Polish-British Belvedere Forum 2022 7 July 2022 TO 8 July 2022 — 12:00PM TO 4:00PM Anonymous (not verified) 13 June 2022 Chatham House and Online

The Belvedere Forum is a leading annual British and Polish dialogue that seeks to strengthen the extensive social, economic and political partnership between the two countries.

Please note this event has reached full in-person capacity. You are welcome to join virtually via the Zoom link: https://chathamhouse.zoom.us/webinar/register/WN_QFwXsXb0RoSt-1ywkuPjfQ  

The video on this page is of the opening remarks from the Belvedere Forum, with addresses from Sir Robin Niblett KCMG, Dr Sławomir Dębski, Prof Zdzisław Krasnodębski, Sir Malcolm Rifkind KCMG QC, Ambassador Anna Clunes CMG OBE, Lord (Tariq) Ahmad of Wimbledon, Min Marcin Przydacz, and Ambassador Piotr Wilczek.

This and other session videos are available to watch on the Belvedere Forum 2022 playlist on YouTube. Photos by Mateusz Jozwiak, Zuzanna Nowak/PISM.

The Belvedere Forum is a leading annual British and Polish bilateral dialogue bringing together a diverse group of actors from civil society, politics, business, academia and NGOs.

It seeks to strengthen and deepen the extensive partnership between the two countries by exploring political, economic, social and cultural issues through debate and discussion.

The forum is an annual event alternating between the UK and Poland. Originally created in 2017 by the governments of the UK and Poland, the forum is now jointly organized by Chatham House and the Polish Institute of International Affairs (PISM) in Warsaw.

The forum brings together a diverse group of actors to debate and discuss not only current British-Polish relations, but also the British and Polish responses to key European and global challenges.

NATO must now transform old missions into new strategy Expert comment NCapeling 21 June 2022

As the war in Ukraine becomes prolonged and unpredictable, risks for the transatlantic alliance will increase, as will the global shockwaves of the conflict.

As a revitalized NATO alliance deals with a crisis that has major economic and humanitarian as well as military dimensions, the need for it to develop both a European and a global containment strategy grows ever more urgent.

Bolstering NATO’s defences so as to provide the capability to repel any form of Russian attack on land, at sea, in the air, or through space and cyberspace is a key aspect of this strategy as, in recent weeks, more combat forces able to defend territory have taken the form of additional troops, ships, and aircraft reinforcing the Baltic states and the Black Sea coastlines of Poland and Romania.

Ten allies have so far contributed to this effort, placing 40,000 troops under direct NATO command. Those sceptical about the future of the transatlantic security relationship have been confounded by the major role the US has played in this effort, sending parts of the 82nd Airborne Division and 3rd Armoured Division to Poland, and redeploying US Stryker brigades from Germany and Italy to the Baltic states and Romania.

Although many other allies have sent useful assets – such as French and UK aircraft to Romania or German and Netherlands Patriot batteries to Slovakia – the US contribution still surpasses all European efforts put together. The US now has 100,000 troops in Europe, the most it has deployed there since the mid-1990s.

Transitioning from temporary to permanent deployment

NATO has also mobilized its high-readiness Reaction Force for the first time and aims to establish four new multinational battalions in the Black Sea region – with France offering to lead the one in Romania, Italy in Bulgaria, and the Czech Republic in Slovakia. Most of these deployments are on a temporary basis, but the receiving allies would understandably like them to stay longer and for NATO to commit to permanent stationed forces.

Although this would oblige the alliance to break formally from the pledge it made to Moscow in 1997 not to station substantial combat forces or nuclear weapons or build military infrastructure on the territory of its new member states in eastern Europe, this was a political undertaking linked to circumstances prevailing at the time.

Given Russia’s behaviour, there is no reason why NATO should not now abandon it. There is also a question over whether NATO could also repeal the NATO-Russia Founding Act and the NATO-Russia Council, or simply leave them in suspension for a future, more cooperative, and less bellicose Russian regime.

Beyond showing the flag along its eastern flank, NATO does face longer-term issues which need to be clarified in its new Strategic Concept. First is whether to abandon its current strategy of reinforcement and military mobility across Europe – known as the Enhanced Forward Presence in the NATO jargon – in favour of the deployment of heavy armoured brigades or even divisions in fixed positions close to borders.

This will be expensive in the long-run and deprive allies of the flexibility they have enjoyed since the end of the Cold War to use their forces as and where they wish – from deployments in the Sahel or Afghanistan to fighting forest fires or building emergency hospitals for COVID-19 patients at home. The only exception is when they have put forces on rotation into the NATO high readiness forces or the European Union (EU) Battle Groups.

Germany’s commitment gives NATO more options

The decision of Germany to increase its defence spending to two per cent of GDP and to devote €100 billion to modernizing the Bundeswehr makes it technically possible for NATO to move to a Cold War-style forward, armoured defence. But it is unclear how quickly Berlin could raise its new divisions given its problems with procurement and government/industry relations in the defence sector.

It may make more sense for Germany not to launch new acquisition programmes but to buy existing off-the-shelf capabilities – as it has recently done with its decision to buy 35 US F35 aircraft – which other European countries are also acquiring, offering economies of scale and cheaper operating and maintenance costs.

But if Germany abandons ambitious defence projects with France – which prefers a ‘buy European’ approach – such as the Future European Air Combat System, the relationship with France will become strained and French plans for EU self-reliance in the military field put at risk.

As a country averse to war fighting and narrow military approaches to security, it is uncertain how much of the conventional defence burden in NATO Germany would be willing to take on, so this could be the opportunity to create more integrated European units with France, the Benelux, Poland, and Italy, even with the post-Brexit UK.

The UK has doubled the size of its forces in Estonia and sent 1,000 troops to Poland, as well as devoting a substantial portion of its army, navy, and airforce to regular NATO exercises in the Baltic region. London was also the first ally to grant Sweden and Finland a temporary security guarantee pending full integration into the alliance.

NATO will likely settle on a compromise, increasing the size of its battalions on its eastern flank – turning them into battle groups – but giving each one a larger reserve force which will remain in Germany or other European allied countries.

A NATO strategic plan is now needed

The other issue for NATO is to develop a single theatre-wide strategic plan managed by the Supreme Allied Commander, Europe (SACEUR) and the NATO command structure. In reinforcing the alliance’s eastern flank, allies have sent forces to wherever they like and largely under national command, but this would not work in a real war.

NATO must revise its exercises to prepare and train for the new threat level, ensuring its forward deployed forces are fully integrated with local forces and the police and border guards to anticipate and respond to any Russian hybrid war tactics. It also needs to step up its joint planning and interoperability with Sweden and Finland and bring their territories into its standing defence plans.

One thing NATO has done well in this crisis is its political messaging. As Russia has become more threatening and reckless, it has been essential for NATO to be consistent and predictable. Re-affirming its core defensive purpose, calmly rejecting Putin’s nuclear posturing, and refusing to put NATO forces in Ukraine may be frustrating for some but it is vital not to play into Putin’s playbook regarding an ‘aggressive NATO’ or give him the sense he is being pushed into a corner. However, NATO strategic ambiguity can be useful when considering how to respond to a Russian escalation in Ukraine itself, such as using chemical weapons.

The key questions for NATO are:

• What should be the balance between permanently deployed and rotational forces in NATO’s new posture?
• What should be the balance of US/Canadian and European forces in this posture?
• How can the capability development programmes under EU Strategic Autonomy (such as PESCO and the European Defence Fund) be geared to support the European role and responsibility in the alliance? Air and missile defence would seem to be priorities given Russia’s reliance on long range strikes.
• How can the EU’s Strategic Compass, NATO’s next Strategic Concept and the third NATO-EU Joint Declaration be harmonized to bring the two institutions more closely together in responding to Russian hybrid operations and influence campaigns, and in assisting both Ukraine and others such as Georgia and Moldova?
• What should be the balance between forces for collective defence with heavy armour and directed artillery fire, and those for expeditionary missions beyond Europe such as counterterrorism, stabilization and peacekeeping?

NATO is revived and refocused

Although the Russian invasion of Ukraine is a catastrophe for Ukraine and Europe more generally, the multilateral system has discovered a new energy and sense of purpose as NATO has been revived and refocused on its core mission.

The EU and the US have pulled together with daily coordination of their policies and actions, and the EU is also facing up to its geo-political role, as recognizing the EU aspirations of Ukraine, Moldova, and Georgia as well as the countries of the western Balkans shows its responsibility for the security and economic integration of the whole of Europe.

President Maia Sandu on democracy and politics in Moldova Video jon.wallace 4 July 2022

The president covers Moldova’s challenges as it seeks closer integration with the European Union.

President Maia Sandu discusses challenges to Moldovan democracy and society during an interview at Chatham House’s 2022 London Conference.

She covers issues including corruption, the presence of Russian troops in the Transnistria region, neutrality in Moldova’s constitution, popular support for EU membership and refugees from Russian aggression in Ukraine.

America's abortion ban will hurt women everywhere The World Today mhiggins.drupal 9 August 2022

In the final part of a series on the impact of the Roe v Wade ruling, Nina van der Mark assesses the global impact of America’s reverse on reproductive rights.

In overturning the constitutional right to an abortion established by Roe v Wade, the Supreme Court of the United States placed the US alongside Poland, El Salvador and Nicaragua as countries that have restricted access to abortion in recent decades. While the Dobbs ruling is a domestic reversal, the US remains the largest funder of global health, family planning and reproductive health services. There is a lot at stake for women and girls around the world. 

Here are four potential global impacts to consider.

Millions of women will be at greater risk 

The Guttmacher Institute, a research and policy organization that aims to improve sexual and reproductive health worldwide, calculated that in 2021 American international family planning assistance saw an estimated 27.2 million women and couples receive contraceptive services, some 12 million pregnancies averted, four million unsafe abortions prevented and 19,000 maternal deaths avoided. These outcomes help to improve gender equity as well as increase women’s education and employment opportunities and boost economic growth. 

This happens despite US funding for international family planning being in decline over the past decade. It peaked during the Obama administration at $715 million in 2010 but since 2017 averaged about $607 million a year. Using US aid to directly fund abortions as a method of family planning is prohibited under the terms of the Helms Amendment of 1973.

In America, the Dobbs ruling has so far led 14 Republican-controlled states to enact anti-abortion legislation. This, in turn, has motivated pro-choice campaigners – on August 2, a referendum in the staunchly conservative state of Kansas returned a decisive vote to preserve abortion rights. That result gives hope to abortion-rights groups that the issue will cut across traditional political loyalties and bring swing voters to their cause in the mid-term congressional elections in November.  

That is important because Congress decides on the level of funding for America’s global health programmes, including family planning and reproductive health. The stakes are high. For instance, Kenya, Nigeria and Ethiopia, with a combined population of more than 370 million, are among the top 10 recipients of US Overseas Development Assistance, most of which goes to health programmes. Nigeria, for instance, received $794 million in such funding from America in 2019-2020. 

A sudden policy reversal affecting funding for reproductive health would lead to clinic closures, reduced access to help and shortages of essential family planning commodities. The result would be more unintended pregnancies, more unsafe abortions and a potential increase in maternal mortality. 

Women will have more unsafe abortions

The Helms Amendment, which prevents recipients of American aid directly funding abortion services, was passed by Congress in 1973 following the Roe v Wade decision. The Global Gag Rule, first enacted by Ronald Reagan in 1984, goes further, forbidding NGOs abroad in receipt of American aid from promoting or counselling abortion as a form of family planning, even when using their own funds. Since its introduction, Republican administrations have enforced the rule while Democratic administrations have rescinded it, as Biden did in January 2021.  

Restricting access to safe abortion services increases the number of unsafe abortions, whereas legalizing abortion services reduces them. During the Bush administration, the Global Gag Rule prompted a 12-per-cent increase in pregnancies in rural Ghana, which led to an additional 200,000 abortions. 

Another study found a substantial increase in abortions, a decline in contraceptive use and an increase in pregnancies in 26 countries in sub-Saharan Africa affected by the rule across three US administrations. It’s estimated that 77 per cent of abortions in the region are unsafe. In 2019 that translated into 6.2 million unsafe abortions.

The failure of America to consistently support safe abortion services contributes to the more than 35 million unsafe abortions that take place each year across 132 lower middle-income countries.  

Under the Trump administration, the Global Gag Rule was extended from family planning funding to cover all US global health assistance, increasing the level of US funding affected from around $600 million to $8.8 billion. Were a Republican administration to be elected in 2024 there is little doubt the rule would be reinstated, possibly in the most restrictive form that Trump enforced. 

