Editors’ Note: For the United States to succeed in its mission in Afghanistan, it is essential that the Obama administration sustain the current level of U.S. forces there. Recognizing this, John Allen spearheaded a move to ask President Obama to do so, in the following open letter to which former leaders from the military and diplomatic corps signed on. This letter originally appeared on The National Interest.

Washington, DC

June 3, 2016

Dear Mr. President,

We are writing, as Americans committed to the success of our country’s Afghanistan mission, to urge that you sustain the current level of U.S. forces in Afghanistan through the remainder of your term. Aid levels and diplomatic energies should similarly be preserved without reduction. Unless emergency conditions require consideration of a modest increase, we would strongly favor a freeze at the level of roughly ten thousand U.S. troops through January 20. This approach would also allow your successor to assess the situation for herself or himself and make further adjustments accordingly.

The broader Middle East is roiled in conflicts that pit moderate and progressive forces against those of violent extremists. As we saw on 9/11 and in the recent attacks in Paris, San Bernardino and Brussels, the problems of the Middle East do not remain contained within the Middle East. Afghanistan is the place where Al Qaeda and affiliates first planned the 9/11 attacks and a place where they continue to operate—and is thus important in the broader effort to defeat the global extremist movement today. It is a place where Al Qaeda and ISIS still have modest footprints that could be expanded if a security vacuum developed. If Afghanistan were to revert to the chaos of the 1990s, millions of refugees would again seek shelter in neighboring countries and overseas, dramatically intensifying the severe challenges already faced in Europe and beyond.

In the long-term struggle against violent extremists, the United States above all needs allies—not only to fight a common enemy, but also to create a positive vision for the peoples of the region. Today, aided by the bipartisan policies of the last two U.S. administrations, Afghans have established a democratic political system, moderately effective security forces, a much improved quality of life, and a vibrant civil society. Afghans are fighting and dying for their country, and in our common battle against extremism, with more than five thousand police and soldiers laying down their lives annually each of the past several years.

Afghanistan is a place where we should wish to consolidate and lock down our provisional progress into something of a more lasting asset. It is a Muslim country where most of the public as well as government officials want our help and value our friendship. Afghanistan is also a crucial partner in helping to shape the calculations of Pakistan, which has been an incubator of violent extremism but which might gradually be induced to cooperate in building a regional order conducive to peace and economic progress.

You have rightly prioritized Afghanistan throughout your presidency and have successfully achieved several crucial objectives. You have prevented the reemergence of a terrorist sanctuary in Afghanistan, from which attacks on Americans might emanate. You have helped Afghanistan develop security forces so that it is principally Afghans who are defending Afghanistan, thereby enabling a 90 percent reduction in the U.S. military presence relative to its peak (and a two-thirds reduction relative to what you inherited in 2009). You have established a long-term strategic partnership with Afghanistan that can address common threats from extremist groups based in Pakistan. To our minds, these are significant accomplishments. They have established much of the foundation for pursuing the ultimate goals of stabilizing Afghanistan and defeating extremism in the region.

To be sure, there have been significant frustrations in Afghanistan along the way. All of us have lived and experienced a number of them. All of us have, like you, deeply lamented the loss of each American life that has been sacrificed there in pursuit of our mission objectives and our national security.

Yet, though the situation is fraught, we have reason to be confident. President Ghani, Chief Executive Abdullah, and many brave Afghans are working hard to rebuild their country. NATO allies and other partners remain committed to the mission. The level of support we must provide to enable continued progress is much lower than in earlier periods.

Our group is taking full stock of the situation in Afghanistan and will make a broader range of recommendations available to the next U.S. president on the interrelated subjects of governance, the economy, and security. But as an interim measure, and with the NATO Warsaw summit as well as other key decision points still looming on your watch, we urge you to maintain the current U.S. troop strength in Afghanistan through the end of your term. Based on longstanding experience in the country as well as recent trips to Afghanistan by some of us, this step would be seen as a positive reaffirmation of America’s commitment to that nation, its people and its security. It would likely have helpful effects on refugee flows, the confidence of the Taliban, the morale of the Afghan military and Afghan people, the state of the Afghan economy and perhaps even the strategic assessments of some in Pakistan. Conversely, we are convinced that a reduction of our military and financial support over the coming months would negatively affect each of these.

