Comparing the 'American Way of War' with the 'American Way of Healthcare'
Last day in Saigon — UPI
When an Entire System Becomes a Self-Licking Ice Cream Cone
Ryan Crocker is a seasoned public servant. He represented the United States as ambassador to Afghanistan, Iraq, Pakistan, Syria, Kuwait, and Lebanon; he was also awarded the Presidential Medal of Freedom by President George W. Bush in 2009. Not long ago, he led a discussion at the Kennedy School, joining the Middle East Initiative’s Faculty Director Tarek Masoud to talk about the U.S. ‘s hasty withdrawal (some, including me, would call it ‘strategic collapse’) from Afghanistan
“At the time of Biden’s inauguration, the Taliban couldn’t hold a single province. It was a presence [the U.S.] could afford, literally,” he said. He characterized the U.S. presence in Afghanistan as an “insurance policy and an affordable one” because, in his view, it managed the threat from the Taliban and Al-Qaeda in a manner which kept U.S. costs and personnel losses to a minimum.
Ultimately, “we ran out of strategic patience,” Crocker explained. He referenced the loss of Americans’ political will to stay in the fight and their disinterest in making it a policy priority, as demonstrated by Afghanistan’s absence in the national political conversation. America’s unwillingness to invest in Afghanistan ultimately benefitted the Taliban. “Americans have the watches; the Taliban have the time — we ran out of patience...Failing to be ready to stay the course is a huge problem for American diplomacy.”
As a general rule, trouble starts when means conquer ends.
This is a chronic, if not epidemic condition in business, government and military settings in the West, where operations is confused for strategy and when technical power (i.e., “the watches” ) dominates and distracts at the strategy-making table. Pure “strategy” is the relationship between means and objectives. And means can never be considered in isolation from their purpose.
Positioning an objective is a hard thing, a very hard thing, for leadership to create, cultivate and sustain beyond The Next Cycle of either earnings or elections. The end state on a roadmap is a tricky place to balance; it takes skill to shape and reshape a strategic narrative in a way the persuades and inspires confidence, to guide and give direction, the messaging around which politics and policy and populations can cohere and collaborate.
On the other hand, finding means to achieve an objective is relatively simple, particularly when it comes to cheap and abundant technology. (For more Blue Spoon thinking on this, see Escaping McKinseyLand is Hard, Even for McKinsey and Technology is More Irrelevant Than Ever). This is one reason why, to quote the Western touchstone of strategy (On War, by Carl von Clausewitz), “everything in strategy is very simple, but simple doesn’t mean easy.”
John F. Sopko, who was the special inspector general for Afghanistan reconstruction, in ‘America, Afghanistan and the Price of Self-Delusion’, a guest essay for the New York Times at the beginning of this year:
We should start with what “success” in Afghanistan was ever supposed to mean. I believe many Americans who worked there over the years wanted to not only achieve important U.S. strategic interests — such as eliminating a haven for terrorists — but also secure a better future for the Afghan people.
But a perverse incentive drove our system. To win promotions and bigger salaries, military and civilian leaders felt they had to sell their tours of duty, deployments, programs and projects as successes — even when they were not. Leaders tended to report and highlight favorable information while obscuring that which pointed to failure. After all, failures do not lead to an ambassadorship or an elevation to general.
They also aren’t good business for the contractors on which the U.S. mission relied to manage and support programs and projects. For contractors, claiming success, whether real or imaginary, was vital to obtaining future business. So spending became the measure of success. (The same, of course, is true in Washington, where unspent allocations are tantamount to failure, leading to budget cuts.) Accountability for how money was spent was poor. One general told us that he faced a challenge: How to spend the remaining $1 billion from his annual budget in just over a month? Returning the money was not an option. Another official we spoke to said he refused to cancel a multimillion-dollar building project that field commanders did not want, because the funding had to be spent. The building was never used.
As one former U.S. military adviser told my office, the entire system became a self-licking ice cream cone: More money was always being spent to justify previous spending. Old staff departed, new staff arrived with “better” ideas, and new iterations of the same old solutions were repeated, for years. At the same time, many of the problems the U.S. programs faced were simply beyond our control. The sudden collapse of the Afghan government and rise of the Taliban showed that the United States could not buy favorable Afghan perceptions of the country’s corrupt leaders and government, or of America’s intentions.
The collapse of the U.S.-backed government in Afghanistan on Aug. 15, 2021, revealed what little American lives and money had purchased over 20 years there, writes Sopko. It also laid bare a gaping disconnect between reality and what senior U.S. officials had been telling Americans for decades: that success was just around the corner.
The same storyline of collapse — the one of a self-licking ice cream cone, where an entire system is capable of running on the power of perverse incentives for decades, where executive management confused operations (data and technology and tactics) for strategy — is a throughline in the screenplay that led to the end (from the United States’ perspective) of the War in Vietnam 50 years ago this week.