Anti-abortion movements will double their efforts 

The repeal of Roe v Wade has not occurred in a silo, nor are its effects contained within the US.

News of the Dobbs ruling, which overturned Roe v Wade, prompted One of Us, a European anti-abortion platform, to mount an immediate, 20,000-strong anti-abortion demonstration in Spain, including leaders of the conservative Vox party.  On Twitter, Sara Larin, an anti-abortion activist from El Salvador, likened the Dobbs ruling to the abolition of slavery in the US, calling it ‘the beginning of the end for abortion [worldwide]’. 

Countries have based their legal protections for abortion access on Roe v Wade or cited it in their case law, which now opens them up to legal challenge domestically. A Christian anti-abortion group in Kenya is legally challenging a pro-choice ruling based on Roe v Wade. Such challenges may increase: anti-choice groups in Mexico and Peru cited the Dobbs ruling as an encouraging development. 

Many American Christian right-wing groups fund anti-abortion activities abroad. OpenDemocracy, an independent global media platform, recently reported that 28 Christian right-wing organizations spent more than $280 million internationally between 2007-2018 on anti-choice activities, targeting Europe primarily, followed by Africa and Asia.  

The American right is not afraid to take direct legal action abroad either. The European Center for Law and Justice, an offshoot of the Trump-backed American Center for Law and Justice, has made interventions in dozens of court cases on sexual and reproductive health and rights in the European Court, including in the case that overturned abortion rights in Poland.   

The European parliament in its most recent motion on the topic expressed concern about the potential for the Dobbs ruling to prompt a surge in the flow of money to anti-choice groups around the world.  

America’s global standing will take a hit 

The Dobbs ruling immediately attracted criticism from many world leaders.  ‘Watching the removal of a woman’s fundamental right to make decisions over their own body is incredibly upsetting,’ said Jacinda Ardern, the New Zealand prime minister. ‘To see that principle now lost in the United States feels like a loss for women everywhere.’  

President Emmanuel Macron of France tweeted: ‘I wish to express my solidarity with the women whose liberties are being undermined by the Supreme Court of the United States.’ 

The ruling is in conspicuous opposition to the Biden administration’s more progressive stance on sexual and reproductive health and rights and its advocacy abroad. It sends a clear message from the world’s most powerful democracy that these rights are not guaranteed. 

While many world leaders reacted to the Dobbs ruling with dismay, other senior figures from the conservative right welcomed it, including the Brazilian President Jair Bolsonaro’s son, Eduardo, and Javier Milei, a potential candidate in Argentina’s presidential election next year.  

In 2020, the Trump administration co-sponsored the ‘Geneva Consensus Declaration on Promoting Women’s Health and Strengthening the Family,’ declaring that there was ‘no international right to abortion.’ It was signed by more than 30 countries, including autocratic and right-wing governments in Brazil, Poland, Hungary and Saudi Arabia.  

The Biden administration withdrew from it – but its signatories are the governments who may yet take advantage of America’s self-inflicted erosion of authority on reproductive rights.  

The Dobbs ruling exposes the limitation of the American executive to act within the US legal system while opening up questions on American support of, and dedication to, fundamental rights.

Read the other two articles in this series: ‘Empowering women aids climate resilience’ and ‘Counting the cost of the abortion ban’

Gorbachev's complex legacy is beyond the popular belief Expert comment NCapeling 3 September 2022

The last major figure with a decisive Cold War role, Mikhail Gorbachev was not as bad as Putin’s Russia portrays him, but also not as heroic as the West thinks.

Arguably the worst year of the Cold War since the Cuban Missile Crisis was 1983, with three major incidents which escalated East-West tensions – and any one of them could have led to a full-scale war.

The first was the Korean Airline KAL007 being shot down by an SU15 fighter aircraft for straying into Soviet airspace, killing all 269 passengers and crew. Then came the identification of signals from Soviet satellites as being incoming US intercontinental ballistic missiles – Colonel Stanislav Petrov, going against all protocols, thankfully decided to report them as a false alarm before he could be sure.

The third was perhaps the most dangerous, being the misinterpretation of a live-fire NATO exercise which was believed by some in both East Germany and Russia to be a front for an imminent attack.

All three incidents occurred in the few months following the infamous March 1983 ‘Star Wars’ speech by US president Ronald Reagan, in which he talked about nuclear arms control and laid out the US case for a ballistic missile defence programme.

At that time Mikhail Sergeyevich Gorbachev was the youngest serving member of the USSR Politburo, known to be a favourite of Soviet leader Yuri Andropov, and it is highly likely he had been aware of these close calls and was part of discussions within Kremlin decision-making circles.

A changemaker both inside and outside the USSR

Following the deaths of Andropov in 1984 and his replacement Konstantin Chernenko in 1985, Gorbachev’s appointment as general secretary of the Communist Party saw him immediately begin to change the Soviet Union from within – and also change relationships with the major Western powers, especially the US, Germany, and the UK.

His policies of glasnost (openness) and perestroika (restructuring) were primarily aimed at internal reforms but translated into a major reset of international relations and international security. During his six years as leader, Gorbachev initiated many arms control negotiations which resulted in treaties and increased both the transparency and the confidence between the USSR and the US.

These included the 1986 Stockholm Accord which emanated from the Helsinki Process and allowed for the observation and inspection of large-scale military exercises, the 1985 resumption of the Strategic Arms Reduction Talks which lead to START I, and the 1987 INF Treaty in which the USSR ‘out-yessed’ the US – the most open and transparent disarmament treaty in terms of notification and verification measures ever agreed.

There was also a reciprocal moratorium on nuclear weapons tests starting from 1985 – which laid the groundwork for the 1996 CTBT – the 1991 Chemical Weapons Convention, and the 1990 Conventional Forces in Europe (CFE) Treaty.

The most dramatic moment of all was when Gorbachev and Reagan met at a summit in Reykjavik and came close to deciding to eliminate nuclear weapons – but the initiative failed to reach agreement, mainly because Reagan could not drop his commitment to ballistic missile defences and Gorbachev could not accept the offer of joint development.

Nonetheless, all these nuclear arms control treaties led the way for their descendants which have kept nuclear weapons in check ever since and are still in place in the form of the New START agreement.

But despite these outstanding achievements, Gorbachev had blind spots – such as enabling rather than destroying the USSR bioweapons programme, unlike the US which had dismantled its own bioweapons offensive capability by 1973.

And it is now known that, despite negotiating the Chemical Weapons Convention, Russia withheld information on new chemical weapons agents – Novichoks – which have since been used to lethal effect by Russia in Salisbury and against figures opposing the current regime.

His misguided faith in a Soviet future

Gorbachev was markedly different to his predecessors as secretary general. He was neither as decrepit nor as hardline, and he understood from the outset that the Soviet Union was, by the 1980s, finally dying.

Using the intellectual abilities of Aleksandr Yakovlev, he forced through the reforms which simultaneously captured the imagination of the free world and liberated his countrymen and women.

But although he built solid relationships – even friendships – with the world’s major heads of state and improved the USSR’s human rights, releasing dissidents such as Andrei Sakharov, but many – especially Ukrainian dissidents – continued to languish in camps.

The greatest disappointment in Gorbachev’s legacy was he completely believed the USSR could be reformed and still survive as an entity while others, such as Boris Yeltsin and Ronald Reagan, understood it had to be dismantled.

This shortcoming is especially uncomfortable as today’s Russia continues to insist it has a given right to control other former Soviet states, to the extent it is willing to destroy them if they do not concede.

Central and Eastern Europe become hawkish on China Expert comment LJefferson 16 September 2022

The recent withdrawal of the Baltic countries from the ‘17+1’ format displays changing perceptions of China due to its ambiguity towards the war in Ukraine.

While the Russian invasion of Ukraine only confirmed Central and Eastern Europe’s views of Russia, it is also affecting their relations with China. Although the relationship was already complicated due to unfulfilled Chinese economic promises to CEE countries and growing indications of efforts to influence their domestic politics, China’s support for Russia is pushing Central and Eastern Europeans even further away.

This shift was highlighted, and formalized, recently by several countries in the region leaving the ‘17+1’ format, through which China cooperates with a group of countries from the region. The shifting attitudes towards China will also influence the relationship between the European Union as a whole and China.

A Trojan Horse that never was

When the format was launched in 2012 between 16 CEE countries at the time and China, the countries jumping on board expected a wave of Chinese investment and an opportunity to diversify mostly west-bound trade.

These hopes never fully materialized as Chinese foreign direct investment (FDI) in CEE has been generally lower compared to the rest of Europe and China never became an important export destination for any of the countries. The growing disillusionment and concern about Chinese security threats has led to some of the countries speaking up about the perceived perils of closer cooperation.

The first to withdraw from what had become ‘17+1’ by 2021 was Lithuania, which also took an interest in strengthening ties with Taiwan and allowed it to open a Taiwanese representative office in Vilnius. This triggered a breakdown in the bilateral relations with China. As a retaliatory response, China blocked Lithuanian imports and imports from other EU states containing inputs from Lithuania, leading the EU to launch an official dispute at the WTO.

War in Ukraine

Since the invasion started, CEE countries have been dealing with large numbers of Ukrainian refugees, organizing shipments of military equipment to Ukraine, and at the same time worrying whether they could be next on Russia’s list.

However, the concerns and security environment that these countries face seems to be almost entirely disregarded by China. On the sidelines of the 2022 Winter Olympics in Beijing, Xi and Putin signed the joint communiqué in which China backed Moscow’s demands to reverse NATO borders to the pre-1997 situation, completely disregarding CEE’s security interests.

China’s implicit support for Russia after the invasion has sowed deep mistrust of its respect for the sovereignty of other nations. The Chinese diplomatic apparatus clearly noticed this changing mood among CEE governments and sent a special envoy to eight capitals in April-May tasked with ‘eliminating misunderstandings regarding Russia-Ukraine conflict’.

However, the trip was not particularly successful. The delegation failed to secure high-level meetings, with the most prominent case being the Polish minister of foreign affairs declining to meet Huo Yuzhen, the Chinese Special Councilor for CEEC cooperation. Given that Andrzej Duda, President of Poland, was the only head of an EU state who attended the Beijing Olympics opening ceremony just before the Russian invasion in February, the change in attitudes is clear.

Following the envoy’s visit to the Czech Republic, the Czech parliament’s foreign affairs committee unanimously approved a resolution calling for the country to quit the ‘16+1’ format and the government is expected to act upon it in the near future. Meanwhile, Latvia and Estonia recently jointly announced that they would no longer be participating in the cooperation framework, turning it into ‘14+1’.

Russian imperial mindset must change for real victory Expert comment NCapeling 8 December 2022

The attitude of Russia’s elite – and wider population – to the states which used to constitute the USSR needs to change in order to solve the Russia challenge.

Although the reverberations of Russia’s invasion of Ukraine clearly stretch around the globe, the strongest shocks are – and will continue to be – felt by those countries Moscow used to directly rule.

These countries struggle to shrug off a Soviet legacy as, to varying degrees – linguistically, technologically, culturally, and politically – they bear psychological and physical scars of Russia’s colonial past and its present mentality.

It does not help that these countries lack an appropriate collective descriptor. Over the years there has been ‘Newly Independent States’ – hardly appropriate after 31 years – the now-defunct ‘Commonwealth of Independent States’, the ‘post-Soviet space’ and ‘Former Soviet Union’ which both reference the past, and simply ‘Eurasia’ which is hardly appropriate for either Ukraine or Turkmenistan.

Some of these former ‘colonies’ are as badly governed and as sinister – albeit not as lethal beyond their borders – as Russia itself. Others, most notably the Baltic states, are modern, liberal, affluent societies, but Moscow’s shadow still looms.

There is a strong mindset in most of Russia’s citizens that, because that it used to rule these other countries, it either still has privileged rights over them or they are not real countries at all – but instead historical aberrations to be extinguished.

What is past is gone

As historian Timothy Snyder has noted, whatever the wrongs of Putin’s ‘history-based’ assertions about the ‘return of historic lands’, all historical claims are bunkum anyway. If the past brings validity, almost no land border on earth would be beyond dispute. It is agreements which count, and Russia signed away the other successor states in 1991.

The Russia and Eurasia programme at Chatham House has, for the last 31 years, always taken as a starting position that these countries are as sovereign as any other. This of course this means they can choose to be in Russia’s embrace if they wish. But none do because Russia is insufficiently attractive. Some have better relationships with Moscow than others – mainly the more autocratic ones – but no former slave goes back to their master willingly.

At the recent Chatham House conference Russia’s war: How will it shape the region’s future? (note the avoidance of a specific descriptor), the overwhelming consensus was that Russia must lose, that Ukraine must be reconstructed and planning for that must start now, and that the regional economy is convulsing.

