In December 2009, the Saban Center for Middle East Policy conducted a day-long simulation of the diplomatic and military fallout that could result from an Israeli military strike against the Iranian nuclear program. In this Middle East Memo, Kenneth M. Pollack analyzes the critical decisions each side made during the wargame.

The simulation was conducted as a three-move game with three separate country teams. One team represented a hypothetical American National Security Council, a second team represented a hypothetical Israeli cabinet, and a third team represented a hypothetical Iranian Supreme National Security Council. The U.S. team consisted of approximately ten members, all of whom had served in senior positions in the U.S. government and U.S. military. The Israel team consisted of a half-dozen American experts on Israel with close ties to Israeli decision-makers, and who, in some cases, had spent considerable time in Israel. Some members of the Israel team had also served in the U.S. government. The Iran team consisted of a half-dozen American experts on Iran, some of whom had lived and/or traveled extensively in Iran, are of Iranian extraction, and/or had served in the U.S. government with responsibility for Iran.

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The potential for confrontation between the United States and Iran, stemming from ongoing tensions over Iran’s nuclear program and western covert actions intended to delay or degrade it, remains a pressing concern for U.S. policymakers. The Saban Center for Middle East Policy hosted a one-day crisis simulation in September that explored different scenarios should a confrontation occur.

The Saban Center's new Middle East Memo, A Series of Unfortunate Events: A Crisis Simulation of a U.S.-Iranian Confrontation, authored by senior fellow Kenneth M. Pollack, presents lessons and observations from the exercise.

Key findings include:

• Growing tensions are significantly reducing the “margin of error” between the two sides, increasing the potential for miscalculations to escalate to a conflict between the two countries.

• Should Iran make significant progress in enriching fissile material, both sides would have a powerful incentive to think short-term rather than long-term, in turn reinforcing the propensity for rapid escalation.

• U.S. policymakers must recognize the possibility that Iranian rhetoric about how the Islamic Republic would react in various situations may prove consistent with actual Iranian actions.

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Last September, as part of its annual conference with the United States Central Command, the Saban Center for Middle East Policy at the Brookings Institution conducted a day-long simulation of a confrontation between the United States and Iran arising from a hypothetical scenario in which the Syrian opposition had made significant gains in its civil war and was on the verge of crushing the Assad regime.  

The simulation suggested that, even in the wake of President Rouhani’s ascension to power and the changed atmosphere between Tehran and Washington, there is still a risk of misunderstanding and miscalculation between the two sides.

This new Middle East Memo examines the possible U.S. foreign policy lessons that emerged from this crisis simulation, and stresses the importance of communication, understanding the Saudi-Iran conflict and the difficulty in limited interventions. 

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• Hard Road to Damascus: A Crisis Simulation of U.S.-Iranian Confrontation over Syria

Editors’ Note: We need to do better with the long-term instruments of counterterrorism, write Raymond Odierno and Michael O’Hanlon. That includes efforts within our own societies to promote social cohesion. This article originally appeared on USA Today.

In the aftermath of the Brussels tragedy, many good ideas are being floated to improve defenses against terrorists who are poised to strike. Belgium needs more resources for police work, including staking out suspects. Europe needs terrorist watch lists that are better automated and integrated. Police forces and national intelligence agencies need to work together more effectively, readjusting the point at which traditional police work ends and counterterrorism raids begin. We need to use technology such as closed-circuit TV, as well as simpler but time-tested methods like bomb-smelling dogs, more effectively in unhardened public places like subway stops and the external lobbies of airports.

The above are immediate and short-term measures. They are crucial. They are also insufficient. We need to continue to go after Islamic State's finances, too, leading a worldwide effort to restrict its sources of revenue and ability to store and move funds around. Beyond these actions, we need to do better with the long-term instruments of counterterrorism. These include the use of social media and other counter-messaging against the so-called caliphate. But they also include efforts within our own societies and especially those in Europe to promote social cohesion. Within many countries the inability to develop programs encouraging assimilation of immigrants, and of the home-born disaffected, has led to substantial pockets of disenfranchised citizens, a large majority being Muslim.

