Saturday, February 27, 2010

Week 9: Why the Stethoscope is on its way out...

Distribution Source:
Content Source: Eric Topol
Format: Video
Length: 16 minutes and 59 seconds
Link: The Wireless Future of Medicine

As many of my friends know, I am a huge fan of the iPhone. From my iPhone I can access my bank account, get directions, send a customized post card (from a photo I took on my phone), read the news, play games.. the list goes on. Hell, my iPhone can also turn into a flute, recognize unknown songs playing on the radio or at a bar, and even repel bugs. Yes, you read that correctly - the phone emits a high frequency noise that keeps bugs away. It is simply unbelievable.

I've always tried to convince people who don't yet "get it" that the iPhone and other smartphones are revolutionary not because they have the internet, or because they have great graphics. They are revolutionary because they represent a very new platform that spans all spheres of life and literally expands the realm of what is possible. I'm not joking when I say that the iPhone has saved me more time than any other single device, person - whatever - in my entire life. By far. And what's exciting to me is that the realization of this potential has barely begun in the two areas in which it may have the most lasting impact on humanity: education and medicine. Indeed, one of the points of this blog is to show how iTunesU - which I access through my phone - provides good, free information to anyone with the internet. But today I will focus on medicine, something my mom and girlfriend know a lot about, but about which I know basically nothing.

Dr. Eric Topol gave a fascinating talk last fall that starts with a bold prediction: the stethoscope, invented in 1816 and still widely used today, will be obsolete by 2016. Why? Because not only will a patient's heartbeat be available to a doctor in real time - anywhere in the world - but so too will all vital signals. Already the technology exists to see a patient's electrocardiogram on an iPhone. In some hospitals, doctors can see from their phones the heart rhythm, blood pressure, oxygen and temperature of their ICU patients - without having to be anywhere near the patients! Here is an example of how this would look on a phone.

Other technologies are equally fascinating - imagine, as an expectant parent, being able to monitor in real-time intrauterine contractions or the fetal heart rate. While we have continuous glucose sensors for diabetes patients, they have to be placed under the skin and then brought to doctors. The technology is almost there to have a non-implantable sensor, link it to a phone, and then send the results electronically to a doctor. Soon every smartphone user will be able to map literally every minute of his or her sleep, with breakdowns by different sleep stages (REM, light sleep, etc). There are already many calorie measurement programs - intake and outtake - on smartphones. Perhaps the most popular exercise-management program is the Apple-Nike partnership where a chip in Nike shoes automatically uploads workout statistics to the iPhone. Over 1.2 million Americans use this technology. The Holter Monitor, according to Dr. Topol, will also soon be obsolete. Now we have peripheral sensors or "smart band-aids" that can be uploaded through a "body area network" to your smartphone. Once it is on your smartphone it can be distributed wherever or however you like - to the hospital, the doctor, etc.

It is important to note that the wireless medical innovations are not limited to just physiologic metrics. They also extend to areas like imaging. For example, GE has introduced a hand-held ultrasound. This device has the capacity to do a Cardiac Echo or fetal monitoring, and is more sensitive than a stethoscope.

While some of this may seem like it is not practically applicable yet, Dr. Topol surprised the audience by revealing he was wearing a wireless device during his talk. He then showed in real time his ECG, heart rate, fluid status, respiration, posture, oxygen level and temperature. All of these are vital for monitoring someone with heart failure, the number one reason for hospital admissions and readmissions. The cost per year is estimated to be $37B, with 80% of costs related to hospitalization. The readmission numbers are staggering: over 50% will be readmitted after six months. This monitoring software is now being used in a trial that will attempt to prevent such high readmission rates among heart failure patients.

The armchair politician in me scratches his head and asks - instead of trying to guess at future health care costs based on models of the number of sick Americans, why not immediately seek bipartisan support for trials like this? In the same way that cheap energy ignited an industrial revolution, shouldn't we be focusing on extremely cheap and scalable preventative monitoring practices? If successful, this would both cut costs and improve the health of Americans in a way that seems to represent the ultimate in consumer-driven health care.

