Introduction:

There is an Egyptian proverb that says those who worry about demons will tend to run into them. Like much folk wisdom, it has solid psychological foundations; the likelihood of a problem rearing its head often appears to be exacerbated by constantly fretting about it. Ever since Hosni Mubarak stepped down as president of Egypt on February 11, 2011, the demon named “Now What?” has been keeping the Israeli government up at night. On August 18, it finally leapt up at them.

That day, a group of armed men attacked Israeli buses, as well as civilian and military vehicles north of Eilat, near the Egyptian border. Eight Israelis, both civilians and soldiers, were killed. The Israel Defense Forces (IDF) set off in hot pursuit, shooting at the attackers from a helicopter. The helicopter crew either failed to notice, or ignored, that they were shooting over the Egyptian side of the border. In the pursuit, three Egyptians— an officer and two enlisted men—were killed and another three later died of their wounds. Israeli minister of defense Ehud Barak, while blaming Palestinian groups for the assault, made comments to the effect that the attacks were largely Egypt’s fault as there had been a major security collapse in Egypt since the former regime had been ousted six months earlier.

The way matters unfolded over the next few days pointedly illustrated the answer to a question that had been asked repeatedly both by international media and the Israeli government since Hosni Mubarak’s ouster: What did Egypt’s January 25 Revolution mean for Israel? The simplest answer is that it is no longer business as usual. The relationship between Egypt and Israel has changed and both countries will have to navigate new waters carefully and wisely.

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Much public focus is being given to a broader role for hospitals in improving the health of their communities. This focus parallels a growing interest in addressing the social determinants of health as well as health care policy reforms designed to increase the efficiency and quality of care while improving health outcomes.

This interest in the community role of hospitals has drawn attention to the federal legal standards and requirements for nonprofit hospitals seeking federal tax exemption. Tax-exempt hospitals are required to provide community benefits. And while financial assistance to patients unable to pay for care is a basic requirement of tax-exemption, IRS guidelines define the concept of community benefit to include a range of community health improvement efforts.

At the same time, the IRS draws a distinction between community health improvement spending–which it automatically considers a community benefit–and certain “community-building” activities where additional information is required in order to be compliant with IRS rules. In addition, community benefit obligations are included in the Affordable Care Act (ACA).

Specifically, the ACA requires nonprofit hospitals periodically to complete a community health needs assessment (CHNA), which means the hospital must conduct a review of health conditions in its community and develop a plan to address concerns. While these requirements are causing hospitals to look more closely at their role in the community, challenges remain. For instance, complex language in the rules can mean hospitals are unclear what activities and expenditures count as a “community benefit.” Hospitals must take additional steps in order to report community building as community health improvement.

These policies can discourage creative approaches. Moreover, transparency rules and competing hospital priorities can also weaken hospital-community partnerships. To encourage more effective partnerships in community investments by nonprofit hospitals:

• The IRS needs to clarify the relationship between community spending and the requirements of the CHNA. 
• There needs to be greater transparency in the implementation strategy phase of the CHNA. 
• The IRS needs to broaden the definition of community health improvement to encourage innovation and upstream investment by hospitals.

Download "Hospitals as Community Hubs: Integrating Community Benefit Spending, Community Health Needs Assessment, and Community Health Improvement" »

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President Obama is right to keep at it in Afghanistan, argues a new policy brief by Michael O’Hanlon, senior fellow and director of research for the Brookings Foreign Policy program.

Some have criticized the president’s decision to maintain a significant troop presence there (5,500 troops), instead of following through on the planned military withdrawal. But Afghanistan remains very important to American security, O’Hanlon contends, and the situation in the country is far from hopeless in spite of recent setbacks. We should reinvigorate American efforts in Afghanistan, he argues—not returning to levels seen in previous years, but ramping up somewhat from our current posture.

