Forum – Spring 2008
Science in the developing world
Mohamed H. A. Hassan is a great spokesman for the role that science, technology, and innovation (ST&I) can play in facilitating the development of the less developed part of our world (“Global Science Gaps Need Global Action,” Issues, Winter 2008). He speaks for Africa because so much of the need is there. I too believe that ST&I can enable development and that investments there will pay off in the future.
He points out that there are now countries more developed and growing (Brazil, China, India, Malaysia, South Africa, Turkey, etc.) that are investing in S&T, creating a multipolar world of science. These are countries with a strong base, positive growth rates, and increasingly replete government coffers. They can afford to build research facilities. But they all had traditions of research and education as well as institutions to build on. Sometimes these date from their colonial period. The African countries have much less, and even when their colonial masters built universities, periods of ruinous dictatorship and wars have left those institutions in a shambles.
It seems to me that there needs to be an emphasis on institution-building in Africa. Africa needs research but perhaps a greater need is more trained people. People trained in S&T can contribute in many ways to economic development. Thus, the institutions that are built should combine teaching and research. It is important to start small, concentrating available resources and talent until there are sufficient trained personnel for further expansion. It will take significant and sustained foreign aid and assistance from universities in the developed world to build such institutions, but the payoff could be immense.
Building S&T capability is a long-term effort. Only in the context of political stability will it work. The nongovernmental organizations of the world have learned this lesson and are putting an increasing fraction of their aid into countries that are stable, reasonably honest, and intelligently led. This is also where the long-term bets should be placed, with the understanding that present stability may not be a guarantee of future stability.
I could not agree more strongly with Mohamed H. A. Hassan’s assertion that: “Expanding the reach of ST&I to countries that have been largely left behind is one of the most critical problems of our time.” It is also true that Africa, in particular, has a host of other problems: HIV/AIDS, malaria, nutrient deficiencies, exhausted soil, not to mention poor transportation and communications infrastructure. These problems need to be addressed in a coordinated, substantive fashion—as the Millennium Village project is striving to do—that has some chance of becoming self-sustaining.
But I think that our research universities and institutes, working together with the business sector and using contemporary electronic resources, have a unique opportunity to accelerate the “flattening” of the world, to use Tom Friedman’s metaphor. There is little doubt that U.S. universities are eager to go global. But according to a recent New York Times article, the most visible and successful outposts have been stimulated by invitations from wealthy countries and have the objective of widening the income pool and foreign student base of the home institution. The task of assisting much less wealthy countries, often in Africa and the Middle East, to bolster the instructional, organizational, and research capacities of their own institutions is a vastly different proposition.
The G8 countries have pledged $8 billion to rebuild Africa’s universities and establish centers of excellence, although only a fraction of it has so far materialized. But the physical infrastructure is only part of the problem. The other is quite human. Most academic scientists in the United States look to foreign institutions for top-notch graduate students and postdocs to populate their laboratories. The notion of taking time out from a busy and competitive career to teach and develop research collaborations in the least advanced countries most in need of help is just not on the academic radar screen.
Corporate America, as evidenced in Bill Gates’ speech at the 2008 World Economic Forum, is recognizing the breakdown of capitalism in the face of extreme poverty. Noting that technological breakthroughs change lives “primarily where people can afford them,” Gates calls for what he terms “creative capitalism”: capitalism leavened by a pinch of idealism and an altruistic desire to better the lot of others.
We could use a bit of such missionary fervor in the scientific community. Science is our best global common language, able to bridge the deepest of political and religious divides. So, too, there is a growing recognition in every country that it is science and technology that drive and will increasingly drive the economy of the 21st century. Our scientists and engineers are still welcome, even in countries that have lost respect for our politics and our culture. Perhaps we need to recognize concretely in the academic reward structure that scientists and engineers have a critical role to play in flattening the world; in creating a future in which the citizens of all countries have the educational and economic opportunities now largely restricted to the developed world.
Dealing with disability
Marilyn J. Field and Alan M. Jette call on the nation to strengthen its commitment to accommodate the needs of its disabled citizens (“Dealing with Disability,” Issues, Winter 2008).
One of the barriers to such a commitment, they note, is that the nation lacks a consistent definition of disability, which limits the nation’s ability to adequately measure the needs of individuals with disabilities and evaluate the effectiveness of policies and programs aimed at mitigating the effects of disabling conditions. Field and Jette call on the federal government to adopt the World Health Organization’s International Classification of Function (ICF) as the conceptual framework for parsing out the multiple dimensions of what it means to have a disabling condition. I believe that the adoption of the ICF would be a major step forward. It would assist federal and state agencies that collect population-based statistics to measure disability and its various components more adequately and more consistently and thus foster comparisons across data sources and over time.
If we are to motivate the nation around the needs of individuals with disabilities, however, we also need to agree on a single ICF-derived disability statistic that can capture national awareness, much like the nation’s unemployment rate, inflation rate, infant mortality rate, poverty rate, or any other indicator of societal well-being despite the limitations inherent in such benchmark statistics. Complex multidimensional concepts such as the ICF by themselves do not capture the public’s imagination or motivate public policy. They can inform policy development but they rarely motivate action.
Field and Jette rightfully note that our health care system plays a disproportionate role in the lives of individuals with disabilities, who depend on the health care system more than others to address recurring, but frequently preventable, health conditions that result in additional disablement. Our health care system is replete with barriers, especially for individuals with disabilities. Barriers include, for example, lack of accessible equipment in hospitals and clinics, lack of “disability competence” among health care providers, risk selection by health plans, inadequate coverage for certain assistive technologies, and inappropriate “medical necessity” criteria. Many of these barriers needlessly add enormous transaction costs for the individual consumer, the health care system, and society at large.
Many of the suggestions and recommendations put forth by Field and Jette do not come cheaply. Accordingly, we also must look beyond increased public funding for solutions. One of the many problems in the delivery of goods and services to individuals with disabilities is the large number of what economists call market failures or imperfections: Consumers cannot obtain the information they need to make informed choices; providers fail to enter what they perceive as small markets; equipment components often lack the standardization and universal design needed to foster greater interchangeability and substitutions, leading to more secondhand markets; third-party payers often distort signals between the supply and demand sides of markets; and third-party payers often require fourth parties to provide prior approvals for select goods and services (such as wheelchair prescriptions) that lead to suboptimal choices.
