WikiLeaks and the Afghan War – Republished

August 8, 2010

The United States’ war efforts in Afghanistan have been carrying on for what is now approaching a decade (alright, approaching 9 years).  Little in that country has changed, Al Qaeda is still active, and Osama bin Laden has not been killed or captured.

To say the American people’s patience with the war in Afghanistan is waning would be an understatement.  Victory in this war is a very unclear concept.  Spreading our “democracy” to people who don’t really care about it is a questionable endeavor.

These sentiments aren’t just a sentiment of my imagination.  These sentiments even reside in some, at least one, member of the U.S. military.  On July 25, 2010, the website WikiLeaks released what it calls the “Afghan War Diary”.  The Afghan War Diary is, essentially, a voluminous set of reports from the U.S. military regarding its efforts and difficulties in Afghanistan.  WikiLeaks obtained the information from a member of the U.S. military.

Opponents of the way cheered.  Proponents of the war have stopped just short of calling the actions treason.  The Pentagon has demanded the information be taken down.

Some proponents of open government see this as an advance in people driven information sharing and an increase in the sunlight on government activities.   Some proponents of open government see this as a setback to the efforts to promote transparency.

Many questions about.  Why was the information shared?  Is the information classified?  Does the information put U.S. soldiers at risk?

I don’t have answers to these questions, but the founder of STRATFOR Global Intelligence has shared some rather enlightening commentary that I think is worth sharing.

The following report is republished with permission of STRATFOR, http://www.stratfor.com/.

WikiLeaks and the Afghan War

By George Friedman

On Sunday, The New York Times and two other newspapers published summaries
and excerpts of tens of thousands of documents leaked to a website known as WikiLeaks. The documents comprise a vast array of material concerning the war in Afghanistan.  They range from tactical reports from small unit operations to broader strategic analyses of politico-military relations between the United States and Pakistan. It appears to be an extraordinary collection.

Tactical intelligence on firefights is intermingled with reports on confrontations between senior U.S. and Pakistani officials in which lists of Pakistani operatives in Afghanistan are handed over to the Pakistanis.  Reports on the use of surface-to-air missiles by militants in Afghanistan are intermingled with reports on the activities of former Pakistani intelligence chief Lt. Gen. Hamid Gul, who reportedly continues to liaise with the Afghan Taliban in an informal capacity.

The WikiLeaks

At first glance, it is difficult to imagine a single database in which such a diverse range of intelligence was stored, or the existence of a single individual cleared to see such diverse intelligence stored across multiple databases and able to collect, collate and transmit the intelligence without detection. Intriguingly, all of what has been released so far has been not-so-sensitive material rated secret or below. The Times reports that Gul’s name appears all over the documents, yet very few documents have been released in the current batch, and it is very hard to imagine intelligence on Gul and his organization, the Inter-Services Intelligence (ISI) directorate, being classified as only secret. So, this was either low-grade material hyped by the media, or there is material reviewed by the selected newspapers but not yet made public. Still, what was released and what the Times discussed is consistent with what most thought was happening in Afghanistan.

The obvious comparison is to the Pentagon Papers, commissioned by the Defense Department to gather lessons from the Vietnam War and leaked by Daniel Ellsberg to the Times during the Nixon administration. Many people worked on the Pentagon Papers, each of whom was focused on part of it and few of whom would have had access to all of it.

Ellsberg did not give the Times the supporting documentation; he gave it the finished product. By contrast, in the WikiLeaks case, someone managed to access a lot of information that would seem to have been contained in many different places. If this was an unauthorized leak, then it had to have involved a massive failure in security. Certainly, the culprit should be known by now and his arrest should have been announced. And certainly, the gathering of such diverse material in one place accessible to one or even a few people who could move it without detection is odd.

Like the Pentagon Papers, the WikiLeaks (as I will call them) elicited a great deal of feigned surprise, not real surprise. Apart from the charge that the Johnson administration contrived the Gulf of Tonkin incident, much of what the Pentagon Papers contained was generally known. Most striking about the Pentagon Papers was not how much surprising material they contained, but how little. Certainly, they contradicted the official line on the war, but there were few, including supporters of the war, who were buying the official line anyway.

In the case of the WikiLeaks, what is revealed also is not far from what most people believed, although they provide enormous detail. Nor is it that far from what government and military officials are saying about the war. No one is saying the war is going well, though some say that given time it might go better.

The view of the Taliban as a capable fighting force is, of course, widespread. If they weren’t a capable fighting force, then the United States would not be having so much trouble defeating them. The WikiLeaks seem to contain two strategically significant claims, however. The first is that the Taliban is a more sophisticated fighting force than has been generally believed. An example is the claim that Taliban fighters have used man-portable air defense systems (MANPADS) against U.S. aircraft. This claim matters in a number of ways. First, it indicates that the Taliban are using technologies similar to those used against the Soviets. Second, it raises the question of where the Taliban are getting them – they certainly don’t manufacture  MANPADS themselves.

If they have obtained advanced technologies, this would have significance on the battlefield. For example, if reasonably modern MANPADS were to be deployed in numbers, the use of American airpower would either need to be further constrained or higher attrition rates accepted. Thus far, only first- and second-generation MANPADS without Infrared Counter-Countermeasures (which are more dangerous) appear to have been encountered, and not with decisive or prohibitive effectiveness. But in any event, this doesn’t change the fundamental character of the war.