O’Hanlon calls Obama’s resolve in Afghanistan commendable, but writes that he and his administration are still making mistakes on U.S. policy toward the war-torn country. He advises that Washington make two specific changes to its military strategy in Afghanistan:

1. Allow U.S. and NATO airpower to target the Islamic State and the Taliban (currently, they can only fight those groups if directly attacked). The narrow rules of engagement constraining foreign forces were intended to push Afghan armed forces to defend their territory themselves. While a worthy goal, O’Hanlon says, these rules often prevent us from attacking ISIS (though the targeting strategy towards the group may be changing) as well as the Taliban. They also impose unrealistically high demands on Afghan forces and make too fine a distinction between an array of aligned extremist groups operating in the country.
2. Expand U.S. force presence from the current 5,500 troops to around 12,000 for a few years. In O’Hanlon’s opinion, our current numbers are not enough to work with fielded Afghan forces, and skimping on ground forces has contributed to security challenges in places like Helmand, for instance, which experienced new setbacks in 2015. More broadly, leaders in Washington and Brussels should stress the value of a long-term NATO-Afghanistan partnership, rather than emphasizing an exit strategy. This will signal Western resolve to the Taliban and other groups. While the next commander in chief should set the United States on a gradual path toward downsizing American troops in Afghanistan, he believes it would be a mistake for Obama to do so in the short term.

The long haul

O’Hanlon also argues that the United States needs to take a longer-term perspective on key political and economic issues in Afghanistan. On the economic front, there seems to be little thinking about an agricultural development plan for Afghanistan, associated infrastructure support, and land reform, among other challenges. On the political front, conversations often tend to focus on shorter-term issues like organizing parliamentary elections, reforming the Independent Election Commission, or modifying the current power-sharing arrangement. In the process, conversations about foundational political strategy focusing on Afghan institutions and the health of its democracy get short-changed. The parliament is in need of reforms, for instance, as is the political party system (which should encourage Afghans to group around ideas and policy platforms, rather than tribes and patronage networks).

O’Hanlon concludes that the situation in Afghanistan today, while fraught, is understandable given the Taliban’s resilience and NATO’s gradual withdrawal of 125,000 troops. We should not be despondent, he writes—rather, we should identify specific strategies that can help improve the situation. At the end of the day, Afghans must make the big decisions about the future of their country. But as long as the United States and its partners are still providing tremendous resources—and as long as security threats emanating from South Asia continue to threaten the United States—leaders in Washington should use their influence wisely.

Event Information

On July 20 and 21, defense ministers from several nations will gather in Washington, D.C. at the invitation of U.S. Secretary of Defense Ash Carter. The meeting will bring together representatives from countries working to confront and defeat the Islamic State (or ISIL). French Defense Minister Jean-Yves Le Drian will be among those at the summit discussing how to accelerate long-term efforts to fight ISIL in Iraq and Syria. The close relationship between France and the United States has provided a solid base for security cooperation for decades, and in recent years, France has become one of America’s strongest allies in fighting terrorism and a prominent member of the international coalition to defeat ISIL.

On July 20, the Foreign Policy program at Brookings hosted Minister Le Drian for a discussion on French and U.S. cooperation as the two countries face multiple transnational security threats. Since becoming France’s defense minister in 2012, Le Drian has had to address numerous new security crises emerging from Africa, the Middle East, and within Europe itself. France faced horrific terrorist attacks on its own soil in January and November 2015 and remains under a state of emergency with its armed forces playing an active role in maintaining security both at home and abroad. Le Drian recently authored “Qui est l’ennemi?” (“Who is the enemy?”, Editions du Cerf, May 2016), defining a comprehensive strategy to address numerous current threats.

