The Implications of the Greek Referendum’s Outcome

Introduction
This paper will examine the social welfare and economic implications of the recent 2015 referendum on Greek bailout conditions offered by the ECB and IMF, starting with and examination of the history behind the crisis, the resulting series of financial bailouts along with the conditions imposed and their economic and social welfare ramifications, and the potential irrelevancy of the recent 2015 referendum on the actual outcome of the negotiations.

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The Background to the Greek Debt Crisis
The Greek debt crisis essentially started in late 2009, after economic reports about the Greek government’s current deficit and debt levels made clear that the Greek government had deliberately under-reported their current deficit and financial situation in 2008 and 2009, with the deficit at the end of 2009 estimated independently at 12.5% of Greek GDP, twice the amount reported by official Greek governmental figures during that time (Simitis, 2014). These issues were further exacerbated by the revelation that Greek sovereign debt exceeded the 91.4% of Greek GDP previously reported, and actually stood at 126.8% of total Greek GDP due to a number of debts and liabilities within the Greek public sector that had been over-looked during the previous reports issued by the Greek Ministry of Finance (Simitis, 2014). These discrepancies in reporting raised serious concerns over Greece’s ability to accurately report its current financial situation, and the resulting sovereign debt ratio of 128% of GDP raised serious questions over the government’s ability to meet its current financial obligations (Ardagna and Caselli, 2014). The results of the revelations, occurring during the aftermath of the recent global financial crisis, led to a downgrading of Standard and Poor’s credit rating of Greece to BB+, a rating which indicates a significant possibility of default on borrowing (Standard and Poor, 2015). This caused the interest rates of 5 year bonds issued by the Greek government to rise to 5.385% in November 2009, a figure 1.42% higher than the average rate of all other similar Euro-zone government bonds during that time (Simitis, 2014). This also occurred at a time where the Greek government was running a significant structural deficit, with governmental spending at 53.2% of GDP, and public revenue of only 37.8% (Ardagna and Caselli, 2014). In other words, only further borrowing would be able to sustain the current level of Greek public services, borrowing which had just became exponentially more expensive to maintain.
Given the developing crisis in the Eurozone, the European Central Bank (ECB) chose to step in and offer assisted bailouts and loans using funds appropriated from other EU member states and the IMF (Baimbridge and Whyman, 2014). To this end, the Commission, the ECB and the IMF established the European Financial Stability Fund (EFSF, 2015). The EFSF issued a bailout loan of €110bn in 2010 to the Greek government, which came with the condition that tight austerity measures be put into place, including a number of cuts across a broad spectrum of public services and a series of tax increases to boost governmental revenue (Ardagna and Caselli, 2014). Similar conditions were given to other recipients of bailout loans from the EFSF, including Ireland and Portugal, who as of 2014 have successfully reduced their national debt levels and current account deficit to that specified by the bailout conditions (Baimbridge and Whyman, 2014). However, the Greek government was hit with a further recession in 2011, with GDP growth contracting by 9.6% in the 4th quarter of 2010, and then a further 10.4% fall in the 1st quarter of 2011 (World Bank, 2015). The continuing economic problems faced by Greece were due to a number of factors, including a severe fall in revenue from both tourism and shipping due to the global economic crisis, two of Greece’s most important industries, and significant discrepancies between total taxes owed and total tax revenue, with total tax income in 2012 being €51.99bn, against the expected €110.79bn as reported by a State Audit Council report (Argitis and Nikolaidi, 2014).
These conditions meant that Greece was unable to continue to meet its financial obligations in 2012 and again faced the possibility of sovereign debt default, requiring another bailout loan to be made by the EFSF of another €130bn, with additional conditions attached that required Greece to cut public spending by a total of €3.3bn by the end of the year, followed by further cuts of €10bn by the end of 2013, and again in 2014 (Ardagna and Caselli, 2014).
The Ramifications of the Imposed Bailout Conditions
The austerity measure conditions that were included as conditions on the two separate bailout loans to the Greek government were met with strong resistance from the Greek populace, and a number of anti-austerity demonstrations and riots occurred throughout the country in 2010, 2011 and 2012 (Simitis, 2014). The public reactions to the suggested austerity measures have been suggested to be responsible for the Greek government’s delay in more fully and efficiently implementing the necessary austerity measures and tax collection reforms necessary to close the gap between public spending and revenue (IMF, 2014).
Despite the social and economic issues resulting from the Greek populace’s resistance to the bailout conditions, in 2014 the Greek economy appeared to be on the road to recovery, with improved economic performance and growth across the Eurozone driving recovery in both the tourism and shipping industries, and the achievement of a structural surplus, mainly due to a series of stringent cuts to governmental spending and public services, including the closure of the state-owned broadcasting company ERT (IMF, 2014). These improved economic conditions allowed Greece to once again issue government bonds on the private equities market since the initial bailout had been implemented, allowing the Greek government a much-needed source of finance to cover any future spending gaps, with Greek government-issued 5 year bonds being traded at interest rates of 4.95% in mid-April of 2014, at their lowest rates since the start of the 2009 debt crisis (IMF, 2014).
An early parliamentary election was called in late 2014 after the current parliament was unable to vote in a new President for the 2015-2020 term with a parliamentary majority (Ardagna and Caselli, 2014). The Syriza party, which had been highly vocal in recent years about their lack of support for the austerity conditions imposed on Greece by the IMF and ECB, won a near majority and formed a coalition with a minority right-wing party in order to have the Syriza party leader Alexis Tsipras elected to the Presidential position. Upon gaining office, Mr Tsipras stated his refusal to respect the current bailout conditions imposed by the EFSF, with the intent of renegotiating more favourable terms (Ardagna and Caselli, 2014). The ECB and IMF responded by suspending any and all aid payments to Greece until either the existing deal was upheld or a new mutually-acceptable deal was agreed upon.
The resulting uncertainty caused significant economic and social upheaval within the country; the Athens stock exchange experienced its worst loss in total value in the following week since the 2011 recession, while interest rates of Greek bonds rose sharply in the private market, eventually reaching a peak of 24.19% in early June, severely reducing the newly-established governmental ability to raise finance in the private equities market (Dellas and Tavlas, 2013). The resulting economic uncertainty caused a run on Greek banks, where customers were desperate to withdraw all their cash to protect against the risk of a banking industry collapse, which ironically severely increased the likelihood of such a collapse occurring (Mankiw and Taylor, 2014).
In response to this socio-economic panic, the government issued a series of capital control measures that restricted the current opening hours of Greek banks while only allowing daily withdrawals of €60 from personal accounts either through the bank or ATM (The Economist, 2015a). The government also placed restrictions on foreign transactions and foreign currency trading, to prevent Greek investors from transferring their funds to a currently more stable currency. However, these measures only served to deepen the social welfare issues within the country, as the number of foreign imports dropped dramatically due to the restrictions placed on foreign transactions, including in a number of key areas such as medical equipment, medication, food and farming materials, leading to severe social welfare issues during the negotiation period (The Economist, 2015b).
The 2015 Referendum
After a series of negotiations with the ECB and IMF that failed to reach agreement on the conditions of a new deal, Mr Tsipras, the Greek President, called for a public referendum on the proposed conditions put forward by the ECB and IMF in the latest meetings of June 25th. The announcement was made on June 26th, with the referendum to be held on the 6th of July (The Economist, 2015c). This is an incredibly short length of time to ruminate on a complicated issue, one which could have profound effects for the social, political and economic future of one’s country. The referendum paper itself also does not contain any details on the June 25th proposals, it merely asked whether the respondent is willing to accept them or not in a straightforward Yes or No ballot (The Economist, 2015c). Mr Tsipras, who campaigned for the No vote, listed those proposals during his campaign, including a controversial suggestion to raise taxes on tourism-related income that was later retracted by the ECB on June 26th, the day Mr Tsipras called the referendum (The Economist, 2015c).
Despite the public excitement surrounding the referendum itself, it is clear that the referendum was a tool that would have failed to provide a welfare maximising outcome regardless of the result. As Arrow (1950) notes, it is impossible for a ranked-order voting system with three or more options to provide a welfare-maximising solution that satisfies three criteria of fairness; first, that each individual holds a set of ordinally-ranked preferences that do not change with the introduction of alternative options; that the final outcome should satisfy the majority of voters; and that no one individual has dictatorship power over the vote. While the referendum at first appears to be a ranked order voting system with only two options, which would negate the relevance of Arrow’s Impossibility Theorem, the options themselves are not clearly defined. The majority No vote of 61.3% (BBC, 2015) merely rejected a specific set of conditions which were already irrelevant and out-dated at the time of the referendum. The results did not indicate whether those voters wish to accept different conditions, or to exit the Eurozone altogether, suggesting that there were more than two reasons for choosing one of the options that voters were inherently unable to express. Thus, those who voted No while expecting it to lead to a Greek exit from the Eurozone or a rejection of all further austerity measures would be ultimately disappointed.
The referendum was also biased in terms of Arrow’s (1950) fairness criteria in one major way; there was indeed one individual with dictatorship power over the vote itself. The referendum results were merely used to gather public opinion on an out-dated bailout condition offer; the results were not legally-binding, and in the event of a Yes vote Mr Tsipras would still be free to return to the negotiating table and attempt to renegotiate further with the ECB and IMF (The Economist, 2015c). The referendum was clearly used as a means for Mr Tsipras to gain leverage during negotiations in the case of a No vote, potentially to imply that Greek voters would support withdrawing from the Eurozone altogether if necessary, though as noted those voters would end up disappointed along with the rest who voted against further austerity measures, as despite the referendum results Mr Tsipras agreed to a further €86bn bailout from the EFSF on the 14th of August, with 4 main conditions to the deal: a structural surplus of 3.5% of GDP to be met by 2018; a series of pension system reforms intended to cut public sector pension spending ( a condition with serious social welfare implications for the elderly and retired); reforms to labour and product markets to increase competitiveness; and a series of banking sector reforms intended to recapitalise the private banking sector (Wearden and Fletcher, 2015).
Conclusion
The 2015 Greek Referendum bailout conditions referendum was never capable of offering a welfare-maximising solution for voters; in fact, it barely offered any social, political or economic solution at all. Voters rejected a set of conditions that had already been altered at the time of the referendum, and were subsequently presented with a new bailout deal containing further harsh austerity measures such as cuts to public pension funding. It is doubtful whether the results of the referendum actually offered Mr Tsipras additional leverage in subsequent negotiations, but it is clear the Referendum results had little impact beyond this meagre measure
References