Supply Lines and Sanctuaries

What it does raise is the question of supply lines and sanctuaries. The most important charge contained in the leaks is about Pakistan. The WikiLeaks contain documents that charge that the Pakistanis are providing both supplies and sanctuary to Taliban fighters while objecting to American forces entering Pakistan to clean out the sanctuaries and are unwilling or unable to carry out that operation by themselves (as they have continued to do in North Waziristan).

Just as important, the documents charge that the ISI has continued to maintain liaison and support for the Taliban in spite of claims by the Pakistani government that pro-Taliban officers had been cleaned out of the ISI years ago. The document charges that Gul, the director-general of the ISI from 1987 to 1989, still operates in Pakistan, informally serving the ISI and helping give the ISI plausible deniability.

Though startling, the charge that Islamabad is protecting and sustaining forces fighting and killing Americans is not a new one. When the United States halted operations in Afghanistan after the defeat of the Soviets in 1989, U.S. policy was to turn over operations in Afghanistan to Pakistan.  U.S. strategy was to use Islamist militants to fight the Soviets and to use Pakistani liaisons through the ISI to supply and coordinate with them. When the Soviets and Americans left Afghanistan, the ISI struggled to install a government composed of its allies until the Taliban took over Kabul in 1996. The ISI’s relationship with the Taliban – which in many ways are the heirs to the anti-Soviet mujahideen – is widely known. In my book, “America’s Secret War,” I discussed both this issue and the role of Gul. These documents claim that this relationship remains intact. Apart from Pakistani denials, U.S. officials and military officers frequently made this charge off the record, and on the record occasionally. The leaks on this score are interesting, but they will shock only those who didn’t pay attention or who want to be shocked.

Let’s step back and consider the conflict dispassionately. The United States forced the Taliban from power. It never defeated the Taliban nor did it make a serious effort to do so, as that would require massive resources the United States doesn’t have. Afghanistan is a secondary issue for the United States, especially since al Qaeda has established bases in a number of other countries, particularly Pakistan, making the occupation of Afghanistan irrelevant to fighting al Qaeda.

For Pakistan, however, Afghanistan is an area of fundamental strategic interest. The region’s main ethnic group, the Pashtun, stretch across the Afghan-Pakistani border. Moreover, were a hostile force present in Afghanistan, as one was during the Soviet occupation, Pakistan would face threats in the west as well as the challenge posed by India in the east. For Pakistan, an Afghanistan under Pakistani influence or at least a benign Afghanistan is a matter of overriding strategic importance.

WikiLeaks and the Afghan War

It is therefore irrational to expect the Pakistanis to halt collaboration with the force that they expect to be a major part of the government of Afghanistan when the United States leaves. The Pakistanis never expected the United States to maintain a presence in Afghanistan permanently. They understood that Afghanistan was a means toward an end, and not an end in itself. They understood this under George W. Bush. They understand it even more clearly under Barack Obama, who made withdrawal a policy goal.

Given that they don’t expect the Taliban to be defeated, and given that they are not interested in chaos in Afghanistan, it follows that they will maintain close relations with and support for the Taliban. Given that the United States is powerful and is Pakistan‘s only lever against India, the Pakistanis will not make this their public policy, however. The United States has thus created a situation in which the only rational policy for Pakistan is two-tiered, consisting of overt opposition to the Taliban and covert support for the Taliban.

This is duplicitous only if you close your eyes to the Pakistani reality, which the Americans never did. There was ample evidence, as the WikiLeaks show, of covert ISI ties to the Taliban. The Americans knew they couldn’t break those ties. They settled for what support Pakistan could give them while constantly pressing them harder and harder until genuine fears in Washington emerged that Pakistan could destabilize altogether. Since a stable Pakistan is more important to the United States than a victory in Afghanistan – which it wasn’t going to get anyway – the
United States released pressure and increased aid. If Pakistan collapsed, then India would be the sole regional power, not something the United States wants.

The WikiLeaks seem to show that like sausage-making, one should never look too closely at how wars are fought, particularly coalition warfare. Even the strongest alliances, such as that between the United States and the United Kingdom in World War II, are fraught with deceit and dissension. London was fighting to save its empire, an end Washington was hostile to; much intrigue ensued. The U.S.-Pakistani alliance is not nearly as trusting. The United States is fighting to deny al Qaeda a base in Afghanistan while Pakistan is fighting to secure its western frontier and its internal stability. These are very different ends that have very different levels of urgency.

The WikiLeaks portray a war in which the United States has a vastly insufficient force on the ground that is fighting a capable and dedicated enemy who isn’t going anywhere. The Taliban know that they win just by not being defeated, and they know that they won‘t be defeated. The Americans are leaving, meaning the Taliban need only wait and prepare.

The Pakistanis also know that the Americans are leaving and that the Taliban or a coalition including the Taliban will be in charge of Afghanistan when the Americans leave. They will make certain that they maintain good relations with the Taliban. They will deny that they are doing this because they want no impediments to a good relationship with the United States before or after it leaves Afghanistan. They need a patron to secure their interests against India. Since the United States wants neither an India outside a balance of power nor China taking the role of Pakistan’s patron, it follows that the risk the United States will bear grudges is small. And given that, the Pakistanis can live with Washington knowing that one Pakistani hand is helping the Americans while another helps the Taliban. Power, interest and reality define the relations between nations, and different factions inside nations frequently have different agendas and work against each other.

