At a National Security Council meeting earlier this week, President Barack Obama and his senior advisers reviewed the consequences of possible airstrikes in Iraq, a bolder push to train Syria’s moderate rebel factions and various political initiatives to break down the sectarian divisions that have stirred Iraq’s Sunni Muslims against the Shiite-led government of Prime Minister Nouri al-Maliki.


Senior administration officials familiar with the discussions say what is clear to the president and his advisers is that any long-term plan to slow the progress of the Islamic State of Iraq and Syria, as the insurgency is known, will have far-reaching consequences on both sides of the increasingly inconsequential desert border that once divided the two countries.

Although spreading faster in Iraq, the advance of ISIS could also force the administration to reconsider its calculations in Syria, where Obama has taken a cautious approach, declining to arm moderate rebel factions or conduct airstrikes on government airstrips, as some advisers have recommended.

“The key to both Syria and Iraq is going to be a combination of what happens inside the country, working with moderate Syrian opposition, working with an Iraqi government that is inclusive, and us laying down a more effective counterterrorism platform that gets all the countries in the region pulling in the same direction,” Obama said at a news conference Thursday. “Rather than try to play whack-a-mole wherever these terrorist organizations may pop up, what we have to do is to be able to build effective partnerships.”

In thinking through options, administration officials say they are drawing on the history of the U.S. experience in Afghanistan and of its own management in recent years of President Bashar al-Assad in Syria. Both cases hold lessons, some learned the hard way, with bearing on the present crisis.

Administration officials are also weighing a set of strategic and legal complications that in key ways will force U.S. policymakers to plan as if the border between the countries still exists, even though for the insurgency’s purposes it does not.

“Everybody here recognizes that you can’t silo what is happening in Iraq from what is happening in Syria,” said one administration official, who, like others, spoke on condition of anonymity to discuss the internal thinking. “There’s no doubt the border is melting away. But while we look at the two in tandem, our responses in each place will be very different.”

Maliki has asked the administration to carry out airstrikes against Islamist insurgents in Iraq, an invitation that administration officials say would make intervention legal under international law. Obama has yet to decide if such strikes would be effective inside Iraq and what the consequences would be in Syria.

No such invitation exists in Syria, even though moderate rebel groups fighting Assad would welcome U.S. military support.

The U.S. training program for Syria’s moderate rebel forces, also at odds with ISIS, is taking place in Jordan under CIA supervision. That could expand under legislation pending before Congress, which would authorize the administration to allow the military to take over training, greatly expanding its scope, and potentially locating some of it inside Syria.

Officials have concluded that, like Afghanistan and Pakistan, where a porous border provided Islamist fighters with a refuge from U.S. military pursuit for years, the boundary between Iraq and Syria presents a similar challenge.

U.S. drones have been deployed, in part, to address the problem in Pakistan. But that has raised sovereignty complaints in Pakistan, legal challenges in the United States and human rights concerns over civilians killed in the strikes. Obama is considering drone use now in Iraq.

“Any strategy that looks at questions on one side of a border is only going to be successful in pushing problems to the other side of the border,” said another administration official involved in the discussions. “These are not two different fights.”

With ISIS on the march and U.S.-trained Iraqi forces abandoning posts across the north of Iraq, Republicans have renewed their criticism of Obama’s decisions on both sides of the border. But the circumstances have changed over time as the Arab Spring has unfolded unpredictably across the region.

The rapid military gains of the brutal Islamist insurgency has challenged Obama’s postwar plan for Iraq, which relied primarily on slow but steady political progress that would help bring together the long-competing Sunni, Kurdish and Shiite sects in governing.

The Islamists now control much of Iraq’s ethnically mixed north and Sunni Muslim west, regions that bump up against the Syrian border and have long served as transit routes for guns and fighters to and from both countries. The group has seized the oil-dependent nation’s key refinery and remains, for the moment, on the northern and western edges of Baghdad.

“Our focus now is on how we cauterize what is happening in Iraq, how we encourage political responsibility by the Iraqi government, and what we can do to address the source of the threat, which is in Syria,” said one of the U.S. officials.

Obama withdrew all U.S. forces from Iraq at the end of 2011, drawing sharp criticism from some congressional Republicans, who warned that the country was not yet ready to defend itself. Maliki had refused to grant U.S. forces immunity from Iraqi prosecution — a basic element of any troop basing agreement — beyond that year.

