What the Dog Saw and Other Adventures

by Malcolm Gladwell

  This is the issue that the US command faced in the most recent Iraq war. Early in the campaign, the military mounted a series of air strikes against specific targets, where Saddam Hussein or other senior Baathist officials were thought to be hiding. There were fifty of these so-called decapitation attempts, each taking advantage of the fact that modern-day GPS-guided bombs can be delivered from a fighter to within thirteen meters of their intended target. The strikes were dazzling in their precision. In one case, a restaurant was leveled. In another, a bomb burrowed down into a basement. But, in the end, every single strike failed. “The issue isn’t accuracy,” Watts, who has written extensively on the limitations of high-tech weaponry, says. “The issue is the quality of targeting information. The amount of information we need has gone up an order of magnitude or two in the last decade.”

  5.

  Mammography has a Schweinfurt problem as well. Nowhere is that more evident than in the case of the breast lesion known as ductal carcinoma in situ, or DCIS, which shows up as a cluster of calcifications inside the ducts that carry milk to the nipple. It’s a tumor that hasn’t spread beyond those ducts, and it is so tiny that without mammography few women with DCIS would ever know they have it. In the past couple of decades, as more and more people have received regular breast X-rays and the resolution of mammography has increased, diagnoses of DCIS have soared. About fifty thousand new cases are now found every year in the United States, and virtually every DCIS lesion detected by mammography is promptly removed. But what has the targeting and destruction of DCIS meant for the battle against breast cancer? You’d expect that if we’ve been catching fifty thousand early-stage cancers every year, we should be seeing a corresponding decrease in the number of late-stage invasive cancers. It’s not clear whether we have. During the past twenty years, the incidence of invasive breast cancer has continued to rise by the same small, steady increment every year.

  In 1987, pathologists in Denmark performed a series of autopsies on women in their forties who had not been known to have breast cancer when they died of other causes. The pathologists looked at an average of 275 samples of breast tissue in each case, and found some evidence of cancer — usually DCIS — in nearly 40 percent of the women. Since breast cancer accounts for less than 4 percent of female deaths, clearly the overwhelming majority of these women, had they lived longer, would never have died of breast cancer. “To me, that indicates that these kinds of genetic changes happen really frequently, and that they can happen without having an impact on women’s health,” Karla Kerlikowske, a breast-cancer expert at the University of California at San Francisco, says. “The body has this whole mechanism to repair things, and maybe that’s what happened with these tumors.” Gilbert Welch, the medical-outcomes expert, thinks that we fail to understand the hit-or-miss nature of cancerous growth, and assume it to be a process that, in the absence of intervention, will eventually kill us. “A pathologist from the International Agency for Research on Cancer once told me that the biggest mistake we ever made was attaching the word ‘carcinoma’ to DCIS,” Welch says. “The minute carcinoma got linked to it, it all of a sudden drove doctors to recommend therapy, because what was implied was that this was a lesion that would inexorably progress to invasive cancer. But we know that that’s not always the case.”

  In some percentage of cases, however, DCIS does progress to something more serious. Some studies suggest that this happens very infrequently. Others suggest that it happens frequently enough to be of major concern. There is no definitive answer, and it’s all but impossible to tell, simply by looking at a mammogram, whether a given DCIS tumor is among those lesions that will grow out from the duct, or part of the majority that will never amount to anything. That’s why some doctors feel that we have no choice but to treat every DCIS as life-threatening, and in 30 percent of cases that means a mastectomy, and in another 35 percent it means a lumpectomy and radiation. Would taking a better picture solve the problem? Not really, because the problem is that we don’t know for sure what we’re seeing, and as pictures have become better we have put ourselves in a position where we see more and more things that we don’t know how to interpret. When it comes to DCIS, the mammogram delivers information without true understanding. “Almost half a million women have been diagnosed and treated for DCIS since the early nineteen-eighties — a diagnosis virtually unknown before then,” Welch writes in his new book, Should I Be Tested for Cancer?, a brilliant account of the statistical and medical uncertainties surrounding cancer screening. “This increase is the direct result of looking harder — in this case with ‘better’ mammography equipment. But I think you can see why it is a diagnosis that some women might reasonably prefer not to know about.”

  6.

  The disturbing thing about DCIS, of course, is that our approach to this tumor seems like a textbook example of how the battle against cancer is supposed to work. Use a powerful camera. Take a detailed picture. Spot the tumor as early as possible. Treat it immediately and aggressively. The campaign to promote regular mammograms has used this early-detection argument with great success because it makes intuitive sense. The danger posed by a tumor is represented visually. Large is bad; small is better — less likely to have metastasized. But here, too, tumors defy our visual intuitions.

  According to Donald Berry, who is the chairman of the Department of Biostatistics and Applied Mathematics at M. D. Anderson Cancer Center, in Houston, a woman’s risk of death increases only by about 10 percent for every additional centimeter in tumor length. “Suppose there is a tumor size above which the tumor is lethal, and below which it’s not,” Berry says. “The problem is that the threshold varies. When we find a tumor, we don’t know whether it has metastasized already. And we don’t know whether it’s tumor size that drives the metastatic process or whether all you need is a few million cells to start sloughing off to other parts of the body. We do observe that it’s worse to have a bigger tumor. But not amazingly worse. The relationship is not as great as you’d think.”

