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Russia’s annexation of Crimea in March and the continuing crisis in Ukraine have triggered the most heated confrontation between Russia and the West since the Cold War. The standoff over Ukraine has raised critical questions about Russia’s ambitions in the post-Soviet space and the future political perspectives of the countries caught between Russia and the European Union. Despite political and economic pressure and ongoing occupation by Russia, Georgia is pursuing democratic transformation and a path toward the West.

On May 5, the Center on the United States and Europe (CUSE) at Brookings hosted Georgian Defense Minister Irakli Alasania for an address on Georgia’s vision for Euro-Atlantic integration during a period of increased insecurity in the region. In his remarks, Minister Alasania shared his insights on the upcoming NATO summit and Georgia’s approach to enhancing its relations with the West while attempting to normalize relations with Russia to lower tensions still simmering from the war six years ago.

Irakli Alasania previously served as Georgia's permanent representative to the United Nations from 2006 to 2009 and before that as special representative of the president in Georgian-Abkhazian negotiations. He is the founder and chairman of the Our Georgia-Free Democrats Party and one of the founders of Georgian Dream Coalition.

CUSE Director Fiona Hill provided introductory remarks and moderated the discussion.

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• Georgia's Euro-Atlantic Aspirations and Regional Security

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• Transcript (.pdf)

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• 20140505_georgia_security_transcript

       

       

       

At the very heart of the American idea is the notion that, unlike in other places, we can start from nothing and through hard work have everything. That nothing we can imagine is beyond our reach. That we will pull up stakes, go anywhere, do anything to make our dreams come true. But what if that's just a myth? What if the truth is something very different? What if we are…stuck?

I. What does it mean to be an American?

Full disclosure: I'm British. Partial defense: I was born on the Fourth of July. I also have made my home here, because I want my teenage sons to feel more American. What does that mean? I don't just mean waving flags and watching football and drinking bad beer. (Okay, yes, the beer is excellent now; otherwise, it would have been a harder migration.) I'm talking about the essence of Americanism. It is a question on which much ink—and blood—has been spent. But I think it can be answered very simply: To be American is to be free to make something of yourself. An everyday phrase that's used to admire another ("She's really made something of herself") or as a proud boast ("I'm a self-made man!"), it also expresses a theological truth. The most important American-manufactured products are Americans themselves. The spirit of self-creation offers a strong and inspiring contrast with English identity, which is based on social class. In my old country, people are supposed to know their place. British people, still constitutionally subjects of Her Majesty Queen Elizabeth, can say things like "Oh, no, that's not for people like me." Infuriating.

Americans do not know their place in society; they make their place. American social structures and hierarchies are open, fluid, and dynamic. Mobility, not nobility. Or at least that's the theory. Here's President Obama, in his second inaugural address: "We are true to our creed when a little girl born into the bleakest poverty knows that she has the same chance to succeed as anybody else because she is an American; she is free, and she is equal, not just in the eyes of God but also in our own."

Politicians of the left in Europe would lament the existence of bleak poverty. Obama instead attacks the idea that a child born to poor parents will inherit their status. "The same chance to succeed as anybody else because she is an American…."

Americanism is a unique and powerful cocktail, blending radical egalitarianism (born equal) with fierce individualism (it's up to you): equal parts Thomas Paine and Horatio Alger. Egalitarian individualism is in America's DNA. In his original draft of the Declaration of Independence, Thomas Jefferson wrote that "men are created equal and independent," a sentiment that remained even though the last two words were ultimately cut. It was a declaration not only of national independence but also of a nation of independents.

The problem lately is not the American Dream in the abstract. It is the growing failure to realize it. Two necessary ingredients of Americanism—meritocracy and momentum—are now sorely lacking.

America is stuck.

Almost everywhere you look—at class structures, Congress, the economy, race gaps, residential mobility, even the roads—progress is slowing. Gridlock has already become a useful term for political inactivity in Washington, D. C. But it goes much deeper than that. American society itself has become stuck, with weak circulation and mobility across class lines. The economy has lost its postwar dynamism. Racial gaps, illuminated by the burning of churches and urban unrest, stubbornly persist.

In a nation where progress was once unquestioned, stasis threatens. Many Americans I talk to sense that things just aren't moving the way they once were. They are right. Right now this prevailing feeling of stuckness, of limited possibilities and uncertain futures, is fueling a growing contempt for institutions, from the banks and Congress to the media and big business, and a wave of antipolitics on both left and right. It is an impotent anger that has yet to take coherent shape. But even if the American people don't know what to do about it, they know that something is profoundly wrong.

II. How stuck are we?

Let's start with the most important symptom: a lack of social mobility. For all the boasts of meritocracy—only in America!—Americans born at the bottom of the ladder are in fact now less likely to rise to the top than those situated similarly in most other nations, and only half as likely as their Canadian counterparts. The proportion of children born on the bottom rung of the ladder who rise to the top as adults in the U.S. is 7.5 percent—lower than in the U.K. (9 percent), Denmark (11.7), and Canada (13.5). Horatio Alger has a funny Canadian accent now.

It is not just poverty that is inherited. Affluent Americans are solidifying their own status and passing it on to their children more than the affluent in other nations and more than they did in the past. Boys born in 1948 to a high-earning father (in the top quarter of wage distribution) had a 33 percent chance of becoming a top earner themselves; for those born in 1980, the chance of staying at the top rose sharply to 44 percent, according to calculations by Manhattan Institute economist Scott Winship. The sons of fathers with really high earnings—in the top 5 percent—are much less likely to tumble down the ladder in the U. S. than in Canada (44 percent versus 59 percent). A "glass floor" prevents even the least talented offspring of the affluent from falling. There is a blockage in the circulation of the American elite as well, a system-wide hardening of the arteries.

Exhibit A in the case against the American political elites: the U. S. tax code. To call it Byzantine is an insult to medieval Roman administrative prowess. There is one good reason for this complexity: The American tax system is a major instrument of social policy, especially in terms of tax credits to lower-income families, health-care subsidies, incentives for retirement savings, and so on. But there are plenty of bad reasons, too—above all, the billions of dollars' worth of breaks and exceptions resulting from lobbying efforts by the very people the tax system favors.

So fragile is the American political ego that we can't go five minutes without congratulating ourselves on the greatness of our system, yet policy choices exacerbate stuckness.

The American system is also a weak reed when it comes to redistribution. You will have read and heard many times that the United States is one of the most unequal nations in the world. That is true, but only after the impact of taxes and benefits is taken into account. What economists call "market inequality," which exists before any government intervention at all, is much lower—in fact it's about the same as in Germany and France. There is a lot going on under the hood here, but the key point is clear enough: America is unequal because American policy moves less money from rich to poor. Inequality is not fate or an act of nature. Inequality is a choice.

These are facts that should shock America into action. For a nation organized principally around the ideas of opportunity and openness, social stickiness of this order amounts to an existential threat. Although political leaders declare their dedication to openness, the hard issues raised by social inertia are receiving insufficient attention in terms of actual policy solutions. Most American politicians remain cheerleaders for the American Dream, merely offering loud encouragement from the sidelines, as if that were their role. So fragile is the American political ego that we can't go five minutes without congratulating ourselves on the greatness of our system, yet policy choices exacerbate stuckness and ensure decline.

In Britain (where stickiness has historically been an accepted social condition), by contrast, the issues of social mobility and class stickiness have risen to the top of the political and policy agenda. In the previous U.K. government (in which I served as director of strategy to Nick Clegg, the deputy prime minister), we devoted whole Cabinet meetings to the problems of intergenerational mobility and the development of a new national strategy. (One result has been a dramatic expansion in pre-K education and care: Every 3- and 4-year-old will soon be entitled to 30 hours a week for free.) Many of the Cabinet members were schooled at the nation's finest private high schools. A few had hereditary titles. But they pored over data and argued over remedies—posh people worrying over intergenerational income quintiles.

Why is social mobility a hotter topic in the old country? Here is my theory: Brits are acutely aware that they live in a class-divided society. Cues and clues of accent, dress, education, and comportment are constantly calibrated. But this awareness increases political pressure to reduce these divisions. In America, by contrast, the myth of classlessness stands in the way of progress. The everyday folksiness of Americans—which, to be clear, I love—serves as a social camouflage for deep economic inequality. Americans tell themselves and one another that they live in a classless land of open opportunity. But it is starting to ring hollow, isn't it?

III. For black Americans, claims of equal opportunity have, of course, been false from the founding.

They remain false today. The chances of being stuck in poverty are far, far greater for black kids. Half of those born on the bottom rung of the income ladder (the bottom fifth) will stay there as adults. Perhaps even more disturbing, seven out of ten black kids raised in middle-income homes (i.e., the middle fifth) will end up lower down as adults. A boy who grows up in Baltimore will earn 28 percent less simply because he grew up in Baltimore: In other words, this supersedes all other factors. Sixty-six percent of black children live in America's poorest neighborhoods, compared with six percent of white children.

Recent events have shone a light on the black experience in dozens of U. S. cities.

Behind the riots and the rage, the statistics tell a simple, damning story. Progress toward equality for black Americans has essentially halted. The average black family has an income that is 59 percent of the average white family's, down from 65 percent in 2000. In the job market, race gaps are immobile, too. In the 1950s, black Americans were twice as likely to be unemployed as whites. And today? Still twice as likely.

From heeding the call "Go west, young man" to loading up the U-Haul in search of a better job, the instinctive restlessness of America has always matched skills to work, people to opportunities, labor to capital.

Race gaps in wealth are perhaps the most striking of all. The average white household is now thirteen times wealthier than the average black one. This is the widest gap in a quarter of a century. The recession hit families of all races, but it resulted in a wealth wipeout for black families. In 2007, the average black family had a net worth of $19,200, almost entirely in housing stock, typically at the cheap, fragile end of the market. By 2010, this had fallen to $16,600. By 2013—by which point white wealth levels had started to recover—it was down to $11,000. In national economic terms, black wealth is now essentially nonexistent.

