NOTE: The views expressed here belong to the individual contributors and not to Princeton University or the Woodrow Wilson School of Public and International Affairs.

Friday, December 16, 2011

Testing Treatments: Building a culture of evidence in public policy

Brett Keller, MPA

Back in September the New York Times reported on an unexpected finding from a clinical trial: “A promising but expensive device to prop open blocked arteries in the brain in the hope of preventing disabling or fatal strokes failed in a rigorous study.” Many promising medical innovations fall short when they finally reach clinical trials, but this story was unusual because the stents had already been approved by the FDA under a so-called humanitarian exemption. The FDA approved the stents to reduce the risk of stroke, but those who received it had twice as many strokes.

How did this happen? The Times chronicled experts’ puzzlement: “Researchers said the device seemed as if it should work.” And Joseph Broderick, a prominent neurologist, is quoted as saying “Quite frankly, the results were a surprise.” Researchers are delving into this case to discover why the stent failed, but policymakers from all fields should take it as a valuable lesson. This is one more argument for testing policies whenever possible: not only does expert opinion sometimes get things wrong, but without good data there is often no way to really know when they are right.

Similar lessons can be gleaned from the history of surgical response to breast cancer. In The Emperor of All Maladies (2010), a new history of cancer, oncologist Siddhartha Mukherjee chronicles the history of such failed interventions as the radical mastectomy. Over a period of decades this brutal procedure – removing the breasts, lymph nodes, and much of the chest muscles – became the tool of choice for surgeons treating breast cancer. In the 1970s rigorous trials comparing radical mastectomy to more limited procedures showed that this terribly disfiguring procedure did not in fact help patients live longer at all. Some surgeons refused to believe the evidence – to believe it would have required them to acknowledge the harm they had done. But eventually the radical mastectomy fell from favor; today it is quite rare. Many similar stories are included in a free e-book titled Testing Treatments (2011).

As a society we’ve come to accept that medical devices should be tested by the most rigorous and neutral means possible, because the stakes are life and death for all of us. Thousands of people faced with deadly illnesses volunteer for clinical trials every year. Some of them survive while others do not, but as a society we are better off when we know what actually works. For every downside, like the delay of a promising treatment until evidence is gathered properly, there is an upside – something we otherwise would have thought is a good idea is revealed not to be helpful at all.

Under normal circumstances most new drugs are weeded out as they face a gauntlet of tests for safety and efficacy required before FDA licensure. The stories of the humanitarian-exemption stent and the radical mastectomy are different because these procedures became more widely used before there was rigorous evidence that they helped, though in both cases there were plenty of anecdotes, case studies, and small or non-controlled studies that made it look like they did. This haphazard, post-hoc testing is analogous to how policy in many other fields, from welfare and education, is developed. Many public policy decisions have considerable impacts on our livelihoods, education, and health. Why are we note similarly outraged by poor standards of evidence that leads to poor outcomes in other fields?

A recent example from New York City helps illustrate how helpful good evidence can be in shaping policy. A few years ago Mayor Michael Bloomberg rolled out a massive program that seemed to make a lot of sense: pay teachers bonuses based on their students’ performance. The common sense proposal was hailed as “transcendent” and gained the support of the teachers’ union. It cost $75 million, and it didn’t work. How do we know? The program was designed from the beginning as a pilot where schools were randomly assigned to the program or to a control group, and the research showing that the program had no effect on outcomes was subsequently published. What would have happened if this policy had been put in place without an effective evaluation plan? In all likelihood New York officials would now be touting its success at conferences and urging other cites to implement similar programs. Instead it was quietly shelved. That this particular program did not have the intended effect is disappointing, but it is much better than if we believed it worked and continued on unaware.

The pros and cons of randomized trials have been discussed here on 14 Points before – see recent posts by Jake Velker and Shawn Powers. The cases I presented here are ones where the results were not “no-brainers” at all, and without systematic evaluation bad policies would have been or tragically were put in place. While good evidence does not have to come from randomized trials, there are still many areas where they are underused. In areas where they are feasible (i.e. not macroeconomics) such evidence should be the norm, and those who implement policies with great optimism but without planning for thoughtful evaluation should be panned. Even without random assignment of the treatment, the best policy evaluations should involve a serious attempt to estimate the counterfactual: what would have happened in the absence of the intervention. Moving beyond arguments over specific programs and whether they work, policymakers can move us towards better outcomes by creating a culture where strong evidence is valued. After all, the clinical trial as we know it in medicine is a 20th century innovation; it hasn’t always been this way.

Establishing an Enduring Peace: A way forward in Darfur

Joshua Owens, MPA

For over five years, peace talks between Darfur rebel groups and the Government of Sudan (GoS) have failed to yield a substantive agreement. Low-level fighting and lawlessness continues, and recent developments indicate a potential relapse into serious conflict. Over the summer major clashes erupted along the North-South border between GoS and Southern-aligned groups (the Sudan People’s Liberation Movement – North, or SPLM-N) in Kordofan, which was not allowed to secede with the rest of South Sudan. In November SPLM-N and the main Darfur rebel groups, the Sudan Liberation Army (SLA) and the Justice for Equality Movement (JEM), united to establish the “Sudanese Liberation Front,” with the aim of launching coordinated military attacks across Sudan and forcefully overthrowing the Bashir regime. According to a recent International Crisis Group report, “...the growing war on multiple fronts poses serious dangers for the country, for its future relationship with the Republic of South Sudan and for the stability of the region as a whole."

To build enduring peace, the international community must first realize that the current mediation strategy of facilitating negotiations between insurgent groups and the GoS is fundamentally flawed. Peace talks have failed because they have neglected (1) traditional tribal leaders and (2) building civil society. My reflections are based on my two-year experience as a development program manager in rebel-held territory in the heart of Darfur – near the fighting lines between Darfuri rebels and GoS forces (together with their Janjaweed allies). While there, I worked on a UNDP project to study and address root causes of ongoing conflict and recognized these pitfalls in the peace-building process.

1. Breakdown of the Traditional Leadership Structure
According to local accounts, a strong tribal leadership structure facilitated relatively stable relations between African and Arab tribes in Darfur for decades before the war. Tribal elders led this structure, and it provided the mechanism for maintaining the balance of power equilibrium between tribes and mediating occasional conflicts.

However, during the 1990s, a new group of young, political activists emerged from the African tribes (Fur, Zaghawa, and Masalit) to protest their enduring socio-economic marginalization under Arab hegemony from Khartoum. As this group (Sudanese Liberation Movement or SLM/SLA) amassed support from neighboring Chad and the people in the isolated tribal areas of Darfur, the balance of power shifted from legitimate tribal elders to young insurgent leaders.

When the SLM finally militarized and attacked Sudanese Armed Forces in early 2003, the GoS responded by arming Arab tribes in Darfur and authorizing them to eradicate African tribes. This intervention further disrupted the delicate balance of power that had long existed between Darfuri tribes.

Nevertheless, peace talks are framed primarily as a negotiation between the GoS and rebel groups. Though these insurgents purport to represent the best interests of the African tribes, their primary concern is their own survival. SLA and JEM present unreasonable demands in peace talks and perpetuate the conflict because peace would deprive these young, zealous rebels of their raison d’ĂȘtre and the basis of their authority. Rebel groups continue to wield considerable power and maintain popular support only because local populations are wholly dependent on them for protection.

Therefore, effective peace negotiations and reconciliation must also engage the traditional tribal leaders. These elders are the only legitimate representatives of the best interests of the tribes, and their continued exclusion will undermine any settlement attempt.

2. Shoring Up Civil Society
Second, in order to facilitate long-term peace-building, the international community must help these areas build strong, village-level civil society institutions. According to conventional social science definitions, civil society is the space that (a) exists between the family and the state, (b) connects different families and individuals, and (c) is independent of the state. (Varshney 2001) Civil society organizations are modern and voluntary and generally take the form of cultural, social, economic, or political associations. For example, in Darfuri villages, we attempted to establish agricultural extension networks, community water and health committees, women’s trade groups, and English classes.

Most scholars of conflict agree that civil society play an important role in mitigating violence because these associations connect people from diverse backgrounds, build trust and reciprocity, and facilitate the exchange of view on public issues. In Darfur, building civil society now is vital for peace-building for two reasons: First, civilian-led organizations will help offset the power and voice of armed rebel groups and promote the legitimate leadership of civilian tribal leaders. Second, these organizations can facilitate the ethnic reconciliation process in Darfur by gradually establishing links with civil society groups in rival tribes with similar interests.

