Make a Killing? US FTAs and Big Tobacco

There is a debate surrounding the pending Trans-Pacific Partnership expansion about whether participants' policies aimed at curbing tobacco use will be dismantled in the name of free trade. Large American tobacco companies--collectively known as "Big Tobacco"--have certainly not shied away from using texts of trade liberalization measures in faulting curbs to their unfettered access to emerging markets.  Outgoing New York Mayor Michael Bloomberg has been especially vocal about what he believes is a major assault on global health led by the United States.

As per current TPP drafts, some argue that negotiating LDCs will be made to relent on the sorts of public policies that have proven effective Stateside in reducing smoking:

The proposal put forward by the US Trade Representative (USTR) last week in Brunei would reduce prices for US tobacco in low- and middle-income countries and make it more difficult for these countries to enforce anti-tobacco policies like package warnings and advertising and marketing restrictions.   This proposal would impact the nine TPP countries – Australia, Brunei Darussalam, Chile, Malaysia, New Zealand, Peru, Singapore, Vietnam, and the United States -- six of these fall into the World Health Organization’s Western Pacific Region, which had the highest smoking rate among men in 2009. 

To put the implications of this proposal into perspective, consider these two points: Tobacco use caused 100 million deaths in the 20^th century.  If current trends persist, it is projected to cause 1 billion deaths in the 21^st century.  More than 80% of those future tobacco-related deaths will occur in low- and middle-income countries (LMICs). Tobacco use in the United States is steadily declining, due largely to widespread anti-tobacco campaigns and stringent anti-smoking policies – the same kinds of policies that the TPP will make difficult to enforce in developing countries.

So, why is the US effectively hindering the export of its good anti-tobacco policies to the LMICs that need them most?  A few key issues have risen to the surface during this debate. A “carve-out” for tobacco – where tobacco would simply be excluded from the terms of the TPP agreement – was proposed by Malaysia and makes sense. But the USTR worries that a carve-out would set a precedent that could be used to block a variety of other US exports on health grounds.

In other words, how exceptional is tobacco based on health grounds? The fear is that all sorts of products would be excluded by other countries and dilute the FTA. Left unresolved, the tobacco issue may even spoil TPP negotiations altogether:

The White House has tried to finesse the issue, recently proposing that the TPP agreement acknowledge tobacco as a health concern but otherwise treat it no differently from other products. That compromise has satisfied no one. Health advocates are furious that the White House dropped its previous proposal for a stronger tobacco control exception in the TPP agreement. The business community opposes any special treatment for tobacco. With that controversy spilling into the press and threatening the conclusion of the TPP talks—the Obama administration's signature international economic initiative [...]

As the tobacco industry's tactics on trade shifted, the controversy reignited. Tobacco companies began using trade and investment agreements to file legal challenges to block new cigarette labeling and advertising restrictions. Australia is fighting four different trade and investment cases against its cigarette packaging law. Similar cases have been filed against Norway and Uruguay and threatened against Togo. Investment disputes are expensive and the outcomes can be unpredictable. Many developing countries do not have the expertise or resources to fight. Even New Zealand and Canada backed away from planned tobacco regulations in the face of litigation threats.

 Thomas Bollyky of the CFR's suggestions in making a limited exception seem to make sense:

• This exception must explicitly encompass the full range of tobacco control measures addressed under the Framework Convention on Tobacco Control and permitted under U.S. laws.
• This exception should be limited to nondiscriminatory tobacco control measures. An exemption from legal challenge cannot serve as a pretext for TPP countries to favor domestic cigarette producers. This condition is consistent with overall U.S. trade policy and the terms of the 2001 U.S. executive order on tobacco and trade.
• This exception must not include the cross-reference that exists in most U.S. trade agreements to the health exceptions in World Trade Organization agreements. Such references might inappropriately interfere with tobacco litigation already filed under those other agreements against Australia and other TPP countries.

My take is that fair warning is appropriate concerning the possible effects of cigarette smoking and ought not to be sacrificed to a distortion of the term "liberalization." Consumer interests are not well-served by hiding the facts about the health consequences of cigarette smoking and arguing otherwise is a sham. Smoke if you must, but do so while knowing the possible consequences.