Half a century after the passing of the Civil Rights Act, the arc of history is no longer bending toward justice. A few years ago, it was reasonable to hope that changing attitudes, increasing education, and a growing economy would surely, if slowly, bring black America and white America closer together. No longer. America is stuck.

IV. The economy is also getting stuck.

Labor productivity growth, measured as growth in output per hour, has averaged 1.6 percent since 1973. Male earning power is flatlining. In 2014, the median full-time male wage was $50,000, down from $53,000 in 1973 (in the dollar equivalent of 2014). Capital is being hoarded rather than invested in the businesses of the future. U. S. corporations have almost $1.5 trillion sitting on their balance sheets, and many are busily buying up their own stock. But capital expenditure lags, hindering the economic recovery.

New-business creation and entrepreneurial activity are declining, too. As economist Robert Litan has shown, the proportion of "baby businesses" (firms less than a year old) has almost halved since the late 1970s, decreasing from 15 percent to 8 percent—the hallmark of "a steady, secular decline in business dynamism." It is significant that this downward trend set in long before the Great Recession hit. There is less movement between jobs as well, another symptom of declining economic vigor.

Americans are settling behind their desks—and also into their neighborhoods. The proportion of American adults moving house each year has decreased by almost half since the postwar years, to around 12 percent. Long-distance moves across state lines have as well. This is partly due to technological advances, which have weakened the link between location and job prospects, and partly to the growth of economic diversity in cities; there are few "one industry" towns today. But it is also due to a less vibrant housing market, slower rates of new business creation, and a lessening in Americans' appetite for disruption, change, and risk.

This geographic settling is at odds with historic American geographic mobility. From heeding the call "Go west, young man" to loading up the U-Haul in search of a better job, the instinctive restlessness of America has always matched skills to work, people to opportunities, labor to capital. Rather than waiting for help from the government, or for the economic tide to turn back in their favor, millions of Americans changed their life prospects by changing their address. Now they are more likely to stay put and wait. Others, especially black Americans, are unable to escape the poor neighborhoods of their childhood. They are, as the title of an influential book by sociologist Patrick Sharkey puts it, Stuck in Place.

There are everyday symptoms of stuckness, too. Take transport. In 2014, Americans collectively spent almost seven billion hours stuck motionless in traffic—that's a couple days each. The roads get more jammed every year. But money for infrastructure improvements is stuck in a failing road fund, and the railophobia of politicians hampers investment in public transport.

Whose job is it to do something about this? The most visible symptom of our disease is the glue slowly hardening in the machinery of national government. The last two Congresses have been the least productive in history by almost any measure chosen, just when we need them to be the most productive. The U. S. political system, with its strong separation among competing centers of power, relies on a spirit of cross-party compromise and trust in order to work. Good luck there.

V. So what is to be done?

As with anything, the first step is to admit the problem. Americans have to stop convincing themselves they live in a society of opportunity. It is a painful admission, of course, especially for the most successful. The most fervent believers in meritocracy are naturally those who have enjoyed success. It is hard to acknowledge the role of good fortune, including the lottery of birth, when describing your own path to greatness.

There is a general reckoning needed. In the golden years following World War II, the economy grew at 4 percent per annum and wages surged. Wealth accumulated. The federal government, at the zenith of its powers, built interstates and the welfare system, sent GIs to college and men to the moon. But here's the thing: Those days are gone, and they're not coming back. Opportunity and growth will no longer be delivered, almost automatically, by a buoyant and largely unchallenged economy. Now it will take work.

The future success of the American idea must now be intentional.

Entrepreneurial, mobile, aspirational: New Americans are true Americans. We need a lot more of them.

There are plenty of ideas for reform that simply require will and a functioning political system. At the heart of them is the determination to think big again and to vigorously engage in public investment. And we need to put money into future generations like our lives depended on it, because they do: Access to affordable, effective contraception dramatically cuts rates of unplanned pregnancy and gives kids a better start in life. Done well, pre-K education closes learning gaps and prepares children for school. More generous income benefits stabilize homes and help kids. Reading programs for new parents improve literacy levels. Strong school principals attract good teachers and raise standards. College coaches help get nontraditional students to and through college. And so on. We are not lacking ideas. We are lacking a necessary sense of political urgency. We are stuck.

But we can move again if we choose.

In addition to a rejuvenation of policy in all these fields, there are two big shifts required for an American twenty-first-century renaissance: becoming open to more immigration and shifting power from Washington to the cities.

VI. America needs another wave of immigration.

This is in part just basic math: We need more young workers to fund the old age of the baby boomers. But there is more to it than that. Immigrants also provide a shot in the arm to American vitality itself. Always have, always will. Immigrants are now twice as likely to start a new business as native-born Americans. Rates of entrepreneurialism are declining among natives but rising among immigrants.

Immigrant children show extraordinary upward-mobility rates, shooting up the income-distribution ladder like rockets, yet by the third or fourth generation, the rates go down, reflecting indigenous norms. Among children born in Los Angeles to poorly educated Chinese immigrants, for example, an astonishing 70 percent complete a four-year-college degree. As the work of my Brookings colleague William Frey shows, immigrants are migrants within the U. S., too, moving on from traditional immigrant cities—New York, Los Angeles—to other towns and cities in search of a better future. Entrepreneurial, mobile, aspirational: New Americans are true Americans. We need a lot more of them.

This makes a mockery of our contemporary political "debates" about immigration reform, which have become intertwined with race and racism. Some Republicans tap directly into white fears of an America growing steadily browner. More than four in ten white seniors say that a growing population of immigrants is a "change for the worse"; half of white boomers believe immigration is "a threat to traditional American customs and values." But immigration delves deeper into the question of American identity than it does even issues of race. Immigrants generate more dynamism and aspiration, but they are also unsettling and challenging. Where this debate ends will therefore tell us a great deal about the trajectory of the nation. An America that closes its doors will be an America that has chosen to settle rather than grow, that has allowed security to trump dynamism.

VII. The second big shift needed to get America unstuck is a revival of city and state governance.

Since the American Dream is part of the national identity, it seems natural to look to the national government to help make it a reality. But cities are now where the American Dream will live or die. America's hundred biggest metros are home to 67 percent of the nation's population and 75 percent of its economy. Americans love the iconography of the small town, even at the movies—but they watch those movies in big cities.

Powerful mayors in those cities have greater room for maneuvering and making an impact than the average U. S. senator. Even smaller cities and towns can be strongly influenced by their mayor.

There are choices to be made. Class divisions are hardening. Upward mobility has a very weak pulse. Race gaps are widening.

The new federalism in part is being born of necessity. National politics is in ruins, and national institutions are weakened by years of short-termism and partisanship. Power, finding a vacuum in D. C., is diffusive. But it may also be that many of the big domestic-policy challenges will be better answered at a subnational level, because that is where many of the levers of change are to be found: education, family planning, housing, desegregation, job creation, transport, and training. Amid the furor over Common Core and federal standards, it is important to remember that for every hundred dollars spent on education, just nine come from the federal government.

We may be witnessing the end of many decades of national-government dominance in domestic policy-making (the New Deal, Social Security, Medicare, welfare reform, Obamacare). The Affordable Care Act is important in itself, but it may also come to have a place in history as the legislative bookend to a long period of national-policy virtuosity.

The case for the new federalism need not be overstated. There will still be plenty of problems for the national government to fix, including, among the most urgent, infrastructure and nuclear waste. The main tools of macroeconomic policy will remain the Federal Reserve and the federal tax code. But the twentieth-century model of big federal social-policy reforms is in decline. Mayors and governors are starting to notice, and because they don't have the luxury of being stuck, they are forced to be entrepreneurs of a new politics simply to survive.

VIII. It is possible for America to recover its earlier dynamism, but it won't be easy.

The big question for Americans is: Do you really want to? Societies, like people, age. They might also settle down, lose some dynamism, trade a little less openness for a little more security, get a bit stuck in their ways. Many of the settled nations of old Europe have largely come to terms with their middle age. They are wary of immigration but enthusiastic about generous welfare systems and income redistribution. Less dynamism, maybe, but more security in exchange.

America, it seems to me, is not made to be a settled society. Such a notion runs counter to the story we tell ourselves about who we are. (That's right, we. We've all come from somewhere else, haven't we? I just got here a bit more recently.) But over time, our narratives become myths, insulating us from the truth. For we are surely stuck, if not settled. And so America needs to decide one way or the other. There are choices to be made. Class divisions are hardening. Upward mobility has a very weak pulse. Race gaps are widening. The worst of all worlds threatens: a European class structure without European welfare systems to dull the pain.

Americans tell themselves and the world that theirs is a society in which each and all can rise, an inspiring contrast to the hereditary cultures from which it sprang. It's one of the reasons I'm here. But have I arrived to raise my children here just in time to be stuck, too? Or will America be America again?

Editor's note: This piece originally appeared in Esquire.

       

Super PACs and other lightly regulated political organizations are dumping hundreds of millions of dollars into American elections. What should be done about it? Unlike many candidates for federal or state office, so-called independent expenditure groups face no restrictions on how much individuals and groups can give to them. And thanks to several federal court decisions, including Citizens United v. Federal Election Commission, independent groups can spend unlimited amounts to influence elections. The public understandably worries about the political clout of wealthy groups—especially since donors often can hide their identities.

Reformers have proposed various remedies: disclosure rules, the appointment of a liberal Supreme Court justice to reverse Citizens United, even a constitutional amendment to overturn that decision. Those long-shot strategies, however, are unlikely to create the kind of small-donor democracy that many reformers seek. Money, like water, will inevitably flow into the political system. Laws can’t do much to reduce the amount of money in politics; what they can change is where the money goes.

An easier path to improving politics

In our new Brookings paper, The State of State Parties, we suggest an easier path to improving politics—one that is right under our nose. Strengthening state political parties can help offset the clout of super PACs.

Our study, based on a survey of 56 state-party organizations plus detailed interviews with 15 of their leaders, points to the distinctive and constructive role that state parties play in American politics. In an era when politics seems to be spinning out of control, party organizations are among the few actors that seek to integrate and balance interests—for instance, by recruiting candidates with broad appeal, by playing honest broker among contending partisan factions, and by building coherent strategies among campaigns up and down the ticket. Party organizations also generate a lot of grassroots activity to mobilize volunteers and voters.