Sincerely,

Ambassadors to Afghanistan

Ryan Crocker

James Cunningham

Robert Finn

Zalmay Khalilzad

Ronald Neumann

Military Commanders in Afghanistan

John Allen

David Barno

John Campbell

Stanley McChrystal

David Petraeus

Special Representatives for Afghanistan/Pakistan

James Dobbins

Daniel Feldman

Marc Grossman

       

From a distance, the finger-pointing and the hand-wringing over the seeming demise of plans to build rail to Dulles Airport make it appear that the project collapsed under its own weight.

The Dulles dust-up is not a unique disease, but rather a symptom of a much larger national transportation illness. As hard as it may be to think of a $5 billion mega-transportation project as a “microcosm” of anything, right now that is exactly how one should consider the Dulles rail controversy.

The disagreements about the planned 23-mile Metrorail line through Tysons Corner in Virginia, continuing to Dulles International Airport — stalled now due to ideological differences over the appropriate federal role in transportation — are a subset of a larger battle taking place.

Around the country, metropolitan-based civic and business leaders are constructing 21st-century visions for transit, engaging local governments in true regional decision making and leveraging private funding for infrastructure projects.

Formerly auto-centric metropolitan areas such as Los Angeles and Dallas have made transformative use of new investments in key transit corridors. Metropolitan Denver is embarking on arguably the most extensive transit expansion this nation has ever seen.

These regions have looked to transit to shape future growth, to provide more choices and to at least somewhat mitigate climate changes.

Unfortunately, most of this innovation is happening in spite of — rather than in conjunction with — the federal government.

The sad fact is that our national government takes an impeding and outmoded approach to transportation innovation, establishing starkly different rules that favor highways over transit projects.

This unlevel playing field has profound effects on metropolitan America and, by extension, on the economic competitiveness of the nation.

The federal program that funds new transit projects is totally discretionary and highly regulated by the U.S. Department of Transportation. Projects must prevail through an onerous review before final recommendation is made. Even then, each project is subject to the annual congressional appropriations process.

Clearly, some kind of competitive process is warranted. However, the current bureaucratic rigmarole is so torturous, it is no wonder that some metropolitan areas are forgoing the federal process completely and funding new transit segments on their own.

In addition, this administration’s inexplicably hostile approach to nonhighway projects has compounded the problem, resulting in shortsighted thinking that ignores the realities and challenges of the modern metropolis.

But no such federal gantlet governs highway projects. Simply put, the states do not have to seek federal permission to build them.

More inequity exists in terms of what the federal government is willing to contribute to investments.

Federal law created 50 years ago establishes 80 percent to 90 percent of the funding for highway projects. For transit investments, the contribution is much lower — just 47 percent, according to the Office of Management and Budget. The Dulles share is only 20 percent.

Finally, developers of federal transit projects must demonstrate a long-term ability to operate and maintain the facility.

Makes sense, right? It is one thing to create a project but, as the collapse of the bridge in Minneapolis underscored, maintaining it is entirely another. Yet recipients of highway dollars amazingly are not responsible for this.

All of this brings us back to the Dulles rail project. Understandably, many feel that the Department of Transportation’s lack of clear guidance and direction, astonishing miscommunication, unprecedented heavy-handedness and traditional, road-centric thinking may be too much to overcome.

Yet the hope is that cooler heads prevail. The focus now must be on making Dulles rail a negotiated success rather than a standoff failure, because too many benefits are on the line.

The project promises to transform a congested suburban corridor, contribute toward energy independence and take advantage of a unique private finance and development partnership to accommodate decades’ worth of metropolitan growth. It also will anchor Washington’s status as an international capital.

Right now, though, our outmoded transportation infrastructure, both here and around the country, is ill-served by an outmoded federal partner.

Robert Puentes is a fellow at the Brookings Institution’s Metropolitan Policy Program.

      

       

Why is Springfield's economy proving so resilient?

Several reasons come to mind: You're a manageably sized regional hub. You've got a university and important hospital assets. And you stand at the brink of an enormously attractive natural area -- the Ozarks.

More and more in today's footloose economy, jobs and people flock to livable places with affordable housing, vibrant downtowns, cultural amenities and lots of close-by outdoor recreation.