But another key view was that, in Russia, rent seeking and buying loyalty are likely to lead to the separation of the Russian people and the regime, especially as the population ages and young men being sent to die at the front. Putin may still be popular in some places in Russia, but not in others – although popularity can rise and fall fast in Russia. However, few at the conference foresaw the disintegration of Russia any time soon.

With continued skill, determination, and more weaponry, Ukraine may well vanquish Russia on the battlefield, and this remains a necessary pre-requisite for European security. But even a Ukraine victory will not erase malign intent.

The Russian imperial itch is so deeply embedded, it must be excised not just from Russian capability but from the intention and mindset of elites and in the popular imagination. That is hard to achieve when so many believe in it as fervently as a religion – even the Russian Orthodox Church invokes a messianism in Russia’s imperial ‘rights’.

The wider region is suffering

Getting Russians to look upon their neighbours as equals requires widescale self-reassessment in a post-Putin Russia. But, for now, the wider region will surely be looking to simply neuter Russia’s destructive capacities.

Why the UK must deliver on Nordic-Baltic security Expert comment NCapeling 16 December 2022

Hard choices are needed but it is crucial the UK provides security and leadership to its European partners given the wider context of the war in Ukraine.

The UK’s role in Nordic-Baltic security has been growing over the past decade. The region is key to core British strategic interest and engagement, and UK threat assessment closely aligns with long-held regional perspectives – the 2021 Integrated Review defines Russia as ‘the most acute threat to our security’.

Since Russia’s invasion of Ukraine, the UK’s strong stance towards Moscow and the concrete steps taken to assist Ukraine and strengthen defence and deterrence on NATO’s eastern flank have been widely appreciated in the Nordic-Baltic region.

The UK is seen as a reliable partner but, for it to continue to deliver in the region, difficult choices must be made with regards to UK defence spending and military capabilities, and London’s more global ambitions.

The UK is a major contributor to NATO’s deterrence posture on the eastern flank, serving as a framework nation for NATO’s Enhanced Forward Presence (EFP) battlegroup in Estonia, and contributing to another battlegroup in Poland.

UK remains crucial to regional security

Coupled with its contribution to NATO’s Baltic Air Policing mission and maritime forces in the area, the UK is a crucial security partner both in the region and in a broader arch across Europe.

Over the past decade and a half, the UK has been developing a dense network of bilateral and minilateral relations in the region which are major assets in the current security environment.

It leads the Joint Expeditionary Force (JEF) which is a military cooperation format highly valued for its flexibility in responding to the needs of the participating nations – including non-NATO Sweden and Finland – and is increasingly focused on the North Atlantic, High North and wider Baltic areas. The UK has also seen increased bilateral defence cooperation with Norway, Denmark, Estonia, and other regional allies and partners.

There are reasonable expectations that Germany or France may at some point assume a greater role in this part of Europe, building on France’s participation in the EFP in Estonia, and Germany’s lead of the EFP in Lithuania.

However, while Paris remains more focused on NATO’s southern (and south-eastern) flank and building the European Union’s defence role, Berlin often underperforms as a leading or an organizing power of collaborative efforts across Europe.

Both also have a credibility problem in the Nordic-Baltic region due to their past policies towards Russia that occasionally reappear when discussing military support to Ukraine or how to treat Russia in the post-war European security order.

By contrast, the UK offers military capability, strong political will, a long-standing tradition of engagement in the Nordic-Baltic area, and fast decision-making.

The latter is exemplified by the bilateral security guarantees provided to Sweden and Finland during their accession to NATO, and the surge of assets sent to the region in the wake of Russia’s full-scale invasion of Ukraine such as an additional battlegroup and Chinook helicopters to Estonia, as well as forward-deployed elements of the Standing Joint Force Headquarters to Latvia and Lithuania as part of the JEF.

Such pragmatic and resolute engagement help substantiate the UK’s post-Brexit claim that although it left the EU, it did not leave Europe. London also understands and facilitates the pivotal role that the US plays in European security – a shared perspective with the Nordic-Baltic partners.

Only the US – which has just recently decided to step up its military presence in the Baltics – has a greater appeal than the UK as a major ally. But Washington’s truly global responsibilities make it more difficult for it to play a regional leadership role.

With the context of the war in Ukraine, the centre of gravity of European security is moving east. The Nordic-Baltic region is likely to feature more prominently in the upcoming refresh of the UK’s Integrated Review, as the war in Ukraine and NATO’s new forward defence approach will focus UK attention and military capabilities on Europe for the foreseeable future.

But the UK still has limited resources and, despite the worsening security environment, there is currently no commitment by the Rishi Sunak government to increase defence spending beyond two per cent of GDP, as set out in the recently-published Autumn Statement.

This difficult fiscal reality contrasts UK ambition to also increase its footprint and engagement in the Indo-Pacific, a region highlighted by Rishi Sunak in his first foreign policy speech. London is already confronted with increasing expectations from its Nordic and Baltic partners, which are rattled by Russia’s aggression and seek more engagement and commitments from larger and more resourceful allies, and are insisting on prompt implementation of NATO’s new defence and deterrence plans.

This all comes on top of the resources that further assistance to Ukraine will require in the coming months and years. Balancing competing priorities and demands from partners is routine for a major power with global ambition but, in the current context, if the UK government fails to prioritize and increase resources, over-extension is in sight for its armed forces.

The war in Ukraine confirms that, beyond the rhetoric around the ‘Indo-Pacific tilt’, the Euro-Atlantic is – and will remain – the priority theatre of engagement for the UK. To keep delivering in the Nordic-Baltic region and remain a reliable partner, UK ambitions should be set clearly, and expectations managed with regional partners.

A good example is the recent UK-Estonia joint statement and defence roadmap, which is an attempt to reconcile London’s vision of modern deterrence with Tallinn’s preference for ‘more boots on the ground’.

The joint statement also clarifies initial misunderstandings regarding the upcoming withdrawal of the second UK battlegroup deployed to Estonia in the wake of Russia’s invasion of Ukraine – support Tallinn expected to continue ‘as long as necessary’ but London saw as temporary. It offsets the poor political ‘optics’ of the withdrawal while providing solid ground for deepening the common agenda in the near future.

By the 2023 NATO summit in Vilnius, progress on implementing the roadmap will be a crucial measure of success for the bilateral relationship, and for the UK’s broader regional role. It should serve as an opportunity for the UK to reflect on its force development priorities and balance, with Baltic partners arguing in favour of the UK rebuilding some mass in its armed forces and providing more resources to the land component.

Much to gain for the UK

The UK gains many benefits from deepening and widening its engagement in the Nordic-Baltic region, and not only by showcasing its regional leadership at a time of dire need or having more weight in Europe and across the Atlantic in strategic debates about future security architecture.

In conversation with Edi Rama, prime minister of Albania 23 March 2023 — 5:30PM TO 6:30PM Anonymous (not verified) 13 March 2023 Chatham House and Online

From migration to Russia and China, how is Albania responding to the geopolitical challenges of today?

In late 2022, the UK government made a pointed remark that many of the illegal migrants attempting to get into the country were from Albania. In response, Albania prime minister Edi Rama replied that targeting Albanians as the cause of Britain’s crime and border problems ‘makes for easy rhetoric but ignores hard fact’. 

This nuanced response demonstrated the challenges and complexities that Albania faces, the same as many other countries. As well as being embroiled in the major challenge of international migration, Albania has suffered from a serious cyber-attack in July 2022 from Iran. Government networks were compromised for a month with Tirana removing the Iranian embassy in the capital.

Then there is the ongoing threat from Russia and China. Nestled in the already volatile Balkans, Albania has been at the heart of international affairs in recent months.

Prime Minister Rama speaks at Chatham House to discuss:

• How is Albania responding to Russian aggression and what is its stance on Ukraine?
• Where does Tirana believe China poses the most serious threat?
• How can countries in Europe best respond to illegal migration and better control the flow of people?
• How is the region of the Western Balkans effected by the war in Ukraine and how can it contribute to the security challenges posed by the war?

As with all member events, questions from the audience drive the conversation.

Review: Rediscovering Milan Kundera’s European tragedy The World Today mhiggins.drupal 28 March 2023

The Czech writer’s 40-year-old essay on the roots of Russia’s empire-building, ‘A Kidnapped West’, reads all too presciently, writes Stefan Auer.

A Kidnapped West: The Tragedy of Central Europe
Milan Kundera, Faber, £10

‘In November 1956, the director of the Hungarian News Agency, shortly before his office was flattened by artillery fire, sent a telex to the entire world with a desperate message announcing that the Russian attack against Budapest had begun. The dispatch ended with these words: “We are going to die for Hungary and for Europe.”’ Thus, Milan Kundera began his 1983 essay for the French journal Le Débat, reflecting on the 1956 Hungarian Uprising.

A seminal essay

The Czech author might well have written a near-identical passage about the fraught hours immediately after Russia’s invasion of Ukraine in 2022. In the event, Russian tanks failed to occupy Kyiv, unlike Budapest in 1956. Nevertheless, Faber has chosen this moment, 40 years later, to republish Kundera’s seminal essay on Europe and Russian aggression in its original translation for the New York Review of Books by Edmund White. How salient are its observations today?

The essay’s original French title, ‘Un Occident kidnappé ou la tragédie de l’Europe centrale’ (The Kidnapped West, or the Tragedy of Central Europe), described the fate of Hungary, Czechoslovakia in 1968 and, to an extent, Poland in 1980-81 at the hands of the Soviet Union. Owing to the Cold War division of Europe, the countries of Central Europe were denied their true destiny, Kundera thought, to be an integral part of the liberal, democratic West. Kundera himself fled Czechoslovakia for France in 1975.

The author of The Unbearable Lightness of Being might no longer be as well-known as he was at the height of his fame in the 1980s, but his novels and essays still deserve attention. So, it is pleasing to see Kundera’s masterpiece republished, even as it is awful to witness the enduring relevance of the questions it raises.

What did the Hungarian journalist mean when he declared his willingness to die for Europe, Kundera asked? That ‘Russians, in attacking Hungary, were attacking Europe itself. He was ready to die so that Hungary might remain Hungary and European’. The journalist did indeed die in the uprising.

It is a line that President Volodymyr Zelenskyy and his supporters abroad have echoed time and again: that Ukrainian soldiers are not just dying for their country, they are dying for Europe at large.

The ‘tragedy’ in Kundera’s essay was that the West didn’t care. ‘Europe hasn’t noticed the disappearance of its cultural home,’ Kundera wrote, ‘because Europe no longer perceives its unity as a cultural unity.’

In other words, as the cultural sphere in Central Europe continued to defy the political restrictions imposed by the Soviet empire, it embodied the western values of freedom and democracy more than the West itself did. The extent to which this analysis remains relevant today will prove decisive for Europe’s future.

As timely as ever

Kundera’s essay is as timely as ever but in ways that both vindicate and challenge his key arguments. His suspicion of Russia has been validated. His frustration about the indifference of the West less so. But the true tragedy of Ukraine would be if the West has not changed sufficiently. So far, the West appears to be doing enough to enable Ukraine to defend itself, but not enough to defeat the aggressor.

Faber has made an excellent decision in combining The Tragedy of Central Europe with a lesser-known text by Kundera: his 1967 speech to the Czech Writers’ Congress given the year before the ill-fated Prague Spring. In it, Kundera addressed what was to become a lifelong preoccupation: the fate of small nations. ‘For Czechs’, Kundera wrote, ‘nothing has ever constituted an indisputable possession – neither their language nor their belonging to Europe.’

Rather than reflecting the size of its territory or population, a small nation ‘is one whose very existence can be put in question at any moment; a small nation can disappear, and it knows it.’ In this way Ukraine, Europe’s largest country, apart from Russia, is fighting to avoid the fate of Kundera’s ‘small nation’.

Historically, the ‘small’ nations of Central Europe were threatened by both Germany and Russia. But after the Second World War, the threat was from the Soviet Union, which for Kundera was indistinguishable from Russia (tacitly including Ukraine). In its expansiveness, Russia was the opposite of Central Europe. While the latter was based on the principle of ‘the greatest variety within the smallest space’, the former represented ‘the smallest variety within the greatest space’.

In this sense, authoritarian communism was the fulfilment of Russian history, Kundera argued, writing that ‘Russian communism vigorously reawakened Russia’s old anti-western obsessions and turned it brutally against Europe’. Vladimir Putin’s Russia appears to build on these same pernicious impulses.

