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THE WALL STREET JOURNAL. Wednesday, January 11, 2017 |A

OPINION

Keep America’s Word Again—and Protect Ukraine

D

oes “making America great
again” include living up to
the country’s commitments
to other nations? Senators should
put that question to Secretary of
State-designate Rex Tillerson at
his confirmation hearing Wednes-
day—especially with regard to
Ukraine, which gave up its nuclear
weapons in the 1990s in exchange
for assurances that the U.S. has
failed to meet.
More than 90% of Ukrainians
voted for independence in a Decem-
ber 1991 referendum; it was the only
former Soviet republic to condition
its independence on a vote of its cit-
izens. Independence would have left
Ukraine with the world’s third-larg-
est nuclear arsenal, but leaders in
Kiev did not wish to be a nuclear-
armed state. The parliamentary dec-
laration of independence, which the
voters approved, included a provi-
sion that Ukraine would be “nuclear
free.” Thus the people of Ukraine
voted for a nuclear-free state.
In several little-known 1992
meetings in Washington, Ukraine
expressed its desire to turn over
its nuclear arsenal to the U.S. But

the State Department took the po-

sition that Ukraine must ship its

weapons to Russia, the last country

Ukraine wanted to arm. Given no

alternative, Ukraine sought secu-

rity guarantees.

Presidents Bill Clinton, Boris

Yeltsin and Leonid Kravchuk signed

the January 1994 U.S.-Russia-

Ukraine Trilateral Statement and

Annex, which set the framework for

protecting Ukraine’s security in ex-

change for its surrendering its arse-

nal. Negotiations continued

throughout that year. Ukraine did

not easily deliver its nuclear weap-

ons to a state it feared would turn

aggressive against it.

In December 1994, Ukraine ac-

ceded to the Nuclear Non-Prolifera-

tion Treaty as a non-nuclear-weapon

state, and the U.S., Russia, Ukraine

and the U.K. signed the Budapest

Memorandum on Security Assur-

ances. The three other signatories

promised to respect the indepen-

dence, sovereignty and existing bor-

ders of Ukraine and to refrain from

threatening or using force or eco-

nomic coercion against Ukraine’s ter-

ritory or political independence.

The assurances were tested in

1995. Yuriy Meshkov, a Russian-

backed official in Crimea, took over

the regional government and

sought to establish independent

Crimean representation in Wash-

ington. Mr. Clinton called Yeltsin

and—citing the Helsinki Final Act,

the United Nations Charter, the

Trilateral Agreement of January

1994 and the Budapest Memoran-

dum—said the takeover in Crimea

could not stand.

Mr. Clinton also sent the U.S. am-

bassador to Kiev, William Miller, to

the Crimean capital of Simferopol

to tell Mr. Meshkov the U.S. would

not recognize his actions, and to

the port city of Sevastopol with the

same message for Adm. Eduard Bal-

tin, commander of Russia’s Black

Sea Fleet. Yeltsin withdrew support

and Mr. Meshkov’s “government”

collapsed. In 1995 Washington kept

its word to Ukraine.

But in 2014 Russia invaded Cri-

mea, which it continues to occupy.

Moscow instigated and has supported

military aggression against Ukraine’s

Donbas region. More than 10,

Ukrainians have been killed and many

more thousands wounded; more than

a million have been displaced. Curi-

ously, Mr. Clinton has not spoken

about the promises of the Budapest

Memorandum. Russia fosters subver-

sive efforts throughout Ukraine and

its propaganda machine misrepre-

sents reality undermining Ukraine’s

sovereignty—the sovereignty the U.S.

promised to protect.

America eventually imposed

sanctions and has provided sup-

plies—nonlethal support—and loan

guarantees, among other assistance.

But the help has been far from suf-

ficient to turn back Russian aggres-

sion. The U.S. has urged but not

participated directly in the Minsk

agreements, an attempt to end Rus-

sia’s war against Ukraine.

But there is no need for Minsk.