And Springfield's got all that. Well, OK: Downtown hardly buzzes with "24-7" meeting and living as yet. But the university keeps students around, and meanwhile, nearby Branson remains one of the nation's foremost "drive-to" cultural attractions. Likewise, the beautiful "lake country" draws visitors and second-home buyers from all over the Midwest. In this case natural beauty really is natural capital: The famous Ozarks ambience continues to support a $1-billion-a-year tourist sector to cushion the blows of any national economic downturn.

No wonder the region paced the state's growth in the 1990s and now holds on better in bad times. Greater Springfield has service jobs, rolling hills, lakes, Andy Williams, retirees and their pensions, and reasonably priced new subdivisions. What's not to like?

But here's the harder question: Can Springfield stay attractive? Can it stay resilient? The worry is that signs of strain have now appeared after a decade of fast growth.

Many of these strains my colleagues and I detailed in a recent Brookings Institution report I co-authored, titled "Growth in the Heartland: Challenges and Opportunities for Missouri."

Springfield, we demonstrated, sprawled in the 1990s. Yes, the city proper grew by 8 percent. But mostly population moved ever outward during the decade, and that, we said, has brought problems.

Thousands of people flocked to smaller outlying towns like Willard, Strafford, Republic, Clever, Nixa and Ozark, which hit "hypergrowth" in the 1990s and struggled to keep up. Christian and Webster counties grew unsustainably by 66 and 31 percent, respectively. And even more disturbing some 28,000 people settled in unincorporated fringe areas ill-equipped to accommodate them with modern sewers and good services.

The result: Septic and fertilizer seepage from scattered new homes exacerbates the water-quality problems that have fouled Lake Taneycomo and Table Rock Lake. Taxes are increasing as local governments strain to provide the necessary roads, services or sewer lines in places that never needed them. And with more sprawl coming, more traffic and more mini-malls could cost the region its reputation as the heartland of rural America -- quaint, scenic and friendly. The bottom line: Highly dispersed, low-density development may well be undermining the durability of its growth.

In that sense, the real test of Springfield's resilience lies ahead and turns on its ability to manage its growth to make it sustainable. What is more, the best way for Springfield to continue to grow in high-quality ways would seem to be to continue to set the standard for land-use and environmental reform in Missouri -- a state that has lagged on promoting sensible land use and planning.

As a state, after all, Missouri needs to update its badly outmoded planning statutes to provide its regions more tools to manage change.

It needs to promote regional solutions among its many localities. And it needs to better align its transportation and infrastructure investment policies with the principles of sound land use and sensible planning.

In this regard, what the state does -- or doesn't do -- to manage growth matters for Springfield because, ultimately, it is the state that sets the rules for what type of growth occurs all over. By remaining virtually laissez-faire on growth and development topics, the state of Missouri may well be undercutting its future competitiveness.

Given that, Springfield should take seriously the fact that with its strong growth, fresh voice and signature environmental assets, it is well positioned to lead the state in promoting reform.

So Springfield should step forward on these issues -- as the state's new economic driver, and as its most progressive region.

Already southwest Missouri business leaders have come together to protect the lakes. Now the region should show the way in other ways, by hammering out a regional system for managing fast growth; rationalizing local government competition; and insisting on state action to allow all regions to make headway.

For that is the way for the Springfield region to prosper: To help itself, it must help nudge the entire state along. Only in that fashion will a distinctive region maintain its distinctive vitality.

      

While Israeli and Palestinian interests are best served by a negotiated two-state state solution, the peace plan that Sam Bahour proposed in his February post disregards Israel's demographic and security concerns and is tantamount to a Palestinian veto on a negotiated solution. His insistence on the right of return for Palestinian refugees and rejection of security limitations on Palestinian sovereignty in effect asks Israel to become a binational state while creating a militarized Palestinian state alongside it. Bahour rejects the notion of unilateral action, but his case only reinforces my belief that Israel may need to act independently to protect its interests.

The logic behind the Clinton parameters and President Obama’s peace plan was that in return for the creation of a Palestinian state, Palestinian refugees would relinquish their claim to Israel; the hope was that this would allow for the "two states for two peoples" to exist side-by-side. Yet Bahour rejects compromise on the refugee issue as the forfeiture of “basic components of statehood and basic principles of Israeli-Palestinian peace that are enshrined in international law.” Any peace agreement that both establishes a Palestinian state and recognizes the rights of millions of Palestinians to enter Israel would hasten the end of Israel's Jewish identity.