Add this to the already lengthy list of obstacles to TPP. 

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MEDSploitation: Pol Eco of Cuban Doctor Exports

A longstanding fixture of Cuba's outreach has been sending physicians to fellow Latin American nations. Witness the still-ongoing Venezuela-Cuba oil-for-doctors scheme: 90,000 barrels per day for 30,000 doctors. Despite its proto-communist economy being in shambles for decades now, Cuba still retains a reputation for training physicians--in quantity if not necessarily in quality. With a surplus of them at home and a perpetual shortage of foreign exchange, it was perhaps inevitable that they became one of the island nation's top exports. TIME talks about the current controversies over Cuban doctor exports to Brazil and the differentials in terms of physicians to population:

According to the World Health Organization (WHO), Brazil — despite its recent economic boom and constitutional guarantee of universal health care — has only 1.8 doctors per 1,000 people. (Cuba, despite its endless economic bust, has 6.7.) Almost two-thirds of all health care spending in Brazil is private, even though three-fourths of the population depends on public medical services.

Coming from a self-styled worker's paradise, what exactly is in it for the Cuban physicians working in Brazil? Unfortunately, it appears the ratio of wages paid to these doctors relative to Cuba's remuneration from host states is very low:

But Cuba’s medical-diplomacy mission, which currently has 40,000 doctors serving abroad and brings the Cuban government some $6 billion a year (of which the doctors themselves get only a tiny fraction), is a fixture in the third world, and was generally praised for its work in Haiti after the 2010 earthquake. And it points up the fact that Brazil’s problems are hardly unique. In fact, six of Latin America’s seven largest economies have two or fewer doctors per 1,000 people. (The exception is Argentina, which has 3.2.)

The Havana Times complains about this opaqueness over how much Cuba receives relative to what the physicians do:

In different comments, we read of “new slaves”, that the Cuban State is a kind of “foreman” and that Cuban doctors are “sheep” denied the right to demand their rights, individuals subjected to that which Jose Marti, when writing of a certain form of socialism much spoken of in his time, called “modern slavery.” Unfortunately, I do not know how much money will be paid directly to the doctors under the agreement entered into with the pertinent agencies of Cuba’s Ministry of Public Health. Our local and biased press has not published this detail, and we will have to find out from the doctors themselves [...]

It is both just and necessary for the Cuban State to take in a reasonable part of the money paid by Brazil, in order to re-invest it in Cuba’s public health programs. This money represents investments in many areas, including the country’s educational system, capable of creating a highly qualified labor force. It is also both just and necessary to respect the individual rights of our medical professionals, to pay them a percentage of the earnings that will guarantee their professional and personal dignity, as well as that of their families (without which they will not be able to practice their profession adequately).

What we need is transparency, on the basis of broader democratic, socialist concepts, throughout the selection, hiring and other processes related to the work of our professionals beyond Cuban borders. If Cuban doctors working in Brazil, for instance, were entitled to openly discuss their payment conditions and to arrive at an agreement with public health authorities that isn’t simply imposed on them, then we would be wrong to speak of any kind of slavery.

Call it Transparency, ah, Internationale. I too would love to know exactly what these Cuban physicians earn relative to the amount of treatment they give to better calculate the rate of exploitation, but alas, the Cuban government is perhaps not the best model of public transparency [!?] Rest assured though that economic necessity drives this increasingly controversial trade.

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"Hurry Up and Die": Japan & the Cost of Eldercare

Former Japanese PM and current Finance Minister Taro Aso has a novel way of dealing with Japan's increasing health care tab that may not resonate so well with their (obviously aging) electorate:

"Heaven forbid if you are forced to live on when you want to die. I would wake up feeling increasingly bad knowing that [treatment] was all being paid for by the government," he said during a meeting of the national council on social security reforms. "The problem won't be solved unless you let them hurry up and die."

Although the phrasing may be very politically incorrect, Japan's tab for caring for the elderly is pronounced and will become only more so given its demographic profile:

To compound the insult, he referred to elderly patients who are no longer able to feed themselves as "tube people". The health and welfare ministry, he added, was "well aware that it costs several tens of millions of yen" a month to treat a single patient in the final stages of life.

