What is happening to the time spent with the patient ?

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 Some years ago when  I  went  to  our  class  batch of medical school reunion ,the 25the year  Osmania medical college  Alumni Association meeting in Hyderabad, India.

I had some interesting  conversations.

I somehow  nostalgically remebered  the  45  minutes to 1 hour  we had to take a compklete  history of   a patient  when  i was  doing the   Medical rotations .

 My  friends  laughed and  told me they see between 80 to 120 patients daily!

and  if i am cribbing about seeing 25 patient's daily in USA in  a general practice where most of the patients are relatively healthy I have  no reason to crib.

"1 Principles of the 10-Minute Diagnosis

Paul M. Paulman

Ten minutes for diagnosis? Really?

Yes, really!

If only we had 90 minutes to perform a diagnostic evaluation, as we did as third-year medical students on hospital rotations. Or, if we had even 30 minutes for diagnosis, as I recall from internship. But those days are gone. Today—as clinicians practicing in the age of evidence-based, cost-effective health care—office visits are of much shorter duration than in years past. For example, in a recent study of 4,454 patients seeing 138 physicians in 84 practices, the mean visit duration was 10 minutes (1). Another study of 19,192 visits to 686 primary care physicians estimated the visit duration to be 16.3 minutes (2). Even when the total visit duration exceeds 10 minutes, the time actually devoted to diagnosis—and not to greeting the patient, explaining treatment, doing managed care paperwork, or even the patient’s dressing and undressing—is seldom more than 10 minutes."

excerpt from 

Taylor's Differential Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter

MACRA OOPS! I guessed wrong

 what happens when you let Politicians  dictate  how you are to treat your patients?

So why do you  study hard  and  get in to all those  extra curricular activities  Ap courses  burning Midnight oil and  facing the stress  and  fore going  family time  and  enjoyment   to become  a good doctor ?

so that  a bunch of Politicians   in washington  whom  the   PREZ T calls the  washington  swam,p  can  tell you what you can  and  can not do.

the  latest  of this farce is the 2400 page ( sniff sniff all those  trees cut down and  pulped ) MACRA rule passed by the  congress.

and  what is  this based on  according to
 Ashby Wolfe, MD, the Centers for Medicare & Medicaid Services (CMS) chief medical officer for Region IX in San Francisco
 "Congress has made a guess that value-based payment policies will help us get to improved quality care and better managed costs."


How about I tell my patient after 2 years of  mismanaging his medical condition .

OPPS! I guessed wrong !

"

• SAVESAVED

• by Cheryl Clark 
  Senior Staff Writer inewsource/MedPage TodayApril 04, 2017

SAN DIEGO -- Though many clinicians remain in the dark, a new menu of quality measures affecting their Medicare pay arrived January 1, with yet another steaming bowl of alphabet soup for them to digest with help from their EHRs.

The final rule for MACRA, the Medicare Access and CHIP Reauthorization Act, has been on the table since October.

Now physicians, physician assistants, clinical nurse specialists, dentists, optometrists, and chiropractors must learn about MIPS and APMs, the merit-based incentive payment system and alternative payment programs that are dictating the size of their future Part B claims.

They'll ponder joining an ACO or PCMH, CCJR, OCM or CESRD model, with one- or two-sided risk, in a patient-centered medical home, or a joint replacement, oncology or end-stage renal disease collaboration.

All that's parsed by a 2,400-page MACRA rule. Failure to participate in MIPS (merit-based incentive payment system) in 2017 carries a financial risk: the loss or gain of as much as 4% in 2019 depending on their 2017 participation, rising to plus or minus 9% in 2022. Some 642,000 clinicians are eligible. (See this link for breakdowns by specialty.) For APMs (alternative payment models), potential gains are even higher and so are the losses.

Many affected doctors attending the American College of Physicians annual meeting here last week expressed a mix of exasperation and fear, to the extent they understand its complexity and price tags.

During the rollout year, compliance is easy. Still, there's widespread concern for 2018 and beyond, when stricter rules set in.

"It's going to cost a huge amount of money that's not getting reimbursed," said Margaret Winkler, MD, of Hammond, La. "We have to hire additional people to comply and it's overwhelming."

Roderick Kim, MD, of Grand Rapids, Mich., wonders "how practical will it be" for his small, five-physician, two physician-assistant practice. "The big hope is that it will make patient care better, that people will live better and longer. But the concern, especially for a small practice, is, can we negotiate these different hoops without it being too cost ineffective?"

Docs as Experiment Subjects

Ironically, even federal officials administering the program aren't absolutely sure all the effort will improve quality of care for patients.

During one ACP session with Ashby Wolfe, MD, the Centers for Medicare & Medicaid Services (CMS) chief medical officer for Region IX in San Francisco, one beleaguered physician asked the question that may have been the elephant in the room.

"Is there any evidence that all this activity is truly going to improve care?"

As attendees chuckled and squirmed in their seats, Wolfe replied, "That's a question I hear a lot. And I think personally, if you read the literature, the jury is still out on whether value based payment policies truly do allow us to reach the triple or quadruple aim."

