Roosevelt Review 2005

ROOSEVELT REVIEW Volume 1 • Issue 1 • Summer 2005

A Publication of the Roosevelt Institution

ROOSEVELT REVIEW

Volume 1 • Issue 1 • Summer 2005

E DITOR - IN -C HIEF Jesse Wolfson E XECUTIVE E DITORS Danielle Gilbert Kevin Hilke Vincent Intersimone A SSOCIATE E DITORS Alexander Bartik Eric Freeman Peter Squeri

S ELECTION C OORDINATORS Gabriel Arana Bianca Gersten Sarah Graham Melisse Morris Elise Taylor L AYOUT E DITOR Sarah Wang

E DITORIAL B OARD Julia Adams, Yale University Jared Bernstein, Economic Policy Institute Sophia Brill, Yale University Jeff Chapman, Economic Policy Institute Chrissie Coxon, Stanford University John Donohue, Yale Law School R. David Edelman, Yale University Brenda Eskenazi, University of California at Berkeley Ben Grant, Stanford University Beth Fiedorek, Yale University Heather Heldman, Yale University

Amb. William vanden Heuvel Todd Huffman, Mackenzie Willamette Hospital Eric Kafka, Yale University Suzanne Kahn, Yale University David Kaiser, Naval War College Madeline Kerner, Yale University Katharine Manning, Yale University Richard Rorty, Stanford University Robert Samet, Stanford University Megan Stacy, Stanford University Melissa Sterry, Democracy for Connecticut Adam Stone, Stanford University

The opinions expressed within the Roosevelt Review are exclusively those of the individual authors and do not represent the views of the editorial staff, the editorial board, the Roosevelt Institution, or any of the organization’s chapters, centers, advisors, or affiliates.

ROOSEVELT REVIEW

Volume 1 • Issue 1 Summer 2005 http://rooseveltinstitution.org

ROOSEVELT REVIEW

Volume 1 • Issue 1 • Summer 2005

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Editors’ Note

CURRENT RESEARCH: ANALYSES OF PRESENT PROBLEMS AND PROPOSALS FOR CHANGE 11

An Apollo Project for Solar Energy Devon Swezey

19

Extraction vs. Taxation: What to Do with ANWR Joseph L. Kastner and David M. Felix

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Medicare, Medicaid, SCHIP, and the Future of America: New Strategies for Improving Access to Health Insurance for America’s 8.5 Million Uninsured Children Amelia Hausauer, Jermaine Archie, Craig Boge, Anthony Ortega, and Sarah Pratt

55

Innocent Until Proven Guilty: Military Use of Depleted Uranium Rachel Saltzman

71

Voices From Rural South Africa Married Women and AIDS Vulnerability: Moving Toward Female-Controlled Prevention Jenny Tolan

85

Globalization and Education: A Case Study in Papua New Guinea Hammad Ahmed

SURVEYS: POLICY AND SOCIAL PERSPECTIVES FROM COMMMUNITY, POLITICAL, AND CORPORATE LEADERS 95

Three Models of Corporate Social Responsibility: Implications for Public Policy Elizabeth Redman

LOOKING AHEAD: PROGRESSIVE THINKING TOMORROW’S ISSUES 109

ON

Genomic Justice: Genetic Testing and Health Insurance in America Dov Fox

Editors’ Note

W E L C O M E T O T H E I N AU G U R A L I S S U E R O O S E V E LT R E V I E W

I

n the fall of 2004, an ongoing political dialogue between students across the country made us realize the need for an organized method of developing and promoting students’ ideas. In response, we created the Roosevelt Institution, the nation’s first student think tank. Through Roosevelt, we hoped to give students a voice in the political process, to develop solutions to the problems facing our society, and to unite and train our nation’s students, laying the groundwork for a strong, progressive future. In only nine months, we have expanded our model to more than 70 campuses across the country and around the world. At each of our chapters, students have come together, founded issue-focused policy centers, and begun studying and developing solutions to the inequalities, inadequacies, and injustices which are present in our current social, political, and economic system. Throughout these months, as students in various centers have developed policy solutions, others have worked to put the best of these solutions into the hands of those who have the ability and the desire to effect positive social change. The inaugural issue of the Roosevelt Review marks the culmination of these combined efforts. Of the initial hurdles we have faced, none has been more commonly discussed by non-students, or less frequently encountered by students, than the supposed disadvantages of youth. Many believe that students are simply too young and inexperienced to contribute meaningfully to the policy process. Others were concerned that regardless of the quality of our work, we would be received not as citizens presenting ideas for change, but as inexperienced, idealistic students. From the beginning, we have believed 7

that these worries would prove to be unfounded, that our political system would benefit from some tempered idealism. Our experience has only confirmed this belief. In fact, we have found only advantages as students. We couple the optimism, energy, and curiosity of youth with access to the scholarship and research facilities of the world’s best universities. Our remove from the daily grind of Washington and state capitals makes us an ideal source of fresh and innovative approaches to contemporary problems. Moreover, as members of the next generation, we are able to call upon the full range of mentoring and assistance of those with a concern for the future of American politics. Over the past nine months, we have used these advantages to overcome many real hurdles and to sail past many imaginary ones. We have been met with enthusiasm and interest on campuses around the country; we have received media coverage in major outlets such as The San Francisco Chronicle and The New York Times; we have been given generous donations which have allowed for the growth of our organization and this publication; and most important, our fellows have begun to produce interesting, original, high quality policy research. We have reached this landmark publication thanks to the many mentors, advisors, donors and friends who have believed in our potential and provided guidance to our young organization. We have recognized as many of them as space would allow in this magazine, but there is never enough room for all the thanks which are properly owed. By the submission deadline for this issue, we had received hundreds of articles from students at centers around the country and across the world. After an intensive selection process conducted by our editorial board, we narrowed this pool down to the eight pieces found here. These articles—which range from proposing an Apollo Project for solar energy, to reducing the threat of AIDS for married women in South Africa, to examining the effects of exposure to depleted uranium on our nation’s soldiers—provide new ways of looking at current problems and propose 8 |

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innovative solutions. We hope that you, our readers, find these discussions to be interesting, insightful, and helpful discussions. More important, we hope that you see in them an indication of the potential of the Roosevelt Institution. The quality of our research will continue to improve as our organization, and our fellows, mature. Sincerely, Danielle Gilbert, Kevin Hilke, Vincent Intersimone, and Jesse Wolfson

A CKNOWLEDGMENTS But for countless contributions from the following individuals, the Roosevelt Review would not have been possible. For your faith and service you have our deepest gratitude. Daniel Appelman Alex Bartik Chris Breiseth Sophia Brill Dan Carol Diane Chin Andrew Cox Chrissie Coxon Helen Danilenko Albert Fang Ted Fertik Leslie Finger Eric Freeman John Gedmark David Grant Nancy Grant Morris Graves

Scott Grinsell Lisa Seitz Gruwell Mary Hughes Mattie Hutton Margot Isman Suzanne Kahn Kapil Kulkarni Nate Loewentheil Stephan Loewentheil Hon. Zoe Lofgren David Merchant Thomas McSorley Nick Moscow Milton Podolsky Vilas Rao Andy Rappaport Deborah Rappaport

Paul Rich Anne Eleanor Roosevelt Steven Rosenzweig Stanley Sheinbaum Jessica Singleton Peter Squeri Melissa Sterry Mark Steitz Kai Stinchcombe Michelle Suski Dorothy Vanderbeck Sarah Wang Quinn Wilhelmi Lauren Young

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population based on historical data, and an average gasoline priceb of $1.48 per gallon. The scenario is characterized by the following equations with the goal of minimizing the gas tax: The parameters α and γ used in the function for fuel economy are based on data from the U.S. Department of Transportation National Household Travel Survey (NHTS) and the penalties for violating corporate average fuel economy (CAFE) standards. The percentage of new carsc within the national fleet has varied between 15 percent and 20 percent over the last 20 years (NHTS, 2001). The infiltration parameter is meant to approximate the percentage of brand new cars, less than one year old, within the fleet and is assumed to be roughly half of the NHTS new car value or 10 percent. The CAFE penalty for not achieving efficiency standards is $50, per mile per gallon, per vehicle. It is assumed this is a good estimation of the cost to increase fuel economy for new cars by one mile per gallon. This equates to over one billion dollars if applied to the roughly 20 million new cars entering the fleetd each year and is within the same order of magnitude as a study by Whitford (1984). More detailed projections by Difiglio (1990) and Greene (2003) suggest these costs increase exponentially as the vehicles become more efficient. To account for this increase and simplify the use of the parameter, a constant value of $5 billion is used for γ. The inverse exponential term in the fuel economy function is used to simulate a lag in manufacturer participation in the research and manufacturing effort, and effectively slows the infiltration of more efficient technologies into the national fleet. Results Because the model is constrained to a constant tax value, the prediction is completely dependent on the first year of the scenario. The model predicts a tax value that exactly covers the Alaskan and federal benefits in the first year. This equates to a tax between $0.04 and $0.44 per gallon for the three USGS scenarios. As population increases, consumption and tax revenues also increase. Since the state and federal benefits remain constant the amount of revenues available for research and development increases with time. As a result, the consumption curve for this scenario begins identically to the business as usual situation and gradually tails off as the national average fuel economy increases. As a result, the scenario conserves an amount of gasoline equivalent to more than four ANWRs This price is net of the additional ANWR tax. A new car is defined as a model less than two years old. d There are roughly 200 million cars on the road in the US. b c

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Total Motor Gasoline Consumption: Tax Scenarios 500

Billions of Gallons

450 400 350 300 250 200 150 BAU Consumption

100

Scenario I: 17 cent tax Scenario I: 33 cent tax Scenario !: 52 cent tax

50

Scenario II: 4 cent tax

Year

0 1940

1960

1980

2000

2020

2040

2060

2080

2100

Figure 4 Projected consumption for Scenarios I and II under the most optimistic petroleum resource projection. The tax values for the three extraction cases do not vary significantly because the drilling benefits are dominated by the constant multi-billion dollar value applied to jobs and because royalty and production benefits do not change greatly under the three extraction projection. The results are illustrated in the previous figure. The results from Scenario II predict a gas tax of roughly $0.04 will result in a 35 percent increase in the national average fuel economy over the next 70 years. Historical data suggests this type of increase is plausible given the nearly 40 percent increase in just 20 years that occurred before and after the oil embargo of the 1970s. It is significant to note that this analysis does not account for changes in the average fuel economy elasticity of demand caused by increased efficiency. Commonly known as “rebounding,” the theory states that consumers will change their driving habits and travel more vehicle miles if fuel efficiency is increased. A study by Greene (1999) suggests up to 20 percent of the expected conservation can be lost due to increased travel in response to greater fuel efficiency.

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Fuel Economy Projection 25

Nationwide Average Fuel Economy (MPG)

BAU

~ 35% Increase from 2005 to 2075

with Tax and R&D Funding

20 ~ 36% Increase from 1970 to 1990

15

10

5

0 1950

1970

1990

2010

2030

2050

2070

Figure 5 Comparison of historical and projected national average fuel economy for Scenario II

C ONCLUSION The conservation model as applied in Scenario I predicts tax levels of $0.17, $0.33, and $0.52 per gallon are required to conserve 5.2, 10.3, and 16 billion barrels of oil, respectively, over the next 70 years. These conservation levels are equivalent to the 95 percent, mean, and 5 percent probability resource estimates for ANWR published by the USGS. A tax at these levels would cost the average driver between $130 and $385 per year, and would provide tax revenues that dwarf expected economic benefits from drilling for Alaska and the federal government. Scenario II predicts a tax of $0.04 per gallon used in part to fund research and development in fuel efficiency would conserve the equivalent of 68 billion barrels of oil over the next 70 years. A tax at this level would cost the average driver $32 per year. Figures 5 and 6 compare the conservation amounts and cost to drivers for Scenarios I and II.

A DDITIONAL O BSERVATIONS • Optimization. The tax value in Scenario II could be minimized further if the model were made slightly more complex KASTNER

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Yearly Cost to Average Driver in 2005

385

(US-Y2K$ per driver) 400 350

Note: Assumes 14,000 miles driven per year with average fuel economy of 17 mpg.

254

300 250 200 150

131

100

32

50 0 95% Scenario 17 cent tax

Mean Scenario 33 cent tax

5% Scenario 52 cent tax

w/4 cent tax and R&D Funding

Figure 6 Direct cost to the average driver and allowed the tax to decrease over time. The large amount of conservation predicted in Scenario II suggests a much lower average tax could be used over the 70-year period and still achieve the conservation goals. • Uncertainty. Any research paper of this nature, which attempts to predict the future of gas prices and the associated behavior, is just that, a prediction. In reality the gasoline market is highly dependent on many factors that are completely unpredictable. OPEC, which controls the vast majority of the world’s oil supply, operates like a monopoly, further complicating the issue. Likewise the extraction path from ANWR is subject to uncertainty. The job growth estimates as mentioned previously are drastically different depending on whose study you research and what the associated assumptions are. • Environment. In detailing the benefits to not drilling in ANWR, we chose to exclude environmental benefits from not burning the three to ten billion gallons of gasoline. Carbon monoxide, nitrogen oxide, and carbon dioxide each have associated impacts on human health, ecosystems, and global climate 32 |

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70-year ANWR Extraction Estimates / Gas Tax Conservation Objectives (Scenario I) vs. Predicted Conservation: Gas Tax and MPG R&D (Scenario II) Source: EIA / USGS

68.83

Billions of barrels 70 60 50 40 30

15.96 20

10.31

10

5.25

0 5% Probability | 52 cent tax

Mean Probability | 33 cent tax

95% Probability | 17 cent tax

4 cent tax and R&D

-

Figure 7 Conservation comparison for Scenarios I and II change. Quantifying these benefits would only further encourage the plan of taxation over extraction. • Discount Rate and Option Value. A more in-depth analysis of the scenarios presented here would also include a calculation of the option value of ANWR. Using option values in analyses such as these are useful when the future costs and benefits are sufficiently uncertain. The analysis also ignored the time value of money because the extraction path was estimated as a constant average value. If the actual estimated extraction path were considered the analysis would need to include discounting. • Rebound Effect. Several studies have shown that increasing energy efficiency often leads to energy savings that are lower than expected. This is due to a tendency to increase the intensity of an activity when it becomes more energy efficient. In the case of cars, this equates to more vehicle miles driven as the act of driving becomes more fuel-efficient. This is often the argument against simply raising CAFE standards, as it does not KASTNER

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fully address the consumption issue, as a gas tax would. A tax encourages consumers to drive less, in addition to purchasing more fuel efficient vehicles. However, even if a 20 percent loss in energy savings was considered in Scenario II as proposed by Greene (1999), the $0.04 per gallon tax would still conserve more than three times the largest USGS resource estimate.

D ISCUSSION

OF

R ESULTS

When considering what to do about America’s dwindling domestic petroleum reserves it is important to consider all options. In this paper we took the specific example of ANWR to demonstrate the point to which we have come to as a nation in trying to satisfy our insatiable appetite for oil. In recent U.S. Senate proceedings the plan to drill in ANWR has continued to be affirmed, and many believe that it will in fact be exploited. Those opposed to drilling have often said that it is a small amount of oil compared to our level of consumption. This paper is an attempt to quantify just how diminutive an amount it is, and how relatively inexpensively it could be protected. No one will claim to know what will happen regarding energy supply and climate change in the coming years. Given the uncertainty that OPEC presents to the oil market, the questions that remain about ANWR resource estimates, peak oil impending and the continuous threat of global climate change, some consider prediction of this sort a “crystal ball” science. The results we have come to using reasonable and generally conservative assumptions clearly shows the issue at hand. The United States is consuming oil at a rate of over 500 gallons per capita per year. Without decisive policy to address this predicament, we are only asking for another oil crisis, and possibly worse. To what end are we going to exploit natural resources for oil exploration? Why has the average U.S. fleet fuel economy been held constant at roughly 17 miles per gallon for over 10 years, especially considering how much it could affect the rate of consumption? Isn’t there more we can do to lower the demand for oil so that irrevocably altering places like ANWR won’t be necessary? For how long can policymakers ignore the fact that Americans are paying less for gasoline than the rest of the western world? Finding creative solutions to reduce energy demands and encourage non-carbon based fuel consumption is imperative to future security and minimizing the damaging effects of climate change.

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A PPENDIX International Gas Prices Belgium

$7.00

France

Germany

Italy

Netherlands

U.S.

U.K.

Source: EIA

$6.00

$5.00

$4.00

$3.00

$2.00

$1.00

$0.00 Jan-96

Jan-97

Jan-98

Jan-99

Jan-00

Jan-01

Jan-02

Jan-03

Jan-04

Jan-05

Figure 8 International gas price comparison (USD$) 600

Consumption/Capita (gallons)

250

Price (in yr 2000, cents)

500

400 150 300 100

YR2000 Cents

Gallons per Capita/Year

200

200

50

100

0

0 1950

1960

1970

1980

1990

2000

2010

Figure 9 Consumption and Price data for the past 50 years (Source: EIA) KASTNER

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Model vs. Actual Data 600

Consumption/Capita (gallons)

Consumption Annual Gallons per Capita

Model

500

400

300

200

100

0 1940

1960

1950

1970

1990

1980

2000

2010

Figure 10 Model verification compares actual consumption data to our model output.

Total Consumption vs. ANWR Extraction 500

Consumption - BAU ANWR Extraction - 95% Probability

450

ANWR Extraction - Mean ANWR Extraction - 5% Probability

400

Billion Gallons per year

350 300 250 200 150 100 50 0 1950

1970

1990

2010

2030

2050

Figure 11 ANWR in context to current US consumption and predictions 36 |

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2070

Response Consumption/Capita - Whole Model Actual by Predicted Plot 550 500

Consumption/Capita Actual

450 400 350 300 250 200 200

250

300

350

400

450

500

550

Consumption/Capita Predicted P<.0001 RSq=0.96 RMSE=16.619

Figure 12 Full JMP output of final model regression

Summary of Fit RSquare

0.958122

RSquare Adj

0.954704

Root Mean Square Error

16.61862

Mean of Response

424.0507

Observations (or Sum Wgts)

54

Analysis of Variance Source Model

DF

Sum of Squares

Mean Square

F Ratio

4

309616.15

77404.0

280.2680

Error

49

13532.75

276.2

Prob > F

C. Total

53

323148.91

<.0001

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Parameter Estimates Term Intercept Price (in yr 2000 $) Income Adjusted Avg Fule Economy Public Perception DUMMY

Estimate

Std Error

t Ratio

Prob > |t|

805.84613

33.01492

24.41

<.0001

-0.52419

0.124202

-4.22

0.0001

0.0173482

0.001151

15.07

<.0001

-46.3554

2.580202

-17.97

<.0001

61.850823

10.67367

5.79

<.0001

Parameter Estimates Source

Nparm

DF

Sum of Squares

F Ratio

Prob > F

Price (in yr 2000 $)

1

1

4919.366

17.8123

0.0001

Income Adjusted

1

1

62740.512

227.1736

<.0001

Avg Fuel Economy

1

1

89142.163

322.7699

<.0001

Public Perception DUMMY

1

1

9273.710

33.5787

<.0001

R EFERENCES Dahl; Sterner. “Analysing Gasoline Demand Elasticities: A Survey.” Energy Economics 13(3) (1991): 203. Difiglio, C; Duleep, K.G. “Cost Effectiveness of Future Fuel Economy Improvements.” Energy Journal 11(1) (1990): 65. Espey. “Explaining the Variation in Elasticity Estimates of Gasoline Demand in the United States: A Meta-analysis.” The Energy Journal, 17(3) (1996): 49. Greene, L; Kahn, R; Gibson, C. “Fuel Economy Rebound Effect for U.S. Household Vehicles.” The Energy Journal, 20(3) (1999): 1. Greene, D.L.; Hopson, J.L. “Analysis of alternative forms of automotive fuel economy standards for the United States.” Transportation Research Record no. 1842 (2003): 20-28. Hsing. “On the Variable Elasticity of the Demand for Gasoline: The Case of the USA.” Energy Economics 12(2) (1990): 132.

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Kayser, A. “Gasoline Demand and Car Choice: Estimating Gasoline Demand Using Household Information.” Energy Economics, 22(3) (2000): 331. Parry and Small. “Does Britain or the United States have the Right Gasoline Tax?” RFF Discussion Paper (2002): 02-12. Ross, H. “Producing oil or Reducing oil: Which is Better for U.S. Energy Security?” Resources, Summer (2002), Issue 148. Schmalensee; Stoker, M. “Household Gasoline Demand in the United States.” Econometrica, 67(3) (1999): 645. West, E.; Williams, C. “Estimates from a Consumer Demand System: Implications for the Incidence of Environmental Taxes.” Journal of Environmental Economics and Management, 47(3) (2004): 535. Whitford, R.K. “Fuel-Efficient Autos: Progress and Prognosis.” Annual Review of Energy, 9(1) (1984): 375.

