Psychiatry's civil war

How DSM-V is written will ultimately affect patients

Editorial: Psychiatry's bible: Its time has passed

Since this article was first posted, the American Psychiatric Association has announced that the publication of DSM-V will be delayed until May 2013. "Extending the timeline will allow more time for public review, field trials and revisions," says APA president Alan Schatzberg.

When doctors disagree with each other, they usually couch their criticisms in careful, measured language. In the past few months, however, open conflict has broken out among the upper echelons of US psychiatry. The focus of discord is a volume called the Diagnostic and Statistical Manual of Mental Disorders, or DSM, which psychiatrists turn to when diagnosing the distressed individuals who turn up at their offices seeking help. Regularly referred to as the profession's bible, the DSM is in the midst of a major rewrite, and feelings are running high.

Two eminent retired psychiatrists are warning that the revision process is fatally flawed. They say the new manual, to be known as DSM-V, will extend definitions of mental illnesses so broadly that tens of millions of people will be given unnecessary and risky drugs. Leaders of the American Psychiatric Association (APA), which publishes the manual, have shot back, accusing the pair of being motivated by their own financial interests - a charge they deny. The row is set to come to a head next month when the proposed changes will be published online. For a profession that exists to soothe human troubles, it's incendiary stuff.

Psychiatry suffers in comparison with other areas of medicine, as diseases of the mind are on the whole less well understood than those of the body. We have, as yet, only glimpses into the fundamental causes of the common mental illnesses, and there are no biological tests to diagnose them. This means conditions such as depression, schizophrenia and personality disorders remain difficult to diagnose with precision. Doctors can only question people about their state of mind and observe their behaviour, classifying illness according to the most obvious symptoms.

We have only glimpses into the causes of mental illnesses and there are no biological tests for them

First published in 1952, the DSM has its origins in a book used by the US military to determine if recruits were mentally fit for combat. The difficulty of separating mental disorders from normal variation in behaviour made it controversial from the start. Over the years, the book's influence has grown, and today it is used by doctors across the globe.

The wording used in the DSM has a significance that goes far beyond questions of semantics. The diagnoses it enshrines affect what treatments people receive, and whether health insurers will fund them. They can also exacerbate social stigmas and may even be used to deem an individual such a grave danger to society that they are locked up.

Some of the most acrimonious arguments stem from worries about the pharmaceutical industry's influence over psychiatry. This has led to the spotlight being turned on the financial ties of those in charge of revising the manual, and has made any diagnostic changes that could expand the use of drugs especially controversial. "I think the DSM represents a lightning rod for all kinds of groups," says David Kupfer of the University of Pittsburgh, Pennsylvania, who heads the task force appointed by the APA to produce the revised manual.

Few would claim that the DSM's current version is perfect. With each revision, the number of conditions it defines has swelled, many surrounded by bewildering lists of symptoms that must be checked to assign a diagnosis. Using current DSM checklists, for example, 114 different combinations of symptoms can lead to a diagnosis of schizophrenia. At the same time, many patients prove hard to fit into the framework.

One aim of the work groups compiling DSM-V is to cut through this chaos. They are streamlining diagnoses by removing various subtypes of schizophrenia, for example, and intend to address the confusion created by the fact that many people with one condition meet criteria for other disorders as well. The DSM-V task force is expected to propose a series of "dimensions" to be considered with a patient's main diagnosis. So as well as deciding whether someone has, say, bipolar disorder, doctors would determine whether they are suffering from problems such as anxiety and sleeping disturbances, and assess them on a simple scale of severity.

Grandiose claims

This is widely seen as a first step towards a future in which psychiatric diagnosis has a more scientific base, where sprawling checklists of symptoms are replaced by sliding-scale measurements of the underlying determinants of mental health. Yet critics worry that even a limited embrace of this "dimensional" approach is running ahead of the science. Until we understand more about the biological basis of psychiatric disease, this approach will not be helpful, they say.

Some of the harshest criticisms have come from those who led previous revisions of the DSM, in 1980 and 1994. In July, Robert Spitzer and Allen Frances, both now retired, wrote a stinging letter to the APA, accusing it of planning unworkable changes and making grandiose claims. In a separate editorial in the magazine Psychiatric Times, Frances complained that most of the authors are university-based researchers who are cut off from typical doctors and patients.

Spitzer and Frances also criticise the fact that members of the various DSM-V work groups have had to sign confidentiality agreements. "The main problem is that we don't know what they're doing," says Spitzer. The APA says the confidentiality agreements are to stop the manual's authors writing their own diagnostic handbooks alongside the official manual. Kupfer points out that discussion does go on: work groups proposing major changes debate their ideas in papers and at meetings. "We've done everything we can to encourage it," he says.

