The education financing in Brazil is conditioned by its federalist political organization which involves three autonomous spheres of government: the Union, the States and the Municipalities. Due to the diversity of economical, political and social conditions of regions and states, the Union takes over, according to the Federal Constitution of, the supplying and redistributing functions in relation to the other federal units. Nevertheless, in the sit was observed a growing centralization in the process for the definition of education financing policies by the federal government, resulting in decentralization of responsibilities, in a context facing the advance of the minimalist conceptions of State. This article considers the education financing policies in the scope of the federative relations in Brazil, taking into consideration the scenery where the educational policies have been developed after the and the contradictions which have resulted from the country’s political organization model.
Two papers in this volume focus on public finance and decentralization as central to resolving India's systemic public health crisis. However, some states and districts have achieved success despite serious financial and administrative deficits; this suggests that factors such as political commitment, community participation, human resource management, women's empowerment, and governance may be as or more important. The success of the National Rural Health Mission will depend on state and local institutional capacity, including strong partnerships with civil society organizations and private-sector actors. Increased resources and decentralization will not be sufficient by themselves.
Three years ago, a process of reform to the Statutes of Autonomy of some of the 17 Autonomous Communities that make up the model of politically decentralized State, designed by the Constitution of 1978, begun in Spain. Doubtless, the one that has sparked off more controversy in the legal and also the political grounds has been the Statute of Catalonia, approved since 2006. The subjects of greatest relevance have been those related to the incorporation of a Letter of Rights; the material and functional determination of the competences for the exercise of the self-government, as well as the relationships with the State, the European Union, and the financing system.
Daniel Roy, Didier Anciaux, Thibaud Monteiro, Latifa Ouzizi
The purpose of this paper is to propose a new approach for the supply chain management. This approach is based on the virtual enterprise paradigm and the used of multi-agent concept. Each entity (like enterprise) is autonomous and must perform local and global goals in relation with its environment. The base component of our approach is a Virtual Enterprise Node (VEN). The supply chain is viewed as a set of tiers (corresponding to the levels of production), in which each partner of the supply chain (VEN) is in relation with several customers and suppliers. Each VEN belongs to one tier. The main customer gives global objectives (quantity, cost and delay) to the supply chain. The Mediator Agent (MA) is in charge to manage the supply chain in order to respect those objectives as global level. Those objectives are taking over to Negotiator Agent at the tier level (NAT). These two agents are only active if a perturbation occurs; otherwise information flows are only exchange between VENs. This architecture allows supply chains management which is completely transparent seen from simple enterprise of the supply chain. The used of Multi-Agent System (MAS) allows physical distribution of the decisional system. Moreover, the hierarchical organizational structure with a decentralized control guaranties, in the same time, the autonomy of each entity and the whole flexibility.
The first section of this paper discusses the scope and nature of the familial rights at stake in a termination of parental rights action. This section demonstrates that familial rights are defined as relational rights throughout our Anglo American tradition and constitutional jurisprudence and thus protect the relationship between the parent and child rather than an individual right of either. The second section of this paper establishes that life is a which, like culture viewed on any scale, shares learned behavior among members and functions as a means of protecting the group and insuring the continuity of its values, beliefs and organization. This section describes United States Supreme Court decisions which expressly protect the familial activities constituting and reflecting the private culture of the family. In view of the United States Supreme Court's recognitions of private culture, this second section concludes by suggesting that a family's private culture is entitled to the same deference accorded to larger cultural groups in other contexts. Taken together, then, the first and second section stand for the proposition that the proper inquiry is never whether removal from parental custody is in the child's best interest but rather whether a family exists, in the constitutional sense. If a exists, the inquiry must end. There should be no inquiry into whether the child's emotional needs are fully met, whether some future likelihood of harm exists or whether it would be better for the child to spend some time with grandmother, or indeed with anyone else. The state is neither permitted to evaluate the of a functioning nor, as an impersonal political institution is it qualified to do so.The third section of this paper provides a selective overview of termination of parental right statutes focusing on recent trends which have increased the incidence of both procedural and substantive due process problems within the statutes. This third section also describes Congress' own, quite different response to some of the criticism of child welfare legislation, a response which is embodied in the Indian Child Welfare Act (hereinafter ICWA). The third section concludes by proposing a more constitutionally acceptable approach to child welfare legislation utilizing the general principles embodied in the ICWA.The fourth and final section of this paper argues that the appropriate burden of proof to place on state actions to remove a child from his or her parents' custody or to terminate parental rights to the child is proof beyond a reasonable doubt. The ICWA requires proof beyond a reasonable doubt in termination of parental rights actions falling within its jurisdiction; the principles Congress endorsed in enacting the ICWA should be applied to all families. This paper reaches this conclusion despite Santosky v. Kramer's apparently different resolution of the issue of the burden of proof required in parental termination actions.
Due to the very large number of local units in the Republic of Croatia, the system of collecting income is mainly insufficient for quality and functional financing of public needs on the local and regional levels. It is therefore necessary to continue the search for new models of regulating financial relations between the state and local units. The executed decentralization of the financing of local and regional self-government is not sufficient. Because of the new work and activities that have fallen into the jurisdiction of counties (as regulated by Amendments to the Act from 2005), it is necessary to increase the state's allocation of funds from common taxes for the units of the local and regional self-government, to increase the autonomy of the local and regional units in the introduction of their own incomes, especially taxes, to take care about the implementation of functional decentralization, and to stimulate local and regional governments in the realization of a larger non-fiscal income of their own. It is a fact that some countries in the European Union have begun with the reorganization and reduction of their local self-government precisely because of too high financial payments for the needs of the local self-government. However, so long as the Republic of Croatia retains the existing organization of local governments, it should also provide for its financing. The local or regional self-government units' own sources of income should be their principal sources of financing.
The 2001 World Health Report made plain the global challenge posed by poor mental health. Worldwide, 20% of individuals may experience mental health problems during their lifetime, and such disorders account for approximately a third of all years lived with a disability 1. The consequences of poor mental health range far and wide, of course; they are associated with higher rates of non-mental health-related comorbidity and premature mortality. Some mental health problems are also associated with poor employment experiences, poor personal relationships, strain on families, and a higher-than-average risk of homelessness and contact with the criminal justice system. The 2001 report helped to raise awareness of the importance of mental health. The need to promote and maintain good mental health and well-being as integral elements of health policy is now quite widely recognised in high-income countries. For instance, the European Commission published in 2005 a Green Paper on mental health 2 and all 52 Member States in the European Region of the World Health Organization (WHO) endorsed a Declaration and Action Plan at Helsinki earlier that same year 3,4. In the United States, a Presidential Commission called for investment in actions to ensure that mental health receives the same level of attention as physical health problems, specifically recommending actions to tackle suicide and reduce stigma, as well as interventions to promote child mental health 5. Positive actions can also be seen in the Pacific region, where, for instance, New Zealand has a ten-year national mental health strategy 6, with implementation monitored by a separate Mental Health Commission. The picture in many other parts of the world is much less encouraging. Although there has been some recent focus on the need to tackle the mental health consequences of major disasters such as the Asian Tsunami 7, policy attention and resources in many low- and middle-income countries are still directed largely at communicable diseases. The purpose of this paper is to reflect on some of the challenges faced in low- and middle-income countries and the role that economic evidence could play in strengthening the policy case for investment in mental health. There is obviously a need to improve our understanding of the cost-effectiveness of specific interventions within the health care system. But there is also a pressing need to expand the role of economic analysis in looking at non-health sector interventions that can have a direct impact on mental health or can indirectly help with the uptake and maintenance of treatment. The ways in which services are delivered are of critical importance and also need evaluation. In particular, we shall argue that non-governmental organizations (NGOs) can be key players in the funding, coordination and delivery of services. The burden of mental illness is predicted to increase from its current level of 12% of global disease burden to approximately 15% by 2020; much of this additional burden is projected to occur in low-income countries 8. The consequences of poor mental health in low-income countries may be even worse than in high-income ones, because of the absence of social protection safety nets, compounded by the high levels of stigma and superstition 9. The cycle between poor mental health and poverty in low-income countries has been observed in several studies 10–12. Poor maternal mental health also has long-term adverse consequences for infants in low- and middle-income countries, limiting their own lifetime opportunities 13. Communicable diseases, the focus of much health policy in poorer countries, are also inextricably linked and exacerbated by poor mental health; interventions to prevent and treat mental health problems could help in the management of these conditions, as for instance in the case of HIV/AIDS 14,15. The economic costs of poor mental health are well documented in high-income countries, conservatively estimated to account for between 3% and 4% of gross domestic product (GDP). Few estimates have been made outside the developed world. One exception is a study in Kenya 16 that estimated that the total costs per patient for 5,678 individuals with mental health problems