Nevertheless, she said, "Congress has made a guess that value-based payment policies will help us get to improved quality care and better managed costs." She added, "We're still learning."

Despite other fast-moving policy changes in the current administration, MACRA does appear to be here to stay, although adjustments are predicted down the line. It was passed with solid bipartisan support in a move to forever abolish the Medicare sustainable growth rate, which annually threatened to cut physicians pay by as much as 21%. In exchange, Congress sought to make physicians more accountable for their quality of care, reduce waste and overutilization, and lower costs.

The new rule in effect consolidates three previous payment mechanisms into MIPS: meaningful use, the physician quality reporting program and the value based payment modifier.

During the 2017 measurement year, clinicians are scored 60% on quality reporting, 15% on improvement activities such as whether they expanded their practice access or integrated behavioral and mental health, and 25% on advancing care information such as use of an electronic information exchange. In later years. The formula will include a percentage on physician spending based on claims data.

Clinicians who bill $30,000 a year in Part B allowed charges a year or less, those in their first year of Medicare participation, those who participate in an a qualified APM, and those and provide care for fewer than 101 Medicare Part B patients a year are excluded.

Yet Stephen Walker, MD, of Gatesville, Texas, thinks the system is still an unfair way to assess a good doctor. "For us to get our patients' blood pressure and diabetes control at certain levels to prove we're good doctors is so inaccurate," he said. In South Texas, the patient mix includes "indigents who don't take care of themselves or don't take their medicine," he said. "And if their diabetes isn't controlled, then you're terrible and you'll get dinged. Ding. Ding. Ding."

Donna Seminara, MD, of Staten Island, said that for some doctors the road will be impossibly tough. "There are unfortunately doctors who are still not electronic. These doctors are unfortunately so far behind the eight-ball, not only are they not going to garner benefits for how they're practicing -- their practice quality may be great -- but there's no way to measure it, collect the data, submit it, and so they will be hurt in terms of their Medicare reimbursements. It's not fair, it's just the way it is."

'MACRA? Never Heard of It'

Many doctors in the ACP conference hallways said they never heard of MACRA or the new alphabet soup, or if they had, didn't know if it would apply to them.

"I have no clue what you're talking about. I just see patients," said Steven Edelman, MD, a University of California San Diego Medical Center endocrinologist and one of the ACP conference speakers. "I don't know even one of those acronyms."

That's not that unusual, said Shari Erickson, the ACP's vice president of governmental affairs and medical practice. "There's a significant number of physicians who I think are not aware of the program," she said, adding that ACP is planning a "big educational" effort to get the word out to Medicare participants, and has a website full of tools for doctors wanting more information.

But one thing to note about this program, she emphasized: "It's not overly onerous. This year, you only need to report on one measure, one clinical improvement activity or one set of measures related to the advancing care information component" to avoid a negative payment adjustment.

Nitin Damle, MD, ACP's immediate past president, said the awareness gap is particularly acute for doctors in smaller practices who "don't have an idea of what's going on, but who need to the most," as well as providers in larger health systems and employed clinicians in academic centers "who also don't know what's going on and really don't want to know because it's being taken care of for them" (by their administrators).

Variation in physicians scores that cost those systems money in penalties down the road will probably result in quality reviews that could eventually be reflected in the salaries or bonuses of doctors who failed to measure up, Damle said. Even though those doctors are not directly managing the implementation, setting up infrastructure, "it is going to trickle down to them because (to the larger organization) it's a matter of dollars and cents. And if they start suffering losses and see quality measures are not being met," that could affect individual physicians' salary adjustments.

One big hospital system administrator weighed in. David Spahlinger, MD, president of the 1,000-bed University of Michigan Health System, which is now in a one-sided risk accountable care organization, agreed that especially in large systems, individual doctors are unaware of the law's impact because measure reporting is done for the group.

But if some of their 2,000 physicians are under-performing, it "might" affect bonuses or payment, especially if the system moves to a two-sided risk model next year.

Rob Nelson, a physician assistant in Greenwood Springs, Colo., said that while quality measurement is good, there is a risk that clinicians will "practice to meet the measures, like teaching to the test" for one measure like hypertension. That might result in a doctor inadvertently ignoring another potentially serious symptom or condition. "You can make the case either way."

Treating the Computer Screen

"Said Walker, the South Texas physician: "I tell my patients, I don't treat them anymore. I treat the computer screen, and check the boxes in the right order in the right way to make the federal government happy.""

the agnostic champion of the ‘path of knowledge

 Gauthama  Buddha

there are clearly remediable injustices around us which we want to eliminate.

There are clearly remediable injustices around us which we want to eliminate.

Class

Caste 

Gender

However, the central point in dealing with this question is that prejudices typically ride on the back of some kind of reasoning – weak and arbitrary though it might be. Indeed, even very dogmatic persons tend to have some kinds of reasons, possibly very crude ones, in support of their dogmas (racist, sexist, classist and caste-based prejudices belong there, among varieties of other kinds of bigotry based on coarse reasoning).

