foreignpolicy--2020-05-11--South Korea Tries a Tentative Reopening—and Pays for It

South Korea Tries a Tentative Reopening—and Pays for It SEOUL— “ How many want iced Americano ?
” said one man to the crowd of co-workers who gathered around him .
Ten hands shot up in the air , and he went to the counter to order while everyone else , standing close , chatted exuberantly .
This was the first day back at work for most people in South Korea after a long time stuck at home , so there was plenty to talk about .
It was Wednesday , May 6 , the first day that South Korea—lauded @ @ @ @ @ @ @ approach to stopping the spread of the novel coronavirus—officially loosened social distancing guidelines .
The people working in the area near Seoul City Hall could now in good conscience go to their nearby coffee shop in groups of 12 , and everyone was in good humor .
“ You owe me 500 won [ about 50 cents ] , ” one managerial-looking guy jokingly told one of the younger members of the group , walking up next to him with the palm of his hand stretched out and poking him in the stomach @ @ @ @ @ @ @ in South Korea almost seemed a thing of the past—the new national policy called for less strict “ distancing in daily life ” —which basically meant that the few places that were still closed before were now open , and schools would soon be as well , while everyone was still asked to wear a mask and keep a small distance between each other .
And of course , to stay home if they are sick .
Then things took a sudden turn—revealing just how tentative Seoul ’ s supposed victory against the @ @ @ @ @ @ @ official loosening , a 29-year-old went out in Itaewon , an international area packed with bars and clubs .
The man was carrying the virus , and a week later at least 86 cases could be traced back to him , causing the biggest single-day spike in reported cases since early April .
Authorities estimate that about 1,500 people could have been exposed to the virus at the clubs he visited .
The Seoul city government issued an administrative order shortly after the numbers went up , effectively suspending clubs and bars from @ @ @ @ @ @ @ s been in the area over that weekend is encouraged to get tested , symptomatic or not .
Of 35 new cases , 29 were found to be linked to Itaewon , the capital ’ s party district , according to officials from the Korea Centers for Disease Control and Prevention .
The spike has caused outrage online among many South Koreans , especially against the LGBT community , because the clubs at the center of the new outbreak reportedly catered to the gay community .
The new cluster of cases also prompted @ @ @ @ @ @ @ of schools by one week , and many officials said they felt justified in their skepticism about the initial reopening policy .
“ This term ‘ new normal ’ is mentioned a lot lately , and we ’ re very curious to see the future of post-COVID Korea , ” said Son Young-rae , a spokesperson for the Ministry of Health and Welfare , at a press briefing for foreign media late last week .
The government says it is fully prepared for a second wave of the virus .
“ The key @ @ @ @ @ @ @ round , more efficiently .
The Korean government is getting ready for the potential second wave , we aim to contain the disease while having the daily life .
So instead of … rooting out the virus itself , it ’ s more about containing the virus , ” Kwon Jun-wook of the Korea Centers for Disease Control said at the press conference late last week .
Even so , despite the Itaewon outbreak , officials said the nation was still doing well overall against the pandemic .
“ In recent days the @ @ @ @ @ @ @ lower than 10 cases , the majority of them are from inbound travelers , and 5 percent or so of the confirmed cases are from unidentifiable sources , ” said Son .
“ This means that we have recovered control of COVID-19 .
So , I think we can maintain this level of containment and control while widening daily life and increase mobility to go back to life before.
” Overall , South Korea has kept its numbers of new cases very low , the recent spike excluded , hovering around 10 per @ @ @ @ @ @ @ experiencing three consecutive days with zero domestic cases , with the only infected people arriving internationally .
And with the economy being battered , half the semester gone , and the weather getting better , now just seemed to be the best time to encourage people to go out and about once again , one expert said .
“ The warm and humid weather is not good for the virus ’ s survival , with human behavior going out rather than inside in summertime , and the lowest recorded number of new confirmed @ @ @ @ @ @ @ it ’ s appropriate to ease restrictions , ” Kim Woo-joo , a professor in infectious diseases at Korea University Guro Hospital , told Foreign Policy .
But it ’ s still too early to completely let go , he warned : “ Korea should be very cautious to avoid a recurrence of an outbreak .
It ’ ll be a step-by-step approach , and the government should asses every situation and the risk of resurgence , deciding to go or not to go or sometimes going back to major social distancing.
” @ @ @ @ @ @ @ of colder weather and people going inside in confined spaces once again , the risk will grow .
“ Without effective vaccine or having protective herd immunity in the community , it will be inevitable , inevitable to have a second big wave in the autumn season , ” Kim said .
The South Korean government agrees .
“ We need to be ready to have the second wave at any time .
I think we need to think of it as a given scenario , it ’ s inevitable , ” said @ @ @ @ @ @ @ South Korea managed to contain the spread of the virus effectively in the first wave by being responsive , he said .
In the beginning , the new coronavirus was a total mystery .
Much of it still is , but officials know more now than in January .
“ Novel infectious diseases are always something new , it ’ s something we do not know .
Against this backdrop we have to make decisions very quickly , and sometimes we make the wrong decisions .
And in that case , we have @ @ @ @ @ @ @ said .
He mentioned the choice by the U.S. Centers for Disease Control and Prevention to use the drug remdesivir to shorten time in the hospital for severe COVID-19 patients , and he mentioned South Korean research into using plasma transfusion from recovered patients as a potential cure .
In short , he ’ s optimistic when it comes to treating the virus that inevitably will return .
Son is also optimistic because he guesses that the conditioning we ’ ve all been through these past months will stick—that there ’ ll be @ @ @ @ @ @ @ or for worse .
“ We all agree that the world is totally different from what we had in the past .
If you visit Seoul after this situation , you will be seeing differences , shops and restaurants will be checking your body temperature , or you ’ ll have to go through some sort of procedure , ” he said .
On the evening of May 6 , as the tepid dusk settled into a chill night , the popular Yeouido Hangang Park was still full of people , as it @ @ @ @ @ @ @ People ate takeout fried chicken or snapped selfies in the bright moonlight that illuminated the clear night sky .
A group of young people sat on a blanket sharing drinks and playing games to determine who had to take the next sip .
At least some of the old ways are sticking around , for better or for worse .

SEOUL—“How many want iced Americano?” said one man to the crowd of co-workers who gathered around him. Ten hands shot up in the air, and he went to the counter to order while everyone else, standing close, chatted exuberantly. This was the first day back at work for most people in South Korea after a long time stuck at home, so there was plenty to talk about.
SEOUL—“How many want iced Americano?” said one man to the crowd of co-workers who gathered around him. Ten hands shot up in the air, and he went to the counter to order while everyone else, standing close, chatted exuberantly. This was the first day back at work for most people in South Korea after a long time stuck at home, so there was plenty to talk about.
It was Wednesday, May 6, the first day that South Korea—lauded around the world for its successfully proactive approach to stopping the spread of the novel coronavirus—officially loosened social distancing guidelines. The people working in the area near Seoul City Hall could now in good conscience go to their nearby coffee shop in groups of 12, and everyone was in good humor.
“You owe me 500 won [about 50 cents],” one managerial-looking guy jokingly told one of the younger members of the group, walking up next to him with the palm of his hand stretched out and poking him in the stomach.
On that day, social distancing in South Korea almost seemed a thing of the past—the new national policy called for less strict “distancing in daily life”—which basically meant that the few places that were still closed before were now open, and schools would soon be as well, while everyone was still asked to wear a mask and keep a small distance between each other. And of course, to stay home if they are sick.
[Mapping the Coronavirus Outbreak: Get daily updates on the pandemic.]
Then things took a sudden turn—revealing just how tentative Seoul’s supposed victory against the coronavirus was. The weekend before the official loosening, a 29-year-old went out in Itaewon, an international area packed with bars and clubs. The man was carrying the virus, and a week later at least 86 cases could be traced back to him, causing the biggest single-day spike in reported cases since early April. Authorities estimate that about 1,500 people could have been exposed to the virus at the clubs he visited.
The Seoul city government issued an administrative order shortly after the numbers went up, effectively suspending clubs and bars from operating. Likewise, anybody who’s been in the area over that weekend is encouraged to get tested, symptomatic or not. Of 35 new cases, 29 were found to be linked to Itaewon, the capital’s party district, according to officials from the Korea Centers for Disease Control and Prevention. The spike has caused outrage online among many South Koreans, especially against the LGBT community, because the clubs at the center of the new outbreak reportedly catered to the gay community.
The new cluster of cases also prompted the government to push back the reopening of schools by one week, and many officials said they felt justified in their skepticism about the initial reopening policy.
“This term ‘new normal’ is mentioned a lot lately, and we’re very curious to see the future of post-COVID Korea,” said Son Young-rae, a spokesperson for the Ministry of Health and Welfare, at a press briefing for foreign media late last week.
The government says it is fully prepared for a second wave of the virus. “The key is to contain COVID-19, the second round, more efficiently. The Korean government is getting ready for the potential second wave, we aim to contain the disease while having the daily life. So instead of … rooting out the virus itself, it’s more about containing the virus,” Kwon Jun-wook of the Korea Centers for Disease Control said at the press conference late last week.
Even so, despite the Itaewon outbreak, officials said the nation was still doing well overall against the pandemic. “In recent days the number of daily confirmed cases are well lower than 10 cases, the majority of them are from inbound travelers, and 5 percent or so of the confirmed cases are from unidentifiable sources,” said Son. “This means that we have recovered control of COVID-19. So, I think we can maintain this level of containment and control while widening daily life and increase mobility to go back to life before.”
Overall, South Korea has kept its numbers of new cases very low, the recent spike excluded, hovering around 10 per day for almost a month now and experiencing three consecutive days with zero domestic cases, with the only infected people arriving internationally.
And with the economy being battered, half the semester gone, and the weather getting better, now just seemed to be the best time to encourage people to go out and about once again, one expert said. “The warm and humid weather is not good for the virus’s survival, with human behavior going out rather than inside in summertime, and the lowest recorded number of new confirmed cases, those conditions all together, it’s appropriate to ease restrictions,” Kim Woo-joo, a professor in infectious diseases at Korea University Guro Hospital, told Foreign Policy.
But it’s still too early to completely let go, he warned: “Korea should be very cautious to avoid a recurrence of an outbreak. It’ll be a step-by-step approach, and the government should assess every situation and the risk of resurgence, deciding to go or not to go or sometimes going back to major social distancing.”
Especially come fall, with the return of colder weather and people going inside in confined spaces once again, the risk will grow. “Without effective vaccine or having protective herd immunity in the community, it will be inevitable, inevitable to have a second big wave in the autumn season,” Kim said.
The South Korean government agrees. “We need to be ready to have the second wave at any time. I think we need to think of it as a given scenario, it’s inevitable,” said Son, the health ministry spokesperson.
South Korea managed to contain the spread of the virus effectively in the first wave by being responsive, he said. In the beginning, the new coronavirus was a total mystery. Much of it still is, but officials know more now than in January. “Novel infectious diseases are always something new, it’s something we do not know. Against this backdrop we have to make decisions very quickly, and sometimes we make the wrong decisions. And in that case, we have to fix them quickly,” Son said.
He mentioned the choice by the U.S. Centers for Disease Control and Prevention to use the drug remdesivir to shorten time in the hospital for severe COVID-19 patients, and he mentioned South Korean research into using plasma transfusion from recovered patients as a potential cure. In short, he’s optimistic when it comes to treating the virus that inevitably will return.
Son is also optimistic because he guesses that the conditioning we’ve all been through these past months will stick—that there’ll be a distinct post-pandemic world, for better or for worse. “We all agree that the world is totally different from what we had in the past. If you visit Seoul after this situation, you will be seeing differences, shops and restaurants will be checking your body temperature, or you’ll have to go through some sort of procedure,” he said.
On the evening of May 6, as the tepid dusk settled into a chill night, the popular Yeouido Hangang Park was still full of people, as it had been even during social distancing. People ate takeout fried chicken or snapped selfies in the bright moonlight that illuminated the clear night sky.
A group of young people sat on a blanket sharing drinks and playing games to determine who had to take the next sip. At least some of the old ways are sticking around, for better or for worse.