hospitalised in 1999 were US$ 2,351. This included out of pocket costs to family members of US$ 51 and productivity losses of US$ 453. Total economic costs for this group alone were more than US$ 13.3 million, equivalent to 10% of the Ministry of Health's budget; yet these figures would have been substantially larger if costs had also been included for those individuals who were not institutionalised or were treated by traditional healers. To put this in context, the average income per head of the population in Kenya is just US$ 580 per annum, and more than half the population live on less than US$ 1 per day 17. Other examples can be found in India, where the overall costs for outpatients with schizophrenia have been found to be similar to those of people living with another long-term condition, diabetes; a key difference between them, however, is the much greater contribution of indirect costs to overall costs (63% versus 29%) in the case of schizophrenia. This included not only the costs of lost opportunities to work for the individuals with the illness and their families, but also the loans taken out to meet the costs of treatment and money spent on repairing damage to property. In total the annual cost per outpatient treated for schizophrenia was estimated to be US$ 274 18. Another Indian study where free access to essential drugs was provided as part of community outreach services for people with schizophrenia reported that these led to a number of improvements in quality of life over an 18-month period. The impact on cost was modest, with the investment in community outreach services partly offset by a reduced need for caring by family members 19. This impact on family caregivers can be considerable. In Ethiopia, Shibre et al 20 looked at the impact of schizophrenia on 300 family caregivers in traditional rural communities. Relatives experienced financial difficulties, constraints on their social life, reduced opportunities to work and strained family relationships. These problems were particularly challenging for female caregivers. Similarly, a study of 66 caregivers in Zimbabwe reported that two-thirds experienced financial difficulties, especially as food consumption by their relative increased 21. Some people have argued a moral case for greater investment in mental health, given the high number of individuals affected and the ensuing profound consequences 22. Such a case obviously needs substantiating with evidence that targeting more investment on mental health will be effective in preventing or treating mental disorders, and that it represents a cost-effective use of a country's scarce resources. In turn, this generates a need for economic analyses to support clinical and strategic decision-making. Of course, decisions should never be made on the basis of cost or cost-effectiveness alone, and other factors such as fairness, human rights and ethics are usually highly relevant. There has been significant growth in the evidence base on the effectiveness and cost-effectiveness of interventions aimed at treating the consequences of poor mental health (particularly drug therapies) 23–26. Increasingly, economic analyses are being undertaken in low- and middle-income countries 27–31, but the overwhelming majority of studies are from high-income countries. This is not surprising: between 1992 and 2001 only 4% of articles in journals on the ISI Web of Science databases were on mental health issues; of these a mere 6% were from low- and middle-income countries 32. Similarly, Patel and Kim 33 found, from their review of publications between 2002 and 2004 in six leading journals, that only 3.7% of papers were from low-income countries. Unfortunately, economic evaluation findings do not transfer easily between countries, because infrastructures, resources, incentives and cultures can be very different. There is therefore a need to develop the evidence base on the effectiveness and cost-effectiveness of interventions in low- and middle-income countries through additional empirical studies. Practically, however, even with a substantial injection of funding, this evidence base will take some time to emerge, given the human and infrastructure capacity constraints within countries 34. In the meantime, how can economics best be used to inform policy making? In the absence of empirical evidence, careful use of economic “models” which seek to adapt evidence on effect to take account of different local circumstances and cost structures can play a role. The most significant such endeavour is the ongoing work of the WHO CHOICE (Choosing Interventions that are Cost Effective) Programme. CHOICE aims to assess the cost-effectiveness of a wide range of interventions for conditions that make significant contributions to the burden of disease in a range of epidemiological and geographical settings. The core aim is to feed information into the policy process 35. Thus far, the CHOICE programme has looked at schizophrenia, bipolar disorder, depression and panic disorder. It has estimated, for example, that cost-effective interventions can be provided for US$ 3–4 per capita in low-income settings of Sub-Saharan Africa and South East Asia, or around US$ 10 in middle-income regions such as Eastern Europe. These are typically a combination of older off-patent antipsychotic or mood stabilising drugs plus psychosocial therapy. It has also been estimated that, globally, between 300 and 500 million healthy years of life could be gained for each additional US$ 1 million invested. Around one third of the gains would be for severe mental disorders, schizophrenia and bipolar disorder, with the most cost-effective interventions being for depression and panic disorder 36. Welcome though the CHOICE programme is, it has largely on health care interventions to improve mental health there is in high-income countries a of evidence to the role of employment and living There is an need to assess the cost-effectiveness of and many of which outside the health for in the or There is also very evidence from low- and middle-income countries on how poverty and factors impact on the of mental health policy and these have an to mental health policy the substantial adverse impact of poor mental health and the evidence base on the of cost-effective there many in to ensure that mental health receives a level of investment in low- and middle-income countries and that, services are there is access to mental health may have to be a for national policy and of this was the that the World World Report that poor mental health was a major to the global burden of but its essential services for health services not seek to mental disorders, even though their overall burden was that of and HIV/AIDS This some and was in a of the it the case that in low- and middle-income countries the focus of much health policy has been communicable that to premature most and have been such as the by aimed at greater access to drug for The the contribution of good health economic and several health-related yet mental health is by its the of papers for the Commission which the between of economic growth and poor mental health This is exacerbated by This has to a of attention from policy and the in leading to a of resources, poor of information and if greater to mental health, a key on the of services and their as to meet needs is the of epidemiological This is not to low-income one recent review could not on mental disorders in of the European Member States Unfortunately, the infrastructure to such information is not in the of needs it is not to on epidemiological The of all need to be yet it for people with mental health problems and their to have an to in or inform the policy a there is a that policy to that can some of the of mental disorders, such as lost opportunities to work or to in There is also the risk that policy to the challenges of on the health care may the to mental health in may be not in many low-income countries One study from Zimbabwe that over of health care in the and of treatment for depression of health care may be compounded by the of mental with some studies that many that such conditions do not or be treated also that only physical or conditions are than the for more than 2 of the population less than of their total sector health care on mental health The majority of countries in Africa are in this of the world population in low-income countries have access to community care services on of mental health services is but at of people with severe mental health problems do not treatment within in some low-income countries One recent in found that only of people with disorders some of treatment for mental health problems during a In where the overwhelming majority of people with schizophrenia are by the it has been estimated that over still do not make use of services where there is a to mental health, the level of resources will be on the of the even if more than of the total health is to mental health, this will not to much in of overall resources if the overall level of national income is The need to or to make also that services have to be mental health services may be particularly in such to drug the WHO found that, by 20% of all countries were not at one one antipsychotic and one This is to be helped by the of World this can of drugs and the of drugs be by the there are some to these for national and which are life there are for mental In a number of free have been between the and some countries. These can be even than for instance the of protection There are also human especially health have to with the of high countries that can and conditions to these but challenges the middle-income countries of the a major to be the high rates of suicide and disorders, which may partly from economic and social mental health services are being put as resources for health the health by many people to in health care typically do not for long-term mental health The for mental health in many low- and middle-income countries that access to many services is on at the of Around of low-income countries reported to be the for mental health with only 3% of high-income countries this of is as it not take account of costs through with traditional healers. This on is and as it of services by those with which is especially given the between poverty and poor mental health for services may to poverty or if from at very to reduce some of the associated with poor mental health are number of challenges in use of resources have been out on by et al these may also be to health they are to be more to in mental health their impact may be in low- and middle-income countries, where human and financial resources are scarce and where there are many on resources. of these have been the of information on effectiveness and and the level of resources to mental health treatment and Another key is the poor of resources, which are in The to be to a mental health can be in one Indian study a key for the of use of antipsychotic was the need for individuals to have to more than 10 to their outreach 19. In some rural of South Africa there is only one per million population particularly from rural to can also as a to treatment. in is with the of that million people for may also be different disorders or for example, depression has been as a to schizophrenia within the health of countries There is also the that resources are used to support services that do not epidemiological needs or the of or the evidence base on effectiveness and The WHO has the of mental health where mental health is into the health countries which to on care are to be an of services. is a it may to and resources as best to meet population Health may be highly with for or local management of In countries where most resources are within a highly as in the it can be to resources from to The uptake of community outreach services also be poor because of the problems of food of and financial resources. To ensure a of treatment is may with food one in Zimbabwe that more than 10% of family could not to for the additional food for with mental health problems 21. It is therefore to ensure that resources are not and for to not only clinical but also some of the factors that the use of services. there is as in India, local structures need to have the to ensure that are to mental health. may also be by a number of different not only health, but also employment and social Poor coordination and between and local and can the of services. In for example, the