Editor's note: This piece was written in response to John McDonough's article in the American Journal of Public Health titled "Shorter lives and poorer health on the campaign trail." Read McDonough's article here. 

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McDonough is right about two very important things. First, that in America we have quite dismal outcomes for the enormous amount we spend on health care. And second, that there is a real opportunity for a new political dialog between left and right to take root—though perhaps one that is more of a quiet agreement than a high-profile grand bargain. 

McDonough wisely draws attention in Figure 3 of his editorial to the sharp distinction between the United States and other Organisation for Economic Cooperation and Development countries in the relative proportions of gross domestic product spent on health services and social services. The United States is a lonely outlier because we overmedicalize our approach to health conditions and community health. Generally a blend of social, housing, public health, and other preventive strategies would yield better health results than calling an ambulance—and at a fraction of the cost. Even our higher survival rates after age 75 years is a mixed blessing, as Gawande points out, because expensive and frequent medical interventions may extend age but often not the quality of life.¹ 

The good news, both substantively and politically in this election year, is the growing recognition that addressing the social determinants of health is a key—perhaps the key—to improving health outcomes while slowing the growth in health spending as a proportion of gross domestic product and public spending. McDonough and I agree on that, despite his affection for Bernie Sanders’ utopian Medicare-for-all, which likely would do little to address the underlying cost and outcomes problem. 

So how could a new conversation develop, of the kind both we both would like to see? I think on several fronts. 

First, building on existing collaboration, serious analysts and policymakers on both sides of the political spectrum should explain more extensively how resources currently restricted to either health care or social services and housing should and could be more routinely braided together. Despite some interesting experiments and demonstrations that allow certain health and housing money to be mixed and used creatively, budget restrictions and payment systems generally make this dif- ficult. We could seek to agree on a mixture of legislative action on payments and budgets, and using Medicaid (Section 1115) waivers, to permit money currently available only for medical services to be used instead for housing and social services where that could be shown to improve the health of individuals in a community. 

Second, we could agree on bipartisan steps to allow states to experiment with more creative approaches to alter the blend of strategies they have available to achieve improved health outcomes. Section 1332 of the Affordable Care Act (Pub L No. 111–148) is a start, since it will allow states to propose alternatives to some Affordable Care Act provisions to improve coverage and outcomes without increasing federal costs. McDonough and I agree on using 1332 waivers in this way. But a further step would be legislation to allow states to seek even broader waivers to shift money between health and social service programs. For that to happen, conservatives would have to accept increases in total spending on some social service programs. Progressives would have to accept reductions in health programs and reduce their reluctance to granting states more flexibility. Both would have to accept rigorous evaluation to determine what works and what does not. 

And third, there is an opportunity for agreement on empowering intermediary institutions² in neighborhoods, including charter and community schools, as well as health systems,³ to serve as hubs for integrated approaches to achieving health communities. That approach combines the conservative emphasis on the importance of nongovernmental institutions with the progressive emphasis on community action. Again, systematic evaluation is needed. 

Hopefully there can be cross-party congressional support agreement on these themes, as McDonough notes has occurred in alternative sentencing. But it is unlikely in the election season that such themes will be seized upon by presidential candidates. In my view, that is probably good, because presidential elections are about differences, not path-breaking agreements. Better, during this election cycle, to foster positive conversations that cause such themes to be taken out of the election debates, so that they will have broad support for enactment after the Election Day dust has settled. 

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1. Gawande A. Being Mortal. New York, NY: Metropolitan Books; 2015. 

2. Singh P, Butler SM. Intermediaries in Integrated Approaches to Health and Economic Mobility. Washington, DC: The Brookings Institution; 2015. 

3. Butler SM, Grabinsky J, Masi D. Hospitals as Hubs to Create Healthy Communities: Lessons From Washington Adventist Hospital. Washington, DC: The Brookings Institution; 2015.

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Editor's note: This piece originally appeared in the American Journal of Public Health. 

      

       

       

       

This paper identifies some of the key characteristics of the emergence of a “new multilateralism.” It offers a number of practical recommendations on how to get the best out of the multilateral development system (MDS) in an increasingly complex environment.

The MDS is a set of institutions and norms that have guided development cooperation since the secondworld war. It has been based on a number of underlying principles that can be summarized as follows: doing no harm to others, solidarity with developing countries, and sharing the burden of investing in global public goods. The MDS has used a broad range of instruments but ultimately the test of its effectiveness is that it enables a collective response to solving a particular problem that is preferred to individual country responses.

To be effective, multilateralism must be a choice that is made because it is the most effective or efficient instrument available to a government. Multilateralism should not become a way of abdicating leadership. It must be a way of exercising it. For a new multilateralism to take root, what is needed is a robust approach to the use of multilateralism as an instrument of choice by a large number of member states.

The MDS has evolved over time and continues to evolve. Initially, it was organized by a small group of like-minded countries with a common vision and principles, and was designed to share the financial burden of development cooperation and to implement programs of support in an effective way. But over the last two decades there have been strong forces reshaping the system. These include shifts in economic size and the emergence of the growth economies, the increasing differentiation among developing countries and the recognition that substantial investment in global public goods is needed to reap the benefits of globalization and reduce the costs. Today, the MDS is continuing to evolve in response to the need to accommodate emerging state powers and non-state actors (business, civil society, and others) as well as the need to broaden responsibility for collective responses.

Agenda 2030, the program for sustainable development endorsed by 193 member states of the United Nations in September 2015, provides important signals for how the MDS institutional landscape should evolve over the next few years. Agenda 2030 is truly multilateral as it underlines the importance of a “goals, targets, and results” framework for every country, against which progress can be transparently monitored. But it also shows where the current MDS falls short. Agenda 2030 is universal in its scope and vision, while the MDS is still mostly organized with a frame that divides the world into developed and developing countries. Agenda 2030 is ambitious and requires solutions at scale, while the MDS today is fragmented and project-oriented. Agenda 2030 argues for integrated solutions extending across development, peace, environment, and humanitarian realms, while the MDS is siloed in its approach. Agenda 2030 calls for contributions from a range of actors, beyond governments, while the MDS, at its core, remains largely intergovernmental. Agenda 2030 requires the mobilization of substantially greater resources from all sources, domestic and external, public and private, while the MDS has focused largely on aid and budgetary contributions from member states. Finally, Agenda 2030 recognizes the importance of investing in global (and regional) public goods and starts to define other means of implementation, highlighting where gaps in the system exist.

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Bernie Sanders may have had no foreign policy advisers until this week, but he can justly claim to have proposed one of the boldest and radical foreign policy ideas of the 2016 presidential campaign. In what he describes as the most important speech of his campaign—on Democratic Socialism at Georgetown University in November 2015—Sanders called on the United States to fight terrorism in the same way it waged the Cold War. He said: “We must create an organization like NATO to confront the security threats of the 21st century” and we must “expand our coalition to include Russia and members of the Arab League.”

NATO was created in 1949 to give the United States a way to forward-deploy its forces so they would immediately be entangled in a war if the Soviets attacked Western Europe. The most important feature of NATO was the mutual defense clause, whereby an attack on one would be treated as an attack on all. In a new NATO to fight terrorism, the United States could find itself having to deploy tens of thousands of troops throughout the Middle East to fight ISIS. The United States may even be treaty-bound to use its troops to fight alongside Russia in Chechnya. 

If that sounds very unlike Bernie Sanders, it's because it is. It is clear from the speech that Sanders had very little idea what NATO actually is or why it was founded. He was looking for a way to pass the burden of fighting terrorism on to other nations, particularly Muslim nations. Lacking any clear idea as to how to do this, a formal treaty must have seemed as good a way as any. Sanders would surely say that he meant an alliance without a mutual defense pact and without the United States taking the lead. But such an organization currently exists—it is called the counter-ISIS coalition. Presidents Bush and Obama also both sought ways to deepen cooperation with Russia and Arab countries on terrorism without a formal NATO-style alliance, which led to the situation Sanders decries. In any event, the new NATO served its purpose. Sanders could later claim to have given a speech on foreign policy. The specifics of the idea went un-scrutinized. 

Mind the gap

Bernie Sanders’ foreign policy remains a mystery because he has said so little about it. Unlike Donald Trump, who has been vocal about his foreign policy views for many decades, Sanders has focused his message on inequality and the nefarious influence of big money in politics. Recently though, he has begun to come out of his shell. He regularly invokes his opposition to the Iraq War in an effort to negate Hillary Clinton’s superior experience in foreign policy. Sanders clearly hopes that this vote will enable him to win over many Barack Obama supporters who remain suspicious of Clinton. In recent weeks, some foreign policy experts have sketched out how Sanders could build on Obama’s foreign policy legacy and distinguish himself from Clinton. 

Sanders-Obama is the real foreign policy fault-line in the Democratic Party.

The conventional wisdom of the foreign policy debate in the Democratic Party sees an Obama wing that is skeptical of military intervention and a Clinton wing that is more willing to use American power overseas. This is a paradigm that Sanders would certainly endorse and hope to capitalize on but it is not an apt description of the 2016 divide. There is a reason why Obama has come close to endorsing Clinton and has left no doubt that he sees her as his true heir. The gap between Sanders and Obama is much greater than between Clinton and Obama. Obama is an avowed globalist who looked outward, even as he was campaigning in Iowa in 2007. Sanders is a liberal nationalist who looks inward, not just in his rhetoric but in his policy. 

A Sanders nomination would be a striking repudiation not just of Clinton but of Obama’s worldview and message. Sanders-Obama is the real foreign policy fault-line in the Democratic Party. 

Obama 2008: Looking outward

Obama’s 2008 campaign is now shrouded in mythology. He is often described as unlikely a candidate as Sanders. Forgotten is the fact that weeks after he started, he secured the support of major donors and dozens of foreign policy experts. He was always the favorite of a particular part of the establishment. He was young but he had thought about the world and America’s role in it. In 2005, he hired Samantha Power to be his foreign policy adviser in the Senate. His 2006 book "The Audacity of Hope" had a chapter on foreign policy that culled ideas from think tank row. 

In April 2007, a full 18 months before the election, Obama gave a revealing interview to The New York Times' David Brooks in which he spoke about the influence that American theologian Reinhold Niebuhr had on his foreign policy. Niebuhr was a seminal figure in U.S. diplomatic thinking during the Cold War and is credited with developing the most sophisticated critique of American idealism. Obama said that Niebuhr provided:

“the compelling idea that there’s serious evil in the world, and hardship and pain. And we should be humble and modest in our belief we can eliminate those things. But we shouldn’t use that as an excuse for cynicism and inaction. I take away...the sense we have to make these efforts knowing they are hard, and not swinging from naïve idealism to bitter realism.”

