Russia and 9/11: Roads not taken Expert comment NCapeling 9 September 2021

Many Russia watchers recall the fleeting moment 20 years ago when the country could have moved away from a path of confrontation with the US.

On 12 September 2001, Russian president Vladimir Putin was the first foreign leader to call George W. Bush to express his condolences – and to offer him support.

Just the previous year, Putin had said Russia joining NATO was a possibility and it suited Russia to draw parallels between the terrorist attacks on the US and its own ‘anti-terrorist’ campaign in Chechnya at the time.

Even though much of the Russian commentary about 9/11 professed empathy rather than sympathy, in their eyes the US was both a victim – as Russia likes to see itself – and ‘had it coming’ while Russia was blameless.

At that time, many in the West were still tempted by the idea Putin’s Russia might develop in a liberal direction, and Putin himself wanted to be seen as constructive especially after Chechnya. He may also have also assumed that, if Russia joined the international alliance, it would be as a co-leader with the US.

An offer which was never stated

Whether he was sincere in his condolences or not, Putin was of course not offering something for nothing – but then few countries ever do. Although less than one-tenth into his time in control of Russia (so far), Putin was still feeling his way but was not a naive president having already been through the controversial sinking of the Kursk submarine.

His first move was to facilitate access to bases in Central Asia for the US campaign in Afghanistan – vital initially but less so later. Apparently, this offer was against the wishes of many of his senior military commanders – although the extent to which it was in his gift to grant such access is questionable.

The quid pro quo, unstated and only dawning on Washington much later, was for the US to keep out of what Russia saw – and still sees – as its backyard. Putin probably misjudged that the US would have neither the inclination nor the capacity to be in that region for anything other than supply chain purposes. And he hoped America now needed Russia after the humiliations of the 1990s.

Common interests could once have been the basis of a partnership with Russia; but to Moscow that meant a partnership of equals which recognized the Kremlin’s self-declared right to conduct out-of-area operations. But the US took a different view and, with nothing written down and no memorandum ever signed, the ensuing disappointment for Russia was gradual but inexorable.

A purely practical reason for declining the ‘offer’ was that, despite its own illusions, Russia had little to bring to the table which was useful and could be offered on acceptable terms. Subsequent initiatives – from specific joint terrorism initiatives to a ‘grand reset’ – could not narrow differences to the point where the character of the relationship changed.

The Northern Distribution Network for supplying US forces in Afghanistan – Russia’s most practical contribution to the notional common cause – took almost a decade to be established and was plagued by problems which often come with a dependence on Russian goodwill.

The Kremlin also had the pleasure of watching US hubris lead to failure in Iraq. And, although knowing the US intervention in Afghanistan would never end well, even Russia could not have foreseen the scale of the defeat and humiliation of chaotic withdrawal.

US achievements with Russia’s neighbours

When it comes to Russia’s post 9/11 ‘offer’ and subsequent expectations, many of the other newly independent countries might never have achieved what they have over the past 20 years if the US had agreed – tacitly or otherwise – to sit back and accept Moscow’s droit de regard over them.

From the Kremlin’s perspective, these states were Russia’s ‘kith and kin’ but it underestimated US willingness to support smaller states over a ‘great power’ – especially as George H.W. Bush pleaded to those states not to go too far too fast. Albeit uneven, most have benefitted from US support for their own independence as well as practical assistance to strengthen their institutions and diversify external relationships.

The three Baltic states consolidated their democracies while their economies, which severed many ties with Russia early, are flourishing and prosperous in contrast to those still in the Russian orbit. They are not only members of NATO and the European Union (EU) but have on occasion been moral leaders as in the case of Lithuania facing down both Belarus and China.

Ukraine has undergone two revolutions in attempting to follow the paths of the Baltic states that continues today. After many false starts Moldova has undergone a similar change recently but at the ballot box not on the streets, to give itself another shot at the prize of true democracy and international acceptance.

Georgia conducted the most radical governance reforms seen in the region after its own revolution although it has taken a few steps backwards of late. Kazakhstan and Uzbekistan have strengthened their independence since then and adjusted their modus vivendi with Russia to their advantage. Putin would hardly be able to give the same assurances about use of bases there today – and indeed reportedly brushed off a request by Biden to use them in the current withdrawal.

Only a minority of formerly Soviet republics have made no progress whatsoever at the governmental level – Belarus and Turkmenistan for sure, perhaps Azerbaijan and Tajikistan too depending on the criteria.

The roads not taken

America’s failure was not so much rejecting Russia’s offer of partnership but failing to pay sufficient attention to it because Russia was still regarded as weak despite being relatively strong in its immediate neighbourhood.

The question of whether it was worth alienating Russia is a moral one. Refusing to sign the Paris Charter – which recognizes the right of independent states to form their own alliances – would have been a further betrayal of people who have long been subjected to their future being decided by stronger powers around them. But Russia may have chosen a path of confrontation anyway as, for the Kremlin, suzerainty over its former republics is considered an entitlement which comes with being a great power.

Although impossible to conclusively prove, all previous frameworks of Russian assumptions and habits of Russian behaviour indicate Moscow would have pocketed the deal and simply moved on anyway. It certainly seems likely that Russia’s other outrages and offenses over the years – from the murders of Litvinenko and Skripal in the UK to the manipulation of information and elections – would still have occurred even if a shabby deal had been made over the heads of the new states on Russia’s borders.

The atrocity of 9/11 was really an opportunity for Russia, a genuine potential turning point and a chance to create a new relationship with the outside world – but its expectations were unrealistic. Russia blew it with demands at the time that could not be met – and rightly were not met. The US rarely receives credit for withstanding Russian blandishments at a moment when its own aura of strength had been so cruelly and effectively punctured by the most brazen of attacks.

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.

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