A BOUT

THE

A UTHORS

Joseph Kastner is a recent graduate of the Donald Bren School of Environmental Science and Management at the University of California at Santa Barbara, where he received an M.S. with a focus in public policy and environmental economics. Kastner has worked as a consultant and project manager in the areas of energy efficiency and renewable energy. Before attending the Bren School, he managed the construction and operation of five commercial solar energy facilities for the U.S. investment arm of the Dutch utility nv Nuon. Kastner has an M.S. in energy engineering from Stanford University and a B.S. in mechanical engineering from the University of Minnesota. Kastner recently accepted a position as the managing director of development and implementation for Renewable Ventures LLC, a renewable energy company in San Francisco focusing on project finance. David Felix is a mechanical engineer with B.S. from the University of Arizona. Felix is currently a candidate for a master’s degree at the Donald Bren School of Environmental Science and Management at the University of California at Santa Barbara. His primary focus is renewable energy policy and climate change. Currently, Felix is an Intern for the New Zealand government at the Energy Efficiency and Conservation KASTNER

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Authority in Wellington. Felix is also an engineering consultant for the College of Optical Sciences at the University of Arizona. In 2002, he led the UofA Formula SAE team to international competition with an ethanol-powered race car, the spark of his interest in renewable energy. For correspondence, please email David Felix at [email protected].

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Current Research: Public Health

Medicare, Medicaid, SCHIP, and the Future of America: New Strategies for Improving Access to Health Insurance for America’s 8.5 Million Uninsured Children Amelia Hausauer, Jermaine Archie, Craig Boge, Anthony Ortega, and Sarah Pratt If statistical data is any indication, then the 8.5 million children in the United States without health insurance are living on borrowed time.1 According to the Journal of the American Medical Association ( JAMA), children without health insurance are nearly 20 percent less likely to have visited a physician in the past year, more than twice as likely to be treated in a hospital emergency department, and almost five times as likely to be unable to obtain medical care.2 Though 90 percent of uninsured children have at least one working parent, their caretakers are often unable provide them with even routine health services like check-ups, dental appointments and eyeglasses. In order to address these disparities and better provide for our nation’s children, we must revamp existing federal health programs to distribute funds more efficiently. We can and must ensure that even the poorest Americans have access to basic medical care. H AU S AU E R ,

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M EDICARE , M EDICAID , I NSURANCE P ROGRAM

AND THE

S TATE C HILDREN ’ S H EALTH

The United States government offers three distinct public health plans—Medicaid, Medicare, and the State Children’s Health Insurance Program (SCHIP). Each provides subsidized health coverage to distinct sectors of the American public. Whereas the federal government funds Medicare, state governments, under the guidance of Congress, administer and finance Medicaid and SCHIP. Consequently, these programs receive and distribute subsidies in fundamentally different ways. Medicare serves Social Security beneficiaries 65 years and older, as well as the long-term disabled.3 In 2003, 85 percent of the 41 million Medicare recipients qualified because of age.4 Of the four “plans” that compose Medicare, parts A and B are relevant to our proposed reformation of the American public health insurance system. Part A, the Hospital Insurance Program, relies on backing from payroll taxes and covers inpatient hospital, hospice, skilled nursing, and home healthcare. Part B is bankrolled by beneficiaries’ premiums and general revenues, and relates to physician and outpatient health care.5 Medicaid insures America’s poorest citizens, regardless of age. In addition to meeting financial criteria, an individual must be a member of at least one of several eligible groups—such as low-income families with children or those with certain disabilities—to qualify for state funding.6 Overall, Medicaid insures over 52 million Americans, including 13 million elderly citizens with long-term disabilities, 14 million low-income working parents, and 25 million children.7 Though nearly half of Medicaid’s recipients are children, many children live in households whose incomes exceed the Medicaid eligibility threshold yet are insufficient to afford private health insurance. For these children, the federal government created the State Children’s Health Insurance Program (SCHIP) in 1997. SCHIP provides roughly 5 million children across the country with many of the same services provided by Medicaid.8 Like Medicaid, SCHIP is funded by the states in collaboration with the federal government, the latter of which uses a formula to cap state allocations. If states do not fully use their federal funds within three years, the U.S. Department of Health and Human Services redistributes these unused funds to states that have exhausted their grants. Together, Medicare, Medicaid, SCHIP provide healthcare coverage to one-quarter of the American population. Though these programs 42 |

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have achieved a great deal of success, additional reforms are urgently needed in order to improve access to aid and raise levels of health throughout the country.

W HAT

IS

W RONG

WITH

P UBLIC H EALTH C ARE ?

Existing public healthcare programs are rife with inadequacies. With regards to healthcare for the elderly, Medicare faces a major crisis: expenditures are increasing at an alarming rate, meaning that Medicare’s financial future is uncertain. Despite these rising costs, benefit packages are increasingly insufficient to support the healthcare needs of many elderly people. About 90 percent of Medicare beneficiaries must purchase supplemental coverage to provide for their medical needs.9 Medicaid has its problems, too. Its daunting enrollment process discourages many eligible Americans from applying, and the general public is largely ignorant of how the program operates and who is eligible to enroll.10 Data from the 1999 National Survey of America’s Families (NSAF) suggests that while 88 percent of low-income parents with uninsured children were somewhat familiar with Medicare and SCHIP, only 38 percent understood that their children could participate in the program even if their families did not receive welfare. Nearly half did not even understand the basic rules.11 This confusion varied by state—in Massachusetts, for instance, 73 percent of low-income families understood Medicaid’s basic rules, in contrast to only 54 percent of Texans.12 To rectify the general public’s lack of understanding, our government must proactively provide information about Medicaid and SCHIP to low-income families in an attempt to ease access and bolster participation. Further, our government must simplify application processes—a practical and cost-effective way of providing medical coverage to greater numbers of impoverished children. Seeking cost-effective solutions is crucial to repairing both Medicaid and SCHIP. Since these programs function under state jurisdiction, they are susceptible to local budget cuts, which in turn reduce federal matching of funding, creating a negative feedback loop. This problem hits SCHIP—which has a limited amount of federal financing—the hardest. Though caps on federal funds allocated to states for SCHIP were initially meant to be beneficial, they now threaten the program: 19 state programs are expected to face federal SCHIP funding shortfalls by 2007.13 H AU S AU E R ,

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A F ACELIFT

FOR

F EDERAL H EALTHCARE

The American public healthcare system clearly has its flaws, chief among them an inability to provide adequate healthcare for all children. To remedy this, our government should reevaluate the unequal distribution of benefits between the young and the old, the wealthy and the poor. Our government should, ultimately, restructure Medicare to eliminate the program’s bias toward affluent individuals. This renovation would limit spending, generating funds that could be used to increase enrollment of eligible children in Medicaid and SCHIP. In order to reduce the number of uninsured American children, we propose cross- enrollment between Medicaid, SCHIP, the National School Lunch Program (NSLP), and the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). NSLP reaches 60 percent of uninsured, low-income Americans between ages six and 17, while WIC provides supplemental nutrition benefits a majority of eligible children under age six.14 Together, the two programs reach a large chunk of America’s uninsured children. Our proposal is a form of “express lane eligibility” (ELE), a concept created by The Children’s Partnership to locate and enroll uninsured children within state budgetary parameters.15 Currently, the Senate Finance Committee is reviewing the Children’s Express Lane to Health Coverage Act of 2003 (S. 1083), which would “reduce bureaucracy by streamlining enrollment processes for the Medicaid and State Children’s Health Insurance Programs through better links with programs providing nutrition and related assistance to low-income families.”16 If passed, this bill could serve as an important first step toward a multilayered policy including: targeted outreach that piggybacks on public services to identify eligible children effectively, simplified application processes which increase efficiency by eliminating application redundancies (ensuring that parents would not have to fill out similar forms for separate programs), and automatic enrollment during the period of application processing to ensure that the maximum number of children are insured in the shortest amount of time. Based on successful case studies in California, Ohio, and Vermont, we propose requiring all states to adhere to an ELE plan involving NSLP and WIC.17 Because the income requirements for these nutrition programs are more stringent than either Medicaid’s or SCHIP’s—below 185 percent of the federal poverty line (FPL)—children who qualify for NSLP or WIC also automatically satisfy Medicaid or SCHIP eligibility criteria. NSLP divides child participants into those with a total 44 |

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household income less than or equal to 130 percent FPL, who receive free lunches, and those whose household income lies between 130 percent and 185 percent FPL, who receive reduced-cost lunches.18 We propose using the higher income cutoff in order to reach as many children as possible. ELE implementation procedures must follow regular, systematic patterns that maximize efficiency, incurring the fewest administration costs without jeopardizing accessibility and convenience. To that end, parents would receive a supplemental insert along with the NSLP or WIC application. This document would ask for parental consent to share basic information, such as date of birth and family income, between programs. After processing the NSLP or WIC application, agencies would enter necessary information into a database connected to state computers. State outreach personnel would access this computer system and then contact the applicant for follow-up appointments. These personnel would also collect the child’s Social Security number and immigration status, additional criteria not necessary for NSLP or WIC participation.19 During the interim period when applications undergo secondary review, children would receive temporary Medicaid cards. Providing Medicaid benefits rather than SCHIP benefits is logical in light of the 2003 census report, which noted that 62 percent of uninsured children live below the FPL, and are thus fully eligible for Medicaid coverage.20 A child’s insurance status would be reevaluated once her application is officially processed. Unfortunately, this form of presumptive eligibility may increase government spending since children who apply but do not qualify for either program will receive insurance while their applications are being evaluated. We believe, however, that the benefits of extending insurance to millions of children outweigh these costs. Though simple in theory, ELE faces several challenges. Most prominent among these is the question of how to calculate income eligibility, as public programs do not have a single, standard method of determining income. Both NSLP and WIC calculate household income, which includes both related and unrelated individuals living under the same roof, while Medicaid and SCHIP rely on family income, which is limited to financial guardians who live in the same home as the child.21 By these inconsistent standards, children who do not qualify for NSLP or WIC may actually be eligible for medical coverage. Amending publicly funded health program eligibility criteria to align with the Medicaid and SCHIP income calculation standard would remedy these inconsistencies. H AU S AU E R ,

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A second problem involves equity and immigration status. Medicaid and SCHIP cover only citizens and legal immigrants, while NSLP and WIC have no such requirements.22 This discrepancy may discourage immigrant families from enrolling their children in social services because parents do not want government agencies sharing information about their citizenship status. Because no family—regardless of citizenship status—should be denied prenatal nutritional counseling or food for a growing child, it is crucial that our government respect families’ privacy and make it clear that eligibility for one program does not impact eligibility for another. In any event, tying programs like NSLP and WIC to insurance through ELE does not appear to negatively affect enrollment. Trials of ELE in five California school districts with high numbers of recent immigrants resulted in an increase in school lunch program enrollment of two and eight percent in two districts, and a decrease of one and two percent in two others—statistics consistent with these districts’ annual fluctuations in enrollment.23 These findings indicate that immigration issues may not have a significant impact on participation in ELE programs. Despite these optimistic figures, it will be critical to prioritize families’ privacy when implementing ELE nationwide. Information sharing, too, could prove difficult. While some states integrate Medicaid and SCHIP, others separate the two programs. For ELE to work successfully in states with segregated insurance programs, there must be an efficient flow of information from one program to the next so that children with family income above Medicaid criteria but below SCHIP requirements can be matched with the appropriate plan.24 Also, any system needs to ensure that states receive the proper federal matching rates for children enrolled in each program. One way of facilitating a productive working relationship between SCHIP and Medicaid would involve a federally funded centralized computer system that would use database information from enrollment in NSLP and WIC to match children with the appropriate insurance policy. Establishing the infrastructure necessary to implement ELE will be costly. But by restructuring Medicare to adhere to a progressive, sliding-scale model—and thus require less funding—our government could lessen the cost of enrolling children in public insurance programs like Medicaid and SCHIP. Decreasing Medicare benefits for senior citizens with liquid assets amounting to $250,000 or more and diverting these funds to states’ Medicaid and SCHIP programs would limit budgetary strain. This change to Medicare involves both parts A and B of the current system. Currently, Part A recipients pay an $840 deductible, while the 46 |

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federal government pays for hospital stays up to 60 days and nursing home care for 20 days.25 Under our proposal, individuals with private assets exceeding $250,000 will be obligated to pay for the first fourteen days of a hospital stay. After this period, Medicare will assume all bills in accordance with the present regulations. These beneficiaries can theoretically afford a complementary Medigap or private insurance plan, so the government saves money without limiting health care to those who cannot afford private coverage. Coinsurance under Part B requires senior citizens to pay for 20 percent of outpatient care: Medicare assumes 80 percent of costs for doctor visits, home health care, ambulance service, x-rays, etc.26 We propose that individuals with $250,000 or more in liquid assets pay for 40 percent of Part B services. This proposal assumes that supplemental healthcare plans will fill this gap and provide insurance packages especially tailored to these Medicare revisions. This proposal uses private rather than net assets to establish wealth because this figure more accurately reflects affluence. Private assets consist of money from mutual funds, stocks, bonds, and personal bank accounts and exclude retirement funds and real estate investments. The assessment of net assets is an unwieldy process that requires a tremendous amount of paperwork as well as administrative time and effort. Calculating liquid assets should both more accurately reflect wealth and cut down on organizational costs.

F ISCAL B ENEFITS , E THICAL O BLIGATIONS Lower organizational costs are not the only fiscal advantage of implementing ELE programs. From a strictly economic perspective, the marginal benefits associated with insuring children exceed those of insuring senior citizens. According to the Kaiser Family Foundation, in fiscal year 2000, children aged zero to 18 (who composed 55 percent of Medicaid recipients) cost an average of $1227 each in Medicaid expenditures. In contrast, mean expenses per Medicare enrollee were $5506 in 1998 (most recent data).27 On average, children’s coverage through Medicaid costs less than one-fifth that of a Medicare beneficiary; a child insured by SCHIP costs somewhere between these two figures depending on the state. On an absolute scale, it is cheaper to insure children than senior citizens. Simply put, children give us more bang for our buck. And because children eventually grow up, securing their health today will produce healthier adults and seniors tomorrow, driving down costs both now and in the future. H AU S AU E R ,

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In addition to reducing spending, our proposal remedies unethical distribution of benefits—both within Medicare and among Medicare, Medicaid, and SCHIP. Today’s Medicare system is by no means fiscally robust and must be reshaped in order to allocate resources more equitably. Since Medicare’s inception, the vast majority of senior citizens have qualified for the program. This universality distinguishes Medicare from Medicaid and private insurance programs, many of which employ strict screening procedures. Despite this universality, the current Medicare system allows for discrepancies in the benefits received by different socioeconomic classes. Studies conducted by researchers at Dartmouth, Stanford and the National Bureau of Economic Research (NBER) conclude that the amount of Medicare funding directed towards elderly individuals directly correlates with their respective income levels—the higher the percentile in earnings during their working years, the more money spent on medical services during their senior years. In fact, the wealthiest ten percent of beneficiaries claimed an average of $1000 more in net Medicare benefits over their lifetimes than did the poorest ten percent.28 Moreover, wealthy beneficiaries often purchase supplemental insurance to cover the gaps in Medicare. Not only are they receiving additional Medicare funds, but they also have complementary coverage. While these studies do not present comprehensive investigations of Medicare’s effectiveness as a whole, they highlight the inequalities present among recipients. By curtailing benefits for affluent seniors, we could dedicate Medicare resources solely to poorer individuals who cannot afford to pay for their own health services. Our proposal attempts to shift funding towards those who need it most. Not only are there financial disparities among elderly beneficiaries, but children receive disproportionately low federal funding. President George W. Bush’s budget for fiscal year 2006 allocates $340 billion dollars to Medicare, yet grants only $1 billion over the next two years to expand SCHIP coverage.29 And though Medicaid’s projected funding, $338 billion, is comparable to that of Medicare, children’s services account for only 16 percent of the Medicaid’s budget.30 It is ethically irresponsible not to allocate resources equitably in order to assist parents who cannot provide their children with health coverage, a central element of a family’s well-being. In the words of one Kentucky parent, “Last year for several months, we were without health insurance...I was constantly worried—what if my daughter breaks her arm, or was in a car 48 |

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accident, or just got really sick—how would I pay for that with no health insurance? It’s a frightening position to be in.”31

O PPOSITION , F EASIBILITY ,

AND

R ESPONSIBILITY

Despite fiscal and moral arguments for redistributing Medicare resources to ensure access to Medicaid and SCHIP, numerous criticisms can be raised against such redistribution. Opponents might claim that it is not our government’s duty to walk parents through the application process, or that it is not our government’s fault if American citizens do not take advantage of their eligibility for public health care. But applying to Medicaid or SCHIP is by no means a simple process—enrollment requires considerable amounts of paperwork, intricate financial information, and multiple face-to-face interviews. More importantly, arguments about our “government’s duty” divert attention away from children. The question becomes whether or not it is socially acceptable to penalize children for their parents’ lack of information about government bureaucracy—completely sidestepping our obligation to ensure that all children have access to reliable healthcare. Beyond arguments involving responsibility, issues of political feasibility surround efforts to amend Medicare, Medicaid, and SCHIP. It is likely that a sliding-scale Medicare system will anger seniors in higher socioeconomic brackets, while gaining favor with those from poorer backgrounds. Overcoming mobilization bias may be difficult since the wealthiest seniors—the small portion of the population which will be the most affected—have the resources to express their opinions and influence policy. Pressuring pharmaceutical companies into reducing prices is one possible way to appease affluent seniors and ease the transition to a progressive Medicare system. Currently, drug prices in the United States are not competitive in comparison to those of other industrial countries. Canadian prices, for instance, are 40 percent lower than American raw fees and 33 percent lower when adjusted for discounts.32 The factor entirely responsible for this difference is the Canadian government’s willingness to negotiate drug prices on behalf of its citizens. Our government, unlike the government of nearly every other country in the western world, will not represent the interests of its citizens to the drug industry—leaving Americans unable to effectively negotiate drug costs. But according to Pfizer vice-president Peter Rost, companies can turn a profit while reducing drug costs—sales doubled when Pfizer decreased H AU S AU E R ,

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charges in Northern Europe.33 Our government must step in and negotiate costs for all citizens in order to limit price gouging and thereby alleviate the financial burden for seniors affected by reduced Medicare benefits. In the hopes of countering political opposition, advertisement campaigns that highlight the plight of uninsured children could be used to evoke sympathy from the American public. Such ads would likely be countered by organized groups of wealthy senior citizens, and possibly the American Association of Retired Persons (AARP). In response to these critics, efforts must be made to emphasize measures to reduce drug costs for seniors. Even if this method does not completely placate those negatively affected, the plan should gain popularity among the families of uninsured children who receive augmented benefits and have easier access to federally provided healthcare.

T HE E QUITABLE E XPRESS L ANE : H EALTHCARE A LL A MERICANS

FOR

Our government should provide a combination of express lane eligibility, progressive health insurance based on socioeconomic status, and reduction in prescription drug costs in an attempt to enhance children’s access to public insurance policies. By amending Medicare, Washington could redirect funds to SCHIP and Medicaid while keeping expenditures in check. Further, because our proposal would transfer money from an affluent population that can afford first-rate services to needy children, it would elevate pediatric care without sacrificing geriatric care, ensuring that all individuals, regardless of age, receive adequate coverage. Though our proposal may seem controversial, it is necessitated by the grave shortfalls of the nation’s healthcare system—a system that can only be fixed by an approach that accounts for problems of access, cost, and quality. Such an approach is the best way of addressing the nation’s health care shortfalls, the best way of providing for America’s 8.5 million uninsured children. 1. “People With or Without Health Coverage by Selected Characteristics: 2002 and 2003,” U.S. Census Bureau 8 Feb 2005. http://www.census.gov/hhes/www/hlthins/ hlthin03/hi03t5.pdf. 2. Newacheck, P et al. “The Role of Medicaid in Ensuring Children’s Access to Care.” JAMA 290(20) (1998): 1789-1793. http://jama.ama-assn.org/cgi/reprint/280/20/1789.pdf.