Some of these themes would reappear in his extraordinary speech in Oslo in 2010 on receiving the Nobel Peace Prize. 

Throughout the 2008 campaign, Obama spoke about reviving American leadership and presenting a new face to the world. In his announcement speech in Springfield in 2007, Obama said “ultimate victory against our enemies will come only by rebuilding our alliances and exporting those ideals that bring hope and opportunity to millions around the globe.” In his acceptance speech in Chicago, he spoke to “those watching tonight from beyond our shores”. “Our stories are singular,” he said, “but our destiny is shared and a new dawn of American leadership is at hand.” 

Obama’s challenge in office, and the challenge of progressives after the Iraq War, was to develop a foreign policy that remained faithful to his internationalist ideals while resisting calls for large-scale military interventions. In this, his record was mixed. The Middle East stands out as a major failure but he had successes elsewhere. He helped rescue the international financial system, he deepened U.S. engagement in Asia, he negotiated several trade deals, and he secured a controversial nuclear deal with Iran. Throughout, he articulated a case for a liberal brand of American exceptionalism and for continued U.S. global leadership. 

Sanders 2016: Drawing inward

That is now at risk, not just by the prospect of a Trump presidency but also from within the Democratic primary. Sanders has had remarkable success with a campaign message that is entirely inwardly focused. Read his speeches, whether at Georgetown or on the stump, and you will see a sharp change of tone from Obama of 2008. Gone are the passages on a new era of American global leadership. Gone are the messages for people beyond these shores. Gone is the optimism about America’s global role. Gone too is the sense that the United States, flawed as it is, has a positive and indispensable role to play in upholding the international order. 

Rhetorically, Sanders is deeply pessimistic about the United States and its role in the world. For Sanders, America is not getting better—it’s getting worse, including on Obama’s watch. And, woe betide those who think that America can be any more successful abroad. In his Georgetown speech, he said that the first element of his foreign policy would be an acknowledgement of how America gets it wrong so frequently. In addition to the Iraq War, he mentioned the toppling of Mossadegh in Iran in 1953, of Arbenz in Guatemala in 1954, of Goulart in Brazil in 1964, and of Allende in Chile in 1973. 

[Sanders] offered no examples of how the United States has made the world a better place.

Apart from the ham-fisted description of NATO, he offered no examples of how the United States has made the world a better place. The toppling of foreign leaders is not, for him, even partially balanced out by successes in promoting democracy in Chile in 1987 or in Eastern Europe in the early 1990s, or in Indonesia in 1998. He did not mention the Kosovo intervention in 1999, which he actually supported at the time. The speech was not without irony however. Sanders organized the domestic section, on democratic socialism, around Franklin Delano Roosevelt’s 1944 State of the Union speech but made no mention of FDR’s heroic—and frequently risky—efforts to win the war and the post-war world.

As the campaign has progressed, Sanders has been pressed on what he would do if he were to be elected president. He said in a February Democratic debate that the “key doctrine of the Sanders administration would be no, we cannot continue to do it alone, we need to work in coalition.” The very idea that a Democratic candidate could make the unilateralist charge against Obama, one of the most multilateral presidents in modern American history, is itself remarkable and rather implausible. 

The very idea that a Democratic candidate could make the unilateralist charge against Obama, one of the most multilateral presidents in modern American history, is itself remarkable and rather implausible.

But this has not deterred Sanders. He has repeatedly argued that the Obama administration has not done enough to get Muslim nations to fight ISIS. At Georgetown he declared, “We need a commitment from these [Muslim] countries that the fight against ISIS takes precedence over the religious and ideological differences that hamper the kind of cooperation we desperately need.” Quite how Sanders would accomplish this was left unsaid. The reason ISIS is difficult to defeat is because Muslim nations see other challenges, particularly the sectarian struggle with Iran, as a much greater threat to their vital interests. 

Simply saying that the president can will other countries to act contrary to what they see as their vital interests is about as plausible as Trump persuading Mexico to pay for his wall. Clinton has repeatedly recognized the challenges associated with persuading Muslim countries to take on more of the anti-ISIS fight, but Sanders has just doubled down on his charge against Obama. “I’ll be dammed,” he told CNN, “if the kids of Vermont have to defend the Royal Saudi family” and take the lead in the fight against ISIS, even if is just with air power. 

On economic policy, Sanders offers an even more radical departure from Obama’s legacy. Sanders has opposed all U.S. trade agreements throughout his political career, including General Agreement on Tariffs and Trade (GATT), the North American Free Trade Agreement (NAFTA), the Central American Free Trade Agreement (CAFTA), and the Trans-Pacific Partnership (TPP). In 2005, he sponsored a bill calling on the United States to withdraw from the World Trade Organization. He has called for tariffs to prevent American industry from investing in China, Vietnam, and Mexico. He was the only Democrat to vote against the Import-Export Bank and he opposed the expansion of the H1-B visa program for high-skilled workers. 

He has offered no positive vision for the world economy and sees it as a zero sum game—either American workers’ win or other nations do. Obama indulged in anti-trade rhetoric, as has Clinton, in the heat of a primary campaign, but Sanders is different. He has consistently sought to disengage from the global economy—the same one that Obama did so much to save in 2009. This is no small matter. As the global economy flirts with recession and a new crisis, this time originating in China, the rest of the world is asking if America can continue to lead or if it is all tapped out. 

He has consistently sought to disengage from the global economy.

A President Sanders would not try to destroy America’s alliances like Donald Trump or leave the Middle East entirely like Rand Paul. But, he would surely try to hide from the world and tend to matters at home. He will be immediately tested by allies and adversaries alike as they try to find the limits of his commitments. All presidents are tested of course—especially those, including Obama and Clinton, who promise to focus on the home front— but they usually try to respond in a resolute way to dispel the concerns. Obama sent additional troops to Afghanistan in 2009, for example. Sanders will probably resist the pressure and focus on his domestic agenda, thus exacerbating foreign crises. He would surely feel a sense of betrayal as America’s allies failed to take up what he considered to be a fair share of the burden. 

America in the world?

2016 is a very different world than 2008. Then, Obama and Democrats saw a world that was full of opportunity, despite the financial crisis and wars in Iraq and Afghanistan. They believed the United States could offer a new face, and a new form of leadership, to the world. When we look back on 2016, it will surely be the year when the United States and much of the rest of the world faced a choice about whether to look outward or turn inward. It is not just the Republican and Democratic primary. Britain will vote on June 23 whether to leave the European Union. Germany and much of the rest of Europe will decide whether to close its borders to refugees.

When we look back on 2016, it will surely be the year when the United States and much of the rest of the world faced a choice about whether to look outward or turn inward.

Of all these tests, the biggest by far is in the United States. Republican and Democratic foreign policy populism is different, of course. Trump and his supporters are both terrified by threats from overseas and determined to lash out as viciously as possible against anything and everything associated with them. To his great credit, Sanders has not peddled fear of the other. His supporters are not frightened by the world. But they are disappointed in it and largely agnostic about what happens outside the United States. The left used to be inherently internationalist, but today Sanders sees no opportunity to lead, only risks of becoming embroiled in someone else’s problems. Sanders will not tear down the liberal international order but he does want to avoid doing much to uphold it. 

Sanders, his aspiring advisers, and much of the media have an interest in situating his foreign policy worldview within the Obama-Clinton paradigm but it is simply not consistent with what he is saying or with what he has done in the very recent past (never mind decades ago). Obama and Clinton obviously differ on some elements on U.S. foreign policy. It is not about large-scale invasions, as is commonly thought. Clinton is not about to send tens of thousands of ground troops to Syria. Rather, she tends to favor small-scale action early on in a conflict to tip the balance while Obama is extremely cautious about a slippery slope. Clinton also tends to see world politics more in terms of power politics while Obama often speaks as if we are headed toward a post-national, more global system. But this all pales in comparison to fundamental questions about whether the United States ought to be engaged in the world, not just militarily but also economically. Obama was elected on a platform of renewing American leadership in the world. He will soon find out if Democrats want to stay on the broad path he set.

       

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U.S. policy towards South Asia has changed considerably over the last seven decades. The nature of U.S. engagement with different countries in the region has varied over time, as has the level of U.S. interest. While India and Pakistan have received the most attention from Washington, the United States has also been engaging with Afghanistan, Bangladesh, Bhutan, Maldives, Nepal, and Sri Lanka, albeit to different degrees. 

On May 19, The India Project at Brookings hosted a panel discussion exploring the past and present U.S approaches towards South Asia, based on Senior Fellow Stephen Cohen’s new book, “The South Asia Papers: A Critical Anthology of Writings” (Brookings Institution Press, 2016). Panelists also assessed the Obama administration’s policies toward the region, and the challenges and opportunities that lie ahead for the next U.S. administration. Fellow Tanvi Madan, director of The India Project, moderated the discussion.

After the discussion, the panelists took questions.

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On September 8, Brookings Senior Fellow Vanda Felbab-Brown participated in a Center for International Policy and Washington Office on Latin America event, “Using Militaries as Police in Latin America: A Discussion on Citizen Security and the Way Forward.” Felbab-Brown was joined on the panel by Adam Blackwell, secretary for multidimensional security at the Organization of American States; Richard Downie, executive vice president for global strategies at OMNITRU; and Adam Isacson, senior associate for regional security policy at the Washington Office on Latin America. Sarah Kinosian, lead researcher on Latin America at the Center for International Policy, moderated the event.

Felbab-Brown argued that police reform across Latin America over the past two decades has often been at best deficient or has failed outright. The lack of rule of law characterizes many countries in the region, including continually Mexico. Police forces are often not only corrupt, but highly abusive, and both police forces and military forces deployed for policing engage in major human rights violations. Even assumed exemplary experiments, such as the Unidade de Polícia Pacificadora (UPP) approach in Rio, have struggled to execute an effective handover from heavily-armed takeover forces to regular policing.

If governments choose to deploy their militaries in local policing roles, suboptimal as that is, the forces should adopt population-centric strategies, immediately develop concrete handover plans to police forces, and operate under a civilian coordinator. A key requirement for military forces is to respect human rights and due process and diligently prosecute perpetrators. Ultimately both police and military forces need to understand that their role is to protect society.

To some extent, Felbab-Brown argues, the resort to military forces for policing purposes is compounded by the lack of expeditionary police capacity by outside partners and donors, who overwhelmingly tend to deploy military forces for training policing. However, if the United States and outside donors want to make their policing assistance more effective, they should consider developing expeditionary police forces for such training purposes as well as a range of stabilization operations.