Taken together, these steps will help resolve the impasse of negotiations over Darfur. Though international attention has shifted in the past year to the plight of South Sudan, this lingering crisis in the country is no less important.

Thursday, December 8, 2011

Occupy Wall Street: Occupying the public discourse

Laura Noonan, MPA

Since the inception of Occupy Wall Street (OWS) in September, critics and commentators have questioned both the motives and tactics of the populist movement. Perhaps the most common objection is that OWS protestors have failed to focus on a single, unifying demand. To be sure, their concerns are broad, and even at times seemingly conflicting. Issues that have been voiced include protesting social and economic inequality, high unemployment, corporate greed and corruption, and the undue influence of corporations – especially financial services firms – on the political process.

The fact is, their demands are far from simple. While some are fairly tangible (e.g. more progressive tax policies), others (like reducing the influence of Wall Street and corporations on the political process) are much more complex, requiring the overall of deeply-embedded systems.

For that reason alone, it was ultimately beneficial for the OWS movement that protestors were recently forced out of Zuccotti Park in New York City and other locations across the country. While an aggressive tactic such as ”occupation” was perhaps necessary to draw initial attention to their cause, over time it was bound to became a war of attrition, one that would be nearly impossible for the protestors to win given the lack of clear solutions to the issues they are protesting.

Semi-permanent encampments also require intense dedication from protestors, tending to draw a higher proportion of the more extreme (less understood, more easily attacked) supporters, while potentially scaring more moderate compatriots away. I, for instance, care deeply about economic and social inequality, but chose for various reasons not to join the protests. To be ultimately successful, the movement of the 99% must gain more support from the 99% of Americans they claim to represent.

In addition, to make changes within our current political system, the movement would be wise to make the distinction that they are protesting against policies which serve to protect the rich at the expense of the rest of us, not the rich themselves. Warren Buffett, who has come out against regressive tax policies, should serve as an example that the wealthiest 1% of Americans are not always the enemy.

The OWS movement does seem to be moving towards more mainstream acceptance, and is now publicly supported by a coalition of more than 70 liberal organizations, including, several large labor unions, and Planned Parenthood, as well as hundreds of prominent and influential individuals. This could help to provide additional resources, legitimize the movement, and ultimately force a prioritization of demands.

It remains to be seen, however, whether the Occupy Wall Street movement will be able to have the electoral impact needed to achieve many of their stated goals. The Tea Party, a similarly ambitious and unfocused movement, was able to successfully attract candidates to run on a platform representing the movement, and to shift mainstream Republicans’ campaigns in an effort to please Tea Party constituents.

While the long-term impact of the OWS movement is still unclear, it has in many ways already been successful, primarily by starting to reframe the public discourse on inequality.

The top 1% of the individuals in the American economy take home 25% of total income, and own 40% of the wealth. Research has shown that most Americans support a much more equal distribution of resources, but are also optimistically ignorant of the level of inequality that currently exists. But this may be changing as more and more attention is drawn to the issue. The term “income inequality” is appearing more and more frequently in the media, rising from 90 mentions in the week before the protests started to nearly 500 by mid-November.

And while most Americans still think of the United States as a land of opportunity, a 2006 report from the Center for American Progress showed that among high-income countries, only the United Kingdom has a lower rate of intergenerational economic mobility than the United States. For example, children from low-income families in the US have only a 1% chance of reaching the top 5% of the income distribution, versus children of the rich, who have about a 22% chance of doing so. Simply bringing awareness to the current reality has the power to subtly change public opinion that may be based on rosier assumptions.

Getting Americans to understand current social and economic inequalities of opportunity would be an important accomplishment. Whether policies ultimately change to prevent them, however, will depend on whether the country as a whole decides that they no longer find them acceptable.

A Self-Defense Mission Abroad: Enhancing Japanese peacekeeping forces in South Sudan and beyond

Atsuko Tsuda, MPA

This January, about 300 Japanese Ground Self Defense Forces (JGSDF) will arrive in South Sudan to join the ongoing United Nations Peacekeeping Operation (PKO) there. Security challenges are mounting in this newborn country; accordingly, local leaders as well as their international friends face daunting tasks. Stepping up to face these challenges head-on, Japan can turn this PKO mission into a pivotal opportunity to further advance its commitment to peace and stability in the region and to make headway in synergizing the 3Ds – diplomacy, development, and defense – in its foreign policy.

Two months after Japan established diplomatic relations with South Sudan on July 9th, newly-minted Prime Minister Yoshihiko Noda announced Japan’s new commitments to South Sudan at his debut at the UN General Assembly. As a start, Japan sent two JGSDF personnel as staff officers of the United Nations Mission in the Republic of South Sudan (UNMISS) Headquarters in November at the UN’s request. Japan is now preparing to dispatch JGSDF’s engineering unit to Juba, the capital, next year. These efforts are commendable and the government should continue to expand its defense commitment in South Sudan and around the world.

Dispatching more defense forces is an excellent opportunity for Japan to further contribute internationally by combining two areas in which it already excels – Official Development Assistance (ODA) and PKOs. JICA, Japan’s aid implementation organization, has an outstanding presence in South Sudan and has long been contributing to nation-building in the country. But as impressive as Japanese diplomacy and development currently is, expanding its defense efforts could create true co-equal synergies across these components of international assistance.

Japan’s Self Defense Force (SDF) has a high reputation both inside and outside Japan. Domestically, SDF increased its public support through its work following the Hanshin-Awaji Earthquake in 1995, and it played a critical role during this year’s natural disaster in the Tohoku area. Regarding international cooperation, the SDF is renowned for its fine-tuned and local-oriented approach, and its engineering units in particular have received special commendation. The technical training provided by Japan’s engineering units is highly regarded and the units are well-known for their diligence and politeness. SDF units have been sent to PKOs in Cambodia, Timor-Leste (East Timor), the Golan Heights, Haiti, and Mozambique.

Granted, in Japan there are legitimate concerns about sending an expanded contingent of SDF to South Sudan. SDF’s operations are constrained by the Constitution – which renounces the threat or use of force as means of settling international disputes – and other relevant laws. The 1992 law on Peacekeeping Operations prohibits “the use of force” and constrains the use of small weapons to the minimum: Self-Defense officials may use stipulated weapons “within the limits judged reasonably necessary according to the circumstances, when reasonable grounds are found for the unavoidable necessity to protect the lives of others or prevent bodily harm to themselves, other SDF Personnel or Corps Personnel who are with them on the scene, or individuals who have come under their control during the performance of duties” (emphasis mine).

Let me paint you a picture as to what this truly means at the operational level. Suppose SDF personnel are facing a heavily-armed group. There is an imminent threat, but they are not allowed to fire immediately. Instead, they have to follow a four-level procedure: oral warning, warning shots, point-blank shots, and only then, finally, sharpshooting.

Yet despite the constraints that the SDF bears, Japan has been seeking to extend its support in the areas of nation-building and PKOs wherever possible. This is a welcome development and should be continued. On the whole, the Japanese public supports Japan’s contribution to PKOs; a public opinion poll conducted last year shows more than 85% of respondents supported the idea that Japan’s cooperation to PKOs should increase or at least remain at the current level. The international community also expects further contributions from Japan, not only because it is the third largest economy but also because of its good work.

There are three UN peacekeeping operations between the two Sudanese republics: UNAMID in Darfur, UNISFA in Abyei, and UNMISS in South Sudan. This not only represents the war-torn history of the two countries but also the attention granted to it by the international community. Although Juba is relatively calm, the border area is still haunted by a possibility of a full-scale war. Therefore, while an ever-growing presence of SDF may be good both for Japan and South Sudan, given the security concerns and the Japanese forces’ severe restrictions, a careful examination of some clauses of the Japanese PKO Act may be necessary to truly fulfill its higher mission.

Atsuko Tsuda is a foreign service officer for the government of Japan. This piece represents the personal observations and opinions of the author. It does not reflect the views, nor represent an official position, of the government of Japan.

The World’s Only Secretariat for Philanthropy

Heather Lord, MPP ’11

Dan Hymowitz

In America, the debate lumbers on about the best way to coordinate the philanthropic sector and the US government. Meanwhile, one post-conflict West African country has jumped right in – the Liberia Philanthropy Secretariat is the fruit of collaboration between recently-reelected President Ellen Johnson Sirleaf and private foundations. It is the world’s only national government office dedicated to engaging private philanthropy.