There is much that the federal government can do, short of massive outlays of new funding, to correct such market imperfections. Government can lead by being an honest broker among market stakeholders. But lawmakers must also be willing, if necessary, to assign new regulatory powers to government agencies in order to create the rules needed for more efficient and competitive markets without creating new burdens leading to new market distortions.
Finally, there is the matter of research leadership at the federal level. Given the multidimensional character of disability, responsibility for disability research is dispersed across the federal government—inevitably so. The nation’s lead disability research agency remains the National Institute on Disability and Rehabilitation Research (NIDRR), a grossly underfunded agency ($106 million per year) orphaned within the Department of Education, from which it receives little internal support.
NIDRR’s misplacement in the Department of Education stems from the breakup of the Department of Health Education and Welfare in 1978. The agency needs to be reunited with its rightful parent, the Department of Health and Human Services, where its interdisciplinary character can flourish and be nourished. In 1997, the Institute of Medicine’s report Enabling America recommended as much. The 2007 IOM report, The Future of Disability, edited by Field and Jette, hesitated to make the same recommendation because of management improvements at NIDRR, but more recent events have once again underscored the agency’s precarious existence within the Department of Education. The change is now 30 years overdue. Future research leadership is vital in helping the nation make more-informed policy and program choices for a growing population who deserve better.
Marilyn J. Field and Alan M. Jette provide a cogent summary of current policies regarding disability and the Institute of Medicine’s recommendations from a recent report. It is difficult to find fault with most of their analyses or recommendations. Perhaps, though, it would be useful to view the issues from some other perspectives. The booming business in plastic surgery and Botox salons and the very limited success of long-term care insurance suggest that many Americans can barely acknowledge the inevitability of aging, let alone the probability of disability. Few healthy Americans view themselves as “temporarily able-bodied”; rather, those with disabilities are “others.”The limited and often distorted view of individuals with disabilities provided by public media has been amply documented.
The concept of “universal design” might be generalized to deal effectively with issues of aging and disability. Just as we now seek to design appliances, housing, and public buildings so that they are accessible to everyone, we can design public policies so that they encompass our entire population. This apparently simple construct will require a major shift in our thinking. Some of our current laws and regulations, as well-intended as many of them are, have Balkanized the social landscape. In part this has been driven by political activism for specific groups of people, and in part by a social philosophy that is extraordinarily fearful that individuals might gain benefits that they are not entitled to. I have heard senior public officials dismiss the option of expanding home care benefits for disabled individuals with reference to the “woodwork effect”: the unwholesome analogy of the effect of turning out the lights in an aging building with the resultant emergence of vermin from the woodwork. We need to recognize that the aged and disabled are not unfortunate others, they are merely ourselves shifted in time. If we want a society based on principles of social justice, we must begin thinking about the entire society.
Individuals with disabilities are at substantially higher risk of incurring health problems. If we can help them gain access to services and preventative care, we may be able to improve their quality of life and contain costs. Field and Jette identify a number of recommendations that merit careful consideration and attention. Particularly cogent are those concerning the boundaries of different health and social programs. We need to ensure that programs are sufficiently flexible that we can maximize the utility of the available resources for individuals with disabilities and avoid cost-shifting and abrupt transitions. Transitions are not only difficult for those undergoing them, but they are also times of increased risk and error.
The International Classification of Functioning (ICF) is a useful beginning to help our thinking, but only a beginning, as Field and Jette point out. Not only does the ICF need an empirical underpinning and solid measurement tools for its domains, it also needs a major theoretical expansion. We need to understand how changes in physiology lead to disability, how the environment interacts with function to eliminate or exacerbate disability and community participation, and how social policies can affect these dynamics.
It is within our grasp to greatly enhance the quality of life, level of function, and community access of all with disabilities. With appropriate research funding, infrastructure, and dissemination, the data necessary to guide practice and policy could be available. As a neurologist and director of the United Cerebral Palsy Research and Educational Foundation, I will address issues of particular focus in cerebral palsy (CP) research, but CP-related disability is an excellent model for considering the research needs and opportunities for the entire disability field.
Scientific and technological advances offer compelling promise. Whether you’re a clinician, an engineer, a researcher, an advocate, a consumer, a policymaker, or a combination of the above, you find yourself in a field where today’s truth is tomorrow’s anachronism.
Early in my career in neurological rehabilitation, my colleagues fought for a place in the rehabilitation research field. Our insistence that genuine recovery was a possibility was often scoffed at as offering false hope. But today more people accept the concept that cure can go hand in hand with care, and research support is absolutely fundamental to these advances.
CP is a nonprogressive disorder of the developing brain that expresses itself early in infancy and childhood as impaired function of neuromuscular control. It is a syndrome characterized by multiple etiologies, a variety of pathologies, several motor control deficits, and a number of co-morbidities. Common coexisting nervous system problems include visual impairment, hearing loss, cognitive difficulties, behavioral disturbances, and convulsive disorders.
Improved quality of life is a universal goal of all people with disabilities. The achievement of that goal involves the collaborative activity of people with CP, families, caregivers, clinicians, scientists, and the community.
Progress will require research into pathophysiology, neuroimaging, and mechanisms of neural repair; enhanced database infrastructure; and new collaborations among scientific, engineering, and clinical disciplines. The past 25 years have seen an increase in the numbers of infants born with CP and a greater number of infants with CP surviving into adulthood. Soon the numbers of adults with CP may exceed the number of children with CP, and the prevalence of CP continues to grow.
Although it is not yet within our grasp, researchers are actively seeking to repair the focal damage done to the motor system of the developing brain.
The implantation of stem cells into selected areas of the injured brain has been studied in adult-onset disorders to enhance the environment for the repair of damaged neural cells and to replace destroyed cells. Research on the implantation of stem cells continues in animal models, including young animals with experimental brain injury and in animal models of cerebral palsy.