The most important factor for security efforts is citizen support. Marginalization, exclusion, and abuse from policing forces—be they police or military ones—have often prevented local populations from cooperating with law enforcement units and buying into rule of law: security or insecurity is co-produced as much as by citizens as by the police or military.

      

       

       

The federal Earned Income Tax Credit (EITC) will boost earnings for over 18 million low-income working families in the U.S. by more than $30 billion this year. This survey finds that the EITC provided a $737 million boost to the Chicago regional economy in 1998, and lifted purchasing power in the city of Chicago by an average of $2 million per square mile. Large numbers of Low-income working families lived not only in inner-city Chicago neighborhoods, but also in smaller cities throughout the region like Aurora, Joliet, Elgin and Waukegan. The survey concludes by describing steps that state and local leaders could take to build on existing efforts to link working families to the EITC, such as increasing resources for free tax preparation services, helping EITC recipients to open bank accounts, and expanding and making refundable the Illinois state EITC.

 

EITC National ReportRead the national analysis of the Earned Income Tax Credit in 100 metropolitan areas. It finds that the EITC provided a $17 billion stimulus to these metro areas in 1998, and that the majority of EITC dollars flowed to the suburbs. National Report 10/01

EITC Regional ReportsRead the local analysis of the Earned Income Tax Credit in 29 metropolitan areas. Using IRS data to analyze the spatial distribution of working poor families, the surveys find that the EITC is a significant federal antipoverty investment in cities and their regions. 29 Metro Area Reports  6/01

 

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INTRODUCTION

As a mechanism for controlling climate change, the Kyoto Protocol has not been a success. Over the decade from its signing in 1997 to the beginning of its first commitment period in 2008, greenhouse gas emissions in the industrial countries subject to targets under the protocol did not fall as the protocol intended. Instead, emissions in many countries rose rapidly. It is now abundantly clear that as a group, the countries bound by the protocol have little chance of achieving their Kyoto targets by the end of the first commitment period in 2012. Moreover, emissions have increased substantially as well in countries such as China, which were not bound by the protocol but which will eventually have to be part of any serious climate change regime.

Although the protocol has not been effective at reducing emissions, it has been very effective at demonstrating a few important lessons about the form future international climate agreements should take. As negotiations begin in earnest on a successor agreement to take effect in 2012, it is important to learn from experience with the Kyoto Protocol in order to avoid making the same mistakes over again and to design a more durable post-2012 international agreement.

The first lesson is that a rigid system of targets and timetables for emissions reductions is difficult to negotiate because it pushes participants into a zero sum game. To reach a given target for global greenhouse gas concentrations, for example, countries must negotiate over shares of a fixed budget of future global emissions. A looser target for one country would have to be matched by a tighter target for another. It is clear that this has been an important obstacle for much of the history of negotiations conducted under the auspices of the United National Framework Convention on Climate Change, not just the Kyoto Protocol. From the beginning, developing countries have refused to participate in dividing up a fixed emissions budget. Not only that, but many observers have argued that if such a budget were ever to be divided, it should be done on the basis of population rather than the historical emissions which were the basis of the Kyoto Protocol.

A second lesson is that it is difficult for countries to commit themselves to achieving specified emissions targets when the costs of doing so are large and uncertain. At its core, the targets and timetables approach requires each participant to achieve its national emissions target regardless of the cost of doing so. Countries facing potentially high costs either refused to ratify the protocol, such as the United States, or simply failed to achieve their targets. Countries on track to meet their obligations were able to do so because of historical events largely unrelated to climate policy, such as German reunification, the Thatcher government’s reform of coal mining in Britain, or the collapse of the Russian economy in the early 1990’s.

The third lesson is perhaps the most important of all: even countries earnestly engaged in a targets and timetables process may be unable to meet their targets due to unforeseen events. Two excellent examples are New Zealand and Canada. No one anticipated during the 1997 negotiations that a decade later New Zealand would be facing a dramatic rise in Asian demand for beef and diary products. The impact on increasing methane emissions in New Zealand has been so large that it has completely offset the reductions New Zealand was able to achieve in the earlier 1990’s via reduced methane from declining numbers of sheep and improved sinks of carbon due to growth in forestry. Similarly, no one expected that Canada would find its tar sand deposits so valuable that extraction would be viable at oil prices reached two years ago let alone at current world oil prices.

One reason there has been so much interest in a targets and timetables strategy has been a widespread misunderstanding about the precision of scientific knowledge regarding the climate. It is widely agreed among atmospheric scientists that atmospheric concentrations of greenhouse gases are rising rapidly, and that emissions should be reduced.1 However, there is little agreement about how much emissions should be cut in any given year, and there is no guarantee that stabilizing at any particular concentration will eliminate the risk of dangerous climate change. Yet it is often implied that climate science translates directly into a specific emissions target and a fixed emissions budget.2 On the contrary, however, the uncertainties still remaining in the science are important and should be a core consideration in the design of climate policy.

All of the lessons above illustrate problems inherent in the targets and timetables approach. First, it forces countries into confrontations during negotiations over shares of a fixed global emissions budget. Second, committing to achieve a rigid emissions target is difficult for countries facing uncertain and potentially very high costs. Third, unexpected events can force even well-intentioned participants into non-compliance. In the face of these problems, some observers have argued that the solution is more of the same: a broader protocol with tighter targets and deeper cuts. However, there is little reason to expect the outcome to be any different, and in the mean time emissions will continue to rise. A better approach would be to recognize that focusing on targets and timetables has undermined the ultimate goal of actual emissions reductions, and that it is critical to move negotiations in a new direction. The Hokkaido Summit to be held in Japan this year is an important opportunity to make that shift, and to move the focus of climate change negotiations in a more realistic direction.

In this paper, we discuss an alternative framework for international climate policy, the McKibbin-Wilcoxen Hybrid3—an approach that focuses on coordinated actions rather than mandated, inflexible outcomes. Rather than committing to achieve specified emissions targets, participating countries would agree to adopt coordinated actions that are clear, measurable and enforceable within national borders. Because it does not start from a fixed emissions target (although an emissions budget does guide the design of the actions we propose), the Hybrid avoids all three of the problems discussed above. Shifting to an approach based on agreed actions, rather than specific emissions outcomes, will be a critical step in the evolution of climate negotiations. It will also make national policy actions more feasible than fixed targets, since a target would be little more than a hopeful pledge given how little is known for certain about the costs of reducing emissions.

Moreover, a framework based on common actions rather than common targets is particularly useful for accommodating the needs of developing countries. Developing countries face even greater uncertainty about their future economic growth prospects and future emissions paths than developed countries, and certainly do not want to undermine their development prospects by committing to an excessively stringent emissions target.

To illustrate the differences between the targets and timetables approach and one based on the Hybrid, we present a number of numerical simulations of the world economy using the G-Cubed global economic model. We focus particular attention on two of the problems with targets and timetables: the high stakes involved in negotiating over emissions budgets, and the risks stemming from uncertainty about costs. We first show that the outcome of a Kyoto-style targets and timetables policy with global emissions trading depends significantly on the allocation scheme for the emissions targets. We present one set of results using an allocation based on historical emissions and another set of results based on an equal per capita allocation. The results show how different the national costs of the policy will be depending on how emissions rights are allocated. We then examine the performance of the Kyoto-style allocation under one source of uncertainty: the rate of growth in developing countries, particularly China and India.

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The drawing of legislative district boundaries is among the most self-interested and least transparent systems in American democratic governance. All too often, formal redistricting authorities maintain their control by imposing high barriers to transparency and to public participation in the process. Reform advocates believe that opening that process to the public could lead to different outcomes and better representation.

On January 20, Brookings hosted a briefing to review how redistricting in the 50 states will unfold in the months ahead and present a number of state-based initiatives designed to increase transparency and public participation in redistricting. Brookings Nonresident Senior Fellows Micah Altman and Michael McDonald unveiled open source mapping software which enables users to create and submit their own plans, based on current census and historical election data, to redistricting authorities and to disseminate them widely. Such alternative public maps could offer viable input to the formal redistricting process.

After each presentation, participants took audience questions.

Learn more about Michael McDonald's Public Mapping Project »

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• Injecting Transparency into Redistricting
• GOP Could Re-Draw 145 Districts
• Towards a New Political Culture
• Coalitions Pushing for Greater Transparency
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• Download the District Builder Summary (.pdf)

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For over 100 years, the driving force of Ohio’s economy has been the state’s so-called Big Eight cities—Columbus, Cleveland, Cincinnati, Toledo, Akron, Dayton, Canton, and Youngstown. Today, though, the driving reality of these cities is sustained, long-term population loss. The central issue confronting these cities—and the state and surrounding metropolitan area—is not whether these cities will have different physical footprints and more green space than they do now, but how it will happen.

The state must adopt a different way of thinking and a different vision of its cities’ future—and so must the myriad local, civic, philanthropic, and business leaders who will also play a role in reshaping Ohio’s cities. The following seven basic premises should inform any vision for a smaller, stronger future and subsequent strategies for change in these places:

• These cities contain significant assets for future rebuilding
  
• These cities will not regain their peak population
  
• These cities have a surplus of housing
  
• These cities have far more vacant land than can be absorbed by redevelopment
  
• Impoverishment threatens the viability of these cities more than population loss as such
  
• Local resources are severely limited
  
• The fate of cities and their metropolitan areas are inextricably inter-connected
  

These premises have significant implications for the strategies that state and local governments should pursue to address the issues of shrinking cities.

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Less than four months after ascending the throne, Saudi King Salman bin Abdul Aziz Al Saud has made unprecedented changes in the line of succession that benefit his own son Prince Mohammed bin Salman. These shifts come as Salman pursues the most assertive foreign policy in recent Saudi history.

The king removed the sitting Crown Prince Muqrin, his half brother, and promoted the third in line Prince Mohammed bin Nayef, his nephew, up to number two. Salman made his own son, Mohammed bin Salman, the new number three. The King also replaced the ailing foreign minister, Prince Saud al Faisal with a non-royal, the current ambassador to Washington, Adel al Jubeir. Prince Saud had been Foreign Minister since 1975.

According to the royal palace, Prince Muqrin asked to be replaced, but no reason was given. No crown prince has ever given up the position in the history of the modern kingdom, founded in 1902. When Salman ascended the throne in January, the press trumpeted Muqrin as heir and there was no sign he was not eager to be the next in line. Many will assume he was asked to quit.

Speculation will be intense about why that might be. Muqrin was a protégé of the late King Abdullah. He is not close to Salman's branch of the family, the Sudeiris. He also appeared less enthusiastic about Salman's war in Yemen. As a former fighter pilot Muqrin understands the limits of air power, and he may have had doubts about the wisdom of what was initially called Operation Decisive Storm, but has now become a stalemate.