Ardagna, S and Caselli, F (2014), ‘The Political Economy of the Greek Debt Crisis: A Tale of Two Bailouts’, American Economic Journal: Macroeconomics, Volume 6, Issue 4, pp291-323
Argitis, G and Nikolaidi, M (2014), ‘The Financial Fragility and the Crisis of the Greek Government Sector’, International Review of Applied Economics, Volume 28, Issue 3, pp273-291
Arrow, K (1950), ‘A Difficulty in the Concept of Social Welfare’, Journal of Political Economy, Volume 58, Issue 4, pp328-346
Baimbridge, M and Whyman, P (2014), Crisis in the Eurozone: Causes, Dilemmas and Solutions, 1st Ed, London: Palgrave-MacMillan
BBC (2015), Greece debt crisis: Greek voters reject bailout offer [Online], Available; http://www.bbc.co.uk/news/world-europe-33403665
Dellas, H and Tavlas, G (2013), ‘The gold standard, the euro, and the origins of the Greek sovereign debt crisis’, CATO Journal, Volume 33, Issue 3, pp491-520
Economist, The (2015a), How Capital Controls Work [Online], Available; http://www.economist.com/node/21656439
Economist, The (2015b), Greece’s Economy Under Banking Controls: When Banks Die [Online], Available; http://www.economist.com/node/21657000
Economist, The (2015c), How Greece’s referendum works [Online], Available; http://www.economist.com/blogs/economist-explains/2015/07/economist-explains-2
EFSF (2015), About EFSF [Online], Available; http://www.efsf.europa.eu/about/index.htm
IMF (2014), IMF Country Report No. 14/151: Greece, New York: International Monetary Fund
Mankiw, G and Taylor, M (2014), Macroeconomics, 2nd Ed, London: W H Freeman
Simitis, C (2014), The European Debt Crisis: The Greek Case, 1st Ed, Manchester: Manchester University Press
Standard and Poor (2015), Ratings Criteria [Online], Available; https://www.standardandpoors.com/en_EU/web/guest/ratings/ratings-criteria/-/articles/criteria/governments/filter/all
Wearden, G and Fletcher, N (2015), Eurozone finance ministers agree to third Greek bailout – as it happened [Online], Available; http://www.theguardian.com/business/live/2015/aug/14/greek-bailout-vote-and-eurozone-gdp-growth-figures-live-updates#block-55ce5ef8e4b076bafa06f640
World Bank (2015), World Development Indicators: Greece [Online], Available; http://data.worldbank.org/country/greece

 

Impacts of Whakama and Implications on Hauora Outcome

1.1 Choose any four of the following and briefly analyse what effect each one would have on the hauora of a Māori client)
Shame: Sometimes Māori clients feel shame to explain personal problems and personal diseases with other person. They feel unsafe or shame to expose their body parts in the front of other person.They feel shy to discuss their problem with female doctor or health worker.The outcome of this problem is that if one doctor or nurse take care to the Māori client by this client trust on him or her and they discuss their problem openly.

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Self doubt: Some clinet have self doubt about somethings so they took wrong way.When the client have self doubt about somethings they dropped their confidence level and it put bad effect on client,s health because they do not explain their problem properly so that’s why doctor or nurse cannot treat the client properly .The outcome of this is that if the doctor or nurse treat,communicate and take care in good way by this client put trust on them.
Feeling inferior: Some client feel inferior to discuss our problems with others and they feel agitate while exposed their body parts in the front of doctor and health worker and they feel uncomfortable when they explain their problem with doctor and health worker.If doctor,health worker and client have a good understanding between them client cannot feel inferior.
Feeling misunderstood: Some Māori client feeling misunderstood regarding culture when their body. Sometime health worker change the client,s pad but not ask him in that situation client feel misunderstood so if health worker communicate with the client before doing their work it is beneficial for client.
1.2 Select any 4 and analyse the impact of each one within a hauora context.
One to one consultation with a health worker: If client discuss their sexualy problem with same gender they not feel shy this is very benefical for him because they like privesy and they explain their problem openly. Docter and health worker treat him with right way so it helpful for him.
One to one consultation with a health worker of a different gender: Client feel hesitate when he discuss their problem with different gender .They cannot explain their problem properly and caregiver also cannot explain their problem to the male doctor .So doctor cannot give the treatment to the client properly and it is not good for client,s health.
Consumer survey: It is not a affective way because Māori client do not response to survey.Doctor cannot give treatment to the client in proper way by this problem cannot be solve and it is not good for client health.So face to face approach is more beneficial
Group consultation with a health worker of a different gender: It may be inappropriate and it is very hard for client because they feel uncomfortable to discuss their problem in the front of other so it put negative empact on client.
1.3 Identify and analyse 2 adverse socio cultural and 2 socio economic factors which could cause whakama and affect hauora outcomes for Māori
Adverse socio cultural factor one
Lack of identity: Māori are affected by lack of identity becauce of cultural and economic factors. Lack of connection, generational impact. These issues put big impacts on Māori health. So if care giver have a knowlage about culture,language by this way they can easly understand the client
Poor education achievement: if care giver have a knowledge about language and cultura by this they can understand the problem of client because if they have no knowledge they can not understand client problem.
Adverse socio economic factor
Education: The Māori people economic factor is not good. Mosty Māori peoples have not peoperly skilled and they do not paid.More Māori are not doing work government take them all the skilles .They are very important part of newzealand economy because this is a land of Māori.
Employment: Mostly Māori people not doing work and they face many difficulties due to lack of education.They face health and income problem.
2.1(a) Negative impacts of whakama on hauora
Isolation and feeling unsafe while in hospital setting: Sometime Māori client feel shy and uncomfortable with other.They cannot discuss their problem confidently because they feel shame by this problem doctor cannot take him proper treatment and it puts bad effect on his health.
Feelings of whakama if using rongoa: some Māori clients feel inferior to discuss our problem with others.They feel agitate in the front of doctor and health worker when exposed their body parts and they feel inferior when explain their peoblem in front of doctor.
Literacy: It can also put effect on Māori client. If Māori client can less literate that can be put effect on their health and our income.
2.1(b) Positive impacts of whakama on hauora
Tikanga best practice guidelines: If care giver give respect to the client and sharing all resources by this client share all the problem with care giver .Good repport is
Literacy: Literacy is also the effect on hauora.Do good arrangement of education for Māori client because education improve the literacy and economic condition.By education Māori safe their culture.
Code of rights: Treat the client with respect,treat with care and receive the right servicesand explain all the condition to the client and listened the client carefully in this way client put trust on the care giver and share all the problem openly this is very good for his health.
1.1(b)

Relationship grouping

Interconnections

First principles

Key concepts

Kohungahunga- Maatua
Matua
Tamariki

Matua: -parent
Kohungahunga: -children

They take care of them ,educate them and help them
They fulfill the all that basic needs of them.
They guide him in all the important decision making in life.

Whanua-relationship between parent and child

Whanau- Its main responsibility of the maatua to take care of kohungahunga and provide him a safe and caring environment
Whenua- Maatua ensures that child is getting safe land to grow up.
Tinana- matua always remember to take care of child’s body movement caring his body.
Hinengaro – all the feelings and the thoughts of the child is highly appreciated by maatua

Whakapapa-matua and kohungahunga has a strong relationship and he is deeply attached with the matua.
Whanaungatanga-matua provide him all that things needed to be survive.
Kaitiakitanga – they all make him feel his is in safe hands and they will always take care of them.

Rangatahi
Pakeke
Kaumatua

Rangatahi: -youth
Pakeke: -adult
Kaumatua: -elder,

These relations are generational
They provide guidance
They give knowledge about their culture and religious beliefs

Wairau
They build relationships
Teach Māori language.
Hinengaro
They provider leadership they become role models, provide guidance.

Whakapapa
The traditional knowledge is nurtured and is not lost
Whanauntanga
Strengthens the relationship, language cultural belongings and mentor.

Pakeke
Kaumatua

Pakeke: -adult
Kaumatua: -elder

They are intergeneratio-nal
The kaumatua are the role models

They pass down about the marae,iwi and hapu by oral history story or by singing wayata

Wairua–
They build relationships
Teach Māori language.
Hinengaro–
They provide leadership they become role models, provide guidance.

Kaitiakitanga–
Exercise mana of hapu and iwi through kawanatanga

Tuakana
Teina

Tuakana: -Elder siblings
Teina- Younger siblings

They are in the same family and they respect each other.
They may be the role models for others.
Includingly they also provide knowledge and guidance

Hinengaro
Looks at the role of older and younger. The siblings.

Whanauntanga–
They guide each other.

Tane
Wahine

Tane: -man
Wahine: -woman

The men have leadership quality in them and they command the family
The women has the role of kahikaronga
They both look after each other

Whenua–
They teach to respect the culture.
Wairau
They meet at marae build relationships and both are role models.

Whanaungatanga Relationship with Marae they play their roles and responsibility.
Tikanga–
Follow the protocols

Hapu
Iwi

Hapu: -sub-tribes
Iwi: -tribes

They are intergenerational.
Mana they share cultures, teach from elders to the youngest
Tane is the leader

Whanua–
They support the families. They have nuclear and extended families,
Whenua–
They provide knowledge on how to look after the land and how to protect it.

Whakapapa

Pass on cultural identity

Whanaungatanga
Strengths the relationship
Whakapapa extends the whanua members.

Kohungahunga
Wahine
Matua

Kohungahunga: -infant,
Wahine: -mother
Matua: -parent

There is very close relation between the mother and the infant, mother feeds the baby through umbilical cord, looks after the baby, nurtures the needs and wants.
Fulfill all the neccesities
Protect the baby from any kind of danger.

Whanua–
The relations between mother and father before pregnancy and after.
Tinana–
Mother looks for the basic necessity of infant.

Whanaugatanga–
Extends the whanau.

Strengthens the relationships substances like feeding teaching, language and customs.

Kaitiakitanga–
They provide guardianships
Looks after the child and teach them knowledge.

1.2

First principles

Key concepts

Development

Maintenance

Continuity

Whenua–
They teach to respect the culture.
Wairua–
They meet at marae build relatioships and both being role models.

Whanaungatanga-Relationship with marae they play their roles and responsibility.
Kaitiakitanga
follow the protocols

Teaching on how to protect the land
The knowledge the gain about the culture

identity

know how to look after the land
making your self confidence in learning about the culture

maintaining the identity

Through building relationsh-ips

learning more about Māori language

Wairua–
They build relationships
Teach Māori language.
Hinengaro
They provider leadership they become role models, provide guidance.

Kaitiakitanga
Excise mana of hapu and iwi through kawanatanga
Provide guardianship

Introducing cultural identity from the very basic spiritual down into the deeper information
Being role models.

Hui-gathering for funerals
Learning karakia and its importance(prayers)

Setting examples to the youths

By learning and practicing mihi-mihi.
Whakataki

Continuing good examples and aspects for others to lean about.

Whauna
The relations between mother and father before pregnancy and after.
Tinana
Mother looks for the basic necessity

Whanaugatanga-extends the whanau.