  In a recent genetic analysis of breast-cancer tumors, scientists selected women with breast cancer who had been followed for many years, and divided them into two groups — those whose cancer had gone into remission, and those whose cancer had spread to the rest of their body. Then the scientists went back to the earliest moment that each cancer became apparent and analyzed thousands of genes in order to determine whether it was possible to predict, at that moment, who was going to do well and who wasn’t. Early detection presumes that it isn’t possible to make that prediction: a tumor is removed before it becomes truly dangerous. But scientists discovered that even with tumors in the one-centimeter range — the range in which cancer is first picked up by a mammogram — the fate of the cancer seems already to have been set. “What we found is that there is biology that you can glean from the tumor, at the time you take it out, that is strongly predictive of whether or not it will go on to metastasize,” Stephen Friend, a member of the gene-expression team at Merck, says. “We like to think of a small tumor as an innocent. The reality is that in that innocent lump are a lot of behaviors that spell a potential poor or good prognosis.”

  The good news here is that it might eventually be possible to screen breast cancers on a genetic level, using other kinds of tests — even blood tests — to look for the biological traces of those genes. This might also help with the chronic problem of overtreatment in breast cancer. If we can single out that small percentage of women whose tumors will metastasize, we can spare the rest the usual regimen of surgery, radiation, and chemotherapy. Gene-signature research is one of a number of reasons that many scientists are optimistic about the fight against breast cancer. But it is an advance that has nothing to do with taking more pictures, or taking better pictures. It has to do with going beyond the picture.

  Under the circumstances, it is not hard to understand why mammography draws so much controversy. The picture promises certainty, and it cannot deliver on that promise. Even after forty years o
f research, there remains widespread disagreement over how much benefit women in the critical fifty-to-sixty-nine age bracket receive from breast X-rays, and further disagreement about whether there is enough evidence to justify regular mammography in women under fifty and over seventy. Is there any way to resolve the disagreement? Donald Berry says that there probably isn’t — that a clinical trial that could definitively answer the question of mammography’s precise benefits would have to be so large (involving more than five hundred thousand women) and so expensive (costing billions of dollars) as to be impractical. The resulting confusion has turned radiologists who do mammograms into one of the chief targets of malpractice litigation. “The problem is that mammographers — radiology groups — do hundreds of thousands of these mammograms, giving women the illusion that these things work and they are good, and if a lump is found and in most cases if it is found early, they tell women they have the probability of a higher survival rate,” says E. Clay Parker, a Florida plaintiff’s attorney, who recently won a $5.1 million judgment against an Orlando radiologist. “But then, when it comes to defending themselves, they tell you that the reality is that it doesn’t make a difference when you find it. So you scratch your head and say, ‘Well, why do you do mammography, then?’ ”

  The answer is that mammograms do not have to be infallible to save lives. A modest estimate of mammography’s benefit is that it reduces the risk of dying from breast cancer by about 10 percent — which works out, for the average woman in her fifties, to be about three extra days of life, or, to put it another way, a health benefit on a par with wearing a helmet on a ten-hour bicycle trip. That is not a trivial benefit. Multiplied across the millions of adult women in the United States, it amounts to thousands of lives saved every year, and, in combination with a medical regimen that includes radiation, surgery, and new and promising drugs, it has helped brighten the prognosis for women with breast cancer. Mammography isn’t as good as we’d like it to be. But we are still better off than we would be without it.

  “There is increasingly an understanding among those of us who do this a lot that our efforts to sell mammography may have been overvigorous,” Dershaw said, “and that although we didn’t intend to, the perception may have been that mammography accomplishes even more than it does.” He was looking, as he spoke, at the mammogram of the woman whose tumor would have been invisible had it been a few centimeters to the right. Did looking at an X-ray like that make him nervous? Dershaw shook his head. “You have to respect the limitations of the technology,” he said. “My job with the mammogram isn’t to find what I can’t find with a mammogram. It’s to find what I can find with a mammogram. If I’m not going to accept that, then I shouldn’t be reading mammograms.”

  7.

  In February of 2002, just before the start of the Iraq war, Secretary of State Colin Powell went before the United Nations to declare that Iraq was in defiance of international law. He presented transcripts of telephone conversations between senior Iraqi military officials, purportedly discussing attempts to conceal weapons of mass destruction. He told of eyewitness accounts of mobile biological-weapons facilities. And, most persuasive, he presented a series of images — carefully annotated, high-resolution satellite photographs of what he said was the Taji Iraqi chemical-munitions facility.