The new crown prince, 55-year-old Mohammed bin Nayef, is famous for defeating Al Qaeda's violent attempt to overthrow the House of Saud a decade ago. MBN, as he is known, led a four-year counter-terrorist campaign that decimated Al Qaeda in the Kingdom and drove its remnants into Yemen. In the process MBN survived at least four assassination plots. His father, the late Crown Prince Nayef, was so reactionary he was nicknamed the Black Prince. But MBN studied in Oregon and with the FBI and Scotland Yard before joining the Saudi interior ministry. He also holds the position of chairman of the Kingdom’s security and political committee coordinating all security issues.

Mohammed bin Salman, MBS, is the face of the Yemen war. He became defense minister in January and has been constantly on Saudi TV appearing to direct the war effort and meeting with foreign leaders to win support for the campaign against the pro-Iranian Zaydi Shia Houthi rebels. He is considered ruthlessly ambitious and is very close to his father. He has given up his position as chief of the royal court but he will undoubtedly keep control of access to the king.

Unlike most Saudi princes, MBS was not educated in the west. Instead he studied at King Saud University. There is controversy over his age, reputed to be anywhere from 29 to 34 (officially his birthday is July 24, 1980). He is chairman of a number of young people's organizations in the Kingdom and seeks to portray himself as the leader of the next generation of Saudis. He also chairs the powerful development and economics committee that coordinates economic policies, including oil price and supply.

In promoting his nephew and son, King Salman is passing the torch to the next generations of royals. Since 1902 the Kingdom has been ruled by the founder of the modern Kingdom Ibn Saud Abd Al Aziz or his sons. Now, Salman will be the last son to reign.

These changes have all been endorsed by the Allegiance Council, the committee of the sons and grandsons of Ibn Saud, but the legitimacy of selecting the next generation has been a question mark over the succession process for years. The king hopes it is now all settled.

The late King Abdullah's own son, Prince Mitab, has kept his powerful position as commander of the Saudi National Guard. The SANG is the family’s praetorian guard, it defends the capital, the holy mosques in Mecca and Medina and the oil industry. SANG troops have occupied Bahrain, the Kingdom’s tiny island neighbor, since the Arab Spring in 2011 to keep a minority Sunni monarchy in power.

The new lineup is solidly pro-American but riven with doubts about American reliability. The royals believe George W. Bush foolishly let Iran gain dominance in Iraq and fear Barack Obama is too eager for a nuclear deal with Iran and a grand rapprochement with Tehran. Repeated assurances by Obama and concrete support for the Yemen war have not altered Saudi doubts about America.

Salman's decision to wage war in Yemen so soon after coming to the throne reflected his acute concern that Iran was gaining a foothold on the Arabian Peninsula in what has always been the soft underbelly of Saudi Arabia, Yemen. The Zaydi Houthi rebels are not pawns of Tehran but they did initiate direct air flights between Sanaa and Tehran early this year, offered Iran port facilities and negotiated a lucrative oil deal. A few Iranian Revolutionary Guard advisers have been assisting the Zaydis for the last few years covertly. From Riyadh's view Iran already dominated decision-making in Baghdad, Damascus and Beirut, it does not want a fourth Arab capital to be aligned with Tehran.

But Salman's intense effort to secure wide Islamic backing for the war has been less than a success. Oman, Yemen's other neighbor, has opted not to join with the other five members of the Gulf Cooperation Council in the fighting, instead staying on the sidelines. The Pakistani parliament voted unanimously to keep neutral and rebuff repeated Saudi requests for ground troops to aid the war effort. Pakistani officials have privately suggested Salman panicked into the war without a viable strategy to get the Houthis out of Sanaa. Even Egypt, which benefits from billions in GCC aid, has opted not to send troops. although it's navy is supporting the Saudi blockade of Yemen.

The Yemen war is part Saudi-Iranian regional rivalry, part the unfinished business of the Arab Spring revolutions and part sectarian Sunni-Shia animosity. It is above all the Salmans’ war, father and son together. The surprise elevation of MBN and MBS underscores how the stakes in this war are crucial, not only to Yemen's future but increasingly to the future of the House of Saud.

This piece was originally published by The Daily Beast.

       

       

       

       

       

       

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To build on its longstanding interest in the evolving transatlantic relationship and to address the serious differences that have emerged between America and Europe after the September 11 terrorist attacks and throughout the ongoing war on terrorism, Brookings announces the launch of its new Center on the United States and Europe. The center offers a forum for research, high-level dialogue, and public debate on issues affecting U.S.-Europe relations.

At the inaugural conference to launch the new center, experts discussed the theme "The United States and Europe: One Year after the War in Iraq." Panelists at this special event included Javier Solana, Robert Kagan, Charles Grant, Klaus Scharioth, Andrew Moravcsik, Martin Indyk, Ulrike Guerot, Pascale Andreani, Cesare Merlini, Reuel Marc Gerecht, Gilles Andreani and others.

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Welcome and Introduction:
Philip H. Gordon , Director, Center on the United States and Europe

Is the European Union Failing? Politics and Policy after the Referendums
Philip H. Gordon , Director, Center on the United States and Europe

Panelists:
Gerard Baker, The Times (London)
Joschka Fischer, Member of Bundestag and former German Foreign Minister
Noëlle Lenoir, President of the European Institute of HEC, former French Minister for European Affairs
Andrew Moravcsik, Princeton University/Brookings

Is Russia Lost? The Future of Russian Democracy and Relations with the West
Fiona Hill, Senior Fellow, The Brookings Institution

Panelists:
Daniel Fried, U.S. Assistant Secretary of State for European Affairs
Anatol Lieven, New America Foundation
Strobe Talbott, President, The Brookings Institution
Dmitri Trenin, Carnegie Moscow Center

Is America above the Law? A U.S.-Europe Dialogue about the War on Terror
Jeremy Shapiro, Director of Research, Center on the United States and Europe

Panelists:
Joschka Fischer, Member of Bundestag and former German Foreign Minister
Tom Malinowski, Human Rights Watch
Pauline Neville-Jones, Chair, British Conservative Party National and International Security Group
Victoria Toensing, former U.S. Justice Department Official
Ruth Wedgwood, Johns Hopkins-SAIS

       

       

EXECUTIVE SUMMARY

In November 2008, President George W. Bush convened the first G-20 summit in Washington to address the worst global financial economic crisis since the Great Depression. This summit provided a long-overdue opportunity for a dramatic and lasting change in global governance. This was followed by the election of Barack Obama, who had campaigned on a distinctly different foreign policy platform compared with his Republican rival, Senator John McCain. These two events were no mere coincidence.

The global crisis has moved the United States, along with the rest of the world, toward a new global economic order, with the G-20 summit as one of the principal manifestations of the new global governance system. Of course, movement toward this new economic arrangement and progress toward reformed global governance are not inevitable. It will take a clear and sustained commitment to a new set of values and strong leadership, especially from President Obama and the United States, to ensure that the G-20 summit is not a short-lived exception to what had been a long-standing stalemate in global governance reform. The effectiveness of the G-20 in addressing the global economic crisis could lay the foundation for a new global order and provide the impetus for the many other necessary global governance reforms. Whether or not this happens will depend to a significant extent on the direction chosen by President Obama.

The president’s vision of inclusion and openness and his approach to governing, which favors innovative and far-reaching pragmatic responses to key national and global challenges, make him a great candidate for this role. In due course the G-20 summit can also serve as a platform for addressing other pressing global issues, including trade, climate change, energy and food security and reform of global institutions. To achieve such an outcome, President Obama and other world leaders need to demonstrate a clear vision and strong leadership starting at the G-20 Summit in Pittsburgh and beyond.

“Old Economic Order” versus “New Economic Order”

From recent debates on foreign policy and global governance, we have identified two different perspectives or sets of principles underlying the approaches toward U.S. and global foreign policy. Table 1 summarizes the key elements of what we call the “Old Economic Order” in juxtaposition to the “New Economic Order.”

Table 1: Old versus New Economic Order

(Note: This table is adapted from one first presented by the authors in a seminar at the IMF in June 2007. See www.imf.org/external/np/seminars/eng/2007/glb/bl030607.pdf )

In the Old Order, the nation state is the point of departure, stressing the importance of sovereignty and national interest as the key principles driving a unilateral and assertive foreign policy. In contrast, the New Order’s starting point considers that we live in a global society, where interdependency and recognition of common interests are the key principles to be pursued in reciprocal relations and with mutual respect across borders. Under the Old Order the rules of national power politics prevail, as competing blocs and fixed alliances strive for predominance, with “hard power” if necessary. Instead, the New Order operates on the basis of a new multilateralism, which builds on the prevalence of global networks in all spheres of life and multiple coalitions across borders, where bargaining for compromise and the tools of “soft power” prevail. Finally, the Old Order promotes the notion that a single economic and political model should prevail, while the New Order accepts that different economic and political models coexist and compete side by side.

In the most simple terms, the Old Order broadly reflects the principles underlying the foreign policy agenda of the Bush administration and Senator John McCain’s presidential platform, while the New Order approximates those underpinning the platform of Senator Barack Obama’s presidential campaign and of his administration’s foreign policy stance. Key elements of the Old Order (except the last one) have also been attributed to the current foreign policy approach of Russia, while New Order principles can be ascribed to the European Union.

In fact, what is reflected in these two approaches is the difference between twentieth-century principles of foreign policy versus principles appropriate to today’s realities. We believe there are three interrelated sets of drivers of change that necessitate moving from the Old Order to the New Order. These drivers include the changing global demographic and economic balance, emerging global threats and the need for a more effective global governance system.

Drivers of Change

The first driver of change is the shifting global demographic and economic balance. By 2050, the world population is projected to reach 9.1 billion, up from 6.4 billion today, with the increase occurring almost entirely in today’s developing countries. China is widely predicted to be the largest economy in the early 2040s, with the U.S. economy in second place and India’s in third. Other emerging market economies, including Brazil, Indonesia and Russia, will be important economic players, while individual European countries will recede in importance. Continental Eurasia will be the new hub of global integration as China, India, Russia, the European Union and the Middle East’s energy-producing countries knit their economies ever closer together. The United States will remain a superpower, but only one among others. Together, the major world powers will have to confront the fact that people in poorer and weaker states will feel left behind. Simultaneously, cross-border networks—economic and political, public and private, elite and grassroots, legitimate and illegitimate—will continue to grow and will weaken the traditional hold states have over the economic, financial, social and political actions of their citizens. These networks will create bonds that will either reinforce or undermine global stability.