Cost aside, caring for the elderly is a major challenge for Japan's stretched social services. According to a report this week, the number of households receiving welfare, which include family members aged 65 or over, stood at more than 678,000, or about 40% of the total. The country is also tackling a rise in the number of people who die alone, most of whom are elderly. In 2010, 4.6 million elderly people lived alone, and the number who died at home soared 61% between 2003 and 2010, from 1,364 to 2,194, according to the bureau of social welfare and public health in Tokyo.

Inarticulacy aside, I think Aso is on to a number of worthwhile points of debate here: First, what he really is addressing that The Guardian and the rest fail to latch on to is the question of prolonging a person's life when they can no longer continue to function in a meaningful way as "tube people." Especially with so many Japanese elders living alone, who makes the decision to (sorry--this may be my Taro Aso moment for the day) pull the plug? Or, can family members veto the decisions of public physicians to do so? Second, the Asian version of the "greedy seniors" argument is more contentious insofar as we are still obligated to care for them instead of, say, following the rather abhorrent American-style habit of putting Mom and Dad out to pasture in some old folks' home. They raised you--and you put them in an "assisted care" facility in return. Such gratitude. That is, do strained national and household finances erode such values? Third, and this is often overlooked, Japan's fiscal woes are inextricably tied to the longevity of seniors. While advances in health care are well and good, there are fiscal implications for people living longer who no longer contribute economically on the public purse.

There are no easy answers, but fumbling for them is probably better than ignoring these questions altogether like certain North Americans who specialize in hiding their heads in the sand.

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How Scuderia Ferrari Improved a Hospital ICU [!]

Longtime readers will know from my blog FAQs that I am most excited about the field of IPE borrowing from different social science disciplines and beyond--anthropology, human geography, neurology, sociology...even moral philosophy and theology. If you look past largely artificial disciplinary boundaries, you'll often find that others have unique insights of their own about the same phenomena you are investigating.

It was thus a pleasure for me to find out that the same sort of thing is happening in the hard (some would say "real") sciences. This may sound incredible, but a bunch of doctors were watching Formula One during their of time when they noted the speed and efficiency with which teams perform pits stops as all four tires are changed in a matter of seconds. Why not ask these experts how to remove inefficiencies in the operating room, they thought? Hence a unique kind of collaboration was born:

Great Ormond Street's head ICU doctor, Allan Goldman, and heart surgeon, Professor Martin Elliott, were watching a Formula One race in the hospital's staff common room having completed a 12-hour emergency transplant operation.  As a car pulled into the pit stop, they noted that a 20-member crew changed the car's tyres, filled it with fuel, cleared the air intakes and sent it off in seven seconds in a manner that was coordinated, efficient and disciplined.

Actually, the art has advanced so much that Ferrari archrivals McLaren set a record this year of a 2.31 second pit stop! These guys are good; these guys are fast. While F1 is perhaps much bigger money, in the overall scheme of things improving emergency health care is a far more important thing to so many people. So, they thought, why not ask the experts and invited F1 pit crews to study operations in an operating theatre to make improvements...

Recognising the similarities with the handover disciplines visible in the pit of a Formula One racing team, they invited the McLaren and Ferrari racing teams to work with them to examine how their processes could be more structured and effective.  They went out to the pits of the British Grand Prix, met Ferrari's technical managers at their base in Italy and invited some of them to come and observe their handovers at Great Ormond Street.

Professor Elliott feels the team enabled them to review what they did with a fresh pair of eyes: "They saw us operating on a solid table with the child under a heating or cooling blanket and all the vital connections to various bits of equipment, and then having to unplug everything and use a hand-operated ventilator as we took the patient out of the theatre, into the lift and along the corridor to intensive care.

"Their first thought was why didn't we do everything on a bed trolley that was equipped with everything we needed and didn't require disconnecting and reconnecting.  I pointed out that the manufacturer did not exist who would invest that sort of money in such a specialised product and that's when they started investigating human solutions and training methods to solve our problems."