The WikiLeaks, from what we have seen so far, detail power, interest and reality as we have known it. They do not reveal a new reality. Much will be made about the shocking truth that has been shown, which, as mentioned above, shocks only those who wish to be shocked. The Afghan war is about an insufficient American and allied force fighting a capable enemy on its home ground and a Pakistan positioning itself for the inevitable outcome. The WikiLeaks contain all the details.

We are left with the mystery of who compiled all of these documents and who had access to them with enough time and facilities to transmit them to the outside world in a blatant and sustained breach of protocol. The image we have is of an unidentified individual or small group working to get a “shocking truth” out to the public, only the truth is not shocking – it is what was known all along in excruciating detail. Who would want to detail a truth that is already known, with access to all this documentation and the ability to transmit it unimpeded? Whoever it proves to have been has just made the most powerful case yet for withdrawal from Afghanistan sooner rather than later.

This following report is republished with permission of STRATFOR, http://www.stratfor.com/.

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Posted by Scott Primeau

Giving Employees Incentives for Innovation

March 18, 2010

Calls for more government efficiency come not just from the public, but also from the public servants who make government’s day-to-day operations possible.  Some of the best ideas come from the people who intimately know the processes that could be improved.  However, implementing those ideas often requires jumping several, tall hurdles.

In an unfortunate case of irony, government budget cuts have precluded some efficiency improvement efforts because those efforts require a financial investment.  Saving money three or four years down the line seems less attractive when employees are facing salary cuts, furloughs, and layoffs.  And, in the case of some Web 2.0 tools whose ROI isn’t measured in dollars, investing in the technology is almost out of the question.

Now, more than ever, more people are in need of government services and agencies need to find ways to provide more service with fewer resources.  To make this happen, agencies can’t just work harder.  Agencies need to find innovative ways to deliver services at less cost.

The Colorado legislature is supporting this effort with a bill, HB10-1264, that provides financial incentives to state agency employees who recommend cost-saving improvements. 

The bill requires the state department of personnel to develop a form, called an “idea application”, for employees to suggest improvements.  The personnel department is also responsible for developing criteria for evaluating the applications.  However, the director of the agency where an employee who makes a suggestion works is responsible for evaluating an application.

Then, for each idea that is implemented, the employee who made the suggestion will receive 5% of the cost savings, up to $5,000, as an honorary award.  The agency will receive 25% of the savings and the rest will be used by the state.

Up to a $5,000 bonus is definitely a strong incentive to put forth new ideas.  But, why is this type of bill necessary?  Why do we need laws to encourage innovation?  Isn’t giving an incentive to suggest improvements like paying a child for getting good grades?  (Disclaimer:  I wasn’t paid for grades when I was a kid, and I don’t have any kids, so I’m not really sure if that works.) 

Shouldn’t directors, managers, supervisors, and other agency leaders already be encouraging employees to share ideas for innovation?  Shouldn’t the leaders already be listening?  Well, it’s not the first time common sense has needed to be legislated.  I don’t mean to suggest this is a bad bill.  I just find the need for such a bill to be disappointing.  But, if Colorado government employees need an incentive to innovate and managers need to be pushed to listen to ideas, and I’m not saying they do, this is a step in the right direction.

What are your thoughts about this type of incentive?  What barriers have you encountered with recommending improvements?  How have you overcome those obstacles?

As of the date of this post, the bill is waiting to be heard in an appropriations committee.  The fiscal note associated with the bill doesn’t specify an amount for projected savings, and, while the fiscal note mentions the possibility of costs for implementing the idea applications, the note assumes those costs will be nominal.

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Posted by Scott Primeau

Designing Government for the People

March 4, 2010

I was talking to a co-worker about our office’s reconfiguration plans, which involve merging divisions and training employees to handle a wider variety of customer needs.  It’s a nice plan, and it is likely to benefit our customers by removing the layers they have to dig through to get to the services they need.

In the physical world the reconfiguration has involved combining two separate customer entrances that were on two different floors into a single entrance with employees from two divisions at the front counter.  One of the next steps is to create a single call center for the two divisions, instead of the existing structure that utilizes an auto-mated phone tree to direct customers to the appropriate division.  But, this post isn’t about the reconfiguration. 

The discussion triggered some other thoughts about providing efficient services.  Government watchdogs and government itself continually make calls for more efficient government- faster, more reliable service, at less cost.

A state government trend in this area has been the creation of Web-based portals that allow customers to access a variety of services from multiple state agencies through a single website.  Some of these portals are a mere collection of information and links to other agencies, such as Colorado’s www.colorado.gov.  Other portals are based on functional needs, such as registering a business through the Utah Division of Corporations’ OneStop Business Registration site, http://www.corporations.utah.gov/osbr_phase_2.html.  (Both of those examples are NIC websites, but they are substantially different.)

Portals and other virtual spaces offer customers an alternative to visiting multiple government agencies to accomplish their tasks.  But, the real key to efficiency is to make people efficient.

Efficiency isn’t just about consolidating locations, whether they are physical or virtual.  Efficiency is about rationalizing functions.

Please hold the backlash for just a moment.  I know this didn’t work so well with homeland security.  That’s what my co-worker mentioned as he laughed, maybe rightfully so, at my suggestion of consolidating state agencies.

Technology is making a lot of improvements in efficiency possible.  I do believe the Internet, social media, mobile devices, and other technological developments are making government better and are helping people get more from their government.  But, can technology make up for inefficient structures?  If a person has to visit at least three state agencies to form a business, get a license, and sign up to pay taxes, can a website make up for the twists and turns, the discrepancies in policies, the processing delays, and the inconsistency in customer service?