of and community services for mental health was to a of coordination also need to be that of services or greater investment not that there will be improvements in mental health in may take several years to in of treatment and policy may therefore be to on of the health where more and can be even if the need for is is the need to ensure that there is a long-term to as to support individuals over time within their communities. one need is to improve access to information on effectiveness and cost-effectiveness of interventions to treat mental health understanding of population needs is also Other information that need to be and cost-effective ways to mental health to care and other and awareness and to tackle some of the consequences of the information and more use of scarce resources would some to strengthening the for mental health. a understanding of how resources are to mental health and other health would also be In many where national health are there is high on of for health Some into the ways that and organizations are in in health and other would help if a case is to be for more investment in mental health. opportunities for mental health and other to in the of would also be particularly as many of these papers to focus on physical health. that have helped the of physical and mental health in different settings also help the case for greater resources for mental health in mental health can also physical health. with that focus on physical health help their in mental health and psychosocial One review of that many they not have the to mental health needs and were in of greater with that in the mental health It is also to expand the role of economic analysis to at the cost-effectiveness of to tackle risk factors for poor mental health, such as poor living conditions, financial economic and levels of For instance, to mental health be through the of in low-income the of such will not be to mental health alone, that a all health would be The in which effective interventions are delivered to mental health-related is also of One is the and of health There is a substantial of in looking at to the of delivery and the need to services different be from care to In the to additional will be as to to services community services are developed and which seek to ensure have to be as to also mental health care as with the in may also The high on is a major to access to and countries should be health on or social major however, is that the structures for do not in low-income countries such as very local community a also need Although the CHOICE programme take into account the of uptake of economic in low- and middle-income countries have this are the to such as of it be to tackle these and if services are delivered by but there is a of information on the effectiveness or cost-effectiveness of the services they as it has been in high-income countries, services that can meet the needs of local in ways that services do with and their with local through the of greater uptake and use of services with To and how are These are key to which we now countries report that they have some in the of mental health. health services were of care in many countries, more or have also to play significant These organizations may be or support from local or other Some may also play significant in and policy it is to that specifically focus on mental health. One recent looked at that mental health services disasters as well as services. Of organizations on the United only reported being in mental health of these had in at one long-term but only were to mental health There are the mental health and the Mental Such organizations may not only raise and for mental health, but also help to services. Another is which in with health to help mental health services at care level in several programme countries in Africa and India, and can some of the to the of mental health policy and for by to raise awareness of the importance of mental health and by for access to services in low-income communities. community or which within local with key and their families, is used because of the challenges in at a high level into on the The community that can help on social in to support the work of health and health can be of to ensure use of and as well as and can also as between traditional and For example, has with traditional as one of their in where some of these have to some people with mental health problems to health services Such between the and the opportunities for health especially to their access to can help in a understanding of how to meet mental health needs in community a greater level of contact with people with mental health problems within local health care local health may make at or levels for drugs and other services to meet these local with can also be for the of mental health services. can as to to for greater In one where for example, the was that a mental health and programme would help to mental health the This has very to a of million US$ for mental health in and a World of Health developed with in to develop community in the and Mental health problems are a major to the global disease they are associated with premature and profound on and they substantial costs to the the of cost-effective interventions in high-income countries and some more but evidence in low- and middle-income countries, mental health and care have been widely with levels of investment in interventions for health where is access to and of services may be even if are of course, they are combination of some to mental health, has to these of within a highly of human rights and to of resources have a in which the to prevent and mental health problems has far largely been these challenges a analysis of the cost-effectiveness of interventions can play a role in this Such analysis needs to interventions that the of mental disorders a understanding is also of the health and the and in which interventions are to be analysis is also of more to risk factors for poor mental health, such as of access to and will have that mental health, and with other are such as those with communicable diseases. of the implementation process is In countries where health are and where mental health is a can play some of the of with can be more this help the case for investment in mental health. have with some in the of HIV/AIDS and maternal and child health. is more or different in looking at mental health problems in the same and in the same The experience from such as that even can have some which in that the of people with poor mental health in low-income countries is not as as is at the policy the key difference between mental disorders and other health is that the are more as a because they are as less mental health only to the attention of local policy a global such as the Asian Tsunami or a high local such as the in The in the of people who had been within a Commission provided the for mental health policy and by and and even the of But as these from it is for mental health to and for the that investment in mental health can economic as well as quality of life is to its on the for economic This is to effective mental health care with in the
Open access
Mental Health Treatment and Access
Health disparities and outcomes
Child and Adolescent Psychosocial and Emotional Development
The American present is at odds with representations of the American past. The American present witnesses the steady aggrandizement of executive, administrative, emergency, penal, military, and war powers as contemporary commentators such as Michael Hardt, Antonio Negri, and Giorgio Agamben contemplate the contours of American hegemony and superpower in a new era of empire.1 The global impact of present American politics, political economy, and foreign policy is obvious to any casual observer of current affairs. The story of the American past, on the other hand, continues to be told in narratives that seem to be heading off somewhere else. In place of the growth of power, the history that America most frequently tells itself highlights a story of relative powerlessness—a usually benign tale of legal-political self-abnegation, emphasizing constitutional restraints such as federalism, checks and balances, the separation of powers, limited government, the rule of law, and laissez-faire. When presented more positively, American history is usually framed as a quest for freedom—the struggle for political liberty, emancipation from bondage, the rise of civil, economic, and social rights. Property, contract, and freedom of speech, press, and association form the constitutional backbone of a free market, a vigorous civil society, and a democratic polity—hallmarks of a free people. Oddly, key elements of this tale are kept alive in both older political histories of the liberal tradition in America and newer histories highlighting the rights and agency of particular cultural communities. Coming to terms with the historical rise of the mechanisms of legal, political, economic, corporate, and technological power that currently shape so much of the globe is thus a more difficult task than it should be. A true philosophical and political history of the American present continues to elude historians.2 This disjunction between historical perception and political reality is not an entirely new phenomenon in the United States. As early as 1887, in a penetrating essay titled “The American State and the American Man,” Albert Shaw chided Americans for their laissez-faire fantasy: “The average American has an unequaled capacity for the entertainment of legal fictions and kindred delusions. He lives in one world of theory and in another world of practice … Never for a moment relinquishing their theory [of laissez-faire], the people of the United States have assiduously pursued and cherished a practical policy utterly inconsistent with that theory, and have not perceived the discrepancy.” Surveying thousands of regulatory laws passed by state legislatures in the late nineteenth century, Shaw concluded that “the one common and striking characteristic of this huge collection of new statutes is its utter disregard of the laissez-faire principle … They deal with the citizen in every conceivable relation. They seem to have left nothing for future Legislatures to regulate.” One hundred years later, in the middle of Ronald Reagan's America, Senator Ernest “Fritz” Hollings (D-SC) similarly observed the powerful role of government in the construction of modern life and its renunciation in the American historical self-conception. Seeking the 1984 Democratic nomination for president, Hollings delivered a stump speech deploying several different versions of a story about “a guy who came home from the Korean War, went to college on a form of the GI Bill, opened a business with a Small Business Administration loan, made sure his parents' farm was adequately wired through Rural Electrification and irrigated with assistance from the Army Corps of Engineers, saw his kids get subsidized school lunches at a school that received lab equipment from a National Science Foundation grant, got his mortgage from the FHA and hurricane disaster relief from FEMA, and one day, took AMTRAK to Washington to complain to his congressman about getting big government off people's backs.” Like many Americans, “the guy” never saw the role of collective power in the creation of his individual declaration of independence.3 Shaw and Hollings reveal a disconnect at the heart of the American experience—a tension between the story that Americans themselves like to tell themselves about individualism, self-reliance, voluntarism, associationalism, free labor, and the free market and the actual history of the “concrete national institutions,” as Shaw put it, that have been capable of wielding such broad interventionist, coercive, and regulatory power at home as well as abroad. Samuel Huntington once dubbed this yawning gap between facts and norms “cognitive dissonance”—an almost pathological tendency to confuse a fictional American ideal with historical political reality. From Thomas Jefferson's elision of slavery in the Declaration of Independence to Ronald Reagan's anachronistic invocation of John Winthrop's shining “city upon a hill,” examples are obvious and legion and not always merely rhetorical. At the turn of the last century, Roscoe Pound surveyed the damage done when the United States Supreme Court took a “long step into the past” and imposed the fallacy of “liberty of