Former administration officials say the intelligence assessment regarding Iraq at the time of the U.S. withdrawal predicted that the country would remain secure and stable, although with two important caveats.

The first was that Iraq’s stability could be severely threatened by an “external shock” to the region, as one former administration official involved in the decision put it. Syria’s civil war exploded the following year, creating a refugee crisis of historic proportions.

The second involved Maliki and his willingness, after decades of persecution under the Sunni-dominated dictatorship of Saddam Hussein, to open up the senior ranks of the government and of the military to other sects, namely Sunnis. The administration backed Maliki over Ayad Allawi, a secular Shiite who drew Arab and Kurdish votes, following the 2010 elections in part with the understanding he would do so.

American intelligence officials at the time of the withdrawal also warned that any indications of revolt from the Sunni tribes in Iraq’s western Anbar province, which borders Syria, should be understood as a significant warning sign and threat to the country’s stability.

Those tribes worked with U.S. intelligence agencies and the military in the war’s later phases to roll back Sunni insurgents, including those aligned with ISIS. Antigovernment demonstration in Anbar flourished last year.

“The intelligence community was both right and wrong — or wrong for the right reasons,” said Colin Kahl, a Georgetown University professor who was responsible for Iraq policy at the Pentagon at the time. “They were wrong to say there would only likely be an uptick in violence, but they were right in identifying the two reasons Iraq could be severely threatened. And both of those things happened.”

Kahl said Maliki resisted proposals for any U.S. forces to remain, including options that called for more than 10,000 troops and would have maintained a presence along the sectarian fault line dividing the autonomous Kurdish province from the rest of northern Iraq.

U.S. troops stood with Kurdish and Arab soldiers along the line for years. That region has emerged again as a Sunni militant hotbed, and a grave threat to Maliki’s government, in the current conflict.

“It was a very visible presence of Americans, that is, Americans serving as peacekeepers between Arabs and Kurds,” Kahl said. “Partly Maliki believed it would give him more leverage with the Kurds if we left, and partly because he didn’t want Americans policing Iraqi ethnic boundaries.”

Administration officials say their planning with both Iraq and Syria is taking into account Assad and Maliki, a pair of problematic leaders with different degrees of political legitimacy.

Maliki won more votes in the recent election than he did four years ago, and the administration, uneasily, is supporting his rule. In Syria, though, Obama called nearly three years ago for Assad to step down, saying he had lost his legitimacy to govern the country. More than 140,000 Syrians have been killed since then.

Administration officials say that, even though internal concerns are growing that Maliki will be able to lead the country through this crisis, there is a reluctance to withdraw backing for the prime minister given his public support and lack of any other obvious alternatives.

As one official put it: “We don’t want to call for Maliki to step down, then spend years trying to figure out how to get him to.”

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A new study shows that Thompson is far from alone.


Nearly 1 of every 10 board positions at health-care companies is held by an academic-affiliated person, ranging from medical school deans to hospital heads to professors, according to an analysis of 2013 data published in the British Medical Journal on Tuesday.

In an age where even relatively small, one-time payments from pharmaceutical companies to doctors have come under intense scrutiny because they may skew prescribing practices or research, the study reveals that some of the most well-paid and influential leaders in medicine are sitting on the boards of publicly traded health-care companies, where they are richly compensated.

“These people who are on boards are among the most famous, the most sought-after academics in the country. At the same time, they are making very large incomes, based on their positions, so what they’re doing is simply padding their incomes, with a lot of extra money,” said Jerome Kassirer, editor in chief emeritus of the New England Journal of Medicine. “I think it’s a bad idea, and I think it’s widespread.”

For years, it’s been known that academics served on drug company boards, but the new study chronicled just how prevalent and remunerative these relationships are throughout the health-care industry. The board members received $193,000, on average, and owned more than 50,000 shares of stock. The study found 279 academically affiliated leaders on the boards of 442 companies – including 17 chief executives of health systems, 11 vice presidents or executive officers, 15 university leaders, and eight medical school deans or presidents. Collectively, they received $55 million in compensation and owned nearly 60 million shares of stock.

“Part of the impetus for this is it’s remarkable that my $15 lunch with a pharmaceutical company is on a public Web site, if this information is not. It is publicly available, but you have to do a lot of searching and connecting,” said Walid Gellad, an associate professor of medicine at the University of Pittsburgh School of Medicine, who led the study.

