It didn't buy ads supporting the incumbent Democrat, Sen. Jon Tester. Instead, it put up radio and TV commercials that urged voters to choose the third-party candidate, libertarian DanCox, describing Cox as the "real conservative" or the "true conservative."

Where did the group's money come from? Nobody knows.

The pro-Cox ads were part of a national pattern in which groups that did not disclose their donors, including social welfare nonprofits and trade associations, played a larger role than ever before in trying to sway U.S. elections. Throughout the 2012 election, ProPublica has focused on the growing importance of this so-called dark money in national and local races.

Such spending played a greater role in the Montana Senate race than almost any other. With control of the U.S. Senate potentially at stake, candidates, parties and independent groups spent more than $51 million on this contest, all to win over fewer than 500,000 voters. That's twice as much as was spent when Tester was elected in 2006.

Almost one quarter of that was dark money, donated secretly to nonprofits.

"It just seems so out of place here," said Democrat Brian Schweitzer, the governor of Montana who leaves office at the end of this year. "About one hundred dollars spent for every person who cast a vote. Pretty spectacular, huh? And most of it, we don't have any idea where it came from. Day after the election, they closed up shop and disappeared into the dark."

Political insiders say the Montana Senate race provided a particularly telling glimpse at how campaigns are run in the no-holds-barred climate created by the Supreme Court's 2010 Citizens United decision, giving a real-world counterpoint to the court's assertion that voters could learn all they needed to know about campaign funding from disclosure.

In many ways, Montana was a microcosm of how outside spending worked nationally, but it also points to the future. Candidates will be forced to start raising money earlier to compete in an arms race with outside groups. Voters will be bombarded with TV ads, mailers and phone calls. And then on Election Day, they will be largely left in the dark, unable to determine who's behind which message.

All told, 64 outside groups poured $21 million into the Montana Senate election, almost as much as the candidates. Party committees spent another $8.9 million on the race.

The groups started spending money a year before either candidate put up a TV ad, defining the issues and marginalizing the role of political parties. In a state where ads were cheap, they took to the airwaves. More TV commercials ran in the Montana race between June and the election than in any other Senate contest nationwide.

The Montana Senate race also shows how liberal groups have learned to play the outside money game — despite griping by Democratic officials about the influence of such organizations.

Liberal outside groups spent $10.2 million on the race, almost as much as conservatives. Conservatives spent almost twice as much from anonymous donors, but the $4.2 million in dark money that liberal groups pumped into Montana significantly outstripped the left's spending in many other races nationwide.

As in other key states, conservative groups devoted the bulk of their money in Montana to TV and radio ads. But sometimes the ads came across as generic and missed their mark.

Liberal groups set up field offices, knocked on doors, featured "Montana" in their names or put horses in their TV ads. Many of them, including Montana Hunters and Anglers, were tied to a consultancy firm where a good friend of Jim Messina, President Barack Obama's campaign manager, is a partner.

The end result? Tester beat Republican Rep. Denny Rehberg by a narrow margin. And the libertarian Cox, who had so little money he didn't even have to report to federal election authorities, picked up more votes than any other libertarian in a competitive race on the Montana ballot.

Montana Republicans blamed Montana Hunters and Anglers, made up of a super PAC and a sister dark money nonprofit, for tipping the race. Even though super PACs have to report their donors, the Montana Hunters and Anglers super PAC functioned almost like a dark money group. Records show its major donors included an environmentalist group that didn't report its donors and two super PACs that in turn raised the bulk of their money from the environmentalist group, other dark money groups and unions.

"Part of what's frustrating to me is I look at Montana Hunters and Anglers and say, 'That is not fair,'" said Bowen Greenwood, executive director for the Montana Republican Party. "I am a hunter. I know plenty of hunters. And Montana hunters don't have their positions. It would be fairer if it was called Montana Environmental Activists. That would change the effect of their ads."

Cox and Tester deny the group's efforts swung the race. No one from Montana Hunters and Anglers returned calls for comment.

Tester, who's argued that all groups spending on elections should disclose their donors and also pushed against super PACs, said he wasn't familiar with any of the outside groups running ads. By law, candidates are not allowed to coordinate with outside spending groups, which are supposed to be independent.

Despite his ambivalence, he said he was glad the outside groups jumped in.

"If we wouldn't have had folks come in on our side, it would have been much tougher to keep a message out there," Tester said. "We had no control over what they were saying. But by the same token, I think probably in the end if you look at it, they were helpful."

* * *

Montana has long prided itself on a refusal to be pigeonholed. It's the kind of place that votes Republican for president but elects Democrats to state office. Politicians wear bolo ties, tout their Montana credentials and use words like "hell" and "crap." People introduce themselves by saying what generation Montanan they are.

Consistently, the state fights against any mandate that smacks of Washington meddling, from the federal speed limit to the Citizens United ruling in early 2010, which opened the door to corporations and unions spending unlimited money on independent ads, echoing an earlier court ruling that equated money with free speech.

Before that, Montana had one of the country's toughest campaign finance laws, dating back 100 years, to the time of the copper kings. After one of those kings bribed state lawmakers to back him as senator, the state banned corporate political spending.

Even after Citizens United, the Montana Supreme Court insisted that Montana's legacy of corruption justified keeping the ban. In June, the U.S. Supreme Court squashed that move, saying the Citizens United decision applied to every state in the nation.

By then, dark money groups were already weighing in on Montana's Senate race.

The TV ads started in March 2011, the month after Rehberg announced. The Environmental Defense Action Fund attacked Rehberg for his stance on mercury emissions. The Electronic Payments Coalition praised Tester for his push to delay implementing new debit-card swipe fees.

"The thing that surprised me a little bit was how early they got involved," said David Parker, an associate professor of political science at Montana State University who tracked all 160 TV commercials as part of a book he is writing on the race. "And I think that was critical, because very early on, they were able to establish the contours of this race. The candidates were just busy putting their organizations together and raising money."

Most of the money spent in 2011 on TV ads came from groups that didn't have to report their donors. They also didn't have to report their ads to the Federal Election Commission, because they didn't specifically tell voters to vote for or against a candidate. Instead of saying "Vote for Rehberg," they said things like "Call Jon Tester. Tell him to stop supporting President Barack Obama." Ads like that only have to be reported to the FEC if they air during the two months before an election.

The only way to compile data on such ad spending is by visiting TV stations, which Parker did. ProPublica helped him collect information on the last round of ads.

Parker's data shows that several heavyweight conservative groups entered the fray in mid-2011 to try to cast Tester, whom they saw as vulnerable, as a big spender.

Crossroads GPS, the dark money group launched by GOP strategist Karl Rove, ran two ads in July 2011 similar to those attacking Democrats in other states for supporting excessive spending.

Also that month, a conservative group called Concerned Women for America Legislative Action Committee ran a sarcastic ad about a new miracle drug called "Spenditol," Washington's answer to America's problems. "Call Sen. Jon Tester," the ad said. "Tell him, stop spending it all." Similar ads ran against Democratic senators up for election in tight races in Florida, Nebraska and Ohio.

Several ads run by conservative groups backfired, messing up in ways that irked Montanans.

The National Republican Senatorial Committee — a party committee that reports its donors — ran an ad that appeared to show Tester with all five digits on his left hand. (Tester is well known for having lost three fingers in a childhood accident involving a meat grinder.) The U.S. Chamber of Commerce misspelled Tester's first name. A Montana cable operator yanked a Crossroads ad for claims the operator deemed false.

"The first one that burned me really bad was from the U.S. Chamber," said Verner Bertelsen, a former Republican state legislator and Montana secretary of state. "I thought — you buggers! We don't need you to come in here and tell us who to vote for."

Starting in July 2011, three new liberal dark money groups ran ads. Patriot Majority USA criticized Republicans for allegedly planning to cut Medicare and help to seniors. The Partnership to Protect Medicare praised Tester for opposing Medicare cuts.

And in October, weeks after forming, the dark money side of Montana Hunters and Anglers, Montana Hunters and Anglers Action!, launched its first TV ad, starring Land Tawney, the group's gap-toothed and camouflage-sporting president, who also served on the Sportsmen's Advisory Panel for Tester. At the time, the super PAC side of the group was basically dormant.