foreignpolicy--2020-05-11--Inspector General Criticizes U.S. Counterterrorism Coordinator

The U.S. government office charged with coordinating counterterrorism initiatives around the world has been dogged by management issues and staffing shortages that hamper U.S. efforts to combat foreign terrorist organizations , according to an inspector general ’ s report issued on Monday .
The report reviewed the State Department ’ s Bureau of Counterterrorism and found that the top counterterrorism envoy , Nathan Sales , “ exhibited decisive leadership ” but also “ engaged in conduct that negatively affected ” the bureau ’ s morale and productivity .
The State Department ’ s Office of Inspector General ( OIG ) @ @ @ @ @ @ @ incidents where Sales “ lost his temper ” in meetings with both U.S. and foreign officials , and said the bureau did “ not provide sufficient policy guidance ” or support to U.S. officials overseas working to coordinate counterterrorism efforts with foreign governments .
The inspector general ’ s report paints a mixed picture of a bureau with a crucial and sweeping mandate for one of the Trump administration ’ s top national security priorities , particularly as terrorism threats grow in the Middle East and Africa and routine counterterrorism operations are hampered @ @ @ @ @ @ @ The bureau has responsibility for parts of the U.S.-led anti-Islamic State coalition and oversees a range of U.S. funding for counterterrorism programs in foreign countries and tracking of terrorist financing networks to combat a resurgence of the Islamic State and weaken terrorist groups in the Sahel and East Africa .
In Iraq , remnants of the Islamic State have stepped up attacks and worked to stage a comeback amid an expected withdrawal of U.S. forces .
In West Africa , the number of terrorist attacks have surged in recent years despite efforts from @ @ @ @ @ @ @ regional militaries to contain the rise of extremist groups in the Sahel .
In response to the report , the bureau ’ s management agreed with all 11 of the recommendations that the State Department inspector general put forth to improve its work and in February set up a steering group to implement the recommendations .
“ We saw the recommendations as an affirmation of changes we ’ ve been working on a for a while now , ” a State Department spokesman said .
Sales wrote a response on May 1 , @ @ @ @ @ @ @ saying the bureau was taking action to course-correct and had “ fully implemented ” five of the 11 recommendations outlined in the report .
“ We are grateful for OIG ’ s feedback on what we are doing well and its recommendations on what we might improve .
We will use these reports to further refine CT ’ s effectiveness in executing our mission , ” Sales wrote .
The watchdog report noted that Sales “ acknowledged the problem and responded positively ” to its suggestions on how to improve .
The report @ @ @ @ @ @ @ s deputy , Alina Romanowski , for her leadership and management .
But the bureau was hindered by other problems , including chronic staffing shortages , unclear policy priorities , and turf battles with other State Department bureaus and federal agencies that undercut effective U.S. counterterrorism policies , according to the report .
As one example , the bureau hadn ’ t effectively used its regional field coordinators posted abroad to help analyze foreign terrorist threats and build up foreign countries ’ counterterrorism capacities .
Officials told the State Department watchdog that “ @ @ @ @ @ @ @ for them to perform their regional responsibilities to coordinate and report on counterterrorism issues and activities.
” The State Department inspector general found that of 27 cables prepared by the field coordinators in fiscal year 2019 , only one of them addressed regional counterterrorism issues .
The bureau , which manages $ 642 million in foreign assistance funds , also did not have in place sufficient internal controls to counter fraud and waste , according to the watchdog .
“ Without a formal process to identify and mitigate risks , the bureau was @ @ @ @ @ @ @ , and mismanagement , ” the report concluded .
The Bureau of Counterterrorism was also “ chronically late ” in submitting Country Reports on Terrorism , one of its flagship work products that members of Congress rely on to help craft legislation and allocate funding on counterterrorism issues .
The bureau has met the statutory deadline to publish the report only once in the past eight years ; the report on 2018 counterterrorism activity worldwide , for example , was submitted six months late .
“ Delays in publishing the reports diminish their @ @ @ @ @ @ @ as a diplomatic tool to influence counterterrorism policy , ” the OIG wrote .
The report didn ’ t offer many specifics on how the management issues hindered specific counterterrorism programs , but the watchdog also produced a classified inspection of the bureau with details of secret information that is not publicly available .
The inspector general routinely inspects State Department bureaus and consulates and releases unclassified reports on their findings .
Officials at State and other agencies appeared torn on the bureau ’ s effectiveness , with some praising Sales and the @ @ @ @ @ @ @ dynamic ” partner .
Others criticized the bureau for advancing its narrow agenda “ without full collaboration with other partners .
”

The U.S. government office charged with coordinating counterterrorism initiatives around the world has been dogged by management issues and staffing shortages that hamper U.S. efforts to combat foreign terrorist organizations, according to an inspector general’s report issued on Monday.
The U.S. government office charged with coordinating counterterrorism initiatives around the world has been dogged by management issues and staffing shortages that hamper U.S. efforts to combat foreign terrorist organizations, according to an inspector general’s report issued on Monday.
The report reviewed the State Department’s Bureau of Counterterrorism and found that the top counterterrorism envoy, Nathan Sales, “exhibited decisive leadership” but also “engaged in conduct that negatively affected” the bureau’s morale and productivity.
The State Department’s Office of Inspector General (OIG), which wrote the report, cited incidents where Sales “lost his temper” in meetings with both U.S. and foreign officials, and said the bureau did “not provide sufficient policy guidance” or support to U.S. officials overseas working to coordinate counterterrorism efforts with foreign governments.
The inspector general’s report paints a mixed picture of a bureau with a crucial and sweeping mandate for one of the Trump administration’s top national security priorities, particularly as terrorism threats grow in the Middle East and Africa and routine counterterrorism operations are hampered or derailed by the coronavirus pandemic.
Read the full report here:
The bureau has responsibility for parts of the U.S.-led anti-Islamic State coalition and oversees a range of U.S. funding for counterterrorism programs in foreign countries and tracking of terrorist financing networks to combat a resurgence of the Islamic State and weaken terrorist groups in the Sahel and East Africa. In Iraq, remnants of the Islamic State have stepped up attacks and worked to stage a comeback amid an expected withdrawal of U.S. forces. In West Africa, the number of terrorist attacks have surged in recent years despite efforts from the United Nations, France, and regional militaries to contain the rise of extremist groups in the Sahel.
In response to the report, the bureau’s management agreed with all 11 of the recommendations that the State Department inspector general put forth to improve its work and in February set up a steering group to implement the recommendations. “We saw the recommendations as an affirmation of changes we’ve been working on a for a while now,” a State Department spokesman said.
Sales wrote a response on May 1, which was included in the report, saying the bureau was taking action to course-correct and had “fully implemented” five of the 11 recommendations outlined in the report. “We are grateful for OIG’s feedback on what we are doing well and its recommendations on what we might improve. We will use these reports to further refine CT’s effectiveness in executing our mission,” Sales wrote.
The watchdog report noted that Sales “acknowledged the problem and responded positively” to its suggestions on how to improve. The report also gave high marks to Sales’s deputy, Alina Romanowski, for her leadership and management.
But the bureau was hindered by other problems, including chronic staffing shortages, unclear policy priorities, and turf battles with other State Department bureaus and federal agencies that undercut effective U.S. counterterrorism policies, according to the report.
As one example, the bureau hadn’t effectively used its regional field coordinators posted abroad to help analyze foreign terrorist threats and build up foreign countries’ counterterrorism capacities. Officials told the State Department watchdog that “they lacked the clear bureau guidance necessary for them to perform their regional responsibilities to coordinate and report on counterterrorism issues and activities.” The State Department inspector general found that of 27 cables prepared by the field coordinators in fiscal year 2019, only one of them addressed regional counterterrorism issues.
The bureau, which manages $642 million in foreign assistance funds, also did not have in place sufficient internal controls to counter fraud and waste, according to the watchdog. “Without a formal process to identify and mitigate risks, the bureau was at elevated risk of waste, fraud, and mismanagement,” the report concluded.
The Bureau of Counterterrorism was also “chronically late” in submitting Country Reports on Terrorism, one of its flagship work products that members of Congress rely on to help craft legislation and allocate funding on counterterrorism issues. The bureau has met the statutory deadline to publish the report only once in the past eight years; the report on 2018 counterterrorism activity worldwide, for example, was submitted six months late. “Delays in publishing the reports diminish their usefulness as a source of information and as a diplomatic tool to influence counterterrorism policy,” the OIG wrote.
The report didn’t offer many specifics on how the management issues hindered specific counterterrorism programs, but the watchdog also produced a classified inspection of the bureau with details of secret information that is not publicly available. The inspector general routinely inspects State Department bureaus and consulates and releases unclassified reports on their findings.
Officials at State and other agencies appeared torn on the bureau’s effectiveness, with some praising Sales and the bureau as a “highly effective and dynamic” partner. Others criticized the bureau for advancing its narrow agenda “without full collaboration with other partners.”