Join the conversation on Twitter using #USFrance

Video

• Introduction and featured speaker
• Discussion
• Introduction et conférencier invité
• Débat

Transcript

• Uncorrected Transcript (.pdf)

Event Materials

• 20160720_france_defense_transcript

Is it possible to isolate the well-established mode of Arctic cooperation from the disruptive impact of the Ukraine crisis? Many stake-holders in cooperative projects with Russia keep insisting on an affirmative answer and seek to bracket out tensions emanating from such obscure locations as Debaltsevo or Mariupol. The European Union (EU), which is due to adopt a new Arctic Policy by the end of the year, would have been content to maintain the focus on environmental protection and economic development; the discussions in Brussels, however, have increasingly shifted to far less appealing “hard security” matters. Officials from the European Commission seem deeply reluctant to deal with Russia’s military activities in the high north but have to acknowledge that they are making it much more difficult to cooperate with Russia. As April’s Arctic Council ministerial meetings approach, the United States and Europe must be realistic about the ways in which far away events will negatively affect the possible achievement of their goals. 

Moscow is expanding rather than camouflaging the scope of exercises undertaken by its newly-formed Arctic Joint Strategic Command. Russian President Vladimir Putin used to proudly proclaim Russia’s abiding interest in Arctic cooperation, but even the most pro-engagement Arctic partners cannot fail to see that Russia’s interest is clearly slackening. This may be partly due to the disappearing attractiveness of exploration of the Arctic resources, since the estimated production costs of the off-shore platforms go far beyond the expected returns on the current level of oil prices. Another reason may be the disappointment in the commercial prospects of the Northern Sea Route (or Sevmorput), where maritime transit contracted by an astounding 77 percent in 2014, after several years of promising growth. A further reason may be Moscow’s recognition that the much trumpeted (and still not submitted) claim for expanding its “ownership” over the Arctic shelf cannot be legally approved because Denmark has presented its own claim, and the U.N. Commission on the Limits of the Continental Shelf cannot make any recommendations on clashing claims.

It is hard to find an active lobby in Russia for sustaining cooperative projects or at least the joint work in the Arctic Council, as many actors who promoted the Barents Cooperation in the 1990s, are either on a short leash (as is the case with regional governors) or branded as “foreign agents” (the NGOs that want to avoid such branding have to curtail or cut ties with Western colleagues). The appointment of Dmitri Rogozin as a chair of the new government commission on Arctic matters bodes ill for the cooperative endeavors because this firebrand “patriot” deservedly holds a spot on U.S., EU, and Canadian sanctions lists. 

The Russian Foreign Ministry is still circulating a message of commitment to the Arctic dialogue. The forthcoming session of the Arctic Council ministers in Iqaluit, Nunavut, Canada, might test this commitment with the issue of granting observer status to the EU. It was Canada who blocked the resolution of this issue at the previous meeting in Kiruna, Sweden, in 2013, but the controversy about seal products has been resolved, and Canada is ready to put the question on the agenda as its chairmanship of the Council expires. European Commission officials expect that during the 2015 meeting, Russia will raise objections because the EU is now seen as an antagonist, but EU officials still feel it is important to force Moscow to put their opposition on the record.

One external party that aims at enhancing and also at reformatting the Arctic cooperation is China, and while Moscow has to show eager attention to Beijing’s opinions, it cannot be comfortable with this “encroachment.” Russia’s traditional position has been that Arctic matters were the responsibility of the littoral states, but China insists on having a say and even entertains notions of the high north as a “global common,” a prospect which Moscow finds hard to swallow. 

It is indeed futile to praise the value of cooperative ties when seven members of the Arctic Council are compelled to tighten step by step the regime of sanctions against the eighth member, which is sinking into a deep economic crisis but persists in building its power projection capabilities in the High North. The usefulness of engaging Russia is beyond doubt, but it would be irresponsible to expect that joint projects in monitoring climate change could reduce the risks from expanding Russian military activities. The high north is one area where Moscow fancies itself to be in a position of power, but so far it has not found a way to enjoy it. It is not my intention to give the Kremlin war-mongers ideas about putting this military advantage to good political use, but when the likes of Rogozin or Nikolai Patrushev (secretary of the Security Council and former head of the Russian Federal Security Service) profess particular interest in the Arctic, it is only prudent to expect a brainstorm of sorts. The technique of “hybrid war” is not only the continuation but also a driver of Putin’s politics of confrontation, and this drive transforms the unique Arctic landscapes into just another “theater.”