Launched in April 2009, the Secretariat is a five-person unit housed in the Liberian president’s office, co-financed by six philanthropic organizations.


Expand and improve philanthropic commitment to Liberia.


1) Is a government Philanthropy Secretariat a good idea?

Early on, some foundations worried that the Secretariat might become a bureaucratic barrier hindering direct impact funding in Liberia. However, after nearly three years of operation, philanthropist feedback indicates that the Secretariat has proven itself a valuable “on the ground” matchmaker, helping donors connect to trustworthy government and nonprofit contacts, information, and grantees. From the Liberian perspective, the Secretariat has increased philanthropic support and built capacity for entrepreneurial Liberian organizations addressing pressing social problems in their communities.

2) What have some achievements and challenges been so far?

Achievements: Increased funding, network leverage, donor satisfaction, grantee empowerment

The Secretariat has facilitated an estimated US$16.4 million in philanthropic giving. But impact is about more than just money – it’s about making connections, identifying and empowering good partners, and developing ideas for social change. The Secretariat has helped facilitate grants from 13 first-time grantmakers in Liberia. Some family foundations say the Secretariat inspired their giving because they know their investments are effectively contributing to priority, high-impact projects. The Secretariat has also engaged the Liberian government and civil society in an educational dialogue about philanthropy, how it works, and how it might help Liberians create long-term, equitable prosperity.

Challenges: Donor coordination, managing expectations

The Secretariat has tried to foster collaboration between foundations and increase philanthropic alignment with Liberia’s Poverty Reduction Strategy. They’ve had some success with strategic alignment but struggled with intra-foundation collaboration, due in part to the diversity of Liberia’s philanthropic partners. Additionally, local nonprofits had difficulty meeting donor expectations in the face of significant post-conflict human resource and infrastructure challenges (e.g. limited access to roads, computers, internet) and lack of experience with philanthropic practices (e.g. writing grant proposals, generating self-assessment metrics). While there has been progress, patience and flexibility remain essential on all sides.

Solar flashlights in a community in Grand Bassa County, Liberia.

3) Is the Secretariat a viable model for other countries?

As donors and governments in other countries consider a Philanthropy Secretariat or similar coordination mechanism, there are a few pre-conditions which may increase chances of success:

  • significant external foundation interest
  • appetite from at least a few key government officials to engage foundations
  • a senior government official “champion” with credibility in government and donor communities and a sophisticated understanding of philanthropy
  • some level of mutual trust between philanthropists and the government

The world’s only Secretariat for Philanthropy has been a promising experiment for donors and for Liberia. It is worth keeping an eye on it and exploring what this model might provide in other countries.

Heather Lord is a philanthropic strategy consultant and authors the blog Dan Hymowitz is a former program manager for the Liberia Philanthropy Secretariat. A version of this article was published earlier this month by the Council on Foundations RE:Philanthropy blog, and is accessible here.

Thursday, December 1, 2011

Shuttle Shutdown: The future of US space exploration

Madhurita Sengupta, MPA

In January 2004, President Bush announced his Vision for Space Exploration, setting forth executive policy that would send us back to the moon and onto Mars. Though it meant that the end of the Shuttle Program – created in 1981 – was imminent, this promise ignited hope and inspiration in those of us who spent their youths dreaming of “slipping the surly bonds of Earth” (to quote Magee by way of Reagan) and setting foot on extraterrestrial soil, while honoring the legacy of those who’ve made space exploration possible.

And yet, on February 1, 2010, the fabric of our nation’s space program was effectively rewoven, as President Obama announced a new plan for the future of NASA. Constellation, the program that would take us to the moon and onto Mars, was abruptly cancelled. In its place, a crop of commercial efforts would soon be undertaken to ferry US crew and cargo to the International Space Station, effectively freeing resources for NASA to concentrate on developing the next generation of launch and crew vehicles and advanced technologies for future missions. In the meantime, as predicted, the shuttle program officially ended in August of this year, one month after the final flight of the space shuttle Atlantis. (Currently, without a shuttle program, the Russian Soyuz vehicle is our sole mode of transportation to the Space Station, for which the US pays on the order of $60M per seat.)

Many protested Obama’s radically different plan and today, a year and a half after that announcement, NASA sits at a pivotal juncture – one that will determine the future of our nation’s human spaceflight program. The recently passed FY12 budget promised the agency $17B for the fiscal year (which equates to roughly $0.005 per taxpayer), but NASA remains at an impasse. In this budget, Congress has not only cut funding to the commercial efforts, but also attached conditions to this funding contingent on progress made in the development of the next generation launch/crew vehicle, effectively forcing NASA to extend the schedules of both programs, or prematurely choose one commercial provider over another.

Regardless of funding allocations, we, as a nation, now have the opportunity to set the course for the future of human space exploration. Never before has NASA been faced with such apathy and lack of support and funding; and yet, it presents the agency and the nation with a challenge to overcome. How can NASA prove to the administration, Congress, the American public, our international partners, and the rest of the world that it is truly capable of pioneering the future of human spaceflight? Moreover, how can NASA demonstrate that investments in science and technology today are apt to yield dividends of various magnitudes for years to come?

Since the inception of the US human spaceflight program, countless individuals have devoted their livelihoods to further the cause of exploration, to test the limits of mankind’s knowledge and experience, and to expand the boundaries of our terrestrial existence. NASA has been, is, and forever will remain an agency of people who believe in space exploration. It is a collective group of passionate, dedicated workers who are inspired by the contributions of spaceflight to humanity. It is men and women who were awed by Sputnik, by Neil Armstrong’s first steps, by the first joint Russian-American venture in space, by the space shuttle’s maiden voyage, by the building of the International Space Station, piece by piece, before our eyes and who are still inspired on a daily basis by the feats that they themselves help accomplish. They are motivated by man’s innate desire to achieve the impossible, to paraphrase Kennedy, not because it is easy, but because it is hard.

Our nation now has the opportunity to draw on all of our many impressive years of experience and inspire others to not only marvel at our ingenuity and initiative, but to contribute and invest in it. With the end of the shuttle program, we now stand at a crossroads, at which we are fortunate to have the opportunity to honor those who have given their lives to help mankind escape the gravitational bonds that have tethered us to this lustrous planet for centuries, and explore the recesses of the unknown, bit by bit, in order to understand, appreciate, and provide for our species. No matter what path we ultimately take, let us not forget that we are all passionate about many common things; let us not ignore our inner child, who declared his/her desire to become an astronaut at age eight; and all the while, let us honor the legacies of the past, by embracing the possibilities and potential of the future. We owe those who have sacrificed their lives for the advancement of mankind, who accomplished seemingly impossible tasks, at the very least, that much.

A Real Remedy for Youth Unemployment in Saudi Arabia: Scrap "Saudization" and emphasize employment education

Mary Svenstrup, MPA

The Kingdom of Saudi Arabia has been relatively unaffected by the Arab Awakening. So far, the government has been able to maintain stability by cracking down on protests while simultaneously providing generous handouts to appease its citizens. Saudi youth, however, are growing increasingly dissatisfied with their government because they cannot find employment. And as recently seen in Egypt, Tunisia, and Yemen, a dissatisfied youth population has proven to be an important factor contributing to instability and, ultimately, regime change.

Employment has significant cultural implications in Saudi Arabia and the Arab world: it is an essential prerequisite for marriage and transition to adulthood. Without employment, youth are stuck in social purgatory, feeling restless and unsuccessful. Yet Saudi Arabia has the highest youth unemployment rate in the Middle East and North Africa region excluding Iraq.

The Saudi government’s answer to youth unemployment is “Saudization,” a policy that sets employment requirements for Saudi nationals. This policy has been ineffective because it does nothing to address the underlying issue that Saudi graduates do not have the skills demanded by private companies. Furthermore, this policy disincentivizes non-hydrocarbon sector growth, which is critical to create more jobs in the Kingdom. The Saudi government should scrap Saudization and instead focus on education that will build skills for employment.

Structural Barriers to Employment in Saudi Arabia
Saudization is an artificial employment requirement that does not address the structural problems with the Saudi economy that contribute to youth unemployment, such as an overreliance on the hydrocarbon sector, a constantly growing social transfer system, and insufficient private sector growth.