Another focus for Spitzer and Frances's concern is the suggestion that DSM-V could include new categories to capture milder forms of illnesses such as schizophrenia, depression and dementia. "The result would be a wholesale... medicalization of normality that will lead to a deluge of unneeded medication," Frances said in his editorial.

For example, one work group is considering whether it is possible to catch people in the early stages of schizophrenia or other psychotic illnesses before they have their first full-blown psychotic episode (Schizophrenia Bulletin, vol 35, p 841). Some doctors prescribe antipsychotic drugs at this early stage in the hope of stopping the illness from progressing.

Libido loss

These medicines can have serious side effects, such as loss of libido, weight gain and distressing tremors and spasms, so no one would want to take them without good reason. Yet it's hard to separate distressed people who will go on to develop a psychotic disorder from the "false positives" - those who will recover or develop a different illness. The available evidence suggests that only about 30 per cent of people identified as being at risk of psychosis will go on to develop it within two years.

These medicines can have serious side effects so no one wants to take them without good reason

Nevertheless, William Carpenter, a psychiatrist at the University of Maryland in Baltimore who chairs the DSM-V work group on psychosis, believes the needs of the "true positives" are so great that adding a diagnostic category to cover "psychosis risk" would, on balance, be a good thing. Frances brands this proposed diagnosis as "the most worrisome suggestion entertained".

Given the controversy, psychosis risk may not make it into the DSM proper, and may instead appear in the appendix, as a condition needing more research. But even that designation might boost prescribing.

Frances and Spitzer are not the only ones with concerns, and there are other flashpoints (see "Hebephilia", "Transgendered" and "Bereavement"). In March, Jane Costello of Duke University in Durham, North Carolina, resigned from the work group on disorders in childhood and adolescence, worried about what she saw as a lack of scientific rigour across the whole DSM revision. "I felt that there was not enough empirical work being achieved or planned," she says.

The disputes are getting ugly. Senior APA figures have even suggested that Spitzer and Frances are motivated by a desire to safeguard their flow of royalties from clinical guides linked to the current DSM. "The fact that Dr. Frances was informed... that subsequent editions of his DSM-IV associated products would cease when the new edition is finalized, should be considered when evaluating his critique," leading APA figures said in a response to Frances's editorial.

Spitzer and Frances reject this charge. "To suggest that I have no concern other than the royalties is a little absurd," says Spitzer. "My annual royalties from DSM-IV related books are $10,000 per year," notes Frances. "These have nothing to do with concerns I expressed."

Attention has also turned to the financial interests of those working on DSM-V. The APA has ruled that members of the task force and work groups may not receive more than $10,000 per year from industry while working on DSM-V, and must keep their stock holdings below $50,000. This doesn't satisfy Lisa Cosgrove of the University of Massachusetts, Boston, who studies financial conflicts in psychiatry (New Scientist, 29 April 2006, p 14). She notes that the APA's ruling places no limit on industry research grants, and has found that the proportion of DSM-V panel members who have industry links is exactly the same as it was for DSM-IV, at 56 per cent (The New England Journal of Medicine, vol 360, p 2035).

The final version of DSM-V is scheduled to be published in 2012, but given the level of controversy and the need to test whether psychiatrists can reliably use the proposed diagnoses, that date seems certain to slip.

For now, there is an uneasy ceasefire, but next month the work groups will post their proposed changes on the APA's website. Stand by for renewed hostilities.

Editorial: Psychiatry's bible: Its time has passed

Hebephilia

How young is too young?

You may have never heard of "hebephilia", but this obscure diagnosis has huge significance in the courts. If it becomes accepted it could lead to hundreds of sex offenders who have served their jail time being locked up indefinitely - on grounds that some say are spurious.

Hebephilia refers to when adults are sexually fixated on teenagers around the time of puberty. This sets it apart from paedophilia, which refers to a focus on pre-pubescent children. The DSM-V work group on sexual disorders is likely to call for paedophilia to be renamed paedohebephilia, and include a hebephilic subtype.

The justification is the research of one work group member, Ray Blanchard of the University of Toronto in Canada. Working with sex offenders, Blanchard used a device that records blood flow in the penis to measure their arousal while they were listening to sexual material. He concluded that some men have a disorder that causes them to fixate on girls aged 11 to 14 (Archives of Sexual Behavior, vol 38, p 335).

The proposed diagnosis has been condemned by critics as dangerously blurring the boundary between paedophilia and normal male attraction to teenage girls - which isn't necessarily acted upon. Karen Franklin, a forensic psychologist in El Cerrito, California, argues that the diagnosis makes a disease out of preferences that have been shaped through human evolution. "People didn't used to live so long and mating started earlier," she says.