How regulations on parties increase super PAC spending

State parties are among the most heavily regulated entities in American politics, a situation that diminishes their influence relative to non-party groups. For instance, the vast majority of state parties face restrictions on the source and size of donations, and some contribution limits are unrealistically low. In Massachusetts, no donor can give more than annual aggregate of $5,000 to all local and state parties. That’s a paltry sum in statewide elections that can easily cost $55 million, including $20 million in independent expenditures.

Super PACs and other groups naturally fill the vacuum because they do not have to contend with limits on raising and spending money. Often, outside groups effectively drown out the parties. In our survey, only half the parties said they advertise on TV and radio sometimes or often, usually because they lack the resources to do more.

The figure below shows that parties’ independent spending is miniscule compared to the growing expenditures of non-party groups over the past five election cycles. In the 2014 election cycle, the parties accounted for just six percent of total independent spending in the states for which we had good data.

An especially significant finding is that restraints on political parties seem to amplify the activities and influence of outside groups. As illustrated in the table below, 65 percent of respondents in states with contribution limits to parties said that independent groups sponsor more than half or almost all political ads, compared to only 23 percent in states without contribution limits. 

In other words, independent spending is significantly lower when parties are not limited. These differences translate into electoral clout. In states with contribution limits, 65 percent of respondents said independent spending is often a key factor in gubernatorial elections, while fewer than half said the same in states with no limits.

Correlation does not prove causality, but our findings provide strong circumstantial evidence that when you restrict the parties, you get more independent expenditures by non-party groups.

It’s not hard to strengthen state parties

We recommend changes to strengthen state parties and restore them to a place of prominence in campaigns. First, state governments should raise or eliminate contribution limits so the parties can acquire sufficient resources to compete with outside actors. This would allow state parties to serve as clearinghouses for campaign money, which would bring more “dark money” toward accountability and transparency.

Second, parties should be allowed full freedom to coordinate their activities with their candidates and allied groups. This would make them more valuable to candidates and would allow the parties to perform their irreplaceable role of supporting candidates across the party ticket.

We also suggest giving parties favorable tax treatment so that donors are more likely to give to parties than candidate-sponsored super PACs or interest groups. We also recommend other regulatory changes that would encourage parties to do more grassroots work with voters.

Loosening the constraints on state parties would not stop the flow of money into politics (nothing can do that), but would channel more of the money to accountable actors. That’s why we think of this solution as building canals, not dams. And the incremental steps we propose require no sea-changes in public opinion or heroic legislation. In fact, they command support in both parties’ establishments, making them a good starting point for reform. That’s why we conclude that strengthening state parties is a realistic path toward a better balanced, more effective, and more accountable political system.

       

       

Ryan’s EITC is pro-mobility… but funding it may not be

Paul Ryan seems to be thinking seriously about the issues of poverty and social mobility. He is a reformer as well as an authentic conservative.

While his willingness to embrace EITC expansion is welcome, his proposed funding methods raise serious questions. Paying for anti-poverty programs by cutting anti-poverty programs runs the risk of being self-defeating. No doubt some of them are not working as intended. But reform is the answer, rather than abolition. Many of these programs help those in the deepest poverty - who in many cases are those least likely to benefit from welfare-to-work policies such as the EITC, according to recent research from the Center for Budget and Policy Priorities and from the National Poverty Center. 

Ryan's package is worthy of serious attention, not least from the perspective of social mobility. It is important, however, not to consider the impact of the EITC expansion alone, but also how - and by whom- it will be paid for. 

      

In his state of the union and his budget, the President spoke of the stagnation of middle class incomes. Whatever growth we have had has not been broadly shared.  More than 78% of the growth in GDP between 1979 and 2013 has gone to the top one percent. Even Republicans are beginning to worry about this issue although they have yet to develop concrete proposals to address it.

Slow Growth in Incomes

Middle class incomes were growing slowly before the recession and have actually declined over the past decade.   In addition, according to the New York Times, the proportion of the population with incomes between $35,000 and $100,000 in inflation-adjusted terms fell from 53% in 1967 to 43% in 2013.  During the first four decades this was primarily because more people were moving into higher income groups, but more recently it was because they have moved down the ladder, not up.  One can define the middle class in many different ways or torture the data in various ways, but there is plenty of evidence that we have a problem.

What to Do

The most promising approach is what I call “the second earner solution.”  For many decades now, the labor force participation rate of prime age men has been falling while that of women has been rising.  The entry of so many women into the labor force was the major force propelling whatever growth in middle class incomes occurred up until about 2000. That growth in women’s work has now levelled off.  Getting it back on an upward track would do more than any policy I can think of to help the middle class.

Imagine a household with one earner making the average wage of today’s worker and spending full-time in the job market.  That household will have an income of around $34,000. But if he (or she) has a spouse making a similar amount, the household’s income will double to $68,000. That is why the President’s focus on a second-earner credit of $500, a tripling of the child care tax credit, expanding the Earned Income Tax Credit, and providing paid leave are so important. These policies are all pro-work and research shows they would increase employment.

No Marriage = No Second Earner

One problem, of course, is that fewer and fewer households contain two potential workers.  So it would also help to bring back marriage or at least its first cousin, a stable cohabiting relationship.  My ideas on this front are spelled out in my new book, Generation Unbound. In a nutshell, we need to empower women to not have children before they have found a committed partner with whom to raise children in a stable, two-parent family. Whatever the other benefits of two parents, they have twice as much time and potentially twice as much income.    

Other Needed Responses

Shouldn’t we also worry about the wages or the employment of men?  Of course.  But an increase in, say, the minimum wage or a better collective bargaining environment or more job training will have far smaller effects than “the second earner solution.”  In addition, the decline in male employment is related to still more difficult problems such as high rates of incarceration and the failure of men to take advantage of postsecondary education as much as women have. 

Still the two-earner solution should not be pursued in isolation. In the short-term, a stronger recovery from the recession is needed and in the longer-term, more effective investments in education, research, infrastructure, and in labor market institutions that produce more widely-shared growth, as argued by the Commission on Inclusive Prosperity. But do we really expect families to wait for these long-term policies to pay off?  It could be decades. 

In the meantime, the President’s proposals to make work more appealing to existing or potential second earners deserves more attention.  

      

       

Event Information

As the prevalence of drug-resistant bacteria continues to rise, there is a pressing need for new drugs to combat infections by these organisms. However, research and development in this area has slowed, creating a public health concern that we lack the drugs necessary to treat multi-drug resistant infections. Challenges to promoting antibacterial drug development may be scientific, methodological, regulatory, or economic in nature.

On Wednesday, May 9, 2012, the Engelberg Center for Health Care Reform convened an expert workshop, "Facilitating Antibacterial Drug Development,” that explored solutions to methodological and regulatory challenges that could make the development process more efficient. This meeting brought together diverse multi-stakeholder experts—including medical product developers, health care professionals, researchers, patient advocates, representatives of the U.S. Food and Drug Administration, and other groups—to explore the following issues:

• Existing paradigms for antibacterial drug development;
• Novel approaches to further antibacterial drug development, including use of pharmacokinetics and pharmacodynamics, Bayesian methods, innovative clinical trial designs, new data sources, alternate clinical endpoints, and new regulatory tools; and
• Short- and long-term opportunities to advance the antibacterial drug development enterprise through collaboration among stakeholders, improved regulatory science, and other means.

For more information on FDA’s Antibacterial Drug Development Task Force, click here.

Event Materials

• May 9 Event Summary
• Antibacterial Drug Development Participant List
• Facilitating Antibacterial Drug Development Agenda
• Facilitating Antibacterial Drug Development Discussion Guide
• Panel 1 Brad Spellberg Presentation
• Panel 1 George Talbot Presentation
• Panel 1 John Powers Presentation
• Panel 1 Thomas Fleming Presentation
• Panel 2 George Drusano Presentation
• Panel 2 Scott Emerson Presentation
• Panel 3 Daniel Benjamin Presentation
• Panel 3 Edward Cox Presentation
• Panel 3 John Rex examples
• Panel 3 John Rex Presentation
• Panel 4 Helen Boucher Presentation

       

Event Information

As part of ongoing cooperative work with the U.S. Food and Drug Administration, the Engelberg Center for Health Care Reform has formed a council to bring together expert perspectives on the challenges facing antibacterial drug development. Designed to include representatives from academia, patient advocacy groups, industry, providers, and government agencies, the Brookings Council on Antibacterial Drug Development (BCADD), will convene twice a year to discuss pressing issues in the treatment of infectious diseases and potential steps to address them.  

The first BCADD meeting, held on August 30, 2012, brought stakeholders together to discuss the following:

• Ongoing antibacterial initiatives at FDA and the Clinical Trials Transformation Initiative
• Statistical and methodological approaches that could be harnessed to improve the efficiency of antibacterial drug development
• Balancing benefit-risk and uncertainty considerations with public health needs
• Next steps for council action

For more information on FDA’s Antibacterial Drug Development Task Force, click here.

Event Materials

• 30 antibacterial drug development summary
• Presentation Slides
• FINAL BCADD Discussion Guide 20120828
• FINAL May 9 Summary 20120828
• Participant List_Final

       

Event Information

As part of an ongoing cooperative agreement with the U.S. Food and Drug Administration (FDA), the Engelberg Center for Health Care Reform at Brookings has formed the Brookings Council on Antibacterial Drug Development (BCADD) to identify steps to address the major technical, regulatory, and financial barriers impeding antibacterial drug development. At the first meeting of the BCADD, stakeholders emphasized the importance of concentrating on discrete policy and program areas to revitalize the antibacterial drug development enterprise.

BCADD convened a diverse group of stakeholders, including FDA officials, industry and biotech representatives, payers, providers, clinicians, and academic researchers Wednesday, February 27, 2013, to discuss two of the economic challenges facing antibacterial drug development:

• Better understanding the potential role of incentives in drug discovery and development; and
• Identifying potential reimbursement models that can support both stewardship and expanded investment for antibacterial drug products.

