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David G. Victor
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The world's energy system seems to have come unhinged. Oil is trading at record high prices because demand keeps rising even as supplies become unreliable. Oil exporters from Iran to Russia and Venezuela are using their petrocash to pursue agendas that undercut western security and interests. Supplies of natural gas also seem less secure than ever.

The world's energy system seems to have come unhinged. Oil is trading at record high prices because demand keeps rising even as supplies become unreliable. Oil exporters from Iran to Russia and Venezuela are using their petrocash to pursue agendas that undercut western security and interests. Supplies of natural gas also seem less secure than ever.

The root cause of these troubles is dysfunctional energy politics. The countries with the strongest incentives to cut their vulnerability to volatile energy markets - notably America - are unable to act because influential politicians view all serious policies as politically radioactive. Efforts to boost supply have little leverage because the most attractive geological riches are found mainly in countries where state-owned companies control the resources and outsiders have little clout. Thus, the current energy debates are generating a volcano of proposals that have no positive impact on tight markets.

Yet these structural barriers to serious policy remain hidden because the debate labours under the meaningless umbrella of "energy security". Proper policy on oil and gas must start with the distinct uses for these fuels - each requiring its own political strategy.

The effort on oil must focus on transportation. Vehicles and aircraft work best with liquid fuels that can store large quantities of energy in a compact space and flow easily through pipes to engines. Searching for a better substitute is worthwhile, but the effort faces an uphill battle. With today's technologies, no other energy liquid can reliably beat petroleum. Liquids can be made from coal, as South Africa and China are doing. But that approach is costly and has unattractive environmental implications. Brazil and the US have focused on ethanol, which they distill from sugar or grain from crops. However, those programmes, which account for less than 0.5 per cent of the world's energy liquids, have a negligible impact on the oil market. Yet, America is redoubling its ethanol effort because it is politically unbeatable to reward corn growers and grain handlers who are a formidable force in US politics. Indeed, requirements for ethanol in America have created a more rigid fuel supply system that actually raises the price of oil products, although ethanol's backers originally claimed they would cut energy costs. That same political force also blocks imports of cheaper Brazilian ethanol. In principle, a better approach is so-called "cellulosic ethanol", which promises lower costs as it converts whole plants into ethanol rather than just the grain. But like most messiahs, its attraction lies in the future. So far, nobody has made the system work at the scale of a commercial refinery.

The best way to temper oil demand today is by lifting efficiency. Even this economic winner is politically difficult to implement. The US, which consumes one-quarter of the world's oil, has not changed fuel efficiency standards for new cars in 16 years. Every big economy - even China's - has stricter fuel economy rules than America's. Political gridlock has stymied even modest proposals to allow trading of efficiency credits. A trading scheme is politically inconvenient as it could force US carmakers (which make generally inefficient cars) to buy valuable credits from foreign brands. No politican wants to multiply Detroit's problems.

Even better ideas - such as a stiffer petrol tax - stay stuck on opinion pages of newspapers and in academic journals. Despite what is increasingly termed today's "energy crisis", these ideas barely cross the lips of politicians who want to remain viable among the thicket of anti-tax conservatives and pro-Detroit lobbyists.

The approaches needed for natural gas are quite different. In western Europe, which has long depended on imported gas from Russia, Algeria and a few smaller suppliers, the vulnerabilities are particularly stark. In principle, though, gas dependencies are easier to manage than oil because gas has rivals for each of its major uses. In electric power generation, countries must preserve diversity - ensuring, for example, that advanced coal and nuclear technologies remain viable. While "diversity" is motherhood in energy policy, in reality it requires difficult choices. In continental Europe, for example, policy-­makers have not seriously confronted the conflict between the need for diversity while, at the same time, opening the power sector to morecompetition. Historically, companies in competitive power markets have invested heavily in gas because gas plants are smaller and require less capital than coal or nuclear plants.

