Introduction

Guaranteeing the right to vote and to participate in public and political affairs for all citizens is an important responsibility. Given the precarious position that IDPs can find themselves in and considering the extent to which they may need to rely on national authorities for assistance, IDPs have a legitimate and a heightened interest in influencing the decisions that affect their lives by participating in elections.   

Internally displaced persons often exist on the margins of society and are subject to a number of vulnerabilities because of their displacement. For instance, IDPs face an immediate need for protection and assistance in finding adequate shelter, food, and health care. Over time, they can suffer discrimination in accessing public services and finding employment on account of being an IDP from another region or town. IDPs also face an especially high risk of losing ownership of their housing, property, and land, something which can lead to loss of livelihoods and economic security as well as physical security. Women and children, who often make up the majority of IDP populations, face an acute risk of sexual exploitation and abuse.  

In addition to influencing public policy, elections can also be about reconciliation and addressing divisions and inequities that exist within society. For these reasons and others, IDPs should be afforded an opportunity to fully participate in elections as voters and as candidates.   

As noted in a press release of the Representative of the Secretary General of the United Nations on the Human Rights of Internally Displaced Persons following an official mission to Georgia in December 2005, 

“[IDP] participation in public life, including elections, needs promotion and support. Supporting internally displaced persons in their pursuit of a normal life does not exclude, but actually reinforces, the option of eventual return. … Well integrated people are more likely to be productive and contribute to society, which in turn gives them the strength to return once the time is right."[1]

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[1] United Nations Press Release - U.N. Expert Voices Concern for Internally Displaced Persons in Georgia, 27 December 2005, available at http://www.brookings.edu/projects/idp/RSG-Press-Releases/20051227_georgiapr.aspx.

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Event Information

On December 5, 2011, the Brookings-LSE Project on Internal Displacement held a private launch event for its report, From Responsibility to Response: Assessing National Approaches to Internal Displacement, which examines government response to internal displacement in fifteen of the twenty countries most affected by internal displacement due to conflict, generalized violence and human rights violations. The analysis presented in the report is based on the first ever systematic use as an assessment tool of the document, Addressing Internal Displacement: A Framework for National Responsibility, developed by the Brookings-Bern Project on Internal Displacement in 2005 to provide guidance to governments in their response to internal displacement.

Roberta Cohen (nonresident senior fellow at Brookings and former co-director of the Project) moderated the event, which featured remarks from the co-authors of the report, Elizabeth Ferris (senior fellow at Brookings and co-director of the Brookings-LSE Project on Internal Displacement), Erin Mooney (senior IDP and protection adviser at the United Nations and former deputy director of the Project) and Chareen Stark (senior research assistant, Brookings-LSE Project on Internal Displacement). In attendance were representatives from the US Department of State and international NGOs, as well as researchers from think tanks and universities.

Cohen opened the event by discussing the background and significance of the Guiding Principles on Internal Displacement. From the very beginning of discussions about internal displacement, there was an emphasis on the fundamental responsibility of national governments to protect and assist those displaced within their territory. And yet over the years there has been an awareness that international actors also have a role to play. She noted the positive strides that have occurred over the past twenty years in regards to government response to internal displacement. Country visits by the UN experts on IDPs—the Representatives of the Secretary-General on IDPs—have been instrumental to improving government response, in some instances leading governments to address internal displacement for the first time. Today, most governments understand their obligations and responsibilities to protect and assist IDPs; the challenge is often translating that understanding into concrete actions.

Elizabeth Ferris gave an overview of the Framework for National Responsibility, which was used to assess government response in each of the fifteen countries in the report (Afghanistan, The Central African Republic, Colombia, the Democratic Republic of the Congo, Georgia, Iraq, Kenya, Myanmar, Pakistan, Nepal, Sri Lanka, Sudan, Turkey, Uganda and Yemen). The Framework outlines twelve minimum steps—or benchmarks—that governments can take to address the protection and assistance needs of internally displaced persons within their territory, from preventing displacement to appointing a focal point on IDP issues, to facilitating the work of the international community. She explained the methodology used in the study and described the challenges the authors faced in conducting the research. For example, basic data on various aspects of government response was lacking in many instances and it was often difficult to determine the impact of a particular government policy in addressing internal displacement. In addition to analyzing the response of the fifteen governments on each of the twelve benchmarks, the study included four extended case studies commissioned for this report: Afghanistan, Georgia, Kenya and Sri Lanka.  Ferris discussed some of the overall findings of the study, noted that the Framework had proven to be a useful assessment tool for examining national responses to displacement, and suggested a number of areas where further research is needed. 

Erin Mooney briefed the audience on benchmark seven—designating an institutional focal point on IDPs—and benchmark ten—supporting durable solutions for IDPs. Mooney noted that designating a governmental focal point for addressing internal displacement is important for clarifying institutional responsibilities and, therefore, for increasing governmental accountability.  Of the 15 countries assessed, all but one had designated a national institutional focal point for addressing internal displacement. She discussed some of the challenges institutional focal points often face, including a lack of funding and a lack of political clout which often challenge their ability to coordinate across government agencies. Benchmark ten, the achievement of durable solutions, was one of the most complex and politicized areas of government action, and is  arguably the one in which government commitment to addressing displacement becomes most apparent. Governments tend to emphasize return as the primary solution to displacement, but, in situations where return has occurred, there is usually little information about whether IDPs have in fact achieved a durable solution. Mooney discussed some of the challenges the fifteen governments faced in finding durable solutions, noting that in none of the countries have durable solutions to displacement been fully achieved.

Chareen Stark discussed the report’s findings on benchmark one—the prevention of arbitrary displacement—and the study’s overall recommendations. Given that the study assessed governments already experiencing large-scale displacement and, in most instances, multiple waves of displacement, Stark said it was obvious that all fifteen governments had failed to prevent displacement. There were three major limitations to governments’ ability to prevent displacement: many of the governments are themselves parties to conflict; many of the governments assessed do not exercise effective sovereignty over all of their territory, due to the presence of nonstate armed actors and/or foreign militaries; and all of the assessed countries face financial and human capacity limitations. She explained that the study found that nearly half of the countries assessed had developed some sort of preventive measures (at least on paper), including several governments that had taken measures to prevent displacement from natural disasters but not conflict. Stark discussed some of these laws, policies and institutional mechanisms as well as the challenges to their effective implementation. She also outlined the report’s recommendations to governments of countries with IDP populations, such as developing and implementing laws and policies in line with the UN Guiding Principles on Internal Displacement and devoting adequate resources at the national and local levels.

Concluding the discussion, the panel responded to questions from the audience on issues such as incentives for governments to address internal displacement using the Framework for National Responsibility and challenges in data reporting and analysis.  Specific questions were also raised on benchmarks five (laws on internal displacement), six (policies on internal displacement), three (designating an institutional focal point for IDPs) and twelve (working with the international community).

Event Materials

• From Responsibility to Response Nov 2011doc

      

Editor's Note: This is the first part of a two piece series on internal displacement that originally appeared online in TerraNullius. The second part is available here.

The Brookings-LSE Project on Internal Displacement recently released a study entitled "From Responsibility to Response: Assessing National Response to Internal Displacement." The study examined 15 out of the 20 countries with the highest number of internally displaced persons (IDPs) due to conflict, generalized violence and human rights violations—Afghanistan, the Central African Republic, Colombia, the Democratic Republic of the Congo, Georgia, Iraq, Kenya, Myanmar, Pakistan, Nepal, Sri Lanka, Sudan, Turkey, Uganda and Yemen.

According to estimates, these 15 countries represent over 70 percent of the world’s 27.5 million conflict-induced IDPs. Wherever possible, we also tried to include government efforts to address internal displacement by natural disasters. But in this and the subsequent blog post, we will focus on our main general conclusions as well as particular issues around housing, land and property (HLP) rights that emerged from our analysis (see Part II of this posting).

The study looks at how governments have fared in terms of implementing 12 practical steps (“benchmarks”) to prevent and address internal displacement, as outlined in the 2005 Brookings publication entitled "Addressing Internal Displacement: A Framework for National Responsibility." The 12 benchmarks are as follows:

1. Prevent displacement and minimize its adverse effects.
2. Raise national awareness of the problem.
3. Collect data on the number and conditions of IDPs.
4. Support training on the rights of IDPs.
5. Create a legal framework for upholding the rights of IDPs.
6. Develop a national policy on internal displacement.
7. Designate an institutional focal point on IDPs.
8. Support national human rights institutions to integrate internal displacement into their work.
9. Ensure the participation of IDPs in decisionmaking.
10. Support durable solutions.
11. Allocate adequate resources to the problem.
12. Cooperate with the international community when national capacity is insufficient.

Stepping back from HLP issues (to be addressed in a subsequent set of comments in Part II of this guest posting), we drew several key observations on our overall findings.

The study found that political will was the main determining factor of response to internal displacement. Governments cannot always control the factors that cause displacement, or may themselves be responsible for displacement, but they can take measures to improve the lives and uphold the rights and freedoms of IDPs. Internal displacement due to con­flict derives from political issues, and all aspects of a government’s response to it therefore are affected by political considerations, including, for example, acknowledgment of displacement, registration and collection of data on IDPs, ensuring the participation of IDPs in decision-making, assistance and protection offered to different (temporal) caseloads of IDPs, support for durable solutions, which durable solutions are supported, and the facilitation of efforts by international organizations to provide protec­tion and assistance to IDPs.

While none of the governments surveyed was fully protecting and assisting IDPs, four stand out in particular—Colombia, Georgia, Kenya and Uganda—for implementing their responsibility toward IDPs while three others—Central African Republic, Myanmar and Yemen—had particular difficulties in fulfilling their responsibilities toward IDPs. In Myanmar, the obstacles were primarily political while in Yemen and the Central African Republic, as in many of the countries surveyed, the limitations appear to arise primarily from inadequate government capacity.

The other eight countries were somewhere in between. For example, some, such as Nepal, have demonstrated a significant commitment at one particular point in time but have failed to follow through. Others, such as Sri Lanka, have at times demonstrated blatant disregard for their responsibility and have moved swiftly to try to bring an end to displacement. Sudan, Pakistan, and to a certain extent, Turkey, have very problematic records with respect to preventing displacement in one part of the country yet have supported efforts to bring an end to displacement in others. In some cases, such as Afghanistan and Yemen, the continuing conflict and the role of nonstate actors (and in Afghanistan, the presence of foreign militaries as well) have made it difficult for the government to respond effectively to internal displacement.

Prevention of internal displacement is paramount, but is probably the most difficult measure to take and the least likely to be taken in the countries as­sessed, which all had large IDP populations. Given the scale of displacement in the fifteen countries surveyed, it was to be expected that these governments would not have been suc­cessful in preventing displacement. Nearly half of the fifteen countries assessed had adopted some preventive measures on paper, but all fifteen have fallen short of actually prevent­ing displacement in practice.

Moreover, many national authorities themselves have been or are perpetrators of violence or human rights abuses that have led to displacement, and many states foster a culture of impunity for alleged perpetrators of serious human rights violations. Further, the presence of foreign military forces and/or non-state armed actors limits the abil­ity of many states to exercise full sovereignty over their territory and therefore to prevent the conditions that drive people into displacement. Some countries have taken steps to prevent dis­placement due to natural disasters or develop­ment but not due to conflict, indicating that the former is perhaps less politically taboo and/or practically less difficult to implement than the latter.

Sustained political attention by the highest authorities is a necessary, though not suffi­cient, condition for taking responsibility for IDPs. Nearly all of the governments surveyed, at least at some point, have exercised their responsibility to IDPs by acknowledging the existence of internal displacement and their responsibility to address it as a national prior­ity, for example, by drawing attention to IDPs’ plight. However, government efforts to raise awareness of internal displacement through public statements was not always a useful indicator of a government’s commitment to upholding the fundamental human rights and freedoms of IDPs.

Among the five countries with laws on or related to internal displacement, there were notable limitations to the scope of the laws and gaps in implementing them. Legislation was quite comprehensive in scope in at least two cases and was narrow in others, address­ing specific rights of IDPs or a phase of dis­placement. Other countries lacked a national legislative framework on IDPs but had generic legislation relevant to IDPs. Still others had laws that violated or could violate the rights of IDPs. Laws on internal displacement must be viewed in the context of other legislation and administrative acts applicable to the general population (e.g., those related to documenta­tion, residency, housing, land and property, and personal status), which this study reviews to the extent possible, particularly in the case studies on Georgia, Kenya, Afghanistan and Sri Lanka. In Africa, the region with the most IDPs, states have recognized in legally binding instruments the importance of addressing internal displace­ment by incorporating the Guiding Principles on Internal Displacement into domestic legisla­tion and policy.

Many of the governments surveyed have adopted policies or action plans to respond to the needs of IDPs, but adequate implementa­tion and dissemination were largely lacking. Nine of the countries surveyed had developed a specific policy, strategy or plan on internal displacement, implemented to varying degrees; those in six of these countries were still active at the time of writing. In addition, at least two countries had national policies in draft form, and one country that does not recognize conflict-induced displacement had a plan for mitigating displacement by cyclones and a plan on disaster risk reduction, although it did not discuss displacement. While in some cases positive steps had been taken, by and large im­plementation of policies on internal displace­ment remains a challenge and has, in some cases, stalled. Available information indicates that efforts to raise awareness of IDP issues and policies have largely been inadequate.

It is difficult to assess governments’ com­mitment of financial resources to address internal displacement, but some trends were identified. Addressing internal displacement, especially over time, is a costly venture. While it was difficult to obtain a full picture of a coun­try’s expenditure on IDPs, several countries allocated funds to assist IDPs, including a few that had no national laws or policies on IDPs. In at least two countries, funds for assisting IDPs seemed to diminish in recent years. In many countries, difficulties arise at the district or municipal levels, where local authorities bear significant responsibility for addressing internal displacement but face many obstacles, including insufficient funds, to doing so. Allegations of corruption and misallocation of funds intended to benefit IDPs at certain points has been observed in some of the countries as­sessed. Some countries seem to rely on inter­national assistance to IDPs rather than national funds.

National human rights institutions (NHRIs) contribute invaluably to improving national responses to internal displacement in a number of countries. In recent years, an increasing number of NHRIs around the world have begun to integrate attention to internal displacement into their work. NHRIs have played an impor­tant role in raising awareness of internal dis­placement, monitoring displacement situations and returns, investigating individual complaints, advocating for and advising the government on the drafting of national policies to address inter­nal displacement, and monitoring and reporting on the implementation of national policies and legislation. In particular, the NHRIs of six of the countries surveyed stand out for their efforts to promote the rights of IDPs in their countries. Interestingly, almost all of their work with IDPs is funded by international sources, raising the question of whether national governments themselves should not be doing more to increase their funding of NHRIs in order to support their engagement with IDP issues.

International actors are valuable resources for efforts aiming to improve government response to IDPs. In many cases, the past Representatives of the UN Secretary-General (RSGs) mandated to study the issue of internal displacement (Francis Deng and his successor Walter Kälin) and the current UN Special Rapporteur on the Human Rights of Internally Displaced Persons (Chaloka Beyani) had exercised significant influence on governments in encouraging and supporting action on behalf of IDPs. Along with these actors, UNHCR and the Brookings Project on Internal Displacement have provided technical assis­tance to support governments’ efforts to de­velop national legal frameworks to ensure IDPs’ access to their rights.

Durable solutions: Return was the durable solution most often supported by the govern­ments assessed. The Framework for National Responsibility identifies three durable solu­tions—return, local integration and settlement elsewhere in the country. However, the fifteen countries surveyed herein reflect a global ten­dency to emphasize return, often excluding the other durable solutions. Yet for solutions to be voluntary, IDPs must be able to choose among them, and local integration or settlement else­where in the country may in fact be some IDPs’ preferred solution. Especially in situations of protracted displacement, those may be the only feasible solutions, at least in the near future.

The most difficult benchmarks to analyze were those whose underlying concepts are very broad and those for which data was seemingly not publicly available. Chief among these were the benchmarks on preventing internal displacement (Benchmark 1), raising national awareness (Benchmark 2), promoting the participation of IDPs in decisionmaking (Benchmark 9), and allocating adequate resources (Benchmark 11). Analysis on all other benchmarks also faced data constraints as in many cases data were outdated or incomplete or simply were not available. Nonetheless, we found that the twelve benchmarks all directed attention to important issues in governments’ responses to internal displacement.

We also found that while protection is central to the Framework, the issue is of such importance that there should be a benchmark explicitly focused on it—and specifically on protection as physical security, provided to IDPs during all phases of displacement. This benchmark would also underscore the responsibility of governments to protect the security of humanitarian workers engaged with IDPs.

Overall, the study found that the Framework for National Responsibility is a valuable tool for analyzing government efforts to prevent dis­placement, to respond to IDPs’ needs for protection and assistance and to support durable solutions. But this study also reveals certain limitations to using the Framework as an assessment tool, particularly in terms of accounting for the responsibility of nonstate actors; accounting for national responsibility for protection, particularly during displacement; and accounting for causes of displacement other than conflict, violence and human rights violations.

       

       

       

The mayoral election in Baltimore has brought local economic development strategies to the forefront. In a city in which inequality—by income, by race, and between neighborhoods—has increased in the past five years, the candidates have made it clear that more action must be taken to close disparities and improve economic outcomes for all residents. In a podcast segment, I commend the much-needed focus on equity but argue that the mayoral candidates should not lose sight of another critical piece of the equity equation: economic growth. Citing lessons from my recent paper, I outline strategies that Baltimore’s presumptive leaders should pursue—as well as several they should abandon—to place the city’s residents on the path to a more prosperous, equitable future.

