Pandora Report 12.4.2015

This week, Washington, DC hosted the Summit on Human Gene Editing, where the ethical and legal implications of gene editing technologies, like CRISPR-Cas9, were heavily discussed. In this week’s report, Greg Mercer works his magic, revealing the internet and social media trends following the shootdown of a Russian SU-24 on November 24th. We’re also reporting updates in the Zika virus and dengue fever outbreaks as well as the Harvard-LSHTM Panel Report on Global Response to Ebola. France is currently experiencing an increase of highly pathogenic avian influenza cases while a Black Angus beef cow in Alberta was discovered to have bovine spongiform encephalopathy (BSE). Fun history fact Friday – on December 3, 1967, the first human heart transplant was performed in Cape Town, South Africa and on December 4, 1945, the Senate approved US participation in the UN. Before we start our weekly roundup, make sure to mark your calendars to attend GMU’s seminar on Ebola surveillance and laboratory response this Monday, December 7th from 4:30-6pm at our Fairfax campus (details below!).

Zika Virus Outbreak – Updates
The growing outbreak of Zika virus has now seen locally acquired cases reach ten countries, causing the Pan American Health Organization (PAHO) to issue an alert, “urging countries in the region to be on the lookout for the disease and to watch for unusual patterns in newborn.” Brazil has been hit hard with a rise from 739 on November 27th, to 1,248 cases reported on November 30th. Six of the ten countries saw cases occur in November, hinting that the outbreak could just be starting. The growing concerns regarding the outbreak are also related to the newest evidence linking microcephaly and maternal cases. Zika virus genome was found in the amniotic fluid of two pregnant women and fetal diagnosis of microcephaly was performed via ultrasound. Even more so, French Polynesian health officials reported an unusual spike in nervous system malformations in babies that were born during a Zika virus outbreak in the region from 2014 to 2015. The concern regarding neurological conditions raises red flags as Brazilian health officials are reporting neurological complications, like that of Guillain-Barre syndrome, in Zika virus patients. The WHO reported 739 Brazilian microcephaly cases in newborns and while there is only ecological evidence linking the virus and microcephaly, investigations are ongoing. The outbreak first started in February 2014, on Easter Island (Chile) and has seen been identified in Colombia, Guatemala, Brazil, El Salvador, Mexico, Paraguay, Panama (confirmed cases as of December 4, 2015), Suriname, and Venezuela. Spread by Aedes mosquitoes, this vector-borne organism has similar symptoms to dengue fever and illness tends to last between four and seven days.

Event: Ebola Surveillance & Laboratory Response – Lessons for Global Health SecurityScreen Shot 2015-12-03 at 9.34.57 AM
Time/Location: Monday, December 7, 2015 from 4:30pm-6pm in Robinson A-203 at George Mason University.
As the recently released Harvard-London School of Hygiene and Tropical Medicine Independent panel on the Global Response to Ebola indicates, the West African Ebola epidemic highlighted
many gaps in national and international health and response systems that are critical for protecting global health security.  Join leaders and experts who helped to lead the U.S. response for Ebola to discuss the international response to the epidemic, the importance of robust biosurveillance systems, and how the experience with Ebola influences our approach to Global Health Security. Speakers:

  • Dr. Matthew Lim, Senior Policy Advisor for Global Health Security, HHS, fmr Civil-Military Liaison Officer to WHO
  • May Chu, Ph.D. fmr Assistant Director for Public Health, Office of Science Technology and Policy, White House; Senior Science Advisor, CDC
  • Jeanette Coffin, Manager U.S. mobile laboratory deployment, MRIGlobal

It’s Definitely Maybe World War 3
GMU’s Greg Mercer breaks down the November 24th Turkish shootdown of a Russian SU-24. Greg reviews the media attention following the event and the “immediate buzz about declarations of war, what exactly NATO owes Turkey vis-à-vis Russia, and the possibility of military confrontation between Russia and the West.” Through his use of google trends and Twitter, Greg shows just how much hype and concern the notion of WWIII got during this time. Take a look at his recap and debunking of the WWIII buzz and how quickly it caught like wild fire.