Israel's interest in the creation of a Palestinian state is also built upon the assumption that a sound agreement would improve its security rather than threaten it. To this end, Israel has called for a demilitarized Palestinian state, and this has been echoed by the United States, France, the Czech Republic, the European Union, and Australia’s Labor Party. Even Mahmoud Abbas accepted the premise of demilitarization, saying, “We don’t need planes or missiles. All we need is a strong police force.” Nevertheless, Bahour’s piece declares any limitations on the sovereignty of Palestine unacceptable. For Israel, a peace deal that grants one’s adversaries access to more deadly weaponry would be absurd.

Bahour argues that my strategies for reaching a two-state solution are doomed because they do not meet the "mutual interests" of the parties to the conflict, but his plan does not offer incentives for Israel to make peace.

Bahour argues that my strategies for reaching a two-state solution are doomed because they do not meet the "mutual interests" of the parties to the conflict, but his plan does not offer incentives for Israel to make peace. His proposal not only fails to improve Israel's situation in any tangible sense, but further endangers it. Rejectionist Palestinian positions like Bahour's (and Abbas's recent dismissal of Biden's initiative) would veto the two-state solution as a means to move towards a single binational state. That is precisely why Israel may need to act independently to keep a two-state solution viable.

      

A wave of retrenchment by global financial institutions may be undermining years of progress in providing the world’s poor with financial services.

What appeared to be only a vague concern a year ago is now front and center in discussions regarding global financial regulation. The reason: new regulatory and legal uncertainty regarding financial services, stemming from record fines levied on a handful of banks for failures to comply with international sanctions and anti-money laundering rules. A recent successful civil action in the U.S. against Arab Bank has further increased banks’ worries about their possible civil liability. Rightly or wrongly, the financial industry is reading these actions as raising the bar for compliance. As a result, we are seeing key and vocal market players use these developments to justify a wholesale retreat from services that are a lifeline for millions of people at the bottom of the economic pyramid.

For example, late last year a big bank in Australia sent letters to companies providing remittance services laying out a stark choice: close their accounts, or the bank would unilaterally shut them down. Accounts held by remittance companies have also been closed by banks in the U.K., the U.S., and New Zealand. If these remittances providers do not find alternatives, we may experience a global reduction in remittance services, and—due to reduced competition—increased cost to use those that remain in operation.

Remittance services are not the only targets. Trade finance and civil society organizations have also been affected. For instance, in the Netherlands an NGO involved in supporting the peace-building work of women's groups and women leaders in the Middle East and North Africa was recently refused a bank account by a large international bank. After the NGO explained to the bank that its work entails working with partners in the region, the bank decided not to provide a bank account in order to avoid any risk of funds (indirectly) ending up in Syria. And there are many examples like this, hampering the work of NGOs and humanitarian organizations, particularly in areas of conflict where they are most needed. In recent months, stories like this have become too numerous—and too widespread geographically—to be ignored; this is a global phenomenon.

This trend of account closures has become known as “de-risking”—a term that confuses more than it clarifies. Risk management, when properly carried out, is an essential and healthy component of running a bank. Under international financial industry norms, banks are expected to use a risk-based approach to evaluate whether to do business with a potential customer, and to monitor transactions for signs of suspicious activity. If there is a reasonable basis to believe a particular client creates significant risks regarding money laundering (ML) or terrorist financing (TF), a bank is fully justified in ultimately refusing to offer services.

 “De-risking,” however, is very different. The influential Financial Action Task Force (FATF), the standard setter for combating money laundering and terrorist financing, noted in an October 2014 statement that “de-risking refers to the phenomenon of financial institutions terminating or restricting business relationships with clients or categories of clients to avoid, rather than manage, risk.” The result, criticized by FATF, is the “wholesale cutting loose of entire classes of customers.”

Our concern lies not with the principle that some clients may be too risky for banks. Rather, the problem is the magnitude of de-risking. Current de-risking measures are excluding many clients that conduct legitimate transactions. And, because de-risking ends up pushing clients and transactions towards the informal and shadow financial system, it can actually increase global risks in this area.