Another approach to restoring brain function due to developmental brain injury is that of understanding and using brain plasticity in order to recruit other areas of the brain to perform functions that have been lost due to focal injury.
Children with a developmental disability become adults with a developmental disability. Because of personal and societal factors, adults with a disability often can now have a full or nearly full lifespan and become aged.
Is a person with a developmental disability more at risk of health problems caused by aging than are others? No one knows. It is said they are; it is also said that these problems occur earlier in the aging process in people with developmental disabilities than in the general population. Again, no one knows. With very rare exception, there have been no protocol-controlled studies of the long-term health status of persons with developmental disabilities. Obviously, until studies are done addressing these questions, we will continue to have to guess at their answers, relying on experience and case reports.
Research on these issues has been largely descriptive. We have defined elements of the problem but have done little to develop interventions. Above all, controlled clinical trials are a necessity, using accepted principles underlying clinical trial methodologies: specified criteria for subject inclusion and exclusion, predetermined and measurable end points, short- and long-term followups, blinded evaluation, and the use of controls.
Every day, the Sun rises in the east, traverses the sky, and sets in the west. We understand that the correct interpretation of the apparent facts is just the opposite: The Sun is not moving, Earth is. We know that’s so, but our telling of the story stems from centuries ago, before scientific evidence effectively countered “common sense.”
I venture that analogy to preface comments on Marilyn J. Field and Alan M. Jette’s article. A dramatic shift is occurring in understanding disability-related phenomena. I can’t say the shift “has occurred”; it remains a view thoroughly accepted only among the vanguard of a social movement around disability. Put sharply, the shift is away from viewing individuals as disabled by limitations in their body or mind and toward perceiving them as disabled by limitations in their social and physical environment. Quoting Field and Jette (who represent a distinguished committee’s proposed national plan): “disability is not . . . an unavoidable result of injury and chronic disease. Rather, disability results, in part, from choices society makes about health care, working conditions, housing, transportation, and other aspects of the overall environment.”
I won’t focus on their qualifying phrase “in part”; that’s a debate for another time. Instead I focus on evidence that not only the language of the discourse but proposed social science methods to carry out the plan are still rooted in and constrained by the old paradigm. I applaud the authors’ achievement in boiling a 550-plus–page book down to 5 pages, but will highlight concerns applying to the book as well.
First, considering the overall discourse: Although civil rights are mentioned in the book, the rights-based rationale of the Americans with Disabilities Act is not sufficiently emphasized or explicated. In the article, no mention appears of civil rights, discrimination, or similar concepts, such as bias, exclusion, or ableism (institutionalized discrimination). Readers can easily miss the idea that the frame of reference for the national plan is a matter of civil (and human) rights.
The old paradigm’s persistence has operational consequences, which are most apparent regarding the plan’s objective to “develop a national disability monitoring (surveillance) program.” It seems obvious, but only from the environmental paradigm, that what should be monitored are disabling conditions built into the nation’s schools, health facilities, housing, transportation and communications systems, etc. Yet the proposal exclusively considers, as monitoring instruments, federal surveys that sample individuals with impairments, however identified. That misses the point.
Research vehicles already exist to begin traveling the correct route toward disability monitoring. The Bureaus of the Census and of Labor Statistics conduct dozens of surveys of organizational characteristics (“establishment surveys”) involving employment settings. Other periodic federal establishment surveys target education, health, prisons, and other settings where accessibility features, including policies, can and should be monitored.
Not an easy task. Existing surveys must eliminate old-paradigm assumptions, such equating “disabled” with “unable to work.” Appropriate questions must be added. For example, the American Housing Survey could query about accessible entrances and bathrooms. A survey that gathers data on employer training practices could query about training in adaptive technologies. Surveys of transportation systems could ask about accessibility features, including information accessibility for people with sensory impairments.
Let’s hope new-paradigm research in disability will be thriving well before our society typically says,“Earth has turned,” rather than “the Sun has risen.”
David Festa, Diane Regas, and Judson Boomhower’s compelling account “Sharing the Catch, Conserving the Fish” (Issues, Winter 2008) echoes mounting theoretical and empirical evidence on the powerful ability of economic incentives to provide resource users with strong motivation for good stewardship. The question for policymakers should no longer be if or when to implement these innovations, but how to design them to achieve biological, economic, and social objectives.
Most current fisheries management approaches generate two inherent conflicts: between a fisherman’s short- and long-term interests and between the short-term incentives of a fisherman and the longer-term public good. These conflicts exist because there are strong incentives for fishermen to overfish and spend too much money doing it. These mismatches can be reversed with appropriate design of secure-access programs that align short- and long-term interests. Providing fishermen with economic incentives to conserve is smart management.
There is reason for optimism because of a fundamental property of renewable resources: To maximize long-term catch, one must leave a significant standing stock for reproduction. As long as the total cap on catch is accurately determined, implementing fisheries management with built-in economic incentives that produce security in the fishing asset should result in a win-win for fishermen, the environment, and the economy.
Security can take diverse forms. Experience with catch shares in the developed world is primarily limited to transferable quotas (highlighted in the Festa et al. article). Other approaches have been used successfully for millennia, particularly in less-developed countries. A promising example is territorial user right fisheries (TURFs), where rather than “owning” a share of the catch, a fisherman (or group thereof) exclusively controls fishing in an area. Used extensively in Chile, Japan, and elsewhere, this approach may be particularly efficient for species with sedentary adults. By allowing TURF owners to match harvest patterns with the unique characteristics of different places, this approach can enhance both biological and economic performance. Similar incentives can be generated by various forms of management-sanctioned cooperatives. When well-functioning cooperatives are provided with exclusive access to an area or a portion of a fish stock, the incentive to protect that stock emerges just as it can for individuals.
Any given institutional design will give rise to different biological, economic, and social outcomes. The encouraging global results from catch shares to date have motivated emerging research designed to predict how any given fishery will respond to different catch-share designs. A fruitful extension analyzes institutional structures that combine two or more approaches to further enhance efficiency and sustainability. For example, a well-designed TURF, with cooperative harvest within each spatial zone, may be designed in conjunction with a network of no-take marine reserves. Scientific evidence suggests that networks of reserves can protect habitat; large-bodied fish and invertebrates, whose reproductive potential far exceeds that of smaller-bodied individuals; and interactions among species. Combining this type of conservation tool with dedicated access programs holds much promise for sustaining healthy, productive, and resilient fisheries and marine ecosystems. If designed in a coherent manner, such a structure has the potential to simultaneously enhance biological, economic, and social objectives well beyond the status quo.