Peter R. Kann is a former publisher of the Wall Street Journal and CEO of Dow Jones & Co. He was a Journal staff reporter who had covered the Vietnam war when he wrote ‘When South Vietnam Died’ on May 2, 1975. The Journal reprinted the essay on Friday, arguing that the fall of Saigon was a foreshadowing of the 2021 U.S. abandonment of Afghanistan, and asking will Ukraine suffer a similar fate?
In the end, of course, the severest critics and profoundest pessimists proved to be right. South Vietnam may have survived longer than some pessimists expected, but it did collapse — suddenly, chaotically, completely. And, I think, tragically.
South Vietnam was, to my mind, no better but no worse than a great many other societies around the world. In at least some ways it was not so very different from our own.
It is true that South Vietnam never was really democratic. Its democratic institutions, imported from America along with bombs and bulgur wheat, were more show than substance.
It is true that the South Vietnamese army (ARVN) in the end proved to be no match for the North Vietnamese army. The end was an inglorious six weeks of retreats, routs, chaos and collapse. Still, the AVRN was not an army of bumblers and cowards. It was an army that stood and fought well at a score of places whose names we have all forgotten. And it stood and fought well in a thousand little engagements and in a thousand little mudwalled outposts whose names no American ever knew.
It was an army of soldiers who deserved better leadership than they got. It was an army that for years watched the Americans try to combat the Communists with every wonder of modern weaponry and which then, all too suddenly, was left to face the Communists with American-style tactics but without American-style resources.
The phrase “we won every battle” in the context of the Vietnam War is a statement that reflects the military’s perspective on tactical victories during the conflict. However, it also is a contrast with the overall outcome, which, like in Afghanistan, saw the United States pull the plug after wandering the wild borderlands between fact and fiction for decades.
There is a fact sheet currently live on the Department of State website describing where things stand on the U.S. relationship with Afghanistan now, keeping in mind that the United States first established diplomatic ties with Afghanistan in 1935. The objective now:
“Since the Taliban takeover in August 2021, the United States has stopped providing assistance for the purpose of the reconstruction of Afghanistan. The United States has changed the nature and scope of its activities in Afghanistan to focus instead on humanitarian aid and targeted assistance to help meet basic human needs and avoid a complete and imminent economic collapse.”
Much like in Iraq.
Over 7,000 U.S. service members died in Afghanistan and Iraq. Approximately 177,000 allies in the national military and police from Afghanistan, Pakistan, Iraq, and Syria also died. An estimated 408,000 civilians also died as a direct result of the post-9/11 wars. The war-related destruction and displacement led to an estimated 3.6-3.8 million indirect deaths due to factors like malnutrition, disease, and lack of access to healthcare, bringing the total estimated death toll to 4.5-4.7 million
Taken together, the Iraq and Afghanistan conflicts will be the most expensive wars in US history – totaling somewhere between $4 to $6 trillion.
Lather. Rinse. Repeat.
Poor strategy is expensive. No strategy is lethal.
Executive management tends to put new operating models ahead of new thinking models, the ‘intellectual overmatch’ from which to compete and create differently against an equally-resourced rival. Modern technology (weaponry, “the watches”, all the AI-enabled and data-powered future visions that money can buy) isn’t the same thing as a modern strategy.
Sopko again:
“As the special inspector general for Afghanistan reconstruction I, with my staff, have audited and investigated U.S. programs and spending to rebuild Afghanistan — a mission that, it was hoped, would turn the theocratic, tribal-based “Graveyard of Empires” into a modern liberal democracy.
In hundreds of reports over the last 12 years, we have detailed a long list of systemic problems: The U.S. government struggled to carry out a coherent strategy, fostered overly ambitious expectations, started unsustainable projects and did not understand the country or its people. American agencies measured success not by what they accomplished, but by dollars spent or checklists of completed tasks.”
The sad irony in all of this is The New Panic by the United States around rare minerals:
“Senior administration officials are scrambling to stem economic damage from China’s restrictions on rare-earth exports, as President Donald Trump’s trade war risks cutting key industries and defense contractors off from supplies of metals crucial to production,” reports The Washington Post over the weekend. “While companies search for alternative suppliers and urge the White House to cut a deal that will keep the materials flowing to U.S. manufacturers, the Trump administration is finding there are no easy solutions. China has a lock on the supply of certain elements that are essential to making such things as military drones, consumer electronics and battery-powered vehicles.”
If there is a road to a happy ending in Afghanistan, much of the path may run underground: in the trillion-dollar reservoir of natural resources — oil, gold, iron ore, copper, lithium and other minerals — that has brought hopes of a more self-sufficient country, if only the wealth can be wrested from blood-soaked soil. For decades, Afghanistan’s people have been told of the vast riches beneath their feet, untapped mineral resources potentially worth trillions of dollars that the world is clamoring to explore, exploit, and export to create jobs in a world-class, sustainable industry that would catapult them into a future of peace and prosperity.