Saudi Arabia’s economy is largely based on petroleum, but the hydrocarbon sector is not a reliable source of job creation. Oil and gas comprise about 45% of fiscal revenues, 55% of GDP, and 90% of export revenue yet, the national oil company employs less than 1% of Saudi labor force. The hydrocarbon sector does create a source of revenues for the government’s generous social transfer programs; these programs, however, may not be sustainable, crowed out other social expenditures, and most of all, do nothing to address unemployment. As an example, in lieu of real social reforms, the Saudi government introduced new fiscal initiatives on February 23 and March 18, 2011 to quell domestic protests. Although these types of social transfers may help to immediately pacify the population, the IMF notes that these programs will require oil prices sustained higher than $90 per barrel for the next several years. That may not be sustainable and puts a huge burden on the Saudi government to control oil prices.

Given the problems created by reliance on the hydrocarbon sector for employment, the non-hydrocarbon sector of the Saudi economy is critical. This sector, however, has not been able to create enough jobs for Saudis. Over the next five years, the IMF estimates that private sector non-oil GDP will need to grow by 7.5% annually to create a sufficient number of employment opportunities for the domestic population. While Saudization addresses the issue that most private sector jobs are being allocated to more qualified expatriate workers, the policy increases the operating costs of private companies in the Kingdom, thereby reducing incentives for investment and hindering non-hydrocarbon growth. For example, a recent equity research report by EFG Hermes suggested that Saudi companies will meet Saudization requirements in the near term by hiring more Saudis rather than reducing the number of expatriates, given the skills mismatches of Saudi workers. Basically, companies are being forced to increase personnel costs simply to satisfy a legislative mandate.

Furthermore, both the appeasement tax and Saudization may have a feedback loop creating more pressure on the government. As Saudis become wealthier and more connected to the rest of the world, their expectations for employment and inclusion in the economy will continue grow. Higher expectations combined with growing dissatisfaction with unfulfilling employment opportunities will further increase the government’s cost of appeasement. Therefore, creating sustainable economic opportunities for its citizens will mitigate the long-run fiscal burden of providing appeasement handouts and remove the need for Saudization, as long as Saudis have the skills necessary to be competitive employees.

Education for Employment
The underlying cause of youth unemployment is that, even with a postsecondary degree, Saudi graduates lack the right skills for jobs in a modern, knowledge-based economy. The Saudi education system itself has flaws, but a main problem is that students choose to study subjects that have no direct linkages to labor markets. For example, in 2008, 40% of university students in Saudi Arabia were concentrating in arts and humanities (versus averages of 20% and 17% in Asia and Latin America, respectively), while only 24% chose to study science or engineering. Furthermore, there is a social stigma against technical and vocational training, and any type of university degree, even one that is very unlikely to lead to employment, is socially viewed as superior.

To reduce youth unemployment—and the risk of social instability in the Kingdom—the government ought to at least address skills mismatches by orienting the education system toward private sector employment opportunities. Ideally, Saudi Arabia should scrap Saudization and instead focus on making their graduates competitive employees. Forcing graduates to compete for jobs will ensure that they choose education tracks that are conducive to employment. Additionally, technical and vocational programs should be associated with prestigious universities and fellowships, which would alleviate some of the social stigma of choosing this track. Lastly, the government should adopt a national quality assurance framework to regulate private education companies doing business in the Kingdom to ensure that degrees and certificates are uniform across the country. These changes, paired with continued investments in upgrading the overall education sector, should help to link skill-based post-secondary education with employment opportunities.

Encouraging youth to select education for employment will result in more qualified workers that will naturally increase the demand for Saudi workers and ultimately reduce the cost of doing business in the country. The government and the royal family should act quickly on this issue, for their own sake and for the sake of the growing youth population in their kingdom.

Big Business, Small Hands: Changing child labor laws in US agriculture

Megan Corrarino, MPA

Imagine a country where twelve-year-old children work twelve-hour days, where wage theft is rampant, and where child workers handle pesticides, operate hazardous machinery, and engage in other dangerous work that contravenes of the International Labor Organization’s Convention 182 on the Worst Forms of Child Labor. In the US, these are the workplace conditions for roughly half a million children currently working on commercial farms. While most forms of child labor are strictly regulated, a farmwork exemption to the Fair Labor Standards Act (FLSA) allows children to work at younger ages, for longer hours, and under more dangerous conditions than in any other industry in the country.

When the FLSA was created in 1938, agricultural lobbyists convinced Congress that applying the same standards to agriculture would spell the end of the rural way of life. But most children working on farms today are not family farmers’ sons and daughters, rising early to milk cows before school or spending summers learning the family business. Most children today work on commercial farms. They are overwhelmingly migrant, poor, and vulnerable. They perform routine tasks for hours on end, leaving them susceptible to repetitive motion injuries, and are often exposed to highly toxic pesticides and other hazards. An average of 104 child agricultural workers die each year, and over 22,000 are injured – a rate more than four times that in other sectors. Sexual harassment and abuse are commonplace. Children employed on farms, like their adult colleagues, work long hours, are not entitled to overtime, and often move in order to follow the growing season. Half of all child agricultural workers never graduate from high school.

Current farm labor law fails to protect the rights of children in two ways. First, the laws themselves fail to require reasonable working conditions that respect the dignity of child workers and that provide sufficient support and time for schooling. For example, in addition to allowing children to perform hazardous work, current farm labor laws allow 14- and 15-year old children to work unlimited hours – even during the school year. In any other sector, the same children would be restricted to three hours of work a day on school days and eight hours on other days.

Second, agricultural labor laws that do exist are often poorly enforced. Children are particularly vulnerable to rights abuses. The 1983 Migrant and Seasonal Protection Act, for example, guarantees a minimum wage. Although farmers may pay by the pieces picked instead, they are required to make up the difference if that does not reach the set wage. But children often pick on family tickets, making it difficult to determine what they should have been paid and allowing employers to hide the hours worked if children ever try to recover unpaid wages.

A proposed Department of Labor rules change, designed to “bring parity between the rules for agricultural employment and the more stringent rules that apply to the employment of children in nonagricultural workplaces,” would, among other things, limit animal and pesticide handling, prevent children under 16 from working on tobacco farms, and restrict operation of power-driven equipment by children under 16. But even these relatively straightforward changes have faced opposition from a wide range of agricultural lobbyists.

Given the resistance to even these small changes, comprehensive child labor reform will be a political challenge. But it is nevertheless necessary; child workers in agriculture typically work out of economic necessity and are among our country’s most vulnerable workers. Workplace laws must protect their fundamental human rights.

One bundle of suggested reforms, the Children’s Act for Responsible Employment (CARE Act), HR 3564, would apply the same workplace standards to agricultural child workers as are currently applied to others. (It would still include a family farm exemption.) Crucially, because enforcement of labor law is often challenging, particularly in agriculture, it would require better data collection by the Department of Labor and would raise the fines for violations from $11,000 to $15,000 – making employers less willing to take a risk.

Advocates for the CARE Act are currently lobbying with a non-traditional coalition of agricultural unions, members of Congress, filmmakers, Hollywood stars, and human rights organizations. Successful advocacy will require continued public mobilization and creative alliance-building – perhaps drawing on coalitions of workers in other informal sectors, or parlaying the growing national interest in food policy to highlight labor practices in the food production chain. As Edward R. Murrow observed in The Harvest of Shame, a 1960 documentary that reflected agricultural working conditions strikingly similar to today’s, “The migrants have no lobby…Maybe we do.”

Friday, November 25, 2011

Empowering Evaluation: Looking beyond the numbers

Elizabeth Hoody, MPA

As a former grant-maker, I was glad to see that 14 Points talked about the challenge of evaluating anti-domestic violence work in a post by Payal Hathi last May. In my own experiences working in a women’s rights foundation, I saw just how difficult it can be to quantify the impact of women’s rights organizing in numerical terms. While numbers can tell an important story (such as how many young women receive sexual and reproductive health education), they often leave out what for me is most compelling about a group’s work. This might be the reflections of an individual young woman who now feels that she can talk to her partner about contraceptives or the story of a group of girls who decided to form their own anti-trafficking student organization after participating in a prevention workshop. So while there are many valid and pressing questions about how to “get the numbers right” in program evaluation, my bigger concern these days is how to evaluate impact beyond the numbers…and then again how to aggregate and share this type of evaluation in a way that donors, policymakers, and peer organizations can easily understand.