The U.S. government should ac-

knowledge Russia’s clear violations

of international law, the Trilateral

Agreement and the Budapest Mem-

orandum and honor its assurance of

Ukraine’s sovereignty.

It has been said the Budapest

Memorandum’s “assurances” are

not “guarantees.” That argument

should be beneath a great nation.

If “assurances” are not “guaran-

tees,” what are they? What was

President Clinton committing to on

behalf of the United States? Was

Ukraine misled? During negotia-

tions the Ukrainian translator,

Walter Sulzysnky, made clear to

the other parties that in Ukrainian

there is no translatable distinction

between “assurance” and “guaran-

tee.” Everyone knew the Ukraini-

ans understood “assurances” as

“guarantees.”

Congress has repeatedly passed

legislation giving the president

authority to be far more support-

ive of Ukraine than the Obama ad-

ministration has been willing to

be. President-elect Trump and

Secretary-designate Tillerson have

an opportunity, and an obligation,

to live up to the U.S. commitments

to Ukraine—to keep America’s

word again.

Mr. McConnell, co-founder of the

U.S.-Ukraine Foundation, served as

assistant attorney general during

the Reagan administration.

By Robert McConnell

Clinton made assurances

when Kiev gave up nukes.

Then Obama broke faith.

Trump can restore it.

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Siri, Am I About to Have a Heart Attack?

nology for Economic and Clinical

Health, or Hitech, Act. Part of the

2009 stimulus largess, it set aside

some $20 billion worth of incentives

for hospitals and doctors to show

“meaningful use” of electronic

health records, or EHRs.

Tons of data come with medical

records. Then there are digital scales,

Fitbit steps, WellnessFX blood tests,

Apple Watch data and 23andMe ge-

netic test results. Eventually there

will be daily commode sensors mea-

suring blood sugar and prostate-spe-

cific antigen levels, among other

things. Now imagine all that data be-

ing crunched, in real time, by ma-

chines looking for patterns—which

then put out a simple text message.

“Your Hemoglobin A1c has spiked

again. I thought we agreed to cut

back on the linguine.”

Describe this to anyone in health

care and you’ll get two words back:

Dream on. Instead of advancing

electronic health record “interopera-

bility”—a fancy word for being able

to share and access electronic health

records—the Hitech Act ended up as

a funding mechanism for electronic

health-record firms like Epic Sys-

tems, Cerner and Allscripts. By 2016,

the government scheduled $23.8 bil-

lion in payments for firms that

could achieve full electronic access

and true interoperability for the full

calendar year. It was later changed

to a much easier 90-day reporting

period for a subset of patients. Call

it meaningless use, but the money

kept flowing.

If you try to transfer your records

from one hospital to another or to a

doctor, you’ll probably end up “walk-

ing with paper,” as they say in the

industry. The average doctor still

deals with reams of faxes every day.

A friend tried to send records from

a Boston hospital to Miami; both

places use Epic Systems’ electronic

files. The records were faxed.

Epic Systems, a private company

based in Verona, Wis., is the indus-

try leader, controlling close to half

of all American medical records.

Still led by 73-year-old founder

Judy Faulkner, Epic also appears to

be the leading obfuscator when it

comes to transferring records and

interoperability.

In 2015, competitors Cerner,

Allscripts, Athenahealth and others

have set up a group known as Com-

monWell Health Alliance to ensure

health IT interoperability. Epic, with

annual revenues easily north of $

billion, refused to join, citing the

$1.4 million upfront fee and

$900,000 annual payments. Oh, and

Epic didn’t want to sign the nondis-

closure agreement.

My industry sources tell me Epic

won’t sign nondisclosure agreements

with anyone but makes outsiders

agree to them. The company doesn’t

co-develop applications with outside

companies. Third parties don’t have

access to application programming

interfaces, or APIs, which are the

gateway for record data. Hospitals

and doctors can have access, if they

beg hard enough, but then they must

hire inside developers to customize

their system.

The company avoids titles, but

good luck contacting any of its 9,

employees, who are forbidden to

give out their cellphone numbers.