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3. “CMS/HFCA History” 22 Dec 2004. Centers for Medicare & Medicaid Services 12 Feb 2005 http://www.cms.hhs.gov/about/history/default.asp?. 4. “CMS/HFCA History.” 5. “Medicare at a Glance” Mar 2004. The Henry J. Kaiser Family Foundation. 12 Feb. 2005. http://www.kff.org/medicare/loader.cfm?url=/commonspot/security/getfile. cfm&PageID=33319. 6. “The Medicaid Program at a Glance.” Jan. 2005. The Henry J. Kaiser Family Foundation, 12 Feb. 2005. http://www.kff.org/medicare/loader.cfm?url=/commonspot/security/getfile.cfm&PageID=33319. 7. “The Medicaid Program at a Glance.” 8. “Medicaid/SCHIP” Feb. 2005. The Henry J. Kaiser Family Foundation, 12 Feb. 2005. http://www.kff.org/medicare/loader.cfm?url=/commonspot/security/getfile. cfm&PageID=33319. 9. Moon, M. “Medicare.” The New England Journal of Medicine 22 Mar. 2001, 12 Feb. 2005 http://content.nejm.org/cgi/content/full/344/12/928. 10. Perry, Michael; et al. “Medicaid and Children: Overcoming Barriers to Enrollment: Findings from a National Survey.” Washington, D.C.: Kaiser Commission on Medicaid and the Uninsured 2000. 11. Kenney, G; Haley, J; Dubay, L. “How Familiar are Low-Income Parents with Medicaid and SCHIP?” New Federalism: National Survey of America’s Families, Urban Institute B-34 (May 2001), 2 Feb 2005 http://www.urban.org/template. cfm?Template=/TaggedContent/ ViewPublication.cfm&PublicationID=7232&Na vMenuID=95. 12. Kenney; Haley; Dubay. 13. “Kaiser Commission on Medicaid and the Uninsured,” 2 Feb. 2005, The Henry J. Kaiser Family Foundation, 12 Feb. 2005 http://www.kff.org/medicaid/loader. cfm?url=/ commonspot/security/getfile.cfm&PageID=50856. 14. “School Lunch Plan: Implementations Strategies,” Express Lane Eligibility, The Children’s Partnership, Feb. 10 2005 http://www.childrenspartnership.org/expresslane/sl-implement.html. 15. Homer, D; Lazarus, W; Marrow, B. “Express Lane Eligibility.” The Future of Children 13(1) (2003): 229, 13 Jan 2005 http://www.futureofchildren.org/usr_doc/ tfoc13-1_iig.pdf. 16. “Children’s Express Lane to Health Coverage Act of 2003 (Introduced in Senate) S1083 IS.” Thomas: Legislative Information on the Internet, The Library of Congress, Jan 20 2005. http://thomas.loc.gov/cgi-bin/query/z?c108:S.1083:. 17. “School Lunch Plan: Implementation Strategies.” 18. “School Lunch Plan: Implementation Strategies.” 19. “Express Lane Eligibility” 226-7. 20. Bhandari, S; Gifford, E. “Children with Health Insurance: 2001.” U.S. Census Bureau, Aug 2003, 30 Jan 2005. http://www.census.gov/prod/2003pubs/p60-224.pdf. 21. Horner, D; Lazarus, W; Morrow, B. “Building an On-ramp to Children’s Health Coverage: a Report on California’s Express Lane Eligibility Program” Sept. 2004. The Henry J. Kaiser Family Foundation, 20 Jan 2005. http://www.childrenspartnership.org/expresslane/ele-CA.pdf.

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22. Horner; Lazarus; Morrow. “Building Health Coverage: a Report on California’s Express Lane Eligibility Program.” 23. “Building an On-ramp to Children’s Health Coverage: a Report on California’s Express Lane Eligibility Program.” 24. “Express Lane Eligibility” 228. 25. “Original Medicare: Getting Care in a Hospital, Nursing Home, at Home and with Hospice.” AARP, 5 Feb. 2005 http://www.aarp.org/healthcoverage/medicare/Articles/a2003-04-28-orginalmedicareA.html. 26. “Original Medicare: Getting Doctor, Home Health and Preventive Care.” AARP, 5 Feb. 2005 http://www.aarp.org/healthcoverage/medicare/Articles/a2003-04-28originalmedicareB.html. 27. “Distribution of Medicaid Spending per Enrollee by Enrollment Group, FY2000.” Statehealthfacts.org, The Henry J. Kaiser Family Foundation, 3 Feb. 2005 http:// www.statehealthfacts.kff.org/cgi-bin/healthfacts.cgi?action=compare&category=M edicaid+%26+SCHIP&subcategory=Medicaid+Spending&topic=Spending+per+E nrollee+by+Group%2c+FY2000. 28. McClellan, Mark; Skinner, Jonathan. “The Incidence of Medicare.” NBER Working Paper No. 6013, Apr 1997: 32. 29. “FY06: Department of Health and Human Services.” Office of Management and Budget, Feb. 2005, http://www.whitehouse.gov/omb/budget/fy2006/hhs.html. 30. “Distribution of Medicaid Spending by Enrollment Group, FY2000.” Statehealthfacts.org, The Henry J. Kaiser Family Foundation, 3 Feb. 2005 http://www.statehealthfacts.kff.org/cgi-bin/healthfacts.cgi?action=compare&category=Medicaid +%26+SCHIP&subcategory=Medicaid+Spending&topic=Spending+by+Enrol lment+Group%2c+FY2000. 31. DeParle, Nancy-Ann Min. “Celebrating 35 Years of Medicare and Medicaid,” Health Care Financing Review 22(1) (2000): 3, 10 Feb. 2005 http://www.cms.hhs. gov/review/00fall/00Fallpg1.pdf. 32. Danzon, P; Furukawa, M. “Prices and Availability of Pharmaceuticals: Evidence from Nine Countries.” Health Affairs W3-524 (29 Oct 2003): 7. http://entrepreneurship.mit.edu/forum/Prices%20and%20Availability%20of%20Pharmaceuticals _9Countries%20HA%20Oct2003.pdf?type=topNews&storyID=5653226 33. Rost, P. “Saving lives, not bottom line must drive drug companies.” SFGate.com. 9 Jan 2005, 3 Feb 2005 http://sfgate.com/cgi-bin/article.cgi?file=/c/a/2005/01/09/ EDGE2AMLSQ1.DTL.

A BOUT

THE

A UTHORS

Amelia Hausauer, Jermaine Archie, Craig Boge, Anthony Ortega, and Sarah Pratt, all Human Biology majors at Stanford University, wrote this policy proposal for “The Human Predicament,” an introductory Human Biology course. 52 |

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Hausauer, a rising junior, concentrates is in Pathophysiology and Disease Mechanisms. Her interests include viral epidemiology and global health. Hausauer is a member of SCOPE, a premedical program placing students in local emergency rooms; and she has researched the gene Nkx 2.5 in Ciona Intestinalis in Dr. Michael Levine’s molecular biology lab at the University of California at Berkeley. She is also an intern at the HEAL pediatric obesity and diabetes clinic at Children’s Hospital Oakland. In 2004, Hausauer received the President’s Award for Academic Excellence. After graduating from Stanford, she plans on attending medical school. Archie, a rising senior, is originally from Motha-Effingham County, Georgia. He is currently conducting neuroscience research at Stanford. Boge, a rising junior, concentrates is in Epidemiology and Infectious Diseases. He is originally from Prosser, a small town in eastern Washington. Ortega, a rising junior, concentrates is in Race, Health Policy, and the Disadvantaged. He is passionate about a variety of political issues, including immigration policy, race and ethnicity studies, and public health. Ortega works at Stanford’s Center for Career Development, where he coordinates the Stanford Immersion in Medicine Series (SIMS), a shadowing program administered in conjunction with the Stanford Hospital. He also volunteers as a translator for EPA.net, an organization that aims to bring internet access and technology to lower-income neighborhoods in the Stanford area. In addition to majoring in Human Biology, Ortega is pursuing a minor in Italian, and hopes to attend medical school after Stanford. Pratt, a rising junior, concentrates is in Comparative Health Policy. Her interests include intersections between policy and reproductive and sexual health, infectious disease, and health in the developing world. She recently worked at the U.S. Department of Agriculture, where she studied the impact of federal programming on education, health, and infrastructure development on Native American reservations; and at the U.K. Medical Research Council Unit in the Gambia, Africa, where she researched the impact of HIV/AIDS serostatus disclosure on antiretroviral adherence, cumulating in a policy proposal that was presented to the Gambian National AIDS Secretariat. Pratt also recently received H AU S AU E R ,

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a grant to research the use of non-prescription hormonal contraception among teenagers in England. She is interested in pursuing a master’s degree in public health and a Ph.D., and would like to eventually work in academia and teaching. For correspondence, please email Amelia Hausauer at [email protected].

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Current Research: Public Health

Innocent Until Proven Guilty: Military Use of Depleted Uranium Rachel Saltzman Since the 1991 Persian Gulf War, debate about the effects of depleted uranium (DU) on the environment and on the human body has gained momentum. The U.S. Department of Defense has always claimed that DU is an indispensable component of munitions, and that any negative toxicological and radiological effects are negligible. Scientists in the private sector, however, have contended not only that an absence of sufficient evidence undermines the Defense Department’s claims of no risk, but that DU in all likelihood causes a variety of adverse health effects. Until conclusive research has been gathered and evaluated by multiple interest groups, the United States should establish a moratorium on military use of DU. DU is a byproduct of the uranium enrichment process, when fissionable U-235 and U-234 are separated from natural uranium.1 A heavy metal made from uranium hexafluoride, DU has about 60 percent of the radioactivity of natural uranium and a half-life of 4.468 billion years.2 Although DU has been used for decades in medical and industrial contexts (e.g. radiation shielding and counterbalance weights in aircrafts), it has more recently been used as a component of munitions by the U.S. military.3 DU’s high density makes it ideal for use both in “penetrators” against armored targets and as armor plate for military vehicles.4 According to the United States Army, it offers a significant performance advantage over other materials, such as tungsten, used for these purposes.5 DU S A LT Z M A N

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may also be attractive for the financial advantage it offers to munitions companies. A waste product of U.S. nuclear weapons and energy facilities,6 DU is stored by the U.S. Department of Energy, which allegedly gives it free-of-charge to U.S. armaments companies and sells it to more than twenty other countries.7 In addition to the estimated 320 tons that were deployed by the Army during the Persian Gulf War, DU has been used in operations in Bosnia, Kosovo, Serbia, Montenegro, and recently in Iraq.8 The most likely victims of DU exposure are the crews of vehicles carrying DU ammunition or fitted with DU armor. Civilians returning to live in conflict areas are also at risk for exposure from contaminated food and water supplies.9 The extent of environmental contamination from DU particles and penetrator fragments left in the soil depends on corrosion rates, the amount of soil resuspension, the depth of DU penetrators buried in the soil, and the water sources that feed into local water supplies—which may also influence the extent of DU uptake by plants and animals.10 However, uncertainties in estimates about inhalation intakes, as well as exposure from food and water after a conflict, result from a lack of knowledge about local soil conditions and human behavior,11 and a lack of empirical information on human DU exposure. Humans can be exposed to DU through inhalation, ingestion, and dermal contact.12 The heavy metal has both chemical and radiological toxicity, and is thought to be especially dangerous to the kidneys and lungs. DU, which is weakly radioactive, emits alpha particles, beta particles, and photons (x-rays and gamma rays).13 If it enters the body, the worst cell damage occurs from alpha particles.14 The greatest risk of inhalation is thought to be increased risk of lung cancer, while there is less estimated risk of contracting leukemia or other cancers.15 DU may also cause hepatic, hematological, respiratory, and cardiac toxic effects, and may even directly damage DNA because of the enhancement of chemical effects by alpha-particle radiation.16 Laboratory research performed over the last few years has shown that cells exposed to DU experience chromosome breaks, DNA cleavage, and cell death—effects that are all commonly accepted precursors to cancer, leukemia, lymphoma, and genetic disturbances, including sterility and birth defects.17 Inhalation is the most likely route of exposure to DU during a military conflict, when the impact of a DU penetrator against its target produces a cloud of fine dust that can be inhaled immediately by anyone within about 25 meters of the destroyed equipment.18 After a conflict, DU dust continues to present a hazard as it travels by wind throughout the surrounding environment.19 This dust is made up of particles 56 |

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of ceramic uranium oxide, over 60 percent of which are smaller than five microns in diameter.20 The small particles are easily inhaled and are likely to be retained in the lungs. After inhalation, some of the particles are cleared in mucus and swallowed, while some are absorbed into the blood.21 Other particles remain in the lungs, possibly for years, and are slowly absorbed into the bloodstream, cleared by the bronchial tree, or passed to nearby lymph nodes.22 When uranium is absorbed by the blood, most is passed out of the body through urine, while about ten percent goes to the kidneys and is lost within weeks, and another ten percent deposits in bone, where it remains for many years.23 The British Royal Society, an independent scientific academy, suggests that after large inhalation intakes, health effects might include short-term respiratory effects or, in case of heavy exposure, fibrosis of the lung or increased risk of lung cancer.24 In 2002, The Royal Society released a report on the health effects of DU munitions. Using information from animal studies considered alongside limited evidence from human exposure, the Royal Society reported that the kidney is the most susceptible organ to the toxic effects of uranium. There have been substantial difficulties, however, in assessing the nephrological health of exposed veterans. Adverse effects of uranium concentrations in human kidneys are not well documented, and the few existing epidemiological studies have been less than conclusive. The only measurements of uranium isotopes in veterans’ urine referenced by the Royal Society report came from a Canadian study which cited uncertainty about the reliability of its measurements.25 The Royal Society maintains that except in extreme circumstances, an increased risk of developing fatal cancers from exposure to DU on the battlefield, or from returning to live the area after a conflict, is undetectable.26 Yet uncertainties in research on battlefield intake have made estimation of general radiological effects difficult.27 Similarly, while exposure to DU may result in short-term kidney dysfunction, speculation about long-term effects has been impossible because of a lack of studies devoted to long-term monitoring of exposed individuals.28 Despite a failure to present conclusive findings, the Royal Society report did show that claims about lack of health risk from DU should be regarded as suspect. Assessments of risk resulting from DU exposure are largely based on poor data for concentrations and properties of DU oxides released during test firings.29 Furthermore, predictions of resulting concentrations in tissues and organs, as well as radiological and toxicological risks, have been based on modeling procedures rather than on actual data.30 S A LT Z M A N

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In a presentation to the Royal Society on July 19th, 2000—two years before the Society’s report was published—radiation expert Chris Busby challenged the deductive method that has been used both to set legal exposure levels and to maintain that exposure to DU is safe for human beings.31 He argued that the physics-based, “nuclear establishment” model for analyzing the health threats of DU is antiquated and reductionist.32 Most problematically, the model uses data from high level, acute, external exposure to predict health effects for low-level, chronic, internal exposure.33 Busby, along with other scientists concerned about the risks associated with the use of fissile materials, recommends that risk evaluation for DU should instead be based on an inductive analytical method that would involve using specific epidemiological information to look at the way in which doses from isotopes directly react with cells in various stages of biological development.34 This type of research, in addition to being more conclusive and scientifically sound, would allow scientists to explore legitimately the dose-response relationship of DU with human cells. The difficulties of finding reliable research methods that can produce conclusive data to describe the effects of DU exposure is compounded by an artificially limited flow of information. A 1994 report to Congress by the U.S. Army Environmental Policy Institute provides an example of the way in which concerns regarding DU’s adverse effects have been downplayed. The report states, “It is highly unlikely that DU is a contributing factor to the unexplained illnesses currently being reported by veterans of Desert Storm. This conclusion is based on assessment that there was little or no internal DU exposure by most Desert Storm soldiers.”35 However, according to a 1991 to 1995 survey of 10,051 Persian Gulf War veterans, 82 percent of veterans reported having entered captured Iraqi vehicles—suggesting that about 123,000 soldiers were directly exposed to DU during that conflict.36 In addition to the claim that U.S. soldiers probably were not exposed during the Persian Gulf War, the Environmental Policy Institute report frequently uses the lack of conclusive data about risk as evidence of no risk: “While there are no data that can be used directly to establish the human cancer and hereditary risks from low-level, low-dose radiation, there is general agreement that the models currently in use do not underestimate either the cancer or hereditary risks.”37 The claim that there is no appreciable risk associated with DU is based on “general agreement”—yet the report does not specify who exactly is included in this consensus. At the same time, it contains an admission that all evaluation of risk has been based on empirically unsupported estimation, for the 58 |

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simple reason that there are no data available. Certainly it is the responsibility of the U.S. Army to achieve “maximum battlefield advantage.”38 It should not follow, however, that the adverse health effects of DU should be regarded as “minimal” simply because the long-term effects are not “well-defined.”39 For the health of our soldiers, we cannot afford to employ an innocent-until-proven-guilty approach with respect to potentially dangerous materials. Whereas the U.S. Army and Defense Department have treated DU as an issue of tactical advantage and not as a potential health threat, scientists and physicians in the private sector have attempted to discover the full effects of DU on the human body. Doug Rokke, the former head of the Pentagon’s Depleted Uranium Project, released an independent paper in November of 2002 on the uses and hazards of DU. During the Persian Gulf War, Rokke left his research job with the University of Illinois Physics Department when he was recalled to active duty in the U.S. Army and assigned to the Depleted Uranium Assessment Team.40 “As the team health physicist and medic,” he explained in a November 2000 address to Vietnam and Desert Storm veterans, “I was responsible for planning and implementing DU (Uranium 238) contaminated equipment and terrain clean-up and for providing medical care recommendations for exposed personnel.”41 Rokke’s work contradicts official claims about the risk associated with DU, maintaining that it poses a significant threat to human health. He lists twelve effects of DU that have been verified by his own personal experience, the observations of physicians, and personal reports from individuals with known DU exposure. The effects include reactive airway disease, neurological abnormalities, kidney stones and chronic kidney pain, rashes, vision degradation and night vision losses, gum tissue problems, lymphoma, various forms of skin and organ cancer, neuro-psychological disorders, uranium in semen, sexual dysfunction, and birth defects in offspring.42 The likelihood that these effects have been caused by DU exposure is supported by the similar effects experienced by residents of several cities in the United States where DU is manufactured and tested for use in munitions.43 Iraqi and other humanitarian agency physicians have similarly reported adverse health effects in populations that were exposed to DU.44 Rejecting the official claims of the U.S. Army, Rokke suggests that one reason no adverse health effects of DU have been definitively proven is that U.S. authorities have engaged in “deliberate denial and delay of medical screening and consequent medical care” for U.S. soldiers exposed to DU.45 The small number of exposed soldiers that have been monitored typically were not approached for testing, or even informed of potential health threats, until S A LT Z M A N

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years after their last contact with DU. Yet according to health physics guidelines, testing should be completed within thirty days—not several years—of exposure.46 Not only have exposed individuals faced difficulties in receiving medical assessments, but they have also encountered an impeded flow of information surrounding DU data. Rokke writes that in 1994 and 1995, “United States Department of Defense medical personnel at a U.S. Army installation hospital removed, separated, and hid documented diagnoses from affected individuals and other physicians.”47 These confiscations occurred around the same time that the Army Environmental Policy Institute made its report to Congress repudiating the notion of health threats associated with DU. The juxtaposition of the Army’s official report and the actions of the Defense Department seems contradictory. It appears that the military has long been aware of a correlation between DU and adverse health effects. Physicians and exposed individuals, however, have found it difficult to pursue treatment once the patients’ problems were associated with DU exposure. Rokke confirms this censorship by U.S. authorities with his reference to a memorandum sent to his team in Saudi Arabia in March 1991. “This memo,” he writes, “told us to be sure no matter what we did or reported that we should only report information so DU could always be used.”48 The Depleted Uranium Assessment Team, it seems, was not used to compile legitimate research to protect U.S. soldiers. In the absence of such research, the Army was able to claim that investigation into DU’s effects had taken place and that members of the U.S. Army were safe. Documented evidence shows that U.S. authorities have known about the hazards of DU for a significant length of time but have not widely publicized this information. A letter sent to General Leslie R. Groves on October 30, 1943, by the Subcommittee of the S-1 Executive Committee on the Use of Radioactive Materials as a Military Weapon, suggested that uranium could be used as an air and terrain contaminant.49 The memo stated: Areas so contaminated by radioactive material would be dangerous until the slow natural decay of the material took place ... for average terrain no decontaminating methods are known. No effective protective clothing for personnel seems possible of development ... Reservoirs or wells would be contaminated [and] food poisoned.50 The letter stated that inhalation of uranium would result in “bronchial irritation coming on in a few hours to a few days.”51 Individuals 60 |

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exposed to DU dust during Operation Desert Storm experienced exactly these symptoms, yet were never informed of their exposure to DU or told to seek medical screening. Without these medical evaluations, the number of reported medical problems experienced by people with DU exposure is far lower than it would otherwise be—thus bolstering the claim that such cases do not exist. A physician in California reported being trained by the Pentagon, with other doctors, months before the 2003 Iraq war began—to diagnose returning soldiers with mental problems only.52 This claim is interesting in light of a recent Gulf War Review, which reported that as of September 2003, only 262 veterans had been treated for DU poisoning.53 Meanwhile, of nearly 700,000 American veterans of the Persian Gulf War, 240,000 are on permanent medical disability, and over 11,000 are dead.54 Furthermore, statistics suggest that veterans exposed to contamination during the Persian Gulf War have passed on health problems to their families. According to a U.S. government study of babies born to 251 Persian Gulf War veterans, 67 percent of the babies had serious illnesses or birth defects.55 Children of veterans were born without eyes and ears, had missing organs, fused fingers, and thyroid or other malfunctions.56 Significantly, similar birth defects have been reported in populations in Iraq, Yugoslavia, and Afghanistan, where DU weapons have been used.57 Using concrete data from the 2003 Iraq war to expand upon previous statistics is difficult, as compiled information is still fragmentary. However, many veterans of the current war are already suffering from Gulf War Syndrome, a disease whose symptoms indicate chemical or radiation poisoning, which was first experienced by veterans of the Persian Gulf War.58 It has been reported that in one unit of twenty U.S. soldiers who were exposed only to DU in 2003, eight developed malignancies within six months.59 As further data from the current Iraq war is compiled, reported adverse health effects will likely echo those of previous conflicts in the Middle East and the Balkans. DU has come to be regarded as one of the main possibilities for the cause of Gulf War Syndrome. Asaf Durakovic of the Uranium Medical Research Center (UMRC) describes Gulf War Syndrome as “a complex, progressive, incapacitating multiorgan system disorder” whose symptoms include incapacitating fatigue, musculoskeletal and joint pains, headaches, neuropsychiatric disorders, affect changes, confusion, visual problems, changes of gait, loss of memory, lymphadenopathies, respiratory impairment, impotence, and urinary tract morphological and functional alterations.60 Generally, only three possibilities have been regarded as potential causes for Gulf War Syndrome: Iraqi chemical and biological weapons, S A LT Z M A N