The problem, of course, is huge: 140MM Americans have one or more chronic diseases, and 80% of the $1.5 Trillion in medical expenditures are related to chronic disease. How can wireless medicine help? Dr. Topol outlined the ten targets for wireless medicine, listing the innovations that will improve each:

Alzheimer's (5MM Affected) - Vital signs, location, activity, balance
Asthma (23MM Affected) - Respiratory rate, FEV1, air quality, oximetry, pollen count
Breast Cancer (3MM Affected) - Ultrasound and self-exam
COPD (10MM) - Respiratory rate, REV1, air quality, oximetry
Depression (21MM) - Med compliance, activity, communicatio
Diabetes (24MM) - Glucose, hemoglobin A1C
Heart failure (5MM) - Cardiac pressures, weight, BP, fluid status
Hypertension (74MM) - Continuous BP, med compliance
Obesity (80MM) - Smart scales, glucose, calorie in/out, activity
Sleep disorders (40MM) - Sleep phases, quality, apnea, vital signs

The potential impact of these technologies on Hospital/Clinical Resources are huge, with major implications for hospital beds, outpatient visits, assisted living facilities, sleep labs, Holter Monitoring, mammography, and ultrasound/echocardiography (to name a few). Also fascinating is the potential for overlap in advancements in genetics with wireless advances. We have learned more about the genetics of diseases in the last three years than in human history. Using technology for both monitoring and cross-referencing, we can begin to predict who is likely to get Type 2 Diabetes, who is at risk for breast cancer, who may get atrial fibrillation, sudden cardiac death, etc. To some degree this capability exists, but not on a widespread, scalable, cheap platform like that which smartphones will allow.

In short, the potential changes and implications of wireless medicine span the globe, span age, sex and race, and span the many types of diseases. Put simply: we need to accelerate the era of wireless medicine. An article on this topic said the following: "The personal metrics movement goes way beyond diet and exercise. It's about tracking every facet of life, from sleep to mood to pain, 24/7/365." This may sound very scary, and in some ways it is. But it's not inconsistent with the underlying theme that to some degree has and will continue to define my generation: uber-transparency and significantly less individual privacy. This is yet another piece of the puzzle that is the exponentially increasing volume of information. To me the two key underlying questions are: how do we use this information, and how do we protect both the integrity and security of sensitive information? These questions, while extremely important, are somewhat irrelevant to the bigger picture. The train has left the station: the unbelievable power and scale of these new platforms has been unleashed. Now we must learn to maximize their benefits and minimize their potential costs. Supporting wireless medicine is a good place to start.

Sunday, February 21, 2010

Week 8: The Lucifer Effect - How Good People Turn Evil

Distribution Source: MIT World and iTunesU
Content Source: MIT
Format: Video
Length: 1 hour 50 minutes and 58 seconds
Link: The Lucifer Effect

I was worried this afternoon - after watching the first few minutes of the MIT world video (a new source recommended by a commentor - thanks), I knew I wanted to write on this topic, but also wanted to go to the gym. Given that the video was 2 hours long, doing both seemed impossible. So I decided to see if iTunesU carried the video as well. Sure enough, I was able to download the full video to my phone in 5 minutes... not only that, I was also able to plug my phone into the treadmill at the gym and watch the video while running. Pretty cool.

This week's topic focuses on the human capacity for both good and evil, from the perspective of Dr. Phillip Zimbardo. Dr. Zimbardo is most famous for his Stanford Prison Experiment, in which he gathered a bunch of "normal" Stanford students and randomly assigned them to be prisoners or guards. The results are fascinating, and are taught in every Pyschology 101 course in the country. In short, the experiment had to be called off after six days because the prisoner-guard dynamic had become so out of control. For me, this experiment has always reinforced the importance of critical thinking and maintaining individuality in the face of social pressures. If a few dozen smart, regular Stanford kids can abuse each other so quickly, we are all susceptible to situational and systemic pressures pushing us to do something that falls outside of our moral code.

Dr. Z makes an interesting parallel between his Stanford Prison Experiment and the tragedy of Abu Ghraib. I call it a tragedy because it was in my mind extremely unnecessary and was damaging to everyone involved: those who were abused, those who took the pictures and carried out the abuse, and the United States and its perception globally. Following the release of the pictures, Dr. Z highlights how the government - like any institution faced with a scandal - pointed to this as an incident of a few "bad apples." If it weren't so serious this shallow explanation would be laughable.