Kundera was widely criticized for observations in his essay that smack of civilizational racism (including by me) describing Russians as fundamentally different from us: ‘Russia knows another (greater) dimension of disaster, another image of space (a space so immense that entire nations are swallowed up in it), another sense of time (slow and patient), another way of laughing, living, and dying’.

Africa and Europe: Climate security for the future 20 April 2023 TO 21 April 2023 — 7:30AM TO 12:00PM Anonymous (not verified) 31 March 2023 Slovenia and Online

The 12th Africa Day International Conference hosted in Slovenia offers a platform for interregional exchange and policy cooperation between African and European countries on climate security.

The 12th Africa Day International Conference offers a platform for inter-regional exchange and cooperation to further contribute to progress on climate security.

The 12th Africa Day International Conference is hosted by the Ministry of Foreign and European Affairs of the Republic of Slovenia, in collaboration with the European Commission and the Chatham House Africa Programme. This high-level annual event seeks to improve policy outcomes for citizens in Europe and Africa on the basis of mutual understanding and cooperation between the two regions, while strengthening bilateral relations between Slovenia and African countries.

Climate change poses one of the most serious threats to global security. No individual country or region can face it alone; strong regional and international partnerships are crucial. Analysing risk and taking action can help towards achieving a number of SDGs and a more secure and sustainable future. Addressing climate security is essential for the well-being and future stability of nations and societies around the world, and for the global community as a whole.

This conference will offer a platform for interregional exchange and cooperation on the topic of climate security policy. It will bring together decision-makers and experts from Europe, Africa and across the globe to identify the key challenges and policy priorities in addressing climate security.

The conference will be broadcast live on the Slovenian Ministry of Foreign Affairs webpage, and on the Africa Programme Facebook page.

Methods to shorten [¹⁸F]FDG Patlak PET imaging procedures ranging from 65–90 to 20–30 min after injection, using a population-averaged input function (PIF) scaled to patient-specific image-derived input function (IDIF) values, were recently evaluated. The aim of the present study was to explore the feasibility of ultrashort 10-min [¹⁸F]FDG Patlak imaging at 55–65 min after injection using a PIF combined with direct Patlak reconstructions to provide reliable quantitative accuracy of lung tumor uptake, compared with a full-duration 65-min acquisition using an IDIF. Methods: Patients underwent a 65-min dynamic PET acquisition on a long-axial-field-of-view (LAFOV) Biograph Vision Quadra PET/CT scanner. Subsequently, direct Patlak reconstructions and image-based (with reconstructed dynamic images) Patlak analyses were performed using both the IDIF (time to relative kinetic equilibrium between blood and tissue concentration (t*) = 30 min) and a scaled PIF at 30–60 min after injection. Next, direct Patlak reconstructions were performed on the system console using only the last 10 min of the acquisition, that is, from 55 to 65 min after injection, and a scaled PIF using maximum crystal ring difference settings of both 85 and 322. Tumor lesion and healthy-tissue uptake was quantified and compared between the differently obtained parametric images to assess quantitative accuracy. Results: Good agreement was obtained between direct- and image-based Patlak analyses using the IDIF (t* = 30 min) and scaled PIF at 30–60 min after injection, performed using the different approaches, with no more than 8.8% deviation in tumor influx rate value (K_i) (mean difference ranging from –0.0022 to 0.0018 mL/[min x g]). When direct Patlak reconstruction was performed on the system console, excellent agreement was found between the use of a scaled PIF at 30–60 min after injection versus 55–65 min after injection, with 2.4% deviation in tumor K_i (median difference, –0.0018 mL/[min x g]; range, –0.0047 to 0.0036 mL/[min x g]). For different maximum crystal ring difference settings using the scan time interval of 55–65 min after injection, only a 0.5% difference (median difference, 0.0000 mL/[min x g]; range, –0.0004 to 0.0013 mL/[min x g]) in tumor K_i was found. Conclusion: Ultrashort whole-body [¹⁸F]FDG Patlak imaging is feasible on an LAFOV Biograph Vision Quadra PET/CT system without loss of quantitative accuracy to assess lung tumor uptake compared with a full-duration 65-min acquisition. The ultrashort 10-min direct Patlak reconstruction with PIF allows for its implementation in clinical practice.

Quantification of ¹⁸F-FDG PET images is useful for accurate diagnosis and evaluation of various brain diseases, including brain tumors, epilepsy, dementia, and Parkinson disease. However, accurate quantification of ¹⁸F-FDG PET images requires matched 3-dimensional T₁ MRI scans of the same individuals to provide detailed information on brain anatomy. In this paper, we propose a transfer learning approach to adapt a pretrained deep neural network model from amyloid PET to spatially normalize ¹⁸F-FDG PET images without the need for 3-dimensional MRI. Methods: The proposed method is based on a deep learning model for automatic spatial normalization of ¹⁸F-FDG brain PET images, which was developed by fine-tuning a pretrained model for amyloid PET using only 103 ¹⁸F-FDG PET and MR images. After training, the algorithm was tested on 65 internal and 78 external test sets. All T₁ MR images with a 1-mm isotropic voxel size were processed with FreeSurfer software to provide cortical segmentation maps used to extract a ground-truth regional SUV ratio using cerebellar gray matter as a reference region. These values were compared with those from spatial normalization-based quantification methods using the proposed method and statistical parametric mapping software. Results: The proposed method showed superior spatial normalization compared with statistical parametric mapping, as evidenced by increased normalized mutual information and better size and shape matching in PET images. Quantitative evaluation revealed a consistently higher SUV ratio correlation and intraclass correlation coefficients for the proposed method across various brain regions in both internal and external datasets. The remarkably good correlation and intraclass correlation coefficient values of the proposed method for the external dataset are noteworthy, considering the dataset’s different ethnic distribution and the use of different PET scanners and image reconstruction algorithms. Conclusion: This study successfully applied transfer learning to a deep neural network for ¹⁸F-FDG PET spatial normalization, demonstrating its resource efficiency and improved performance. This highlights the efficacy of transfer learning, which requires a smaller number of datasets than does the original network training, thus increasing the potential for broader use of deep learning–based brain PET spatial normalization techniques for various clinical and research radiotracers.

C-X-C motif chemokine receptor 4 (CXCR4)–directed imaging has gained clinical interest in aiding clinical diagnostics in primary aldosteronism (PA). We retrospectively evaluated the feasibility of CXCR4-directed scintigraphy using the novel CXCR-4 ligand [^99mTc]Tc-pentixatec in patients with PA. Methods: Six patients (mean age ± SD, 49 ± 15 y) underwent CXCR4-directed scintigraphy (including planar imaging and SPECT/CT) 30, 120, and 240 min after injection of 435 ± 50 MBq of [^99mTc]Tc-pentixatec. Adrenal CXCR4 expression was analyzed by calculating lesion-to-contralateral ratios (LCRs). Imaging results were correlated to clinical information. Histopathology and clinical follow-up served as the standard of reference. Results: Three subjects showed lateralization of adrenal tracer accumulation, with a mean maximum lesion-to-contralateral ratio of 1.65 (range, 1.52–1.70), which correlated with morphologic findings on CT. One individual underwent adrenalectomy and presented with complete biochemical and clinical remission at follow-up. Histopathologic workup confirmed unilateral aldosterone-producing adenoma. Conclusion: [^99mTc]Tc-pentixatec scintigraphy with SPECT in patients with PA is feasible and might offer a valuable alternative to CXCR4-directed imaging with [⁶⁸Ga]Ga-pentixafor PET.

The peptide hormone ghrelin is produced in cardiomyocytes and acts through the myocardial growth hormone secretagogue receptor (GHSR) to promote cardiomyocyte survival. Administration of ghrelin may have therapeutic effects on post–myocardial infarction (MI) outcomes. Therefore, there is a need to develop molecular imaging probes that can track the dynamics of GHSR in health and disease to better predict the effectiveness of ghrelin-based therapeutics. We designed a high-affinity GHSR ligand labeled with ¹⁸F for imaging by PET and characterized its in vivo properties in a canine model of MI. Methods: We rationally designed and radiolabeled with ¹⁸F a quinazolinone derivative ([¹⁸F]LCE470) with subnanomolar binding affinity to GHSR. We determined the sensitivity and in vivo and ex vivo specificity of [¹⁸F]LCE470 in a canine model of surgically induced MI using PET/MRI, which allowed for anatomic localization of tracer uptake and simultaneous determination of global cardiac function. Uptake of [¹⁸F]LCE470 was determined by time–activity curve and SUV analysis in 3 regions of the left ventricle—area of infarct, territory served by the left circumflex coronary artery, and remote myocardium—over a period of 1.5 y. Changes in cardiac perfusion were tracked by [¹³N]NH₃ PET. Results: The receptor binding affinity of LCE470 was measured at 0.33 nM, the highest known receptor binding affinity for a radiolabeled GHSR ligand. In vivo blocking studies in healthy hounds and ex vivo blocking studies in myocardial tissue showed the specificity of [¹⁸F]LCE470, and sensitivity was demonstrated by a positive correlation between tracer uptake and GHSR abundance. Post-MI changes in [¹⁸F]LCE470 uptake occurred independently of perfusion tracer distributions and changes in global cardiac function. We found that the regional distribution of [¹⁸F]LCE470 within the left ventricle diverged significantly within 1 d after MI and remained that way throughout the 1.5-y duration of the study. Conclusion: [¹⁸F]LCE470 is a high-affinity PET tracer that can detect changes in the regional distribution of myocardial GHSR after MI. In vivo PET molecular imaging of the global dynamics of GHSR may lead to improved GHSR-based therapeutics in the treatment of post-MI remodeling.

Mutations of p53 protein occur in over half of all cancers, with profound effects on tumor biology. We present the first—to our knowledge—method for noninvasive visualization of p53 in tumor tissue in vivo, using SPECT, in 3 different models of cancer. Methods: Anti-p53 monoclonal antibodies were conjugated to the cell-penetrating transactivator of transcription (TAT) peptide and a metal ion chelator and then radiolabeled with ¹¹¹In to allow SPECT imaging. ¹¹¹In-anti-p53-TAT conjugates were retained longer in cells overexpressing p53-specific than non–p53-specific ¹¹¹In-mIgG (mouse IgG from murine plasma)-TAT controls, but not in null p53 cells. Results: In vivo SPECT imaging showed enhanced uptake of ¹¹¹In-anti-p53-TAT, versus ¹¹¹In-mIgG-TAT, in high-expression p53^R175H and medium-expression wild-type p53 but not in null p53 tumor xenografts. The results were confirmed in mice bearing genetically engineered KPC mouse–derived pancreatic ductal adenocarcinoma tumors. Imaging with ¹¹¹In-anti-p53-TAT was possible in KPC mice bearing spontaneous p53^R172H pancreatic ductal adenocarcinoma tumors. Conclusion: We demonstrate the feasibility of noninvasive in vivo molecular imaging of p53 in tumor tissue using a radiolabeled TAT-modified monoclonal antibody.

Preclinical data have shown that ¹⁶¹Tb-labeled peptides targeting the somatostatin receptor are therapeutically more effective for peptide receptor radionuclide therapy than are their ¹⁷⁷Lu-labeled counterparts. To further substantiate this enhanced therapeutic effect, we performed cellular dosimetry to quantify the absorbed dose to the cell nucleus and compared dose–response curves to evaluate differences in relative biological effectiveness in vitro. Methods: CA20948 cell survival was assessed after treatment with [¹⁶¹Tb]Tb- and [¹⁷⁷Lu]Lu-DOTATATE (agonist) and with [¹⁶¹Tb]Tb- and [¹⁷⁷Lu]Lu-DOTA-LM3 (antagonist) via a clonogenic assay. Cell binding, internalization, and dissociation assays were performed up to 7 d to acquire time-integrated activity coefficients. Separate S values for each type of particle emission (Auger/internal conversion [IC] electrons and β^– particles) were computed via Monte Carlo simulations, while considering spheric cells. Once the absorbed dose to the cell nucleus was calculated, survival curves were fitted to the appropriate linear or linear-quadratic model and corresponding relative biological effectiveness was evaluated. Results: Although the radiopeptide uptake was independent of the radionuclide, [¹⁶¹Tb]Tb-DOTATATE and [¹⁶¹Tb]Tb-DOTA-LM3 delivered a 3.6 and 3.8 times higher dose to the nucleus, respectively, than their ¹⁷⁷Lu-labeled counterparts on saturated receptor binding. This increased nucleus-absorbed dose was mainly due to the additional emission of IC and not Auger electrons by ¹⁶¹Tb. When activity concentrations were considered, both [¹⁶¹Tb]Tb-DOTATATE and [¹⁶¹Tb]Tb-DOTA-LM3 showed a lower survival fraction than did labeling with ¹⁷⁷Lu. When the absorbed dose to the nucleus was considered, no significant difference could be observed between the dose–response curves for [¹⁶¹Tb]Tb- and [¹⁷⁷Lu]Lu-DOTATATE. [¹⁶¹Tb]Tb-DOTA-LM3 showed a linear-quadratic dose response, whereas [¹⁶¹Tb]Tb-DOTATATE showed only a linear dose response within the observed dose range, suggesting additional cell membrane damage by Auger electrons. Conclusion: The IC, rather than Auger, electrons emitted by ¹⁶¹Tb resulted in a higher absorbed dose to the cell nucleus and lower clonogenic survival for [¹⁶¹Tb]Tb-DOTATATE and [¹⁶¹Tb]Tb-DOTA-LM3 than for the ¹⁷⁷Lu-labeled analogs. In contrast, [¹⁶¹Tb]Tb-DOTATATE showed no higher dose response than [¹⁷⁷Lu]Lu-DOTATATE, whereas for [¹⁶¹Tb]Tb-DOTA-LM3 an additional quadratic response was observed. Because of this quadratic response, potentially caused by cell membrane damage, [¹⁶¹Tb]Tb-DOTA-LM3 is a more effective radiopeptide than [¹⁶¹Tb]Tb-DOTATATE for labeling with ¹⁶¹Tb.