Strengthens the relationships substances like feeding teaching, language and customs

.
Kaitiakitanga
They provide guardianships
Looks after the child and teach them knowledge

Whanaugatnaga linked through relationships.

Procreation
Proper diet of the child

Exercise

Participating in the stuff the child will learn.
Maintaining personal hygiene for the child.

The growth and support to the child given by the parents

Keeping the child away from harmful substance.

Whanua–
Teach about the marae/hapu/iwi
Provide security
Support them in times of need.

Whakapapa–
The traditional knowledge is nurtured and is not lost
Whanauntanga-strengthens the relationship, language cultural belongings and mentor.

Learning the traditional knowledge.

Strengthening the relationship

Making them do things that they can learn about

Usual gathering with families and friends.
Supporting them

Hinengaro–
Looks at the role of the older and younger siblings.

Whanauntanga–
They guide each other.

Provide leadership
Providing guidance

Leading the friendship or family, being a role model for them
Showing them the correct path

Living accordance to moral and value.
Continued to educate others

Maintaining positive attitude

 

Glasgow Coma and Glasgow Outcome Scales for Brain Injury

ABSTRACT
Traumatic brain injury (TBI) is a leading cause of death in adults under the age of 45 and an estimated 7.7 million people in the European Union are living with a disability caused by TBI. The severities of these injuries are differentiated by the use of the Glasgow Coma Scale (GCS), and the outcome is assessed by the Glasgow Outcome Scale (GOS). These scales can be used to develop a prognosis for individuals with TBI’s in various ways. Primarily, the lower the GCS score the more severe the brain injury and therefore the worse the outcome for the patient. The GOS is applied 6 months after injury and provides a score of 1-5 with a lower score indicating the worse outcome, death. To conclude GCS by itself cannot be used to provide a long term prognosis for brain injuries. GCS can be used in addition to other factors such as presence of a midline shift on Computer Tomography and fixed pupil dilations are significant in determining prognosis. The presence of lesions on the brainstem correlates with the GCS and GOS scores allowing reliable and valid prognosis’ to be made.

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INTRODUCTION
Traumatic brain injury (TBI) affects an estimated 1.4 million people every year in the United Kingdom (UK)[1], and is a leading cause of death in adults under the age of 45. [2] It is currently estimated that at least 7.7 million people in the European Union are living with disabilities caused by TBI’s. [3] TBI’s account for 6.6% of the Accident & Emergency (A&E) attendees. [4] 95% of all TBI’s presented at A&E are mild, 5% severe and moderate injuries. [5] It is extremely important to determine the severity of the TBI as it has implications on the treatment and later rehabilitation of the patient. TBI can be open or closed injuries, with open TBI injuries being linked to worse functional outcomes and increased mortality.
The most common method of assessing TBI is the Glasgow Coma Scale (GCS) and a common method for addressing the outcome of a patient is the Glasgow Outcome Scale (GOS).
WHAT IS THE GLASGOW COMA SCALE?
The GCS is a test to ascertain the consciousness of a patient after being subject to a TBI. The maximum score with this scale is 15 and the minimum 3, this is comprised of three sections: eye opening, verbal response and motor response. (Table 1). GCS is included in National Institute for Health and Clinical Excellence (NICE) guideline on head injury3 to provide information on survival rates for patients suffering different severities of TBI. The guideline also indicates that GCS is a measurement that should be taken at the scene of the injury by paramedics. If this is not possible it should be taken at admission to A&E as early indication of TBI severity is imperative in the later treatment.
The GCS differentiates between the severities of head injury by score ranges. A GCS of 13-15 indicates a mild head injury, 9-12 moderate and 3-8 severe. The GCS score can be affected by the time it is applied after injury, therefore in order to universalise this, GCS is often used once the patient has been stabilised.4
The GCS can be difficult to use in trauma cases, as localised trauma, swelling, sedation and intubation can affect testing the eye and verbal responses. [6] [7] In a survey performed by The European Brain Injury Consortium only 49% of patients could be tested fully against the scale after being stabilised in resuscitation.[8]

Feature

Response

Score

Total

Eye Opening

Spontaneously

4

 

To speech

3

 

To pain

2

 

No response

1

 

 
 
 

E: /4

Verbal Response

Orientated

5

 

Confused

4

 

Inappropriate words

3

 

Incomprehensible words

2

 

No response

1

 

 
 
 

V: /5

Motor Response

Obeys commands

6

 

Localises pain

5

 

Withdraws from pain

4

 

Flexion to pain

3

 

Extension t pain

2

 

No response

1

 

 
 
 

M:/6

Total Score

 

GCS

/15

Table 1- Glasgow Coma Scale Components of the GCS and how each section is scored individually Adapted from: Bethel J. 2012, Emergency care of children and adults with head injury, Nursing Standard, 26(43), 49-56
The GCS is considered by some to have acceptable inter-rater reliability[9] when used by experienced practitioners. However mistakes are made consistently by inexperienced users of up to 1 mark per section. Inter-rater reliability was shown to improve after exposure to a training video.[10] Reliability with scoring is imperative in making accurate TBI severity diagnosis, and then the relevant treatment associated with them.
In severe TBI’s the motor component of the GCS is the best indicator of prognosis, this is due to verbal and eye scores not being able to be performed. [11] This has led to an adaption of the motor score of the GCS, called the simplified motor score (SMS). The SMS has 3 scores: 2 obey commands, 1 localises pain and 0 withdrawal to pain.[12] It was found that the SMS and GCS were useful in indicating whether neurosurgery was needed and also intubation. Overall GCS was better in predicting chance of death, however SMS was able to be used to assess patient involved in trauma more effectively as intubation and eye swelling would not be detrimental.12 This indicates that SMS may be better used in conjunction with GCS with patients who present to A&E with severe head trauma.
HOW CAN THE GLASGOW COMA SCALE BE USED IN BRAIN INJURY PROGNOSIS?
A more severe TBI will lead to a worse 6-month functional outcome for the patient. 30% of patients with initial GCS [13] and 50% of patients with GCS ≤8 after being stabilized in resuscitation will die.6 Patients who have a GCS score of 3-5 have a 5% chance of survival 6 months after injury.[14]
There is no direct correlation between GCS score and the patient’s ability to function in daily life afterwards. This is due to varied functional outcomes being linked to different scores on the GCS.[15]
Patients with GCS ≥8 had 85% chance of favourable prognosis, if this score was obtained 24 hours post-admission.[16] The predictive value of GCS scores alter according to the time at which the score was obtained. GCS scores obtained at least 24 hours after trauma were linked to the grade the TBI was classified by MRI data. These grades are associated with brain stem lesions, grade 4 being the worst and grade 1 the best.
The higher the GCS score the lower the grade of brainstem lesion and therefore the better prognosis in terms of functional outcome for the patient. 14 In a study performed by Utomo et al there were no patients with GCS 3-8 that were living independently 6 months after injury. In addition patients with this GCS score were 24 times more likely to die when compared to patients with GCS score 13-15.[17]
GCS alone cannot accurately predict the brain injury prognosis for a patient. However, if GCS is applied with computer tomography (CT) evidence and pupil dilations, then a prognosis of possible functional outcome can be made for an individual patient.[18]
WHAT IS THE GLASGOW OUTCOME SCALE?
The GOS was developed to assess functional recovery of patients with brain injuries.[19] The GOS is based on a structured interview that assesses 7 areas: consciousness, independence at home, independence in the community, work, leisure and social events, relationship with family and friends and finally return to normal life.[20] The area in which the patient is living is not taken into account with the GOS but is taken note of separately.
GOS is often split into two broad outcomes: favourable and unfavourable. Favourable outcome encompasses good recovery and moderately disabled. Unfavourable outcome includes: death, persistent vegetative state and severely disabled.9
The standard GOS has a 5 point scale (Table 2) but was extended after concerns were raised that it was not sensitive enough in detecting minor disabilities that may restrict the patient in returning to work. This led to the GOS extended (GOSE) being devised.
Guidance has been published to increase the universal reliability of the GOSE[21], but there are still issues with its application. This is mainly due to the time period between the TBI and the GOSE being applied, this is normally taken at 6-12 months post injury. A GOS assessment at 12 months was more reliable than at 6 months[22], but it may increase the number of patients lost in follow up. 10% of patients who were moderately or severely disabled at the 6 month GOS test improved by one category.

 

GOS

 

GOS(extended)