Antibacterial development has moved slower than other therapeutic areas in part due to the challenges of achieving a return on investment under the current reimbursement system. New models are needed to incentivize research and development of antibacterial products and to separate reimbursement from unit sales in order to help preserve the effectiveness of existing and new antibacterial drugs. The workshop’s objectives are to support the development of pragmatic proposals for the larger stakeholder community to consider.

Event Materials

• meeting summary 20130925 FINAL
• Discussion Guide
• Participant List
• Presentation

       

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

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

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

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

How do we turn the tide?

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

Creating incentives for drug development

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

Balancing benefit and risk for severely-ill patients

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

De-link reimbursement from return on investment

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

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

       

Event Information

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

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

Event Materials

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

       

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

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

Fundamental Approaches to Slowing Resistance

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

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

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

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

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

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

       

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

Combating resistance

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

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

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

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

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

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

Key obstacles to antibiotic development

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

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

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

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

Opportunities to streamline innovative antibiotic development

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Downloads

• Antibiotics Stewardship and Innovation

       

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

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

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

The Need for Financial Incentives and Better Reimbursement

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

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

       

Event Information

Antibacterial drugs are a critical component of the nation’s public health armamentarium, and have saved millions of lives by preventing and treating a range of bacterial infections. However, antibacterial drug development has been hampered by challenges unique to the antibacterial drug market, which have stifled innovation and left patients and providers with fewer options to treat increasingly resistant infections. One consequence of the dwindling antibacterial drug pipeline has been a reduction in effective oral antibacterial drug treatment options, which are particularly important in the ambulatory and transitional care contexts. Recent proposals to re-invigorate the antibacterial pipeline are geared towards serious infections treated in the inpatient setting, which may lead to a greater focus on intravenous therapies. However, addressing both current and future needs in the infectious diseases space will require a balanced mix of both oral and parenteral antibacterial drugs.

In cooperation with the U.S. Food and Drug Administration (FDA), the Engelberg Center for Health Care Reform at Brookings held an expert workshop on November 20, 2014, to identify the most promising strategies to support oral antibacterial drug development. 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 regulatory, scientific, and economic strategies to reinvigorate the oral antibacterial drug pipeline. 

Event Materials

• Reinvigorating the Oral Antibacterial Drug Development Pipeline Agenda
• Reinvigorating the Oral Antibacterial Drug Development Pipeline Discussion Guide
• Biographies 20141118
• Reinvigorating the Oral Antibacterial Drug Development Pipeline Slide Deck

       

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

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

Fundamental Approaches to Slowing Resistance

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

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

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

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

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

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

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

       

       

       

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

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

Fundamental Approaches to Slowing Resistance

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

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

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

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

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

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

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

      

Despite the undeniable benefits of education to society, the educational needs, particularly in the world’s poorest countries, remain strikingly great. There are more than 67 million children not enrolled in primary school around the world, millions of children who are enrolled in school but not really learning, and too few young people are advancing to secondary school (van der Gaag and Adams 2010). Consider, for instance, the number of children unable to read a single word of connected text at the end of grade two: more than 90 percent in Mali, more than 50 percent in Uganda, and nearly 33 percent in Honduras (USAID n.d.).

With more young people of age 12 to 24 years today than ever before who are passing through the global education system and looking for opportunities for economic and civic participation, the education community is at a crossroads. Of the 1.5 billion young people in this age group, 1.3 billion live in developing countries (World Bank 2007). The global community set the goal of achieving universal primary education by 2015 and has failed to mobilize the resources necessary, as UNESCO estimates that $16.2 billion in external resources will be need to reach this goal.

Read the full report »

Read the executive summary »

Results from this report were presented at an April 6 Center on Universal Education event at the Brookings Institution.

Learn more about the launch event »

Downloads

• Executive Summary
• Download the Full Report

       

Employment is down among everyone between the ages of 16 and 64—particularly among teens, but with a great deal of variation by geography, race, and education. The disparity between blacks and whites is especially stark. For example, unemployment among white young adults peaked at 14% in 2010—still considerably lower than unemployment rates for black young adults at any point in the 2008 to 2014 time period. Unemployment for black 20- to 24-year-olds rose to 29.5% in 2010 and fell to 22.3% in 2014, compared to 10.3% among whites in 2014.

While there is no silver bullet, higher levels of education and work experience clearly improve job prospects down the line for young people. There are multiple strategies local and regional leaders can use to build more structured pathways into employment.

Teens and young adults (referring to 16- to 19-year-olds and 20- to 24-year-olds, respectively) are not monolithic populations. Age is an obvious differentiator, but so are a number of other factors, such as educational attainment, skill level, interests, parental support, and other life circumstances.  Schools, families, and neighborhoods all play a role in a young person’s trajectory—both positive and negative. But at the most basic level, a program for a 17-year-old high school student is likely not appropriate for a 23-year-old, regardless of educational attainment. Successful programs integrate education, training, work-readiness, and youth development principles, but the particular blend of these elements and settings vary: more school-based and educationally focused programs for younger youth, and more community-based and career-focused programs with strong ties to education for older youth.

An admittedly non-comprehensive review includes the following types of promising and proven programs:  

For high school students:

• Paid internship programs, such as Urban Alliance and Genesys Works
• High school programs that bridge school and work with occupationally-focused courses and career exposure, such as Career Academies, Linked Learning, High Tech High, Advanced Career, Alamo Academies, and P-Tech, some of which also incorporate post-secondary courses and credentials into their programs
• Youth apprenticeships, such as state programs in Georgia and Wisconsin 

For out-of-school youth and young adults:

• Highly structured programs offering work readiness and technical skills development, often in partnership with community colleges, and coupled with paid internships, such as Year Up, i.c.stars, npower, and Per Scholas
• Programs that offer stipends and combine academics, job training, mentoring, and supportive services while carrying out community improvement projects, such as YouthBuild and Youth Corps

The sobering fact is that promoting employment and economic security among young people is not a straightforward proposition. To succeed in today’s economy and earn middle-class wages, a young person needs to complete several steps: graduate from high school or earn an alternate credential; enroll in and complete some post-secondary education or job training; preferably gain meaningful work experience; and enter the labor market with in-demand skills. (A decent economy and some luck help, too.) There are many points along that path from which a young person can get off-track, particularly young people of color and those from high-poverty neighborhoods. And while high youth unemployment is increasingly in the news these days, the difficulties youth without college degrees face in finding good jobs has been a problem for decades.

Programs such as the ones listed above are part of the solution. But they are not enough, given the magnitude of the problem. In order to produce better employment outcomes at scale, leaders from all sectors and levels of government need to make broader shifts in how education and workforce programs are designed, and how they interact with each other and employers. That is a heavy lift, but it is worth it to address the high costs imposed by the status quo: high unemployment, poverty, and untapped potential.  

      

       

       

The European Union’s international partners often accuse it of not speaking with a single voice on key global issues. Yet, there are instances when Europe does display a coherent approach to policy-making in international affairs. In this paper for the Center on the United States and Europe, Matteo Garavoglia argues that EU Election Observation Missions (EU EOMs) are a worthy example of such occurrences.

Unlike in most other foreign policy domains, EU supranational institutions, rather than national capitals, lead EOMs' policymaking. More specifically, the European External Action Service’s Democracy and Electoral Observation Division, the European Commission’s Foreign Policy Instrument, and the European Parliament’s Directorate for Democracy Support are the key actors behind this policy area.

Writing for Brookings’s U.S.-Europe Analysis Series, Matteo Garavoglia investigates why European supranational actors are at the core of EOMs policymaking. Having done so, he analyzes the role that national governments and non-institutional agents play in conceptualizing and operationalizing EOMs. Finally, he explores ways in which Europe’s international partners could build bridges with Brussels in this policy area.

Downloads

• EU election observation policy: A supranationalist transatlantic bridge?

       

       

In the three months since the EU-Turkey migrant pact came into force, the number of migrants arriving on Greek shores has dropped precipitously. But the number of migrants making the even more dangerous crossing to Italy has increased substantially. After months of chaos, Rome—having adopted a variety of measures in partnership with European authorities—is now much better prepared than last summer to deal with a new migrant surge. But, despite its efforts, Italy—like its peers—cannot possibly cope on its own with a new wave of migration on the order of magnitude as the one witnessed last summer.

Yet that possibility is real. With almost 19,000 arriving from Libya in the first three months of this year, an EU-Libya migration compact is urgently needed. But for it to work, Europe as a whole must engage with Libya comprehensively and across policy areas. That will require time—and an interim solution in the meantime. 

Fewer arrivals in Greece, more in Italy

Notwithstanding its many flaws, the EU-Turkey deal appears to be working at deterring people from making the treacherous crossing from Turkey to Greece. Although weather conditions have improved, the number of migrants reaching Greece dropped by 90 percent in April, to less than 2,700. Syrians, Pakistanis, Afghans, and Iraqis made up the bulk of new arrivals, as has been the case for the last few months. Further north, along the Western Balkans route, the number of migrants reaching Europe’s borders in April dropped by 25 percent, down to 3,830. In this case, Macedonia’s de facto closure of its southern border with Greece clearly contributed to stemming the flow. 

With the Eastern Mediterranean and the Western Balkans routes sealed, the Central Mediterranean pathway presents new and worrying trends. In the month of April alone, 9,149 migrants arrived in Italy. As in the past, they were overwhelmingly from Sub-Saharan Africa (mostly Nigeria), many of them economic migrants unlikely to be granted asylum. For the first time since May 2015, more migrants are now reaching Italy than Greece. Many more are likely to have lost their lives trying to do so. 

For the first time since May 2015, more migrants are now reaching Italy than Greece.