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the cocktail of vaccinations given to coalition soldiers, and DU.61 As there were no detectable biological agents used during the 2003 Iraq war, the possibilities for the cause of adverse health effects experienced by U.S soldiers are likely limited to prewar vaccinations and DU.62 However, Iraqi children who did not receive vaccinations experienced the same adverse effects as U.S. veterans.63 DU is thus becoming more widely regarded as the most likely culprit of Gulf War Syndrome. Perhaps the most telling study to date correlating DU exposure with adverse health effects was begun in 2002 by the Uranium Medical Research Center of Washington D.C., an independent non-profit organization founded in 1997 to provide scientific and medical research into the effects of uranium, transuranium elements, and radionuclides produced by the process of uranium decay and fission.64 Entering Afghanistan at the end of Operation Anaconda in March 2002, the UMRC team conducted studies of populations in the Jalalabad, Spin Gar, Tora Bora, and Kabul regions and identified civilians suffering from the same symptoms encountered in the Persian Gulf War and the Balkan conflicts.65 These symptoms included physical weakness, headache, muscular and skeletal pains, respiratory changes, fever, persistent dry cough, chest pain, gastrointestinal problems, neurological symptoms, memory loss, anxiety, and depression.66 Twenty-four hour urine samples were collected from test subjects who were present in the area of the bombings, displayed symptoms that began relative to the bombing raids, and showed clinical manifestations.67 High uranium levels were found in the urine of 100 percent of the test subjects, averaging 20 times higher than uranium levels in the urine of the non-exposed population.68 In a subsequent study later in the year, the UMRC found uranium concentrations up to 200 times higher than in the control population.69 This study is important to establishing the correlation between adverse health effects and DU exposure. However, Durakovic points out that there is still “a conspicuous absence of a meaningful comprehensive research effort that would correlate [Persian Gulf War and Balkan Syndromes] with uranium contamination.”70 The UMRC remains the only organization that has performed sustained research on DU using advanced methodology.71 As DU has begun to receive increasing attention as a possible cause of Gulf War Syndrome, reliable press coverage of its hazards has faced difficulties at every step. Investigative reporting about DU has mostly appeared in independent publications, such as American Free Press, rather than in mainstream newspapers. John Hanchette, editor of USA Today from 1991 to 2001, reports having written several news articles about the effects of DU on Persian Gulf War veterans, none of which 62 |

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were published because of pressure from the Pentagon.72 This silencing of speculation about the dangers of DU has allowed the U.S. Army to continue using the DU munitions that are strategically effective in the short run, but that are ultimately damaging both citizens of foreign nations and U.S. veterans in ways that are not yet fully understood. President George W. Bush has repudiated efforts to question the morality of continued use of DU munitions, referring to the “false claim that the depleted uranium rounds fired by coalition forces have caused cancers and birth defects in Iraq.”73 However, as representatives from the United Nations Environment Program have not been allowed into Iraq to assess DU pollution, no one has even had the opportunity to attempt to substantiate the president’s claim that the association of health problems with DU is “false.”74 Keith Baverstock, formerly the top expert on radiation and health at the World Health Organization (WHO), has experienced first-hand the type of censorship that impedes both journalistic commentary and scientific research on DU. Baverstock’s own study on DU’s health effects was suppressed by WHO, suggesting that the control of certain information is not isolated to the United States. In November 2001, Baverstock composed a paper with two other scientists on the radiological toxicity of DU that was allegedly blocked from publication by WHO. He believes that if the article had been published at the time of its completion, the United States and the United Kingdom would have been compelled to restrict use of DU in military combat, and to clean up contaminated sites.75 In February 2004 he told the Sunday Herald, an independent newspaper in Scotland, “Our study suggests that the widespread use of depleted uranium weapons in Iraq could pose a unique health hazard to the civilian population.”76 Baverstock’s study challenged the research of the Royal Society and WHO with criticism of previous methods of risk evaluation. His paper suggested that the study of DU’s health effects should include consideration of a “bystander effect,” in which unirradiated cells growing close to cells exposed to radiation from DU display genetic alteration supposed to be related to cancer induction.77 The alpha particles emitted by heavy metals such as DU are known to be a potent cause of bystander effects, which may be enhanced by combined radio-chemical exposure.78 These findings cast uncomfortable doubt on the claims of multiple organizations that the health effects of DU are negligible. In email correspondence from March 17, 2005, Baverstock wrote that both the International Commission on Radiological Protection (ICRP) and the International Atomic Energy Agency (IAEA) have S A LT Z M A N

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“considerable leverage over the WHO, not so much in a formal mandate sense but through interagency committees and personal contacts.”79 Both of these agencies reaffirmed in 2003 the “establishment”80 position that DU dust could be treated as a natural insoluble uranium oxide—meaning that permissible levels would be based on radiotoxicity rather than chemical toxicity. Yet Baverstock’s research suggests that the chemical toxicity of DU, especially as it interacts with the radiological properties, may be more important than previously assumed. Thus, it may have been more convenient for ICRP and IAEA that Baverstock’s paper was not formally published. He told the Sunday Herald in 2004, “I believe our study was censored and suppressed by the WHO because they didn’t like its conclusions. Previous experience suggests that WHO officials were bowing to pressure from the IAEA, whose remit is to promote nuclear power.”81 Baverstock reconfirmed through email correspondence that in the past, “The Geneva Office [of the WHO] has acted to my certain knowledge on the wishes of IAEA and against the best interests of public health.”82 This situation, then, may simply be one of many in which politics trumps human well-being. Whether WHO publication of the article was prevented by a bureaucratic “turf war”83 within the agency or by pressure, for political reasons, from the IAEA, its suppression has allowed continued—and largely un-criticized—use of DU by the United States and the United Kingdom during renewed conflict in Iraq. Some of the most immediate victims of censorship have been members of the U.S. Armed Forces. Despite the U.S. government’s longstanding knowledge that exposure to DU causes health problems, U.S. soldiers participating in military conflicts during the 1990s were never officially warned about the danger. UMRC’s Durakovic reported that during his service in Operation Desert Shield as a unit commander, “My expertise of internal contamination was never used because we were never informed of the intended use of DU prior to or during the war.”84 As a member of the Depleted Uranium Assessment team, Rokke was one of the few soldiers aware of his and others’ exposure. However, after his 1991 stint on the DU assessment team, he was ordered to restrict discussion of his knowledge of DU hazards to commanders and medical personnel.85 Under orders to stop informing commanders and troops about the hazards, Rokke was prohibited from helping U.S. soldiers take preventative measures to protect themselves, or deal with health consequences after exposure.86 It appears that such active perpetuation of veterans’ ignorance continued long after the end of the conflict. A comment by Senator Paul Wellstone, before his death in 2002, to Joyce Riley, the 64 |

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executive director of the American Gulf War Veterans Association, suggests continued secrecy of the type that Rokke describes.87 Wellstone informed Riley that 95 percent of Persian Gulf War veterans had been released from military service by 1995.88 Meanwhile, any Desert Storm veterans remaining in the U.S. military were isolated from each other in order to prevent information about DU from being transferred to new troops.89 Members of the U.S. Armed Forces, however, are not the only victims of DU exposure. Both military personnel and civilians of nations against whom the United States has used DU weapons suffer from a host of cancers and developmental problems. In 1990, the United Kingdom Atomic Energy Authority (UKAEA) released a report that predicted, “If 50 tonnes of residual DU dust remained [in Iraq] there could be half a million extra cancers by the end of the century.”90 The estimated amount of DU used during Persian Gulf War ranges from the Pentagon’s admitted 320 tons to estimates of other scientific bodies reaching as high as 900 tons.91 According to the UKAEA’s estimate, the projected number of cancer cases could reach as high as 9,000,000 from the Persian Gulf War alone.92 Since the renewal of conflict in 2003, human rights activists have mobilized against the usage of DU. Leuren Moret, an independent scientist and radiation specialist, has bluntly described U.S. use of DU against third world countries as “genocide.”93 Moret believes that the irreversible pollution of the landscape by a radioactive and chemically toxic substance will permanently damage the genetic makeup of the third world populations against which DU has been used.94 The United States has been further criticized by proponents of international law, who object to the use of weapons that target civilians as well as military personnel and have encouraged the United Nations to take a stand on DU. In 1996, a subcommission of the U.N. Human Rights Commission declared DU a weapon of mass destruction, concluding that its use violates the Geneva Convention on four counts: “the principle that there is no unlimited right to choose the means and methods of warfare,” “the ban on causing unnecessary suffering and superfluous injury,” “indiscriminate warfare,” and “the use of poison or poisoned weapons.”95 An international ban, however, has not been officially enacted. This is not the first time that munitions have been employed without sufficient knowledge as to their adverse health effects. During the 1960s and 70s, the Defense Department maintained that Agent Orange did not cause adverse health effects in humans long after it was proven that dioxin, a potent carcinogen, was a major contaminant of the herbicide.96 S A LT Z M A N

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As a result, eighty million liters of herbicides were spread across the landscape in South Vietnam between 1961 and 1971.97 People living in that region now suffer from cancers, nervous system damage, and other debilitating diseases comparable to the problems now experienced by populations that have been exposed to DU. This approach to military conflict should not be allowed to continue. The United States must act to protect the members of its Armed Forces, and to spare civilians of other nations from getting caught in the crossfire of international politics. At least until sufficient epidemiological studies have been conducted and evaluated by reputable interest groups that are not associated with the nuclear power industry, the U.S. Department of Defense, the U.K. Ministry of Defense, or military suppliers, the U.S. military should stop using DU. While there is still research to be done to establish the exact scientific relationship between DU exposure and adverse health effects, the wealth of research that points to DU as dangerous to human health should be enough to warrant a moratorium on military use of this radioactive and chemically toxic heavy metal. In March 2003, Rep. Jim McDermott (D-WA) introduced a bill in the House of Representatives entitled the Depleted Uranium Munitions Study Act of 2003 (H.R. 1483). McDermott’s bill proposed that a study be conducted by the Agency for Toxic Substances and Disease Registry (ATSDR) to establish the effects of exposure to DU on veterans and their children. The bill also called for a cleanup effort of contaminated sites in the United States. In May 2004, Rep. José Serrano (D-NY) introduced the Depleted Uranium Screening and Testing Act of 2004 (H.R. 4463), calling for identification and screening of exposed members of the U.S. Armed Forces. Until the kind of evaluation proposed in these two bills is undertaken and completed, a moratorium on the use of DU weapons must be enacted. It seems unlikely, however, that the federal government will take action in the near future as these bills continue to receive little attention. In the meantime, a secondary solution may be to combat the problem at the state level. Louisiana and Connecticut, which both recently passed laws providing for screening of veterans, are the only states thus far to aid veterans in dealing with DU exposure. Both laws, which go into effect October 1, 2005, require the adjutant generals of their respective states to assist members of the National Guard who served in the Persian Gulf War, Operation Enduring Freedom, or Operation Iraqi Freedom in obtaining federal treatment services.98 These services include a health screening test for DU exposure that uses a bioassay procedure able to detect DU at low levels.99 Although no state funds are to be used,100 the 66 |

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laws are designed to help veterans receive recognition and access to federal services. Furthermore, both laws call for research into the feasibility and cost of adding pre-deployment training for members of the Armed Forces concerning potential exposure to DU and other toxic substances,101 and Connecticut’s law calls for a task force dedicated to studying the health effects of exposure to DU and other hazardous substances in a military context.102 This united effort, equally supported by Democrats and Republicans in both Louisiana and Connecticut, should encourage officials in other states to take action on an issue that must remain free of partisanship. State legislatures should continue to pass laws that acknowledge the health problems of veterans and commit to training soldiers in the necessary precautions to avoid being exposed to DU in the first place. The legislative battle, however, cannot end here. The steps taken by the Connecticut and Louisiana legislatures are more concerned with evaluating the problems associated with DU than with directly improving the situation. Furthermore, state laws cannot protect civilians around the world that continue to be exposed to the hazards of DU munitions used by the U.S. military. State involvement is a good first step. However, until our federal government bans the use of DU munitions and make efforts to repair the damage caused by these weapons, the United States will continue to engage in conduct that both violates the Geneva Convention and places its own citizens at risk. 1. Rokke, D. “Depleted Uranium: Uses and Hazards” 2000. 2. Ibid. 3. U.S. Army Environmental Policy Institute. “Health and Environmental Consequences of Depleted Uranium Use by the U.S. Army” 1994. 4. Ibid. 5. Ibid. 6. Bollyn, C. “Depleted Uranium Released During Canadian Plane Crash.” American Free Press 22 October 2004. 7. Moret, L. “U.S. Nuclear Policy and Depleted Uranium” June 2003. 8. Flatow, I. “Health and environmental hazards posed by depleted uranium exposure.” NPR Science Friday 2003. 9. The Royal Society. “The health effects of depleted uranium munitions: Summary” 2002: 4. 10. Ibid. 11. Ibid. 12. World Health Organization. “Depleted uranium: sources, exposure and health effects: Executive summary” 2001: 2. 13. Murray, V. “Depleted Uranium: A New Battlefield Hazard.” The Lancet 360, no. 1 (2002): s31-s32.

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14. Ibid. 15. Ibid. 16. Ibid. 17. Bishop, D. “IDUST Report to Parliament on DU.” Letter to the Environmental Audit Committee. 2004. 18. Rokke. “Depleted Uranium: Uses and Hazards.” 19. Ibid. 20. Bishop. “IDUST Report to Parliament on DU.” 21. Murray. “Depleted Uranium: A New Battlefield Hazard.” 22. Ibid. 23. Ibid. 24. The Royal Society. “The health effects of depleted uranium munitions: Summary”: 3. 25. The Royal Society. “The health effects of depleted uranium munitions: Summary”: 4. 26. The Royal Society. “The health effects of depleted uranium munitions: Summary”: 5. 27. Ibid. 28. Ibid. 29. Murray, “Depleted Uranium: A New Battlefield Hazard.” 30. Ibid. 31. Busby, C. “Science on Trial.” Invited Presentation to the Royal Society, 19 July 2000. 32. Ibid. 33. Ibid. 34. Ibid. 35. U.S. Army Environmental Policy Institute. “Health and Environmental Consequences of Depleted Uranium Use By the U.S. Army.” 36. Bollyn, C. “Cancer Epidemic Caused by U.S. WMD.” American Free Press 13 August 2004. 37. U.S. Army Environmental Policy Institute. “Health and Environmental Consequences of Depleted Uranium Use By the U.S. Army.” 38. Ibid. 39. Ibid. 40. Rokke, D. “Address on Depleted Uranium.” True Democracy 2, no. 2 (2002). 41. Rokke. “Address on Depleted Uranium.” 42. Ibid. 43. Rokke. “Depleted Uranium: Uses and Hazards.” 44. Ibid. 45. Ibid. 46. Ibid. 47. Ibid. 48. Ibid. 49. Ibid. 50. Moret, L. “Depleted Uranium: Dirty bombs, dirty missiles, dirty bullets.” San Francisco Bay View 16 March 2005. 51. Ibid. 52. Ibid.

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53. Bollyn, C. “DU Syndrome Stricken Vets Denied Care.” American Free Press 20 August 2004. 54. Ibid. 55. Ibid. 56. Moret, L. “Depleted Uranium: The Trojan Horse of Nuclear War.” World Affairs—The Journal of International Affairs 8, no. 2 (2004). 57. Ibid. 58. Busby. “Science on Trial.” 59. Moret. “Depleted Uranium: Dirty bombs, dirty missiles, dirty bullets.” 60. Durakovic, A. “Undiagnosed Illnesses and Radioactive Warfare.”: 520. 61. Bollyn. “Cancer Epidemic Caused by U.S. WMD.” 62. Ibid. 63. Busby. “Science on Trial.” 64. www.umrc.net 65. Durakovic, A. “Undiagnosed Illnesses and Radioactive Warfare.” Croatian Medical Journal 44, no. 5 (2003): 527. 66. Ibid. 67. Ibid. 68. Durakovic. “Undiagnosed Illnesses and Radioactive Warfare”: 528. 69. Ibid. 70. Durakovic. “Undiagnosed Illnesses and Radioactive Warfare”: 526. 71. Ibid. 72. Bollyn. “DU Syndrome Stricken Vets Denied Care.” 73. Moret. “Depleted Uranium: The Trojan Horse of Nuclear War.” 74. Ibid. 75. Edwards, R. “WHO ‘suppressed’ scientific study into depleted uranium cancer fears in Iraq.” Sunday Herald. Scotland, 22 Februrary 2004. 76. Ibid. 77. Baverstock, K. “Radiological toxicity of DU.” 2001. 78. Ibid. 79. Keith Baverstock, Personal Correspondence, keith.baverstock@uku.fi, 17 March 2005. 80. Ibid. 81. Edwards. “WHO ‘suppressed’ scientific study into depleted uranium cancer fears in Iraq.” 82. Baverstock. Personal Correspondence. 83. Baverstock. Personal Correspondence. 84. Bollyn, C. “Depleted Uranium Blamed for Cancer Clusters Among Iraq War Vets.” WagingPeace.org. 15 August 2004. 85. Rokke. “Address on Depleted Uranium.” 86. Ibid. 87. Moret. “Depleted uranium: Dirty bombs, dirty missiles, dirty bullets.” 88. Ibid. 89. Ibid. 90. Moret. “Depleted Uranium: The Trojan Horse of Nuclear War.” 91. Ibid.

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92. Ibid. 93. Ibid. 94. Ibid. 95. Ibid. 96. Bishop. “IDUST Report to Parliament on DU.” 97. “Vietnam: ‘The Biggest Chemical War’ in History,” Truthout.org. 14 March 2004. 98. Connecticut House of Representatives. “File No. 840.” approved by the Legislative Commissioner 4 June 2005; Louisiana House of Representatives, “Act No. 69.” signed by the Governor 16 June 2005. 99. Ibid. 100. Ibid. 101. Ibid. 102. CT House of Representatives. “File No. 840.”

ABOUT

THE

AUTHOR

Rachel Saltzman is a rising sophomore at Yale. A prospective English major from Evansville, Indiana, Saltzman graduated cum laude from Choate Rosemary Hall in 2004. Her interests include social justice and environmental concerns as they relate to global policy. She hopes to combine her study of literature and the cultural politics imbedded in texts with her concern for environmental politics. After graduating from Yale, Saltzman plans to attend law school. For correspondence, please email Rachel Saltzman at [email protected].

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Current Research: International Development

Voices From Rural South Africa Married Women and AIDS Vulnerability: Moving Toward Female-Controlled Prevention Jenny Tolan South Africa, Africa’s wealthiest nation, faces one of the fastest growing rates of HIV/AIDS infection in the world. In the past fifteen years the nation has seen a huge jump in HIV prevalence, from one percent of the population in 1990 to 20 percent in 2001.1 In 2004 these figures reached over 26 percent, making South Africa the nation with the world’s highest rate of HIV/ AIDS infection.2 But HIV/AIDS does not affect all populations equally. As in most of sub-Saharan Africa, women in South Africa are 30 percent more likely to be HIV positive than men.3 Even more surprising, AIDS does not target all women consistently. Research has found that married women and women in long-term monogamous relationships run a greater risk of contracting HIV than non-married women.4 Because most cultures and policies encourage monogamy and commitment in the face of AIDS, these statistics are shocking. Why are women in South Africa, and particularly married women, more susceptible to HIV/AIDS than men? What conditions of South African marriage make women more vulnerable to the effects of this global pandemic? Married women in rural South Africa have specific vulnerabilities to HIV/AIDS as a result of three major factors: migrant TOLAN

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labor, lobola, and gendered economic inequality. These three factors lead to heightened AIDS vulnerability in two ways: they lower the agency of women and they increase sexual risk behavior. Women experience lowered agency in that they have virtually no ability to refuse sex or demand the use of condoms. They experience increased sexual risk behavior in that they have higher coital frequency, decreased condom use, and exposure to partners with higher rates of infection. Although women are also twice as biologically vulnerable to HIV as men, it is their lack of power and high-risk behavior that make them most vulnerable to HIV infection.5 The danger of this vulnerability lies not only in its impact on women, but also on the population at large as women pass the disease onto their children.6 Despite this danger, current AIDS prevention policies prove largely ineffective when applied to married women.a Effective policy must abandon current trends and put greater resources into female-controlled prevention, specifically, microbicide. Up to this point little research has focused specifically on married women and HIV/AIDS. But one study focusing on marriage and HIV risk was published in September of 2004 by Shelley Clark, an HIV/ AIDS researcher at the Irving B. Harris Graduate School of Public Policy Studies. The study looked at adolescent girls and concluded that married girls aged fifteen to nineteen were 75 percent more likely to be HIV-positive than sexually-active unmarried girls.b This statistic illustrates the urgent need for further research on married women and AIDS. In the summer of 2004, I spent eight weeks at the Masoyi Home Based Care Project in Mpumalanga, South Africa. The Masoyi tribal area is a rural district home to 220,000 black Africans, most of whom live in extreme poverty. The unemployment rate is nearly 75 percent, and approximately 32 percent of the adult population—an estimated 132,000 people—are HIV positive.7 During my stay, I interviewed ten women and two men who work with the Masoyi program. Each of my subjects was either married or in long-term relationships. Though the interviews did not reveal the HIV status of my subjects, the common themes that arose from their stories a This set of arguments is not exclusive to South Africa. South Africa as a nation shares many cultural and historical commonalities with neighboring countries, and the majority of my findings apply to regions throughout southern Africa. In this paper I look at some factors specific to South Africa as well as many broader topics that apply to married women across the region. b For a review of past research mentioning married women and HIV see: Clark, Shelley. “Early Marriage and HIV Risks in Sub-Saharan Africa.” Studies in Family Planning. 35(3) (Sept 2004): 150.

