How to Bring Healthcare Home

New Integrated patient lift for use in home ca...

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Perhaps the single most important change that is taking place in health care in the United States is the effort to shift non-intensive patient care out of hospitals and back into their homes. Convalescence and long-term care are no longer cost-effective in a hospital environment, the thinking goes; patients recover more quickly in familiar and comfortable surroundings; and, at the macro level, as the nation ages we are going to find ourselves with a shortage of hospital beds unless we either a) spend the national treasure on building more and bigger hospitals, or b) shift care outside of the hospital.

America is not alone in this regard. Look at any society in the world that is aging, and you will find policymakers and medical professionals wrestling with the same issue, and the next major country to do so will be China.

For that reason, Health Care Comes Home: The Human Factors is not only timely, it is also relevant far beyond the U.S. In the book, the authors begin by shooting a commonly-held misconception: the success of in-home care does not hinge on technology as much as it does on the caregivers who must use it.

Preparing a new generation of caregivers as home caregivers is, therefore, essential, as is designing a new generation of machines. The success of home care means that the caregivers must be able to use the technology that will make the practice practicable, and the companies designing home-care equipment will have to take into account a series of factors vastly different from those they use to develop devices for hospital use.

As an example of one device where this has already happened, look at the automated external defibrillator, or AED. Forty years ago, defibrillators were used outside of hospitals only by doctors, nurses, or paraprofessionals with six months training. Today, anybody with a modest IQ and a calm disposition can use an AED. That type of change now has to be extended to dozens of complex medical devices in order to make home care both feasible and effective. The better the designers get at their work, the more care that can be moved outside of the hospitals.

This book is a fascinating look at the future of healthcare. All of us will be affected by its conclusions, so whether you are a medical professional, or if you pride yourself on being an informed consumer of medical services, this book is well worth reading.

After 9/11: Have We Come A Long Way, Baby?

In a few weeks, we will be marking the 10th anniversary of the 9-11 terrorist attacks on the United States. The retrospectives have already begun, including one triumphalist piece I glanced in the Huffington Post this morning that suggested that Al-Queda is essentially collapsing. While I think the latter might be stretching things a bit, there is little question that we are on the verge of a milestone if not a point in what used to be called the Global War on Terror, and has since been renamed The Long War: the great bogeyman is dead, the U.S. is leaving Iraq, and attention is shifting back to southern Asia.

There are still unforeseen challenges and incidents ahead of us: whatever we have accomplished in the past decade, the level of discontent in what Thomas P.M. Barnett calls “the non-integrating gap” running from Northern Africa across to Eastern Indonesia remains high. Those regions are bound to produce individuals and groups who believe that their only course of action is to foment death and destruction.

For that reason, a retrospective at this point is fitting, and the RAND Corporation has crafted one in The Long Shadow of 9/11: America’s Response to Terrorism. The book probes how the U.S. as a government and as a nation responded to 9/11, and the effects that has had on the country and, to a lesser extent, the world. The essays in the book cover everything from military readiness to economic policy to health care implications of terrorism, and significantly warns against the government’s tendency to think too short-term.

They authors take especial aim at the government’s obsession with airline security, and note that the problem is not the increase in security, but the belief that better security (or even better intelligence) will stop the attacks. The aim must continue to be addressing terrorism at its roots, not at its fruits.

This is an essential read for anyone interested in U.S. domestic politics or international relations. While we are preoccupied these days by such mind-numbing sideshows as the budget crisis and the coming election, it is also time to hold up a mirror and look at what has happened to the country as a result of the attacks of September 11.

Saving the Kurds

House of Kurd family in Sheikh Jarrah.

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If things go as currently planned, the U.S. military will be out of Iraq by the end of 2011. Regardless of the other issues facing Iraq as a nation, one that concerns the U.S. and most countries in the region is the matter of how to help the Arab peoples and the Kurds in the region find a modus vivendi.

In Managing Arab-Kurd Tensions in Northern Iraq After the Withdrawal of US Troops, Larry Hanauer, Jeffrey Martini, and Omar Al-Shahery point out that the modest pace of Iraqi reconstruction politics makes it unlikely that a domestic political solution will come in time. They make clear that the U.S. will need to maintain involvement in Northern Iraq to manage the issue until Iraq can craft a federalist system that will allow for a degree of Kurdish autonomy.

The authors advocate using a series of “Confidence Building Measures” (CBMs) to keep inter-communal tensions low enough in the interim to allow for a longer-term solution to come out of Baghdad.

Saddam Hussein’s solution to the problem of Kurds within his borders was to kill as many as possible and thrust the rest on Turkey and Syria as refugees. The authors are trying to save Iraq’s current government from having to go down that path simply because nobody was paying attention after the last American dogface was flown out of the region. They understand that failure to do so will have a polarizing effect on the politics of the entire region for decades to come.

Rethinking America’s Science Education

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There is wide agreement that the future competitiveness of the United States, and more specifically of American children, rests on raising the quality of science and mathematics education in primary and secondary schools. Making that happen, in turn, requires that those students actually take to learning those subjects. There is considerable debate as to whether the right approach to getting the kids to do well in maths and sciences is to instill more discipline and focus in the students, add greater structure to education, or somehow craft the subject matter into more palatable forms.