In the past year, I have come across several creative examples of evaluation strategies that do attempt to move beyond the numbers. Many of these strategies attempt to articulate, verbally or visually, the systemic impact of an organization’s work. One example is a map that was released by the Global Fund for Women just this past week, which captures the Fund’s impact around the world using bright spots. In the Global Fund’s words, this map “explores where a relationship between Global Fund for Women and grantee groups is more likely to yield a higher movement building impact.” While the map does rely on a series of numerical indicators, the visual analysis tells a bigger story about the collective impact of Global Fund for Women grants on women’s rights movements around the world.

The second example is the Gender At Work Framework, which “helps organizations see their work from new perspectives by combining best practices in organizational development with feminist thought.” One tool that the framework uses is a graph where civil society organizations can plot the different types of social changes they are addressing through their work. The graph places the continuum of “individual versus systemic” change on vertical axis and “formal vs. informal” changes on the horizontal axis, resulting in four quadrants of change:
  • Women’s access to resources (quadrant I)
  • Women’s and men’s consciousness (quadrant II)
  • Informal cultural norms and exclusionary practices (quadrant III)
  • Formal institutions, laws, and policies (quadrant IV).
Women’s organizations use the tool to visually represent the changes that they are trying to impact through their work. The graph is also a good indicator of what programs will be easier to quantitatively evaluate (such as programs that work for specific policy changes) and those that will be difficult to track through traditional metrics (how do you measure changes in men’s and women’s consciousness?).

What I like most about the Gender At Work Framework is that it encourages grassroots organizations to define evaluation framework themselves at the beginning of their planning processes. When this happens, evaluation shifts from being a chore for donors to being an effective way of tracking and reflecting on an organization’s progress towards its goals. In my personal, unquantifiable opinion, the resulting story more often than not contains richer analysis, more honest reflections, and genuine learning.

For the past year, I have been working on the Advisory Committee of FRIDA – The Young Feminist Fund, which is a newly formed foundation that is run for and by young feminist activists. As FRIDA prepares for its first grant-making round, these questions about evaluation are on my mind. How do we tell our story to our first funders and how do we empower the first FRIDA grantees to take ownership over evaluation of their work? Can we be accountable and collaborative in evaluation? As a starting point, we are planning to develop the first grant evaluation process in partnership with FRIDA’s first round of grantees. As we begin to hash out exactly what the process will look like, I am grateful for these new tools that push us towards more creative, dynamic ways of articulating our goals, visions, and impacts.

Saving Congress From Itself: Can the Independent Payment Advisory Board make Congress’s Medicare cost control problems go away?

David Mitchell, MPA

With the Joint Select Committee on Deficit Reduction – a.k.a., the Super Committee – missing a major deadline this week, the prospects for a debt deal before the next election seem bleaker than ever.

Eventually, Congress will have to act. The long-term deficit situation is truly unsustainable and the sequestration trigger agreed upon in August will begin sharply cutting Defense Department programs and Medicare provider payments in January 2013 (assuming Congress and the President allow it to stay in effect).

But for those hoping that responsible decision-making on the country’s entitlement and tax programs will materialize after next year’s election, prepare to be disappointed. In particular, Medicare – the public health insurance program for the aged and disabled, and by far the largest contributor to our long-term fiscal mess – has been subject to congressional mismanagement now for years.

As Wes Joines pointed out in a post earlier this month, the Medicare physician payment system is broken and has been so for more than a decade. Private insurance carriers that participate in the Medicare Advantage program have been overpaid since 2003, when the Republican-controlled Congress set artificially high payment rates as part of the same bill that expanded subsidized prescription drugs at the government's expense. And members of both parties have proven themselves unable to withstand the temptation of using the Medicare program to steer benefits to special interests. Whether it’s boosting payments to rural hospitals, delaying competitive bidding for durable medical equipment, or shielding beneficiaries from scheduled benefit cuts, there are many recent examples of costly Congressional micromanaging on both sides of the aisle.

Underlying this mismanagement is a simple political calculus: members of Congress believe that they must avoid being linked to any policy that will hurt the country’s 47 million Medicare beneficiaries (not to mention the tens of millions more about to join the program) or risk defeat at the polls. Cutting benefits is one obvious no-no, but cutting provider payments is also politically dangerous, since doctors and hospitals may then stop treating Medicare patients or otherwise incite seniors’ anger.

So what can be done? One hope is that legislators themselves may be looking for a way out of this Medicare cost-control political vortex, especially given the hard decisions that most political elites know will have to be made as part of an eventual debt reduction deal.

One sign of this thinking is Congress’s recent decision to establish an Independent Payment Advisory Board (IPAB) as part of last year’s health reform legislation.[1] The IPAB is designed to take Medicare payment policymaking out of the hands of Congress and put it into the hands of expert technocrats. Though the IPAB was not a major focus of the yearlong debate on health care legislation (Americans were otherwise obsessed with abortion, the public option, and death panels[2]), it may prove to be one of the most consequential provisions included in the ACA. In the words of former budget director Peter Orszag, IPAB represents “the largest yielding of sovereignty from the Congress since the creation of the Federal Reserve.”

Here’s how it works: A 15-member board appointed by the president and confirmed by the Senate will propose sharp cuts to Medicare payments if cost growth in the program continues on its current trajectory. What makes this Board different from past Medicare commissions – or even the current Super Committee – is that the recommended cuts will go into effect unless Congress finds equal savings elsewhere in the program or supermajorities in Congress vote to waive the new rules (and even then only if the president signs the resulting bill). There is concern that future Congresses will not allow themselves to be constrained by these parliamentary hurdles and will try to prevent the cuts by simply not confirming IPAB appointees or passing a new law revoking some or all of IPAB’s powers. But the IPAB provision includes rules to check these congressional urges, so there is reason to believe that IPAB will have teeth.

Beyond the technical details, one’s optimism about the Board depends in large part on what one believes is ailing the US health care system. If high prices are the culprit (as many on the left believe), IPAB could prove effective at withstanding political pressure from doctors, hospitals, and other providers and keeping prices low. If over-utilization is the main cost driver (as many on the right believe), IPAB’s usefulness will be limited. This is partly by design: currently, the Board can only recommend changes to provider payment rates, not benefits.

But many outside experts – including some who sat on the US Fiscal Commission last year – recommend expanding IPAB’s powers. And the president has urged Congress to lower IPAB’s cost growth rate target, making it more likely that recommendations will be triggered. Some have even speculated that IPAB could be the vehicle by which a new all-payer rate setting scheme could be implemented.

It’s unlikely that Congress will go along with any of the above proposals any time soon. Indeed, many in Congress have called for IPAB’s repeal. And it’s true that further empowering a board of unelected technocrats is not an easy sell to the American people (especially since the biggest problems facing Medicare – and the federal budget as a whole – require moral, not mathematical, answers). But as the extent of our long-term structural deficit becomes more apparent – and the situation grows more urgent – members of Congress may be tempted to delegate more and more tough decisions to IPAB. Some might view this as an undemocratic and irresponsible abdication of authority – in other words, the coward’s way out. But as Edgar Allan Poe once wrote: “That man is not truly brave who is afraid either to seem or to be, when it suits him, a coward.”


[1] The Affordable Care Act also created the Center for Medicare and Medicaid Innovation (CMI), which has broad powers to experiment with new payment systems like accountable care organizations and bundling, and then apply the most successful models nationwide – all without further congressional action. This is a promising idea, but the Congressional Budget Office and others are skeptical of its cost-saving potential and so it will not figure as prominently as IPAB in debt reduction negotiations.

[2] Since the bill’s passage, some have used the “death panel” moniker to describe IPAB, but during the debate that phrase was used in reference to a provision that attempted to expand the use of living wills.

21st Century Slavery: The scourge of human trafficking and how we can fight it

Elina Sarkisova, MPA

Human trafficking, although not a new phenomenon, has experienced exceptional growth in the last quarter of the 20th century, becoming one of the fastest growing criminal enterprises in the world. According to the State Department, an estimated 600,0000 to 800,000 men, women, and children are trafficked across international borders each year, the majority being women and children. When accounting for internal trafficking, the number of victims jumps to 12.3 million. Most states have taken steps, both on an individual and collective level, to try to reverse this trend; most noticeably in the form of international legal instruments and national laws aimed at migration controls, crime prevention, and victims’ assistance programs. However, these efforts have proved largely ineffective and are even to blame, in some circumstances, for making matters worse.