Learning from past mistakes 

Italy is doing its homework. A revamped headquarters for the European Union Regional Task Force (EURTF) overseeing migrant arrivals across the Central Mediterranean opened at the end of April in the town of Catania. Five of its six hotspots—first reception centers fully equipped to process new arrivals—are now in place, with a combined reception capacity for 2,100 people and the involvement of Frontex, the European Asylum Support Office, Europol, Eurojust, the International Organization for Migration, and the Office of the United Nations High Commissioner for Refugees. Fingerprinting rates have now reached virtually 100 percent at all active hotspots. Long-term reception capacity across the country is currently at 111,081, and plans are in place to boost this to 124,579. This would probably not be enough to host the share that the country could be expected to take under a permanent and fair pan-European relocation mechanism. And yet, at least for the time being, the European Commission judged the Italian reception system to be more than sufficient.

Within this context, European partners seem to be slowly becoming more confident in Rome’s willingness to take up its responsibilities. It is no coincidence that on the same day that German Finance Minister Wolfgang Schäuble invited Vienna to support Italy in its efforts to control migrant movements within the Schengen area, Austria’s Interior Minister Wolfgang Sobotka announced that work on building a “migrants protection fence” at the Italy-Austria border was halted. 

A sustainable solution before it’s too late

Still, should a new massive migrant wave reach its shores, Italy could not cope on its own. Indeed, no single European country could. Should such a new wave materialize, Libya would be by far the most likely country of origin. Italy is the key to fighting ISIS and stabilizing Libya, but it would be unrealistic to expect Italy to do so on its own. 

The current European migrant crisis is part of a broader global refugee crisis and Europe has a shared interest and responsibility in dealing with it. Because of that, an EU-Libya deal is now necessary. This must—and can—be better than the agreement between the EU and Turkey. But a strategic pan-European approach is urgently needed. As Mattia Toaldo recently highlighted, a joint EU-Libya migration plan would be one of five priority areas for Libya. These would also include supporting a Libyan joint command to fight ISIS, a diplomatic offensive in support of the recently-established unity government, a reconciliation of local militias through power devolution, and the re-launch of the country’s economy. In April, Italy shared proposals with its European partners for a new migration compact with Libya but which also involves the broader region. That might be wise: since Europe is certainly unable to stabilize Libya in the short term, its leaders should start thinking about the country as a variable within a far broader equation. 

What can Italy do in the meantime?

The European Union should step up its support for Italy and an interim solution to migrant crisis in the Central Mediterranean must be found. Meanwhile, Italy has to brace itself for the potential arrival of over 800,000 migrants currently in Libya and waiting to cross the Mediterranean. While Rome could never cope with such a surge in migrant flows on its own, it still can—and must—plan for such an eventuality.

Three measures could be taken to address this challenge. First of all, Italy could consider setting up a seventh—and possibly even an eight—hotspot. This would be an important step given that an idea Italian Interior Minister Angelino Alfano floated—to set up “hotspots at sea”–is unlikely to be viable on both legal and humanitarian grounds. Second, Italy should increase its long-term reception capacity to around 150,000 people. The exact number would depend on the calculations that the European Commission is currently finalizing. Crucially, this should mirror the number of individuals beyond which an emergency relocation mechanism would be activated to re-distribute asylum seekers from Italy to another EU member state. Finally and should a sudden surge in the number of arrivals materialize, Italy could prepare contingency plans to mobilize virtually its entire navy to support ongoing EU efforts with its Operation Sophia. These policy proposals involve a significant effort in terms of state capacity. Yet, Italy has both a moral responsibility as well as a vested interest in implementing them. 

       

In the three months since the EU-Turkey migrant pact came into force, the number of migrants arriving on Greek shores has dropped precipitously. But the number of migrants making the even more dangerous crossing to Italy has increased substantially. After months of chaos, Rome—having adopted a variety of measures in partnership with European authorities—is now much better prepared than last summer to deal with a new migrant surge. But, despite its efforts, Italy—like its peers—cannot possibly cope on its own with a new wave of migration on the order of magnitude as the one witnessed last summer.

Yet that possibility is real. With almost 19,000 arriving from Libya in the first three months of this year, an EU-Libya migration compact is urgently needed. But for it to work, Europe as a whole must engage with Libya comprehensively and across policy areas. That will require time—and an interim solution in the meantime. 

Fewer arrivals in Greece, more in Italy

Notwithstanding its many flaws, the EU-Turkey deal appears to be working at deterring people from making the treacherous crossing from Turkey to Greece. Although weather conditions have improved, the number of migrants reaching Greece dropped by 90 percent in April, to less than 2,700. Syrians, Pakistanis, Afghans, and Iraqis made up the bulk of new arrivals, as has been the case for the last few months. Further north, along the Western Balkans route, the number of migrants reaching Europe’s borders in April dropped by 25 percent, down to 3,830. In this case, Macedonia’s de facto closure of its southern border with Greece clearly contributed to stemming the flow. 

With the Eastern Mediterranean and the Western Balkans routes sealed, the Central Mediterranean pathway presents new and worrying trends. In the month of April alone, 9,149 migrants arrived in Italy. As in the past, they were overwhelmingly from Sub-Saharan Africa (mostly Nigeria), many of them economic migrants unlikely to be granted asylum. For the first time since May 2015, more migrants are now reaching Italy than Greece. Many more are likely to have lost their lives trying to do so. 

For the first time since May 2015, more migrants are now reaching Italy than Greece.

Learning from past mistakes 

Italy is doing its homework. A revamped headquarters for the European Union Regional Task Force (EURTF) overseeing migrant arrivals across the Central Mediterranean opened at the end of April in the town of Catania. Five of its six hotspots—first reception centers fully equipped to process new arrivals—are now in place, with a combined reception capacity for 2,100 people and the involvement of Frontex, the European Asylum Support Office, Europol, Eurojust, the International Organization for Migration, and the Office of the United Nations High Commissioner for Refugees. Fingerprinting rates have now reached virtually 100 percent at all active hotspots. Long-term reception capacity across the country is currently at 111,081, and plans are in place to boost this to 124,579. This would probably not be enough to host the share that the country could be expected to take under a permanent and fair pan-European relocation mechanism. And yet, at least for the time being, the European Commission judged the Italian reception system to be more than sufficient.

Within this context, European partners seem to be slowly becoming more confident in Rome’s willingness to take up its responsibilities. It is no coincidence that on the same day that German Finance Minister Wolfgang Schäuble invited Vienna to support Italy in its efforts to control migrant movements within the Schengen area, Austria’s Interior Minister Wolfgang Sobotka announced that work on building a “migrants protection fence” at the Italy-Austria border was halted. 

A sustainable solution before it’s too late

Still, should a new massive migrant wave reach its shores, Italy could not cope on its own. Indeed, no single European country could. Should such a new wave materialize, Libya would be by far the most likely country of origin. Italy is the key to fighting ISIS and stabilizing Libya, but it would be unrealistic to expect Italy to do so on its own. 

The current European migrant crisis is part of a broader global refugee crisis and Europe has a shared interest and responsibility in dealing with it. Because of that, an EU-Libya deal is now necessary. This must—and can—be better than the agreement between the EU and Turkey. But a strategic pan-European approach is urgently needed. As Mattia Toaldo recently highlighted, a joint EU-Libya migration plan would be one of five priority areas for Libya. These would also include supporting a Libyan joint command to fight ISIS, a diplomatic offensive in support of the recently-established unity government, a reconciliation of local militias through power devolution, and the re-launch of the country’s economy. In April, Italy shared proposals with its European partners for a new migration compact with Libya but which also involves the broader region. That might be wise: since Europe is certainly unable to stabilize Libya in the short term, its leaders should start thinking about the country as a variable within a far broader equation. 

What can Italy do in the meantime?

The European Union should step up its support for Italy and an interim solution to migrant crisis in the Central Mediterranean must be found. Meanwhile, Italy has to brace itself for the potential arrival of over 800,000 migrants currently in Libya and waiting to cross the Mediterranean. While Rome could never cope with such a surge in migrant flows on its own, it still can—and must—plan for such an eventuality.

Three measures could be taken to address this challenge. First of all, Italy could consider setting up a seventh—and possibly even an eight—hotspot. This would be an important step given that an idea Italian Interior Minister Angelino Alfano floated—to set up “hotspots at sea”–is unlikely to be viable on both legal and humanitarian grounds. Second, Italy should increase its long-term reception capacity to around 150,000 people. The exact number would depend on the calculations that the European Commission is currently finalizing. Crucially, this should mirror the number of individuals beyond which an emergency relocation mechanism would be activated to re-distribute asylum seekers from Italy to another EU member state. Finally and should a sudden surge in the number of arrivals materialize, Italy could prepare contingency plans to mobilize virtually its entire navy to support ongoing EU efforts with its Operation Sophia. These policy proposals involve a significant effort in terms of state capacity. Yet, Italy has both a moral responsibility as well as a vested interest in implementing them. 

       

       

       

       

       

The debate surrounding net energy metering (NEM) and the appropriate way to reform this policy is under scrutiny in many U.S. states. This is highly warranted since NEM policies do indeed need reforming because NEM often results in subsidies to private (rooftop) solar owners and leasing companies. These subsidies are then “paid for” by non-NEM customers (customers without private rooftop solar installations). The fundamental source of the NEM subsidy is the failure of NEM customers (customers with private rooftop solar installations) to pay fully for the grid services that they use 24/7. These subsidies are well-documented and underpin much of the regulatory reform efforts underway across the United States.[1]

In a recent Brookings paper, “Rooftop solar: Net metering is a net benefit,” Mark Muro and Devashree Saha contend that net metering is a net benefit for non-NEM customers.[2] I fundamentally disagree with their findings, and argue that NEM is not a net benefit; it is, in fact, a tariff that much of the time results in a subsidy to NEM customers and a cost shift onto non-NEM customers. As Executive Director of the Institute for Electric Innovation, a non-lobbying organization focused on trends in the electric power industry, I have followed this debate and written about it for several years.