foreignpolicy--2020-05-11--A Powerful Iran-Backed Militia Is Losing Influence in Iraq

BAGHDAD—Five months after its charismatic leader Abu Mahdi al-Muhandis was killed by a U.S. drone strike at the Baghdad airport , the Iran-backed group Kataib Hezbollah ’ s influence on Iraq may be quietly eroding .
Despite an institutional void since widespread protests across Shiite-majority central and southern Iraq forced the previous government to resign late in 2019 and the international coalition ’ s recent withdrawal from several Iraqi bases , moves are afoot to more fully integrate some Popular Mobilization Units ( PMU ) factions into government chains of command and structures that existed prior to 2014 .
If @ @ @ @ @ @ @ do so , it could reduce the influence of powerful armed groups with questionable loyalty to the Iraqi state .
The PMU were officially formed in 2014 through a fatwa by Grand Ayatollah Ali al-Sistani for volunteers to fight against the Islamic State in order to defend Shiite holy sites and Iraq in general .
They played a key role in the country ’ s territorial defeat of the transnational terrorist group .
Several of the brigades within the PMU belong to armed groups that had existed for many years prior to the @ @ @ @ @ @ @ These factions have long been supported by Iran ’ s Islamic Revolutionary Guards Corps .
Others set up in 2014 and loyal to Sistani are known as “ shrine units.
” Kataib Hezbollah ’ s influence on Iraq may be quietly eroding .
On April 23 , the official announcement that four of these shrine-linked PMU would be placed directly under the prime minister ’ s office seemed to signal an attempt to draw some of the factions from the more than 100,000-strong motley fighting force further away from Iranian and Kataib Hezbollah @ @ @ @ @ @ @ PMU have previous experience in Iraq ’ s armed forces .
Liwa Ali al-Akbar commander Ali Hamdani , for example , told me he had previously served as an air force officer when I interviewed him in Hawija during the operation to retake the city from the Islamic State .
Also answering directly to the prime minister ’ s office is Iraq ’ s Counter Terrorism Service ( CTS ) , which played a key role in the fight against the Islamic State and were supported and trained by the international anti-ISIS coalition @ @ @ @ @ @ @ by pro-Iran factions of being too close to the United States .
The international coalition quietly continued to support the CTS after it temporarily halted its training and advisory missions for other Iraqi forces earlier this year amid the surge in U.S.-Iranian tension and a vote by the Iraqi parliament to call for the removal of all foreign forces .
Both Iraqi army and CTS officers have told Foreign Policy that the coalition ’ s withdrawal would deprive the CTS of intelligence that is key to the fight against the Islamic State .
@ @ @ @ @ @ @ Iran-linked armed groups active in Iraq but it has long been considered the greatest danger to the Iraqi government ’ s aspiration to be a proper state in the classical sense—by exerting a monopoly over the use of force within its territory .
It also holds territory in Iraq which even government officials are allegedly prevented from entering .
Some of Kataib Hezbollah ’ s brigades have been incorporated into Iraqi government-salaried PMU , most likely as part of an attempt to rein in the group .
Many of its fighters nevertheless continue @ @ @ @ @ @ @ and Syria , according to local security officials in border areas .
Two of Kataib Hezbollah ’ s government-incorporated brigades were targeted in a U.S. airstrike in late December near Qaim , in Iraq ’ s western Anbar province , killing at least 25 fighters .
This in turn led to an attack on the U.S. embassy by supporters of Kataib Hezbollah and other armed factions—which was followed by the drone strike on Muhandis and Iran ’ s most powerful general , Qassem Suleimani , on Jan. 3 .
Few Iraqis seem willing @ @ @ @ @ @ @ and none will provide details about its hierarchy .
The shadowy armed group “ is happy to keep it that way , ” I was told in 2019 by one so-called PMU media volunteer who had helped to arrange meetings with commanders .
Muhandis , who was also officially deputy chief of the Shiite-dominated , government-salaried PMU , was a charismatic strategist and able to coopt some local Sunni fighting groups and their commanders as well as part of the fight against the Islamic State .
He was key to providing them with @ @ @ @ @ @ @ territory.Kataib Hezbollah has long been considered the greatest danger to the Iraqi government ’ s aspiration to be a proper state .
The most well known was Yazan al-Jabouri , a native of Salahuddin province whom I interviewed in Baghdad in March .
Despite Jabouri ’ s long-standing close relationship with Muhandis , he noted that even to him Kataib Hezbollah was “ like a ghost.
” The onetime Sunni protégé of Muhandis said there had long been tension between the Iran-linked armed group and the Iraqi intelligence services , because of both @ @ @ @ @ @ @ and various threats .
Kataib Hezbollah , he said , had at various times threatened the parliament speaker , Mohamed al-Halbousi , and the head of intelligence , Mustafa al-Kadhimi , who became Iraq ’ s prime minister on May 7 .
Kataib Hezbollah strongly opposed Kadhimi , and have accused him of being linked to the killing of Muhandis and Suleimani through providing intelligence to the United States .
Even as Kadhimi takes the country ’ s reins , Kataib Hezbollah continues to occupy the entire town previously known as Jurf al-Sakr @ @ @ @ @ @ @ the nearby Iraqi Shiite holy city of Karbala against possible Islamic State attacks coming from Sunni-majority Anbar province .
The town was renamed Jurf al-Nasr ( nasr means “ victory ” ) —though its original residents , many of whom are now IDPs in Anbar , continue to refer to it as Jurf al-Sakr .
Kataib Hezbollah continues to prevent its Sunni residents from returning—and allegedly anyone else , including government officials , from entering .
When I asked public officials how to get permission to report from the area , they responded @ @ @ @ @ @ @ to enter.
” One CTS officer claimed that there are British-Iranian engineers working in the town as well as weapons factories .
Halbousi told me in a 2018 interview that he believed many of the men who disappeared from the Razaza checkpoint during anti-Islamic State operations might be held in the town , since no one except Kataib Hezbollah is allowed in .
The Iran-backed armed group also seems to have recently occupied an area in the capital ’ s Green Zone near the prime minister ’ s office .
After reports that @ @ @ @ @ @ @ to them by the prime minister ’ s office were denied , Iraq analyst Michael Knights noted in a tweet that “ KH don ’ t have to wait for the PMO to give them something .
They just take it , and then try to keep it.
” Whatever the Iraqi government and other stakeholders are doing to separate other armed groups from Kataib Hezbollah is being done quietly because of the risks such moves could entail .
Jabouri noted that Muhandis had been able to exert significant control over the vast @ @ @ @ @ @ @ He is now concerned that , with Muhandis gone , there is no one able to do the same .
For example , he said , the PMU group known as Saraya al-Khorasani was forced to leave Salahuddin province after “ we asked Muhandis to tell them to do so ” because their fighters had been “ treating the [ local Sunni ] population as if they [ Saraya al-Khorasani ] were an occupying force.
” The risk is that Kataib Hezbollah may now become even more uncontrollable in its attempt to prevent @ @ @ @ @ @ @ The risk is that Kataib Hezbollah , without Muhandis at its helm , may now become even more uncontrollable in its attempt to prevent a loss of power and influence .
In reporting on Iraq ’ s protest-hit central and southern areas over the past few months , vague reference was often made to “ parties ” —afraid as many people were to even mention the names of several Iran-linked armed groups initially—as being responsible for killing protesters involved in the mass demonstrations that started in October 2019 , as well as assassinations @ @ @ @ @ @ @ that some locals now find it hard to imagine political parties are not linked to armed groups .
A number of activists cited Asaib Ahl al-Haq and the Badr Organization—both of which are Iran-linked armed groups with parts incorporated into government-salaried PMU but which existed long before 2014 and which are now involved in politics—as being the most dangerous in Nasiriyah .
Baghdad locals can name specific streets in the Iraqi capital where Kataib Hezbollah allegedly acts as a sort of mafia .
Support for Kataib Hezbollah seems thin on the ground in @ @ @ @ @ @ @ , as is the case in any area with high unemployment and poverty , there is fertile terrain for recruitment among young men for anyone with the money to pay them .
Some Iraqi politicians have told me in interviews over the past six months of reporting on anti-government protests that the dizzying array of armed groups in the country must get more fully involved in politics in order for them to put down their guns and compete at a different level .
Kataib Hezbollah , however , has shown little serious interest @ @ @ @ @ @ @ , according to several MPs Foreign Policy spoke to—and it continues to ignore demands that it leave areas where locals see it as unnecessary or a threat to stability .
Al-Halbousi , the speaker of Iraq ’ s parliament , told me in an interview before being appointed to his present position , when he was serving as governor of Anbar province , that he wanted to thank Muhandis for the Shiite-led PMU ’ s help against the Islamic State .
However , he argued , they should now leave the Sunni-majority province @ @ @ @ @ @ @ , he said , and was causing problems with the local population .
Years later , Kataib Hezbollah fighters and their weapons are still crossing the Iraqi-Syrian border in western Anbar .
Indeed , over years of reporting from western Anbar since the operations to retake the area from Islamic State in late 2017 , I have witnessed Sunni locals complaining in private about the Shiite-led forces ’ alleged land grabs , cross-border smuggling negatively affecting the local market , and , especially , missing male relatives they say have simply “ disappeared.
@ @ @ @ @ @ @ as the likely perpetrator of many of these disappearances.Kataib Hezbollah fighters and their weapons are still crossing the Iraqi-Syrian border in western Anbar .
There has recently been an uptick in Islamic State attacks in Diyala province , along Iraq ’ s border with Iran , as well as continuing security incidents in the nearby provinces of Kirkuk and Salahuddin .
“ Kataib Hezbollah is very , very active in Diyala near the Iranian border now and they are constantly moving back and forth across it , ” a local security official , @ @ @ @ @ @ @ had not been authorized to speak to the media , told Foreign Policy via a WhatsApp call in late April .
This likely means that Kataib Hezbollah is moving weapons and fighters across the border from Iran , which could pose a risk to anyone seen as opposing them .
The fact that Kataib Hezbollah strongly opposed Kadhimi for the position of prime minister , but that he still received enough support to form a government , may point to an erosion of the group ’ s influence .
Kadhimi ’ s cabinet @ @ @ @ @ @ @ May 7 .
This , alongside the government-led move to distance some of the PMU from Kataib Hezbollah and others , seems to signal some halting progress toward reducing influence by Iran-backed armed groups .
Many in Iraq feel this is necessary .
A prime minister openly opposed by Kataib Hezbollah , with parts of the PMU now answering to him—and a government program that calls for bringing all arms under state control—may very well mark an important first step .