And, fruitfully, there were observable methodological improvements as a result:

The input of the Formula One pit technicians resulted in a major restructuring of their patient handover from theatre to the ICU.  This involved adopting a new protocol, better training and rehearsals. The protocol outlined who should be the leader throughout the process (the anaesthetist), provided a step-by-step checklist covering each stage of the handover process and included a diagram of the patient surrounded by the staff so that everyone knew their exact position as well as their precise task...

Following the adoption of the protocol, an industrial psychologist monitored 27 operations and found that the number of technical errors and information handover mistakes had almost halved. The process is now being adapted to other areas of this hospital and others and the team want to examine how hospitals can learn from other high risk industries, including NASA and the Navy.

What more can you ask of interdisciplinary collaboration? The glamour of F1 rubs off on the medical profession, which in turn gains valuable insights on how to better provide health care in a pinch to those who need it most.  It's a win-win situation all around. And that is my feel-good story du jour. Have a nice day!

PS: Race aficionados will undoubtedly note that the Ferrari racing car above is the 2008 model, but do keep in mind that the collaboration mentioned here happened around that time.

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Need More Proof Patent Systems Favour the West?

It's sad but true that the more you know about our world, the more disillusioned you become. However, in the name of normative inquiry, I am duty-bound to bring you the truth (no matter how hard it hurts). Today we return to that old IPE chestnut, global patent regimes. Recently, the distinguished patent law expert Carlos M. Correa (no relation to either the ballplayer of the same name or the president of Ecuador) contributed a piece to the South Centre that illustrates the magnitude of the problem. Before heading to the developing world, consider the case in Europe alone according to the EC: 

Although the intrinsic value of the technology protected under such patents is low, they are often strategically used to generate or keep monopolistic positions that affect competitors and consumers. Thus, the proliferation of patents that do not make a genuine technical contribution limits legitimate competition and undermines innovation. An investigation conducted by the European Commission on the pharmaceutical industry, for instance, concluded that:

· Filing numerous patent applications for the same medicine (forming so called "patent clusters" or "patent thickets") is a common practice… to delay or block the market entry of generic medicines.
 · individual medicines are protected by up to nearly 100 product-specific patent families, which can lead to up to 1,300 patents and/or pending patent applications across the Member States.
· patent litigation cases increased by a factor of four between 2000 and 2007; generic companies prevailed in 62% of 149 litigated cases that lasted from six months to more than six years.
· European governments and consumers paid around 3 billion Euros in excess between 2000 and 2007 (in relation to 219 drugs) due to abuses in the exercise of patent rights.

The acquisition of a large number of patents around a single technology has become common practice. Contrary to the ordinary belief that one product will deserve one patent, a single medicine may be covered by hundreds of patents. Thus, a WIPO study identified around 800 patents on ritonavir, an important component in the treatment against HIV/AIDS. In order to preserve a monopolistic position after the expiry of basic patents, pharmaceutical companies routinely apply (and often obtain) patents on derivatives, dosage forms, new uses, etc. of existing medicines thereby ‘evergreening’ the original patents. 

Heading to the rest of the world, we discover that it's even in a worse mess, particularly the offensive positions Western firms take through abusing patent systems elsewhere:

Patent offices in developing countries have followed similar patterns regarding the patentability criteria. Technical assistance programs, intense advocacy and business lobbying, have been effective in creating pro-patent practices that transform the patent system in a convenient mechanism of market control and exclusion. In most cases, patent activity by foreign companies does not encompass any investment in production (since markets are mainly supplied through imports) nor a real transfer of technology to the countries where protection is sought.

A research conducted in five developing countries (Argentina, Brazil, Colombia, India and South Africa) on patenting in the pharmaceutical field revealed several aspects of the functioning of the patent system that raise significant concerns. Some of the findings of the study were as follows:

· Pharmaceutical patents are overwhelmingly concentrated in the hands of foreign companies (with the exception of India).
· The introduction of product patent protection has had no impact in terms of promoting local innovation in pharmaceuticals.
· There is a significant proliferation of patents over minor technical changes that are often used to create undue constraints on legitimate competition that negatively affect access to medicines.
· A large proportion of granted patents are based on the so-called ‘Markush claims’; if ‘selection patents’ are later on allowed on elements already disclosed in such claims, market control may be maintained through ‘evergreening’ of the original patent.
· Many patents and patent applications do not mention the International Nonproprietary Name (INN) of known drugs, thereby making patent searches and oppositions extremely difficult and costly. 