1

Death

1

Death

2

Persistent Vegetative State

2

Persistent Vegetative State

3

Severely Disabled

3

Lower Severely Disabled

4

Upper Severely Disabled

4

Moderately Disabled

5

Lower Moderately Disabled

6

Upper Moderately Disabled

5

Good recovery

7

Lower Good Recovery

8

Upper Good Recovery

Table 2 – Glasgow Outcome Scale Shows on the left hand side the original GOS (5 point scale) and on the right the extended GOS (8 point scale) Adapted from: Nichol A, Higgins A, Gabbe B, Murray L, Cooper D, Cameron P. 2011, Measuring functional and quality of life outcomes following major head injury: Coma scales and checklists, Injury, 42(3), 281-287
The 5 sections of the GOS refer to the functional ability that will ultimately be achieved by the patient. Vegetative state refers to the patient being unable to respond; severely disabled patients cannot live on their own; moderately disabled patients can live by their selves but have reduced ability to work; good recovery infers that the patient returns to work fully.[23]
It is also possible that the patient when interviewed presents a more positive outlook of their situation leading to the GOS score being faulty. In addition to this a patient may be given a GOS score of 5 indicating a good recovery, but this only refers to the patient being able to return to work. With a good recovery prognosis may still have changes in personality and an inability to cope in social situations.20 This leads to the GOS not fully indicating a good recovery, again highlighting the reason why the GOSE was devised. Under these circumstances a patient can be given a GOSE score of 7 indicating a lower good recovery.
The GOS and the GOSE scores can be obtained via phone call increasing their practicality as a scale. This scale is reliable when performed over the phone due to the standardized interview which informs the score that the patient will receive.19
HOW CAN THE GLASGOW OUTCOME SCALE BE USED IN BRAIN INJURY PROGNOSIS?
When applied to the GOS a patient with a severe TBI had 40% likelihood of death; 4% chance of being in a vegetative state; 16% severe disability; 19% moderate disability and 21% chance of a good recovery.6 This was a 40% likelihood of a favourable functional outcome at the 6-month GOS test.
This is compared to mild brain injury that had 9% chance of dying; 0% of being in a vegetative state; 14% of severe disability; 24% of moderate disability and 53% of having a good recovery.6 This has a 77% overall prognosis of a favourable outcome for individuals with a mild brain injury. This shows that the GOS will make a differentiation in functional outcome for different severity of brain injury.
This score is unlikely to change from an unfavourable to favourable outcome after this time period although some small improvements may be seen.18 Any further improvement is probably linked to rehabilitative treatment, and not the improvement of the patient’s TBI.
There is a 94% chance of a good recovery with GCS >8.5 (9 +) and age ≤49.5 years. This is compared to an 81% chance of good recovery with GCS >8.5 (9 +) and age ≥49.5 years. This highlights how age can affect the probability of a patient achieving a good recovery from their brain injury.[24]
Patient’s aged >75 years with a moderate or severe TBI were three times more likely to die from their TBI than patients aged 65-74 years. It was also less common for patients aged >75 years to be living independently 6 months post-injury than patients that were younger.15
The age of the patient and the severity of their TBI need to be taken into account when deciding on treatment. The prognoses for individuals in the 75+ age range are unfavourable according to the GOS. 15 Due to this treatment should be decided based on this factor.
There is a correlation between the GOC score a patient is given and the grade of their brainstem lesion that is provided by MRI data. A higher grade of brainstem lesion correlates to a more unfavourable outcome for the patient.14
CONCLUSIONS
Overall the GCS cannot by itself provide either long or short term brain injury prognosis. This is because there are too many variables that affect each GCS score, including the fluctuation of the GOS associated with these scores and the difference in reliability depending on who has applied the scale. The GCS is used to assess the severity of a brain injury and to allow medical professionals to constantly monitor the patient’s progress.
GOS can be used to give prognosis 6 to 12 months after injury; if the scale is used before this time then the score will not indicate the full functional outcome of the patient. This time period of scoring is not beneficial for prognosis at such a time that it will be used to inform treatment of the patient. The GOS does not provide a long term prognosis for brain injury as over time and with rehabilitation improvements can be made past what is predicted. Due to the time period necessary for GOS to be more accurately applied, the GCS can be used for the interim on a general scale in order to infer the likely GOC score a patient may receive. This score will be linked to other factors such as age, pupil dilation and presence of a midline shift on computer tomography, in addition to initial GCS score.18
To conclude the GCS and GOS are vital in identifying the severity of brain injury and are still the most used scales for their purpose due to their simplicity and acceptable reliability. The use of these scales in brain injury prognosis helps direct treatment for individual patients, and allows realistic individual rehabilitation goals to be made for that individual.
References
[1]Hodgkinson D, Berry E, Yates D. 1994, Mild head injury – a positive approach to management, European Journal of Emergency Medicine, 1(1), 9-12
[2] Moppett I. 2007, Traumatic brain injury: assessment, resuscitation and early management, British Journal of Anaesthesia, 99(1), 18-31
[3] Roozenbeek B, Maas A, Menon D. 2013, Changing patterns in the epidemiology of traumatic brain injury, Nature Reviews Neurology, 9(4), 231-236
[4] Swann I, Walker A. 2001, Who cares for the patient with head injury now?, Emergency Medicine, 18(5), 352-357
[5] National Institute for Health and Clinical Excellence (NICE) 2014 Head Injury; Triage, assessment, investigation and early management of head injury in children, young people and adults Available at: http://www.nice.org.uk/guidance/cg176/resources/guidance-head-injury-pdf (Accessed 18/03/2015)
[6] Chieregato A, Martino C, Pransani V, Nori G, Russo E, Simini B et al. 2010, Classification of traumatic brain injury: the Glasgow Coma Scale is not enough, Acta Anaesthesiologica Scandanavica, 54(6), 696-702
[7] Kushner D, Johnson-Greene D. 2014, Changes in cognition and continence as predictors of rehabilitation outcomes in individuals with severe traumatic brain injury, Journal of Rehabilitation Research & Development, 57(7), 1057-1068
[8] Murray G, Teasdale G, Braakman R et al. 1999, The European Brain Injury Consortium survey of head injuries, Acta neurochirurgica, 141(3), 223-236
[9] Rowley G, Fielding K. 1991, Reliability and accuracy of the Glasgow Coma Scale with experienced and inexperienced users, Lancet, 337(8740), 535-538
[10] McLernon S. 2014, The Glasgow Coma Scale 40 years on: A review of its practical use, British Journal od Neuroscience Nursing, 10(4), 179-184
[11] Lingsma H, Roozenbeek B, Steyerberg E, Murray G, Maas A. 2010, Early prognosis in traumatic brain injury: from prophecies to predictions, Lancet Neurology 9(5), 543-554
[12] Singh B, Murad H, Prokop L, Erwin P, Wang Z, Parsaik A, et al. 2013, Meta-analysis of Glasgow Coma Score and Simplified Motor Score in predicting traumatic brain injury outcomes, Brain Injury, 27(3), 293-300
[13] Thornhill S, Teasdale G, Murray G, McEwan J, Roy C, Penny K. 2000, Disability in young people and adults one year after head injury: prospective cohort study, British Medical Journal 320(7250), 1631-1635
[14] Maas A, Stocchetti N, Bullock R. 2008, Moderate and severe traumatic brain injury in adults, the Lancet Neurology, 7(8), 728-741
[15] Udekwu P, Kromhout-Schiro S, Vaslef S, Baker C, Oller D. 2004, Glasgow coma scales score, mortality, and functional outcome in head-injured patients, Journal of Trauma and Acute Care Surgey, 56(5), 1084-1089
[16] Woischneck D, Firsching R, Schmitz B, Kapapa T. 2013, The prognostic reliability of the Glasgow Coma Scale in traumatic brain injuries: evaluation of MRI data, European Journal of Trauma and Emergency Surgery, 39(1), 79-86
[17] Utomo W, Gabbe B, Simpson P, Cameron P. 2009, Predictors of in-hospital mortality and 6-moth functional outcomes in older adults after moderate to severe brain injury, Injury, 40(9), 973-977
[18] Husson E, Ribbers G, Willemse-van Son A, Stam H. 2010, Prognosis of six-month functioning after moderate to severe traumatic brain injury: A systematic review of prospective cohort studies, Journal of Rehabilitation Medicine, 42(1), 425-436
[19] Brooks D, Hosie J, Bond M, Jennett B, Aughton M. 1986, Cognitive sequelae of severe head injury I relation to the Glasgow Outcome Scale, Journal of Neurological and Neurosurgical Psychiatry, 49(5), 549-553
[20] Jourdan c, Bosserelle V, Azerad S, Ghout I, Bayen E, Aegerter P, Weiss J, Mateo J, Lescot T, Vigue B, Razarourte K, Pradat-Diehl P, Azouvi P. 2013, Predictive factors for 1-year outcome of a cohort of patients with severe traumatic brain injury: results from PariS-TBI study, Brain Injury, 27(9), 1000-1007
[21] Wilson J, Pettigrew L, Teasdale G. 1998, Structured interviews for the Glasgow Outcome Scale and the extended Glasgow Outcome Scale: Guidelines for their use, Journal of Neuro-trauma, 15(8), 573-587
[22] Nalt J. 2001, Prediction of outcome in mild to moderate head injury: A review, Journal of Clinical and Experimental Neuropsychology, 23(6), 837-851
[23] : Nichol A, Higgins A, Gabbe B, Murray L, Cooper D, Cameron P. 2011, Measuring functional and quality of life outcomes following major head injury: Coma scales and checklists, Injury, 42(3), 281-287
[24] Oh H, Seo W. 2013, Development of a decision tree analysis model that predicts recovery from acute brain injury , Japan Journal of Nursing Science, 10(1), 89-97
 

Diagnosis, Management and Outcome Measures

‘Dysphagia’ is the medical term for a difficulty in swallowing, further described as any complication passing food or drink from the mouth to the stomach (Logemann, 1998). It occurs in three phases: the oral phase, the pharyngeal phase and the esophageal phase. Speech and language therapists (SLT) specialize in identifying, assessing and managing Feeding, Eating, Drinking and Swallowing disorders (FEDS) (IASLT, 2018) located in the oral and pharyngeal stages of swallowing, called oropharyngeal dysphagia. Ill-management of dysphagia can have detrimental consequences for the patient such as aspiration, malnutrition, dehydration and depression impacting pulmonary, nutritional and psychological well-being (Helldén, Bergström & Karlsson, 2018; Tanner, 2006).

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The International Classification of Functioning, Disability and Health framework (ICF) put forward by the World Health Organisation (WHO, 2001) is used in the broader assessment of dysphagia to provide intervention that fulfills ethical tenets of autonomy and beneficence (Threats, 2007). The ICF boasts a ‘biopsychosocial’ design whereby aspects of the medical and social models of functioning are integrated to provide a dynamic, holistic picture of the person with dysphagia (Cichero & Murdoch, 2006). Dysphagia is described using three categories: Body Functions and Structures, Activities and Participation, and Environment and Personal factors.

Outcome measures are the used in the management of dysphagia to assist clinicians and researchers in making informed decisions regarding the most accurate intervention pathway and comparative effectiveness of dysphagia strategies (Patel et al., 2017). Dysphagia outcomes measures, however, rarely focus on the effect on the patient’s life, concentrating mainly on the direct ill-health effects of the symptom (Threats, 2007). Martino et al. (2009) support this viewpoint as while patients consider psychosocial obstacles as a direct result of their dysphagia to outweigh biomedical consequences, both clinicians and caregivers value biomedical, pulmonary and nutritional health to be of greater importance in recovery of dysphagia. The WHO’s ICF therefore, seeks to expand the SLT’s view on dysphagia and offer outcome measures that capture the patient’s experience (Penderson, Wilson, McColl, Carding & Patterson, 2016). Patient related outcome measures (PRO) provide substantial evidence directly related to the social importance of dysphagia treatment, advocating for an increased quality of life (Patel et al., 2017). This paper seeks to critically discuss available outcome measures in the management of dysphagia and how they relate to the ICF in terms of three domains.

The Clinical Bedside Examination (CBE) is often the SLT’s first step towards providing critical information relevant to the diagnostic and therapeutic processes as it is quick and readily available at bedside (Lenord & Kendall, 2008). The CBE involves gathering relevant case history from the client, medical team and carers, collation of comprehensive oro-motor assessment to examine sensory and motor aspects of the oral mechanism and clinical observation during swallow trials at bedside. Despite providing a general yet limited overview of the pharyngeal phase of the swallow, the CBE gauges the patient’s cognitive-behavioral abilities, baseline of orofacial functioning, helps determine the optimum positioning for feeding and explores of feeding options such as diet alterations or compensatory strategies (Ward & Morgan, 2009). The three ICF domains are broadly addressed during this initial assessment of the patient whereby Body Structures and Function impairments are hypothesized based on clinical impression, Activities and Participation limitations are indicated by the patients case history, and Environmental and Personal factors are observed by the clinician are reported by patient and caregivers (McAllister, Kruger, Doeltgen & Tyler-Boltrek, 2016). Moreover, the CBE results determine whether instrumental assessment is warranted (Lenoard & Kendall, 2008).