Event Information

Antibacterial drugs are a critical component of the nation’s public health armamentarium, and have saved millions of lives by preventing and treating a range of bacterial infections. However, antibacterial drug development has been hampered by challenges unique to the antibacterial drug market, which have stifled innovation and left patients and providers with fewer options to treat increasingly resistant infections. One consequence of the dwindling antibacterial drug pipeline has been a reduction in effective oral antibacterial drug treatment options, which are particularly important in the ambulatory and transitional care contexts. Recent proposals to re-invigorate the antibacterial pipeline are geared towards serious infections treated in the inpatient setting, which may lead to a greater focus on intravenous therapies. However, addressing both current and future needs in the infectious diseases space will require a balanced mix of both oral and parenteral antibacterial drugs.

In cooperation with the U.S. Food and Drug Administration (FDA), the Engelberg Center for Health Care Reform at Brookings held an expert workshop on November 20, 2014, to identify the most promising strategies to support oral antibacterial drug development. Participating stakeholders included experts from the drug development and health care industries, the clinical community, government, and academia. These stakeholders shared their insights on potential regulatory, scientific, and economic strategies to reinvigorate the oral antibacterial drug pipeline. 

Event Materials

• Reinvigorating the Oral Antibacterial Drug Development Pipeline Agenda
• Reinvigorating the Oral Antibacterial Drug Development Pipeline Discussion Guide
• Biographies 20141118
• Reinvigorating the Oral Antibacterial Drug Development Pipeline Slide Deck

Event Information

The Risk Evaluation and Mitigation Strategies (REMS) program has become an important tool of the U.S. Food and Drug Administration (FDA) in ensuring that the benefits of a given medical product outweigh the associated risks, and has enabled FDA to approve a number of products that might not otherwise have been made available for patient use. Since the implementation of the REMS program, however, concerns have been raised regarding its impact on patient access to products and the associated burden on providers and health care systems. In an effort to address these concerns—and as part of its commitments under the Prescription Drug User Fee Act reauthorization of 2012—FDA has undertaken efforts to standardize and improve the effectiveness of REMS, and to better integrate REMS programs into the health system. As part of this broader initiative, the Agency is currently assessing the feasibility of integrating accredited continuing education (CE) programs and activities into REMS programs that have been developed for a single drug.

Under a cooperative agreement with the FDA, the Center for Health Policy held an expert workshop on May 18, titled “Incorporating Continuing Education into Single-Drug REMS: Exploring the Challenges and Opportunities”. This workshop provided an opportunity for pharmaceutical manufacturers, regulators, CE providers, accreditors, and other stakeholders to explore the ways that CE can be a valuable addition to the REMS toolkit, discuss potential barriers to the development and implementation of REMS-related CE for single products, and identify strategies for addressing those barriers.

Event Materials

• Bio sheet
• REMS CE Meeting Agenda
• REMS_CE_Meeting_Discussion_Guide_Final
• REMS CE Meeting Summary

The Risk Evaluation and Mitigation Strategies (REMS) program has become an important tool of the U.S. Food and Drug Administration (FDA) in ensuring that the benefits of a given medical product outweigh the associated risks, and has enabled FDA to approve a number of products that might not otherwise have been made available for patient use. Since the implementation of the REMS program, however, concerns have been raised regarding its impact on patient access to products and the associated burden on providers and health care systems. In an effort to address these concerns—and as part of its commitments under the Prescription Drug User Fee Act reauthorization of 2012—FDA has undertaken efforts to standardize and improve the effectiveness of REMS, and to better integrate REMS programs into the health system. As part of this broader initiative, the Agency is currently assessing the feasibility of integrating accredited continuing education (CE) programs and activities into REMS programs that have been developed for a single drug.