Epic has one phone number to the

main switchboard. It’s still the 1970s

in many ways.

I called it. Eric Helsher, vice pres-

ident of client success at Epic, re-

sponded: “Today 100% of health sys-

tems using Epic are sharing patient

information to better care for pa-

tients. They exchange over 1.3 mil-

lion patient records a day and inter-

operate with all major EHR vendors

and government agencies.”

Epic is talking up something it

calls the App Orchard, a portal for

vendors to sell apps that dig into

Epic’s electronic records. Except

the proposed pricing comes to four

cents per message sent. Machine

learning would drive millions or

billions of messages. The company

might cap fees at 30% of the ven-

dor’s revenue: Even Apple isn’t

that greedy.

I’m trying to get my medical re-

cords from a hospital with Epic sys-

tems. The best I have been able to

do is a PDF file, a modern way of

walking with paper.

How do we fix this? Dr. Eric Topol

at Scripps in San Diego proposes

health records be patient-owned and

controlled, perhaps on a flash drive

or iPhone or in the cloud. Maybe

next to health savings account info.

It’s a start.

But forget government mandates.

The real incentive is insurers paying

for this data, and they are figuring

out that early detection is worth it.

It’s a lot cheaper to find a disease be-

fore it turns into expensive chronic

care for heart disease or cancer. The

machine learning output might be:

“You may have pre-Stage 1 cancer in

your pancreas, but no worries—we

can zap it out for you.”

That’s how you bend the cost

curve in medicine. Make firms like

Epic look at interoperability as an

incremental profit center rather than

an opening for competitors. The

dream of smart machines crunching

health info is real. Don’t let the

dream walk with paper.

Mr. Kessler, a former hedge-fund

manager, is the author of “Eat Peo-

ple” (Portfolio, 2011).

By Andy Kessler

GETTY IMAGES/ISTOCKPHOTO

O

bamaCare was always
about paying for health
care—costs have outpaced
inflation for decades—but
seldom about keeping peo-
ple healthy. As Republicans repeal
and replace, they need a vision for
the path to better care. Technology
now exists to provide cheaper and
higher-quality health care, but giant
roadblocks stand in the way.
That technology is artificial intel-
ligence and machine learning. The
algorithms behind AI are painfully
complex, but the final product is
simple—think Google Translate or

Amazon’s Alexa. Saying a phrase and
immediately having it translated is
cool. Being told that your week of
bad sleep and slight stomach pains
could be cancer is life-altering.
Machine learning is already in-
vading health care. Experts at Kag-
gle, an artificial-intelligence research
firm, shared a few real-world appli-
cations of the technology with me:
Predicting heart failure by looking at
massive amounts of MRI scans, diag-
nosing diabetic retinopathy from eye
imaging, and successfully predicting
seizures with a machine analyzing
electroencephalogram data.
The key is data. With more of it,
accuracy gets better over time. At
least on the surface, the Obama
administration did something
right—the Health Information Tech-

Big data could provide

early warning of disease—

if medical records can

learn to talk to one other.

Meryl Streep Upstages Obama

Back when her hus-
band was president,
Laura Bush found
herself in the thick
of a fashion faux
pas when she ap-
peared at a White
House reception
wearing the same
red Oscar de la
Renta dress three
other women were
wearing. Mrs. Bush handled the situ-
ation the way you would expect her
to handle it: Quietly and without
drama, the first lady went upstairs
and changed into a navy blue dress,
in an effort to spare the other
women embarrassment.
On Tuesday Barack Obama found
himself in the same pickle Mrs.

Bush did back at that 2006 gala.

Only this time the awkwardness

isn’t sartorial but rhetorical: some-

one who’s just delivered the speech

you were planning to give.

Tuesday night in Chicago, Presi-

dent Obama was scheduled to give

his farewell address. But what was

left for him to say after the Trump-

thump Meryl Streep handed down

Sunday night at the Golden Globes?