Objective, instrumental assessment techniques are used as outcome measures in dysphagia. The Video Fluoroscopic Swallowing Study (VFSS) and Fiberoptic Endoscopic Evaluation of Swallowing (FEES) are typically considered the ‘gold standard’ of dysphagia assessment, although they are not always readily available in clinical practice. VFSS, more commonly known as ‘videofluoroscopy’, is an imaging technique widely used to detect oropharyngeal dysphagia (Tomita et al., 2018). Videofluoroscopy provides a detailed, objective view of the internal anatomical structures involved in the swallow and its physiology during this process. The procedure is regarded as ‘gold standard’ as the presence or absence of aspiration can be immediately confirmed or denied, and prevented in order to avoid chronic aspiration, malnutrition and lengthy mealtimes (McNair & Reilly, 2003). VFSS is invasive as it requires food and fluid trails to be mixed with a radioactive chemical, called barium, which highlights boluses on x-ray as they travel from mouth to stomach. Patient’s mobility also has to be taken into consideration when deciding on whether VFSS is a suitable outcome measure as assessments take place the radiology department, away from the bedside.

According to the IASLT (2018), Fiberoptic Endoscopic Evaluation of Swallowing (FEES) involves the insertion of a fibreoptic nasendoscope transnasally to the level of the pharynx allowing optimum evaluation of laryngopharyngeal anatomy and physiology. Images are recorded as the patient manages his/her own secretions, and swallows’ food and fluid (IASLT, 2018). Studies have indicated that FEES achieves good intra- and inter-rater reliability considering it to be ‘gold standard’ practice (Kelly, Drinnan, Leslie, 2007; Kelly, Leslie, Beale, Payten, & Drinnan, 2006; Colondy, 2002). However, lack of validated and standardised rating scales, variable image quality and experience of endoscopist/assessing clinician, contribute to reliability of the FEES instrument (Kelly et al., 2007; Cichero & Murdoch, 2006).

VFSS and FEES assessments account solely for the Body Structures and Functions category of the ICF. Dysphagia evaluation and management, based strictly on the results from these instrumental assessments may lead to recommendations with limited relevance or practicality for the patient. Therefore, cautious interpretation of assessment findings along with evaluation from other categories of the ICF allows for more client-centered, relevant and practical recommendations (Threats, 2007).

The Penetration-Aspiration Scale (PAS) is a clinician-rated scale used in conjunction with fluoroscopy studies, such as the VFSS and FEES (Leonard & Kendall, 2008). The objective of the scale is to quantify ‘whether or not material enters the airway, the level to which the material descends to and whether or not the swallower responds to penetration or aspiration’ (Cichero & Murdoch, 2006, p.549). The Dysphagia Outcome Severity Scale (DOSS), is second a clinician-rated scale which measures the severity of dysphagia based on videofluoroscopy and makes recommendations based on nutritional level, diet and independence (Zarkarda & Regan, 2018). The psychometric properties of these scales provide information on the Body Structures and Functions domain only. The Functional Oral Intake Scale (FOIS) documents the patient’s current level of functional oral intake and considers functional changes that have occurred due to dysphagia adhering to Body Structures and Functions, and Activity and Participation psychometric domains (McMicken, Muzzy & Calahan, 2010).

Outcome measures that incorporate a patient’s own opinions of their eating or swallowing abilities and difficulties are addressed in the Activity and Participation category of the ICF framework. The SWAL-QOL is a patient-centered outcome measure that assesses the ‘physical, social, psychological and cultural experiences associated with eating’ and drinking (Keage, Delatycki, Corben & Vogel, 2015). Probing for descriptions of behaviours that may influence food and liquid manipulation, such as couching with oral intake, is accounted for in the SWAL-QOL which falls under Body Functions and Structure. Moreover, anxieties linked to dysphagia are reported and are considered psychological impairments of the disease again categorized as Body Function (Keage et al., 2015). Activities and participation behaviours are reported whereby patients admits limiting or restricting themselves socially as a consequence of their dysphagia (Threats, 2007). The SWAL-QOL is therefore considered ‘holistic’ as evidenced by the inclusion of all elements of the ICF (Keagle, 2015). The EAT-10 is a patient-administered, symptom specific outcome measure for dysphagia (Wilmskoetter et al., 2017). Body Structures and Functions are predominantly outlined with only two items referring to impact on Activity, failing to meet social and emotional circumstances (Keagle et al., 2015).

Other available outcome measures involve the SWAL-CARE and MD Anderson Dysphagia Inventory (MDADI). The SWAL-CARE is tool commonly used in partnership with the SWAL-QOL as it provides Environmental information regarding interaction between the patient and clinician, quality of care and patient satisfaction (Keagle et al., 2015; Threats, 2007). The MDADI is a self-administered survey that looks globally at a patient’s difficulty in swallowing and how it affects their life overall, rather than specifically about modified diets (Khan et al., 2015).

(Cichero)In clinical practice, SLT’s are influenced by what outcome measures to use based on one’s philosophy of evaluation and treatment. Clinicians dedicated to biomechanics are more likely to use instrumental assessment with the underlining belief that with biomechanical improvements comes improvements in other domains, such as increased quality of life. A second factor that influences a SLT’s choice of outcome measure for a patient is the amalgamation of what the patient wants and what the clinician believes is appropriate and achievable. However, the foundations for choosing outcome goals are influenced by reliability and validity. There is a current paucity of reliable and valid outcome measures available that address body structures and functions, activity and participation, environmental and personal factors, all of which contribute to the ICF. Continuous growth and expansion of such measures will allow clinicians to learn more of persons with swallowing difficulties. The more that is known, the more efficiently one works.

 

Reference List

Colodny, N. (2002). Interjudge and intrajudge reliabilities in fiberoptic endoscopic evaluation of swallowing (fees((R))) using the penetration-aspiration scale: A replication study.Dysphagia, 17(4), 308-315. doi:10.1007/s00455-002-0073-0

Helldén, J., Bergström, L., & Karlsson, S. (2018). Experiences of living with persisting post-stroke dysphagia and of dysphagia management – a qualitative study. International Journal of Qualitative Studies on Health and Well-being, 13(sup1), 1522194. doi:10.1080/17482631.2018.1522194

IASLT |Clinical Guidelines. (2018). Retrieved from http://www.iaslt.ie/membership/documents/Clinical%20Guidelines%20and%20Procedures/Standards%20of%20Practice%20for%20SLTs%20on%20the%20Management%20of%20Dysphagia-2012.pdf

Keage, M., Delatycki, M., Corben, L., & Vogel, A. (2015). A systematic review of self-reported swallowing assessments in progressive neurological disorders. Dysphagia, 30(1), 27-46. doi:10.1007/s00455-014-9579-9

Kelly, A. M., Drinnan, M. J., & Leslie, P. (2007). Assessing penetration and aspiration: How do videofluoroscopy and fiberoptic endoscopic evaluation of swallowing compare? The Laryngoscope, 117(10), 1723-1727. doi:10.1097/MLG.0b013e318123ee6a

Kelly AM, Hydes K, McLaughlin C, Wallace S Fibreoptic Endoscopic Evaluation of Swallowing (FEES) The Role of Speech and Language Therapy: Policy Statement RCSLT 2007

Kelly, A. M., Leslie, P., Beale, T., Payten, C., & Drinnan, M. J. (2006). Fibreoptic endoscopic evaluation of swallowing and videofluoroscopy: Does examination type influence perception of pharyngeal residue severity? Clinical Otolaryngology, 31(5), 425-432. doi:10.1111/j.1749-4486.2006.01292.x

Leonard, R., & Kendall, K., M.D. (2008). Dysphagia assessment and treatment planning: A team approach (2nd ed.). San Diego: Plural Pub.

Logemann, J. A. (1998). Evaluation and treatment of swallowing disorders (2nd ed.). Austin, Tex: PRO-ED.

Martino, R., Beaton, D., & Diamant, N. E. (2009). Using different perspectives to generate items for a new scale measuring medical outcomes of dysphagia (MOD). Journal of Clinical Epidemiology, 62(5), 518-526. doi:10.1016/j.jclinepi.2008.05.007

McAllister, S., Kruger, S., Doeltgen, S., & Tyler-Boltrek, E. (2016). Implications of variability in clinical bedside swallowing assessment practices by speech language pathologists.Dysphagia, 31(5), 650-662. doi:10.1007/s00455-016-9724-8

McMicken, B. L., Muzzy, C. L., & Calahan, S. (2010). Retrospective ratings of 100 first time-documented stroke patients on the functional oral intake scale. Disability & Rehabilitation, 32(14), 1163-1172. doi:10.3109/09638280903437238

McNair, J., & Reilly, S. (2003). The pros and cons of videofluoroscopic assessment of swallowing in children. Asia Pacific Journal Of Speech, Language And Hearing, 8(2), 93-104. doi: 10.1179/136132803805576282

Patel, D. A., Sharda, R., Hovis, K. L., Nichols, E. E., Sathe, N., Penson, D. F., . . . Francis, D. O. (2017). Patient-reported outcome measures in dysphagia: A systematic review of instrument development and validation. Diseases of the Esophagus, 30(5), 1-23. doi:10.1093/dote/dow028               

Pedersen, A., Wilson, J., McColl, E., Carding, P., & Patterson, J. (2015;2016;). Swallowing outcome measures in head and neck cancer – how do they compare? Oral Oncology, 52, 104-108. doi:10.1016/j.oraloncology.2015.10.015

Steele, C. M., & Grace-Martin, K. (2017). Reflections on clinical and statistical use of the penetration-aspiration scale. Dysphagia, 32(5), 601-616. doi:10.1007/s00455-017-9809-z

Tanner, D. (2006). Case studies in communication sciences and disorders. Upper Saddle River, N.J: Pearson/Merrill Prentice Hall.’

Threats, T. (2007). Use of the ICF in dysphagia management. Semin Speech Lang, 17;28;(4), 323-333. doi:10.1055/s-2007-986529

Tomita, S., Oeda, T., Umemura, A., Kohsaka, M., Park, K., Yamamoto, K., . . . Sawada, H. (2018). Video-fluoroscopic swallowing study scale for predicting aspiration pneumonia in Parkinson’s disease. PLoS One, 13(6), e0197608. doi:10.1371/journal.pone.0197608

Ward, E. C., Dr, & Morgan, A. T. (2009). Dysphagia post trauma. San Diego: Plural Pub

Wilmskoetter, J., Bonilha, H., Hong, I., Hazelwood, R. J., Martin-Harris, B., & Velozo, C. (2017). Construct validity of the eating assessment tool (EAT-10). Disability and Rehabilitation, , 1-11. doi:10.1080/09638288.2017.1398787

World Health Organization. International Classification of Functioning, Disability and Health (ICF). Geneva: WHO, 2001. http://www.who.int/classifications/icf/en (accessed 27 Dec 2010).