The second driver of change is a set of emerging global threats:

• The current financial and economic crisis—triggered by poor macroeconomic management and lax financial regulation—reflects the realities of long-term financial imbalances among key economies. It proves the difficulties of managing a highly interdependent global financial system in the absence of agreed-upon global financial surveillance, supervision and regulation. It is likely that risks of global financial stress will continue in the coming decades.
• Global disparities will increase as the rich and the rapidly growing economies do well, while many poor and stagnating countries are left behind. There is potential for rising disparities within countries, too. These inequities will reinforce risks of domestic and cross-border conflict and terrorism. At the same time, the United States and other industrialized countries face a progressive loss of traditional industries, jobs and wages. Aging populations and overburdened pension systems will challenge their fiscal stability and may lead to groundswells of anti-globalization sentiments.
• Rising food and energy prices, environmental threats and the risks of global epidemics—reinforced by population pressures—particularly affect the poorest countries.
• Growing global interdependencies across borders and sectoral lines mean that individual countries can no longer address these threats alone and that a global response has to be coordinated across sectors.

The third driver of change is the growing and widespread recognition that the current system of global governance has become increasingly fragmented, ineffective, outdated and resistant to change. This systemic weakness is reflected in the persistent stalemate on many of the pressing global issues—most notably the Doha trade round—but also on global poverty, climate change and the risk of pandemics. Moreover, global institutions have become unrepresentative in the face of the changed global economic and political balances. Hence their legitimacy is suffering badly, and yet there is stalemate in the reform of individual international organizations.

Together, these three factors have made the principles of the Old Order irrelevant and strongly point in the direction of a New Order. They represent the new reality for governments, citizens and international institutions and force them to adopt new principles and reform existing institutions.

While the drivers are strong and the new global reality is seemingly unassailable, change is not inevitable. Old habits die hard. In the United States, traditions of self-reliance and “exceptionalism” continue to shape Americans’ views of the rest of the world. At the same time, the widespread belief in the virtues of unfettered markets and low taxes, the influence of special interests for protection (agriculture, labor, old industry, banking) and the prevailing fractiousness of political decision-making may well undermine President Obama’s efforts to move toward a new global paradigm. Compounding the entrenchment of the Old Order, new nations that are still recovering from centuries of colonialism—facing economic and political instability and wishing to catch up with the successful industrial countries—are lured to a strong sovereign nation state, unfettered control over their borders and their citizens, and a confrontational approach to foreign policy. Even the much admired willingness of the Europeans to give up sovereignty in favor of supranational institutions has its limits, not least when it comes to giving up their prerogatives of dominating the governing boards of the international financial institutions and other global forums.

Leadership, conviction and persistence will be required among many actors on the global stage to ensure there is progress toward effective reform of global institutions. This potential for change is exemplified by the recent emergence of the G-20 summit as a vehicle for global governance.

The G-20 Summit—Origins, Options and Obstacles

Origins. The G-20 summit had its origins in the annual meetings of the G7—the leaders of a group of seven major Western industrial countries who gathered annually starting in the 1970s, initially to enhance economic and financial policy coordination in reaction to a major financial crisis. After the break-up of the Soviet Union, the G8 was formed by the addition of the Russian Federation. The G8 increasingly became preoccupied with global economic and political issues—in effect assuming the role of a global steering group. But widespread criticism began to mount about its role. The G8 summits were seen as ritualistic in process, ineffective in impact and increasingly unrepresentative in the face of global population and economic shifts, and hence lacking in legitimacy as a global steering group. The onset of the global financial crisis in mid-2008 pushed President George W. Bush into convening the G-20 Summit on November 15, 2008.

The ministerial-level G-20 was first created in the aftermath of the 1997-98 East Asia financial crisis. By convening representatives from 10 industrialized economies and 10 emerging market economies, the G-20 presented a much more geographically and culturally diverse group than the G8. With about 90 percent of the world’s economy and two thirds of the world’s population, the G-20 is also much more representative than the G8. Emerging market economies have been fully engaged in managing the proceedings of the meetings of G-20 finance ministers and central bank governors. It is therefore not surprising that there had been persistent calls by some experts and politicians for using the G-20 as a platform to replace the G8. While moving from G8 to G-20 summit might not create an optimal global steering group, it is a pragmatic and effective step, especially in response to crisis.

Options. Will the G-20 be a short-lived experiment or will it prove an effective tool of global governance? Various options are under debate among experts and practitioners. One possibility is to return to the G8 summits like the one Italy hosted in 2009 and Canada plans to host in 2010. There is concern that the G-20 format is too unwieldy for effective exchanges among the key players. Hence, there will be continuing debates about reducing the size of the summit to somewhere between thirteen and sixteen members, as reflected in the recent proposal by the French President, Nicolas Sarkozy, to create a G14. However, there are pressures to expand the number of participants to include more countries and to expand regional representation. Then there are proposals to develop a constituency-based approach to membership, with universal participation as in the case of the international financial institutions. Further, German Chancellor Angela Merkel and a United Nations Commission chaired by Nobel laureate Joseph Stiglitz propose to establish an Economic Security Council at the UN.

None of these options will likely materialize in the foreseeable future. Instead there are two probable outcomes: The first is the continuation of the G-20 summit with a gradually expanding mandate beyond the current crisis. For this to be successful, it is critical that the G-20 format proves its effectiveness in the coming months and years. This outcome has three requirements: that the number of participants does not expand; that participants focus on a limited number of action items; and that a small but effective secretariat is established to support and monitor the G-20 summit with logistics and technical expertise.

The most likely alternative to the G-20 summit is what is frequently referred to as “variable geometry.” Under this scenario, selected world leaders would convene on specific topics in shifting constellations, with participation of the most important actors decided separately for each topic. For example, the G-20 might continue to meet on global financial and economic matters for some time to come, while different groups would convene for action on climate change, nuclear proliferation or other topics. Support for this plan appears to be emerging from the Obama administration. It co-convened the summit on climate change at the tail-end of the 2009 G8 Summit, hosts the September 2009 G-20 economic summit in Pittsburgh and has called for a summit on nuclear non-proliferation in the spring of 2010. The challenge for summits of “variable geometry” is the ever-shifting number and composition of participants, the difficulty of systematic organization and follow-up and continuing debates about who would convene the summits, when, and with what participation.

Obstacles. As we look ahead, we see a number of challenges for the evolution of global summits beyond the G8, whether toward an effective G-20 or some alternative, especially summits of variable geometry. These challenges emanate from the diverging interests of four sets of players: the United States, Europe, the new emerging powers and the rest of the world.

For the foreseeable future, active U.S. leadership is needed to overcome inertia and collective action problems in addressing global challenges and breaking the stalemate in global governance reform. The Obama administration appears to strongly support a paradigm shift toward a new global order, but so far has not announced its position on summit modalities.

Europe is a key player and has proven a major obstacle to global governance reform as it continues to claim far too many chairs at the G-20 (and in other global forums and institutions) for its economic and demographic weight. In effect, Europeans can either retain their over-representation, which gives them a fragmented voice and weakens their influence while also weakening the global institutions; or they can bundle their votes, chairs and voice for greater impact and to ensure more effective international organizations. Unfortunately, the current stalemate on internal EU governance reform blocks any new European approach to global governance reform.

The new emerging powers, especially China, India and Brazil, will face the challenge of moving beyond their traditional role of the “excluded” and “representatives of the South.” They will need to accept co-responsibility for solving global problems and creating effective global governance institutions. They will have to look beyond issue-specific South-South coalitions to North-South coalitions where it is in their and the global interest (e.g., the push for international financial institution reform, for EU for consolidation, for the completion of the Doha Round, etc.). There are hopeful signs that this is beginning to happen. South Korea’s leadership of next year’s G-20 represents a critical test of whether the new powers are ready to participate and conduct a G-20 forum at the leaders’ level, not only ministerial.

Finally, there is the challenge of how to include the “excluded.” The G-20 is much more inclusive than the G8, but it still leaves out a majority of countries with a third of the world’s population. Options for associating the rest of the world with the summit include ad hoc outreach (as the G8 has done), expanding regional representation (as already practiced with the EU), introducing a constituency approach (as for the IFIs) and seeking a closer alignment with the UN (perhaps through an Economic Security Council). With the exception of the first two—which risk further expanding the number of participants at G-20 summits—none of the other options are likely to materialize soon. However, G-20 leaders will have to be sensitive to the needs of the “excluded” and ensure that the interests of the poorest countries are not neglected.

Conclusion

Great changes in the economic and political balance among countries, global threats and an antiquated global governance system confront the world community today. With the economic crisis as an immediate driver and a new U.S. president, the G-20 summit format has the potential to make a real shift in the global economic order in which a new set of values underpin the way countries and people cooperate across borders. To the extent that President Obama has articulated his vision of the global order and America’s role in it, we believe he is headed in the direction that stresses common interests in a global society, the need for multilateral action and understanding for alternative approaches to economic and political development. This is very promising. The effectiveness of the G-20 in addressing the global economic crisis could lay the foundation for a new global order and provide the impetus for the many other necessary global governance reforms.

However, Europe, China and India are also critical for progress. Moreover, if President Obama is believed to fail the test of competence at home or a major shock hits the United States, a reversal is possible in the U.S. In any case, significant changes in global governance will take time to transpire. We may well see a long period of transition with only gradual improvement in current institutions. In the meantime, pressures for increased regionalism, bilateral deals among the big players, geopolitical competition among power blocs and growing instability and threats from the “excluded” will undermine international cooperation and the whole idea of a global order.

The G-20 summit forum represents a great opportunity for world leaders to begin to put into action the principles of a new global order. It will allow them to address the immediate global financial and economic crisis in a collaborative spirit. And in due course the G-20 summit can also serve as a platform for addressing other pressing global issues, including trade, climate change, energy and food security, and reform of global institutions. To achieve such an outcome, President Obama and other world leaders need to demonstrate a clear vision and strong leadership at the G-20 Summit in Pittsburgh and beyond.

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Policy Brief #180

	EXECUTIVE SUMMARY
	The year 2010 in Afghanistan had some encouraging signs but on balance it was less positive than had been hoped. In 2011, therefore, it is important to do two things: first, look for further improvements in our strategy; and second, develop a backup plan, should the current approach not yield the kind of progress that is necessary and expected. This policy brief addresses the first challenge, improving the U.S./NATO counterinsurgency campaign. The basic logic of current strategy is accepted, but several new initiatives or ideas are explored to make it more promising and more effective. Three main ideas are developed: Promoting Afghan political organizations built around ideas and platforms, not individuals and ethnicities, in a change from longstanding American policy that could improve the quality of governance in the country. Taking pressure off the bilateral U.S.-Afghan relationship on the issue of anticorruption, largely by creation of an international advisory board consisting of prominent individuals from key developing countries like Indonesia and Tanzania that have had considerable success improving their own nations' governance in recent times. Offering a civilian nuclear energy deal to Pakistan, conditional on clear action by Islamabad to shut down insurgent sanctuaries that are currently using its territory to attack the Afghan government as well as NATO forces.

