Roosevelt Review 2005

ROOSEVELT
REVIEW
Volume 1 • Issue 1 • Summer 2005
A Publication of the Roosevelt Institution

ROOSEVELT REVIEW
E DITOR - IN -C HIEF
Jesse Wolfson
E XECUTIVE E DITORS S ELECTION C OORDINATORS

Danielle Gilbert Gabriel Arana
Kevin Hilke Bianca Gersten
Vincent Intersimone Sarah Graham
Melisse Morris
A SSOCIATE E DITORS Elise Taylor
Alexander Bartik
Eric Freeman L AYOUT E DITOR
Peter Squeri Sarah Wang
E DITORIAL B OARD
Julia Adams, Yale University Amb. William vanden Heuvel
Jared Bernstein, Economic Policy Todd Huffman, Mackenzie Willamette
Institute Hospital
Sophia Brill, Yale University Eric Kafka, Yale University
Jeff Chapman, Economic Policy Suzanne Kahn, Yale University
Institute David Kaiser, Naval War College
Chrissie Coxon, Stanford University Madeline Kerner, Yale University
John Donohue, Yale Law School Katharine Manning, Yale University
R. David Edelman, Yale University Richard Rorty, Stanford University
Brenda Eskenazi, University of Robert Samet, Stanford University
California at Berkeley Megan Stacy, Stanford University
Ben Grant, Stanford University Melissa Sterry, Democracy for
Beth Fiedorek, Yale University Connecticut
Heather Heldman, Yale University Adam Stone, Stanford University
The opinions expressed within the Roosevelt Review are exclusively those of the
individual authors and do not represent the views of the editorial staff, the
editorial board, the Roosevelt Institution, or any of the organization’s chapters,
centers, advisors, or affiliates.
ROOSEVELT
REVIEW
Volume 1 • Issue 1
Summer 2005
http://rooseveltinstitution.org
ROOSEVELT REVIEW
7 Editors’ Note
CURRENT RESEARCH: ANALYSES OF PRESENT

PROBLEMS AND PROPOSALS FOR CHANGE
11 An Apollo Project for Solar Energy
Devon Swezey
19 Extraction vs. Taxation: What to Do with ANWR

Joseph L. Kastner and David M. Felix
41 Medicare, Medicaid, SCHIP, and the Future of America: New

Strategies for Improving Access to Health Insurance for America’s 8.5
Million Uninsured Children
Amelia Hausauer, Jermaine Archie, Craig Boge, Anthony Ortega,
and Sarah Pratt
55 Innocent Until Proven Guilty: Military Use of Depleted Uranium

Rachel Saltzman
71 Voices From Rural South Africa

Married Women and AIDS Vulnerability: Moving Toward
Female-Controlled Prevention
Jenny Tolan
85 Globalization and Education: A Case Study in Papua New Guinea

Hammad Ahmed
SURVEYS: POLICY AND SOCIAL PERSPECTIVES

FROM COMMMUNITY, POLITICAL, AND
CORPORATE LEADERS
95 Three Models of Corporate Social Responsibility: Implications for
Public Policy
Elizabeth Redman
LOOKING AHEAD: PROGRESSIVE THINKING ON