Listen to the full podcast segment here: 

       

Totaling more than $111,000,000.00, the 2014 North Carolina Senate contest between Kay Hagan and Thom Tillis is the most expensive Senate election in the nation’s history (not adjusted for inflation). As we investigated earlier this week, outside money has been flowing into American politics in the wake of the Supreme Court’s Citizens United decision in 2010.

When candidate and independent spending are combined, 2014 ranks among the most expensive, if not the most expensive, in history. However, understanding campaign spending takes more than a simple examination of total dollars. Spending differences across states can occur for a variety of reasons, including geographic size, population size, and the expense of media markets.

As a result, a more useful metric for understanding the magnitude of campaign activity is spending per voter, and 2014 offers an interesting case: Alaska. This year, Alaska saw a highly competitive Senate race in which both outside groups and candidates spend substantial amounts of money. Alaska ranks 47th in population with just over 700,000 residents and an estimated 503,000 eligible voters. After adjusting spending (both candidate and independent expenditures) for each state's estimated voting eligible population, Alaska's 2014 Senate race, unsurprisingly, ranks as the most expensive in US history.

Alaska originally ranked 6^th most expensive in 2014, with about $60 million spent total. But it jumps to first place in dollars spent per voter. Candidates and outside groups spent roughly $120 per voter in Alaska this year, about double the next most-expensive race, Montana 2012, where candidates and outside groups spent $66.5 per voter. By comparison, the $111 million Senate race in North Carolina—with a voting-eligible population of about 6,826,610—equaled only $16.25 per voter. That’s still far above the median spending per race for all three cycles ($7.3 per voter) but certainly serves to put the spending in context.

Relative to 2012 and 2014, in terms of both combined and per-voter spending, 2010 could be considered one of the cheaper cycles for Senate races thus far.

These data lend some support to the observation that, since Citizens (and more recently McCutcheon v. FEC) independent expenditures are quickly outpacing contributions to candidates. But given changes in reporting requirements and limited data, there is still a lot about outside spending we still don’t know.

All in all, candidate and outside group spending totaled just over a billion dollars in Senate races in 2014. The fact that North Carolina alone accounted for more than ten percent of that spending is astonishing, but no less remarkable is the intensity of spending per voter in Alaska. But if spending continues to grow as it has the last three election cycles, both of those records will likely be shattered in 2016.

      

       

       

       

Nearly eight years after a U.S.-led invasion toppled the Taliban regime, Afghanistan remains far from stable. As President Barack Obama considers alternatives to increasing the number of U.S. troops in Afghanistan, his administration’s new counternarcotics strategy meshes well with counterinsurgency and state-building efforts in the country. It is a welcome break from previous ineffective and counterproductive policies. The effectiveness of the policy with respect to counternarcotics, counterinsurgency and state-building, however, will depend on the operationalization of the strategy. The details are not yet clear, but the strategy potentially faces many pitfalls.

Efforts to bankrupt the Taliban through eradication are futile and counterproductive since they cement the bonds between the population and the Taliban. But interdiction is very unlikely to bankrupt the Taliban either. Security needs to come first before any counternarcotics policy has a chance of being effective. Counterinsurgent forces can prevail against the Taliban, without shutting down the Taliban drug income, by adopting an appropriate strategy that provides security and rule of law to the population and by sufficiently beefing up their own resources vis-à-vis the Taliban. Rural development is a long term and multifaceted effort. Simplistic strategies that focus simply on price ratios or try to raise risk through “seed-burn-seed” approaches are ineffective. Wheat replacement strategy as a core of the alternative livelihoods effort is singularly inappropriate for Afghanistan. Shortcuts do not lead to sustainable policies that also mitigate conflict and enhance state-building.

The Obama administration will need to reduce expectations for quick fixes and present realistic timelines to Congress, the U.S. public and the international community for how long rural development and other counternarcotics policies in Afghanistan will take to show meaningful and sustainable progress that advances human security of the Afghan people, mitigates conflict and enhance state building. Unless this is conveyed, there is a real danger that even a well-designed counternarcotics policy will be prematurely and unfortunately discarded as ineffective.

The New Strategy in Afghanistan’s Context

In summer 2009, the Obama administration unveiled the outlines of a new counternarcotics policy in Afghanistan. The new policy represents a courageous break with previous misguided efforts there and thirty years of U.S. counternarcotics policies around the world. Instead of emphasizing premature eradication of poppy crops, the new policy centers on increased interdiction and rural development. This approach strongly enhances the new counterinsurgency policy focus on providing security to the rural population, instead of being preoccupied with the numbers of incapacitated Taliban and al Qaeda.

In Afghanistan, somewhere between a third and a half of its GDP comes from poppy cultivation and processing and much of the rest from foreign aid, so the illicit poppy economy determines the economic survival of a large segment of the population. This is true not only of the farmers who cultivate opium poppy frequently in the absence of viable legal and illegal economic alternatives. But, as a result of micro- and macro-economic spillovers and the acute paucity of legal economic activity, much of the economic life in large cities is also underpinned by the poppy economy. After a quarter century of intense poppy cultivation, the opium poppy economy is deeply entrenched in the socio-economic fabric of the society. Islamic prohibitions against opiates notwithstanding, the poppy economy inevitably underlies Afghanistan’s political arrangements and power relations. Profits from taxing poppy cultivation and protecting smuggling rings bring substantial income to the Taliban. A recent CRS report (August 2009) estimates the income at $70-$100 million per year, which accounts for perhaps as much as half of Taliban income. But many other actors in Afghanistan profit from the opium poppy economy in a similar way: former warlords cum government officials; members of Afghanistan’s police; tribal chiefs; and independent traffickers.

Moreover, the Taliban and many others who protect the opium poppy economy from efforts to suppress it derive much more than financial profits. Crucially, they also obtain political capital from populations dependent on poppy cultivation. Such political capital is a critical determinant of the success and sustainability of the insurgency since public support or at least acceptance are crucial enablers of an insurgency. Indeed, as I detail in my forthcoming book, Shooting Up: Counterinsurgency and the War on Drugs, along with providing order that the Afghan government is systematically unable to provide and capitalizing on Ghilzai Pashtun sentiments of being marginalized, protection of the poppy fields is at the core of the Taliban support. By not targeting the farmers, the new counternarcotics strategy is thus synchronized with the counterinsurgency efforts because it can deprive the Taliban of a key source of support. Its overall design also promises to lay the necessary groundwork for substantial reductions in the size and impacts of the illicit economy in Afghanistan.

However, while appropriate in its overall conception, the new strategy has pitfalls. Specifically how to operationalize interdiction and rural development will to a great extent determine the effectiveness of the strategy—not only with respect to the narrow goal of narcotics suppression, but also with respect to counterinsurgency and state-building. While many of the details still remain to be developed, some of those that have trickled out give reasons for concern.

Effects of Previous Eradication-Centered Policy

During the 2008-09 growing season, the area of cultivation in Afghanistan fell by 22% to 123,000 hectares and opium production fell by 10 percent to 6,900 metric tons (mt). Much of this decline in cultivation was driven by market forces largely unrelated to policy: After several years of massive overproduction in Afghanistan that surpassed the estimated global market for opiates by almost three times, opium prices were bound to decline. Even at 6,900 mt, production still remains twice as high as world demand, leading to speculation that someone somewhere is stockpiling opiates.

More significant, the persistence of high production betrays the ineffectiveness of simplistic policies, such as premature forced eradication before alternative livelihoods are in place, which since 2004 (until the new Obama strategy) was the core of the counternarcotics policy in Afghanistan. Policies that fail to address the complex and multiple structural drivers of cultivation and ignore the security and economic needs of the populations dependent on poppy cultivation generate vastly counterproductive effects with respect to not only counternarcotics efforts, but also counterinsurgency, stabilization and state building.

The eastern Afghan province of Nangarhar provides a telling example. For decades, Nangarhar has been one of the dominant sources of opium poppy. But over the past two years, as a result of governor Gul Agha Shirzai’s suppression efforts—including bans on cultivation, forced eradication, imprisonment of violators and claims that NATO would bomb the houses of those who cultivate poppy or keep opium—cultivation declined to very low numbers. This has been hailed as a major success to be emulated throughout Afghanistan.

In fact, the economic and security consequences were highly undesirable. The ban greatly impoverished many, causing household incomes to fall 90% for many and driving many into debt. As legal economic alternatives failed to materialize, many coped by resorting to crime, such as kidnapping and robberies. Others sought employment in the poppy fields of Helmand, yet others migrated to Pakistan where they frequently ended up recruited by the Taliban. The population became deeply alienated from the government, resorting to strikes and attacks on government forces. Districts that were economically hit especially severely, such as Khogiani, Achin and Shinwar, have become no-go zones for the Afghan government and NGOs. Although those tribal areas have historically been opposed to the Taliban, the Taliban mobilization there has taken off to an unprecedented degree. The populations began allowing the Taliban to cross over from Pakistan, and U.S. military personnel operating in that region indicate that intelligence provision to Afghan forces and NATO has almost dried up. Tribal elders who supported the ban became discredited, and the collapse of their legitimacy is providing an opportunity for the Taliban to insert itself into the decision-making structures of those areas. And all such previous bans in the province, including in 2005, turned out to be unsustainable in the absence of legal economic alternatives. Thus, after the 2005 ban, for example, poppy cultivation inevitably swung back.

The Ingredients of Success

Security
The prerequisite for success with respect to narcotics is security, i.e. sustained state control of territory. Without it, Afghanistan cannot be stabilized and the state strengthened; nor can counternarcotics policies be effective. Whether one adopts iron-fisted eradication or sustainable rural development as the core of a counternarcotics policy, security is essential. Without security first, counternarcotics efforts have not yet succeeded anywhere. Suppression without alternative livelihoods in place requires firm control of the entire territory to prevent illicit crop displacement and harsh suppression of the population dependent on illicit crops. Apart from being problematic with respect to human rights, this harsh approach is also very costly politically. Rural development requires security, otherwise investment will not come in, the population will not make risky long-term investments in legal crops and structural drivers of cultivation will not be effectively addressed. Development under a hail of bullets simply does not work, and in the context of insecurity, illicit economies persist and dominate.

Nor have counternarcotics policies, such as eradication or interdiction, succeeded in bankrupting or severely weakening any belligerent groups profiting from drugs anywhere in the world. Not in China, Thailand, Burma, Peru, Lebanon or even Colombia. Instead, they cement the bonds between marginalized populations dependent on illicit crops and belligerents plus severely reduce human intelligence flows to the counterinsurgent forces.

But counterinsurgent forces can prevail against insurgents and terrorists without stopping or reducing the terrorists’ drug-based financial inflows—either by increasing their own forces and resources vis-à-vis the belligerents or by adopting a smarter strategy that is either militarily more effective or wins the hearts and minds. This was the case in China, Thailand, Burma, and Peru where counterinsurgents succeeded without eradication. Evidence that counterinsurgent forces can prevail without bankrupting the belligerents through eradication also holds in the case of Colombia where the FARC has been weakened militarily not because of the aerial spraying of coca fields, but in spite of it. Today, more coca is grown there than at the beginning of Plan Colombia; but as a result of U.S. resources and training, Colombian forces were capable of greatly weakening the FARC even though forced eradication virtually eliminated human intelligence from the population to the government.

Interdiction with the Right Focus
The broad focus of the new counternarcotics strategy on interdiction is well placed, but interdiction’s effectiveness will depend on its objectives and execution. Just like eradication, interdiction will not succeed in bankrupting the Taliban. The Taliban has many other sources of income, including donations from Pakistan and the Middle East, taxation of legal economic activity, smuggling with legal goods, wildlife and illicit logging. In fact, it rebuilt itself in Pakistan between 2002 and 2004 without access to the poppy economy. Overall, drug interdiction has a very poor record in substantially curtailing belligerents’ income, with only a few successes registered in, for example, highly localized settings in Colombia and Peru.

Instead, the objective of the policy should be to reduce the coercive and corrupting power of organized crime groups. But achieving that requires a well-designed policy and a great deal of intelligence. Previous interdiction efforts in Afghanistan have in fact had the opposite effect: they eliminated small traders and consolidated the power of big traffickers, giving rise to the vertical integration of the industry. They also strengthened the bonds between some traffickers and the Taliban (although many traffickers continue to operate independently or are linked to the government).

Large-scale interdiction that targets entire networks and seeks to eliminate local demand for opium from local traders, which some are arguing for, is extraordinarily resource-intensive given the structure of the Afghan opium industry. Prioritization will need to be given to devoting scarce resources to drug interdiction or directly to counterinsurgency. The odds of success are not high. But even if such an interdiction strategy did succeed in shutting down local demand, the policy would become counterproductive since in local settings its effects would approximate the effects of eradication, thus once again alienating the population. Such large-scale interdiction is thus not currently appropriate for Afghanistan.

But even the NATO-led selective interdiction of targeting designated Taliban-linked traffickers (the United States has identified fifty such traffickers) is not free from pitfalls. First, selective interdiction can actually provide opportunities for the Taliban to directly take over the trafficking role or strengthen the alliance between the remaining traffickers and the Taliban, thus achieving the opposite of what it aims for. In fact, interdiction measures in Peru and Colombia frequently resulted in tightening the belligerents-traffickers nexus and belligerents’ takeover of trafficking.

Second, uncalibrated interdiction can provoke intense turf wars among the remaining traffickers, thus intensifying violence in the country and muddling the battlefield picture by introducing a new form of conflict. Mexico provides a vivid example of such an undesirable outcome. In the Afghan tribal context, such turf wars can easily become tribal or ethnic warfare.

Third, such selective interdiction can also send the message that the best way to be a trafficker is to be a member of the Afghan government, thus perpetuating a sense of impunity and corruption and undermining long-term state building and legitimacy.

Finally, the effectiveness of interdiction is to a great extent dependent on the quality of rule of law in Afghanistan plus the capacity and quality of the justice and corrections systems, all of which are woefully lacking in Afghanistan and are deeply corrupt.

Comprehensive Rural Development
Rural development appropriately lies at the core of the new strategy because, despite the enormous challenges, it has the best chance to effectively and sustainably strengthen the Afghan state and reduce the narcotics economy. But for rural development to do that, it needs to be conceived as broad-based social and economic development that focuses on improvements in human capital—including health care and education—and addresses all of the structural drivers of opium poppy cultivation. In Afghanistan, these drivers include insecurity; lack of physical infrastructure (such as roads), electrification and irrigations systems; lack of microcredit; lack of processing facilities; and the absence of value-added chains and assured markets. They also include lack of land titles and, increasingly, the fact that land rent by sharecroppers has become dependent on opium poppy cultivation as land concentration has increased over the past eight years. Poppy cultivation and harvesting are also very labor-intensive, thus offering employment opportunities unparalleled in the context of Afghanistan’s economy.

The price-profitability of poppy in comparison to other crops is only one of the drivers and frequently not the most important one. Without other structural drivers being addressed, farmers will not switch to licit crops even if they fetch more money than the illicit ones. By the same token, however, farmers are frequently willing to sacrifice some profit and forgo illicit crop cultivation as long as the licit alternatives bring them sufficient income and address all of the structural drivers, including the insecurity to which farmers are exposed in illicit economies.

Unfortunately, the wheat distribution program that was the core of rural development in Afghanistan last year (and that is slated to be its key component this year) is likely to be woefully ineffective for several reasons. First, in 2008, the program was based solely on an unusually high price ratio of wheat to poppy, driven by poppy overproduction and a global shortage of wheat. However, this price ratio is unlikely to hold; Afghanistan’s wheat prices are dictated anyway by surrounding markets, such as Pakistan and Kazakhstan. Second, the program did nothing to address the structural drivers. In fact, it had counterproductive effects because the free distribution of wheat undermined local markets in seeds. Afghan farmers can obtain seeds; their challenge lies in how to obtain profit afterwards. Thus, some sold the wheat seed instead of cultivating it. Third, those who actually cultivated wheat frequently did so not for profit, but for subsistence to minimize costs of buying cereals on the market. In fact, because of land distribution issues, many Afghan farmers do not have access to enough land to cover even their subsistence needs with wheat monocropping. A key lesson from alternative development over the past thirty years is that monocropping substitution strategies are particularly ineffective. Fourth, if all of current poppy farmers switched to wheat cultivation, Afghanistan would experience a great increase in unemployment since wheat cultivation employs 88% less labor than poppy cultivation and harvesting do.

Instead of wheat, rural development in Afghanistan needs to emphasize diversified high-value, high-labor-intensive crops, such as fruits, vegetables and specialty items like saffron. Generating lasting off-farm income opportunities will also be important, but even more challenging than jump-starting legal agromarkets.

After eight years of underresourcing and neglecting agriculture development, the new counternarcotics policy’s focus on the farm is appropriate. But the new strategy needs to take care not to throw away the baby with the bath water. The effort still needs to include developing value-added chains and assured internal and external markets plus enabling sustained access to them. Once again, thirty years of history of alternative livelihoods show that without value-added chains and accessible markets even productive legal farms become unsustainable and farmers revert back to illicit crops.

Finally, rural development requires time. Perhaps in no country in the world since Mao wiped out poppy cultivation in China in the 1950s did counternarcotics efforts face such enormous challenges as they do in Afghanistan—in terms of the scale of the illicit economy, its centrality to the overall economy of the country and hence its vast marco- and micro-economic and political effects, the underdevelopment of the country and its human capital and the paucity of viable economic alternatives. Even under much more auspicious circumstances along all the above dimensions, counternarcotics rural development in Thailand took thirty years.

