The essay provides support to the hypothesis that financing of provincial public spending through national transferences leads to overspending. We rest on persuasive economic and politicoinstitutional arguments. Fiscal illusion and the Leviathan model help to explain the overspending. And cartelization of tax collection helps to explain why governors are so reluctant to decentralize this task. We conclude that a fiscal organization closer to that of a confederation would be desirable. Two ways of organizing fiscal relations between the Nation and the provinces are considered. One way consists of paying for national spending by means of periodic provincial transferences; control of public spending by tax-payers would be the greatest possible in this scenario, though leaving national financing in provincial hands could be a risky affair. Another way consists of allowing the Nation some taxing power and incorporating constitutional restrictions as regards the kinds of public goods the national government is permitted to provide.
In OLG economies with life-cycle saving and exogenous growth, competitive equilibria in general
fail to achieve optimality because individuals accumulate amounts of physical capital that differ from the one that maximizes welfare along a balanced growth path (the Golden Rule). With human capital, a second potential source of departure from optimality arises, related to education decisions. We propose to recover the Golden Rule of physical and also human capital accumu-
lation. We characterize the optimal policy to decentralize the Golden Rule balanced growth path
when there are no constraints for individuals to finance their education investments, and show that
it involves education taxes. Also, when the government subsidizes the repayment of education
loans, optimal pensions are positive
Zero-knowledge proofs protocols are effective interactive methods to prove a node's identity without disclosing any additional information other than the veracity of the proof. They are implementable in several ways. In this thesis, I investigate the graph isomorphism based zero-knowledge proofs protocol. My experiments and analyses suggest that graph isomorphism can easily be solved for many types of graphs and hence is not an ideal solution for implementing ZKP.
Discussion Points1Cruz et al1Cruz C.O. Meshberg E.G. Shofer F.S. et al.Interrater reliability and accuracy of clinicians and trained research assistants performing prospective data collection in emergency department patients with potential acute coronary syndrome.Ann Emerg Med. 2009; 54: 1-7Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar contains 2 parts, a comparison of the values gathered by trained research assistants and physicians about historical information in chest pain patients and the comparison of these participants' recordings with a âcorrectâ value for each item.A. For each part, indicate whether the authors are studying reliability or validity and explain the difference between these concepts.B. What did the authors use as their criterion standard for the validity analysis?C. What are potential problems with their method of defining the criterion (gold) standard? Can you think of alternative approaches?D. The authors report crude agreement and interquartile range for their validity analysis. What part of a distribution is described by the interquartile range? List other statistics used to describe the validity of a measure and why they might be preferable to reporting crude agreement.2Tabled 1MD Recorded âYesâMD Recorded âNoâTotalRA recorded yes1176123RA recorded no18220Total1358143MD, Medical doctor; RA, research assistant. Open table in a new tab A. Calculate the crude percentage agreement for this table. What is the range of possible values for percentage agreement?B. Calculate Cohen's Îș for this table. What is the formula for Îș for raters making a binary assessment (eg, yes/no or true/false)? Discuss the purpose of Cohen's Îș, its range, and the interpretations of key values such as â1, 0, and 1.C. What other measures can be used to measure reliability for binary, categorical, and continuous data? 3Cruz et al quote the oft-cited Landis and Koch2Landis J.R. Koch G.C. The measurement of observer agreement for categorical data.Biometrics. 1977; 33: 159-174Crossref PubMed Scopus (49675) Google Scholar article stating that a Îș of âless than 0.2 represents poor agreement; 0.21 to 0.40, fair agreement; 0.41 to 0.60, moderate agreement; 0.61 to 0.80, good agreement; and 0.81 to 1.00, excellent agreement.â Consider studies of the agreement of airline pilots deciding whether it is safe to land and psychologists deciding whether interviewees have type A or type B personalities. the studies the Îș the by Landis and Koch be 2 are in of a and to such as is a a or by a in the for and in the for are and the are to a for each that they percentage agreement is and Îș is of are and are that the is the for a the the this the percentage agreement and Îș for the the of the are and of the are by the of the are and of the are by the the are and of the are by the and of the are and of the are by the Discuss the of percentage agreement and Îș in these Consider the 2 and percentage agreement and Îș for is Îș the What this that the table the described and that that to 2 in the raters are that are and the raters are that be with with or in with each of Îș the in these 2 the of Îș, that such that and or are for the and percentage agreement and Îș for these is the measure for Consider the of the raters in the in this be reliability is might this be the percentage agreement Îș for the in of et The are to indicate the in the and 2 Open table in a new tab A. in the table are with the the pain it to the it to the it to the for these Can you explain why these have percentage agreement you is the the Can you the between the of the in the table and the to Îș percentage the problems with percentage agreement and Îș in these you think it be the in the of each table of reporting the percentage agreement or et al contains 2 parts, a comparison of the values gathered by trained research assistants and physicians historical information in chest pain and the comparison of these participants' recordings with a âcorrectâ value for each For each part, indicate whether the authors are studying reliability or validity and explain the difference between these part is assessment of and the is assessment of The between reliability and validity is the that the in a that a a The reliability of a to the agreement the the or assessment of validity a observer a or the criterion standard is to be validity studies report the of the observer statistics such as and or reliability such as percentage agreement or What did the authors use as their criterion standard for the validity the and the research it is that their is they a research the of the 2 is What are potential problems with their method of defining the standard? 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agreement percentage agreement is and is with a The of a with data that the are as in the to as agreement and Îș a percentage that the in Îș the in of the et al article have to with the of the than of the of in the of the are to have of the reliability of the the problems with percentage agreement and Îș in these you think it be the in the of each of reporting the percentage agreement or that this of the and that can a table data is to a reliability such as of reporting the reliability data than percentage agreement or information in it is to in the Discussion Points1Cruz et al1Cruz C.O. Meshberg E.G. Shofer F.S. et al.Interrater reliability and accuracy of clinicians and trained research assistants performing prospective data collection in emergency department patients with potential acute coronary syndrome.Ann Emerg Med. 2009; 54: 1-7Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar contains 2 parts, a comparison of the values gathered by trained research assistants and physicians about historical information in chest pain patients and the comparison of these participants' recordings with a âcorrectâ value for each item.A. For each part, indicate whether the authors are studying reliability or validity and explain the difference between these concepts.B. What did the authors use as their criterion standard for the validity analysis?C. What are potential problems with their method of defining the criterion (gold) standard? Can you think of alternative approaches?D. The authors report crude agreement and interquartile range for their validity analysis. What part of a distribution is described by the interquartile range? List other statistics used to describe the validity of a measure and why they might be preferable to reporting crude agreement.2Tabled 1MD Recorded âYesâMD Recorded âNoâTotalRA recorded yes1176123RA recorded no18220Total1358143MD, Medical doctor; RA, research assistant. Open table in a new tab A. Calculate the crude percentage agreement for this table. What is the range of possible values for percentage agreement?B. Calculate Cohen's Îș for this table. What is the formula for Îș for raters making a binary assessment (eg, yes/no or true/false)? Discuss the purpose of Cohen's Îș, its range, and the interpretations of key values such as â1, 0, and 1.C. What other measures can be used to measure reliability for binary, categorical, and continuous data? 3Cruz et al quote the oft-cited Landis and Koch2Landis J.R. Koch G.C. The measurement of observer agreement for categorical data.Biometrics. 1977; 33: 159-174Crossref PubMed Scopus (49675) Google Scholar article stating that a Îș of âless than 0.2 represents poor agreement; 0.21 to 0.40, fair agreement; 0.41 to 0.60, moderate agreement; 0.61 to 0.80, good agreement; and 0.81 to 1.00, excellent agreement.â Consider studies of the agreement of airline pilots deciding whether it is safe to land and psychologists deciding whether interviewees have type A or type B personalities. the studies the Îș the by Landis and Koch be 2 are in of a and to such as is a a or by a in the for and in the for are and the are to a for each that they percentage agreement is and Îș is of are and are that the is the for a the the this the percentage agreement and Îș for the the of the are and of the are by the of the are and of the are by the the are and of the are by the and of the are and of the are by the Discuss the of percentage agreement and Îș in these Consider the 2 and percentage agreement and Îș for is Îș the What this that the table the described and that that to 2 in the raters are that are and the raters are that be with with or in with each of Îș the in these 2 the of Îș, that such that and or are for the and percentage agreement and Îș for these is the measure for Consider the of the raters in the in this be reliability is might this be the percentage agreement Îș for the in of et The are to indicate the in the and 2 Open table in a new tab A. in the table are with the the pain it to the it to the it to the for these Can you explain why these have percentage agreement you is the the Can you the between the of the in the table and the to Îș percentage the problems with percentage agreement and Îș in these you think it be the in the of each table of reporting the percentage agreement or et al1Cruz C.O. Meshberg E.G. Shofer F.S. et al.Interrater reliability and accuracy of clinicians and trained research assistants performing prospective data collection in emergency department patients with potential acute coronary syndrome.Ann Emerg Med. 2009; 54: 1-7Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar contains 2 parts, a comparison of the values gathered by trained research assistants and physicians about historical information in chest pain patients and the comparison of these participants' recordings with a âcorrectâ value for each item.A. For each part, indicate whether the authors are studying reliability or validity and explain the difference between these concepts.B. What did the authors use as their criterion standard for the validity analysis?C. What are potential problems with their method of defining the criterion (gold) standard? Can you think of alternative approaches?D. The authors report crude agreement and interquartile range for their validity analysis. What part of a distribution is described by the interquartile range? List other statistics used to describe the validity of a measure and why they might be preferable to reporting crude agreement.2Tabled 1MD Recorded âYesâMD Recorded âNoâTotalRA recorded yes1176123RA recorded no18220Total1358143MD, Medical doctor; RA, research assistant. Open table in a new tab A. Calculate the crude percentage agreement for this table. What is the range of possible values for percentage agreement?B. Calculate Cohen's Îș for this table. What is the formula for Îș for raters making a binary assessment (eg, yes/no or true/false)? Discuss the purpose of Cohen's Îș, its range, and the interpretations of key values such as â1, 0, and 1.C. What other measures can be used to measure reliability for binary, categorical, and continuous data? 3Cruz et al quote the oft-cited Landis and Koch2Landis J.R. Koch G.C. The measurement of observer agreement for categorical data.Biometrics. 1977; 33: 159-174Crossref PubMed Scopus (49675) Google Scholar article stating that a Îș of âless than 0.2 represents poor agreement; 0.21 to 0.40, fair agreement; 0.41 to 0.60, moderate agreement; 0.61 to 0.80, good agreement; and 0.81 to 1.00, excellent agreement.