overseas, experience different cultures, and do something different from traditional office- or hospital-based practice.

For physicians working in the MPHSC, much of their job is about understanding the human factor in foreign policy. US leaders want to know if a foreign leader is impaired physically or mentally, perhaps leaving others to make major decisions.

US leaders also need to understand how best to negotiate with foreign leaders. Foreign leaders who are ill or have psychological issues may feel a stronger desire to seal a historic deal and leave a lasting legacy. Alternatively, a leader’s physical or mental impairment may lead to dangerously bad decision-making.

For instance, President Jimmy Carter credited the psychological profiles of Israeli Prime Minister Menachem Begin and Egyptian President Anwar Sadat put together by Jerrold Post, MD, a psychiatrist who headed the CIA’s Center for the Analysis of Personality and Political Behavior, for the success of his negotiations leading to the landmark Camp David Peace Accords.

“The overarching goal is to avoid strategic surprise,” Clemente said. “We don’t want to find out that someone has a long-term chronic condition that we could have known about years in advance and could have developed policy responses if there was a sudden exit from power.”

It’s widely believed that US national interests were hurt by a huge medical intelligence failure involving Mohammad Reza Pahlavi, the Shah of Iran. In 1979, he fled his country and sought medical treatment abroad, handing government control to Islamic revolutionaries. Unbeknownst to the US government, he’d been suffering from leukemia since 1974. American policymakers had counted on the Shah remaining in power for many more years.

If US leaders had known earlier that the Shah was seriously ill, they might have pushed him sooner to reach a power-sharing deal with his Islamic fundamentalist foes, Clemente said.

The daily briefing for the US President often includes intelligence assessments about the health of foreign leaders, said Nicholas Dujmovic, director of intelligence studies at the Catholic University of America, Washington, DC, who edited President Bill Clinton’s daily brief.

“The health of certain leaders of the countries that cause us the most difficulties is going to be a huge priority,” Dujmovic said. “If we have a presence in those countries, we might try to work on that. If those leaders travel abroad to a third country, we’d try to collect as much information as we can.”

Accurate assessments of foreign leaders’ health can assist US foreign policy and military decision-making. For instance, learning more about North Korean leader Kim Jong-un’s uncertain health could potentially have enormous consequences for US policy on North Korean denuclearization, while knowing more about COVID-19 infections and deaths among Iran’s elderly religious leaders could influence US contingency planning for leadership changes there, say experts in the field.

There’s no way for the public to know for certain which foreign leaders or overseas health conditions US medical intelligence analysts are currently evaluating given the programs’ secrecy. Two physicians who reportedly were active in these programs, including one who headed the CIA program profiling foreign leaders, did not respond to interview requests.

“The CIA is not releasing any primary source material, they aren’t making officials available to interview, and we are not going to get any current stories that will be confirmed by the CIA,” Clemente said.

Other advanced countries likely have similar medical intelligence and leadership analysis programs evaluating US officials, particularly older people with known health issues like former President Donald Trump, and President Joe Biden, said Lawrence Altman, MD, who covered the health of world leaders for decades for The New York Times.

“It’s a two-way street,” Altman said. “I assume others would look at us.”

“I’m sure foreign governments are very concerned about Biden’s health and carefully watch his performance, given that he had a brain aneurism 20 years ago,” said Rose McDermott, PhD, a professor of international relations at Brown University, Providence, Rhode Island, who has written about US medical intelligence and leadership profiling efforts.

The challenge for physicians trying to make these assessments is that they can’t personally examine the foreign leaders. And they can only see test results and other medical data if intelligence operators are able to obtain them surreptitiously, through data hacking or getting bodily samples like DNA, blood, urine, or feces.

But Morgan, who worked with Post, the famed CIA profiler, argues that the ability of CIA medical and psychiatric analysts to analyze foreign leaders and reliably predict their behavior without personally examining them and reviewing their medical records is overhyped.

“It’s difficult for physicians to pretend to know about people they’ve never met,” said Morgan, who has performed forensic evaluations of criminal defendants. “The fantasy is this somehow helps the US government do something better. But I’m a real skeptic. I don’t think it’s real.”

Medical intelligence analysts may gain greater access to hacked data on leaders as more medical data is transmitted electronically and as digitally linked medical devices increasingly are used to capture and send physiological measures on patients.

Most often, however, physicians assessing the health of foreign leaders must rely on photographs, videos, or personal observations of people who have interacted with the leader. It’s particularly difficult to gather reliable information on dictators in closed societies, unless those leaders travel abroad to receive treatment in countries where US intelligence has sources in the medical facilities.

Physicians working with intelligence agencies may brief diplomats and other US officials on health clues to watch for while meeting with foreign leaders. They particularly look for changes over time in the way leaders walk, talk, and move, their facial expressions, and their weight.

Dujmovic said there is competition and jockeying within the US intelligence agencies between physicians and nonphysician leadership analysts. “The analysts sometimes fancy themselves amateur doctors and psychiatrists, and that sometimes created a bit of conflict with the actual medical specialists,” he said.