The past year was not without good news in Afghanistan. It saw a successful deployment of nearly another 40,000 NATO troops to Afghanistan; twice as much growth in Afghan security forces together with a much more robust approach to their training; increases in American civilian capacity in Kabul and in the field; and highly effective targeting of Afghan (and Pakistani) insurgents within Afghanistan and just over the border with Pakistan. I would also count the September parliamentary elections as more good than bad, since it was Afghans who held other Afghans accountable for infractions, and since the Karzai government appears on balance to be tolerating an outcome that will reduce the strength of its cronies in the elected assembly (though this issue remains a work in progress). Finally, NATO's decision at the November Lisbon Summit to emphasize the year 2014 as the time when Afghanistan would assume full control of security operations-rather than President Obama's earlier preference to emphasize July 2011 as the point when the U.S. departure would begin-clarified the American and international commitments to get the job done right before going home. Among other benefits, this change should help convince more Afghan and Pakistani fence-sitters that they can count on us, rather than encouraging hedging behavior out of fear of a premature, hurried NATO exit.

However, 2010 also witnessed a roughly 50 percent increase in the overall level of violence that can only partially be explained by our increased presence and tempo of operations. That increase reflects a very resilient insurgency. Problematic relations between the Obama administration and the Karzai government have also continued, the corruption problem has remained intractable (largely fueled by the western presence with all of its trappings), and the Pakistani government still tolerates sanctuaries for the Haqqani network and the "Quetta Shura Taliban" (that is, the Afghan Taliban) on its territory.

For the most part, the strategy of the International Security Assistance Force (ISAF) under General David Petraeus, and the efforts of the international community more broadly, seem sound. The paramount goal in Afghanistan is to put the country's government in a position to control its own territory. That is the way to ensure that no large terrorist sanctuaries re-emerge there that could threaten the United States, nuclear-armed Pakistan, or other core western interests. But to achieve that goal, a comprehensive counterinsurgency approach that helps build up the Afghan state is needed, because establishing control of territory requires that the government possess a certain legitimacy among its people-which in turn requires some measure of economic and political progress. Hence, to achieve a fairly simple goal, we have properly undertaken a fairly ambitious strategy, after having tried the opposite, minimalist approach for the first half dozen years of the war only to see the Taliban make a comeback. Yet the strategy still needs improvement to address its two main vulnerabilities: the weakness and corruption of the Afghan government, and the schizophrenic approach to the war on the part the Pakistani government. This policy brief proposes ideas to address each of these problems. The proposals would also improve the prospects of any sound backup plan that might have to be considered this year, such as the concept that Brookings Senior Fellow Bruce Riedel and I have recently developed that we call a "Plan A-" for the country.

Afghan Governance and Anti-Corruption Efforts

Working with the Karzai government is an inherently complex matter. On the one hand, we have no choice but to partner with Afghanistan's elected leader, who in fact remains reasonably popular among his own people with a 62 percent favorability rating according to the latest polls. On the other hand, the government is widely seen as ineffective by many of its own citizens, helping generate motivation and recruits for the insurgency. So do we work with Karzai, or work around him? In fact, we must do both. We need a better way to help the Afghan government improve its performance without inciting periodic public spats along the way that set back our efforts to cooperate. And we also need a way to help build for Afghanistan's post-Karzai future, the sooner the better.

Improving Afghan Governance and Fighting Corruption

General Stanley McChrystal's 2009 assessment of the situation in Afghanistan famously and dramatically concluded that corruption in the Afghan government was comparable to the insurgency itself in posing a serious threat to the country. As such, General Petraeus has been right to focus intently on corruption since assuming command, including assigning the formidable Brigadier General HR McMaster to the task, and some positive things are happening as a result. More intelligence assets are being devoted to the problem. Field commanders and development specialists are more aware of the need to understand the power of money, and to be cognizant of whom they are empowering or embittering through their contracting processes and economic development efforts.

Yet problems remain. Corruption remains very serious. And disputes about corruption with President Karzai still go public too often. The United States and the international community more generally should reframe the issue of fighting corruption, as Marine Colonel Greg Douquet and I have previously argued. The challenge should be seen and described primarily as one of improving governance in Afghanistan rather than tackling a culture of criminality.

Blantant, extreme corruption must be prosecuted. But by criminalizing routine corruption, we not only encourage unrealistic expectations in the U.S. Congress and elsewhere about the progress that is achievable over the next few years, we may miss opportunities to work with Afghan "reconciliables"-individuals who may have had some corrupt tendencies yet also try to provide a certain level of effective governance. We also fail to recognize our own past role in the dynamic. Pumping billions of dollars a year into a poor economy, and inadvertently favoring certain power brokers and tribes over others in the process, feeds the very corruption that we so abhor.

Research on fighting corruption and improving governance points to a better way of thinking about this problem. One key insight from renowned development expert Paul Collier and others is that young democracies with weak checks on presidential powers and an easy source of cash tend to have major problems with corruption-so Afghanistan's challenges, rather than being viewed primarily as criminal, should be expected in some ways. Taking this tone with the Karzai government can improve atmospherics and bolster our odds of eliciting cooperative behavior from Kabul.

Another key finding from MIT's Benjamin Olken and other researchers is that trained, independent auditors deployed from the central government to various parts of the country can improve the quality of government performance. Government auditors could also counter the "inverse pyramid" patronage network that is common in the Karzai administration, a network in which corrupt officials "invest" in purchasing government positions and their "dividends" are paid to them in the form of bribes and extortion. Reforming Afghanistan's government will require reversing this trend, or at least mitigating it, through such auditors and other governmental improvements.

And perhaps most important of all, the development literature shows that a number of countries around the world have made headway in combating corruption and improving governance over the years. Brookings and World Bank scholars Daniel Kaufmann, Aart Kraay and Pablo Zoido-Lobaton document progress in places including Indonesia, Hong Kong, Georgia, Albania, Tanzania and Rwanda. We should try to involve more experts from such countries in the effort. President Karzai and others might react more positively to hearing suggestions about how to reduce bribes, check nepotism, and improve governance from Indonesians or Tanzanians rather than Americans.

With U.S. assistance, Afghanistan's government has improved. We are now seeing points of light in the anticorruption effort, such as President Karzai's new specialized anticorruption agency-the High Office of Oversight. Several key ministers in the Karzai cabinet are also exemplary on this front, including for example Minister of Interior Mohammadi. We should emphasize their sound efforts more often. But there is clearly a long way to go, and an international contact group may help.

Strengthening Afghan Political Parties and Institutions

Afghanistan's corruption problem is largely rooted in the fact that the young political system is still too driven by personalities-and to a lesser extent ethnicity-and not enough by ideas.

Part of the challenge is to make sure that Mr. Karzai relinquishes power in 2014, when he reaches the constitutional limit of two full presidential terms. Prudence requires that we assume Mr. Karzai will seek to change the constitution or otherwise manipulate the electoral and legal process to stay in office-not out of any megalomania, but as much as anything out of fear for himself and his friends and relatives given the uncertainty of who might follow him in office. As such, it is possible that Karzai could declare martial law and suspend future elections. He could seek a peace deal with insurgents that makes him the compromise candidate under a future modified constitution. He could even consider a military coup.

It is important to deflate this possibility before it gains momentum. U.S. policymakers should, for example, mention publicly that Mr. Karzai will no longer be president after 2014. This is unobjectionable as a point of legal fact-at least right now-so there is no reason to shy away from saying so. Talking about it enough will help clarify the international community's intentions and expectations. And given Afghanistan's long-term need for international security and economic assistance, Afghan leaders would have to take notice.

The second imperative is to strengthen Afghan political organizations. That means helping Afghanistan's reformers and patriots, of whom there are many, to form strong political movements. Mr. Karzai has chosen some good cabinet officials and governors, but these are just a few individuals. Afghanistan's organized political parties are very weak. There are some fledgling new movements-like the one spearheaded by former foreign minister and presidential candidate Abdullah Abdullah. But they are loosely organized and have relatively vague policy platforms.

Afghanistan needs political movements tied to ideas and governing principles rather than ethnicity or individuals. Mr. Karzai has so far discouraged their formation. He has argued that Afghans dislike political parties because of the legacy of Communist Party abuses in the late 1970s and 1980s. But the 1980s are increasingly ancient history. Those who oppose parties today seem motivated mostly by their own desire to divide and conquer a weak, inchoate opposition.

It is time for the U.S. government and the many other governmental and nongovernmental organizations present in Afghanistan to strongly support the activities of new political movements. They should encourage and fund Afghans as they hold policy conferences, create research institutes, do grass-roots political organizing, and talk policy and politics in print, on television and on the radio. This approach need not be anti-Karzai; the president himself could form a party.

Such dynamics could affect even the shorter-term calculations of Afghan politicians. If Afghan voters in 2014 and thereafter are empowered to make real policy choices, candidates will take notice and start developing ideas they can run on. That may be as good an antidote to weak governance and rampant corruption as we can find-not only for the future but for today as well.

Getting Pakistan Off the Fence

Pakistan arguably remains the most complex ally the United States has ever had in wartime. Nine years into the campaign, we still cannot clearly answer the question of whether Pakistan is with us or against us. America needs bold new policy measures to help Islamabad-in all its many dimensions and factions-make up its mind.

Despite allowing massive NATO logistics operations through its territory and helping the United States pursue al Qaeda operatives, Pakistan tolerates sanctuaries on its soil for the major insurgencies fighting in Afghanistan. These include the Afghan Taliban (known as the Quetta Shura Taliban because its principle base remains in Quetta in the Pakistani province of Baluchistan) as well as the Haqqani and Hezb-i-Islami Gulbuddin (HiG) networks. The Haqqanis straddle the border between the Afghan provinces of Khost, Paktia, and Paktika as well as North Waziristan and other tribal areas within Pakistan; HiG is further north, operating in and around the Khyber Pass connecting Kabul and Jalalabad in Afghanistan with Peshawar and points east in Pakistan. Thus, all three major Afghan insurgent groups have home bases in Pakistan, and despite the occasional drone strike are generally beyond NATO's reach as a result.