"Parisians would not have stormed the Bastille, Gandhi would not have challenged the empire on which the sun used not to set, Martin Luther King would not have fought white supremacy in ‘the land of the free and the home of the brave’, without their sense of manifest injustices that could be overcome. They were not trying to achieve a perfectly just world (even if there were any agreement on what that would be like), but they did want to remove clear injustices to the extent they could."

"practical reasoning must include ways of judging how to reduce injustice and advance justice, rather than aiming only at the characterization of perfectly just societies"

reject the quiet tolerance of chronic hunger (for example in India, despite the successful abolition of famines).*

Democracy has to be judged not just by the institutions that formally exist but by the extent to which different voices from diverse sections of the people can actually be heard.

INTRODUCTORY REMARKS BY PROF. AMARTYA SEN PROFESSOR AMARTYA SEN: I feel deeply privileged and honoured by the opportunity to speak here at our parliament, on the invitation of the distinguished Speaker, giving the Hiren Mukerjee Lecture, in memory of a political thinker and leader for whom I have very great admiration. In probing the idea of social justice, it is important to distinguish between (1) an arrangement-focused view of justice, and (2) a realization-focused understanding of justice. Sometimes justice is conceptualized in terms of certain organizational arrangements-some institutions, some regulations, some behavioural rules-the active presence of which indicates, in this view, that justice is being done. This approach has strongly influenced the leading theories of justice in contemporary political philosophy. In contrast, a realization-focused understanding of justice broadens the evolution of justice to the assessment of the actual world that emerges, which includes the institutions and arrangements that are present, but also much else, including – most importantly – the lives that the people involved are able to lead. Two distinct words – “niti” and “nyaya”- both of which stand for justice in classical Sanskrit, actually help us to differentiate broadly between these two separate concentrations. Among the principal uses of the term niti are organizational propriety and behavioural norms. In contrast with niti, the term nyaya stands for actual social realizations, going beyond organizations and rules. For example, classical legal theorists in India talked disparagingly of what they called matsyanyaya, “justice in the world of fish”, reflecting the kind of society we can see among the fish, where a big fish can freely devour a small fish. We are warned that preventing matsyanyaya has to be an overwhelming priority. Realizations of justice in the sense of nyaya is not just a matter of judging institutions and rules, but of judging the societies themselves. In the lecture I shall illustrate the distinction by examining the varying roles of two important institutions in the Indian context viz. (1) democracy, and (2) trade unions of organized labour. I will discuss how the realization of justice is critically influenced by the alterable ways in which these institutions actually work and impact on the society. A realization-focused perspective of nyaya also makes it easy to see the importance of preventing manifest injustice in the world (like matsyanyaya), rather than dreaming about achieving some perfectly just society, or about instituting some flawless set of social arrangements. When people agitated for the abolition of slavery in the eighteenth and nineteenth centuries, they were not labouring under the illusion that the abolition of slavery would make the world perfectly just. It was their claim, rather, that a society with slavery was totally unjust, calling for immediate removal. It was on that basis that the anti-slavery agitation, with its diagnosis of intolerable injustice, saw the pursuit of that cause to be an overwhelming priority. That historical case can also serve as something of an analogy that is very relevant to us today in India. There are, I would argue, similarly momentous manifestations of severe injustice in our own world toady in India, such as appalling levels of continued child undernourishment (almost unparalleled in the rest of the world), continuing lack of entitlement to basic medical attention of the poorer members of the society, and the comprehensive absence of opportunities for basic schooling for a significant proportion of the population. Whatever else nyaya may demand (and we can have all sorts of different views of what a perfectly just India would look like), the reasoned humanity of the justice of nyaya can hardly fail to demand the urgent removal of these terrible deprivations in human lives. A government in a democratic country has to respond to on-going priorities in public criticism and political condemnation. The removal of long-standing deprivations of the disadvantaged people of our country may, in effect, be hampered when the bulk of the social agitation is dominated by new problems that generate immediate and vocal discontent, to the neglect of the gigantic older problems of persistent deprivation of human lives, tolerated without much political protest. Justice demands that we make a strong effort to identify the overwhelming priorities that have to be confronted with total urgency. We have to ask what should keep us awake at night. (For full version of Prof. Amartya Sen’s Lecture, \




Kautilya, the ancient Indian writer on political strategy and political economy, has sometimes been described in the modern literature, when he has been noticed at all, as ‘the Indian Machiavelli’. This is unsurprising in some respects, since there are some similarities in their ideas on strategies and tactics (despite profound differences in many other – often more important – areas), but it is amusing that an Indian political analyst from the fourth century bc has to be introduced as a local version of an European writer born in the fifteenth century. What this reflects is not, of course, any kind of crude assertion of a geographical pecking order, but simply the lack of familiarity with non-Western literature of Western intellectuals (and in fact intellectuals all across the modern world because of the global dominance of Western education today)


we may miss out on possible leads in reasoning about justice if we keep our explorations regionally confined.

niti and nyaya. The former idea, that of niti, relates to organizational propriety as well as behavioural correctness, whereas the latter, nyaya, is concerned with what emerges and how, and in particular the lives that people are actually able to lead.

