Heroin-Asisted Treatment of Drug Addicts and the Political Pitfalls of Harm Reduction

By Jesse Singal, MPA 2013

In a piece published Monday in The Daily Beast, I covered a new study in the Canadian Medical Association Journal suggesting that the most cost-effective treatment for certain types of long-term heroin addicts might be... heroin. It's the latest in a rather long line of studies offering similar results.

It's a counterintuitive idea, and it highlights some of the political challenges of a favorite concept among public-health policy wonks: harm reduction. In short, harm reduction is the idea that rather than approach health issues with unrealistic, overly idealistic notions of the power of public policy, we need to understand that in many cases, the best we can hope to do is improve—not fix entirely—difficult, complicated situations. And as we seek to do so, evidence-based approaches should guide our efforts.*

Given how accustomed we are to big claims about quick fixes, it can be a hard concept to swallow. If one mayoral candidate promises to greatly drive down the "epidemic" of teen sex, and her opponent promises to improve sex education so as to reduce the number of teen pregnancies and the spread of STDs—well, it's easy to tell who will face more of an uphill battle come election day. A lot of people don't want to admit that teenagers always have had sex and always will.

Heroin-assisted treatment, or HAT, highlights this concept perfectly. No one wants to admit that a lot of addicts remain addicts for a long time, and the best we can hope to do (at a reasonable level of investment, at least) is to mitigate the damage they do to society. As I point out in the piece, even researchers sold on HAT's promise will admit that there’s something inherently crazy-sounding about the idea of giving heroin addicts heroin. “You sort of have to get over some pretty large hurdles of face implausibility,” Peter Reuter, a drug-policy expert at the University of Maryland, told me. “There’s something strange about the notion that on the one hand you prohibit this drug, but… if the user causes enough damage to society and to himself, well, we’ll give it to you free.”

But the idea starts to make sense the more one thinks about the neighborhoods that have been wrecked not because long-term heroin users use heroin (there is no more docile creature in the world than an addict who has just shot up), but because of the collateral damage done by their search for it—the petty crime, the violence, the black-market forces that shoot out of cracks in the social structure like thick tangled weeds. If heroin addicts didn't have to search for heroin, the damage wrought by the drug would be greatly ameliorated.

The notion of giving heroin to heroin addicts may make us uncomfortable; it just doesn't feel right in some deep, visceral way. But harm reduction is about being an adult, about realizing that sometimes you need to follow what the science tells you, even if it doesn't feel right.

* Thanks to fellow MPA1 and budding public-health expert Brett Keller for letting me run this language by him.

“Chasing Ice” Catches Up to Earth’s Changing Climate

By Elisabeth A. Cohen, MPA candidate 2012

It’s probably hard to imagine all of Manhattan tumbling into the Hudson River and washing away in less than five minutes, but that’s the equivalent of what you’ll see in the film “Chasing Ice,” as a city’s worth of towering icebergs collapse violently into the ocean — and that’s just one of countless spectacular images that flash across the screen in this astonishing documentary by director and cinematographer Jeff Orlowski, which premiered at Sundance in January and is opening at SXSW this week. 

The film is a documentary about a documentarian — a scientist-turned photographer named James Balog, whose obsession with images of ice has gotten him into the pages of The New Yorker and National Geographic. Despite his training as a geographer and geomorphologist, Balog was stunned to see how fast some of the glaciers that he shot were receding in the face of global warming. So he decided to create a long-term photography project he called the Extreme Ice Survey (EIS), which he hoped would merge art and science into a compelling story in pictures about what humans are doing to the climate.

A layer of cryoconite, dust which absorbs solar radiation, melting the snow, at the bottom of a Greenland Ice Sheet channel, July 2009. Credit: James Balog/Extreme Ice Survey. 

Originally, Balog planned to set up two time-lapse cameras to photograph glaciers, but within a few weeks his ambition had grown: he bought 23 more cameras, then assembled a team of 30 scientific experts, engineers, and photographers to help him carry out his vision.  Balog also asked Orlowski to film the project. “I wanted to work with James in some capacity,” said Orlowski, and the collaboration turned into “Chasing Ice.”