Afghanistan does sit atop huge deposits of copper, iron, marble, talc, coal, lithium, chromite, cobalt, gold, lapis lazuli, gemstones, and more — making Afghanistan one of the world’s most resource-rich countries on paper. The tricky part, as it has been for the better part of two decades, is turning potential into reality.
The mining sector — which never really took off under the former Afghan government, due in no small part to security risks posed by the Taliban insurgency — has yet to fully bloom, even though those at the top of the Islamist group understand its earning and jobs-creation potential. But last year, Chinese engineers and the Taliban government officially started work on a massive project in Afghanistan to mine the world's second-largest deposit of copper….after 16 years of delays.
The United States intervened in Afghanistan in response to the September 11 2001 terror attacks by al-Qaeda. The objective positioned back then was framed in military (i.e., tactical) terms, to combat international terrorism — to kill as many of “them” as possible — and chart a new global order, a different economic system, a better vision that’s a better ‘strategic fit’ to reality. That, of course, has not happened, at least not in a way that sustained United States brand leadership.
The purpose of strategy is to continue to exert influence. Like “value” in healthcare, strategy is a flow, an unending process that can never lead to conclusion. Continuation is the goal, not culmination.
Celestial Messaging
“This will happen in healthcare — rather than having to use your judgment about which digital health app to use for what, there will be an AI doctor superapp that knows your full personal context and auto triages across a network of "subcontracted" providers in the backend based on your expressions of clinical need.”
So says Meta CTO Andrew Bosworth, who joined a16z Growth General Partner David George to share how he's translated emerging technologies into products people use and love. He also explores how breakthroughs in AI and hardware could turn the existing app model on its head, introduce entirely new competitive dynamics and business models for startups, and usher in a post-mobile phone era. If we get it right, Bosworth says, the next wave of consumer tech won’t run on taps and swipes — it’ll run on intent.
Here’s that clip:
Self-licking ice cream cones are entities that serve no purpose except to sustain themselves. The phrase came into usage among observers of the Vietnam War.
A self-licking ice cream cone is a program, project or policy that costs a lot of money and resources, generates a great deal of activity, and produces indicators of its own success, preferably quantitative (according to ‘the data’, the Untied States won the Vietnam War); but does not actually achieve its announced goals. Indeed, a proper self-licking ice cone undermines the very purposes for which it was created, while at the same time sucking in ever more resources from worthy and effective activities.
Like most technology projects.
That next big wave of consumer health tech — all the new “watches” and technical weaponry, if you will, that Silicon Valley visionaries can envision, and which the media outlets that adore them will then dutifully cover — is really celestial messagingpromoting a future that will fail to launch in a meaningful way for this simple reason: it’s success will all be based on the intent of a $5 trillion payment system, one that’s currently managed by a small handful occupying and controlling the middle, including Epic, UnitedHealthcare and ExpressScripts.
Sachin Jain has earned a reputation for speaking bluntly about the shortcomings of the American healthcare system. Jain is the CEO of SCAN Group and SCAN Health Plan, which operates nonprofit Medicare Advantage plans in California, Nevada, Arizona and Texas.
In an interview with Chief Healthcare Executive, Jain discussed a range of problems in the healthcare industry. He talked about the prevalence of middlemen in healthcare (see above about the intent of a $5 trillion payment system), the lack of progress in improving outcomes (despite all the money and technical innovation), and the need to solve fragmentation.
“We've normalized the abnormal in American healthcare,” Jain says. “I think the fact that we don't even call out some of that abnormality is a function of the fact that we've just accepted it as being a necessary part of our landscape.”
“I think it's a leadership issue at the end of the day,” Jain says. “I think what's happened in healthcare over the last 10 years, and nobody is saying this truth, is you can be incredibly mediocre and be very, very successful.”
“We're one of the few industries where there's almost unlimited demand,” he continues. “There's local monopolies now, so you don't have to be very good … or getting better. You don't have to be very good at doing the thing that you do.”
As a result, Jain says the pace of improvement in healthcare is comparable to molasses.
“I think we have a leadership crisis, wherein we've normalized a very slow pace of change,” Jain says. “That, unfortunately, isn't yielding the kind of results that we'd like to see.”
Saigon fell to the Communist North on April 30, 1975. Which was around the same time that the word "crisis" was first used to describe healthcare in the United States.
Happy Anniversary.
This is what happens when an entire system becomes a self-licking ice cream cone.
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John G. Singer is Executive Director of Blue Spoon, the global leader in positioning strategy at a system level. Blue Spoon specializes in constructing new industry ecosystems