Morgan said it’s valuable for the intelligence agencies to have physicians around to put a check on scientifically unfounded ideas. For instance, while working in the CIA’s science office, he stopped a plan to build a room-size magnetic resonance imaging machine to surreptitiously scan the brains of people talking in a room in Afghanistan. “I told them that such a huge magnet would kill the people,” he said with a laugh. “My job was to be Dr No and say, ‘No, that won’t work.'”

To make up for lack of personal exams and medical records, US intelligence agencies have sought to develop remote physiological sensing devices, Clemente said. Such tools are capable, for instance, of detecting a leader’s heart rate by focusing a laser at his or her carotid artery or measuring oxygen saturation or skin temperature through a specially equipped chair. But such monitoring is risky because adversaries may be able to spot the use of such devices.

“Their goal isn’t so much that this person has a particular diagnosis,” Clemente said. “It’s how the condition or treatment affects their behavior or their longevity in power.”

That’s one reason why former President Bill Clinton brought along his personal physician, Roger Band, MD, on a trip to North Korea in 2009 to free two American journalists. Band reportedly was assigned to observe and assess the health of then-North Korean leader Kim Jong-il, the current leader’s father. But Kim and his aides were suspicious.

Band, an emergency physician, declined to comment for this article.

That’s not the only time the United States has placed medical specialists in situations where they could eyeball foreign leaders, though the physician may need to be there undercover, Dujmovic said. “If you identify the person as a doctor, the other side may know what you’re trying to do and exclude that person,” he added.

But even if a physician has the opportunity to do an in-person observation, the lack of a personal exam and medical records means these medical and psychiatric assessments can be of questionable accuracy and value. For instance, a 2008 Defense Department study concluding that Russian President Vladimir Putin had Asperger syndrome has never been substantiated.

“There are lots of examples where American ignorance of the health of certain leaders has caused problems,” Brown University’s McDermott said. “The reality is we don’t know because we don’t have good human intelligence on the ground. You don’t know what’s going on unless you have a spy in the hospital.”

To obtain medical information about foreign leaders, Dujmovic said US medical intelligence operatives try to recruit janitors or records clerks in medical facilities that treat them. “You don’t necessarily want the chief surgeon or nurse,” he said. “You might want the low-level person who might have a need for money.”

There also are ethical issues. The American Psychiatric Association (APA) considers it unethical for psychiatrists to assess or diagnose people without personally examining them and obtaining their consent, though it makes an exception for psychiatrists working with US intelligence agencies.

“A lot of physicians consider it bad medicine to make inferences or diagnoses about people without seeing the patient,” McDermott said.

The APA indirectly criticized a group of prominent psychiatrists who published a 2017 book and spoke out publicly about the mental and emotional fitness of President Donald Trump. The psychiatrists said Trump showed symptoms of narcissistic personality disorder, sociopathy, and other disorders.

Bandy Lee, MD, who organized the psychiatrists who spoke out, was terminated by Yale University from her faculty position last year, at least partly due to her public statements about Trump. She has sued Yale seeking reinstatement. She argues that she and her group accurately predicted that Trump’s mental impairments would lead him to disastrously mishandle the COVID-19 pandemic.

“The US evaluates foreign leaders to assess danger and determine how to protect national security,” Lee said in an interview. “When our own leader poses a threat to the nation, it’s potentially an even greater danger. We have a professional responsibility to protect our society against that danger.”

The APA said it permits psychiatrists to offer their professional opinions to national security agencies as long as it’s done with “proper authority and methods” and with confidentiality. In contrast, it bars its members from doing this outside that framework, under its so-called Goldwater Rule, which was issued after psychiatrists publicly questioned the mental health of Arizona Republican Senator Barry Goldwater during his 1964 presidential campaign.

“Psychiatrists should not give professional opinions in the media about the mental state of high-profile individuals that they have not evaluated and about whom they do not have permission or legal authority to speak,” said Rebecca Brendel, MD, JD, the APA’s president-elect, in a written statement.

But some psychiatrists disagree with how the APA has applied its ethics rule, seeing a contradiction in allowing psychiatrists to assess foreign leaders but not US leaders. “They are okay with the CIA profiling Putin without an interview but not with APA members commenting on Trump,” said John Martin-Joy, MD, a psychiatrist in Cambridge, Massachusetts, who wrote a book on remote diagnosis. “I don’t see how those two things should be viewed differently.”

No other medical professional associations are known to have ethics rules against members doing remote evaluations, either on their own or for US intelligence agencies.

“If I’m a neurologist and I see a major public figure look a little wobbly and I say something, that’s not criticized,” said Jonathan Moreno, PhD, a bioethics professor at the University of Pennsylvania, Pittsburg. “But prediction is hazardous, which is why doctors try not to tell you how long you’ve got to live.”

Clemente said that although he’s never done medical intelligence work himself, he wishes he could participate.

“I’ve made it known that if I were asked, I would do it for free,” he said. “It’s a fascinating application of medicine and psychiatry.”

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