The work group is also considering whether some men are specifically turned on by rape - a proposed condition termed paraphilic coercive disorder. Again, the evidence is based largely on measurements of penile blood flow in response to sexual images and stories, and the validity of the condition is hotly contested.

The rows over hebephilia and paraphilic coercive disorder aren't academic, because 20 US states have passed laws that allow sex offenders who have served their sentences to be detained indefinitely in a secure hospital if they are deemed "sexual predators" (New Scientist, 24 February 2007, p 6). This can only be done if the offenders have a psychiatric disorder that increases their risk of reoffending - which few do, according to DSM-IV.

Franklin says that if hebephilia and paraphilic coercive disorder make it into DSM-V, they will be seized upon to consign men to a lifetime of incarceration. This argument cuts little ice with Blanchard, however. "The clinical facts are what they are," he says.

Transgendered

We are who we say we are

Is history repeating itself? That's the question facing psychiatrists considering how gender identity should be defined in DSM-V. The APA has a legacy of uneasy relations with the lesbian, gay and transgender community, having included homosexuality in the DSM's list of psychiatric disorders until 1973. Some transgender activists want issues of gender identity kicked off the list of mental illnesses too.

These activists are up in arms over the membership of DSM-V's sexual and gender identity disorders work group, in particular the selection of Kenneth Zucker of the University of Toronto, Canada, as its chair. Zucker is reviled by some transgender activists for his work on therapy to reorient children who feel that they were born into the wrong sex. An online petition objecting to the work group's composition has more than 9500 signatures.

The group is nevertheless likely to recommend changes that could actually ease tensions. One of these is a change in the name of a diagnosis that as currently phrased is inherently offensive to transgender people. "'Gender identity disorder' falsely implies that the gender identities of gender variant people are in themselves disordered," says Kelley Winters, founder of GID Reform Advocates.

The work group has not yet revealed its proposed name, but "disorder" will be dropped. "We're sensitive to issues of language," says Zucker. One possibility is "gender dysphoria", which focuses on the inherent distress of people living in a body that doesn't match their identity.

That would not satisfy those transgender activists who want issues of gender identity removed from the DSM altogether. But others argue for the retention of a renamed condition to make it easier for those distressed by the mismatch between their identity and their bodies to seek assistance, and also to help those who need sex-change surgery to get it paid for. Even now, many transgender people face problems when insurers refuse to recognise the treatment as a legitimate medical expense.

Bereavement

When does grief become an illness?

Losing a loved one is the most devastating event that most people ever experience, yet the official diagnosis of depression specifically excludes people who have recently been bereaved. Now there may be a major shift.

Not only is bereavement a known trigger for depressive symptoms, but bereaved people respond just as well to antidepressant treatment as others with similar symptoms, says Jan Fawcett of the University of New Mexico, Albuquerque, who heads the DSM-V work group on mood disorders. He thinks it may be time to class people who are severely distressed due to a recent bereavement as depressed.

For most people time proves at least a partial healer. But about 10 per cent of bereaved people are still debilitated by their loss more than six months later - and they can remain locked into this loop of grief for many years. Acknowledging their plight, the proposals for DSM-V are expected to include a new diagnosis of "complicated grief" or "prolonged grief syndrome".

The impetus for this comes from a team led by Holly Prigerson of Harvard Medical School in Boston, who has shown the condition can be reliably diagnosed (PLoS Medicine, vol 6, p e1000121). Katherine Shear, now at Columbia University in New York, has also found that the condition responds well to a form of psychotherapy designed to help bereaved people begin resuming their lives (Journal of the American Medical Association, vol 293, p 2601).

"Oh Lord, come to our Senators to stop Health Reform"

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Obama's Most Creative Speech Yet

One of the greatest things about being president is the ability to paint broad strokes. The man in charge can usually get by with expounding large themes like “vision” or “hope” or the “challenge of humanity.” Less visible executive staffers are the ones who sort out particulars of a new policy or diplomatic agreement after the motorcade departs.

But that won’t cut it for President Obama when he speaks to delegates Friday at the U.N.-sponsored climate conference in Copenhagen. When Obama agreed to attend the negotiations last month, he planned his speech to be the icing on an otherwise bland cake. Or, at the most, give one final push to an agreement hammered out by delegates. That, however, was before talks nearly deteriorated this week, hitting a stalemate just days before finishing. (Large countries have agreed only to small steps, while small countries refuse to accept anything less than giant leaps.) The result is an Obama forced to transform rather dramatically from America’s grand orator to its top negotiator.