A spokeswoman for Memorial Sloan Kettering said Thompson was out of town giving talks and could not be reached but that his outside activities are reviewed and evaluated by the cancer center’s board – including his board membership with Merck and another company for which he received more than half a million last year, Charles River Laboratories International.

“Although trained as a physician, he does not see patients and does not participate in clinical research or the decisions about which therapeutic agents are included in the hospital formulary,” said Avice Meehan, a spokeswoman for Memorial Sloan Kettering.

The study did not show that these conflicting positions led any professor, hospital chief executive or medical school dean to make choices in the interest of a company they worked for on the side. In fact, the study refrained from even naming any individuals at all. Gellad said that was because his team sought instead to map the scope of potential influence that exists at the very highest levels of academic medicine and not to limit the attention to a single case. Among medical schools that receive taxpayer money from the National Institutes of Health, 19 of the top 20 best-funded schools had a leader, professor or trustee represented on a company’s board.

Some argue that these relationships can benefit medical schools and hospitals, especially as they increasingly attempt to work more closely with the industry to bridge the “valley of death” – the gap between basic research and commercial products and drugs.

“Some people will look at this as a good thing, that there’s this kind of interaction between industry and academia,” Gellad said. “We’re talking so much about conflict of interest – let’s talk about all of it, and let’s not leave out a certain part because it involves certain people we don’t like to talk about.”

Kassirer argues that disclosure is not enough, but many medical schools have policies in place to avoid conflicts of interest that tend to lean heavily on disclosure and transparency.

For example, Vanderbilt University Medical Center has had a policy in place since 2009 that requires such relationships to be reviewed by a committee. Gordon Bernard is Vanderbilt’s associate vice chancellor of research and chair of the Pharmaceutical and Therapeutic Use Committee, which makes decisions about the formulary, the approved list of drugs the hospital uses. He is also on the board of directors of Cumberland Pharmaceuticals.

“These activities were long ago institutionally vetted and approved. Dr. Bernard recuses himself from any institutional matters where there could be a potential conflict of interest,” said John Howser, assistant vice chancellor for news and communications.

Cumberland’s proxy statement, however, particularly mentions Bernard’s expertise in this regard as an asset: “The Board believes Dr. Bernard’s medical background is extremely valuable as the Company seeks to continue expanding its pipeline with promising products that offer advancement to patient care and are well-positioned competitively.”

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Shares of Alexion fell the most in five years as analysts questioned whether it was overpaying.


The transaction values Synageva at $230 a share, based on Alexion’s average closing price for the past nine days, the companies said in a statement. That’s more than twice Synageva’s closing price of $95.87 on Tuesday.

Alexion developed a medicine called Soliris, which garnered sales of $2 billion last year, for patients with two rare but life-threatening disorders. The drug is used for a blood ailment known as atypical hemolytic uremic syndrome, which can cause kidney failure. Lexington, Massachusetts-based Synageva has similar drugs in development, including a medicine called Kanuma for the organ-damaging condition known as LAL deficiency.

While the price is “rich,” the deal makes sense, and Kanuma could reach as much as $1.5 billion in annual sales, Geoff Meacham, a Barclays Plc analyst, said Wednesday in a note.

“It raises questions on what hidden value Alexion sees in Synageva’s pipeline,” wrote Asthika Goonewardene, a Bloomberg Intelligence analyst. “Given the limited contenders in rare diseases, this may also have been a result of a bidding war.”

Alexion has lagged behind the biotech industry’s stock- market surge, with its stock rising 93 percent in the past three years, or about half the increase in the Nasdaq Biotechnology Index.

“A recent area of concern for Alexion has been an overt reliance on Soliris and an inability of the Street to see what compelling product(s) are next,” said Hartaj Singh, an analyst at BTIG, in a note.

Along with Kanuma, Alexion’s new drug Strensiq for a metabolic bone disease called hypophosphatasia should eventually help the company broaden its sources of revenue, Singh said.

Alexion is offering $115 in cash and 0.6581 Alexion shares for each share of Synageva, the Cheshire, Connecticut-based company said in the statement. The two companies’ boards backed the transaction and it is expected to be completed by mid-2015.