â Consider studies of the agreement of airline pilots deciding whether it is safe to land and psychologists deciding whether interviewees have type A or type B personalities. the studies the Îș the by Landis and Koch be 2 are in of a and to such as is a a or by a in the for and in the for are and the are to a for each that they percentage agreement is and Îș is of are and are that the is the for a the the this the percentage agreement and Îș for the the of the are and of the are by the of the are and of the are by the the are and of the are by the and of the are and of the are by the Discuss the of percentage agreement and Îș in these Consider the 2 and percentage agreement and Îș for is Îș the What this that the table the described and that that to 2 in the raters are that are and the raters are that be with with or in with each of Îș the in these 2 the of Îș, that such that and or are for the and Calculate percentage agreement and Îș for these is the measure for Consider the of the raters in the in this be reliability is might this be the percentage agreement Îș for the in of et The are to indicate the in the and 2 Open table in a new tab A. in the table are with the the pain it to the it to the it to the for these Can you explain why these have percentage agreement you is the the Can you the between the of the in the table and the to Îș percentage the problems with percentage agreement and Îș in these you think it be the in the of each table of reporting the percentage agreement or et al contains 2 parts, a comparison of the values gathered by trained research assistants and physicians historical information in chest pain and the comparison of these participants' recordings with a âcorrectâ value for each For each part, indicate whether the authors are studying reliability or validity and explain the difference between these part is assessment of and the is assessment of The between reliability and validity is the that the in a that a a The reliability of a to the agreement the the or assessment of validity a observer a or the criterion standard is to be validity studies report the of the observer statistics such as and or reliability such as percentage agreement or What did the authors use as their criterion standard for the validity the and the research it is that their is they a research the of the 2 is What are potential problems with their method of defining the standard? Can you think of alternative a standard for this is For can be 2 the and is For a you have pain in the might that is a for in the is a might that is its the with is the criterion standard for this the the have or the the information The of is that have to the emergency have the of reporting part of a to their and the the a be or the other of the physicians the in a that to the or or in the a the the or are or whether they are to the and the patients be in or to the authors have to the in the research and each and the of to a in accuracy with The authors report crude agreement and interquartile range for their validity analysis. What part of a distribution is described by the interquartile range? List other statistics used to describe the validity of a measure and why they might be preferable to reporting crude interquartile range to the of a of is a that represents the the to the this is the and the the can be by the to the that a distribution the is used to these The is the the the and the the The is the difference between the and is a by than the range of a and it is data are in the of a the and are to and and the the or you the to the and you the or a to in the research and did the authors report the percentage agreement with the âcorrectâ by the criterion agreement is a for a reliability is the to describe this validity assessment of a observer with a criterion that are to a validity report statistics such as and or reliability such as percentage agreement or et al contains 2 parts, a comparison of the values gathered by trained research assistants and physicians historical information in chest pain and the comparison of these participants' recordings with a âcorrectâ value for each For each part, indicate whether the authors are studying reliability or validity and explain the difference between these The part is assessment of and the is assessment of The between reliability and validity is the that the in a that a a The reliability of a to the agreement the the or assessment of validity a observer a or the criterion standard is to be validity studies report the of the observer statistics such as and or reliability such as percentage agreement or What did the authors use as their criterion standard for the validity the and the research it is that their is they a research the of the 2 is What are potential problems with their method of defining the standard? Can you think of alternative a standard for this is For can be 2 the and is For a you have pain in the might that is a for in the is a might that is its the with What is the criterion standard for this the the have or the the information The of is that have to the emergency have the of reporting part of a to their and the the a be or the other of the physicians the in a that to the or or in the a the the or are or whether they are to the and the patients be in or to A the authors have to the in the research and each and the of to a
âBad times have a scientific value. These are occasions a good learner would not missâ Ralph Waldo Emerson (1803â1882) MRI contrast agents have been routinely used to enhance various structures, organs and lesions in the body for over 20 years now. There is strong evidence that these agents are highly efficacious, and routine clinical practice seems unthinkable without them. Almost all MR contrast agents are based on chelated heavy metals from the lanthanide group of elements, mainly gadolinium (Gd3+). Gadolinium is a rare earth metal that is known to be highly toxic in the free, unchelated form. However, when caged in a chelating molecule (from the Greek âÏηλαÎčâ, meaning âlobster clawâ), gadolinium chelates can be safely administered by means of intravenous injection because the kidneys rapidly excrete them. Since the late 1980s, many toxicological and pharmacokinetics studies have been conducted by the major contrast vendors with various gadolinium-based contrast agents (GBCA). In all of these studies an extremely favorable safety profile was found. Therefore, the recent discovery of the association between administration of GBCA and nephrogenic systemic fibrosis (NSF) came as a surprise to almost everyone involved, although in retrospect maybe we should not have been so surprised. Perhaps after giving GBCA to over 200 million patients and rarely experiencing any adverse effects of any kind, we thought we could administer these drugs with impunity. On the other hand, would we not expect some adverse effects eventually to surface? We were injecting a heavy metal (albeit as a chelate), in ever larger doses, often multiple times, and often in patients with severely compromised renal excretion, knowing that these agents were primarily excreted by the kidneys. NSF is a rare, idiopathic systemic fibrosing disorder and is characterized clinically by pain, dermopathy, and joint contractures. NSF affects the skin, skeletal muscle, esophagus, lungs, heart, and kidneys. The first suggestion of the link between GBCA and NSF by Grobner et al. 3 years ago (1), sparked intense interest in this subject, illustrating just how important MR contrast media are today. It is now clear that NSF is a condition that almost exclusively affects patients with severely limited renal function. However, despite the deluge of publications on this subjectâas of October 9, 2009, there were over 438 publications available on PubMedâsurprisingly little is known about the exact pathogenesis of the disease, and who exactly is at risk for developing the disease. The discovery of NSF has been unfortunate for patients, and particularly patients with acute or chronic kidney disease (CKD) with severely impaired renal function. Worldwide, regulatory agencies have issued warnings on the use of GBCA in patients with severe CKD, which has led to a virtual cessation of use of contrast-enhanced MRI in this vulnerable patient group. Patients with CKD are a difficult population for the imaging community. MRI has always been and remains of high value in this patient group, because it is well known that administration of iodinated contrast agents is contraindicated, especially in the presence of residual renal function. Because of all the attention NSF has attracted, many clinicians are now ordering CT examinations instead of MRI. Many radiologists have experienced situations in their own practices where contrast-enhanced MRI examinations on their patients have been substituted with contrast-enhanced CT because of fear of NSF with GBCA-MRI only to have these patients go on to develop renal failure due to contrast induced nephropathy (CIN). While the desire to avoid NSF is understandable, care should be taken that contrast-enhanced MRI is not withheld in more patients than absolutely necessary. Paradoxically, the current FDA advice to only give GBCA to patients with estimated glomerular filtration rates (eGFR) greater than 60 mL/min/1.73 m2 may do more harm than good as there is no evidence of NSF occurring in patients with eGFR >30 mL/min/1.73 m2. The FDA guidelines can lead to patients in the eGFR 30â60 mL/min group being exposed to the high risk for negative effects from the administration of iodinated contrast agents, even though they have a negligible risk for development of NSF. Furthermore, whereas the FDA regards all GBCA as having an equal risk for inducing NSF, the FDA guidelines take no account of the chemical structure of the compound, and especially of the kinetic stability, which seems to be an important factor to consider. To date, no unequivocal NSF cases have been reported in patients who exclusively received macrocyclic agents with high kinetic stability, although some reports have suggested this possibility (2) . It is indeed highly likely that there is a relation between GBCA and NSF. The incidence of biopsy-confirmed NSF cases has dropped to nearly zero after the FDA warning and the institution of similar measures by the European Medicines Agency and similar regulatory bodies in other parts of the world. There have been no cases of NSF with onset after August 2008 reported by any of the GBCA vendors. Convincing proof is lacking that NSF can develop without administration of GBCA. NSF only occurs in patients with severe renal impairment (eGFR < 30). The few cases of NSF in cases with eGFR > 30 have been in situations of acute renal failure where the GFR was decreasing rapidly and did not accurately reflect renal excretory function (4, 5). Accumulating evidence suggests that GBCA with low kinetic stability confers a higher risk for NSF (4, 5). No unequivocal NSF cases have been reported after sole administration of GBCA with high kinetic stability. Higher cumulative doses of low kinetic stability GBCA confer a higher risk for NSF in patients with severely impaired renal function (6-8). Risk is relative, not absolute. Not only is the risk of NSF with GBCA-MRI small compared with the risk of CIN with iodinated CT, but also with risk of severe allergic reactions with iodine and allergic reactions with GBCA. The concern about NSF has masked our concerns for GBCA's other potential adverse effects. A survey of major American centers published in 1999 by Murphy et al indicated an incidence of severe allergic reactions to GBCA of approximately 20 cases per million doses administered (9). This is approximately 10-fold greater than the incidence of NSF. And what of the risk of making an incorrect diagnosis because the most appropriate imaging study was not done? Why do some patients with severely impaired renal function get NSF, whereas others, with similar degrees of impairment, do not? In fact, the vast majority of patients with severely impaired renal function do not get NSF, even when administered a high dose of low kinetic stability GBCA. This remains one of the most puzzling questions in the NSF saga. Which patients need to be screened for renal disease, and what is the safest and most cost-effective way to do this? Is a questionnaire sufficient? Or does every patient need to have their creatinine measured before a contrast-enhanced MRI examination can be performed? Or should laboratory screening only apply to certain subgroups of patients? Is the class of macrocyclic GBCA inert regardless of renal function, and can they be administered safely in patients with stage 4 and 5 CKD without causing NSF? At what level of renal function do the risks for NSF outweigh the risk for complications associated with administration of iodinated contrast agents? In other words: Is the newest generation of iodinated contrast agents safe or unsafe in patients with CKD? Can these agents be administered safely? In this special issue of the Journal of Magnetic Resonance Imaging, we present a series of review articles with the aim of summarizing the current knowledge about NSF in relation to administration of GBCA, and to answer some of the questions posed above. The issue begins with a summary of Dr. Jeff Weinreb's excellent keynote lecture as given at the 17th annual meeting of the ISMRM in May of this year (10). Subsequent articles cover a wide variety of related topics, ranging from a basic primer on gadolinium chemistry (11), the role of thermodynamic and kinetic parameters in gadolinium chelate stability (12), the biodistribution of GBCA, including gadolinium deposition (13), and biological effector mechanisms (14-16), to the clinical spectrum of NSF (17), to practical insights on measurement of renal function (18) as well as a review on how to remove gadolinium by dialysis (19). We present current guidelines for injection of GBCA as used in the United States, Canada, Europe (20) and Japan (21). Furthermore, risk factors for NSF are reviewed (22), and NSF is discussed in the context of renovascular (23) and liver disease (24). The issue of relative risk of NSF versus CIN is addressed in the excellent review by Martin and other experts on this topic (25). Finally, retrospective reviews of data from China (26) and the United States (27) confirm the safety of low-dose contrast-enhanced MRI, even in patients with renal impairment. It is our sincere hope that the material selected for this special issue will help with the further understanding of the relationship between the administration of GBCA and the development of NSF, and that the material in this issue will form the basis for further research and subsequent rational choices in patient management that ultimately lead to better clinical care for patients. We hope that by bringing together the most recent insights regarding the pathogenesis and strategies on how to avoid NSF in patients at high risk, contrast-enhanced MRI will again be used whenever indicated, except in that very small number of patients that are truly and significantly at risk. As Emerson eloquently stated: âBad times have a scientific value. These are occasions a good learner would not missâ. We extend our gratitude to Dr. Leon Partain, Editor-in-Chief, for his support for this project and his insightful suggestions, and to the dedicated and skilled editorial office staff Martha Tanner, Barbara Sammons, and Kerry King. Finally, we would like to thank the contributors, all of whom are highly regarded experts in the field, for their time and effort to create this special issue of the Journal.