Ms. Streep was on stage to ac-

cept Hollywood’s Cecil B. DeMille

award for her “outstanding contri-

butions to the world of entertain-

ment.” Say this about her contribu-

tion that night: Would anyone even

be talking about the Golden Globes

today if she hadn’t used the occa-

sion to go after Donald Trump?

The problem for Mr. Obama is

that Ms. Streep managed to step on

many of the themes the president

was expected to hit in his last big

presidential speech, right down to a

snarky reference to foreign birth

certificates. Here are some of the

lines Ms. Streep delivered, followed

by a short interpretation of what

she really means:

• “All of us in this room really
  belong to the most vilified seg-
  ments in American society right
  now.” Translation: You may think of
  us as rich and powerful and good
  looking, but we are really just vic-
  tims who live in fear.


• “When the powerful use their
  position to bully others, we all
  lose.” Translation: In case you ha-
  ven’t heard, Donald Trump is a
  lout.


• “We need the principled press
  to hold power to account, to call
  him on the carpet for every out-
  rage.” Translation: The big problem
  today is that journalists aren’t will-
  ing to criticize Mr. Trump.


• “You’ll have nothing to watch
  but football and mixed martial arts,
  which are not the arts.” Transla-

tion: This is a warning for all you

deplorable people clinging to guns

and “Monday Night Football.”

• “Ryan Gosling, like all of the
  nicest people, is Canadian.” Trans-
  lation: Under President Trump, the
  actor who just won a Golden Globe
  for “La La Land” lives in fear his
  home will be raided by the INS and
  he will be deported back to Ontario.

OK, this last one might not

make it into an Obama speech. But

the rest—the preening, the ritual

invocation of victimhood, the belit-

tling of working-class tastes, the

idea that no right-thinking person

might have a different view of this

election—these are all Obama

chestnuts. In Ms. Streep’s case,

Sunday night’s address was natu-

rally followed by a flood of celeb-

rity tweets attesting to how brave

she was to speak this way before

an audience made up almost exclu-

sively of people who think exactly

the same way she does.

Mr. Trump responded to Ms.

Streep as you would expect. He

tweeted, and had three points.

First, that as an actress the three-

time Oscar winner is “over-rated”;

second, that she is a “Hillary

flunky”; and third, that he didn’t

mock a disabled reporter the way

she said he did.

There are arguments for No. 1,

though they are beyond the scope

of this column. With regard to No.

3, the reader can judge the conten-

tion by Team Trump that he’s used

the same arm gestures with others

that he did when he berated a re-

porter with a congenital joint con-

dition for equivocating about a

story he’d written years before.

But it’s hard to argue with Mr.

Trump’s No. 2, much as Ms. Streep

might dispute the word “flunky.”

In July she spoke at the Demo-

cratic convention on behalf of Hil-

lary Clinton. As she would later

tell Variety, “when I went out, I

just felt what I felt. I did my How-

ard Dean scream.”

Now she’s done it again. And it’s

a tough act for President Obama to

follow.

It used to be said of Ginger Rog-

ers that she did everything dance

partner Fred Astaire did—only

backward and in heels. In much the

same way, Ms. Streep has now de-

livered a speech on what the Trump

succession means to all those in-

vested in the Obama legacy—in

barely six minutes, without the aid

of presidential speechwriters and

just two nights before President

Obama delivered his.

Peniel Joseph writing in the

Guardian, Jan. 7:

The Obamas leave the White

House, if not the world stage, hav-

ing accomplished, through sheer

force of will, something entirely un-

precedented in American history:

humanizing the black experience by

simply being themselves.

In the process they normalized

black excellence, codified graceful

resistance to white supremacy and

illustrated the profundity of black

romantic and familial love. And

they looked great doing it. The

Obamas will be missed by mil-

lions—but no one will miss them

more than black Americans. We

found in Obama a president who

justified the faith of generations

who persisted in loving America—

even when the nation refused to

love us back.

Notable & Quotable:TheObamas

Her Trump-thumping

wasahardactforthe

president to follow.

MAIN
STREET
By William
McGurn

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