“Synageva is an ideal strategic and operational fit for Alexion that aligns with what we know well and do well — providing life-transforming therapies to an increasing number of patients with devastating and rare diseases,” David Hallal, chief executive officer of Alexion, said in the statement.

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“You have an opportunity to make a difference in the Republican primary,” Cruz’s father, Rafael, told a woman drinking white wine, a GOP button pinned to her tank top.


This was no rubber chicken dinner in Iowa or New Hampshire; waves lapped the beach behind the handful of activists looking to increase the small number of Republicans in the Virgin Islands and its clout in the presidential election.

With a packed, unpredictable Republican field, several well-funded candidates are playing the long game, betting on the idea that a primary race will stretch well into the spring – and that just as Democrats learned in 2008, amassing support from people in and delegates to the national convention from places traditionally on the sidelines of the primary process could help lead to the nomination.

Presidential candidates are veering far from the traditional campaign trail, stumping in Alaska and Wyoming and sending emissaries to far-flung locals such as Guam and American Samoa early in the primary process.

“You’ve got to chase delegates everywhere. You can’t just pick your spots,” said David Kochel, senior strategist for former Florida governor Jeb Bush.

Sen. Rand Paul, R-Ky., blitzed across the delegate-rich West this summer. Bush has started recruiting delegates in Illinois and New Jersey. Cruz has traveled to Michigan and Wyoming, and Sen. Marco Rubio, R-Fla., has rolled out state chairs in Nebraska, Oregon and Montana. A 2012 rule change makes later contests even more valuable: Now a candidate must win a majority of delegates from eight states in order to have his or her name put forward for nomination.

“To me, it’s like niche farming for delegates,” said Saul Anuzis, former chair of the Michigan Republican Party who is supporting Cruz and is spearheading his hunt for support in unusual places. “We’re looking at this as a marathon, not a sprint.”

Cruz’s campaign says it sees the careful courting of delegates – along with coalescing his base of conservative and religious voters – as a linchpin of its primary strategy. The Texas senator has been pouring time and resources into the delegate-heavy South, where many states vote March 1. But investing in the presidential race in Alabama or Georgia is one thing; devoting campaign attention to Guam, about 8,000 miles from Washington, is something very different.

Cruz’s campaign started dispatching people in August to five U.S. territories to hunt for delegates. Dennis Lennox, a former Michigan county drain commissioner and hockey official with a penchant for bespoke suits, exclusive parties and travel blogging, went to the Pacific territories for more than a month. Along the way, he encountered an uncommon trail hazard: a typhoon. Lennox met with elected and party officials – the Guam Republican chairman threw him a pizza party – and worked to convince anyone he could meet to support Cruz.

Anuzis and Rafael Cruz, a pastor, recently visited the Virgin Islands, where boats bob lazily in turquoise waters, people drive on the left and free shots of rum are offered to travelers getting off flights at the airport in St. Thomas.

The men held political meetings, spoke to gatherings of pastors and made a pit stop at a Catholic school, reminding 17-year-olds that they would be able to vote next year. At a park in Charlotte Amalie on St. Thomas, roosters strutted and crowed nearby as Cruz told two men that he believes the primary is more important than the general election.

Residents of U.S. territories cannot vote for president, but have the ability in the primary to cast ballots for delegates who choose the party nominee at the nominating convention in July.

“Puerto Rico, the Virgin Islands, have the same vote as Michigan or California. Only in the primary. Only in the nominating process. And you guys have so few people that vote,” Anuzis pitched the group. Bush and Rubio stumped in Puerto Rico earlier this year.

“So if you can get a critical mass of people supporting a candidate, you guys . . . can make a big difference,” he said.

John Canegata, chairman of the Virgin Islands Republican Party, said only a handful of people in this territory of 104,000 are registered as Republicans, and few presidential campaigns have paid attention in the past. Anuzis said that “less than 200” Republicans here voted in the last primary.

“Don’t take our vote for granted,” said Canegata, who is working to recruit and organize the islands’ small number of Republicans. According to FEC filings, the Virgin Islands Republican Party has paid small fundraising commissions to Anuzis’s company, Coast to Coast Strategies.

Canegata said he has heard from representatives from the campaigns of Paul and Ben Carson. He said Bush met with Virgin Islands Republicans at a meeting in Arizona; Bush has also met with officials from Guam.