As I said, it's a very ugly picture. Even if generic manufacturers win nearly two-thirds of the time, Western Big Pharma firms have the capability to tie proceedings up for a very period. Which, truth be told, is their intention to keep their strangleholds intact on items such as needed medicines poor countries have long been denied.

The rest of the article gives suggestions on overhauling the defective global patent system, but let's just say that, in the pharmaceutical area more than most, he who has the gold makes the (convoluted) rules.

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The International Political Economy of Obesity

To be honest, IPE is usually not quite on the leading edge of social science in many respects. Prior to the breakout of the subprime crisis, there were next to no scholars focusing on real estate for instance save for a few exceptions like Herman Schwartz and Len Seabrooke. It thus bothers me that a quick Google search for "the international political economy of obesity" yielded my blog posts in the top three spots. Aargh.

Make no mistake, however: I believe that this subject matter will be a topic of, ah, w-i-d-e-r interest as the globalization of American-style obesity gathers pace and its fiscal implications become more evident. It's the worst of both worlds as far as industrialized countries are concerned. Not only will many folks live longer but they will also require more (costly) health care given the myriad of obesity-related illnesses. It's just another thing USA#1 cheerleaders routinely overlook: the strain placed on the public purse by the gut-busting expansion of American waistlines that's being copied the world over.

Anyway, Yahoo! News has an interesting feature on how ultrafat Americans--over a third of them are now not just overweight but downright obese [oink, oink]--bolster add more crippling poundage to already soft-in-the-middle budget deficits. Based on the percentage of health care costs thought to be associated with obesity in 2003, they predict that by 2018 the godforsaken US federal budget will include a hefty $343 billion forking out for these rotund Americans AKA "the nearly average Joe." That's not all health care spending but just that related to obesity. Throw in things alike other health care, pensions, unemployment benefits (I am not betting the US will have recovered a decade after the subprime crisis and it's indicative how bad things are that few will disagree) and it's too scary to contemplate.

It will become literally the survival of the fittest among industrialized economies as they struggle to keep in passable fiscal shape. Who will succeed in slimming down health care costs by doing the same to the general population? I don't know about you, but I doubt whether Americans will succeed at all given their track record in which things just get progressively worse, with no significant improvements in sight.

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Is Being Fat Related to Being Dumb? The US Case

Being apart from the Anglo-Saxon blogging crowd allows me to probe questions they are generally uncomfortable with but need to be asked. Yesterday we considered the general unresponsiveness of Anglophone academia to reforming higher education despite producing so many unemployed and unemployable graduates. Today I consider the unpalatable combination of being overweight and intellectual underachievement. Is there a link between the two? Once more, let us consider the United States which exemplifies much of both.

It is not exactly a secret that the performance of the United States' education system is middling at best compared to other developed nations' systems despite considerable spending on the godforsaken thing. What's more, recent OECD data suggests some from developing nations alike China are walloping American kids. Which is not difficult to do, really, but to see some PRC youth topping OECD league tables is a warning sign. Further evidence is shown in other standardized tests. Not only does the United States' youth underperform their international peers, but they are falling behind in exams administered by Americans themselves. Witness continuously falling test scores on the Scholastic Aptitude Test (SAT) which high school students wishing to enter college must take. While some apologists have claimed this was due to more young people taking SATs alike minorities who haven't done as well as white and Asian students, that scores have been falling while No Child Left Behind (NCLB) is being implemented suggests a link between poor K-12 and test performance.

Meanwhile, today I came across an interesting feature on how already-fattening sugar impairs cognitive performance. As with most studies of this sort, there are generalizability questions insofar as the subjects were lab rats. However, it does point out future directions for study given the massive amount of sugar Americans consume:

"Because insulin can penetrate the blood-brain barrier, the hormone may signal neurons to trigger reactions that disrupt learning and cause memory loss," [UCLA researcher] Gomez-Pinilla said. In other words, eating too much fructose could interfere with insulin's ability to regulate how cells use and store sugar, which is necessary for processing thoughts and emotions.