The new Hunters ad accused Rehberg of pushing a bill — House bill 1505 — that supposedly would give Washington politicians control of access to public lands in Montana. Rehberg, one of 60 cosponsors, argued the legislation was necessary to help the Department of Homeland Security protect the state from illegal immigrants, drug smugglers and terrorists.

"Nobody in Montana was talking about that bill," Greenwood said. "I've only heard it talked about in campaign ads. And it played a role throughout the election."

* * *

The gusher of outside money into Montana's Senate race was part of a larger pattern. Nationally, in addition to the $5.1 billion spent by candidates and parties, almost 700 outside spending groups dumped more than $1 billion into federal elections in the 2012 cycle, FEC filings show.

Of that, about $322 million was dark money, most of it from 153 social welfare nonprofits, groups that could spend money on politics as long as social welfare — not politics — was their primary purpose.

Relating those numbers to previous elections is a largely pointless exercise, akin to comparing statistics from baseball and lacrosse. The Citizens United ruling changed the game, opening the door to unlimited corporate donations to super PACs and to a new breed of more politically active nonprofits.

"Instead of being in a boxing match in a ring, you're in a dark alley being hit by four or five people, and you don't know who they are," said Michael Sargeant, the executive director of the Democratic Legislative Campaign Committee, which helps Democrats run for state offices.

Some of the players in the 2012 cycle were longtime activist organizations such as the liberal Sierra Club and the conservative National Right to Life Committee, with clear social welfare missions and only a limited amount of political spending. Other dark money groups were juggernauts like Crossroads GPS and Americans for Prosperity, founded years ago by conservative billionaire brothers Charles and David Koch, which crank up their fundraising during election years and devote more money to election ads than other nonprofits.

Finding out about some of the less prominent nonprofits was no easy feat. Many were formed out of post-office boxes or law firms. On their applications to the Internal Revenue Service, they minimized or even denied any political activity.

Documents for pop-up nonprofits like the conservative America Is Not Stupid and A Better America Now, both of which formed in 2011, led back to a Florida law firm that offered no explanations. The Citizens for Strength and Security Action Fund, a liberal pop-up group that spent millions on elections in 2010, closed down in 2011. In its place came a new group: the Citizens for Strength and Security Fund, which earlier this year bought almost $900,000 in ads attacking Rehberg and the Republican Senate candidate in New Mexico.

Groups picked names that seemed designed to confuse: Patriot Majority USA is liberal. Patriotic Veterans is conservative. Common Sense Issues backed conservatives. Common Sense Movement backed a Democrat.

As in the 2010 midterms, the dark money spent in 2012 had a partisan tilt. Conservative groups accounted for about 84 percent of the spending reported to the FEC — mainly through Crossroads GPS, Americans for Prosperity and the U.S. Chamber of Commerce. Liberal groups spent 12 percent of the dark money. Nonpartisan groups made up the rest.

Despite shelling out hundreds of millions of dollars, conservatives lost big. Only about 14 percent of conservative dark money went to support winners.

Still, campaign-finance reformers say it's a mistake to minimize the influence of this money.

"What these donors were buying was access and influence, not only to the candidates but to the party machine," said Paul S. Ryan, senior counsel for the Campaign Legal Center. "And they will get that access. On the Republican side, you have people lining up to kiss the ring of (billionaire donor) Sheldon Adelson. And on the Democratic side, you have even people critical of these groups meeting with the funders of these groups. This money is not going away."

Even though liberal groups spent far less than conservative ones, they had a higher success rate. About 70 percent backed winning candidates.

Some Democrats have shown distaste for the dark-money arts, pushing for more transparency. But liberal strategists are preparing to ramp up their efforts before the next election, unless the IRS, Congress or the courts change the rules.

"We probably have a lot less comfort with some of the existing rules that allow for the Koch brothers to write unlimited checks to these groups," said Navin Nayak, the senior vice president for campaigns at the League of Conservation Voters, a liberal social welfare nonprofit for more than 40 years. "But as long as these are the rules, we're certainly going do our best to make sure we're competitive and that our candidates have a shot at winning. We're certainly not going to cede the playing field to the Koch brothers."

* * *

By the time Tester and Rehberg started buying TV ads, outside groups had been defining the race for a year.

Rehberg, 57, a six-term congressman and rancher often pictured wearing a cowboy hat and a plaid shirt, was portrayed as voting five times to increase his pay and charging an SUV to taxpayers. Tester, 56, a farmer with a flat top, was dinged for voting with Obama 95 percent of the time.

Tester's campaign went up with ads in March, mainly to counter the outside messages.

"The original plans were going up 60 or 90 days later than that," Tester said. "But it was important...We had to remind people of who I am."

His early ads highlighted his Montana roots, depicting him riding a combine on his farm and packing up Montana beef to carry back to Washington.

Rehberg had less money, so his earliest TV ads, which mainly attacked Tester, went up in May.

Neither Rehberg nor anyone from his media staff responded to requests for an interview on his views on campaign finance. In the past, he has said he supports the Citizens United ruling.

Meanwhile, conservative groups bought TV ads that hit at Tester but stopped just short of telling people how to vote. For instance, the conservative 60 Plus Association spent almost $500,000 buying TV ads featuring crooner Pat Boone criticizing Tester over the health care law. None of that was reported to the FEC.

Over the summer, the Concerned Women for America's legislative committee, Crossroads GPS and the U.S. Chamber of Commerce all weighed in. The TV spots were overwhelmingly negative, and many of them were cookie-cutter ads, similar to those that ran in other states against Democrats.

Liberal groups bought TV ads, too, but that was only part of their game plan. They spent their dark money on retail politics, hitting the streets and knocking on doors.

In January, the League of Conservation Voters set up two offices in Montana — one in Missoula and one in Billings. It canvassed voters and hired a full-time organizer, reaching out to 28,000 sporadic voters to urge them to vote early by mail.

Lindsay Love, the spokeswoman at Planned Parenthood Advocates of Montana, another nonprofit that doesn't report its donors for election spending, said the group targeted 41,000 female voters. More than 1,500 people ended up knocking on 28,500 doors and making 162,000 phone calls, she said. The group sent out about 470,000 pieces of mail.

"It's hard to unpack this," Parker said. "But it's fascinating to look at groups like the League, unions and Planned Parenthood. By and large, they did phones, canvassing, mail, very little TV. One of the best ways to get out the vote is personalized contact."

Many liberal groups active in Montana, including Montana Hunters and Anglers, were connected through Hilltop Public Solutions, a Beltway consulting firm.

Barrett Kaiser, a former aide to Montana's other Democratic senator, Max Baucus, is a partner at Hilltop and runs its office in Billings. The Hilltop website notes that Kaiser helped with Tester's upset Senate win in 2006. Kaiser is also a good friend of Messina, the manager of Obama's 2012 campaign, who also once worked for Baucus.

Kaiser was on the board of the Montana Hunters and Anglers dark money group. Another Hilltop employee in Billings served as the treasurer for the Montana Hunters and Anglers super PAC.

Hilltop partners in Washington also helped run two other dark money groups that spent money on the Montana race: the Citizens for Strength and Security Fund and the Partnership to Protect Medicare.

The League of Conservation Voters and Planned Parenthood Advocates of Montana paid management fees to Hilltop.

No one from Hilltop returned calls, but Nayak and Love said they worked with Hilltop independently of other groups.

Outside groups are allowed to coordinate with each other or use the same consultants — they're just not allowed to coordinate with a candidate. By working together, groups can disguise who is actually behind an ad.

In early July, for instance, the League of Conservation Voters gave $410,000 to the Montana Hunters and Anglers super PAC — almost all the money the group raised as of that date.

When the super PAC spent the money on TV ads against Rehberg later that month, the spots were paid for by what appeared to be an organization of Montana hunters, not some Washington-based conservationist group. Nayak said that was not a coincidence.

"We figured having a local brand like that and partnering with them on local issues made more sense than having a D.C. brand," he said.

Nayak said the League did not donate money for the later ads pushing Cox, the libertarian.

It's not clear where that money came from. The dark money side of Montana Hunters and Anglers paid for the radio ads. The super PAC bought the TV ads and had to disclose its donors, but FEC filings show its money came mainly from two other super PACs, which in turn reported getting most of their money from unions and dark money groups, including the League.

