by Joe Biden
All four of us—Presidents Molina, Hernández, Sánchez Céren, and me—signed the document and released it to the public. This was the crucial product of the trip, in black and white. I could present the statement to the members of Congress as proof of seriousness on the part of the Northern Triangle leaders, and proof of the accountability we had built into the agreement. My plan was to make it absolutely clear to Congress that I would not permit the State Department to release funds unless and until explicit granular commitments—such as hiring and training set numbers of teachers and cops in particular at-risk neighborhoods, or hitting targets on increasing tax revenues from the wealthiest of their citizens—had been executed. I would give my word that we would not write a check for any program until they had hit their mark on that program. I was going to put my credibility on the line in the halls of Congress, where members knew I had never broken a commitment.
* * *
I had a long heart-to-heart with my key staff in the main cabin of Air Force Two on the way back. There were a lot of obstacles that stood in the way of this plan actually working, I said to them, but I had been really impressed that the three Northern Triangle presidents seemed so willing to rise to the crisis at hand. I told the staff they had done a great job, but that there was a lot more to do when we got home. We had to start lobbying Congress for the appropriation, and we had to draw out more detailed commitments from the Northern Triangle leaders. We needed to align our assistance so that we were supporting both the short-term needs—like addressing the violence and the lack of opportunity in the most vulnerable communities—while also working patiently with the three countries on structural reforms and improved governance that could lead to real prosperity there.
It was nearing midnight on Tuesday and still below freezing in Washington when Jill and I arrived at the Naval Observatory. I had a hard time sleeping that night, thinking about Beau’s first anti-PD-1 antibody injection, which was scheduled for the next day. Beau was still on my mind the next morning, at the office, as I filled in the president on what we had accomplished in Guatemala. I spent much of the day after that in my own office, waiting for the call from Houston about Beau’s procedure. I was tired and worried and a little bit angry at the Fates. Why was this happening to my son? He just didn’t deserve this. I glanced through the schedule for the rest of the week and was relieved to see that it didn’t seem too taxing. It felt like I finally had some breathing room to focus on Beau. And then came the call from Haider al-Abadi. He was not an excitable man, but he was clearly in the middle of a serious crisis. “Joe,” said the new prime minister of Iraq, “I need your help.”
CHAPTER SEVEN
Calculated Risks
Prime Minister Abadi needed serious military assistance in the new battle for Tikrit, he told me on the phone that day, March 4, 2015, and he needed it in a hurry. Abadi was in danger of losing control of a pivotal fight against the vicious new malignancy of terror growing in the Middle East, the Islamic State of Iraq and the Levant, or ISIL. His ask was a big one, consequential both to Iraq and to the United States. And beyond the global implications, this was an issue of great personal import to me. The majority of Americans had surely wearied of our costly twelve-year slog in Iraq, and many had tuned it out like so much annoying background noise. I could not. Having worked since 2003 to help build a functioning, inclusive government in Iraq that might develop into a real democracy, I was deeply invested. I had traveled to Iraq more than twenty times, first as ranking member and chairman of the Senate Foreign Relations Committee, and later as vice president, after Barack announced to me in a 2009 meeting of senior officials in the Oval Office, “Joe will do Iraq.”
Iraq had arguably been the most frustrating issue of my forty-year career in foreign relations. Relations among the three main factions in Iraq—Shia Arabs, Sunni Arabs, and Kurds—were characterized by anger and paranoia, and punctuated by spasms of outright violence. The three factions nursed grudges both ancient and modern. The modern borders of the country were carved out of the Ottoman Empire following the first World War. Saddam Hussein’s Baathist regime favored the country’s Sunni Arab minority, while the aspirations of the majority Shia Arab population, concentrated in central and southern Iraq, and the Kurdish minority in the north were brutally repressed. The 2003 American invasion overturned this order, disenfranchising the Sunnis, empowering the Shia, and rekindling Kurdish dreams of independence. A dozen years trying to persuade the political leaders in Iraq to see the benefits of a government based on something other than raw power and sectarian dominance had been time-consuming, draining, and ultimately nearly impossible. But I wasn’t ready to give up on it. Beau had risked life and limb serving a yearlong deployment in Iraq. He saw death and destruction there, though he didn’t talk about it much. But he always insisted that what the United States was trying to do was noble. If there was a reasonable chance to get it right in Iraq—for the long term—Beau believed we should try. We had sacrificed too many good people already to give up. And on the day of Abadi’s call, I thought we finally had a chance. The irony of all ironies was that the very outfit that intended to tear the country apart, ISIL, was actually bringing Iraqis together, at least temporarily.