Few events have received as much scrutiny and military, government and journalistic review as the Abu Ghraib scandal. Across the board, they describe a fundamentally screwed up institution. Similar to the Stanford Prison Experiment, most of the abuses took place on the night shift. For three months, no senior officer so much as visited the prison after hours. The stress level was extremely high - one Army reservist was in charge of over 1,000 prisoners, 60 Iraqi policemen, and 12 Army reserviests. He had received no specific training for the job and as mentioned, had no supervision. The chaotic conditions included constant weapons smuggling by Iraqi policemen, a neverending sewer stench, power blackouts, prisoner escapes, grenade attacks, noise and rationed water. The head Army reservist worked 40 days straight in 12 hour shifts per day. In his off-shift he slept in the prison. In social psychology, this 100% engulfment is called a "total situation."

Because of its proximity to dangerous Iraqi slums, the British told the US not to use the Abu Ghraib prison. Furthermore, for the first time Military Intelligence units were actively encouraging the Military Police (the Army reservists) to help break down prisoners. Of course, this is not the job of the police, whose job it is to keep order in the prison. When viewing this in the context of the administration's policy condoning "soft" torture tactics, it isn't hard to imagine how prisoner abuse resulted.

None of this serves to excuse any of the behavior that took place. Rather, it shows how putting "normal" people into a terrible situation, coupled with a lack of training and supervision, as well as tacit (and in some cases explicit) approval from superiors, results in a total disaster. Dr. Z and others had the opportunity to meet with and review the files of those who took the pictures and committed some of the acts; in his and military psychologists' opinions, these people were very normal. Indeed, Dr. Z points out that the lead officer was someone with the capacity to be a hero in a different situation. Yet instead he was a perpetrator of evil, smearing someone with his own feces and forcing others to similate sex acts while naked.... how is this possible?

Dr. Z's underlying point is that good and evil are hardly black and white. The human brain has an unbelievable capacity to be selfish and caring, heroic or villanous, creative or destructive. In other words, both good and evil are core aspects of human nature, and people can be transformed by powerful situational forces. After describing some other historical examples (the Jim Jones mass suicide, Eichman and the Nazis, etc.), he put together ten simple lessons on how to create evil in good people:

- Create an ideology to justify any means ("national security", etc.)
- Take small steps/minor action first
- Successively increase small actions
- Make sure a seemingly “just authority” is in charge
- Introduce a compassionate leader who changes gradually to become authoritarian monster
- Implement ever-changing/vague rules
- Re-lable situational actors & actions (“Teacher helping” when reality is aggressor hurting)
- Provide social models of compliance
- Allow verbal dissent, but insist on behavioral compliance (verbal dissent is the feel good thing)
- Make exiting difficult (this, he says, is the key to date rape…)

Perhaps some of you have seen a few of these steps in action, either from bosses, religious or government leaders. Dr. Z views corporate or institutional evil as the biggest evil, because it has the capacity to affect many people. In the case of corporations or governments, the rules of action are defined not by ethics, but rather by laws. The question is often not "what is right," but "what can we get away with?" He also described how corporate evil is always about the first little step - perhaps in the name of being a "team player." None of this is meant to be conspiratorial; it should instead reinforce to all of us that doing things because "that's what has always been done" or because someone "says so" is a poor reason that can have serious consequences. It's also clear to me that in a corporate or institutional setting, many of these evils can happen in marginal and indeed insignificant ways... with powerful disincentives to stand up for what is right.

So how do we keep ourselves from being even marginally evil? Dr. Z has also conveniently put together a list of twenty ways of preventing unwanted influences... while I won't list all of them here, you can click on this link to see the full list. Probably the most useful for me will be the following:

In all authority confrontations: be polite, individuate yourself and the other, make it clear it is not “your problem” in the process, or situation; describe the problem objectively, do not get emotional, state clearly the remedy sought, and the positive consequences expected – hold off on the threats and costs to them or their agency as last resort.

See ya'll next week.

Saturday, February 20, 2010

General Petraeus on Strategic Leadership

I had the privilege of hearing General Petraeus speak today at Princeton University (and also was very fortunate to have met him in 2009). This is not this week's official "post", but I did want to at least jot down a few of the notes I took from his speech.

For those of you who don't know who General Petraeus is, he is the four-star general who leads the Iraq and Afghanistan wars, and was the force behind the Iraq "surge" that has proven so successful in stabilizing the country following years of misguided US efforts.

He spoke briefly on strategic leadership, and gave these three guidelines:

1) Come up with the "right" big ideas.... as a leader of an organization you are expected to come up with the ideas that shape and determine the future of that organization. If the ideas are built on shaky or even faulty grounds, the organization becomes susceptible to failure. In Petraeus' opinion, the success of the surge in Iraq was more about a surge of ideas than a surge in troops. Specifically, it was about improving local sentiment, it was about living in the field and not in the barracks, it was about not just leaving after a location was cleared, and it was about partnering with insurgent groups that could be turned.