BACKGROUND: In recent years there have been innovations in immunization financing and new technologies, and the scaling up of investment by the Global Alliance for Vaccines and Immunization (GAVI) in the Asia region. The main mechanism for coordination of this global health initiative (GHI) investment is country-level 'Inter-Agency Coordination Committees' (ICCs). AIM: The aim of the evaluation was to determine the utility and future perspectives of stakeholders regarding the role of ICCs in improving immunization services in the Asian Region. METHODS: A literature review, documentary analysis and semi-structured interviews (n = 65) were undertaken in five countries (India, Bangladesh, Nepal, Sri Lanka and Indonesia), with senior level members of Ministries of Health and the GAVI partnership. RESULTS: The evaluation has identified that there have been significant changes recently in the strategic environment for immunization, including developments in new vaccines, increasing GAVI investment, trends towards health system integration and decentralization, and institutional development of the non-government sector. This evaluation found that ICCs are functioning well in relation to information sharing and GAVI application processes. However, they are performing less well in the areas of evaluation, strategic gap analysis and coordination of immunization technical co-operation. CONCLUSIONS: There are high levels of institutional and contextual complexity at country level that require a more focused global response by GAVI to the governance challenges of institutions and partners implementing GHIs at the country level. ICCs should be maintained and strengthened in the more pluralistic context of an 'immunization coordination system' that is represented by the wider health sector, regulatory authorities, and civil society and private sector interests. Managing through systems, rather than being over-reliant on committees, will broaden participation in implementation and, in doing so, expand the reach of immunization and maternal and child health care services in developing countries.
This paper analyses health reforms in Tanzania since 1924 to 1993 to determine how each paradigm influenced the next by using the recent World Health Organization (WHO) framework of health system. Published and gray documents were reviewed and analyzed for the four discrete attempts at reforming the health sector, focusing on the district health system decentralization. The findings revealed that for each wave, there was a review of the health system, making information from preceding efforts to be available to the subsequent reforms. After independence the political party in power played a major role in ensuring availability of information and its utilization. Predominant information in each wave showed that the health system was underfinanced, there was poor performance of PHC strategies, non-integration of DMO and poor health workers income. Health reforms should focus on health system finance, integrated district health system, health workers welfare and community participation.
My 90 years have witnessed a basic transformation in the understanding of disease in terms of molecules, largely through the application of new instruments and technologies. The ultimate distillation of what really works at this levelâthe quantitative measurements that generate clinical insight from specimens like bloodâis clinical chemistry. This field has fascinated me for a long time, partly because of my interest in inventing or improving analytical instruments, and partly as an anchor to real-world biology that is frequently missing in academic research. A second thread of interest to me is how successful research gets done, and how to know when a solitary inventor is needed and when it takes an army. Here I recount some personal experiences relevant to these interests, ranging across several fields and in organizations of widely varying scale, all ultimately linked to clinical chemistry and the human proteome. Interdisciplinary R&D has always fascinated me, and my introduction to it occurred in unusual times, during World War II. I was on active duty in the US Navy before Pearl Harbor as a Photographerâs Mate 2nd Class, and was discharged at the warâs end as a Lieutenant (jg) line officer, with zero instruction in between on how to be a naval officer. Despite (or because of) this fortuitous absence of formal tuition, I found that much of the fun and adventure in life lies in the cracks between disciplines, and that these cracks can be wider in large organizations (like a Navy in wartime) than smaller ones. Flying in blimps off the Carolina coast during the height of antisubmarine warfare, it occurred to me that maybe, lacking a bombsight, we couldnât actually sink a German submarine if we found it. After developing proper instrumentation, I found experimentally this was largely true, and a proper bombsight was developed. This was the start of a series of projects that put together all sorts of technologies, raised interesting questions, and whose results were usually translated into immediate action. Transferred to the Pacific and the submarine service, I worked as a movie photographer on a project to be called âThe Silent Service.â This was authorized by a personal letter from Franklin Delano Roosevelt, which proved to be a magical passport to getting things done far from home. As I was shooting background footage of 2 submarines I had arranged to do the required postrefit maneuvers, a radioman came topside to say that Truman had announced use of the atomic bomb. This ended the war and with it my introduction to interdisciplinary work with effectively unlimited resources. Suddenly I found myself at Duke University immersed in the culture of Little Science. I was taught (by a future president of the National Academy of Sciences) that proteins and nucleic acids were too complex to ever be sequenced, that chromatography, while interesting, could never be quantitative, and that no one knew for certain where and how genetic information was stored. The general attitude was very different from the âwin at all costsâ approach adopted in warâit was painstaking and slow, but it was biology. I began to realize I had been contaminated by the notion of Big Science, but felt I should learn to be comfortable at both ends of the Big ScienceâLittle Science spectrum (1). This pendulum has swung back and forth for me several times, and is an invigorating oscillation. Returning to the Big end, I obtained an Atomic Energy Commission (AEC)1 postdoctoral fellowship in the Biology Division of the Oak Ridge National Laboratory (ORNL). My PhD thesis had concerned subcellular components isolated using very simple centrifuges, and my hope at Oak Ridge was to extend this work to proteins in different subcellular particles using some new type of centrifuges, yet to be conceived. ORNLâs unprecedented facilities, with staffs running into the tens of thousands, included almost all disciplines of science and engineering. Almost anything one could reasonably imagine was either available or could be designed and built quickly, even if it happened to involve nonstandard laboratory supplies like large titanium forgings. The saying, âWhy use lead when gold will do?â reflects a little of the flavor. Separation, either physical (as in the case of uranium isotopes) or chemical (as was the case for plutonium), and accurate analysis were the key technologies at most of the Manhattan Project facilities. My initial laboratories were in the same valley that housed more than a thousand giant Calutrons (preparative mass spectrometers) used to enrich kilograms of U-235. After World War II, this facility was used to go straight through the atomic table, isolating and characterizing all the stable isotopes. I wondered if the same sort of effort and philosophy could be adapted to the comfortable field of biology? Could one ever separate the components of living cells into a âparts listâ for man? If so, it should provide a powerful way to study and ultimately understand disease. As it happened, the major nuclear weapons laboratories needed new missions after the success of the Manhattan Project. I suggested one in the winter of 1959â60 entitled âThe Cell Fractionation Project,â an effort to separate and characterize all the molecules in cells, which much later became the Molecular Anatomy Program. It appealed to nearly everyone at ORNL except my fellow biologists, who did not like big projects (unless it was mouse genetics). We had thought about sequencing DNA but were assured by biochemists that, while RNA could in theory be sequenced, DNA simply could not be for purely chemical reasons (this was before the discovery of restriction enzymes or dideoxy sequencing). So the thinking focused on proteins. Protein fractionation had been advancing on multiple fronts during the preceding decades. In the 1930s and â40s, Svedberg had developed the analytical ultracentrifuge which showed, unexpectedly, that proteins had well-defined masses, and Tiselius, who once described to me how he had inadvertently left his gardening shoes on when he went to hand out Nobel Prizes, had developed electrophoresis by which plasma proteins could be classified into 4 discrete groups (albumin and the famous α, ÎČ, and Îł globulins). By the mid-1950s, Sober and Peterson had begun to fractionate proteins on cellulose columns, and Waldo Cohn, who had pioneered separating fission products on ion-exchange columns at Oak Ridge, began to work on nucleic acids, convincing Moore and Stein to use ion exchange in place of starch columns for amino acid analysis. Precipitation was explored in parallel by Gerhard Schwick at the Behring Institute in Germany. He isolated dozens of human plasma proteins, made antibodies to them, and distributed these worldwide. This approach with distributable reagents allowed specific protein assays to be performed on clinical samples, thus starting immunodiagnostics on the present road to broad coverage of the human proteome. While largely forgotten in the field of proteomics, this effort has survived through multiple commercial marriages with Hoechst, then Dade Behring, and finally Siemens Diagnostics. My own work really began with the invention of the zonal centrifuge (2) to fractionate subcellular particles. In this device, the volume limitation inherent in swinging bucket gradient separations was surmounted by using large, hollow, bowl-shaped (zonal) rotors. In these, gradients and samples were caused to flow through rotating seals into a rotor spinning at low speed and then accelerated to maximum speed to effect a separation based on either sedimentation rate or isopycnic banding density (or, in later designs, both). This was followed by deceleration to a low speed and recovery of the gradient as isolated fractions by displacement from either the center or the edge. I had designed and built a slow and crude proof-of-principle zonal rotor and then had arranged to have one built commercially, which was unfortunately unstable at high speed. Instability of a large rotor at 40 000 rpm, especially if it leads to catastrophic self-disassembly (a phrase we adopted from Los Alamos, which knew about such things) is undesirable. We needed real engineering expertise in rotating systems, an unusual discipline but one that was by chance very popular at Oak Ridge. Gas centrifugation for uranium enrichment had been tried and abandoned in 1943 because of its high cost. Subsequently it was discovered that a captured German Luftwaffe engineer named Guernot Zippe had designed for the Russians a remarkably simple centrifuge that used very little power and was surprisingly efficient. The need to catch up with this development accounted for the presence of an engineering staff working at top speed (in all meanings of the phrase) in Oak Ridge. The resulting urgency, money, and minimal administration helped as usual to eliminate the curse of delayed gratification, chief destroyer of creativity. We built (and sometimes blew up) a lot of centrifuges, and they became progressively better at separating biological materials. In the early â60s, Robert Huebner of the National Institute for Allergy and Infectious Diseases and others found that many animal cancers were caused by viruses, especially if the viruses were given to newborns. Numerous groups were set up across the US to attempt to isolate cancer viruses, grow them in culture, test them in primates, and see if a cancer vaccine was possible. When these efforts failed to find culturable human cancer viruses, I suggested to Huebner that we try to isolate them by physical means, using density gradient centrifugation, instead of relying on growth in culture. If this were successful, then similar physical methods could be used for large-scale purification of virus for a vaccine. The US Food and Drug Administration (FDA) was insistent that any killed virus vaccine should contain no (or at least very little) cancer cell DNA to be sure that the vaccine itself did not cause cancer. To make a pure virus vaccine for large-scale human use by physical means would require a liquid centrifuge of a size never before built. Testing these systems required large quantities of virus, and neither Sabin nor Salk, who were very cooperative, had poliovirus in the quantities we needed (milligrams rather than infectious doses). Initially we settled on seawater obtained from the Woods Hole laboratory and discovered to our surprise that the ocean has about the same viral load as a viremic humanâs blood (3). For more realistic development, though, we obtained a batch of human viral vaccine that did not meet FDA standards and thus could not be sold. To avoid risk of viral contamination to ORNLâs enormous mouse genetics facility, we relocated the centrifuge development program to the most distant site available on the Oak Ridge reservation, which was, fortunately, right next to the giant Oak Ridge Gaseous Diffusion Plant, locus of the gas centrifuge project. Our âlabâ was a mothballed power plant, whose Manhattan Project pedigree was visible on the wall as a framed single-page purchase order for âOne coal-fired steam-driven electrical generating plant, 237 megawatt.â It had railroad tracks coming in one end of the 100-yard long main floor and a 30-ton overhead crane for moving large equipment, among other conveniences. We needed a general theory on which to base our search for viruses in tissue homogenates. To see the possibilities of such a separation, I plotted the sedimentation coefficient S against the banding density Ï for viruses and for the major subcellular particles and discovered that viruses generally are found in the middle of this plot in an otherwise thinly populated area away from nuclei, mitochondria, proteins, etc. (4). This plot was key to the whole project, and it suggested that we combine sequentially rate and banding techniques into one 2-dimensional (2D) SâÏ separation. This theoretical plot was converted into a real one in which bacteriophage were recovered from rat liver and other tissue homogenates (5), perhaps the first integrated high-resolution 2D separation in biology. As it became clear that no cancer viruses were being found around which to design a vaccine purification system, I decided that we should work on an existing vaccine that required better purification. We would thus be ready if a human cancer virus was actually found. At that time, egg-grown influenza vaccines contained appreciable amounts of egg proteins, resulting in many deaths from anaphylactic shock each year and the requirement that they be given under close medical supervision. We approached Eli Lilly about designing a centrifugal system specifically to purify influenza vaccine. Their batch size was 100 L, and the purification run had to be completed in an 8-h day. Knowing these parameters and both the sedimentation coefficient and banding density of influenza, it was possible to design a rotor system that used continuous flow to band the virus from 100-L batches in a narrow gradient that could be recovered at the end of a run. The result was the K-II continuous-sample-flow-with-banding ultracentrifuge (6). Use of this centrifuge essentially eliminated vaccination deaths from anaphylactic shock and allowed vaccination in supermarkets under minimal supervision. Almost 40 years later, it is still in use around the world with minimal modifications for vaccine manufacture, and we have recently proposed its use to isolate the viral load from 100-L batches of pooled diagnostic serum discarded in clinical reference laboratories each week (7). The viral DNA and RNA, concentrated and free of host nucleic acids, could then be shotgun-sequenced to screen for new viruses, while providing a running index of the known viruses âgoing around.