  “Let me say a word about satellite images before I show a couple,” Powell began. “The photos that I am about to show you are sometimes hard for the average person to interpret, hard for me. The painstaking work of photo analysis takes experts with years and years of experience, poring for hours and hours over light tables. But as I show you these images, I will try to capture and explain what they mean, what they indicate, to our imagery specialists.” The first photograph was dated November 10, 2002, just three months earlier, and years after the Iraqis were supposed to have rid themselves of all weapons of mass destruction. “Let me give you a closer look,” Powell said as he flipped to a closeup of the first photograph. It showed a rectangular building, with a vehicle parked next to it. “Look at the image on the left. On the left is a closeup of one of the four chemical bunkers. The two arrows indicate the presence of sure signs that the bunkers are storing chemical munitions. The arrow at the top that says ‘Security’ points to a facility that is a signature item for this kind of bunker. Inside that facility are special guards and special equipment to monitor any leakage that might come out of the bunker.” Then he moved to the vehicle next to the building. It was, he said, another signature item. “It’s a decontamination vehicle in case something goes wrong.…It is moving around those four and it moves as needed to move as people are working in the different bunkers.”

  Powell’s analysis assumed, of course, that you could tell from the picture what kind of truck it was. But pictures of trucks, taken from above, are not always as clear as we would like; sometimes trucks hauling oil tanks look just like trucks hauling Scud launchers, and, while a picture is a good start, if you really want to know what you’re looking at, you probably need more than a picture. I looked at the photographs with Patrick Eddington, who for many years was an imagery analyst with the CIA. Eddington examined them closely. “They’re trying to say that those are decontamination vehicles,” he told me. He had a photo up on his laptop, and he peered closer to get a better look. “But the resolution is sufficient for me to say that I don’t think it is — and I don’t see any other decontamination vehicles down there that I would recognize.” The standard decontamination vehicle was a Soviet-made box-body van, Eddington said. This truck was too long. For a second opinion, Eddington recommended Ray McGovern, a twenty-seven-year CIA analyst, who had been one of George H. W. Bush’s personal intelligence briefers when he was vice president. “If you’re an expert, you can tell one hell of a lot from pictures like this,” McGovern said. He’d heard another interpretation. “I think,” he said, “that it’s a fire truck.”

  December 13, 2004

  Something Borrowed

  SHOULD A CHARGE OF PLAGIARISM RUIN YOUR LIFE?

  1.

  One day in the spring of 2004, a psychiatrist named Dorothy Lewis got a call from her friend Betty, who works in New York City. Betty had just seen a Broadway play called Frozen, written by the British playwright Bryony Lavery. “She said, ‘Somehow it reminded me of you. You really ought to see it,’ ” Lewis recalled. Lewis asked Betty what the play was about, and Betty said that one of the characters was a psychiatrist who studied serial killers. “And I told her, ‘I need to see that as much as I need to go to the moon.’ ”

  Lewis has studied serial killers for the past twenty-five years. With her collaborator, the neurologist Jonathan Pincus, she has published a great many research papers, showing that serial killers tend to suffer from predictable patterns of psychological, physical, and neurological dysfunction: that they were almost all the victims of harrowing physical and sexual abuse as children, and that almost all of them have suffered some kind of brain injury or mental illness. In 1998, she published a memoir of her life and work entitled Guilty by Reason of Insanity. She was the last person to visit Ted Bundy before he went to the electric chair. Few people in the world have spent as much time thinking about serial killers as Dorothy Lewis, so when her friend Betty told her that she needed to see Frozen it struck her as a busman’s holiday.

  But the calls kept coming. Frozen was winning raves on Broadway, and it had been nominated for a Tony. Whenever someone who knew Dorothy Lewis saw it, they would tell her that she really ought to see it, too. In June, she got a call from a woman at the theater where Frozen was playing. “She said she’d heard that I work in this field, and that I see murderers, and she was wondering if I would do a talk-back after the show,” Lewis said. “I had done that once before, and it was a delight, so I said sure. And I said, ‘Would you please send me the script, because I want to read the play.’ ”

  The script came, and Lewis sat down to read it. Early in the play, something caught her eye, a phrase: “it was one of those days.�
�� One of the murderers Lewis had written about in her book had used that same expression. But she thought it was just a coincidence. “Then, there’s a scene of a woman on an airplane, typing away to her friend. Her name is Agnetha Gottmundsdottir. I read that she’s writing to her colleague, a neurologist called David Nabkus. And with that I realized that more was going on, and I realized as well why all these people had been telling me to see the play.”

  Lewis began underlining line after line. She had worked at New York University School of Medicine. The psychiatrist in Frozen worked at New York School of Medicine. Lewis and Pincus did a study of brain injuries among fifteen death-row inmates. Gottmundsdottir and Nabkus did a study of brain injuries among fifteen death-row inmates. Once, while Lewis was examining the serial killer Joseph Franklin, he sniffed her, in a grotesque, sexual way. Gottmundsdottir is sniffed by the play’s serial killer, Ralph. Once, while Lewis was examining Ted Bundy, she kissed him on the cheek. Gottmundsdottir, in some productions of Frozen, kisses Ralph. “The whole thing was right there,” Lewis went on. “I was sitting at home reading the play, and I realized that it was I. I felt robbed and violated in some peculiar way. It was as if someone had stolen — I don’t believe in the soul, but, if there was such a thing, it was as if someone had stolen my essence.”