Developing countries and the hordes of demonstrators at the talks have wanted to know one thing from the U.S. since the conference began: will it agree to sweeping emissions-reduction targets? The answer until now has been no, not without further economic analysis and assurance that other large countries like China and India will also play ball. The U.S. has, for good measure, thrown a bone to critics at the talks. Early Thursday, Secretary of State Hillary Clinton agreed to a $100 billion transfer of mitigation funding to poorer countries to deal with local effects of climate change. That's a drop in the bucket for those small countries, which have asked for at least a trillion. And so the bickering has continued.

So when Obama arrives in Denmark on Friday, the American president will be forced to deliver his most creative speech yet. At the risk of the negotiations utterly collapsing, he’ll have to agree to further emissions cuts without overpromising what the Senate may agree upon next year. He’ll have to offer large sums for deforestation mitigation and adaptation for small countries without knowing exactly how much Congress will authorize. And he’ll have to make a repeated case for urgency in the face of the world’s environmental challenges while admitting that his country has, in fact, been one of the biggest foot-draggers of them all.

Obama’s no amateur when it comes to polished speaking, and his speechwriters will undoubtedly draft some shiny lines. But in the open plenary session that will follow, he’ll be asked for specifics. He’ll be asked to offer firm numbers on exactly what the U.S. will put in writing by a conference full of international delegates who won’t know or care just how slow the U.S. Senate actually works.

Never unprepared, the president will have some numbers in his pocket. Last month the White House announced that Obama would propose cutting emissions 83 percent by 2050, which would entail a 30 percent reduction below 2005 levels by 2025. But still, that's not nearly enough for the other frustrated parties around the table. One of Obama’s most valuable weapons will be the EPA findings released last week that too much carbon in the atmosphere can cause unhealthy lungs, essentially authorizing his administration to cut domestic emissions on its own.

But if Obama goes out on a limb, so as to say “If Congress doesn’t take up this issue, I will,” the delegation of senators and congresspeople in the audience may remind him that they don’t have to fund the effort.

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Not Flying South

Backyard feeders plus a strange sense of direction may have begun to split one bird species into two.
In southern Germany, some 10 percent of blackcaps (Sylvia atricapilla) fly not south, toward warmth, but rather northwest for the winter, says evolutionary biologist H. Martin Schaefer of the University of Freiburg in Germany. This novel journey, on record since the 1960s, probably became survivable thanks to the rise of backyard bird feeding in Britain, he says. Enthusiasts setting out seed and suet have kept the birds from starving until it’s time to wing back to Germany to nest.
The returnees from Britain nest in the same German forests as the more conventional migrators that fly to Spain. Yet the two groups now show subtle but distinct genetic and visible physical differences, Schaefer and his colleagues report online December 3 in Current Biology.
“It’s a good example of how humans can influence evolutionary trajectories,” Schaefer says.“The really cool thing here is that it seems to be driven by migration,” says behavioral ecologist Jeff Podos of the University of Massachusetts in Amherst. Other researchers have looked for these kinds of genetic differences between populations with different migration destinations, but have not found any, he says.
One or just a few genes are thought to control the migration direction for blackcaps, Schaefer notes. A classic study showed that offspring of parents that flew in divergent directions for winter grew up to migrate in an intermediate direction.
Migratory genes would, of course, differ between differently migrating populations, but Schaefer and his colleagues wanted to look for other genetic differences as well. Northwesters and southwesters varied slightly in parts of their genome that don’t involve migration. Small as that difference was, it was greater than the difference between southwest migrators hailing from far-flung parts of Germany, says Schaefer.
Northwester birds also had slightly rounder wings than the southwesters, the researchers said. Rounder wings improve flight maneuverability but don’t perform as well on long hauls. The northwester birds fly only two-thirds the distance the others do, so the slight shift in wing shape might be the beginning of adaptation to their new route.
Likewise, beaks on Anglophile blackcaps tended to take on a different shape, one more like the narrow beaks on generalist feeders. Schaefer speculates that winter feasting on olives and other big, fruity mouthfuls encourages wider beaks in the Spanish migrators. These blackcaps are more likely to choose mates that have similar winter tastes, thus preserving migratory differences in their offspring. The two bird groups aren’t new species yet, Schaefer says. But they’ve taken a few flights in that direction. More than 50 species that have recently rerouted their migrations may be experiencing similar changes, Schaefer says.