The strength of ISIL in Iraq had caught not only the United States but the entire coalition by surprise in the summer of 2014, when its forces made a lightning offensive in the north and west of the country. ISIL fighters blew through the Iraqi security forces, gaining their first solid footholds in the extravagant and improbable project to create a repressive “Caliphate of the Islamic State” across the whole of the Middle East and then beyond. ISIL took almost a third of Iraq, most of it in the Sunni-majority areas. The group gorged itself on cash from banks it looted and on hundreds of millions of dollars’ worth of sophisticated weaponry and equipment left on the battlefield when poorly commanded Iraqi units fled. ISIL terrorized the population with beheadings, mass executions, the burning and crucifixion of prisoners—and did it in public, recorded on video for all the world to see. It desecrated or destroyed Shia religious sites and libraries, and threatened minority Christian and Yezidi populations with genocide. ISIL menaced the oil-rich Kurdish stronghold of Kirkuk and took control of Iraq’s second-largest city, Mosul, as well as Tikrit, the provincial capital of Salah ad Din.
The spread of ISIL’s bloody rule changed the political calculus for all three factions in Baghdad, forcing them to think like the old American revolutionary Ben Franklin. “We must all hang together,” Franklin had famously said, at the signing of the Declaration of Independence, “or assuredly, we shall all hang separately.” My team used that moment of crisis to real advantage. I spent hours on the phone in 2014—along with Ambassador Stuart Jones in Baghdad, Deputy Special Presidential Envoy Brett McGurk, and my national security team—trying to pry sufficient concessions from each faction to form the basis of an inclusive coalition government. Because the stubbornly sectarian policies of former prime minister Nouri al-Maliki helped give rise to ISIL, we worked like hell to negotiate the deal among the three factions that ultimately installed Haider al-Abadi, a Shia committed to a more inclusive government, as prime minister. After spending time with him and watching him work, I came to see Abadi as the single best shot at creating a true, working coalition government. He talked with me about his country becoming an anchor democracy in the Middle East. We agreed on the need for what he called “functioning federalism”—which meant allowing more autonomy to the separate provinces, some controlled by Sunnis and some by Kurds. And we spoke of the incredible economic potential of the country’s enormous oil reserves. Iraq had more oil than Kuwait and Russia, and almost as much as Iran. Oil could be a boon fairly shared by all—the glue that could hold Iraq together.
We had worked right alongside Abadi to shape an Iraqi security force and a strategy capable of defeating ISIL—one that ensured that Iraqis stayed in the lead, so we could avoid sending tens of thousands of U.S. troops back into Iraq. The Maliki govern
ment had decimated the military and its command structure. Both would have to be rebuilt. Our military advisers helped Prime Minister Abadi identify Iraqi commanders he could appoint on the basis of competence, not religious sect. We tasked our Special Forces to assess which Iraqi units could actually be salvaged, helped them reconstitute their divisions, and began training new soldiers. We reequipped this new force with armored vehicles, ammunition, small arms, Hellfire missiles, and bomb detection technology.