Radiolabeled small-molecule DOTA-haptens can be combined with antitumor/anti-DOTA bispecific antibodies (BsAbs) for pretargeted radioimmunotherapy (PRIT). For optimized delivery of the theranostic - and β-emitting isotope ¹⁷⁷Lu with DOTA-based PRIT (DOTA-PRIT), bivalent Gemini (DOTA-Bn-thiourea-PEG4-thiourea-Bn-DOTA, aka (3,6,9,12-tetraoxatetradecane-1,14-diyl)bis(DOTA-benzyl thiourea)) was developed. Methods: Gemini was synthesized by linking 2 S-2-(4-isothiocyanatobenzyl)-DOTA molecules together via a 1,14-diamino-PEG4 linker. [¹⁷⁷Lu]Lu-Gemini was prepared with no-carrier-added ¹⁷⁷LuCl₃ to a molar-specific activity of 123 GBq/μmol and radiochemical purity of more than 99%. The specificity of BsAb-¹⁷⁷Lu-Gemini was verified in vitro. Subsequently, we evaluated biodistribution and whole-body clearance for [¹⁷⁷Lu]Lu-Gemini and, for comparison, our gold-standard monovalent [¹⁷⁷Lu]Lu-S-2-(4-aminobenzyl)-DOTA ([¹⁷⁷Lu]Lu-DOTA-Bn) in naïve (tumor-free) athymic nude mice. For our proof-of-concept system, a 3-step pretargeting approach was performed with an established DOTA-PRIT regimen (anti-GPA33/anti-DOTA IgG-scFv BsAb, a clearing agent, and [¹⁷⁷Lu]Lu-Gemini) in mouse models. Results: Initial in vivo studies showed that [¹⁷⁷Lu]Lu-Gemini behaved similarly to [¹⁷⁷Lu]Lu-DOTA-Bn, with almost identical blood and whole-body clearance kinetics, as well as biodistribution and mouse kidney dosimetry. Pretargeting [¹⁷⁷Lu]Lu-Gemini to GPA33-expressing SW1222 human colorectal xenografts was highly effective, leading to absorbed doses of [¹⁷⁷Lu]Lu-Gemini for blood, tumor, liver, spleen, and kidneys of 3.99, 455, 6.93, 5.36, and 14.0 cGy/MBq, respectively. Tumor–to–normal tissue absorbed-dose ratios (i.e., therapeutic indices [TIs]) for the blood and kidneys were 114 and 33, respectively. In addition, we demonstrate that the use of bivalent [¹⁷⁷Lu]Lu-Gemini in DOTA-PRIT leads to improved TIs and augmented [¹⁷⁷Lu]Lu-Gemini tumor uptake and retention in comparison to monovalent [¹⁷⁷Lu]Lu-DOTA-Bn. Finally, we established efficacy in SW1222 tumor-bearing mice, demonstrating that a single injection of anti-GPA33 DOTA-PRIT with 44 MBq (1.2 mCi) of [¹⁷⁷Lu]Lu-Gemini (estimated tumor-absorbed dose, 200 Gy) induced complete responses in 5 of 5 animals and a histologic cure in 2 of 5 (40%) animals. Moreover, a significant increase in survival compared with nontreated controls was noted (maximum tolerated dose not reached). Conclusion: We have developed a bivalent DOTA-radiohapten, [¹⁷⁷Lu]Lu-Gemini, that showed improved radiopharmacology for DOTA-PRIT application. The use of bivalent [¹⁷⁷Lu]Lu-Gemini in DOTA-PRIT, as opposed to monovalent [¹⁷⁷Lu]Lu-DOTA-Bn, allows curative treatments with considerably less administered ¹⁷⁷Lu activity while still achieving high TIs for both the blood (>100) and the kidneys (>30).

Fibroblast activation protein (FAP) is abundantly expressed in the stroma of most human solid tumors. Clinical-stage radiolabeled FAP ligands are increasingly used as tools for the detection of various cancer lesions. To unleash the full therapeutic potential of FAP-targeting agents, ligands need to remain at the tumor site for several days after administration. We recently described the discovery of OncoFAP, a high-affinity small organic ligand of FAP with a rapid accumulation in tumors and low uptake in healthy tissues in cancer patients. Trimerization of OncoFAP provided a derivative (named TriOncoFAP, or OncoFAP-23) with improved FAP affinity. In this work, we evaluated the tissue biodistribution profile and the therapeutic performance of OncoFAP-23 in tumor-bearing mice. Methods: OncoFAP-23 was radiolabeled with the theranostic radionuclide ¹⁷⁷Lu. Preclinical experiments were conducted on mice bearing SK-RC-52.hFAP (BALB/c nude mice) or CT-26.hFAP (BALB/c mice) tumors. ¹⁷⁷Lu-OncoFAP and ¹⁷⁷Lu-FAP-2286 were included in the biodistribution study as controls. Toxicologic evaluation was performed on Wistar rats and CD1 mice by injecting high doses of OncoFAP-23 or its cold-labeled counterpart, respectively. Results: ¹⁷⁷Lu-OncoFAP-23 emerged for its best-in-class biodistribution profile, high and prolonged tumor uptake (i.e., ~16 percentage injected dose/g at 96 h), and low accumulation in healthy organs, which correlates well with its potent single-agent anticancer activity at low levels of administered radioactivity. Combination treatment with the tumor-targeted interleukin 2 (L19-IL2, a clinical-stage immunocytokine) further expands the therapeutic window of ¹⁷⁷Lu-OncoFAP-23 by potentiating its in vivo antitumor activity. Proteomics studies revealed a potent tumor-directed immune response on treatment with the combination. OncoFAP-23 and ^natLu-OncoFAP-23 exhibited a favorable toxicologic profile, without showing any side effects or signs of toxicity. Conclusion: OncoFAP-23 presents enhanced tumor uptake and tumor retention and low accumulation in healthy organs, findings that correspond to a strongly improved in vivo antitumor efficacy. The data presented in this work support the clinical development of ¹⁷⁷Lu-OncoFAP-23 for the treatment of FAP-positive solid tumors.

To date, the imaging and diagnosis of hepatocellular carcinoma (HCC) rely on CT/MRI, which have well-known limitations. Glypican-3 (GPC3) is a cell surface receptor highly expressed by HCC but not by normal or cirrhotic liver tissue. Here we report initial clinical results of GPC3-targeted PET imaging with [⁶⁸Ga]Ga-DOTA-RYZ-GPC3 (RAYZ-8009), a peptide-based GPC3 ligand in patients with known or suspected HCC. Methods: [⁶⁸Ga]Ga-RAYZ-8009 was obtained after labeling the peptide precursor with ⁶⁸Ga from a ⁶⁸Ge/⁶⁸Ga generator and heating at 90°C for 10 min followed by sterile filtration. After administration of [⁶⁸Ga]Ga-RAYZ-8009, a dynamic or static PET/CT scan was acquired between 45 min and 4 h after administration. Radiotracer uptake was measured by SUVs for the following tissues: suspected or actual HCC or hepatoblastoma lesions, non–tumor-bearing liver, renal cortex, blood pool in the left ventricle, and gastric fundus. Additionally, tumor–to–healthy-liver ratios (TLRs) were calculated. Results: Twenty-four patients (5 patients in the dynamic protocol; 19 patients in the static protocol) were scanned. No adverse events occurred. Two patients had no lesion detected and did not have HCC during follow-up. In total, 50 lesions were detected and analyzed. The mean SUV_max of these lesions was 19.6 (range, 2.7–95.3), and the mean SUV_mean was 10.1 (range, 1.0–49.2) at approximately 60 min after administration. Uptake in non–tumor-bearing liver and blood pool rapidly decreased over time and became negligible 45 min after administration (mean SUV_mean, <1.6), with a continuous decline to 4 h after administration (mean SUV_mean, 1.0). The opposite was observed for HCC lesions, for which SUVs and TLRs continuously increased for up to 4 h after administration. In individual lesion analysis, TLR was the highest between 60 and 120 min after administration. Uptake in the gastric fundus gradually increased for up to 45 min (to an SUV_max of 31.3) and decreased gradually afterward. Conclusion: [⁶⁸Ga]Ga-RAYZ-8009 is safe and allows for high-contrast imaging of GPC3-positive HCC, with rapid clearance from most normal organs. Thereby, [⁶⁸Ga]Ga-RAYZ-8009 is promising for HCC diagnosis and staging. Further research is warranted.

Our purpose was to prospectively assess the distribution of NETPET scores in well-differentiated (WD) grade 2 and 3 gastroenteropancreatic (GEP) neuroendocrine tumors (NETs) and to determine the impact of the NETPET score on clinical management. Methods: This single-arm, institutional ethics review board–approved prospective study included 40 patients with histologically proven WD GEP NETs. ⁶⁸Ga-DOTATATE PET and ¹⁸F-FDG PET were performed within 21 d of each other. NETPET scores were evaluated qualitatively by 2 reviewers, with up to 10 marker lesions selected for each patient. The quantitative parameters that were evaluated included marker lesion SUV_max for each tracer; ¹⁸F-FDG/⁶⁸Ga-DOTATATE SUV_max ratios; functional tumor volume (FTV) and metabolic tumor volume (MTV) on ⁶⁸Ga-DOTATATE and ¹⁸F-FDG PET, respectively; and FTV/MTV ratios. The treatment plan before and after ¹⁸F-FDG PET was recorded. Results: There were 22 men and 18 women (mean age, 60.8 y) with grade 2 (n = 24) or grade 3 (n = 16) tumors and a mean Ki-67 index of 16.1%. NETPET scores of P0, P1, P2A, P2B, P3B, P4B, and P5 were documented in 2 (5%), 5 (12.5%), 5 (12.5%) 20 (50%), 2 (5%), 4 (10%), and 2 (5%) patients, respectively. No association was found between the SUV_max of target lesions on ⁶⁸Ga-DOTATATE and the SUV_max of target lesions on ¹⁸F-FDG PET (P = 0.505). ¹⁸F-FDG/⁶⁸Ga-DOTATATE SUV_max ratios were significantly lower for patients with low (P1–P2) primary NETPET scores than for those with high (P3–P5) primary NETPET scores (mean ± SD, 0.20 ± 0.13 and 1.68 ± 1.44, respectively; P < 0.001). MTV on ¹⁸F-FDG PET was significantly lower for low primary NETPET scores than for high ones (mean ± SD, 464 ± 601 cm³ and 66 ± 114 cm³, respectively; P = 0.005). A change in the type of management was observed in 42.5% of patients after ¹⁸F-FDG PET, with the most common being a change from systemic therapy to peptide receptor radionuclide therapy and from debulking surgery to systemic therapy. Conclusion: There was a heterogeneous distribution of NETPET scores in patients with WD grade 2 and 3 GEP NETs, with more than 1 in 5 patients having a high NETPET score and a frequent change in management after ¹⁸F-FDG PET. Quantitative parameters including ¹⁸F-FDG/⁶⁸Ga-DOTATATE SUV_max ratios in target lesions and FTV/MTV ratios can discriminate between patients with high and low NETPET scores.