Pakistan has taken some worthy actions against extremists in its remote northern and western areas in recent years. Specifically, it has recognized the so-called Pakistani Taliban (the Tehrik-i-Taliban Pakistan, or TTP) as a mortal threat to the Pakistani state and responded accordingly in some tribal areas. Pakistanis argue, however, that limited numbers of ground troops combined with the past year's devastating floods prevent them from doing more. Quetta, North Waziristan, and other key places remain dens of iniquity, havens for extremists who continue to attack NATO and Afghan troops across the border and then return home for rest, regrouping, and fresh recruiting. Major command-and-control hubs are permanently located within Pakistan as well, and key insurgent leaders like Mullah Omar (to say nothing of Osama bin Laden) probably remain safely ensconced on Pakistani territory where U.S. forces cannot get at them. But it is perhaps not just a matter of available troops. Pakistan would rather have the Taliban and the Haqqanis back in power, especially in the country's south and east, than any group like the former Northern Alliance, which it views as too close to India. Since Islamabad cannot be sure that the current Afghan political system will survive, therefore, it keeps a backup plan based largely on the Taliban and its associates.

Under these circumstances, part of the right policy is to keep doing more of what the Obama administration has been doing with Pakistan-building trust, as with last fall's strategic dialogue in Washington; increasing aid incrementally, as with the new five-year, $2 billion aid package announced during that dialogue; encouraging Pakistan-India dialogue (which would help persuade Islamabad it could safely move more military forces from its eastern border to its western regions) and coordinating militarily across the Afghanistan-Pakistan border region. But President Barack Obama needs to think bigger. The clarification that the U.S.-led ISAF mission will continue until 2014, and indeed beyond, at the November Lisbon summit was a step in the right direction but more is needed.

Obama should offer Islamabad a much more expansive U.S.-Pakistani relationship if it helps win this war. Two major incentives would have particular appeal to Pakistan. One is a civilian nuclear energy deal like that being provided to India, with full safeguards on associated reactors. Pakistan's progress on export controls in the wake of the A.Q. Khan debacle has been good enough so far to allow a provisional approval of such a deal if other things fall into place as well, including Islamabad’s compliance with any future fissile production cutoff treaty. Second is a free trade accord. Struggling economically, Pakistan needs such a shot in the arm, and a trade deal could arguably do even more than aid at this point.

But the key point is this: Pakistan should be told that these deals will only be possible if the United States and its allies prevail in Afghanistan. Small gestures of greater helpfulness are not adequate; bottom-line results are what count and what are needed. If Afghanistan turns around in a year or two, the deals can be set in motion and implemented over a longer period that will allow the United States to continually monitor subsequent Pakistani cooperation in the war. These terms are really just common sense, and they are based on political realism about America's domestic politics as well as its strategic interests, since there is no way the Congress would support such a nuclear deal if Pakistani policy ultimately contributed to our losing the war in Afghanistan.

Conclusion

Current strategy in Afghanistan is built on reasonably sound counterinsurgency principles and is fairly promising in its prospects for the year ahead. But every such operation is different. That is a basic corollary of counterinsurgency theory, with its emphasis on local politics, conditions, and personalities-meaning that there is no reason to believe that current strategy is good enough just because its fundamentals are time-tested.

A number of other policy reforms, beyond those discussed here, may be worth considering in the coming months as well. The numerical goal for the Afghan security forces is probably still too low, and should approach 400,000 uniformed personnel rather than the current 305,000 target (this debate is well underway as of this writing). The legal system remains weak, with glaring problems such as a major dearth of judges and severely inadequate pay for prosecutors, as well as no clear strategy for linking the formal justice system to the local, traditional justice systems that remain important in Afghanistan today. Finally, in the aftermath of the September 2010 parliamentary elections, some patchwork solution to the disenfranchisement of Pashtuns in provinces like Ghazni where many of them could not vote (or had their votes thrown out) is probably needed. Perhaps some additional modest number of Pashtuns could be given non-voting adjunct status in the parliament, allowing their voices to be heard even if they were ultimately not able to win seats.

But the three changes to our current approach discussed in this policy brief are central, and have not received their due attention. On the anticorruption front, adoption of a less bilateral approach that includes a high-level international advisory body on good governance for the Karzai government could improve the tone and substance of the effort. On the Afghan politics front, the international community should be unapologetic about supporting Afghan political parties built on ideas and agendas more than personalities and ethnicities. And finally, in regard to Pakistan, an informal but public U.S. offer to pursue a bilateral civilian nuclear energy deal should Pakistan help us win the war by clamping down on insurgent sanctuaries, might motivate greater efforts by our on-again off-again allies across the border. Adoption of these recommendations would improve our prospects for at least moderate success in Afghanistan and help make 2011 the belated turnaround year that we so badly need.

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The Ferguson Commission—convened by Missouri Governor Jay Nixon in the aftermath of the police shooting death of Michael Brown—was given a daunting task. Its charge was not only to examine the underlying causes of “the social and economic conditions that impede progress, equality, and safety in the St. Louis region,” but also to issue a report “containing specific, practical policy recommendations for making the region a stronger, fairer place for everyone to live.”

Reflecting the magnitude of that charge, the Ferguson Commission’s final report, released on Monday, totals almost 200 pages and contains 189 calls to action that span a range of issue areas, from police and court reform, to creating higher-quality education and training opportunities, to improving access to jobs, transportation, and affordable housing.

The sweeping scope of the report’s recommendations is in proportion to the complexity of the shifting economic and demographic trends and the legacy of racial discrimination that helped set the stage for last summer’s events. Like many of its neighboring communities, and suburbs across the country, Ferguson has recently experienced rapid demographic and economic changes, transitioning from a largely white to a majority black community that has seen its poor population double since 2000.

The report’s authors emphasize that they want readers to “realize how interconnected all of these issues are.” (That’s one reason for the interactive online design—to allow users to navigate across related initiatives, even if they fall in different issue areas.) And the commission situates their calls to action within a regional framework that recognizes these issues operate at a scale broader than one neighborhood or suburb.

Even so, the challenge of municipal fragmentation looms large, both in the commission’s report and in any move towards implementing its recommendations. The report acknowledges that “the current state of municipal fragmentation is both a result of and a propagator of racial disparity” and that many of St. Louis’ suburbs “have problems with budgets because of their small size.” The commission calls for consolidation of the region’s 60 local police departments and 81 municipal courts, a move which could improve oversight and compliance and save the region millions of dollars a year.

But the commission stops short of addressing the municipalities themselves, many of which would continue to struggle with strapped budgets even after these reforms. Capping the share of municipal revenue generated by fines and fees, as the state legislature has done, could help curb abusive practices, but it doesn’t solve the underlying problem. Many of these small municipalities don’t have the resources they need to meet their current budget obligations, let alone pay for additional services and programs that increase access to opportunity (like those called for in the Ferguson Commission’s report).

There is no easy solution, but there are models for the region to consider that could ameliorate the negative effects of fragmentation (e.g., municipal collaboration, municipal consolidation, and regional revenue sharing and governance structures) and potentially ease the way for the broader slate of reforms recommended by the commission.

Presented with a Gordian knot of a challenge, the Ferguson Commission has put forward its framework for changing the status quo—what it believes “to be the best starting point, the beginning of a path toward a better St. Louis.” And the reality is that failing to act on the deep-seated challenges facing the region means struggling suburbs like Ferguson, and their residents, will only fall further behind.

       

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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
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• 07 antibacterial expert workshop public agenda
• 07 antibacterial expert workshop meeting summary

       

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].

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U.S. policy towards South Asia has changed considerably over the last seven decades. The nature of U.S. engagement with different countries in the region has varied over time, as has the level of U.S. interest. While India and Pakistan have received the most attention from Washington, the United States has also been engaging with Afghanistan, Bangladesh, Bhutan, Maldives, Nepal, and Sri Lanka, albeit to different degrees. 

On May 19, The India Project at Brookings hosted a panel discussion exploring the past and present U.S approaches towards South Asia, based on Senior Fellow Stephen Cohen’s new book, “The South Asia Papers: A Critical Anthology of Writings” (Brookings Institution Press, 2016). Panelists also assessed the Obama administration’s policies toward the region, and the challenges and opportunities that lie ahead for the next U.S. administration. Fellow Tanvi Madan, director of The India Project, moderated the discussion.

After the discussion, the panelists took questions.

Video

• U.S. policy toward South Asia: Past, present, and future

Audio

• U.S. policy toward South Asia: Past, present, and future

Transcript

• Uncorrected Transcript (.pdf)

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• 20160519_south_asia_transcript

       

INTRODUCTION

In an earlier policy brief, Where is the Learning? Measuring Schooling Efforts in Developing Countries, we drew attention to what was labeled “the global learning crisis.” While tremendous progress has been made over the past couple of decades to get tens of millions of additional children to enroll in school, progress in improving learning outcomes has been considerably less impressive. Although, shockingly, comprehensive learning outcome data are not available for most of the developing world, the many small scale, local or, in some cases, national studies that have been done show a dismal picture. For instance, Uwezo, an East African initiative, found that in Tanzania, only 44 percent of students in Grade 4 were able to read a basic story from Grade 2. Similarly, the Annual Status of Education Report (ASER) facilitated by Pratham found that in rural India, less than half of Grade 4 students were able to do basic subtraction. These examples demonstrate the gravity of “the global learning crisis” as students fail to master competencies appropriate for their grade level, hindering the development of life skills and success in further schooling, as well as performance in the labor market.

With about 61 million children in the developing world still not yet in school, it is too early to declare victory on the “enrollment agenda”. But we would do a disservice to the 250 million children around the world who fail to reach Grade 4 or attain minimum learning standards, if we don’t step up efforts to improve learning outcomes.

This policy brief is part of a larger effort to link resources in the education sector with outcome measures. As we have documented elsewhere, few countries systematically collect comprehensive financial data on education, although fortunately an increasing number of initiatives is trying to address this issue by producing, for instance, National Education Accounts (NEAs). When the focus of the sector changes from enrollment to enrollment plus learning, efforts to better grasp the size and use of financial resources should evolve accordingly. For instance, much learning takes place outside of the classroom, especially in the early years. For NEAs to be a useful tool for adjusting the allocation of scarce resources, the “learning” sector should be defined more broadly than the education or “schooling” sector. We will address this and related issues in a subsequent policy brief.

Once our focus becomes enrollment plus learning, we have to broaden our view and look at the entire environment in which a child develops skills, starting with the households in which children are born. It has beenknown for many decades and throughout the world, that among the best predictors of future school performance are some basic household characteristics, such as income and mother’s education level.