"Insulin is important in the body for controlling blood sugar, but it may play a different role in the brain, where insulin appears to disturb memory and learning," Gomez-Pinilla said. "Our study shows that a high-fructose diet harms the brain as well as the body. This is something new." In the US, high-fructose corn syrup is commonly found in soft drink, condiments, applesauce, baby food and other processed snacks. The average American consumes more than 40 pounds (18 kilograms) of high-fructose corn syrup per year, according to the US Department of Agriculture.

That American kids are among the portliest in the world is well-known.and utterly unsurprising. What is new here though may be that a source of their obesity and mediocre academic performance may be traced to the same source: excessive consumption of sugars, more specifically high-fructose corn syrup. It's an eminently researchable question that may help in answering why the US is in such a wretched state educationally, financially, and unhealthily. There's certainly a good chance these are all linked. In academic jargon, portliness and thick-headedness should covary.

Reminiscent of the tobacco lobby denying negative health effects from consuming too much of their products, we too have similar interests doing the same for sugar. According to lobby group The Sugar Association, sugar is not the cause of obesity, nor is it a primary factor to increased caloric intake.Their wording is careful in avoiding the more readily verifiable observation that sugars do contribute to both problems. However, such PR is aided by heavy-handed lobbying to preempt legislation that may attach more health warnings to sugar. Lest you doubt their capacity for political machinations, they reportedly even petitioned US lawmakers not to fund the UN after the World Health Organization accused this lobby of watering down a report on the harmful effects of consuming excessive sugar.

Again, I wouldn't be so keen on criticizing the United States if it didn't hold itself up time and again as a shining example for the rest of the world. American exceptionalism, they call it. Truth be told, there are far better systems to emulate instead of following certain hubris-filled folks. For findings jobs for young people, study the German example. For improving academic performance at all levels, study Singapore.

True, there is no magic bullet to solving American mediocrity. However, it does help pointing out to these folks that they are mediocre in so many things and are thus not worthy of emulation but condemnation. Making tidy profits for sugar lobbies is all well and good, but if it comes at the expense of national health and even intelligence, well, tough. American society is broken, and there's no one fixing it in this respect as in so many others. But hey, sugary treats are cheap, so what the heck! Twinkies for all (kids especially).

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World Bank Boss: Kim, Okonjo-Iweala or Ocampo?

I'd like to say the competition to become the next World bank president is heating up if it weren't for the common understanding that it will be another American stitch-up. While I'd have preferred the term "whitewash," the White House has thrown those of us who are critical of Western domination of these institutions a curveball by nominating an Asian-American candidate in Jim Yong Kim. Thinking it over, I can offer a number of pros and cons. Starting with the good stuff I can think of--I am a charitable lad, yes...

1. Global health is one of the areas where multilateral development institutions have actually made significant strides. Disease prevention is usually a large-scale intervention, and it is here where top-down efforts have shown promise. Witness the eradication of smallpox and the near-eradication of river blindness for instance. Since Kim's global advocacy is more on TB and HIV/AIDS, the more tentative results there are not really indicative of a lack of skill but of the increased difficulty in addressing the illness at hand;
2. Becoming a university president--especially at a venerable Ivy League institution like Dartmouth--involves no small amount of political skill (Larry Summers notwithstanding);
3. It will be a welcome change to have a physician by training head the World Bank instead of yet another economist or political scientist;
4. It is also good that Jim Yong Kim is not a loyal party figure alike Zoellick and his American predecessors but rather someone who does not really come from the inner circles of US politics.

On the downside, though...

1. This "pick a non-Caucasian to silence the critics" strategy would work better even as a token if he came from an LDC. Remember, South Korea famously joined the OECD in 1996 just before the outbreak of the Asian financial crisis a year after. We kicked it out of the G-77 after acceding to this rich country club, so he's not really someone who comes from today's Global South;
2. His post as a university president aside, he will need to juggle conflicting interests from rich countries wishing to keep their hegemony at the World Bank as is and poor ones that are interested in being more involved in global governance but have found it hard to be among the big boys. There is not much from his previous experience that may prepare him for the rough-and-tumble of development politics.