Gas suppliers who dream of extending their powers forget that it is harder to corner gas markets when users have a choice. Algeria learnt that lesson in 1981 when it left a key pipeline empty in a pricing dispute with Italy - extracting a better price at the time but losing billions of dollars for the future by destroying its reputation as a reliable supplier.

That lesson should be sobering for Russia today. In December, Gazprom, Russia's giant state gas company, cut deliveries to Ukraine, which then siphoned supplies that flow on to Europe. The company rattled its pipes again last month - threatening retaliation if Europe dared try to wean itself from Russia's gas. While Gazprom's management must pander to Russian nationalism (where pipe-rattling is welcome), the company's long-term viability rests on its reliability as a supplier to lucrative west European markets. Similarly, the recent decision by Evo Morales, Bolivia's president, to nationalise his country's gas fields will give him a boost domestically and might generate some instant extra revenue, but it will also encourage his customers in Brazil and Argentina to look elsewhere for energy.

"Resource nationalism" is back in vogue. But for gas suppliers in particular, it usually ends badly - not least because the infrastructure is costly to build and buyers can afford to be choosy. Gas users can further subdue Russia's rattling by multiplying sources of supply. A robust market for liquefied natural gas will help.

The tendency for gridlock in energy politics means that policymakers must focus where tough decisions matter most, such as efficiency in the use of oil and diversity in the application of gas. Yet, prospects for serious policy are poor - not least because the US, which should be a leader, is the most hamstrung. Luckily, the markets are responding on their own - albeit slowly and patchily. Costly oil is encouraging conservation and new supplies; LNG is accelerating, and gas buyers are more wary of Russian gas than they were a decade ago when Russia was seen as a reliable supplier. If the political structure remains dysfunctional on matters of energy, then the best second is perhaps no policy at all.

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David Holloway
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Jeffrey T. Richelson's history of American nuclear intelligence, Spying on the Bomb, is timely, writes CISAC's David Holloway, given the faulty intelligence about nuclear weapons that was used to justify the U.S. invasion of Iraq. In fact the book could have gone further toward analyzing the relationship between the intelligence community and policy makers, Holloway suggests in this New York Times book review.

Before attacking Iraq in March 2003, the United States told the world that Saddam Hussein had reconstituted his nuclear weapons program in defiance of the United Nations. That claim, used to justify the war, was based on assessments provided by the United States intelligence community. But as everyone now knows, those assessments were wrong. So Jeffrey T. Richelson's history of American nuclear intelligence, including our attempts to learn about Iraq's nuclear program, could hardly be more timely.

In "Spying on the Bomb," Richelson, the author of several books on American intelligence, has brought together a huge amount of information about Washington's efforts to track the nuclear weapons projects of other countries. He examines the nuclear projects of Nazi Germany, the Soviet Union, China, France, Israel, India, South Africa, Taiwan, Libya, Pakistan, Iran and North Korea, as well as Iraq. Through interviews and declassified documents as well as secondary works, he sets out briefly what we currently know about those projects and compares that with assessments of the time.

This may sound like heavy going, but Richelson writes with admirable clarity. And along the way he has fascinating stories to tell: about plans to assassinate the German physicist Werner Heisenberg during World War II; about discussions in the Kennedy and Johnson administrations on the possibility of attacking Chinese nuclear installations; about Indian measures to evade the gaze of American reconnaissance satellites; and about the bureaucratic infighting over the estimates on Iraq.

The United States has put an enormous effort into gathering information about the nuclear projects of other countries. After World War II it equipped aircraft with special filters to pick up radioactive debris from nuclear tests for isotopic analysis. It created a network of stations around the world to register the seismic effects of nuclear explosions. Most important, in 1960 it began to launch reconnaissance satellites that could take detailed photographs of nuclear sites in the Soviet Union and China. Richelson occasionally speculates about the role of communications intercepts and of spies, but these appear from his account to have been much less important than the other methods of collecting information.