Much of the talk about NEM focuses too often on the “value” of the energy that is sold back to the grid by a NEM customer. In reality, the amount of energy sold back to the grid is relatively small. The real issue is the failure of NEM customers to pay fully for the grid services that they use while connected to the grid 24/7, as shown in Figure 1.[3] Customers need to constantly use the grid to balance supply and demand throughout the day, and the cost of these grid services can be sizeable. In fact, for a typical residential customer in the United States with an average electricity bill of $110 per month, the actual cost of grid services can range from $45 to $70 per month–however, the customer doesn’t see that charge.[4] That means, in the extreme, if a customer’s energy use “nets” to zero in a given month because the customer’s private solar system produced exactly what the customer consumed, that customer would pay $0 even though that customer is connected to the local electric company’s distribution grid and is utilizing grid services on a continuous around-the-clock basis.[5]

Although exactly netting to zero energy in a month is highly unlikely, this example demonstrates the point that the customer would pay nothing, despite using grid services at a cost ranging from $45 to $70 per month. Over the course of one year, this customer could receive a subsidy resulting from NEM of between $540 and $840. Over the life of a private rooftop solar system, which ranges from 20 to 25 years, this is a significant subsidy resulting from NEM.

Granted, this is an extreme example, and most NEM customers will pay for some portion of grid services. However, the fundamental source of the NEM subsidy is the failure of NEM customers to pay fully for the grid services that they use 24/7, and the cost of these services can be quite substantial. When a NEM customer doesn’t pay for the grid, the cost is shifted onto non-NEM customers.[6] It is a zero-sum game; plain and simple. This is the elephant in the room.

This issue was directly addressed by Austin Energy when the company implemented a “buy-sell” arrangement for the private rooftop solar customers in its service territory. The rationale for the buy-sell approach is that the customer buys all of the energy that is consumed on-site through the electric company’s retail tariff and sells all of the energy produced by their private rooftop solar system at the electric company’s avoided cost. This addresses the “elephant in the room” because, by buying all energy consumed at the retail tariff, the customer does pay for grid services that are largely captured through the retail tariff. It is an unfortunate fact that under ratemaking practices today in the United States, the majority of fixed costs (i.e., grid and other costs) are captured through a volumetric charge.

Hence, I fundamentally disagree with the Muro/Saha paper–NEM does need to be reformed. NEM is not a net benefit; it is a tariff that the much of the time results in a cost shift onto non-NEM customers. One of the first studies to quantify the magnitude of the NEM subsidy was conducted by Energy+Environmental Economics (E3) for the California Public Utilities Commission (CPUC) in 2013. There was no mention of this analysis for the CPUC in the Muro/Saha paper. The E3 study estimated that NEM would result in a cost shift of $1.1 billion annually by 2020 from NEM to non-NEM customers if current NEM policies were not reformed in California.[7] A cost shift of this magnitude–paid for by non-NEM customers–was unacceptable to California regulators. As a result, California regulators set to work to reform rates in their state; many other states followed suit and conducted similar investigations of the magnitude of the NEM subsidy.

In reviewing NEM studies, Muro and Saha chose to focus on a handful of studies that show that net metering results in a benefit to all customers. In this small group of NEM studies, they included a study that E3 conducted for the Nevada Public Utilities Commission (PUC) in 2014–perhaps the most well-known and cited of the five studies included in the Muro/Saha paper. Very soon after the E3 Nevada study was published, the cost assumptions for the base-case scenario which showed a net benefit of $36 million to non-NEM customers (assuming $100 per MWh for utility-scale solar) were found to be incorrect, completely reversing the conclusion. The $36 million benefit associated with NEM for private rooftop solar turned into a $222 million cost to non-NEM customers when utility-scale solar was priced at $80 per MWh.[8] Today, based on the two most recent utility-scale contracts approved by the Nevada PUC, utility-scale solar has an average lifetime (i.e., levelized) cost of $50 per MWh, meaning that the NEM cost shift would be far greater today. In February 2016, the Nevada PUC stated that “the E3 study is already outdated and irrelevant to the discussion of costs and benefits of NEM in Nevada…”[9] Hence, because the E3 study for the Nevada PUC that the Muro/Saha paper included has been declared outdated and irrelevant to the discussion and because costs for utility-scale solar have declined significantly, that study does not show that NEM provides a net benefit.

No doubt there is an intense debate underway about NEM for private rooftop solar, and much has changed in the past two years in terms of both NEM policies and the growth of private solar projects:

• First, several state regulatory commissions now recognize that the NEM cost shift is both real and sizeable and that all customers who use the grid, including NEM customers, need to pay for the cost of the grid. As a result, many electric companies have proposed and state regulatory commissions have approved increases in monthly fixed charges over the past few years; this partially addresses the issue of NEM customers paying for the cost of the grid services that they use.
• Second and related, getting the pricing right for distributed energy resources of all types is important because we expect those resources to grow significantly in the future. Work is underway in this area and it is one focus of the New York Reforming the Energy Vision proceeding; but there is still much to be done.

By focusing on a select group of studies that show that NEM benefits all customers (as stated by the authors); by excluding the E3 study for the CPUC which was fundamental to the NEM cost shift debate; and by not providing an update on the NEM debate today, I believe that the Muro/Saha paper is misleading.

In the second part of their paper, Muro and Saha suggest some helpful regulatory reforms such as moving toward rate designs that “can meet the needs of a distributed resource future” and moving “toward performance-based rate-making (PBR).” Some electric companies have already implemented PBR or some type of formula rate and PBR is under discussion in several states.[10] Lawrence Berkeley National Labs is looking closely at this and related issues in its Future Electric Utility Regulation series of reports currently underway.[11]

Mura and Saha also suggest decoupling as a way forward–I disagree. In my view, decoupling is a not solution for private rooftop solar. Revenue decoupling is currently used to true-up revenues that would otherwise be lost due to declining electricity sales resulting from electric company investments in energy efficiency (EE). Decoupling explicitly shifts costs from participating EE customers to non-participating EE customers causing the same cost-shifting problem that is created by NEM. However, a fundamental difference is that the magnitude of the cost shifting onto non-NEM customers is on a much larger scale than the cost shifting due to EE. A recent study revealed that decoupling rate adjustments for EE are quite small–about two to three percent of the retail rate.^[12] In contrast, as described earlier in this paper, a NEM customer could shift a significant cost onto non-NEM customers (and the NEM cost shifting is essentially invisible to customers, which is one reason that NEM customers do not believe they are subsidized).[13]

Finally, Muro and Saha suggest that electric companies should invest in a more digital and distributed power grid. In fact, electric companies across the United States are doing just that. In 2015, electric companies invested $20 billion in the distribution system alone and this is expected to continue. Over the past five to six years, electric companies invested in the deployment of nearly 65 million digital smart meters to about 50 percent of U.S. households. In addition, electric companies are investing in thousands of devices to make the power grid smarter and more state-aware. Today, in states such as California, Hawaii, and Arizona, electric companies are investing to enable and integrate the distributed energy resources that are growing exponentially. And, in some states–where regulation allows–electric companies are offering rooftop solar or solar subscriptions to their customers.

No doubt, the electric power industry is undergoing a period of profound transformation–our power generation resource mix is getting cleaner and more distributed; the energy grid is becoming more digital; and customers have different expectations.[14]

Collaboration, good public policy, and appropriate regulatory policies are critical to a successful transformation of the power sector. In the context of this paper, this means reforming NEM so that private rooftop solar customers who use the energy grid pay for the grid. One straightforward approach is to require NEM customers to pay a higher monthly fixed charge thereby reducing the cost shift.[15] Ultimately the challenge is to make the transition of the electric power industry–including the significant growth in private rooftop solar and other distributed energy resources–affordable to all customers.

Lisa Wood is a nonresident senior fellow in the Energy Security and Climate Initiative at Brookings. She is also the executive director of the Institute for Electric Innovation and vice president of The Edison Foundation whose members include electric companies and technology companies.

       

Editors’ Note: Science diplomacy can help countries solve on-the-ground challenges and improve standards of living for their citizens, writes David Hajjar. But it can also lay groundwork for improving relations through functional, scientific cooperation that is less politicized. This post originally appeared on Lawfare.

In the Middle East, governments and non-state actors alike have tried all forms of diplomacy to solve the challenges they face, with mixed results: shuttle diplomacy by the United States between the Israelis and Palestinians worked for a time, great-power diplomacy over the Syrian civil war largely hasn’t, and direct negotiations with unsavory groups like the Taliban have moved in fits and starts. 

But progress can come from unlikely sources, and science diplomacy—whereby experts collaborate scientifically to address common problems and build constructive international partnerships—has more potential than is often recognized. Science diplomacy can of course help countries solve on-the-ground challenges and improve standards of living for their citizens. But it can also lay groundwork for improving relations in a region often defined by tension (if not outright conflict) through functional, scientific cooperation that is less politicized. 

Efforts in science and technology, on the one hand, and diplomacy on the other, can achieve more if they are thoughtfully merged—rather than siloed. Science diplomacy, therefore, can contribute to peace- and security-building in the Middle East (and with the United States) in unique ways. 

Science and global governance

Across the world, science diplomacy has helped set the stage for advancing foreign policy and global governance goals.

The 2015 nuclear deal between Iran and the P5+1 illuminated how negotiating over and collaborating on science and technology issues can be an important gateway to achieving significant foreign policy goals. Direct (and often very technical) diplomacy between U.S. Secretary of Energy Ernest Moniz and the head of the Atomic Energy Organization of Iran, Ali Akbar Salehi, was key to achieving the framework agreement, as was collaboration between Iranian and Western nuclear scientists more broadly. Provided that the agreement is thoroughly enforced, it’s a major victory for global nuclear nonproliferation efforts—and much credit goes to effective science diplomacy. 

Global efforts to combat climate change are another area in which science diplomacy has had a real impact on policy. The United Nations’ Intergovernmental Panel on Climate Change has become a model for critical science policy research and recommendations. The 2015 conference in Paris brought together hundreds of political leaders and experts to examine the scientific evidence that the globe is warming, discuss remedies, and chart a path forward that can help slow environmental damage. So, science diplomacy was again central—this time in shaping and implementing the global climate governance framework. 