It is therefore urgent for the international community to act. We need to better grasp what is really happening, and why. We believe that the solutions going forward will have to build on three pillars:

1. Public authorities need to provide more meaningful information on ML/TF risks to the financial industry, clarify their regulatory expectations, and adopt a genuinely risk-based approach in their supervisory and enforcement actions.
2. Financial institutions need to step up their understanding of the risks of their customer base, and direct internal control efforts accordingly. Risk management approaches should focus more on individual clients, and not write off entire sectors.
3. Countries with significant inflows of remittances need to improve the effectiveness of their regulatory regimes to combat ML/TF, and to provide more comfort to global financial institutions with banking relationships with clients in the developing world.

Millions of people in developing countries depend on remittances to help pay for basic necessities like food and shelter. In recent years we have seen important progress with banks and mobile network operators introducing innovative ways to serve the poor—including “mobile money” solutions that have enormous potential for enabling cross-border transactions. It would be a shame to see that trend reversed. Let’s not have those at the bottom of the economic pyramid pay for the criminal behavior of a few, and let’s make sure that enforcement action really targets the “bad guys.” Preserving access to the global financial system for the poorest and most vulnerable is a critical imperative, both economically and ethically.

      

President Obama's announcement last month that earlier this year a “U.S. counterterrorism operation” had killed two hostages, including an American citizen, has become a fresh occasion for questioning the rationales for continuing attacks from unmanned aerial vehicles aimed at presumed, suspected, or even confirmed terrorists. This questioning is desirable, although not mainly for hostage-related reasons connected to this incident. Sometimes an incident has a sufficient element of controversy to stoke debate even though what most needs to be debated is not an issue specific to the incident itself. More fundamental issues about the entire drone program need more attention than they are getting.

The plight of hostages held by terrorists has a long and sometimes tragic history, almost all of which has had nothing to do with drones. Hostage-taking has been an attractive terrorist tool for so long partly because of the inherent advantages that the hostage-holders always will have over counterterrorist forces. Those advantages include not only the ability to conceal the location of hostages—evidently a successful concealment in the case of the hostages mentioned in the president's announcement—but also the ability of terrorists to kill the hostages themselves and to do so quickly enough to make any rescue operation extraordinarily difficult. Even states highly skilled at such operations, most notably Israel, have for this reason suffered failed rescue attempts.

It is not obvious what the net effect of operations with armed drones is likely to be on the fate of other current or future hostages. The incident in Pakistan demonstrates one of the direct negative possibilities. Possibly an offsetting consideration is that fearing aerial attack and being kept on the run may make, for some terrorists, the taking of hostages less attractive and the management of their custody more difficult. But a hostage known to be in the same location as a terrorist may have the attraction to the latter of serving as a human shield.

The drone program overall has had both pluses and minuses, as anyone who is either a confirmed supporter or opponent of the program should admit. There is no question that a significant number of certified bad guys have been removed as a direct and immediate consequence of the attacks. But offsetting, and probably more than offsetting, that result are the anger and resentment from collateral casualties and damage and the stimulus to radicalization that the anger and resentment provide. There is a good chance that the aerial strikes have created more new terrorists bent on exacting revenge on the United States than the number of old terrorists the strikes have killed.

This possibility is all the more disturbing in light of what appears to be a significant discrepancy between the official U.S. posture regarding collateral casualties and the picture that comes from nonofficial sources of reporting and expertise. The public is at a disadvantage in trying to judge this subject and to assess who is right and who is wrong, but what has been pointed out by respected specialists such as Micah Zenko is enough to raise serious doubt about official versions both of the efforts made to avoid casualties among innocents and of how many innocents have become victims of the strikes.

The geographic areas in which the drone strikes are most feasible and most common are not necessarily the same places from which future terrorist attacks against the United States are most likely to originate. The core Al-Qaeda group, which has been the primary target and concern in northwest Pakistan, is but a shadow of its former self and not the threat it once was. Defenders of the drone strikes are entitled to claim that this development is in large part due to the strikes. But that leaves the question: why keep doing it now?

The principal explanation, as recognized in the relevant government circles, for the drone program has been that it is the only way to reach terrorists who cannot be reached by other tools or methods. It has been seen as the only counterterrorist game that could be played in some places. That still leaves more fundamental questions about the motivations for playing the game.