Reporting from the Panel on the Final Report of the Harvard-LSHTM Independent Review of the Global Response to Ebola
If you missed the Center for Strategic & International Studies (CSIS) Global Health Policy Center’s Launch of the final report of the Harvard-LSHTM Independent Panel on the Global Response to Ebola, don’t worry! I was fortunate to attend and a great deal of the report (we reported on last week) heavily emphasized “on the ground” capacity. Dr. Peter Piot, Director and Handa Professor of Global Health, London School of Hygiene and Tropical Medicine (LSHTM), joined via video link and started by saying that this would not be a WHO-bashing event. As one of the original researchers on Ebola during its 1976 discovery, he mentioned that the Democratic Republic of Congo (DRC) is a great example of local capacity in their success of ridding themselves of the disease within a few months of the outbreak starting. Dr. Piot heavily emphasized the work of several countries and how the WHO brought together multiple ethicists to review research during such a terrible outbreak. Lastly, Dr. Piot noted that “we risk focussing too much on global and not enough on local” in our future efforts. Dr. Suerie Moon, Research Director and Co-Chair of the Forum on Global Governance for Health at Harvard Global Health Institute, then spoke on the “weak coordination of global response” and how it severely aided the spread of Ebola. Dr. Moon highlighted the need for a global strategy to ensure adequate funding (external financing for the poorer countries and transparent tracking of financing) and the necessity for external assessment of country capacity. She pointed to the need for political and economic incentives and disincentives to not only report cases but also discourage the hiding of outbreaks. Reviewing each recommendation, the panel noted that “human health is a vital part of human security”. In one of her closing comments, Dr. Moon stated that “there are many unanswered questions regarding ebola response and we need to address a number of aspects that went wrong” and “a major theme is accountability at all levels, across all types of players.” Dr. Moon pointed out that the necessity of so many reforms shows just how much work is needed and that now is the time to see political support occur. Muhammad Pate, former Nigerian Minister of State for Health, expressed that “one of the lessons, at the national level, in terms of surveillance and accountability to respond, was missing and something that national leaders need to own up to is building their own public health systems.” Dr. Sophie Delaunay, Doctors Without Borders/MSF, then discussed the role of medical innovations and how the outbreak provided us with a unique opportunity to collect data. Dr. Delaunay said it will “be a complete nightmare to connect all the dots” in this outbreak and there is a desperate need for better R&D regarding disease outbreaks and response. “We ask for governments and policy makers to support collaboration on R&D to demonstrate their willingness to be more effective in the next outbreak” noted Dr. Delaunay. She heavily pushed for global financing efforts to facilitate investment in R&D and response. After the initial panel, there was a secondary group that shared their thoughts on the report, including Dr. Tom Frieden (CDC Director), Julie Gerberding (Exec. VP for Strategic Communications, Global Public Policy and Population Health, Merck) and Ron Klain (Former US Ebola Response Coordinator, White House and General Counsel, Revolution LLC). Ron Klain pointed to the failure of the WHO and “if institutions failed us, individuals shined. We did see extraordinary compassion from the rest of the world and tremendous outpouring of support. ” Mr. Klain mentioned that “the scariest thing about Ebola is the warning signs of how badly we failed this when the threat could’ve been worse and the epidemic we face could be much much more dangerous in the future.” Dr. Frieden emphasized the need of human resources management improvement at the WHO and how global outbreak response could work to support each other better. Lastly, Dr. Frieden emphasized a topic near and dear to my heart; infection control and it’s necessity in global disease prevention. Overall, the panel touched on several key points to the outbreak, emphasizing the need for the biggest players (including MSF) to lead by example via data sharing, etc. The push for political support on incentives and local capacity/accountability was perhaps one of the biggest recommendations and points emphasized from this event.

Gene Editing and CRISPR!
This was a busy week in the biotech world. The International Gene Editing Summit kicked off in Washington, DC. Bringing together experts from around the world, the summit touched on the newest technical innovations, ethical and legal concerns, and even social implications of genome editing advances. Genome Web has provided a great overview of the summit. Nature also published their Four Big Questions related to genome editing, touching on points related to editing the human germline and the ethical implications for technology that “researchers are still grappling with the known unknowns”. Recently, biologist, Emmanuelle Charpentier, discussed CRISPR-Cas9 and that it’s simply too early to begin gene editing as “the tools are not ready” and “as of today, I’m in favor of not having the manipulation of the human germlines. As long as they’re not perfect and ready, I think it’s good to have this ban against editing the germline.” Buzzfeed noted that over the course of the conference, there was a substantial push for a delay in the use of genetic engineering in fertility clinics due to the risk of making “designer babies”. Given the heavily debated nature of this topic it’s not surprising that the US National Academy of Sciences, Engineering and Medicine, the UK’s Royal Society, and the Chinese Academy of Science, all agreed that it “would be irresponsible to proceed with any clinical use of germline editing.” While the future is left open to gene editing on humans, there was heavy accentuation throughout the conference on the ethics and societal views of these scientific breakthroughs and the necessity to revisit their applications on a regular basis.