Why human trafficking is on the rise
The competing and often conflicting forces of globalization and national sovereignty help explain the increase in the overall volume of human trafficking. While globalization has brought about unprecedented opportunities for economic growth and prosperity, the results of economic liberalization (a key feature of globalization) have been mixed for developing countries. The swift spread of free markets has led to increased levels of inequality both within and between states and widespread economic instability, thus fostering strong “push” factors in migrants’ countries of origin. Meanwhile, increased demand for cheap labor in developed countries (characterized by a growing ratio of elderly to working-age people), declining birth rates, and high cost of labor, fosters strong “pull” factors.

On the other hand, governments have stepped up efforts to limit the movement of people across their borders, even when such policies are highly inconsistent with national labor market demands. This is usually the result of strong societal resistance to immigration and/or political pressures. Such restrictive immigration policies have the effect of increasing undocumented migration flows. However, trafficking flourishes where an additional factor is present: few opportunities to overcome barriers to illegal migration without the help of a third party. Most trafficking cases start out as voluntary transactions between a potential migrant and a smuggler – an exchange that is usually initiated by the migrant. However, the situation quickly deteriorates upon arrival at the destination country, where the victim often finds himself in a situation of forced labor.

National responses to human trafficking and why they haven’t worked
States tend to perceive human trafficking through the lens of national security, best addressed through migration controls, crime prevention and victims’ assistance programs. The United States, for instance, has increased border control enforcement along its 2,000-mile border with Mexico over the last two decades. However, strong migratory pressures render such efforts useless at best and counterproductive at worst, contributing to an increasing death toll in the border area and driving increasing numbers of economic migrants to seek the services of unscrupulous migration intermediaries intent on exploiting the gap between labor supply and demand. Law enforcement (e.g. police raids) has also become a key tool in countries’ toolbox for combating human trafficking. However, such efforts simply drive the trade further underground, where victims become more and more isolated and vulnerable to abuse, especially in the case of prostitution. Lastly, while some countries have initiated victims’ assistance programs, efforts have largely been limited to “rescue” operations that offer little in the way of long-term solutions and conditional assistance programs that overlook underlying incentives.

A way forward
The human security framework can offer a new, more useful way of conceptualizing an old problem – namely, from the standpoint of the driving forces behind the trade, the mechanisms that facilitate the trade, and the threat that such a trade poses to society. Broadly, policy response should focus on prevention (targeting underlying causes of supply and demand specific to each country), prosecution (law enforcement), and protection (victim assistance programs). Policy options should include, at a minimum:
  • Women, children, and minority empowerment programs: Past projects aimed at the economic empowerment of women have, for instance, tended to be components of broader economic development programs rather than anti-trafficking strategies. Efforts need to be streamlined and incorporated into a broader anti-trafficking strategy.
  • Immigration reforms: Destination countries should create temporary guest worker programs, perhaps in a more targeted way than some countries have already done, as part of a broader anti-trafficking agenda.
  • Anti-corruption programs among border patrol officials: Trafficking would not be as widespread were it not for the help of corrupt government officials, especially in border patrol areas, who are complicit in this trade.
In the end, improving the track record of international anti-trafficking programs will require both structural changes in the manner in which the issue is conceptualized by states and operational changes in the manner in which programs are implemented. Only then could we realistically attempt to end this scourge of the 21st century.

Friday, November 18, 2011

The Dragon has been Domesticated: A benign view on the rise of China

Ankit Panda, BA

As early as 1941, historian Henry Luce controversially called the 20th century the “American Century.” And today, just 11 years in, many are ready to bestow the 21st century honors to China. In retrospect, one may argue it makes sense to dub the previous century an “American” one because the United States did, in a sense, singlehandedly drive the normative alignment of modern international institutions and norms, albeit only after Luce’s declaration. So China’s impressive growth and greater face on the international stage should cause at least some change, right? Conventional realist wisdom would have us think so, but there is good evidence that the People’s Republic, and the Chinese Communist Party, have neither the interest nor the ability to do so.

Under any regime of international law (institutional or treaty-based), states have options to 1) comply with statutes and norms, 2) create statues and norms, and 3) “evade” statutes and norms. Starting with the leadership of Deng Xiaoping, the PRC has moved more from a rule-evading country towards one more interested in complying with existing institutions. Although conventional wisdom and the media might paint a very different picture of Chinese compliance, a quick look at China’s record at the World Trade Organization and the International Monetary Fund (IMF), in addition to its response to the 2008 financial crisis, provides strong evidence to believe otherwise.

At the IMF, the PRC, once chastised for its stalwart rule-evading (and frankly, rule-ignoring) behavior, has moved towards greater compliance. While the ongoing Article IV consultations on China’s controversial monetary policy and the depreciation of the renminbi remain a source of friction, notably, Chinese rhetoric in defense of this policy emphasizes mutual interests (between the West and China) and demonstrates a real stake in the continued “success” of the global financial system. Similarly, China’s reaction to the financial crisis in 2008 was swift and in line with systematic recommendations from the IMF and the US – a $580 billion asset-relief program similar to TARP in the US. Furthermore, Chinese support of the Eurozone during its sovereign debt woes demonstrates a further willingness to take a stake in the success of the status quo (although this final point may be more politically-motivated than I’m willing to admit in this short post).

The PRC’s short history at the WTO so far also demonstrates a mixed compliance record trending towards greater compliance over the years. Initially, Chinese accession encountered several obstacles, but it ultimately managed to convince the organization that without China, the WTO wasn’t truly a “world” trade organization. The WTO is struggling with China, which, as a mechanically-complex economy based on a particular set of normative principles, refuses in several cases to acquiesce to the exogenous and incompatible norms of the institution. On the other hand, China's victory over the European Union in a December 2010 case demonstrates an example of Chinese rule-taking and compliance with the WTO. Granted, this paints China as a rule-taker when the rules enforce its self-interest. Such victories come at the cost of leverage for the West, but bring with them greater Chinese stakes in the success of the rules-based order. The liberal international order is slowly beginning to accommodate China.

While experts like Robert Kaplan and C. Fred Bergsten may identify the many political and security threats that result from a stronger China, it’s important to consider the less-exciting but equally important economic perspective. It’s difficult to say definitively that there is one lens through which we should view China – frankly that would be an oversimplification – but overall, it’s important to recognize that China has been accommodated into the current system of international political economy and that this accommodation has made it an important stakeholder in the success of that system. Unfortunately for the US, even the liberal international order will move us away from the “American Century” towards a more complex and multi-polar global order.

Game Changer: Israel’s new calculus on attacking Iran

Jordan Reimer, MPA

After a long hiatus, there is renewed international focus on Iran’s nuclear program, from hyperventilating Israeli media reports last month on an imminent attack on Iran’s nuclear facilities to the recent release of an unprecedented International Atomic Energy Agency report pointing to Iranian activities “relevant to the development of a nuclear device.”

In the international debate on what to do about Iran’s nuclear ambitions, for those who advocate taking military action against the Islamic Republic the conventional wisdom has settled on Israel doing the world’s dirty work – as it did against Iraq in 1981 and Syria in 2007. Those who oppose Iran's nuclear activities but are still circumspect of this course of action advance a counterargument that falls essentially along two lines of thought: logistical infeasibility and geopolitical inadvisability.

The first contention details several obstacles: a) the vast geographic distance between Iran and Israel, b) the fact that Iranian nuclear sites are dispersed throughout the country (a lesson learned no doubt from Iraq’s vulnerability), c) the reality that such sites are situated in hardened bunkers located either underground or deep inside mountain ranges, and d) the possible existence of secret sites unknown to Israeli and American intelligence.

A successful action plan would therefore mandate continuous multi-sortie strikes over several parts of the country by Israeli fighter jets. (Israel does have a long-range missile program, but such a weapon is inappropriate for precision strikes.) However, an attack of this sort would soon fall susceptible to advanced Iranian anti-aircraft capabilities. Israeli airplanes would therefore be limited to execute only a quick once-over before returning home. And, in light of Israel’s deep concern for the lives of its soldiers, given the distance between Jerusalem and Tehran a viable plan would require mid-air refueling to guarantee the pilots’ safe return, a near impossibility considering the non-hospitable airspace Israel must traverse to reach Iran.

With all of these constraints, even if Israel did successfully pull off this type of limited mission, it would hardly improve Israel’s national security: experts assume Israel would set back Iranian efforts only a few years at the most. If anything, it would be merely a strategic victory, signaling the resolve behind Israel’s rhetoric and indicating its sincere desperate determination to prevent Iran from going further in its nuclear work.