BAGHDAD—Five months after its charismatic leader Abu Mahdi al-Muhandis was killed by a U.S. drone strike at the Baghdad airport, the Iran-backed group Kataib Hezbollah’s influence on Iraq may be quietly eroding.
BAGHDAD—Five months after its charismatic leader Abu Mahdi al-Muhandis was killed by a U.S. drone strike at the Baghdad airport, the Iran-backed group Kataib Hezbollah’s influence on Iraq may be quietly eroding.
Despite an institutional void since widespread protests across Shiite-majority central and southern Iraq forced the previous government to resign late in 2019 and the international coalition’s recent withdrawal from several Iraqi bases, moves are afoot to more fully integrate some Popular Mobilization Units (PMU) factions into government chains of command and structures that existed prior to 2014.
If Iraq’s new government manages to do so, it could reduce the influence of powerful armed groups with questionable loyalty to the Iraqi state.
The PMU were officially formed in 2014 through a fatwa by Grand Ayatollah Ali al-Sistani for volunteers to fight against the Islamic State in order to defend Shiite holy sites and Iraq in general. They played a key role in the country’s territorial defeat of the transnational terrorist group.
Several of the brigades within the PMU belong to armed groups that had existed for many years prior to the PMU’s formation in 2014. These factions have long been supported by Iran’s Islamic Revolutionary Guards Corps.
Others set up in 2014 and loyal to Sistani are known as “shrine units.”Kataib Hezbollah’s influence on Iraq may be quietly eroding.
On April 23, the official announcement that four of these shrine-linked PMU would be placed directly under the prime minister’s office seemed to signal an attempt to draw some of the factions from the more than 100,000-strong motley fighting force further away from Iranian and Kataib Hezbollah influence.
Some of those in the PMU have previous experience in Iraq’s armed forces. Liwa Ali al-Akbar commander Ali Hamdani, for example, told me he had previously served as an air force officer when I interviewed him in Hawija during the operation to retake the city from the Islamic State.
Also answering directly to the prime minister’s office is Iraq’s Counter Terrorism Service (CTS), which played a key role in the fight against the Islamic State and were supported and trained by the international anti-ISIS coalition.
The CTS has long been accused by pro-Iran factions of being too close to the United States. The international coalition quietly continued to support the CTS after it temporarily halted its training and advisory missions for other Iraqi forces earlier this year amid the surge in U.S.-Iranian tension and a vote by the Iraqi parliament to call for the removal of all foreign forces. Both Iraqi army and CTS officers have told Foreign Policy that the coalition’s withdrawal would deprive the CTS of intelligence that is key to the fight against the Islamic State.
Kataib Hezbollah is only one of several Iran-linked armed groups active in Iraq but it has long been considered the greatest danger to the Iraqi government’s aspiration to be a proper state in the classical sense—by exerting a monopoly over the use of force within its territory. It also holds territory in Iraq which even government officials are allegedly prevented from entering.
Some of Kataib Hezbollah’s brigades have been incorporated into Iraqi government-salaried PMU, most likely as part of an attempt to rein in the group. Many of its fighters nevertheless continue to cross in and out of Iran and Syria, according to local security officials in border areas.
Two of Kataib Hezbollah’s government-incorporated brigades were targeted in a U.S. airstrike in late December near Qaim, in Iraq’s western Anbar province, killing at least 25 fighters. This in turn led to an attack on the U.S. embassy by supporters of Kataib Hezbollah and other armed factions—which was followed by the drone strike on Muhandis and Iran’s most powerful general, Qassem Suleimani, on Jan. 3.
Few Iraqis seem willing to speak openly about Kataib Hezbollah, and none will provide details about its hierarchy. The shadowy armed group “is happy to keep it that way,” I was told in 2019 by one so-called PMU media volunteer who had helped to arrange meetings with commanders.
Muhandis, who was also officially deputy chief of the Shiite-dominated, government-salaried PMU, was a charismatic strategist and able to coopt some local Sunni fighting groups and their commanders as well as part of the fight against the Islamic State. He was key to providing them with weapons and support to retake their home territory.Kataib Hezbollah has long been considered the greatest danger to the Iraqi government’s aspiration to be a proper state.
The most well known was Yazan al-Jabouri, a native of Salahuddin province whom I interviewed in Baghdad in March. Despite Jabouri’s long-standing close relationship with Muhandis, he noted that even to him Kataib Hezbollah was “like a ghost.”
The onetime Sunni protégé of Muhandis said there had long been tension between the Iran-linked armed group and the Iraqi intelligence services, because of both the secrecy employed by the Iran-linked group and various threats.
Kataib Hezbollah, he said, had at various times threatened the parliament speaker, Mohamed al-Halbousi, and the head of intelligence, Mustafa al-Kadhimi, who became Iraq’s prime minister on May 7.
Kataib Hezbollah strongly opposed Kadhimi, and have accused him of being linked to the killing of Muhandis and Suleimani through providing intelligence to the United States.
Even as Kadhimi takes the country’s reins, Kataib Hezbollah continues to occupy the entire town previously known as Jurf al-Sakr in Babil province, allegedly to protect the nearby Iraqi Shiite holy city of Karbala against possible Islamic State attacks coming from Sunni-majority Anbar province.
The town was renamed Jurf al-Nasr (nasr means “victory”)—though its original residents, many of whom are now IDPs in Anbar, continue to refer to it as Jurf al-Sakr. Kataib Hezbollah continues to prevent its Sunni residents from returning—and allegedly anyone else, including government officials, from entering. When I asked public officials how to get permission to report from the area, they responded: “even we are not allowed to enter.”
One CTS officer claimed that there are British-Iranian engineers working in the town as well as weapons factories. Halbousi told me in a 2018 interview that he believed many of the men who disappeared from the Razaza checkpoint during anti-Islamic State operations might be held in the town, since no one except Kataib Hezbollah is allowed in. The Iran-backed armed group also seems to have recently occupied an area in the capital’s Green Zone near the prime minister’s office.
After reports that the Green Zone land had been given to them by the prime minister’s office were denied, Iraq analyst Michael Knights noted in a tweet that “KH don’t have to wait for the PMO to give them something. They just take it, and then try to keep it.”
Whatever the Iraqi government and other stakeholders are doing to separate other armed groups from Kataib Hezbollah is being done quietly because of the risks such moves could entail.
Jabouri noted that Muhandis had been able to exert significant control over the vast array of Iran-linked Iraqi armed groups. He is now concerned that, with Muhandis gone, there is no one able to do the same.
For example, he said, the PMU group known as Saraya al-Khorasani was forced to leave Salahuddin province after “we asked Muhandis to tell them to do so” because their fighters had been “treating the [local Sunni] population as if they [Saraya al-Khorasani] were an occupying force.”The risk is that Kataib Hezbollah may now become even more uncontrollable in its attempt to prevent a loss of power and influence.
The risk is that Kataib Hezbollah, without Muhandis at its helm, may now become even more uncontrollable in its attempt to prevent a loss of power and influence.
In reporting on Iraq’s protest-hit central and southern areas over the past few months, vague reference was often made to “parties”—afraid as many people were to even mention the names of several Iran-linked armed groups initially—as being responsible for killing protesters involved in the mass demonstrations that started in October 2019, as well as assassinations of activists. This demonstrates the fact that some locals now find it hard to imagine political parties are not linked to armed groups.
A number of activists cited Asaib Ahl al-Haq and the Badr Organization—both of which are Iran-linked armed groups with parts incorporated into government-salaried PMU but which existed long before 2014 and which are now involved in politics—as being the most dangerous in Nasiriyah. Baghdad locals can name specific streets in the Iraqi capital where Kataib Hezbollah allegedly acts as a sort of mafia.
Support for Kataib Hezbollah seems thin on the ground in both Baghdad and the south. However, as is the case in any area with high unemployment and poverty, there is fertile terrain for recruitment among young men for anyone with the money to pay them.
Some Iraqi politicians have told me in interviews over the past six months of reporting on anti-government protests that the dizzying array of armed groups in the country must get more fully involved in politics in order for them to put down their guns and compete at a different level.
Kataib Hezbollah, however, has shown little serious interest in trading its weapons for parliamentary representation, according to several MPs Foreign Policy spoke to—and it continues to ignore demands that it leave areas where locals see it as unnecessary or a threat to stability.
Al-Halbousi, the speaker of Iraq’s parliament, told me in an interview before being appointed to his present position, when he was serving as governor of Anbar province, that he wanted to thank Muhandis for the Shiite-led PMU’s help against the Islamic State.
However, he argued, they should now leave the Sunni-majority province. Their presence was no longer necessary, he said, and was causing problems with the local population. Years later, Kataib Hezbollah fighters and their weapons are still crossing the Iraqi-Syrian border in western Anbar.
Indeed, over years of reporting from western Anbar since the operations to retake the area from Islamic State in late 2017, I have witnessed Sunni locals complaining in private about the Shiite-led forces’ alleged land grabs, cross-border smuggling negatively affecting the local market, and, especially, missing male relatives they say have simply “disappeared.” Some have specifically named Kataib Hezbollah as the likely perpetrator of many of these disappearances.Kataib Hezbollah fighters and their weapons are still crossing the Iraqi-Syrian border in western Anbar.
There has recently been an uptick in Islamic State attacks in Diyala province, along Iraq’s border with Iran, as well as continuing security incidents in the nearby provinces of Kirkuk and Salahuddin.
“Kataib Hezbollah is very, very active in Diyala near the Iranian border now and they are constantly moving back and forth across it,” a local security official, who declined to be named as he had not been authorized to speak to the media, told Foreign Policy via a WhatsApp call in late April.
This likely means that Kataib Hezbollah is moving weapons and fighters across the border from Iran, which could pose a risk to anyone seen as opposing them.
The fact that Kataib Hezbollah strongly opposed Kadhimi for the position of prime minister, but that he still received enough support to form a government, may point to an erosion of the group’s influence.
Kadhimi’s cabinet passed a vote of confidence early on May 7.
This, alongside the government-led move to distance some of the PMU from Kataib Hezbollah and others, seems to signal some halting progress toward reducing influence by Iran-backed armed groups. Many in Iraq feel this is necessary.
A prime minister openly opposed by Kataib Hezbollah, with parts of the PMU now answering to him—and a government program that calls for bringing all arms under state control—may very well mark an important first step.