contract” on modern industrial labor relations, as if the parties were still individual “farmers haggling over the sale of a horse.” As Pound's example suggests, the problem is one not so much of psychology as of political economy. Shaw and Hollings foreground a particular American version of the tension at the center of social and political thought—the between and power, freedom and and and and A of this American the power, and of the American much of modern history with the of powerful and the of their and of the American state one of the more in in a different and a The “the American is as of an in a of and When at the American version of a state is as not to the that modern and tendency to the American state its history as continues to a with American power in the The and of this historical of the American The of the American state is to the history of American the is to American constitutional and laissez-faire is to American political economy. Like the of and the of a American state is the of a tendency to American history as the history of the of a the historical and of is of the of America as a place of American from a state of As John with almost in the the was The the of individualism, civil society, free labor, and a free in American it the more historical and role of collective law, government, and in American In this the state itself is as of a that never a place in a and The of a American state in and on individualism, associationalism, and to the power of the state in many of democratic and have his American state was in “the government of the United States is to get by it from its of it the of the tradition of in the American state not on perceived to be an from the United States was a at “The of the of this State is not and and the for a not for a State and a a of has the of the late nineteenth and were of commentators to the to is in the United in an American political a characteristic the for the of the of the 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nineteenth The tendency to about the American state the of has never been more for most the of that an of still to be The American state in of the most historical and “a “a “a and “a a an of the modern American state is an and its in the has a historical This on the of an of Samuel Thomas and the and the actual power and of the American state in this have been for the new and into state by their and early to such as in American and the of this has on a life and of its a more of and political who have of in an era when state have and more the American form of legal and is the The obvious present reality of American state power in the early is a of the history of the rise of a global The most and of this is that the American state is and always has been more interventionist, and than was in of histories of the American state to one of the facts about modern American of a and is contemporary American to the of of the and of the American American history has the in the of one of the most 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Describing the process of public sector decentralization is a aim of the article. Increasing the responsibility and competence of local government units is aimed at a taken of decentralization process of the sector of the public finance. Thanks to granted competence, the local authority together with the community take decisions concerning the path of the development of given local government unit. In the article tasks and competence of government units on different level were discussed. Also critically, issues connected with financial resources of local government units and the connection of these resources with the expenses side were presented.
In April 2008, the US Food and Drug Administration (FDA) performed a safety review of the US-approved perflutren microsphere contrast agents (Definity and Optison) and revised a previous black box warning. The new contraindications are much less restrictive than the previous contraindications and satisfy the needs of clinical echocardiography. These changes have come after an intensive debate with the American Society of Echocardiography but also with significant European support. The correction of the contraindication for contrast agents is a good example, how inadequate decisions by the health administration can be reversed by competent and decisive actions of scientific and professional bodies like the ASE and EAE. Before April 2008, the use of contrast agents was contraindicated in patients with unstable cardiopulmonary status, including patients with unstable angina, acute myocardial infarction, respiratory failure, or recent worsening congestive heart failure. The contraindications were established temporarily after the reports of 199 serious cardiopulmonary reactions including 11 deaths during and shortly after the administration of contrast agents in post-marketing use. Ten of the events were observed with Definity over 6 years with more than 2 million applications; one fatal event was reported with Optison for 1 million applications. At least six of these cases (five Definity and one Optison) occurred 1–12 h after dosing and were attributed to serous underlying conditions. The FDA revised the benefit/risk assessment for patients with unstable conditions and acknowledged that some of the fatal events may be coincidental and not related to the contrast media. Only four fatal events with Definity occurred within 30 min after the application of contrast agents. Within this time frame, a negative role of contrast agents appears to be possible, but this is difficult to prove or exclude. Indeed, two patients had severe heart failure and one patient was ventilated because of respiratory failure, sepsis, and multiple emboli. The FDA and European Medicines Agency (EMEA) usually are concerned about a temporal relation of an adverse event and administration of the drug. They assume a possible causal relation as long as there is no proof of another explanation. But even if we assume that all four cases are related to the ultrasound contrast agent, the fatal event rate would be only 1 in 500 000 for Definity and zero for Optison. This rate is far less than the fatal event rate in exercise and Dobutamine stress echocardiography. 1 Meanwhile, several studies demonstrate the safety of ultrasound contrast agents in more than 20 000 patients including stress echocardiography and myocardial perfusion imaging using the flash-replenishment technique. 2–5 In order to provide further safety data, external, independent safety monitoring boards for the agents will be established by the manufacturers. So, it is time to be less worried about the safety of contrast echocardiography and it is good news to have ultrasound contrast agents not contraindicated in unstable conditions. However, as good physicians we still have to be prepared for a serious adverse event, e.g. hypersensitivity reactions, even if they are very rare. Like in the angiography suite, there should always be appropriate equipment and skilled personnel for resuscitation available during administration of contrast agents. According to the FDA, the risk for severe adverse reactions may be increased among patients with pulmonary hypertension or unstable cardiopulmonary conditions (acute myocardial infarction, acute coronary artery syndromes, worsening or unstable congestive heart failure, serious ventricular arrhythmias, or respiratory failure, including patients receiving mechanical ventilation). In these patients, vital signs, electrocardiography, and cutaneous oxygen saturation have to be monitored during the contrast agents application and for at least 30 min after DEFINITY® and OPTISON® administration. Surprisingly, the manufacturer of LUMINITY® (name of Definity in Europe) announced a temporary cessation of the marketing and supply of LUMINITY in Europe. There may be purely commercial reasons for that decision. For clinical echocardiography, OPTISON is not yet available in Europe. Thus, the only available contrast agent is SonoVue®. However, SonoVue has not been included in the FDA review, because it is not licensed in the US. For SonoVue, the contraindications have not changed yet! SonoVue remains contraindicated in acute coronary syndromes, patients with heart failure III and IV, serious ventricular arrhythmias, and respiratory failure. In the setting of an acute myocardial infarct, urgent and repeated echocardiographic examinations may be necessary to evaluate LV function, intracardiac thrombi, and other complications of myocardial infarction. Contrast agents have been shown to be useful to improve the image quality (endocardial definition) in 2D and 3D echocardiography. 6 Therefore, it appears to be straightforward to use contrast echocardiography for better image quality in those with suboptimal image quality. Contrast echocardiography also provides important information about myocardial perfusion. Using the state-of-the-art ultrasound scanners, LV cavity opacification is usually associated with myocardial tissue opacification, if the tissue is viable. Thus, contrast echocardiography after a coronary intervention shows the amount of non-reflow and necrosis in the myocardium. The prognostic significance of myocardial contrast echocardiography has been demonstrated: The extent of microvascular damage during myocardial contrast echocardiography was superior to other known indexes of post-infarct reperfusion in predicting left ventricular remodelling. 7 , 8 But what is the real clinical benefit of a more accurate assessment of the LV early after acute myocardial infarction? The best way to address this question is to ask what would have been happened to the patients should they not have had a contrast echocardiography study. To my knowledge, there are no controlled clinical studies at all addressing the question, how the contrast agents applications changed the management of patients in acute myocardial infarction. Until such time that adjunctive therapies following primary percutaneous coronary intervention are shown conclusively to alter the outcome in relation to myocardial perfusion, the role of myocardial contrast echocardiography in this scenario will be limited. 7 At present, it is the approved indication for LV opacification and endocardial border delineation, which makes contrast agents valuable for patient management: by reviewing case studies, Grayburn 1 recently demonstrated the catastrophic sequences of inaccurate assessment of LV function and misdiagnosis of complications such as pseudoaneurysms and thrombi. Even if there would be a moderate risk by the contrast agent, the risk/benefit still would be very favourable for using contrast agents in acute myocardial infarction! Nucifora et al.9 provide further reassurance about the safety of LUMINITY in the acute phase of myocardial infarction: in 115 consecutive patients with ST-elevation, myocardial infarction contrast echocardiography was performed with LUMINITY. Administration of echo contrast did not induce any significant change in vital signs, physical examination, and ECG. There were no serous adverse events, and minor events occurred only in five patients. Of course, this study cannot rule out all concerns about the safety of ultrasound contrast agents in unstable patients. Firstly, only patients were included after coronary intervention. These patients are probably in a lower risk group compared with patients who would get a contrast agent before the intervention. Secondly, the number of patients is not large enough for a definite answer to our safety questions. However, I agree with the authors that the results of this pilot study should encourage studies in larger cohorts. In Europe, we need ultrasound contrast agents that can be used within the first 24 h after myocardial infarction. There are conditions, where there is no real alternative to the diagnostic value of bedside LV opacification. In the debate with the FDA, the clinical and scientific echocardiographic community has demonstrated their impact on the health administration. We should use this momentum in the discussions with the EMEA in order to achieve a revision of the contraindications of SonoVue. Multi-centre randomized studies are needed to demonstrate how myocardial contrast echocardiography can change patient management. Finally, we need a registry of patients who have got a contrast agent within 24 h after myocardial infarction or other conditions of clinical instability.