Policy-makers do not use a counterterrorist tool just because the tool is nifty—although that may be a contributing factor regarding the drones—but rather because they feel obligated to use every available tool to strike at terrorists as long as there are any terrorists against whom to strike. In the back of their minds is the thought of the next Big One, or maybe even a not so big terrorist attack on U.S. soil, occurring on their watch after not having done everything they could to prevent it, or doing what would later be seen in hindsight as having had the chance to prevent it.

The principal driver of such thoughts is the American public's zero tolerance attitude toward terrorism, in which every terrorist attack is seen as a preventable tragedy that should have been prevented, without fully factoring in the costs and risks of prevention or of attempted prevention. Presidents and the people who work for them will continue to fire missiles from drones and to do some other risky, costly, or even counterproductive things in the cause of counterterrorism because of the prospect of getting politically pilloried for not being seen to make the maximum effort on behalf of that cause.

This piece was originally published by The National Interest.

      

       

Erica has a history of cardiac issues. She visits her doctor for a regular checkup and her doctor writes a new prescription to better control her heart disease. Unfortunately, her doctor didn't mention any instructions, except to take it once a day. Erica thanks her doctor and heads to the pharmacy. At the check-out counter, the clerk hands Erica her new prescription drug, in addition to three documents stapled to the bag that he says "will explain everything you need to know about your medication." Later on, while reviewing the materials at home, Erica is overwhelmed by the information, which is in fine print and difficult to understand. She is frustrated and confused, and tosses the documents in the trash.

This scenario is not uncommon. Research suggests that about 50 percent of Americans find it difficult to read health information.[i] Consumers who cannot find the information they need, or who do not understand the information because it is presented in a convoluted manner, are less likely to use it to prevent unnecessary medical errors. In Erica’s case, she could have ended up in the emergency room because she missed some basic warnings about her prescription. For example, one warning might have been that she should not chew the medication because it was an extended release capsule. Chewing the capsule could release the entire day’s dose at once, resulting in an unintended overdose.

We know that consumers are receiving information – sometimes too much information. Not only are consumers receiving pages of medication information, the information they receive is uncoordinated and sometimes conflicting. Some documents are written by the drug manufacturer, and others are written by pharmacies or another third party. Some medication information documents are FDA-approved and others are not.

The real question is – could medication information be presented in such a way that it would be more useful for consumers? The answer is a resounding “yes.” One study found that just 75 percent of consumer medication information met the minimum criteria for usefulness.[ii] That number might be impressive as a field goal percentage in the NBA, but for consumers it represents an unmet need for high quality medication information.

The U.S. Food and Drug Administration (FDA) has spent the past several years working with stakeholders to determine the most effective methods for conveying medication information. One overarching principle that has emerged from FDA’s engagement with the health care community is the need for a single, standardized document to replace the numerous existing documents. This document is identified as Patient Medication Information (PMI).

PMI creates an easier way for consumers to access and understand their medication information. By presenting the most salient pieces of information – including drug uses, warnings, side effects, and directions – on a single page that is easy to navigate, PMI can be a useful tool for enhancing treatments and preventing avoidable medication errors or side effects. PMI holds promise both for consumers and the broader health care system. For consumers, PMI could contribute to better outcomes and an overall improvement in patient experience. For health systems, PMI’s positive impact on medication adherence could improve performance on quality measures, such as hospital readmissions, that could lead to shared savings or other rewards.

Through a cooperative agreement, the Engelberg Center for Health Care Reform at the Brookings Institution has worked in collaboration with FDA over the past few years to convene a series of workshops focused on identifying best PMI practices – for example, how to make PMI both more usable and accessible.  Workshop participants identified several guiding principles for improving the content, format, and distribution of PMI.

PMI Guiding Principles

PMI content should be consumer-friendly. Expert stakeholders identified a lack of consumer-friendly information as one of the most important barriers to effectively communicating critical medication information. To fix this problem, the language used in PMI will need to be simplified, patient-centric, and understandable across the entire spectrum of health literacy levels. The types of information that should be included in PMI must be essential for taking a medication properly. Extraneous information, such as a discussion of previous treatments a consumer must have previously tried and failed before receiving the new prescription, may be more confusing than helpful.

The best PMI formats are simple and easy to navigate. Consumers don’t want to be given a technical-looking instruction manual when they pick up their prescriptions. Participants at the workshops generally agreed that it would be ideal to keep PMI to a single page. They also agreed that actionable headers that help consumers locate the information they are looking for are preferable to the question and answer format (e.g., “Uses” and “Directions” are more effective than “What does the drug treat?” and “How do I use the drug?”). There was consensus on the point that consumers will ultimately decide the best format.