TOMORROW’S ISSUES
109 Genomic Justice: Genetic Testing and Health Insurance in America
Dov Fox
Editors’ Note
W E L C O M E T O T H E I N AU G U R A L
I S S U E R O O S E V E LT R E V I E W
I
n the fall of 2004, an ongoing political dialogue between students
across the country made us realize the need for an organized method
of developing and promoting students’ ideas. In response, we created
the Roosevelt Institution, the nation’s first student think tank. Through
Roosevelt, we hoped to give students a voice in the political process, to
develop solutions to the problems facing our society, and to unite and
train our nation’s students, laying the groundwork for a strong, progres-
sive future. In only nine months, we have expanded our model to more
than 70 campuses across the country and around the world. At each of
our chapters, students have come together, founded issue-focused policy
centers, and begun studying and developing solutions to the inequalities,
inadequacies, and injustices which are present in our current social, politi-
cal, and economic system. Throughout these months, as students in vari-
ous centers have developed policy solutions, others have worked to put
the best of these solutions into the hands of those who have the ability
and the desire to effect positive social change. The inaugural issue of the
Roosevelt Review marks the culmination of these combined efforts.
Of the initial hurdles we have faced, none has been more commonly
discussed by non-students, or less frequently encountered by students,
than the supposed disadvantages of youth. Many believe that students are
simply too young and inexperienced to contribute meaningfully to the
policy process. Others were concerned that regardless of the quality of our
work, we would be received not as citizens presenting ideas for change, but
as inexperienced, idealistic students. From the beginning, we have believed
7
that these worries would prove to be unfounded, that our political system
would benefit from some tempered idealism.
Our experience has only confirmed this belief. In fact, we have found
only advantages as students. We couple the optimism, energy, and curios-
ity of youth with access to the scholarship and research facilities of the
world’s best universities. Our remove from the daily grind of Washington
and state capitals makes us an ideal source of fresh and innovative ap-
proaches to contemporary problems. Moreover, as members of the next
generation, we are able to call upon the full range of mentoring and as-
sistance of those with a concern for the future of American politics.
Over the past nine months, we have used these advantages to over-
come many real hurdles and to sail past many imaginary ones. We have
been met with enthusiasm and interest on campuses around the coun-
try; we have received media coverage in major outlets such as The San
Francisco Chronicle and The New York Times; we have been given generous
donations which have allowed for the growth of our organization and
this publication; and most important, our fellows have begun to produce
interesting, original, high quality policy research. We have reached this
landmark publication thanks to the many mentors, advisors, donors and
friends who have believed in our potential and provided guidance to our
young organization. We have recognized as many of them as space would
allow in this magazine, but there is never enough room for all the thanks
which are properly owed.
By the submission deadline for this issue, we had received hundreds

of articles from students at centers around the country and across the
world. After an intensive selection process conducted by our editorial
board, we narrowed this pool down to the eight pieces found here. These
articles—which range from proposing an Apollo Project for solar energy,
to reducing the threat of AIDS for married women in South Africa, to
examining the effects of exposure to depleted uranium on our nation’s
soldiers—provide new ways of looking at current problems and propose
8 | S U M M E R 2005 R O O S E V E LT R E V I E W
innovative solutions. We hope that you, our readers, find these discussions
to be interesting, insightful, and helpful discussions. More important, we
hope that you see in them an indication of the potential of the Roosevelt
Institution. The quality of our research will continue to improve as our
organization, and our fellows, mature.
Sincerely,
Danielle Gilbert, Kevin Hilke, Vincent Intersimone, and Jesse Wolfson
A CKNOWLEDGMENTS
But for countless contributions from the following individuals, the Roosevelt
Review would not have been possible. For your faith and service you have
our deepest gratitude.
Daniel Appelman Scott Grinsell Paul Rich
Alex Bartik Lisa Seitz Gruwell Anne Eleanor Roosevelt
Chris Breiseth Mary Hughes Steven Rosenzweig
Sophia Brill Mattie Hutton Stanley Sheinbaum
Dan Carol Margot Isman Jessica Singleton
Diane Chin Suzanne Kahn Peter Squeri
Andrew Cox Kapil Kulkarni Melissa Sterry
Chrissie Coxon Nate Loewentheil Mark Steitz
Helen Danilenko Stephan Loewentheil Kai Stinchcombe
Albert Fang Hon. Zoe Lofgren Michelle Suski
Ted Fertik David Merchant Dorothy Vanderbeck
Leslie Finger Thomas McSorley Sarah Wang
Eric Freeman Nick Moscow Quinn Wilhelmi
John Gedmark Milton Podolsky Lauren Young
David Grant Vilas Rao
Nancy Grant Andy Rappaport
Morris Graves Deborah Rappaport
9
population based on historical data, and an average gasoline priceb of
$1.48 per gallon. The scenario is characterized by the following equations
with the goal of minimizing the gas tax:
The parameters α and γ used in the function for fuel economy are
based on data from the U.S. Department of Transportation National
Household Travel Survey (NHTS) and the penalties for violating cor-
porate average fuel economy (CAFE) standards. The percentage of new
carsc within the national fleet has varied between 15 percent and 20
percent over the last 20 years (NHTS, 2001). The infiltration parameter
is meant to approximate the percentage of brand new cars, less than one
year old, within the fleet and is assumed to be roughly half of the NHTS
new car value or 10 percent. The CAFE penalty for not achieving ef-
ficiency standards is $50, per mile per gallon, per vehicle. It is assumed
this is a good estimation of the cost to increase fuel economy for new cars
by one mile per gallon. This equates to over one billion dollars if applied
to the roughly 20 million new cars entering the fleetd each year and is
within the same order of magnitude as a study by Whitford (1984). More
detailed projections by Difiglio (1990) and Greene (2003) suggest these
costs increase exponentially as the vehicles become more efficient. To ac-
count for this increase and simplify the use of the parameter, a constant
value of $5 billion is used for γ. The inverse exponential term in the fuel
economy function is used to simulate a lag in manufacturer participation
in the research and manufacturing effort, and effectively slows the infil-
tration of more efficient technologies into the national fleet.
Results
Because the model is constrained to a constant tax value, the predic-
tion is completely dependent on the first year of the scenario. The model
predicts a tax value that exactly covers the Alaskan and federal benefits
in the first year. This equates to a tax between $0.04 and $0.44 per gallon
for the three USGS scenarios. As population increases, consumption and
tax revenues also increase. Since the state and federal benefits remain
constant the amount of revenues available for research and development
increases with time. As a result, the consumption curve for this scenario
begins identically to the business as usual situation and gradually tails off
as the national average fuel economy increases. As a result, the scenario
conserves an amount of gasoline equivalent to more than four ANWRs
b
This price is net of the additional ANWR tax.
c
A new car is defined as a model less than two years old.
d
There are roughly 200 million cars on the road in the US.
KASTNER AND FELIX | 29