Let's now turn to Ngozi Okonjo-Iweala, the Nigerian who's put her name up for candidacy via her supporting countries' World Bank representative. Also there's Jose Antonio Ocampo, the Colombian candidate put forward by a number of Latin American nations. Alike the bid by the Mexican Agustin Carstens to replace the infamous Dominique Strauss-Kahn at the IMF, it's probably best not to take these two bids very seriously (unfortunately)...

1. The Jim Yong Kim ploy aside, the US shows no signs of breaking its stranglehold on World Bank leadership anytime soon, so both bids are forwarded more as "protest" votes;
2. Alike Carstens, both LDC candidates are hampered by iffy support from disunited developing countries. After all, they've again failed to rally around a single candidate. Alike the Americans with their blinders, those that have volunteered someone have chosen a person from their own region. Not much "third world solidarity" here, eh? United we stand, divided we fall it is once more;
3. Moreover, many other LDCs would probably be dissuaded from backing someone other than the US pick in justifiable fears of retribution from the West through vetoing future World Bank loans and grants;
4. What's more, many "realists" would prefer to just aim for the backup spots alike being a World Bank managing director (the #2s). Indonesia's Sri Mulyani Indrawati probably understands this glass ceiling more than most. Call it the Zhu Min strategy;
5. Okonjo-Iweala and Ocampo are hardcore development persons familiar with those working in this area and many LDC grandees. However, this status may actually detract from the idea of bringing in new blood in development work.

So in some (symbolic) ways Jim Yong Kim marks a real break as the American nominee--in terms of being a doctor by profession and an outsider to US politics. That said, these token gestures are unlikely to comfort the likes of yours truly since the guy probably knows who butters his bread when push comes to shove. At least U2's Bono was non-American. The more things change, the more things stay the same.

UPDATE: There is a lot of relevant material on the succession debate from the "World Bank President" site co-authored by my colleague Peter Chowla of the Bretton Woods Project.

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Singapore's Fat-Fighting Tool: Military Conscription

Given its sheer girth, the globalization of American-style obesity is not a problem you can sit on and forget about. Industrialized countries already burdened with sizeable health and pensions obligations may, in all likelihood, be underestimating this weighty problem as their citizens become US-huge and encounter all sorts of related problems. Aside from the aesthetic pitfalls of being a nation of fatties, there is an all-you-can-eat buffet of illnesses associated with mega-tubbiness.

Venerable medical journal The Lancet recently featured a series of alarming studies about the consequences of what medical types call "obesogenic" cultures--of which the United States is the prime (rib?) example with forecasts predicting that half of all Yanks will be obese by 2030. Which is not much of a stretch given that over a third of them already are obese. Definitely, health is a very understudied issue in IPE and this gap should be addressed since the health of nations will certainly shape patterns of national indebtedness. A study out of Emory estimates that obesity-related costs for the US will amount to $344B by 2018--about 21% of a gargantuan health care tab. For several nations, health care is the largest line item in the national budget and will only become more so given their aging populations.

Certainly the likes of the United States ought to concern themselves more with their cellulite-superindebtedness complex than their military-industrial one. American indiscipline is a multifaceted construct, with their legendary fiscal depravity combined with physical inactivity and unprecedented gluttony resulting in a health crisis that turbocharges the national debt via endlessly mounting health care costs. Perhaps it's in the genes, though I hope that's not the case.

Such despair. It's depressing enough to make a Yank down a milkshake or twenty. Is there any way out of this bottomless American-style debts 'n' fats trap? Thankfully, there is. Just as Singapore shows the potential way forward for the intensely wasteful and mediocre US education system, so does its lesser known fat-fighting tool of military conscription show a way out. To be sure, many other industrialized countries also have mandatory national service. However, Singapore alone makes it a continuing exercise apart from a few months to a year in your late teens / early twenties. You see, Singaporean males need to devote a couple of weeks each year after completing basic training to military drills. Further, they need to undertake fairly strenuous tests annually to prove their worth lest they be sent off to boot camp indefinitely until they pass. From the Singaporean Ministry of Defence website comes this description:

All PES A, B and C1 active NSmen [national servicemen or "reservists" which include practically all younger Singaporeans] below the age of 45 years for Officers and 40 years for Warrant Officers & below are required to take the IPPT [Individual Physical Proficiency Test] annually. All IPPT eligible NSmen must attempt IPPT once within their IPPT year. They may attempt IPPT during or outside their ICT [in-camp training] and may make as many attempts as they want to improve their IPPT results. The best result achieved will be taken as the record for the IPPT year.