For all of these reasons, an Israeli attack with potential to severely cripple Iranian nuclear ambitions was largely considered a fantasy.

No longer. On February 21st, 2010, Israel Aerospace Industries unveiled a new unmanned aerial vehicle (UAV), the Heron TP, nicknamed “Eitan.” Able to fly at medium-to-high altitudes for over 20 hours while carrying a variety of payloads, equipped with a silent engine ensuring stealth, and significantly, capable of reaching Iran, the drone relieves Israeli military logisticians of concerns regarding refueling and the safety of its airmen against anti-aircraft artillery. The drones could be mass-produced and then flown incessantly until all Iranian nuclear sites are obliterated. Even if the drones are shot down, it would come at a relatively modest cost (the price tag might be steep but it would be infinitely better than an Israeli soldier in Tehran’s hands). The UAVs could be equipped with self-detonation devices should they be captured to avoid Iran gaining insight into Israeli military technology.

Importantly, the second line of reasoning against an attack – geopolitical considerations – remains unchanged: bombing Iran is still a terrible idea. It will indefinitely delay the moribund Middle East peace process, inflame the Arab and Muslim world against the US at a time when it has a legitimate chance to turn over a new leaf, force a wedge between both US-Israel and US-Arab/US-Muslim relations, and almost certainly provoke Hezbollah and possibly Hamas to launch retaliatory attacks against the Israeli civilian populace. Not least, it could conceivably convince Iran to finally declare its intention for a nuclear weapon as a deterrent against future Israeli aggression, a stand which it has consistently refused to take.

To (mis)quote Rudy Giuliani, “The use of military force against Iran would be very dangerous. It would be provocative.” Yes. And it shouldn’t be done. (Though it’s outside the purview of this article, let me at least acknowledge that though there is no silver bullet, a healthy mix of sanctions, coalition-building, and containment should be sufficient to keep Iran at bay, should it develop the dreaded weapon.)

The revelation of the “Eitan,” then, is both a blessing and a curse. On the positive side it signals to Iran Israel’s credible conventional deterrent against development of a bomb (no doubt why the UAV’s unveiling was so public), which might induce the ayatollahs to rethink any potential attempts to acquire such a weapon. And yet, on the other hand, it removes the only barrier that Israel’s security hawks faced in their myopic and monomaniacal desire to carry out a strike on Iran. We can only hope that cooler heads prevail and the remaining reasons buttressing the argument not to attack remain foremost in the minds of Israeli policymakers and American interlocutors.

Non-Communicable Diseases: The Sword of the Damocles for developing countries

Siddharth Chatterjee, MPP ’11
Dr. Ayham Alomari

Thanks to the excellent work done by the United Nations Children’s Fund (UNICEF), the World Health Organization (WHO), the Global Alliance for Vaccines and Immunization (GAVI), the International Federation of Red Cross and Red Crescent Societies (IFRC), the Bill and Melinda Gates Foundation, governments, and other institutions to ramp up immunization for vaccine-preventable diseases, it is having the desired effect in reducing infant and child mortality. This important initiative has to be kept up and would contribute greatly to achieving the UN’s Millennium Development Goals by 2015.

But there is another threat that looms like the Sword of the Damocles: non-communicable diseases (NCDs) such as cardiovascular, cancer, diabetes, and lung diseases. To some extent, of course, the increasing prevalence of NCDs is an arithmetic consequence of reducing morbidity and mortality from communicable diseases. If people do not suffer and die from communicable diseases, they typically will die from an NCD. The tragedy, however, is that humans around the world suffer and die from NCDs prematurely, long before the natural limit to which modern medicine and non-medical interventions, including community-based efforts, can push the onset of suffering and the occurrence of death. In addition, the high burden of NCDs makes them a laden threat to health and development. NCDs are barriers to poverty reduction, health equity, economic stability, and human security.

A recent issue of the Economist states: “Indeed, of the 36m people killed by NCDs [annually], some 80% live in low- and middle-income countries. These diseases are associated with increased prosperity and longevity, and the results are costly. The World Economic Forum estimates that NCDs will cost low- and middle-income countries $7 trillion over the next 15 years.”

The most striking feature of NCDs is that, contrary to what most people think, it’s not just the rich that are feeling the damaging effects of physical inactivity, obesity, and poor diets. Far from it, the poor and middle class within the developing world are facing NCDs-related deaths exponentially. According to the statistics above, each day there are 100,000 deaths from NCDs, with 80% occurring in the world’s poorest countries. And unless we act collectively and with conviction the future looks ominous. According to WHO, NCD deaths are projected to increase by 15% globally between 2010 and 2020.

With the lives of 36 million people annually at stake, we all know what it takes to prevent NCDs – healthy lifestyles. NCDs could be preventable by eliminating shared risk factors such as tobacco use, unhealthy diet, physical inactivity, and harmful use of alcohol. Those risk factors are the main contributors to the magnitude and scale of NCDs worldwide. But many hurdles stand in our way, most stemming from a lack of urgency as well as political will to deal with this growing scourge.

To find ways to engage broader community involvement in NCDs, prevention through dialogue and concrete action were the topic of an event co-hosted by the IFRC and the International Federation of Pharmaceutical Manufacturers Association (IFPMA) at this year’s UN General Assembly in September. The panelists – who represented leaders among Red Cross Red Crescent National Societies, WHO, the private sector, and academia (including the active participation of two prominent members of Princeton University) – reinforced the call for integrated multi-sector and multi-partner NCD prevention initiatives.

Greg Vickery, President of the Australian Red Cross, shared his experience in working with Indigenous Australians, who are among the most vulnerable to NCDs. “Our response is threefold – through the ‘Save-a-Mate’ resuscitation and education program tackling the alcohol problem they face; breakfast clubs that teach school children healthy eating habits; and the ‘Food Cents Programme’ that shows families how to eat healthily on a tight budget, i.e. simple strategies to support healthy eating habits.” Professor Uwe Reinhardt, James Madison Professor of Political Economy at the Woodrow Wilson School, reminded the audience that part of this community-based effort must be to make the individual be both able and willing to play an active role in the management of his or her own health.

So basically, the message we want to stress is simple. Says IFRC’s Secretary General, Mr. Bekele Geleta, “Humanitarian organizations such as the Red Cross Red Crescent, whose staff and close to 13 million active volunteers world-wide work closely with local communities, play an enormous role in bringing about changes in behavior and attitudes towards health and lifestyle.” We at the IFRC strongly believe that including NCDs in our health programs is consistent with our Red Cross Red Crescent Strategy 2020 to enable healthy and safe living. Our Framework for NCDs focuses on prevention, innovation & research, monitoring & evaluation, partnership, and advocacy.

But we cannot do it in silos or on our own. To make a real difference for those who are not on a health services radar screen, it is critical that we forge robust partnerships not only with governments, the UN, and NGOs but also with important thought leaders and opinion leaders like Princeton University. This has to be a collective and well-orchestrated endeavour to prevent what the UN has called “a public health emergency in slow motion” from spreading. Simple lifestyle change is the key. Resources – intellectual and financial, as well as partners from the public and private sectors alike – need to come together.

The IFRC is keen to move forward on this important initiative. In the words of Professor Reinhardt, “One thinks of the Red Cross Red Crescent more in connection with earthquakes, tsunamis, and other spectacular and sudden natural disasters. I was surprised and encouraged to learn how much the organization is doing in response to another, albeit slowly developing, natural disaster, the growing burden of premature deaths due to NCDs, much of that burden the result of people’s inability or unwillingness, or both, to manage their own health better.”

The actions, then, appear to be simple, and the outcomes desirable. But it will take a significant investment of time and money to strengthen the ties that bind the Sword above us.

Siddharth Chatterjee is the Chief Diplomatic Officer and Head of International Relations at the IFRC. Dr. Ayham Alomari is a Senior Health Officer, Community Based Health and First Aid, NCDs at the IFRC.

Friday, November 11, 2011

Vying with Velker: RCTs reconsidered

Shawn Powers, MPA ’11

In “Randomized Controlled Trials on Trial,” Jake Velker proposes several reasons to be skeptical of randomized controlled trials (RCTs) as a method of program evaluation. While Jake makes some good points, as a “randomista” I think the picture he paints of the RCT movement is far too pessimistic. I will consider each of his arguments in turn.

