Tag Archives: Karen Hitchcock

David Kilkullen’s Blood Year

David Kilkullen, Quarterly Essay 57: Blood Year: Terror and the Islamic State (Black Inc May 2015)

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I think most people would agree that war is a major failure of human rationality. But the question of what to do once a war is under way is not so easily agreed on. When the subject of possible intervention against ISIS came up at a Sydney Writers’ Festival panel on the weekend, Nick Davies of the Guardian and Dan Mori, David Hicks’s defence lawyer, came close to calling each other stupid and arrogant respectively. This Quarterly Essay brings much more light than heat to the debate.

David Kilkullen was a senior adviser to General David Petraeus in 2007 and 2008, when he helped to design and monitor the Iraq War coalition troop ‘Surge’. This ‘insider’ status may mean that the essay will have some influence with those in power, so one doesn’t read it with the background despair one often feels when reading brilliant analyses by writers who can be dismissed as latte-sipping etceteras. His privileged insider perspective means that the essay is full of small and large revelations. For instance, he describes a meeting at which George W. Bush spoke in his familiar, ‘folksy, shallow and upbeat’ manner about how well the war in Iraq was progressing but then, once the TV cameras had left the room, ‘he began to talk to talk in a concrete, specific, realistic way’. Who knew?

The essay tells the story of the development of the Islamic State in the aftermath of the 2003 invasion of Iraq, the ‘Surge’, the botched withdrawal of coalition forces, Obama’s policy of targeted drone strikes, the failure of the Arab Spring, and the rise of ‘a host of insurgent groups’. It gives a clear account of the contending terrorist groups, explaining in simple enough terms the role of Sunni–Shi’a conflict, and the way Iranian loyalties play out in that context. It outlines the thinking behind changing US strategy over the last decade or more, noting successes, shortcomings and outright failures. It’s hard to imagine a discussion further removed from our Prime Minister’s discourse of Good Guys vs Bad Guys, ‘Death Cult Death Cult Death Cult’ (could it be that behind closed doors he too becomes concrete, specific and realistic?). Arguing that the Surge was not a failure, Kilkullen writes:

Counterinsurgency (in fact, warfare generally) is a complex discipline, like medicine or architecture. if your building fails, it doesn’t mean ‘architecture doesn’t work’ – it means you built a bad structure. If violence drops when you apply a given approach, then returns when you stop, it doesn’t mean the approach doesn’t work; it means it does work, and you shouldn’t have stopped.

Forgetting for the moment that a defining feature of warfare (including counterinsurgency) is that people kill people, which makes comparison to architecture or medicine seem grotesque, this is a fair indication of the approach the essay takes to its subject: discipline rather than rhetoric, a search for solutions rather than a replay of grievances, assessment rather than blame. Blame isn’t a concept it avoids altogether:

President Bush conflated enemies, defaulted to attacking states rather than thinking about how to deal with non-state actors, and – mother of errors – invaded Iraq, and then botched the occupation. … President Obama compounded Bush’s errors – pulling out of Iraq without putting in enough effort to cement the gains of the Surge, indulging in a dangerous addiction to drones and special ops, acting opportunistically in Libya, remaining passive in the face of massacre in Syria … Allies, too – the United Kingdom, other NATO countries, Australia – went along with whatever was asked of them, made only limited efforts to influence the strategy, and then (in many cases) ran for cover when things went wrong … This is a multi-sided, multi-national, bipartisan screw-up, for which we all bear some responsibility, and the task now is to figure out what to do next: what a viable strategy might look like.

Having outlined the history, the essay goes on to offer a definition of the threat. Acknowledging that his view is not universally accepted, Kilkullen argues that ISIS is no longer an insurgent organisation but in fact a state, just as Nazi Germany was a state, so should be met with appropriate strategies – including non-military ones, though the essay focuses on the military, that is, conventional warfare. The current prioritising of countering the threat from unorganised individuals inspired by ISIS brings ‘boomerang effects’  – such the increased erosion of our privacy, or the militarisation of police that has contributed to recent clashes in the USA – that are on the way to turning our societies into police states, a response that is far worse than what it seeks to prevent.

This is an essay that casts light in a very murky area. I’m grateful for it, and recommend it. Kilkullen quotes something attributed to Trotsky: ‘You may not be interested in war, but war is interested in you.’

Black Inc have put an extract from Blood Year up on The Monthly website.
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A number of people have tweeted that every Australian should read the previous Quarterly Essay, Karen Hitchcock’s essay on the treatment of elderly people, Dear Life. This issue includes 40 pages of robust correspondence about it, which should also be required reading.

It begins with word from an elderly resident of a nursing home. Given that Hitchcock’s concern is that ‘the elderly’ need to be treated with respect, it’s a healthy jolt to ageist assumptions that this elderly contributor happens to be national treasure Inga Clendinnen, and that the other self-identified octogenarian correspondent, Ian Maddocks, speaks as a palliative care provider of many decades.