Under a cooperative agreement with the FDA, the Center for Health Policy held an expert workshop on May 18 titled, “Incorporating Continuing Education into Single-Drug REMS: Exploring the Challenges and Opportunities”. This workshop provided an opportunity for pharmaceutical manufacturers, regulators, CE providers, accreditors, and other stakeholders to explore the ways that CE can be a valuable addition to the REMS toolkit, discuss potential barriers to the development and implementation of REMS-related CE for single products, and identify strategies for addressing those barriers.

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President Obama is right to keep at it in Afghanistan, argues a new policy brief by Michael O’Hanlon, senior fellow and director of research for the Brookings Foreign Policy program.

Some have criticized the president’s decision to maintain a significant troop presence there (5,500 troops), instead of following through on the planned military withdrawal. But Afghanistan remains very important to American security, O’Hanlon contends, and the situation in the country is far from hopeless in spite of recent setbacks. We should reinvigorate American efforts in Afghanistan, he argues—not returning to levels seen in previous years, but ramping up somewhat from our current posture.

O’Hanlon calls Obama’s resolve in Afghanistan commendable, but writes that he and his administration are still making mistakes on U.S. policy toward the war-torn country. He advises that Washington make two specific changes to its military strategy in Afghanistan:

1. Allow U.S. and NATO airpower to target the Islamic State and the Taliban (currently, they can only fight those groups if directly attacked). The narrow rules of engagement constraining foreign forces were intended to push Afghan armed forces to defend their territory themselves. While a worthy goal, O’Hanlon says, these rules often prevent us from attacking ISIS (though the targeting strategy towards the group may be changing) as well as the Taliban. They also impose unrealistically high demands on Afghan forces and make too fine a distinction between an array of aligned extremist groups operating in the country.
2. Expand U.S. force presence from the current 5,500 troops to around 12,000 for a few years. In O’Hanlon’s opinion, our current numbers are not enough to work with fielded Afghan forces, and skimping on ground forces has contributed to security challenges in places like Helmand, for instance, which experienced new setbacks in 2015. More broadly, leaders in Washington and Brussels should stress the value of a long-term NATO-Afghanistan partnership, rather than emphasizing an exit strategy. This will signal Western resolve to the Taliban and other groups. While the next commander in chief should set the United States on a gradual path toward downsizing American troops in Afghanistan, he believes it would be a mistake for Obama to do so in the short term.

The long haul

O’Hanlon also argues that the United States needs to take a longer-term perspective on key political and economic issues in Afghanistan. On the economic front, there seems to be little thinking about an agricultural development plan for Afghanistan, associated infrastructure support, and land reform, among other challenges. On the political front, conversations often tend to focus on shorter-term issues like organizing parliamentary elections, reforming the Independent Election Commission, or modifying the current power-sharing arrangement. In the process, conversations about foundational political strategy focusing on Afghan institutions and the health of its democracy get short-changed. The parliament is in need of reforms, for instance, as is the political party system (which should encourage Afghans to group around ideas and policy platforms, rather than tribes and patronage networks).

O’Hanlon concludes that the situation in Afghanistan today, while fraught, is understandable given the Taliban’s resilience and NATO’s gradual withdrawal of 125,000 troops. We should not be despondent, he writes—rather, we should identify specific strategies that can help improve the situation. At the end of the day, Afghans must make the big decisions about the future of their country. But as long as the United States and its partners are still providing tremendous resources—and as long as security threats emanating from South Asia continue to threaten the United States—leaders in Washington should use their influence wisely.

Event Information

On July 20 and 21, defense ministers from several nations will gather in Washington, D.C. at the invitation of U.S. Secretary of Defense Ash Carter. The meeting will bring together representatives from countries working to confront and defeat the Islamic State (or ISIL). French Defense Minister Jean-Yves Le Drian will be among those at the summit discussing how to accelerate long-term efforts to fight ISIL in Iraq and Syria. The close relationship between France and the United States has provided a solid base for security cooperation for decades, and in recent years, France has become one of America’s strongest allies in fighting terrorism and a prominent member of the international coalition to defeat ISIL.