“Sharing the Catch, Conserving the Fish” highlights some important considerations for managers in moving the nation toward sustainable marine fisheries. My experience has shown that fishermen participating in catch-share programs have enjoyed higher profits, lower costs, longer fishing seasons, and a safer and more stable industry.
Through its U.S. Ocean Action Plan, the Bush administration has strongly supported the use of dedicated access privilege programs or, as generally referred to in the article, catch-share programs. The administration set a goal of doubling the number of such programs (from 8 to 16) by 2010. As of the beginning of 2008, the National Oceanic and Atmospheric Administration’s (NOAA’s) National Marine Fisheries Service has implemented 11 such programs and several others are on the drawing boards of the eight regional fishery management councils. The NOAA Fisheries Service’s proposed fiscal year 2009 budget includes $6 million to support implementation of these programs.
The Limited Access Privilege Program (LAPP) provisions in the Magnuson-Stevens Fisheries Conservation and Management Reauthorization Act of 2006 (MSRA) provide a wealth of guidance and direction for developing these programs. Designing LAPPs under the open, transparent, public-participatory MSRA process will take time to ensure that the allocation of privileges is fair and equitable. Although time-consuming, it is essential that the design be coordinated and supported by the fishing industry to ensure effective implementation. In particular, the councils have a great deal of design flexibility to ensure that the transition to LAPPs will account for the interests of fishermen, crew, fishing communities, and other interested stakeholders. Adoption of these programs has been slow, but as our experience has grown, so has the number of programs under consideration.
The development and implementation of catch-share programs are positive steps toward building sustainable fisheries. Overfishing remains a serious problem and progress is being made. During my last year with the NOAA Fisheries Service, we were able to remove seven stocks from the overfishing list. The MSRA mandates that annual catch limits that prevent overfishing be in place by 2010 for all stocks currently experiencing overfishing. With their application of hard catch limits and ability to align fishermen’s individual economic incentives with conservation objectives, LAPPs should at least be considered as a fishery management option for every U.S. fishery. Taken together, our progress on ending overfishing and implementing additional catch-share programs foretells a brighter future for the nation’s marine fisheries.
Some time ago, the National Academy Press published a book, Our Common Journey, about achieving sustainable development in the United States. It strongly advocated adaptive management of our natural resources: adjusting management policies in the light of their ongoing results in order to correct shortcomings and bring about better, more sustainable outcomes.
Nowhere is adaptive management more urgently needed than in our national fisheries. The management approaches based on controlling fishing effort that have been pursued in past decades have failed. Most of our fishing stocks have declined well below the level of maximum economic yield and are deemed overfished. Harvesters and processors have been induced into inefficient and irrational investments and practices, raising costs and reducing net incomes. Excessive and hasty fishing has imposed heavy collateral damage on habitat and nontarget species. And the management system itself has become expensive, clumsy, and contentious.
As David Festa and his colleagues point out, experience—to say nothing of logic—points to a better way. Fisheries management systems that give participants a stronger economic stake in the long-term sustainability of the fishery through secure usufruct rights to shares in the harvest have dramatically outperformed the older approach in just about every way. Variously described as dedicated access, rights-based, or tradable catch quota fisheries, these newer approaches lead to healthier stocks, more efficient harvesting, less collateral damage, higher net incomes for fishermen, and lower management costs. In some fisheries, the improvements have been dramatic. The Alaskan halibut and sablefish sector was the poster child of irrational fishing, marked by hazardous races by overpowered vessels to harvest within a ridiculously constricted open season, injuring vessels, gear, crew, and nontarget species, followed by plummeting prices as the year’s harvest was all dumped on the docks within one week. Within a few years after the change in management approach, all that has been remedied, and even those participants who were originally skeptical or opposed concede that the new approach works better.
By chance, another comparison of old and new approaches arose in the Atlantic sea scallop fishery, because Canadian and U.S. fishermen were using the same gear, fishing side by side on opposite ends of the George’s Bank, but using different management approaches. The Canadians relied on a transferable catch quota system. The U.S fishery imposed controls on fishing days, gear, and crew size. By every measure, the Canadian fishery worked better: higher incomes per vessel, less fishing pressure and bycatch damage, less management conflict, more innovation, and so on.
This should come as no surprise. When fishermen share securely in the capital gain from rebuilding the fishery or the loss from depleting it, they care more about conservation. When they can exit an overcrowded fishery by selling or leasing out their share, efficiency improves. When they can securely harvest their share when and how they choose, they maximize the value of that right.
Fortunately, fisheries management policy in this country is adapting, though still lagging behind many other countries. Restrictions on the development of these dedicated access management programs have been relaxed, more fisheries management councils are studying and adopting them, and experience with them is accumulating. Let’s hope that these trends accelerate and we can return our potentially rich fisheries and fishing industries to a productive and sustainable condition.
Innovation in poor countries
At the World Economic Forum, Bill Gates spoke about creative capitalism as an approach that combines business principles, government policies, and nonprofit activism as a way to expand the reach of market forces so people can participate in the economic engine and become part of the effort to reduce inequities. This is an interesting way to think about creating markets at the bottom of the pyramid, which is essentially what “How to Use Technology to Spur Development” is focusing on (Renee Kuriyan, Isha Ray, and Daniel Kammen, Issues, Winter 2008).
I believe that there are a number of ways in which such new technologies and entrepreneurism can come together to spur development and meet the needs of the poor. There are four approaches being used today, two of which are more traditional yet innovative: differential pricing and public/private partnerships (PPPs). Both have been used by many companies, including Microsoft, to help seed markets and drive economic opportunity. More interesting and more recent efforts are affinity campaigns and new products.