â separations of cell components many To specific across these we used from clinical chemistry. I once to had most of the that be some other way to clinical chemistry. He that this was not possible. I thought about this a It was my introduction to clinical and clinical chemistry. The was to a system for between samples and reagents in parallel rather than It out that centrifugal is an way to and liquid while at the of a rotor spinning a provide measurements that very accurate The rate was in that we needed to a like the to it. these in the early was given ORNLâs but we that a a caused no The resulting was named the Energy centrifugal It was a commercial success for and and in many it did to the and it still be the system for very accurate The the rotor of an early centrifugal system At right is a of the system used to and measurements from at the of the spinning in during one of the Despite the success of zonal and the centrifugal the National that human cancer was to viral with interest in me to to the University of I was to be in by my who had completed a PhD at the University of under Nobel and done a with had famous on 2D electrophoresis and had the we set up a laboratory and a research to the most we ever had worked out a which was, of a In a system and the major plasma proteins by with the whole of Behring The of plasma proteins, called was many and Protein on were clear We found the 2D of plasma proteins to be and to an but it was more to a than a clinical 2D plasma and serum from the same The and the and on with This was in of plasma proteins, The plasma and genetic 2nd It became clear that to 2D we needed once the of a National and this with an to the biology at For several we worked in during the week and at on designing together what we called the system for and running large of 2D in parallel Our initial analysis system was an designed to 2 by between them, a used by to the This was by an and large for these we explored the protein called of human as as rat liver and many other We were to host the first 2 major on 2D first at and the second at the both as of (in and The results at these 2D are in some surprisingly similar to the of with the of protein using mass perhaps was before DNA we felt that of all the human proteins by cell fractionation and 2D electrophoresis was the way to in biology the effect that the had in chemistry. This was as the Protein at providing a for and ultimately what is systems biology. an effort would require large and so, with several we suggested of a Protein the general we had in Oak Ridge, to and this who was the of the US at the time, was in research with on and on in his in the on these a Protein was and in a was out the and size of a on the human and a new of much to and more to the the National Laboratory it that study of proteins was to a in the that time, the in biology to the Big Science approach of the National We left in and set up Biology to 2D and protein index and the the years a with in protein and finally a successful initial in the year an 2D electrophoresis system running 100 we explored in rat the of and to the of human a approach we had developed at Oak Ridge we the first columns that the plasma proteins used as the of the system columns with fractionation the of 2D from the most plasma proteins to more than The of mass for protein allowed finally to all the or we had in of and analysis quantitative of in specific protein this I to a in centrifugal systems, developing a large-scale centrifugal for and a centrifuge for viruses from clinical samples, banding them or them in to a plasma This has to and concentrated viruses from serum in about 2 in quantities that the of thus the way and sequencing of human viral it is a little for my own the broad of a approach to understanding the human and it for has recently begun to To start the of a human has the means to the proteins, and perhaps most that are really about of them rather than the 100 000 we were once to the and to on a protein of each this like a to at a or several large-scale are with an effort to the of all the proteins. because is really this is being done at Big Science like the at (in a large The resulting should provide a for understanding and thus the of cell and In and are of a project antibodies to each human and then to see where these proteins are in and success in this a broad for major clinical in will be the to be protein real with clinical to be into A new of mass for is that can ultimately in terms of and while and this it possible to specific assays for proteins starting from a and project to quantitative, and specific assays for all human proteins a of assays in the present protein and even into the clinical laboratory mass is for better of and It to me that this of project, up basic clinical research and clinical chemistry at the same time, is even more than the human and for a of Big Science thinking in the protein If all this to it will a in clinical it at the of biological and at the of clinical would be Atomic Energy Oak Ridge National US Food and Drug Energy Protein Biology initial and they have to the of this and have the to the and of or analysis and of or the for and of the of of any of of The organizations no in the design of of and of or or of I in to the of I have not and I my many and for at Oak Ridge, and through the especially of which extend through his
At a time when the Obama administration, the rest of the G20, and other governments, are emphasizing multilateral action to address global problems, such as global warming, terrorism, financial regulation, monetary policy, failed states, and public health, much is at stake in theoretical and empirical arguments about the possibility for effective collective action among groups of states. In The Perils of Global Legalism, Eric Posner argues that these efforts are largely futile. Can it be true that international law offers little or no assistance in response to global collective action problems? Posner grimly asserts that âif a world government is not possible, then solving global collective action problems is also not possibleâ1 (at 8). If he is right, and given that the kind of world government he has in mind is indeed implausible, then the efforts of policy-makers and diplomats should immediately be diverted from efforts to craft international legal responses to global collective action problems, and reallocated to more productive pursuits. The implication of Posner's book: call home the diplomats and be content with the inefficiency implicit in unilateral action to address global collective action problems. From one perspective, this book might be viewed as a welcome dissenting voice amid general calls for more international law, and it rightly rejects what are by now caricatures of the American and European idealists who believe that the world could be perfected if only we wrote and complied with the right laws. Indeed, international law is not a nirvana solution to all our global problems, but merely part of the toolbox of practical political efforts to improve our situation. Posner has applied his considerable analytical talent to the question of when and how international law may be useful. He has no doubt provided a provocative and interesting book. The problem is that Posner is not content merely to show the flaws in the idealistic general argument for more international law. He goes on to make a general argument against more international law. I do not believe that it is possible to make a general argument either for or against more international law. More refined and context-specific analysis will be necessary to know whether more international law is or is not useful in particular contexts. But there is little doubt that international law has been, and will be, useful to solve some global collective action problems. This utility is just as clear as the utility of contracts to solve some inter-firm collective action problems and the utility of social institutions to solve some village-level collective action problems, as shown by the 2009 Nobel economics laureates, Oliver Williamson and Elinor Ostrom, respectively. Posner defines âlegalismâ as âthe view that law and legal institutions can keep order and solve policy disputesâ (at 21), while âglobal legalismâ is âan excessive faith in the efficacy of international lawâ (at xii). Posner describes American-style global legalists as overestimating the social value of international law, and therefore overestimating the reciprocal, retaliatory, or systemic costs of violation, with the effect that they overestimate the effectiveness of international law. How does Posner know that the legalists have generally overestimated the value of international law? Neither he nor they has the necessary context-specific data. Instead of presenting context-specific data, Posner makes a general theoretical argument that multilateral international law has little value to solve collective action problems (as contrasted with coordination problems, where there is by definition no reason to cheat), because it is generally ineffective to do so. For Posner, European-style global legalists simply make unwarranted natural law-based presumptions requiring unmitigated compliance with international law, even where, all things considered, compliance is not beneficial to the acting state. Posner ascribes a progressive vision to these global legalists, stating that the central tenet of global legalism is âfaith that if international law advances then eventually true international law-enforcing (and eventually law-making) institutions will follow in its wake, and then people will transfer their loyaltyâ (at 91, emphasis in original). More international law leads to more international institutions, which together lead to a transfer of loyalty and thus global government. Posner rightly rejects this millennial dialectic. But this is a straw man and in my experience very few, if any, European international lawyers or âliberalâ American international lawyers believe in this dialectic. And while we will not soon have global government of the kind Posner envisions, we need to know whether international law offers possible mechanisms to deal with practical, on the ground, global collective action problems. For Posner, a certain scale of institutional infrastructure, and a transfer of loyalty to a world government, would be necessary before international law can be effective. In this way, Posner's views are aligned with the most romantic, pie-in-the-sky, idealistsâthe only difference is in Posner's pessimism that this romantic vision can be achieved. He sees the transfer of loyalty as necessary to the establishment of a world state, and he sees a world state as essential to the effectiveness of international law. Posner fixates on the state as the exclusive repository of authority and loyalty, and thus argues that it is necessary that there be a world state in order for international law to have strength (at 128). Unlike most international lawyers, his evaluation of existing international law and institutions, and his view of the future, do not identify or anticipate possible centres of authority, and the possibility of law or government, outside even if not in place of, the state. For Posner, international law is generally epiphenomenal in connection with multi-state cooperation problems.2 As part of this fixation on the state, Posner argues that the biggest problem with global legalism is that it espouses law without government. For Posner, in order to have law, you need government in the form of the traditional institutions of the state, including fully empowered legislatures, judiciaries and executives, as well as a monopoly on the use of force. He posits that âif it is true that national governments are needed to solve national collective action problems, then it seems that it would follow that a world government would be needed to solve global collective action problemsâ (at 8). Consider this syllogism. The premise is debatable, and its extension to the international setting is dependent on a highly questionable, and unsupported, assimilation of the international setting to the domestic setting. That is, even if we accept that a certain type of institution is needed within the state to solve intra-state collective action problems, it cannot simply be assumed that precisely the same institutions are needed or appropriate to solve international collective action problems. A parallel, and equally faulty, syllogism would state that âif it is true that humans need oxygen tanks to remain under water, then it follows that oxygen tanks would be needed by fish to remain under waterâ. In order for this syllogism to be true, a fish would have to be the same as a human with respect to the relevant characteristic. But Posner offers no evidence that the international setting is the same as the state in the relevant characteristic that concerns him. Based on this faulty syllogism, Posner does not allow that collective action problems might be solved by a variety of institutional mechanisms short of a kind of global government modelled on a strong national government. He neglects the possibility of a Coasian choice between the firm and the market â between integration and contract â to solve collective action problems, but insists on integration as the only basis for resolution. He seems to entertain no possibility for nuance or for distinct institutions that may be appropriate for distinctly international collective action problems, or for the distinct international context. In fact, he seems to see no difference between the role of law in the international context as compared to the domestic context. But while for Posner the dynamics of the international and domestic contexts are the same, there is for him a critical difference. The difference is that the domestic setting contains institutions that solve cooperation problems, while the international setting simply does not and will never do so. Posner thus purports to draw âa crisp analytic distinction between intrastate cooperation, which is capable of solving major nation-level collective action problems, and interstate cooperation, which is itself subject to collective action problems and thus cannot solve them, except in a very rudimentary fashionâ (at 7). He argues that âglobal collective action problems cannot be solved â or not very wellâ (at 7â8). Note his evaluation: what exists or what can be is only ârudimentaryâ or ânot very goodâ. How can he know that what exists is not precisely what states wish to exist? A fundamental point in Posner's argument is that we âcannot solve global collective action problems by creating institutions that themselves depend on global collective actionâ (at 34). This glib assertion is patently false: consider as an example the formation of any constitution â constitutions themselves depend on collective action, and they are used to address collective action problems. In domestic society, and in all other social contexts, the creation of institutions always depends on collective action, and always is intended to solve collective action problems. Similarly, Posner later emphasizes that âit is the conceit of global legalism that people â ordinary people, government officials, bureaucrats â will obey law even though they would not obey or consent to the international versions of government institutions that we all agree are necessary to make law workable at the domestic levelâ (at 128). Here, Posner makes the additional error of extrapolating from the domestic context to the international context without recognizing contextual and teleological differences. The result is the breathtaking assertion that international law, to be effective, requires the same supporting institutions that domestic law has. Furthermore, when Posner specifies that the type of institutions for enforcement of law found in the state are the only adequate ones, he assumes a very idealized and narrow set of institutions available in the state for enforcement of law. A quick survey of comparative politics and comparative constitutionalism would confirm that state institutions are actually quite varied and malleable, and nuanced, even within the narrow category of advanced liberal states. And the literature of social norms, led by Robert Ellickson, shows how in domestic society rules can arise and be stable and effective without formal organizational support.3 Institutional economists distinguish between institutions, which may be formal or informal, and organizations, which are formal. Posner seems to consider that only organizations, of the type found in the state, are sufficient to support international law. An institutional economist surveying the existing field of international law would find a rich variety of institutions, including