Consider any of the great many changes that can be proposed for reforming the institutional structure of the world today to make it less unfair and unjust (in terms of widely accepted criteria). Take, for example, the reform of the patent laws to make well-established and cheaply producible drugs more easily available to needy but poor patients (for example, those who are suffering from AIDS) – an issue clearly of some importance for global justice. The question that we have to ask here is: what international reforms do we need to make the world a bit less unjust?

the idea of global justice without a world government is a chimera

‘minimal humanitarian morality’

The pot calling the kettle black ?

The  White people of this world have a peculiar way of thinking that they are the  most wise and  virtuous people of this world  while painting all other races are war mongering or just downright  stupid.

They talk of Iran obtaining nuclear weapons to decimate the small and  lonely Israel,
or they picture nuclear winter caused by a nuclear exchange between the religious Bigots of India  and  pakistan.
ot they  have sleep less nights imagining the chinese dragon overtaking all of Asia ,Africa and  may be south america too .

But if one  really looks at some sane  analysis of what one single nation possesses and what a single nation has caused  human  misery in this century  then  US takes the top spot.
Such an ana;ysisi comes from the book written by an  MIT proferssor/

This downsizing, in other words, has not removed the wherewithal to destroy the earth as we know it many times over. Such destruction could come about indirectly as well as directly, with even a relatively “modest” nuclear exchange between, say, India and Pakistan triggering a cataclysmic climate shift – a “nuclear winter” – that could result in massive global starvation and death.

Nor does the fact that seven additional nations now possess nuclear weapons (and more than 40 others are deemed “nuclear weapons capable”) mean that “deterrence” has been enhanced. The future use of nuclear weapons, whether by deliberate decision or by accident, remains an ominous possibility. That threat is intensified by the possibility that non-state terrorists may somehow obtain and use nuclear devices.

What is striking at this moment in history is that paranoia couched as strategic realism continues to guide US nuclear policy and, following America’s lead, that of the other nuclear powers. As announced by the Obama administration in 2014, the potential for nuclear violence is to be “modernized.”

In concrete terms, this translates as a 30-year project that will cost the United States an estimated U0S$1 trillion (not including the usual future cost overruns for producing such weapons), perfect a new arsenal of “smart” and smaller nuclear weapons, and extensively refurbish the existing delivery “triad” of long-range manned bombers, nuclear-armed submarines, and land-based intercontinental ballistic missiles carrying nuclear warheads.

Nuclear modernization, of course, is but a small portion of the full spectrum of American might –a military machine so massive that it inspired President Obama to speak with unusual emphasis in his State of the Union address in January 2016. “The United States of America is the most powerful nation on earth,” he declared. “Period. Period. It’s not even close. It’s not even close. It’s not even close. We spend more on our military than the next eight nations combined.”

Official budgetary expenditures and projections provide a snapshot of this enormous military machine, but here again numbers can be misleading. Thus, the “base budget” for defense announced in early 2016 for fiscal year 2017 amounts to roughly US$600 billion, but this falls far short of what the actual outlay will be.

When all other discretionary military and defense-related costs are taken into account – nuclear maintenance and modernization, the “war budget” that pays for so-called overseas contingency operations like military engagements in the Greater Middle East, “black budgets” that fund intelligence operations by agencies including the CIA and the National Security Agency, appropriations for secret hi-tech military activities, “veterans affairs” costs (including disability payments), military aid to other countries, huge interest costs on the military-related part of the national debt, and so on – the actual total annual expenditure is close to US$1 trillion.

Such stratospheric numbers defy easy comprehension, but one does not need training in statistics to bring them closer to home. Simple arithmetic suffices. The projected bill for just the 30-year nuclear modernization agenda comes to over US$90 million a day, or almost US$4 million an hour. The US$1 trillion price tag for maintaining the nation’s status as “the most powerful nation on earth” for a single year amounts to roughly US$2.74 billion a day, over US$114 million an hour.

Creating a capacity for violence greater than the world has ever seen is costly – and remunerative.

So an era of a “new peace?” Think again. We’re only three quarters of the way through America’s violent century and there’s more to come.

This extract is adapted from “Measuring Violence,” the first chapter of John Dower’s new book, The Violent American Century: War and Terror Since World War Two

How to fight the islamic terrorism in India specially in Jammu and kashmir

 It may look like bad advise coming from a country besieged by enemies all around, but what is written by Benjamin Netanyahu in 1995, makes great sense to me , when it comes to the present day situation in  India.

"ISRAEL AND A PALESTINIAN STATE ZEROSUM GAME?

blackmail which they are supposed to defuse: All that Timothy McVeigh's colleagues need to know is that the United States government would consider releasing him in exchange for the lives of innocent hostages in order to get the terrorists to make just such a demand. Only the most unrelenting refusal ever to surrender to such blackmail can prevent most such situations from arising.

Train special forces to fight terrorism

Greater emphasis must be placed on the training of special units equipped for antiterror operations. În anti-terror training, laW enforcers learn to fight a completely different kind of gun battle, in which the goal is to hold their fire rather than to unleash it. Operations against terrorists often involve the rescue of hostages or the possibility that innocent bystanders might be hurt. This necessarily means that the soldiers or policemen charged with fighting terrorism must learn to subdue the natural temptation to concentrate overwhelming fire on the enemy. Counter-terrorist operations usually require the barest minimum application of force necessary to overcome the terrorists, Who often use hostages as a human shield.