On July 20, the Foreign Policy program at Brookings hosted Minister Le Drian for a discussion on French and U.S. cooperation as the two countries face multiple transnational security threats. Since becoming France’s defense minister in 2012, Le Drian has had to address numerous new security crises emerging from Africa, the Middle East, and within Europe itself. France faced horrific terrorist attacks on its own soil in January and November 2015 and remains under a state of emergency with its armed forces playing an active role in maintaining security both at home and abroad. Le Drian recently authored “Qui est l’ennemi?” (“Who is the enemy?”, Editions du Cerf, May 2016), defining a comprehensive strategy to address numerous current threats.

Join the conversation on Twitter using #USFrance

Video

• Introduction and featured speaker
• Discussion
• Introduction et conférencier invité
• Débat

Transcript

• Uncorrected Transcript (.pdf)

Event Materials

• 20160720_france_defense_transcript

Event Information

On July 20 and 21, defense ministers from several nations will gather in Washington, D.C. at the invitation of U.S. Secretary of Defense Ash Carter. The meeting will bring together representatives from countries working to confront and defeat the Islamic State (or ISIL). French Defense Minister Jean-Yves Le Drian will be among those at the summit discussing how to accelerate long-term efforts to fight ISIL in Iraq and Syria. The close relationship between France and the United States has provided a solid base for security cooperation for decades, and in recent years, France has become one of America’s strongest allies in fighting terrorism and a prominent member of the international coalition to defeat ISIL.

On July 20, the Foreign Policy program at Brookings hosted Minister Le Drian for a discussion on French and U.S. cooperation as the two countries face multiple transnational security threats. Since becoming France’s defense minister in 2012, Le Drian has had to address numerous new security crises emerging from Africa, the Middle East, and within Europe itself. France faced horrific terrorist attacks on its own soil in January and November 2015 and remains under a state of emergency with its armed forces playing an active role in maintaining security both at home and abroad. Le Drian recently authored “Qui est l’ennemi?” (“Who is the enemy?”, Editions du Cerf, May 2016), defining a comprehensive strategy to address numerous current threats.

Join the conversation on Twitter using #USFrance

Video

• Introduction and featured speaker
• Discussion
• Introduction et conférencier invité
• Débat

Transcript

• Uncorrected Transcript (.pdf)

Event Materials

• 20160720_france_defense_transcript

Event Information

On July 20 and 21, defense ministers from several nations will gather in Washington, D.C. at the invitation of U.S. Secretary of Defense Ash Carter. The meeting will bring together representatives from countries working to confront and defeat the Islamic State (or ISIL). French Defense Minister Jean-Yves Le Drian will be among those at the summit discussing how to accelerate long-term efforts to fight ISIL in Iraq and Syria. The close relationship between France and the United States has provided a solid base for security cooperation for decades, and in recent years, France has become one of America’s strongest allies in fighting terrorism and a prominent member of the international coalition to defeat ISIL.

On July 20, the Foreign Policy program at Brookings hosted Minister Le Drian for a discussion on French and U.S. cooperation as the two countries face multiple transnational security threats. Since becoming France’s defense minister in 2012, Le Drian has had to address numerous new security crises emerging from Africa, the Middle East, and within Europe itself. France faced horrific terrorist attacks on its own soil in January and November 2015 and remains under a state of emergency with its armed forces playing an active role in maintaining security both at home and abroad. Le Drian recently authored “Qui est l’ennemi?” (“Who is the enemy?”, Editions du Cerf, May 2016), defining a comprehensive strategy to address numerous current threats.

Join the conversation on Twitter using #USFrance

Video

• Introduction and featured speaker
• Discussion
• Introduction et conférencier invité
• Débat

Transcript

• Uncorrected Transcript (.pdf)

Event Materials

• 20160720_france_defense_transcript