organizations. The rich literature of international regime theory, pioneered by Robert Keohane, recognizes the critical role of informal institutions in international society. So, while it is true that law requires institutions, or more accurately that certain types of law will be more efficiently made and enforced with certain types of institutions, we cannot move from there to the proposition that the government organizational features found in the state â indeed in Posner's idealized state â exhaust the category of institutions that may be effective to support international law. A social scientist examining international problems of cooperation would not take the top-down approach of asking whether there is a need for a global state that simply replicates the organizational features of the strong national state. Rather, a social scientist would take a bottom-up approach, examining each type of cooperation problem separately, in order to determine which institutional solutions would resolve strategic or transaction cost problems endemic to that problem. Only after examining the range of international problems, and their individual solutions, would a social scientist go on to examine the need for institutional or organizational responses and the potential synergies among the solutions. In this way, we might say that the state, with its wide range of internal subsidiarity, as well as its capacity to enter into international legal arrangements, is only a first approximation of the level at which collective action problems might be addressed. Posner says that the organizational features that are missing at the international level are legislatures, enforcers and adjudicators. And a cursory examination of the broad international legal system will confirm that there is little that looks like the organizational features of a strong state. At the multilateral level, there is no real parliament and no sheriff, and there are few courts of mandatory jurisdiction. And yet, the social scientific question is not whether there are institutions with these labels, or these formal functions, or that look like an idealized set of domestic institutions. State-type institutions are not the exclusive means to resolve collective action problems, even within the state. The social scientific question is whether there is a sufficient institutional structure to have the desired level of behavioural effect. And the appropriate reference is not the idealistsâ desired level of behavioural effect, but the level of behavioural effect sought and agreed upon by the states parties. While Posner is obviously right that there is no world government modelled on strong national governments, it is not necessarily so that there is no world government at all. Much depends on what we mean by âgovernmentâ. If we mean a formal set of institutions (including, but not limited to, organizations) that have some degree of legislative, adjudicative, and enforcement power â sufficient to affect behaviour â we already have that in international society. States follow agreed rules regarding legislation through treaty and custom, they adjudicate international law, and they enforce international law. As to mechanisms for legislation, while at the international level most of these require unanimity, all sorts of devices, including package deals, log-rolling, payoffs, and other mechanisms, are available to induce states to agree to rules that may not otherwise be in their narrower interests. While there is indeed generally no sheriff to engage in enforcement activities, there may be and other enforcement While there are few courts of mandatory there are and in some there are other of more or How does Posner know that this set of mechanisms, with existing international law, has no behavioural how does Posner know that this set of mechanisms is not precisely what states to to global collective action problems, given state one can say whether the existing international law institutions are responses to government but nor can that they are without the transaction costs or strategic problems that to remain or that they in to the of states. If Posner has a for a of a particular level of institutional or power to affect it is not in this book. If he has a to know that the level of that exists is to the that states to it is not in this book. So, it is simply to that the institutional structure for international law have the and power of a strong national state in order to be effective. that Posner's question is whether international law can address international cooperation the question is not whether this system looks like a domestic but whether it has the to address international cooperation by and to Posner's are distinct from cooperation How are they as Posner international cooperation compared with domestic cooperation will generally of individual of and and social This is implicit in the of we to do at the state level what is at the state level, and we to do at the international level what is at the international The of actually that cooperation at the international level be from cooperation at the domestic In international cooperation problems that can be by international law the behaviour of governments, and not the behaviour of so it would indeed be if domestic appropriate for use in the behaviour of the same needed to the behaviour of states. the structure of international cooperation and the structure of international society, that we would see institutions for cooperation at the international is no need for a world state to in order to have international law with real social effect. is no reason to that international formal institutions for legislation, and would look like domestic that international government would look like a world state. Posner has no reason to know that the types of institutions in in the international legal system are to address the collective action problems that states wish to He has no reason to know that if states their and to address collective action problems, they would be to do so. He has no reason to know that if states that it would be to additional institutions in order to have more effective law, they would be to do so. At the of this book is Posner's argument that international law is generally ineffective to address international collective action problems. He states (at that that cooperation to solve global collective action problems will be Neither this nor his does much to this theory, and analysis shows that no such For Posner, while world government is it as the of states in the world and the of states in the world seems to be Posner posits that there will be for cooperation as the of states because these states would necessarily be and therefore to public at the level when the level is their may also be social and more international law may for Posner the is that as the of states cooperation is does an of states mean that effective international law is this is central to Posner's it is not and in fact, while it is to be true in some particular it cannot be generally Posner (at that there is no basis for his stating that he that compliance with the of states, this is central to his Indeed, as and have shown in in response to by Posner and compliance with international law could either or with the of states on other For in the of public where the from the public with the of states that cooperation will more as the of states So, there will never be the Posner that compliance with international law generally with the of states. In fact, there may be reason to the effect. Posner posits that for cooperation will arise from a of states. This value of cooperation would make cooperation more not Furthermore, even if we accept Posner's assertion that cooperation generally more with more states, he has no of which effect is the value of cooperation or the of So, even if we to accept Posner's that cooperation generally more as the of states this effect makes it to draw the by that cooperation if Posner right in theory, cooperation with the of states, we have no of the of the or where we are on the might be that the effect he of is very at states, and only at states. this type of there simply is no of In fact, if we follow Posner's approach, is it that the for human cooperation not at the of Elinor the Nobel for 2009 for that they How we to the state with of How is it that the States and formal cooperation among its it Posner argues that there is a to the in the for cooperation to the of cooperation as the of states (at But he also that there is a to the right of the to the for cooperation by the same of states. He has no of the or of these So, even Posner's it is as that the level of cooperation would remain the same, or as it is that it would is no theoretical or empirical basis for Posner's pessimism regarding the social of international law. diplomats just Posner's is that international law has with collective action problems because it what he views as the needed institutions. He no evidence that the global has failed to solve the collective action problems it has desired to in he with a to his the of the European from to The European is an example of states to strong international institutions, and solving a wide variety of collective action problems. Indeed, the European has collective action problems to institutions in order to collective action problems. As the of not all at or to a but to time to for law and institutions. the of the Posner with a has in a strong legal but for him integration the effectiveness of international law in the international system (at is not this point European integration has the capacity for international would be given Posner's view that by the of the does where it of its cooperation in the international system more possible, not way, behaviour in the international system about the utility of the European experience as a to Posner's The critical to which Posner does not is that has precisely what he says cannot be in the international of has of states, and of and exists in the this is all a of and Posner offers no of these would distinguish the European the of these would be a useful to our of the potential of international law and institutions. But Posner simply an between the European experience and the multilateral setting. Furthermore, it may well be that or international law will be the more for cooperation global or multilateral international it depends on a of to each particular is only natural that a of more states, such as the European would see in cooperation, and so would But is it that a of states would not see some in cooperation, and is it that this possibility is to Posner offers no theoretical or empirical evidence that it is as he The general international law with its rules of treaty law, of state is the institutional setting for international law. But where cooperation can be with or with by organizational or other institutional states to do so. This is the of the European of the and indeed of all international to for that as in the European to legislation to address collective action problems, and in with the European it to be that would be useful in the global regime to make more or to against excessive and in with the of the it broad institutional features to on the as its approach to the establishment of institutions. The problem with Posner's is that it rejects on the basis of a and it that legal and institutional solutions to our multilateral cooperation problems are the of human society, with its of our for cooperation the broad of is or or has to determine to at of we have found to do so. it is true, as Posner that international cooperation is not necessarily or to and it is useful to have his response to any idealists who see international law as a for the problems. the argument in this to that international cooperation is or at (at because we simply do not and can never the appropriate institutions. as world there may well be in which states would from international The of The Perils of Global is that its pessimism about the possibility for cooperation, if it could our of and we cannot to the between and
Regional form of Organization of the health care that are called today DyPE, have as a main \ngoal to promote more rational resource allocation through decentralization in the decision \nmaking process. The concern for more effective and efficient use of resources devoted into \nthe health care sector renders hospitals a critical vehicle of the quest for superior economic \nperformance, especially if we take into our consideration their mounting over time deficits. \nEconomic performance is primarily traced through a set of specific financial ratios, which \nembrace important elements that constitute the substance of the financial well-being of \nhospitals as economic units. An array of financial ratios is critically reviewed and a \ncombination of them is proposed as a means of effective financial management. The later is \nnecessary to ameliorate the funding strain imposed on the health care system and especially \non hospitals. The financial performance is determined by the return on capital (profitability) \nin connection with the risk involved. Both factors determine the value created, which in turn \naffects the amount of financing attracted in the sector. The financial information available \nto the supervising regional bodies (DyPE), donât considered sufficient for their management \nto assess financial management of hospitals effectively. The lack of the appropriate economic \ndata is due to the fact that double entry accounting has not yet fully adopted by the economic \nunits that report to the corresponding DyPE. So, double entry accounting is prerequisite for \nreporting and monitoring acceptable financial performance. The later is vital in securing \nthat the financial needs of the health sector that are growing at an ever accelerating pace, \nare met.
The European Union (EU) is built on the federalist principle of subsidiarity, which we consider in the policy field of financial reporting. We attempt to answer the question, whether the current accounting regulation in Europe is sensibly balanced between centralized and decentralized decision making. Drawing on comparative accounting research to identify criteria for âlocal preferences,â we conclude that local solutions currently remain preferable for small and medium-sized companies. For them, a centralized solution would result in additional costs for at least some member states and their residents. Large international firms, in contrast, face an increasingly integrated capital market and rather need a central solution as currently implemented by the EU. However, recent developments in corporate finance may align local preferences on accountancy in the future.
Daily concentrate allowances for individual dairy cows are usually based on empiric models. These models are generally based on regression equations derived from population data and do not take into account individual and temporal variation. An application was implemented in common practice which consists of an adaptive model for estimating the actual individual response in milk yield on concentrate intake using individual real time process data. Before the application was implemented, a prototype was developed by a team consisting of biometricians, animal nutritionists and ICT application specialists. It was tested in an animal experiment and further developed into a proof of principal, which was implemented for testing in a common practical setting on a research farm. Because the results were very promising, a workshop was organised to introduce the concept to software, hardware and feed industries where they were challenged to participate. In the next collaborative phase with industry involvement the further implementation into a management system was stepwise: (1) technical documentation of algorithms, (2) programming, (3) verification of algorithms, (4) on-farm implementation of the integrated software, and (5) on-farm evaluation. During the implementation it became clear that steps 1 to 3 were not difficult to perform and did not take much time. Steps 4 and 5 were more complicated because: (1) correct data must be generated from the management system as an input for the model, and (2) the output of the model has to be interpreted correctly for calculating concentrate allowances in the management system. However, not only technical aspects of an implementation process are important, also the communication with end users and stakeholders requires particular attention, for successful implementation of a new concept. While testing and implementing the application it became clear that end users and stake holders were willing to accept and use the innovative concept but interpreted the outcome based on traditional population knowledge and paradigms.