While those branches of Western security services specializing in counter-intelligence and surveillance generally enjoy a high level of professionalism and training, this is often not the case with the forces that have to do the actual fighting against terrorists, it may be impossible to guarantee that there will be no more scenes such as the one in Waco, Texas, in which scores of cultists and four lawmen were killed. But the likelihood of avoiding such catastrophes is considerably increased if the forces involved are proficient in anti-terror techniques. Such units at the national or federal level are usually adequately trained for these missions, but in a

ISRAEL AND A PALESTINIAN STATE ZEROSUM GAME?

.Western countries in the late 1980s, it has returned in ferocious and fearful new forms. In the United states, the bombings of the World Trade Center in Manhattan and the Federal Building in Oklahoma City demonstrated to Americans that terrorism could now strike on Main Street internationally, terrorist attacks from Beirut to Buenos Aires Were recalling the familiar scenes of carnage from the 1980s on the television screens and front pages of the free World in the 1990s in Paris, bombs exploded in a crowded subway after nearly a decade's respite from such outrages. And in Japan

a horrifying new form of chemical terrorism struck fear in the hearts of millions of commuters in one of the World's most advanced societies

However, the modus operandi of this new wave of terrorism is usually different from that of the earlier terrorism that afflicted the World for two decades beginning in the 1960s. The new terrorism boasts few, if any hostage takings and practically no hijackings it specializes in the bombing of its targets. The reason for this change is that punishment meted out in the 1980s to hostage takers and airline hijackers and to their sponsors made the more overt kind of terrorisma costly affair. The new terrorism seeks to evade this punishment by hiding more deeply in the shadows than did its predecessors, Terrorism thrives in the dark and withers when stripped of its deniability. Yet it is a fact that today's domestic and international terrorists may be identified fairly easily, and it is therefore possible to deter and prevent them from pursuing the policies of terror

X 一 5 × o - a.

FIGHTING TERROR - AND WINNING

Binyamin Netangahu

Today's terrorism can be driven back, even though the current breed of interlocking domestic and international terrorists is certainly not to be taken lightly. They know the West Well and have developed strategies designed to take advantage of all its weaknesses. An effective battle against terrorism must of necessity require a shift in the domestic and international policies that enable terrorism to grow and the intensification of those efforts that can uproot it. Domestically in the United States this requires a reassessment of the legal instruments necessary for combating homegrown terrorism, alongside the means to monitor added powers given to the government to pursue these ends. Internationally, this means identifying the great change that has taken place in the forces driving worldwide terrorism since the 1980s, and shaping a powerful international alliance against thern

What this new terrorism portends for Israel America and the world and what can be done about it has not yet been sufficiently understood. The growth of terrorism has been accompanied by a steady escalation in the means of violence arms used to assassinate individuals from small arms used to mow down groups, to car bombs now capable of bringing down entire buildings, to lethal chemicals that (as in lapan) can threaten entire cities. The very real possibility that terrorist states and organizations may soon acquire horrific weapons of mass destruction and use them to escalate terrorism beyond our wildest nightmares has not been addressed properly by Western governments it must be recognized that barring firm and resolute action by the United States and the West terrorismin the 1990s will expand dramatically both domes. tically and internationally. Today's tragedies can either be the harbingers of much greater calamities yet to come or the turning point in which free societies once again mobilize their resources, their ingenuity, and their will to wipe out this evil from our midst. Fighting terrorism is not a policy option, it is a necessity for the survival of our democratic society and our freedoms. But in order to fight terrorism effectively, we must first understand its nature and its goals. Terrorism is the deliberate and systematic assault on civilians to inspire fear for political ends Although one may quibble with this definition, for example by broadening political ends to include ideological or religious motives, it nonetheless captures the essence of terrorism- the purposeful attack on the innocent, those who are kors decoxial, outside the field of legitimate conflict. In fact, the more removed the target of the attack from any connection to the grievance enunciated by the terrorists, the greater the terror. What possible connection is there between the kindergarten children savaged in an office building in Oklahoma to the purported grievances of the Patriots of Arizona? What do the incidental shoppers in the World Trade Center in Manhattan have to do with the Islamic Jihad? Yet for terrorism to have any impact, it is precisely the lack of connection, the lack of any possible involvement or complicity of the chosen wictims in the cause the terrorists seek to attack that produces the desired fear. For terrorisms underlying message is that every member of society is guilty, that anyone can be a victim, and that therefore, no one is safe. Although their professed purpose is invariably couched in the language of freedom and the battle for human rights there is a built-in contradiction between such professed aims and the method chosen to implement them. In fact, the methods reveal the totalitarian strain that runs through all terrorist groups. Those who deliberately bomb babies are not interested in freedom, and those who trample on human rights are not interested in defending such rights. It is not only that the ends of the terrorists do not succeedin justifying the means