Another area where we have observed substantive gains from science diplomacy is the global management of infectious diseases. The Zika outbreak in Latin America, Ebola epidemic in West Africa, dengue in the Caribbean and Asia, MERS in the Gulf region and in South Korea, and the global threat of pandemic influenza all underscore that international cooperation is key to fighting modern plagues, which spread more rapidly in an era of constant global travel. In some cases more than in others, political leaders have devoted considerable resources to promoting international scientific cooperation—whether in clinical monitoring, medical interventions, research into pathogen biology and diagnostics, and treatments (including vaccine development). In fact, the global response to severe acute respiratory syndrome (SARS) is an example where international collaboration helped identify affected populations and coordinate treatment through the WHO Global Alert and Response System (which has identified new cases in Europe, the Middle East, Australia, Canada, Vietnam, Taiwan, and Hong Kong). The system’s main goal is to send supplies and medical specialists (including epidemiologists), design clinical trials, provide diagnostic tests, identify modes of transmission, and provide treatment. This coordinated response effort has controlled the pandemic.

Science in a fraught region

In the Middle East, opportunities abound for science diplomacy. Not only can this type of approach help solve practical, quality-of-life challenges—from energy to health and beyond—it can bring together expert communities and bureaucracies. In the process, it can contribute to more normalized people-to-people and government-to-government relations. Even at the height of the Cold War, for example, U.S. and Russian nuclear scientists and other experts worked together to monitor each other’s nuclear facilities; even though Moscow and Washington had nuclear-armed intercontinental ballistic missiles aimed directly at each other, bureaucratic cooperation on technical issues became a normal part of the relationship and helped enhance transparency and trust.

In the energy sector, for example, innovation in science and technology will play a crucial role in helping to transition Middle Eastern states in the region away from a dependence on fossil fuels—a broad goal of the Paris accords and a specific strategic goal of states like Saudi Arabia and Iran. Notwithstanding the sectarian disagreements between Iran and Saudi Arabia, both need to address their fast-growing demand for electricity; they need not be in competition with each other. Saudi Arabia currently fuels its own 10 percent annual rise in electricity needs with crude oil, owing to domestic natural dry gas reserves. Iran’s vast gas reserves could be used to meet the kingdom’s growing energy needs, but Iran’s decaying gas fields need $250 billion in major repairs. Many think that if Saudi Arabia used its investment power to revitalize Iran’s gas industry, it would secure the energy it needs to meet demands. The economic benefits of cooperation on energy could promote better relations. Another area of cooperation that can drive the local economies is the Arab Gulf’s first major cross-border enterprise, the Dolphin Gas Project, which was started in 2007. The project involves the transportation of natural gas from Qatar to Oman and to the UAE. Finally, international cooperation between Oman and Iran is developing, where Oman intends to import natural gas from Iran for industrial development. This would require investing in an underwater pipeline from the Iranian coast to Oman. The UAE could do the same to build its economy: import natural gas from Iran, since the pipelines exist. The technical know-how for all these initiatives already exists—to date the main stumbling block has been overcoming regional politics.

Qatari Oil Minister Abdullah bin Hamad al-Attiyah (L) and Dolphin Energy Chief Executive Ahmed Ali Al Sayegh hold a news conference about the inauguration of the Dolphin Energy plant in Doha May 12, 2008. Photo credit: Reuters.

In health, there is also room for mutually-beneficial cooperation. Back in 1996, the U.S. State Department’s Bureau of Near Eastern Affairs helped establish the Middle East Cancer Consortium—that effort continues to help train the next generation of scientists and medical professionals in cancer biology in the region. Other programs have focused on vaccine development for childhood diseases; preventing HIV, malaria, and tuberculosis infections; ending childhood malnutrition; and managing unwanted pregnancies. Programs like these have yielded important advances in public health and have enhanced cooperation between countries like the Palestinian Authority, Egypt, Cyprus, Turkey, and Israel with the United States.

And in a unique cross-sectoral approach, Jordan is host to a promising initiative called the Synchrotron Light for Experimental Science and Application in the Middle East (SESAME). Modeled after the European Organization for Nuclear Research (CERN), SESAME is a partnership between Bahrain, Egypt, Israel, Iran, Jordan, Pakistan, the Palestinian Authority, and Turkey that aims to create research career opportunities that will limit “brain drain” from the region and serve as a model for scientific collaboration.

STEM education: The root of science diplomacy

Science diplomacy has the potential to deliver real dividends that extend beyond the science and technology spaces themselves. When states cooperate on functional, non-politicized (or at least less politicized) issues—whether at the level of non-state scientific communities or at the level of state bureaucracies focused on energy, health, or other issues—they become more accustomed to working together and trusting each other. This can gradually have spillover effects into politics and security arenas.

Science diplomacy doesn’t just happen, though—it requires real efforts on behalf of policymakers and experts. One crucial step is advancing STEM education (science, technology, engineering, and mathematics) to build more robust and diverse expert communities. This is something that President Obama emphasized in his speech at Cairo's Al-Azhar University in 2009. He identified possible areas of cooperation, both within the region and with the United States, including researching and piloting new sources of energy, creating “green” jobs, enhancing communication and informatics, sharing medical information, generating clean water, and growing new crops. 

In some countries in the region, particularly in the Gulf, there are signs of new investment in STEM education and related efforts. For example, Qatar has pledged to spend 3 percent of its GDP on scientific research, and the United Arab Emirates (UAE) has decided to create the world’s first sustainable city. Saudi Arabia created the King Abdullah University of Science and Technology (KAUST) with a $20 billion endowment, $200 million of which has been used to attract scientists and educators from the West. Saudi Arabia, Qatar, and the UAE continue to build and sustain partnerships with European and American universities. 

Interest in science among students and the general citizenry in many Middle Eastern countries remains low, which is problematic at a time when the region’s young people need to compete in a world increasingly centered around STEM. More governments in the region—perhaps with U.S. help—need to increase efforts to attract their young people to STEM education and careers.

International cooperation on STEM issues—led by science diplomats—can strengthen relationships between Middle Eastern states and with the United States. Science and technology disciplines transcend politics, borders, and cultures, and are thus an important bridge between nations. During a time of strained geopolitical relationships, we can focus on making progress in health and disease, food and water security, and other areas—and thereby enhance domestic stability and international security in the process. 

       

       

       

        

       

       

       

Event Information

A conversation with French Minister of Defense Jean-Yves Le Drian

On July 20 and 21, defense ministers from several nations will gather in Washington, D.C. at the invitation of U.S. Secretary of Defense Ash Carter. The meeting will bring together representatives from countries working to confront and defeat the Islamic State (or ISIL). French Defense Minister Jean-Yves Le Drian will be among those at the summit discussing how to accelerate long-term efforts to fight ISIL in Iraq and Syria. The close relationship between France and the United States has provided a solid base for security cooperation for decades, and in recent years, France has become one of America’s strongest allies in fighting terrorism and a prominent member of the international coalition to defeat ISIL.

On July 20, the Foreign Policy program at Brookings hosted Minister Le Drian for a discussion on French and U.S. cooperation as the two countries face multiple transnational security threats. Since becoming France’s defense minister in 2012, Le Drian has had to address numerous new security crises emerging from Africa, the Middle East, and within Europe itself. France faced horrific terrorist attacks on its own soil in January and November 2015 and remains under a state of emergency with its armed forces playing an active role in maintaining security both at home and abroad. Le Drian recently authored “Qui est l’ennemi?” (“Who is the enemy?”, Editions du Cerf, May 2016), defining a comprehensive strategy to address numerous current threats.

Join the conversation on Twitter using #USFrance

Video

• Introduction and featured speaker
• Discussion
• Introduction et conférencier invité
• Débat

Transcript

• Uncorrected Transcript (.pdf)

Event Materials

• 20160720_france_defense_transcript

         

Editor's Note: The current U.S. presidential race demonstrates the deep political divisions that exist in our country. But what does it mean to be "liberal" or "conservative," "Republican" or "Democratic"? According to Shadi Hamid, certain values transcend political chasms. This post originally appeared on PBS NewsHour.

What does it mean to say that the Republican Party is on the “right”? The GOP, long defined (at least in theory) by its faith in an unbridled free market, the politics of personal responsibility, and a sort of Christian traditionalism, is no longer easily plotted on the traditional left-right spectrum of American politics. Under the stewardship of presidential nominee Donald Trump, the Republican Party appears to be morphing into a European-style ethnonationalist party. With Trump’s open disrespect for minority rights and the Bill of Rights, the GOP can no longer be considered classically “liberal” (not to be confused with capital-L American Liberalism). This is a new kind of party, an explicitly illiberal party.

These developments, of course, further constrain Republicans’ appeal to minority voters (I haven’t yet met an American Muslim willing to admit they’re voting for Trump, but they apparently exist). This makes it all the more important to distinguish between conservative values and those of this latest iteration of the Republican Party.

There are some aspects of Burkean conservative thought – including aspects of what might be called civic communitarianism – that could plausibly strike a chord in the current cultural landscape across “left” and “right,” categories which, in any case, are no longer as clearly distinguishable as they once were. (Take, for example, British Labour leader Jeremy Corbyn’s Euroskepticism and that of his opponents on the right, or the populist anti-elitism and trade protectionism that are now the province of both Republicans and Democrats).

Everyone seems angry or distrustful of government institutions, which, even when they provide much needed redistributive fiscal stimulus and services, are still blamed for being incompetent, inefficient, or otherwise encouraging a kind of undignified dependency. After the Brexit debacle, it seemed odd that some of the most Europhobic parts of Britain were the very ones that benefited most from EU subsidies. But this assumes that people are fundamentally motivated by material considerations and that they vote – or should vote – according to their economic interests.

If there’s one thing that the rise of Trump and Brexit – and the apparent scrambling of left-right divides – demonstrates, it’s that other things may matter more, and that it’s not a matter of people being too stupid to realize what’s good for them. As Will Davies put it in one of the more astute post-Brexit essays, what many Brexiteers craved was “the dignity of being self-sufficient, not necessarily in a neoliberal sense, but certainly in a communal, familial and fraternal sense.”