* * *

As the Montana Senate race approached its climax, as many as five fliers landed in voters' mailboxes daily. Robocalls, supposedly illegal in Montana, interrupted meals. Strangers knocked on doors, promising free pizza for voting. People turned off their TVs, dumped their mail without looking at it and stopped answering the phone.

"My ex and I moved in together, because he had cancer and I took care of him," said Louise McMillin, 51, who lives in the university district in Missoula. "He kept getting polling calls as he was dying. After he died, I kept saying, 'He's dead, could you take his name off the list?' And they said, 'Sure, sure.' And they kept calling."

The race stayed tight. Demand for TV ad slots spiked, so the TV stations started raising their prices. The law required them to charge candidates their lowest rate. But outside groups? They could be hit up for whatever the market would bear.

Rehberg's campaign paid $400 to run a 30-second ad during the show Blue Bloods on Oct. 19 on the CBS affiliate in Great Falls. A week later, Crossroads GPS paid $2,000 for a slot during the same show.

Anything was fair game for the ads. One, from the super PAC Now Or Never, made fun of Tester's buzz cut, then showed his hair growing down to his shoulders, a bizarre sequence apparently designed to signal his ties to Obama. Another ad, from the dark money group America Is Not Stupid, featured a baby with a gravelly voice saying he didn't know what smelled worse, his diaper or Tester.

"By the middle of October, people were just so tuned out and quite frankly disgusted by all these third-party ads," said Ted Dick, the executive director of the Montana Democratic Party. "We found that face-to-face conversations toward the end were most persuasive and effective. That's the lesson we're taking forward."

There are other lessons. Tester said the Montana race made clear that candidates will have to raise money sooner, and go up with TV ads faster. Although uncomfortable with outside money, Tester also said it's just the way things are now, even on the liberal side.

"I mean, look, they did it," he said. "And with as many ads that were against me, I was glad they did. But it needs to be transparent. I mean, everybody's needs to be transparent... It's important to know who's spending money on who so you know why they're doing it. And the way the system is set up right now, there is no transparency. Very little."

Campaign finance reformers agree that knowing who is behind a message helps people assess it.

One example: Two postcards sent to thousands of Montanans just before the election didn't include the required notice saying who paid for them. One said Rehberg had wasted "hundreds of millions of our tax dollars on pork barrel projects," and urged people to vote for Cox, "a champion for fiscal responsibility." The other called Rehberg "the king of pork" and told people to vote for Cox.

Cox said he didn't send them. The bulk-mail permit on the postcards came back to a Las Vegas company called PDQ Printing, according to the U.S. Postal Service. In an online manual, PDQ describes itself as "Nevada's preeminent Union printer." No one there returned phone calls.

Greenwood, the head of the Montana Republican Party, filed a complaint with the FEC over the mailers. The complaint blames liberal groups and says they "engaged in a duplicitous strategy of supporting the libertarian candidate, Dan Cox, in a desperate attempt" to siphon votes from Rehberg.

More than likely, that complaint won't be resolved for years.

Greenwood said he didn't think disclosure was a cure-all. But he also said the current system marginalized political parties.

"Whether it's Montana Hunters and Anglers or (the conservative super PAC) American Crossroads, they are not responsive to the grassroots," Greenwood said. "These are the professionals and the money men who are not responsive at all to people. The system as it is now does not reflect what people want."

Besides picking between Tester and Rehberg, Montanans got a chance in this election to say how they want the system to work. On the ballot was an initiative — largely symbolic in light of recent court decisions — that declared that corporations are not human beings and banned corporate money in politics.

Gov. Schweitzer, a Democrat, and Bertelsen, the former Republican secretary of state, campaigned for the initiative. In a shocker for backers, almost 75 percent of voters supported it.

"I realized it absolutely didn't have any legal basis to do anything dramatic," said Bertelsen, who is 94. "But it's a case of saying, 'We don't like it.' I guess we could just sit down and not say a word. But the Supreme Court — I think they made a mistake. Money isn't speech, anyhow. It's just money."

 EPA records show that portions of at least 100 drinking water aquifers have been written off because exemptions have allowed them to be used as dumping grounds.

The regime of Bashar al-Assad is increasingly in need of cash to stay afloat and continue financing the military’s efforts to crush the uprising. U.S. and European sanctions, including a ban on minting Syrian currency, have damaged the country’s economy. As a result, Syria lost access to an Austrian bank that had printed its bank notes.

“Having currency that you can put into circulation is certainly something that is important in terms of running an economy and more so in an economy that is become more cash-based as things deteriorate,” said Daniel Glaser, Assistant Secretary of the Treasury for Terrorist Financing and Financial Crimes.  “It is certainly something the Syrian government wants to do, to pay soldiers or pay anybody anything."

According to the flight records, which are in English and Farsi, eight round-trip flights between Damascus International Airport and Moscow’s Vnukovo Airport each carried 30 tons of bank notes back to Syria.

Syrian and Russian officials did not respond to ProPublica's questions about the authenticity and accuracy of the flight records. It is not possible to know whether the logs accurately described the cargo or what else might have been on board the flights. Nor do the logs specify the type of currency.

But ProPublica confirmed nearly all of the flights took place through international plane-tracking services, photos by aviation enthusiasts, and air traffic control recordings.

Each time the manifest listed “Bank Notes” as its cargo, the plane traveled a circuitous route. Instead of flying directly over Turkish airspace, as civilian planes have, the Ilyushin-76 cargo plane, operated by the Syrian Air Force, avoided Turkey and flew over Iraq, Iran, and Azerbaijan.

Tensions have been rising between Syria and Turkey since the spring. Last month, Turkey forced down a Syrian passenger plane traveling from Moscow. Turkey suspected the flight of carrying military cargo but officials have not said what, if anything, was confiscated.

If the flight manifests are accurate, a total of 240 tons of bank notes moved from Moscow to Damascus over a 10-week period beginning July 9th and ending on September 15th.

U.S. officials interviewed said evidence of monetary assistance, like military cooperation, point to a pattern of Russian support for Assad that extends from concrete aid to protecting Syria from U.N. sanctions.

In September, 2011, six months into the violence, the European Union imposed sanctions that prohibited its members from minting or supplying new Syrian coinage or banknotes. In a statement, the EU said the sanctions aimed “to obstruct those who are leading the crackdown in Syria and to restrict the funding being used to perpetrate violence against the Syrian people.” At the time, Syria’s currency was being minted by Oesterreichische Banknoten- und Sicherheitsdruck GmbH, a subsidiary of Austria’s Central Bank.

President Obama has issued five Executive Orders that prevent members of the Assad regime from entering the United States and accessing the U.S. financial system.

“Increasingly, it is more difficult to finance the war machine and the cost of the war is becoming more expensive for the Assad regime,” said one U.S. official who spoke on the condition of anonymity. “Targeted sanctions on those leading the violence are working and start to bite into their pocket books.”

Russia appears to be helping Syria blunt the impact of the sanctions.

This past June, Reuters reported that Russia had begun printing new Syrian pounds and that an initial shipment of bank notes had already arrived.  The report was denied by the Syrian Central Bank, which claimed the only new money in circulation were bills that had replaced damaged or worn bank notes. Such a swap, the bank contended, would have no effect on the economy.

On August 3rd, the official Syrian news agency SANA, reporting from a news conference in Moscow with Syrian and Russian economic officials, quoted Syrian officials acknowledging that Russia is printing money. Qadr Jamil, Syria’s deputy prime minister for Economic Affairs, was quoted by SANA as calling the deal with Russia a “triumph,” over sanctions.

Syrian Finance Minister Mohammad al-Jleilati said that Russia was providing both replacement notes and additional currency to, as SANA put it, “reflect the country’s changing GDP.”

Al-Jleilati said the money would have no effect on inflation. Printing new notes beyond simply replacing old ones could undermine Syria’s already battered currency.

At the time of the meeting, at least 30 tons of currency had already been delivered, according to the flight records, and another 210 tons would be delivered in subsequent flights.