they choose; their choice of means indicates what their true ends are. Far from being fighters for freedom, terrorists are the forerunners of tyranny. It is instructive to note, for example, that the French Resistance during World War II did not resort to the systematic killing of German women and children, although they were well within reach in occupied France The unequivocal and unrelenting moral cordemnation of terrorism must therefore constitute the first line of defense against its most insidious effect. Terrorists who blow up buildings in Oklahoma or buses in Jerusalem must never be accorded the status of misguided or desperate men using desperate means. Worst still is calling the murderer a martyr or shaheed The citizens of free societies must be told again and again that terrorists are savage beasts of prey, and should be treated as such. Terrorism should be given no intellectual quarter. To do otherwise is to elevate both to a higher status, thereby undermining the ability of governments to fight back. On the domestic level, the fact that terrorists are politically motivated criminals is irrelevant, except in providing clues for their apprehension. If the first obstacle to the spread of domestic terrorism in most democracies is in the realm of political culture, the second is in the realm of operations. The advanced democracies usually have at their disposal a vast array of surveillance and other intelligence-gathering capabilities that give them the ability to track down terrorists put them on trial, and punish them. The United States is especially capable of monitoring the activities of terrorists, it has technical capabilities that exceed anything available to any other country, especially formidable eavesdropping and photographic capabilities. The movements and activities of potential terrorists can thus be observed, and they may be apprehended before they strike-at least when the law enforcement agencies are permitted to act. The Western democracies are capable of elimimating the domestic terror in their midst only if they decide to make use of the operational tools presently at their disposal. But such optimism

in the 1990s will expand dramatically both domes. tically and internationally. Today's tragedies can either be the harbingers of much greater calamities yet to come or the turning point in which free societies once again mobilize their resources, their ingenuity, and their will to wipe out this evil from our midst. Fighting terrorism is not a policy option, it is a necessity for the survival of our democratic society and our freedoms. But in order to fight terrorism effectively, we must first understand its nature and its goals. Terrorism is the deliberate and systematic assault on civilians to inspire fear for political ends Although one may quibble with this definition, for example by broadening political ends to include ideological or religious motives, it nonetheless captures the essence of terrorism- the purposeful attack on the innocent, those who are kors decoxial, outside the field of legitimate conflict. In fact, the more removed the target of the attack from any connection to the grievance enunciated by the terrorists, the greater the terror. What possible connection is there between the kindergarten children savaged in an office building in Oklahoma to the purported grievances of the Patriots of Arizona? What do the incidental shoppers in the World Trade Center in Manhattan have to do with the Islamic Jihad? Yet for terrorism to have any impact, it is precisely the lack of connection, the lack of any possible involvement or complicity of the chosen wictims in the cause the terrorists seek to attack that produces the desired fear. For terrorisms underlying message is that every member of society is guilty, that anyone can be a victim, and that therefore, no one is safe. Although their professed purpose is invariably couched in the language of freedom and the battle for human rights there is a built-in contradiction between such professed aims and the method chosen to implement them. In fact, the methods reveal the totalitarian strain that runs through all terrorist groups. Those who deliberately bomb babies are not interested in freedom, and those who trample on human rights are not interested in defending such rights. It is not only that the ends of the terrorists do not succeedin justifying the means

they choose; their choice of means indicates what their true ends are. Far from being fighters for freedom, terrorists are the forerunners of tyranny. It is instructive to note, for example, that the French Resistance during World War II did not resort to the systematic killing of German women and children, although they were well within reach in occupied France The unequivocal and unrelenting moral condemnation of terrorism must therefore constitute the first line of defense against its most insidious effect. Terrorists who blow up buildings in Oklahoma or buses in Jerusalem must never be accorded the status of misguided or desperate men using desperate means. Worst still is calling the murderer a martyr or shaheed The citizens of free societies must be told again and again that terrorists are savage beasts of prey, and should be treated as such. Terrorism should be given no intellectual quarter. To do otherwise is to elevate both to a higher status, thereby undermining the ability of governments to fight back. On the domestic level, the fact that terrorists are politically motivated criminals is irrelevant, except in providing clues for their apprehension. If the first obstacle to the spread of domestic terrorism in most democracies is in the realm of political culture, the second is in the realm of operations. The advanced democracies usually have at their disposal a vast array of surveillance and other intelligence-gathering capabilities that give them the ability to track down terrorists put them on trial, and punish them. The United States is especially capable of monitoring the activities of terrorists, it has technical capabilities that exceed anything available to any other country, especially formidable eavesdropping and photographic capabilities. The movements and activities of potential terrorists can thus be observed, and they may be apprehended before they strike-at least when the law enforcement agencies are permitted to act. The Western democracies are capable of eliminating the domestic terror in their midst only if they decide to make use of the operational tools presently at their disposal. But such optimism

Israel has had some spectacular successes in this area, including the rescue of 103 hostages at Entebbe. But it has also had its share of spectacular failures, the worst of which was the loss of twenty-six schoolchildren being held hostage in a school building in Maalot. Having specially trained troops that accumulate and refine anti-terror techniques reduces the probability of failure, it does not, of course, mean that terrorists may be fought and hostages rescued without risk. What is crucial to recognize is that the risk to society of not challenging the terrorists forcefully - that is, of negotiating With them and accepting their demands- is far greater than the risk involved in the use of special forces. For in negotiating, the government issues an open invitation for more terror, an invitation which puts at risk the safety of every citizen in society.