Conclusion

Clearly, there is a need to quickly bring some economic, social and rule of law improvements to the lives of the Afghan people. Without such quick, visible and sustainable change, it will become impossible to rebuild the confidence of the Afghan people in the future, harness their remaining aspirations and to persuade them that the central state with support of the international community is preferable to the Taliban or local warlord- or tribal-based fiefdoms. But there is an equal need to urge strategic patience in the United States—both for counterinsurgency and for counternarcotics.

Eradication can be a part of the mix of counternarcotics policies, but should only be adopted in areas that are free of violent conflict and where sufficient legal economic alternatives are available to the population. Interdiction needs to focus on reducing the coercive and corrupting power of crime groups. Before interdiction measures are undertaken, an analysis of second and third- order effects needs to be conducted. It needs to be carefully calibrated with the strength of law enforcement in Afghanistan to avoid provoking dangerous turf wars, ethnic violence and cementing the relationship between the Taliban and the traffickers. It also needs to target top traffickers linked to the Afghan government. Interdiction needs to encompass building the justice and corrections system in Afghanistan and broad rule of law efforts. Rural development needs to address all structural drivers of poppy cultivation. It needs to focus not only on the farm, but also on value-added chains and assured markets. It needs to emphasize diversified high-value, high-labor intensive crops, and not center on wheat.

Evaluations of counternarcotics policies need to back away from simplistic and inappropriate measures, such as the numbers of hectares eradicated or traffickers caught. Instead, the measures need to encompass the complexity of the issue, including, size of areas cultivated with licit as well as illicit crops, human development indexes, levels of education, the number of resource-poor farmers dependent on illicit crops for basic subsistence or vulnerable to poverty-driven participation in illicit economies, food security, availability of legal microcredit, prevalence of land titles and accessibility of land, infrastructure density and cost of infrastructure use (such as road tolls), availability of non-belligerent dispute resolution and arbitrage mechanisms, quality of property rights, prevalence of value-added chains, and accessibility of markets. The United States and its allies must reduce public expectations for quick fixes and dedicate increased resources to rural development for a long time. Although U.S. forces do not need to stay in Afghanistan for decades, economic development will take that long.

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Policy Brief #178

One of the strongest narratives in U.S. history has been the contribution made by talented, hard-working and entrepreneurial immigrants whose skills and knowledge created a prosperous new country. Yet today, the nation’s immigration priorities and outmoded visa system discourage skilled immigrants and hobble the technology-intensive employers who would hire them. These policies work against urgent national economic priorities, such as boosting economic vitality, achieving greater competitiveness in the global marketplace and renewing our innovation leadership.

In the long term, the nation needs comprehensive immigration reform. In the short term, policymakers should focus on reforms that are directly related to increasing the "brain gain" for the nation—creating new jobs and producing economic benefits—to produce tangible and achievable improvements in our immigration system.

	RECOMMENDATIONS
	Rebalance U.S. immigration policies to produce a "brain gain," with changes to visas that will allow employers to access workers with the scientific and technological skills they need to improve economic competitiveness, employment and innovation Tie immigration levels to national economic cycles to meet changing levels of need Use digital technologies to modernize the current visa system

Background

Immigrants are now one-tenth of the overall U.S. population—a situation that defies facile stereotyping. Immigrants have made significant contributions to American science and economic enterprise, most notably in the areas of high-tech and biotech.

• Immigrants’ productivity raises the U.S. Gross Domestic Product (GDP) by an estimated $37 billion per year
   
• More than a quarter of U.S. technology and engineering businesses launched between 1995 and 2005 had a foreign-born founder
   
• In Silicon Valley, more than half of new tech start-up companies were founded by foreignborn owners
   
• In 2005, companies founded by immigrants produced $52 billion in sales and employed 450,000 workers
   
• Nearly a quarter of the international patents filed from the United States in 2006 were based on the work of foreign-born individuals (more than half of whom received their highest degree from an American university)
   
• Economists calculate that, as a result of immigration, 90 percent of native-born Americans with at least a high-school diploma have seen wage gains
   
• Historically, immigrants have made outsize contributions to American science and technology, with Albert Einstein perhaps the leading example. One-third of all U.S. winners of Nobel prizes in medicine and physiology were born in other countries Far from "crowding out" native-born workers and depressing their wages, well-educated, entrepreneurial immigrants do much to create and support employment for Americans.

In order to fully reap the benefits of the worldwide talent market, U.S. immigration policy must be reoriented. Current policy is significantly—and negatively—affected by the unintended consequences of the 1965 Immigration and Nationality Act that made family unification its overarching goal. Although the law may have contributed to the high-tech boom by removing long-standing, country-specific quotas and expanding immigration from places with strong science and engineering education programs, its main effect was to enable immigrants to bring in family members, without regard for the new immigrants’ education, skill status or potential contributions to the economy.

Thus, in 2008, almost two-thirds of new legal permanent residents were family-sponsored and, over the past few years, the educational attainment of new immigrants has declined.

U.S. employers have a large, unmet demand for knowledge workers. They are eager to fill jobs with well-trained foreign workers and foreign graduates of U.S. universities—particularly those with degrees in the sciences, technology, engineering and mathematics—the "STEM" fields that continue to attract too few U.S.-born students. In 2008, the "Tapping America’s Potential" business coalition reported that the number of U.S. graduates in STEM had been stagnant for five years, and that number would have to nearly double by 2015 to meet demands.

Meanwhile, the United States is falling behind in the pace of innovation and international competitiveness. Evidence for the decline in innovation is the decreasing U.S. share of international patents. In 2009, for the first time in recent years, non-U.S. innovators earned more patents (around 96,000) than did Americans (93,000). Only a decade earlier, U.S. innovators were awarded almost 57 percent of all patents.

To date, Congress—for a variety of reasons, including partisanship—has stalled in addressing the problems of immigration and immigration policy. Unfortunately, this inaction extends to problems hampering the nation’s economy that, if remedied, could help the United States grow employment, pull out of the current recession more quickly and improve its position in the global economy.

Game-Changing Policy Reforms

Rebalance Fundamental Goals

The goals of U.S. immigration policy should be rebalanced to give priority to immigrants who have the education and talent to enhance America’s economic vitality, by stimulating innovation, job creation and global competitiveness. At the same time, it should decrease emphasis on family reunification (other than parents and children of U.S. citizens). Changing the composition of the immigration stream, even without increasing its size, would result in a "brain gain" for the United States.

Other countries, such as Canada, the United Kingdom and Australia, strategically craft immigration policy to attract skilled and unskilled workers, making the benefits easy to see and strengthening public support for immigration in the process. Canada, for example, explicitly targets foreign workers to fill positions for which there are not enough skilled Canadians. Applicants for admission to the country accumulate points based on their field of study, educational attainment and employment experience. Upon reaching the requisite number of points, the applicant is granted a visa. Some 36 percent of all Canadian immigrant visas are in the "skilled-worker" category, as opposed to only 6.5 percent in the United States.

An interesting by-product of this strategy—which is both clearly articulated and of obvious benefit to the national economy—is that Canadians see the benefits of the policy and, as a result, immigration is far less controversial than in the United States. In 2005 polling by The Gallup Organization, only 27 percent of Canadians wanted to decrease immigration, whereas 52 percent of U.S. citizens did. And, three times as many Canadians (20 percent) as Americans (seven percent) actually wanted to increase it.

An obvious place to begin the rebalancing process would be with the many foreign students who come to the United States for education in scientific and technology fields. They are familiar with our culture and speak English. Many would like to stay and build careers here. But, under current visa rules, most are sent home as soon as they graduate. A complete policy reversal is needed, with automatic green cards for foreign graduates of U.S. science and technology programs.

In fact, the United States should make it as easy as possible for these highly trained students to stay, since the expansion of job opportunities in India, China and other growth-oriented countries now offers them attractive options. Our current counterproductive policy, quite simply, puts the United States in the position of training our global competitors.

New York City mayor Michael Bloomberg, in a December 2009 Meet the Press interview, said about immigration: "We’re committing what I call national suicide. Somehow or other, after 9/11 we went from reaching out and trying to get the best and the brightest to come here, to trying to keep them out. In fact, we do the stupidest thing, we give them educations and then don’t give them green cards."

Universities collectively invest huge sums in the development of these students. In addition, research suggests that increasing the number of foreign graduate students would increase U.S. patent applications by an estimated 4.7 percent and grants of university patents by 5.3 percent.

Another strategic policy change would be for the federal government to take U.S. workforce and economic conditions into account when setting immigration levels and annual H-1B visa numbers for scientists and engineers. Such a flexible approach would reflect labor market needs, protect American workers’ jobs and wages, and dampen public concerns about employment losses during lean economic times.

Revamp the Antiquated Visa System

Increase the Number of Visas for Highly-skilled Workers

Today’s visa programs for high-skilled workers are not large enough to fill the numerical demand for such employees and are too short in duration. For example, H-1B visas for workers in "specialty occupations" are valid for a maximum of six years. Between fiscal years 2001 and 2004, the federal government increased the annual allocation of H-1B visas for scientists and engineers to 195,000. The rationale was that scientific innovators were so important for the country’s long-term economic development that the number set aside for those specialty professions needed to be high. Since 2004, that number has returned to its former level, 65,000—only a third of the peak, despite rapid technologic change in almost every field, such as information, medicine, energy and logistics.

Most of these visas are allocated within a few months of becoming available. Even in recessionplagued 2009, applications exceeded the supply of visas within three months. Almost half of the visa requests came from U.S. employers, most of them in high-tech industries. Clearly the demand for visas is greater than the supply, and a minimal step would be to raise the set-aside for high-skilled workers to the previous, 195,000 level.

Only a small percentage of aliens with student visas and aliens with H-1B visas are able to change directly to legal permanent resident status—about seven percent of each category, according to a study published in 2005—although about half of H-1B visa-holders eventually become legal permanent residents. Such an uncertain path is not conducive to career (or employment) planning in a competitive environment.

Several additional small programs support talented scientists and entrepreneurs. These, too, could be aligned with economic goals, expanded or more effectively promoted:

• The O-1 "genius" visa program allows the government to authorize visas for people with "extraordinary abilities in the arts, science, education, business, and sports." In 2008, around 45,000 genius visas were granted. The clear intent is to encourage talented people to migrate to America. However, the current program is too diffuse to have much impact on the level of scientific and technological innovation talent in the United States.
   
• The EB-5 visa program offers temporary visas to foreigners who invest at least $500,000 in the nation’s rural or "targeted employment areas" or at least $1,000,000 in other areas. If the investment creates at least ten jobs, the visa automatically becomes a permanent green card. The program is authorized by Congress to offer approximately 10,000 visas per year, but it is significantly underutilized—about 500 EB-5 visas a year were granted between 1992 and 2004. In 2009, 3,688 people did become legal permanent residents under the "employment creation (investors)" category, a number that includes spouses and children.

According to a March 2009 report from the Department of Homeland Security, the causes of the persistent underutilization of this program include "program instability, the changing economic environment, and more inviting immigrant investor programs offered by other countries." The report makes a number of recommendations designed to streamline program administration and encourages greater efforts to promote the program overseas.

Update the Visa System Infrastructure

Aside from questions about the number of visas allowed, the infrastructure for considering and granting visas needs a major upgrade. Currently, the U.S. visa process requires people seeking entry to provide paper copies of sometimes hard-to-obtain documents. Often these are lost in the system and must be submitted repeatedly. Obtaining a visa can take months and, in some cases, years. Implementation of the USA PATRIOT Act has slowed the process even further.

The visa system should adopt digital technology to reduce both errors and delays. Further, if the nation’s immigration policy moves toward a more credential-based approach, any new electronic processes should be designed to minimize the potential that false documents regarding an individual’s education and experience will be accepted.

Tie Immigration Levels to National Economic Indicators

To ease U.S.-born workers’ understandable worries about job competition from immigrants, Congress should tie overall annual levels of immigration to the unemployment rate and growth in the Gross Domestic Product. Immigration levels can be adjusted up or down depending on the level of economic conditions. These fluctuations should occur automatically, triggered by authoritative statistical reports.

Political Hurdles to Immigration Reform

U.S. news reporting on immigration focuses heavily on illegality and largely ignores the benefits of immigration. Sadly, important news organizations follow the tradition set in the 19th century, when many journalists railed against groups of newcomers, such as immigrants from Ireland and China. Immigration opponents’ unfavorable media narratives, often widely publicized, have a discernible impact on public opinion and affect policymaking. The economic, social, and cultural benefits of immigration are rarely reported.

The State of Public Opinion

Immigration does not rank high on Americans’ lists of the country’s most important problems. In 2008, only four percent of Americans (mostly people from Southwestern border states concerned about illegal entry) thought immigration was the country’s most important problem. Even during 2007’s acrimonious national debate about comprehensive reform, 60 percent of Americans believed new arrivals benefit the country. But public opinion can shift quickly, which makes politicians wary. Fifty-seven percent of voters in the November 2010 mid-term election considered immigration a "very important" issue, ranking it 7th and on a par with taxes and national security/war on terror, according to the Rasmussen report.

The Need for Reform Follow-Through

Administration and enforcement of immigration laws and visa programs are complex, in part because federal, state and local officials are involved in various aspects and are overseen by multiple federal agencies. Aligning the goals of these different entities to put an emphasis on the brain gain can help build support for policy improvements.

As the report of a 2009 Brookings Forum on Growth Through Innovation pointed out with regard to promoting innovation more broadly, "while the actions we need to take are clear and reasonably simple to outline, our political culture erects insurmountable barriers to long-term planning, funding and implementation."

Achieving an Improved Immigration Policy

It will be difficult to achieve comprehensive, coherent policy reform in the face of many competing goals and interest groups and in the current polarized political environment. The task is made more difficult by the divided authority over immigration matters within Congress, involving several committees and subcommittees with competing interests and different political dynamics. Individual members of Congress tend to focus on local concerns, forestalling consideration of broad, long-term national interests.

In the past, elected officials have overreacted to specific episodes of problems related to immigrants or anti-immigrant sentiments in developing policy, rather than taking into account long-term national economic priorities. Just as deleterious, stalemate and inaction have prevented needed reforms, despite a frustrating status quo for employers who need talented scientists and engineers, and who could hire many more Americans if they could fill key slots with skilled workers they cannot find in their local workforce.

A spectrum of experts has suggested creation of a broadly representative, independent federal immigration commission that could develop specific policies under parameters set by Congress. Proposals for such a body have the common themes of depoliticization, insulating members from parochial political pressures and relying on technical experts. Given past missteps and the current policy stalemate, it makes sense to consider such proposals seriously, in the hope that all aspects of immigration—especially those that affect U.S. economic vitality—receive the thoughtful attention they need.

Conclusion

The immigration policy reforms in this paper focus on those that would have swift and direct positive impact on the nation’s economy. Clearly, these are not the only reforms the system needs. A fairer, more comprehensive immigration policy also would:

• Develop more effective and cost-effective border control strategies
   
• Strengthen the electronic employment-eligibility ("e-verify") system and add an appeals process
   
• Improve the immigration courts system and the administration of immigration law
   
• Work harder to integrate immigrants into American life and teach them English and
   
• Create a path to citizenship for illegal immigrants with requirements that applicants learn English, pay back taxes, and pay fines.

Meanwhile, a number of the needed corrections to the system as it affects national economic goals, employment, innovation, and global competitiveness can be addressed, including:

• Tying visa and immigration levels to U.S. economic indicators, in order to assuage American workers’ concerns about threats to employment and wage levels
   
• Creation of an automatic green card for foreign graduates of U.S. science, technology, engineering, and mathematics educational programs and other steps to make staying in the United States a desirable option
   
• Expansion of visa programs (especially H-1B for highly skilled workers) and making more effective the O-1 and EB-5 visa programs and
   
• Creating a modern, electronic visa system.

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Policy Brief #182

Protection of people from oppressive governments, civil conflict and disasters has moved to the top of the international agenda. The United Nations Security Council authorized all measures necessary to protect civilians in Libya as the airstrikes began. Humanitarian agencies-working in more places and under more difficult conditions than ever before-are grappling with the aftermath of Japan's massive earthquake even as they are also working with displaced people in Haiti and Ivory Coast and responding to hundreds of thousands of people fleeing Libya. And increasingly these agencies are not only trying to assist people through provision of relief items, but also trying to protect them. But with so many global organizations mobilizing to protect civilians when disasters strike and conflicts break out, the concept of protection has begun to lose its distinctive meaning.

Can anyone "do" protection? In The Politics of Protection: The Limits of Humanitarian Action (Brookings Institution Press, 2011), I describe how protection has been stretched to include all manner of important activities-from provision of food to curriculum development, from advocacy to monitoring, from building latrines to voter registration. Beyond affirming the responsibility of governments to protect their people, international law offers no clear guidance on how to translate the principles of protection into action.

Given the likelihood that conflicts will continue and natural disasters will increase in the future, much more attention is needed on the question of protection, which has emerged over the years from international humanitarian law, refugee law and human rights law. The most visible part of the international humanitarian system is the vast array of U.N. agencies and nongovernmental organizations. Yet military forces, the International Committee of the Red Cross, and thousands of civil society organizations are also major actors in humanitarian response. This brief describes observations and recommendations on protection in humanitarian work culled from my forthcoming book.