foreignpolicy--2020-05-11--China Is Still Wary of Invading Taiwan

China Is Still Wary of Invading Taiwan

China Is Still Wary of Invading Taiwan U.S.-China relations have never been worse .
Verbal sparring between a Trump administration determined to find someone to blame for the pandemic and China ’ s aggressive diplomats pushing conspiracy theories has exacerbated tensions and overshadowed previous pandemic cooperation , including donations of tons of equipment and antiviral medicines to Wuhan and Chinese exports of personal protective equipment to major U.S. cities .
With bilateral trade crashing , diplomatic relations at their worst , and a politically divided United States fighting an epidemic , this seems like an opportune time for Chinese President @ @ @ @ @ @ @ of his “ China Dream ” and call on the People ’ s Liberation Army ( PLA ) to force Taiwan to unify with the People ’ s Republic .
But despite a recent outbreak of jingoistic language , the chances of China ’ s military crossing the Taiwan Strait to subdue the self-governing island still remain small .
China has flexed its military muscles on its periphery throughout the pandemic , flying fighters across the centerline of the strait and bomber encirclement missions around Taiwan .
Maritime missions in the South China @ @ @ @ @ @ @ , a survey ship now operating in Malaysia ’ s exclusive economic zone , and coast guard vessels ramming and sinking a Vietnamese fishing boat .
China ’ s threats directed at Taiwan go beyond demonstrations of military might .
On Jan. 15 , a spokesperson for the Beijing-run Taiwan Affairs Office noted that calls for “ reunification by force ” were growing on the mainland , and on April 15 , the office published an article articulating China ’ s long-standing triggers for a military attack of Taiwan .
This bellicosity is @ @ @ @ @ @ @ that his grand vision , the China Dream , and his own place in history require China-sized accomplishments on par with the country ’ s great emperors—the first emperor ’ s unification of China , the Great Wall , Kangxi ’ s economic dominance , Qianlong ’ s conquering of China ’ s periphery , and Jiang Zemin ’ s reclaiming of Hong Kong .
The Belt and Road Initiative ’ s messy legacy of debt-driven diplomacy and half-finished projects does not do his imperial legacy justice .
Taiwan , however , is @ @ @ @ @ @ @ plans , with all trends on the island pointing to political , social , and economic divergence from the mainland .
Taiwanese President Tsai Ing-wen has just been elected to a second term and remains steadfastly committed to engaging the mainland from a position of equality without acknowledging China ’ s “ One China ” policy .
Taiwan ’ s citizens themselves increasingly identify themselves as Taiwanese , rather than part of China .
Taiwan ’ s businesses are joining their global counterparts in reducing their reliance on China by shifting production to @ @ @ @ @ @ @ Taiwan itself .
Taiwan is not going to unify with China of its own free will .
Twenty years of military buildup gives Xi a military option to solve a policy problem that his predecessors didn ’ t have .
What had been impossible in the past is theoretically possible now .
The coronavirus has also driven the risk of miscalculation higher .
It ’ s possible that China perceives the United States as weak and too inwardly focused to deal with a conflict in the Western Pacific , particularly as China congratulates @ @ @ @ @ @ @ the coronavirus and the United States continues to flail .
Widespread reporting of the COVID-19 outbreak on the USS Theodore Roosevelt , and the decision to recall Guam-based B-52 bombers to the U.S. mainland , may cause Beijing to perceive U.S. military readiness for a conflict at a low point .
Meanwhile , although the truth is hard to discern , the PLA has not admitted that a single case of COVID-19 affects its troops .
Yet despite the triumphal tone in public , China is far from ready to launch an invasion @ @ @ @ @ @ @ are far from confident in the Communist Party ’ s ability to remain in power , to the point of paranoia , and continually emphasize the threats and risks that they face , both internally and externally .
China ’ s top think tank affiliated with the Ministry of State Security , the China Institutes of Contemporary International Relations , reportedly advised party members in an internal report to prepare for armed conflict with the United States , which is driving global anti-China sentiment in the aftermath of the COVID-19 pandemic to levels @ @ @ @ @ @ @ war over Taiwan in the face of both internal and external threats is the greatest risk imaginable .
Regardless of these risks , invading Taiwan would not be a cakewalk .
Taiwan has been upgrading and reforming its defense over the past decade , adopting an asymmetric strategy designed to capitalize on its strengths to counter PLA power projection capabilities .
U.S. President Donald Trump ’ s unpredictability , and his administration ’ s steadfast support for Taiwan , makes it impossible for Xi to believe China ’ s hawks who claim that @ @ @ @ @ @ @ the costs of coming to Taiwan ’ s defense .
Japan ’ s steady turn away from China also raises doubt about whether it would sit out a Taiwan contingency .
An even bigger factor is the global economic impact of the pandemic and whether or not economic decline in China is long- or short-term and whether it causes persistently high unemployment , public dissatisfaction , and domestic unrest , which will focus the immediate attention of senior leaders in Beijing to these internal challenges .
The uncertainty of the global economy , @ @ @ @ @ @ @ high debt-to-GDP ratios also argue against Beijing starting a potentially costly war .
I do not believe that Beijing will start a war with Taiwan to distract from domestic problems either , since it is unlikely that the Politburo will want to create major new risks on top of growing existing ones .
There is no historical precedent for China starting external wars to distract from internal problems either , even though China has used force in the past against its neighbors India and Vietnam .
Those conflicts were initiated to signal the @ @ @ @ @ @ @ lesser extent , the United States ) , not to distract from internal challenges .
China was enjoying the novelty of domestic stability with Deng Xiaoping ’ s rise to power and normalizing relations with the United States after a decade of turmoil during the Cultural Revolution under Mao Zedong when it initiated its invasion of Vietnam in 1979 .
In 1962 , China calculated that the United States was distracted by the Cuban missile crisis and would not intervene on India ’ s side in its border conflict with China .
Almost @ @ @ @ @ @ @ critical calculation remains the disposition of the United States .
Retired PLA Air Force Maj. Gen. Qiao Liang recently argued that retaking Taiwan by force would prove too costly , “ unless it ’ s almost certain that COVID-19 will lead to the collapse of the United States.
” While retired generals may preach caution , the PLA ’ s Eastern Theater Command , the unit responsible for mounting a Taiwan invasion , last month published four saber-rattling articles on its Weibo account to mark “ National Security Awareness Day , ” quoting @ @ @ @ @ @ @ U.S. Secretary of State Dean Acheson , “ Cast Away Illusions , Prepare for Struggle !
” Can we rule out that China will seek to unify Taiwan by force in the midst of the pandemic ?
No , but it is the job of military planners to prepare for such a contingency .
Only the reunification of Taiwan is a fitting accomplishment for Xi ’ s legacy .
The anti-corruption campaign and the Belt and Road Initiative are significant , but their success alone would not guarantee Xi a spot in the @ @ @ @ @ @ @ would it protect him and his family from his successor ’ s own anti-corruption campaign , which undoubtedly will also be used for the next leader ’ s political gain .
But the risks of achieving Taiwan reunification by force in the midst of an economic downturn and global pandemic are likely to be assessed as far too high .
Should Xi openly continue as China ’ s paramount leader following the 20th Party Congress in 2022 , he ’ ll have five more years to achieve his China Dream .
Of course @ @ @ @ @ @ @ the 20th sitting of the Central Committee , at the age of 74 he could convince them that to achieve the China Dream he must remain in power at the 21st Party Congress—starting in 2027 .
Serving at the top of four Central Committees is not unprecedented .
Mao served from the 7th until his death during the 10th .
Perhaps Xi will also negotiate for a promotion and reintroduce Mao ’ s title of “ chairman ” —or perhaps he ’ ll wait to have the military victory that justifies it .