Sediment dynamics in the Rhine catchment :

Quantification of fluvial response to climate change and human impact
Dissertation
Publisher: www.knag.nl
Author: Erkens, Gilles

Pointer's birth place
Fluvial systems are strongly respon- sive to changes in climate and land use — but take their time to show it. Accurate prediction of the timing and degree of future fluvial response requires comprehensive understanding of fluvial response in the past. This PhD-thesis studied the response of the river Rhine over the last 20,000 years, as recorded in the morphology, composition and volumes of its sediment. Borehole data and various dating techniques were combined to time-slice cross-sections and to construct a series of palaeogeographic maps. A method to calculate amounts of sediment carried both in suspension and as bed load during millennia-long time slices was developed. This research shows that only climate changes during the glacial-interglacial transition and the strong rise of human land use during the late Holocene were large enough to trigger response and overwhelm ongoing autogenic behaviour of the river and the buffering capacities of the Rhine catchment. The climatic changes at the glacial-interglacial transition triggered incision and abandonment of the Pleniglacial braidplain terrace along the entire Rhine valley. This was accompanied by a shift from a braided to a meandering fluvial style, but it took several millennia to complete the transition to a single meandering channel. As a result, the Rhine was a multi-channel river during the Late Glacial and most of early Holocene. The last phase of fluvial response to the glacial-interglacial transition consists of increased delivery of fine sediment during the first half of the Holocene (until ~ 6000 years ago). This sediment had been stored in the upstream tributary valleys since the full glacial, and was released by incision of the Rhine and its tributaries when they adapted to the interglacial climate conditions.



Overall, this study shows that sizable fluvial catchments adapted slowly to large scale climatic changes, in both spatially and temporally complex ways. During the Holocene other external factors than climate change became important for the development of the Rhine system. In the Rhine delta, the combination of eustatic sea level rise and subsidence provided in large accommodation space for sediment delivered from upstream. Release of bed load by the meandering and incising Rhine in the trunk valley forms the source for bed load delivery to the delta. Both the Rhine trunk valley and delta are sinks for suspended sediment, and the amount of stored sediment in these areas was used to reconstruct fine sediment transfer through the lower Rhine. Following the aforementioned increased delivery of fine sediment during the first part of the Holocene, sediment transfer stabilised during the middle Holocene. During the last 2000 years the delivery of fine sediments to the sinks is up to 150 % higher compared to the directly preceding millennia. This can only be explained as the result of progressive deforestations for agricultural land use since the late-Neolithic (6300 years ago). The timing of the increased delivery of fine sediments suggests that pre-Roman land use was already extensive. Hence, prehistoric land use should be regarded as a drainage basin-wide forcing factor for fluvial systems.

No Health Care For All

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Copenhagen Climate Talks Set to Begin: What's Likely to Happen and What's at Stake

Here are a few of the places that bear watching, to see if some kind of consensus develops over the course of the proceedings:

• What's the science really saying? For almost five years, the consensus position of those who cared about producing a treaty has been that we're struggling to avoid a temperature rise greater than two degrees, and that to do that we'll need to limit atmospheric concentrations of carbon dioxide to less than 450 parts per million. These sound like the kind of eye-glazing numbers that journalists try to avoid -- but the vast and slow-moving bureaucracy of the climate negotiations process has adopted them as the goal, and most of the proposals on the table are geared to reaching (or plausibly approaching) those targets.
  
  The problem is, that's not good science any more. After the rapid melt of Arctic sea ice in the summer of 2007, researchers recalibrated. A NASA team said that the right figure is 350 -- that anything more is not compatible with "the planet on which civilization developed and to which life on earth is adapted." That assertion has been backed up by no less than Rajendra Pachauri, the UN's chief scientist, who has gotten grief for saying -- most recently in an interview with Yale Environment 360 -- that 350 is where we need to go. Ninety-two of the poorest nations on Earth have officially signed on to that target, and at the moment it's still in the negotiating text, albeit in a preamble about a "shared vision" for the future.
  
  The problem, of course, is that meeting a 350 target goes far beyond anything the Obama administration, much less the Senate, or the Chinese, or many of the other big players, are currently contemplating. We now know that Obama will arrive on Dec. 9 en route to Oslo, and that he will offer roughly a 17 percent cut in 2005 emissions levels by 2020. That would be about a zero percent cut from 1990 levels; in other words, not very ambitious -- the absolute minimum for saving face, but not enough to save the world.
  
  Going further would be fundamentally disruptive -- it would mean not incremental change but a wartime footing. So the question of which science you embrace is really a proxy for how much you're willing to do. And in this case "political realists" are the opposite of "scientific realists." If you're figuring the odds, there will more politicians than scientists on hand in Copenhagen.


• How tough will the developing countries be? Since Obama's announcement that he will go to Copenhagen robbed journalists of their first cliffhanger, the next is likely to be whether the most vulnerable nations walk out on the proceedings. Here's Mohammed Nasheed, president of the Maldives, whose country sets aside money in its budget each year in case it needs to buy a new homeland when its current one sinks beneath the waves, talking about what a 2 degree Celsius temperature increase would mean: "At two degrees we would lose the coral reefs. At 2 degrees we would melt Greenland. At 2 degrees my country would not survive." He called the proposals from the big players a "suicide pact" and pledged to try and stop them. "As a president I cannot accept this. As a person I cannot accept this. I refuse to believe that it is too late, and that we cannot do anything about it."
  