Rafael Pass, Wei-Lung Dustin Tseng, Muthuramakrishnan Venkitasubramaniam
Few techniques for obtaining concurrent zero-knowledge exist; all require a complex and subtle analysis. We provide an arguably simpler and more general analysis of the oblivious simulation technique of Kilian and Petrank (STOC’01) while achieving the same bounds as Prabhakaran, Rosen and Sahai (FOCS’02). Using this analysis, and relying on tools recently developed by Ong and Vadhan (Eurocrypt’07, TCC’08) we are able to establish the following unconditional results: • every language inNP which has a ZK proof (resp. ZK argument, statistical ZK argument) also has a black-box concurrent ZK proof (resp. ZK argument, statistical ZK argument). • every languge which has a statistical ZK proof also has an ω(log n)-round black-box con-current statistical ZK proof.
We devise an abstraction of zero-knowledge protocols that is accessible to a fully mechanized analysis. The abstraction is formalized within the applied pi-calculus using a novel equational theory that abstractly characterizes the cryptographic semantics of zero-knowledge proofs. We present an encoding from the equational theory into a convergent rewriting system that is suitable for the automated protocol verifier ProVerif. The encoding is sound and fully automated. We successfully used ProVerif to obtain the first mechanized analysis of (a simplified variant of) the Direct Anonymous Attestation (DAA) protocol. This required us to devise novel abstractions of sophisticated cryptographic security definitions based on interactive games. The analysis reported a novel attack on DAA that was overlooked in its existing cryptographic security proof. We propose a revised variant of DAA that we successfully prove secure using ProVerif.
We proposed a new zero-knowledge proof of identity protocol based on Mandelbrot and Julia Fractal sets. The Fractal based zero-knowledge protocol was possible because of the intrinsic connection between the Mandelbrot and Julia Fractal sets. In the proposed protocol, the private key was used as an input parameter for Mandelbrot Fractal function to generate the corresponding public key. Julia Fractal function was then used to calculate the verified value based on the existing private key and the received public key. The proposed protocol was designed to be resistant against attacks. Fractal based zero-knowledge protocol was an attractive alternative to the traditional number theory zero-knowledge protocol.
This paper focuses on the IMF’s training program as part of the Medium–Term Strategy (MTS) for capacity building in member countries.1 It updates Executive Directors on the current features of the program, reviews the efforts that have been made in recent years to strengthen the curriculum and to enhance value for money, and considers options for boosting external financing of training through charging and increased donor contributions. The paper also provides background for addressing the following issues: — Are the objectives of IMF training fully consistent with the broader objectives of the institution? And are these training objectives being met? — Is Fund training efficiently organized—i.e., is the current degree of decentralization sensible? — Are adequate evaluation and feedback mechanisms in place? —In the absence of market signals and with a large unsatisfied demand, how can we determine the “right” volume of training and how can we assess its worth?
Millions of American children are raised primarily by people other than their parents, mostly by grandparents and other kin, and millions more are raised by third parties for some period of their childhood. In most such situations, informal arrangements negotiated by family members and kinship networks effectively provide care for these children. Many cases, however, require some formal legal arrangement; third party custody orders are needed to obtain necessary services and benefits for children whose parents are absent, and to protect children in the rare but still significant instances in which a parent is abusive or neglectful.\nStates currently have widely varying means of adjudicating child custody disputes between parents and third parties. One Supreme Court case, Troxel v. Granville, addresses contests between parents and third parties. While Troxel ruled for the parent in that particular case, it neither represents a strong parents’ rights opinion nor does it provide states with clear guidance on how to shape third party custody statutes. This Article argues that states should enact child custody statutes according to three primary points. First, due to the wide range of situations in which a third party custody order may be necessary, states should permit a broad set of individuals to seek custody. Concerns that broad standing provisions would lead to a flood of meritless lawsuits are not borne out by actual data in states that have had nearly unlimited standing. Second, recognizing the constitutional primacy of the parent-child relationship, states should hold third parties to a high substantive standard, and require them to prove that parental custody would harm the child in some way. Any lesser standard — such as the best interests of the child standard applied in some states — insufficiently protects relationships between parents and children. Third, recognizing that the core parental right of the “care, custody and control” of a child is at stake, states should generally hold third parties to a clear and convincing burden of proof. Most states apply a preponderance burden or have not specified a burden. One exception should apply: When a third party has acted as a parent for a significant time and a child’s birth parent has not done so, then that parent’s constitutional rights are diminished, society’s interest in maintaining the long-term bond between the child and third party is enhanced, and a lower burden of proof should apply.
A Publicly Veri able Secret Sharing (PVSS) scheme, as introduced by Stadler, has a feature
where anyone, besides the participants, can verify the validity of the shares distributed by
the dealer. Schoenmakers added a new feature, by providing a proof of correctness of the
shares released by the players in the reconstruction process. This protocol is claimed to
be an improvement on Stadler's and Fujisaki-Okamoto's, both in eciency and in the type
of intractability assumptions. However, Young-Yung improved Schoenmakers' PVSS, using a
Discrete-Log instead of a Decision Die-Hellman. In this paper, a new PVSS is presented,
having an intrinsic di erence with its predecessors, that is, the participants can prove the validity
of their given shares, implicitly, proving their membership by a zero-knowledge protocol. This
feature prevents cheaters from participating in the reconstruction process to gain valid shares.
Hence, the new proposed PVSS is more secure than previous ones. Besides, the dealer only
sends the amount of commitments limited to the threshold value, regardless of the number of
shareholders; this leads to a more dynamic protocol.
El Sistema Nacional de Salud (SNS) presenta una compleja situación de equilibrio, que aunque puede ser satisfactorio a corto plazo, plantea grandes problemas de sostenibilidad y gobernabilidad; el incierto balance del proceso de descentralización sanitaria en España señala claramente la senda de buscar nuevas alternativas organizativas para hacer efectivas las ventajas de la descentralización, a la vez que ser capaces de aprovechar las economías del sistema y conseguir la equidad pretendida. Se proponen cuatro líneas de actuación: redefinición del SNS en torno al aseguramiento público y derecho cívico igual para todos; replanteamiento del sistema de financiación y del papel del fondo de cohesión; redefinir el papel del gobierno central y el Ministerio de Sanidad, y crear un nuevo organismo, la Agencia del SNS con un Comisionado que de soporte organizativo e identidad al SNS como ámbito de acción cooperativa. The Spanish National Health System (SNHS) is currently in a complex equilibrium which, even if acceptable in the short term, faces major sustainability and governance challenges; the so far inconclusive outcome of the SNHS decentralization process clearly underlines the importance of seeking new alternatives to effectively bring about the real benefits of decentralization, while taking advantage of the system's economies of scale and achieving its equity objectives. To this end, four lines of action are proposed in this paper: first, redefine the SNHS based on universal public coverage, as a civic right and equal for all; second, reframe the financing system and the role of the Cohesion Fund; third, review the role of central government and its Ministry of Health, and fourth, create of a SNHS Agency headed by a Commissioner, for providing an organizational framework and identity for the SNHS, and serving as the cooperative body of the seventeen Autonomous Communities’ Health Services.