U.S.-China relations have never been worse. Verbal sparring between a Trump administration determined to find someone to blame for the pandemic and China’s aggressive diplomats pushing conspiracy theories has exacerbated tensions and overshadowed previous pandemic cooperation, including donations of tons of equipment and antiviral medicines to Wuhan and Chinese exports of personal protective equipment to major U.S. cities. With bilateral trade crashing, diplomatic relations at their worst, and a politically divided United States fighting an epidemic, this seems like an opportune time for Chinese President Xi Jinping to achieve a critical element of his “China Dream” and call on the People’s Liberation Army (PLA) to force Taiwan to unify with the People’s Republic. But despite a recent outbreak of jingoistic language, the chances of China’s military crossing the Taiwan Strait to subdue the self-governing island still remain small.
U.S.-China relations have never been worse. Verbal sparring between a Trump administration determined to find someone to blame for the pandemic and China’s aggressive diplomats pushing conspiracy theories has exacerbated tensions and overshadowed previous pandemic cooperation, including donations of tons of equipment and antiviral medicines to Wuhan and Chinese exports of personal protective equipment to major U.S. cities. With bilateral trade crashing, diplomatic relations at their worst, and a politically divided United States fighting an epidemic, this seems like an opportune time for Chinese President Xi Jinping to achieve a critical element of his “China Dream” and call on the People’s Liberation Army (PLA) to force Taiwan to unify with the People’s Republic. But despite a recent outbreak of jingoistic language, the chances of China’s military crossing the Taiwan Strait to subdue the self-governing island still remain small.
China has flexed its military muscles on its periphery throughout the pandemic, flying fighters across the centerline of the strait and bomber encirclement missions around Taiwan. Maritime missions in the South China Sea have included deploying an aircraft carrier, a survey ship now operating in Malaysia’s exclusive economic zone, and coast guard vessels ramming and sinking a Vietnamese fishing boat.
China’s threats directed at Taiwan go beyond demonstrations of military might. On Jan. 15, a spokesperson for the Beijing-run Taiwan Affairs Office noted that calls for “reunification by force” were growing on the mainland, and on April 15, the office published an article articulating China’s long-standing triggers for a military attack of Taiwan.
This bellicosity is worrying. Xi has given every indication that his grand vision, the China Dream, and his own place in history require China-sized accomplishments on par with the country’s great emperors—the first emperor’s unification of China, the Great Wall, Kangxi’s economic dominance, Qianlong’s conquering of China’s periphery, and Jiang Zemin’s reclaiming of Hong Kong. The Belt and Road Initiative’s messy legacy of debt-driven diplomacy and half-finished projects does not do his imperial legacy justice.
Taiwan, however, is not playing along with China’s plans, with all trends on the island pointing to political, social, and economic divergence from the mainland. Taiwanese President Tsai Ing-wen has just been elected to a second term and remains steadfastly committed to engaging the mainland from a position of equality without acknowledging China’s “One China” policy. Taiwan’s citizens themselves increasingly identify themselves as Taiwanese, rather than part of China. Taiwan’s businesses are joining their global counterparts in reducing their reliance on China by shifting production to cheaper Southeast Asia or back home to Taiwan itself. Taiwan is not going to unify with China of its own free will.
Twenty years of military buildup gives Xi a military option to solve a policy problem that his predecessors didn’t have. What had been impossible in the past is theoretically possible now.
The coronavirus has also driven the risk of miscalculation higher. It’s possible that China perceives the United States as weak and too inwardly focused to deal with a conflict in the Western Pacific, particularly as China congratulates itself for winning its own war against the coronavirus and the United States continues to flail. Widespread reporting of the COVID-19 outbreak on the USS Theodore Roosevelt, and the decision to recall Guam-based B-52 bombers to the U.S. mainland, may cause Beijing to perceive U.S. military readiness for a conflict at a low point. Meanwhile, although the truth is hard to discern, the PLA has not admitted that a single case of COVID-19 affects its troops.
Yet despite the triumphal tone in public, China is far from ready to launch an invasion of Taiwan.
China’s leaders are far from confident in the Communist Party’s ability to remain in power, to the point of paranoia, and continually emphasize the threats and risks that they face, both internally and externally. China’s top think tank affiliated with the Ministry of State Security, the China Institutes of Contemporary International Relations, reportedly advised party members in an internal report to prepare for armed conflict with the United States, which is driving global anti-China sentiment in the aftermath of the COVID-19 pandemic to levels not seen since 1989. Initiating a war over Taiwan in the face of both internal and external threats is the greatest risk imaginable.
Regardless of these risks, invading Taiwan would not be a cakewalk. Taiwan has been upgrading and reforming its defense over the past decade, adopting an asymmetric strategy designed to capitalize on its strengths to counter PLA power projection capabilities. U.S. President Donald Trump’s unpredictability, and his administration’s steadfast support for Taiwan, makes it impossible for Xi to believe China’s hawks who claim that the United States is unwilling to brave the costs of coming to Taiwan’s defense. Japan’s steady turn away from China also raises doubt about whether it would sit out a Taiwan contingency.
An even bigger factor is the global economic impact of the pandemic and whether or not economic decline in China is long- or short-term and whether it causes persistently high unemployment, public dissatisfaction, and domestic unrest, which will focus the immediate attention of senior leaders in Beijing to these internal challenges. The uncertainty of the global economy, shifting trade and investment trends, and high debt-to-GDP ratios also argue against Beijing starting a potentially costly war.
I do not believe that Beijing will start a war with Taiwan to distract from domestic problems either, since it is unlikely that the Politburo will want to create major new risks on top of growing existing ones. There is no historical precedent for China starting external wars to distract from internal problems either, even though China has used force in the past against its neighbors India and Vietnam. Those conflicts were initiated to signal the Soviet Union (and, to a lesser extent, the United States), not to distract from internal challenges. China was enjoying the novelty of domestic stability with Deng Xiaoping’s rise to power and normalizing relations with the United States after a decade of turmoil during the Cultural Revolution under Mao Zedong when it initiated its invasion of Vietnam in 1979.
In 1962, China calculated that the United States was distracted by the Cuban missile crisis and would not intervene on India’s side in its border conflict with China. Almost 60 years later, China’s critical calculation remains the disposition of the United States.
Retired PLA Air Force Maj. Gen. Qiao Liang recently argued that retaking Taiwan by force would prove too costly, “unless it’s almost certain that COVID-19 will lead to the collapse of the United States.” While retired generals may preach caution, the PLA’s Eastern Theater Command, the unit responsible for mounting a Taiwan invasion, last month published four saber-rattling articles on its Weibo account to mark “National Security Awareness Day,” quoting Mao’s famous 1949 essay denouncing U.S. Secretary of State Dean Acheson, “Cast Away Illusions, Prepare for Struggle!”
Can we rule out that China will seek to unify Taiwan by force in the midst of the pandemic? No, but it is the job of military planners to prepare for such a contingency.
Only the reunification of Taiwan is a fitting accomplishment for Xi’s legacy. The anti-corruption campaign and the Belt and Road Initiative are significant, but their success alone would not guarantee Xi a spot in the pantheon of great Chinese leaders, nor would it protect him and his family from his successor’s own anti-corruption campaign, which undoubtedly will also be used for the next leader’s political gain. But the risks of achieving Taiwan reunification by force in the midst of an economic downturn and global pandemic are likely to be assessed as far too high.
Should Xi openly continue as China’s paramount leader following the 20th Party Congress in 2022, he’ll have five more years to achieve his China Dream. Of course, if conditions are not right during the 20th sitting of the Central Committee, at the age of 74 he could convince them that to achieve the China Dream he must remain in power at the 21st Party Congress—starting in 2027. Serving at the top of four Central Committees is not unprecedented. Mao served from the 7th until his death during the 10th. Perhaps Xi will also negotiate for a promotion and reintroduce Mao’s title of “chairman”—or perhaps he’ll wait to have the military victory that justifies it.


foreignpolicy--2020-05-12--Why the U.S. Health Care System Failed the Coronavirus Test