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expose this group’s particular vulnerabilities to HIV/AIDS and lead to a broader discussion of gender, marriage, and disease in South Africa.

T HE F ACTORS

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V ULNERABILITY

The system of migrant labor leads to high sexual risk behavior for women by increasing their exposure to partners with high rates of infection.8 The migrant labor system is a consequence of overwhelming unemployment in rural areas where men seeking jobs are forced to travel to the mines or cities. Jabulile, Orphan Coordinator of Masoyi Home Based Care Project, describes the situation: “My husband is working in Witbank, welding some broken things. He is working in a workshop. He has been there a long time––he got this job in 1987––when I got the first child. He comes home month end. He says he’s not enjoying working there, but because there is no work here, he is working there.” While men are away from home, it is common for them to have multiple sexual partners.9 This is a result of the conditions of their work as well as the cultural acceptance of male infidelity. Workers’ housing in the mining and urban industries is often unbearable. Men live in single-sex barracks, often 12 to 16 per room, with little space and no privacy.10 Studies show that men say they cannot stay celibate while separated from their wives for such long periods of time.11 Jabulile describes the norm of separation from her husband, “Since I was married to him––we didn’t stay together for a long time. He stay for three days and go––stay for three days and go. If there was work here for him to work every day and come home, he would stay. But there is none––and he’s not somebody who is educated so he can find any job.” The practice of male polygamy is also culturally accepted by most men and women in South Africa. In a 2003 study conducted by researchers Claudia C. Da Cruz and Bermudes Ribeiro about HIV and condom use in South Africa, the male participants described having multiple partners as acceptable and even desirable.12 Of the subjects interviewed, 59 percent of males had more than one sexual partner, and 22 percent had three or more sexual partners.13 Most of my subjects were aware of this risk. As Jabulile said, “About sickness––I’m worried about that. Because I know my husband––he is not someone who is faithful. Ah, I’m really worried.” Migrant men can be sexually involved with women at work in several ways: engagement with prostitutes, short-term casual relationships, and long-term relationships with “second wives.”14 The greatest risk comes with prostitution. Commercial TOLAN

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sex industries are rampant in mining and industrial areas. As John C. Caldwell, John K. Anarfi, and Pat Caldwell put it in a 1997 paper relating migration to risk of HIV/AIDS, “[in] most of Africa it is rural migrants to the city who are most likely to be found in the slum and shanty town bars where the commercial sex workers are more likely to have uncured STDs and are probably more likely to have many different customers and be HIV positive.”15 The culture of poverty and prostitution leads men to high exposure to STDs and HIV. In 1993 it was already estimated that nearly half of the mineworkers returning to rural areas after work were infecting their wives and other women.16 Since then, AIDS rates in South Africa have skyrocketed, and so have the levels of infection of migrant workers. According to Caldwell et al., “With the exception of [mother to child and infected blood transmission,] the HIV levels in rural areas may be almost entirely the result of persistent reinfection brought back from the towns by returning migrants.”17 Because migrant workers generate income, they are more likely to be able to afford brides and are therefore more likely to be married.18 Lobola, the custom of paying a bride’s family in exchange for marriage is a lingering element of traditional patriarchy, and further exacerbates vulnerability of HIV/AIDS among married women. Lobola, or “bride price,” is a tradition that dates back to the founding of the Zulu nation. In the past century, however, it has shifted from traditional symbolism to a commercial practice often paid in cash.19 As the marriage transaction has grown more commercial, the woman has become more like the property of the man.20 Today, the payment of lobola is extremely widespread. Likhapha Mbatha, of the Gender Research Project at the Centre for Applied Legal Studies (CALS), University of Witwatersrand, studied women in three South African provinces and found that bride price had been paid for 98 percent of the wives.21 The tradition of lobola lowers female agency by creating a sense of male ownership that leaves the wife subject to her husband’s demands. Author Uli von Kapff writes: “No wife will dare to oppose her husband as she would be sent home, and her father would have to return most of the cattle.”22 Though divorce is accepted in South Africa today, a woman is responsible for repayment of the lobola to her ex-husband. Repayment is nearly impossible in poor areas; oftentimes, the woman’s family has already eaten the lobola.23 Lobola gives the husband full rights over his wife’s productive and reproductive capabilities.24 According to Barbara Klugman, director of the Women’s Health Project at the University of Witwatersrand, “[if ] a 74 |

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husband initiates sex, his wife may not refuse him.”25 This standard also applies to condom use. According to customs of traditional marriage, a woman may not use contraceptives without the consent of her husband.26 Unfortunately, studies have shown that women have a greater desire for condom use than their male counterparts.27 For men in South Africa, a deep stigma surrounds the use of condoms. One subject in Da Cruz and Ribeiro’s study stated: “My boyfriend says using a condom is like eating a sweet with the wrapper on it.”28 Because husbands do not like to use condoms, the women are forced to comply. Jabulile said: At one time I didn’t want my husband to come to me without a condom. In that moment he saw that I was cross, so he accept the condom––he accept it. But as time goes on he say, “I’m tired. I’m tired––I’ve paid lobola for you––you’re my wife.” And––there was a fight. In the end––he wins the fight. We don’t use the condom. At the moment––I’m just afraid––I don’t know my status. As Jabulile’s story illustrates, lobola can reaffirm male sexual dominance and deny women the right to request condoms. A shocking study from Zambia found that only 11 percent of women believed they had the right to ask their husbands to use a condom—even if he had proven himself to be unfaithful and was HIV-positive.29 In addition to lowering a woman’s agency, lobola also contributes to HIV risk by increasing the sexual risk behavior of women. The first example of this is higher coital frequency. A study in Kenya and Zambia found that married girls have unprotected sex much more often and have been engaged in sexual activity for a longer period of their lives than have unmarried girls.30 Considering that many partners are HIV positive, the mere reality of coital frequency is a sexual risk behavior. A second instance of sexual risk behavior involves condom use. HIV/AIDS researcher Agathe Latre-Gato Lawson writes: “In rural communities social control, particularly over the sexual behavior of women, is strong because women are regarded as childbearers, whose duty it is to perpetuate the lineage of the husband’s family.”31 With this high emphasis placed on producing children, Brooke Grundfest Schoepf writes: “[couples] that have not reached their desired family size will reject condoms, even when one spouse is HIV positive.”32 This reality compounds the HIV risk for married women. A final factor of sexual risk behavior stemming from lobola is the tendency for women to be ‘bought’ and married by men who are significantly older and therefore able to pay. At least two studies have shown TOLAN

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that the age of a woman’s partner is a major risk factor, and that having an older partner substantially raises HIV rates among adolescent girls.33 Despite the connections between lobola, gender inequality, and AIDS, a contrasting viewpoint argues that lobola can actually benefit women. Thanduxolo, a 13-year-old Masoyi girl, told me in an interview that she did not like men having ownership over their wives. When I asked her why the community did not end the practice of lobola, however, her response was strong: “We cannot get rid of lobola! If there was no lobola, men could just go from wife to wife. Once the man pays lobola he has given his money so he will stay with that wife. He has paid for her, so he must stay. Without lobola, men would never stay with one wife. They could just go.” In this way, the tradition of lobola may actually give women some social power. Von Kapff writes: “The more cattle paid, the better the marriage seems to work in the long-term, as the bridegroom frequently has to save over several years for the lobola and therefore chooses his bride carefully.”34 For these reasons, many South African women want to keep the custom alive. The paradox created by lobola creates an extremely difficult situation. A policy solution would have to confront the gendered norms while somehow preserving the positive components of lobola that are part of African cultural tradition. The final way that married women are at high risk is through their economic dependence on men. Rural African women form the majority of the poorest of the poor in South Africa with an average income of between 400 and 700 rand [$64 to $112] per month.35 In an area like Masoyi, where the majority of those employed are migrant workers, women are unlikely to find employment. The mining industry, for example, employs 97 percent men and only 3 percent women.36 Furthermore, while men are away for long periods of time, it is the woman’s duty to stay at home to care for the family. Busisiwe, a preschool teacher and Masoyi Home Based Care volunteer, speaks of her lack of money and subsequent reliance on her husband: “I need money. I want enough money to send my children to school. I get 280 rand [$45] for volunteering. My husband he is working at Kinrose mine. Do you know this mine? It is a gold mine. I think he is getting 1000 rand [$160] a month.” This economic reality leaves women little agency to stand up to men in fear of losing financial support. Catherine Albertyn, Director of CALS, writes: “The prevalence of women seeking sexual relationships to ensure food and shelter for themselves and their families is a widespread consequence of gendered poverty and inequality in South 76 |

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Africa.”37 This situation is common for the women of Masoyi. Mumsy, a childcare worker for Masoyi Home Based Care Project, said: In my family I was suffering. My husband—he was at Joburg since March—not coming back. No money to give me to buy some food. So my children are suffering. My husband is working at Kinrose mine. Since 1988 until today—it’s a long time. He is making good money there, but he gives me little money. He is getting 1200 or 1300 rand [approximately $210] and he is giving me 400 rand [approximately $66]—is a little money—to buy some food. Mumsy’s words present a classic case of a migrant husband who refuses to give his wife a fair share of income. If Mumsy’s husband does not want to use condoms, she has little power to demand otherwise. She said: “My husband doesn’t like the condom. He doesn’t like! So I’m scared about this. I advise him long time, but he say condom is a plastic. He doesn’t like, he doesn’t use. I say use a condom, he say no. I don’t know what I can do.” Ezekiel Kalipeni, Susan Craddock, and Jayati Ghosh confirm that “[women] are not always in the economic position to say no to partners who will not assent to using condoms.”38 This is true regardless of women’s knowledge of HIV risk. The women of Masoyi were all aware of the risk of AIDS, but they were more concerned with the immediate necessity of feeding their children. The most common question surrounding married women and AIDS was the following: “If it’s a choice between leaving a man to lower the risk of AIDS and putting food on the table for your children, what would you choose?”39 The answer for most women was simple: stay with your husband, accept his demands, and pray you do not fall victim to AIDS.

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In view of the conditions facing women in South Africa, the current policies addressing HIV/AIDS prevention prove widely ineffective for married women. Dominant global strategies emphasize increased education with messages to abstain from sex, stay faithful, or use condoms.40 For married women, all of these methods are impractical or fall beyond their control. Today’s high relative AIDS rates for married women may in fact be a sign that prevention methods have been effective for single women. To target the larger population of married TOLAN

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women, however, an innovative solution must bypass the control of the husband and give the woman agency. The most promising prospect for female-controlled prevention is the use of microbicide.41

C URRENT P OLICY S HORTCOMINGS With some variation, prevention programs across southern Africa have focused on educational outreach and increased condom availability.42 Kalipeni et al. write: “These strategies, while constituting a necessary first step in AIDS prevention, have proven to be of limited value in diminishing transmission of HIV in most regions.”43 Education and greater awareness do not necessarily equal the ability to change risk behaviors. This certainly holds true for married women. Though the women I interviewed had a great knowledge of AIDS from their work in home-based care, they were unable to change the risk behaviors in their marriages. Kalipeni et al. discuss a National Research Council study that found that “[knowledge] of AIDS and its transmission routes is rarely a predictor of less risky behavior.”44 This is also true for men. The husbands of the women I interviewed received HIV/AIDS education at their jobs, but did not choose to change their behavior. The issue, then, does not come from a lack of knowledge, but from cultural standards that override that knowledge. The method of condom distribution has also proven ineffective for married women. As of 1995, 98 million condoms had been distributed nationally to all the provinces in South Africa.45 Still, married women have little ability to demand the use of condoms from their husbands. Norms of male dominance and stigma surrounding condoms are more powerful than condom availability or education to prevent HIV/AIDS. A policy that seemed successful in Uganda and that has been adopted by the United States for the Bush Administration’s global AIDS effort is called the “ABC Strategy.”46 ABC stands for “Abstain, Be Faithful, Condomize,” and, in that order, the mantra dictates policy for a majority of AIDS projects. Unfortunately, this policy collapses with respect to married women. Married women do not have the choice to abstain from sex, they can be faithful but cannot control their husbands’ behavior, and they cannot demand condoms. Dr. Kathleen Cravero, deputy director of UNAIDS, believes the ABC method is a good start, but realizes it is not enough, “We tell women to be faithful to their partners, but we know that their partners are unfaithful to them,” she 78 |

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said at a conference at the Woodrow Wilson International Center for Scholars on November 10, 2004. “We tell women to use condoms, but we know that their partners will refuse. If we are going to help protect women, and help them protect themselves, we have to acknowledge the realities in which they live.”47 The realities for married women are especially binding. While single women have some potential to abstain from sex or demand condoms—to employ the education available to them—married women do not have these options. Because gender norms will not change rapidly, the best current strategy to decrease women’s HIV risk is female-controlled prevention.48

T HE M ICROBICIDE The most promising method of female-controlled prevention currently under development is microbicide. A microbicide is a spermicide-like gel that women can apply before intercourse to protect against HIV and other STDs.49 This method could revolutionize a woman’s agency over her HIV risk because she could use the gel without consulting her partner.50 Today there are approximately 60 candidate microbicides under development, but none has reached the market.51 This is due to a severe lack of resources devoted to microbicide research and development. Small biopharmaceutical companies, nonprofit organizations, and smaller public companies are the only groups currently investigating microbicide products.52 Large pharmaceutical and biotech companies have not sponsored microbicides because a first generation product may not be highly profitable. In the short-term, microbicide funding must therefore come from governments and philanthropic donors of the public sector.53 The U.S. government currently invests approximately $88.8 million a year in microbicide research.54 The Rockefeller Foundation estimates that roughly $775 million over five years is needed to guarantee a successful product by 2010.55 The three federal agencies with significant research and development for microbicides are the U.S. Agency for International Development (USAID), the Center for Disease Control (CDC), and the National Institute of Health (NIH).56 Though spending on microbicides in all three agencies has increased in the past five years, it is still less than two percent of total AIDS spending.57 There is also a problem of coordination between the agencies, as no official mechanism exists to regulate overall microbicide research and development. TOLAN

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Certain policy makers have made a bold effort towards microbicide legislation. In 2001, Representative Connie A. Morella (R-MD) and Senator Jon S. Corzine (D-NJ) introduced the first Microbicide Development Acts to Congress.58 On March 8, 2005, Corzine, joined by Senator Barack Obama (D-IL), Senator Olympia Snowe (R-ME), and others introduced a revised version of the earlier legislation (S. 550). The bill, which currently has 19 cosponsors, was referred to the Senate Committee on Health, Education, Labor and Pensions, but no further action has occurred.59 The Microbicide Development Act would expand investments for microbicide research at NIH, CDC, and USAID; expedite the implementation of the NIH’s five-year strategic plan for microbicide research; and expand coordination among the three federal agencies.60 The legislation would also establish a Microbicide Research and Development Branch within the National Institute of Allergy and Infectious Diseases that would be essential to providing appropriate staff and funding for microbicide development.61 Today the general public is largely unaware of the existing research on microbicides and the potential they have for HIV prevention.62 People must become familiar with microbicides so they can pressure the government to pass this legislation. A final challenge to the success of the microbicide is effective distribution. If microbicides are to reach the most vulnerable women, they must be widely available, affordable, user friendly, and culturally accepted.63 The Rockefeller Foundation funded a report entitled “Preparing for Microbicide Access and Use,” which outlined specific priorities such as investment focused on distribution and access; as well as research and development; an international working group to specify policy, legal, fiscal, and monetary measures needed for accessibility; and pilot initiatives between three and five countries to establish a framework for “microbicides preparedness.”64 Resources must be devoted to a plan for microbicide distribution as well as scientific development. Despite the obstacles, the potential of a successful microbicide is tremendous. Conservative estimates suggest that the introduction of even a partially effective microbicide could result in 2.5 million averted cases of HIV over three years.65 Further, the estimated cost savings to governments of developing countries from the introduction of a microbicide are $3.7 billion.66 The microbicide is the single most promising strategy to combat the gender inequity of AIDS. To assure women’s empowerment in the fight against HIV/AIDS, microbicides must be put on the global agenda. 80 |

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1. UNAIDS / UNICEF / USAIDS Report. Children on the Brink 2002: A Joint Report on Orphan Estimates and Program Strategies. July 2002. 2. Avert.org Adverting HIV & AIDS http://www.avert.org/safricastats.htm 3. UNAIDS 2004 Report section on “The Impact of AIDS on People and Societies.” http://www.fightglobalaids.org/files/phatfile/New%20AIDS%20Statistics%20from %20UNAIDS.doc 4. International Women’s Health Coalition. Women and HIV/AIDS Fact Sheet. http:// www.iwhc.org/resources/hivaidsfactsheet.cfm 5. Albertyn, C. “Contesting Democracy: HIV/AIDS and the Achievement of Gender Equality in South Africa.” Feminist Studies 29(3) (Fall 2003), 597. (Women are said to be two times more likely than men to contract HIV from a single act of unprotected sex.) 6. Lawson, A. “Women and AIDS in Africa: sociocultural dimensions of the HIV/AIDS epidemic.” UNESCO, Blackwell Publishers, Oxford and MA, 1999. 393. 7. Masoyi HBC. History of the Organization. www.masoyi.org 8. Sexual Cultures and Migration in the Era of AIDS: Anthropological and Demographic Perspectives. Ed. Gilbert Herdt. Oxford: Clarendon Press, 1997. 48. 9. Caldwell, J; Anarfi, J; Caldwell, P. “Mobility, Migration, Sex, STDs, and AIDS: An Essay on Sub-Saharan Africa with Other Parallels.” Sexual Cultures and Migration in the Era of AIDS: Anthropological and Demographic Perspectives. Ed. Gilbert Herdt. Oxford: Clarendon Press, 1997. 44. 10. Campbell, C. “Migrancy, Masculine Identities, and AIDS: The Psychosocial Context of HIV Transmission on the South African Gold Mines.” HIV and AIDS in Africa: Beyond Epidemiology. Eds. Kalipeni, Ezekiel, Susan Craddock, Joseph R. Oppong, and Jayati Ghosh. Malden, MA: Blackwell Publishing, 2004. 144. 11. Jochelson, K; Mothibeli, M; Leger, J.P. “Human Immunodeficiency Virus and Migrant Labor in South Africa.” International Journal of Health Services, 21(1) (1991): 164. 12. Da Cruz, C; Ribiero, B. “From Policy to Practice: the Anthropology of Condom Use.” AIDS and South Africa: The Social Expression of a Pandemic. Eds. Kyle D. Kauffman and David L. Lindauer. New York: Palgrave Macmillan Ltd, 2004. 153. 13. Ibid, 152. 14. Jochelson et al., op. cit, 165. 15. Caldwell et al., op. cit, 45. 16. Kalipeni E; Craddock, S; Ghosh, J. “Mapping the AIDS Pandemic in Eastern and Southern Africa: A Critical Overview.” HIV and AIDS in Africa: Beyond Epidemiology. Eds. Kalipeni, Ezekiel, Susan Craddock, Joseph R. Oppong, and Jayati Ghosh. Malden, MA: Blackwell Publishing, 2004. 60. 17. Caldwell et al., op. cit, 48. My emphasis. 18. Lobola: Its implications for women’s reproductive rights. Harare, Zimbabwe; Women and Law in Southern Africa Research Trust: Weaver Press [distributor], 2002. 19. Ibid, 12. 20. Ibid, 28.

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21. “South African Wimmin.” The Economist, 341(1986) (5 Oct. 1996): 79. 22. Von Kapff, U. Zulu: “People of Heaven.” South Africa: Holiday Africa Publications, 1997. 37. 23. Discussion with Thanduxolo, home of Florence, August 2004. 24. Women and law in Southern Africa Research Trust, op. cit, 25. 25. Klugman, B. “Sexual Rights in Southern Africa: A Beijing Discourse or a Strategic Necessity?” Health and Human Rights 4(2) (2000). 26. Women and law in Southern Africa Research Trust, op. cit, 40. 27. Da Cruz, op. cit, 157. 28. Ibid, 139. 29. UNAIDS 2004 Report on “Women and AIDS.” http://www.unaids.org/wad2004/ EPIupdate2004_html_en/Epi04_04_en.htm#P28_3962 30. Clark, op. cit, 154. 31. Lawson, op. cit, 394. 32. Schoepf, B. “AIDS in Africa: Structure, Agency, and Risk.” HIV and AIDS in Africa: Beyond Epidemiology. Eds. Kalipeni, Ezekiel, Susan Craddock, Joseph R. Oppong, and Jayati Ghosh. Malden, MA: Blackwell Publishing, 2004. 127. 33. Gregson, S;Nyamukapa, C; Garnett, G; Mason, P; Zhuwau, T; Carael, M; Chandiwana, S; Anderson, R. “Sexual mixing patterns and sex differentials in teenage exposure to HIV infection in rural Zimbabwe.” Lancet 359(9,321) (2002): 903. Kelly, R; Gray, R; Sewankambo, N; Serwadda, D; Wabwire-Mangen, F; Lutalo, T; Wawer, M. “Age differences in sexual partners and risk of HIV-1 infection in rural Uganda.” Journal of Acquired Immune Deficiency Syndromes 32(4) (2003): 446-451. 34. Von Kapff, op. cit, 37. 35. Maharaj, Z. “Gender Inequality and the Economy: Empowering Women in the new South Africa.” Keynote speech at Professional Women’s League of KwaZuluNatal, 9 Aug. 1999. www.africaaction.org/docs99/gen9908.htm 36. Moleke, P. “The state of the labor market in contemporary South Africa.” State of the Nation: South Africa 2003-2004. Eds. John Daniel, Adam Habib and Roger Southall. Cape Town, South Africa: Human Sciences Research Council, 2003. 37. Albertyn, op. cit, 598. 38. Kalipeni et al., op. cit, 65. 39. Participant Observation, Masoyi area, August 2004. 40. UNAIDS 2004 Report on “Women and AIDS” op. cit. 41. Lawson, op. cit, 399. 42. Kalipeni et al., op. cit, 65. 43. Ibid. 44. Ibid, 66. 45. Da Cruz, op. cit, 136. 46. Loconte, J. “The White House Initiative to Combat AIDS: Learning from Uganda.” September 29, 2003. The Heritage Foundation. http://www.heritage.org/Research/ Africa/BG1692.cfm 47. Harter, E. “Women’s Vulnerability to AIDS Key Element in UNAIDS Agenda.” Washington DC. Allafrica.com/stories/200411160799.html 48. Lawson, op. cit, 399.