Open access
Global Health Care Issues
Health Systems, Economic Evaluations, Quality of Life
From a historical perspective, the multiverse is just one more step in our progress from geocentric to heliocentric to galactocentric to cosmocentric worldview. Indeed, several lessons of relevance to the multiverse debate can be gleaned from considering the history of this progression. To the ancient Greeks, the heavenly spheres were the unchanging domain of the divine and therefore outside science by definition. It required Tycho de Brahe's observation of a supernova in 1572 and the realization that its apparent position did not change as the Earth moved around the Sun to dash that view. Because this contradicted the Aristotelian view that the heavens cannot change, the claim was at first received sceptically. Frustrated by those who had eyes but would not see, Brahe wrote: “O crassa ingenia. O coecos coeli spectators.” (Oh thick wits. Oh blind watchers of the sky.) Lesson 1: Theoretical prejudice should not blind one to the evidence. Of course, we will never see the other universes themselves — in that sense we are necessarily blind, so this point might seem irrelevant to the multiverse. However, I would claim that the analogue of Tycho's supernova is the fine-tunings. Long after Galileo had speculated that the Milky Way consists of stars like the Sun and Newton had shown the laws of Nature could be extended beyond the solar system, there was still a prejudice that the investigation of this region was beyond the domain of science. In 1842 August Comte said of the study of stars: “Never, by any means, will we be able to study their chemical compositions. The field of positive philosophy lies entirely within the Solar System, the study of the universe being inaccessible in any possible science.” Comte had not foreseen the advent of spectroscopy, which identified absorption features in stellar spectra with chemical elements. Lesson 2: New observational developments are hard to anticipate. Perhaps we will find extra dimensions at the Large Hadron Collider or even create baby universes in the laboratory one day. Cosmology attained the status of a proper science in 1915, when the advent of general relativity gave it a secure mathematical basis. Nevertheless, for a further decade there was resistance to the idea that science could be extended beyond our galaxy. Indeed many astronomers refused to believe that there was anything beyond. Although Kant had speculated as early as 1755 that some nebulae are “island universes” similar to the Milky Way, most astronomers continued to adopt a galactocentric view until the 1920s. Indeed, the most popular model of the galaxy at the start of the 20th century — Kapteyn's Universe — even had the Sun at its centre! The controversy came to a head in 1920 when Heber Curtis defended the island universe theory in a famous debate with Harlow Shapley. The issue was finally resolved in 1924, when Edwin Hubble measured the distance to M31 using Cepheid variable stars. In many ways this parallels the current debate about whether anything exists beyond our horizon. Lesson 3: More conservative cosmologists might prefer to maintain the cosmocentric view but perhaps the tide of history is against them. The evidence for other universes can never be as decisive as that for extragalactic nebulae but the transformation of worldview required may be just as necessary. A few years later Hubble obtained radial velocities and distance estimates for several dozen nearby galaxies, thereby discovering that all galaxies are moving away from us with a speed proportional to their distance. The most natural interpretation of this is that space itself is expanding, as indeed had been predicted by Alexander Friedmann in 1920 on the basis of general relativity. Einstein rejected this model at the time because he believed the universe (i.e. the Milky Way) was static and he even introduced an extra repulsive term into his equations — the cosmological constant — to allow this possibility. After Hubble's discovery, he described this as his “biggest blunder”. Lesson 4: One should not necessarily reject theoretical predictions because they have no observational support. In fact, Einstein continued to uphold the static model even after the evidence was against it — he only accepted the Friedmann model in 1931, several years after Hubble published his data — so knowing how much weight to attach to theory and observation can be tricky. Let me now address George's specific issues. There are plausibly galaxies just beyond the visual horizon, where we cannot see them, so we can extend this argument, step by step, to way beyond the horizon and infer there are many different universes that we cannot see. Even though we can never prove what happens outside our visual horizon, the standard FRW model has been well tested within it, so there is surely some probabilistic sense in which one can extrapolate models at least some way beyond it. Also the smooth dependence of the CMB fluctuations on angular separation (whatever the source of those fluctuations) gives no reason to suppose that anything strange happens just beyond the horizon. George himself seems to accept this, which illustrates the problem of regarding speculations as non-scientific just because they involve the unobservable. Admittedly one's confidence in any proposed model must decrease as one extrapolates ever further beyond the horizon, but one should beware of using Rees's slippery slope argument in reverse: we cannot extrapolate to scales much larger than the horizon, so we should not extrapolate to scales only slightly outside it. The problem comes when one makes the jump from the Level I to Level II multiverse (which is where George's argument that the FRW solution extends everywhere must fail). In fact, the inflationary scenario does provide an answer to this. For if the amplitude of the density fluctuations increases slightly with scale (as appears to be the case), one can predict the scale at which the FRW approximation breaks down. Current data suggest that this happens at around 10100 horizon scales. The existence of a multiverse is implied by inflation, which is verified by the CMB anisotropy observations. In particular, known physics leads to chaotic inflation and this implies a multiverse. There are two distinct issues here: does one believe in inflation and does inflation lead to a multiverse? Inflation is attractive because it resolves several cosmological conundra. Quantum fluctuations of the scalar field can also generate the small density perturbations that eventually give rise to galaxies and large-scale structure and it is impressive that the predicted dependence of the CMB fluctuations on angular separation is almost exactly as observed by the WMAP satellite (Spergel et al. 2003). Of course, the evidence for inflation is not conclusive — there is still no evidence for any scalar field in Nature!— but the Level I multiverse is still a good bet. As regards the second issue, I agree with George that the evidence for the sort of chaotic inflation that leads to a Level II multiverse is more equivocal, and certainly one cannot infer this from the form of the CMB anisotropies. There are now around 100 models of inflation and, while Linde (1990) claims that the existence of other domains with different coupling constants is generic, this is debatable. The multiverse idea is testable, because it can be disproved if we determine there are closed spatial sections in the universe (for example, if the curvature is positive). This is really a straw man argument because we have seen that inflation is only one of several multiverse proposals — for example, quantum cosmology models give closed spatial sections — and not all inflationary models require that the spatial sections be open anyway. However, George is surely right to stress the importance of looking for circles in the CMB. The idea of small universes is not mainstream but it has the advantage that it can be tested. The existence of a multiverse is the only physical explanation for the fine-tuning of parameters that leads to our existence. In the absence of direct evidence for other universes, I regard the anthropic fine-tunings as the best indirect evidence. (A multiverse in which the constants were the same everywhere would have no explanatory value.) I agree with George that the fine-tunings do not constitute proof, but they still carry weight. One can argue about how impressive the fine-tunings are (could we really exclude life if the constants changed a lot?), but I still think the number and precision of the tunings is remarkable. Nearly 30 years ago I wrote a review with Martin Rees about these fine-tunings (Carr and Rees 1979). In the intervening period a few of them have gone away (e.g. inflation may explain the value of the cosmological density parameter) but most of them have got stronger. Without a multiverse one may be forced to adopt a non-physical explanation like a fine-tuner, which is why Neil Manson (2003) claims that “the multiverse is the last resort of the desperate atheist”. This is not necessarily true — Paul Davies (2006) advocates a “third way” in which the laws of Nature evolve in a single universe in such a way that life can arise — but if you reject the multiverse, you certainly lower the scientific status of the anthropic arguments. I agree with George's argument against physical infinities. However, we do not need an infinity to validate the anthropic principle — just a large number. The existence of a multiverse is implied by a probability argument: the universe is no more special than it need be to create life. In particular, the small value of the cosmological constant shows that other universes exist. George argues that multiverse theories are not useful because they cannot be disproved: if all possibilities exist somewhere, then they can explain all conceivable observations. However, the fact that we only observe one sample of the multiverse still allows the proposal to be refuted at a given confidence level. Statistical predictions still qualify as science and that is why Rees has stressed the importance of calculating the probability distribution for various parameters across the universes. Indeed, a core difference between the Bayesian and frequentist views is the former's willingness to make inferences from single, and possibly unrepeatable, pieces of data. George rejects the Λ argument but there is no doubt that this has been very influential in attracting many physicists to the multiverse cause. It used to be thought that Λ was exactly zero and it was then plausible that there might be some physical (non-anthropic) explanation