Total Motor Gasoline Consumption: Tax Scenarios
500
Billions of Gallons
450
400
350
300
250
200
150
BAU Consumption
100 Scenario I: 17 cent tax
Scenario I: 33 cent tax
Scenario !: 52 cent tax
50
Scenario II: 4 cent tax
Year
0
1940 1960 1980 2000 2020 2040 2060 2080 2100
Figure 4 Projected consumption for Scenarios I and II
under the most optimistic petroleum resource projection. The tax values
for the three extraction cases do not vary significantly because the drill-
ing benefits are dominated by the constant multi-billion dollar value ap-
plied to jobs and because royalty and production benefits do not change
greatly under the three extraction projection. The results are illustrated in
the previous figure.
The results from Scenario II predict a gas tax of roughly $0.04 will
result in a 35 percent increase in the national average fuel economy over
the next 70 years. Historical data suggests this type of increase is plau-
sible given the nearly 40 percent increase in just 20 years that occurred
before and after the oil embargo of the 1970s.
It is significant to note that this analysis does not account for chang-
es in the average fuel economy elasticity of demand caused by increased
efficiency. Commonly known as “rebounding,” the theory states that con-
sumers will change their driving habits and travel more vehicle miles if
fuel efficiency is increased. A study by Greene (1999) suggests up to 20
percent of the expected conservation can be lost due to increased travel
in response to greater fuel efficiency.
Fuel Economy Projection
25
Nationwide Average BAU ~ 35% Increase from 2005 to 2075
with Tax and R&D Funding
Fuel Economy (MPG)
20
~ 36% Increase from 1970 to 1990
15
10
0
1950 1970 1990 2010 2030 2050 2070
Figure 5 Comparison of historical and projected national average fuel