Our objective is to explore quantitative imaging markers for early prediction of treatment response in patients with gastroenteropancreatic neuroendocrine tumors (GEP-NETs) undergoing [¹⁷⁷Lu]Lu-DOTATATE therapy. By doing so, we aim to enable timely switching to more effective therapies in order to prevent time-resource waste and minimize toxicities. Methods: Patients diagnosed with unresectable or metastatic, progressive, well-differentiated, receptor-positive GEP-NETs who received 4 sessions of [¹⁷⁷Lu]Lu-DOTATATE were retrospectively selected. Using SPECT/CT images taken at the end of treatment sessions, we counted all visible tumors and measured their largest diameters to calculate the tumor burden score (TBS). Up to 4 target lesions were selected and semiautomatically segmented. Target lesion peak counts and spleen peak counts were measured, and normalized peak counts were calculated. Changes in TBS (TBS) and changes in normalized peak count (nPC) throughout treatment sessions in relation to the first treatment session were calculated. Treatment responses were evaluated using third-month CT and were binarized as progressive disease (PD) or non-PD. Results: Twenty-seven patients were included (7 PD, 20 non-PD). Significant differences were observed in TBS_second-first, TBS_third-first, and TBS_fourth-first (where second-first, third-first, and fourth-first denote scan number between the second and first, third and first, and fourth and first [¹⁷⁷Lu]Lu-DOTATATE treatment cycles), respectively) between the PD and non-PD groups (median, 0.043 vs. –0.049, 0.08 vs. –0.116, and 0.109 vs. –0.123 [P = 0.023, P = 0.002, and P < 0.001], respectively). nPC_second-first showed significant group differences (mean, –0.107 vs. –0.282; P = 0.033); nPC_third-first and nPC_fourth-first did not reach statistical significance (mean, –0.122 vs. –0.312 and –0.183 vs. –0.405 [P = 0.117 and 0.067], respectively). At the optimal threshold, TBS_fourth-first exhibited an area under the curve (AUC) of 0.957, achieving 100% sensitivity and 80% specificity. TBS_second-first and TBS_third-first reached AUCs of 0.793 and 0.893, sensitivities of 71.4%, and specificities of 85% and 95%, respectively. nPC_second-first, nPC_third-first, and nPC_fourth-first showed AUCs of 0.764, 0.693, and 0.679; sensitivities of 71.4%, 71.4%, and 100%; and specificities of 75%, 70%, and 35%, respectively. Conclusion: TBS and nPC can predict [¹⁷⁷Lu]Lu-DOTATATE response by the second treatment session.

Unspecific bone uptake (UBU) related to [¹⁸F]PSMA-1007 PET/CT imaging represents a clinical challenge. We aimed to assess whether a combination of clinical, biochemical, and imaging parameters could predict skeletal metastases in patients with [¹⁸F]PSMA-1007 bone focal uptake, aiding in result interpretation. Methods: We retrospectively analyzed [¹⁸F]PSMA-1007 PET/CT performed in hormone-sensitive prostate cancer (PCa) patients at 3 tertiary-level cancer centers. A fourth center was involved in performing an external validation. For each, a volume of interest was drawn using a threshold method to extract SUV_max, SUV_mean, PSMA tumor volume, and total lesion PSMA. The same volume of interest was applied to CT images to calculate the mean Hounsfield units (HU_mean) and maximum Hounsfield units. Clinical and laboratory data were collected from electronic medical records. A composite reference standard, including follow-up histopathology, biochemistry, and imaging data, was used to distinguish between PCa bone metastases and UBU. PET readers with less (n = 2) or more (n = 2) experience, masked to the reference standard, were asked to visually rate a subset of focal bone uptake (n = 178) as PCa metastases or not. Results: In total, 448 bone [¹⁸F]PSMA-1007 focal uptake specimens were identified in 267 PCa patients. Of the 448 uptake samples, 188 (41.9%) corresponded to PCa metastases. Ongoing androgen deprivation therapy at PET/CT (P < 0.001) with determination of SUV_max (P < 0.001) and HU_mean (P < 0.001) independently predicted bone metastases. A composite prediction score, the bone uptake metastatic probability (BUMP) score, achieving an area under the receiver-operating-characteristic curve (AUC) of 0.87, was validated through a 10-fold internal and external validation (n = 89 bone uptake, 51% metastatic; AUC, 0.92). The BUMP score’s AUC was significantly higher than that of HU_mean (AUC, 0.62) and remained high among lesions with HU_mean in the first tertile (AUC, 0.80). A decision-curve analysis showed a higher net benefit with the score. Compared with the visual assessment, the BUMP score provided added value in terms of specificity in less-experienced PET readers (88% vs. 54%, P < 0.001). Conclusion: The BUMP score accurately distinguished UBU from bone metastases in PCa patients with [¹⁸F]PSMA-1007 focal bone uptake at PET imaging, offering additional value compared with the simple assessment of the osteoblastic CT correlate. Its use could help clinicians interpret imaging results, particularly those with less experience, potentially reducing the risk of patient overstaging.

This analysis aimed to identify clinical factors associated with positivity on repeat ⁶⁸Ga-PSMA-11 PET/CT after a negative scan in patients with recurrent prostate cancer (PCa) under observation. Methods: This single-center, retrospective analysis included patients who underwent at least 2 ⁶⁸Ga-PSMA-11 PET/CT scans (PET1 and PET2) at UCLA between October 2016 and June 2021 for recurrent PCa with negative PET1 and no PCa-related treatments between the 2 scans. Using Prostate Cancer Molecular Imaging Standardized Evaluation criteria to define negative and positive scans, the final cohort was divided into PET2-negative (PET2-Neg) and PET2-positive (PET2-Pos). The same PET1 was used twice in the more than 2 PET cases with inclusion criteria fulfilled. Patient characteristics and clinical parameters were compared between the 2 cohorts using Mann–Whitney U test and Fisher exact test. Areas under the curve (AUCs) of the receiver operating characteristic and the Youden index were computed to determine the discrimination ability of statistically significant factors and specific cut points that maximized sensitivity and specificity, respectively. Results: The final analysis included 83 sets of 2 PET/CT scans from 70 patients. Thirty-nine of 83 (47%) sets were PET2-Neg, and 44 of 83 (53%) sets were PET2-Pos. Prostate-specific antigen (PSA) increased from PET1 to PET2 for all 83 (100%) sets of scans. Median PSA at PET1 was 0.4 ng/mL (interquartile range, 0.2–1.0) and at PET2 was 1.6 ng/mL (interquartile range, 0.9–3.8). We found higher serum PSA at PET2 (median, 1.8 vs. 1.1 ng/mL; P = 0.015), absolute PSA difference (median, 1.4 vs. 0.7 ng/mL; P = 0.006), percentage of PSA change (median, +270.4% vs. +150.0%: P = 0.031), and median PSA velocity (0.044 vs. 0.017 ng/mL/wk, P = 0.002) and shorter PSA doubling time (DT; median, 5.1 vs. 8.3 mo; P = 0.006) in the PET2-Pos cohort than in the PET2-Neg cohort. Receiver operating characteristic curves showed cutoffs for PSA at PET2 of 4.80 ng/mL (sensitivity, 34%; specificity, 92%; AUC, 0.66), absolute PSA difference of 0.95 ng/mL (sensitivity, 62%; specificity, 71%; AUC, 0.68), percentage of PSA change of a positive 289.50% (sensitivity, 48%; specificity, 82%; AUC, 0.64), PSA velocity of 0.033 ng/mL/wk (sensitivity, 57%; specificity, 80%; AUC, 0.70), and PSA DT of 7.91 mo (sensitivity, 71%; specificity, 62%; AUC, 0.67). Conclusion: Patients with recurrent PCa under observation after a negative ⁶⁸Ga-PSMA-11 PET/CT scan with markedly elevated serum PSA levels and shorter PSA DT are more likely to have positive findings on repeat ⁶⁸Ga-PSMA-11 PET/CT.

Single-domain antibodies (sdAbs) demonstrate favorable pharmacokinetic profiles for molecular imaging applications. However, their renal excretion and retention are obstacles for applications in targeted radionuclide therapy (TRT). Methods: Using a click-chemistry–based pretargeting approach, we aimed to reduce kidney retention of a fibroblast activation protein α (FAP)–targeted sdAb, 4AH29, for ¹⁷⁷Lu-TRT. Key pretargeting parameters (sdAb-injected mass and lag time) were optimized in healthy mice and U87MG (FAP⁺) xenografts. A TRT study in a pancreatic ductal adenocarcinoma (PDAC) patient-derived xenograft (PDX) model was performed as a pilot study for sdAb-based pretargeting applications. Results: Modification of 4AH29 with trans-cyclooctene (TCO) moieties did not modify the sdAb pharmacokinetic profile. A 200-µg injected mass of 4AH29-TCO and an 8-h lag time for the injection of [¹⁷⁷Lu]Lu-DOTA-PEG₇-tetrazine resulted in the highest kidney therapeutic index (2.0 ± 0.4), which was 5-fold higher than that of [¹⁷⁷Lu]Lu-DOTA-4AH29 (0.4 ± 0.1). FAP expression in the tumor microenvironment was validated in a PDAC PDX model with both immunohistochemistry and PET/CT imaging. Mice treated with the pretargeting high-activity approach (4AH29-TCO + [¹⁷⁷Lu]Lu-DOTA-PEG₇-tetrazine; 3 x 88 MBq, 1 injection per week for 3 wk) demonstrated prolonged survival compared with the vehicle control and conventionally treated ([¹⁷⁷Lu]Lu-DOTA-4AH29; 3 x 37 MBq, 1 injection per week for 3 wk) mice. Mesangial expansion was reported in 7 of 10 mice in the conventional cohort, suggesting treatment-related kidney morphologic changes, but was not observed in the pretargeting cohort. Conclusion: This study validates pretargeting to mitigate sdAbs’ kidney retention with no observation of morphologic changes on therapy regimen at early time points. Clinical translation of click-chemistry–based pre-TRT is warranted on the basis of its ability to alleviate toxicities related to biovectors’ intrinsic pharmacokinetic profiles. The absence of representative animal models with extensive stroma and high FAP expression on cancer-associated fibroblasts led to a low mean tumor-absorbed dose even with high injected activity and consequently to modest survival benefit in this PDAC PDX.

Cancer of unknown primary (CUP) represents a heterogeneous group of metastatic tumors for which standardized diagnostic work-up fails to identify the primary site. We aimed to describe the Peter MacCallum Cancer Centre experience with ¹⁸F-FDG PET/CT in extracervical CUP with respect to detection of a primary site and its impact on management. A secondary aim was to compare overall survival (OS) in patients with and without a detected primary site. Methods: CUP patients treated between 2014 and 2020 were identified from medical oncology clinics and ¹⁸F-FDG PET/CT records. Information collated from electronic medical records included the suspected primary site and treatment details before and after ¹⁸F-FDG PET/CT. Clinicopathologic details and genomic analysis were used to determine the clinically suspected primary site and compared against 2 independent masked reads of ¹⁸F-FDG PET/CT images by nuclear medicine specialists to determine sensitivity, specificity, accuracy, and the rate of detection of the primary site. Results: We identified 147 patients, 65% of whom had undergone molecular profiling. The median age at diagnosis was 61 y (range, 20–84 y), and the median follow-up time was 74 mo (range, 26–83 mo). Eighty-two percent were classified as having an unfavorable CUP subtype as per international guidelines.¹⁸F-FDG PET/CT demonstrated a primary site detection rate of 41%, resulted in a change in management in 22%, and identified previously occult disease sites in 37%. Median OS was 16.8 mo for all patients and 104.7 and 12.1 mo for favorable and unfavorable CUP subtypes, respectively (P < 0.0001). Median OS in CUP patients when using ¹⁸F-FDG PET/CT, clinicopathologic, and genomic information was 19.8 and 8.5 mo when a primary site was detected and not detected, respectively (P = 0.016). Multivariable analysis of survival adjusted for age and sex remained significant for identification of a potential primary site (P < 0.001), a favorable CUP (P < 0.001), and an Eastern Cooperative Oncology Group status of 1 or less (P < 0.001). Conclusion: ¹⁸F-FDG PET/CT plays a complementary role in CUP diagnostic work-up and was able to determine the likely primary site in 41% of cases. OS is improved with primary site identification, demonstrating the value of access to diagnostic ¹⁸F-FDG PET/CT for CUP patients.