1. External validity
Jake first takes up the critique, championed by Princeton’s Angus Deaton, that RCTs suffer from external validity problems—in other words, the results of an evaluation may not generalize well to other contexts. While the criticism is frequently leveled at RCTs, the question of external validity applies to all empirical work. In general, I find these discussions about the differences between Deaton and RCT proponents a bit overblown. Perhaps this is because everyone loves a good spat between high-profile intellectuals (see also: Sachs and Easterly). In reality, according to the profile of Esther Duflo in The New Yorker that Jake references, Deaton has described his criticisms “as more in the form of an amicus brief than an attack." The arguments raised by Deaton and others are having an impact, as Jake acknowledges, and RCTs increasingly are testing rich behavioral hypotheses. The incentives of academic publication are also moving RCTs toward greater theoretical sophistication. Gone are the days when a randomized design was a novel enough identification strategy that it could propel a study to publication in a top economics journal.

Considerations of theory aside, whether or not a particular result generalizes is itself a testable, empirical question. We cannot—and should not—test everything everywhere, but if a particular approach proves effective in multiple contexts, our confidence in its “generalizability” should increase accordingly. Replication studies can also test variations in the length or intensity of treatment, disentangle the impact of different components of a program, or test how a small-scale intervention performs as it is scaled up.

If the goal is to achieve certainty that intervention X will achieve result Y in context Z, we will never achieve it, with RCTs or any other method. However, considering evidence from even one rigorous evaluation is a big improvement over flying blind. As we consider multiple evaluations, together with insights from theory and other empirical work, the picture becomes that much clearer.

2. Institutional constraints
Jake’s main criticism is that economists conducting RCTs “have been accused of ignoring the institutional constraints against which their interventions would inevitably contend if scaled up.” He cites corrupt bureaucracies, weak institutions, a lack of (or perverse) performance incentives, and budgetary problems as barriers to successful replication of programs found to be effective. The underlying message seems to be that if the RCT movement wants to influence policy successfully, it cannot just publish research findings and hope for the best.

I could not agree more with this last point, but the RCT community is much farther along on this front than Jake suggests. Both J-PAL and our sister organization, Innovations for Poverty Action (IPA), have policy staff dedicated to bringing research findings to bear on the often-messy world of policymaking. While our academic affiliates are involved with policy outreach, non-academic policy staff help extend the reach of their research findings. This process is never easy and not always successful, for all the reasons Jake mentions, but we have found that it is possible to improve policy even in very constrained environments.

As an aside, Jake also suggests that governance in developing countries is not amenable to quantitative study. I would have thought the same before I started with J-PAL, but in fact, J-PAL affiliates currently have at least 42 completed or ongoing evaluations in political economy and governance, including many that address precisely the issue he raises of the incentives of government officials and service providers.

3. Do we already know what works?
Finally, Jake entertains the idea that perhaps we already know what works, since “many of the most celebrated finds of the RCT movement are relative ‘no-brainers’.” I find this argument troubling for two reasons. First, we have been following our intuition about what works in development for decades, with not a lot to show for it. What we have seen is succession of fads, with decidedly mixed results in terms of reducing poverty. There was a time when infrastructure was the “no brainer,” later it was basic needs, still later the focus turned to sustainable development, and today infrastructure seems back in vogue. To suggest that we already know what to do invites just this kind of intellectual drift.

Second, while it may be true that many RCTs report seemingly obvious findings, some of them surprise us—and we never know in advance which those will be. For example, a number of NGOs and opinion leaders have championed the idea that distributing sanitary products to adolescent girls will remove a barrier to female education. The underlying common-sense assumption is that menstruation causes many missed days of school. However, a randomized evaluation of a program that distributed an easy-to-use sanitary product in Nepal found no significant effect on school attendance (although the girls used, and liked, the product). As always, we should avoid over-generalizing from one study, but at minimum these findings suggest that proponents of this approach should adjust their expectations about what it can deliver. In other cases, RCTs have contributed clear evidence to debates where both camps have common-sense arguments on their side, such as the vexed issue of whether, and how much, to charge poor people for basic health and education products and services. Finally, even if the qualitative findings of an RCT seem to confirm common sense, policymakers may still want to know how an intervention stacks up quantitatively against other interventions with the same goal, in terms of both raw impact and cost-effectiveness.

RCTs are no more a panacea for development than anything that came before them. But as long as there is more ideology and wishful thinking in development policymaking than evidence, I believe that the continuing growth of the RCT movement is a welcome trend.

Shawn Powers is a Policy Manager at the Abdul Latif Jameel Poverty Action Lab (J-PAL). The opinions expressed here are his own.

New Year's Irresolution: Medicare’s sustainable growth rate and physician reimbursement

Wes Joines, MPA

Unless Congress acts between now and the end of 2011, at least one group will not be experiencing a happy New Year: physicians who provide services to Medicare patients. Under current law, starting in 2012, reimbursement for Medicare-provided services will be reduced by an estimated 30%. Why is this happening? It is all related to policies enacted nearly 15 years ago in an earlier iteration of debt reduction efforts.

The Balanced Budget Act of 1997 was signed into law on August 5, 1997 and was designed to balance the federal budget by 2002. Of its $160 billion in spending cuts during that time period, $112 billion was applicable to the Medicare program, which is the primary health coverage program for older and some disabled Americans. A key component of the cuts to Medicare included, for the first time, a budgetary restraint on Medicare’s total expenditures to maintain budget neutrality. Known as the sustainable growth rate (SGR), it is a major component of the current formula for determining annual updates to physician reimbursement. While Medicare payment rate increases since 1992 had been tied to trends in physician utilization (i.e. efficient use of medical tests and facilities by a doctor), in 1997, for the first time, the implementation of the SGR meant that Medicare reimbursement changes would be linked to four factors: 1) changes in input costs, 2) changes in Medicare fee-for-service enrollment, 3) changes in the volume of physician services relative to growth in the national economy, and 4) changes in expenditures due to changes in law and/or regulation.

The SGR resulted in annual increases to the Medicare fee schedule until 2002, when a 4.8% reduction took place. Since that time, rate reductions called for by the formula have been deferred, although Congress has not changed the underlying SGR formula or the cumulative spending targets. Because of vast increases in the volume and complexity of health care services for the Medicare population in recent years, especially when compared to the SGR designers’ projections, the formula specifies cuts in physician payments that become more severe with each passing year. In fact, at a cost of $19 billion, a last-minute December 2010 vote delayed a scheduled 25% reduction in the SGR that was to take place in January 2011.

So, here we are again, this time in late 2011, deciding whether or not reimbursement for Medicare providers will be cut. Even before the current debt reduction debate and increasing prevalence of political gridlock in Congress, policy movement regarding the SGR involved numerous short-term fixes. For example, from 2003 through 2010, Congress included provisions in 13 separate pieces of legislation to forestall reimbursement cuts. As a long-term fix for the SGR – e.g. replacing it with a current fee freeze – would be extremely costly to the taxpayer (some estimates currently peg it around $300 billion over 10 years), short-term fixes have generally proved to be an easier bargain (as much as they have irritated physicians and their respective trade associations).

At this point, anyone’s guess is as good as another’s regarding the level of reimbursement for Medicare services on January 1, 2012. Although the current political climate is not one that generally supports massive spending to doctors that would be required for a long-term fix, many believe that cuts of the magnitude prescribed by the SGR would not be conducive to ensuring beneficiary access to services. Therefore, another short-term fix might be in the works as a stop-gap measure. However, there is also a chance that the currently-convened deficit reduction “Super Committee” might address the SGR as part of its proceedings.

If compromise is within reach, within or outside of the Joint Select Committee on Deficit Reduction, it may be similar to a plan recently recommend by the Medicare Payment Advisory Commission (MedPAC), which ironically enough, was also established by the Balanced Budget Act of 1997 and serves as an independent advisor to Congress. MedPAC’s plan, which would cost $200 billion over 10 years (instead of the $300 billion of the fee freeze), would protect both primary care and specialty physicians from the deep cuts called for by SGR. Primary care physicians would see physician fees associated with Medicare services frozen for 10 years, while specialists would see smaller cuts (of 5.9% per year) over the first three years that would then remain frozen for the remaining seven years in the budget window.

Granted, MedPAC’s suggestion is not a panacea, but it is a good start. At the very least, it should focus us on attempting to resolve this looming crisis.