Through these means the United States has gathered a vast quantity of data, sometimes to surprising effect. Intelligence played a crucial role in the cold war, for instance, by reducing uncertainty about Soviet nuclear forces. Alongside such successes, however, there have been failures. One notable example concerned the first Soviet test, which took place in August 1949, much sooner than the C.I.A. had predicted. Another was the failure to detect Indian preparations for tests in May 1998, even though at an earlier time the United States, with the help of satellite intelligence, had managed to learn about preparations the Indians were making and to head off their tests.

But the most serious failure of all was in Iraq in 2003, because in no other case did the intelligence assessments serve as justification for the use of military force. The information needed for avoiding political surprise is one thing. That needed for preventive war is quite another, if only because of the consequences of making a mistake.

Beyond making the uncontroversial recommendation that "aggressive and inventive intelligence collection and analysis" should continue, Richelson draws no general conclusions. That is a pity, because his rich material points to issues that cry out for further analysis. He suggests in one or two cases that failures sprang from the mind-set of the intelligence community, but he does not elaborate on this point. He has little to say about relations between policy makers and the intelligence community, even though the quality of intelligence and the use made of it depend heavily on that relationship.

His focus is no less narrow in his discussion of foreign nuclear projects. He concentrates on the programs themselves, paying very little attention to their political context. Does that reflect a technological bias in nuclear intelligence? Would, for example, the prewar assessment of Iraqi nuclear capabilities have been more accurate if it had paid more attention to the broader political and economic circumstances of Hussein's regime?

The task of intelligence has become more complex than it was during the cold war. A single dominant nuclear opponent has now been replaced by a number of nuclear states, along with states and stateless terrorists that are aiming to get their hands on nuclear weapons. Meanwhile, the technology needed for producing nuclear weapons has become easier to acquire.

Many critics believe the recent performance of the intelligence community shows it has not responded adequately to this new situation. Richelson does not have much to say on this question; nor does he discuss the likely impact of the current reforms, initiated in response to the Iraq war, on the quality of intelligence. His reticence may imply that he does not think reform is necessary. Still, it is disappointing that he does not draw on his historical survey to discuss whether new approaches are needed for dealing with nuclear threats, and, if so, what those new approaches might be.

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Gideon Maltz
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In an op-ed in the Baltimore Sun on March 13, the CDDRL fellow Gideon Maltz argues that the international community's strategy on Zimbabwe has failed, and suggests that it is time to focus international attention on the prospect of Zimbabwe's only genuine political opening in the years ahead: the exit of Mr. Mugabe.

It is time to acknowledge that the international community's strategy on Zimbabwe has failed.

Robert G. Mugabe's regime has survived even as the economy deteriorates further (unemployment is above 70 percent, and gross domestic product will decline another 7 percent this year) and personal freedom suffers greater assaults (the recent "drive out the rubbish" campaign left 700,000 people homeless).

Indeed, with the opposition Movement for Democratic Change (MDC) on the verge of collapse - following a bitter fight over whether to boycott the recent Senate elections and after years of sustained government pressure - the regime has a stronger grasp on power than ever. Doddering though he may be, Mr. Mugabe, who recently turned 82, has foiled the pressure of the United States and Britain and the quiet diplomacy of his neighbors in southern Africa.

Predictions of imminent change still crop up in Western newspapers on the occasion of every new crisis in Zimbabwe. But these predictions have not come to bear, and they likely will not. So long as Mr. Mugabe reigns, his Zimbabwe African National Union-Patriotic Front (ZANU-PF) regime will survive.

The international community tried to change things. It embarked on a strategy of concerted economic and diplomatic pressure to weaken the Mugabe regime, trying to force it to either back down or submit to the democratic opposition. It's clear that strategy has failed.

It is, therefore, time to focus international attention on the prospect of Zimbabwe's only genuine political opening in the years ahead: the exit of Mr. Mugabe, whether through retirement or death, which will leave the regime internally and externally vulnerable.