In A Framework for K-12 Science Education: Practices, Crosscutting Concepts, and Core Ideas, the authors dodge the philosophical arguments that frame the debate above. Instead, they begin with the levels of subject knowledge that high school graduates should possess, and from that build backwards, creating a framework of concepts, ideas, and best practices from which a unified primary and secondary curriculum can be developed.

Not satisfied with making recommendations in the basic theoretical sciences, the authors devote extensive coverage into introducing applied science fields like engineering and space science into the curriculum. From the point of view of this former student, who eschewed sciences after his first year in university, this approach looks like a winner – if followed. At a time when school systems in the US are struggling just to pay the bills, one wonders how many administrators will opt for a major revamp of their science curricula.

For the sake of the nation, I hope the answers is “a lot.”

The British Army and Modern Counterinsurgency

The attention given to failed efforts to contain insurgencies like Vietnam tend to drown out the cases of successful outcomes where insurgent groups were defeated. Of the successes, the one that proponents and practitioners of counterinsurgency continue to come back to is Britain’s defeat of Malayan communists between 1947 and 1960. Given the conflicts in Afghanistan, Iraq, and Libya, interest in the lessons of the Malayan Emergency is high again.

As a result, there is plenty of current literature on the topic, the best of which is probably John A. Nagl’s Learning to Eat Soup with a Knife. Contemporary accounts, on the other hand, drawn as they are from the context of the times, can often be more enlightening as they lack the additional haze that comes with the passage of time. Such an account is Riley Sunderland’s Army Operations in Malaya, 1947-1960.

Given unprecedented access to the files of the War Office in the United Kingdom, Sunderland made his study just as the U.S. was expanding its involvement in Vietnam. The intent, therefore, was to give the U.S. Army as much insight as possible into how to fight a successful counterinsurgency. The work is interesting not only because it provides some interesting perspective on what the Americans did and did not learn before escalating the Vietnam effort, but also because it informs the today’s conflicts without using Vietnam as a yardstick.

Even a superficial analysis suggests that the U.S. Army could have learned little from the Malayan experience. The British succeeded in their effort because they were able to contain the growth of the insurgency long enough to secure the countryside. By the time the U.S. showed up in Vietnam in force, not only was the guerrilla infrastructure well into its second decade of development, it had a sympathetic and supportive sovereign country next door to sustain it. Nonetheless, some of America’s more successful tactics in Vietnam (the USMC’s Combined Action Platoons, for example) were rooted in the Malayan playbook.

Sunderland’s account is a testament to the need to stop insurgencies early, and the futility of fighting them once they have reached a critical mass. For anyone interested in whether and how it is possible to quell an uprising with armed force, this book will provide much food for thought.

The Ripple Effects of “Collateral Damage”

If there is a single factor driving the U.S. armed forces and militaries around the world to explore airborne and surf unmanned combat vehicles, it is the growing political cost of battlefield casualties. What those technological marvels have been unable to do, however, is eliminate unintended casualties to civilians in wartime – a phenomenon commonly and somewhat coldly referred to as “collateral damage.”

As part of making a case for finding new ways to reduce or eliminate casualties among non-combattants in wartime, Eric Larson and Bogdan Savych wrote Misfortunes of War: Press and Public Reactions to Civilian Deaths in Wartime. In the book, the authors look at the communications aspect of the problem, not only assessing the different responses to the issue in Europe, the US, and elsewhere, but also urging military leaders to address the problem and specific incidents with the public in a more forthright manner.

This is going to continue to be an issue with all armed forces around the world, especially in an age where the Internet has altered the political and psychological effects of conflict. Indeed, the authors note that the challenge is likely to get worse with time, as incidents that would once have been buried in the scale of the conflict are magnified and twisted for the purposes of one side or the other. Part of the solution is finding ways to eliminate such damage altogether, but in a day of precision weapons and tactics, mistakes are still unavoidable.

Save eschewing “wet works” altogether, governments and non-state actors are going to find themselves enmeshed in a war of words over every mistake, and the states have the most to lose. The communications war will thus grow in importance, so this book is an essential read for anyone communicating – or being communicated to – such tragedies.

Bringing the Bad Boys Home

Kilcullen (Dept. of State) ecosystem of insurgency

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One of the most important aspects of a successful counterinsurgency effort is how the government handles former insurgents once they have effectively switched sides. Simply letting them go leaves them susceptible to the same forces that put them into the insurgency in the first place, but relocation leaves them both disconnected and alienated, once again making them perfect recruiting fodder for the movements they had left.

In Reintegrating Afghan Insurgents, Seth Jones examines the experience in Afghanistan and comes up with recommendations for turning former insurgents into productive members of society, even as the insurgency continues.

Jones’ recommendations are operational rather than political or strategic: to a certain extent he assumes that the insurgency is on the wrong side of history. Nonetheless, what makes this a worthy read is that the conclusions apply not only to Afghanistan, but to any insurgency. Jones keeps his recommendations short and to the point, making this accessible to the layman as well as the expert. Free download.