Access to PMI will be bolstered by multiple channels of distribution. Paper is still the primary source of medication information, and is preferred by certain demographics. However, technology is revolutionizing the way consumers receive information. This is generally good for society, but it introduces some challenges, including the fact that consumers now have more access to information of questionable quality.  One method for ensuring access to consistent and high quality PMI would be to have a central repository for all PMI documents. This approach could support distribution of both printed and electronic PMI. Access to PMI could be further enhanced by making it available on smartphones and via email.

On July 1, the Center will convene a public meeting that will provide an opportunity for the health care community to discuss the issues mentioned above. Researchers will give an update on progress made since the previous meetings and share the lessons they learned from recent studies. Diverse stakeholders – including patient advocacy groups, providers, pharmacies, and drug manufacturers – will provide their perspectives on the future of PMI and assess their role in making high quality PMI a reality. 

There are many issues that need to be addressed in exploring the promise of PMI. However, one thing that participants at the July 1 meeting should remember is this: Keep it simple, stakeholders.

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The tide of uncertainty that has swept the United Kingdom after its vote to leave the European Union has spared few—including its emerging class of innovation districts.

These hubs of innovation—where anchor institutions, such as universities and R&D laden companies cluster and connect with startups, incubators, and a host of public spaces, coffee shops, retail and housing—are now asking themselves important questions that will affect their future. Will the U.K. broker a deal to continue free trade with Europe? Will access to talent across Europe be curtailed? Will the devalued pound keep U.K. advanced manufacturers competitive for the medium to long term? Will European Union legal frameworks be replaced with a regulatory platform that continues to support advanced sectors? What will happen to EU funding on science and innovation, such as Horizon 2020?

Of course, innovation districts are no stranger to uncertainty, if not chaos. These districts thrive on random mixing, on smashing different kinds of disciplines and people together to generate new ideas and new products for the market. In this close-knit, highly networked ecosystem, chaos breeds creativity. At the same time, the backbone of districts is a clear regulatory and legal framework with rules on intellectual property, investment, and funding streams. The twinning of chaos and certainty is what makes these places simply superb spaces to incubate new technology, aggregate talent, and experiment in linking placemaking with innovation.

Yet from the distinctive innovation districts in London to those emerging in the middle of England, such as in Sheffield and Manchester, to those rising in Scotland, such as in Glasgow, this moment of uncertainty could be not only painful—it could be downright dangerous. 

In the face of such uncertain times, the temptation will be to sit back and wait for the cards to fall. But this tempered, conservative approach is ironically the more risky tactic.

We recommend another path.

Now is the time for the institutions and firms that are driving innovation districts to strengthen their competitive position and expand their reach.

Now is the time to try new forms of collaboration between universities, large companies, and local enterprises.

Now is the time to test more democratic modes of innovation with maker spaces, fab labs, and shared infrastructure and equipment.

Now is the time to forge new partnerships with other innovation districts in the United States and Europe to share promising strategies around commercialization, networking, and financing.

Now is the time to apply new energy to creative placemaking, including strengthening the innovation–place nexus around key nodes and applying quick interventions around traffic calming, bike lanes, and pop-up gathering spaces. 

U.S. cities and innovation districts have demonstrated that progress can persist even when higher levels of government are adrift. U.K. cities and districts can do the same.

       

Employers continued to boost payrolls in 2015, capping six straight years of job gains. It was the third year in a row in which employment gains topped 210,000 a month. In the 12 months ending in November, public and private payrolls increased 220,000 a month, or about 1.9 percent over the year. Virtually all the growth in payrolls was in the private sector, which added 212,000 jobs a month. The public sector added modestly to its payrolls last year, but the number of government employees remains more than one million (4.4 percent) below the peak level attained in 2010. 

Nearly all major industries except mining contributed to job gains in the past 12 months, though gains in manufacturing were weaker than in any year since the expansion began in 2010.  Payrolls in the mining industry tumbled more than 10 percent, hurt by a steep fall in oil and gas prices and the decline in exploration for new energy reserves. The construction industry continued to add to payrolls last year at about the same pace as in the previous two years, although the level of employment is still about 1.2 million (15 percent) below the peak level achieved in 2006.