Neoadjuvant therapy in patients with locally advanced rectal cancer (LARC) has achieved good pathologic complete response (pCR) rates, potentially eliminating the need for surgical intervention. This study investigated preoperative methods for predicting pCR after neoadjuvant short-course radiotherapy (SCRT) combined with immunochemotherapy. Methods: Treatment-naïve patients with histologically confirmed LARC were enrolled from February 2023 to July 2023. Before surgery, the patients received neoadjuvant SCRT followed by 2 cycles of capecitabine and oxaliplatin plus camrelizumab. ⁶⁸Ga-labeled fibroblast activation protein inhibitor ([⁶⁸Ga]Ga-FAPI-04) PET/MRI, [¹⁸F]FDG PET/CT, and contrast-enhanced MRI were performed before treatment initiation and before surgery in each patient. PET and MRI features and the size and number of lesions were also collected from each scan. Each parameter’s sensitivity, specificity, and diagnostic cutoff were derived via receiver-operating-characteristic curve analysis. Results: Twenty eligible patients (13 men, 7 women; mean age, 60.2 y) were enrolled and completed the entire trial, and all patients had proficient mismatch repair or microsatellite-stable LARC. A postoperative pCR was achieved in 9 patients (45.0%). In the visual evaluation, both [⁶⁸Ga]Ga-FAPI-04 PET/MRI and [¹⁸F]FDG PET/CT were limited to forecasting pCR. Contrast-enhanced MRI had a low sensitivity of 55.56% to predict pCR. In the quantitative evaluation, [⁶⁸Ga]Ga-FAPI-04 change in SUL_peak percentage, where SUL_peak is SUV_peak standardized by lean body mass, had the largest area under the curve (0.929) with high specificity (sensitivity, 77.78%; specificity, 100.0%; cutoff, 63.92%). Conclusion: [⁶⁸Ga]Ga-FAPI-04 PET/MRI is a promising imaging modality for predicting pCR after SCRT combined with immunochemotherapy. The SUL_peak decrease exceeding 63.92% may provide valuable guidance in selecting patients who can forgo surgery after neoadjuvant therapy.

Understanding which patients with human epidermal growth factor receptor 2 (HER2)–negative or –low metastatic breast cancer (MBC) benefit from HER2-targeted strategies is urgently needed. We assessed the whole-body heterogeneity of HER2 expression on ⁸⁹Zr-trastuzumab PET (HER2 PET) and the diagnostic performance of HER2 PET in a large series of patients, including HER2-negative and -low MBC. Methods: In the IMPACT-MBC study, patients with newly diagnosed and nonrapidly progressive MBC of all subtypes were included. Metastasis HER2 status was determined by immunohistochemistry and in situ hybridization.⁸⁹Zr-trastuzumab uptake was quantified as SUV_max and SUV_mean. HER2 immunohistochemistry was related to the quantitative ⁸⁹Zr-trastuzumab uptake of all metastases and corresponding biopsied metastasis, uptake heterogeneity, and qualitative scan evaluation. A prediction algorithm for HER2 immunohistochemistry positivity based on uptake was developed. Results: In 200 patients, ⁸⁹Zr-trastuzumab uptake was quantified in 5,163 metastases, including 186 biopsied metastases. With increasing HER2 immunohistochemistry status, uptake was higher (geometric mean SUV_max of 7.0, 7.6, 7.3, and 17.4 for a HER2 immunohistochemistry score of 0, 1, 2, or 3+, respectively; P < 0.001). High uptake exceeding 14.6 (90th percentile) was observed in one third of patients with a HER2-negative or -low metastasis biopsy. The algorithm performed best when lesion site and size were incorporated (area under the curve, 0.86; 95% CI, 0.79–0.93). Conclusion: HER2 PET had good diagnostic performance in MBC, showing considerable whole-body HER2 heterogeneity and uptake above background in HER2-negative and -low MBC. This provides novel insights into HER2-negative and -low MBC compared with standard HER2 immunohistochemistry on a single biopsy.

This study evaluates the diagnostic utility of PET/MRI for primary, locoregional, and nodal head and neck squamous cell carcinoma (HNSCC) through systematic review and metaanalysis. Methods: A systematic search was conducted using PubMed and Scopus to identify studies on the diagnostic accuracy of PET/MRI for HNSCC. The search included specific terms and excluded nonhybrid PET/MRI studies, and those with a sample size of fewer than 10 patients were excluded. Results: In total, 15 studies encompassing 638 patients were found addressing the diagnostic test accuracy for PET/MRI within the chosen subject domain. Squamous cell carcinoma of the nasopharynx was the most observed HNSCC subtype (n = 198). The metaanalysis included 12 studies, with pooled sensitivity and specificity values of 93% and 95% per patient for primary disease evaluation, 93% and 96% for locoregional evaluation, and 89% and 98% per lesion for nodal disease detection, respectively. An examination of a subset of studies comparing PET/MRI against PET/CT or MRI alone for evaluating nodal and locoregional HNSCC found that PET/MRI may offer slightly higher accuracy than other modalities. However, this difference was not statistically significant. Conclusion: PET/MRI has excellent potential for identifying primary, locoregional, and nodal HNSCC.

Tumor hypoxia, an integral biomarker to guide radiotherapy, can be imaged with ¹⁸F-fluoromisonidazole (¹⁸F-FMISO) hypoxia PET. One major obstacle to its broader application is the lack of standardized interpretation criteria. We sought to develop and validate practical interpretation criteria and a dedicated training protocol for nuclear medicine physicians to interpret ¹⁸F-FMISO hypoxia PET. Methods: We randomly selected 123 patients with human papillomavirus–positive oropharyngeal cancer enrolled in a phase II trial who underwent 123 ¹⁸F-FDG PET/CT and 134 ¹⁸F-FMISO PET/CT scans. Four independent nuclear medicine physicians with no ¹⁸F-FMISO experience read the scans. Interpretation by a fifth nuclear medicine physician with over 2 decades of ¹⁸F-FMISO experience was the reference standard. Performance was evaluated after initial instruction and subsequent dedicated training. Scans were considered positive for hypoxia by visual assessment if ¹⁸F-FMISO uptake was greater than floor-of-mouth uptake. Additionally, SUV_max was determined to evaluate whether quantitative assessment using tumor-to-background ratios could be helpful to define hypoxia positivity. Results: Visual assessment produced a mean sensitivity and specificity of 77.3% and 80.9%, with fair interreader agreement ( = 0.34), after initial instruction. After dedicated training, mean sensitivity and specificity improved to 97.6% and 86.9%, with almost perfect agreement ( = 0.86). Quantitative assessment with an estimated best SUV_max ratio threshold of more than 1.2 to define hypoxia positivity produced a mean sensitivity and specificity of 56.8% and 95.9%, respectively, with substantial interreader agreement ( = 0.66), after initial instruction. After dedicated training, mean sensitivity improved to 89.6% whereas mean specificity remained high at 95.3%, with near-perfect interreader agreement ( = 0.86). Conclusion: Nuclear medicine physicians without ¹⁸F-FMISO hypoxia PET reading experience demonstrate much improved interreader agreement with dedicated training using specific interpretation criteria.

Bispecific antibodies (bsAbs) are engineered to target 2 different epitopes simultaneously. About 75% of the 16 clinically approved bsAbs have entered the clinic internationally since 2022. Hence, research on biomedical imaging of various radiolabeled bsAb scaffolds may serve to improve patient selection for bsAb therapy. Here, we provide a comprehensive overview of recent advances in radiolabeled bsAbs for imaging via PET or SPECT. We compare direct targeting and pretargeting approaches in preclinical and clinical studies in oncologic research. Furthermore, we show preclinical applications of imaging bsAbs in neurodegenerative diseases. Finally, we offer perspectives on the future directions of imaging bsAbs based on their challenges and opportunities.

Following early acceptance by urologists, the use of surgical robotic platforms is rapidly spreading to other surgical fields. This empowerment of surgical perception via robotic advances occurs in parallel to developments in intraoperative molecular imaging. Convergence of these efforts creates a logical incentive to advance the decades-old image-guided robotics paradigm. This yields new radioguided surgery strategies set to optimally exploit the symbiosis between the growing clinical translation of robotics and molecular imaging. These strategies intend to advance surgical precision by increasing dexterity and optimizing surgical decision-making. In this state-of-the-art review, topic-related developments in chemistry (tracer development) and engineering (medical device development) are discussed, and future scientific robotic growth markets for molecular imaging are presented.

EU-Turkey Customs Union: Lessons for Brexit 15 March 2018 — 11:00AM TO 12:00PM Anonymous (not verified) 5 March 2018 Chatham House, London

Turkey and the EU are preparing to open negotiations to modernize their 22 year old customs union and expand its scope beyond goods to include services, public procurement and a more liberal regime for agriculture. At the same time, the UK is debating whether to seek a customs union with the EU to facilitate a frictionless flow of goods and to prevent a hard border with Ireland. The speaker will discuss Turkey’s customs union modernization agenda and share his insights on the lessons for the UK’s future relationship with the EU.

Attendance at this event is by invitation only.

Turkey Is on the Road to a Severe Economic Crisis Expert comment sysadmin 12 July 2018

The deteriorating state of the economy is President Erdoğan’s Achilles’ heel and the biggest threat to his currently unrivalled leadership.

Fifteen days after Turkey’s parliamentary and presidential elections, Turkish President Recep Tayyip Erdoğan appointed a new government under radically enhanced executive powers granted by the constitution. He chose 16 loyalists and partisan figures to ensure that he remains front and centre in decision-making and policy formation.

Most notably, Erdoğan sacrificed the former deputy prime minister and ex-Merrill Lynch chief economist Mehmet Şimşek in favour of his inexperienced son-in-law Berat Albayrak as finance and treasury minister to manage the fragile economy. Whether he has the competence to placate jittery financial markets and foreign investors is debatable.

Erdoğan will prioritize short-term growth at all costs to the detriment of macroeconomic and financial stability. That entails foregoing interest rate hikes needed to contain runaway double-digit inflation and to support a plummeting lira that depreciated nearly 20 per cent this year. It also means loosening the purse strings, flooding the markets with cheap credit and sponsoring rampant construction and mega-infrastructure projects.

True to his promise, he has appropriated to himself, by presidential decree, the right to hire the central bank governor, deputies and monetary policy committee members for a four-year term. This completes the politicization of the once-respected and independent central bank and is in line with his unorthodox monetary views that higher interest rates equates with higher inflation.

Erdoğan associates progress with gleaming high-rise buildings, gargantuan infrastructure show-pieces and elevated growth rates. He is spiking the fuel to boost the speed of the sputtering mid-sized Audi-style Turkish economy to achieve superior Ferrari growth rates. As any mechanic knows, these tactics are unsustainable in the long term. Eventually, the engine will burn out.

He does not seem to appreciate that Turkey’s growth model requires an overhaul to join the league of rich economies. It is too reliant on consumer spending and government-sponsored infrastructure and construction projects funded by speculative financial flows rather than on sustained private investment and exports.

Net result: the corporate sector’s foreign-exchange liabilities have climbed to a record $328 billion as of the end of 2017. When netted against foreign-exchange assets, it is still a worrying $214 billion. Its US dollar and euro debt pile has more than doubled since 2008, 80 per cent of which is held by domestic banks. Given these acute balance-of-payments conditions, it is not farfetched that Turkey may impose capital controls in the short-to-medium term to restrict the outflow of foreign assets. At $50 billion, the current account deficit – defined as the sum of the trade balance and financial flows – is not even covered by the central bank’s net international reserves at nearly $45 billion.

Unsurprisingly, some major Turkish companies are negotiating with their bondholders to restructure their sizeable foreign loan obligations as lira devaluation increases the financial burden. Should a significant number of Turkish corporates default on their foreign obligations, this would reverberate across the Turkish economy, cause mass consumer panic, shake the confidence of international financial markets and potentially lead to a crisis within the Turkish financial system and to a deep and prolonged economic recession.

Revealingly, Erdoğan’s nationalist allies, the Nationalist Movement Party (MHP), refused to join his government. Perhaps Devlet Bahçeli, the MHP leader, learned the lessons of the 2001 financial crisis as a member of a three-party government. So he is opting to project influence from the outside, rather than risk being tainted with responsibility for an economic downturn.

Turkey’s president is doubling down on his singular approach to governance irrespective of the fallout. Notwithstanding his current political dominance, the deteriorating state of the economy is his Achilles’ heel and the biggest threat to his currently unrivalled leadership.

EU-Turkey Customs Union: Prospects for Modernization and Lessons for Brexit 12 December 2018 — 12:30PM TO 1:30PM Anonymous (not verified) 26 November 2018 Chatham House | 10 St James's Square | London | SW1Y 4LE

Turkey and the EU have been in a customs union since 1995. Both sides recognize that the current agreement is in need of modernization and have agreed to open negotiations to expand its scope to include services, public procurement, agriculture and other elements that would help bring it into the 21st century.