Intergovernmental fiscal transfers are critical elements of public finance in decentralized countries. In the context of IndonesiaĂąâŹâąs decentralization reforms, their design and implementation have significant impacts on the potential revenue and fiscal capacity of basic public service provision. The case of IndonesiaĂąâŹâąs 2001 Big Bang decentralization illustrates the challenges associated with implementing significant reforms in the intergovernmental fiscal system. The practice of decentralization policy in Indonesia since the time has not generally improved local development performance yet. This study evaluates fiscal decentralization, focusing on fiscal capacity as the impacts of the intergovernmental fiscal equalization transfers, in the case of Gunung Kidul, Yogyakarta. The study shows a low percentage of its own revenue compared to its total budget. It indicates the failure of fiscal decentralization policy in improving local government fiscal capacity.
Academic physicians are under attack in the United States. Federal and state politicians, the lay media, some regulatory agencies, medical journals, and even medical schools have voiced strong concerns over the relationships between academic physicians and the pharmaceutical and device industries. These industries have been accused of corrupting medical research, education, and practice; and so, by extension, academic physicians who participate in these activities have become a focus of unfriendly attention. In their clamor, critics have not been reluctant to use the pejorative and misleading term conflict of interest in describing these academic-industry relationships. Physicians are notoriously slow to react, but in the end a group of academics from diverse medical specialties met at Harvard in late July to conduct the inaugural public meeting of a new organization: The Association of Clinical Researchers and Educators (obviously now known as ACRE). And, in the interests of transparency, let me immediately state that not only do I participate in research and educational services supported by industry, but that I was one of the founders of ACRE and took part actively at the Harvard meeting. Why in the United Statesâand throughout much of the world, for that matterâhave academic physicians and industry forged their collaborations? In reality, a large part of medical research and education in contemporary times is based on this relationship. Dr Jeffrey Flier, Dean of Harvard Medical School, acknowledged at the ACRE meeting that his schoolâs mission to promote medical education and research requires interaction with industry.1 Most of the major advances in recent decades in conditions such as cancer and heart disease, and their incorporation into medical practice, have resulted from this partnering between academia and industry. Academic physicians are uniquely qualified to identify unmet medical needs and, working collaboratively with industry colleagues, to devise and conduct the types of basic research and clinical trials that lead to therapeutic breakthroughs. It is not difficult to understand why our critics have come to question this relationship, including legitimate concerns about preserving the independence of academic physicians. But one of the dominant motivations for this negativity comes from the costsâadmittedly, often quite highâof new developments in patient care. Government agencies with limited budgets and commercial health plans with financial obligations to investors understandably look with dismay as relatively more costly tests, procedures, and therapies are developed and made available by industry and its academic advisors. From the perspective of health plan operators, the situation only gets worse when academic physicians teach their practicing colleagues about the attributes of these new developments. ACREâs first meeting, which played to a packed house in the Bornstein Amphitheater at the Brigham and Womenâs Hospital, attracted a wide range of speakers. There were representatives of medical societies, including such disciplines as diabetes, lymphoma, myeloma, and hypertension. As well, there were representatives of patient advocacy groups passionately committed to preserving the productive academia-industry collaboration needed to address unmet needs across a broad range of serious illnesses. An important insight came from a nationally recognized medical ethicist, Lance Stell, who is a professor of philosophy and Director of the Medical Humanities Program at Davidson College. âConflict of interestâ in the medical context has a clear meaning. Specifically, it occurs when practitioners accept personal rewards (such as fees, grants, awards, or recognition) in return for actions that could violate their professional obligations. In essence, to accuse a clinician of conflict of interest would require empirical proof that, in return for a reward, an action was taken that resulted in diminished care or even harm to patients. Clearly, such occurrences are extraordinarily rare in the conduct of medical research and education activities. There are words that are more accurate and less emotive than âconflict,â and we are starting to see a preference for such terms as duality, concordance, or alignment of interests. It is ironical that another speaker at the ACRE meeting discussed how certain actions in the medical setting, which perhaps really do represent true conflicts of interest, go without criticism. For instance, some commercial health plans offer practitioners direct monetary rewards for switching their patients from more expensive to less expensive drugs, or, possibly, for reducing their use of tests, referrals, and therapies so as to minimize the insurersâ outlays. Much of the information received by practicing clinicians comes from events that are funded, directly or indirectly, by industry. Partly, this is by default. After all, who else has both the responsibility as well as the resources to provide ongoing education in the clinical sciences? Inevitably this type of sponsorship has been criticized on the grounds that industry is not providing support out of altruistic principles, but rather is more intent on marketing its products. Apart from unrestricted grants that industry can provide to medical schools or hospitals to support educational ventures of their own choosing, there are two main types of industry-supported education. The first of these comes under the heading of promotional activities, and the second is labeled as continuing medical education, or CME. Each of these has its share of critics. Promotional education programs can take place in hospitals, medical offices, or at outside venues such as restaurants and are designed to provide information directly about a companyâs product. These types of activities are regulated by such agencies as the Food and Drug Administration. In the case of a pharmaceutical agent, the information presented must be balanced, providing information about risks as well as benefits, and must conform largely to what is stated about the drug in its approved product label. Claiming a desire to comply with these rules, many pharmaceutical companies have tightly scripted the content of these presentations, typically demanding that presenters faithfully use a company-provided slide set without allowing them the option to add, delete, or make any other changes. This requirement obviously creates fundamental problems for academic physicians invited to present at such events. After all, how can well-regarded experts stake their reputations, not to mention the reputations of their academic institutions, on material that has been created by unknown persons at the behest of a pharmaceutical company? Not surprisingly, some major medical schools have now instructed their faculty members not to give such lectures unless they have meaningful control over the content. For community practitioners who attend such events, this is an unfortunate development, for it deprives them of beneficial teaching interactions with true medical leaders. Some observers believe that industry lawyers, in imposing this censorship, have overreacted to regulatory requirements, and there is even a suspicion that these rulesârather too convenientlyâenable companies to focus more directly on their marketing messages. Rescuing this situation and re-creating collegial educational experiences in the community will require negotiations between industry and academia and, in all likelihood, regulatory agencies as well. CME is a very demanding proposition. On the one hand, industry has a compelling obligation to facilitate high-quality educational opportunities and updates for the users of its products. But, at the same time, CME rules demand that industry has a âhands offâ involvement in such events, merely serving as a provider of grants. The contents of CME programs usually are created by academic faculty and are subjected to peer review (similar to an article submitted to a journal) to ensure their objectivity. Even so, some critics still claim that industry can exert a bias on this process simply by selecting which types of programs they will support. But while it is true that pharmaceutical companies are more likely to support CME activities within their areas of medical interest, industry now goes to considerable pains to ensure that its grant decision processes are kept entirely separate from marketing activities. The opponents of industry support for CME activities still claim that, despite the firewalls, industry is still rewarded for its support of CME activities by increased sales of its products. Even if this were true, it is a not unreasonable proposition that if well-balanced data, presented in an unbiased fashion, affects the subsequent utilization of drugs or devices, this will very likely be to the benefit of patients. From the perspective of academic clinicians, rigorously conducted CME events in which they are free to select the content and ideas represent ideal opportunities to enhance practitioner knowledge and patient care. Attempts by legislators (and others who regard medical education as a healthâcare cost driver) to prevent or limit industry support of CME could have the effect of diminishing the quality of medical practice. Again, it is the responsibility of physicians and organizations like ACRE to argue the value to patients of cooperation between academia and industry in medical education as well as in research. Many medical societies, particularly small specialty organizations, depend on industry support. The operating costs of societies, as well as the cost of meetings, publications, patient education and other professional activities cannot be fully funded by member subscriptions. Support from industry is often essential and comes in the form of corporate memberships, sponsorship of CME or other activities at scientific meetings, exhibit fees, and journal advertising. This support has been criticized by the media as indicative of excess industry influence on professional activities. And, indeed, it might be appropriate for societies to consider whether funding from industry and income from members should be directed selectively to purposes relevant to those funding sources. It is worth noting that the mistrust between the provider of health services and the worlds of academia and industry became a major public issue in Great Britain about 4 years ago. In fact, a committee of Parliament issued a report expressing concern at the failure of the academic community and the health service to work more closely with the pharmaceutical industry to minimize inappropriate or suboptimal use of drugs in clinical practice.2 Subsequently, in a high-profile report issued early this year, the Royal College of Physicians (which represents a broad range of medical specialists) stated that the interests of patients and their clinicians are best served by close cooperation between academia, industry, and the health services.3 It is unfortunate that we have lagged behind on this side of the Atlantic. Indeed, one of the most telling statements made at the Harvard meeting came from Massachusetts State Representative Michael Rodrigues, who helped lead the opposition in the legislature to a now-enacted law that dramatically curtails interactions between physicians and industry in that state. It was particularly discouraging to hear from this representative that he and his colleagues lost their opportunity to block the legislation when local physician leaders gave up the fight and decided to remain silent. The responsibility of ACRE is to re-establish the partnership of academia, industry, clinicians, and patients in the United States. Among its initial goals is educating the lay public as well as the medical community about the value to patients of the research and educational collaborations between academia and industry. This will be no easy task, for so many negative items have already appeared in the media regarding the alleged manipulation of physicians by industry, usually with only weak rebuttals by academic or industry leaders. Indeed, one of ACREâs main responsibilities will be to develop a public voice that gets heard and quoted when such issues arise. There already has been one such success: Dr Thomas Stossel, one of ACREâs leaders and the chair of the Harvard meeting, was invited to testify at a high-profile US Senate hearing on CME in late July. Another of ACREâs main tasks will be to set up codes of conduct or guidelines designed to ensure that relationships between academic physicians and industry are ethical and clearly targeted at improving outcomes for our patients. This, again, will take considerable thought and discussion. As Dean Flier pointed out, we still need to figure out how best to âstrike a wise balanceâ and create âmanageable tensionâ in optimizing productive interactions between academics and industry. From the perspective of the many of us involved in cardiovascular medicine, it is easy to see the dramatic improvements in patient care that have resulted from the academic-industry partnership in recent years. Major clinical events and mortality have been sharply reduced in such areas as hypertension, lipid disorders, diabetes, heart failure, acute coronary syndromes and chronic kidney disease by this collaboration. ACREâs members, in common with most physicians, no longer find it acceptable to let others unilaterally set up the rules by which we are expected to function in performing these vital tasks. It is long overdue that we take responsibility for our professional activites in research, education, and practice. More information about ACRE can be found on its Web site: http://www.acreonline.org The site also has information about how to become a member.
Bankruptcy proceedings tend to involve civil disputes where nothing more than money is at stake. In such instances, the application of the preponderance-of-the-evidence standard of proof offers the greatest utility and is aligned with the comparatively minimal importance society places on purely monetary disputes. However, bankruptcy courts are not viewed as typical civil courts. Rather, many view these courts as âcourts of equityâ and this perception serves as a crutch which many bankruptcy judges use in advocating the application of the clear-and-convincing standard of proof to customary civil disputes. These actions distort the accepted risk allocation schemes implicit in standards of proof; the consequence of which often is inequitable results. A lack of direction by the Supreme Court is a key factor in this process failure. The Court has addressed the application of standards of proof infrequently and, when it has, the holding has been narrowly tailored. In 1990, the Court issued a ruling in Grogan v. Garner, 498 U.S. 279 (1991), that appeared to provide guidance. Unfortunately, as of late, the ruling has been misinterpreted by a number of courts and has led to additional confusion on an issue that was already elusive. In my article, I propose a new, comprehensive normative approach to determine which standard of proof is applicable in disputes involving debtors in possession under the Bankruptcy Code. My approach is based on a coextensive reading of applicable Supreme Court precedent that honors the narrow basis on which many of these rulings are made. I urge use of an approach that will engender greater uniformity on this fundamental issue. Further, I analyze some key forms of relief available under the Bankruptcy Code in which courts have advocated the application of the clear-and-convincing standard of proof but failed to provide any explanation for this action. By applying my approach, I evaluate bankruptcy case law and isolate instances where bankruptcy courts impermissibly distort accepted risk allocation schemes. Finally, I attempt to show that some unexplained applications of the clear-and-convincing standard of proof are justified.