In its regional economic outlook released earlier this month, the International Monetary Fund noted that Syria’s currency has lost 44 percent of its value since March 2011, trading for about 70 pounds to the dollar compared with about 47 pounds when the conflict began.

Ibrahim Saif, a political economist based in Jordan and a resident scholar at the Carnegie Middle East Center said 30 tons of bank notes twice a week is a significant amount for a country like Syria.

“I truly believe it’s not only that they’re exchanging old money for new notes. They are printing money because they need new notes,” Saif said.

“Most of the government revenue that comes from taxes, in terms of other services, it’s almost now dried up,” noted Saif. Yet, “they continue to pay salaries. They have not shown any signs of weakness in fulfilling their domestic obligations. The only way they can do this is to get some sort of cash in the market.”

Before the unrest broke out, Syria had about $17 billion in foreign currency reserves. Saif said he and other economists in the region estimate they now have about $6-8 billion in reserves, dwindling about $500 million a month for salaries and supplies to keep the government running.

In Moscow, the Syrian finance minister had said that his country required additional foreign currency reserves, which Russia may provide in the form of loans.

“It’s possible the Syrians are acquiring foreign currency reserves, either Euros or US dollars, which they would need to conduct any serious commerce,” said Juan Zarate, who served as Assistant Secretary of the Treasury for Terrorist Financing and Financial Crimes during the Bush administration.

Zarate noted that other countries, when faced with economic sanctions, have leaned on allies for foreign currency reserves. China supplied North Korea with such funds in the past and Venezuela agreed to sell reserves to Iran.

Syria’s currency is still traded on open markets, but there is limited on-the-ground information about the economy, including inflation.

Officials at the IMF “have not been able to get direct information about Syria for at least a year,” Masood Ahmed, director of the group’s Middle East and Central Asia department, told reporters at a conference in Tokyo last month.

Glaser, at Treasury, declined to put a figure on Syria’s current reserves but said the Syrian economy is suffering in part from a lack of tourism and a ban on oil sales, both of which provided Damascus with foreign currency. “There is significant inflation in the country. It can be caused by adding new currency or not having foreign reserves to prop up the existing currency.”

Quinn Norton contributed to this story.

But the U.S. won't let him in. And they won't say why.

In March, Sarvestani's visa request was denied. The consulate cited a clause in the Immigration and Nationality Act: Activity "relating to espionage or sabotage." No further information is provided.

"We were absolutely shocked," said his daughter Sahra. "My father is a sociologist. He has cancer."

Sarvestani, who is 64, has recently been confined to a wheelchair and weakened by severe anemia. Sahra says she can barely hear him on the phone: "I would assume he would need to talk and move to spy on the U.S."

The family has made a last-ditch effort to bring him here on humanitarian parole — a short-term, discretionary travel permit for extraordinary circumstances. The family has collected dozens of letters of support from academic colleagues and family members in the U.S., as well as one from his daughter Soureh's congressman, André Carson, D-Ind.

The U.S. could have incriminating information on Sarvestani. But without knowing the details, the family doesn't know how to respond to them.

Instead, they are left to speculate. Sarvestani studied at University of Akron, in Ohio in the 1970s. Two of his daughters were born in the U.S. Like many Iranian students at the time, he supported the overthrow of the Shah and the Iranian Revolution. He belonged to a student group that organized protests in support of Ayatollah Ruhollah Khomeini.

But traveling to the U.S. hadn't been a problem before — Sarvestani spent a sabbatical year in California in 1994. And more recently, Sarvestani has been an open critic of the Iranian government.

"I can't believe they are dismissing his application over something that happened three or four decades ago," said his son, Hadi, who works at a law firm in Indiana. "It's at the point where he's so ill it takes multiple people to care for him, multiple people to get him out of bed. It's baffling." (ProPublica was not able to speak directly with Sarvestani. We reviewed supporting documents and interviewed former colleagues, students and others.)

In denying a visa, the State Department is required only to cite the relevant provision of the law, not provide evidence or rationale. That is the case for all denials, not just those related to national security.

There is also almost no way to appeal a visa decision. A precedent known as the doctrine of consular non-reviewability holds that they can rarely be challenged in court.

Spokesmen for the State Department and the U.S. Citizenship and Immigration Services told ProPublica they could not comment on individual cases.

Sarvestani was known for his work on poverty, drug addiction, and urban spaces. His students recall him as religious and politically moderate. His ties to officialdom, according to his family, are limited to work for the Iranian Olympic Committee, and acquaintances among the upper echelons of academia in Iran, such as Mohammed Javad Zarif, a former colleague at the University of Tehran and previously Iran's envoy to the U.N.

His son Hadi said that if his father felt a sense of duty, "it was to the academic world in Iran, to the doctoral students he was close to, and to his position of academic leadership."

According to Sarvestani's wife, Mahboobeh Ayatollahzadeh, Islamic student groups regularly criticized him as pro-Western. In 1985, a hardline Islamic student group campaigned against Sarvestani's appointment as dean of social sciences at his university. The group circulated pamphlets tying him to the U.S. and mentioning his family, who are Baha'i, a persecuted religious minority in Iran. He was forced to step down, eventually returning as a regular faculty member. (Ayatollahzadeh is a school psychologist in Indianapolis, but is currently in Tehran, caring for her husband.)

Sarvestani began keeping a blog in August 2008, where he wrote academic and social commentary, including often barbed invectives directed at members of the Iranian government.

Reza Akbari, who chronicled the Iranian blogosphere on the website InsideIran, characterized Sarvestani's stance as liberal for Iran.

"He could express critical views of the government because of his academic credentials, because he was very well respected," said Dr. Zohreh Bayatrizi, a former student who is now an assistant professor of sociology at the University of Alberta.

"During the election it got so dangerous. I would call him, crying, and say please don't post anything about this on the blog," recalled Sarvestani's daughter Sahra.

The government shut down the blog in July 2009, shortly after Mahmoud Ahmadinejad won re-election. (The disputed vote sparked widespread protests from the reformist opposition, which came to be known as the Green movement. Bayatrizi remembered Sarvestani coming to class with a green armband.)

Last year, Sarvestani was pressured into retiring early from the university. After 2009, said Abbas Milani, director of Iranian Studies at Stanford University, the government "went methodically through and purged members of the Green movement." Iran has also made a concerted effort to rid the educational system of Western influences.

Sarvestani has also experienced personal tragedy. In 2006, his mother was found murdered in her home. No investigation was conducted, but the family believes it was because she led Baha'i prayer meetings.

His family has not yet told Sarvestani that the U.S. denied his visa because of "espionage."

He is "weak and highly vulnerable, both physically and emotionally," his daughter Soureh wrote in a letter submitted with his parole application.

After the 9/11 attacks, the U.S. began to treat immigration and visas as a front line in counterterrorism. Iranians, whose country has long been designated a state sponsor of terrorism, have faced particular scrutiny.

Trita Parsi, founder and president of the National Iranian American Council, said that his organization frequently receives complaints from Iranians perplexed by visa denials. "You've already got Iranian passport. That's a red flag," Parsi said. "Then you have something in the past, and that's another red flag. Too many red-flags and that's it."

Last year, the State Department denied 268 visas under the espionage clause, more than double the number from five years ago. In 2001, there were just 19 such denials. The State Department doesn't provide denial statistics by nationality. But earlier this year, Bloomberg reported at least six Iranian engineering students denied visas under the espionage clause.

If a consular officer has concerns about an application, the officer requests input from intelligence agencies. Consulates now request these reviews with increasing frequency, according to Edward Alden, a senior fellow at the Council on Foreign Relations. Before 9/11, he says, there were a few thousand a year. In the financial year 2011, there were 366,000, according to figures provided to Congress by the State Department this March.

The review, which must be repeated each time a visa is sought, also often causes delays in visa decisions.

Sarvestani has waited nearly nine years. He first applied for permanent residence through his daughter Soureh, a U.S. citizen, in 2003. In 2009, finally, the application was approved — a good sign, the family thought. But after an interview with a State Department official in Turkey, and more waiting, the denial arrived this March.

Sarvestani's lawyer, Denyse Sabagh, has represented several other clients whose visas were denied under other national security grounds, such as material support for terrorism. In most cases, she said, it was near-impossible to figure out what the exact issue could be, let alone challenge it.

