Saturday, May 05, 2007

Docs Change the Way They Think About Death by Jerry Adler

Consider someone who has just died of a heart attack. His organs are intact, he hasn't lost blood. All that's happened is his heart has stopped beating—the definition of "clinical death"—and his brain has shut down to conserve oxygen. But what has actually died?

As recently as 1993, when Dr. Sherwin Nuland wrote the best seller "How We Die," the conventional answer was that it was his cells that had died. The patient couldn't be revived because the tissues of his brain and heart had suffered irreversible damage from lack of oxygen. This process was understood to begin after just four or five minutes. If the patient doesn't receive cardiopulmonary resuscitation within that time, and if his heart can't be restarted soon thereafter, he is unlikely to recover. That dogma went unquestioned until researchers actually looked at oxygen-starved heart cells under a microscope. What they saw amazed them, according to Dr. Lance Becker, an authority on emergency medicine at the University of Pennsylvania. "After one hour," he says, "we couldn't see evidence the cells had died. We thought we'd done something wrong." In fact, cells cut off from their blood supply died only hours later.


But if the cells are still alive, why can't doctors revive someone who has been dead for an hour? Because once the cells have been without oxygen for more than five minutes, they die when their oxygen supply is resumed. It was that "astounding" discovery, Becker says, that led him to his post as the director of Penn's Center for Resuscitation Science, a newly created research institute operating on one of medicine's newest frontiers: treating the dead.


Biologists are still grappling with the implications of this new view of cell death—not passive extinguishment, like a candle flickering out when you cover it with a glass, but an active biochemical event triggered by "reperfusion," the resumption of oxygen supply. The research takes them deep into the machinery of the cell, to the tiny membrane-enclosed structures known as mitochondria where cellular fuel is oxidized to provide energy. Mitochondria control the process known as apoptosis, the programmed death of abnormal cells that is the body's primary defense against cancer. "It looks to us," says Becker, "as if the cellular surveillance mechanism cannot tell the difference between a cancer cell and a cell being reperfused with oxygen. Something throws the switch that makes the cell die."


With this realization came another: that standard emergency-room procedure has it exactly backward. When someone collapses on the street of cardiac arrest, if he's lucky he will receive immediate CPR, maintaining circulation until he can be revived in the hospital. But the rest will have gone 10 or 15 minutes or more without a heartbeat by the time they reach the emergency department. And then what happens? "We give them oxygen," Becker says. "We jolt the heart with the paddles, we pump in epinephrine to force it to beat, so it's taking up more oxygen." Blood-starved heart muscle is suddenly flooded with oxygen, precisely the situation that leads to cell death. Instead, Becker says, we should aim to reduce oxygen uptake, slow metabolism and adjust the blood chemistry for gradual and safe reperfusion.


Researchers are still working out how best to do this. A study at four hospitals, published last year by the University of California, showed a remarkable rate of success in treating sudden cardiac arrest with an approach that involved, among other things, a "cardioplegic" blood infusion to keep the heart in a state of suspended animation. Patients were put on a heart-lung bypass machine to maintain circulation to the brain until the heart could be safely restarted. The study involved just 34 patients, but 80 percent of them were discharged from the hospital alive. In one study of traditional methods, the figure was about 15 percent.


Becker also endorses hypothermia—lowering body temperature from 37 to 33 degrees Celsius—which appears to slow the chemical reactions touched off by reperfusion. He has developed an injectable slurry of salt and ice to cool the blood quickly that he hopes to make part of the standard emergency-response kit. "In an emergency department, you work like mad for half an hour on someone whose heart stopped, and finally someone says, 'I don't think we're going to get this guy back,' and then you just stop," Becker says. The body on the cart is dead, but its trillions of cells are all still alive. Becker wants to resolve that paradox in favor of life.

Friday, May 04, 2007

Death, Confusion and Networks by Douglas Farah

The recent announcement of the death of Muharib Abdul Latif al-Jubouri in Iraq, and the confusion surrounding the possible deaths of other leaders, highlight the importance of the network-based Islamist insurgencies in Iraq and elsewhere.

As the deaths of Zarqawi and much of the senior leadership of the core al Qaeda and Al Qaeda in Iraq have shown, individual deaths have a short-term impact.


