Paul Wise watched as children ran around a playground attached to a health clinic at a displaced persons camp on the outskirts of Mosul — the northern city in Iraq once controlled by the Islamic State but now back in the hands of the Iraqi government.

The children had survived the Battle of Mosul, which had fallen to ISIS in 2014 but was retaken by the government forces and allied militias during a nine-month military campaign that ended in July. Many of the children suffer from physical and mental wounds and Wise wondered how they would recover with so little medical infrastructure.

Wise was part of a small delegation of physician-academics asked to evaluate a World Health Organization-led system to treat civilians injured in the Mosul fighting. Wise and his colleagues recently slipped into Mosul to visit field hospitals, review health care on the ground and determine whether there is a better way to distribute medical aid during armed conflict.

The visit left the Stanford Medicine professor of pediatrics and senior fellow at the Freeman Spogli Institute for International Studies with questions about health care, humanitarian ethics, and conduct of war: Are there better ways to deliver emergency medical care during the height of battle? How do relief workers maintain neutrality when embedded with government security forces? Has the system of financing humanitarian interventions — one that was essentially created during the Cold War — become dangerously outdated?

Answering these questions is the mission of a new health-and-security initiative at Stanford led by Wise, a core faculty member at Stanford Health Policy who has spent 40 years working to improve the health of children impacted by conflict. Much of his work has been in Guatemala through his Children in Crisis project, the first university-based program to address the needs of children in areas of unstable governance and civil war.

“In talking with the groups that are running these humanitarian efforts in Mosul, there was this uneasiness, this kind of disorientation with the way things are now,” said Wise. “It was a kind of recognition that humanitarian norms are changing, the health personnel and facilities are at greater risk; the financial gap between humanitarian need and humanitarian capability is growing; and the old way of financing humanitarian intervention is inadequate, archaic.”

An Interdisciplinary Approach

Wise believes academics are well suited to help resolve these humanitarian conundrums.

“So we are going to move ahead and try to bring all the players together to reconsider this global challenge. Here at Stanford, we have the capacity to draw upon remarkable resources,” he said.

The new biosecurity initiative led by Stanford Medicine physician and FSI senior fellow, David Relman, together with world-renowned political scientists, security specialists, computer scientists and health policy experts will “attempt to craft new strategies for the provision of critical services to populations affected by conflict and political stability.”

The initiative will collaborate with other institutions such as Johns Hopkins, UCSF, Harvard, and the American Academy of Arts and Sciences. It will also seek the engagement of partners committed to providing humanitarian services, including WHO, the U.N. High Commissioner for Refugees, Doctors Without Borders and the International Committee of the Red Cross.

“The voice of communities impacted by war should also be an essential element in this ambitious effort,” Wise said. “To break new ground, we’re going to have to do things differently; the health strategies need to take into consideration fundamental understanding of the political dynamics. But we have a special opportunity here at Stanford because we take an interdisciplinary approach.”

Children of War

Most of the children Wise saw will never be the same, he said, nor the humanitarian workers who risked their lives to treat them, their families, and fighters from all sides of the battle to oust the Islamic extremists from the city on the Tigris River.

“I look at these little kids with horrendous emotional trauma and PTSD, and I think to myself, it’s the collision of all these questions playing out within a 50-square-meter little playground,” he said. “It’s these broader, strategic and ethical questions that are really profound. And as a pediatrician who is dedicating the last phase of my career to these questions of security and the political dimensions — I have to engage on all of these levels. That’s not easy.”

Wise traveled with WHO officials, as well as Paul Spiegel, a physician who leads the Center for Humanitarian Health at Johns Hopkins Bloomberg School of Public Health; Adam Kushner, a trauma surgeon affiliated with Johns Hopkins; and Kent Garber, a surgical resident at UCLA and research associate at Johns Hopkins.

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Spiegel also believes academics are uniquely positioned to help assess the current system of responding to medical crises during conflict.

“I believe that we can bring objectivity and rigor to analyzing and evaluating important and innovative responses, such as the trauma response by WHO and others in Mosul,” Spiegel said. “Humanitarian organizations are often busy responding quickly to rapidly changing situations; they don’t always have the luxury of time to do what academic humanitarians can do.”

Making the two-hour drive from Erbil to Mosul in armored, bulletproof SUVs provided by the United Nations, they slipped into field hospitals to meet with Iraqi physicians and medical teams with the humanitarian agencies.

Wise, who was able to take a few photos and video on his smartphone, described the devastation on the ground, noting that not since the siege of Leningrad has a city of this size experienced such street-by-street fighting. In large parts of the city, virtually every building was bombed or bulleted. It will take years to clear the rubble and rebuild.

“It’s just a remarkable story of tragedy and resilience,” he said.

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Since the city was not long ago controlled by ISIS, the field hospitals are still surrounded by massive concrete barricades and tactical trucks stationed outside with mounted machine guns.