This spring, Sarvestani's family filed Freedom of Information Act requests to try to determine the block on his record. In September, the FBI wrote to say it had more than 2,000 pages of potentially responsive documents. They haven't been released yet, but there is evidence that the agency has long investigated the student group that Sarvestani belonged to in the U.S.

Sarvestani arrived in the U.S. in 1977, a tumultuous period in U.S.-Iranian relations. The shah — who had come to power in a U.S.-backed coup — faced mounting protests. Hefled the country in January 1979, and by the end of that year Iran was an Islamic republic under Khomeini.

During these years, Sarvestani belonged to the Muslim Students Association Persian Speaking Group (MSA-PSG), comprised mostly of Iranian Shiite Muslims in the U.S. (and sometimes known as Anjoman Islami, the Farsi phrase for an Islamic student group). According to Sarvestani's family, he went to demonstrations, ran a call-in news hotline, distributed Iranian media to the diaspora, and organized sales of religious books. He also acted as a liaison between bickering factions of Iranian students, traveling frequently to other centers of Iranian life to mediate confrontations.

In August 1980, as the hostage crisis at the U.S. Embassy in Tehran stretched on, Sarvestani joined about 50 members of MSA-PSG staging a hunger strike in front of the White House. They were protesting alleged mistreatment of pro-Khomeini demonstrators arrested in D.C. in late July.

Federal investigators told reporters at the time that the demonstrations were funded by Iran, which MSA-PSG denied.

Hamid Algar, a professor at University of California, Berkeley, who has written on Iranian Islamic groups, says that MSA-PSG did not have formal ties to the government, but was "thoroughly in support of the revolution."

According to the family, most of Sarvestani's colleagues in MSA-PSG returned to Iran, and Sarvestani had only periodic contact with the U.S. group once he left. The Sarvestani children all went to Catholic school in the U.S., where Sarvestani's wife had the children attend Mass daily, though the school did not require it. (She has long worked on interfaith educational initiatives.)

Today, MSA-PSG continues to hold a yearly conference. A photo of Iran's Supreme Leader Ali Khameini adorns one corner of its website, an Iranian flag the other. The most recent public statement from a government official on the group is Senate testimony by then-FBI Director Louis Freeh in 1999. He described it as "comprised almost exclusively of fanatical, anti-American Iranian Shiite Muslims," which "the Iranian government relies heavily upon...for low-level intelligence and technical expertise." In 2004, the New York Times profiled an Iranian-American couple that was fired from government jobs after failing a security check, apparently because they had attended MSA-PSG conferences in the late 90s. Beyond Freeh's statement, there is no public evidence linking MSA-PSG to criminal activity.

When Sarvestani returned to school in Akron after the White House demonstration, his department chair told him the FBI had questioned them about his activities. Sarvestani assured his boss he had done nothing illegal.

Shortly before Sarvestani returned to Iran in 1984, according to his family, he was also approached by U.S. government officials who said they had observed his work as a student organizer and would like for him to stay in the U.S. Sarvestani skipped a follow-up meeting at the Chapel Hill Mall, in Akron, and returned to Iran as planned. Soon after, Sarvestani's in-laws received an envelope from the U.S. addressed to Sarvestani. Inside was a greeting card with the printed line, "hope we get together real soon." Beneath it, written in block letters: "AT CHAPEL HILL MALL." Sarvestani still has the card.

None of this seemed to matter in 1994. That year, Sarvestani returned to the U.S. for a yearlong sabbatical in California, during which he translated a book on coaching strategies into Farsi. (Gary Walton, the book's author, remembers him fondly. Sarvestani arranged for Walton to give a seminar to Iranian Olympic coaches in 1997, Walton says, but the State Department advised against it.)

Sarvestani's wife, Ayatollahzadeh, says that when processing their visas for the sabbatical, their consular office said that her husband was "on a list," but that he would approve their visa anyway. Sarvestani returned to Iran the following year, leaving behind Ayatollahzadeh, who was by that time pursuing her own PhD, and all of the children.

The plan was for Sarvestani to join them after a few more years. It has been 17.

Ayatollahzadeh and the children now take turns traveling to Iran to care for Sarvestani. They worry constantly about their safety or that one of them will be stranded in Iran with visa troubles of their own. They have nearly exhausted leaves from work, says Sarvestani's eldest daughter Sahra, who is a professor of electrical and computer engineering at the Missouri University of Science and Technology. (A permanent resident of the U.S., she has done work for the Department of Defense.)

After doctors in Iran found the pelvic tumor this summer and ceased treating either cancer, the family sought out second opinions in the U.S. Several oncologists reviewed his case and said Johns Hopkins in Baltimore could offer, as one doctor wrote, "novel treatments unavailable in Iran or neighboring countries." Postponing treatment "will significantly reduce this patient's chance of survival."

Humanitarian parole is a discretionary, temporary permit based on either extreme need or pressing public interest, to be turned to if no ordinary visa is available. It is not the same as asylum, or refugee status. There is no appeal, and no reason given for a decision. Roughly 25 percent of the humanitarian parole requests received each year are approved, according to a Citizenship and Immigration Services spokesman. Last year, there were 1,500 applications.

The family applied for parole right after his visa was denied, on the basis of financial and emotional hardship, but was denied. They applied again last month, citing urgent medical need.

For now, Sarvestani waits in Iran. His daughter Soureh, who recently returned from a visit, says he is receiving only minimal medical attention, as his doctors consider him "incurable." On top of the cancers, Sarvestani is an amputee and now suffers blood clotting. Obtaining prescriptions and medical equipment in Tehran can be a costly bureaucratic nightmare. Back in the U.S., Soureh, who is a computer specialist for Indianapolis Public Schools, says it fills her with guilt to "simply pull up to a CVS drive-thru window. Medical care in Iran and the U.S. is like night and day."

Soureh brought her two-year-old daughter Fatimah with her to Iran — Sarvestani's only grandchild. They spent long hours together in Tehran. Now, Internet bans have made video chats difficult, so Soureh lets Fatimah chatter on the phone with him.

"My father is a gentleman and a scholar," Soureh wrote in a letter alongside photos of Sarvestani and Fatimah. "This is a plea for human dignity."

The columns, written by two businessmen, a lawyer, and an academic, heap praise on the Russian government for its “ambitious modernization strategy” and “enforcement of laws designed to better protect business and reduce corruption.” One of the CNBC opinion pieces, authored by an executive at a Moscow-based investment bank, concludes that “Russia may well be the most dynamic place on the continent.”

There’s nothing unusual about Ketchum’s work on behalf of Russia. Public relations firms constantly peddle op-eds on behalf of politicians, corporations, and governments. Rarely if ever do publications disclose the role of a PR firm in placing an op-ed, so it’s unusual to get a glimpse behind the scenes and see how an op-ed was generated.

What readers of the CNBC and Huffington Post pieces did not know — but Justice Department foreign agent registration filings by Ketchum show — is that the columns were placed by the public-relations firm working on a contract with the Russian government to, among other things, promote the country “as a place favorable for foreign investments.”

In at least one case, a Ketchum subcontractor reached out to a writer and offered to place his columns in media outlets. The writer, Adrian Pabst, a lecturer in politics at the University of Kent, said that his views were his own and that he was not influenced or paid by Ketchum.

A spokesman for CNBC, which published the pieces on the Guest Blog section of its website, declined to comment. A Huffington Post spokesman said the column placed by Ketchum did not violate the site’s policy.

Ketchum spokeswoman Jackie Burton told ProPublica that when the firm corresponds with experts or the media on behalf of Russia, “consistent with Ketchum’s policies and industry standards, we clearly state that we represent the Russian Federation.”

Russia, often criticized for human rights abuses and corruption, paid handsomely for the public-relations work. From mid-2006 to mid-2012, Ketchum received almost $23 million in fees and expenses on the Russia account and an additional $17 million on the account of Gazprom, the Russian state-controlled energy giant, according to foreign agent filings.

Op-ed editors interviewed by ProPublica said they work to include full disclosure of relevant financial interests or conflicts — or decline to run pieces that read like advertorial.

“People write op-eds because they have agendas. Separating out what’s an ethical agenda from an unethical agenda is really tough,” says Sue Horton, op-ed editor of the Los Angeles Times.