Technology can make up for a lot, but improving government is not just about making government more efficient; it’s about making people more efficient.

The question shouldn’t be how can government do it?  The question should be how would a person do it?  Processes should be designed around people’s practices and expectations.  Government agencies shouldn’t expect people to adapt to the government’s ideas.

Redesigning government around people will take a lot more than new websites.  Redesigning government will take changes to legal frameworks, a lot of vision, and a whole lot of cooperation.

I’m sure there are a lot of holes to this idea that I haven’t filled, but I’ll settle for starting with a little idealism.

(If you’re interested in some similar ideas, check out Nicholas Charney’s discussion on Govloop, Envisioning a fully web enabled government department/agency and the related comments.)

7 Comments | Efficiency, government, Public Service | Tagged: , , , , , , , | Permalink
Posted by Scott Primeau

Creative Budgeting – Home Redistribution

January 26, 2010

The Colorado legislature introduced a series of tax credit reductions with the goal of saving the state money.  Eliminating the tax credits will save the state money, but the loss of tax credits will cause prices to increase, which means people will have to pay more, which means they will either spend or save less or both.

I commend the legislature for pursuing options, but we, as a state, still need to look for options that create revenue without hurting individuals.  Specifically, we need solutions for education funding.  K-12 education funding in Colorado is already near the lowest in the country according to the Center on Budget and Policy Priorities.  Those schools are funded largely through property tax revenue, and the state doesn’t have enough of it. 

A possibility that could be looked into is for the state to claim foreclosed homes by eminent domain, rent or give those homes to state citizens, and create jobs through an agency responsible for overseeing the program, repairing, and maintaining the homes.

Redistributing foreclosed homes would:

  • Increase state revenue through rental income or property tax;
  • Create jobs in a state oversight agency;
  • Create more jobs through a state home repair and maintenance service; and
  • Discourage banks from foreclosing on homes.

Yes, of course, there are downsides.  The home redistribution program would be big government at its biggest, but that, in and of itself, isn’t necessarily a bad thing.  And, the program would require some state constitution amendments.  Homeowners who are meeting their responsibility by making mortgage payments are sort of left out to dry.  I’m sorry, but this is for the greater public good.  Without help, those people won’t have schools to send their kids to; at least they won’t have very good schools. 

I’m only half joking.  It’s laughable until you think about it.

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Posted by Scott Primeau

Speed Pass

January 6, 2010

The state of Colorado has been facing an ever expanding budget shortfall, and there is little recovery in sight.  State agencies have avoided filling job vacancies and have made additional staff cuts.  Some state services and programs have been decreased or even eliminated. 

The state has raised fees and withheld tax breaks.  But, revenue is not coming in.  Colorado has faired better than most states, but the recession has had a substantial impact.  People are out of work and spending less, so tax revenue is growing scarce.

Colorado needs innovative ideas to raise revenue, so that the state can continue to provide the services the people need. 

One new idea from left-field I’ve had is to create a Colorado speed pass for drivers.  Drivers would be able to buy a monthly pass that would allow them to drive over the speed limit on state and interstate highways. 

The speed pass would mechanically operate similarly to a toll pass.  Drivers would put a transmitter in their car that would send a signal to a receiver in police and highway patrol cars.  Drivers could renew their speed pass online each month.

Of course, speed limits are set to help ensure drivers’ safety, so precautions will be necessary.  In order to qualify for the speed pass, a driver would be required to have a valid driver’s license and to be ticket free for six months.

Drivers would still be subject to reckless driving tickets.  Speeding excessively in poor weather conditions, following too closely, excessive weaving, and other reckless tactics would still be causes to be pulled over.

The price for the pass is uncertain, but it could probably go for a couple hundred dollars a month.  The speed pass would create additional revenue, would improve driver satisfaction, and would enable law enforcement to focus on other issues.

The speed pass idea may need some revision and might be pretty far-fetched, but we need to start brainstorming somewhere.

The legislative session starting on January 13, 2010, should be interesting.

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Posted by Scott Primeau

Mammography Guidelines

November 25, 2009

The following is a response from Dr. Jerome Schroeder, a radiologist with Exempla St. Joseph’s Hospital in Denver and a good friend, to the recent mammography screening guidelines.  Dr. Schroeder can be contacted at jschroeder@divrad.com.

Considering the controversy of the new guidelines and the potential impacts on women’s health, I wanted to share Dr. Schroeder’s insight with the hope of spreading awareness, knowledge, and support of efforts to promote well-being.

Screening Mammography Guidelines

In the week of November 16th, 2009, the United States Preventative Service Task Force (USPSTF) issued guidelines changing the widely accepted recommendations for screening mammography by eliminating the recommendation completely for women in their 40s and changing the recommendation for screening in women over the age of 50 to every other year.  Although the USPSTF is an ‘independent panel of private-sector experts in prevention and primary care,’ no breast screening experts were a part of the panel that devised these guideline changes.

Even though the USPSTF ‘…recognizes that the benefit of screening seems equivalent for women aged 40 to 49 years and 50 to 59 years…’ (their website), they have chosen to drop all recommendations for screening women in their 40s, mostly due to the number of women needed to be screened (1904 women in their 40s invited to be screened compared to 1339 women in their 50s and 337 women in their 60s) in order to save one life and their concerns over ‘psychological harms’ and ‘inconvenience due to false-positive screening results.’ 