But in the mid to long term, these deaths, while necessary in the struggle, do not do away with the underlying structures that give the groups’ their viability. Al-Jubouri’s alleged direct involvement in the killing of a journalist and others, and his directorship of the propaganda machine make him a valuable target, no doubt. But he was likely replaced before his body was cold.


As a (much) younger person covering the cartel wars in Colombia, I initially fully bought the DEA and CIA’s line that killing Gonzalo Rodriguez Gacha, then Pablo Escobar, then the arrest of the Rodriguez Orejuela brothers, who have a direct impact on the cocaine trade.


Of course, none of those activities did diminish the flow of cocaine, and it was evident after a while that the structures had almost a life of their own, independent of the individuals involved at any particular time.


The killings and arrests were not useless and they forced the cartels to adapt. But the volume of money in the drug business was such that there was always someone else to step up.


I would argue that, in the jihadist structures, the ideological and theological imperative driving the groups is such that there is little trouble in replacing those that fall. The deaths and/or arrests cause hiccups along the way, and the replacements may not be, at least initially, as adept as their predecessors. But they get there.


Hence the argument for a network-based strategy rather than a strategy that primarily targets individuals. The U.S. military is getting better at this, often viewing the jihadi organizations as flat rather than pyramical. But there is still a long way to go in implementing a strategy that directly targets networks.


Getting one person with an IED is good and useful. Getting the cohort that provides the devices from Iran, across the border to the cell that planned to carry out the attack is much better.


The same is true on the financial front. Catching the person with the suitcase full of cash crossing the Syrian border is good for stopping an attack. Pressuring the infrastructure that raises the money in Saudi Arabia from individuals and charities, will likely stop several attacks. Hence my constant harping on the need to go after the underlying financial structure of the wahhabist groups, rather than just shutting down one individual charity.


It is the nature of this type of warfare that new routes and new networks will constantly be evolving. Like water running down hill, they look for the paths of least resistance.


Given that, the central idea has to be to raise the cost of doing operations to those networks, force them to be less efficient and force them to make mistakes, increase the risks and maximize the possible cracks in the system.


The more pressure networks experience, the greater the potential for disrupting it. The more the network has to spend to operate, the fewer resources it has to actually attack.


One of the keys to a network’s survival is the support of the civilian population. The fact that a large crowd was openly gathering for the funeral rites of al-Jubouri highlights just how much remains to be done in that field.

Monday, April 30, 2007

Rebranding China's Military for Tomorrow's Challenges by Thomas Barnett

Last week in Honolulu, I spoke at a high-level conference hosted by our Pacific Command of special operations forces (SOF) commanders from numerous Pacific Rim countries. This gathering was notable primarily for the attendance - for the second year in a row - of senior officers from the People's Republic of China.

Now, depending on your worldview, you might be aghast that: (1) the U.S. military even interacts with SOF personnel from China, our rising competitor in the East or (2) that it's taken this long for such interactions to begin with a power already as globally significant as China is today.


I fall into the second category.


I know most great power experts have long argued that America's sole superpower status simply cannot last, that history demands a balance must somehow be achieved.


Yet no such military has arisen since the Cold War's end, not even China's rapidly modernizing force, whose overall spending is reasonably estimated as less than one-fifth our own. Moreover, China's acquisition strategy is narrow: clearly focused on threatening America's capability to threaten its own capability to threaten Taiwan's ability to defend itself from possible invasion.


If you define Taiwan's defense as a key pillar of American national security in this globalizing world, where Taiwanese businesses routinely ship high-tech manufacturing facilities to Shanghai's technology corridor, then clearly something's amiss. But if you have a hard time, as I do, contemplating the folly of letting Taiwan declare war between globalization's two most important economies, then China's build-up underwhelms.


China's economic and network connectivity with the global economy grows far beyond its current ability to manage that interdependency through diplomatic and security means. China punches far below its weight.


This is troubling today, but it becomes worse tomorrow, especially as China's dependency on energy from the unstable Middle East skyrockets in coming years. America, by contrast, imports little of its foreign oil from the Persian Gulf, now and in the future. Increasingly, it's America's blood for China's oil.


If China can continue free-riding on the global security system maintained by America's military forces, this "say/do" gap might never be revealed - much less become crucial. But consider: Globalization's advance, currently equating in the minds of many with becoming more Western - especially American, will soon enough start being equated with becoming more Asian - especially Chinese.