2) Communicate these ideas... he mentioned that the most important communication is communication DOWN the chain of command. In any type of organization those who are executing a strategy will be the ones who are further down the chain of command. Without a proper understanding of the strategy, tactics at the lower level can interfere with strategy at a higher level.

3) Direct and oversee the proper implementation of these ideas... what stuck out to me here was that General Petraeus, a career military man, said that this requires empowerment and not micromanagement. To me this is extremely interesting - I would have guessed that of all bureaucracies, the military would rank near the top in terms of micromanagement. However he said (correctly) that this stifles the ability to implement ideas and adapt ideas to ever-changing conditions on the ground. I couldn't agree more.

Also interesting was his statement that in planning for the Afghanistan troop increase, Petraeus met with President Obama "9 or 10" times, sometimes for more than three hours at a time! To me, this shows that Obama has taken this situation seriously and instead of simply hearing a briefing and making a decision (like so many decision makers have done and do), he decided to spend meaningful chunks of time to discuss and debate strategy. Political affiliation aside, this is encouraging to me. No matter what the ultimate decisions are, I hope we have more politicians and leaders who are willing to use this kind of process to come to decisions on the many major problems we are facing.

Monday, February 15, 2010

Week 7: McMafia

Distribution Source:
Content Source: Misha Glenny
Format: Video
Length: 19 minutes, 30 seconds
Link: Misha Glenny investigates global crime networks

After a fun but exhausting weekend in Las Vegas, I will be writing a shorter post this week... following Sin City I decided to watch a talk by BBC journalist Misha Glenny on organized crime. Misha chronicles the globalization of organized crime in "McMafia," a book he wrote after spending years traveling the world meeting with both perpetrators and victims, from the drug trade to human trafficking to cyber crime.

While I think Misha was a little too ambitious in his attempt to somehow link all types of organized crime across multiple regions of the world, his basic point - that globalized crime has thrived and evolved in the last two decades, and that "we" are ill-equipped to fight it - makes sense. Organized crime is estimated by Misha to account for 15% of global GDP. If true, this is a staggering number; 2009 global GDP is roughly $57 Trillion, which would put organized crime GDP at over $7.5 Trillion. Were it a country (isn't that a lovely thought), this would make the organized crime industry the third largest economy in the world, after the US ($14.5 Trillion) and China ($8.8 Trillion). In short, we are no longer facing your old-school Italian mob family.

Today's organized crime is not only bigger than before, but significantly more connected. Misha talks about how, when faced with a problem of declining membership, Japan's Yakuza mob simply outsourced their killings to the Chinese mob. He views the various organized crime players as savvy, well-resourced businesses supported by a significant demand base for illicit products and services and greatly assisted by access to off-shore banking services.

He divides the global organized crime business into zones of production (e.g., Afghanistan & Colombia), zones of distribution (e.g., Balkans & Mexico), and zones of consumption (e.g., the EU, US and Japan). The zones of production and distribution tend to take place in the developing world, and are often accompanied with extreme violence. Last year some 6,000 people have been killed as a direct consequence of cocaine trade through Mexico. And this pales in comparison to the Democratic Republic of Congo where, since 1998, 5 million people have died in the fight to control the illegal mineral trade. To give some perspective, in terms of deaths, this represents the largest conflict on the planet since WWII. Mafias around the world cooperate with local Congolese paramilitary officers to coordinate supply of minerals. The trade is simple: Congolese warlords send minerals to mobs in exchange for guns, and the various mobs sell the minerals to western markets.

With this production, distribution and consumption model in place, organized crime has become an increasingly efficient business, and one area in particular, the Balkans, has emerged as a hotbed, for two primary reasons. The first is geography; the Balkans are in many ways a gateway to Europe and are surrounded by the Black, the Aegean, the Mediterranean and the Adriatic Seas. All kinds of illicit goods come to Europe through the Balkans: heroin from Central Asia through Iran & Turkey, cocaine from Columbia through Western Africa, women from Russia through the Ukraine & Romania and of course minerals from Africa. In addition to geography, like many Soviet satellites, the Balkans experienced a major institutional collapse following the fall of communism. Governments fell, of course, but so too did the underlying institutions, from the legal systems to the security forces. Across Eastern Europe and the Balkans, tens of thousands of police and intelligence officers, trained in surveillance, fighting and killing, were left jobless. With such a massive structural void, and a supply of unpaid, disgruntled thugs-in-training, it is easy to see how organized crime could thrive. After all, even legitimate business owners would in this environment be forced to buy protection for their assets. And while important political progress has been made in the Balkans since the fall of the Berlin Wall (most obviously the splitting up of Yugoslavia), it is unfortunate that a political void allowed these players to gain power and legitimacy, further entrenching them and their businesses.