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49. “Microbicides, Women and AIDS.” UNAIDS The Global Coalition on Women and AIDS. www.unaids.org/html/pub/una-docs/GCWA_Microbicides_02Feb04_en_pdf/GCW... 50. Lawson, op. cit, 399. 51. “About Microbicides.” MAS: Microbicides As an Alternative Solution. http://www. mas-health.org/microbicides.htm 52. The Body – The Complete HIV/AIDS Resource http://www.thebody.com/aac/brochures/microbicides.html 53. Global Campaign for Microbicides http://www.global-campaign.org/about_microbicides.htm 54. Senator Corzine, J. “Microbicide Development Act Introductory Statement.” 8 March 2005. www.amsa.org/legislativecenter/MDA109testimony.doc 55. “Microbicides, Women and AIDS.” Op. cit. 56. Alliance for Microbicide Development http://www.microbicide.org/microbicideinfo/legislation.shtml 57. Ibid. 58. Office of Legislative Policy and Analysis: Linking the National Institutes of Health and Congress http://olpa.od.nih.gov/legislation/109/pendinglegislation/microbicide.asp 59. Ibid. 60. Senator Corzine, op. cit. 61. Ibid. 62. The Body, op. cit. 63. “Preparing for Microbicide Access and Use” A Report by the Access Working Group of the Microbicide Initiative funded by the Rockefeller Foundation. http://www. microbicide.org/microbicideinfo/rockefeller/access.and.use.rockfound.pdf 64. Ibid. 66. International Partnership for Microbicides. http://www.ipm-microbicides.org/about_microbicides.cfm 67. Ibid.

A BOUT

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A UTHOR

Jenny Tolan graduated from Stanford in June 2005 with a B.A. in International Relations and a minor in Spanish. Her academic interests include African and Latin American Studies, human rights, and international development. While at Stanford, Tolan was the founder of Bursting the Bubble, a group that hosts current events discussion panels for students living in the “Stanford bubble”; a coordinator of Ravenswood Reads, a tutoring and mentoring program for youth in East Palo Alto; and co-president of Students for Kerry. Tolan spent her junior fall studying abroad in Spain at the University of Sevilla. Tolan is TOLAN

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currently working at Partners for Democratic Change, an international organization committed to building sustainable local capacity and a culture of conflict management worldwide. For correspondence, please email Jenny Tolan at [email protected].

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Current Research: International Development

Globalization and Education: A Case Study in Papua New Guinea Hammad Ahmed Many new sites of corporate growth and economic development have emerged as a result of political and economic restructuring under globalization. Such sites are marked by inflows of knowledge and capital from the developed world, and by changes to infrastructure and institutions, especially educational systems. Proponents of traditional economic development models often cite these institutional changes as evidence of a new world in which capitalism brings prosperity, a world in which multinational corporations lead the charge to modernize undeveloped sectors of the globe. In reality, the entry of multinational corporations and extractive industries has different consequences in different countries. Scholarship has increasingly monitored the effects of globalization on the developing world; and education, as an intersection of cultural, economic, and political change, is an apt lens through which to examine these effects. Globalization’s influence on education in Papua New Guinea makes that country an ideal case study. Papua and New Guinea— formerly colonies under the successive rule of the Netherlands, Germany, England, and Australia—achieved independence in 1975, merging into modern Papua New Guinea.1 Since achieving independence, the state has depended on aid grants from Australia. The geographic characteristics of Papua New Guinea deterred developers throughout the early part of the 20th century, but the discovery of substantial copper and gold in 1968 made multinational corporations eager to begin operations AHMED

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in the country.2 Ever since, the development of infrastructure in Papua New Guinea—including education—has increasingly been driven by these multinational corporations. In this proposal, I will broadly chart the course of scholastic education in Papua New Guinea from the earliest colonial systems to contemporary models. Beginning with history, I will examine various colonial rationales for education. I will then discuss contemporary curricula, focusing on the political privileging of certain knowledge, linking education in Papua New Guinea to larger forces of corporate economic growth, and making a preliminary inquiry into the social and ecological consequences of an educational system that is subservient to globalization. I conclude by recommending that policymakers scrutinize the purpose, implementation and effects of education in postcolonial settings, and strive to reinvigorate existing systems by fostering healthy political and intellectual communities. Ultimately, our government should encourage multinational corporations to abdicate the political agency they are given under globalization, and pressure them to genuinely empower natives of developing countries to control their own educational and economic fates.

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In many ways, colonialism and missionary work were the antecedents of contemporary economic development. Under globalization, however, the actors have changed from imperial and religious powers to global corporations. One important difference drawn between cultural imperialism and globalization is that the latter lacks a center or stateoriented character.3 But both contemporary and colonial educational systems ultimately serve a global economy. A more careful look at the first globalized educational institutions in Papua New Guinea—colonial systems, that is—will clarify just how “modern” the modern versions are. At the end of the 19th century, missionaries increased activity in Papua New Guinea and began operating the country’s first schools. All the schools were religious in nature; instructors hoped to civilize the natives through Christianity.4 A major emphasis was put on literacy, in order to put the Gospel in the hands of the people. The missionaries’ religious goals were not shared by most of the indigenous population.5 By the early 1900s, both colonial administrators and the indigenous population began to realize the usefulness of education as a form of 86 |

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power. Some enthusiasts of German colonialism argued that educating the natives was necessary to make them good assistants and laborers, which would allow colonists to better exploit indigenous labor.6 Other colonialists maintained that the natives must become industrious and could, through education, become self-sufficient. Such were the motives behind the policies of Sir J.H.P. Murray, a colonial administrator for 35 years beginning in 1908 who preached the merits of “habits of industry.”7 Murray suggested that by working for white settlers, black natives would become stronger and better equipped to help their own villages. For the natives of Papua and New Guinea, education began to be seen as a way of acquiring some of the material goods that colonizers brought with them.8 The schools were seen as an access point to the colonizers’ power, because manual labor and theft had proven not to be particularly effective. In the 1960s, transitions from colonial occupation to postcolonial independence saw the entry of multinational corporations. This coincided with the reform of education to orient natives for careers in public service and government and the subsequent stratification of native society. At the same time, community-based education started taking its place as the model of choice.9 Education in Papua New Guinea has served shifting functions, including “civilizing” native people, creating more productive laborers, transitioning to agricultural self-sufficiency, and strengthening community. But, throughout all this, education has predominantly been a vehicle for natives to get jobs. With the increase in the number of secular schools relative to mission schools, villagers acknowledged the potential usefulness of education—the “true knowledge” that would bring them the high status jobs and way of life of Europeans.10 This view of education is decidedly optimistic, and some have even compared it to a “cargo cult” in which the mere imitation of the colonizer brings the material riches of his kind.11 Attitudes like this one, though perhaps naïve, persist today, suggesting that colonial legacies are still a strong force in Papua New Guinea’s globalized educational system.

C URRICULUM D ESIGN Though the education of Papua New Guinea islanders is widely cited as a prerequisite to economic development, the content of this education is highly contested. In many ways, debates over the composition of school curricula represent one front where the larger debate over AHMED

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economic opportunity and capitalism is staged. Because any school curriculum will necessarily teach some things and omit others, we must ask what knowledge is privileged,12 and whether these choices reflect the forces of globalization. A common criticism leveled against postcolonial educational systems cites the “irrelevance” of teaching material—for example, teaching algebra to someone who will most likely be involved in local agriculture as an adult. Despite this alleged irrelevance, many parents and children in Papua New Guinea prize this technical education as a primary route to employment and social mobility.13 In fact, schools with rural-biased syllabi, such as Vunamami in 1959, incite the disapproval of parents. Agriculture, they argue, is something necessarily learned at home and in the village, while education is something they still have not received.14 These complaints evince the different understandings of the purpose of education among developers and locals, but they also point to the disparity between job aspirations and job realities perpetuated by globalization. As more villagers receive education—as the pool of potential employees becomes more skilled—employers raise their standards for hiring. If the primary goal of education in developing countries is to provide natives with “good” jobs, then competitive labor markets controlled by foreigners work against that goal, attracting laborers who would otherwise be working in industries like agriculture with the mirage of the colonizers’ wealth. Thus, debates over the relevance of school curricula reflect the difficulty of implementing a rural-based curriculum while the society offers higher rewards in the urban, non-agricultural sector.15 While recognizing that debates over curricula often point to problems beyond the teaching material, it is important to look at what is being taught. Curricula differ from school to school, but one widespread model is the Primary and Secondary Teacher Education Project (PASTEP), cosponsored by Papua New Guinea Department of Education, Australian Agency for International Aid, and GRM International (a resource and development management company based in Brisbane).16 PASTEP, a product of global collaboration, consists of modules which represent “appropriate” subjects for village students: Agriculture and Resource Science, Community Development, Expressive Arts, Gender Equity, Health, Information Communication Technology, Language Development, Mathematics, Professional Studies, Science, Social Science, Special Education, Spiritual and Moral Education, Technology, and Vernacular to English Transition Strategies 88 |

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Training.17 Even at a quick glance, this list embodies all of the aforementioned tensions between rural relevance and global demand. What is more interesting is the content of some of the modules themselves. The module on Spiritual and Moral Education, for example, is a cosmopolitan caricature of the “shrinking world.” Though a small portion is devoted to indigenous religions of Papua New Guinea, most of the chapter is an outline of other world religions such as Islam, Hinduism, and Christianity.18 This sort of multiculturalism appears more and more often in texts produced in contemporary globalized systems.19 Such multicultural syllabi deploy a narrow and essentialist discourse in which particular groups are described in terms of their nationalist histories, their unique knowledge, and their key figures. Hidden from view are highly unequal political economies and the oppression of subaltern groups and their practices. In such a flattened world, resentment pops up among students working through representations with which they do not identify.20 Both perceptions of cultural death and surges of fierce nationalism become more likely,21 but one can expect nothing less from such a narrow model of education. With globalization, economic considerations and political identities have turned school syllabi into arenas in which sweeping cultural battles are waged. As the economic and political ties of the world have changed, so too have the demographics of the educated in Papua New Guinea. Whether individuals obtain the results they expected when they began schooling depends as much on the curricula as it does on the structures of economic globalization.

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Though we sometimes talk of globalization as a set of changes in a broad structure, emphasis must certainly be placed on the agents that act upon and within that structure. This is where multinational corporations and foreign capital investors enter the discussion. Because Papua New Guinea possesses incredible mineral and natural resources, it is home to a large number of multinational corporations and other publicly owned extractive industries. Finding a complete list of these groups is nearly impossible, so I limited my research to three specific groups: Freeport-McMoRan, Ok Tedi Mining, and Lihir Gold. Other multinationals in Papua New Guinea certainly do exist, but their activities are less visible. These companies see themselves as “community partners” and the AHMED

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bringers of development, but they sometimes bring development in overtly imperialist ways.a 22 Statistics on their corporate websites boast their employment figures, donations, and local involvement. These statistics are classically misleading. For example, Lihir Gold cites the percentage of its employees who are natives of Papua New Guinea (53 percent) without stating the absolute number, what sorts of positions they hold, or what percentage of the local population works for the company.23 And though the companies trumpet their donations to the government to increase educational spending, little mention is made of the huge sums donated by international investors and export credit agencies to the companies themselves. Lihir received a $250 million (USD) guarantee of commercial bank finance from Australian Export Finance Insurance Corporation (interestingly, the U.S. Overseas Private Investment Corporation turned down the project on environmental grounds).24 A $2.8 million corporate charitable donation by Lihir in 2004 pales in comparison.25 These are all signs that the relationship between the corporations and the people is a distorted one. In many ways, multinational corporations obscure their tracks by publicizing their charitable activities, while failing to acknowledge that their presence owes much to the prior history of marginalization during the colonial period. At times, companies even do violence to the historical record. For instance, the Ok Tedi website claims that “Prior to...1968, people lived off the land as they had for centuries...with virtually no contact with the outside world.”26 The absolute erasure of seventy years of colonial domination is stark evidence that the corporations operate in a world of their own construction—a world in which primitive, undeveloped, untouched people desperately desire the coming of modernity. Corporations, as powerful agents of globalization, have wide-ranging effects on the economy, just as colonial powers did before them. These effects include a spike in the demand for educated labor, and therefore a demand for institutions of education. It should come as no surprise that secondary schools always appear on the map alongside the operations of multinational corporations.b But when these schools do appear, an increase in the number of educated indigenous people does not necessarily translate to a higher proportion with jobs in the a Moffett J.B., CEO claimed that Freeport would “thrust a spear of economic development into the heart of Irian Jaya.” b See the websites of the three multinational corporations (http://www.fcx.com; http://www. oktedi.com; http://lihir.com.pg).

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company. Instead, we find more competition for scarce jobs. Education may bring some workers a higher income—but when the operations close, the jobs will likely disappear. Ok Tedi will cease operations in Papua New Guinea in 2012.27 What will be the value of education then?

S OCIO -E COLOGICAL C ONSEQUENCES Because education built around global corporate presence severely destabilizes the labor market, it also has an array of social and environmental consequences. Though Papua New Guineans may see education as the road to a higher standard of living, this view takes for granted many existing inequalities and barriers. Given that corporations like Freeport-McMoRan provide comparatively high salaries to the narrow set of local people whom they employ, there is strong incentive for individuals to acquire an education that prepares them to work for companies like Freeport-McMoRan. But many of these graduates are simply not hired and are forced to choose between going back to the village, where they will work off the debt they owe to the financiers of their education (typically parents and family members), or staying in the urban centers and finding other means of employment and survival. Herein lies one of the major sources of urban slums.28 Graduates who are hired enjoy positions of community leadership and a modern lifestyle,29 creating a sense of “deserved privilege” that exacerbates social tensions and centralizes wealth. The presence of global corporations enables this situation. Inequalities between rural and urban sectors have environmental consequences as well. When a sizeable portion of students migrates to the city, the agricultural work is left to fewer people. This decrease in labor can increase the dependence of those left behind on farming technology like pesticide and fertilizer. Fields may be planted with less diverse and simpler crops, which exhaust the soil,30 and falling rural incomes may contribute to a desperate environmental degradation. Furthermore, the often overlooked field of political ecology has demonstrated that as much as poverty, affluence is a source of environmental destruction.31 The increased burden in the cities and the rising wealth of the educated class can put extra stress on the environment as a whole. Education, like many other national institutions, benefits people and regions in different manners and to different degrees. Schools AHMED

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in Papua New Guinea exist in a highly unequal distribution. Many localities simply did not have access to schools until corporations entered their lands, as was the case with Ok Tedi.32 Thus, when a school is built, the decision of where to place it can determine whether or not a generation of a village will receive education. This can be an intensely political moment.

P OLICY R ECOMMENDATIONS In Papua New Guinea, as in much of the developing world, these politics must be reemphasized when talking about institutions like education. As with the curriculum debate, it is not sufficient to assert that development problems are the result of economic inefficiencies. The point is not whether certain subjects are being taught too much or not enough. More important to a discussion of development is the location of political power—who decides where schools are placed and what is taught.33 Under the present system, this political power rests squarely with multinational corporations. The local people who live with these corporations in their backyards are robbed of this power, and thus face choices under globalization that are little better than the choices they faced under colonialism. Although education can benefit some members of developing communities, it should not be seen as the primary development solution for poor countries. With increasing money being spent on institutional education in postcolonial settings, we must critically examine the purpose of this education, how it is implemented, and what its consequences are. For educational policymakers, there are several immediate steps to be taken. If anything is to be taught, reading should be the priority. Estimates from 2002 show that only 64.6 percent of Papua New Guinea’s population is literate (71.1 percent of males and 57.7 percent of females).34 Without access to written communication, people do not have access to the instruments of widely organized politics. Both inside and outside the classroom, engagement with the curricula should be encouraged, as disagreement can be quite constructive in fostering intellectual and political community. Educational exchanges between Papua New Guinea and countries like Australia, New Zealand, the United States, and the European nations should be used to reinvigorate the schooling experience for all children. Policymakers should also encourage a more complicated and democratic representation of the 92 |

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world than is currently available in the curricula. In addition to working with the global community to push for each of these reforms, our government should consider requiring U.S.based multinational corporations to reserve high-level positions for locals. More than just submitting annual sustainable development reports, these companies must prioritize the needs of their native hosts. Ultimately, the control of resources should be in the hands of the people most closely affected by their extraction. Moving forward will mean putting political power back in the hands of the people whose lives and livelihoods are at stake. 1. Swatridge, C. Delivering the Goods: Education as Cargo in Papua New Guinea. Manchester University Press, 1985. 12. 2. Pintz, S. “Education and Cultural Transition in Papua New Guinea.” Occasional Papers in Social Foundations of Education (7) (March 1985): 4. 3. Burbules; Torres. “Globalization and Education: Critical Perspectives”. Social Theory, Education, and Cultural Change. Routledge, 2000. 208. 4. Smith, P. Education and Colonial Control in Papua New Guinea: A Documentary History. Longman Cheshire Printery, 1987. 2. 5. Smith, G. “Education in Papua New Guinea.” The Second Century in Australian Education no. 11. Melbourne University Press, 1975. 6. Smith, P. 30. 7. Smith, P. 61. 8. Swatridge, C. 13. 9. Pintz, S.:18. 10. Smith, P. 245. 11. Swatridge, C. 4. 12. Burbules; Torres. 243 13. Smith, G. 42. 14. Ibid. 46. 15. Ibid 52. 16. GRM – Leading Resources and Development Management Company http://www.grm. com.au/ 17. “Pastep Curriculum Materials.” Teacher Education in Papua New Guinea. http://www. PNGteachereducation.com/pastep/curriculummaterials.php 18. “Social and Spiritual Development Strand: Spiritual and Moral Education.” Teacher Education in Papua New Guinea. http://www.PNGteachereducation.com/filestore/sme1.2sp iritualityinmelanesia.pdf 19. Burbules; Torres. 188. 20. Ibid 193. 21. Smith, G. 268.

22. Freeport in Indonesia: Mining the Earth in the face of ecological devastation and human rights violations. A Project Underground Fact-Sheet. Berkeley, CA. (course website).

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23. “2003 Report to the Community, Part 1.” Lihir Gold Limited. http://www.lihir.com.pg/ community/2004/comrep2003_part1.pdf 24. “Australian Firms Plunder Papua New Guinea.” Mines and Communities. http://www. minesandcommunities.org/Country/png3.htm 25. “2003 Report to the Community, Part 2.” Lihir Gold Limited. http://www.lihir.com.pg/ community/2004/comrep2003_part2.pdf 26. “Community.” Ok Tedi Mining Limited. http://www.oktedi.com/community/community. php 27. Ok Tedi Mining Limited. http://www.oktedi.com 28. Smith, P. 263. 29. Ibid 261. 30. Watts; Peet. “Liberating Political Ecology.” Liberation Ecologies: Environment, Development, Social Movements. London: Routledge, 2004. 27. 31. Ibid 32. 32. Pintz, S: 12. 33. Smith, G. 51. 34. “Field Listings - Literacy.” CIA World Factbook. June 2005. http://www.cia.gov/cia/publications/factbook/fields/2103.html

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Hammad Ahmed is a rising junior at Stanford University majoring in International Relations and hoping to minor in Cultural and Social Anthropology. Originally from Pakistan, he is interested in the cultural politics of globalization, the environment, and social movements. Ahmed has worked with CARE, the Immigration and Refugee Services of America, and the Stanford LGBT Community Resources Center. Since 2002, he has been an affiliate of the Telluride Association. His future plans are uncertain, but law and academia are possibilities. For correspondence, please email Hammad Ahmed at [email protected].