Educate the public. The terrorist uses violence to erode the resistance of the public and leaders alike to his political demands. But the resistance of a society to terrorist blackmail may likewise be strengthened by counter-terrorist education, which clearly puts forth what the terrorists are trying to achieve, elucidates the immorality of their methods, and explains the necessity of resisting them. Such education is usually unnecessary in the case of sporadic and isolated terrorist attacks, which are almost universally met with an appropriate and natural revulsion. But in the case of a prolonged and sustained campaign lasting months or years, the natural disgust of the public with the terrorists' message begins to break down and is often replaced by a Willingness to accommodate terrorist demands. By preparing terrorism-education programs for various age groups and including them in the school curriculum, the government can inoculate the population.

other idea of civil freedom, which should be brought to a speedy end Tighten immigration laws. It is now well known that terrorists from the Middle East andelsewhere hawe made the United States, Germany, Italy, and other countries into terrorist havens because of laxity in immigration regulation. This era of immigration free-for-all should be brought to an end. An important aspect of taking control of the immigration situation is stricter background checks of potential immigrants, coupled with the real possibility of deportation. The possibility of expulsion must be a threat howering over all terrorist and pro-terrorist activity in the democracies. The new Clinton Administration initiative, for example, defines spokesmen and fund-raisers for terrorist organizations as liable to deportation, makes immigration files available to federal investigators, and establishes a special judicial process for deportations in which classified evidence may be brought without giving the terrorist organizations access to the materials Require periodic legislative review to safeguard civil liberties. The concern of civil libertarians over possible infringements of the rights of innocent citizens is well placed, and all additional powers granted the security services should require annual renewal by the legislature, this in addition to judicial oversight of actions as they are taken in the field. Thus hearings may be held to consider the record of possible abuses which have resulted from changes in police authority. If the abuses prove to be too frecuent or the results inconclusive in terms of the citizens, the particular provisions in question can be jettisoned automatically. The legal provisions suggested above constitute a roster of measures available to a democracy subjected to a sustained threat of terror. A lesser threat usually could require fewer measures. In some countries these measures would necessarily mean

shifting the legal balance between civil liberties and security. There is nothing easy in making this choice. But it is nevertheless crucial that the citizens of the West understand that such options are legitimately available to them, and that, judiciously applied, they may serve to put terrorism back on the defensive.

would be misplaced with regard to international terrorism, a much hardier and more implacable nemesis. What road should the United States and other democracies pursue if they are to overcome not only the domestic terror of Oklahoma City but the potentially much more insidious international terror which produced the World Trade Center bombing, and which may wery well produce other such tragedies before it has been defeated? To answer this question, We must first understand the nature and genesis of international terrorism and the process by which it has assumed its present form.

international terrorism is the use of terrorist violence against a given nation by another state which uses the terrorists to fight a proxy war as an alternative to conventional war. Sometimes the terror is imported at the initiative of a foreign movement which nevertheless enjoys the support of a sovereign state, at the very least in the form of a benign passivity which encourages the growth of such groups on its own soil. The reason that international terrorism is so persistent and so difficult to uproot is that the support of a modern state can provide the international terrorist with everything that the domestic terrorist usually lacks in the way of cultural and logistical assistance. An alien, non-democratic society may be able to provide the depth of support for terrorist ideas to spawn a genuine terrorist army; it can offer professional training and equipment for covert operations as well as diplomatic cover and other crucial logistical aid; it can make available virtually unlimited funds and most important of all, it can ensure a safe haven to which the terrorists may escape and from which they can then emergeanew. Thus, with the support of a terrorist state, the terrorist is no longer alonely and hunted fugitive from society. He becomes part of a different social milieu, which encourages him, nurtures him, protects him, and sees to it that he succeeds. The absurdly lopsided contest between the Western security services and the terrorist is, under these circumstances, no longer lopsided. It now pits the formidable resources of the West against the nearly comparable resources of a foreign state or network of states - and in this contest it is by no

36 ISKAELANDA PALESTINAN STATEzEROSUM GAME

means immediately clear who will emerge the victor.

The second wave of international terrorism, that of the 1990s, is the direct result of all these developments. And the growth of militant Islamic terrorism, with independent states in the Middle East serving as its launching ground, and bases of Islamic militants in the West offering alternate bridgeheads, has already been felt in the West in more ways than one. Just as Soviet-Arab terrorism produced its imitators, so too, the growth of this kind of chaos is bound to hawe an effect on its would-be imitators. It may not be pure coincidence that the method used to bomb the federal building in Oklahoma City was a mimicry of the favorite type of Islamic fundamentalist carbombing. If this kind of domestic international terrorism is not cut out at the root, it is bound to grow, with disastrous consecuences.