By new products, I refer to when a company designs products from the ground up to meet the specific needs of people at the bottom of the social and economic pyramid. This is the most exciting long-term aspect of creative capitalism and is the main focus of the work that Microsoft is doing as part of its Unlimited Potential initiative.
This article states that “Microsoft Corporation India has committed to initiating an additional 50,000 kiosks on the premise that such kiosks can be drivers of growth and facilities development through business opportunities.” What is interesting here is not the number of kiosks that Microsoft will initiate but what technologies the company is developing to ensure that kiosk entrepreneurs and users have relevant, affordable, and accessible products in areas such as education, low-cost computing, and shared-access computing. This to me is the next breakthrough necessary if we are to use technology to spur development.
It’s about recognizing that people who are in the middle and bottom of the social and economic pyramid have greater opportunity to advance in their lives if there are morechoicesforproducts and services that are relevant, accessible, and affordable to them. This shift in thinking will create opportunity for companies, but more importantly it will achieve a social good because the creative energies of businesses will be focused on the needs of people who were previously ignored. This goes beyond market expansion to creating a virtuous cycle of economic empowerment.
A libertarian movement that emphasizes free markets to reduce poverty has grown strong in recent years. It argues that selling to poor people at the “bottom of the pyramid” (BOP) can simultaneously be profitable and help eradicate poverty. Renee Kuriyan, Isha Ray, and Daniel Kammen present a case study showing that the BOP approach does not work in the context of information and communication technologies for development projects in India, and conclude that the BOP model is “ambiguous” and “impractical.” I think a stronger conclusion is warranted: The BOP proposition is logically flawed and inconsistent with the empirical evidence.
The growing appeal of the BOP proposition has been fueled by the premise that poor people represent a large and lucrative market. The problem is that the BOP literature grossly exaggerates the size of this market by using a very high “poverty line” and overestimating the number of people below the poverty line. The World Resources Institute and International Finance Corporation study cited by Kurien et al. uses a poverty line of $3,000 per year at purchasing power parity (PPP) in 2002 prices. Virtually all discussion of poverty in development economics and public policy uses a poverty line of $2 (or less) per day at PPP in 1990 prices, which is roughly equivalent to $1,000 per year in 2002 prices.
Kuriyan et al. quote a common BOP assertion that 4 billion people live on less than $2 per day. This is a significant overstatement: The World Bank estimates the number at 2.7 billion in 2001.
Not only is the BOP market quite small, it is unlikely to be very profitable. The costs of serving the markets at the bottom of the pyramid can be very high because of several factors: geographic dispersion, cultural heterogeneity, weak infrastructure (transportation, communication, media, and legal), and small size of each transaction. In addition, poor people are, of course, price-sensitive. This is understandable since the poor spend about 80% of their meager income on the basic necessities of food, clothing, and fuel alone.
The alleged large and lucrative market at the bottom of the pyramid is a fantasy. Several of the examples that apparently support the BOP proposition involve companies that are profitable by selling to people well above the $2/day poverty line. The case study by Kuriyan et al. of the Akshaya project in India provides further support for this conclusion.
A dangerous byproduct of the BOP proposition is its de-emphasis of the critical role and responsibility of the state for poverty reduction. This results in too little emphasis on legal, regulatory, and social mechanisms to protect the poor, who are vulnerable consumers. Second, the state must be responsible for services such as basic education, public health, water, sanitation, public safety, and infrastructure, which help increase the productivity and employability of the poor and thus their income and well-being.
Racial disparities at birth
In “Racial Disparities at Birth: The Puzzle Persists” (Issues, Winter 2008), Paula Braveman does a superb job of outlining the case for discrimination as a source of disparities in birth outcomes. As Braveman ably argues, many of the “usual suspects” promoted as causes of racial disparities in pre-term birth and low birth weight fail to explain much when examined closely. Risk behaviors, access to care, socioeconomic status, and genetics may each play some role in producing disparate outcomes under some circumstances, but none appears to provide a complete answer. Of course, as Braveman acknowledges, the research on discrimination needs further development, both theoretically and empirically.
We agree that stress pathways are a highly promising target for advancing an understanding of birth outcomes, and that the focus should be on stress processes throughout the life course, not only during pregnancy. We believe, however, that advances must be made in conceptualizing stress and stressors over the course of development before we can adequately test the pathways. Stress is an individual response to demands that overwhelm capacity. Much outstanding work has been done to illuminate the biological consequences of the stress response; much less to articulate the ways in which actual social and behavioral circumstances in real-world settings interact with psychological and other capacities to produce it. Too often, “stress”is conflated with “stressors” such as neighborhood crime and discrimination that may or may not elicit a stress response.
Implicit in Braveman’s essay is a focus on developmental processes. Health disparities among women before conception surely contribute to differences in birth outcomes, and understanding how those disparities arise over a lifetime of advantage or disadvantage is crucial. Disparities are easier to observe at older ages; their roots in differential trajectories of psychological and physiological development during childhood and early adulthood are important but difficult to study. What developmental successes enable some individuals to respond positively to stressors while others do not? What developmental conditions help mitigate or augment the effects of stressful events?
Two research initiatives here at the National Institute of Child Health and Human Development may help to meet the challenges Braveman poses. The Community Child Health Network examines linkages among social conditions, stress, and allostatic load during interbirth intervals and their effects on subsequent pregnancy outcomes. Community members from five communities are joining researchers from a variety of scientific fields to address how external social conditions contribute to stress pathways and birth outcomes. On a larger scale, the National Children’s Study (NCS) will address the emergence of health disparities over the course of development as a function of social as well as physical, chemical, and biological environmental exposures. Linked with other studies that relate pre-pregnancy health to birth outcomes, the NCS could contribute greatly to the questions Braveman raises. The NCS has recently announced a process for adding adjunct studies to complement the core protocols of the NCS (see ), and investigators are encouraged to explore how these might further this research agenda.
Paula Braveman’s article is particularly relevant to me personally and professionally, as later this year I will complete a four-year term of service on the Health and Human Services Secretary Advisory Committee on Infant Mortality (SACIM). My colleagues and I have reached some of the same conclusions that Braveman articulates. In fact, there will be a Surgeon General Conference on Prematurity and Low Birth Rate that will draw heavily on the recommendations of SACIM and the Institute of Medicine, among which is a call for greater investments in determining the cause of low birth rates, which includes attention to poorly understood factors such as stress, racism, and social disadvantage.