The team found that at the height of the battle for Mosul, there was tremendous pressure to treat injured civilians and discharge patients very quickly, due to the lack of medical infrastructure and personnel and the continuous wave of new injuries coming in.

“The charge for us was to evaluate the system and how well it worked, what ways could it be improved, how many lives that it saved,” Wise said. “One of the concerns, for example, was that in order to put in medical people that close to the frontline, you have to give them some kind of security. This raised issues among the humanitarians about their need for independence and neutrality, since you’re essentially embedding them with Iraqi security forces.”

Epidemiology and Ethics

“We are looking at the technical issues and the epidemiologic issues, but also dealing with the ethical issues and their implications,” he said.

They intend to write an internal report and then publish their findings in a major medical journal, to get the word out about the issue and gain support for ongoing collaborative work. They’re looking to partners like the American Academy of Arts and Sciences, which recently devoted an entire issue of its journal, Daedalus, to the factors and influences of contemporary civil war. One of the essays in that issue by Wise and his Stanford colleague, Dr. Michele Barry, who directs the Center for Innovation in Global Health, talks about the threat of a global pandemic as a potential byproduct of the 30 ongoing civil wars around the world.

“We’re trying to get the report completed quickly because the model of trauma care for civilians in Mosul is a new model and could be implemented in other combat areas, like the fighting in Syria and other places in Iraq,” Wise said.

Wise worries some see Stanford University as an insulated Silicon Valley institution in a beautiful setting and not always engaged in the real world.

“Well, this is about as engaged in the real world as you can get — this is Stanford moving and doing things out there, not just sitting around in seminar rooms. Sometimes you need to get close to the front lines to save lives,” he said.

When asked what surprised him during this trip to Mosul, Wise smiled.

“I’m sort of old and I’ve seen a lot of the world and not a lot surprises me anymore,” he said. “But it was a reminder of how desperate are the lives of millions of people — that we could do so much more. It’s a reminder of just how fragile physical security really is in this world."

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The Center for International Security and Cooperation now has more than 46 podcasts, dating all the way back to Oct. 19, 2016. Listen to them on the CISAC page on the iTunes website. Simply mouse over the title and click play. Open iTunes to download and subscribe to CISAC podcasts. Seminars and events at CISAC are routinely audiotaped for use as podcasts. Also, the Freeman Spogli Institute for International Relations offers the World Class podcast series, featuring scholars and experts from FSI, CISAC and beyond.

CISAC co-director Amy Zegart wrote the following essay in the Oct. 25 online edition of The Atlantic:

Pity the professionals. In the past month, President Trump has sideswiped certification of the Iran nuclear deal, sandbagged his own secretary of state’s diplomatic efforts with North Korea, and even provoked the ever-careful Senate Foreign Relations Committee Chairman, Bob Corker, to uncork his deepest fears in a series of bombshell interviews. “The volatility, is you know, to anyone who has been around, is to a degree alarming,” Corker told the Times earlier this month, revealing that many in the administration were working overtime to keep the president from “the path to World War III.” He doubled down on those comments a few weeks later, declaring that Trump, among other things, was “taking us on a path to combat” with North Korea and should “leave it to the professionals for a while.”

The professionals sure have their hands full. So far, the Trump Doctrine in foreign policy appears to consist of three elements: baiting adversaries, rattling allies, and scaring the crap out of Congress. The administration has injected strategic instability into world politics, undermining alliances and institutions, hastening bad trends, and igniting festering crises across the globe. “America first” looks increasingly like “America alone.” The indispensable nation is becoming the unreliable one. Even without a nuclear disaster, the damage inflicted by the Trump presidency won’t be undone for years, if ever.

But it’s also important to understand that today’s foreign-policy challenges— whether it’s Iran’s hegemonic ambitions in the Middle East, North Korea’s breakneck nuclear breakout, China’s rise, Russia’s nihilism, Europe’s populism and fragmentation, Syria’s civil war, or transnational terrorism and cyber threats—did not start with Trump. This is the most challenging foreign-policy environment any White House has confronted in modern history.

Three swirling complexities explain why.

Threat complexity

Take a look at any of the annual threat assessments issued by the Director of National Intelligence over the past few years. They will make your head spin. They are filled with rising states, declining states, weak states, rogue states, terrorists, hackers, and more. Bad actors don’t just threaten physical space these days. Adversaries are working on ways to cripple America in cyberspace and even outer space—by compromising all those satellite systems on which its digital society depends. In this threat landscape, the number, identity, magnitude, and velocity of dangers facing America are all wildly uncertain. Exactly how many principal adversaries does the United States have? Who are they and what do they want? What could they do to us? How are these threats changing and how can we keep up without spending ourselves into oblivion or leaving ourselves vulnerable to other nasty surprises? These are fundamental questions. There are no consensus answers. Uncertainty is what fuels America’s foreign-policy anxieties today.