Dengue Fever Outbreak in Hawaii 
The Dengue fever outbreak on Hawaii Island is still growing. Now at 122 confirmed cases, this is one of the biggest outbreaks they’ve seen with local transmission. As of 12/2, the confirmed cases involved 106 Hawaii Island residents and 16 visitors. The Hawaii Department of Health (HDOH) has published information, hoping to aid prevention efforts, regarding the Aedes aegypti and Aedes albopictus mosquitos that are responsible for spreading the disease. There have been 313 reported potential cases and you can even find a map of the case distribution here!

Stories You May Have Missed:

  • 2015/2016 Flu Season- Where Are We?– The CDC 2015/2016 influenza activity showed a bit of a spike during the November 15-21 week. Influenza A (H3) is still the predominant species in laboratory confirmed cases. If you’re looking to keep an eye on seasonal flu, Google Flu Trends may no longer be operational, but you can still keep an eye on Flu Near You or the CDC’s page.
  • MERS-CoV Severity and Incubation Period– The CDC & Emerging Infectious Diseases published a report regarding the association of severe MERS-CoV illness and a shorter incubation period. Analyses of 170 patents in South Korea revealed a longer incubation period associated with a decreased risk for death while “patients who died had a shorter incubation period.” This mirrors the results of a previous study that had similar results with SARS coronavirus.
  • Salmonella Outbreak Associated With Recalled Nut Butters – The CDC is currently investigating 11 illnesses across nine states that may be linked to recalled nut butters. The Salmonella serotype is Paratyphoid B variant L (+) tatrate (+) (previously called Salmonella Java) and has caused illness in California, Colorado, Georgia, Hawaii, Idaho, Illinois, North Carolina, and New Jersey.
  • Taiwan CDC Holds Bioterrorism Drill – Involving 70 participants, the course utilized a subway union station to allow people to simulate first responders and real-life operations. “CDC bioterrorism teams are tasked with the investigation and identification of biological threats and attacks. Members take on containment and mitigation of damage for any individuals that are harmed during and as a result of an attack.” Go Taiwan!

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GMU Biodefense Published

Dr. Sonia Ben Ouagrham-Gormley, Associate Professor in the George Mason Graduate Program in Biodefense, has published a new book, Barriers to Bioweapons: The Challenges of Expertise and Organization for Weapons Development.

The New Scientist has reviewed it, and this is just one of the wonderful things they had to say:

Her fascinating book, Barriers to Bioweapons, also shows that anyone wanting to develop biological weapons faces a raft of other difficulties. Of the five main bioweapons programmes to date, their key feature has been their failures, not their successes. In a forensic and compelling analysis, she describes how the Soviet Union, the US, South Africa and the Japanese terrorist group Aum Shinrikyo, all fell well short, despite spending billions of dollars over decades

Click here to read the whole review or click here to purchase the book online.

Dr. Gregory Koblentz on Background Briefing with Ian Masters

KoblentzLast week, Dr. Gregory Koblentz, Deputy Directory of the GMU Biodefense Program was interviewed on Background Briefing with Ian Masters to discuss the ongoing Ebola outbreak in West Africa. He covers the role of the Pentagon in combating the disease in Liberia and the virulence of Ebola that was weaponized as a biological weapon in the former Soviet Union.

You can listen to the interview here.

Dr. Michael Smith at the September BPS Talk

WP_20140917_004On Wednesday, September 17, Dr. Michael Smith, Director of the Department of Defense’s Critical Reagents Program (CRP) was the first speaker in the GMU Biodefense Program’s Biodefense Policy Seminars for Fall 2014. Dr. Smith’s spoke on the “Ebola Virus Epidemic 2014: Where the Rubber Met the Roadmap.”