When Abadi called me that morning in March 2015, a major operation against ISIL in Tikrit was just getting under way. And the prime minister made it clear to me on the phone that he was extremely worried about this unfolding assault. Tikrit was a flashpoint of sectarian grievance. Nine years earlier, violence between the Shia and Sunni in neighboring Samarra had tipped the country into a bloody civil war, and following ISIL’s brutal killing of fifteen hundred air force cadets, many of them Shia, at a nearby Iraqi air base in June 2014, the prospect of a repeat was real. The operation to take the city had been planned—and was now being executed—outside the purview of the central government in Bagdad and outside the control of his minister of defense. A loose assortment of Shia militia groups known as the Popular Mobilization Forces (PMF) made up about three-quarters of the thirty-thousand-man attack; many were aligned with the government of Iran. Tehran seemed to be in the driver’s seat of the operation. It had supplied artillery, tanks, drones, and military advisers. The most visible and well-known commander on the ground was Qasem Soleimani, head of Iran’s notorious Islamic Revolutionary Guard Corps Quds Force. Soleimani was parading around the battlefield, flying an Iranian flag, taking selfies to be circulated in both Iran and Iraq. If the attack worked, Soleimani would be seen as the hero of Tikrit by much of the Shia population in the region, and the Iraqi government in Baghdad would be in debt to Iran. There would also be a dangerous precedent for a parallel security operation run by the Iranians in other places in Iraq. On top of that, Abadi feared that the violent reprisals by angry Shia fighters against Sunnis that were sure to follow the liberation of Tikrit would lead to escalating Sunni-Shia tensions that could splinter his tenuous new government.
We both knew that pushing ISIL out of Tikrit had to be done the right way, with the right forces. Abadi needed to gain control of the operation, and get his own Iraqi national troops in the lead, before it got out of hand. He needed help from the United States to do that, and he was counting on me to deliver. He asked for firepower from us to match or exceed Tehran’s: drones to provide intelligence, surveillance, and reconnaissance (ISR); targeted air strikes from U.S. warplanes on ISIL fighters on the ground; additional ammunition and body armor; and U.S. advisers and planners to help coordinate the offensive. I still believed Abadi to be worthy of our help. I told him I would do what I could do, as fast as I could, but that there would have to be conditions attached to any American military assistance.
* * *
When the call came in from Houston that same day, the report was straightforward. The procedure to inject Beau with the anti-PD-1 antibody pembrolizumab—or pembro, as the doctors called it—had gone well. The procedure itself was a simple one. They put an IV into his arm, shot about 150 milligrams of pembro into his bloodstream over the next thirty minutes, and it was done. But as I stood in my office in the West Wing, I knew in my gut that little else would be simple in the coming months. We had crossed the medical Rubicon. The real fight was on now, for Beau and for our family. There was no telling how long it would last, because it was a novel fight in the history of glioblastoma treatment—a three-pronged attack on the cancer that had never before been executed in full. Dr. Sawaya would be performing the second risky maneuver, a surgery to excise the excisable part of Beau’s tumor, at the end of March; as soon as Beau had healed from that operation, Dr. Frederick Lang would be injecting a specially engineered live virus into the remaining tumor. Then another injection of pembro a few weeks later, or as soon as Beau could handle it. At least, that was the plan.
The live virus itself was a relatively new treatment, developed by researchers and clinicians at M. D. Anderson over the previous fifteen years. The microbiology that underpinned the science of the treatment, however, dates back billions of years. Viruses have been around almost as long as living organisms, and the two have evolved on parallel, and sometimes crossing, tracks. Viruses are opportunists; they infiltrate and then manipulate living cells to their own ends. A virus invades normal human cells, knocks out the protein that prevents those healthy cells from dividing, and, using all the now-active division machinery of the host cell, starts making copies of itself. The doctors at M. D. Anderson were perfecting ways to put those malicious viral means to good ends. They had actually engineered a virus capable of destroying cancer cells while leaving healthy tissues untouched. This viral smart bomb, called Delta-24, lacks the ability to knock out the cell guardian protein, so it does no harm to healthy host cells. But a cancer cell does not have the gene that prevents the cell from dividing, so once Delta-24 has infiltrated a tumor, it uses the machinery of the already-dividing malignant cells to divide and replicate itself.