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

Yearly Cost to Average Driver in 2005
(US-Y2K$ per driver) 385

400
Note: Assumes 14,000 miles driven per year
with average fuel economy of 17 mpg.
350
300 254
250
200
131
150
100
32
50
0
95% Scenario 17 cent tax Mean Scenario 33 cent tax 5% Scenario 52 cent tax w/4 cent tax and R&D Funding
Figure 6 Direct cost to the average driver
and allowed the tax to decrease over time. The large amount of
conservation predicted in Scenario II suggests a much lower
average tax could be used over the 70-year period and still
achieve the conservation goals.
• Uncertainty. Any research paper of this nature, which attempts

to predict the future of gas prices and the associated behavior,
is just that, a prediction. In reality the gasoline market is highly
dependent on many factors that are completely unpredictable.
OPEC, which controls the vast majority of the world’s oil supply,
operates like a monopoly, further complicating the issue. Like-
wise the extraction path from ANWR is subject to uncertainty.
The job growth estimates as mentioned previously are drastically
different depending on whose study you research and what the
associated assumptions are.
• Environment. In detailing the benefits to not drilling in

ANWR, we chose to exclude environmental benefits from not
burning the three to ten billion gallons of gasoline. Carbon
monoxide, nitrogen oxide, and carbon dioxide each have associ-
ated impacts on human health, ecosystems, and global climate
70-year ANWR Extraction Estimates / Gas Tax Conservation Objectives (Scenario I) vs.
Predicted Conservation: Gas Tax and MPG R&D (Scenario II)
Source: EIA / USGS
Billions of barrels
68.83
70
60
50
40
30
15.96
20
10.31
5.25
10
0
5% Probability | 52 Mean Probability | 33 95% Probability | 17 4 cent tax and R&D
cent tax cent tax cent tax
-
Figure 7 Conservation comparison for Scenarios I and II
change. Quantifying these benefits would only further encour-

age the plan of taxation over extraction.
• Discount Rate and Option Value. A more in-depth analysis of the

scenarios presented here would also include a calculation of the
option value of ANWR. Using option values in analyses such as
these are useful when the future costs and benefits are sufficient-
ly uncertain. The analysis also ignored the time value of money
because the extraction path was estimated as a constant average
value. If the actual estimated extraction path were considered the
analysis would need to include discounting.
• Rebound Effect. Several studies have shown that increasing en-

ergy efficiency often leads to energy savings that are lower than
expected. This is due to a tendency to increase the intensity of
an activity when it becomes more energy efficient. In the case
of cars, this equates to more vehicle miles driven as the act
of driving becomes more fuel-efficient. This is often the argu-
ment against simply raising CAFE standards, as it does not

fully address the consumption issue, as a gas tax would. A tax
encourages consumers to drive less, in addition to purchasing
more fuel efficient vehicles. However, even if a 20 percent loss
in energy savings was considered in Scenario II as proposed by
Greene (1999), the $0.04 per gallon tax would still conserve
more than three times the largest USGS resource estimate.
D ISCUSSION OF R ESULTS
When considering what to do about America’s dwindling domestic petro-
leum reserves it is important to consider all options. In this paper we took
the specific example of ANWR to demonstrate the point to which we have
come to as a nation in trying to satisfy our insatiable appetite for oil. In recent
U.S. Senate proceedings the plan to drill in ANWR has continued to be af-
firmed, and many believe that it will in fact be exploited. Those opposed to
drilling have often said that it is a small amount of oil compared to our level
of consumption. This paper is an attempt to quantify just how diminutive an
amount it is, and how relatively inexpensively it could be protected.
No one will claim to know what will happen regarding energy supply
and climate change in the coming years. Given the uncertainty that OPEC
presents to the oil market, the questions that remain about ANWR resource
estimates, peak oil impending and the continuous threat of global climate
change, some consider prediction of this sort a “crystal ball” science. The
results we have come to using reasonable and generally conservative assump-
tions clearly shows the issue at hand. The United States is consuming oil at a
rate of over 500 gallons per capita per year. Without decisive policy to address
this predicament, we are only asking for another oil crisis, and possibly worse.
To what end are we going to exploit natural resources for oil exploration?
Why has the average U.S. fleet fuel economy been held constant at roughly
17 miles per gallon for over 10 years, especially considering how much it
could affect the rate of consumption? Isn’t there more we can do to lower
the demand for oil so that irrevocably altering places like ANWR won’t be
necessary? For how long can policymakers ignore the fact that Americans are
paying less for gasoline than the rest of the western world? Finding creative
solutions to reduce energy demands and encourage non-carbon based fuel
consumption is imperative to future security and minimizing the damaging
effects of climate change.
A PPENDIX
International Gas Prices