Why the U.S. Health Care System Failed the Coronavirus Test Remote Area Medical ( RAM ) , a provider of pop-up medical clinics for underserved communities , was founded in 1985 to operate medical missions in the Amazon .
Over the next 30 years , 90 percent of its operations shifted to the United States , where 740,000 people have lined up for its services—some driving hundreds of miles .
In 2014 , the group rented out the Javits Center in New York City to provide free care to the uninsured or anyone who needed care they couldn ’ t @ @ @ @ @ @ @ the event , the New York State Health Department blocked RAM from holding it , declaring that “ no hospital can be operated without a valid operating certificate.
” Six years later , amid a pandemic , there are makeshift tents in Central Park operated by medical missionaries , and the Javits Center has become a field hospital—valid operating certificate be damned .
Although they have been heralded as bold acts of ingenuity , these stopgap solutions are better understood as emblems of a health care system that is uniquely vulnerable to failing @ @ @ @ @ @ @ The coronavirus pandemic has revealed that the U.S. health care system is in bad shape ; it is both overdeveloped and underdeveloped , creating a confusing pattern of excellence and profound failure .
Any pandemic can cause devastation , but COVID-19 has a higher mortality in people with diabetes , obesity , and heart disease and among older adults .
Its secondary impacts on the economy also intensify the risk of deaths of despair ( by suicide and addiction ) or other causes .
For most people , chronic conditions come in twos @ @ @ @ @ @ @ set in and reverberate across generations .
The prevalence of chronic conditions in the U.S. population was already projected to grow substantially over the next decade , a burden disproportionately borne by the poor and working class , particularly devastating for people of color , and intensifying for all with age .
At first glance , the U.S. health care system appears to just fail on the margins ; however , COVID-19 illuminates that these failures are vast and growing .
The current design of the health care system is failing Americans , @ @ @ @ @ @ @ question is why .
This power plant model of health care fails four types of people : ( 1 ) economically distressed people who can ’ t afford to access it , ( 2 ) people in rural communities who live far from it , ( 3 ) people of color who have experienced institutional racism and do not trust it , and ( 4 ) people with disabilities , who are challenged at every turn if they seek to access it .
Today , as U.S. hospitals and clinics are struggling , @ @ @ @ @ @ @ Instead of reflexively rescuing this distressed brick-and-mortar model , policymakers need to look beyond its walls .
There is an alternative : health care delivered at home and in communities , being pushed to people when they need it by local teams .
The pattern is decentralized and powered by local talent , more akin to a microgrid than a power plant .
Challenges that individuals and families face are identified and addressed in the context where they arise , unless they require higher levels of action .
A new generation of microgrid-style @ @ @ @ @ @ @ United States : home-based primary care , hospital-level care at home , remote monitoring of chronic conditions at home , or telemedicine at home .
However , most of these innovations have been designed through the lens of consumer convenience , which the nation ’ s wealthy are best positioned to incorporate into their lives .
As isolated solutions , they lack the coherence , urgency , and vision to establish a microgrid form of delivering care that is cheaper , serves rural communities , is trusted by people of color , and @ @ @ @ @ @ @ In the absence of a comprehensive effort to create a new locally oriented health care model , the forces that make these four groups vulnerable to COVID-19 are intensifying at breathtaking speed .
Today , U.S. health care facilities are overwhelmed and seen as dangerous places to be , and Americans shuttered at home are looking for alternatives to waiting for their doctor in a waiting room .
Some are simply avoiding health care altogether : Rough estimates project that COVID-19 ’ s secondary toll—deaths due to non-COVID-19 health issues ( like heart @ @ @ @ @ @ @ as mental health impacts ) —may be in the same order of magnitude as the primary death toll from the disease .
In response , the federal government is deregulating the sector—by removing barriers to using telehealth , enabling some nurses and physician assistants to work without physician oversight , paying for some care at home at the same rate as in a clinic or hospital , and accelerating the use of remote care monitoring devices and self-testing kits .
Taken together , these regulatory changes could accelerate the shift to care at @ @ @ @ @ @ @ and scattered ways .
This scatter threatens to spill into Americans ’ living spaces without a vision to guide it .
That said , there is a visible and growing space where a missing half of the U.S. health care system can emerge—one that is flexible and responsive in times of need .
Americans will have arrived when the care they need moves through their homes and communities with ease , instead of standing aloof in the institutions outside of them .
One of the downsides of the futurism that will undoubtedly accompany @ @ @ @ @ @ @ life is that we all carry our old instincts with us into it .
Anything that ’ s left to theory is liable to snap back to habit—and in the case of America ’ s $ 4 trillion health care industry , the gears of habit are well oiled .
It is therefore crucial to get a practical understanding of what a national-scale health care microgrid must accomplish in order to do what the United States ’ infrastructure-heavy and physician-led workforce can not do alone .
Fortunately , both wealthy and poor countries @ @ @ @ @ @ @ toward developing health care microgrids .
Americans don ’ t need to imagine what it should look like on their own .
Both wealthy and poor countries around the world—from the Netherlands to Rwanda—are successfully developing health care microgrids .
Americans don ’ t need to imagine what it should look like on their own .
In 2006 , a nurse in the Netherlands founded the home-care organization Buurtzorg ( Dutch for “ neighborhood care ” ) .
It comprises local , self-governing teams of nurses that provide home-based care for older adults @ @ @ @ @ @ @ They work with people in their homes to help them develop independence but are also available around the clock and in communication with physicians .
A small technology and administration team supports their operations and enables them to focus on solving the specific problems their clients face , including those beyond health care that inevitably impact their health .
The organization is financially independent and by 2018 had more than 10,000 nurses in 900 teams .
More than half of all community-based nurses in the Netherlands work for the organization , and they @ @ @ @ @ @ @ citizens seem to agree ; instead of throttling their capability and independence , regulators have enabled professionals who care for people in their homes to lead .
In Rwanda , a country of 12 million people that is about the size of Vermont , a network of 50,000 health workers have been mobilized across its communities .
This network was initially focused on identifying and supporting people with HIV/AIDS and tuberculosis , many of whom were at risk of these diseases because they were already economically marginalized .
This community-based network finds and @ @ @ @ @ @ @ provides home-based medication and support , which are critical for the management of both conditions .
They are paid for performance , and they have delivered remarkable results : The network has better HIV/AIDS management statistics than most U.S. states , and people who are supported by these teams have better mental health and access to benefits .
Rwanda has bolstered this microgrid network with aerial drones that carry labs and medicines and expanded its scope of work into areas like maternal care and child health .
Although Rwanda still has work to @ @ @ @ @ @ @ and managing this workforce , necessity has forced these networks to evolve in sophisticated ways .
Like in Rwanda , a tuberculosis outbreak in Alaska pushed the state ’ s tribal health authorities to search for an approach to health care that worked for the extremes of harsh weather and remote living .
The state worked with the U.S. federal government to develop a telehealth system on a mobile cart that could be accessed in outposts that are staffed by health assistants .
Instead of sending in a costly emergency medical helicopter to @ @ @ @ @ @ @ first be assessed near where they lived before further action was taken .
A tuberculosis outbreak in Alaska pushed the state ’ s tribal health authorities to search for an approach to health care that worked for the extremes of harsh weather and remote living .
These carts have become more sophisticated over time and include a range of remote diagnostic equipment .
The health assistants have also taken on more responsibility , riling those who see it as encroaching on their turf ; in 2006 , the American Dental Association and the @ @ @ @ @ @ @ s tribal health authorities because they trained health assistants to remove cavities in children who would have otherwise gone without care .
After more than 100,000 visits , this creative mix of remote technology and local teams continues to significantly cut the cost of health care delivery in a difficult setting .
In each of these cases , physicians , hospitals , and clinics have an undisputedly important role .
However , their presence is peripheral to the microgrid work done by other health care professionals , aided by remote technologies , and @ @ @ @ @ @ @ homes and communities .
In these three cases , the pressure to develop microgrid strategies emerged from infectious diseases or rises in the costs of care for chronic conditions and older adults .
For a highly infectious disease like COVID-19 , it is an untenable national strategy to not care for migrants , the homeless , and undocumented or marginalized people .
A country with a national pandemic strategy that leaves anyone out is a threat to itself and other countries beyond its borders .
Waiting until fewer people show up at hospitals @ @ @ @ @ @ @ costs of health care rise for people who do not overcome their circumstances is not a plan .
Building a microgrid of localized health care is .
Taken together , the missing half of a full health care system—one that is home- and community-based first—is vital to America ’ s COVID-19 response , as well as for reaching the groups where the lopsided U.S. system fails .
Over the next months , and perhaps years , policymakers will be asking about a lot of missing systems .
For example , the United States @ @ @ @ @ @ @ COVID-19 , trace whom they interacted with , and then find those contacts and test or isolate them .
These contact tracing systems have been deployed in settings across the world with varying degrees of technological sophistication , from Iceland to Uganda .
Some experts estimate that America will need 300,000 people to do this type of work .
Other systems—such as quickly responding to symptoms of COVID-19 in a community setting , such as for a cough or a fever , and administering a test—are also missing .
These syndrome surveillance systems @ @ @ @ @ @ @ deployed in China .
In the uniquely American setting , each of these systems requires community endorsement and engagement .
People have to accept having these systems enter their lives and homes .
Instead of building new fragmented and segmented systems , the United States should integrate them into microgrids of care , powered by local teams that are well paid , digitally equipped , and well organized .
Doctors and hospitals need them , too .
Waiting until fewer people show up at hospitals is not a plan .
Watching the costs @ @ @ @ @ @ @ do not overcome their circumstances is not a plan .
Building a microgrid of localized health care is .
Investing in Americans ’ health and in communities across the country will pay dividends beyond its immediate purpose , just as the Alaskan system was established to address tuberculosis and has since been repurposed to address a broad array of health challenges from dental care to common injuries .
An event like COVID-19 is larger than any one individual , and it illuminates both failed preexisting patterns of action and the new approaches that @ @ @ @ @ @ @ also reveal that it is not good enough for the United States to simply get rid of COVID-19 and get back to where it was .
The U.S. health care system must adapt and advance , and that means learning from what works—wherever it is from—and then making it better .
Save the makeshift tents in Central Park and Javits Center makeovers for countries that lack the means , wisdom , or will to do better .