Internally, the ZANU-PF regime without Mr. Mugabe at the helm will be uniquely susceptible in an election. In sub-Saharan Africa, opposition candidates have won post-transitional elections only 5 percent of the time against incumbents but 33 percent of the time against regimes' designated successors.

The most important reason for that is the incumbent's exit removes the regime's glue. The regime fractures into competing factions and is left with a substantially reduced capacity to repress the political opposition and rig an election.

In Kenya, after President Daniel T. arap Moi, and in Ghana, after President Jerry J. Rawlings, the regimes did not - could not - resort to all the dirty tactics that they certainly would have used had the incumbents run. In turn, these political openings have tended to galvanize the fractured opposition to successfully cooperate.

A ZANU-PF that is deeply unpopular, badly fractured among ethnic groups and between moderates and hard-liners (the expulsion of the information minister, Jonathan Moyo, is the beginning) and facing a reinvigorated opposition will not likely be able to effectively rig elections, let alone win the popular vote.

It will be critical, then, that presidential elections be held within a year of Mr. Mugabe's exit, before the regime has too much time to consolidate. If Mr. Mugabe's exit does not occur within that window before the 2008 elections, then international, and particularly regional, pressure will be crucial in forcing early elections.

Externally, Mr. Mugabe's exit may prompt genuine regional pressure. Analysts have long emphasized that international pressure requires the support of Zimbabwe's neighbors - especially South Africa - that have significant political and economic leverage. But to the great frustration of Western governments, southern African countries have thus far refused to publicly challenge Mr. Mugabe.

Their reluctance has much to do with Mr. Mugabe's status as a hero of Zimbabwe's anti-colonial struggle and a champion of liberation struggles elsewhere. Southern African nations will have much greater political room to apply real pressure on Zimbabwe when its leader lacks such credentials.

Simultaneously, the prospect of an altogether different level of violence might shake the complacency of southern African nations. Zimbabwe's implosion has not, thus far, been entirely bad for its neighbors. They have benefited from the elimination of economic competition and from the influx of professionals, and they have retained confidence that Mr. Mugabe can keep control.

But there is a real danger, if a post-Mugabe Zimbabwe is not handled adroitly, that elements of the opposition, disaffected war veterans and youth militia and losers in the ZANU-PF factional battle will take up arms and plunge Zimbabwe into civil war.

This specter should push neighboring countries to step up their efforts, especially to press the post-Mugabe regime to hold new presidential elections and encourage moderate elements within ZANU-PF.

Notwithstanding its occasional fulminations against Zimbabwe, the United States has failed in its efforts to unseat Mr. Mugabe's regime. The United States should focus now on his eventual exit by helping the MDC to overcome its bitter infighting and engaging Zimbabwe's neighbors, especially South Africa, in vigorous diplomacy, pushing them to prepare for the occasion.

The stakes could not be higher, for if the post-Mugabe period is the first genuine opportunity for political change in Zimbabwe, it may also be the last for some time.

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"The United States is the most powerful since the Roman Empire," stated Stephen Walt, the Belfer Professor of International Affairs and academic dean of the John F. Kennedy School, Harvard University, delivering the 2005 Robert G. Wesson Lecture in International Relations Theory and Practice, at the Freeman Spogli Institute on November 16, 2005. America's unmatched power is therefore of great interest and concern to leaders in most other parts of the world, from President Putin in Russia, to President Chirac in France, and President Musharraf in Pakistan. For Americans, however, the key issue is how others are now responding to U.S. power.

Speaking before an audience of Stanford faculty, students, and the broader community, Professor Walt examined three interwoven themes: why other states do not welcome U.S. power; what are the main strategies available to them for dealing with American power? and what should the United States do in response?