The movie is nothing short of spectacular. As you watch, you can see how Balog and his team set up all of those cameras on three continents, in places including Alaska, the Rockies, Greenland, Iceland, and Mt. Everest.  The team worked in below-freezing temperatures and high winds, rigged cameras to the sides of cliffs, and programmed them to take automatic photos every half-hour, powered by solar panels.  In total, they captured more than a million glacier portraits over five years.  “Without a doubt,” Orloski said, “this has been the most challenging project in my life.”

The same is clearly true for Balog and the rest of the team, but the photos they brought back are incredibly valuable. It’s one thing to see an image of a single retreating glacier, but Balog’s cameras recorded dramatic changes in glaciers around the world.  The Columbia glacier in Alaska is just one striking example. Since 1984, the Columbia has deflated by a thickness equivalent to height of the Empire State Building. Over the life of the project, it retreated so quickly that to keep the edge of the glacier in the frame, the team had to keep returning to adjust the camera’s angle. “We never expected to see the glaciers change as much as we’ve seen,” Orlowski said. “That was the most shocking part for us.”

On one trip to Alaska, Orlowski recalled, “there are entire areas where we spent days and days climbing on ice, using our ice tools, and going up and down parts of the glacier. When we revisited them, all that ice was gone. The landscape looks so different that you almost don’t recognize it . . . that giant playground, that world of ice we were pretty much living on for a week, is completely gone.”

For the director, the experience was eye-opening.  “We think of glaciers as being part of geologic time,” he said, “something that happens over centuries and thousands of years.” What Balog has shown so vividly, he said, is that in a warming world, this conception is completely out of date.

On the other side of North America, in Greenland, Orlowski and project engineer Adam LeWinter stood watch in frigid conditions waiting for the end of a massive tidewater glacier to break off into the sea — a calving event, a glaciologist would call it. Finally, on the 17^th day, it happened. With nine cameras rolling, they recorded a chunk of ice some 400 feet deep and three miles wide calve off of the Ilulissat Glacier — and in a little more than an hour, the glacier continued disintegrating until it had retreated a total of about 1 mile. The block of ice that retreated and broke off into the ocean could have fit about 3,000 U.S. Capital buildings in it. Orlowski and his team condensed this event into a 3-minute clip that was, to put it simply, awesome.  For Orlowski, watching this live “was a life-changing event. Adam [the engineer] and I were the only two there and we felt we were watching history unfolding in front of us.”

James Balog hangs off a cliff near Columbia Glacier, Alaska to install a time-lapse camera. Credit: Tad Pfeffer/Extreme Ice Survey. 

“Chasing Ice” has lots of this natural drama, but there’s plenty of human drama as well. A couple of years into the project, for example, Balog had surgery on his knee. He opted for a procedure that had a quicker recovery time, so he could get back into the field faster, but it wasn’t as effective in the long run. His doctor ordered him to quit ice climbing — an order he promptly ignored. One night Balog even walked out onto the ice on crutches to capture one of Orlowski’s favorite photos of the entire project.  There are also lots of action scenes, with members of the team rappelling into gaping crevasses, making the movie a cross between a frozen “Planet Earth” and an action film.  In fact, “Chasing Ice” won the best adventure film award at the Boulder International Film Festival.

What is perhaps most surprising about the film is that Balog used to be a climate skeptic. He explains how he once thought that climate change theory was based solely on computer models, where in fact it’s based on scientific measurements of both modern and ancient climates. Once Balog learned that tree rings, sea floor sediments, and ice core data were showing that the climate is warming on average, he changed his mind. Orlowski’s film about Balog could, in turn, change the mind of other climate skeptics. One thing that struck me, however, was that although the evidence of climate change is overwhelming in “Chasing Ice,” there’s very little about slowing or stopping the planet from warming. 

It is hard to decide whether the jaw-dropping imagery or the climate-change messages in this film were more compelling. But it’s  no surprise that the film received the “Excellence in Cinematography Award: U.S. Documentary” during the 2012 Sundance film festival. In at least one screening at the Sundance Film Festival, the audience leapt to its feet cheering.

To do this film justice, go see it on the big screen.  The next opportunity to see the film is at the South by Southwest (SXSW) arts and music festival in Austin, TX the second week of March. The TV rights to “Chasing Ice” have been acquired by the National Geographic Channel and its website says a theatrical partner will follow shortly. To find out more see  National Geographic Channel Takes 'Chasing Ice' and visit the movie’s website. For “Chasing Ice” movie show times at SXSW click here.

* This article is reposted, with permission, from Climate Central. 