	RECOMMENDATIONS
	With changes in the nature of conflict and with the likelihood of increasing severity and frequency of sudden-onset disasters because of climate change, more attention needs to be paid to understanding how humanitarian actors can-and cannot-protect people. The United Nations and other humanitarian actors should consider the following recommendations: Humanitarian agencies need to re-evaluate what protection means in the context of today's conflicts and to recognize their own limitations in keeping people safe. If they are serious about protecting people, they need to work with national military and police forces which have the resources to provide such physical protection. This is hard for humanitarian agencies that see their work as grounded in principles of impartiality, independence and neutrality. NGOs should review their current policies and practices on protection to ensure that they are not promising more than they can deliver or being used as a cover for the lack of effective political action.   " As the term "protection of civilians" has come to mean different things for different actors, the U.N. Office for the Coordination of Humanitarian Affairs should develop a very short summary statement of what it means to protect civilians that can be broadly used by a range of different communities and individuals in different contexts. The office should then collect the best practices to illustrate how protection of civilians is effectively carried out on the ground.   As both conflicts and disasters take on a distinctive form when they occur in urban areas, much more work is needed to retool humanitarian assistance for urban environments. This means that humanitarian agencies need to work with municipal authorities in preparing for and responding to urban residents affected by violence and disasters.   In light of the fact that climate change is likely to result in more large-scale and varied types of displacement, U.N. agencies and researchers should analyze the gaps in international legal protection for those forced to leave their countries because of climate change-induced environmental factors. Guidelines should be developed to assist governments considering evacuation or relocation of populations from areas likely to be affected by natural disasters or climate change.   Given the pace of technological change taking place with robotic armaments, the International Committee of the Red Cross should convene a group of experts from the military research and international law communities to begin to identify the gaps in international humanitarian law resulting from the widespread use of those technologies.

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Missouri's population is spreading out, adding to the costs of providing services and infrastructure across the state, according to a new study released today by the Brookings Institution Center on Urban and Metropolitan Policy.

The 84-page study, Growth in the Heartland: Challenges and Opportunities for Missouri, reports that Missouri's population is quickly dispersing, with smaller metropolitan areas experiencing some of the state's fastest growth and residency in unincorporated areas on the rise. Though new residents and jobs fueled prosperity in the 1990s, the report finds that growth has slowed in the past year, and suggests that the state's highly decentralized development patterns could become troublesome as Missouri contends with a slowing economy and serious budget deficits.

Sponsored by the Ewing Marion Kauffman Foundation, Growth in the Heartland provides the most comprehensive and up-to-date body of research and statistics yet assembled analyzing the direction, scope, and implications of development in Missouri. In addition to assessing the consequences of those trends for the state's fiscal health, economic competitiveness, and quality of life, the report addresses the potential role of state and local policy in shaping those trends in the future. Specific findings of the report conclude that:

• Growth in the Columbia, Springfield, Joplin, and St. Joseph metropolitan areas strongly outpaced that of the Kansas City and St. Louis metropolitan areas in the 1990s. Altogether the four smaller areas captured fully one-quarter of the state's growth and doubled the growth rate of the Kansas City and St. Louis areas.
  
  
• Population and job growth also moved beyond the smaller metro areas and towns into the state's vast unincorporated areas. Overall, residency in these often-outlying areas grew by 12.3 percent in the 1990s—a rate 50 percent faster than the 8.1 percent growth of towns and cities.
  
  
• Most rural counties reversed decades of decline in the 1990s, with eight in ten rural counties experiencing population growth and nine in ten adding new jobs. By 2000, more rural citizens lived outside of cities and towns than in them, as more than 70 percent of new growth occurred in unincorporated areas.

"Missouri experienced tremendous gains during the last decade, but the decentralized nature of growth across the state poses significant fiscal challenges for the future," said Bruce Katz, vice president of Brookings and director of the policy center. "The challenge for Missouri is to give communities the tools, incentives, and opportunities to grow in more efficient and fiscally responsible ways."

The Brookings Institution Center on Urban and Metropolitan Policy is committed to shaping a new generation of policies that will help build strong neighborhoods, cities, and metropolitan regions. By informing the deliberations of state and federal policymakers with expert knowledge and practical experience, the center promotes integrated approaches and practical solutions to the challenges confronting metropolitan communities. Learn more at www.brookings.edu/urban.

      

The news Monday from the Centers for Disease Control and Prevention (CDC) on the incidence of resistant infections is disturbing but not surprising. CDC estimates that over two million Americans every year are affected by drug-resistant infections and of those, 23,000 die annually. The report notes that these figures are conservative and are likely an underestimate of the burden of resistant infections. While these numbers reflect domestic rates, antibiotic resistance is a global issue as well.

To further compound the issue, today’s antibiotic pipeline is nearly dry and has been for some time, with only a handful of large pharmaceutical companies and smaller biotech firms still engaged in antibiotic development. The threat of a so-called ‘post-antibiotic era’ – a time when there are no longer any effective antibiotic treatments – could become a reality without a concerted and comprehensive effort to combat this global threat. The evolution of drug resistance is an inherent risk of antibiotic use. The CDC report cited the development of new antibiotics and diagnostic tools, as well as programs and policies to support appropriate use of antibiotics, as being among the core strategies to combat resistance.

Clinical effectiveness and the relatively low cost of antibiotics have had the unintended consequence of contributing to overuse, accelerating the development of antibiotic resistance to all major classes of antibiotics. While there are some diagnostic tools available to support targeted treatment, it is often more time- and cost-effective for a physician to prescribe a relatively inexpensive, broad-spectrum antibiotic than to conduct a diagnostic test (if one exists at all). Antibiotic overuse can also be driven by patients who see antibiotics as safe and often low-cost cure-alls. Recognizing that these past patterns of overuse are dangerous, the clinical community is working diligently to curb inappropriate use and promote public health through stewardship and education programs. However, given the weakness of the current antibiotic development environment, it may be too little-too late; rates of resistance continue to rise globally while the number of effective therapies to treat many pathogens is dwindling. According to the CDC, resistance can be ”slowed but not stopped” – there will always be a need for novel antibiotics that can combat the evolution of these pathogens.

The current system for manufacturer return on investment for antibiotics, which are typically reimbursed at very low levels, is oriented towards volume sales. As a result, stewardship and educational programs geared toward limiting use of novel antibiotics create an ‘antibiotic development paradox.’ How can we incentivize investment in developing new effective antibiotics and also have successful programs that limit the use of these antibiotics in an effort to prevent or delay the development of resistance? Unless this fundamental conflict in the current business model is addressed, pharmaceutical firms are unlikely to expand development efforts.

How do we turn the tide?

There are several proposals that address aspects of the antibiotic development paradox with the goal of reinvigorating the antibiotic drug development ecosystem in a way that maximizes our ability to stay ahead of resistance. While none of these proposals alone will solve this problem, each could support the long-term goal of reinvigorating antibiotic discovery, development, and treatment.

Creating incentives for drug development

Antibiotic drug development has been a losing prospect for drug developers and has driven many of them to exit the antibiotic innovation space in the last few decades in favor of other therapeutic areas that have much larger markets and are easier areas to study. In order to make antibiotic development more attractive, various mechanisms have been proposed to stimulate or better reward successful clinical development. Incentives that can lower the financial risks associated with development include grants, tax credits, public-private partnerships, and intellectual property protections. Post-approval, prizes, advanced market commitments, and value-based pricing could all potentially provide additional incentives to invest in this research. Some potential incentives were discussed at the Incentives for Change: Addressing the Challenges in Antibacterial Drug Development workshop convened by Brookings in February 2013.

Balancing benefit and risk for severely-ill patients

Other incentives are related to the drug approval process. Novel mechanisms for expedited development and approval can speed time to market while still meeting traditional evidentiary requirements for safety and efficacy. In the last several years, a number of proposals – including from the Infectious Diseases Society of America and the President’s Council of Advisors on Science and Technology – have sought to reduce development time and cost and increase regulatory clarity through a more targeted clinical trial process directed at the highest-risk patients. A narrower study population would allow the U.S. Food and Drug Administration to make a more targeted assessment of the product’s safety, efficacy, and benefit-risk profile that could accelerate innovation for patients with serious drug-resistant infections. The need to steward these antibiotics, which was noted as a core action in the CDC report, would be especially important to both prevent the growth of resistance and to reduce the risk of adverse effects in less seriously-ill populations. Additional information on the proposed limited-use pathway and appropriate use is available on the Brookings website.

De-link reimbursement from return on investment

In order to attract investment for new antibiotic research, we must develop a business model that can support ongoing and expanding development without compromising the effectiveness of new therapies. Recognizing the need to “de-link” return on investment from the volume of antibiotics sold, efforts to move away from the volume-based reimbursement system could become an attractive path forward. Promising models, which were discussed at the Brookings workshop in February, included several guaranteed payment schemes supported by public funding. Taken to an extreme, such a system could even allow new antibiotics to be reserved indefinitely until needed, removing the developer’s incentive to sell any drugs in the years following approval. While such a program would likely be expensive (with sufficient returns estimated on the order of $1.75-2.5 billion over five years), government intervention is needed to fix this public health crisis and dangerous market failure. Its societal value in curtailing resistance and providing critical drugs would outweigh the cost to taxpayers.

The antibiotic development paradox will require a multi-pronged strategy that includes incentives to support front-end drug discovery and development, and new reimbursement policies that de-link unit volume sales from return on investment. However, this is by no means a quick fix. Even if this approach is successful, it will take decades for manufacturers to rebuild lost antibiotic development infrastructure and expertise, and to successfully develop and market new treatments. For the few drugs currently in development, even with expedited development and review pathways, they are still years from reaching the market.

       

Event Information

Antibacterial drug resistance is a global public health threat poised to worsen due to the combination of the inappropriate use of existing drugs and a marked decline in innovative antibacterial drug development. In order to tackle this problem, stakeholders must consider comprehensive strategies that address both drug development and stewardship.

On February 7, the Engelberg Center for Health Care Reform convened an expert workshop, “Modernizing Antibacterial Drug Development and Promoting Stewardship” to explore a two-pronged approach to combating antibacterial drug resistance that includes: 1) the development of pathogen-focused antibacterial drugs that target the most serious public health threats; and 2) stewardship efforts for all antibacterial products in order to preserve their utility. Participating stakeholders included experts from the drug development and health care industries, the clinical community, government, and academia. These stakeholders shared their insights on potential frameworks and evidentiary considerations for pathogen-focused drug development, and efforts underway to promote the appropriate use of commonly used antibacterial drugs in the ambulatory care setting.

Event Materials

• Antibiotic Development Slides
• 07 antibacterial expert workshop discussion guide
• 07 antibacterial expert workshop public agenda
• 07 antibacterial expert workshop meeting summary

       

While antibiotics are necessary and crucial for treating bacterial infections, their misuse over time has contributed to a rather alarming rate of antibiotic resistance, including the development of multidrug-resistance bacteria or “super bugs.” Misuse manifests throughout all corners of public and private life; from the doctor’s office when prescribed to treat viruses; to industrial agriculture, where they are used in abundance to prevent disease in livestock. New data from the World Health Organization (WHO) and U.S. Centers for Disease Control and Prevention (CDC) confirm that rising overuse of antibiotics has already become a major public health threat worldwide.

As drug resistance increases, we will see a number of dangerous and far-reaching consequences. First, common infections like STDs, pneumonia, and “staph” infections will become increasingly difficult to treat, and in extreme cases these infections may require hospitalization or treatment with expensive and toxic second-line therapies. In fact, recent estimates suggest that every year more than 23,000 people die due to drug-resistant infections in the U.S., and many more suffer from complications caused by resistant pathogens. Further, infections will be harder to control. Health care providers are increasingly encountering highly resistant infections not only in hospitals – where such infections can easily spread between vulnerable patients – but also in outpatient care settings.

Fundamental Approaches to Slowing Resistance

Incentivize appropriate use of antibiotics. Many patients and providers underestimate the risks of using antibiotics when they are not warranted, in part because these drugs often have rapid beneficial effects for those who truly need them.  In many parts of the world the perception that antibiotics carry few risks has been bolstered by their low costs and availability without a prescription or contact with a trained health care provider. Education efforts, stewardship programs, and the development of new clinical guidelines have shown some success in limiting antibiotic use, but these fixes are limited in scope and generally not perceived as cost-effective or sustainable. Broader efforts to incentivize appropriate use, coupled with economic incentives, may be more effective in changing the culture of antibiotic use. These options might include physician or hospital report cards that help impact patient provider selection, or bonuses based on standardized performance measures that can be used to report on success of promoting appropriate use.  While these might create additional costs, they would likely help control rates of drug resistant infections and outweigh the costs of treating them.

Reinvigorate the drug development pipeline with novel antibiotics. There has not been a new class of antibiotics discovered in almost three decades, and companies have largely left the infectious disease space for more stable and lucrative product lines, such as cancer and chronic disease. Antibiotics have historically been inexpensive and are typically used only for short periods of time, creating limited opportunities for return on investment. In addition, unlike cancer or heart disease treatments, antibiotics lose effectiveness over time, making them unattractive for investment. Once they are on the market, the push to limit use of certain antibiotics to the most severe infections can further constrict an already weak market.

Late last year, H.R. 3742, the Antibiotic Development to Advance Patient Treatment (ADAPT) Act of 2013, was introduced and referred to the House Energy and Commerce Subcommittee on Health. If enacted, the ADAPT Act would create a streamlined development pathway to expedite the approval of antibiotics that treat limited patient populations with serious unmet medical needs. This could potentially reduce costs and development time for companies, thereby encouraging investment in this space. Regulators have indicated that they would also welcome the opportunity to evaluate benefits and risk for a more selective patient subpopulation if they could be confident the product would be used appropriately. The bill has received a great deal of support and would help address a critical public health need.

Advance new economic incentives to remedy market failure. Innovative changes to pharmaceutical regulation, research and development (R&D), and reimbursement are necessary to alleviate the market failure for antibacterial drugs. A major challenge, particularly within a fee-for-service or volume-based reimbursement system, is providing economic incentives that promote investment in drug development without encouraging overuse.  A number of public and private stakeholders, including the Engelberg Center for Health Care Reform and Chatham House’s Centre on Global Health Security Working Group on Antimicrobial Resistance, are exploring alternative reimbursement mechanisms that  “de-link” revenue from the volume of antibiotics sold. Such a mechanism, combined with further measures to stimulate innovation, could create a stable incentive structure to support R&D.

Improve tracking and monitoring of resistance in the outpatient setting. There is increasing concern about much less rigorous surveillance capabilities in the outpatient setting, where drug-resistant infections are also on the rise. Policymakers should consider new incentives for providers and insurers to encourage a coordinated approach for tracking inpatient and outpatient resistance data. The ADAPT Act, mentioned above, also seeks to enhance monitoring of antibiotic utilization and resistance patterns. Health insurance companies can leverage resistance-related data linked to health care claims, while providers can capture lab results in electronic health records. Ultimately, this data could be linked to health and economic outcomes at the state, federal, and international levels, and provide a more comprehensive population-based understanding of the impact and spread of resistance. Current examples include the Food and Drug Administration’s (FDA) Sentinel Initiative and the Patient-Centered Outcomes Research Institute’s PCORnet initiative. 

Antibiotic resistance is an urgent and persistent threat. As such, patients and providers will continue to require new antibiotics as older drugs are forced into retirement by resistant pathogens. Stewardship efforts will remain critical in the absence of game-changing therapies that parry resistance mechanisms. Lastly, a coordinated surveillance approach that involves diverse stakeholder groups is needed to understand the health and economic consequences of drug resistance, and to inform antibiotic development and stewardship efforts.

       

Antimicrobial resistance is one of the most significant threats to public health globally. It will worsen in the coming decades without concerted efforts to spur the development of new antibiotics, while ensuring the appropriate use of existing antibiotics. Antimicrobial therapy is essential for treating and preventing bacterial infections, some of which can be life-threatening and acquired as a result of
critical medical interventions, including surgery, chemotherapy and dialysis. However, the international rise in antimicrobial resistance has weakened our antibiotic armamentarium and multi-resistant bacteria now cause over 150,000 deaths annually in hospitals around the world (WHO, 2013). Unfortunately, the evolution of drug-resistant pathogens is unavoidable due to random genetic changes in the pathogens that can render antibiotics ineffective. While antibiotic therapy can succeed in killing susceptible pathogens, it also inadvertently selects for organisms that are resistant. Because each exposure to antibiotics contributes to this process, efforts to restrict antibiotic usage only slow the development of resistance. Ultimately, innovative antimicrobial drugs with diverse mechanisms of action will be needed to treat emerging resistant pathogens.

Combating resistance

Inappropriate use of antibiotics contributes significantly to the acceleration of resistance. Needlessly exposing patients to antibiotics (for example, for viral or mild infections likely to resolve on their own), the use of overly broad-spectrum antibiotics and suboptimal doses of appropriate therapy hasten the evolution of resistant pathogens. While affordable, rapid and accurate point-of-care diagnostics are essential for determining appropriate therapy for many bacterial diseases, routine clinical use will be limited if the tests are too expensive or not accessible during routine clinical encounters. In the absence of a clear diagnostic result, many health care providers prescribe empiric broadspectrum therapy without knowing exactly what they are treating. Although inappropriate use is widespread in many parts of the world, where antibiotics are available without a prescription or oversight by a health care provider or stewardship team, overuse abounds even where antibiotic prescribing is more tightly regulated.

Studies conducted in the USA indicate that around 258 million courses of antibiotics are dispensed annually for outpatient use (Hicks, 2013) and up to 75 per cent of ambulatory antibiotic prescriptions are for the treatment of common respiratory infections, which may or may not be bacterial in origin (McCaig,1995). Recent evidence suggests that over half of these prescriptions are not medically indicated. For example, 60 per cent of US adults with a sore throat receive an antibiotic prescription after visiting a primary care practice or emergency department, despite the fact that only ten per cent require treatment with antibiotics. This is particularly troubling given the availability of rapid tests that can detect Group A Streptococcus, the bacteria responsible for the ten per cent of cases that require antibiotic treatment.