  Nasheed rallied a dozen of the most vulnerable nations earlier this month at a summit in his capital of Male. And virtually every poor nation is starting to realize how badly they're going to be hit by climate change: The vulnerability of Andean glaciers, Asian monsoons, African rainfall patterns become clearer with each passing year. But the pressure from the rich nations -- and indeed from some of the big environmental groups -- not to be a skunk at the garden party will be intense. And it will come with sums of money attached — the kind of money that traditionally has been enough to buy off the anger of the poor world.


• Which leads to the next obvious question -- just how much money will be on the table? The sums required are staggering. The World Bank recently estimated that keeping temperature rise to 2 degrees Celsius would mean spending $140 to $675 billion a year in the developing countries -- which, after all, will only be developing if they keep figuring out how to acquire more energy. And adaptation -- dealing with the effects of the climate change we can't prevent — would run another $75 billion a year (an estimate that other research paints as extremely optimistic).
  
  Sums like that are not on offer. The Europeans have talked about a deal in the range of $100 billion a year, but that depends on the Americans ponying up, and so far the U.S. has been as coy about its willingness to pay as about its willingness to rein in emissions. Everyone outside the U.S. knows that this is -- overwhelmingly -- a problem we've caused; since the carbon molecule has a residence time of over a century in the atmosphere, it will be the decades before the Chinese, despite their vastly larger numbers, are as responsible for climate change as Americans. But if Obama puts a realistic number on the table, Senator James Inhofe (R-Armageddon) will be on hand to take it off. (Inhofe originally announced he was going to Denmark as a "one-man truth squad," but then added John Barasso (R-WY) and "a secret person" to his delegation). In our poisonous politics, the idea of the U.S. meeting anything like its moral obligation seems small -- and without that, the politics gets harder for everyone else in the world.

Against this backdrop, there's a lot of important and less flashy stuff that has to move forward if we're ever going to reach an agreement. Nations with large swaths of forest, for instance, seem willing to make a deal to stop their destruction. It's cheap compared with the other steps we'll need to take, so it will probably happen -- though the devil is deeply in the details. The same with credits for farmers for keeping carbon in the soil -- it could be a big help, or a loophole large enough to drive an endless fleet of combines through.

Reactions of the Afghan people to Obama's new strategy

Sign the Petition

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Iran: No uranium stockpile abroad to be processed for peaceful purposes

Outgoing Director General of the International Atomic Energy Agency, IAEA, Mohamed ElBaradei, left, talks to U.S. Ambassador Glyn Davies prior to the start of the IAEA's 35-nation board meeting at Vienna's International Center, in Vienna, on Friday, Nov. 27, 2009
With a decision on Afghanistan, we will now see whether a reluctant president can persuade a reluctant Congress and inspire a reluctant nation to accept additional wartime sacrifice. But the administration must feel relieved. The mere act of choosing releases accumulated tension like shooting a bow, wherever the arrow lands.

That relief, however, will be short-lived. Coinciding with the Afghan decision, Iran has entered a final stage of irrevocable choices about its nuclear program. It has backed out of a deal that would have sent most of its uranium stockpile abroad to be processed for peaceful purposes. Following a censure of Iran by the International Atomic Energy Agency (IAEA), President Mahmoud Ahmadinejad announced plans to construct 10 additional nuclear enrichment sites. Iran's parliament passed a resolution urging decreased cooperation with the IAEA. Ayatollah Ahmad Khatami preached a sermon at Tehran University pledging that Iran would produce its own high-grade uranium for "medical research." This is a regime in total defiance of international demands, moving toward breakout nuclear weapons capability.