From Misha's brief video, it's clear that the illicit goods and services trade represents a complex problem for which there doesn't seem to be a globally coordinated, comprehensive counterbalance. While he does not make any policy recommendations, the lecture takeaway is that organized crime is a massive economic force that has to be taken seriously. I won't pretend to have any answers, but what is clear to me is the impossibility (and futility) of using top-down "bans" on drugs or prostitution in hopes of ultimately eliminating them. It simply doesn't work. So if the zone of consumption cannot be eliminated by force, either another method must be attempted, or we must instead focus on incentives to disrupt zones of production and distribution.

Saturday, February 6, 2010

Week 6: The Way of the Samurai

Distribution Source: Hulu
Content Source: PBS
Format: Video
Length (Combined): 55 minutes
Link: The Way of the Samurai

"For existence is impermanent as the dew of evening, and the hoarfrost of morning, and particularly uncertain is the life of the warrior…"
- Code of the Samurai

I have never been to Japan, and have had only limited exposure to the country and people. Outside of Quentin Tarantino movies I've had no exposure to the samurai culture. But what little I've seen has made me fascinated with samurai warriors. Their intense training from a young age and unyielding devotion to the warrior lifestyle in conjunction with a deep sense of honor, code of ethics and philosophy seems historically unique. Their status as powerful warriors is unquestioned... earlier today I was trying to figure out who would emerge if you locked a spartan, a Navy SEAL and a samurai in a room for a fight to the death (leave a comment if you have any strong views on this).

The video I watched focused on what was in years a relatively brief period (roughly 100 years), but which represented an immensely important part of Japanese history. It chronicled the ascent to power of one of the most famous and powerful samurai, Tokugawa Ieyasu. Ieyasu would ultimately pull Japan out of its feudal civil wars, implement a peace that lasted for almost three centuries, and build the city of Edo (modern-day Tokyo) from a fishing town into one of the world's largest cities.

Ieyasu was born in 1543, the year of the water and the hare, and also the year that the Portuguese "discovered" Japan. After observing the Japanese culture and its complex political system, the Portuguese for the first time viewed an Asian people as equals, not as an inferior group to be conquered. Interestingly, the Japanese were not so kind in their assessment of the Europeans - they regarded as defects their large noses, messy beards, and rudimentary eating style and utensils. The Japanese bathed daily while the Portuguese went months without bathing. It is perhaps unsurprising that the Japanese called the Portuguese "Southern Barbarians."

At this time, Japan was divided into many fiefdoms, with powerful daimyo lords - and their armies of samurai warriors - battling for territory. Ieyasu was born into the samurai class, an honor bestowed on only 10% of the Japanese population. In other words, one could not simply decide to become a samurai. But with the honor of being born into the samurai class came a deep, lifelong obligation. Many Samurai boys, Ieyasu included, were given up as part of the intricate game of feudal politics. There was deep distrust between various political factions; giving a child was a way to guarantee or solidify one's intentions. Ieyasu's father gave him as a "hostage" to a powerful daimyo, and the two would never again meet. But even as a hostage, samurai boys were privileged - they traveled in style and were educated.

This education included training in the art of kendo - the way of the sword - which among other things exposed Ieyasu to the rigors of unending training and taught him to remain clearminded in the face of danger and to accept death stoically. Ieyasu was also trained in the Chinese and Japanese classics, martial arts, and military strategy. This education taught him above all the philosophy of the samurai lifestyle. At the age of 15, Ieyasu became a man and was given the right to carry the two samurai swords - the larger katana sword and a smaller sword, called the wakizashi. Once samurai became men, their swords would never leave their sides, and would even be kept by their pillows at night.

True glory for a samurai came on the battlefield, defending his lord. The samurai had to be ready to be killed and die for honor at anytime. There is a Japanese analogy that suggests samurai are like cherry blossoms - very presentable, but it only takes one storm for them to blow away.