Kochel said Bush’s team has people gathering signatures to get Bush on the ballot in numerous states – he wasthe first to file in Vermont and Kentucky.

“It’s not enough to just go park in one state, win one state and expect that momentum is going to carry you through the long and difficult nominating process,” Kochel said. “You have to have a national organization that is working to get delegates in every state.”

Rand Paul is particularly looking to find delegates in states that caucus, such as Idaho, Utah and Vermont, because, he said, they are easier to organize – a strategy that played a large role in the presidential campaigns of his father, Ron Paul.

Ron Paul won the Virgin Islands in 2012, and his campaign’s Virgin Islands chair is Cruz’s campaign chair.

In 2012, Ron Paul was able to game the delegate system at the Nevada and Maine state conventions, snagging all of their delegates to the national convention in Tampa. There, Paul supporters walked out after a decision to replace some of those delegates. Delegate math sealed Barack Obama’s nomination over Hillary Clinton in 2008, with delegates from Montana and South Dakota, as well as superdelegate endorsements, propelling him to victory.

This year, the Republican National Committee tried to change its calendar and delegate rules to speed the nominating process. That resulted in a deluge of key nominating contests compressed into a short period in March – and the urgency of some candidates to give their campaigns a national reach early.

On the Virgin Islands, organizing and getting people to understand how they can play a role in the presidential race without being able to vote next fall is a challenge.

“I don’t understand the process,” said Julie Rhymer, who heard Rafael Cruz speak and said she would consider changing her party affiliation to Republican to vote for his son.

For Canegata and the Cruz campaign, that means more organization and outreach to current or potential Republicans.

“We’ve been making an effort to get delegates wherever we can,” Anuzis said as rain clouds gathered over the park in Charlotte Amalie. “To some extent, if you just pay attention and ask, it’s more than most other campaigns do.”

Jose A. DelReal and David Weigel contributed to this report.

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Today, at 34, Martinez is once again a prisoner, this time in federal immigration custody at the Howard County Detention Center in Jessup, Md.


The government is seeking to deport him, but he has mounted a controversial defense that is being closely watched by human rights experts and lawmakers as his case plays out in the federal courts.

Technically, Martinez is only being held because he is an illegal immigrant; after a decade of living and working quietly in Maryland, he was stopped by police in 2011 for making an illegal left turn and then arrested. But as a repentant former gang member in El Salvador who fled to the United States at age 20, he has requested asylum on the grounds that he deserves permanent protection from his former associates.

If he wins his case, it could dramatically expand U.S. asylum laws that are mostly used to protect victims of political or religious persecution. He has a bond hearing scheduled for Wednesday.

“I ran away from my country to save my life, and I never did any harm,” Martinez said in Spanish during a telephone interview from the detention center in Jessup. “The gang leaders said we were all brothers, but it was a lie. They just want to use you. Once you’re in, the only way you leave is dead. They already tried to kill me twice, and if I am sent back, they will still be hunting for me.”

Although the chances of former gang members such as Martinez obtaining permanent asylum might appear to be slim, the courts remain divided on the issue. In several recent rulings on his case and two others, federal immigration and appeals courts have given contradictory answers as to whether such people deserve American sanctuary from the violent consequences of their former lives.

One issue is how to decide whether the person is truly repentant; another is the more technical question of how to define a gang. Currently, asylum-seekers must belong to a recognizable class of people who are vulnerable to persecution based on their race, religion, ideology or membership in a “particular social group.” Does a gang qualify as a social group?

Maureen Sweeney, director of the immigration clinic at the University of Maryland’s Carey School of Law, is representing Martinez. She thinks U.S. asylum law should be changed to allow such immigrants to seek protection if they renounce gang life at their peril. Thousands of gang members in the United States have been deported to El Salvador in the past two decades; there is no estimate of how many others have attempted to repudiate their past.

“One foundation of our asylum law is that someone’s conscience should not have to be sacrificed for their safety,” Sweeney said. “The burden of proof in asylum cases is difficult to meet, but if someone can convince a judge they genuinely left a gang and face danger as a result, they have met that burden of proof and should be protected.”

The other side of the argument is that members of violent gangs should never be rewarded, and that granting asylum to those who claim repentance would open the floodgates to predatory immigrants who want to avoid deportation.

