Afghanistan: Reconstituting a Collapsed State

LTC Raymond A. Millen examines warlordism as the principal impediment to Afghanistan\u27s revival and offers a shift in strategy that addresses the war of ideas, the counternarcotics initiative, and the incorporation of the Afghan National Army into the provincial reconstruction teams. As Lieutenant Colonel Millen observes, all the resources are in place; they simply need a shift in focus. LTC Millen takes into account the historical, cultural, and economic factors that impede central authority and the eforms needed for modern states. His problem-solving approach is insightful, pragmatic, and innovative.https://press.armywarcollege.edu/monographs/1748/thumbnail.jp

Pax NATO: The Opportunities of Enlargement

The author examines NATO\u27s extraordinary performance and incisive initiatives during the immediate post-Cold War years. He scrutinizes the impact of enlargement on the Alliance, not only from a military but also a geopolitical perspective. He is quick to point out that, without the needed reforms, new members will bring more fat than muscle to the Alliance. However, the process of enlargement has served to harmonize Central and Eastern Europe with Western Europe in a remarkable manner. That achievement alone has made enlargement worthwhile. He goes beyond the next round of enlargement and makes a case for a reorientation of NATO enlargement towards the Middle East and North African regions. They may never receive the full security umbrella of NATO, but they can enjoy the shade.https://press.armywarcollege.edu/monographs/1817/thumbnail.jp

Reconfiguring the American Military Presence in Europe

The author examines America\u27s options regarding the basing of ground troops in Europe and considers three major options available to the United States--complete withdrawal, annual rotations, and restructuring the Alliance to accommodate a smaller U.S. presence. While weighing the advantages and disadvantages of each option, he does not lose sight of the ultimate objective of NATO--to provide credible land power for the full spectrum of operations. He introduces a NATO 3-3 Force Structure concept that rests on a smaller NATO ground force adaptive to the capabilities and wealth of member states; increases interoperability (technologically and procedurally); and supports the expeditionary force structure already in progress by the formal establishment of three standing combined joint task forces (CJTF). Additionally, he recommends the adoption of nine division-sized bases in Europe located at key geostrategic points for greater access to the Middle East and Africa.https://press.armywarcollege.edu/monographs/1774/thumbnail.jp

Strategic Effects of Conflict with Iraq: Europe

War with Iraq signals the beginning of a new era in American national security policy and alters strategic balances and relationships around the world. The specific effects of the war, though, will vary from region to region. The author has been asked to analyze four issues: the position that key states in their region are taking on U.S. military action against Iraq; the role of America in the region after the war with Iraq; the nature of security partnerships in the region after the war with Iraq; and the effect that war with Iraq will have on the war on terrorism in the region. The vast majority of European states will contribute to the peacekeeping mission in Iraq if asked bilaterally. Four conclusions have been reached. 1. Given its proximity, the European Union can provide substantial economic and diplomatic resources for stabilizing the region. 2. The European Union will seize upon the opportunities of greater regional democratization to practice diplomacy and crisis resolution. 3. The post-Iraqi war era provides an opportunity for NATO to reorient towards the Middle East. 4. European active participation on the global war on terrorism is predicated on clear success in the Middle East. Failure will result in a period of European isolationism.https://press.armywarcollege.edu/monographs/1802/thumbnail.jp

Future War/Future Battlespace: The Strategic Role of American Landpower

The authors examine the trends in the strategic environment in their development of the Future War/Future Battlespace. One fact is clear. Traditional warfighting has changed in the post 9-11 era. The U.S. military must adapt or fail. There is no other recourse. The authors have superbly framed the strategic environment into four strategic battlespaces and have examined the ways future adversaries will operate within them to thwart U.S. strategic initiatives. In this context, these variables influence the path that Transformation must take.https://press.armywarcollege.edu/monographs/1800/thumbnail.jp

Insurgency and Counterinsurgency in the 21st Century: Reconceputalizing Threat and Response

Modern insurgency warfare presents fresh challenges for the United States, which must re-conceptualize its approach to fighting such conflicts. Because the dominant characteristics of insurgency--protractedness and ambiguity--effectively stymie the American military\u27s approach to war, the United States needs to reorient its strategic thinking. The key to success is not for the U.S. military to become better at counterinsurgency, but for the U.S. military (and other elements of the government) to be skilled at helping local security and intelligence forces become effective at it. Adapting tactics and strategies to the realities on the ground is the not only pragmatic, but also crucial to success.https://press.armywarcollege.edu/monographs/1760/thumbnail.jp