The overuse of antibiotics has been driven largely by their low cost and clinical effectiveness, which has led many patients to view them as cure-alls with few risks. This perception is reinforced by the fact that antibiotics are curative in nature and used for short durations. However, the clinical effectiveness of these drugs decreases over time, as resistance naturally increases, and this process is accelerated with inappropriate use. Moreover, there are numerous consequences associated with the use of antibiotics, including over 140,000 emergency department visits yearly in the USA for adverse incidents (mostly allergic reactions; CDC, 2013a). In addition, antibiotics can eliminate protective bacteria in the gut,
leaving patients vulnerable to infection with Clostridium difficile, which causes diarrhoeal illness that results in 14,000 deaths every year in the USA (CDC, 2013b). It is estimated that antimicrobial resistance costs the US health care system over US$20 billion annually in excess care and an additional $35 billion in lost productivity (Roberts et al., 2009).

The inappropriate use of antimicrobial drugs is particularly concerning because highly resistant pathogens can easily cross national borders and rapidly spread around the globe. In recent years, strains of highly drug-resistant tuberculosis, carbapenem-resistant Enterobacteriaceae and other resistant pathogens have spread outside their countries of origin within several years of their detection. Because resistant bacteria are unlikely to stay isolated, stewardship efforts must be improved globally and international attention is needed to improve surveillance of emerging pathogens and resistance patterns.

A major challenge for clinicians and regulators will be to find stewardship interventions that can be scaled-up and involve multiple stakeholders, including providers, drug manufacturers, health care purchasers (insurers), governments and patients themselves. Such interventions should include practical and costeffective educational programmes targeted towards providers and patients that shift expectations for antibiotic prescriptions to a mutual understanding of the benefits and risks of these drugs.

Educational programmes alone, however, will not be sufficient to lower prescribing rates to recommended levels. Pushing down the inappropriate use of antibiotics also warrants stronger mechanisms that leverage the critical relationships between the stakeholders. For example, health care purchasers can play an important role by using financial disincentives to align prescribing habits with clinical guidelines that are developed by infectious disease specialists in the private and public sectors. This type of approach has the potential to be effective because it includes multiple stakeholders that share responsibility for the appropriate use of antibiotics and, ultimately, patient care.

Key obstacles to antibiotic development

The continual natural selection for resistant pathogens despite efforts to limit antibiotic use underscores the need for new antibiotics with novel mechanisms of action. To date, antimicrobial drug innovation and development have not kept pace with resistance. The number of approved new molecular entities (NME) to treat systemic infections has been steadily declining for decades (see Figure 1). Some infections are not susceptible to any antibiotic and in some cases the only effective drugs may cause serious side effects, or be contra-indicated due to a patient’s allergies or comorbidities (e.g. renal failure). There is significant unmet medical need for therapies that treat serious and life-threatening bacterial diseases caused by resistant pathogens, as well as some less serious infections where there are few treatment alternatives available (e.g. gonorrhoea).

Antibiotic development for these areas of unmet medical need has been sidelined by a number of scientific, regulatory and economic obstacles. While the costs and complexity of any clinical trial necessary for approval by drug regulators can be substantial, in part due to the large study samples needed to demonstrate safety and efficacy, the infectious disease space faces a number of unique clinical challenges. Patients with serious drug-resistant infections may be in need of urgent antibiotic therapy, which can preclude efficient consent and timely trial enrolment procedures; prior therapy can also confound treatment effects if the patient is later enrolled in a trial for an experimental drug. In addition, many patients with these pathogens are likely to have a history of longterm exposure to the health care setting and may have significant comorbidities that render them less likely to meet inclusion criteria for clinical trials.

Emerging infections for which there are few or no treatment options also tend to be relatively rare. This makes it difficult to conduct adequate and well-controlled trials, which typically enrol large numbers of patients. However, clinical drug development can take many years and waiting until such infections are more common is not feasible. Another issue is that it may also not be possible to conclusively identify the pathogen and its susceptibility at the point of enrolment due to the lack of rapid diagnostic technologies. Ultimately, uncertainty about the aetiology of an infection may necessitate trials with larger numbers of patients in order to achieve sufficient statistical power, further compounding the challenge of enrolling seriously ill infectious disease patients in the first place.

The need to conduct large trials involving acutely ill patients that are difficult to identify can make antibiotic development prohibitively expensive for drug developers, especially given that antibiotics are relatively inexpensive and offer limited opportunities to generate returns. Unlike treatments for chronic diseases, antibiotic therapy tends to last no longer than a few weeks, and these drugs lose efficacy over time as resistance develops, leading to diminishing returns. The decline in antimicrobial drug innovation is largely due to these economic obstacles, which have led developers to seek more durable and profitable markets (e.g. cancer or chronic disease) in recent decades. There are only a handful of companies currently in the market and the development pipeline is very thin. Changes to research infrastructure, drug reimbursement and regulation are all potentially needed to revitalise antibiotic innovation.

Opportunities to streamline innovative antibiotic development

In the USA, several proposals have been made to expedite the development and regulatory review of antibiotics while ensuring that safety and efficacy requirements are met. In 2012, the US President’s Council of Advisors on Science and Technology recommended that the US Food and Drug Administration (FDA) create a ‘special medical use’ (SMU) designation for the review of drugs for subpopulations of patients with unmet medical need. Drug sponsors would be required to demonstrate that clinical trials in a larger patient population would need much more time to complete or not be feasible. A drug approved under the SMU designation could be studied in subgroups of patients that are critically ill, as opposed to the broader population, under the condition that the drug’s indication would be limited to the narrow study population. The SMU designation was discussed at an expert workshop convened by the Brookings Institution in August 2013. Many participants at the meeting agreed that there is a pressing need to develop novel antibiotics and that such a limited-use pathway could support the appropriate use of newly approved drugs.

The Infectious Diseases Society of America developed a related drug development pathway called the Limited Population Antibacterial Drug (LPAD) approval mechanism. The LPAD approach calls for smaller, faster and less costly clinical trials to study antibiotics that treat resistant bacteria that cause serious infections. Both the SMU and LPAD approaches would allow drug developers to demonstrate product safety and efficacy in smaller patient subpopulations and provide regulatory clarity about acceptable benefit–risk profiles for antibiotics that treat serious bacterial diseases. The US House of Representatives is currently considering a bill¹ that incorporates these concepts.

A recent proposal from the drug manufacturer industry for streamlined antibiotic development is to establish a tiered regulatory framework to assess narrow-spectrum antibiotics (e.g. active versus a specific bacterial genus and species or a group of related bacteria) that target resistant pathogens that pose the greatest threat to public health (Rex, 2013: pp. 269–275). This is termed a ‘pathogen-focused’ approach because the level of clinical evidence required for approval would be correlated with the threat level and feasibility of studying a specific pathogen or group of pathogens. The pathogen-focused approach was also highlighted at a recent workshop at the Brookings Institution (Brookings Institution, 2014). Some experts felt that the approach is promising but emphasised that each pathogen and experimental drug is unique and that it could be challenging to place them in a particular tier of a regulatory framework. Given that pathogen-focused drugs would likely be marketed internationally, it will be important for drug sponsors to have regular interactions and multiple levels of discussion with regulators to find areas of agreement that would facilitate the approval of these drugs.

Antibiotics with very narrow indications could potentially support stewardship as well by limiting use to the most seriously ill patients. Safe use of these drugs would likely depend on diagnostics, significant provider education, labelling about the benefits and risks of the product, and the scope of clinical evidence behind its approval. Because these antibiotics would be used in a very limited manner, changes would potentially need to be made to how they are priced and reimbursed to ensure that companies are still able to generate returns on their investment. That said, a more focused drug development programme with regulatory clarity could greatly increase their odds of success and, combined with appropriate pricing and safe use provisions, could succeed in incentivising antimicrobial drug development for emerging infections.

Endnote
1 H.R. 3742 – Antibiotic Development to Advance Patient Treatment (ADAPT) Act of 2013.

References
Barnett, M. L. and Linder, J. A., 2014. ‘Antibiotic prescribing to adults with sore throat in the United States, 1997–2010’. JAMA Internal Medicine, 174(1), pp. 138–140.

Brookings Institution, 2013. Special Medical Use: Limited Use for Drugs Developed in an Expedited Manner to Meet an UnmetMedical Need. Brookings Institution. Available at: www.brookings.edu/events/2013/08/01-special-medical-use

Brookings Institution, 2014. Modernizing Antibacterial Drug Development and Promoting Stewardship. Available at: www.brookings.edu/events/2014/02/07-modernizing-antibacterialdrug-development [Accessed 11 March 2014].

CDC, 2013a. Antibiotic resistance threats in the United States,2013 [PDF] CDC. Available at: www.cdc.gov/drugresistance/threatreport-2013/pdf/ar-threats-2013-508.pdf#page=25 [Accessed 16 January 2014].

CDC, 2013b. Clostridium difficile. Antibiotic resistance threats in the United States, 2013 [PDF] CDC. Available at: www.cdc.gov/drugresistance/threat-report-2013/pdf/ar-threats-2013-508.pdf#page=50 [Accessed 16 January 2014].

Hicks, L. A. et al., 2013. ‘US Outpatient Antibiotic Prescribing, 2010’. New England Journal of Medicine, 368(15), pp. 1461–1463.
Infectious Disease Society of America, 2012.

Limited Population Antibacterial Drug (LPAD) Approval Mechanism. Available at: www.idsociety.org/uploadedFiles/IDSA/News_and_Publications/IDSA_News_Releases/2012/LPAD%20one%20pager.pdf [Accessed 5 March 2014].

Infectious Disease Society of America, 2012. Limited Population Antibacterial Drug (LPAD) Approval Mechanism [PDF] Infectious
Disease Society of America. Available at: www.idsociety.org/uploadedFiles/IDSA/News_and_Publications/IDSA_News_Releases/2012/LPAD%20one%20pager.pdf  [Accessed 18 January 2013].

Kumarasamy, K. K., Toleman, M. A., Walsh, T. R. et al.,2010. ‘Emergence of a new antibiotic resistance mechanism in India,
Pakistan, and the UK: A molecular, biological, and epidemiological study’. Lancet Infectious Diseases, 10(9), pp. 597–602.

McCaig, L. F. and Hughes, J. M., 1995. ‘Trends in antimicrobial drug prescribing among office-based physicians in the United
States’. Journal of the American Medical Association, 273(3), pp. 214–219.

President’s Council of Advisors on Science and Technology, 2012. Report to the President on Propelling Innovation in Drug
Discovery, Development and Evaluation. Available at:www.whitehouse.gov/sites/default/files/microsites/ostp/pcast-fdafinal.pdf    [Accessed 5 March 2014].

Rex, J. H. et al., 2013. ‘A comprehensive regulatory framework to address the unmet need for new antibacterial treatments’. Lancet Infectious Diseases, 13(3), pp. 269–275.

Roberts, R. R., Hota, B., Ahmad, I. et al., 2009. ‘Hospital and societal costs of antimicrobial – Resistant infections in a Chicago
teaching hospital: Implications for antibiotic stewardship’. Clinical Infectious Diseases, 49(8), pp. 1175–1184.

WHO (World Health Organization), 2010. Fact Sheet: Rational Use of Medicines [webpage] WHO. Available at:
www.who.int/mediacentre/factsheets/fs338/en [Accessed 28 February 2014].

WHO (World Health Organization), 2013. Antimicrobial Drug Resistance [PDF] WHO. Available at: http://apps.who.int/gb/ebwha/pdf_files/EB134/B134_37-en.pdf [Accessed 6 March 2014].

WHO (World Health Organization), 2013. Notified MDR-TB cases (number per 100,000 population), 2005–12. WHO. Available at:
https://extranet.who.int/sree/Reports?op=vs&path=/WHO_HQ_Reports/G2/PROD/EXT/MDRTB_Indicators_map [Accessed 28 February 2014].

Downloads

• Antibiotics Stewardship and Innovation

       

After years of warnings from the public health community about the growing threat of antibiotic resistance, yesterday the White House announced a national strategy to combat the growing problem of antibiotic resistance within the U.S. and abroad. The administration’s commitment represents an important step forward, as antibiotic-resistant infections are responsible for 23,000 deaths annually, and cost over $50 billion in excess health spending and lost productivity.  The administration’s National Strategy on Combating Antibiotic-Resistant Bacteria includes incentives for developing new drugs, more rigorous stewardship of existing drugs, and better surveillance of antibiotic use and the pathogens that are resistant to them.  President Obama also issued an Executive Order that establishes an interagency Task Force and a non-governmental Presidential Advisory Council that will focus on broad-based strategies for slowing the emergence and spread of resistant infections. 

While antibiotics are crucial for treating bacterial infections, their misuse over time has contributed to a rather alarming rate of antibiotic resistance, including the development of multidrug-resistance bacteria or “super bugs.” Misuse manifests throughout all corners of public and private life; from the doctor’s office when prescribed to treat viruses; to industrial agriculture, where they are used in abundance to promote growth in livestock. New data from the World Health Organization (WHO) and U.S. Centers for Disease Control and Prevention (CDC) confirm that rising overuse of antibiotics has already become a major public health threat worldwide.

The administration’s announcement included a report from the President’s Council of Advisors on Science and Technology (PCAST) titled “Combatting Antibiotic Resistance,” which includes recommendations developed by a range of experts to help control antibiotic resistance. In addition, they outline a $20 million prize to reward the development of a new rapid, point-of-care diagnostic test. Such tests help health care providers choose the right antibiotics for their patients and streamline drug development by making it easier to identify and treat patients in clinical trials.  

The Need for Financial Incentives and Better Reimbursement

A highlight of the PCAST report is its recommendations on economic incentives to bring drug manufacturers back into the antibiotics market. Innovative changes to pharmaceutical regulation and research and development (R&D) will be welcomed by many in the health care community, but financial incentives and better reimbursement are necessary to alleviate the market failure for antibacterial drugs. A major challenge, particularly within a fee-for-service or volume-based reimbursement system is providing economic incentives that promote investment in drug development without encouraging overuse.

A number of public and private stakeholders, including the Engelberg Center for Health Care Reform and Chatham House’s Centre on Global Health Security Working Group on Antimicrobial Resistance, are exploring alternative reimbursement mechanisms that “de-link” revenue from the volume of antibiotics sold. Such a mechanism, combined with further measures to stimulate innovation, could create a stable incentive structure to support R&D. Further, legislative proposals under consideration by Congress to reinvigorate the antibiotic pipeline, including the Antibiotic Development to Advance Patient Treatment (ADAPT) Act of 2013, could complement the White House’s efforts and help turn the tide on antibiotic resistance. Spurring the development of new antibiotics is critical because resistance will continue to develop even if health care providers and health systems can find ways to prevent the misuse of these drugs.

       

While antibiotics are necessary and crucial for treating bacterial infections, their misuse over time has contributed to a rather alarming rate of antibiotic resistance, including the development of multidrug-resistance bacteria or “super bugs.” Misuse manifests throughout all corners of public and private life; from the doctor’s office when prescribed to treat viruses; to industrial agriculture, where they are used in abundance to prevent disease in livestock. New data from the World Health Organization (WHO) and U.S. Centers for Disease Control and Prevention (CDC) confirm that rising overuse of antibiotics has already become a major public health threat worldwide.

As drug resistance increases, we will see a number of dangerous and far-reaching consequences. First, common infections like STDs, pneumonia, and “staph” infections will become increasingly difficult to treat, and in extreme cases these infections may require hospitalization or treatment with expensive and toxic second-line therapies. In fact, recent estimates suggest that every year more than 23,000 people die due to drug-resistant infections in the U.S., and many more suffer from complications caused by resistant pathogens. Further, infections will be harder to control. Health care providers are increasingly encountering highly resistant infections not only in hospitals – where such infections can easily spread between vulnerable patients – but also in outpatient care settings.

Fundamental Approaches to Slowing Resistance

Incentivize appropriate use of antibiotics. Many patients and providers underestimate the risks of using antibiotics when they are not warranted, in part because these drugs often have rapid beneficial effects for those who truly need them.  In many parts of the world the perception that antibiotics carry few risks has been bolstered by their low costs and availability without a prescription or contact with a trained health care provider. Education efforts, stewardship programs, and the development of new clinical guidelines have shown some success in limiting antibiotic use, but these fixes are limited in scope and generally not perceived as cost-effective or sustainable. Broader efforts to incentivize appropriate use, coupled with economic incentives, may be more effective in changing the culture of antibiotic use. These options might include physician or hospital report cards that help impact patient provider selection, or bonuses based on standardized performance measures that can be used to report on success of promoting appropriate use.  While these might create additional costs, they would likely help control rates of drug resistant infections and outweigh the costs of treating them.

Reinvigorate the drug development pipeline with novel antibiotics. There has not been a new class of antibiotics discovered in almost three decades, and companies have largely left the infectious disease space for more stable and lucrative product lines, such as cancer and chronic disease. Antibiotics have historically been inexpensive and are typically used only for short periods of time, creating limited opportunities for return on investment. In addition, unlike cancer or heart disease treatments, antibiotics lose effectiveness over time, making them unattractive for investment. Once they are on the market, the push to limit use of certain antibiotics to the most severe infections can further constrict an already weak market.

Late last year, H.R. 3742, the Antibiotic Development to Advance Patient Treatment (ADAPT) Act of 2013, was introduced and referred to the House Energy and Commerce Subcommittee on Health. If enacted, the ADAPT Act would create a streamlined development pathway to expedite the approval of antibiotics that treat limited patient populations with serious unmet medical needs. This could potentially reduce costs and development time for companies, thereby encouraging investment in this space. Regulators have indicated that they would also welcome the opportunity to evaluate benefits and risk for a more selective patient subpopulation if they could be confident the product would be used appropriately. The bill has received a great deal of support and would help address a critical public health need (I cover this topic in more detail with my colleagues Kevin Outterson, John Powers, and Mark McClellan in a recent Health Affairs paper).