Horton said the role of the Russian government’s public-relations firm in placing the CNBC and Huffington Post op-eds "absolutely seems like something the reader would want to know.”

The op-eds placed by Ketchum for Russia, according to the filings, are:

• A March 2010 CNBC piece by Peter Gerendasi, then managing partner of PricewaterhouseCoopers Russia, that praises the government of then-President Dmitry Medvedev for its “strategic priorities [of] diversification, innovation, promoting small business, supporting families and strengthening the country's financial system so that it can provide the investment capital that will enable business to grow and people to realize their potential.” Gerendasi declined to comment on the piece and PricewaterhouseCoopers said it did not pay Ketchum to place the piece and declined to comment further.
• An April 2010 CNBC piece by Kingsmill Bond, then chief strategist at the Moscow investment bank Troika Dialog, that ran under the headline “Russia—Europe's Bright Light of Growth.” It called Russia possibly “the most dynamic place on the continent” for investors. Bond, now at Citigroup, told ProPublica he could not recall Ketchum’s role in the piece.
• A September 2010 Huffington Post piece, titled “President Medvedev's Project Of Modernization,” by Pabst, the University of Kent academic. While acknowledging human rights and corruption problems, the thrust of Pabst’s op-ed was praise for Medvedev’s “transformational vision for Russia's domestic politics and foreign policy.” Pabst told ProPublica he was contacted by a Kethcum subcontractor, Portland Communications, and that he was not paid to write the piece. The piece, as well as another he wrote for a web site run by Ketchum, “reflect my own ideas and arguments,” he said in an email.
• A January 2012 CNBC piece by Laura Brank, the head of the Russia practice for the international law firm Dechert. Brank praised the Russian government for working to overcome the perception of an inhospitable investment climate “through the implementation and enforcement of laws designed to better protect business and reduce corruption.” Brank did not respond to requests for comment.

While Ketchum maintains it always identifies its client when dealing with the media, the 2010 email sent by Ketchum to Huffington Post pitching the Pabst column did not mention that Russia was the firm’s client. (See the full email.)

“Below is a piece from Adrian Pabst, a leading Russia scholar in Europe,” wrote then-Ketchum Vice President Matt Stearns, who is now at UnitedHealth Group.

Ketchum says that Stearns had in previous correspondence identified Russia as his client to the Huffington Post editor, including to set up "a blog on the editor’s site for a member of the Russian government." The company did not provide that correspondence.

Huffington Post spokesman Rhoades Alderson said the site has a policy requiring bloggers to disclose any financial conflicts of interest related to the issue they are writing about, but Pabst did not violate the policy.

“The job of our blog editors is to make sure all of our posts add value for our readers,” Alderson said in a statement. “Part of that is making judgment calls about the transparency of each blogger's motive, even in cases when there is no technical violation of the disclosure policy. A submission by a PR firm raises flags but is not automatically disqualified if the blog adds value and is in keeping with our guidelines.”

Placement of op-eds is a standard part of the influence game, but it’s rare for readers ever to find out who is behind the curtain.

In 2011, top public-relations firm Burson-Marsteller came under criticism after it askeda blogger to author an op-ed criticizing Google’s privacy standards. Burson was working on a contract for Facebook at the time.

Public-relations firms have also been known to write op-eds and have them placed under the byline of a third party, and even to pay experts to write favorable op-eds. There’s no evidence Ketchum paid any of the authors of the Russia op-eds or that it ghost-wrote them.

Update: This post has been updated with more detail on Ketchum's correspondence with Huffington Post.

So Butler made a simple request to the Army — for Jake's casualty report. Rules require one when soldiers are killed in a war zone. Unit commanders are supposed to create and maintain them, along with numerous other field records.

Tangney, a senior vice president, already had plenty to worry about -- 16 North Shore-LIJ hospitals spread across New York and Long Island. Minutes later, a member of the team delivered an alarming report about a community hospital in Bay Shore, N.Y.

"Water is still rising at Southside," corporate safety officer Robert Gallagher said. "We have a good hour before high tide."

Hours earlier, corporate leaders had called Southside and Staten Island University Hospitals to go over how they would handle the worst-case scenarios: Had they thought about what they would do if backup systems failed and part or all of their facilities suddenly lost power?

Officials huddled around a speakerphone. "There's a good possibility it will occur," warned a Staten Island University hospital official. Part of the power system, he said, was below ground. "It cannot be used if it floods."

Everyone on the call understood what this meant. Modern medicine depends on electricity, from the ventilators that keep seriously ill patients breathing to the monitors that detect life-threatening changes in vital signs.

Now, in the late evening hours, the worst-case scenario was unfolding at the main campus of NYU's Langone Medical Center in Manhattan, which had lost much of its backup power at the height of the storm. Could North Shore-LIJ dispatch ambulances from its Lenox Hill Hospital in New York City to pick up four critically ill babies from the neo-natal intensive care unit?

New York City hospital and nursing home patients and their loved ones might reasonably have believed they were safe as Hurricane Sandy approached. Mayor Michael Bloomberg had exempted hospitals and nursing homes in low-lying "Zone A" areas of the city from his pre-storm evacuation order. Much thought and planning had gone into the decision to "shelter in place."

But anyone following the recent history of how hospitals and nursing homes have fared in American disasters had ample reason for concern.

In many New Orleans hospitals after Hurricane Katrina in 2005, floodwaters knocked out vulnerable backup power systems. A day later, still awaiting rescue in intense summer heat, doctors at Memorial Medical Center were so desperate, they intentionally hastened the deaths of some patients by injecting them with morphine and sedatives, and ultimately 45 bodies were found at the hospital.

Over the past five years, I've reported on the impact of disasters on hospitals and medical systems, from Hurricanes Katrina, Gustav and Isaac in New Orleans to Hurricane Irene in New York. I'm also writing a book about this subject. So when Hurricane Sandy approached, I interviewed city and state health and emergency commissioners about their plans and the reasons for their decision this time not to mandate hospital and nursing home evacuations in the city's most vulnerable areas.

I pressed them on this even though there was every indication they and their staffs had diligently prepared for the storm. Last year, these commissioners decided that many of the same hospitals and nursing homes should be evacuated before Hurricane Irene, many of them shutting their doors for the first time in history in part due to the lessons of Katrina.In interviews, they told me that the decision to evacuate last year was based on fears that an eight-foot storm surge could knock out backup power. Even after Irene proved less damaging than expected in New York City, they stood by their decision to shift thousands of patients to safer locations. It was much better, they said, to move patients in a controlled, calm environment with full power than it would be to empty hospitals in the midst of an emergency.

As Irene approached, NYU Langone Medical Center transferred or discharged all but a few very critically ill patients. It kept a full complement of staff on duty to care for them and respond to storm-related emergencies. Coney Island Hospital was also fully evacuated before Irene. Many of its staff members and doctors traveled with their patients to other hospitals, including sections of Long Island College Hospital and Maimonides Medical Center in Brooklyn.

This time around, the commissioners decided not to order as many evacuations, an approach that puzzled me since the weather service was predicting as early as Sunday morning that the storm surge could reach 11 feet in lower Manhattan and, as early as Saturday morning, up to eight feet from Ocean City, Md., to the Connecticut-Rhode Island border.

What had changed in the intervening year? Were the hospitals and nursing homes better prepared to handle a hurricane? Were the lessons from other recent disasters being applied to a storm being described as the worst in a century?

I rented a car and drove to the Long Island command center in hope of finding out. The answers I came away with after reporting from crippled hospitals in Manhattan and Coney Island and darkened, sand-swept nursing homes by the ocean in the Rockaways highlight the complexities of that decision and raise some serious questions.

There was a clear payoff from recent efforts to improve preparedness. No one at a hospital had died in a storm-related incident as of Thursday morning, according to New York state health commissioner Dr. Nirav R. Shah. Shah said he had heard of only one injury, a single fractured limb he understood was due to a fall caused by slipping on a wet floor.

"Outcomes matter," Shah said. "Outcomes speak louder than anything else."