The Cold War was different. Then, certainty was what fueled American foreign-policy anxieties. It was clear to all that the U.S. faced a single principal adversary. The Soviet Union had territory on a map and soldiers in uniforms. Thanks to U.S. intelligence, Soviet intentions and capabilities were fairly well understood. The threat landscape was deadly but slower-moving: Communists never met a five-year plan they didn’t like. And while superpower nuclear dangers were terrifying, they were also constraining in a helpful but insane sort of way. In 1961, President Kennedy invoked the specter of a “nuclear sword of Damocles, hanging by the slenderest of threads” over the earth. Every American foreign-policy decision had to consider the question: What would Moscow think of that? Today, the nuclear sword of Damocles is still hanging—indeed, China, India, Pakistan, and North Korea have all successfully tested nuclear devices since 1961—but no singular threat guides U.S. foreign policy as the Soviet Union once did.

Organizational complexity

As threats have grown more complex, organizational arrangements to deal with them have, too. Coordinating Soviet policy was one thing. Developing coherent U.S. foreign policy in the face of so much uncertainty across so many issues is quite another. Little wonder special advisers, envoys, commissions, boards, initiatives, czars, and new agencies have been growing like mushrooms. This may not sound so bad. But it is. Every new agency or czar or special arrangement says, “the regular process here ain’t working.” The crux of the problem is that bureaucracies are notoriously hard to kill or change. Ronald Reagan famously quipped that bureaucracy is the closest thing to immortal life on earth. Whenever a crisis hits, the natural response is to add a new organization and stir. But if today’s chief challenge is developing coherent, coordinated policy in the face of complexity, creating more organizations to coordinate doesn’t get you very far. Over time, the whole bureaucratic universe just keeps growing bigger, filled with obsolete organizations alongside new organizations; fragmented jurisdictions, overlapping jurisdictions, and unclear jurisdictions; and silos so specialized that nobody can see across all the key issues easily.

Cognitive complexity

Humans are not superhuman. Research finds that most people can remember at most seven items at a time, fewer as they grow older. Even the biggest brains have limits. In 2001, Peter Pronovost of Johns Hopkins noticed that highly trained medical teams at the university’s medical center were screwing up insertions of central line catheters, causing infections in critically ill patients at alarming rates. Why? Because they often forgot one of just five simple steps (like washing their hands) before starting the procedure. (Pronovost instituted a checklist that has since become widely used and is credited with saving thousands of lives.)

In foreign policy, too, the stakes are high and humans are frequently overloaded by complexity, resulting in catastrophic errors that nobody ever intended. One of the chief findings of the 9/11 Commission, for example, was that many inside the FBI simply didn’t know or couldn’t remember all the legal requirements and rules for sharing intelligence and law-enforcement information. Even the Bureau’s own 1995 guidelines were “almost immediately misunderstood and misapplied,” the commission concluded. As a result, clues to the terror plot emerged weeks before 9/11 but were marooned in different parts of the bureaucracy.

In 1935, an advanced bomber nicknamed “the Flying Fortress” crashed during a test flight. The Army Air Corps investigation found that the machine worked fine. The problem was the human. The airplane was so sophisticated, flying required the pilot to remember too many things, and he forgot one of them: unlocking the rudder and elevator controls during takeoff. It was “too much airplane for one man to fly,” one reporter later wrote. That crash sparked the invention of pilot checklists which have been used for nearly a century, transforming global aviation.

U.S. foreign policy is becoming too much airplane for one person to fly. “The professionals” surrounding Trump—Secretaries James Mattis and Rex Tillerson, Chief of Staff John Kelly, National-Security Adviser H.R. McMaster, and others—are trying to keep the whole thing from crashing with a pilot who has never flown before. Let’s hope they can.

America’s approach to the world is a complicated mess, for reasons that predate the current president.

Amy Zegart is co-director of the Center for International Security and Cooperation and professor of political science, by courtesy. She is also the Davies Family Senior Fellow at the Hoover Institution and directs the Cyber Policy Program. She wrote this essay as a contributing editor to The Atlantic.

Deep policy discussions between journalists and top Stanford scholars highlighted a recent media roundtable at the Hoover Institution.

The event drew about 30 members of the national media from a variety of print and broadcast outlets, including CNN, CBS, The New York Times, Wall Street Journal, MSNBC, The Washington Post, and Politico.  The two-day media roundtable on Oct. 15-16 was titled, “Outside the Beltway.”

Over the course of the two-day conference, participants engaged in robust discussions with Hoover Institution fellows and Freeman Spogli Institute for International Studies scholars, including former U.S. Secretary of State and Hoover and FSI senior fellow Condoleeza Rice, who kicked off the event with a foreign policy conversation.