Removing Nigeria’s Oil Subsidy

Ayokunde Abogan, MPA

Nigeria is well known for its vast natural and human resources. It has the largest population in Africa (the 10^th largest population globally) and its crude oil resources gives it a respectable 6^th position in the world in terms of its export levels in the global oil market. Despite the country’s wealth, it has been difficult to leverage these resources to reduce the high levels of youth unemployment and poverty in country. While oil revenues represent only 14 percent of Nigeria’s GDP, it accounts for 98% of export earnings and close to 90% of the federal government’s revenue according to World Bank estimates in 2009. A significant proportion, about 31.4% of the country’s GDP is connected to exports and this is largely driven by its vast crude oil resources.

In essence, my country is primarily dependent on its oil resources for a lot of things. Although the economy is very much diversified with the burgeoning financial services, entertainment and telecommunications sectors moving up the ranks to take their respective places in the overall economy, the country’s vast agriculture and manufacturing sectors are crumbling. Government bias, mismanagement and inconceivable policies have all made it impossible to grow both sectors. This is further compounded by high electricity costs, dilapidated transportation networks, high business costs and political instability arising from religious and ethnic violence.




The "Occupy Nigeria" Logo

 

A couple of my classmates have asked me about my thoughts regarding the removal of these fuel subsidies. Although I supported the government’s policy to remove it, I questioned the way this policy was hurriedly implemented. I supported it because this subsidy was costing the country about $7 billion every year. This is a lot of money that the government can spend on revamping our lagging educational system and improve our decaying infrastructural framework. Our health services systems are lacking needed funds to improve health interventions and delivery while the youths in the country are largely unemployed. Social welfare for the impoverished will go a long way to reduce the high levels of income inequality in my country.

However, I don’t support the way the entire fuel subsidy was removed without any recourse as to how the citizenry will mitigate the impact of any shocks to their incomes and overall well-being. Rather, this subsidy ought to have been removed gradually. Nevertheless, any promises by the federal government to devote the proceeds of this fuel subsidy to tangible investments is something all Nigerians would wish for due to the crass levels of patronage and corruption. Government subsidies for diesel fuel and kerosene that were removed in the past have yet to translate into any meaningful investments in the country apart from the small number of people who have lined their pockets with the country’s wealth.




Fuel prices before the oil subsidy was eliminated was N65 per litre. Prices rose to as much as N140 when the subsidy was removed.

 



Occupy Nigeria protestor in Lagos, Nigeria

 

To speak about this madness called “fuel subsidy” requires a walk down memory lane. However, let me start by saying a country like Nigeria, which is also the largest crude oil exporter in the African continent, imports fuel into the country. Aaaah, yes, I know this makes no sense. Unfortunately, it does. Nigeria has four national refineries that are barely functional because of the country’s poor planning and maintenance culture, and even more, our refining plants are ageing while the pipelines linking these plants have lacked adequate investments and they are terribly unreliable to support uninterrupted domestic production. Thus, Nigeria is forced to refine its crude oil resources outside its borders and then it imports the refined products, mostly from European suppliers, to satisfy the energy needs of its large population.

Estimates according to the Nigerian oil and gas industry reveal that the country imports about 85 percent of its fuel needs, while the country subsidizes these imported products to ensure that fuel prices at the pump is around half of the market rate to its citizens. In 2010, Nigeria spent 1.20 trillion naira (about $6.7 billion) to import fuel into the country. Sadly, a system ingrained in corruption makes it very difficult to know how these large amounts of money are accounted for in Nigeria’s budgetary processes. Worse, the bill all Nigerians have hoped will fix the country’s oil sector is yet to be passed.

Although things have calmed because the government had to reverse its stand, on the fuel subsidy, when the country was teetering on the brink of political and economic catastrophe, I still think that the fuel subsidy is nothing more than an opportunity for some people in the country to enrich themselves, while the country is continually lagging behind its peers both in the African continent and globally. Yes, Nigerians, including me, have benefitted from these subsidized fuel prices but the question should be: for how long are we going to keep on subsidizing fuel prices in Nigeria? Nigeria has a lot of potential and it has always frustrated me that a country which prides itself as the “Giant of Africa” cannot get its act together. The issue is Nigerians cannot trust its government to do anything meaningful while the government is finding it very difficult to address the challenges faced by average Nigerians.