The communitarian instinct – the recognition that meaning ultimately comes from local communities rather than happiness-maximizing individuals or bloated nanny-states – transcends the Republican-Democratic or the Labour-Conservative chasm. In other words, an avowedly redistributive state is fine, at least from the standpoint of the left, but that shouldn’t mean neglecting the importance of local control and autonomy, and finding ways, perhaps through federal incentives, to encourage things like “local investment trusts.”

Setting up local investment trusts, expanding the child tax credit, or introducing a progressive consumption tax aren’t exactly a call-to-arms, and various traditionalist and communitarian-minded philosophers have, as might be expected from philosophers, tended to stay at the level of abstraction (authors armed with more policy proposals are more likely to be young conservative reformers like Ross Douthat, Reihan Salam, and Yuval Levin). Douthat and Salam want to use wide-ranging tax reform to alter incentives in the hope of strengthening families and communities. This is a worthy goal, but realizing such policies requires leadership on the federal level from the very legislators who we should presumably become less dependent on.

This is the reformer’s dilemma, regardless of whether you’re on the left or right. If your objective is to weaken a centralized, overbearing state and encourage mediating or “middle” institutions, then you first need recourse to that same overbearing state, otherwise the proposed changes are unlikely to have any significant impact on the aggregate, national level.

The fact that few people seem interested in talking about any of this in our national debate (we instead seem endlessly intrigued by Melania Trump’s copy-and-paste speechwriting) suggests that we’re likely to be stuck for some time to come. Incidentally, however, the Hillary Clinton campaign slogan of “Stronger Together” has an interesting communitarian tinge to it. I doubt that was the intent, and it’s only in writing this column that I even took a minute to think about what the slogan might actually mean. I, as it happens, have been much more interested in talking about – and worrying about – an unusually fascinating and frightening man named Donald Trump.

       

       

        

Editor’s Note: The National Perspectives on Global Leadership (NPGL) project reports on public perceptions of national leaders’ performance at important international events. This fifth installation of the NPGL Soundings provides insight on the issues facing leaders at the Seoul G-20 Summit and the coverage they received in their respective national media. Read the other commentary »

The fifth G-20 Summit held in Seoul seems to show signs of a gradual maturing of the process and the forum as a mechanism for communication among leaders and a means of connecting leaders and finance ministers with their national publics, judging from National Perspectives on Global Leadership (NPGL) country commentaries. These growing strengths — looking from the G-20 capitals toward the Seoul summit contrasted with looking from the summit toward the countries — seemed particularly impressive at this Seoul summit, which was characterized by the most intense policy conflicts yet at a G-20 meeting.

Policy Conflicts and the Trajectory of G-20 Summits

The responses to the first question — “Did coverage seem to threaten or enhance the viability of G-20 summits?” — seemed to indicate that, despite the conflicts over external imbalances and currency policies, these issues did not threaten the viability of the G-20 summits as much as one might have expected. Given the focus of the NPGL project on national leadership, what is interesting about this positive result is that the coverage in the media was not just of the debate itself, but the portrayal of their national leader at the summit.

With the exception of an excellent and balanced article on Saturday, November 13 in The Washington Post by Howard Schneider and Scott Wilson, the coverage in Washington and in the Financial Times would lead readers to conclude that the Seoul G-20 Summit was less successful than anticipated, and did not enhance the viability of G-20 summits as much as the Koreans hoped it would.

“Agreements did not have to be worked out,” Andrew Cooper wrote, quoting Canadian Prime Minister Stephen Harper, “this month or next month in order to avert [a] cataclysm…I’m confident we will make progress over time.”

Olaf Corry reported from London that UK Prime Minister David Cameron was quoted in The Guardian as saying that rebalancing “is being discussed in a proper multilateral way without resort to tit-for-tat measures and selfish policies.”

U.S. President Barack Obama said in his press conference that “in each of these successive summits we’ve made real progress.”

Lan Xue and Yanbing Zhang wrote that Chinese President Hu Jintao “highlighted the importance of (the) framework (for strong, sustainable and balanced growth) and also pointed out that it should be further improved,” a far cry from a rejection of it.

“In contrast to previous summits,” Peter Draper reported from Johannesburg, “President Zuma’s interventions did receive some press coverage at home…To judge from this coverage, he seems to have played his cards reasonably well and to have been visible.”

Melisa Deciancio commented from Buenos Aires that ”Cristina Fernandez’s contribution to the G-20 summits has always been substantive…She has also called the members of the (G-20) to work together, cooperate and avoid entering into conflict in relation to the ongoing currency war between China and the U.S.”

“Both (German Chancellor Angela) Merkel and (finance minister) Schaeuble spent considerable effort to explain the positive aspects of summit agreements and praised the ‘spirit of cooperation,’” reported Thomas Fues from Germany.

In each of the cases above, the leader offered a positive interpretation of the Seoul G-20 Summit and the G-20 summit process even in the context of intense policy disputes, which constrained the practical agreements that could have been reached, especially on the global economic adjustment issues. This optimistic stance indicates a forward movement by G-20 leaders on a metric of global leadership in Seoul that the four previous NPGL “Soundings” had found to be wanting at previous summits.

In some countries, the problem continued with the press focusing on the shortcomings and failures of the Seoul G-20 Summit, including the coverage in the influential Financial Times. G-20 leaders were, however, more aggressive in pushing against the media’s interpretation of weakness and failures at the G-20, advancing an alternative narrative that focused on the gradual progress being made and stronger relationships developing with each G-20 summit experience. Leaders now need to assure that the G-20 “framework” and the “mutual assessment process” (MAP) of peer review that goes with it, are able to deliver a credible way forward for global economic adjustment by the time of the French G-20 Summit in November 2011.

Global Economic Adjustment as a Visible Theme

With regard to question two — “How was the rebalancing issue dealt with?”— the common thread running through each of the country commentaries is reflected in Olaf Corry’s comment that “explicit mention of the G-20’s formal ‘framework for strong, sustainable and balance growth’ is very sparse in UK public debate, but the themes it highlights definitely shine through.” The one exception may have been the explicit, detailed understanding of the issue conveyed by Schneider and Wilson in their Washington Post article titled “G-20 nations agree to agree; Pledge to heed common rules; but economic standards have yet to be met.” (See U.S. country commentary.)

The G-20 framework and the MAP may not have received much visibility or coverage from the media, but the intensity of the currency wars, the debate about U.S. quantitative easing (QE 2) and the differences over current account targets were all widely covered, and the message communicated to most publics was that global imbalances are a real problem for all countries and a concerted global economic adjustment is essential. The G-20 leaders will, therefore, have to do far more than simply explain the process to their publics; they need to continue to push each other and their economic officials to reach agreement on a path forward by the time of the French summit in November of 2011.

The difficulty of reaching agreement is reflected in a comment by Ryozo Hayashi of Japan who wrote, “Therefore, it sounds wise to let these countries (the U.S. and China) keep their current policy paths with a political commitment to avoid a currency war and for the G-20 to agree to develop economic indicators. It may become urgent or it may become irrelevant as the situation develops. Given the difficulty of establishing agreed economic indicators, the time element would be important.”

Leadership at Summits and Its Linkages to Domestic Political Support

What emerged more clearly at this summit than in previous G-20 summits was the degree to which the role of individual countries and their leaders (or finance ministers) in G-20 processes had domestic political valence in their home countries.

“The amount of attention devoted by the media to this summit was considerably more than previous ones,” wrote Andres Rozental, “partially because the Calderón administration will host the G-20 in 2012 and Mexico is now part of the G-20 ‘troika.’”

Thomas Fues commented that “The media also appreciatively noted that Germany had been asked to co-chair the G-20 working group on the international currency system, tasked with formulating policy proposals” for the French G-20 Summit.

In South Africa, Peter Draper also found that the press paid attention to the fact that it co-chairs the G-20 working group on development with South Korea, and “the importance of this group’s work to the future of the G-20.”

“In terms of summit diplomacy,” wrote Andrew Cooper, “Harper’s main success was in gaining the role for Canada as one of the co-chairs (with India, supported by the International Monetary Fund [IMF]) with respect to the process of working out a set of economic indicators that all members of the G-20 could use as guideposts for a stable global economy.”

This is all evidence that G-20 activities now generate positive repercussions in domestic public opinion.
Other dimensions of linkages between international committee positions assumed at G-20 summits and domestic political capital are beginning to emerge as the G-20 matures.

In South Africa, Finance Minister Gordhan’s strong criticism of U.S. QE2 in the international press seems “to have added to his growing reputation at home” commented Peter Draper.

German Finance Minister Schaeuble’s criticism of the U.S. Federal Reserve’s move as “clueless,” “forced Merkel to reiterate unswerving support of her key official” at the Seoul summit, Thomas Fues noted.

Cristina Fernandez has consistently and adroitly used her substantive policy positions at G-20 summits to buttress her position at home. Argentina is head of the G77, so Argentine support for development increases its status as a leader of the South and her domestic prestige. Argentine discontent with the IMF has been legend since the 1990s; support of President Fernandez for the G-20 framework and MAP process arises as an alternative to the IMF article IV exercise, which most Argentines are against, reported Melisa Deciancio.

Conclusion

Despite media attention being riveted on the showdown between the United States, Germany and China on currency manipulation and external imbalances at the Seoul G-20 Summit, leaders defended the G-20 processes for working through these issues over time, rather than emphasizing the failure to reach agreement at Seoul. The leaders and their finance ministers found that taking an aggressive stance on key issues paid dividends in terms of their domestic political support.

Explicit efforts by leaders to link international policies to domestic politics is a positive step forward for G-20 summits toward a greater engagement between leaders and their publics. NPGL observers have been watching this dimension of G-20 summitry in London, Pittsburgh, Toronto and now Seoul. (See: www.cigionline.org; Papers; “Soundings”)

The challenge going forward will be finding a way to align the global economic adjustment policy with domestic political linkages in a consistent and reinforcing manner, that will allow for policy convergence rather than the divergence manifested at the Seoul G-20 Summit.