As an integral part of his analysis, Walt showed opinion polls demonstrating a striking gap between American views of U.S. primacy and other countries' perceptions of the current U.S. role. For example, although the 2002 Pew Global Attitudes Project found that 79 percent of U.S. citizens believe it is good that "American ideas and customs are spreading around the world," and 70 percent think that U.S. foreign policy takes the interests of other states into account either "a great deal" or "a fair amount," overwhelming majorities overseas say the United States considers the interest of others "not much" or "not at all." Similarly, a 2005 BBC survey of 21 countries found only five, India, the Philippines, Poland, South Africa, and South Korea, where a majority of people had "positive" attitudes toward the United States.

There are three major sources of anti-Americanism, Walt explained. First, our sheer power makes other nations nervous. Second, there is a perceived sense of hypocrisy between our words and our actions. The case of nuclear weapons provides a vivid example. We preach nonproliferation, yet accord new respect and policy cooperation with newly nuclear states, such as India. Third, how the United States behaves in the world-what we do-invites antipathy. This latter point is abundantly clear in global opinion polls: Even in regions where anti-Americanism seems most strident, nations and individuals report that they do not object to our values or to what we stand for but rather to what we do.

Other nations, Walt pointed out, can choose a strategy of accommodation to our power or a strategy of resistance. Commonly adopted strategies of accommodation include 'bandwagoning," or realigning foreign policies with U.S. wishes, such as Libya's abandonment of nuclear weapons; "regional balancing"-using U.S. power to balance regional threats; "bonding" to curry favor with the United States; and "penetration," a strategy aimed at infiltrating the American political system to influence foreign policy outcomes.

In contrast, countries that choose to resist American power pursue five strategies:

"balancing" our power, alone or in alliance with others; "asymmetric responses," such as terrorism, which try to exploit specific areas of U.S. vulnerability; "blackmail," like North Korea's efforts to extract concessions from its nuclear weapons program; "balking," or tacit non-cooperation; and "delegitimizing," or attempts to turn others against the legitimacy of our actions or policies.

In light of the growing antipathy to U.S. primacy in so many parts of the world, Walt proposed three major courses of action to produce a more favorable response to U.S. power. First, he urged that we reduce American's military footprint abroad-and especially our ground force deployments-and return to a more traditional policy of regional balancing in cooperation with other nations. This policy would make greater use of American air and naval power and limit American intervention to cases where vital U.S. interests are threatened. Second, we should work harder to defend our international legitimacy and rebuild the U.S. image abroad, through a sustained campaign of public diplomacy and by keeping key American institutions-such as higher education-available to foreign visitors. Third, he advocated a more nuanced approach to America's traditional support for Israel, one that balances our genuine support for Israel's existence with the urgent need to bring a lasting settlement to the Israeli-Palestinian conflict.

"The more the United States uses its power in an overwhelming and capricious manner," Professor Walt warned, "the more the rest of the world will resist us." Conversely, the more the United States recognizes and respects the interests of others, while using its power to defend its own interests, the more other nations will welcome U.S. power. "The task we face," he advised, "is to rebuild the trust, admiration, and legitimacy the United States once enjoyed, so the rest of the world can focus not on taming U.S. power but on reaping the benefits it can bring."

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This pilot course on international environmental issues is a collaboration among faculty and students at Stanford and three universities in Africa - the University of the Western Cape in South Africa, Mweka College of African Wildlife Management in Tanzania and Makerere University in Uganda. The course offers students the opportunity to learn from leading experts in environmental sciences from several countries and to debate issues through Internet and mobile technology interactions.

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Lyman and Morrison will discuss the Council on Foreign Relations-sponsored Independent Task Force Report on the US and Africa. The Report argues that Africa is becoming steadily more central to the United States and to the rest of the world in ways that transcend humanitarian interests. Africa now plays an increasingly significant role in supplying energy, preventing the spread of terrorism, and halting the devastation of HIV/AIDS. Africa's growing importance is reflected in the intensifying competition with China and other countries for both access to African resources and influence in this region. A more comprehensive U.S. policy toward Africa is needed, the report states, and it lays out recommendations for policymakers to craft that policy. The report is available at www.cfr.org.