Nigerians' view about the relationship between the Nigerian government and its citizens.

 

I have always wondered what it will take to fix my country and get it on a path to economic success. This is the reason why I decided to come to the Woodrow Wilson School to get a better sense of what to do to address development challenges and economic growth cases like Nigeria’s, that don’t create enough employment opportunities for their citizens but only makes the rich richer while the poor continue to suffer in order to meet their daily needs. I am happy to take suggestions from people who care about the success of my country however, as the adage goes, “heaven helps those who help themselves.” Nigeria needs all hands on deck to move it forward and I think this is a responsibility of all including my fellow compatriots.

Call me elitist or dumb, I will still support the removal of this government fuel subsidy if this issue rears its ugly head again. However, this time, it is important to use better tools that will ease the impact of subsidies particularly on wallets of poor and middle-income Nigerians. Still, I imagine it might be the right path to reduce the current challenges in Nigeria’s oil sector, and a significant step towards measurable progress on good governance and development. I don’t usually agree with Jeffrey Sachs on a lot of development issues but I am forced to concur that the “oil subsidy benefits the rich more than the poor and that the subsidy, when removed, [should] be used in targeted investments that serve the poor and more meaningful social investments.”




Occupy Nigeria in Lagos. The economy of the country was virtually at a standstill while the protests went on for eight days

 



Occupy Nigeria in London. Nigerians in diaspora also joined their family and friends in Nigeria to protest the actions of the Federal government.

 

Will Senegal Get a New President? An Analysis of the February 2012 Elections

By Jennifer Browning, MPA

Senegal’s elections are today. After months of mass protests against the current President Abdoulaye Wade’s candidacy, election day has finally arrived, amidst great anticipation and uncertainty. Many people are worried that President Wade, who is at least 85 years old, will win a controversial third term and worse, use his next term to install his son, Karim Wade. I am going to Harlem soon where there is a large Senegalese diaspora to follow news on the RTS (Radio Télévision Sénégalaise) and other Senegalese channels if available.

As is often stated, Senegal is the only country in West Africa that has had uninterrupted elections without military rule since Independence. It is considered by the international community to be a stable democracy that has escaped the fate of its neighbors.

Above, President Abdoulaye Wade, Feb. 23, 2012, approximately 85 years old.

And regional instability is a fact. I lived and worked in Senegal for three years until returning to the U.S. for graduate school last July 2011. During one nine month period (August 2008- March 2009), three of the five countries bordering Senegal experienced a coup. The fourth (internal) neighbor, The Gambia, has been ruled since 1994 by a dictator.

Senegal’s democracy stands in stark contrast to this trajectory. Senegal has achieved political stability, almost too much one could argue. For the first forty years, Senegal had only two different Presidents, Léopold Sédar Senghor followed by Abdou Diouf who both were part of the Socialist Party. Wade, leader of the Socialist Democratic Party, was the first opposition leader to be elected President in 2000. Despite the lack of power sharing in its first forty years, Senegal’s democracy stands as a great achievement post-colonialism in West Africa. Here we will not explore the possible contributions by the international community to some of this history of instability. Rather I want to focus on how the protests in Senegal have shown the importance of Senegalese people’s agency and commitment to democracy.

In late spring 2011, President Wade attempted to amend the constitution in a flagrant attempt to facilitate his victory today. He wanted to lower the percentage it would take to win the first round of the election (to win easily over a divided opposition) and create a Vice Presidency position (people worried for his son). On June 23, 2011, the biggest protests in a decade occurred in front of National Assembly in downtown Dakar and accompanied to a lesser extent, in cities throughout the country. The protests were successful in forcing Wade to withdraw his reform. They marked a turning point, and suddenly most radios and television stations aired aggressive critiques of Wade.

Protests on June 23, 2011 in Dakar against Wade’s proposed constitutional amendments.

I liked what candidate (and former longtime Minister of Foreign Affairs under Wade) Cheikh Tidiane Gadio said on a television interview I saw while visiting Senegal in early January 2012. To paraphrase loosely from my memory, Gadio stated, “June 23 has shown that Senegal can handle its own problems. Senegal does not need the international community to solve its domestic problems.” Certainly, the protesters handled the threat to their constitution with a mass mobilization and succeeded in forcing Wade to back down from the constitutional amendment.