Remote Area Medical (RAM), a provider of pop-up medical clinics for underserved communities, was founded in 1985 to operate medical missions in the Amazon. Over the next 30 years, 90 percent of its operations shifted to the United States, where 740,000 people have lined up for its services—some driving hundreds of miles. In 2014, the group rented out the Javits Center in New York City to provide free care to the uninsured or anyone who needed care they couldn’t otherwise afford. A few weeks before the event, the New York State Health Department blocked RAM from holding it, declaring that “no hospital can be operated without a valid operating certificate.”
Remote Area Medical (RAM), a provider of pop-up medical clinics for underserved communities, was founded in 1985 to operate medical missions in the Amazon. Over the next 30 years, 90 percent of its operations shifted to the United States, where 740,000 people have lined up for its services—some driving hundreds of miles. In 2014, the group rented out the Javits Center in New York City to provide free care to the uninsured or anyone who needed care they couldn’t otherwise afford. A few weeks before the event, the New York State Health Department blocked RAM from holding it, declaring that “no hospital can be operated without a valid operating certificate.”
Six years later, amid a pandemic, there are makeshift tents in Central Park operated by medical missionaries, and the Javits Center has become a field hospital—valid operating certificate be damned. Although they have been heralded as bold acts of ingenuity, these stopgap solutions are better understood as emblems of a health care system that is uniquely vulnerable to failing the people who need it most.
The coronavirus pandemic has revealed that the U.S. health care system is in bad shape; it is both overdeveloped and underdeveloped, creating a confusing pattern of excellence and profound failure.
Any pandemic can cause devastation, but COVID-19 has a higher mortality in people with diabetes, obesity, and heart disease and among older adults. Its secondary impacts on the economy also intensify the risk of deaths of despair (by suicide and addiction) or other causes. For most people, chronic conditions come in twos and threes. They take decades to set in and reverberate across generations. The prevalence of chronic conditions in the U.S. population was already projected to grow substantially over the next decade, a burden disproportionately borne by the poor and working class, particularly devastating for people of color, and intensifying for all with age.
At first glance, the U.S. health care system appears to just fail on the margins; however, COVID-19 illuminates that these failures are vast and growing. The current design of the health care system is failing Americans, and the $4 trillion per year question is why.
Firefighters and paramedics with Anne Arundel County Fire Department assist a potential COVID-19 patient at his home in Glen Burnie, Maryland, on April 25.
The U.S. health care system has a basic repeating motif: regional hospitals at its center and satellite clinics in a starburst pattern around it. It is led by doctors and trailed by informal or underpaid caregivers. The basic idea is that when you’re sick, you’ll come to the clinic or hospital if your issue is serious enough. Then you’re sent home to figure out the rest of your life. The system’s job is to maintain sufficient flow and manage surges—like a power plant that delivers a regular output and protects itself from blackouts.
This power plant model of health care fails four types of people: (1) economically distressed people who can’t afford to access it, (2) people in rural communities who live far from it, (3) people of color who have experienced institutional racism and do not trust it, and (4) people with disabilities, who are challenged at every turn if they seek to access it. Today, as U.S. hospitals and clinics are struggling, calls for quick fixes grow louder. Instead of reflexively rescuing this distressed brick-and-mortar model, policymakers need to look beyond its walls.
There is an alternative: health care delivered at home and in communities, being pushed to people when they need it by local teams. The pattern is decentralized and powered by local talent, more akin to a microgrid than a power plant. Challenges that individuals and families face are identified and addressed in the context where they arise, unless they require higher levels of action.
A new generation of microgrid-style solutions has been slowly emerging across the United States: home-based primary care, hospital-level care at home, remote monitoring of chronic conditions at home, or telemedicine at home. However, most of these innovations have been designed through the lens of consumer convenience, which the nation’s wealthy are best positioned to incorporate into their lives.
As isolated solutions, they lack the coherence, urgency, and vision to establish a microgrid form of delivering care that is cheaper, serves rural communities, is trusted by people of color, and is designed for people with disabilities. In the absence of a comprehensive effort to create a new locally oriented health care model, the forces that make these four groups vulnerable to COVID-19 are intensifying at breathtaking speed.
Today, U.S. health care facilities are overwhelmed and seen as dangerous places to be, and Americans shuttered at home are looking for alternatives to waiting for their doctor in a waiting room. Some are simply avoiding health care altogether: Rough estimates project that COVID-19’s secondary toll—deaths due to non-COVID-19 health issues (like heart disease) and socioeconomic conditions (such as mental health impacts)—may be in the same order of magnitude as the primary death toll from the disease.
In response, the federal government is deregulating the sector—by removing barriers to using telehealth, enabling some nurses and physician assistants to work without physician oversight, paying for some care at home at the same rate as in a clinic or hospital, and accelerating the use of remote care monitoring devices and self-testing kits.
Taken together, these regulatory changes could accelerate the shift to care at home that was already underway in small and scattered ways. This scatter threatens to spill into Americans’ living spaces without a vision to guide it. That said, there is a visible and growing space where a missing half of the U.S. health care system can emerge—one that is flexible and responsive in times of need. Americans will have arrived when the care they need moves through their homes and communities with ease, instead of standing aloof in the institutions outside of them.
A nurse talks via video from Sioux Falls, South Dakota, with a woman in Abilene, Kansas, hundreds of miles away, who needed a consultation for her 4-year-old son on Oct. 16, 2019.
For every technology-driven advance of the health care industry, such as the rapid growth of telehealth visits or the potential for remote monitoring of chronic conditions, there will be an academic cottage industry ready to measure how the same groups as before are left behind yet again. But critique without creation is a recipe for other people’s misery.
One of the downsides of the futurism that will undoubtedly accompany the reimagining of every aspect of post-coronavirus life is that we all carry our old instincts with us into it. Anything that’s left to theory is liable to snap back to habit—and in the case of America’s $4 trillion health care industry, the gears of habit are well oiled.
It is therefore crucial to get a practical understanding of what a national-scale health care microgrid must accomplish in order to do what the United States’ infrastructure-heavy and physician-led workforce cannot do alone. Fortunately, both wealthy and poor countries around the world have made significant strides toward developing health care microgrids. Americans don’t need to imagine what it should look like on their own.
Both wealthy and poor countries around the world—from the Netherlands to Rwanda—are successfully developing health care microgrids. Americans don’t need to imagine what it should look like on their own.
In 2006, a nurse in the Netherlands founded the home-care organization Buurtzorg (Dutch for “neighborhood care”). It comprises local, self-governing teams of nurses that provide home-based care for older adults and those with chronic health conditions. They work with people in their homes to help them develop independence but are also available around the clock and in communication with physicians. A small technology and administration team supports their operations and enables them to focus on solving the specific problems their clients face, including those beyond health care that inevitably impact their health.
The organization is financially independent and by 2018 had more than 10,000 nurses in 900 teams. More than half of all community-based nurses in the Netherlands work for the organization, and they see themselves as community builders. Dutch citizens seem to agree; instead of throttling their capability and independence, regulators have enabled professionals who care for people in their homes to lead.
In Rwanda, a country of 12 million people that is about the size of Vermont, a network of 50,000 health workers have been mobilized across its communities. This network was initially focused on identifying and supporting people with HIV/AIDS and tuberculosis, many of whom were at risk of these diseases because they were already economically marginalized.
This community-based network finds and logs new cases on mobile phones and provides home-based medication and support, which are critical for the management of both conditions. They are paid for performance, and they have delivered remarkable results: The network has better HIV/AIDS management statistics than most U.S. states, and people who are supported by these teams have better mental health and access to benefits.
Rwanda has bolstered this microgrid network with aerial drones that carry labs and medicines and expanded its scope of work into areas like maternal care and child health. Although Rwanda still has work to do when it comes to properly paying and managing this workforce, necessity has forced these networks to evolve in sophisticated ways.
Like in Rwanda, a tuberculosis outbreak in Alaska pushed the state’s tribal health authorities to search for an approach to health care that worked for the extremes of harsh weather and remote living. The state worked with the U.S. federal government to develop a telehealth system on a mobile cart that could be accessed in outposts that are staffed by health assistants. Instead of sending in a costly emergency medical helicopter to transport someone for evaluation, patients could first be assessed near where they lived before further action was taken.
A tuberculosis outbreak in Alaska pushed the state’s tribal health authorities to search for an approach to health care that worked for the extremes of harsh weather and remote living.
These carts have become more sophisticated over time and include a range of remote diagnostic equipment. The health assistants have also taken on more responsibility, riling those who see it as encroaching on their turf; in 2006, the American Dental Association and the Alaska Dental Society unsuccessfully sued Alaska’s tribal health authorities because they trained health assistants to remove cavities in children who would have otherwise gone without care. After more than 100,000 visits, this creative mix of remote technology and local teams continues to significantly cut the cost of health care delivery in a difficult setting.
In each of these cases, physicians, hospitals, and clinics have an undisputedly important role. However, their presence is peripheral to the microgrid work done by other health care professionals, aided by remote technologies, and welcomed by patients and families in their homes and communities.
In these three cases, the pressure to develop microgrid strategies emerged from infectious diseases or rises in the costs of care for chronic conditions and older adults. For a highly infectious disease like COVID-19, it is an untenable national strategy to not care for migrants, the homeless, and undocumented or marginalized people. A country with a national pandemic strategy that leaves anyone out is a threat to itself and other countries beyond its borders.
Waiting until fewer people show up at hospitals is not a plan. Watching the costs of health care rise for people who do not overcome their circumstances is not a plan. Building a microgrid of localized health care is.
Taken together, the missing half of a full health care system—one that is home- and community-based first—is vital to America’s COVID-19 response, as well as for reaching the groups where the lopsided U.S. system fails.
Over the next months, and perhaps years, policymakers will be asking about a lot of missing systems. For example, the United States needs people who can identify people with COVID-19, trace whom they interacted with, and then find those contacts and test or isolate them. These contact tracing systems have been deployed in settings across the world with varying degrees of technological sophistication, from Iceland to Uganda. Some experts estimate that America will need 300,000 people to do this type of work.
Other systems—such as quickly responding to symptoms of COVID-19 in a community setting, such as for a cough or a fever, and administering a test—are also missing. These syndrome surveillance systems are already being proposed in Australia and deployed in China.
In the uniquely American setting, each of these systems requires community endorsement and engagement. People have to accept having these systems enter their lives and homes. Instead of building new fragmented and segmented systems, the United States should integrate them into microgrids of care, powered by local teams that are well paid, digitally equipped, and well organized. Doctors and hospitals need them, too.
Waiting until fewer people show up at hospitals is not a plan. Watching the costs of health care rise for people who do not overcome their circumstances is not a plan. Building a microgrid of localized health care is.
Investing in Americans’ health and in communities across the country will pay dividends beyond its immediate purpose, just as the Alaskan system was established to address tuberculosis and has since been repurposed to address a broad array of health challenges from dental care to common injuries.
An event like COVID-19 is larger than any one individual, and it illuminates both failed preexisting patterns of action and the new approaches that could be adopted. But it should also reveal that it is not good enough for the United States to simply get rid of COVID-19 and get back to where it was.
The U.S. health care system must adapt and advance, and that means learning from what works—wherever it is from—and then making it better. Save the makeshift tents in Central Park and Javits Center makeovers for countries that lack the means, wisdom, or will to do better.