So, have President Obama's diplomats failed? Were their honeyed words not sweet enough? Not really, because the current crisis has little to do with their skill, or lack of it. It is being caused by internal dynamics in Iran that seem immune to the rational offers and counteroffers of diplomacy.
In Iran, we are seeing the consolidation of a military dictatorship. Since the Iranian revolution of 1979, the nation's clerical leaders have had a military arm -- the Revolutionary Guard Corps -- that has acted as their ideological enforcers. It polices Tehran, organizes paramilitary forces, effectively runs Iranian elections, dominates large sectors of the economy, operates missile systems, directs Iran's international support for terrorism, controls Iran's chemical and biological weapons, and would be in charge of an Iranian nuclear bomb. Ahmadinejad and many other leaders are former Guard officers.
But in reaction to mass protests after the fraudulent presidential election in June, the Guard's control has expanded comprehensively. Supreme Leader Ayatollah Ali Khamenei recently reorganized Iran's intelligence services to give the Guard the lead role -- clearly fearful that the regular intelligence agencies were unreliable. The Guard has assumed greater power over Iranian media. It is increasing Internet censorship and placing militia instructors in elementary schools. Experts on Iran now debate whether the Guard is fully under Khamenei's control or whether it may be beyond all control.
Iran's theocracy has become a military junta with a veneer of religion. There are fatigues beneath the robes. On the nuclear issue, the main question is: Does this regime believe that nuclear weapons will help ensure its survival? There is every reason to believe that it does. As the disorders since June revealed the regime's vulnerability, it has sped up its nuclear program. Drained of legitimacy and fearing a color revolution, Iran's military government seems to believe that the bomb will confer influence and permanence. It is not an irrational calculation.
In this light, Obama's policy of setting deadlines for cooperation that are violated with impunity, and continually extending the hand of engagement after it is slapped again and again, is both weak and irrelevant. But the alternatives are not easy or obvious. The crippling economic isolation of Iran is worth trying, again. But it would require a number of unreliable nations to sacrifice large economic interests in Iran -- something they have been unwilling to do before. Direct military options are uncertain and opposed by the military itself. It is difficult to imagine Obama, the Great Deliberator, taking actions that George W. Bush concluded were too risky.
But the security implications of a nuclear Iran could be greater than failure in Afghanistan. Iran is an unstable revolutionary power with global ambitions and terrorist ties. Nuclear proliferation does not get more dangerous than this.
There is, however, an untried option. So far, President Obama has seemed to view Iran's ongoing democratic uprising as a pesky obstacle to engagement. The administration has reduced funding for human rights programs in Iran and looked the other way as exiled opponents of the Iranian regime have been attacked within Iraq.
In addition to serious economic and military pressure, Obama could try the strategy the Iranian regime most fears: supporting, overtly and covertly, the democratic resistance against military rule. Not out of idealism, but realism. It would be a source of leverage on the Iranian regime, at a time when American leverage is limited. And it might hasten the return of civilian control in Iran, so that America would actually have a negotiating partner.

SPIEGEL Interview with Pakistan's Prime Minister

'American Drone Attacks Are Counterproductive'

In a SPIEGEL interview, Pakistani Prime Minister Yousuf Raza Gilani talks about the fight against terrorism in his country, the future of Afghanistan and why US drone attacks do more harm than good.

SPIEGEL: Mr. Prime Minister, Pakistan is being shaken by more and more terror attacks. In the past few weeks, the number of assaults has increased noticeably. Moreover, your government is at war with militants in Waziristan. Do you still enjoy being prime minister?

Yousuf Raza Gilani: I have taken a special responsibility in a unique situation of my country. Pakistan is a frontline state in a conflict which will decide the peace, progress and prosperity not only of Pakistan or South Asia, but of the whole world. So you can imagine what my job is about. I personally feel that it is our duty to perform successfully. As far as our military activities in South Waziristan are concerned, I followed the policy of dialogue and development first. But when the country was challenged by the militants, there was no other option left than military action.

SPIEGEL: Many people in Pakistan consider this approach a war against the country's own people.

Gilani: The people we are fighting are militants. They are not from Pakistan, they are Uzbeks, they are from Chechnya, they are Arabs and Afghans. And they cooperate with foreign agents to disturb the peace in Pakistan.

SPIEGEL: Are you saying that there are no Pakistani Taliban?

Gilani: Of course there are Pakistani militants, but the insurgencies are driven by foreign elements.

SPIEGEL: Let me guess: You believe that the Indian intelligence service is behind it.

Gilani: In fact, to some extent there is a lot of interference in Afghanistan. This is not only our opinion, but also the belief in the United States.

SPIEGEL: But there has not been any proof of Indian involvement.

Gilani: I am not saying that there is. But the insurgency in Afghanistan has been analyzed by many experts, including from American think tanks, and they have mentioned this.

SPIEGEL: You are talking about Afghanistan, but it is Pakistan that has been repeatedly described as the "most dangerous place in the world." Don't you think it is too easy to say that only foreign elements are responsible?

Gilani: The world is always only focusing on terrorism when it comes to Pakistan. This has, of course, harmed the reputation of our country. We must not forget that there are so many other areas and avenues which are very conducive for Pakistan. Despite all the things that are going on here, there are so many places not affected by terrorism. We are giving a lot of security to the employees here, also to those who have come from other countries. There are many engineers, for example. But, unfortunately, we see many lost opportunities for investment because of this focus on terrorism -- and that harms not only Pakistan, but also the foreign investors. Can't one see that there is a lot of development in Pakistan going on?

SPIEGEL: Are you disappointed about the world's opinion of Pakistan?