Belgium France Germany Italy Netherlands U.K. U.S. Source: EIA
$7.00
$6.00
$5.00
$4.00
$3.00
$2.00
$1.00
$0.00
Jan-96 Jan-97 Jan-98 Jan-99 Jan-00 Jan-01 Jan-02 Jan-03 Jan-04 Jan-05
Figure 8 International gas price comparison (USD$)
600 250
Consumption/Capita (gallons) Price (in yr 2000, cents)
500
200
Gallons per Capita/Year
400
150
YR2000 Cents
300
100
200
50
100
0 0
1950 1960 1970 1980 1990 2000 2010
Figure 9 Consumption and Price data for the past 50 years

(Source: EIA)

Model vs. Actual Data
600 Consumption/Capita (gallons)

Consumption
Model
Annual Gallons per Capita
500
400
300
200
100
0
1940 1950 1960 1970 1980 1990 2000 2010
Figure 10 Model verification compares actual consumption data to

our model output.
Total Consumption vs. ANWR Extraction

500
Consumption - BAU
ANWR Extraction - 95% Probability
450 ANWR Extraction - Mean
ANWR Extraction - 5% Probability
400
350
Billion Gallons per year
300
250
200
150
100
50
0
1950 1970 1990 2010 2030 2050 2070
Figure 11 ANWR in context to current US consumption and

predictions
Response Consumption/Capita - Whole Model Actual by Predicted
Plot
550
500
450
Consumption/Capita Actual
400
350
300
250
200
200 250 300 350 400 450 500 550
Consumption/Capita Predicted P<.0001
RSq=0.96 RMSE=16.619
Figure 12 Full JMP output of final model regression
Summary of Fit
RSquare 0.958122
RSquare Adj 0.954704
Root Mean Square Error 16.61862
Mean of Response 424.0507
Observations (or Sum Wgts) 54
Analysis of Variance
Source DF Sum of Squares Mean Square F Ratio
Model 4 309616.15 77404.0 280.2680
Error 49 13532.75 276.2 Prob > F
C. Total 53 323148.91 <.0001

Parameter Estimates
Term Estimate Std Error t Ratio Prob > |t|
Intercept 805.84613 33.01492 24.41 <.0001
Price (in yr 2000 $) -0.52419 0.124202 -4.22 0.0001
Income Adjusted 0.0173482 0.001151 15.07 <.0001
Avg Fule Economy -46.3554 2.580202 -17.97 <.0001
Public Perception DUMMY 61.850823 10.67367 5.79 <.0001
Parameter Estimates
Source Nparm DF Sum of F Ratio Prob > F
Squares
Price (in yr 2000 $) 1 1 4919.366 17.8123 0.0001
Income Adjusted 1 1 62740.512 227.1736 <.0001
Avg Fuel Economy 1 1 89142.163 322.7699 <.0001
Public Perception 1 1 9273.710 33.5787 <.0001
DUMMY
R EFERENCES
Dahl; Sterner. “Analysing Gasoline Demand Elasticities: A Survey.” Energy Economics
13(3) (1991): 203.
Difiglio, C; Duleep, K.G. “Cost Effectiveness of Future Fuel Economy Improvements.”

Energy Journal 11(1) (1990): 65.
Espey. “Explaining the Variation in Elasticity Estimates of Gasoline Demand in the

United States: A Meta-analysis.” The Energy Journal, 17(3) (1996): 49.
Greene, L; Kahn, R; Gibson, C. “Fuel Economy Rebound Effect for U.S. Household
Vehicles.” The Energy Journal, 20(3) (1999): 1.
Greene, D.L.; Hopson, J.L. “Analysis of alternative forms of automotive fuel economy
standards for the United States.” Transportation Research Record no. 1842 (2003): 20-28.
Hsing. “On the Variable Elasticity of the Demand for Gasoline: The Case of the USA.”
Energy Economics 12(2) (1990): 132.
Kayser, A. “Gasoline Demand and Car Choice: Estimating Gasoline Demand Using
Household Information.” Energy Economics, 22(3) (2000): 331.
Parry and Small. “Does Britain or the United States have the Right Gasoline Tax?” RFF
Discussion Paper (2002): 02-12.
Ross, H. “Producing oil or Reducing oil: Which is Better for U.S. Energy Security?”
Resources, Summer (2002), Issue 148.
Schmalensee; Stoker, M. “Household Gasoline Demand in the United States.”