for this. However, the fact that Λ is non-zero but very tiny is a profound mystery that completely changes the situation. Critics say that we cannot know what distribution for Λ is predicted across the multiverse and that is correct. It may be simplistic to assume that the distribution is uniform, but postulating that there is a spike in precisely the observed region is just as improbable as what we are trying to explain. Even if one does not accept inflation, multi-verses are predicted by many theories of particle physics. It is still legitimate to invoke the existence of other universes for which there can be no direct evidence if one has a theory (like M-theory) that predicts this. It is not necessary to check all predictions of the theory for it to be considered scientific (e.g. we cannot probe inside black holes and we cannot see quarks but we still regard these as subjects for scientific discourse); it is only necessary to test some of them. Does M-theory qualify in this respect? George claims no; it does not come under the purview of science because our confidence in it is based on faith and aesthetic considerations (mathematical beauty etc) rather than experimental data. Certainly he is not alone in this attitude. For example, Woit (2006) and Smolin (2007) dismiss M-theory as mathematics rather than physics because it has not made contact with observations after 20 years. However, I feel this rejection is premature. It may take 200 years to solve the equations of M-theory and test them, but the definition of what constitutes a scientific question should not depend on how difficult it is. The nature of science changes, so what is illegitimate science today may be legitimate tomorrow. The fundamental issue in the dispute between myself and George concerns which features of science are to be regarded as sacrosanct. Experimentation used to be regarded as sacrosanct but by that criterion all of astronomy would be excluded since one cannot experiment with stars and galaxies. Fortunately, one can still make observations and — since there are billions of these objects — Nature effectively performs experiments for us. Cosmologists are in worse shape because there is only one universe to observe and speculations about processes at very early and very late times have to be viewed as ultra-speculative. For this reason, more conservative physicists regard even relatively standard cosmological speculations as trespassing into metaphysics. George places a lot of emphasis on falsifiability, but not everybody in the philosophy of science agrees with Popper on this and it is surely dangerous to impose a philosophical prescription that prevents scientists changing the border of their field. As Susskind cautions, it would be a pity to miss out on some fundamental truth because of an over-restrictive definition of science. Of course, one needs some degree of falsifiability, but the question is, how much? It is certainly not fair to put M-theory in the same class as astrology. On the other hand, I share George's scepticism of the Level IV multiverse, which corresponds to universes governed by different mathematical structures. The view that any mathematically possible universe must exist somewhere seems untestable in a deeper sense than Levels I to III. The notion of a multiverse entails a new perspective of the nature of science and it is not surprising that this causes intellectual discomfort. But this situation has often occurred before and one should not be surprised if it happens again. The Cosmic Uroborus in figure 2 shows that the history of physics might be regarded as the extension of knowledge into ever smaller and ever larger scales. The ideas encountered at the two frontiers have often been viewed as part of philosophy rather than science, so in a sense the debate is nothing new. However, there is another sense in which the current situation is very special. This is because — for the first time — the boundaries at the largest and smallest scales have connected, as indicated by the top of the Cosmic Uroborus, so the two science/philosophy frontiers have merged. Does this merging represent the completion of science or merely the sort of transformation in the perceived nature of science that accompanies every paradigm shift? This is a contentious issue and clearly we do not yet know the answer. I accept that there may eventually be a limit to the sort of questions that science can address; George and I merely disagree on whether we have reached that limit with the multiverse. In any case, we are surely behoven to try to take science as far as possible. I will end with a comment by Steven Weinberg (2007) in his contribution to Universe or Multiverse?: “We usually mark advances in the history of science by what we learn about Nature, but at certain critical moments the most important thing is what we discover about science itself. These discoveries lead to changes in how we score our work, in what we consider to be an acceptable theory.”
The very nature of the scientific enterprise is at stake in the multiverse debate. Its advocates propose weakening the nature of scientific proof in order to claim that the multiverse hypothesis provides a scientific explanation. This is a dangerous tactic. Two central scientific virtues are testability and explanatory power. In the cosmological context, these are often in conflict with each other and there has been an increasing tendency in theoretical physics and cosmology to say it does not matter whether a proposal is testable: if it fits into our other theories in a convincing way, with great explanatory power, then testing is superfluous. The extreme case is the multiverse proposal, where no direct observational test of the hypothesis is possible. Despite this, many articles and books dogmatically proclaim that the multiverse is an established scientific fact. In this context one must re-evaluate what the core of science is: can one maintain one has a genuine scientific theory when direct and indeed indirect tests of the theory are impossible? If one claims this, one is altering the meaning of science. One should be very careful before so doing. There are many other theories waiting in the wings, hoping for a weakening of what is meant by “science”. Those proposing this weakening in the case of cosmology should be aware of the flood of alternative scientific theories whose advocates will then state that they too can claim the mantle of scientific respectability. The key observational point is that the domains considered are beyond the visual horizon and are therefore unobservable. You cannot receive signals of any kind from beyond the horizon, as there has not been time for messages to reach us from there since the universe began. Hence no object out there is detectable by any kind of astronomical observation. To see this clearly one should look at the space-time diagrams of our past light cone (figure 5). The assumption made in justifying the multiverse is that we can extrapolate to 10100 times the horizon distance or even more (the word “infinity” is casually used in these writings). The extraordinary pretentiousness of this attempt should be clear. This shows the space-time diagrams of our past light cone in both the usual form (a) and conformal form (b), in which one expands the spatial distances in order to see the causal structure. The light cones are then at ±45°, making clear the observational and causal limits; any observation beyond the visual horizon is impossible. The Hubble distance is where galaxies recede at the speed of light (v=c). The redshift measures the expansion factor and goes to infinity at the horizon itself. (c) shows more clearly the vast extrapolation envisaged in justifications of the multiverse. Note that there is a distinction betweeen the visual horizon and the event horizon. The latter relates to causality in the far distant future and is irrelevant to present-day observations, but becomes relevant if the universe accelerates. (Mark Whittle, University of Virginia) The often claimed existence of physical infinities in the multiverse context — of either universes or spatial sections of universes (Vilenkin 2006) — is dubious. What has been forgotten here is that infinity is an unattainable state rather than a large number — its character is totally different from any finite number and it is a mathematical rather than physical entity. According to David Hilbert (1964): “The infinite is nowhere to be found in reality, no matter what experiences, observations, and knowledge are appealed to.” Even if there were an infinite number of galaxies, and we could see them all (which we could not), we could not count them in a finite time. So there is no way the existence of an infinity can ever be proven correct by observation or any other test. The concept of physical infinities is not a scientific one if science involves testability by either observation or experiment. The claim of infinites in the multiverse context emphasizes how tenuously scientific that idea is. It is a huge act of hubris to extrapolate from one small domain to infinity when infinity is never attainable. Seven different kinds of justification have been proposed for the existence of a multiverse and I will now consider these in turn. There are plausibly galaxies just beyond the visual horizon, where we cannot see them, so we can extend this argument, step by step, to way beyond the horizon and infer there are many different universes that we cannot see. This is the “slippery slope” argument and Rees (2001) uses it to defend both Level I and Level II multiverses. The argument is fine as regards extrapolation in the vicinity of the visual horizon, but the assumption that it can be continued to very distant domains or other universes is an untestable major extrapolation, which assumes a continuity that may or may not be true. If each link in a chain of evidence is well understood and tenable, then indirect evidence such as this carries nearly as much weight as direct evidence. But not all the links in the chain are tenable. If employed to its logical conclusion it seems a priori to lead to the old idea of spatial homogeneity extending forever (“The Cosmological Principle”) rather than the multiverse of chaotic cosmology with domain walls separating different phases. For if the universe within the horizon is almost exactly Friedmann-Robertson-Walker (FRW) — a statistically spatially homogenous and isotropic space-time — it is plausible that it is also FRW just outside the horizon, and a simple extrapolation suggests that it is spatially homogeneous without limit. But supporters of chaotic inflation claim that there are completely different