Tuesday, October 31, 2006

How Iraq Is Like Reconstructive Knee Surgery

I think I understand the deeply-rooted dreams of my fellow citizens, and the vision is not encouraging. The only acceptable military goal today seems to be the Powell Doctrine of military engagement: take a sledgehammer ("overwhelming force") to the international problem, but only provided that-

a) no one anywhere in the world objects, and
b) you can be assured of “total clean victory”, complete with dancing in the streets and V-E celebrations, in less than a year.

That’s a great strategy- it avoids all the tough problems associated with those enemies who simply refuse to cooperate. As in, well, they fight back. Or refuse to surrender. Or, pretend to surrender, but also covertly fight an on-going guerrilla war.

Unfortunately, the bad guys in Iraq have decided to be obstreperous and resist. This has led to the usual American reaction- if the millennium doesn’t come by the day after tomorrow (we aren’t so bad as to expect the millennium in the morning; we’ll give it at least two days), we quit!

Our time horizon is measured in biennial terms- every election cycle brings out another occasion to find excuses to declare victory and go home. Sort of the way the Russians did in Afghanistan after a decade of fighting the mujahideen. And these are the same people who (correctly) criticize corporate CEO’s for making strategic decisions based on quarterly financial reports and the associated effects on the company’s stock price.

Look past the fact that a lot of the “more (American) troops” fervor is fueled by some members of the careerist general officer class of the US Army (not the Kaplanesque "Imperial Grunts", but the high-ranking heavy armor bureaucrats who got passed over for promotion), in its ongoing war against Rumsfeld to prevent military transformation (that is, a shift from 1975 European warfare doctrine and force structure to something a bit more useful in today’s world); the logic simply doesn’t hold.

Read all the arguments of those who are supposedly in favor of the GWOT- from Lowry to Kristol and beyond, and note that almost every proposed “new” strategy is based on wishful thinking in the attempt to speed up the clock by turning up the heat. Win now, so we can declare the war over and get back to border security and reducing government spending (fat chance). Or, understandably, focus on Iran, as though that were somehow a severable issue. Or made easier when you don't have a few airfields and divisions right next door ready to pounce if needed.

I have a secret for everyone: if you want to bake bread, it takes 30 to 45 minutes at 350 degrees. Running the oven at 600 degrees doesn’t bake the same bread faster, it simply produces something very different. Something inedible.

A better analogy is recovery from an anterior cruciate ligament (ACL) tear of the knee, the dreaded “reconstructive knee surgery” you hear about so often in football. In this case, a small bundle of collagen fibers woven together sort of like a guy wire cable, runs from the back of your thigh bone (femur) to the front of your shin bone (tibia). It is small, but has a very important job- when you straighten out your leg, it prevents the quadriceps muscle (the big “one”- actually four- on top of your thigh) from pulling the shin bone forward and locking the joint as the kneecap serves as the lever fulcrum for the contraction. The hinge joints for the knee are on the side- the medial and lateral collateral ligaments. For a variety of reasons, they can get injured, but they heal very nicely by themselves simply left alone for about six weeks. The ACL is the Big One; God simply didn’t make it to deal with some of the stresses applied by modern athletics.

When the injury occurs, the time scale is unforgiving. The good news is that we can come back and be about as strong as we were before getting hurt. The bad news is- it takes a year to get all the way back. Period.

No matter who your doctor is, no matter what you do, you won’t be yourself athletically for just about 12 months. There are some few freaks of nature who may come back sooner, taking a big risk on revision surgery (check the story of Rod Woodson), but for all of us “normal people”, we are looking at a year of recovery to get back to what we did before the injury in the same way.

Why? It is simple- tissue healing is all biochemistry, which simply requires the chemical elements, and the time, in order to work.

When the knee is first injured, everything is swelled and inflamed. You almost cannot see the injury because of all the extra fluid and blood, so you wait a few weeks before surgery to get the knee to “calm down”. When all of the trauma except for the torn ligament has subsided, you can have the procedure, usually by replacing the ACL with tissue from a cadaver, or from the middle third of your patellar ligament (often wrongly called the patellar tendon), or a piece of the hamstring muscle folded over to get to the right length. At each end, a little plug of bone is cut out and left on the new graft, because the easiest way to heal it is to drill a little hole in the bone of your femur and tibia, and tap the graft bone plug into the hole, fastened further by a titanium screw, rather than try to heal “new”collagen onto bone.

When you wake up and the anaesthesia wears off, it hurts, but at that point the graft is about as strong as it will ever be- theoretically, if you could forget pain, and the inflammation was gone, you could go do almost anything at that point, provided the screw holds.

However, the body also immediately starts to tear down the new ligament, literally dissolving it biochemically and turning it into a different type of collagen (sound like Iraqi society yet?). After about 6 weeks to three months, it is very weak, as the tissue breakdown process is almost done, but the conversion to the right version of type 1 collagen is still in process, and that goes on for about a year to get to 90% and much longer for more.

This doesn’t change or speed up, no matter what you do. The National Football League has lots of money ready for the genius who figures out how to heal and rehab an ACL repair in six weeks. But you can apply heat, ultrasound, prednisone and other antiinflammatories, hyaluronic acid, glycous amino glycans, insulin, alkaline phosphatases, TGF beta, HGH, you name the growth or metabolic factor.

You can hire the world’s best physical therapists, bring in the best exercise machines. But if you overdo the rehab exercises, you actually damage the repaired joint.

No matter what you do, there is a natural process that only plays out at its own pace. Just like baking bread.

So, throw money at Iraq (or not- Speaker Pelosi would owe a lot to a lot of constituencies). Some added cash might help somewhat in some places, or it might also cause more corruption opportunities, create a colonial-style addiction, and permanent dependency.

Go ahead, send “More Troops! More Troops!” Fine, add more US targets to shoot at; but the US military believes that what they need are more Iraqi troops- who are not infiltrators or beholden to bad guys. Cleaning that group out and training more and more takes... time.

The government? After several decades of direct ethnic and religious subjugation, building trust and believing in the democratic process while fighting against the agendas of the bad guys (Sadr’s Mahdi Army, Iranian-linked SCIRI, former Baathists, etc.) takes... time.

The message is that everything here that needs to be done to produce something in the end that is better, takes time. At least another five years, more likely ten.

And, as we see frpom the polls, America may not be ready to pay that price. We may not believe that it is necessary- we forget now, but we weren't ready in late 1944, or 1864, either.

And looking at home front today, it is clear that the price in blood and cash is nothing like it has been in any prior war, but we are still whining, louder than ever. As the sainted Dr. Sowell said, “frivolous politics”. I have news for you- if you really believe that fighting back against the fundamentalist Salafist and Wahabi terrormasters causes more terrorism long run, you also believe that the NutRoots only oppose Bush because of Iraq.

It is times like this that you can be happy to be 50 rather than 20, so you have a better shot at avoiding dealing with the long term consequences of failing to seriously address terrorism, social security reform, and the like. Just remember- I told you so.

Time.

44 Comments:

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