Undoubtedly the two greatest obstacles to dealing with this problem are, first, recognizing the nature of the threat and, second, understanding that it can be defeated. My first intention when writing about terrorism has been, accordingly, to alert the citizens and decision-makers of the West as to the nature of the new terrorist challenge which the democracies now face. In this time of historic flux, Western leaders have a responsibility to resist the tendency for passivity, the temptation to rest on the laurels of the victory over Communism as though nothing else truly could jeopardize their societies. The leaders of the democracies must solicit the understanding and support of the public and its elected representatives for vigorous policies against terrorism. Oösta pricipi- oppose bad things when they are small- was the motto of Israel Zangwill, one of the first leaders of the modern Iewish national movement at the beginning of this century Alas, many of his colleagues did not heed this warning, and the Jewish people paid a horrendous price in the decades that followed. The same advice must be directed today to presidents and prime ministers, congressmen and parliamentarians, with one proviso: When it comes to terrorism, the bad things are no longer small. They have already reached disturbing proportions, although it must be said that they have not yet grown to dimensions

Actively pursue terrorists Legal powers are of course meaningless if they are not accompanied by a commensurate mustering of will to act on the part of the executive branch and the security services. Rooting out terrorist groups must become a top priority for elected officials of all parties - andone that cannot be allowed to slide from political relevance after a few cases have been cracked. in an age in which the power of the Weapons which individuals may obtain grows incredibly from one year to the next, and in which information about how to obtain and use such weapons can be instantly transmitted by electronic mail from any part of the World, an active internal Security policy and aggressive counter-terrorism actions are becoming a crucial part of the mandate of every government, and officials must learn to rise to this challenge

Potential sources of terror must be studied and understood, groups preaching violence must be penetrated and catalogued, and groups actually preparing for it must be uprooted

Do not release jailed terrorists. Among the most important policies which must be adopted in the face of terrorism is the refusal to release convicted terrorists from prisons. This is a mistake that Israel, once the leader in anti-terror techniques, has made over and over again. Release of convicted terrorists before they have served their full sentences seems like an easy and tempting way of defusing blackmail situations in which innocent people may lose their lives. But its utility is momentary at best. Prisomer releases only embolden terrorists by giving them the feeling that even if

that prevent them from being contained and defeated with relatively little cost Several months before his tragic assassination Prime Minister Yitzhak Rabin repeated several times that terrorism in Israel, Judea, Samaria and Gaza had orice again become a strategic problem Naively dismissing the PLO's professed ultimate aims as propaganda for internal consumption, the Labor government attempted for the first time to grant many of the PLO's demands-in the hope of being able to forge an alliance with it. At Oslo, Israel ineffect accepted the first stage of the PLO's Phased Plan a gradual withdrawal to the pre-1967 border and the creation of the conditions for an independent PLO state on its borders (except for Jerusalem and Jewish communities in Judea and Samaria which were left for later negotiation) The Likud Government was determined not to accepta Palestinian state Within Israels borders We wanted to pursue peace and dialogue with the Palestinians without deluding ourselves and without excusing the dangerous rhetoric and support activities that help spawn terror Instead of accepting terror, we propose a global campaign against terror. We will abide by the following rules, and we ask that other democratic societies heed the following rules in order to combat terrorism: | Impose sanctions on suppliers of nuclear technology to terrorist states. The United States must lead the Western world in preventing the proliferation of nuclear technology, fissionable materials and nuclear scientists to Iran and any other regime with a history of practicing terrorism. While such action under UN supervision has been taken against Iraq in the wake of the Gulf War little or no action was taken until recently against the Iranian nuclear program. Israeliefforts to warn of the danger of the Iranian nuclear program and the Clinton Administrations moves to prevent Russia from supplying Iran with gas centrifuges should serve as two examples of what needs to be done on a far broader scale. All nuclear technologies and know-how should be denied to such states for they will invariably deploy them in the

service of their aggressive purposes it should be noted that all nuclear proliferation is bad, but some of it is worse. Nuclear weapons in the hands of say, the Dutch government are simply not the same as nuclear weapons in the hands of Oadhdafior the Ayatollahs in Teheran Action must be directed first against the suppliers and not the buyers, and it must beled by the United States. The supplying countries must be told bluntly that they must choose between trade with terrorist states and trade with the United States. A special American effort must be made to harness to this regime of anti-nuclear sanctions all the Western countries as well as Russia, China, lapan, and North Korea. The European countries in particular often hide behind liberal trade laws that enable European companies to engage in such trade without strict government supervision. The United States should insist that those laws be changed, i.e., that free trade, like free speech, has its limits, and these limits do not include the supply of laser triggers, gas centrifuges, and enriched uranium

The United States Congress has successfully pressed for enforcement of other standards of international behavior by denying preferred trade status and other economic favors to states limiting free emigration, sponsoring terrorism, or trafficking in drugs The Soviet Union was largely moved to permit Soviet Jews to begin emigrating during the 1970s when the Congress passed the Jackson-Vanik Amendment linking Soviet trade with the United States to freedom of emigration. Similar legislation could create an official list of states supplying nuclear technologies to other countries which could likewise be subjected to trade sanctions Countries which hawe international trading regulations so liberal that they can trade in nuclear death will find themselves having to change their laws or feel the pain where it matters to them most -in their pocketbooks. Suchalist should in