The USPSTF also raises concerns about ‘over diagnosis’ and treating cancers that wouldn’t otherwise kill the patient.  They further state that ‘a large proportion of the benefit of screening mammography is maintained by biennial screening’ thereby justifying their recommendation for every-other-year screening in women over age 50.

These new guidelines are contradictory to the recommendations of the American Cancer Society, the American College of Radiology, the Susan G. Komen for the Cure Foundation, the American College of Obstetrics and Gynecology, the Society of Breast Imaging and the National Cancer Institute all of which recommend at least biennial mammography beginning at age 40, with most recommending annual mammography.

Breast cancer is the most common non-skin cancer in women with nearly 230,000 new cases of invasive or non-invasive cancer in American women annually, or one case diagnosed every 2-3 minutes.  It is second in cancer deaths to lung cancer, killing over 41,000 American women annually.  This is about the same number of deaths from annual motor vehicle accidents, with one death every 13 minutes on average.

Since the establishment of regular screening mammograms in the US in the mid 1980s, there has been a precipitous decrease in the death rate from breast cancer, dropping over 2% per year since 1990, after remaining completely unchanged for the previous 50 years.  Since the treatment of breast cancer has improved only minimally in that same time, the main reason for the drop in the death rate is screening mammography.

Part of the controversy over whom and when to screen with mammography stems from the various analyses of 9 ‘original’ Randomly Controlled Trials (RCTs), which established the utility of mammography screening, the newest of which was completed in the early 1980s with the oldest ones from the 1960s.  We are indebted to these ground-breaking studies as they were the first to firmly establish a death rate decrease among women invited to screening with mammography.  These studies showed a significant decrease in breast cancer death rate in the group invited to screening compared to the age-matched not-invited control group, with individual trials showing up to a 31% decrease. The RCTs naturally underestimate the benefit of screening on the individual level, since they estimate the “intention-to-treat” benefit (i.e. mortality among screen-detected cases plus cases among non-attendees and compare it with the mortality among control cases).  When evaluating “service screening” and adjusting for potential biases, one can see that the benefit for women regularly attending screening is a 43% decrease in risk of dying from breast cancer.

Dr. Daniel Kopans, professor of Radiology at Harvard and senior radiologist in the Breast Imaging Division at Massachusetts General Hospital points out that the USPSTF used computer models over direct data to reach their conclusions and ignored other models which contradicted their results and even ignored their own data proving a significant death benefit for women screened in their 40s.  He also reminds us that the National Cancer Institute issued guidelines similar to the USPSTF in 1993, reversing them (back to annual or biennial screening beginning at age 40) in 1997 when it became ‘clear that they had misinterpreted the data.’

Kopans also illustrates that, while the death rate overall has dropped by 2.3% per year in screening populations since 1990, the drop in death rate has averaged 3.3% per year in women in their forties.  Furthermore, nearly 41% of life years lost to breast cancer occur in women diagnosed in their forties, despite accounting for only 15% of breast cancer cases overall. 

Disturbingly, there have been claims that these new guidelines have been released during the Health Care Debate in order to offer a way to ‘decrease’ the costs of breast cancer screening.  Certainly, costs have to be weighed before recommending any screening test.  Arguably, in terms of lives saved per dollar spent, a better benefit would be to shift health care funds towards programs like immunizations, which have a much larger ‘bang for the buck.’  However, our society has determined that spending money to diagnose curable breast cancers is a worthwhile endeavor, considering the breadth and reach of this disease.  Furthermore, if the USPSTF used its own data and logic, they would stop recommending screening for all women under age 60 as it still takes over 1300 women in their 50s invited to be screened to save one life.  They seem to imply that it is worth spending the money to save a woman in her 50s but not to save a woman in her 40s, as both groups have a similar screening benefit.  Although no insurance company has, as yet, publicly changed its annual mammogram benefits, in states like Utah, the only state that does not require insurance companies to provide annual mammograms, these recommendations may have deadly results.

Since the inception of regular screening mammograms, the percentage of non-invasive cancer (DCIS) diagnosed has gone from a rarity to up to 40% of cancers diagnosed in some settings.  It is theoretical that a certain percentage of these cancers, and even some low-grade invasive cancers, will never pose a lethal threat to the woman diagnosed.  Currently, however, there is no reliable method of determining which of these cancers needs to be treated and which can be left alone, with no threat to the patient.  We are, however, beginning to understand the biology and genetics of individual breast cancers and this knowledge is already influencing our treatment of certain cancers, obviating the need for chemotherapy in cases which previously would have been treated with aggressive and often debilitating and toxic agents.  This is where I feel the debate about breast cancer should be heading.  Instead of forming recommendations that may have political, financial or even personal biases, we should be working harder to understand the biology and science of this disease in order to develop more intelligent screening and treatment methods.   This may mean performing breast MRI in addition to or instead of mammography in some patient populations.  Newer, faster MRI imaging protocols may soon bring the costs of performing an MRI and the time it takes to do an MRI down to the currently accepted time and costs of doing a mammogram. Knowing who is performing and interpreting mammograms and ensuring high quality outcomes is another way of maximizing the usefulness of screening mammography. 

Using ‘anxiety’ over callback imaging and/or biopsies and citing the ‘inconvenience’ of having to undergo additional tests to justify screening recommendation changes is demeaning to women and their ability to withstand periods of uncertainty.  In fact, many studies have indicated only minimal and fleeting anxiety in women having to undergo additional tests with most women stating that the anxiety was ‘worth it’ to be certain of a negative final result with virtually none stating that their experience would prevent them from returning for annual screening.  In my own practice, I’ve experienced nearly universal cooperation with recommended additional imaging and biopsies, with an overwhelming percentage of women grateful for the ‘thoroughness’ of their care and their relief of having a negative final result.