Still, even though the larger health care community averted an immediate catastrophe, the question remains: After everything we've learned about those horrific days in New Orleans, how could another hospital in a major American city find itself without power, its staff fighting to keep alive their most desperately sick patients?

New York's hospitals and nursing homes continue to deal with the impact of the storm. On Thursday morning, two days after the winds subsided, patients were still being moved out of Bellevue Hospital, which had 712 patients when the storm came, according to Shah. Air National Guard, Army National Guard and Marine Reserve troops carried them on brightly colored plastic litters, five troops to a patient. "Eat quick," a nurse told a patient on the sixth floor. "They're coming to get you."On Wednesday evening at 5 p.m., there were still a few patients to transfer from Coney Island Hospital and four nursing homes in Brooklyn and the Rockaways, according to the New York State Department of Health. In several of these places, backup power systems were inadequate for prolonged use or nonfunctioning, and city power had not been restored.

The long-term health effects on vulnerable patients like these might not be immediately calculable.

To Evacuate or Not To Evacuate

The scene at the Department of Veterans Affairs hospital in Manhattan on Sunday, Oct. 28, was strikingly different from the chaotic scramble some have described at NYU hospital after the storm hit.

The VA moved all of its 132 patients out of the building before Sandy's arrival, discharging those who could safely go home, and transferring others to hospitals less threatened by rising waters. The director of the hospital based her decision on geography, according to Jennifer Sammartino, public affairs officer for the VA New York Harbor Health Care System. The hospital sits in a flood zone, close to New York City's East River. "It's critical to evacuate before the storm hits," she said.

Most of the hospital's essential facilities, including its elevator banks and steam systems, are at sea level or below, she said. The hospital's backup generators are on street level. Depending on how high the waters rose, Sammartino said in an interview at the hospital before the storm, "we could be in a critical situation in terms of patient care." The director's main priority was that "everybody's safe."

The transfer process at the VA appeared calm and orderly. One by one, patients rode down elevators and were wheeled into waiting vehicles. By about 2:45 p.m. on Monday, about half of the patients had been moved.

I traveled a few streets up First Avenue to NYU Langone. A double line of ambulances stretched around the block. EMTs told me they had been waiting hours to carry out what they expected would be a pre-storm evacuation of the hospital.

Just after 4 p.m., NYU Langone public relations director Lisa Greiner walked toward the hospital carrying what looked like supplies for a long stay. "I don't know what these ambulances are here for," she said, assuring me the hospital wasn't evacuating.

I had asked her about NYU's vulnerabilities before the storm hit. We spoke again by phone on Tuesday morning after the power outage. She said that after Irene, the hospital had invested in raising generators above ground level. "This had been tested several times," she said. "I don't think anybody anticipated the level of flooding that occurred." The National Ocean Service reported a peak tide height of 13.7 at the southern tip of New York, topping Monday morning's prediction of 6 feet to 11 feet.Greiner said there was as of yet no official answer to why the backup systems had failed. Based on the New Orleans experience, I would speculate that while generators had been moved up, key elements that allow electricity to flow through the system remained at flood level.

Before Hurricane Sandy's arrival, I had requested permission to report on the storm from within NYU Langone as I've reported from other hospitals in previous storms.

Greiner apologized. My request, and one from CNN, was declined because "having media present could be distracting" to staff who needed to focus on patient safety. New York City's Health and Hospitals Corp. similarly declined to open Coney Island Hospital's emergency operations to public view.

NYU Langone and Coney Island ended up, of course, being the two New York City hospitals that experienced extensive power and backup generator system failures during the storm. (Coney Island Hospital's facilities staff was able to restore backup power to some patient areas after several hours, but the hospital began evacuating on Tuesday due to persistent safety concerns.)

Lessons From the Last Battle?

The health commissioners for New York State and New York City are highly regarded, even beloved, hands-on leaders with substantial experience. City health commissioner Dr. Thomas A. Farley was working in New Orleans at Tulane University at the time of Hurricane Katrina. New York State's commissioner of health, Dr. Shah, based himself with the team at New York City's emergency operations center.

Both men speak passionately about preparedness and have worked as an effective duo dealing with recent hurricanes. Before Hurricane Irene hit last year, Farley and Shah helped oversee the transfer of roughly 10,000 patients from seven New York City acute-care hospitals and 39 nursing, psychiatric and adult-care homes in partnership with the city's fire and homeless services departments, emergency management office, the Greater New York Hospital Association, North Shore-LIJ and many others.

"We were not confident any could withstand flooding on the first floor without a loss of power and an inability for them to be rescued quickly," Farley told me last September. "Our assessment was it was safer for them to evacuate than stay in place."

State commissioner Shah's stance was similar. "It was the right decision," he told me last year. "Imagine what would have happened if there was an 8-foot surge? All those places would have been under water and would have been really on little islands right now."

On Monday as Sandy was churning up the coast, I asked both men why a different decision was being made this time, with the storm surge expected to be even higher. They said they and their colleagues were making contact every four hours throughout the day with a list of 53 facilities in Zones A and B that could potentially experience flooding.According to the storm surge graph, Farley said, "We can say with a high degree of confidence, the high degree of water should be three feet more than high tide this morning. We spoke to every facility. We said look at the water and tell us, will you have water on the first floor?" All but one said no, he said, and the other said maybe.

He acknowledged there was always uncertainty. "I cannot guarantee there wouldn't be loss of power and loss of generators in a hospital. We're in very close contact should that happen," Farley said

"There's a chance one will go down," Shah told me of the more vulnerable facilities on the Rockaways and Coney Island. "But we can't say which of 30 will go down."

Shah pointed to the substantial risks involved in pre-storm evacuations for vulnerable patients. "It's extremely agitating," he said. "We learned there's a risk-benefit of moving people versus sheltering in place."

It's true there have been fatalities in pre-storm evacuations. A bus carrying nursing home residents away from Houston in advance of Hurricane Rita in 2005 overheated and burst into flames, igniting oxygen tanks and killing about two dozen people. When New Orleans implemented city-wide hospital and nursing home evacuations prior to Hurricane Gustav in 2008, many patients were transferred to Baton Rouge, which was harder hit by power outages from the storm, necessitating the re-transfer of a number of patients.

Though health officials do not much like to talk about this aspect of emergency preparations, it's also expensive for hospitals and nursing homes to shut their doors proactively. Dr. Shah said this played no part in the decision-making. "We never thought about money," he said. "We thought about patient safety."

Commissioner Farley said the decision not to evacuate -- "to shelter in place" -- was made because the dangers involved in moving patients were viewed as greater than the dangers of staying.

Health officials took other actions to protect patients. They instructed the vulnerable nursing homes to move residents to higher floors and to transfer roughly 100 residents who required mechanical ventilators to help them breathe. The state also ordered nursing homes to staff their facilities at more than 50 percent higher than usual.

Health and emergency officials surveyed the facilities before the storm "to eyeball generators," watch them be turned on, and assess fuel and food supplies, Shah said. He said he felt confident that if anything should go wrong, the city was ready to respond quickly. He and Farley noted that New York City's Fire Department EMS units were sheltered on higher ground above nursing homes."It's a very different storm," Shah said. "It's a longer-duration storm, and the planning inter-year has allowed us to improve the assets and plans of these nursing homes and adult-care facilities."

The commissioner of the city's Office of Emergency Management, Joseph Bruno, told me Monday he was impressed by the smooth, well-coordinated medical preparedness for Sandy taking place in the emergency operations center, which had designated a larger space for the teams supporting health facilities after Irene. "I'm very confident in the way it's been handled," he said.

Sandy's Impact

As the high tide clock ticked down on Monday night for Staten Island University Hospital, tension spread through the North Shore-LIJ emergency command center, a vast room in a former warehouse near Syosset Hospital. Several large screens projected television coverage and a spreadsheet of status reports and action items from the health system's hospitals.

"I'm just counting minutes," said Tangney, the leader of the overnight team. Floodwaters had already wiped out power at a data center serving Staten Island University Hospital, forcing the hospital to shut down its electronic recordkeeping system.

Now all attention focused on the rising water. "We've got six minutes to high tide" at the Staten Island location, Tangney said. "If it doesn't breach by a quarter to nine, we made it."