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Surveys: Policy and Social Perspectives from

Community, Political, and Corporate Leaders

Three Models of Corporate Social Responsibility: Implications for Public Policy Elizabeth Redman Less than a year ago in The Miami Herald, Henry Miller wrote, “Businesses do not have social responsibilities; only people do.”1 The Economist also recently offered a skeptical view of corporate benevolence; the feature article in the January 22, 2005 issue criticizes companies contributing to the tsunami relief effort for spending “other people’s money” and concludes, “All things considered, there is much to be said for leaving social and economic policy to governments.”2 The rejection of a “social conscience of business” is nothing new; in fact, the sentiment dates back to at least 1970 when Milton Friedman declared, “There is one and only one social responsibility of business—to use its resources and engage in activities designed to increase its profits.” But what happens when governments fail in the arena of social and economic policy? And where do companies who believe in the philosophy of “doing well by doing good” fit into the picture? While groups like Business for Social Responsibility (BSR) tirelessly promote the value added from socially responsible behavior, scholars and practitioners debate whether increasing expenditures on social or environmental obligations can boost the bottom line. For example, while Michael Porter and Class van der Linde REDMAN

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believe that strict environmental regulations can stimulate innovation and enhance competitiveness, others dismiss the possibility of “virtually costless environmental regulation” and argue that increasing the stringency of environmental laws necessarily results in reduced profits for the firm.”3 The ongoing philosophical debate and contradictory anecdotal evidence require explanations for the varying relationships between social responsibility and profit that could have profound impacts on the structure of government policies toward corporate social responsibility (CSR). As thousands of CEOs worldwide make substantial investments in their workforces, their communities, and the environment, it is important that we understand the perceptions that executives have of the relationship between their firms’ social and financial goals. Interviews with corporate executives and case studies reveal three models of thinking about CSR, though firm decisions are often based on some combination of the models. While these models do not offer one “right” way to conceptualize CSR, they do provide a framework for considerations about public policy and the future of socially responsible business behavior. The three models offer policymakers a more effective way of organizing thinking about the often elusive and multifaceted concept of CSR.

M ODEL O NE : T HE T RADITIONAL C ONFLICT In the traditional neoclassical model, tradeoffs between social and environmental goals and profits are inevitable. Since firms only consider private marginal costs when making production decisions, firms overproduce products or services, and operate at less than the socially optimum market equilibrium when social costs exceed firms’ private costs. These decisions create negative externalities and require government policies or other market-correcting interventions to restore the socially optimal equilibrium. Consistent with Friedman’s views, private expenditures on environmental or social objectives represent dollars stolen from either employees or stockholders. More stringent environmental protections limit firms’ ability to use “free” receptacles—such as rivers, open land, and the air—for their production waste. Many companies rely on a strategy of “built-in obsolescence,” thereby increasing production inefficiencies (e.g. pollution) and adding to the growing piles of junk in landfills. As The Economist points out, donations of time or money to natural disaster victims or impoverished communities represent dollars stolen from equity 96 |

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owners. Firms with this mindset consider only short-run private costs and benefits, leading them to overproduce public bads and undervalue socially beneficial decisions. The view of social responsibility and profits as mutually exclusive objectives has been well documented. In Cradle to Cradle, McDonough and Braungart define the longstanding problem: “We are accustomed to thinking of industry and the environment as being at odds with each other, because conventional methods of extraction, manufacture, and disposal are destructive to the natural world. Environmentalists often characterize business as bad and industry itself (and the growth it demands) as inevitably destructive. On the other hand, industrialists often view environmentalism as an obstacle to production and growth.... It appears these two systems cannot thrive in the same world.”4 Indigo Teiwes, Research Analyst for the Portland-based socially responsible investment fund Portfolio 21, believes a majority of today’s firms follow this ideology.5 She cites the example of Scottish and Southern Energy, a firm she initially considered a great potential investment. Seeking to diversify its mix of generation plants to increase capacity and boost earnings, the company made a strategic business decision to buy two coal-fired power stations in July 2004.6 The acquisition of the coal plants, which represent two of the United Kingdom’s top four worst coalfired stations with respect to greenhouse gas emissions,7 represents a clear conflict between financial gains and environmental integrity. When business externalities create social and environmental problems, traditional market-correction policies may be necessary. In Corporate Responsibility in the Global Village: The Role of Public Policy, Susan Ariel Aaronson and James T. Reeves explain, “Although market forces are increasingly pressing companies to act responsibly, markets have not succeeded in prodding corporations to ‘do the right thing’ everywhere they operate. To some degree, public policies to promote CSR arise from market failures.”8 To encourage socially responsible behavior the government should give tax breaks or rebates to companies that meet certain requirements, give out awards or recognition for good behavior, and the development of social or eco-labels that companies can obtain by meeting relevant standards. Legislation to encourage particular components of corporate responsibility can take many forms, from minimum-wage laws to command-and-control strategies to reduce pollution. While Dan Bross, Microsoft’s Director of Community Outreach, believes competition brings about better results than government regulation and claims that “firms bristle at more government mandates,”9 other companies, such as the energy provider PacifiCorp, prefer the clear messages and REDMAN

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straightforward detail that mandatory requirements provide.10 Regardless of whether governments impose harsher regulations or create more incentives to spur voluntary business programs to solve social and environmental problems, outside forces are necessary to restore the socially optimal market equilibrium when firms view other societal goals as an impediment to profit-seeking.

M ODEL T WO : C ORPORATE S OCIAL R ESPONSIBILITY B RINGS IN THE C ASH While the traditional view of conflict between industrial and social goals is far from obsolete, many companies are redefining the relationship between financial, social, and environmental performance. Executives from these companies view environmental integrity and healthy communities as means to achieve greater profits. Model two represents the ideology of the majority of companies that make it into socially responsible investment (SRI) portfolios. These companies choose to be socially responsible for a variety of profit-oriented reasons: increased sales, greater innovation, decreased production inefficiencies, decreased future risks, and greater access to capital. Many indicators suggest that 21st century businesses view social and environmental excellence as strategic business tools: from 1995 to 2003, assets put into in social investments grew 40 percent faster than all professionally managed investment assets in the United States.11 In response, companies are developing CSR departments, rewriting their mission statements to include ethical goals, and developing codes of conduct that extend to employees and contractors worldwide, to the point that by the end of 2003, more than 2,000 companies had issued CSR reports.12 While publicly held companies are still slaves to the numbers on their quarterly SEC filings, many have found ways to turn social responsibility into economic success. One major reason CSR is on the rise is that executives believe it can help them attract new customers or boost sales. Whether they use CSR as a strategic marketing tool to capture a niche market or believe their good works will be recognized and rewarded later, CEOs often cite reputation as their most valuable intangible asset.13 Kara Hartnett of BSR explains, “Brand differentiation is important for known companies. Social responsibility can set them apart.”14 Companies with direct consumer interaction want a reputation for good corporate citizenship, though their definitions of citizenship vary. US Bank tracks the number of Community 98 |

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Reinvestment Act (CRA) accounts opened and tries to quantify gains from investing in disenfranchised segments of the population. While US Bank does not specifically market its community outreach, executive Linda Wright asserts that, “when you give back to the community, it comes back to you. Accounts have been opened with US Bank because of the respect people have for the company.”15 At Microsoft, where CSR is “all about the bottom line,” the company places emphasis on achieving the greatest market share possible and becoming a market leader.16 Realizing the number of potential Xbox customers concerned about labor and environmental issues, Microsoft decided to push compliance with vendor codes and reexamine the environmental rules of the countries where their manufacturers are located. In addition to helping businesses that sell directly to consumers, CSR can also increase demand for business-to-business transactions. While Levi’s has found that vendors are resistant to embrace its codes of conduct, the demand from purchasers for safe, healthy, and compliant factories has created a new marketing strategy for many offshore production sites. According to Levi’s executive Suzanne Beck, many factories now tout their “Levi’s certification” to attract contracts with other big name purchasers.17 CSR programs also build connections within the community. Duncan Wyse, President of the Oregon Business Council, explains, “A lot of business is connections. Companies are not islands, they are not isolated from the world; their business depends on their engagement in networks. When a company strengthens its relationship with the community, this is part of its mission.”18 In “The Business Case for Corporate Citizenship,” Arthur D. Little elaborates, “The perceptions that stakeholders have of a company’s corporate citizenship performance can significantly affect the business’s license to operate. Companies with a poor reputation in this area can find themselves continually responding to criticism of their approach to a whole range of environmental and social issues.”19 Community involvement and activism help companies garner the good will of politicians and regulators in ways that may help the business later. Model two businesses believe that by enhancing their reputation, they also bolster recruitment and retention of quality employees. Numerous psychological studies have found that job satisfaction correlates with greater commitment to a company and greater business success. A 2004 survey reveals that more than three-fourths of MBA graduates would forgo financial benefits to work for an organization with a better reputation CSR and ethics.20 In fact, the business case between CSR and human resources is often so clear that many companies fail to acknowledge REDMAN

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excellent treatment of employees as a social responsibility. When asked about the company’s high wages and presence at community events, the Human Resources Director of fast-food chain, In-N-Out, remarked: Efficiency wages are self-serving. Our store managers may make 100 to 120 percent over industry norms, but the money spent on salaries is seen as an investment. Our wages not only broaden the applicant pool from which we can choose employees, but increase performance levels and retention rates.... Although you can never know for sure why people stay with a company, I certainly believe it may influence why people like their job here.21 Resources devoted to employees also contribute to health and productivity. The International Labour Organization (ILO) estimates that “on the job accidents and illnesses annually take some two million lives and cost the global economy an estimated 1.25 trillion, or four percent of annual global GDP.”22 Overall, fewer accidents and sickness translate to more productive employees. Furthermore, studies have shown that corporate community service programs, common at many companies touting their social responsibility, can help spur financially valuable innovation by “developing a variety of competencies, including teamwork, planning and implementation, communication, project management, listening skills, and customer focus.”23 And while NGOs and watchdog groups may in some cases be out to fight the “rise of the corporation,” in others, they collaborate with companies to provide new sources of information or strategies for management. Risk avoidance is another area where NGOs can be useful to businesses, and an additional reason why many company executives believe CSR can improve financial performance. In Conversations with Disbelievers, Simon Zadek writes: Advocates advance two primary arguments for how CE [Corporate Engagement] can help a company manage its risks. The first claim is that engaging in CE can help avoid harms associated with socially irresponsible or illegal behavior perpetrated by employees, and to mitigate the harms to the corporation created by accidents or mistakes.... The second, more complex claim, is that engaging in increased CE will help companies better understand and manage risks that come from new and unfamiliar sources.24 100 |

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GAP, Starbucks, Patagonia, and Adidas are just a few companies whose partnerships with NGOs help them acquire knowledge about production sites, working conditions, environmental damages, and other core components of their business. Early strategic investments in CSR can improve product and service quality, defray future lawsuits, and prevent or at least mitigate the effects of negative media coverage. Sourcing guidelines and ethical codes help companies avoid the future costs of shoddy workmanship, unreliable business relationships, financial mismanagement, and disruptions of operations by improving the quality of products and services. At Occidental Petroleum, community involvement and their environmental precautions have everything to do with risk avoidance. Vice President of Communications and Public Affairs, Lawrence Meriage, explains: In the indigenous communities where we operate in Ecuador, we have a long-standing relationship with the people. Having them look at us as friends, instead of enemies, means our operations will not be disrupted and we will be able to negotiate new agreements later on. Building these relationships helps us avoid protests, strikes, or other disruptions such as people blocking roads.”25 After unveiling plans to build pipelines through land belonging to the U’wa community in Colombia, Meriage spent time responding to over 40,000 protestors’ postcards and letters. The negative publicity led to a “time sink” for the company and has forced them to take fiscal and moral obligations into account when making company decisions about where to operate.26 Now, before entering into new contracts, Occidental asks a series of questions about many types of risks, ranging from geological to political. If any of these outweigh the potential rewards, Occidental may choose not to operate even if the deal appears profitable in the short run. Being the first company to act in an area of CSR can also create a competitive advantage by helping the company anticipate future legislation. Sidney Espinosa of Hewlett Packard (HP) explains, “It is important for a company to identify policy issues that are hot and take a stance/find a position before laws are passed.”27 In an interview in 2003, Espinosa discussed how the company was already addressing the issues of product take-backs and computer recycling through its own private recycling program and by pushing for national legislation that the company could reasonably accommodate. New directives requiring REDMAN

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manufacturers to take back and recycle electrical products show that HP correctly predicted the trend, and the company will no doubt have an easier time dealing with the new rules than will its less forwardthinking competitors. PacifiCorp uses a similar strategy: the company continues to increase its use of renewables while simultaneously pushing government policies that give incentives for using wind power and mandate renewable portfolio standards.28 By accurately anticipating future policy trends and responding with the appropriate social or environmental programs, companies believe they can become market leaders. Finally, many model two companies may view CSR as a way to increase their access to capital. As early as 1971, the development of (SRI) funds created a new market for capital. From “green funds” which focus on environmentally beneficial practices, to investors who push for living wages at Responsible Wealth, SRI funds use a variety of strategies to select companies that are qualified under their definition of “socially responsible.” As would be expected, these targeted investments have convinced some companies to adopt CSR practices—Portfolio 21’s Teiwes recalls a few cases where companies initially rejected from the investment fund reapplied after adopting more environmentally friendly policies—and while most companies have not developed CSR programs or reevaluated their business strategy solely to attract SRI capital, it is certainly another incentive for good works. As companies make strategic ventures into the social and environmental arena, little government involvement seems necessary to promote business considerations of more than just profit margins and investors’ pocketbooks. However, business involvement in social and environmental affairs alone is not a recipe for success and does not guarantee that all stakeholder groups will be considered fairly. In model two cases, rather than promoting general CSR, public policy should focus on increasing transparency about companies’ CSR practices by encouraging comparable, comprehensive reporting standards or disclosure laws, and fostering collaborations between businesses, governments, and NGOs to tackle specific issues. Though debate continues over the effectiveness of mandatory CSR reporting (often called “triple bottom line reporting”) due to costs and the risk of stifling creativity and leading to “lowest common denominator” practices,29 there is something to be said for greater transparency about companies’ social and environmental interventions. Reporting can be an effective tool for companies to reevaluate their programs in a number of areas, as well as a way for outsiders to monitor their progress. Further, while groups like BSR in the United States foster communication and collaboration between business and 102 |

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NGOs, and while many companies have strategically aligned with nonprofits or charities to work on particular issue areas, governments could play a greater role in the development of such partnerships by offering funding and education, and by showing an active interest in promoting the dialogue between organizations and sectors with different ways of thinking.

M ODEL T HREE : M ULTIPLE F IRM G OALS , A LL C REATED E QUAL Though model two companies predominate among SRI portfolios, Teiwes believes it is model three businesses that we should really strive to encourage. Model three explains the ideology of firms that have made commitments to environmental and social goals without evidence that corporate citizenship leads to tangible financial gains. The owners or managers have decided that social and environmental achievements are independently worthy of attainment and should be pursued with equal enthusiasm to profits. Wyse explains, “A large part of CSR is the individuals involved in senior ranks. CEOs like to be involved in policy and service; it helps them to lead a fulfilling life. Just like others, executives feel good about giving back to their community and consider it part of their responsibility as a professional.”30 While uncommon in a society that measures success by GDP per capita or by the amount of economic activity generated regardless of its source or deleterious effects, there are companies who view their business in terms of its social and environmental contributions. Generally privately run by social entrepreneurs, philanthropists or environmentalists, these companies often have CEOs or owners with deep personal convictions. Their companies make profits but financial goals do not trump social or environmental considerations. This ideology functions on the idea that businesses, like people, have moral obligations and responsibilities that extend beyond the financial world. Adidas’s Social and Environmental Affairs Manager, Gregg Nebel, scoffs at the idea of using CSR is as a marketing strategy. He explains, “Why market what you are doing if you are simply doing what is right? The feeling here is that there is an expectation that a company will do the right thing, and there is no reason to advertise that we are fulfilling this obligation.” Newman’s Own is one example of a company with a social purpose. Owner Paul Newman donates all of the company’s profits and royalties after taxes to educational and charitable causes, ensuring that the company will only increase profit margins to increase the firm’s ability to contribute REDMAN

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to social welfare. Lighting fixture manufacturer Rejuvenation and forest products provider Collins Companies also exemplify businesses with deeprooted commitments to the environment and their community. While each of these companies runs a business with traditional financial goals, they do not view their commitment to sustainable environmental practices as a strategy for business, but rather as an important end in and of itself. However, the degree to which such socially oriented firms can succeed is unclear. Although BSR reports that a “2001 Hill & Knowlton/Harris Interactive poll showed that 79 percent of Americans take corporate citizenship into account when deciding whether to buy a particular company’s product [and] 36 percent consider corporate citizenship an important factor when making purchasing decisions,”31 the evidence often is not there to support this, in either their buying patterns or shareholder votes. There are consumers willing to pay higher prices for peace of mind over the production methods of the goods they buy, but their limited numbers create niche markets for socially responsible brands rather than pushing the business community to evaluate the triple bottom line in all scenarios or markets. To encourage companies to follow model three, policymakers should reconsider current indexes for business success, accounting practices, and the valuation of intangible assets. Model-three thinking requires more than teaching business owners and managers how to be responsible corporate citizens; it requires transforming average citizens’ understanding about value creation and expanding definitions of success to include social and environmental triumphs. Tools to place dollar values on intangibles like these social and environmental triumphs are already underway. By working within the old framework, many hope to quantify the financial returns on intangible investments and to translate intangible successes into tangible results.32 Some organizations, such as the New Economics Foundation (NEF) in London offer even more radical approaches to measuring firm success. Challenging the traditional national accounts of material wealth—GDP or GNP—NEF created the Index of Sustainable Economic Welfare (ISEW) which measures well-being by factoring in “goods” which are not captured by GNP (e.g. household labor), and deducting “bads” such as long-term environmental damage and the costs of crime.33 Policies to promote socially responsible behavior from a model-three perspective need to encourage further research, education, and discussions of societal value creation.

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Though executives often structure their thinking around one of the three models, businesses have many top executives, each with different feelings about the interaction between profits and CSR. To avoid giving off contradictory messages, they present themselves as a combination of the three models. The fact that Patagonia’s founder, Yvon Chouinard is famous for saying, “Every time I’ve done the right thing for the environment, I’ve made a profit”34 makes Patagonia appear to be the perfect example of a model-two business. Yet Patagonia’s Social Audit Coordinator, Huntley Dornan, believes that Chouinard and his wife are so committed to their principles that they would probably be more likely to let the company go bankrupt than change the company’s core values, and maintains that in reality, the firm’s decisions reflect of a combination of models two and three.35 Though Qualcomm’s investments in the community are strategic, Vice President Dan Sullivan adds, “You make investments in your community because you live in it. Employees live in the area, they go to the library, they breathe the air. A good company knows it needs to do more than time and motion studies.”36 Even with these blurred distinctions, the three models provide a useful framework for developing appropriate policies toward CSR. In all cases, government can play a proactive role in supporting policies promoting an awareness and emphasis on sustainable development. The European Commission has taken steps to learn more about the “knowledge economy and the importance of intangibles as competitiveness factors,” study the links between intangible investments and performance across companies and sectors, outline strategies for future financial reporting in Europe, and hold forums to discuss intangible assets as well as methods and practices of measuring and reporting.37 Efforts like that of the European Commission further the discussion of CSR without assuming that all companies embrace CSR in the same way.

M OVING F ORWARD While the field of CSR and public comprehension of its significance have expanded tremendously in the last decade, the broad range of motivations, programs, and policy suggestions suggest that there is no one solution that will encourage sustainable business practices among all U.S. companies. REDMAN

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There will always be companies that see any government policy as more “red tape” and to whom CSR will just be window dressing. And there always will be companies that follow ethical standards and consider the social consequences of their actions, not because consumers demand it or government encourages it, but because someone in the business believes it is the right thing to do. But there are also many middle-ground companies that are trying to decide not only how far their social and environmental commitments should extend, but also how to conceptualize the interaction between their social, environmental, and financial performance. Given the pressure placed on companies by various stakeholder groups and the many groups trying to define socially responsible behavior, it is no surprise the debate continues over the existence of “true CSR.” The three models presented here simplify the discussion in a way that makes it possible to identify the interactions among social, environmental, and financial goals across a variety of situations: a necessary first step in paving the way for a discussion about how to proceed. Plans to promote CSR—and thus sustainable economic development—must be tailored to fit the prevailing business models for CSR. Trying to encourage CSR without first understanding the motivations for corporate citizenship is a lot like trying to design a building before you know what the ground is made of. Using the three models, we can come to a better understanding of the surface we have to build on. 1. Miller, H. “Businesses don’t have social responsibilities; people do.” The Miami Herald 21 July 2004. 2. “The Good Company.” The Economist. 22-28 Jan. 2005: 11. 3. Porter, M; van der Linde, C. “Toward a New Conception of the Environment-Competitiveness Relationship.” & Palmer, K, Oates, W; Portney, P. “Tightening Environmental Standards: The Benefit-Cost or the No-Cost Paradigm?” Journal of Economic Perspectives 9(4) (Fall 1995). 4. Braungart, M; McDonough, W. Cradle to Cradle. New York: North Point Press, 2002. 5. Teiwes, I. Portfolio 21 Research Analyst. Personal Interview. 21 Jan. 2005. 6. “Scottish and Southern buys AEP’s UK power plants.” Reuters, 30 July 2004. http:// www.planetark.com/dailynewsstory.cfm/newsid/26375/newsDate/3-Aug-2004/ story.htm 7. “UK’s worst climate polluters named” Friends of the Earth, 10 Aug. 2003 http://www. foe-scotland.org.uk/press/pr20030803.html 8. Aaronson, S; Reeves, J. Corporate Responsibility in the Global Village: The Role of Public Policy. Washington, DC: National Policy Association, 2002. 9. Bross, D. Director, Community Outreach, US Legal-Community Affairs. Microsoft Corporation. Personal Interview. 23 June 2003.