In the end, whether or not to have an annual screening mammogram is and should be the decision of the individual patient after she has weighed the risks and benefits and has applied it to her own personal situation.  The benefits of annual screening mammography for all women over 40 are clear and far outweigh the risks.  The Breast Care Center at Exempla St. Joseph Hospital continues to strongly recommend annual mammography for all average-risk women from age 40 on and more aggressive screening for women determined to be at higher-than-average risk.

STATEMENTS OF SUPPORT FOR ANNUAL MAMMOGRAPHY FROM AGE 40:

REFERENCES

THE RANDOMIZED CONTROLLED TRIALS OF SCREENING

Duffy SW, Tabar L, Smith RA.  The Mammographic Screening Trials:  Commentary on the Recent Work by Olsen and Gotzsche.   CA A Cancer J Clin.  2002;52:68-71.

Kopans DB.  The Most Recent Breast Cancer Screening Controversy About Whether mammographic Screening benefits Women at Any Age: Nonsense and Nonscience.  AJR 2003;180:21-26

SCREENING REDUCES DEATH RATE IN THE GENERAL POPULATION

Kopans DB.  Beyond Randomized, Controlled Trials:  Organized Mammographic Screening Substantially Reduces Breast Cancer Mortality.  Cancer 2002;94: 580-581.

Tabar L, Vitak B, Tony HH, Yen MF, Duffy SW, Smith RA.  Beyond randomized controlled trials: organized mammographic screening substantially reduces breast carcinoma mortality.  Cancer 2001;91:1724-31

Duffy SW, Tabar L, Chen H, Holmqvist M, Yen M, Abdsalah S, Epstein B, Frodis Ewa, Ljungberg E, Hedborg-Melander C, Sundbom A, Tholin M, Wiege M, Akerlund A, Wu H, Tung T, Chiu Y, Chiu Chen, Huang C, Smith RA, Rosen M, Stenbeck M, Holmberg L.  The Impact of Organized Mammography Service Screening on Breast Carcinoma Mortality in Seven Swedish Counties.  Cancer 2002;95:458-469.

Otto SJ , Fracheboud J, Looman CWN,  Broeders MJM, Boer R, Hendriks JNHCL, Verbeek ALM,  de Koning HJ, and the National Evaluation Team for Breast Cancer Screening*  Initiation of population-based mammography screening in Dutch municipalities and effect on breast-cancer mortality: a systematic review Lancet 2003;361:411-417.

Feig S.  Estimation of Currently Attainable Benefit from Mammographic Screening of Women Aged 40-49 Years.  Cancer 1995;75:2412-2419.

Swedish Organised Service Screening Evaluation Group. Reduction in breast cancer mortality from organized service screening with mammography: 1. Further confirmation with extended data. Cancer Epidemiol Biomarkers Prev. 2006;15:45-51.

SCREENING WOMEN AGES 40-49

Kopans DB.  The Breast Cancer Screening Controversy and the National Institutes of Health Consensus Development Conference on Breast Cancer Screening for Women ages 40-49.  Radiology 1999;210:4-9.

Kopans DB, Halpern E, Hulka CA. Statistical Power in Breast Cancer Screening Trials and Mortality Reduction Among Women 40-49 with Particular Emphasis on The National Breast Screening Study of Canada.  Cancer 1994;74:1196-1203.

Shapiro S. Evidence on Screening for Breast Cancer from a Randomized Trial.  Cancer. 1977;39:2772-278

Hendrick RE. Smith RA, Rutledge JH, Smart CR.  Benefit of Screening Mammography in Women Ages 40-49:  A New Meta-analysis of Randomized Controlled Trials.  Monogr Natl Cancer Inst 1997;22:87-92.

Kopans DB, Moore RH, McCarthy KA, Hall DA, Hulka C, Whitman GJ, Slanetz PJ, Halpern EF.  Biasing the Interpretation of Mammography Screening Data By Age Grouping:  Nothing Changes Abruptly at Age 50.  The Breast Journal 1998;4:139-145

Kopans DB. Bias in the Medical Journals: A Commentary. Am. J. Roentgenol 2005; 185: 176 – 182.

Kopans DB. Informed decision making: age of 50 is arbitrary and has no demonstrated influence on breast cancer screening in women. Am J Roentgenology 2005;185:177-82

Kopans DB. The Canadian Screening Program: A Different Perspective. AJR 1990;155:748-749

Yaffe MJ.  Correction: Canada Study.  Letter to the Editor JNCI 1993;85:94

Tarone RE.  The Excess of Patients with Advanced Breast Cancers in Young Women Screened with Mammography in the Canadian National Breast Screening Study.  Cancer 1995;75:997-1003.

SCREENING INTERVAL

Michaelson JS, Halpern E, Kopans DB.  Breast Cancer: Computer Simulation Method for Estimating Optimal Intervals for Screening.  Radiology 1999;21:551-560.

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Posted by Scott Primeau

Realizing Democracy through Technology

September 16, 2009

Government is often thought of as having closed doors, being insensitive, inflexible, unbending, secretive, and controlling.  In short, the public doesn’t think highly of government.  And, it’s not just because the public has high expectations.  The public should have high expectations of the government of the greatest nation in the world. 