Braveman’s arguments challenge research and public health to explore new areas of study and ways of working with populations, especially African American women, that experience disparities in birth outcomes, including:
1) Looking at women’s health over the life span. Prenatal care alone is not showing the results expected for any population.
2) Examining the role of social and emotional factors in birth outcome disparities. Biological causes are not explaining all the disparities. Chronic stress, neighborhood impact, social disadvantage, and racism are examples of these factors.
3) Expanding our vision and research focus to address other, often harder-to-measure, factors that affect women’s health over the life span. Braveman does not advocate ending prenatal care programs or research into biological factors.
There is a growing body of evidence to support Braveman’s theories as well as her call for more research on the impact on birth outcomes of preconception health, stress, social disadvantage, and racism.
I have long been an advocate of investing in women’s health. Historically, policies in this country appear not to care about women unless they are pregnant. At that time, we provide nine months of care and then neglect them until they are pregnant again! Ensuring the mental, physical, and emotional health of women, and particularly women who are socially disadvantaged, I believe, like Braveman, is fundamental to improving birth outcomes and eliminating the racial gap.
It is vital that leaders in public health, clinical medicine, health policy, and research step up to support programs and policies that address the health of women over the life span, even though the research isn’t yet fully developed. Women at risk of poor birth outcomes should not have to wait years for research to confirm something in order to be given a chance at mediating social influences on health.
The points Braveman makes about stress, racism, and social disadvantage all deserve further inquiry, and the Surgeon General’s Conference in June will be a good venue to embrace this compelling direction once and for all.
Paula Braveman provides a comprehensive review of the literature on the issue of racial disparities in infant mortality. I would like to highlight and further address one point that she makes: the effects of a lifetime of social disadvantage on health and health outcomes.
A mother’s health is paramount to understanding the health of a fetus or infant. Epidemiologist David J. P. Barker emphasizes the role of a mother’s nutritional status as a key mechanism linking fetal and early childhood conditions to organ development and the subsequent onset of cardiovascular disease, diabetes, and kidney problems. Furthermore, biomedical scientist Francesco D’Armiento found evidence that vascular deterioration that begins in the fetus is related to the development of chronic diseases throughout one’s life.
As Braveman points out, however, medical care, improved diet, and overall better health behaviors in the period before conception are unlikely to reverse a lifetime of effects from social disadvantages. Take the role of the health care system in perpetuating racial health disparities. Health insurance status and health insurance type both independently and jointly influence the quality of care that people of color receive. A lifetime of being uninsured or under-insured because of an inability to afford insurance could cause an individual to forego needed medical care, perpetuating poor health.
Furthermore, the long reach of residential segregation has been very detrimental to the health of racial and ethnic minorities, through its effect on the delivery of health care services and on educational and economic attainment. Desegregating health care facilities after 1965 increased access to quality facilities for African Americans, yet finding quality facilities in predominantly black neighborhoods remains a challenge even today. And the impact of residential segregation on low educational and economic attainment has generational effects that translate into poor understanding of how to navigate the health care system and poor employment opportunities for people of color.
The correlation between race and inequities in the health care system and race and residential segregation have proven to be decisive factors in an individual’s overall health. These are social disadvantages that do not have quick fixes but should be remedied by targeted public policies focused on addressing the known social determinants that negatively affect the health of people of color. The policy of securing affordable, quality health care for everyone is one such policy deserving of focus.
Energy in all directions
The excellent and interesting set of articles about U.S. energy policy in the Winter 2008 Issues (headed “Ending the Inertia on Energy Policy”) probably went to press before the recent congressional passage of an energy bill. The articles refer to, and the energy bill mandates, increased emphasis on biofuels, especially ethanol, and increased fuel mileage standards for the vehicles that make up most of the U.S. passenger fleet: automobiles and light trucks, including vans, SUVs, and pickups. Nowhere in the articles, and certainly not in the energy bill, does there seem to be recognition of the inherent contradiction between increased emphasis on ethanol as an automotive fuel and increased vehicle fuel mileage.
Emphasis on creating and using more ethanol works against the 35mile-per-gallon (mpg) average mileage goal mandated in the energy bill because ethanol has about two-thirds of the heating value of gasoline (roughly 11,000 BTU per pound of ethanol and 18,000 BTU per pound of gasoline). Therefore, the more ethanol vehicles use the lower their fuel mileage will be. I have already experienced a loss of about one mile per gallon in the fuel mileage of my conventional passenger sedan as all the local manufacturer-recommended fuel it uses has come to include 10% ethanol.
Achieving the 35-mpg standard will of necessity drive vehicle designs toward more efficient diesel engines that can use biodiesel fuel, with their increased noise and more difficult cold-weather starting, and toward hybrid engines that will lead to a huge battery replacement cost and battery disposal problem in future years. Neither of these trends that will be enforced by the technological facts of life has been recognized in any of the public discussion of energy problems and policy, nor has the likely outcome that vehicle costs will increase markedly. Eventually, hydrogen-fueled vehicles may become practical. For that to happen, the country—and consumers, in one way or another—would have to pay the buy-in costs of an entirely new automotive technology as well as the costs for establishing a new infrastructure to handle the new type of fuel.
Such trends in automotive evolution will affect the broader energy sector in terms of energy use to make the new fuels, powering plug-in hybrid vehicles if they become common, the final demand for electrical energy as the transportation infrastructure evolves, and the means for meeting that demand in an environmentally sustainable way. Our country and its energy policy-makers have yet to see a comprehensive systems analysis of the entire energy sector’s potential evolution that takes all such factors into account. Such an analysis should be undertaken promptly by a new administration when it takes office in 2009, before the above apparently unforeseen but likely trends mess up the national energy and environmental-impact situations even further.
In “The Whys and Hows of Energy Taxes” (Issues, Winter 2008), Kevin A. Hassett and Gilbert E. Metcalf accept that the main purpose of taxes is altering public behavior in ways that are “good” rather than funding government operations. Unfortunately, few of us can fully agree on what constitutes “good” and “bad” public behavior, so government inevitably taxes and subsidizes many conflicting practices, which also undermines other government policies and vice versa.