China will then find itself targeted like America is today by those who violently oppose globalization. Good example? Last week rebels attacked a Chinese oil well in eastern Ethiopia, killing nine. Violent extremists seeking civilizational apartheid with a "corrupt, materialistic world" will attack Chinese influence just as they today seek to limit Westernization.


In that future, a China that cannot adequately defend its economic interests globally in the manner similar to America - and, to a lesser extent, Europe through NATO - will represent a serious source of global instability.


China will either be forced to retreat from the world or rely on others to defend its interests, neither being a path we should welcome for all the reasons America itself would find such a situation unbearable.


To avoid that scenario, China needs to rebrand its military from its revolutionary origins into a force with moderate capacity to project itself around the planet, focusing on crisis response, humanitarian relief, and post-conflict stabilization and reconstruction.


This rebranding process should mirror - in function but not in magnitude - our own military's emergence from relative international obscurity in the late 1800s to a position of trusted prominence following its successful entry into and conclusive impact on World War I in Europe.


America's role in China's military rebranding should be one of mentor, much like Britain's role vis-a-vis the United States in the first half of the 20th century.


Viewed in that grand historical light, China's embryonic military and strategic dialogue with the United States should be viewed as anything but adequate.


Rather than continuing to size our conventional forces implicitly with China's residual threat in mind, our military commands around the world should rapidly and dramatically expand their military-to-military cooperation with the People's Liberation Army.


Not because we trust China nor because we fear it but simply because it makes strategic sense in a complex international security environment America cannot hope to govern on its own.

Military Problems on the Horizon by Douglas Farah

I have spent time with military officials and civilian DOD officials in different parts of the country in recent weeks, and found a disturbing consensus on events, which, if correct, will have long-term implications for our national security.

The first is the broad feeling that the military is being asked to do everyone else’s job in government, particularly the job of the State Department.


The public diplomacy wing of the State Department seems to have virtually disappeared (except for the little shop run by Shaha Riza, Paul Wolfowitz’s girlfriend, and a shop that has a $45 million annual budget but has made no grants in 18 months of existence).


Partly because of the security conditions and partly because the army is already on the ground, many of the leaders feel they are being ordered to do things they are not trained for, have no resources for, and that take them away from crucial missions.


The second is that, as a result of the massive strain on human and physical resources of the Iraq conflict, the military and the rest of the Intelligence Community are falling further and further behind in monitoring vital events in the rest of the world.


This is not entirely the fault of this administration, of course. The hollowing out of the military and the drastic reduction of human intelligence capabilities began under Bush I, was continued under Clinton and not adequately addressed by the current administration. So there are plenty of people responsible.


One area of acute concern in the intelligence community is Venezuela and its growing orbit in Latin America, thanks largely to the close ties of Hugo Chavez to Iran.


Another area where intelligence, both military and civilian, has huge gaps, is most of sub-Saharan Africa. Despite the plans to stand up the Africa Command, it will take years before the new command is operational. There is still no consensus on where the headquarters should be located IF the command is based outside of Germany, where it currently is housed as part of the European Command.


This means that, even as lip service is paid to the rapid emergence of non-state armed actors, the unnerving rise in the number of failed and failing states and the clearly-demonstrated threat to national security these factors represent, there are few resources to actually DO anything about the challenges. This includes studying and training for different types of emerging threats.


The third thing is that those officers with hard-earned experience and knowledge, the captains and the majors, are leaving in droves because of the heavy rotations away from home in combat zones.


This is leaving a huge hole between the fresh, young officers with little or no experience and the colonels who see little field action. This loss of experience on the ground is compounded by a similar phenomenon in the upper ranks of enlisted men.


The final point was the feeling that public support for the military is eroding because the political establishment has done little to prepare the public for extended military commitments. There is broad recognition that, under ideal circumstances, the stabilization of Iraq would have taken a decade. Now, if it is possible at all, it will take far longer. Yet no one wanted to say that publicly or lay out the case for such an engagement.


All this adds up to the possibility of even more acute shortages in the near future, both in terms of personnel and capacity. The men and women of the armed forces are professionals, doing the heavy lifting in an ill-defined war against Islamist militants. They deserve better.