Endre Bangerter, Stephan Krenn, AhmadâReza Sadeghi, Thomas Schneider · 5 authors
Abstract. Zero-knowledge proofs of knowledge (ZK-PoK) play an important role in many cryptographic applications. Direct anonymous attestation (DAA) and the identity mixer anonymous authentication system are first real world applications using ZK-PoK as building blocks. But although being used for many years now, design and implementation of sound ZK-PoK remains challenging. In fact, there are security flaws in various protocols found in literatur. Especially for non-experts in the field it is often hard to design ZK-PoK, since a unified and easy to use theoretical framework on ZK-PoK is missing. With this paper we overcome important challenges and facilitate the design and implementation of efficient and sound ZK-PoK in practice. First, Camenisch et al. have presented at EUROCRYPT 2009 a first unified and modular theoretical framework for ZK-PoK. This is compelling, but makes use of a rather inefficient 6-move protocol. We extend and improve their framework in terms of efficiency and show how to realize it using efficient 3-move ÎŁ-protocols. Second, we perform an exact security and efficiency analysis for our new protocol and various protocols found in the literature. The analysis yields novel- and perhaps surprising- results and insights. It reveals for instance that using a 2048 bit RSA modulus, as specified in the DAA standard, only guarantees an upper bound on the success probability of a malicious prover between 1/2 4 and 1/2 24. Also, based on that analysis we show how to select the most efficient protocol to realize a given proof goal. Finally, we also provide low-level support to a designer by presenting a compiler realizing our framework and optimization techniques, allowing easy implementation of efficient and sound protocols.
A persistent headache is a symptom, but the underlying cause can be anything from a migraine to a brain tumor. Good medicine means identifying and treating the cause as well as the symptom. The same is true in health care reform.
Though most Americans are satisfied with their own health care, they also see the need for substantial reform. Unfortunately, the well-meaning plans currently presented to Congress are the wrong therapy because they mistake the symptoms for the underlying disease. Nearly everyone agrees on the symptoms: rapidly growing health expenditures, diminished access to affordable insurance causing many to be uninsured, and inadequate quality and outcomes for the dollars spent. But what are the root causes? While there are many contributing factors, three merit special attention.
First, there is our inefficient and inequitable system of tax-advantaged, employer-based health insurance. While the federal tax code promotes overspending by making the majority unaware of the true cost of their insurance and care, the code is grossly unfair to the self-employed, small businesses, workers who stick with a bad job because they need the coverage, and workers who lose their jobs after getting sick.
This employer-based system arose not by thoughtful design but as an unforeseen result of price controls during World War II and subsequent tax policy. How this developed and persisted despite its unfairness and maladaptive consequences is a powerful illustration of the law of unintended consequences and the fact that government can take six decades or more to fix its obvious mistakes.
Second, in health care as in other markets, real progress depends on innovation. Yet health care markets rarely conduct successful experiments with new ways of paying for and organizing health care delivery. Why? Although health care markets have some unique attributes, these are not the explanation for lack of successful innovation. Rather, health insurance markets suffer from overregulation, which limits innovation in both insurance and new ways of delivering medical care.
Third, we have Medicaid and Medicare. These enormous federal programs address critical needs by delivering health care to the poor, the disabled, and the elderly. These programs pay providers by administrative pricing formulas that are well documented to promote both overuse and underuse of appropriate care, have led to rising expenditures decoupled from better health, and obligate massive future deficits that everyone agrees are unsustainable. They are also rife with fraud and abuse.
And yet the current political debate and the several and incomplete versions of âreformâ proposals do little to address these core problems. Proposals such as those that would create a new public insurance program, for example, would likely magnify them and create a new generation of problems that will be as difficult to fix as Medicare has proven to be.
Why does the current set of reforms fall short? One reason is that all changes must pass through the political process. For example, any effort at Medicare reform rapidly morphs into a struggle for influence between insurers and pharmaceutical companies, big-city academic health centers and hospitals in rural areas, specialists and primary care providers, federal and state governments, and on down the line. Sadly, innovators â and all too often patients â get lost in these power struggles. Any reform effort that fails to correct the acknowledged fiscal and organizational flaws of Medicare and Medicaid while extending the political gridlock that attends it to a broader segment of the health care system is doomed to failure.
Some have offered novel approaches to âpayment reform,â but none of these can realistically claim to both increase quality and reduce costs, while being acceptable to Congress. One proposal would create a new executive branch commission to propose changes to Medicare benefits and price controls that Congress could only override with a supermajority vote. While such an experiment might have the potential to reduce political gridlock, it would centralize power in a manner that seems exceptionally risky for a field that accounts for one-sixth of our economy and affects the lives of hundreds of millions of people. I anticipate many new advances in diagnostics, therapeutics, and devices over the coming decades. Optimal development and application of these will flow from a decentralized and innovative health care market and will be suppressed by a system that relies on politics and an all-powerful commission.
Some have proposed that comprehensive reform must be achieved quickly, capitalizing on a sense of crisis. I see unacceptable risks to this approach. Instead of achieving a far-reaching and necessary solution for our economy and the nationâs health, the necessity of pleasing enough special interests to get a bill passed will exacerbate our long-term crisis of cost and access. Who can tell what deals within a thousand-page bill that few, apart from lobbyists, have read will influence the state of health care for decades to come?
Now that a vote on health care reform will not occur until at least the fall, we should seize this opportunity by stepping back, making the right diagnosis, and then applying therapies that address the underlying disease. Here are a few ideas, based on the diagnoses discussed above, that may work. As with any therapy, these should be introduced as pilot programs, to be extended only if data reveal the desired outcomes. While such an approach will not fulfill the wish to produce a dramatic cure through a single stroke of legislation, it may avoid the pitfalls of the latter approach and have a greater likelihood of reducing the number of uninsured while controlling costs and enhancing outcomes. I propose this without any relationship to the partisan politics of the day that substitutes slogans and misinformation on both sides for meaningful analysis.
First, make the tax shelter for health insurance, currently limited to employers, independent of employment. This single, and morally imperative, step would enable the uninsured to use tax-sheltered money to buy health insurance for themselves while permitting insured employees, who are currently limited to a few employer-selected health insurance choices, to become more central in decision making.
Second, identify and eliminate the many barriers to entry and innovation in the health care and insurance marketplace. Eliminating what are often hidden barriers to competition will encourage entrepreneurs to offer lower-cost ways of financing and delivering health care, approaches that will deliver greater health care value for the dollars spent.
Third, make a serious effort, despite the context of widespread political demagoguery, toward deeply reforming Medicare and Medicaid. As one of many possible examples, try giving some Medicare and Medicaid enrollees earned income credits so they can make cost-conscious decisions among competing health plans. The sicker and less affluent should receive larger transfers, so they can buy adequate coverage. Among other benefits, such an experiment could break the logjam in payment reform and reliance on fee for service and centralized price controls.
Reducing rather than increasing the role of politics in health care decisions, while providing assistance for those in need, these pilot therapies would have the salutary effect of placing patients and innovators in a more central role as we determine the future of health care in America. And we would then, at last, be able to align the treatment with the disease, a fundamental principle of responsible medicine.
Addendum. I coauthored an article on health care reform and its underlying issues in 1994, and although it was written fifteen years ago, some of the concepts within this article may be relevant today (1). In addition, a recent article in the Atlantic magazine addresses key issues underlying this discussion that I find quite compelling but could not address due to considerations of length (2).
We use an idea of linear representations of the symmetric group to reduce the number of communication rounds in the verification protocol, proposed in Crypto 2005 by Peng et al., of a shuffling. We assume Paillier encryption scheme with which we can apply some known zero-knowledge proofs following the same line of approaches of Peng et al. Incidence matrices of 1-subsets and 2-subsets of a finite set is intensively used for the implementation, and the idea of <TEX>$\lambda$</TEX>-designs is employed for the improvement of the computational complexity.
There are three reasons why land policies in Africa are attracting greater amounts of attention. First, it is recognized that enhancing smallholder productivity is critical for sustainable and broad-based growth as well as poverty reduction (World Bank 2007). However, land-related investment, technology adoption, establishment of processing, markets, and value chains, all are unlikely to come about unless land tenure is secure. Moreover, increased productivity will be capitalized in land values and unless explicit attention is devoted to traditional land rights and land access by weaker groups, in particular women, interventions aiming to increase agricultural productivity may have negative social consequences. This is particularly relevant in contexts where current interpretations of customary systems define women's rights only through their relationship with men and women are often unable to inherit land which is considered the property of their husband's lineage. Negative implications for productivity can be severe, in particular if, as almost everywhere, women make a major contribution to agricultural production and its management.Second, demand for land, and in many cases land prices, have vastly increased with population growth, urbanization, and overall economic development. While higher land values makes land registration more rewarding, leaving land rights undefined increases the risk of having them appropriated by outsiders in a way that may neither be consistent with principles of equity nor conducive to the most productive use of this resource.Third, in a decentralized setting, land administration can not only help provide public goods and improve government finance but also that are rural areas will not develop based on agriculture alone. Nonagricultural development will imply migration of households out of agriculture that requires secure land rights so as to allow transfer of land rights, either through rental on a temporary basis or through sale, to others who are able to make more effective use of it without the fear of losing it. In many cases, this is now complemented by demand for land by investors who want to use it for food production, bio-fuels, or in anticipation of carbon payments has increased significantly in the wake of recent commodity price booms. It has highlighted that, without clear processes to process requests or assign of land rights, land acquisition by outsiders may end up fostering corruption and leading to inequality and dispossession of traditional land users rather than as a positive force for growth.This paper examines the theories identifying channels through which land rights can affect socioeconomic outcomes, points to realities which often prevent such effects from materializing, summarizes quantitative evidence on the actual impact of land registration interventions to assess the validity of theoretical arguments, and derives conclusions that can help guide applied work in this area. An example from Ethiopia is used to illustrate the potentially far-reaching impacts of ânew' models of formalizing land rights and a number of policy conclusions are drawn.
Some health systems faced difficulties to ensuring equity and efficiency in resource allocation have generated processes reforms including decentralization policies. Argentina implemented: Decentralization of Public Hospitals, Strategy Primary Health Care, Plan Remediar and Provincial Health Insurance. The aim of this work is to analyze the decentralization policies since the economic and administrative approaches. The methodology included: a review of the conceptual framework of decentralization, historical analysis of decentralization in Argentina, description and conceptual analysis of public policies implemented in the â90s. In all cases involve policies transfer of administrative responsibilities to subnational levels with the incorporation of the processes, delegation and devolution. From the economic standpoint, the measures prioritized regional demands satisfaction, through the transfer of responsibilities for provision, financing and assurance of some goods and services.
This paper focuses on the fiscal decentralization in the Philippines after the 1991Local Government Code. It first examines the intergovernmental fiscal relationshipbetween central and local governments by using fiscal decentralization indicators,and then investigates its impact on local finance. After fiscal decentralization, thelocal expenditure responsibility is expanded while the local fiscal capacity is notstrengthened in the Philippines. Local governments consequently comes to dependheavily on fiscal transfers from the central government, internal revenue allotments(IRAs), which has a substantial influence on local finance. The heavy dependence onIRAs makes local finance unpredictable and unstable. The distribution of IRAs alsoaffects the horizontal balance between provincial governments.