For example, the authors argue that “current federal energy tax policy is premised in large part on a desire to achieve energy independence by promoting domestic fossil fuel production.” If that premise were correct, the federal government has a very effective policy readily available: Simply open federal lands to oil and gas exploration and development. Either the authors’ premise is wrong, or federal policy prohibiting drilling is wrong, or both are.
As another example, a mandated vehicle fuel economy standard; that is, corporate average fuel economy (CAFE), with its various taxes and subsidies, is regarded as good. But a quick review of its history suggests that CAFE, like a second marriage, is mostly a triumph of hope over experience. In the past quarter-century, automobile fuel economy has improved from 16 to 22.9 miles per gallon (mpg), with a constant CAFE standard of 27.5 mpg. At that rate, 27.5 mpg will not be achieved until the year 2035, and the higher new standard of 35 mpg, set late in 2007, not until 2072.
Meanwhile, the fuel economy of light trucks and SUVs, exempt from CAFE standards in what the authors characterize as a loophole, has improved from 12.2 to 16.2 mpg, or almost by the same percentage as automobiles. That’s a loophole? Also, of course, light trucks and SUVs, as a percentage of the automotive fleet, have grown from 18 to 41%, as the public has voted with its own money on its vehicles of choice.
Government mandates can control only what manufacturers build, not what the public buys, or as Bob Lutz so eloquently describes it, “CAFE is like trying to fight obesity by requiring tailors to make only small size clothing.”
As a nation, we are, in fact, in critical need of a clear, concise understanding of future energy needs and viable alternatives, and their various impacts on economic growth and the environment. Such an understanding must recognize all of the interactions and mutual conflicts embedded in our current conventional wisdom and resolve them appropriately. The objective should be a single comprehensive, effective, and definitive government energy policy, with appropriate and consistent tax and subsidy policies. The authors don’t really provide this, but rather give us their own particular spin as to what is good and bad tax policy.
In “A Blind Man’s Guide to Energy Policy” (Issues, Winter 2008), Jane C. S. Long makes a welcome plea to raise the level of sophistication of the ongoing debate about energy, security, economic growth, and climate change. As Long describes, protagonists of each view too often advance arguments characterized by overworked half-truths or misleading assertions, resulting in unsatisfying outcomes, or worse, misguided or harmful policy. The truth is that these four important goals are inextricably intertwined. They can be, but are not fundamentally, in conflict.
In the U.S. Climate Change Technology Program, we take the long view. Finding solutions to climate change is the long pole in the tent. The task is daunting, but if approached intelligently, the solutions needed for climate change, which are the most technically challenging, will give rise to the solutions for energy, security, and continued prosperity. Like the blind man and the proverbial elephant, we just can’t see it yet. This is not to say that short-term concerns about energy, security, and disruptions of economic activity are not serious. They are real and must be addressed within informed frameworks of domestic and foreign policy and national and global security. One can hope that such concerns will be addressed in view of the principles of cooperation, diversification, trade, and economic interdependence, as well as respectful deterrence, if needed.
But short-term solutions will be more robust when formulated within a visionary long-term framework of the so-called climate stabilization end state. This is where greenhouse gas (GHG) concentrations in Earth’s atmosphere stabilize at levels that are healthy for both humans and vital ecosystems. Ultimately, this means that the world will need to find ways to prosper and with near net-zero GHG emissions. The pathways forward are many and innovative. They will certainly open new horizons that will also relieve stresses on traditional energy fronts. Yes, it will require a transformation of unprecedented proportions, but the goal is not out of reach.
Long’s closing note is about becoming makers of our fate. Let us agree on what that fate should be—that all four goals can be achieved—and redouble our efforts to make that fate an affordable reality. For those in the businesses of science, engineering, technology development, innovation, investment, entrepreneurship, and related policy, progress toward this end will present extraordinary opportunities. Let us imagine what is possible and get on with the job.
Newt Gingrich and Terry L. Maple offer a welcome and thought-provoking set of ideas to tackle the nation’s and the world’s major environmental problems (“Forging a New, Bipartisan Environmental Movement,” Issues, Winter 2008). Their call for a return to bipartisanship on environmental matters, improved scientific and environmental literacy, and an emphasis on incentives to encourage and reward environmental results is a message with which one cannot disagree.
And yet one wishes they might have returned to a tantalizing subject they raise only briefly in their essay’s opening sentence. There they note that their shared passion for the living earth stems from a common source: the joyful youth that each spent outdoors. Like many others, their firsthand exposure to nature in their childhoods lit a spark in each of them that still burns today.
Urbanization, security anxieties, and the modern phenomenon of highly structured, scheduled play have dramatically reduced the opportunities that today’s youth have to experience nature in a spontaneous and intensive way. What will inspire the environmental passion of a generation whose primary exposure to nature is through the computer screen?
To Gingrich and Maple’s call for “a national commitment to strengthen math, science, and engineering training,” I would add a no less urgent need for a national commitment to increasing opportunities for nature-oriented outdoor recreation, a commitment that engages governments at all levels, gives private landowners incentives to participate, and ensures that enough of the natural world will remain in place to inspire new generations of committed environmental problem solvers.
There can be no doubt that technology provides the means to better connect developing-country scientists to the larger scientific community. In “Open Access to Research for the Developing World” (Issues, Winter 2008), Matthew J. Cockerill and Bart G. J. Knols identify the constraints and provide a compelling argument for overcoming them. The authors cite the open-source Malaria Journal for disseminating published studies to Zambian researchers; however, there were only two Zambia-specific articles published in that journal in 2007. Although the Malaria Journal must be eager to publish quality articles on Zambia, consider the many projects and questions of high interest to Zambian researchers that are not being evaluated or whose evaluation is not of sufficiently high quality to merit publication. This illustrates what I call the “million-dollar publication bias.” Assuming a minimum study cost of around $100,000 to meet quality standards for publication, with 10% of the budget for evaluation, then the minimum total project budget for a quality publication is a million dollars. This bias selects for more expensive and large-scale interventions. How can we lower these cost barriers to allow less expensive and smaller-scale interventions to be evaluated and published?