Dr. Smith discussed the role of the Critical Reagents Program (CRP) in DoD’s biodefense program and its role in the West African Ebola outbreak. CRP is responsible for the characterization, production, and distribution of reagents and consumables employed on deployed diagnostic and detection platforms and those under development by other programs. The CRP provides standardized assays which can detect the presence of certain biological agents such as bacteria or viruses to the U.S. Government, companies with U.S. government contracts, and foreign governments. The CRP also maintains a large collection of microbial cultures, antibodies, and antigens for research and development purposes.

During the 2012 Ebola outbreak in Uganda and Democratic Republic of Congo, Dr. Smith and his team learned that the assay they had developed to test for the Ebola virus did not detect that specific strain of virus effectively. Learning this enabled the CRP to re-work their testing, which has been of great benefit during this 2014 outbreak. When Ebola virus emerged in Guinea—the first time the disease had appeared in West Africa—CRP was able to provide the new tests—free of charge—to neighboring Sierra Leone before the first case emerged in that country.

Given Sierra Leone’s almost complete lack of public health laboratory capacity, diagnosis and treatment had been based solely on clinical judgment. Since the initial stages of Ebola virus disease are similar to the early signs of other diseases such as malaria, basing diagnosis on clinical presentation is unreliable. The pre-positioning of advanced diagnostic systems in Sierra Leone enabled the country to identify patients much more quickly than during previous Ebola outbreaks.

While the use of the new assays has enabled real time confirmation of virus, Dr. Smith discussed other obstacles to getting the outbreak under control. The medical system in Sierra Leone relies on family members providing patients with food and supplies at hospitals that have no electricity or air conditioning. In situations like this, many patients may stay home rather than going to a clinic or isolation unit. Because of this, it is very possible that the numbers of infections and deaths could be significantly higher than estimated. According to reports cited by Dr. Smith, an estimated 1 in 3 individuals infected with Ebola are not seeking medical attention. In densely populated cities in West Africa, this provides an opportunity for the unchecked spread of the disease.

Despite these obstacles, however, the relationships that CRP has forged on the ground in Sierra Leone to improve laboratory capacity and the accuracy and timeliness of diagnostic tests has allowed CRP to expand its fight against Ebola. CRP has been granted access to clinical data and samples from patients who have survived the disease. CRP and its interagency partners hope that the blood and sera of those patients can be used to create new therapeutics or a vaccine for the Ebola virus.

 

The GMU Biodefense Policy Seminars are monthly talks that are free and open to the public and feature leading figures from the academic, security, industry and policy fields discussing critical issues in biodefense. For more information, please visit https://pandorareport.org/events/biodefense-policy-seminar-series/.

Dr. Gregory Koblentz discusses Ebola on CTV News

In case you haven’t watched the news today (or looked at a newspaper, or been on the internet), yesterday, President Obama pledged he would send 3,000 American military personnel to West Africa in order to help with the Ebola outbreak which is continues to ravage that region.

George Mason University Biodefense Deputy Director, Dr. Gregory Koblentz was on CTV News this morning to discuss the continuing outbreak and reaction to the President’s decision.

Watch Dr. Koblentz’s interview here

If you’re interested in learning more about the West African Ebola outbreak, join us tonight at 7:00 for the September Biodefense Policy Seminar featuring Dr. Michael Smith, of the Department of Defense, who will discuss, “Biosurveillance and the Atypical Epidemic: The 2014 West African Ebola Epidemic”. The talk will be held at the GMU Fairfax Campus in Research Hall room 163.

The Epidemiologist: Dark Horse of Public Health

By Chris Healey

Many identify physicians as the preeminent professional in the health field – followed by dentists, physical therapists, pharmacists, and nurses – to name a few. However, one of the most important cogs in the health infrastructure mechanization is publicly obscure, yet works almost exclusively with the public. The epidemiologist is the most important health professional you may never meet.

An epidemiologist is not intentionally obscure. The occupation simply does not require as much face-to-face interaction as other health professionals. Instead, epidemiologists analyze data collected by healthcare providers to discern patterns overlooked on a patient-by-patient basis. That data is often analyzed offsite, away from patients. While physicians are treating the individual, epidemiologists are looking at the big picture.