Advance new economic incentives to remedy market failure. Innovative changes to pharmaceutical regulation, research and development (R&D), and reimbursement are necessary to alleviate the market failure for antibacterial drugs. A major challenge, particularly within a fee-for-service or volume-based reimbursement system, is providing economic incentives that promote investment in drug development without encouraging overuse.  A number of public and private stakeholders, including the Engelberg Center for Health Care Reform and Chatham House’s Centre on Global Health Security Working Group on Antimicrobial Resistance, are exploring alternative reimbursement mechanisms that  “de-link” revenue from the volume of antibiotics sold. Such a mechanism, combined with further measures to stimulate innovation, could create a stable incentive structure to support R&D.

Improve tracking and monitoring of resistance in the outpatient setting. There is increasing concern about much less rigorous surveillance capabilities in the outpatient setting, where drug-resistant infections are also on the rise. Policymakers should consider new incentives for providers and insurers to encourage a coordinated approach for tracking inpatient and outpatient resistance data. The ADAPT Act, mentioned above, also seeks to enhance monitoring of antibiotic utilization and resistance patterns. Health insurance companies can leverage resistance-related data linked to health care claims, while providers can capture lab results in electronic health records. Ultimately, this data could be linked to health and economic outcomes at the state, federal, and international levels, and provide a more comprehensive population-based understanding of the impact and spread of resistance. Current examples include the Food and Drug Administration’s (FDA) Sentinel Initiative and the Patient-Centered Outcomes Research Institute’s PCORnet initiative. 

Antibiotic resistance is an urgent and persistent threat. As such, patients and providers will continue to require new antibiotics as older drugs are forced into retirement by resistant pathogens. Stewardship efforts will remain critical in the absence of game-changing therapies that parry resistance mechanisms. Lastly, a coordinated surveillance approach that involves diverse stakeholder groups is needed to understand the health and economic consequences of drug resistance, and to inform antibiotic development and stewardship efforts.

Editor's note: This blog was originally posted in May 2014 on Brookings UpFront.

       

After decades of neglect, Latin American governments are increasingly focusing on urban slums. What often spurs their policy interventions is a desire to counter violent criminality leaking out from the poor marginalized slums controlled by gangs into the city centers the better-off residents want to keep safe. But tackling the socioeconomic dynamics of slums -- the trap of poverty, discrimination, lack of public goods and social services, and rule by nonstate actors -- is not only complex, but also costly. Governments, elites, and middle classes tend not to want to spend resources on slums. Effective policies have to be sustained for decades, and political will and tax revenues for such complex state-building are frequently scarce.

Focusing on a discreet intervention – providing low-cost housing – becomes tempting. Rarely is it sufficient. The condition of the buildings alone is not what makes a slum a slum. Moving residents from slums to better low-cost housing has encountered systematic challenges not just in Latin America, but also in other places where it has been tried, such as Kenya. Instead, policies need to focus on broader community dynamics, including public safety, legal job creation with sufficient income, human capital development, and robust connectivity of slums to economically-thriving areas, something residents of the latter often don’t want.

Paradoxically, real estate dynamics can have pernicious effects. If broader pacification does take hold and public safety in slums increases, some slum areas can become desirable real estate with vast development possibilities. Developers may well seek to buy the land by offering “better” low-cost housing to slum residents to get them to move. Since many slum residents do not have title to their residences, forced displacement also occurs, albeit under the cloak of being nice to the poor.

Instead of being limited to the provision of alternative residences, policies to address slums need to be about inclusion, economic growth, safety, and connectivity of slums with the thriving city parts, and accountability of city-governance authorities.

This commentary was originally published by the Inter-American Dialogue’s Latin America Advisor. 

      

       

       

Let’s take a moment for a thought experiment. I do this days after more Palestinian attacks on Israelis, including the horrific murder of a mother of six children; soon after Israel announced the expropriation of another 370 acres of land near Jericho; and after Majed Faraj, the Palestinian security chief, announced that Palestinian security forces had intercepted 200 potential terrorist attacks against Israel. The thought experiment focuses on whether the “Plan B” for the Israel-Palestine dispute should be Israel’s annexation of the territories it occupied in 1967 and the extension of full citizenship rights to the Palestinians in those areas.

To be sure, I still count myself among the dying breed of those who believe fervently in the two-state solution—two states living side by side in peace and security, each enjoying sovereignty and political independence in part of the land that both claim as their exclusive national homes. This is still the best, by far, of all possible outcomes of the dispute. This is not to say that the two-state solution is without faults. Thus far, the two sides have not been able to agree on critical details, and there is no guarantee that achieving two states would assure peaceful relations. But the two-state solution, based on partition of the land, appears to offer the best chance for long term peace. I would dump all Plan B’s and C’s in a heartbeat if leadership emerged in Israel and Palestine—and in the United States—that proved willing to move toward a two-state outcome. 

I still count myself among the dying breed of those who believe fervently in the two-state solution.

But hoping for better, stronger, more farsighted leadership is not a substitute for policy. The fact is that both Israel and the Palestine Liberation Organization (PLO) are further today from bringing forth such leaders than at any time before. Even if Benjamin Netanyahu yields the prime minister’s office to another contender, no one in Israel is proposing the kind of far-reaching accommodation toward which Ehud Olmert was heading in 2008. None of Mahmoud Abbas’s likely successors has even articulated a reasonable peace plan. And none of the candidates for U.S. president is likely to be as committed to the search for peace as Barack Obama has been, and even his commitment has fallen far short of what is needed to move the recalcitrant parties toward peace. The sad reality is that politics—not policy, per se—is what blocks progress toward a two-state solution.

The sad reality is that politics—not policy, per se—is what blocks progress toward a two-state solution.

Regional solution?

In the absence of progress toward two states, are there better alternatives than throwing in the towel and looking at annexation as Plan B? The search for alternative Plan B’s is a fool’s errand. Some of those ideas are creative, but none of them will be accepted by both sides. For example, one Plan B variant du jour rests on the premise of a “regional solution”—that is, having Israel and the Arab world reach a comprehensive peace agreement that includes a resolution of the Palestinian issue. Sounds good, except it makes no sense. 

First, Israel has not accepted the Arab Peace Initiative (API) of 2002, the closest the Arab world has come to accepting Israel within the borders of the 1949 armistice line and agreeing to normalize relations with Israel once peace has been achieved. But no Israeli government has liked its terms, especially the paragraph on Palestinian refugees, the notion of a Palestinian capital in Jerusalem, and the API’s insistence on full Israeli withdrawal. Thus, the question to those who propose a regional solution today is whether there is a coalition in Israel ready to use the API as the basis for negotiating a comprehensive peace. I think not.

Second, the Arab world is in no position to deliver on what the API promises. The Arabs have never followed up the API by engaging Israel. And the premise of the API has been that the Arabs will recognize Israel and agree to normalize only after peace is concluded with the Palestinians (and the Syrians and Lebanese)– not a very attractive incentive for Israelis to enter a risky peace process.

[T]he Arab world of 2002, however dysfunctional, was far more stable than the Arab world of 2016.

And third, the Arab world of 2002, however dysfunctional, was far more stable than the Arab world of 2016. The opponents of the two-state solution in Israel point to this when describing the security dangers that Israel would face were it to concede anything now to the Palestinians. Even if a comprehensive solution were to rest on the shoulders of Egypt and Jordan, Israel’s peace treaty partners, would Israeli skeptics truly be assuaged that these countries could assure Israel’s security in the face of continued instability (Egypt) or the impact of refugees and economic distress (Jordan)? Indeed, the idea of a regional or comprehensive solution based on Arab stability today is chimerical. 

Status quo?

The alternatives to the regional idea are equally unrealistic. The idea of confederation rests on the agreement of Jordan (and potentially Egypt) to join a political entity with the Palestinians. However, neither state has indicated any interest in doing so. 

“Maintaining the status quo” is a non-starter, because status quos are never static—as the events of recent years prove, they tend to get worse. How many Intifadas or stabbings will it take for the people of Israel to believe their own security chiefs, who recognize that these actions are born of frustration over the occupation and related grievances? Why should Israelis believe that the majority of Palestinians are interested in peace when Hamas—opposed to Israel’s very existence—still rules Gaza and commands significant popular support, and while the Palestinian Authority is crumbling and hardly represents anyone anymore? And how long will it take Palestinian supporters of armed and violent resistance to recognize that their abortive efforts to destroy Israel and indiscriminate attacks on Israeli civilians are repugnant: targeting civilians is a morally unacceptable tactic for any resistance movement. 

Thus, the idea of “conflict management” or even “conflict mitigation”—staple products of those who support maintaining the status quo until somehow things change—is pernicious, for it rests on an assumption that the rest of us simply don’t understand the conflict.

[T]he idea of a regional or comprehensive solution based on Arab stability today is chimerical.

A futile search for alternatives

And so it is for all other Plan B’s. Several years ago, my Princeton graduate students embarked on an effort to find a viable alternative to the two-state solution; and they told me at the outset that they intended to prove that such an alternative existed. In the end, they failed and returned to the idea that the only viable solution was to partition the land into two states. Others, too, have tried to find alternatives, and some retain the hope that their policy proposal might win the day. I wish them well—for I really do believe in peace, whether it’s via two states or otherwise. But I have no confidence they will succeed.

[T]he idea of “conflict management” or even “conflict mitigation”—staple products of those who support maintaining the status quo until somehow things change—is pernicious, for it rests on an assumption that the rest of us simply don’t understand the conflict.

And so we are back to the thought experiment. This would take as a starting point what Israeli Minister Uri Ariel told my students several years ago: we (Israel) have won, and the land of Israel is ours. Under this scenario, Israel would:

• Formally annex the territories it occupied in 1967, basing its legal argument on its belief that these are “disputed” rather than “occupied” territories. 
• In connection with this act of annexation, Israel would offer full citizenship rights to all the Palestinians living in the territories. While Israel would probably want to include only the West Bank in this arrangement, excluding Gaza would make it impossible to secure any support internationally, in that Gaza is as much a part of Resolution 242 as is the West Bank.
• Those Palestinians who accept citizenship would then enjoy equal rights with all other Israelis; those Palestinians who reject citizenship would be offered permanent residency, a status that would include certain rights and privileges but not full citizenship rights (for example, voting in national elections). 
• Israel would then approach the United Nations Security Council to argue that these measures constituted an act of self-determination, and that the outcome represented an end of the conflict in accordance with Resolution 242. I am not a lawyer and I assume that many—including Palestinians and Arabs—would dispute this Israeli argument. But the process would change the status quo fundamentally and offer a real alternative to the two-state solution.

Could this work, and is it a real Plan B for the conflict? This is but a thought experiment. I suppose most Israelis will hate this idea for it exposes the most significant weakness of the Israeli right wing and the settlements movement, namely that it undercuts fundamentally the idea of a permanent Jewish majority state. Similarly, most Palestinians will also hate this idea because it forecloses the possibility of a real act of self-determination culminating in an independent state and forces Palestinians to confront the emptiness of the slogans that their leaders have employed over the years in the context of the Arab-Israeli dispute. 

The thought experiment is thus not very sound. Perhaps, then, it will scare everyone enough for leaders to get serious about peace.

      

       

While antibiotics are necessary and crucial for treating bacterial infections, their misuse over time has contributed to a rather alarming rate of antibiotic resistance, including the development of multidrug-resistance bacteria or “super bugs.” Misuse manifests throughout all corners of public and private life; from the doctor’s office when prescribed to treat viruses; to industrial agriculture, where they are used in abundance to prevent disease in livestock. New data from the World Health Organization (WHO) and U.S. Centers for Disease Control and Prevention (CDC) confirm that rising overuse of antibiotics has already become a major public health threat worldwide.

As drug resistance increases, we will see a number of dangerous and far-reaching consequences. First, common infections like STDs, pneumonia, and “staph” infections will become increasingly difficult to treat, and in extreme cases these infections may require hospitalization or treatment with expensive and toxic second-line therapies. In fact, recent estimates suggest that every year more than 23,000 people die due to drug-resistant infections in the U.S., and many more suffer from complications caused by resistant pathogens. Further, infections will be harder to control. Health care providers are increasingly encountering highly resistant infections not only in hospitals – where such infections can easily spread between vulnerable patients – but also in outpatient care settings.

Fundamental Approaches to Slowing Resistance

Incentivize appropriate use of antibiotics. Many patients and providers underestimate the risks of using antibiotics when they are not warranted, in part because these drugs often have rapid beneficial effects for those who truly need them.  In many parts of the world the perception that antibiotics carry few risks has been bolstered by their low costs and availability without a prescription or contact with a trained health care provider. Education efforts, stewardship programs, and the development of new clinical guidelines have shown some success in limiting antibiotic use, but these fixes are limited in scope and generally not perceived as cost-effective or sustainable. Broader efforts to incentivize appropriate use, coupled with economic incentives, may be more effective in changing the culture of antibiotic use. These options might include physician or hospital report cards that help impact patient provider selection, or bonuses based on standardized performance measures that can be used to report on success of promoting appropriate use.  While these might create additional costs, they would likely help control rates of drug resistant infections and outweigh the costs of treating them.

Reinvigorate the drug development pipeline with novel antibiotics. There has not been a new class of antibiotics discovered in almost three decades, and companies have largely left the infectious disease space for more stable and lucrative product lines, such as cancer and chronic disease. Antibiotics have historically been inexpensive and are typically used only for short periods of time, creating limited opportunities for return on investment. In addition, unlike cancer or heart disease treatments, antibiotics lose effectiveness over time, making them unattractive for investment. Once they are on the market, the push to limit use of certain antibiotics to the most severe infections can further constrict an already weak market.

Late last year, H.R. 3742, the Antibiotic Development to Advance Patient Treatment (ADAPT) Act of 2013, was introduced and referred to the House Energy and Commerce Subcommittee on Health. If enacted, the ADAPT Act would create a streamlined development pathway to expedite the approval of antibiotics that treat limited patient populations with serious unmet medical needs. This could potentially reduce costs and development time for companies, thereby encouraging investment in this space. Regulators have indicated that they would also welcome the opportunity to evaluate benefits and risk for a more selective patient subpopulation if they could be confident the product would be used appropriately. The bill has received a great deal of support and would help address a critical public health need (I cover this topic in more detail with my colleagues Kevin Outterson, John Powers, and Mark McClellan in a recent Health Affairs paper).

Advance new economic incentives to remedy market failure. Innovative changes to pharmaceutical regulation, research and development (R&D), and reimbursement are necessary to alleviate the market failure for antibacterial drugs. A major challenge, particularly within a fee-for-service or volume-based reimbursement system, is providing economic incentives that promote investment in drug development without encouraging overuse.  A number of public and private stakeholders, including the Engelberg Center for Health Care Reform and Chatham House’s Centre on Global Health Security Working Group on Antimicrobial Resistance, are exploring alternative reimbursement mechanisms that  “de-link” revenue from the volume of antibiotics sold. Such a mechanism, combined with further measures to stimulate innovation, could create a stable incentive structure to support R&D.

Improve tracking and monitoring of resistance in the outpatient setting. There is increasing concern about much less rigorous surveillance capabilities in the outpatient setting, where drug-resistant infections are also on the rise. Policymakers should consider new incentives for providers and insurers to encourage a coordinated approach for tracking inpatient and outpatient resistance data. The ADAPT Act, mentioned above, also seeks to enhance monitoring of antibiotic utilization and resistance patterns. Health insurance companies can leverage resistance-related data linked to health care claims, while providers can capture lab results in electronic health records. Ultimately, this data could be linked to health and economic outcomes at the state, federal, and international levels, and provide a more comprehensive population-based understanding of the impact and spread of resistance. Current examples include the Food and Drug Administration’s (FDA) Sentinel Initiative and the Patient-Centered Outcomes Research Institute’s PCORnet initiative. 

Antibiotic resistance is an urgent and persistent threat. As such, patients and providers will continue to require new antibiotics as older drugs are forced into retirement by resistant pathogens. Stewardship efforts will remain critical in the absence of game-changing therapies that parry resistance mechanisms. Lastly, a coordinated surveillance approach that involves diverse stakeholder groups is needed to understand the health and economic consequences of drug resistance, and to inform antibiotic development and stewardship efforts.

Editor's note: This blog was originally posted in May 2014 on Brookings UpFront.

      

Event Information

Over the past decade, drug shortages and product recalls in the U.S. have occurred at unprecedented rates, limiting patient access to critical medicines and undermining health care. A majority of these shortages and recalls have been due to manufacturing quality issues. In response to these problems, and as part of its ongoing efforts to ensure a continuous supply of high-quality pharmaceuticals in the U.S., the U.S. Food and Drug Administration (FDA) is pursuing a range of strategies designed to improve the flexibility, reliability, and quality of pharmaceutical manufacturing. Among these strategies is the promotion of new manufacturing technologies, including continuous manufacturing. Continuous manufacturing offers several important advantages over current approaches to manufacturing and has the potential to significantly mitigate the risks of quality failures. At present, however, these technologies and processes are not widely used by the pharmaceutical industry, and there remain a number of barriers to their broader adoption. In collaboration with a range of stakeholders, FDA is currently exploring ways in which it can help to address these barriers and facilitate the uptake of new manufacturing technologies.