Equally interesting, rappers have played a crucial role in the resistance against Wade. Senegal has one of the world’s most important hip hop scenes, and nothing mobilizes the youth in Senegal like smart, politically charged rap. A contingent of rappers formed the group “Y en a marre” or “We’ve had enough/We are fed up” to protest Wade’s candidacy and to call for voter registration and citizen participation in the elections. While this group along with M23, the Movement of the 23rd of June, have been very successful at mobilizing huge protests and using social and traditional media to get out their views, they do not officially endorse a candidate in the opposition.

Y en a marre rappers and protesters in Dakar.

A major obstacle to their movement has been the divided opposition. The protesters agree that Wade has to go, but there is no agreement on who should replace him. At a panel I attended at Columbia University a couple of weeks ago, Professor Mamadou Diouf highlighted three leading candidates Moustapha Niasse (who was a former strongman of the Socialist Party), Idrissa Seck (current Mayor of Thies and former Prime Minister under Wade for the Social Democratic Party (PDS)), and Macky Sall (who followed Idrissa Seck as Prime Minister under Wade).

Several opposition candidates, most famously the international music star, Youssou Ndour, were not allowed to run in the controversial decision by the Constitutional Court, who also issued a decision that Wade could run for a third term. I want to emphasize that the exclusion of Youssou Ndour’s candidacy has probably made him more important than if he had been allowed to run. I was in Senegal when he announced his decision to seek the Presidency early January 2012. While his declaration made international headlines, my impression was that most people take him seriously as a musician but not as a candidate. They often cited that he little formal schooling and therefore not qualified. However, his exclusion from being a candidate has made him an even more vocal critic and visible participant in the mass protests.

Youssou Ndour at a protest in Dakar where he was injured.

The constitutional court decision on January 27, 2012 that allowed Wade to seek a third term has been highly criticized by the opposition. However, Awadi, a leading rapper and intellectual in Senegal, may have found the most clever way of mocking the legality of President Wade’s candidacy. At the end of his new music video, Mame Boye, if you scroll to minute 2:46, Awadi creates a parody of the ataya tea drinking custom to criticize Wade’s bid for a third term. After meals in Senegal, people drink Mauritanian mint tea, ataya. In this highly ritualized tradition, you are offered a first cup of tea which is more bitter and then as the tea cooks down more, you are offered a second cup of tea which is sweeter.

For those that do not speak French, I will try to translate what unfolds...

In Awadi’s video, we have an old man (representing Wade) next to a younger, paler man (representing Karim whose mother is French and who speaks little Wolof, the dominant African language in Senegal). Wade asks for a second cup of tea, but the other young men making the ataya point out that he already drank his second cup. They then point to the “ataya constitution” that the old man has posted on the wall, clearly limiting everyone to two cups. Wade insists that he did not get a second cup, prompting a young man asks if he is losing his memory (a reference to his advanced age). So Wade finally asks for a third cup. When they refuse, he takes down the constitution and stands on it, saying, “Fine, I said only two; well, I take it back” referring to when he at one time said he would only stand for two terms. The ending caption says that “any resemblance to actual persons or events was entirely on purpose and not accidental. And that what is coming next [i.e. the elections] should really be watched.”

Awadi also mocks Wade’s attempt to install Karim in power by having Wade say when he learned that Karim bought the real Mauritanian tea, “ I will tell your mom that you did a good job./ Je dirais a ta maman que tu as bien travaillé.” In reality, Wade uttered this now famous phrase when praising Karim for his mdirection in organizing the Organization of the Islamic Conference meetings in Dakar in March 2008. The management of the OIC meetings was later criticized as being corrupt.

Local elections setback for presidential succession plans.

Despite the strong and highly mediatized protests by Y en a marre, M23, and other opposition groups, many people will vote for Wade. There have also been large protests in favor of Wade, although some people claim that Wade pays these supporters to show up. But Wade does have many legitimate supporters, and faced with a divided opposition, people may choose the evil that they know rather than the one they do not.

However, I believe though that if elections are transparent today, no candidate will get a majority and elections will thus advance to a second round with just two candidates, Wade and an opposition candidate. This may give the opposition the unity it has been lacking around one candidate.

I don’t want to see the hope broken for youth who have protested in this movement and tried to take charge of their democracy. I want what I want for my own country, that we believe the system can still be changed and we act to change it.

I’m off to Harlem.

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’être 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.

Conclusion
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.