State and federal regulations require physicians and other health professionals to report pertinent diagnosis and patient information to local health departments. That data is collected and analyzed by regional and district epidemiologists to detect unusual disease instances or patterns in their respective regions and districts. Data from local health departments is collected and further consolidated on the state and federal level by state health departments and the Centers for Disease Control respectively.

Epidemiologists serve as the vanguard in outbreak and bioterrorism detection. A clandestine bioterrorism event will likely be detected first by epidemiologists. For example, while several physicians may treat several different E. coli casesin the same day, they are unlikely to communicate mutual diagnoses among themselves. However, an epidemiologist whom analyzes all E. coli diagnoses that day may be able to discern unusual incidence. A physician can identify a single illness, but epidemiologists identify outbreaks and epidemics.

Incidence and pattern detection is only one function of the typical epidemiologist. Once pathogens of interest are detected, epidemiologists investigate patients to determine how they became infected with the respective agent. While physicians can serve in an investigative capacity, diagnosis and treatment of the patient at hand is often their focus. Epidemiologic investigations typically include patient interviews and environmental sample collection. In instances of foodborne illnesses, those investigations are critical to identify the tainted food and water sources. Product recalls and water treatment advisories are often the result of epidemiologic investigations.

Epidemiologists are often marginalized in popular culture and cinema. They are conflated, and often completely replaced, with physicians. However, the 2011 film Contagion portrayed epidemiologists as discrete health professionals with accurate—though dramatized—job functions.

Epidemiology is a growing field. According to the Bureau of Labor Statistics, epidemiologist employment is projected to grow 10 percent from 2012 to 2022, which is about as fast as the average for all occupations.

 

(Image Credit: Contagion)

Bioweapons Alarmism in Syria

by Dr. Sonia Ben Ouagrham-Gormley, originally published in the Bulletin of Atomic Scientists

As Secretary of State John Kerry challenged Syrian President Bashar al-Assad to hand over Syria’s chemical weapons in early September, articles published in the Washington Post and National Interest argued that the current focus on Syria’s chemical weapons is distracting the international community from a much deadlier threat: Syria’s biological weapons. The sources for the Washington Post article (one of whom also happens to be a co-author of the National Interest piece) warn that Assad’s regime could use its biological weapons in retaliation against Western forces or its own population. Both articles assert that Syria has maintained a dormant program since the country last engaged in biological weapons developments in the 1970s and 1980s and could easily reactivate its program to produce, on short notice, the stockpile of agents required to retaliate against its enemies. This threat is real, the argument goes, because Syria could tap into its pharmaceutical and agricultural industries to support the effort. Finally, the articles warn that Syria might have retained a strain of smallpox from a 1972 outbreak, which could be used to develop a devastating biological weapon.

These two articles provide no tangible evidence to support their claims. More important, their speculations contradict extant empirical evidence on the difficulty of achieving the level of biological weapons capability that the articles claim Syria maintains or could reestablish. To avoid falling prey to the same biological weapons hysteria that led to the invasion of Iraq in 2003, it is important to look carefully at such claims. Close examination shows them to be exaggerated, at best.

To evaluate Syria’s ability to revive a dormant program, one would need to know what kind of research and production infrastructure the Syrian government currently possesses. There is, however, very little publicly available information on the scope of Syria’s bioweapons program, if any.

If Syria retains only a small research capability developed in its bioweapons program of the 1970s and ‘80s, the likelihood that it would be able to quickly produce sufficient amounts of bioweapons for retaliation is very slim. The country would first need to create the research, development, production, and weaponization infrastructure needed for a crash program, a process that may take several months to even years, particularly in a war zone. Assuming that the Syrians already have stocks of agents—and it is pure speculation to say they do— they will need to conduct exploratory research to determine which agent is the most promising as a bioweapon and develop a production process that will maintain the agent’s lethal characteristics during scale-up and storage. Creating this production capability is also neither easily or quickly achieved.

In the early 1980s, Iraq attempted to reactivate a biological weapons program that had been largely abandoned in the preceding decade; it took the Saddam Hussein regime three years—from 1983 to 1986—to conduct the needed exploratory research and identify the agents most desirable for bioweapons work. Even then, the Iraqis were able to develop only crude liquid agents that lost toxicity within six to eight months. They were also unable to develop a bioweapons-specific dissemination capability, relying instead on personnel from their chemical weapons program to adapt chemical bomb casings and warheads for bioweapons use. This strategy resulted in ineffective weapons that would have released agents upon impact, destroying most of the bio-agent in the process.