Drones and cybersecurity, for example, were topics of conversation for Amy Zegart and Herb Lin from the Center for International Security and Cooperation (CISAC).

Drones and new warfare

Zegart said, “New technology is being used in ways never imagined ... The question is, could drones be next?”

Drones are possible “coercion tools,” more effective than people would believe, Zegart said. “We need to figure out how the logic works with coercion, in regard to states.”

How do you get others to back down without a fight? You need to issue a costly threat, she said. For example, “trip-wire” forces of more than 20,000 in South Korea represent such a credible threat to North Korea. “Low-cost is low credibility,” or “cheap talk,” on the other hand.

Drones lower the cost of coercion, Zegart said. One point is that such strikes have huge public support, as the risk of U.S. casualties are very low, according to polls – 62 percent favor such drone strikes.

Zegart said drones could shift the “relative costs” of war and are better able to sustain military action over a lengthy time frame. They also affect the “psychology of punishment.” Hovering over a target for long periods of time, decapitation strikes against regime leaders, and the constant state of “near-ambush” changes the character of war and for a military campaign to stay the course.

“Certainty of punishment is a very powerful way to change the behavior of the adversary,” moreso than “severity of punishment, said Zegart, who has affirmed these conclusions through surveys with foreign military officers. That research also showed that domestic political support for military reaction is the most popular reason for making threats credible. But a deeper dive into such issues is urged, she added.

“We’re really behind the curve in figuring out how to make military threats credible in the world,” said Zegart. “Lots of questions remain.”

Hacking, information attacks

Lin spoke about the recent Equifax data hacking, among other topics.

He said, “The harm we all feel is both tangible and intangible” in regard to such hacks. In other words, there is both material threat and a peace of mind threat, he explained.

The “Internet-of-Things” is another looming problem, Lin said. In the future, liability issues will factor into how all these devices are connected and who is responsible in case of misdeeds, he said.

In the case of health care, confidentiality is a critical societal goal, but hacking creates numerous scenarios: “Would you prefer your blood type posted online or changed in your medical records,” Lin said, explaining the different ways information misuse may affect people.

On the global security front, “cyber war” takes advantage of the flaws of information technology (IT), and “information warfare” takes advantage of the virtues of IT, he noted. Such efforts begin to level the playing field between international actors and agencies.

“You give large megaphones to small players,” Lin said.

In Russia, information warfare is actually studied as a theory of warfare. And the results show that it works – it’s easier to destroy democratic  values online than create or reinforce them, Lin said. For example, Russia’s meddling in the 2016 elect stoked political polarization in America.

One media member asked Lin how the U.S. could prevent Russia from using cyber and information warfare in upcoming U.S. elections.

Lin said, “It’s not clear to me that the U.S. government is really going to be willing to do anything,” but some public pressure may move entities like media companies to respond more effectively.

And Zegart noted, “The Russians are still here.” They are present right now in any number of settings, from social media to traditional media and in public spheres, for example, she said.

“Attacking brains” was how Zegart described Russia’s goal. For American social media companies, she suggested, “Think about battleground states” and focus on “triaging” these areas.

WWII, Russia

The media also heard presentations from Hoover's Kori Schake on defense policy; Hoover's Victor Davis Hanson on “The Second World Wars,” his new book; Hoover's Michael Auslin on the Asian century; Hoover and FSI's Michael McFaul discussed the U.S-Russia relationship; and Hoover and FSI's Larry Diamond on democracy in the world order.

McFaul spoke about the hot spots in the relationship between the U.S. and Russian governments, his time as the U.S. ambassador to Russia during the Obama administration, and his suggested approaches to today’s engagement with Russia. He noted how Russia's President Vladimir Putin has prevailed on many recent occasions against the best interests of the U.S. One instance is Syria and how complicated that issue was for foreign policy makers during his tenure.

"The objective we sought to achieve -- the end of the civil war -- our policies did not achieve," said McFaul, who urges stronger U.S. action against Russian cyber attacks on the U.S. electoral process, now and into the future.

Hanson said that people today often fail to appreciate the deadly scope of the WWII conflict. For example, he pointed out that more people died in that conflict than any in human history, with 27,000 people dying every day in WWII. It was also the first time that more civilians were killed than soldiers. Of all the six major powers involved in the conflict, Japan killed about 10 people for every person they lost.

Lessons from WWII? “Things change very quickly in a war,” Hanson said. In 1942, it looked like the Axis powers had the upper hand; the next year, the Allies were surging. Also, a country should rely on a formidable deterrence strategy to discourage would-be attackers.

Once you lose it, “deterrence is very, very hard to recapture,” Hanson said.

MEDIA CONTACTS:

Clifton B. Parker, Center for International Security and Cooperation: (650) 725-6488, cbparker@stanford.edu