Make no mistake: the IPPT is no wussy exercise, either:

As frontline soldiers, it is essential for all NSmen to maintain physical fitness. The IPPT is designed to test the basic components of physical fitness and motor skills of the NSmen. It comprises the following tests (see diagram below):

Test Item	Fitness Component(s)
Sit-Up	Abdominal muscular strength and endurance
Standing Broad Jump	Lower limbs extensor muscular power
Chin-up	Upper limbs muscular strength and endurance
4 * 10m Shuttle Run	General speed, agility and co-ordination
2.4Km Run	Cardio-respiratory endurance and lower limbs muscular endurance

Your typical sofa-ridden, iPad-fondling Yankee would probably keel over after a 0.24 km run [lotsa wheezing in the background], but that would be no surprise. As I like to say, there are good reasons why even (unbiased) Americans take the example of a society that works rather than one that doesn't--and hasn't for a very long time now. In the case of Singapore, there's a strong incentive to stay fit or face pretty negative consequences. There's no subtle "nudge"-style nannying here. It's so un-American--being practically forced to stay fit, but hey, just see how fat land is faring to see what their indiscipline has resulted in.

Singaporean children are quite a fit bunch, then they have years of military training to keep things that way. While obesity rates have inched up in recent years, they are far from American levels and haven't gone unnoticed. There are noticeable government efforts to fight the fat. To be sure, there too are whingers who would rather park themselves on the La-Z-Boy and fondle the iPad in Singapore. One justification for doing away with the practice is lost economic productivity:

Military service works this way: At 18 all youths have to report for a two-year stint, followed by 10 years of reservist duty, potentially frontline troops in the event of war. The reservists are recalled for annual in-camp training or military exercises, which last one or two weeks. The government has done much to recognise the sacrifice of NS men, giving perks that range from tax incentives to higher savings top-ups and fee discounts. The civil service also offers a slightly higher salary scale for employees who have completed their service.

With Singaporeans facing growing competition from foreign workers, however, national service has become a strain when bosses pass them over in favour of permanent residents (PRs) because of their “cumbersome” reservist duties. Singaporean employers who have gone through it are generally more ready to employ reservists, but foreign companies often feel no such responsibility. They often turn away locals who are still doing reservist duty, preferring to hire foreigners or PRs, who are free of the obligation...

Recently, a fresh Singaporean 26-year-old graduate related his interview at a foreign-owned fabrication plant here. The first question the Taiwanese manager asked him was: “I see you are a Singaporean. Do you need to go back to serve NS every year?” When he replied that he had to report back for in-camp training every year, the manager reacted negatively, observing that reservists who failed fitness tests would need to train until they passed.

Ah, "economics"--the last refuge of a modern-day scoundrel. From talking to folks from Singapore, however, I gather that the couch potatoes are outnumbered (though this assertion can definitely be subject to surveys). Certainly there's no mass movement at present to do away with the practice. Aside from escaping the tedium of office slaving, many young Singaporeans actually look forward to spending some time away with their school buddies. Add in the benefits of camaraderie and fitness and the equation should be clear. Moreover, Singaporeans take their training seriously and are rewarded accordingly. Unlike many other countries' mandatory services, it is possible to become a pilot or suchlike as NSMen.

So yes, it's not only military conscription but also the way the programme is designed with strong disincentives to becoming American-sized at work here. Execution matters. As in so many other things, Singaporeans take pride in their accomplishments and don't tolerate Bart Simpson-esque brattiness which contemporary America is renowned for. While they may be smugly self-superior sometimes, they achieve things the likes of which bumbling America can only dream of nowadays. As a basis of comparison, that Charles "Guantanamo Ghraiber" Graner remains the world's best known US reservist tells you something.

As I said, indiscipline manifests itself in so many ways, but in the end such pathologies are reflective of the societies from whence they came. Anyone else want to end up with American obesity rates? No? That's what I thought.

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