Even if Syria already has significant bioweapons infrastructure in place, reactivating it would not necessarily be a quick or simple process. When in the early 1980s Soviet-era authorities decided to activate the mobilization facility in Stepnogorsk, Kazakhstan in order to produce anthrax, it took about two years to launch production, even though the facility had been established for several years and had the equipment and minimum staff needed for its operation. The suggestion that Syria could swiftly launch a crash program from a long-dormant infrastructure and produce effectively weaponized agents in amounts sufficient for a retaliatory military attack seems a considerable stretch from likely reality.

Read the rest of the piece here.

(Image credit: Scott Montreal/Flickr)

Koblentz on Syria

Dr. Gregory Koblentz, Deputy Director of the Biodefense Graduate Program, was featured in three pieces on Syria last week. Dr. Koblentz was quoted in an USA Today article, “Syria chemical weapons plan poses unprecedented challenge“. Speaking to the specific challenges the Syrian case presents, Koblentz explained that “[t]here has never been an effort to disarm an entire country of its chemical weapons during a civil war.” Dr. Koblentz was also featured in an interview with CTV Canada and CCTV (China).

Koblentz on the Difficulties of Destroying Syria’s Stockpile

Dr. Gregory Koblentz was quoted in two articles on Syria yesterday. In the first piece in the New Republic, Dr. Koblentz discusses the potential use of Tomahawk missiles (pictured above) should the US decide to pursue military action in Syria.

“The advantage to Tomahawks, according to Gregory Koblentz, a George Mason University political scientist who specializes in weapons of mass destruction, is they are highly accurate, fly low to the ground (and can therefore typically evade air defenses), and can be fired from ships hundreds of miles away (hence the frequently used term “lobbed”)—thereby putting American soldiers at very little risk. The downside to Tomahawks is they pack a comparatively small explosive punch and, particularly because they cannot be reprogrammed in-flight, are best used on stationary targets—an especially problematic proposition given that the regime will likely have had several weeks to move whatever they want to move to different locations.”

In the second piece in Voice of America, Koblentz is quoted on the likelihood of Syria eliminating its chemical weapons stockpile.

“‘I don’t think the Syrian regime is serious about actually turning over all of their chemical weapons, and even if they were to do so in the middle of a civil war would make it virtually impossible for any kind of international group to conduct their work safely and securely. So I don’t see this happening anytime soon, if ever,’ said Koblentz.”

Read the New Republic piece here, and the Voice of America piece here.

(image: U.S. Navy photo by Petty Officer 3rd Class Jonathan Sunderman)

Thrall on the Syrian Compromise – “Let’s Make a Deal!”

Dr. Trevor Thrall, GMU Biodefense Director, reviewed the latest developments in the ongoing Syrian saga yesterday in a piece in the National Interest. In it, he discusses the implications of the recent compromise proposal and potential US responses. Here’s an excerpt:

“The apparently accidental diplomatic overture from Secretary of State John Kerry, suggesting that Syria transfer its chemical weapons to international control to avoid U.S. airstrikes, has immediately received traction. How seriously either the U.S. or Syria will consider this proposal remains unknown. On the one hand, it is easy to argue that Syria will simply latch on to the proposal as a tactic to forestall U.S. action but has no intention of agreeing to give up its weapons. On the other hand, Syria needs Russian support more than it needs chemical weapons, and Assad may calculate that his chances against the rebels are better if the U.S. does not get directly involved militarily.

From the U.S. perspective the proposal has immediate political impact. Obama cannot strike Syria when his primary justification is in such serious question. There may be other reasons for the U.S. to engage in Syria directly, but the White House’s own PR campaign has emphasized the danger of Syria’s chemical weapons and the potential for them to wind up in the wrong hands. If Syria tells the world they are willing to consider giving them up, Obama’s argument crumbles and he cannot take action until the issue is resolved one way or another.

Ironically, for the U.S. this would be a far better outcome than Obama had any right to imagine just days ago. Having foolishly drawn the red line in the first place, and then having made a complete mess of the campaign to build both public and Congressional support, Obama may now have found a path that both gives him a big win while avoiding either an ugly defeat in Congress or having to launch airstrikes of wildly uncertain consequence…”

Read the rest of the piece here.

(image: Freedom House)