Zarkada, A., & Regan, J. (2018). Inter-rater reliability of the dysphagia outcome and severity scale (DOSS): Effects of clinical experience, audio-recording and training. Dysphagia, 33(3), 329-336. doi:10.1007/s00455-017-9857-4

 

Factors that Determined the Outcome of the Battle of Britain

The Battle of Britain has been described as the first major battle contested entirely by air forces, fought between 10th July and 31st October 1940.[1]  It resulted from German efforts to drive Britain out of the war, whether directly by seaborne invasion or by its threat,[2] forcing Britain to sue for peace.[3]   For these efforts to succeed the Luftwaffe had to attain air superiority over the Royal Air Force (RAF), which objective the Germans failed to achieve. 

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This essay will argue that British air defence organisation and the ability to maintain effective forces combined with inadequate German intelligence were the key factors in determining the result.  It will consider the world’s first Integrated Air Defence System (IADS), the Dowding System,[4] enabling Fighter Command to effectively control the deployment of its resources and manage its assets such that it never reached the point of collapse.  It will analyse British success in achieving levels of aircraft production and serviceability that prevented the Luftwaffe from establishing effective numerical superiority.  Finally the failure of the Germans to secure accurate intelligence of RAF aircraft numbers, losses and deployments will be considered, together with the effect of this upon Luftwaffe planning, strategy and tactics and in encouraging the overconfidence of its leadership.
A key factor in the outcome of the battle was the RAF’s effective use of its IADS, which gave Fighter Command the ability to ‘see, control and influence what was happening using the maximum economy of force’.[5] Central to this was the Chain Home system of Radio Direction and Finding (RDF) stations which by 1940 covered the length of Britain’s eastern and southern coasts from the Orkneys to Weymouth. These could provide early warning of incoming enemy aircraft at ranges of up to 200 miles, or 110 miles for low flying aircraft.[6]
The aerials of the Chain Home stations did not rotate, a broad beam of radio pulses being transmitted to ‘floodlight’ a fixed area of sea approaches.  The Chain Home Low (used to identify low flying aircraft) aerials did rotate, however their signals were affected by returns from the land surface.[7]  Therefore once enemy aircraft crossed the coast and moved inland they were unsighted by the RDF stations and hence responsibility for tracking them was passed to the Observer Corps.
In 1940 there were 30,000 observers continuously manning 1,000 observation posts, largely made up of volunteers self-trained in aircraft recognition and height estimation.[8]  While the system worked well in good weather the observers struggled in rain or low cloud, however the Observer Corps constituted the sole means of tracking enemy raids once they had crossed the coastline.  Supplemented by low-level radio interception based around the RAF wireless interception station at Cheadle (taking advantage of the slack radio discipline frequently displayed by German aircrew),[9] information on incoming aircraft was sent by landline to Fighter Command headquarters or, in the case of the Observer Corps, to Sector Stations (i.e. airfields) and Group Headquarters.
The cumulative effect of these multiple sources of intelligence was to create a network of information that could be internally compared for consistency, one source confirming, refuting or supporting another, to build a composite picture of enemy activity.  The IADS information network had such an effective flow of secure intelligence it allowed Fighter Command the crucial time to flexibly organise responses to German attacks.[10] This gave the RAF an essential counter to the element of surprise enjoyed by an enemy who could pick and choose when and where to attack.
The heart of the system lay in the Filter Room at Fighter Command headquarters, where information on incoming aircraft was relayed by landline from RDF stations.  Here plots were recorded and once the track of incoming aircraft was clearly established information would be relayed in turn to Group Headquarters and individual Sector Stations.  Group commanders decided which of their sectors to activate while Sector Station commanders selected which squadrons should fly on a particular operation. The whole process, from target discovery to aircraft deployment, was intended to take only minutes however without speed and clear instructions based on accurate and timely information the system could not be effective and for this the IADS was critical. 
As a result Fighter Command no longer needed constant airborne patrols to track the enemy and could use the minimum assets necessary for an interception.[11] The effectiveness of the RAF squadrons was thus increased, with pilot flying hours reduced and aircraft and fuel usage minimised, maximising the efficient utilisation of personnel and aircraft.[12]
The effectiveness of the IADS was supported by the maintenance of operational aircraft numbers.  Despite advances in monoplane aircraft technology prior to the war which greatly increased the speed, reach and potential of air power the British aircraft industry had been unable to properly exploit these developments due to years of austerity and disarmament.[13]  Great strides were made, however, to enable British aircraft production to catch up with Germany’s by the outbreak of war.
The Air Minister, Lord Swinton, introduced a scheme to generate a reserve of productive capacity by creating ‘shadow factories’ across Britain that would be provided with all the resources necessary to establish a functional production line by their ‘parent’ firms.[14] Increased aircraft production was supported by the Civilian Repair Organisation (CRO) placed under the energetic Lord Beaverbrook at the Ministry of Aircraft Production.  The CRO proved highly effective, co-ordinating the maintenance and repair of military aircraft by civilian firms with such success that 60% of aircraft repaired were able to return to operational service, the remainder being utilised for spares.[15]  The foundations of success had been laid with new aircraft being constructed at an unprecedented rate and damaged aircraft returned to service in ever increasing numbers.  The numbers confirmed this: in addition to nearly 300 new aircraft a week, in the last two weeks of June more than 250 were repaired and sent back to squadrons.[16], [17]
Throughout the battle British aircraft industry out-produced its German rival by a considerable margin, allowing a continuous flow of replacements to compensate for the high loss rates sustained by Fighter Command.  Indeed RAF fighter numbers grew steadily stronger between June and October. On 19 June there were 548 operationally ready fighters (with 200 more ready for the following day); by 31 October 729 ready to fly, 370 in store at a day’s notice, and a further 110 at four days’ notice.[18]  At no point during the battle did Fighter Command suffer from a shortage of serviceable front-line aircraft.[19]
Unlike the increasingly efficient British aircraft production and repair systems the German aviation industry suffered from generally poor levels of performance, constructing less than half the number of aircraft produced by the British during 1940.[20] Despite possessing the most advanced aeronautical technology in the world, with larger resources of machinery, raw materials and manpower than the British, productivity often fell more than 30% below target.[21]  
German aircraft were some of the most technically complex of the period therefore could frequently not be suitably repaired in the field, [22] often having to be transported back to Germany by land or rail.  This exposed the long supply and logistical chain of the Luftwaffe from its forward bases back to German factories, in direct contrast to the RAF based in its home airfields. The RAF and the CRO could repair an aircraft in hours, depending on its level of damage, and have it serviceable for front-line combat the next day. Luftwaffe repair times were long:  ‘just over a thousand Me 109s and just fifty-nine Ju 88s would be repaired and back in the air during the whole of 1940’.[23]   This poor supply and repair system restricted the operational capabilities of the Luftwaffe, preventing it from achieving a decisive numerical advantage in the air.[24]
By the summer of 1940 Germany’s series of speedy and spectacular victories had left the Luftwaffe’s high command feeling arrogant and unbeatable.[25]  Led by Goering, who lacked ‘the technical knowledge and strategic forethought necessary to develop the German Air Force’s full potential’,[26] Luftwaffe leadership had come to believe that they could defeat Britain as quickly and efficiently as their other recent campaigns. This overconfidence was supported by German Air Intelligence failures.
The Luftwaffe never understood the efficiency and effectiveness of Britain’s defences,[27] as late as July 1940 producing intelligence reports which failed to appreciate the significance of either IADS or RDF.[28] This contributed to the German failure to give a higher priority to attacks upon the RDF stations.  Luftwaffe intelligence was ‘disorganised and inefficient’,[29] displaying a clear lack of understanding of RAF capabilities. This resulted in ever changing operational aims and objectives and plans that were disjointed with contradictory targets.[30] 
The true balance of forces was never properly appreciated, the outcome being a misperception that played a critical part in the conduct of the battle.  German intelligence reports consistently underestimated the size of Fighter Command and the scale of British aircraft production while exaggerating RAF losses. This encouraged the Luftwaffe to believe that attrition had pushed Fighter Command to the very edge of defeat, leading first to complacency then strategic misjudgement. It was assumed that Fighter Command was virtually eliminated: at the end of August it was estimated that the RAF had lost 50% of its fighters. On 16th September Goering announced that Fighter Command had only 177 operational aircraft, while intelligence estimated that only 300 British fighters were left, including reserves, with a monthly output of 250.[31] 
This miscalculation led to the mistaken shift of targets from air bases to industry and communications.  In reality on 19th September Fighter Command had an actual operational strength of 656 with 202 aircraft in reserve, 226 in preparation; output of fighters between 7th September and 5th October being 428.[32]  This difference was critical, leading the Luftwaffe to fight in September as if Fighter Command had been all but destroyed and resulting in a level of attrition so high that the Luftwaffe could not sustain it for more than a few weeks.
The outcome of the Battle of Britain was technically a stalemate, neither side being defeated in a conventional sense as both remained operationally effective.  However, the failure of the Luftwaffe to achieve its primary objective of air supremacy enabled the RAF’s Fighter Command to claim victory by the removal of the threat of invasion. 
This essay has argued that the German failure resulted from effective British preparation contrasted with an overconfident Luftwaffe lacking efficient logistics and whose intelligence failures led to poor strategic decision making.  The development of the IADS, supported by innovative RDF technology, gave the RAF a greatly enhanced early warning and resource management capability that supplied Fighter Command with a vital force multiplier. The use of IADS was underpinned by a swift and revolutionary transformation of the British aircraft industry to produce a collaborative, nation-wide mass production and repair capacity in the form of shadow factories and CRO. 
These developments enabled the RAF to replace its losses and increasingly negate the Luftwaffe’s initial numerical superiority.  German inability to produce and repair their own aircraft in similar numbers eroded the balance of forces as the battle progressed and the Luftwaffe leadership’s misperception of these factors, driven by a lack of accurate intelligence, encouraged first complacency and then fatal strategic misjudgement.
Bibliography
Addison, Paul & Jeremy Crang (2000), The Burning Blue: a New History of the Battle of Britain, (London: Pimlico).
Barley, Wing Commander M.P. (2004), ‘Contributing to its Own Defeat: The Luftwaffe and the Battle of Britain’, Defence Studies Vol 4, No 3, pp.387-411.
Bungay, Stephen (2009), The Most Dangerous Enemy: A History of the Battle of Britain (London: Aurum Press).
Cole, Gerald (1990), The Battle of Britain the Siege that Failed (Berkhamsted: Firefly Publications).
Commander in Chief of the Luftwaffe (n.d.), Royal Air Force Museum, https://www.rafmuseum.org.uk/research/online-exhibitions/history-of-the-battle-of-britain/commander-in-chief-of-the-luftwaffe.aspx, accessed 17 Dec 2019.
Guerlac, Henry (1987), RADAR in World War II (Cambridge: Tomash Publishers).
Holland, James (2010), The Battle of Britain: Five Months that Changed History May-October 1940 (London: Transworld Publishers).
Introduction to the Phases of the Battle of Britain (n.d.), Royal Air Force Museum, https://www.rafmuseum.org.uk/research/online-exhibitions/history-of-the-battle-of-britain/introduction-to-the-phases-of-the-battle-of-britain.aspx, accessed 20 Dec 2019.
Ledwidge, Frank (2018), Aerial Warfare: The Battle for the Skies (Oxford University Press).
Orange, Vincent (2008), Dowding of Fighter Command: Victor of The Battle of Britain (London: Grub Street Publising).
Overy, Richard (2005), The Air War (Dulles: Potomac Books).
Overy, Richard (2010), The Battle of Britain: Myth and Reality (London: Penguin Books).
RADAR – The Battle Winner? (n.d.), Royal Air Force Museum, https://www.rafmuseum.org.uk/research/online-exhibitions/history-of-the-battle-of-britain/radar-the-battle-winner.aspx, accessed 02 January 2020.
Shields, John (2015), ‘The Battle of Britain: A Not So Narrow Margin’, Air Power Review, Vol 18, No2, pp.182-196.
Support from the Ground in the Battle of Britain (2018), Imperial War Museums, https://www.iwm.org.uk/history/support-from-the-ground-in-the-battle-of-britain, accessed 15 January 2020.
Wood, Derek & Derek Dempster (2010), The Narrow Margin (Barnsley: Hutchinson & Company).
Wright, Robert (1969), Dowding and the Battle of Britain (London: Macdonald &Co).
Zimmerman, David (2001), Britain’s Shield: Radar and the Defeat of the Luftwaffe (Stroud: Sutton Publishing).