Delta-24 multiplies nonstop, until the cancer cell, glutted with expanding viral matter, explodes. The burst shoots viral particles into other nearby cancer cells and the process starts all over again. So Dr. Lang only had to inject one tiny spot and Delta-24 would, it was hoped, spread through Beau’s entire tumor and destroy it in a series of cellular explosions. This particular virotherapy was an untested theory just a decade ago, and the doctors at Anderson could not rule out dangerous consequences back then. The first time a patient at M. D. Anderson was injected with a live virus, the doctor overseeing the procedure was too fretful to sleep that night. But the Anderson team was starting to have some success by the time Beau presented as a candidate for the Delta-24 injection. Dr. Lang had just finished the first major study, and he was encouraged and inspired by the results. Of the twenty-five patients in the study, there were three whose tumors had been blasted away. And those tumors had been large and recurrent, like Beau’s was now. The treatment had extended those three lives by more than three years and Dr. Lang had detected a promising pattern in the successes. The live virus had induced an interesting reaction in the immune system of each of the three patients who had emerged tumor-free. Cancer cells have a way of eluding the detective force of the immune system, but a virus does not. The immune system recognizes the virus as foreign and attacks it. Delta-24, once it got into the cancer cells, appeared to have flipped a critical switch. The immune system had apparently begun to recognize the tumor proteins as foreign as well and started its own campaign to destroy the glioblastoma.
Lang and Yung were already considering ways to boost the immune system separately while the live virus was also at work—and the best available was pembro, the anti-PD-1 antibody. Pembro was designed to help the immune system do what it could not do on its own: the drug would unmask the tumor as an unwelcome and dangerous foreign agent, and the body’s own T cells would go to work to destroy it. Cancer cells put the brakes on the killer T cells. The anti-PD-1 antibody goes in and releases those brakes. Pembro had already been successful in treating melanoma and lung cancer, and the two doctors thought that using it on Beau might prove to be a real breakthrough in glioblastomas. Dr. Lang and Dr. Yung had both been clear about the risks when they laid out the plan to Beau and Hunter. The live virus alone could cause raging swelling in the brain, which could result in long-term damage or death. Even if it did work as hoped, Beau was likely to get much worse before he got better. The addition of the pembro increased the chances for complications. There were a lot of unknowns, Lang told them, because Beau was Patient Zero. Beau took it all in and looked over at Hunter, who was by his side for every consultation. Hunter appeared resolute, and Beau looked back at Lang and said, “Let me get it.”
I found out only later that the medical professionals at Anderson had started to talk among themselves about Beau—how he neve
r showed fear and never sagged. He wanted the doctors to throw everything at him they possibly could. He kept reassuring them that he could handle it. “We think we are brave if we go when we have a 50-50 chance of winning,” the anesthesiologist who saw Beau at every one of his visits to Houston for twenty months said of my son. “True bravery is when there is very little chance of winning, but you keep fighting.”
* * *
The first call I made after talking about Abadi with my national security adviser, Colin Kahl, and the rest of my team was to the U.S. military commander in charge of the Middle East, General Lloyd Austin. Austin was the heartbeat of Operation Inherent Resolve, our administration’s six-month-old campaign to destroy ISIL. Working alongside our diplomats in the State Department, the general had already built a broad international coalition to counter ISIL, and he had shown a willingness to be aggressive on the battlefield. “My goal is to defeat and ultimately destroy ISIL. And if [ISIL] continues to present us with major targets,” Austin had said soon after the first bombing campaigns began, “then clearly, we’ll service those targets.”
General Austin made it clear to me that he wanted to find a way to help Abadi, but he thought it unwise to provide air support and advisers to the operation in Tikrit in its current form. The chances were too great that U.S. or coalition air strikes would accidently hit Shia militiamen or their Iranian minders and spark an unnecessary conflict with Tehran. And he sure didn’t want to be in the business of providing support for an Iranian-run operation. If Abadi wanted real help from the U.S. military, he was going to have to take charge of the operation, clear the field of the Shia militia units, and replace them with soldiers under his command.