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10. Singh, V. PacifiCorp. Telephone Interview. 25 March 2004. 11. Social Investment Forum. “2003 Report on Socially Responsible Investing Trends in the United States.” December 2003. http://www.socialinvest.org/areas/research/ trends/SRI_Trends_Report_2003.pdf 12. The Center for Corporate Citizenship at Boston College http://www.onphilanthropy.com/tren_comm/tc2003-12-31a.html 13. Aaronson; Reeves. 14. Hartnett. K. Senior Manager, Business for Social Responsibility. Personal Interview. June 2003. 15. Wright, L. Vice President, Community Relations. US Bank. Personal Interview. 25 June 2003. 16. Bross, D. 17. Beck, S. Manager, Worldwide Government Affairs & Public Policy. Levi-Strauss & Co. Personal Interview. 17 June 2003. 18. Wyse, D. President. Oregon Business Council. Personal Interview. June 2003. 19. Little, A. “The Business Case for Corporate Citizenship.” Distributed at the World Economic Forum Annual Meeting. 31 Jan.- 4 Feb. 2002. 20. Roner, L. “MBA graduates want jobs with ethical companies.” Ethical Corporation Online. 2 Aug. 2004. 21. Iriart, K. Vice President of Human Resources. In-N-Out Burger. July 2003. 22. International Labour Organization. “ILO: Work hazards kill millions, cost billions.” World of Work Magazine. ILO Online, 23 May 2003. 23. “Overview of Business and the Community.” www.bsr.org 24. Zadek, S. Conversations with Disbelievers. The Ford Foundation, 2000. 25. Meriage, L. Vice President of Communications and Public Affairs, Occidental Petroleum. Personal Interview. July 2003. 26. Meriage, Larry. July 2003. 27. Espinosa, S. Manager of Public Affairs, Hewlett-Packard Company. Personal Interview. 30 June 2003. 28. Edmonds, B. Director, Environmental Policy, Pacificorp. Personal Interview. 24 June 2003. 29. Beck, S. Manager, Worldwide Government Affairs & Public Policy. Levi-Strauss & Co. Personal Interview. 17 June 2003. & “Is it time to make CSR reporting compulsory?” EU Business, 2003. www.eubusiness.com 30. Wyse, D. 31. “Overview of Corporate Social Responsibility.” Issue Briefs. Business for Social Responsibility. www.bsr.org 32. Keen, J. “Don’t Ignore the Intangibles; Even benefits that are hard to quantify can be an important part of a successful business case.” CIO 16(22). Framingham: 1 Sept. 2003. 33. “nef ’s well-being programme.” New Economics Foundation, http://www.neweconomics.org/gen/well-being_current.aspx 34. http://www.onepercentfortheplanet.org/whyjoin.htm 35. Dornan, H. Social Audit Coordinator, Patagonia. Personal Interview. 11 July 2003.

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36. Sullivan, D. Executive Vice President, Human Resources. Personal Interview. July, 2003. 37. “European Commission Work on Intangible Assets” http://www.ll-a.fr/intangibles/ ec_work.htm

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Elizabeth Redman graduated summa cum laude from Pomona College with a B.A. in Public Policy Analysis and Economics. The recipient of two undergraduate research grants, Redman spent a year traveling nationally and internationally to interview business leaders and policymakers about their views on corporate social responsibility. Her research findings were compiled in May 2004 in her senior thesis, The Motivations for Corporate Social Responsibility and the Role of Public Policy in the U.S. Redman’s understanding of the complex linkages among firms’ social, environmental, and financial goals led to her selection as a Business Today scholar for the 2003 International Business Conference on the Social Conscience of Business, and to scholastic awards from both the Economics and Public Policy Analysis departments at Pomona College. In 2006, Redman will study the dynamics of corporate citizenship in Latin America as an Ambassador of Goodwill for Rotary International. She is currently working in Portland, Oregon as a policy analyst for the Oregon Business Council and as the director of the Youth Caucus for the Oregon Bus Project. For correspondence, please email Elizabeth Redman at [email protected].

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Looking Ahead: Progressive Thinking on Tomorrow’s Issues

Genomic Justice: Genetic Testing and Health Insurance in America Dov Fox We have long known that all people are not created equal, biologically speaking. However, new knowledge about which people are bound by the genetic burdens of ill health threatens to undermine the assumptions underlying the institution of health insurance. Now that the Human Genome Project has made it possible to discover previously concealed hereditary inequalities, how should we, as a society, respond to disparities among individuals’ genetic risks of ill health? Advancements in genetic technologies have private insurance providers clamoring for access to new types of predictive health information. Such information would allow for markedly more accurate risk forecasts, and thus foretell a range of difficulties for health insurance in the United States. Increasingly precise genetic prognoses may render risk pools so small that it no longer makes fiscal sense for individuals to pay for costly insurance policies. Fear of genetic discrimination may also prevent individuals from reaping the health benefits that can result from genetic testing. Most alarmingly, genetic risk classification may be used to deny coverage to those with the worst genetic luck. While lawmakers have begun to take note of these issues, anti-discrimination legislation, the current policy solution to these problems, could cripple private insurance providers. To protect the privacy and wellbeing of Americans, we should abandon the present scheme of setting health insurance rates according to individual risk-factors, and, in its place, adopt a system of roughly equal premiums across communities—a system that balances the values of free-market liberalism with those of mutual trust and solidarity. F OX

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C URRENT S TRESSES : H EALTH C ARE

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The recent mapping of the human genome holds enormous potential for beneficial use in personalized clinical health care. The 2003 completion of Human Genome Project promises to facilitate medical research and genetic testing to identify at-risk individuals and guide them in strategies for disease prevention, diagnosis, and treatment. The increasing number and sophistication of tests resulting from this new genetic information has enabled researchers to uncover the genetic components of over 5,000 diseases and disorders.a Mutations in the α-synuclein gene, for instance, increase the risk of Parkinson’s disease, while single mutations in BRCA and MODY genes increase the risk of breast cancer and diabetes.b Advances in genetic testing promise to greatly expand the field of biomedical research, and to enhance lifelong health by identifying those at-risk of developing debilitating diseases and guiding them towards reducing any risk-elevating health behaviors. However, such precise and personalized genetic knowledge also promises to profoundly transform health insurance in the United States.1 The institution of health insurance relies on the connection between ignorance and fairness in bringing people together to provide collective security against their individual risk of ill health. Some people have the good fortune of being blessed with lifelong health, while others are subject, through no fault of their own, to disease and disability that limits functioning and opportunity. Where all are deprived of knowledge about how their health will play out, all have reason to contribute regular payments as insurance against the future cost accompanying the unknown risk of individual infirmity. As risk can be roughly foreseen across large groups, insurance providers can reap commercial gain by collecting clusters of premiums in exchange for compensating policyholders for the actual medical expenses they encounter.2 The combination of individual uncertainty and group predictability which existed up until the genomics era thus gave policyholders and providers incentive to maintain the present system of health insurance. In the process, health insurance promotes social values of solidarity and mutual support by encouraging citizens—even if unwittingly—to share their fates with one another a Examples of genetic testing include: medical examination; family history; chemical, biochemical, or immunochemical analysis; examination of chromosomes by microscopy; or determination of DNA composition using molecular genetic techniques that provide carrier or presymptomatic information indicating probable disease or disorder. b Genetic research has discovered that monogenic disorders, for example, such as cystic fibrosis, Duchenne muscular dystrophy, and Huntington Disease, result from defects in a single gene. Chromosomal disorders, such as Down, Turner, and Klinefelter syndromes, result from too few, too many, or disorder of chromosomes within an individual’s genes. Multifactorial disorders, such as schizophrenia, spina bifida, juvenile onset diabetes, and most cancers, result from the interaction of multiple genes with environmental factors.

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by spreading among them the chance that any individual among will suffer the misfortune of infirmity. In the United States today, approximately 240 million Americans obtain health insurance through employer, state, or individual plans, and 40 million have no health insurance at all. Of those insured, approximately 110 million receive group insurance coverage from an employer or Blue Cross/Blue Shield, 65 million receive publicly-funded coverage from government programs like Medicare and Medicaid, 40 million receive self-insurance coverage from an employer, and 25 million receive individual coverage directly from a provider. Of those insured, about 50 million Americans receive coverage under an experience-rated health insurance system that relates premiums to risk under the principle of actuarial fairness.3 Under such coverage plans, policyholders contribute premiums according to the expected cost of their future claims. Actuarially fair providers engage in a process called underwriting, in which they determine a policyholder’s expected risk according to the costs of health care incurred by those with similar risk-related characteristics, such as age, sex, occupation, height, weight, blood pressure, cholesterol profile, tobacco and alcohol consumption, and family history. Providers obtain medical information by requiring the applicant to answer questions on an insurance proposal form or submit medical examination reports. Individual premiums are then set in proportion to these risk classifications. With the completion of the Human Genome Project, private health insurance providers are now seeking to acquire predictive information about genetic diseases in order to disaggregate risk along more finely stratified classifications according to the way in which adverse genes, taken in combination, contribute to an individual’s risk of ill health. Insurance companies argue that in order to maintain actuarial fairness, policyholders must submit data available from genetic testing, so that providers can differentiate premium levels as accurately as information permits. However, allowing genetic information to enter into the calculation of health insurance rates may render the whole institution commercially self-defeating. More precise predictive information would enable individuals’ eventual medical costs to be anticipated to a degree never before possible. If foreseeable risks of personal illness become known, providers will assign policyholders to sharply defined risk pools, with correspondingly precise premiums distinguishing the lucky from the unlucky. When pools become too small, many policyholders will find it cost-effective to save up their individual earnings for future health expenses than to contribute to a system of health insurance which offers far less security than it once did. If enough individuals opt out of the system, providers will no longer be F OX

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able to collect premiums across groups large enough to make it profitable to cover individuals’ health care expenses. Aside from fiscal complications, underwriting on the basis of increasingly accurate genetic information is morally suspect in that it sanctions indirect racial and ethnic discrimination in health insurance. Some genetic diseases and disorders are strongly correlated with particular racial or ethnic groups, such as Tay-Sach’s disease among Ashkenazi Jews of Eastern European descent and sickle cell anemia among individuals of African descent. Extensive associative studies indicate that Ashkenazi Jews are ten times more likely than the general American population to carry the genetic mutation for TaySachs.4 Similar studies show that individuals of African descent are twelve times more likely than the general American population to carry the patterns of gene expression associated with sickle cell anemia.5 By charging higher rates or denying coverage to prospective policyholders who are genetically predisposed to sickle cell anemia or Tay-Sachs disease, providers would, in effect, discriminate against those of Jewish or African ancestry. The use of genetic information by health insurance providers also threatens to compromise the availability of health insurance for millions of Americans. Currently, 15 percent of U.S. citizens lack health insurance and 30 percent of all applicants for individualized coverage are denied on the basis of approximate risk predictors. Compared to those who have health insurance, the uninsured get sick more often, heal slower, use emergency rooms with greater frequency, and die sooner. Genetic information exacerbates the problem of coverage denial and its attending health problems in that it enables providers to predict risk with better precision.c The more certainty the provider has that insuring any particular applicant will not be profitable, the more likely it becomes that the provider will decline coverage.6 Fear of genetic discrimination and coverage denial will also preclude society from reaping the full benefits of biomedical research and healthcare that are predicated on genetic information. For example, one-third of prospective volunteers in a series of recent studies conducted by NIH refused to undergo testing for genetic disorders out of fear that providers might uncover risk factors that would lead them to limit the patient’s access to insurance coverage. Similar fears keep millions of at-risk applicants and policyholders each year from getting testing for HIV.7 The moral difficulties that accompany underwriting on the basis of genetic information point to deeper problems that underlie experience-rated systems of health insurance. The practice of setting premiums according to expected risk c Director of the Human Genome Project Francis Collins estimates that the average individual carries between five and fifty genes that may predispose them to expensive-to-treat disease.

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engenders inequalities in coverage and premiums to whatever extent people experience advantages or disadvantages from morally arbitrary differences, including but not limited to those arising from genetic chance.8 Actuarial fairness punishes the most genetically vulnerable members of society on the basis of conditions they did not choose and cannot control. Blind to broader social values of solidarity and mutuality, actuarial fairness is an impoverished way of thinking about institutions like health insurance—institutions that are geared toward bringing together communities of individuals with the common goal of achieving security and good health. A more compassionate alternative to actuarial fairness would guarantee adequate coverage to genetically susceptible citizens without sacrificing the variety, choice, competition and responsiveness enjoyed under the current insurance system. Just as the American government taxes those with the most highly rewarded talents and skills in a way that helps those lacking such gifts, society ought likewise in the context of insurance to regulate inequalities in the distribution of basic social provisions such as nutrition, education and healthcare in a way that ensures all citizens possess the capacity for genuine choice from among a meaningful range of life plans.9 We would do well to share the costs suffered by individual members whose genetic inheritance predisposes them to adverse health. Such a system must also remain commercially viable. In the United States, the sole policy response to the issues raised by genetically informed underwriting has been legislation barring genetically informed discrimination. Federal laws such as the Health Insurance Portability and Accountability Act of 1996, the Genetic Information Nondiscrimination in Health Insurance Act of 2001, the proposed Genetic Information Nondiscrimination Act of 2003, and statutes passed in over half the states prohibit health insurance companies from requiring genetic tests as a condition for coverage or from denying coverage or charging higher rates based on the results of genetic tests.10 There are, however, important commercial, practical, and ethical reasons why legislation barring genetic discrimination cannot sufficiently resolve matters of distributive justice in health care. Where asymmetric information denies providers access to accurate genetic knowledge, adverse selection threatens the survival of for-profit private insurance providers. Were underwriters barred from using genetic information of actuarial significance, high-risk individuals would buy insurance in greater proportion than low-risk individuals, creating a spiral of premium raises and low-risk opt-outs. Furthermore, there is little if any empirical distinction between genetic information and traditional medical information like family history and health physical. Family history provides explicit information about an individual’s genetic constitution, while health F OX

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physicals identify conditions which typically implicate specific contributory genes. Likewise, many “non-genetic” medical tests point directly to underlying genetic sources of potential disease or disorder. For instance, a positive test for high cholesterol in the detection of heart disease or for occult fecal blood in the detection of colon cancer points directly to mutations in the genes conferring susceptibility to those conditions. Even were it possible to distinguish between genetic and non-genetic risks, the two would not differ in any morally relevant way. Except in the few cases where individuals could be held at least partially responsible for those risks, it can hardly be said that any diseases or disabilities are chosen, controllable, or deserved. People cannot be held morally accountable for environmental circumstances that adversely affect health, such as pollution, malnutrition, and low socioeconomic status, which are beyond their reasonable control. Moreover, new genetic information shows that even food, nicotine, and alcohol addictions, once thought to be purely voluntary behavioral choices, are at least partly influenced by an individual’s genetic makeup. As such, there is no sound basis upon which to differentiate rates among similar risks of ill health such as, say, genetic susceptibility to diabetes and non-genetic susceptibility to the Lyme disease spirochete. The ethical and economic difficulties generated by the introduction of genetic information into health insurance markets call for more substantive solutions than legislation that does nothing more than prohibit discrimination on the basis of genetic information.11

H EALTH I NSURANCE

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The answer to these problems is a nuanced system of privatized community rating. Such a system assigns broadly equal premiums among individual policyholders across similar “communities.” Though communities are ordinarily divided along geographic regions (whether a single congested city block or multiple counties and districts in less heavily populated regions), communities may be determined by particular interests or affiliations, such as membership in political or religious groups, so long as the community includes a rough balance of healthy and unhealthy individuals. Since coverage rates set uniformly across a given community do not vary along individual risk factors or health status, the lucky subsidize the unlucky, even when each has genetic knowledge of her individual health risks. A community rating system would thus preserve the advantages of free-market pluralism while promoting the cooperation and camaraderie that lie at the heart of the institution of health insurance. To be effective, this system must be built around a collective participation, guaranteed issue, guaranteed renewal, non-cancelable indemnity program that 114 |

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prevents providers from discriminating against those susceptible to adverse health, and protects against adverse selection by those with low personal risk levels. That coverage could not be cancelled would provide individuals with security against long-term changes in expected risk and expense across the course of a policyholder’s transition from youth to old age. Guaranteed issue and renewal would ensure basic health care coverage for even the most at-risk citizens. Tax-subsidized vouchers for high-risk individuals would spread the burden of insuring these cases across a broad population base. Meanwhile, by making genetic tests required as proof of need for a voucher, this system would keep people from obtaining such vouchers unfairly. Government or selfregulation could ensure that all providers allow access to at least “basic” health care coverage, as determined by a balanced committee of ethicists, economists, politicians, consumer advocates, and insurance representatives.12 Ours is a society unwilling to deny care in cases of medical emergency. While our current system of optional health insurance is forced to guard against financially capable free riders, a system of community-rated insurance plans that provides coverage to all citizens would prevent anyone from using medical resources without providing their fair share of contributions. Contractual incentives would maintain an aspect of personal responsibility for individual health by discouraging potentially damaging lifestyle behaviors to the extent that people can be said to exercise control over those behaviors. Other incentives for appropriate use of medical resources would realign policyholder interests with social goals and minimize the moral hazard that could encourage overuse of care. Removing providers’ incentive to seek genetic test results for purposes of risk classification would help protect confidentiality of sensitive personal information while curtailing the administrative and transaction costs incurred in the process of experience-rated underwriting. Without market competition from self-insurance or experience-rated providers, communityrated providers could remain profitable and survive in the private sector. By allowing people their choice of plans, rates, and benefits among providers, this system would sustain commercial feasibility in the marketplace, while owning up to society’s ethical duty to help those most vulnerable to ill health. In the course of genetic advancements, it will soon become necessary for our nation to dissolve an institution no longer capable of tending to injustices which we as a society will not permit. Deficiencies inherent in the current system leave us ill-equipped to reap the full promise that new genetic knowledge will yield for medical care in the United States. We need a system of health insurance that corrects for the deep inequalities borne in the natural lottery. By restoring the union of ignorance and fairness, cooperative involvement in a system of community-rated premiums presents the best solution to the problem of genetic testing and health insurance in America. F OX

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1. Advances in Genetic Information. Eds. Karen Marshall and Stephen Brown. Lexington, KY: The Council of State Governments, 1993: 55. 2. Knoppers, B. “Who Should Have Access to Genetic Information.” The Genetic Revolution and Human Rights. Ed. Justine Burley. New York: Oxford University Press, 1999. 47. 3. Greely, Henry T. “Health Insurance, Employment Discrimination, and the Genetics Revolution.”The Code of Codes: Scientific and Social Issues in the Human Genome Project. Eds. Leroy Hood and Daniel J. Kevles. Cambridge, MA: Harvard University Press, 1992. 277. 4. Myerowitz, R. “Splice Junction Mutation in Some Ashkenazi Jews with Tay-Sachs Disease.” Proceedings of the National Academy of Sciences of the United States of America 82(7) ( June 1988): 3955. 5. Pauling, L; et al. “Sickle Cell Anemia, a Molecular Disease.” Science 110(2865) (Nov. 1949) : 543-548. and Dunda-Belkhodja, O; et al. “Common Haplotype Dependency of High G γ-globin Gene Expression and High Hb F Levels in β-thalassemia and Sickle Cell Anemia Patients.” Proceedings of the National Academy of Sciences of the United States of America 82(7) (Apr. 1985): 2111-2113. 6. Cutler, D. “A Guide to Health Care Reform.” The Journal of Economic Perspectives 8(3) (Summer 1994): 20. 7. Harris, J. Wonderwoman and Superman. New York: Oxford University Press, 1992. 222. 8. Nozick, R. Anarchy, State, and Utopia. New York: Basic Books, 1977. 149-164, 167-182. 9. Rawls, J. A Theory of Justice. Cambridge: Harvard University Press, 1971. 78-79. 10. Friedrich, M.J. “Preserving Privacy, Preventing Discrimination Becomes the Province of Genetics Experts.” The Journal of the American Medical Association 288(7) (Aug. 2002): 817-818. 11. Beckwith, J; Alper, J.. “Reconsidering Genetic Antidiscrimination Legislation.” The Journal of Law, Medicine, and Ethics 26(3) (Fall 1998): 207. 12. Pauly, M. “The Welfare Economics of Community Rating.” The Journal of Risk and Insurance 37(3) (Sept. 1970): 409-412.

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A UTHOR

Dov Fox is currently a D. Phil. candidate on a Rhodes Scholarship at Oxford University and J.D. candidate at Yale Law School. Before this he received his M.S. from Oxford and a B.A. from Harvard. Fox has researched with the President’s Council on Bioethics, contributing to reports on the ethics of stem cell research and genetic enhancement. He recently published “Human Growth Hormone and the Measure of Man, in The New Atlantis, vol. 1, no. 7 (2004/2005): 75-89. For correspondence, please email Dov Fox at [email protected].

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