At least on issues concerning Muslim-majority communities, the United States can help point the way. We are fortunate, largely to the credit of our nation's Muslims who join our society in full and pursue the American dream, to have relatively few problems with Islamist extremism. Of course, there are exceptions, but on the whole, Muslim-American communities are our single greatest domestic allies in the struggle against extremism at home. They help provide information on would-be terrorists in their midst; they do not typically shelter, aid or condone the thinking of such extremists. Most of all, acting as loyal citizens, they provide role models and hopeful visions to their young, reducing the odds that the 20-somethings who seem to wind up the main culprits in most attacks abroad will feel the same urge within the United States. Because our own terror watch lists have gotten better since 9/11, and because of the hard work of border and immigration agencies, we are also often able to limit the movements of suspected terrorists to the United States from abroad.

None of this is to sound complacent. More than 70 individuals were arrested on American soil last year on suspicion of interest in supporting Islamic State or otherwise conducting extremist activity, and we suffered the San Bernardino tragedy.

Beyond matters of culture and assimilation, specific programs here contribute as well. In Montgomery County, Maryland, a coalition of faith leaders, school officials and law enforcement officers collaborate to try to identify and help would-be radicals before they turn to dangerous ways. In Ohio, fire departments try to reach into difficult neighborhoods and recruit workers. They recognize that their role in society can be less polarizing to some disaffected than would, say, certain types of police outreach, but that by extending the presence of the government into places where it is not always welcome, they can tamp down the temptations of some to turn to violence.

Many places in Britain are doing the same thing. Britain is a sort of bridge to Europe on this issue, like on many others—not having the apparent problems of say Molenbeek, the enclave in Brussels from which recent attackers have originated, but also having more concentrations of recent immigrants from the Middle East than does the United States. Aware of this situation, British authorities also try to extend the state's connections with shaky neighborhoods in ways that seek to engender trust in the state and better community rapport. Sometimes this can rely on police, who in the United Kingdom are usually unarmed. However, at other times, less traditional instruments, or less potentially imposing symbols of state authority, can be better. Again, fire departments come to mind, as do work programs that foster a sense of community involvement and cohesion (while also providing a paycheck). Sometimes armies can help, depending on their roles and reputations in given societies. Any of these can improve the government's image in key neighborhoods, while also helping create the kinds of communications between community leaders and authorities that produce intelligence leads when things start to go off the tracks.

U.S. presidential candidates are not talking much about these kinds of issues. But efforts to build social cohesion are not at odds with what some of them are advocating in response to Brussels. Greater police presence in jurisdictions like Molenbeek, intelligence surges and reforms, and also stronger actions against Islamic State in the Middle East and beyond are needed, to be sure. But such measures are not, in themselves, adequate.

Building social cohesion is difficult, of course, and often the strides forward are slow to come and hard to measure. It usually must happen at the city level. It is usually manpower-intensive work. It is always painstaking. Sometimes, of course, it simply fails. But without a reinvigorated emphasis on building social cohesion, in which cities and other jurisdictions learn from each other and share best practices to tie their communities more strongly together, we will not succeed in this crucial challenge of our times.

Erica has a history of cardiac issues. She visits her doctor for a regular checkup and her doctor writes a new prescription to better control her heart disease. Unfortunately, her doctor didn't mention any instructions, except to take it once a day. Erica thanks her doctor and heads to the pharmacy. At the check-out counter, the clerk hands Erica her new prescription drug, in addition to three documents stapled to the bag that he says "will explain everything you need to know about your medication." Later on, while reviewing the materials at home, Erica is overwhelmed by the information, which is in fine print and difficult to understand. She is frustrated and confused, and tosses the documents in the trash.