Princeton N. Lyman is the Ralph Bunche Senior Fellow and Director for Africa Policy Studies at the Council on Foreign Relations. He is also an Adjunct Professor at Georgetown University. Ambassador Lyman served for over three decades at the U.S. Department of State and the U.S. Agency for International Development (USAID), completing his government service as Assistant Secretary of State for International Organization Affairs. He was previously Ambassador to South Africa, Ambassador to Nigeria, Director of Refugee Programs and Director of the USAID Mission to Ethiopia.

From 1999 to 2000, he was Senior Fellow at the United States Institute of Peace. Ambassador Lyman held the position of Executive Director of the Global Interdependence Initiative of the Aspen Institute (1999 to 2003) and has received the President's Distinguished Service Award and the Department of State Distinguished Honor Award. Ambassador Lyman has published on foreign policy, African affairs, economic development, HIV/AIDS, UN reform, and peacekeeping. He coauthored the Council on Foreign Relations Special Report entitled Giving Meaning to "Never Again": Seeking an Effective Response to the Crisis in Darfur and Beyond. His book, Partner to History: The U.S. Role in South Africa's Transition to Democracy, was published in 2002. He earned his B.A. from the University of California at Berkeley and his Ph.D. in Political Science from Harvard University. He serves as the Co-Director of the Council on Foreign Relations-sponsored Independent Task Force on Africa.

J. Stephen Morrison is Director of the Africa Program and the Task Force on HIV/AIDS at the Center for Strategic and International Studies (CSIS). He joined CSIS in January 2000 and in late 2001, launched the CSIS Task Force on HIV/AIDS. The task force is a multiyear project co-chaired by Senators Bill Frist (R-TN) and John Kerry (D-MA) and funded by the Gates Foundation and the Catherine Marron Foundation. Dr. Morrison co-chaired the reassessment of the U.S. approach to Sudan that laid the basis for the Bush administration push for a negotiated peace settlement, and in the summer of 2002 he organized an energy expert mission to the Sudan peace negotiations in Kenya.

From 1996 through early 2000, Dr. Morrison served on the Secretary of State's Policy Planning Staff, where he was responsible for African affairs and global foreign assistance issues. In that position, he led the State Department's initiative on illicit diamonds and chaired an interagency review of the U.S. government's crisis humanitarian programs. From 1993 to 1995, Dr. Morrison conceptualized and launched USAID's Office of Transition Initiatives; he served as the office's first Deputy Director and created post-conflict programs in Angola and Bosnia. From 1992 until mid-1993, Dr. Morrison was the Democracy and Governance Adviser to the U.S. embassies and USAID missions in Ethiopia and Eritrea. He serves as the Co-Director of the Council on Foreign Relations-sponsored Independent Task Force on Africa.

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Princeton Lyman Ralph Bunche Senior Fellow and Director for Africa Policy Studies Keynote Speaker Council on Foreign Relations
J. Stephen Morrison Director of the Africa Program and Task Force on HIV/AIDS Keynote Speaker Center for Strategic and International Studies
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David Backer is a CDDRL post-doctoral fellow in the academic year 2005-2006. He is also an Assistant Professor of Politics at the College of William and Mary. He received his Ph.D. in Political Science at the University of Michigan. His dissertation project was an evaluation of the impact of participation by victims in South Africa's Truth and Reconciliation Commission (TRC). He is extending this research by comparing attitudes of victims and the general public, as well as conducting a longitudinal study of victims' attitudes about reparations. In addition, Backer is undertaking a parallel study of victims' responses to the truth commission processes in Ghana, Nigeria and Sierra Leone. His talk at the CDDRL seminar will focus on the South African experience with transitional justice.