Sunday, April 29, 2007

Failure to See Jihad for What it is by Diana West

Someday, when the war in Iraq has become a historical episode, we will tally up the lessons learned-if, that is, we ever learn any. Here are two worth mastering because failing to do so probably means we will no longer exist.

Lesson 1. Nation-building in a war zone is nuts. Nation-building in an Islamic war zone is suicide.


When the United States embarked on its most successful cases of nation-building in Germany and Japan, both countries lay in ruins, their cities and infrastructure devastated, their populations decimated. These appalling conditions worked wonders toward opening both countries to all manner of Americana: democracy, de-Nazification, de-militarization and, in Japan's case, not just a constitution practically written by Gen. Douglas MacArthur, but also baseball. In other words, Total War was followed by Total Pacification.


In Iraq we have fought a Limited War for Limited Pacification, which has resulted in a perpetual, if limited, war zone. At about $200 million a day, this war may not sound very "limited," but consider where "Sunni insurgents," "Shi'ite militias," and assorted thugs and jihadi groups go at night after a hard day's maiming and killing and IED-ing. They go home to safe houses. Now, ask yourself whether, say, a George Patton or a Curtis LeMay would allow them to wake up again, chow down breakfast and return to maim, kill and IED another day.


The answer is no, not on your life. Such generals would have seen to it that the enemy's home, his neighborhood, his entire town if necessary, was destroyed, doubtless killing innocent (and not innocent) civilians in the process. Total War. It's ugly and barbaric, but it leads to Total Pacification, not to mention Total Victory, which is supposed to be the point. Limited War is ugly and barbaric, but it just leads on and on. And where is the moral purity in war unending? The Limited Warrior struggles for the answer, and comes up with... Hearts and Minds: The superpower that doesn't want to use its super powers will instead make everyone like it a lot. To that end, Gen. David Petraeus, our top commander in Iraq, has ordered troops out of their well-fortified bases into "outposts" in Iraq's most dangerous enclaves. (One such outpost was recently struck by suicide-bombers, killing nine Americans and wounding 20.) Often described as the linchpin of Gen. Petraeus' counterinsurgency strategy, this outpost-plan is supposed to "establish regular contact with Iraqi civilians and win their allegiance," according to the New York Times.


Win their allegiance -- is he kidding? I hate to be the one to break it to Gen. Petraeus, not to mention President Bush, but the fact is, in an Islamic war zone, an "infidel" army just isn't going to win Islamic allegiance. There are many religious and cultural reasons I could offer in explanation, but instead I'll turn to the underreported story of the week: two findings contained within an extensive new poll of Muslim opinion conducted in four major Islamic countries, Egypt, Indonesia, Morocco and Pakistan.


According to WorldPublicOpinion.org, more than half of those polled in Indonesia, and three-quarters of those polled in Egypt, Morocco and Pakistan believe in the strict application of Shariah, or Islamic law. Nearly two-thirds of all respondents expressed their desire to see the Islamic world united in a caliphate.


Which brings me to:


Lesson 2. With numbers like these, portraying jihadist war goals (Shariah, caliphate) as belonging to a "tiny band of extremists" is nuts. Persisting in this PC fantasy as part of the narrative and strategy of the "war on terror" is suicidal.


But such PC fantasy fuels hearts-and-minds efforts that go beyond "allegiance"-winning outposts in Iraq as the United States now weirdly cheers on world Islamization to curry Islamic favor. "Just a reminder to the predominantly Muslim-led government in this world," said House Foreign Affairs Committee Chairman Tom Lantos at a recent Kosovo hearing, as reported by journalist Julia Gorin. "Here is yet another example that the United States leads the way for the creation of a predominantly Muslim country in the very heart of Europe. This should be noted by both responsible leaders of Islamic governments, such as Indonesia, and also for jihadists of all color and hue. .. The United States stands foursquare for the creation of an overwhelmingly Muslim country in the very heart of Europe."


Aren't we nice?
Aren't we lovable?
Or are we just too dumb to live?

Private C.I.A. by John Robb

A strong sign that the nation-state is in decay is the frequency we see announcements of companies that are replicating some of the most sensitive government services. The most recent mover is Walmart, which is in the process of putting together its own intelligence arm (it's being built by a former C.I.A./ F.B.I. officer Kenneth Senser). For those unable to afford their own global intelligence unit, Blackwater's Cofer Black is building one called Total Intelligence Solutions.