Data from international assessments also show a relationship between income and educational performance, exemplified by intra and intercountry results. In Colombia, average Trends in International Mathematics and Science Study (TIMSS) math scores at Grade 8 for the richest quintile of students were close to 100 points higher than those from the poorest quintile. On the other hand, the difference in average scores between the poorest quintile in the United States and the richest quintile in Colombia was about 50 points. Income is not the only predictor of success, as exemplified in Peru, where children whose mothers have completed primary school and whose maternal language is Spanish rather than an indigenous language, have a greater probability of reaching the appropriate school grade for their age. In Kenya, Uwezo found that the higher their father’s educational attainment, the more likely children were able to read a story at Grade 3 or attend extra tutoring sessions.

In addition, the larger environment (such as the village or the urban neighborhood) in which the young child grows up also has a major and lasting impact. In Tanzania, urban students in Grade 3 are three times more likely than their rural counterparts to meet standards in literacy and numeracy. Related to the impact of the larger environment, data from Nigeria suggest that girls are more disadvantaged in school attendance, as parents may be reluctant to send girls to school because of perceived fears for their safety while traveling and concerns about the physical strength required for walking the distance.

Clearly, especially in the early years, most learning takes place outside of the classroom. Consequently, children who grow up in deprived circumstances will start life with a disadvantage leading to a lack of learning in the early grades, which will have lifetime effects.

In the next section, we will summarize the evidence that the early years (ages 0 to 5) are crucial for subsequent learning achievements. From this evidence we conclude that many of the problems with learning outcomes in the developing world (and in many developed countries) need to be addressed well before school age. Before delving into what happens in schools, we explore the relationship between enrollment, learning and dropout. As the crux of this brief is to lay out the evidence on what contributes to learning, we must acknowledge the factors leading to low enrollment and dropout. Next, we turn our attention to what happens in schools and what can be done to improve these activities, as well as try to summarize the evidence about the relationship between specific school-based inputs and learning outcomes. As it turns out, this evidence is, in many cases, rather feeble. Therefore, we will first focus on school-level inputs that are necessary for a good learning environment, i.e. without which we cannot expect any learning to take place. Most of these inputs are rather obvious, but they are worth mentioning. Subsequently, we will discuss additional inputs that have proven to contribute to learning outcomes in some cases, but not in others. Clearly how these inputs are applied matters.

Next, we address factors that contribute to learning outside of a formal environment, after which we review issues in health and nutrition that are closely linked to learning outcomes. We then review the need for the collection and dissemination of learning assessments in order to impact further improvements in these areas and we try to answer the question: what are the building blocks for an education sector that promote learning? Finally we explore needs for future research in learning.

Downloads

• Download the full paper

       

For over 100 years, the driving force of Ohio’s economy has been the state’s so-called Big Eight cities—Columbus, Cleveland, Cincinnati, Toledo, Akron, Dayton, Canton, and Youngstown. Today, though, the driving reality of these cities is sustained, long-term population loss. The central issue confronting these cities—and the state and surrounding metropolitan area—is not whether these cities will have different physical footprints and more green space than they do now, but how it will happen.

The state must adopt a different way of thinking and a different vision of its cities’ future—and so must the myriad local, civic, philanthropic, and business leaders who will also play a role in reshaping Ohio’s cities. The following seven basic premises should inform any vision for a smaller, stronger future and subsequent strategies for change in these places:

• These cities contain significant assets for future rebuilding
  
• These cities will not regain their peak population
  
• These cities have a surplus of housing
  
• These cities have far more vacant land than can be absorbed by redevelopment
  
• Impoverishment threatens the viability of these cities more than population loss as such
  
• Local resources are severely limited
  
• The fate of cities and their metropolitan areas are inextricably inter-connected
  

These premises have significant implications for the strategies that state and local governments should pursue to address the issues of shrinking cities.

Full Paper on Ohio's Cities » (PDF)
Paper on Shrinking Cities Across the United States »

Downloads

• Full Paper

       

"At the end of the day, we need to remember that Daesh is more a product of the civil wars than it is a cause of them. And the way that we’re behaving is we’re treating it as the cause.  And the problem is that in places like Syria, in Iraq, potentially in Libya, we are mounting these military campaigns to destroy Daesh and we’re not doing anything about the underlying civil wars.  And the real danger there is—we have a brilliant military and they may very well succeed in destroying Daesh—but if we haven’t dealt with the underlying civil wars, we’ll have Son of Daesh a year later." – Ken Pollack

“Part of the problem is how we want the U.S. to be more engaged and more involved and what that requires in practice. We have to be honest about a different kind of American role in the Middle East. It means committing considerable economic and political resources to this region of the world that a lot of Americans are quite frankly sick of… There is this aspect of nation-building that is in part what we have to do in the Middle East, help these countries rebuild, but we can’t do that on the cheap. We can’t do that with this relatively hands off approach.” – Shadi Hamid

In this episode of “Intersections,” Kenneth Pollack, senior fellow in the Center for Middle East Policy and Shadi Hamid, senior fellow in the Project on U.S. Relations with the Islamic World and author of "Islamic Exceptionalism: How the Struggle over Islam is Reshaping the World," discuss the current state of upheaval in the Middle East, the Arab Spring, and the political durability of Islamist movements in the region. They also explain their ideas on how and why the United States should change its approach to the Middle East and areas of potential improvement for U.S. foreign policy in the region. 

Show Notes

Fight or flight: America’s choice in the Middle East

Security and public order

Islamists on Islamism today

Temptations of Power: Islamists & Illiberal Democracy in a New Middle East

Ending the Middle East’s civil wars

A Rage for Order: The Middle East in turmoil, from Tahrir Square to ISIS

Building a better Syrian opposition army: How and why

With thanks to audio engineer and producer Zack Kulzer, Mark Hoelscher, Carisa Nietsche, Sara Abdel-Rahim, Eric Abalahin, Fred Dews and Richard Fawal.

Subscribe to the Intersections on iTunes, and send feedback email to intersections@brookings.edu.

       

Editor’s Note: Brookings will hold an event and live webcast on Wednesday, August 26 to discuss the findings of the 2015 Financial and Digital Inclusion (FDIP) Report and Scorecard. Follow the conversation on Twitter using #FinancialInclusion 

Access to affordable, quality financial services is vital both for ensuring the financial well-being of individuals and for fostering broader economic development. Yet about 2 billion adults around the world still do not have formal financial accounts.

The Financial and Digital Inclusion Project (FDIP), launched within the Center for Technology Innovation at Brookings, set out to answer three key questions:

• Do country commitments make a difference in progress toward financial inclusion?
• To what extent do mobile and other digital technologies advance financial inclusion?
• What legal, policy, and regulatory approaches promote financial inclusion?

To answer these questions, the FDIP team spent the past year examining how governments, private sector entities, non-government organizations, and the general public across 21 diverse countries have worked together to advance access to and usage of formal financial services. This research informed the development of the 2015 Report and Scorecard — the first in a 3-year series of research on the topic.

For the 2015 Scorecard, FDIP researchers assessed 33 indicators across four dimensions of financial inclusion: Country commitment, mobile capacity, regulatory environment, and adoption of selected basic traditional and digital financial services.

The 2015 FDIP Report and Scorecard provide detailed profiles of the financial inclusion landscape in 21 countries, focusing on mobile money and other digital financial services.

On August 26, the Center for Technology Innovation will discuss the findings of the 2015 Report and Scorecard and host a conversation about key trends, opportunities, and obstacles surrounding financial inclusion among authorities from the public and private sectors.

Register to attend the event in-person or by webcast, and join the conversation on Twitter at #FinancialInclusion.

      

Event Information

On September 30, 2011, the U.S.-born radical Islamic cleric, Anwar al-Awlaki, was killed by an American drone strike in Yemen, marking the first extra-judicial killing by the United States government against a U.S. citizen. Placed at the top of a CIA kill list in 2010 by the Obama administration, al-Awlaki was known for his intimate involvement in multiple al-Qaida terrorist plots against U.S. citizens, including the 2009 Christmas Day airline bombing attempt in Detroit and the 2010 plot to blow up U.S.-bound cargo planes. His calls for violent jihad remain prominent on the Internet, and his influence has turned up in many cases since his death, including the Boston Marathon bombing of 2013 and the Charlie Hebdo shootings in Paris early this year. In a new book, “Objective Troy: A Terrorist, A President, and the Rise of the Drone” (Crown, 2015), The New York Times national security reporter Scott Shane, drawing on in-depth field research in Yemen and interviews with U.S. government officials, charts the intimate details of the life and death of al-Awlaki, including his radicalization, his recruiting efforts for al-Qaida in the Arabian Peninsula, and the use of drone strikes by the United States to prosecute its counterterrorism goals.

On September 17, the Intelligence Project hosted Shane to examine the roles played by al-Awlaki in al-Qaida plots against the United States, al-Awlaki’s continued influence on terrorism, and the current state of al-Qaida today. Brookings Senior Fellow Bruce Riedel, director of the Intelligence Project, provided introductory remarks and moderated the discussion.

Audio

• Anwar al-Awlaki, Yemen, and American counterterrorism policy

Transcript

• Uncorrected Transcript (.pdf)

Event Materials

• 20150917_awlaki_yemen_transcript

       

Also in this podcast: Russ Whitehurst discusses the cost of universal education for preschool, and David Wessel comments on the current state of the economy

"To use some of the time honored clichés, 'The enemy may get a vote too.' Or the Bolshevik line, 'You may not have an interest in war, but war may have an interest in you' I paraphrase that to say we may not, at the moment, have an interest in counterinsurgency and stabilization missions, but they may have an interest in us… we can't be like the ostrich putting our head in the sand just because we're tired of these kinds of wars. They might come back, whether we like it or not." says Senior Fellow Michael O'Hanlon about his new book, "The Future of Land Warfare."

After learning about the various scenarios that might necessitate land warfare, we'll hear Russ Whitehurst, senior fellow in Economic Studies and Editor of the Evidence Speaks project, discuss the cost of universal Pre-K. "The question is: what should the nation or states do to increase participation rates to a universal level?" Whitehurst asks in this project. "And what I've found by looking at the evidence is that actually people haven't provided very good evidence on how many children are presently served."

Also, stay tuned to hear expert David Wessel update us on one of the nation's most alarming economic problems – wage stagnation.

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Show Notes:

• Read more about O'Hanlon's book, "The Future of Land Warfare"
• The future of the U.S. army
• Toward a "Reaganov" Russia: Russian Security Policy after Putin
• Obama the Carpenter: The President's National Security Legacy
• What role will evidence play in the 2016 election?
• Do we already have universal preschool?
• Why public school vouchers could have bi-partisan appeal
• Hutchins Roundup: wealth inequality, student borrowing, and more

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