Apart from one snarky piece that makes Hitchcock in her reply wonder if the writer had actually read the essay, all the correspondence is worth reading. In particular, more than one correspondent (most tellingly economist Peter Martin) takes a swipe at the recent Intergenerational Report’s shonky portrait of a future burdened by old people.

Quarterly Essay 57: Dear Life

Karen Hitchcock, Quarterly Essay 57: Dear Life: On Caring for the Elderly (Black Inc February 2015)

qe57Like every Quarterly Essay, this one includes lively correspondence on the previous one. Guy Rundle’s Clivosaurus drew thoughtful responses from a number of writers of the left, defensive missives from representatives of The Australian, fascinating psephology from Malcolm Mackerras, and more. Much of it was too technical for my pay grade, but one thing is clear to me: if you get into an argument with Guy Rundle, it would be unwise to let him have the last word – he’s very good at the devastating rebuttal.

A number of people have already tweeted that every Australian should read Karen Hitchcock’s essay on the treatment of elderly people in our health system. She is a general physician who has worked in large hospitals in several Australian states, and so has extensive hands-on experience in working with frail and/or demented elderly people. As she says:

There are two strong narratives in our culture about the ageing population and death. The first is that medicine is keeping elderly patients alive against their will – medicine is denying a death the patient desires. The second is that elderly patients are seeking to stay alive unreasonably – the patient (or their family) is denying an unavoidable death.

The essay takes these narratives on fiercely, and does a brilliant job of unpicking the ageist assumptions and fanciful versions of sickness and hospitals on which they are built. She marshals her own personal and professional experience as well as current research to mount a convincing counter-narrative.

She describes the way modern medicine is fragmented into specialities, a situation that makes it hard to treat elderly people with multiple conditions.

She explores the concept of futility: is treatment futile if it extends a person’s life for just a few days but those few days allow them to say goodbye to family? can a hospital specialist who is as drenched in ageism as the rest of us and has no personal knowledge of a patient be trusted to make a sound judgement about the futility or otherwise of treatment?

She savagely rips into the often heard argument that the increasingly aged population will make the health care system unsustainable.  ‘Sustainable’, she argues, ‘is just a word for “what we are willing to pay”.’ And the real challenge to the health system comes not from the aged but from ‘a population of increasingly poor, obese, diabetic, sedentary young and middle-aged who are the multi-morbid patients of the future and who will require many drugs, doctors, operations (joint replacements, bariatic surgery, amputations, coronary vessel interventions) and hospitalisations’.

Advanced medical directives, documents that spell out ahead of time conditions that are not to be treated if a person is incapable of making their wishes known, are singled out for special opprobrium. Hitchcock is an excellent storyteller, and her story of 84-year-old Fred who came to hospital begging to be allowed to die is enough to win her case without any further discussion: he was wretched, and didn’t want to be a burden (an often heard an internalised version of the message with which older people are too often bombarded); she listened to him, encouraged him, treated him, and followed up some time after he was discharged:

I said, ‘Fred , you told me you didn’t ever want to come back to hospital.’
He said, ‘Of course I want to come back if I get sick. I get silly when I’m sick. I hate everything. I say silly things.’

Not all her stories have such cheerful endings. Death does happen. But if we are to have a national electronic system where people’s advanced care directives are recorded, then these directives, she argues, should be reviewed regularly, even monthly, by the people whose lives they concern.

The essay discusses the isolation that is the lot of many elderly people, including those who are placed in nursing homes when their families can no longer care for them. It argues that this is an issue that should be taken up by the society as a whole – ‘if we are to attend to the social needs of our elderly citizens both inside and out of institutions, then we need government interventions and funding, along with the community’s engagement and help’. What is needed, and what is beginning to happen in some places is

a shift in perspective: the elderly are not a growing cost to be managed or a burden to be shifted or a horror to be hidden away, but people whose needs require us to change our society. They are those for whom we are responsible and to whom we owe real care.

Another sacred cow the essay takes head-on is the idea that it is better to die at home than in hospital. My own father had himself discharged from hospital in Townsville when he knew he was dying, and was flown and driven the 500 miles to Innisfail because he wanted to die at home. I have no doubt that that was a good decision: he spent his last days surrounded by friends and family, being visited by a doctor he’d known most of his life and a nurse he’d known all hers. He died in bed beside my mother, his wife of more than 50 years. But Hitchcock makes it very clear that his situation was exceptional in the western world today. A hospital death can be a good death.

In short, this Quarterly Essay is a call to arms against the oppressive attitudes and practices which we have insinuated their way into our minds and practices around older people. I’m 68, not yet in the frail and/or demented group that Hitchcock is talking about. I hope I never will be. But reading her essay, I wonder if my GP’s slightly disturbing lack of interest in my symptoms on my most recent visit, which I put down to his having had a long day or perhaps the lack of drama in my presentation, might have grown from an assumption that once you’re past a certain age you just have to put up with a certain amount of suffering. And that’s partly Karen Hitchcock’s point: if the problems she writes about are chickens, then we are all roosts waiting to happen.
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aww-badge-2015This is the fourth book I’ve read for the Australian Women Writers Challenge for 2015.