Yet, government is simply made up of people.  Our government administrators and our elected officials are our friends, neighbors, and colleagues.  Sometimes, something transforms these people with good intentions within the halls of bureaucracy.  Maybe it’s the tradition of facing negative public opinion.  Maybe it’s the stress of trying to please everyone.  Maybe government really is made up of self-serving, power-hungry, deaf-to-the-public, bureaucrats.  I don’t think that’s the case. 

Not every person can attend public hearings, speeches, debates, and other government events.  Many government events are held between 8 AM and 5 PM, Monday through Friday, which immediately excludes many people with regular, full-time jobs.

Luckily, technology and some dedicated, honest, citizen-oriented administrators are charging towards opportunities for informing and collaborating with the public.

Online technology, notably social media, enhances and expands the opportunities people have to share their opinions and participate in government decision-making.

Colorado Senate President Brandon Shaffer, for example, is using an online survey to supplement his personal visits around Colorado to invite suggestions from people about how to improve life in the state.  He’s also reaching out to people via Twitter and Facebook.  His follower and fan counts aren’t extensive, but these online efforts have a lot of potential to complement in-person events.

The Colorado Secretary of State’s Office involved the public in an informal comment period regarding changes to administrative rules.  Subject-matter experts who participated in past collaborative efforts were directly invited, and the public-at-large was welcomed to participate in commenting on proposed rules as well as making direct changes to the proposed rules using a Google Group site.  Government agencies are required to conduct open public comment periods prior to holding hearings to pass administrative rules, but this informal effort brought the public into direct communication with employees in the Secretary of State’s Office and gave people the opportunity to write the rules that will affect their transactions with the office.

To support citizens’ sharing their opinions and experiences with health care, Colorado Governor Bill Ritter launched a website to help citizens send letters to the editors of newspapers.  The site allows people to enter a zip code and retrieve the contact information for nearby newspapers.  People can then write their message and send it directly to the editors.  There are even pre-written points that people can add to their own messages or use to help get their thoughts flowing.

The Colorado legislature has been broadcasting its sessions since January 2008 on the Colorado Channel and online streaming video.  Former Colorado Speaker of the House Andrew Romanoff helped pioneer this effort to share the actions of state lawmakers with people who can’t come down to the Capitol to watch.

Current Speaker of the House Terrance Carroll is successfully using Facebook to both share political updates and to foster personal relationships. 

These are just a few examples of Colorado public officials using social media to further connect with people.  Several federal government agencies are also conducting social media efforts to share data and more easily obtain citizen feedback.  The TSA blog is one of the most successful examples.

While there are many admirable citizen engagement efforts being undertaken, there are still some efforts that are coming up short.  For example, Gov. Ritter issued a press release seeking comments to rules regarding roadless lands, a controversial issue here in the West.  However, the press release did not provide any information about how to submit comments.  That makes for a seemingly empty request for citizen input.  To be fair, however, Gov. Ritter is making several other efforts to promote communication with citizens and transparency in state government, such as with the Transparency Online Project.

Government, however, encounters several obstacles to successfully undertaking collaborative efforts.  Resources for developing and monitoring communication tools are often limited and specifications in terms of service and other regulations sometimes prevent the use of free tools. 

“But,” as former EPA CIO Molly O’Neill said, “technology is the easy part – creating truly collaborative services is much harder and brings big changes. True government collaboration means being open and transparent with data, assumptions, debates, and decisions.”

On top of the physical constraints, people’s perspective of government sometimes prevents them from participating.  Through years of tightly-held decision-making, some citizens have become disillusioned and have come to anticipate a lack of recognition from government- along the lines of “your comments will be disregarded in the order they were received.”  People may be reluctant to participate because they think it’s a waste of their time.  Then, there’s the old-guard that’s standing behind the closed doors. 

Through consistent, sincere efforts government is overcoming these obstacles.  The public needs to see that their comments and suggestions are being seriously considered.  The doors of the old-guard can be broken down with the dedication of thoughtful employees.

Public officials and administrators and the public are responsible for using these opportunities to establish better policies and programs and to push our government to truly support life, liberty, and the pursuit of happiness.  Government needs to provide the tools that are available and share information.  People need to share their voices and expertise.  And, government needs to listen.

Thomas Jefferson said, “An informed democracy will act responsibly.”  About 200 years later we may be realizing that vision.

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Posted by Scott Primeau

Meeting Citizens’ Needs

July 2, 2009

I re-learned some very important things at tonight’s Denver Democrats House District 5 (HD5) meeting. Citizens want an open government- they don’t just want to know what decisions are made, but they also want to see the process in action. They need to know who the decision-makers are. And, they want access to those decision-makers. Public hearings can’t continue to be held only during working hours; that prevents working citizens from participating. Most importantly, citizens want elected officials who have solutions and have the ability to make those solutions happen.

I’m pleased that my experience in the Colorado Secretary of State’s Office is leading to the realization of all of those citizen needs. Through being responsive to constituents’ inquiries and complaints we have been able to develop web-based systems (some things are still under development) that provide constituents with efficient public record filing and searching tools. Records can be filed in minutes and retrieved in real-time.

Business registration and commercial lien recording are pretty small functions of state government, but they do serve important roles in commerce. Most importantly, those are the duties assigned to the Division I work in, so we administer those duties as efficiently as possible.

Our next endeavor is to bring our constituents into our processes, into the creation of our policies, and into state government. We’re doing what democracy is meant to be. We’ve provided extraordinary constituent support for many years, but many of these efforts to further involve citizens should have been undertaken much earlier. We’re not perfect, so we’re getting underway as quickly as possible. Also, new web tools (referred to as Web 2.0 or Gov 2.0) have greatly improved our ability to involve constituents.