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Post-doctoral Fellow 2005 - 2006
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David Backer is a post-doctoral Fellow (Ph.D. Michigan) at CDDRL. His dissertation project was an evaluation of the impact of participation by victims in South Africa's Truth and Reconciliation Commission (TRC). He is extending this research by comparing attitudes of victims and the general public, as well as conducting a longitudinal study of victims' attitudes about reparations. In addition, he is undertaking a parallel study of victims' responses to the truth commission processes in Ghana, Nigeria and Sierra Leone.

In another project, Backer looks at modes of transitional justice around the world and their effects on political development including regime stability, human rights practices, inter-group conflict, political violence and rates of violent crime.

David Backer Assistant Professor of Political Science, Post Doctoral Fellow Speaker College of William and Mary and CDDRL
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This study employed aRicardian model to measure the impact of climate change on South Africa's field crops and analysed potential future impacts of further changes in the climate. A regression of farm net revenue on climate, soil and other socio-economic variables was conducted to capture farmer-adapted responses to climate variations. The analysis was based on agricultural data for seven field crops (maize, wheat, sorghum, sugarcane, groundnut, sunflower and soybean), climate and edaphic data across 300 districts in South Africa. Results indicate that production of field crops was sensitive to marginal changes in temperature as compared to changes in precipitation. Temperature rise positively affects net revenue whereas the effect of reduction in rainfall is negative. The study also highlights the importance of season and location in dealing with climatechange showing that the spatial distribution of climatechangeimpact and consequently needed adaptations will not be uniform across the different agro-ecological regions of South Africa. Results of simulations of climatechange scenarios indicate many impacts that would induce (or require) very distinct shifts in farming practices and patterns in different regions. Those include major shifts in crop calendars and growing seasons, switching between crops to the possibility of complete disappearance of some field crops from some region.

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Global and Planetary Change
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Glwadys A. Gbetibouo
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The latest volume in this popular series focuses on the best ways to evaluate and improve the quality of new democratic regimes. The essays in part one elaborate and refine several themes of democratic quality: the rule of law, accountability, freedom, equality, and responsiveness. The second part features six comparative cases, each of which applies these thematic elements to two neighboring countries: Brazil and Chile, South Africa and Ghana, Italy and Spain, Romania and Poland, India and Bangladesh, and Taiwan and Korea.

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Johns Hopkins University Press
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Larry Diamond
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BACKGROUND: Cervical-cancer screening strategies that involve the use of conventional cytology and require multiple visits have been impractical in developing countries. METHODS: We used computer-based models to assess the cost-effectiveness of a variety of cervical-cancer screening strategies in India, Kenya, Peru, South Africa, and Thailand. Primary data were combined with data from the literature to estimate age-specific incidence and mortality rates for cancer and the effectiveness of screening for and treatment of precancerous lesions. We assessed the direct medical, time, and program-related costs of strategies that differed according to screening test, targeted age and frequency, and number of clinic visits required. Single-visit strategies involved the assumption that screening and treatment could be provided in the same day. Outcomes included the lifetime risk of cancer, years of life saved, lifetime costs, and cost-effectiveness ratios (cost per year of life saved). RESULTS: The most cost-effective strategies were those that required the fewest visits, resulting in improved follow-up testing and treatment. Screening women once in their lifetime, at the age of 35 years, with a one-visit or two-visit screening strategy involving visual inspection of the cervix with acetic acid or DNA testing for human papillomavirus (HPV) in cervical cell samples, reduced the lifetime risk of cancer by approximately 25 to 36 percent, and cost less than 500 dollars per year of life saved. Relative cancer risk declined by an additional 40 percent with two screenings (at 35 and 40 years of age), resulting in a cost per year of life saved that was less than each country's per capita gross domestic product--a very cost-effective result, according to the Commission on Macroeconomics and Health. CONCLUSIONS: Cervical-cancer screening strategies incorporating visual inspection of the cervix with acetic acid or DNA testing for HPV in one or two clinical visits are cost-effective alternatives to conventional three-visit cytology-based screening programs in resource-poor settings.

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New England Journal of Medicine
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Jeremy Goldhaber-Fiebert
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