In this troubling and wise book on the European Union (EU), Alexander Somek puts forward a provocative reconstruction and assessment of the jurisprudence of the European Court of Justice (ECJ) and of the policy advocated by the European Commission. The core claim of Individualism is that magistrates and Eurocrats are slowly but steadily driving European polities away from the basic tenets of the democratic Rechtsstaat and into forms of inverted authoritarianism. Through a handful of leading cases and through a myriad of âsoft law initiatives,â the idea of a government of laws and the normative dignity of a constitution authored by the people is being subverted. Indeed, the democratic constitution is in the process of being replaced by a congeries of norms aimed at the pragmatic realization of the ideal of a free market inhabited by apolitical individuals. This is the peculiar European road to Tocquevillian individualism through the mirage of absolute freedom, through liberty unencumbered by political ties and loyalties toward a particular national community. At some points, the reader senses that this is a detail in what the author conceives of as the larger fresco of the history of modernity (or to be more precise, of how modernity has gone awry). Indeed, the logical conclusion of the book (even if not physically at the text's end) is the extremely somber passage in which Somek claims that â[t]he ideas of the French Revolution finally seem to be lost in Europe. The age of modern constitutional law is coming to its conclusionâ (p. 243).1 Striking a very dissonant note, the author thus claims that the usual Kantian optimism about the emergence of a ânewâ and âcosmopolitanâ European order is, at best, delusionary. There is a very dark side to European integration besides the rough and tumble of referenda. This grand argument is rendered powerful by the gusto with which the author moves across disciplinary borders. Indeed, the book is at least three things at the same time, namely: (1) a politico-theoretical assessment of the basis of legitimacy of European constitutional law, as it stands; (2) a constitutional and normative assessment of European policy making, with a special focus and emphasis on the Commission; (3) a critical and original legal-dogmatic reconstruction of some of the leading constitutional cases of the European Court of Justice. The core of the disheartening thesis of Individualism is that the judges sitting in Luxembourg and the Eurocrats mingling in the Bruxellois buildings of the Commission would transform not only the concrete substance of supranational and national fundamental laws (as the standard narrative goes) but also the very structure of social integration in the old Continent. While the Court's rulings and the Commission's enactments have retained the form and appearance of a legal-constitutional discourse,2 the leading judgments of the men in robes and the myriad policy initiatives by the fonctionnaires have mutated the fundamental law of the Union into a dubious body of âdissonantâ law,3 no longer informed by the normativity of the self-government proper to democratic constitutional law but by that of (neoliberal) âapproximation.â The latter would sever the connection between law and critical practical reason by dissolving the very idea of the legal system as a normatively coherent whole and replacing it with the âpragmaticâ reduction of law to a casuistic logic of appropriateness. It would also make political power vanish by negating the political condition and pretending to bring about a full decentralization of sovereignty, which Somek describes with poignant irony in chapter 11. On the one hand, Somek places considerable emphasis on the regulatory inventiveness of the Commission. In chapters 5 and 12, for example, he peers behind the jargon used by the Commission in explaining itself, providing a crucial diagnosis of how individualism is tied to a peculiar form of âcradle to grave,â inexpensive, and paternalistic welfare state (a kind of welfare state on the cheap). Instead of classical and expensive redistributive measures involving personal taxes and personal benefits, the inexpensive European welfare state would seem to be about the zero-cost policing of personal habits. Thus, the obsession with initiatives aimed at rectifying the smoking, drinking, eating, and exercising habits of the population. Add to this the further twist of grounding such initiatives on the need to realize the internal market, and you must agree with the author's sarcasm: âApparently, regulatory difference causes melancholiaâ (p. 250) and justifies the exercise of a liberal priesthood on the side of European institutions (p. 255). But the most intriguing part of the argument is Somek's discordant interpretation of the case law of the European Court of Justice. By a skilled dissection of the leading cases concerning, on the one hand, the division of competences among the Union and the member states and, on the other, citizenship in the Unionâor, to be more precise, the free movement of workers relabeled as the free movement of citizens by the Court itselfâSomek reveals the extent to which the Court has radically altered the relationship between economics, society, and law on the old Continent. Rulings concerning the powers of the Union and, very significantly, the key Tobacco Advertising decision,4 have, he claims, consecrated a radical shift in the understanding of what the âinternal marketâ is about. While seeming to ârein inâ the power of the Union, the Court, in truth, has abandoned any attempt at limiting the societal sphere of the single market and the radiating normative force of economic freedoms. In particular, the Court has reversed its old limiting jurisprudence according to which the Union's competence was to be determined by the âcenter of gravityâ approach or, what is the same thing, by pinpointing the regulatory interest of a measure and determining whether it was about creation of the internal market or achievement of a socioeconomic objective (the latter being reserved to member states). From Tobacco Advertising onward, the âinternal marketâ has trumped other interestsâthat is, any measure that removes a sufficiently serious obstacle to an economic freedom is held by the Court to fall within the competence of the Union, even if its regulatory center of gravity lies in an area of national competence, such as protection of health, promotion of education, or combating tax fraud. As a result, the ECJ has abandoned the so-called liberal market paradigmâwhich regarded economic integration as a way to achieve wider political goalsâand replaced it with a supposedly holistic market understanding that looks upon the four economic freedoms5 as the ultimate objective to which the organization of all of society must be subordinated. Thus, all socioeconomic norms are consequently viewed with suspicion as potential obstacles to economic freedoms.6 Once envisaged as a means of realizing openly political goals, economic freedoms have become the core of the material constitution of the Union. They are now at the heart of the conception of politics and society as enshrined in positive European constitutional law, a conception that, while well known in European constitutional history, is somewhat at odds with the one endorsed by postwar national constitutions. Meanwhile, the line of cases led by MartĂnez Sala7 and Baumbast8 threatens to redefine the very understanding of European citizenship. On the face of it, these cases might seem to have replaced the âmarketâ denizen of Community law with a âpoliticalâ European citizen by extending the number of holders of the Community right to free movement beyond the rank and file of workers to the general class of nationals of a member states and, perhaps, even more widely to permanent residents of a member state. However, such rulings have far less benevolent implications, because the practical effect of this kind of rights discourse is to expand the possibilities for the ECJ to review any national law on the ground that it violates economic freedoms. The upshot of the Commission's regulatory activities and the courtsâ deregulatory activities is a full recalibration of Community law, which is softened, regarding the strong parties in socioeconomic relations even as it is hardened into abrasive forms of âliberal paternalismâ that ânudgeâ9 us for our own good and purported freedom. The overall political result is the decadence of citizenship, which becomes a hollow category, inadvertently supersededâby what, we cannot be sure. The weak pulse of European constitutional and ordinary politics only amplifies the consequences of these developments. The complex blend of intergovernmentalism and supranationalism that lies behind the institutional structure of the Union is, indeed, an impediment to the interconnection of national political debates. Consequently, both the Court and the Commission lack democratic reference points by which to orientate their decisions. As a result, the active citizen is being superseded by the oxymoronic âindividualisticâ citizen (chapters 10 and 12), who is persuaded that it is in her own interest to become a docile subject delegating all power to rulers. It is because politics has vanished from the picture that political strife can be presented as a distraction or a threat, from which the really free individual has to be liberated by proper men in the know, or, put differently, by the selected few capable of handling and, above all, managing the restless many. All these major transformations would account forâamong other thingsâthe infatuation with a range of new and fanciful political idioms: no longer government, but âgovernance.â No longer capitalists, but âstakeholders.â No longer democratic confrontation, but arcadic âpartnerships.â Somek takes considerable pains to show that, while the terms may be new, this is not uncharted territory but, rather, a political involution toward a mixed constitution of sorts, guided by the neoliberal mirage of absolute individualistic freedom. The form of law is kept but put to the service of a rather Lenin-inspired regulatory politics, limited to the administration of things (chapters 10 and 13). Both the legal-dogmatic reconstruction of the ECJ's case law and the normative assessment of the EU's legitimacy seem more than âdisturbingly plausible,â to quote a blurb printed on the book's cover. However, what seems to be absent from the train of reasoning of Individualism, unfortunately, is a proper consideration of the temporal dimension of European integration. A question that might be raised is whether the âpost-constitutionalâ and âindividualisticâ drives that Somek describes are intrinsic to European integration, or whether they result from a mutation caused by political and judicial decisions. The point is not only of historical interest but is extremely salient in pragmatic terms. Indeed, the reader is left pondering whether European Union and Community law are doomedâis European law, indeed, postconstitutional in character?âor whether they can be redeemed and their normative promise realized. And if they can be, what is to be done to extricate the Union from its present fix? In that regard, the author seems to point in conflicting directions (in the affirmative, on pages 31, 241, or 267, and, in the negative, on pages 121 and 123). One can only guess that somebody who devotes time and effort to write a brilliant book about European integration is likely to find some promise in a federal Continental union. Be that as it may, it seems to me that Somek's thesis needs to be tested by going further back in time. It was in the early and mid-â80s when a major turn in the perception of the relationship between politics, economics, and law took place both at the national and at the supranational level.10 This event consisted in the massive albeit slow transformation of the understanding of both national and constitutional law. At the European level, the rulings in Cassis de Dijon11 (certainly following the opening in Dassonville);12 the policy decisions reflected in the White Paper on the Completion of the Internal Market of June 1985;13 and the constitutional option for the Single European Act14 were conducive to the rise of what Somek labels âmarket holismâ and âhollowâ European citizenship. This turn of events is also reflected in the substantive shifts from the common to the single market15 and from the understanding of economic freedoms as a way of operationalizing the principle of nondiscrimination (and thus reconcilable with autonomous national socioeconomic policies) to their characterization as realizations of European citizenship. Individually, each of these shifts may be supported by reasonable arguments; however, as a whole, they provided cover for âprivatizingâ our understanding of freedom, and for the recharacterization of national welfare and tax norms as obstacles to economic freedoms. If this is correct, we could claim that it was these decisions that changed the structural and substantive genetic code of the Union and of its law. These decisions, and not some intrinsic features of Community law, are to blame for the progressive erosion of the socioeconomic preconditions for meaningful national socioeconomic policies. Thus, if there is nothing intrinsically rotten in the state of Europe and in its legal order, Individualism perhaps should be read less as a diagnosis of the unavoidable fate of the Union, of its institutions and its laws, than as a dystopic projection of what can go wrong if we keep on treading our present path. Furthermore, it seems to me that Individualism merely suggests, without fully developing, the links between integration through postconstitutional law and the emergence of the so-called governance paradigm. Indeed, the Panglossian description of radically innovative procedures of collective will-formation through governance, such as the Open Method of Coordination,16 which, with little critical research underpinning it, nonetheless attracted wide comment, or the more esoteric mechanism of coordination of economic policies in Euroland through the Eurogroup seem to point in the same directionâthat of overriding constitutional law. To use words that were very popular in policy circles in the â90s, European governance should become the new grammar of European law. In more pedestrian English, this means replacing supposedly quaint or obsolete constitutional law, tainted by its relationship with the nation-state, with a new array of procedures and institutional formations; it will be through that the collective will may be formed. That sounds very similar, indeed, to the âdissonant lawâ that Somek reads into the jurisprudence of the European Court of Justice and the policy initiatives of the Commission. Still, it is ultimately uncalled-for to criticize an author for what was not done in a book that is as rich and suggestive as Somek's Individualism.