As an example, earlier today, we launched an informal administrative rules review effort using a Google Group to obtain feedback on the proposed rules. Using the group allows constituents to view and edit the rules and share comments with other reviewers. Participation is available to constituents who are invited to join the group or who request to join the group. That limitation is in place so that we can obtain contact information for future efforts to collaborate with the public. It shouldn’t be, but this is a unique venture, at least in the Secretary of State’s Office, into giving citizens visible, hands-on opportunities to shape government policy.

This experience can be applied to nearly every government endeavor. During today’s HD5 meeting we talked about two substantial issues- improvements to and potential re-routing of I-70; and needle exchange services, specifically the Underground Syringe Exchange of Denver (USED). (I would have hesitated to bring up the illegally operated USED, but they already have a website and people need to know about that service, not that posting here will greatly spread the word until my readership expands beyond immediate family members.)

Government officials are responsible for both proposing solutions and for obtaining public feedback on those proposals. The public is responsible for utilizing those opportunities. Together, the collective wisdom and fortitude can achieve any needed objective.

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Posted by Scott Primeau

Denver Police Promote Use of Surveillance Cameras

June 24, 2009

The Westword recently reported an update on the Denver Police Department’s (DPD) use of surveillance cameras. The cameras are part of the DPD’s High Activity Location Observation (H.A.L.O.) Program.graffiti, to track down drug dealers, to keep watch during the 2008 Democratic National Convention, and to generally keep an eye on things. The Westword article mentions a few camera locations, but where are the rest of the 259 cameras around the city?policies in the DPD Operations Manual indicate the H.A.L.O. Program Commander shall maintain a list of H.A.L.O. approved locations for cameras for the department website. I have not been able to find any such list. The lack of camera location listings could be an oversight or due to a simple lack of resources. Given the frequency of news stories about the surveillance program, the cameras obviously are not a secret. Sharing the specific locations could make vandalism easy, but the choice was obviously already made to inform the public about the cameras’ existence.

The cameras have been installed at various times to combat

The H.A.L.O. Program

I’m sure there are many considerations to take into account when implementing a public surveillance program. Precedents in New York, London, and other cities are probably helpful. I admire the DPD’s effort to explore alternative crime-fighting strategies and to inform the public about those strategies. But, what is the efficacy of using surveillance cameras?

As the Westword story points out, the ACLU has claimed surveillance cameras “do not work to reduce crime. Study after study shows that surveillance cameras push crime around to other locations, but they don’t actually reduce the overall rate of crime.” Even if crime is just moved, eliminating the remaining crime in those areas may be easier given a concentration of resources. Also, using cameras may reduce the manpower needed to patrol the city. And, a good public outreach program could educate people that they are being watched. Knowing a criminal act will be caught on tape is likely to reduce crime. (Maybe you’ve seen people slam on their brakes at intersections with red-light cameras.)

I was unable to find contact information specifically for the H.A.L.O. program, but I have submitted an e-mail to Denver’s 311 e-mail address to ask for information about how the DPD measures the program and if a list of camera locations is in fact available. (I’ll update this post if I receive any information.)

Fighting crime is always an admirable effort. But, where is the line between fighting crime and invading privacy? Obviously, no one has clearly answered that question.

Benjamin Franklin said, “They who can give up essential liberty to obtain a little temporary safety deserve neither liberty nor safety.”

Alternatively, if someone is not committing a crime, there is no need to be concerned about being videotaped.

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Posted by Scott Primeau

Unions and Pushing for a Better Future

April 27, 2009

I went to my first union rally event on Saturday, April 25th. International Brotherhood of Electrical Workers Local 68 hosted Colorado Senator Michael Bennet to discuss the Employee Free Choice Act (EFCA) that is making its way through the U.S. Congress.

I was very impressed to see not just several unions, such as the AFL-CIO, SEIU, and IFCW, represented, but also hundreds of individuals. The unions’ goal was to encourage Sen. Bennet to take a stand on the EFCA.

Despite the Senator’s continued abstinence from taking a stance, the event appeared to be a great success. For about 15 minutes during the event, attendees were encouraged to write letters to Sen. Bennet and Sen. Udall to encourage their support of the EFCA. Hundreds of letters must have been written in just minutes. It was remarkable. (Think Mr. Smith Goes to Washington.)

On a personal level, my eyes were opened to the real use and purpose of unions. I saw hundreds of people who are working for their families and are concerned for their ability to put food on their tables, put roofs over their families, put clothes on their children, enable their children to obtain an education, and generally maintain a quality standard of living.

Sen. Bennet expressed concerns that the EFCA is still needs to be improved, and that it does not address and correct all of the concerns of unions and business interests. Unfortunately, the Senator is using the goal of perfection as a scapegoat for not taking a stand. Each time elected officials are scared of offending someone, they claim they are waiting for a perfect solution.

Perfect solutions, especially in government, are nearly impossible to create. With so many stakeholders and so many different interests, elected officials can only weigh the interests and fight for the most beneficial solution for the most people (along the lines of the greater good idea/cliché).

Unions represent hard-working, middle-class Americans, and they deserve an opportunity to have their voices heard and their concerns addressed.

I was inspired by the attendees’ sincerity, openness, and commitment, and I’m looking forward to being able to support Colorado’s hard-working families.

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Posted by Scott Primeau

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