domains out there with different values of the constants, so which is the case? You can say what you like and nobody can prove it right or wrong. The existence of a multiverse is implied by inflation, which is verified by the Cosmic Microwave Background anisotropy observations. In particular, known physics leads to chaotic inflation and this implies a multiverse. A multiverse is implied by some forms of inflation but not others. Inflation is not yet a well defined theory and chaotic inflation is just one variant of it. For example, inflation in a small closed universe fits all the observations, without requiring a multiverse. In any case, the key physics involved in chaotic inflation (Coleman-de Luccia tunnelling) is extrapolated from known and tested physics to quite different regimes; that extrapolation is unverified and indeed unverifiable. The physics is hypothetical rather than tested. We are being told that what we have is “known physics → multiverse”. But the real situation is “known physics → hypothetical physics → multiverse” and the first step involves a major extrapolation which may or may not be correct. The multiverse idea is testable, because it can be disproved if we determine there are closed spatial sections in the universe (for example, if the curvature is positive). The claim is that only negatively curved FRW models can exist in a multiverse based on chaotic inflation, either because Coleman-de Luccia tunnelling only gives negative curvature or because a closed spatial section necessarily implies a single universe. But the first argument is disputed (there are already papers suggesting that tunnelling to positively curved universes is possible) and the second argument would not apply if we lived in a high-density lump imbedded in a low-density universe (i.e. the extrapolation of positive curvature to very large scales may not be valid). Neither argument is conclusive. Certainly observational confirmation of negatively curved space sections would not constitute proof of a multiverse, for that can occur in a single universe. However, chaotic inflation versions of the multiverse can be disproved if we observationally prove that we live in a universe with closed spatial sections that are so small that we have already seen round the universe. We can test this possibility by searching for identical circles in the CMB, together with low anisotropy power at large angular scales (which is indeed observed). This is an important test as it would disprove the chaotic inflation variety of multiverse. But not seeing the circles would not prove a multiverse exists: their non-detection is a necessary but not sufficient condition for multiverses. The existence of a multiverse is the only physical explanation for the fine-tuning of parameters that leads to our existence. The multiverse is a reasonable theoretical explanation of the fine-tunings, but this does not help in observationally confirming the hypothesis. The issue here is, which is more important in cosmology: theory (explanation) or observations (tests against reality)? The essential proposal is that one should downgrade observational testing in favour of theory — a dangerous road to take. In any case, the major problem with this proposal is that it can explain anything at all, because in a multiverse with an infinite or extremely large variety of universe properties — for example, the 10500 possibilities allowed by the landscape of string theory — virtually anything can happen. In that case, the hypothesis does not predict any specific testable fact. The existence of universes with giraffes is certainly predicted by many multiverse proposals, but universes where giraffes do not exist are also predicted. Observing a giraffe neither confirms nor disproves the multiverse. The existence of a multiverse is implied by a probability argument: the universe is no more special than it need be to create life. In particular, the small value of the cosmological constant shows that other universes exist. But the statistical argument invoked here only applies if a multiverse exists; it is simply inapplicable (because the probability distribution has no meaning) if there is no multiverse, so it cannot prove a multiverse exists. It is a calculation that assumes the answer (that a multiverse exists) before it begins. If we only have one object to observe, we can make many observations of that object, but it is still only one object (one universe), and you cannot do statistical tests on its nature. This is a consistency test if there is indeed a multiverse, but it says nothing if there is not. It is not a sufficient condition for its existence. The argument that the actual value of Λ is extremely different from the “natural” one predicted by theoretical physics (120 orders of magnitude smaller!) makes very clear the nature of the multiverse project: it is an attempt to make the extremely improbable appear probable. Even if one does not accept inflation, multiverses are predicted by many theories of particle physics. One example of this is the string landscape of M-theory, but that is a hypothetical proposal with no solid evidence in its favour. Indeed, even many string theorists are sceptical about the landscape, despite the enthusiasm with which some propose it. A major problem arises when one has a theory where no verification is possible. It is not necessary to check all the predictions of a theory for it to be considered scientific — one can check some predictions to help the theory gain credence, but that does not prove the theory because it has to be the only one that makes the prediction for it to carry weight; it cannot be conclusive unless no other explanation is possible Let me illustrate with an example. I can propose that there are leopards hidden in the mountains of Scotland. They are very shy, so they hide away and no-one ever sees them. But you can tell they are there because sheep vanish without trace every year. I can put together an exciting research project that will look at statistics of lost sheep in Scotland for the past 50 years, and hence prove the existence of these rare mountain leopards. This seems to me to be analogous to the argument for proof of the existence of a multiverse through any specific property (e.g. the smallness of Λ) that might possibly exist somewhere in the landscape. This may be something that is predicted by some multiverse theory, but it hardly proves it true. I am all for the exercise of applying known physics in more extreme conditions: do it and see what happens. But admit that it is an untested extrapolation and that different extrapolations are possible. You can extrapolate different aspects of known physics to the unknown and different predictions will result. For example, if one extrapolates classical physics to the quantum domain, the answers will be wrong. But in that case you can show this is so by experimental tests. That is what is missing in the multiverse case: you can make the extrapolation but cannot then determine if it is right or not. The nature of science changes, so what is illegitimate science today may be legitimate tomorrow. This is true, but the foundations must be respected if one is to preserve the core features of science that have led to its phenomenal success: that is the feedback from reality to theory provided by experiment and observational testing. One abandons that at one's peril. For example, today's philosophical definition of science excludes astrology, despite all the claimed theory and data supporting it. But now astrologers can take hope from the arguments of string theorists and multiverse enthusiasts: with the weakened kinds of criteria proposed, astrology too will soon be a strong candidate for recognition as a genuine science. The Popperazi (a derogatory term used by Susskind for those who believe testing scientific theories is an indispensible aspect of science) will no longer be able to deny astrology its place as a proper scientific theory. Is that what we really want? At the very least, we must be given a clear statement as to what broader definition of the nature of science is being proposed, and in particular what criteria of testing will be taken to be adequate (Ellis 2006); this then needs to be assessed in relation to cases such as astrology and “intelligent design”, as well as multiverses and string theory, in order to see what its implications are. The multiverse idea is provable neither by observation, nor as an implication of well established physics. It may be true, but it cannot be shown to be true. It does have great explanatory power — it provides an empirically based rationalization for fine tuning, developed from known physical principles — but one must distinguish between explanation and prediction. Successful scientific theories make predictions that can be tested. The multiverse theory cannot make any testable predictions because it can explain anything at all. Even though multiverse proposals are good empirically based philosophical proposals for the nature of what exists, they are not strictly within the domain of science. There is nothing wrong with empirically based philosophical explanation — indeed it is of great value provided it is labelled for what it is — but I suggest that cosmologists should be very careful not to make methodological proposals that erode the essential nature of science in their enthusiasm to support specific theories. For if they do so, there will very likely be unintended consequences in other areas where the boundaries of science are in dispute. Let me state it more strongly: it is dangerous to weaken the grounds of scientific proof in order to include multiverses under the mantle of “tested science”. It is a retrograde step towards the claim that we can establish the nature of the universe by pure thought without having to confirm our theories by observational or experimental tests. This abandons the key principle that has led to the extraordinary success of science. The claim that multiverses exist is a belief rather than an established scientific fact. It is a reasonable belief with strong explanatory nature, but a belief nonetheless. The appropriate statement we can make is not “multiverses exist” or “multiverses have been proved to exist” or even “multiverses can be proved to exist”, but rather “multiverses are a useful explanatory hypothesis”. We should not state more. Martin Gardner (2003) puts it this way: “There is not the slightest shred of reliable evidence that there is any universe other than the one we are in. No multiverse theory has so far provided a prediction that can be tested. As far as we can tell, universes are not as plentiful as even two blackberries.”