[1] Introduction to the Phases of the Battle of Britain (n.d.), https://www.rafmuseum.org.uk/research/online-exhibitions/history-of-the-battle-of-britain/introduction-to-the-phases-of-the-battle-of-britain.aspx.
[2] Overy (2010), p.19.
[3] Ibid., p.xii.
[4] Ledwidge (2018), p.68.
[5] Id.
[6] RADAR – The Battle Winner? (n.d.), https://www.rafmuseum.org.uk/research/online-exhibitions/history-of-the-battle-of-britain/radar-the-battle-winner.aspx.
[7] Id.
[8] Support from the Ground in the Battle of Britain (2018), https://www.iwm.org.uk/history/support-from-the-ground-in-the-battle-of-britain.
[9] Overy (2010), p.20.
[10] Wright (1969), p.64.
[11] Bungay (2009), p.235.
[12] Guerlac (1987), p.11.
[13] Orange (2008), p.69.
[14] Smith (2000), p.50.
[15] Wood & Dempster (2010), p.103.
[16] Id.
[17] Holland (2010), p.325.
[18] Overy (2010), p.45.
[19] Holland (2010), p. 325.
[20] Overy (2010), p.50.
[21] Id.
[22] Ibid, p.51.
[23] Holland (2010), p.325.
[24] Overy (2005), p.23.
[25] Zimmerman (2001), p.195.
[26] Commander in Chief of the Luftwaffe (n.d.), https://www.rafmuseum.org.uk/research/online-exhibitions/history-of-the-battle-of-britain/commander-in-chief-of-the-luftwaffe.aspx.
[27] Shields (2015), p.185.
[28] Cole (1990), p.49.
[29] Wood & Dempster (2010), p.41.
[30] Barley (2004), p.403.
[31] Overy (2010), p.114.
[32] Id.
 

Role of Intelligence in the Outcome of the Vietnam War

INTRODUCTION
The “Red Scare” placed fear of a communist takeover at the forefront of American consciousness in the 1950s. The perceived spread of communism in Southeast Asia was ignited by Ho Chi Minh’s new alliances with the Soviets and Mao Zedong—following his failed attempts to curry U.S. and Western support.[1] Ultimately, this fear underpinned the U.S decision to go to war, despite evidence suggesting that the Minh movement was revolutionary in nature.[2] An increasingly conservative political culture[3] fostered an environment whereby policymakers and military leaders dismissed options deemed ‘too soft on communism’ and opted instead for a more aggressive approach.[4] Thus, the political apparatus desired the military instrument of power to what could arguably be resolved through diplomatic negotiations. Limited war objectives set the tone for how the war would be fought, with the absolute minimum force possible.[5]

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In examining the role of intelligence in the overall outcome of the war, this paper will focus specifically on lead-up to U.S. escalation between 1962 and 1968.  This paper contends that the deliberate politicization of intelligence by senior military officials in the Military Assistance Command, Vietnam, resulted in the inability of the Intelligence Community (IC) to provide objective assessments, ultimately resulting in a continuation of failed policies and a protracted war that culminated in U.S. defeat in 1973. Two critical inflection points will be discussed, (1) President Diem’s overthrow and (2) the Tet Offensive.
MILITARY ASSISTANCE COMMAND, VIETNAM (MACV)
The MACV was established in 1962 as a central headquarters responsible for directing the war effort in Vietnam and coordinating with President Ngo Dinh Diem’s government.[6] General Paul Harkins was appointed as the Commander and Col Winterbottom as his Chief of Intelligence.[7] The Military Assistance Advisory Group (MAAG), responsible for training the Army Republic of Vietnam (ARVN) forces, fell under the MACV headquarters. At MACV’s inception, the guerilla insurgents proved to be a formidable force—evading the large offensive operations and seeking safe havens in neighboring countries. Their strength can largely be attributed to the considerable support provided by the Soviet Union and the People’s Republic of China.[8] Although the MAAG employed a “Pacification strategy” aimed at countering the insurgency, ARVN training consisted of conventional tactics—easily countered by the Vietcong and ineffective at reducing enemy strength.[9]
National Intelligence Estimates reflected an unfavorable outlook for the political and security environment under President Diem.[10] Despite evidence from the field that the strategy was ineffective, General Harkins persisted in his self-delusion—publicly touting success and claiming the reports were localized in nature.[11] He was also a staunch supporter of Diem, despite indications that his policies were fomenting a general uprising in the south.[12]  Thus, Secretary of Defense McNamara tasked MACV with developing an enemy Order-of-Battle (OB) and Col Winterbottom became responsible for assessing the enemy threat and providing finished intelligence products for policy-makers.[13]
THE ORDER-OF-BATTLE CONTROVERSY
The initial OB generated by MACV included 20,000 regular forces (main forces) and 100,000 guerilla forces, but Col Winterbottom revised the total number to 16,300.[14] Under his leadership, the OB would remain static for the next two years of the war and irregular elements (guerilla-militia forces) would never be included.[15] MACV intelligence assessments during the early years of escalation failed to account for the three types of military forces employed in the North Vietnamese strategy, (1) main forces, (2) regional forces, and (3) guerilla-militia forces—the same forces employed during the French conflict.[16] Quantitative metrics would dominate the prevailing understanding of the security situation in Vietnam and U.S. progress was henceforth calculated by the number of offensive patrols, enemy attacks, and the enemy body count.[17]
The MACV’s weekly situation report, the Headway Report, became Washington’s primary source of ‘news’ on military developments. Reportedly, commanders at multiple levels were “estimating upward.” Col Winterbottom rationalized his indiscretions as sound judgments based on the number of bombs dropped in a given location.[18] This politicization of intelligence was made even more apparent during a Spring 1962 briefing by General Harkins to Secretary of Defense McNamara, Chairman of the Joint Chiefs, General Lemnitzer, and the Pacific commander, Admiral Harry Felt. General Harkins argued that the country-wide map depicted an incorrect ratio of Vietcong control and insisted that the ‘contested’ areas be converted to government control to show a more accurate assessment of the situation. Col Winterbottom all too willingly obliged, removing the enemy overlays and thus “improved the security situation.”[19]
Efforts by DIA analysts to provide realistic assessments on Vietnam were stymied by JCS and DoD officials who mandated that agency reports fall in line with reporting from field.[20] MACV reporting was never weighed against ARVN intelligence and military officials refused to accept the notion that enemy forces were being replenished at a rate that could sustain and overcome U.S. attrition efforts. Col Winterbottom refused to update the OB despite intelligence suggesting a growth in enemy forces.[21] In early 1963, the optimistic outlook was briefed to President Kennedy during deliberations on President Diem’s overthrow; ultimately, leading decisions-makers to grossly underestimate the enemy potential and miscalculate what would become an increasingly deteriorated security environment post-Diem.
At a critical inflection point in the Vietnam War, politicized intelligence permitted ill-fated policies to persist. This was further compounded by the pervasive inclination of government officials to overvalue MACV’s rosy assessments while ignoring alternative assessments from the CIA and DIA.[22] This ultimately barred objective assessments and associated analysis on costs and risks from coming to the forefront of U.S. policy decisions. The Diem overthrow drew the U.S. deeper into a losing strategy in Vietnam and led to subsequent U.S. escalation—but, the same limited military objectives from the Kennedy Administration would continue under President Lyndon Johnson.
THE WAR OF ATTRITION
The Diem overthrow only served to reignite Communist hopes of a victory. With continued support from China and the Soviet Union, the combat capabilities of Communist forces increased, despite the ongoing U.S. bombing campaign in the north.[23] By 1964, the Soviets were providing sophisticated weaponry to the People’s Army of Vietnam (PAVN), to include AK-47s, airplanes, tanks, warships, and anti-aircraft rockets and artillery.[24] In the same year, General William Westmoreland, the new MACV Commander, implemented an attrition strategy in his attempt to meet Pres. Johnson’s intent for a “minor reinvigoration” of the war.[25]
PAVN forces flowing from the north reinforced the enemy’s ability to withstand offensive operations in the south, and the range and frequency of enemy attacks started to increase.[26] Westmoreland’s “search and destroy” strategy and use of the ARVN as a conventional force continued to be ineffective.[27] Throughout 1964, enemy attacks increased in intensity and by 1965 Saigon was isolated.[28] McNamara grew suspicious of MACV’s overly-optimistic reporting and tasked the CIA with illuminating the situation in the south. Once again, the Order-of-Battle would play a critical role in U.S. strategy and policy. The self-delusion of General Harkins seemingly matriculated into General Westmoreland’s consciousness.
By 1966, the CIA assessed the enemy force strength to be 500,000. This assessment was derived from a review of hundreds of documents and captured enemy material. The MACV contested CIA estimates on the basis that the new number would mislead consumers into believing enemy strength had increased; and instead, offered an estimate of 300,000—one that excluded the guerilla-militia figures. MACV’s new intelligence chief, Maj Gen Philip Davidson, Jr., was obstinate in his belief that enemy forces were not replacing themselves. In the midst of the debate, MACV intelligence staff briefed the press that the “crossover” point had been reached (i.e., enemy losses exceeded the ability of the enemy to replenish). DIA and CIA capitulated under pressure, agreeing to the new number put forth by MACV.[29] In the year of 1967 alone, 31,700 enemy forces and 6,500 tons of weapons and supplies were infiltrated into the south along with—a prelude to the scale and scope of the 1968 Tet Offensive.[30]
The Tet Offensive would ultimately serve as the second major inflection point for intelligence’s role in the outcome of the Vietnam War. Although the possibility of an attack was known, the scale and timing of the attack was unanticipated. Intelligence analysts overlooked the possibility of an unorthodox strategy that consisted of attacking population centers with the totality of Vietcong and PAVN forces, approximated at 400,000.[31] The ensuing media coverage of the attack resulted in significant political embarrassment. Arguably, the media would not have been so unforgiving had MACV military officials provided a more objective assessment on the war. Public distrust in military and political leaders continued to deteriorate following the media coverage of the My Lai Massacre and release of the Pentagon Papers.[32]
PEKING’S STRATEGY
Ho Chi Minh’s initial alliance with Peking was opportunistic in nature,[33] but this alliance would prove to be decisive as victory could not have been achieved without the economic and military support from Mao. China, weary of invoking a larger U.S. intervention, refrained from deploying troops beyond the southern Chinese border. They opted instead to publicly support negotiations and reunification of Vietnam, while covertly supplying weapons and provisions to north Vietnam—thus, indirectly supporting the guerillas in the south.[34] In the lead-up to the 1964 U.S. elections, China believed the U.S. would probably accept the loss of South Vietnam and was prepared to “disengage” along with the Soviets. However, following President Johnson’s victory both countries reversed their strategy.[35] By 1968, the relationship between Mao and Ho Chi Minh became strained. Mao disagreed with the decision to move to a “limited general offensive” war in the south and recommended persisting in a protracted people’s war. Although Mao remained supportive, material support ceased in mid-1968.[36]
Ultimately, Mao’s strategy succeeded in terms of avoiding U.S. confrontation. The extent of external support to North Vietnam was in large part overlooked, and thus never became a vulnerability that the U.S. could exploit as a means to weaken Minh’s base of strength. China’s rhetoric to become involved militarily if the U.S. invaded the north probably served as a deterrent. However, in doing so, China risked invoking greater U.S. aggression. Mao appropriately assessed the precarious nature of the American will and was keenly attune to political sensitivities leading up to U.S. elections. However, had the nuclear-capable U.S. been provoked into total war against the North Vietnamese and the Chinese, both countries would have almost certainly capitulated.
SUMMARY
Ho Chi Minh’s adoption of Mao’s protracted war doctrine coupled with Mao’s material support allowed for the preservation of forces and ability to inflict psychological damage in an attempt to exhaust the American will to fight. In the end, the will of the Vietnamese people outlasted the will of the American people. The first missed opportunity in the Vietnam war was the decision to forego diplomatic negotiations with Ho Chi Minh who demonstrated a desire for a Western alliance. This would have allowed for a peaceful resolution and potentially driven a wedge between Vietnam and the two communist states. Cold War ideology arguably underpinned the proclivity to favor aggressive material solutions. Secondly, the Vietcong were decimated after the Tet Offensive (45,000 killed) and the Minh-Mao relationship was fractured. Had the U.S. utilized this battlefield victory to drive negotiations from a position of strength, negative public perceptions of a political defeat might have been mitigated. Arguably, this opportunity was largely lost as a result of the deliberate politicization of intelligence by MACV.
The role of intelligence in the outcome of the war had a two-fold effect: (1) gross underestimations of enemy strength allowed failed policies to perpetuate and (2) gross overestimations of U.S. progress exacerbated the psychological impact of the Tet Offensive on the consciousness of the American populace.[37] MACV’s willingness to alter intelligence estimates reduced the inability for the IC to provide an objective and unified assessment of the war that might have forced planners and policy-makers to adopt a new strategy, such as negotiations. The claims of U.S. success ultimately enabled a losing strategy in an increasingly protracted war and resulted in a loss of public trust in governing officials and U.S. defeat in 1973.
BIBLIOGRAPHY