This scenario is not uncommon. Research suggests that about 50 percent of Americans find it difficult to read health information.[i] Consumers who cannot find the information they need, or who do not understand the information because it is presented in a convoluted manner, are less likely to use it to prevent unnecessary medical errors. In Erica’s case, she could have ended up in the emergency room because she missed some basic warnings about her prescription. For example, one warning might have been that she should not chew the medication because it was an extended release capsule. Chewing the capsule could release the entire day’s dose at once, resulting in an unintended overdose.

We know that consumers are receiving information – sometimes too much information. Not only are consumers receiving pages of medication information, the information they receive is uncoordinated and sometimes conflicting. Some documents are written by the drug manufacturer, and others are written by pharmacies or another third party. Some medication information documents are FDA-approved and others are not.

The real question is – could medication information be presented in such a way that it would be more useful for consumers? The answer is a resounding “yes.” One study found that just 75 percent of consumer medication information met the minimum criteria for usefulness.[ii] That number might be impressive as a field goal percentage in the NBA, but for consumers it represents an unmet need for high quality medication information.

The U.S. Food and Drug Administration (FDA) has spent the past several years working with stakeholders to determine the most effective methods for conveying medication information. One overarching principle that has emerged from FDA’s engagement with the health care community is the need for a single, standardized document to replace the numerous existing documents. This document is identified as Patient Medication Information (PMI).

PMI creates an easier way for consumers to access and understand their medication information. By presenting the most salient pieces of information – including drug uses, warnings, side effects, and directions – on a single page that is easy to navigate, PMI can be a useful tool for enhancing treatments and preventing avoidable medication errors or side effects. PMI holds promise both for consumers and the broader health care system. For consumers, PMI could contribute to better outcomes and an overall improvement in patient experience. For health systems, PMI’s positive impact on medication adherence could improve performance on quality measures, such as hospital readmissions, that could lead to shared savings or other rewards.

Through a cooperative agreement, the Engelberg Center for Health Care Reform at the Brookings Institution has worked in collaboration with FDA over the past few years to convene a series of workshops focused on identifying best PMI practices – for example, how to make PMI both more usable and accessible.  Workshop participants identified several guiding principles for improving the content, format, and distribution of PMI.

PMI Guiding Principles

PMI content should be consumer-friendly. Expert stakeholders identified a lack of consumer-friendly information as one of the most important barriers to effectively communicating critical medication information. To fix this problem, the language used in PMI will need to be simplified, patient-centric, and understandable across the entire spectrum of health literacy levels. The types of information that should be included in PMI must be essential for taking a medication properly. Extraneous information, such as a discussion of previous treatments a consumer must have previously tried and failed before receiving the new prescription, may be more confusing than helpful.

The best PMI formats are simple and easy to navigate. Consumers don’t want to be given a technical-looking instruction manual when they pick up their prescriptions. Participants at the workshops generally agreed that it would be ideal to keep PMI to a single page. They also agreed that actionable headers that help consumers locate the information they are looking for are preferable to the question and answer format (e.g., “Uses” and “Directions” are more effective than “What does the drug treat?” and “How do I use the drug?”). There was consensus on the point that consumers will ultimately decide the best format.

Access to PMI will be bolstered by multiple channels of distribution. Paper is still the primary source of medication information, and is preferred by certain demographics. However, technology is revolutionizing the way consumers receive information. This is generally good for society, but it introduces some challenges, including the fact that consumers now have more access to information of questionable quality.  One method for ensuring access to consistent and high quality PMI would be to have a central repository for all PMI documents. This approach could support distribution of both printed and electronic PMI. Access to PMI could be further enhanced by making it available on smartphones and via email.

On July 1, the Center will convene a public meeting that will provide an opportunity for the health care community to discuss the issues mentioned above. Researchers will give an update on progress made since the previous meetings and share the lessons they learned from recent studies. Diverse stakeholders – including patient advocacy groups, providers, pharmacies, and drug manufacturers – will provide their perspectives on the future of PMI and assess their role in making high quality PMI a reality. 

There are many issues that need to be addressed in exploring the promise of PMI. However, one thing that participants at the July 1 meeting should remember is this: Keep it simple, stakeholders.