Rep. Bob Goodlatte, R-Va., chairman of the House Judiciary Committee, objected strongly to a February court ruling in Martinez’s favor, saying it “encourages fraud and creates a new loophole where gang members can simply claim they are no longer a member of a gang in order to game the immigration system.” The result, he added, would be to “endanger our communities” through the scourge of gang violence.

Despite his off-putting resume and the gang initials MS (for Mara Salvatrucha) tattooed on his stomach when he was 14, Martinez is in some ways a perfect example for his cause.

According to Martinez, he was lured into gang life at a young age, committed no serious crimes and made extraordinary attempts to escape the gang once he realized its coldblooded agenda of extorting money from ordinary people and brutally enforcing members’ fealty.

“They wanted me to take money from people I had known all my life, but I didn’t want to,” he said. As punishment for his change of heart, gang leaders ordered his execution. One group of enforcers stabbed him and left him for dead, he said. After recovering, he fled to a relative’s village, but gang members tracked him down, shot at him and threatened his family.

Finally, he fled to the United States and moved in with his oldest sister, Melva Ordonez, a housecleaner in Baltimore. Last week, Ordonez recounted the hardships and terrors of their childhood — growing up without parents, fleeing from crossfire between Salvadoran soldiers and guerrillas. She left for the United States as soon as she could, while her adolescent brother gravitated to a local gang.

“We all suffered, but we were still innocent back then,” she said. “The gangs seemed to offer so much. They had come from America with their promises and their tattoo machines. But all they really offered was death.”

Still close to Martinez, she visits him often at Jessup. “I don’t justify what he did, but I ask God to help him,” she said. “The gangs are much worse now. I know after 20 years, even 40 years, they will still come after him.”

Martinez’s track record in the United States has been far from flawless. He accumulated multiple traffic citations, missed court dates and filing deadlines after an initial run-in with immigration authorities, and was finally jailed after the 2011 traffic violation. But for a full decade, he also avoided serious trouble and worked steadily — cutting grass, hanging drywall, washing dishes, driving a cab — until his arrest.

His legal case has been protracted and dizzying. Last year, two immigration courts ruled he was not eligible for legal protection, but in January they were overruled by the U.S. Court of Appeals for the 4th Circuit. In that decision, Judge Paul Niemeyer found that Martinez risked being killed if forced to return to El Salvador, and that his earlier gang involvement did not disqualify him from protection.

“Martinez is not a gang member. Rather, the social group he has identified is defined by rejection of gang membership and its attendant violence,” the judge wrote, adding that Martinez had repudiated gang life as a matter of “conscience” and should not be penalized for it.

Two other appeals courts have issued similar rulings, but the 1st Circuit reached an opposite conclusion in October in the case of Kevin Claros, a Salvadoran who came to the United States as a child, spent two years in a violent Latino gang in Boston, and claimed he feared reprisals from related gang members if deported to his homeland.

Although they found Claros “sincere” in wanting to leave the gang, the judges in that case did not think he would face persecution in El Salvador. They also found that Congress, in passing humanitarian laws, never meant to “grant asylum to those whose association with a criminal syndicate has caused them to run into danger.” To do so, the court added, would “offer an incentive for aliens to join gangs here as a path to legal status.”

But immigration lawyers and rights groups said the threats of harm to people such as Martinez and Claros are real, and that the lethal reach of Central American gangs is wide and persistent, with ex-members and their families often hunted across multiple borders and killed. The two largest gangs — MS-13 and 18th Street — have between 50,000 and 85,000 members in El Salvador, Honduras and Guatemala. MS-13 also has an entrenched presence in the United States.

The groups point out that U.S. law already bars anyone with a history of serious or violent crime from obtaining asylum or other forms of exemption from deportation. In some cases, they contend, former gang members are more victims of gang predations than willing participants.

U.S. Immigration and Customs Enforcement officials declined to comment on Martinez’s case, citing the pending appeals, and also rejected a reporter’s request to visit Martinez in detention.

After three years of being shifted among detention centers around the country, Martinez said he has spent a lot of time thinking about how he fell into gang life, and how he would advise other young Latinos to avoid it. He has met other former gang members who became more deeply involved than he did and are even less likely to find safety.

“I would tell young boys stay in school, stay close to their families, and not believe what the gangs tell them,” Martinez said. “For a lot of the older ones, it is too late. By the time they realize what’s going on, they are in a hole and they can never climb out.”

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