Under a cooperative agreement with FDA, the Center for Health Policy at Brookings held a workshop on October 19 entitled “Promoting Continuous Manufacturing in the Pharmaceutical Sector.” This workshop provided an opportunity for industry, academia, and government partners to identify the major barriers to the adoption of continuous manufacturing, discuss regulatory policies and strategies that could help to address those barriers, and explore approaches to improving public and private sector alignment and collaboration to promote the adoption of continuous manufacturing.

Event Materials

• Continuous Manufacturing Agenda
• CM Panelist Bio Sheet
• Participant list
• Continuous manufacturing discussion guide
• allslides_Continuousmanufacturingworkshop_101915
• meetingsummary_101915_continuousmanufacturing

       

On Monday, July 18, 2016, the world celebrated Nelson Mandela International Day, a day recognizing the former president of South Africa’s commitment to fostering peace and freedom. Every year the Nelson Mandela Foundation hosts a lecture, inviting prominent individuals to discuss significant social issues affecting the African continent. For this year’s lecture, Bill Gates was selected to speak on the theme of “Living Together” in front of a packed stadium in Pretoria. Gates focused on a topic Mandela returned to repeatedly throughout his life—the power of the youth. In the words of Gates, “…young people are better than old at driving innovation because they are not locked in by the limits of the past… we must clear away the obstacles standing in young people’s way so that they can seize all of their potential.”

Unfortunately, South Africa, the second-largest economy on the continent, has the highest youth unemployment rate at 54 percent, as seen in the figure below. Surprisingly, according to the figure the highest rates of youth unemployment lie in the upper-middle-income countries as classified by GNI per capita. Additionally, these unemployment rates might be depressed due to the fact that unemployment refers to people looking for jobs, and many of Africa’s youth are forced into the informal sector after giving up on their search for employment.

Although youth unemployment in Africa is often seen as a growing challenge, a number of experts interpret the large youth population as an opportunity, as long as the youth have access to the economic opportunities through which they can channel their energy into progress. As Africa’s youth is predicted to grow exponentially, achieving broad-based economic growth and development will rely on breaking down the barriers to economic opportunity, by investing in human capital (through education) and in improving business environments. 

Figure 2.3. Youth unemployment will continue to be a growing challenge in 2016

Interestingly, GDP and income classification have little correlation with youth unemployment rates. For example, South Africa, which has the second-largest economy on the continent and is considered an upper-middle-income country based on its GNI per capita, has the highest youth unemployment rate at nearly 54 percent. Meanwhile, the Liberian economy, which is nearly 200 times smaller than South Africa’s, has a youth unemployment rate 10 times smaller. Youth unemployment is measured as the share of the labor force (ages 15-24) without work but available for and seeking employment. Estimates may be low in some low-income countries like Liberia because many young people cannot afford not to work to seek employment and as a result, end up in low-paying jobs.

Source: Youth unemployment figures from World Development Indicators and GDP data from the World Bank databank.

See the Brookings Africa Growth Initiative’s Foresight Africa 2016 report, from which the figure below comes, for more highlights on the growing challenge of youth unemployment in Africa. In addition, earlier this month the Brookings Institution hosted an Africa Policy Dialogue on the Hill on jobs in Africa, alluding to the shortcomings of the educational systems and the importance of infrastructure and electricity to support business and attract investment. For a summary of the conversation, see here.

Tor Syvrud contributed to this post.

       

       

       

Introduction

The post-World War II era has witnessed the nearly exclusive building of low density suburbia, here termed “drivable sub-urban” development, as the American metropolitan built environment. However, over the past 15 years, there has been a gradual shift in how Americans have created their built environment (defined as the real estate, which is generally privately owned, and the infrastructure that supports real estate, majority publicly owned), as demonstrated by the success of the many downtown revitalizations, new urbanism, and transit-oriented development. This has been the result of the re-introduction and expansion of higher density “walkable urban” places. This new trend is the focus of the recently published book, The Option of Urbanism: Investing in a New American Dream (Island Press, November 2007).

This field survey attempts to identify the number and location of “regional-serving” walkable urban places in the 30 largest metropolitan areas in the U.S., where 138 million, or 46 percent, of the U.S. population lives. This field survey determines where these walkable urban places are most prevalent on a per capita basis, where they are generally located within the metro area, and the extent to which rail transit service is associated with walkable urban development.

The first section defines the key concepts used in the survey, providing relevant background information for those who have not read The Option of Urbanism. The second section outlines the methodology. The third section, which is the heart of the report, outlines the findings and conclusions of the survey.

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WALK SCORE, a new Web site popular with urbanists and environmentalists (walkscore.com), rates places for their walkability—the ease of meeting daily needs on foot.

The popularity of the site is an indicator that how the American Dream plays out on the ground has been fundamentally changing over the last 10 to 15 years.

The Ozzie and Harriet drivable suburban version of the American Dream is being supplemented by the Seinfeld vision of "walkable urbanism." Led by late-marrying young adults and empty-nester baby-boomers, many households are looking for the excitement and options living and working in a walkable urban place can bring. With almost nine of 10 new households over the next 20 years being singles or couples without children, this trend promises to continue.

A recent Brookings Institution survey of the largest 30 metro areas in the country identifies the 157 walkable urban places that play a regionally significant role. It also ranks the Top 30 metros in per capita number of walkable urban places. The Philadelphia metropolitan area ranks as the 13th highest on the number of walkable urban places per capita.

Certainly the many already revived downtowns like those in Denver, Washington, Portland, Seattle and San Diego are the most visible signs of the walkable urban trend. But there are many other places you might not suspect.

This includes the emergence of "downtown-adjacent" places like Chelsea and Union Square in New York, suburban town centers like Pasadena and Long Beach in the L.A. area and even built-from-scratch spots like Reston Town Center near Dulles Airport, 30 miles outside Washington.

A major benefit of walkable urban development is that it keeps and attracts young adults to the metro area, many of whom willingly trade crushing car commutes and high gas prices for lively walkable places to live and work.

Walkable urban places seem to attract the well-educated, the so-called "creative class."

Approximately 26 percent of Americans over 25 have college degree - but 99 percent of the new residents moving to Center City this decade have a college degree.

Walkable urbanism increases the economic development potential of the metro area in the knowledge economy. If many of the Gen X-ers and the Millennial generations do not get this lifestyle, they'll move to New York or Washington, depriving Philadelphia of the entrepreneurs it needs to grow.

Walkable urbanism is also essential to create sustainable places to live and work, reducing greenhouse-gas emissions. It is probable that walkable urban households emit less than half the greenhouse gas as driving suburban households - they walk more and unavoidably share heat with upstairs neighbors.

Center City and Society Hill are the most obvious, though not the only, locations of this trend in the Philadelphia region. The recent emergence of University City around Penn and Drexel, Manayunk and New Hope are other significant walkable urban places in the Delaware Valley.

Missing are additional places in the suburbs, particularly around commuter and subway stations.

Rail transit is crucial for walkable urbanism places to emerge.

The investment has already been made for this comprehensive, if underfunded, rail system. Building high-density, mixed-use places around these stations will fulfill pent-up market demand, promote economic growth, lower greenhouse emissions and even give their suburban neighbors a great place for a restaurant within walking distance.

Over the next few years, Philadelphia metro will no doubt see its ranking in the Brookings survey rise while more households will see their Walk Score numbers soar. Seinfeld is coming to Philadelphia. *

Leinberger is a visiting fellow at the Brookings Institution, professor at the University of Michigan and a limited partner in Arcadia Land Co., which has projects in the Philadelphia and Kansas City areas. His most recent book is "The Option of Urbanism: Investing in a new American dream" (Island Press, 2007).

       

I have been coming to Charlotte for 25 years, consulting for the likes of Crosland and Faison Enterprises, and have observed in Charlotte one of the most remarkable metropolitan transformations in the country. The economy has obviously changed, becoming one of the largest concentrations of U.S. financial institutions, thanks to the likes of Hugh McColl, Bank of America and Wachovia.

Your town has seen the metropolitan edge grow into South Carolina and up past Davidson. This sprawl is balanced by the splendor of uptown, or Center City, partially a benefit of McColl's focus on your downtown.

I returned to Charlotte two weeks ago, courtesy of the Charlotte Region Civic By Design Forum, sponsored by AIA Charlotte, to see what has happened since my last visit and to give a speech about the structural shift in how the country is building its built environment. As I mentioned in a column in the Observer before I came (March 8, "Charlotte, walk this way"), the metro areas are changing from just offering the Ozzie and Harriet version of the American Dream and adding a "walkable urban" Seinfeld version as well.

So what did I see in Charlotte?

First, I saw the beginning of the end of sprawl. Like much of the rest of the country, the over-production of automobile-driven suburban development at the fringe of your metropolitan area has reached its limits. The combination of outrageous commutes, high gas prices, and the increasing number of consumers preferring a walkable urban way of life have combined to end the geometric increase in land consumption.

The sub-prime crisis has just accelerated an underlying trend. That trend demonstrates that a lifestyle predicated on cheap gas, subsidized infrastructure and long commutes could not last.

Walkable, urban places

But what is emerging to take its place?Metro Charlotte seems to be following a national trend in creating and growing high-density, walkable urban places. The opening of the Lynx light rail line to the south is showing the way. It starts in a re-energized Center City with the one-of-a-kind performing arts center, museums, high-rise temples of commerce, sports venues, a convention center, high-end hotels, the central library, among other regionally significant treasures. There is now a "there there" in Center City.

However, housing is the true sign that a downtown is viable. For years, the few urbanites in Charlotte found refuge in the Fourth Ward, one of the special places in the South. However, resilient, safe and racially and socially integrated housing districts have emerged in the First, Second and Third Wards, as well as the beginning of luxury high-rise living in the heart of Center City. There even are small grocery stores and some of the best dining in the region. You are seeing the emergence of a Big City.

But it definitely is not confined to Center City.

Downtown-adjacent places such as Southend, arts-focused places like NoDa, and emerging Elizabeth Avenue and Midtown all are providing rich options. Each of these places has its own character. These places offer a somewhat lower density, but still walkable urban, alternative to Center City.

There is going to be a major hurdle to transforming SouthPark into what it wants to be, an upscale walkable urban place like Winter Park in Orlando or Bethesda near Washington, D.C. It was built for the easy movement and storage of the car, and a decision will have to be made as to whether it wants to be a drivable place -- or a walkable place. Right now, it is trying to be both, is neither fish nor fowl, and this will fail. The fact that there are no plans for rail transit nearby is just one of many signs that it is a very confused area.

Metro Charlotte's future

Regardless of whether SouthPark figures out what it wants to be when it grows up, there will be 8-10 regionally significant, walkable urban places to develop in Metro Charlotte over the next two decades. Each will have a unique character and different density. What they will have in common is that they are walkable (also bikable) for most residents' everyday needs and maybe even employment.

Only four or five have begun to germinate so far. SouthPark should be on that list but won't be until it solves its identity crisis. Where will the others emerge? Best bet is to follow the rails. Most will be anchored by a transit station.

I think I have seen the future of Charlotte. Continue to build out the light-rail system and encourage mixed-use, high-density zoning around the stations. You will find that your extraordinary growth of the past generation will continue but in a new and different manner since the market demands different options. You will also find that this new kind of growth will be economically, financially and environmentally more sustainable.

       

John Kerry to travel to Kenya and Djibouti next week

Exactly one year after U.S. Secretary of State John Kerry’s last multi-country tour of sub-Saharan Africa, he is preparing for another visit to the continent—to Kenya and Djibouti from May 3 to 5, 2015. In Kenya, Kerry and a U.S. delegation including Linda Thomas-Greenfield, assistant secretary of state for African affairs, will engage in talks with senior Kenyan officials on U.S.-Kenya security cooperation, which the U.S. formalized through its Security Governance Initiative (SGI) at the U.S.-Africa Leaders Summit last August. Over the past several years, the U.S. has increased its military assistance to Kenya and African Union (AU) troops to combat the Somali extremist group al-Shabab and has conducted targeted drone strikes against the group’s top leaders.  In the wake of the attack on Kenya’s Garissa University by al-Shabab, President Obama pledged U.S. support for Kenya, and Foreign Minister Amina Mohamed has stated that Kenya is currently seeking additional assistance from the U.S. to strengthen its military and intelligence capabilities.

Kerry will also meet with a wide array of leaders from Kenya’s private sector, civil society, humanitarian organizations, and political opposition regarding the two countries’ “common goals, including accelerating economic growth, strengthening democratic institutions, and improving regional security,” according to a U.S. State Department spokesperson. These meetings are expected to build the foundation for President Obama’s trip to Kenya for the Global Entrepreneurship Summit in July of this year.

On Tuesday, May 5, Kerry will become the first sitting secretary of state to travel to Djibouti. There, he will meet with government officials regarding the evacuation of civilians from Yemen and also visit Camp Lemonnier, the U.S. military base from which it coordinates its counterterror operations in the Horn of Africa region.

Protests erupt as Burundian president seeks third term

This week saw the proliferation of anti-government street demonstrations as current President Pierre Nkurunziza declared his candidacy for a third term, after being in office for ten years.  The opposition has deemed this move as “unconstitutional” and in violation of the 2006 Arusha peace deal which ended the civil war. Since the announcement, hundreds of civilians took to the streets of Bujumbura, despite a strong military presence. At least six people have been killed in clashes between police forces and civilians. 

Since the protests erupted, leading human rights activist Pierre-Claver Mbonimpa has been arrested alongside more than 200 protesters. One of Burundi’s main independent radio stations was also suspended as they were covering the protests.  On Wednesday, the government blocked social media platforms, including Twitter and Facebook, declaring them important tools in implementing and organizing protests. Thursday, amid continuing political protests, Burundi closed its national university and students were sent home. 

Amid the recent protests, Burundi’s constitutional court will examine the president’s third term bid. Meanwhile, U.N. secretary general Ban Ki-moon has sent his special envoy for the Great Lakes Region to hold a dialogue with president Nkurunziza and other government authorities. Senior U.S. diplomat Tom Malinowski also arrived in Bujumbura on Thursday to help defuse the biggest crisis the country has seen in the last few years, expressing disappointment over Nkurunziza’s decision to run for a third term.

China invests billions in African infrastructure

Since the early 2000s, China has become an increasingly significant source of financing for African infrastructure projects, as noted in a recent Brookings paper, “Financing African infrastructure: Can the world deliver?” This week, observers have seen an additional spike in African infrastructure investments from Chinese firms, as three major railway, real estate, and other infrastructure deals were struck on the continent, totaling nearly $7.5 billion in investments.

On Monday, April 27, the state-owned China Railway Construction Corp announced that it will construct a $3.5 billion railway line in Nigeria, as well as a $1.9 billion real estate project in Zimbabwe. Then on Wednesday, the Industrial and Commercial Bank of China (one of the country’s largest lenders) signed a $2 billion deal with the government of Equatorial Guinea in order to carry out a number of infrastructure projects throughout the country. These deals align with China’s “One Belt, One Road” strategy of building infrastructure in Africa and throughout the developing world in order to further integrate their economies, stimulate economic growth, and ultimately increase demand for Chinese exports. For more insight into China’s infrastructure lending in Africa and the implications of these investments for the region’s economies, please see the following piece by Africa Growth Initiative Nonresident Fellow Yun Sun: “Inserting Africa into China’s One Belt, One Road strategy: A new opportunity for jobs and infrastructure?”

      

William Galston and E.J. Dionne, Jr. make the case for universal voting – a new electoral system in which voting would be regarded as a required, civic duty. Why not treat showing up at the polls in the same way we treat a jury summons, which compels us to present ourselves at the court? Galston and Dionne argue that universal voting would enhance the legitimacy of our governing institutions, greatly increasing turnout and the diversity of the American voter base, and ease the intense partisan polarization that weakens our governing capacity.

Citing the implementation of universal voting in Australia in 1924, the authors conclude that universal voting increases citizen participation in the political process. In the United States, they write, universal voting would promote participation among citizens who are not likely to vote—those with lower levels of income and education, young adults, and recent immigrants. By evening out disparities in the electorate, universal voting would put the state on the side of promoting broad civic participation.

In addition to expanding voter participation, universal voting would improve electoral competition and curb hyperpolarization. Galston and Dionne assert that the addition of less partisan voters in the electorate, would force candidates to shift their focus from mobilizing partisan bases to persuading moderates and less committed voters. Reducing partisan rhetoric would help ease polarization and increase prospects for compromise.. Rather than focusing on symbolic, political gestures, Washington might have an incentive to tackle serious issues and solve problems.

Galston and Dionne believe that American democracy cannot be strong if citizenship is weak. And right now, they contend citizenship is strong on rights but weak on responsibilities. Making voting universal would begin to right this balance and send an important message: we all have the duty to help shape the country that has given us so much.

Galston and Dionne recognize that the majority of Americans are far from ready to endorse universal voting. By advancing a proposal that stands outside the perimeter of what the majority of Americans are likely to support, Galston and Dionne aim to enrich public debate—in the short term, by advancing the cause of more modest reforms that would increase participation; in the long term, by expanding public understanding of institutional remedies to political dysfunction. 

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• Dionne and Galston discuss their paper on universal voting

      

In a new research paper—The case for universal voting: Why making voting a duty would enhance our elections and improve our government—Brookings scholars E.J. Dionne, Jr. and William Galston make the case for universal voting—an electoral system in which voting would be regarded as a required, civic duty. Why not treat showing up at the polls in the same way we treat, say, a jury summons? Dionne and Galston argue that universal voting’s benefits would include enhancing the legitimacy of our governing institutions, increasing turnout and the diversity of the American voter base, and easing the intense partisan polarization that weakens our governing capacity.

What do you think of Dionne and Galston’s proposal? Specifically, if voting and registration rules were made easier, should voting in national elections be universal and mandatory for all eligible citizens?