Why They Fight: Combat Motivation in the Iraq War

With the recent lightning swift combat successes of Operation IRAQI FREEDOM, there may be a tendency to view with awe the lethality of U.S. technology and training. The researchers, however, argue that the true strength of America\u27s military might lies not in its hardware or high-tech equipment, but in its soldiers. Dr. Leonard Wong and his colleagues traveled to Iraq to see what motivated soldiers to continue in battle, to face extreme danger, and to risk their lives in accomplishing the mission. As a means of comparison, they began by interviewing Iraqi Regular Army prisoners of war to examine their combat motivation and unit dynamics. The researchers then interviewed U.S. combat troops fresh from the fields of battle to examine their views. What they found was that today\u27s U.S. soldiers, much like soldiers of the past, fight for each other. Unit cohesion is alive and well in today\u27s Army. Yet, Dr. Wong and his fellow researchers also found that soldiers cited ideological reasons such as liberation, freedom, and democracy as important factors in combat motivation. Today\u27s soldiers trust each other, they trust their leaders, they trust the Army, and they also understand the moral dimensions of war. This year marks the 30th anniversary of the all-volunteer Army. This monograph is a celebration of the success of that radical idea and the transformation of the U.S. Army from a demoralized draft army, to a struggling all-volunteer force, to a truly professional Army.https://press.armywarcollege.edu/monographs/1787/thumbnail.jp

Effect of angiotensin-converting enzyme inhibitor and angiotensin receptor blocker initiation on organ support-free days in patients hospitalized with COVID-19

IMPORTANCE Overactivation of the renin-angiotensin system (RAS) may contribute to poor clinical outcomes in patients with COVID-19. Objective To determine whether angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) initiation improves outcomes in patients hospitalized for COVID-19. DESIGN, SETTING, AND PARTICIPANTS In an ongoing, adaptive platform randomized clinical trial, 721 critically ill and 58 non–critically ill hospitalized adults were randomized to receive an RAS inhibitor or control between March 16, 2021, and February 25, 2022, at 69 sites in 7 countries (final follow-up on June 1, 2022). INTERVENTIONS Patients were randomized to receive open-label initiation of an ACE inhibitor (n = 257), ARB (n = 248), ARB in combination with DMX-200 (a chemokine receptor-2 inhibitor; n = 10), or no RAS inhibitor (control; n = 264) for up to 10 days. MAIN OUTCOMES AND MEASURES The primary outcome was organ support–free days, a composite of hospital survival and days alive without cardiovascular or respiratory organ support through 21 days. The primary analysis was a bayesian cumulative logistic model. Odds ratios (ORs) greater than 1 represent improved outcomes. RESULTS On February 25, 2022, enrollment was discontinued due to safety concerns. Among 679 critically ill patients with available primary outcome data, the median age was 56 years and 239 participants (35.2%) were women. Median (IQR) organ support–free days among critically ill patients was 10 (–1 to 16) in the ACE inhibitor group (n = 231), 8 (–1 to 17) in the ARB group (n = 217), and 12 (0 to 17) in the control group (n = 231) (median adjusted odds ratios of 0.77 [95% bayesian credible interval, 0.58-1.06] for improvement for ACE inhibitor and 0.76 [95% credible interval, 0.56-1.05] for ARB compared with control). The posterior probabilities that ACE inhibitors and ARBs worsened organ support–free days compared with control were 94.9% and 95.4%, respectively. Hospital survival occurred in 166 of 231 critically ill participants (71.9%) in the ACE inhibitor group, 152 of 217 (70.0%) in the ARB group, and 182 of 231 (78.8%) in the control group (posterior probabilities that ACE inhibitor and ARB worsened hospital survival compared with control were 95.3% and 98.1%, respectively). CONCLUSIONS AND RELEVANCE In this trial, among critically ill adults with COVID-19, initiation of an ACE inhibitor or ARB did not improve, and likely worsened, clinical outcomes. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT0273570