At the same time, the UK Parliament is debating whether to approve the agreement on the UK’s withdrawal from the EU. It includes a backstop which – if triggered – would keep the UK and the EU in a single customs territory which would limit the disruption of withdrawal but hamper Britain’s ability to pursue an independent trade policy. The political declaration proposes building on this customs arrangement as the basis for the future relationship.

In this context, the speaker will discuss the current EU-Turkey customs union arrangement and its shortcomings, examine the prospects for its modernization and share his insights on the lessons for the UK’s future trading relationship with the EU.

The event will launch the briefing paper ‘EU-Turkey Customs Union: Prospects for Modernization and Lessons for Brexit’.

Attendance at this event is by invitation only.

Turkey's Foreign Policy in the Middle East 14 May 2019 — 12:30PM TO 1:30PM Anonymous (not verified) 29 April 2019 Chatham House | 10 St James's Square | London | SW1Y 4LE

Turkey is cooperating closely with Russia to secure its border with Syria and to encourage a long-term political resolution to the Syrian conflict. Its efforts have staved off a humanitarian catastrophe in the northern Syrian province of Idlib and initiated the trilateral ‘Astana Process’ with Russia and Iran as the primary framework to settle the future of Syria.

By contrast, Turkey and the US disagree on a range of important issues including Turkey’s purchase of the Russian-made S-400 air missile defence systems and American support for the PKK-affiliated Peoples’ Protection Units (YPG) in Syria.

In this session, the speaker will outline Turkey’s foreign policy priorities in the Middle East and share his country’s perspectives on the US and Russian policies in that region.

Attendance at this event is by invitation only.

A Credit-fuelled Economic Recovery Stores Up Trouble for Turkey Expert comment sysadmin 17 February 2020

Turkey is repeating the mistakes that led to the 2018 lira crisis and another freefall for the currency may not be far off.

Since the 2018 economic crisis, when the value of the lira plummeted and borrowing costs soared, Turkey’s economy has achieved a miraculous ‘V-shaped’ economic recovery from a recession lasting three quarters to a return back to quarterly growth above 1 per cent in the first three months of 2019.

But this quick turnaround has been built on vast amounts of cheap credit used to re-stimulate a consumption and construction boom. This so-called ‘triple C’ economy generated a rapid growth spurt akin to a modestly able professional sprinter injected with steroids.

This has made the currency vulnerable. The lira has steadily depreciated by 11 per cent against the US dollar since the beginning of 2019 and crossed the rate of 6 lira versus the US dollar on 7 February. And there are further warning signs on the horizon.

Credit bonanza

Statistics reveal that Turkish domestic credit grew by around 13 per cent on average throughout 2019. The credit bonanza is still ongoing. Mortgage-backed home sales jumped by a record high of 600 per cent last December alone and the 2019 budget deficit catapulted by 70 per cent due to higher government spending.

Turkey’s central bank fuelled this credit expansion by cutting interest rates aggressively to below inflation and, since the start of this year, purchasing lira-denominated bonds equivalent to around one-third of total acquisitions last year to push yields lower.

Equally, it has linked bank lending to reserve requirements – the money that banks have to keep at the central bank – to boost borrowings via state and private banks. Banks with a ‘real’ loan growth (including inflation) of between 5 and 15 per cent enjoy a 2 per cent reserve ratio on most lira deposits, which authorities adjusted from an earlier band of 10-20 per cent that did not consider double-digit inflation.

Cumulatively, bond purchases (effectively quantitative easing) and reserve management policies have also contributed to eased credit conditions.

Commercial banks have also reduced deposit rates on lira accounts to less than inflation to encourage consumption over saving. Together with low lending rates, the boost to the economy has flowed via mortgages, credit card loans, vehicle leasing transactions and general business borrowings.

Accordingly, stimulus is at the forefront of the government’s economic approach, as it was in 2017 and 2018. It does not seem to be implementing structural change to re-orient growth away from consumption towards productivity.

In addition, governance is, again, a central issue. President Recep Tayyip Erdogan’s near total monopolization of policymaking means he guides all domestic and external policies. He forced out the previous central bank governor, Murat Cetinkaya, in July 2019 because he did not share the president’s desire for an accelerated pace of interest rate reductions.

New challenges

Despite the similarities, the expected future financial turbulence will be materially different from its 2018 predecessor in four crucial respects.

Firstly, foreign investors will only be marginally involved. Turkey has shut out foreign investors since 2018 from lira-denominated assets by restricting lira swap arrangements. Unsurprisingly, the non-resident holdings of lira bonds has plummeted from 20 per cent in 2018 to less than 10 per cent today.

Secondly, the Turkish government has recently introduced indirect domestic capital controls by constraining most commercial transactions to the lira rather than to the US dollar or euro to reduce foreign currency demand in light of short-term external debt obligations of $191 billion.

Thirdly, the Turkish state banks are intervening quite regularly to soften Lira volatility, thereby transitioning from a ‘free float’ to a ‘managed float’. So far, they have spent over $37 billion over the last two years in a futile effort to buttress the lira. This level of involvement in currency markets cannot be maintained.

Fourthly, the Turkish state is being far more interventionist in the Turkish stock exchange and bond markets to keep asset prices elevated. Government-controlled local funds have participated in the Borsa Istanbul and state banks in sovereign debt to sustain rallies or reverse a bear market.

All these measures have one running idea: exclude foreign investors and no crisis will recur. Yet, when the credit boom heads to a downturn sooner or later, Turks will probably escalate lira conversions to US dollars; 51 per cent of all Turkish bank deposits are already dollar-denominated and the figure is still rising.

If Turkey’s limited foreign reserves cannot satisfy the domestic dollar demand, the government may have to impose comprehensive capital controls and allow for a double digit depreciation in the value of the lira to from its current level, with significant repercussions on Turkey’s political stability and economic climate.

To avoid this scenario, it needs to restore fiscal and monetary prudence, deal the with the foreign debt overhang in the private sector and focus on productivity-improving economic and institutional reforms to gain the confidence of global financial markets and Turks alike.

Turkey's Foreign Policy: The Perspective of the Main Opposition Party 5 November 2020 — 12:00PM TO 1:00PM Anonymous (not verified) 14 October 2020 Online

The Republican People’s Party (CHP), the main Turkish opposition party, is becoming a serious contender for a leading role in the country’s politics.

This is an online only event.

CHP’s mayoral candidates defeated the Justice and Development Party (AKP) incumbents in the 2019 local elections in Ankara and Istanbul, which held both cities for a quarter of a century. Its ascendency in Turkish politics is improving prospects for a CHP-led government after the next general election in 2023.

In this webinar, the speaker will share CHP’s stance on the country’s foreign policy towards key regional allies in Europe, as well as its take on relations with Russia, the US and Turkey’s position and role in the Middle East. Finally, the speaker will share how CHP’s external policy might differ from the ruling AKP. 

Turkey-Russia Relations: A Marriage of Convenience? 26 November 2020 — 12:00PM TO 1:30PM Anonymous (not verified) 17 November 2020 Chatham House

Speakers discuss the complex but, so far, durable ties between Putin and Erdogan and the perspectives of each leader. Other issues will include the impact of the Biden presidency and the unfolding situation in Nagorny Karabakh.

This is an online only event

Russia-Turkey relations are governed by a unique dynamic between presidents Vladimir Putin and Recep Tayyip Erdogan. They pursue contrasting objectives in Libya, the Eastern Mediterranean, Caucasus and Ukraine; yet they have managed to compartmentalize their differences to avoid any spill-over into diplomatic, military and economic cooperation.

Erdogan purchased the Russian S400 missile defence system at the cost of ejection from the US-led fourth generation F35 stealth fighter programme; and at the risk of sanctions by Washington. Russia is also proceeding with the construction of the Akkuyu Nuclear Power Plant near Turkey’s Mediterranean coast.

Turkey Needs Radical New Direction to Save the Economy Expert comment NCapeling 23 November 2020

Turkey should emulate the reformist approach it adopted after the 2001 crisis to prevent an economic and financial breakdown - but this looks highly unlikely.

Although Ankara has witnessed what appears to be an abrupt change of its top economic team with two fresh appointments to key positions – Naci Ağbal as governor of the central bank and Lütfi Elvan as finance and treasury minister – a cardinal rule of thumb in Turkish politics is that the more drama one sees, the less policy change there will actually be.

Financial markets reacted positively to the moves in the expectation they will signal a change of Turkey’s overall economic approach, but the reality is Turkish president Recep Tayyip Erdoğan is simply putting loyalists into key bureaucratic positions to help ensure the primary role of these functions becomes ‘selling’ his policies more effectively, rather than altering them.

The hope from the markets – which saw the beleaguered Turkish lira appreciate against the US dollar at the news – is that Turkey adopts substantial interest rate increases as well as measures to repress liquidity expansion in order to temper its controversial so-called ‘Triple C’ approach of using cheap credit to stimulate growth with an unsustainable consumption and construction boom.

But instead, Erdoğan’s declaration after the appointments were made indicates the new restrictions in which they will now operate, saying ‘we are in a historic struggle against those who want to force Turkey into modern capitulations through the shackles of interest rates, foreign exchange rates and inflation’.

Learn from past successes

To resolve its current underlying economic problems, Turkey should actually be looking to its recent past and aiming to emulate the approach pursued by former prime minister Bülent Ecevit during the 2001 financial crisis when he recruited Kemal Derviş, a senior World Bank official with extensive experience and international contacts in economic, financial, and monetary affairs.

As economy minister with a broad mandate to spearhead a durable economic recovery plan, Dervis established independent market regulatory agencies covering banking, telecommunications, energy, and other key sectors, and strengthened the competition authority.

He also either liquidated or merged insolvent banks, granted central bank autonomy to guarantee price stability, and ensured recruitment was based on competence, expertise, and meritocracy. Crucially, his productivity-enhancing restructuring blueprint was designed in Turkey rather than being imposed by the International Monetary Fund (IMF) or another external agency.

Ecevit also turbocharged reforms motivated in part by a desire to join the EU with constitutional, political and legal modernization which widened personal freedom, significantly curtailed capital punishment, liberalized the cultural environment for Kurds, and fortified the rule of law. And one of his coalition partners in that work, the right-wing pro-Turkish National Action Party (MHP), is now allied with the current ruling Justice and Development Party (AKP).

His foreign minister Ismail Cem also enhanced Turkey’s relations with both Europe and the US, initiated the so-called ‘earthquake diplomacy’ with his Greek counterpart George Papandreou after twin tragedies struck both nations in 1999, and largely avoided entanglement in Middle Eastern conflicts.

The net result of all these actions was that Turkey emerged from the crisis with greater resilience, a more robust regulatory framework, upgraded political and economic institutions, rapidly decreasing inflation, a credible central bank, a stronger financial system, closer relations with the EU and US, and heightened domestic and foreign investor confidence.

But now that similar woes are engulfing Turkey anew, is Erdogan and the AKP/MHP alliance able – and willing – to repeat the Ecevit recipe? Present signs indicate they are highly unlikely to as they are too committed to entrenching the Triple C model.

Although this model will likely further consolidate their power, it will also empty the civil service of qualified professionals, restrict civil liberties and freedoms, and create more ideological politics, affecting Turkey’s foreign policy.

Such a stubborn refusal to shift direction is increasing the inevitability of a deep economic and financial breakdown and so, unless Turkey undertakes a serious policy departure instead of continuing to resort to the quick fix approach, there is real likelihood it will simply accelerate towards disaster.

Turkey’s foreign and domestic policy: A story of mutual creation? 1 November 2022 — 2:00PM TO 3:00PM Anonymous (not verified) 12 October 2022 Online

Panellists discuss the link between Turkey’s domestic and foreign policies under President Erdoğan.

From Turkey’s ongoing rapprochement with its erstwhile Middle Eastern antagonists to its Syria policy and earlier approach towards the West, there has been extensive discussion on the domestic drivers behind Ankara’s foreign policy.

Less discussed but no less important is how Turkish foreign affairs have shaped its internal politics. Under the rule of the Justice and Development Party (AKP) government and President Recep Tayyip Erdoğan, Turkey’s foreign and domestic policies have mutually reshaped each other.

In this webinar, launching Gönül Tol’s new book Erdoğan’s War: A Strongman’s Struggle at Home and in Syria, panellists will take stock of how Turkey’s domestic and foreign policies under the leadership of President Erdoğan have influenced and shaped each other. Speakers will also discuss the internal drivers behind Turkey’s current reset in relations with the Middle East, and examine how Ankara’s foreign affairs play into the country’s political and identity fault lines.

The event will be held on the record and will be live-streamed on the MENA Programme’s Facebook page.

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