To voice your opinion, click the image below and vote. We will share the results on social media.

       

President Paul Kagame of Rwanda has been a very effective leader for his small Central African nation. First, he led the Rwandan Patriotic Front when it ended the 1994 genocide and brought a measure of stability to a land that had just suffered a terrible holocaust. Then as vice president until 2000, and president since then (being formally elected under the current constitution twice, in 2003 and 2010), he has helped usher in remarkable economic growth and human development. Many Western leaders have personally offered high praise for Kagame—calling him a “visionary” and among “the greatest leaders of our time”—and have marshalled considerable resources to aid in Rwanda’s post-genocide development.

But his leadership has not been without controversy. There have been some excesses and allegations of abuses of political opponents during the Kagame years. And his abuses of power have arguably increased in recent years—suggesting that, whatever his past accomplishments, his real motives for wanting to stay in office may have less to do with a call to service and more with his increasingly autocratic tendencies.

On balance, though, he has been an effective leader who has saved countless lives. Does that legacy justify his seeking what would be a third seven-year term in the nation’s 2017 presidential elections? Rwandan voters choose today whether to approve a constitutional amendment—already passed by the Senate—that would allow President Kagame another stint in power.

Murky waters 

Kagame has been for his nation arguably what Franklin D. Roosevelt was for our own, given the nature of the emergencies facing Rwanda that led to his ascent to power. And we elected FDR four times. To be sure, after the fact, we thought better of it and decided never to allow that again. But we did it. George Washington chose not to run for a third term, but he was blessed with a legion of founding fathers of remarkable ability all around him, and was succeeded by Adams and Jefferson. Lincoln never had the chance to consider a third term—and maybe we would have been better off in the day if he could have served for many years. 

I am not comparing Kagame with Washington, Lincoln and Roosevelt to assert that he belongs in their league. But to dramatize the issue, suppose that he is just as important to his nation as those three gentlemen have been to ours. Would that justify another term? Putting the question this way muddies the waters, but I think it is the only fair way to address the issue. 

More often than not, of course, two terms is more than a given leader deserves. Witness President Hamid Karzai in Afghanistan, or Pierre Nkurunziza in Burundi who just garnered a third term amidst much violence, or Joseph Kabila next door in the Democratic Republic of Congo who is due to step down next year. Indeed, Kabila may or may not do so—and it would be unambiguously bad for his country and American interests if he stayed past that date. All the more reason that, for consistency, we should want Kagame to step down—otherwise leaders like Kabila could use his behavior to excuse and justify their own attempts to hold onto power indefinitely. 

But is it really so simple in his case, and is it really such an easy call? Another tough case is President Yoweri Museveni of Uganda, who has brought a degree of peace and development to his nation after the Amin and Obote periods—but who is now in his sixth term. Perhaps once in a blue moon, a nation can benefit from multiple terms in office for a particularly gifted leader at a particularly fraught and important period in a country’s history.

Mr. Kagame: Prove us wrong 

Ultimately, institution building and the establishment of solid democratic procedures are the only sure guarantor of long-term national stability. Kagame is only 58, but he will not live forever. At some point, Rwanda really will need a succession strategy. 

So I hope Kagame chooses not to run again. But if he does run, we need to pressure him to justify it in terms of the legacy he is helping to create so that Rwanda will have future leaders and institutions that can keep the country moving forward.

Ultimately, institution building and the establishment of solid democratic procedures are the only sure guarantor of long-term national stability.

Thus, if Kagame does persuade the public to change the constitution and does win a third elected term, we should cut aid (though not impose stronger measures like trade sanctions) to show our disapproval. That is, we should cut aid unless he uses the third term—which must certainly be his last—to show his countrymen and the world that in fact his rule is about improving his country, not turning it into another fiefdom run by an African strongman. 

For us, taking this approach will necessitate creating a method for evaluating whether Rwanda’s institutions gradually move closer to true democracy in the years ahead so that, whatever might happen with a third term, a fourth term becomes entirely unjustifiable. Presidents for life are bad for their countries while they are alive, and they are dangerous for their countries when they die. Kagame needs to understand this basic fact before he becomes the next world leader who starts out a noble man and then allows power to corrupt him.

More than two decades after the genocide, Rwanda is ready for a more vigorous democratic process—and any responsible leader should be building up the institutions to prepare for that eventuality. Stronger political parties that do not have exclusive ties to just one ethnic group, clear laws constraining and regulating the nature of political competition so that it is inclusive and nonviolent, strong courts—these are the essence of an established democracy, and Rwanda needs them.

       

Editor's Note: In an interview with La Repubblica's Rosalba Castelletti, Jonathan Laurence discussed the significance of the revelations that the United States has continued to spy on Germany, and what they mean for the future of the transatlantic relationship.

"È un momento delicato, ma non penso che la Germania abbia interesse ad esagerare le tensioni con gli Stati Uniti". A sostenerlo è Jonathan Laurence, professore di Scienze politiche al Boston College ed esperto di Relazioni transatlantiche presso il think tank Brookings Institution di Washington.

Professor Laurence, quest'episodio come inciderà sulle relazioni tra i due Paesi?

"La situazione è tesa. Berlino stavolta non ha espresso solo la consueta indignazione, ma ha compiuto un atto formale con l'espulsione del capo dei servizi segreti, perché è la terza volta che il popolo tedesco apprende di essere spiato dagli americani. La prima volta è successo con il Datagate, la seconda con l'intercettazione del cellulare della cancelliera e ora con due spie tedesche al soldo degli americani".

In cosa differisce quest'ultimo caso dai precedenti?

"Non si tratta di programmi d'alta tecnologia, ma di spionaggio più "vecchia maniera": documenti in cambio di soldi. Stavolta poi non c'è in ballo un problema di sicurezza internazionale. È un nuovo colpo per la reputazione Usa perché ancora una volta si dimostra indifferente alla sensibilità europea riguardo alla raccolta di dati".

E i tedeschi sono forse i più sensibili, visto che hanno sperimentato lo spionaggio della Gestapo e della Stasi...

"Di fatti. L'attuale cancelliera ha fatto il suo debutto in politica proprio dopo il crollo della Stasi. Ecco perché dobbiamo aspettarci che la Germania dichiari a gran voce la sua collera".

Cosa può fare l'amministrazione Usa per riparare?

"Qualcosa di più che cercare infruttuosi colloqui bilaterali o accordi di non spionaggio reciproco. La Germania non è ingenua, sa che i servizi americani hanno bisogno di operare soprattutto dopo il 2001, ma vuole che si lavori insieme. Non credo però che cerchi il conflitto. Berlino e Washington hanno bisogno l'una dell'altra sia sulle sanzioni contro la Russia in merito alla crisi Ucraina sia sull'accordo di libero scambio".

      

Event Information

The Brookings Doha Center (BDC) hosted a panel discussion on April 21, 2015 regarding Libya’s displacement crisis amid the country’s ongoing violence. The panelists were Houda Mzioudet, a journalist, researcher, and commentator on Libyan and Tunisian affairs; Megan Bradley, a non-resident fellow at the Brookings-LSE Project on Internal Displacement and assistant professor at McGill University, and Ibrahim Sharqieh, the deputy director of the BDC. Sultan Barakat, the BDC’s director of research, moderated the event, which was attended by members of Qatar's diplomatic, academic, and media community.

Sultan Barakat opened the discussion by explaining that the main difference between refugees and internally displaced persons (IDPs) is whether they are able to cross a border. By doing so, refugees gain access to certain types of status and assistance. Otherwise, both groups’ experience of being uprooted is similar, as they are likely to lose their livelihoods, friends, family, and end up in a difficult environment where they are at the mercy of others. Barakat argued that the international community has proven it cannot deal with these challenges, especially in a dignified way, and called for a reexamination of the 1951 Refugee Convention.

Ibrahim Sharqieh then described the displacement crisis within Libya, starting with the 2011 revolution that removed Gadhafi from power. He reported that the number of IDPs in the wake of the fighting reached 550,000, most of whom fled for political reasons, as they were Gadhafi supporters. He said that most IDPs returned to their homes after Gadhafi’s defeat, with the numbers falling to 56,000 by early 2014, though some groups such as the Tawerghans and the Mashashya tribe continued to face difficult situations. Sharqieh noted that due to Libya’s current civil war, the number of IDPs has now increased to 400,000. Many of them are scattered over 35 towns and cities, often lacking shelter due to the small number of available camps. He added that Libya’s IDPs often get caught in crossfire between militia groups, particularly in Benghazi and near Tripoli’s airport, and their movements have been restricted. He found that IDPs from Tawergha at the Janzour camp near Tripoli faced discrimination when they left the camp, which extended to their children that attend area schools.

According to Sharqieh, the ultimate solution is a successful transition where there is national reconciliation and the establishment of a transitional justice law, but he noted that this is not very likely because of the ongoing civil war and presence of rival governments. In the meantime, he expressed that parties to the conflict have an obligation to protect IDPs, providing humanitarian support and education as well. Sharqieh also advocated for IDPs being represented in the ongoing U.N.-sponsored negotiations to ensure that their situation is addressed. He reported that the Tawerghans are highly organized, in communication with the state, and have been able to forge some agreements with Misrata, while more recently displaced IDPs are basically just on the run.

Houda Mzioudet then discussed the Libyans who have crossed into Tunisia, noting that Tunisians historically have not considered Libyans refugees because of their close relations. She said that in 2011 these Libyans’ presence was not considered a major problem, as many found refuge with Tunisian families in the south and Tunisia received U.N. support. She noted, however, that a new wave of Libyans last summer had complicated matters, as these communities were more politically and ideologically diverse. Asked by Barakat whether refugees were bringing Libya’s politics with them, Mzioudet said the Libyans were accused at one time of trying to stir up trouble, but the government took a firm stance against them getting involved in Tunisia’s politics.

Mzioudet argued that the main concern now is how Libyans can be assisted, as many of them have lost trust in the Libyan authorities and are fearful of approaching the Libyan embassy. She reported that Libyans are now living in a state of limbo: they do not need visas, which enables them to live underground, but also prevents them from getting jobs. Mzioudet described this as a challenge for Tunisian authorities, as clear information about these Libyans is hard to come by. She cited estimates of their numbers ranging from the government’s 1.5 million (roughly 10 percent of Tunisia’s population) to a recent study’s 300,000-400,000.

Mzioudet noted that the U.N. High Commissioner for Refugees (UNHCR) has encouraged Libyans to come forward and register, but many have refused to do so. She also recounted that the Tunisia’s extradition of ex-Libyan Prime Minister Al-Baghdadi Al-Mahmoudi caused an uproar and frightened many Libyans. Though Mzioudet noted that civil society groups have done much to help Libyan refugee communities, the U.N. has prioritized other needs and Tunisia is not recognized as a host country by international community. She added that at this point some Libyans are not able to make ends meet and some women have turned to prostitution as a result.

Megan Bradley’s presentation stressed the need for a holistic approach to Libya’s displacement crisis and the importance of thinking about the relationships between the refugee and IDP populations. She explained that the accepted durable solutions for each were similar: local integration in the country of asylum or community where they are sheltering, resettlement to a third country or community, or voluntary repatriation in conditions of safety and dignity. Bradley noted that the expectation generally seems to be that repatriation and return will be the predominant approach for Libyan refugees and IDPs, as occurred remarkably quickly following the revolution. She said this was possible largely because Libyans were able to finance their own returns—rare in displacement situations. Similarly, many displaced Libyans are continuing to depend on their own resources, which Bradley warned is not sustainable.

Bradley went on to make four specific points. First, she emphasized that under international law, the return of displaced persons must be voluntary. She argued that the vast majority of Libyan exiles have legitimate security concerns and should benefit from protections against refoulement, defined as the expulsion of vulnerable individuals. Secondly, Bradley said it was time to think about resources and increased donor contributions, challenging as it may be. She then turned to transitional justice and reconciliation, noting how the overly punitive nature of Libya’s political isolation law and the concept of collective responsibility had needlessly increased displacement. Lastly, Bradley called for delivering current support in ways that can lay groundwork for durable solutions, such as getting Libyan children in schools, providing adequate healthcare, and bringing them out of the shadows.

When Barakat asked about European support for Tunisia, Bradley noted that these countries have a huge potential role to play. At the same time, she suggested that the Tunisian government has not forceful enough in requesting their assistance. With regards to the migration crisis in the Mediterranean, Bradley and the other panelists urged the international community and especially the European Union to put greater emphasis on resolving the political vacuum in Libya and elsewhere on the continent, while allowing for resettlement and legal labor migration in the meantime. In response to a suggestion from an attendee that Libyans should not be considered refugees because they are all still receiving stipends from Libyan institutions, Bradley countered that refugee status has nothing to do with financial resources, but the need for protection. Mzioudet added that some Libyans have reported that their salaries have been withheld, perhaps for past misdeeds, pushing them into destitution.

Sharqieh condemned the failure to recognize what are clearly refugees in Tunisia as such, suggesting that it is convenient for the UNHCR and government of Tunisia because it limits their obligations. Still, he held that many IDPs would return home given effective rule of law and a reliable judicial system, though otherwise they could not risk it. Barakat closed the discussion by suggesting that, considering the trend of intractable conflicts, it was time for a regional approach to handling the resulting displacement issues.

Video

• Uprooted, unprotected: Libya’s displacement crisis
• المقتلعون غير المحميين: أزمة النازحين في ليبيا

Transcript

• Event Transcript (.pdf)

Event Materials

• libya transcript

      

       

       

Good morning and welcome to the "future." At approximately 4:29 p.m. Hill Valley time on Oct. 21, Doc Brown and Marty McFly arrive at the present day. For many millennials especially, the 1985 film series Back to the Future represented the far-flung fantastical future that many dreamed would come. But how does the Reagan-era vision of a future where we don't need roads compare to our daily lives today?

Sadly, you probably came to work today on the same street you may have trodden as a child back in 1985 without a hover board. But our future is still pretty fantastic, and many of the outlandish futuristic devices you saw in the 1989 film Back to the Future II are closer than you think—or already here. Here are three predictions that the film made that today might actually turn the head of an ‘80s time traveler

Drone proliferation

When Doc Brown and Marty McFly arrived in 2015, the sky was filled with more flying cars than the drones that sometimes dot our skies, but the film did point to some potential uses for unmanned remote flying devices. In the future, the film envisioned drones for walking the dog and even remote photography drones reporting on the day's news. While drones today don't exactly fill these roles, that future is perhaps closer than you think.

"Private actors will soon operate drones in equal if not greater numbers than the government," Brookings Fellow Wells Bennett wrote in a report on civilian use of drones last year. Amazon has tested drones to aid in home and business delivery. CNN has been given clearance by the government to explore the use of drones for reporting. Even law enforcement and public safety officials have used drones to aid in policing and fighting fires.

The widespread use of drones in daily life is probably still part of our future rather than our present in 2015, but regulations for this future are being written today. Federal regulators just this week announced that recreational drones will need to be registered. Last year as part of our project on civilian robotics, Gregory McNeal offered his own suggestions for federal and state regulators on how best to tackle civilian drone regulations.

Cybernetic humans and wearable technology

In the 1989 film, Marty faces off against his son's cybernetic bully, Griff Tannen. The bullies of the present don't exactly resemble Griff or Locutus of Borg, but cybernetics is closer than you think—even resting in your palm right now.

Taking a walk through Hill Valley in the real 2015, a time traveler might see several pedestrians immersed in their smartphones or glancing at notifications on their wearable devices. In our homes, virtual reality is becoming more prominent as well. Systems like Oculus and Google Cardboard resemble very closely the remote television visors worn by Marty's kids in the future.

"The proverbial visitor from Mars might conclude that [cell phones] were an important feature of human anatomy," Chief Justice John Roberts wrote in a 2014 opinion referencing the cybernetic future we are living today. Benjamin Wittes and Jane Chong acknowledge in their report on the emerging cyborg future that the connection we have with technology is becoming more personal. While surveillance laws of the past might make distinctions between human tissue and the devices we use in our daily lives, Wittes and Chong argue that perhaps the separation between the human being and technology in some cases is no longer there—and the law should adapt to acknowledge this.

Flying cars and the transportation of the future

The most-often panned prediction of the film is admittedly the most disappointing—there are no flying cars in our future. This has been a fantasy for even Baby Boomers who were thrilled by the Jetsons' view of the 21st Century. Flying cars do exist in a limited form, but they are more accurately described as ultra-portable planes that require a pilot’s license to fly. However, the future of transportation is even better than Marty or Doc Brown ever realized; they just needed to travel a few more years in the future to see it happen.

Driverless cars have the potential to be the biggest seismic shift in transportation that many of us will experience in our lifetime. Numerous automotive makers and even Google are preparing for the autonomous future. Imagine your vehicle circling the parking lot to pick you up after a film; traversing rush hour traffic to deliver your daughter to softball practice; even serving as designated driver on Friday night after drinks at the bar.

The future seems like a fantasy, but liability concerns about whom to sue when an automated vehicle gets in a fender bender—or worse—clouds this would-be future.

"While liability will always be important with respect to motor vehicle operation, automation will dramatically increase safety on the highways by reducing both the number and severity of accidents," writes John Villasenor in his report on how to tackle liability in the driverless era. Despite many reservations about driverless cars, Villasenor argues that current liability law frameworks would be well equipped to address concerns.

Of course, whether the DeLorean Motor Company will come out of mothballs and produce a driverless DeLorean remains to be seen.

Discuss the future's impact on the modern workforce

At least according to Robert Zemeckis, we've arrived in the future. Not that you’re here, join us at 2 p.m. Oct. 26 when we'll discuss one of the important consequences of all of this technological automation: its impact on the workforce and the availability of social benefits.