"The switch gear room is still dry," safety officer Robert Gallagher reported at 8:15 p.m. Five minutes later came bad news from the hospital in Bay Shore. "Water has breached a creek near Southside."

More bad news arrived by phone from Staten Island. "Water is at the door of the north site," Tangney said. It had crossed Father Capodanno Boulevard and raced to the hospital along Seaview Avenue. At the south site, the waters were reportedly 65 feet from the building and continuing to rise.

"Is there anything we can do for them?" someone in the command room asked.

"No," Tangney said. The hospital's leaders had sounded calm on the phone. Workers had placed sandbags and high-powered suction pumps to protect the room with electrical switches. Many critical care patients had been transferred out before the storm. New York City Fire Department equipment had been positioned there in case help was needed. All they could do was wait.

"It's 50-50 they're going to get flooded out," Tangey said.Safety officer Robert Gallagher received an email from Staten Island's Joseph Weiner at 8:29 p.m. "Still dry," it said. "Dry is good," Gallagher said.

Unverified reports arrived of widespread flooding on Staten Island, of drownings and rescues and people swimming to the hospital for help. Someone suggested that the National Guard might bring displaced residents of the island to the hospital.

As the hours passed, backup power kept functioning at all of North Shore-LIJ's hospitals. And even as it became clear that a decision to shelter in place had come out very differently at NYU, Tangney was convinced his most vulnerable hospitals, now serving their devastated communities, had made the right decision to remain open.

"These assets wouldn't have been there if we'd closed," he said.

The system's hospitals began accepting transfers from NYU Langone, and later Coney Island and Bellevue hospitals, 158 by Wednesday night, including the critically ill infants.

At 2:58 a.m. on Tuesday, at the city's Emergency Operations Center, Dr. Shah's cell phone received a text.

"This is Michael Kraus at Lawrence Nursing Care Center. My cell service has become spotty, and I am not able to receive or make any calls. My residents and staff are all fine. We assessed the damage to the first floor. Everything [is] ruined. We are in need of supplies. We may be able to last another day. But once more, everything is fine. Michael Kraus."

Dr. Shah nearly cried. He knew everything was not fine, but Kraus was telling him he could focus on supporting others who might be more in need. Other nursing home directors sent similar messages, some of whom Shah called "geniuses" for the resourcefulness and care they had shown through the disaster so far.

At Dr. Shah's request, a team of North Shore-LIJ safety officers drove out at first light to the Rockaways to assess the conditions at Lawrence and several nursing and adult-care homes that had lost cell and land line phone contact with the city's command center overnight.

At Horizon Care Center in Arverne, near the Atlantic Ocean, elderly residents sat in chairs in darkened, foul-smelling hallways. It had been hard to change patient diapers all night in the dark. It was chilly.

"If I'm freezing, the residents gotta be, too," administrator Nicole Markowitz said. She was worried about one resident who required oxygen and had only about a five-hour supply left.

The facility needed easy-to-prepare foods and to recharge administrators' phones. There was no easy way, even by car batteries. Cars parked on the Care Center's grounds had been flooded.Within five minutes on Monday night, Markowitz said, the water rose to knee height on the first floor. The 269 residents and medical supplies had already been moved to the third floor. Those with more serious medical needs had been transferred before the storm.

The backup generator had worked for only about 10 minutes after the power failed. Markowitz had barely slept in two nights, and commended her large and hard-working complement of staff members, 70 of whom had answered the call to work through the storm.

I asked why she had decided not to evacuate from the potential flood zone. The nursing home, she said, "wasn't mandated to leave. It's much harder to leave than to stay. I leave it up to OEM [the city's Emergency Operations Center] to decide whether to leave or not."

The Storm Ends And The Crisis Continues

NYU Langone Hospital completed its evacuation on Tuesday afternoon, with some patients having spent more than 12 hours in a facility with little power.

That same day, National Guard troops and staff members began ferrying patients out of Bellevue Hospital just blocks away. The 25-story hospital was on partial backup power without working elevators, its basement flooded along with many hospital supplies. Its remaining working generators were being fed with fuel carried up the staircases to the 13th floor by hand. Even patient corridors smelled like diesel. According to a sign posted in the hospital, Bellevue's largest generator, its sixth, was in the basement.

Bright orange extension cords connected to the backup generator system snaked along patient corridors in part of the intensive care unit and labor and delivery floor.

Evacuations were still occurring Thursday morning. "It's because they're being ultra careful," Shah said. "There's no need to rush."

According to doctors I spoke with, it was initially difficult to find appropriate beds for the many patients who needed to be moved from disabled hospitals and nursing homes. However, Shah said on Thursday morning that staffing at area hospitals was now back up to normal levels and there was again a cushion of extra space in the system. Critically ill patients had been moved early in the process for their safety, he said. Some psychiatric patients remain at Bellevue.

Making Sense of the Decisions

"It's worth looking at what would be the costs and advantages of making hospitals a little more capable of withstanding a flood of a certain height," Commissioner Farley told me last year after Hurricane Irene.

That sounds like an understatement now. And it is certainly worth it for everyone who might rely on a hospital in a flood zone across the country to look at whether their facility has similar vulnerabilities.

The question is: Who pays to improve the systems? Many hospitals were built years ago to different building codes and then expanded with additions, North Shore-LIJ President and CEO Michael J. Dowling pointed out to me last year. Hospital wiring diagrams I've reviewed in Katrina hospital liability cases look like masses of spaghetti.

"Whenever we build new, we make sure everything's up high," including at the new Long Island Jewish hospital, Dowling said Sunday afternoon when he visited the command center.He said hospital leaders had "talked about" moving mechanical systems higher at the Staten Island locations and he was committed to doing it to reduce susceptibility to flooding. "These are not easy things to do," he said. "These are very complicated, expensive endeavors." But, he added, they were necessary and would get done.

Raising generators above flood level is just the first step in protecting a hospital's backup power. Often, transfer switches and other elements of the electrical systems and fuel and water pumps need to be moved or made submersible as well.

There are already suggestions that this was a factor in the failure of Langone's power systems.

Some say flood-proofing these systems should be considered public investments. Others argue it is unreasonable to expect hospitals to gird against all foreseeable, but unlikely, catastrophes.

Perhaps hospital accreditation standards and electrical codes should also be tightened. Currently, hospital backup generator system codes and standards are more oriented to short-term power losses like those that might occur when a tree branch falls and cuts off city power for a few hours. Generators must be tested under load for only short periods. There is no dress rehearsal for the days-long outages that are likely to follow a severe disaster like a hurricane. Often it takes a real crisis for hospital engineers to discover pre-existing problems -- for example problems switching back from generator load to city electricity.

Even if backup power systems ran for longer periods, at many hospitals, they are not designed to power critical hospital functions, particularly heat, air conditioning and ventilation. Current hospital standards do not require this and are "not always sufficient" in major catastrophes, according to a post-Katrina warning issued by the largest hospital accreditation body, the Joint Commission. National Fire Protection Association standards call only for "careful consideration" to be given to protecting electrical components from "natural forces common to the area" such as storms, floods and earthquakes.

Nor is there a standard for how the flow of information is to be handled. As of Wednesday evening, there was no central place for relatives of hospital patients and nursing home residents to find out where their loved ones were or whether they were safe. (North Shore-LIJ, however, offered a Hurricane Sandy Patient Information Hotline for their system at 1-855-473-6399, and important safety information can be found on the state health department website.)

The health care officials I've interviewed over the past several years are clearly trying to learn from the past. The threat from extreme weather events highlights the importance of investing in preparedness.

The city's and state's attention to health care evacuation planning since Irene appears to have improved communication and smoothed the response. Officials paid attention to the emergency needs and vulnerabilities of individual health facilities, working with nursing and care homes in the months after Irene to address their vulnerabilities, personally visiting and placing multiple calls offering assistance both before and after the storm struck, opening emergency shelters and sending tens of thousands of automated messages to advise health care providers.

"You can never say what's going to go wrong," Dr. Shah reflected in an interview this morning, "but if you have planning in place, have structures in place, you can be much more resilient in ways you can't anticipate.

"Even though there was more than what planning anticipated, we were able to get everyone out successfully and safely, and it was because of the heroism of front line workers.

"Planning worked," he said several times. "Planning worked."