A principal constraint on developing-country research is the cost of data collection. Although developed countries have largely moved from paper to electrons for data dissemination, most data collection in Africa still uses paper and pencil. Why don’t investigators use new technology for data collection? For the same reason that they don’t access electronic journals now: The hardware and software are too expensive and unfriendly. During a recent field study, we tried to explore the limits of what could be done to radically increase the ease and lower the cost of quality data collection. The underlying study question was to measure the population coverage of a mass bed net campaign in Ghana, using a cluster sampling method. We put the study questionnaires on Palm Pilot PDAs for the field data collectors, who then entered the survey data directly into the PDA. The PDA data were then synced into a master database. Because the data were available immediately, we used the 10hour ride back to Accra for analysis and writing and presented a report to the Ministry of Health later that day and published it later. Field costs for the study were $8,000, including the cost of the PDAs.
Why was the cost so low? Using the PDAs resulted in a cascade of savings and quality improvements: Training took one day instead of three; field work took three days instead of five; photocopying was eliminated; no laptops, staff, or office space were needed for data entry; etc. Conceptually, we applied the same technologies to data collection as Cockerill and Knols are proposing for data dissemination. Within three years of our initial study, PDAs have become the standard method of data collection for this type of survey in Africa. (Open source software to program PDAs, EpiSurveyor, is available from www.datadyne.org.) This suggests that technology can be adopted rapidly in Africa, provided it is low-cost and meets a specific need. The most striking example is the exponential increase in the use of those other handheld computers in Africa: mobile phones.
Our experience merely scratches the touch screen of what is possible with new technologies. PDAs, smart phones, and GSM mobile phone networks provide a platform for innovations in research methods. Applying these new tools will lead to additional innovations: interactive, multiplayer, open-source data analysis on cell phones, anyone? There must also be an innovative business model that can support continuous product development and technical support. As we improve the tools for sharing knowledge with scientists in developing countries, let’s also work to improve the tools they use to create knowledge.
As the article by Matthew J. Cockerill and Bart G. J. Knols makes clear, the Wellcome Trust has led the way in developing policies to ensure that the outputs of the work we fund are made freely available as soon as possible and, in any event, within six months of publication.
Open access, however, goes beyond simply providing unrestricted access. Already researchers are beginning to exploit the real potential of research papers through the development of text and mining tools. For example, TextPresso is a text-mining system that facilitates the extraction of new facts from the research literature, such as gene-gene interactions. Similarly, the Nerocommons project is working on building a semantic web for neurological research. For these services to be truly effective, however, researchers need full and unrestricted access to and the ability to reuse the full text of research papers.
In recognition of the almost endless research possibilities provided by text mining, mash-ups, etc., the Trust has developed a policy that, when it provides funding to cover open-access charges, the publisher must licence these papers in ways that allow reuse for noncommercial purposes. Publishers such as Elsevier, Wiley, Oxford University Press, and Springer all now provide this type of open licence for open-access articles.
Some years ago, the International Human Genome Sequencing Consortium pioneered the then-radical notion that genomic sequence data should be made freely available wherever possible: the Bermuda Principles. Advances in technology mean that research outputs in the form of literature itself now offer a new information landscape: The fundamental tenets of the Bermuda Principles—that information should be freely accessible to maximize benefits to society—are just as relevant in this context.
Freedom of speech
In “Freedom of Speech in Government Science” (Issues, Winter 2008), David B. Resnik raises troubling issues about the politicization of government science and threats to the freedom of speech of government scientists. The issue is complicated because government scientists necessarily work under conditions different from those of academic scientists. Unlike academia, where any scientist can manage to be heard (and perhaps be ignored), government scientists are perceived as speaking for their agency, and for legitimate reasons their public statements are subject to internal peer review. For example, a government scientist might be stopped from disseminating work that was judged to reflect poorly on the government and possibly damage public trust in government science. However, scientific peer review is subject to the perspectives of each reviewer. Although science is productive when there is free debate about perspectives, it is also harmed when opposing perspectives of reviewers result in limited communication of scientific ideas and results. Just as biased institutional review boards and editors can limit the expression of scientists’ ideas, so too can government peer review boards err when they decide what is appropriate discussion of scientific controversy and what is not. Or worse, such boards may succumb to political pressures to bias their decisions under the guise of honest disagreement.
Resnick suggests that an oversight committee outside of government might review government peer review procedures for fairness, and also investigate cases of alleged bias and report their findings to Congress. Some cases of political bias in the evaluation of a scientist’s proposed public statements are probably so egregious that they would be clearly recognizable as such by a committee of competent scientists whose expertise is in the field in which the case occurs.
But who would identify such important cases and bring them before a committee? Anyone who has been in government science (or any science anywhere) has heard legendary accounts about scientists whose careers continually suffer because of the abuses of power by others in their work organization. If government scientists could self-refer their cases to a committee, a long line of supplicants might quickly swamp the committee with their complaints. This probably is not the kind of referral that Resnick envisions. Some criterion of importance or high standard of relevance to societal good would be needed to screen cases. Presumably the issues of government bias would be ones already discussed within the scientific establishment, and a self-referred case would be taken up by the committee if it deemed the case socially relevant and the scientist highly qualified and credible. Thus, the voice of an expert committee concerning a clear-cut case of bias would be added to a rising complaint about alleged political meddling in science. This is the kind of process one would hope for in a modern democratic society.
The committee would have interesting work to do, and its report might stir well-informed discussion in Congress and the mass media. This might encourage citizens to vote the culprits out of office. Such a committee, if it attained a high profile, might deter some political meddling and might embarrass some blatantly guilty meddlers. If its report were issued quickly to a responsive Congress, the muted scientist might be cleared to speak to a responsive audience in time to make a difference. The political meddling and subsequent freedom of the scientist to speak might receive much public attention. The resulting discussion might even catalyze a change in government policy on the given issue. But this is a lot of “ifs” and “mights.” Creating such an effective external oversight committee would require careful planning.