Gilani: Pakistan should not be portrayed only as a country at war. When there was a Soviet invasion in Afghanistan, there were many allies fighting the invaders in this war. We were part of this alliance. After this war, the world forgot about this region, and that vacuum was filled by the militants. We are facing those problems even today. They have been thrust upon us.

SPIEGEL: Since you are already letting the US carry out its drone attacks against militants on Pakistani territory along the border with Afghanistan, why don't you let them help you with soldiers on Pakistani territory?

We Need Huge Public Support to Combat Terrorism'

Gilani: We haven't stopped them from helping us. In fact, we have a multi-dimensional cooperation with the United States, including defense and intelligence, but also economics, trade, development, health education and even in cultural affairs. But these drone attacks are counterproductive.

SPIEGEL: Really? The leader of the Pakistani Taliban, Baitullah Mehsud, was killed by an American drone. Don't you call this a success?

Gilani: The political and the military leadership have been very successful in isolating the militants from the local tribes. But once there is a drone attack in their home region, they get united again. This is a dangerous trend, and it is my concern and the concern of the army. It is also counterproductive in the sense that it is creating a lot of anti-American sentiment all over the country. But in order to fight the militants in Waziristan, we have to carry the public with us. One cannot go into any war without the support of the masses. We need huge public support to combat terrorism. But we do not get that if there is American interference, which we do not ask for.

SPIEGEL: But no matter what the Americans do, there will always be anti-American sentiment.

Gilani: Right now, the whole nation is supporting our military action because they feel that terrorism is a menace.

SPIEGEL: In the past few weeks, US Secretary of State Hillary Clinton, National Security Adviser James Jones and CIA Director Leon Panetta all visited Islamabad. Were the visits an attempt to improve America's reputation here?

Gilani: The war in Waziristan is our own war. Once there is American interference, as with the drones, the public starts thinking that it is a proxy war. At times, the public sentiment is quite anti-American. That is why we are convincing Washington that there should be more cooperation in the fields of defense and intelligence. And cooperation means cooperation, not doing anything without our consent. At the same time, we need a regional balance, too. It should not be seen that the Americans are doing something on behalf of the Indians. If this was the case, then public opinion would totally turn against the Americans.

SPIEGEL: Are you in favor of the US staying in Afghanistan? Once it withdraws, there will be no balance at all in the region.

Gilani: A stable Afghanistan is very much in the interest of Pakistan. We have been coping with millions of refugees in Pakistan, and they have been here for many decades. Now they have merged into our society, they are doing business here and their children have grown up here. There is a lot of cross-border activity going on, too. So that is why we need a stable Afghanistan. There people should be able to go back to their own country with dignity.

SPIEGEL: So you support the new strategy of US President Barack Obama to first increase the number of soldiers and then leave Afghanistan in the near future?

Gilani: We support any policy which is in the interest of the Afghani people. The main goal should be stability in the region.

SPIEGEL: The picture you are drawing is not exactly ideal for attracting more foreign investment to Pakistan. This week you are visiting Germany to try to accomplish just this. What are you going to tell German companies?

Gilani: Again, we should not stick to terrorism. Not the whole country is attacked by terrorists. Only specific areas -- those close to the border to Afghanistan -- are affected and we are very successfully handling the situation. Nowhere else in the world have 2 million refugees, so-called internally displaced persons, been sent back to their homes within only 10 weeks, as happened after our military action in the Swat Valley this summer. This is unprecedented in the history of the world. Therefore we are confident even about South Waziristan. We have already taken over the militants' strongholds, which has never happened before in that region. At the same time there is a lot of investment already coming to Pakistan.

SPIEGEL: That does not seem convincing enough for German companies.

Gilani: We have a special relationship to Germany. Pakistan and Germany were the first countries in the world to sign a bilateral investment treaty, back in 1959. Why shouldn't we continue with this good relationship? Germany is already our fourth biggest investor; the European Union is number one.

SPIEGEL: Can you imagine what the German public would say if German arms manufacturers were to invest in Pakistan?

Gilani: We are looking for investments in all fields. We have a lot of opportunities, for example, in the agricultural sector or in the fields of power generation and infrastructure.

SPIEGEL: There have been a lot of media reports in recent months about Pakistan's plans to buy submarines from Germany, something which is controversial in Germany given the political situation in Pakistan. Do you also plan to talk about buying German submarines during your visit to Berlin? Or has your government already decided to buy French submarines instead?

Gilani: It will take some time. The army chief to whom I talked about this on Thursday told me that we are successfully moving forward. But this is related to all kinds of defense matters, not only about the issue you are talking about. But I can assure you, there is a defense cooperation with Germany, too, and we are already in the process of signing a memorandum with the Germans.

SPIEGEL: Mr. Prime Minister, thank you very much for the interview.

Interview conducted by Hasnain Kazim in Islamabad.

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