Knowing when - and how - to die was crucially important for a samurai. On the battlefield, during the last moment of life one must show his control and die with honor. Outside of dying in battle, the most common death for a samurai was through a highly scripted suicide routine called harikari (also called Seppuku). A samurai would carry out harikari for many reasons, ranging from a loss in battle to angering his lord. The samurai would write his death poem and, without expression, stab himself in the abdomen with his sword. Any indication of pain or suffering would undermine the honor of the death... one samurai wrote:

For the samurai to learn
There's only one thing,
One last thing -
To face death unflinchingly.

By his twenties, Ieyasu had become battle-hardened and had been exposed to death. When his lord died, Ieyasu made the decision to return to his homeland and reclaim his title as a daimyo (an independent lord). At the time the most powerful daimyo was Nobunaga, who had gained control of about half of Japan. Ieyasu and his eventual rival, Hideyoshi, were both loyal to Nobunaga until his death. Hideyoshi became the most powerful, and instead of fighthing, Ieyasu made a series of savvy moves, including offering his second son to Hideyoshi to show his allegiance.

Perhaps the biggest risk Ieyasu took was accepting a deal from Hideyoshi that gave Ieyasu a few provinces (including Edo) in exchange for his submission. This would serve the dual purpose of both keeping Ieyasu as an ally and keeping him far from the political center of Osaka. However Ieyasu used the distance to his advantage, as it gave him more autonomy from Hideyoshi.

Hideyoshi did not have a male heir until the age of 60, and when he died his son was only 5. Before his death, Hideyoshi made a deal with Ieyasu and four other leaders to oversee the country until his son was old enough to take power. Ieyasu swore allegiance to Hideyoshi's son. Soon after Hideyoshi's death, however, Ieyasu began a campaign to rule all of Japan, culminating in arguably the most historic battle in Japanese history: the Battle of Sekigahara. Severely outnumbered, Ieyasu sent his troops into battle with this rallying cry: "there are two ways to come out of battle: with the head of the enemy or without your own." Ieyasu's army won, and the era of warring states had finally ended. Three years later the emperor bestowed the title of shogun to Ieyasu, making him the undisputed ruler of Japan.

Ieyasu quickly eliminated foreigners from Japan and outlawed Christianity (many of the Europeans were there in an effort to convert the Japanese). His only remaining problem was the son of Hideyoshi, Hideyori, who was growing older and to whom Ieyasu had pledged his life and subservience. The young Hideyori began to assemble forces in Osaka, and Ieyasu decided he would have to go back on his word. In 1614 he accused Hideyori of subversion and decided to attack. Hideyori had tens of thousands of loyal warriors, and the castle of Osaka was thought to be impregnable. After a stalemate, Ieyasu decided to try a different tactic - he sent a woman samuri to negotiate a truce with Hideyori's mother. He offered a safehaven for all troops if Hideyori agreed not to fight, and signed this pledge with his own blood. Hideyori's mother convinced him to accept the deal. As soon as the fighting stopped, Ieyasu filled the moats with dirt and stormed the castle, slaughtering everyone inside.

The samurai battle ritual calls for the decapitation of all enemy warriors, which are then cleaned and placed together as a sign of respect. It is estimated that 100,000 heads were assembled following the victory at Sekigahara. Hideyori refused to surrender, and committed Seppuku.

The choice to go back on his word was problematic for Ieyasu. It is believed that he deeply regretted having to eliminate Hideyori, and was said to have done penance by writing the name of Buddha 10,000 times on scrolls of parchment. However, it is clear that Ieyasu thought the dynasty and lasting peace was worth the dishonor of eliminating Hideyori. Indeed, the peace that followed lasted through the industrialization of Japan in the 19th century.

Together the three famous samurai leaders, Nobunaga, Hideyoshi and Ieyasu are known as "The Three Unifiers." There is a Japanese parable that summarizes Ieyasu's strategy of outlasting the other powerful samurai leaders:

The three samurai are watching a cuckoo bird, waiting for it to sing. Nobunaga says to the bird: "If you don't sing, I will kill you." Hideyoshi says: "If you don't sing, I will make you." Ieyasu, however, says: "If you don't sing, I will wait for you to sing."

I think my biggest lesson from this post involves the extreme patience of Ieyasu. As part of a borderline narcissistic generation that has come to expect real time gratification, it is enlightening to see how decades of patience and work resulted in Ieyasu's ultimate victory. It is clear to me that his strategy and tactics, as well as the self-discipline prescribed by the samurai code, are useful guides and deserve further study.