Based on the age composition of the U.S. population, between 65,000-80,000 new jobs are needed every month to keep the unemployment rate from rising. Since late 2010, monthly payroll gains have comfortably exceeded this threshold. As a result, the jobless rate has declined steadily. In the 12 months through November 2015, the unemployment rate dropped another 0.8 percentage point, falling to 5.0 percent. The jobless rate is now within a half percentage point of its level immediately before the Great Recession. Since reaching a peak in the autumn of 2009, the unemployment rate has been cut in half.

We’ve also seen improvement in other indicators of job market distress in the past year. The number of Americans who want full-time jobs but have been forced to take part-time positions fell more than 11 percent in the 12 months through November 2015. About 9 million workers who wanted a full-time job were employed part-time in the middle of 2010. That number has fallen to about 6 million in recent months.  Similarly, the number of Americans in long spells of unemployment continues to shrink. Workers reporting they were unemployed 6 months or longer fell to 2.05 million in November, representing a considerable improvement since 2010. In that year, more than 6 million jobless workers reported they had been looking for work for at least a half a year.

The most welcome news for Americans who hold jobs is that inflation-adjusted wage levels improved last year.  Real average hourly earnings increased 1.8 percent between November 2014 and November 2015, and real weekly earnings climbed 1.6 percent.  These gains represent a considerable improvement compared with earlier years in the recovery, when real wage gains were negligible.  Nonetheless, nominal wage gains in 2015 were only slightly faster than they were in earlier years of the recovery. The reason for the startling turnaround in real wage growth is that consumer prices increased very little over the past year.  In the 12 months ending in November, the CPI edged up just 0.5 percent, almost a full percentage point more slowly than the average rate of consumer inflation in the previous three years.  The slowdown was driven by lower prices for energy and other key commodities.  (The “core” consumer inflation rate, which strips out the effects of price changes in energy and food, was 2.0 percent last year, a bit higher than the rate in the previous year.) 

Back when politicians and voters cared more about inflation than they currently do, Brookings economist Arthur Okun proposed an economic indicator called the “misery index” to summarize the dual hardships of inflation and unemployment. To measure economic misery Okun suggested adding the current unemployment rate and a measure of consumer price inflation.  In Chart 1 below I have added the civilian unemployment rate and the trailing 12-month percentage change in the CPI.  In the 11 months of 2012 through November, the misery index averaged just 5.4, its lowest level since the 1950s and well below its average levels in the 1990s (8.8) and in the period from 2000 to 2007 (7.8). When inflation is benign and has remained subdued for a long time, Americans may forget the pain they feel when price increases are frequent and large. Okun’s misery index fell to an exceptionally low level in 2015, even if a small majority of Americans continues to believe the economy is getting worse.

The good news in 2015 is that unemployment continued to fall and real wages began to rise.  The less welcome news is that key measures of labor force participation failed to improve.  For example, the labor force participation rate of Americans between 25 and 54 was the same in November 2015 as it was in November 2014. More worryingly, it was 2.1 percentage points below its level in November 2007, just before the Great Recession.  So far we have seen no rebound in participation among people in prime working ages, despite abundant signs that it’s easier to land a job. 

Low participation is the main explanation for depressed employment rates among prime-age Americans.  Participation rates are not only low in comparison to levels seen before the Great Recession, they are also now below those in other rich countries.  Charts 2 and 3 compare employment-to-population rates among 25-54 year-olds in seven OECD member countries (Canada, France, Germany, Japan, Sweden, the United Kingdom, and the United States).  The charts show employment rates separately for men and women in two different years, 2000 and 2014.  The countries are ranked, from left to right, by their employment rates in 2014. In 2000 the U.S. had the second highest male employment rate (Chart 2) and the second highest female employment rate (Chart 3) of the seven countries listed.  By 2014, the U.S. had the lowest male and female employment rates among the countries compared.  Although several nations saw declines in their prime-age male employment rate, only the U.S. also experienced a decline in its prime-age female employment rate.  The other six countries all saw increases in female employment.

The main reason for the drop in prime-age U.S. employment was the decline in prime-age participation. An enduring puzzle of the current recovery is the failure of participation rates to rebound, even in the face of steady improvement in the job market.