A&E Television Networks, “Red Scare,” History.com, https://www.history.com/topics/cold-war/red-scare. Last modified September 13, 2018.
Cosmas, Graham A. MACV The Joint Command in the Years of Escalation 1962-1967. Washington, DC: Library of Congress Cataloging-in-Publication data, https://history.ary.mil/html/books/091/91-6/CMH_Pub_91-6.pdf.
“How the Media Shapes Public Opinion of War,” PBS, https://www.rewire.org/pbs/vietnam-war-media-shapes-public-opinion/. Last Modified August 04, 2017.
Hunt, Richard. “On our Conduct of the Vietnam War: A Review Essay of Two New Works.” In Assessing the Vietnam War. Edited by Lloyd J. Matthews and Dale E. Brown. McLean, VA: Pergamom-Brassey’s International Defense Publishers, 1987.
Lawrence,Mark. Vietnam War: A Concise International History. New York: Oxford Press, 2008.
Papp, Daniel. Vietnam: The View from Moscow, Peking, Washington. Jefferson, NC: McFarland & Company, Inc., Publishers, 1981.
Petersen, Michael. “The Vietnam Cauldron: Defense Intelligence in the War for Southeast Asia.” Defense Intelligence Historical Perspectives, no. 2 (2012): 8.
Radvanyi, Janos. “Vietnam War Diplomacy: Reflections of a Former Iron Curtain Official.” In Assessing the Vietnam War. Edited by Lloyd J. Matthews and Dale E. Brown. McLean, VA: Pergamom-Brassey’s International Defense Publishers, 1987.
Weigley, Russell F. The American Way of War: A History of United States Military Strategy and Policy (Bloomington, IN: Indiana University Press), 1973.

 [1] Mark Lawrence, Vietnam War: A Concise International History (New York: Oxford Press, 2008), 35-39.
 [2] George W. Allen, None So Blind: A Personal Account of the Intelligence Failure in Vietnam (Chicago: Library of Congress, 2001), 19-36.
 [3] A&E Television Networks, “Red Scare,” History.com, last modified September 13, 2018. https://www.history.com/topics/cold-war/red-scare.
 [4] Allen, None So Blind: A Personal Account of the Intelligence Failure in Vietnam, 23-25.
 [5] Lawrence, Vietnam War: A Concise International History, 102-107; Allen, None So Blind: A Personal Account of the Intelligence Failure in Vietnam, 89.
 [6] Graham A. Cosmas, MACV The Joint Command in the Years of Escalation 1962-1967 (Washington, DC: Library of Congress Cataloging-in-Publication data), 20-21, https://history.ary.mil/html/books/091/91-6/CMH_Pub_91-6.pdf
 [7] Cosmas, MACV The Joint Command in the Years of Escalation 1962-1967, 48.
 [8] Cosmas, MACV The Joint Command in the Years of Escalation 1962-1967, 478.
 [9] Cosmas, MACV The Joint Command in the Years of Escalation 1962-1967, 478; Allen, None So Blind: A Personal Account of the Intelligence Failure in Vietnam, 114-116.
 [10] Allen, None So Blind: A Personal Account of the Intelligence Failure in Vietnam, 125-131.
 [11] Cosmas, MACV The Joint Command in the Years of Escalation 1962-1967, 89-92.
 [12] Allen, None So Blind: A Personal Account of the Intelligence Failure in Vietnam, 151-154; Cosmas, MACV The Joint Command in the Years of Escalation 1962-1967, 11-14.
 [13] Allen, None So Blind: A Personal Account of the Intelligence Failure in Vietnam, 134-136; Michael B. Petersen, “The Vietnam Cauldron: Defense Intelligence in the War for Southeast Asia,” Defense Intelligence Historical Perspectives, no. 2 (2012): 8.
 [14] Petersen, “The Vietnam Cauldron: Defense Intelligence in the War for Southeast Asia,” 8.
 [15] Allen, None So Blind: A Personal Account of the Intelligence Failure in Vietnam, 134-136.
 [16] Allen, None So Blind: A Personal Account of the Intelligence Failure in Vietnam, 27-39.
 [17] Cosmas, MACV The Joint Command in the Years of Escalation 1962-1967, 92.
 [18] Allen, None So Blind: A Personal Account of the Intelligence Failure in Vietnam, 142-145.
 [19] Allen, None So Blind: A Personal Account of the Intelligence Failure in Vietnam, 142.
 [20] Allen, None So Blind: A Personal Account of the Intelligence Failure in Vietnam, 159-235.
 [21] Allen, None So Blind: A Personal Account of the Intelligence Failure in Vietnam, 160-161.
 [22] Petersen, “The Vietnam Cauldron: Defense Intelligence in the War for Southeast Asia,” 10.
[23] Allen, None So Blind: A Personal Account of the Intelligence Failure in Vietnam,189-191.
 [24] Janos Radvanyi, “Vietnam War Diplomacy: Reflections of a Former Iron Curtain Official,” in Assessing the Vietnam War, ed. Lloyd J. Matthews and Dale E. Brown (McLean, VA: Pergamom-Brassey’s International Defense Publishers, 1987), 57-59.
 [25] Mark Lawrence, The Vietnam War: A Concise International History (New York: Oxford Press, 2008), 85.
 [26] Allen, None So Blind: A Personal Account of the Intelligence Failure in Vietnam, 168-191.
 [27] Richard A. Hunt, “On our Conduct of the Vietnam War: A Review Essay of Two New Works,” in Assessing the Vietnam War, ed. Lloyd J. Matthews and Dale E. Brown (McLean, VA: Pergamom-Brassey’s International Defense Publishers, 1987), 13-17.
[28] Russell F. Weigley, The American Way of War: A History of United States Military Strategy and Policy (Bloomington, IN: Indiana University Press), 1973.
 [29] Allen, None So Blind: A Personal Account of the Intelligence Failure in Vietnam, 244-254.
 [30] Cosmas, MACV The Joint Command in the Years of Escalation 1962-1967, 468.
[31]Allen, None So Blind: A Personal Account of the Intelligence Failure in Vietnam, 256-259.
[32] “How the Media Shapes Public Opinion of War,” PBS, last modified August 4, 2017, https://www.rewire.org/pbs/vietnam-war-media-shapes-public-opinion/
[33] Allen, None So Blind: A Personal Account of the Intelligence Failure in Vietnam, 23-25.
[34] Daniel S. Papp, Vietnam: The View from Moscow, Peking, Washington (Jefferson, NC: McFarland & Company, Inc., Publishers, 1981), 21-43.
[35] Papp, Vietnam: The View from Moscow, Peking, Washington, 41.
[36] Papp, Vietnam: The View from Moscow, Peking, Washington, 112-119.
[37] Allen, None So Blind: A Personal Account of the Intelligence Failure in Vietnam, 285.