Econometrica, 67(3) (1999): 645.
West, E.; Williams, C. “Estimates from a Consumer Demand System: Implications

for the Incidence of Environmental Taxes.” Journal of Environmental Economics and
Management, 47(3) (2004): 535.
Whitford, R.K. “Fuel-Efficient Autos: Progress and Prognosis.” Annual Review of

Energy, 9(1) (1984): 375.
A BOUT THE A UTHORS

Joseph Kastner is a recent graduate of the Donald Bren School of Envi-
ronmental Science and Management at the University of California at
Santa Barbara, where he received an M.S. with a focus in public policy
and environmental economics. Kastner has worked as a consultant and
project manager in the areas of energy efficiency and renewable energy.
Before attending the Bren School, he managed the construction and op-
eration of five commercial solar energy facilities for the U.S. investment
arm of the Dutch utility nv Nuon. Kastner has an M.S. in energy engi-
neering from Stanford University and a B.S. in mechanical engineering
from the University of Minnesota. Kastner recently accepted a position
as the managing director of development and implementation for Re-
newable Ventures LLC, a renewable energy company in San Francisco
focusing on project finance.
David Felix is a mechanical engineer with B.S. from the University of

Arizona. Felix is currently a candidate for a master’s degree at the Donald
Bren School of Environmental Science and Management at the Uni-
versity of California at Santa Barbara. His primary focus is renewable
energy policy and climate change. Currently, Felix is an Intern for the
New Zealand government at the Energy Efficiency and Conservation

Authority in Wellington. Felix is also an engineering consultant for the
College of Optical Sciences at the University of Arizona. In 2002, he led
the UofA Formula SAE team to international competition with an etha-
nol-powered race car, the spark of his interest in renewable energy.
For correspondence, please email David Felix at dfelix@bren.ucsb.edu.
Current Research: Public Health
Medicare, Medicaid,
SCHIP, and the Future of
America:
New Strategies for Improving Access to
Health Insurance for America’s 8.5
Million Uninsured Children
Amelia Hausauer, Jermaine

Archie, Craig Boge, Anthony
Ortega, and Sarah Pratt
If statistical data is any indication, then the 8.5 million children in

the United States without health insurance are living on borrowed
time.1 According to the Journal of the American Medical Association
( JAMA), children without health insurance are nearly 20 percent
less likely to have visited a physician in the past year, more than
twice as likely to be treated in a hospital emergency department,
and almost five times as likely to be unable to obtain medical care.2
Though 90 percent of uninsured children have at least one working
parent, their caretakers are often unable provide them with even
routine health services like check-ups, dental appointments and
eyeglasses.
In order to address these disparities and better provide for our
nation’s children, we must revamp existing federal health programs
to distribute funds more efficiently. We can and must ensure that
even the poorest Americans have access to basic medical care.
H AU S AU E R , ET AL. | 41
M EDICARE , M EDICAID , AND THE S TATE C HILDREN ’ S H EALTH
I NSURANCE P ROGRAM
The United States government offers three distinct public health
plans—Medicaid, Medicare, and the State Children’s Health Insur-
ance Program (SCHIP). Each provides subsidized health coverage to
distinct sectors of the American public. Whereas the federal govern-
ment funds Medicare, state governments, under the guidance of Con-
gress, administer and finance Medicaid and SCHIP. Consequently,
these programs receive and distribute subsidies in fundamentally dif-
ferent ways.
Medicare serves Social Security beneficiaries 65 years and older, as
well as the long-term disabled.3 In 2003, 85 percent of the 41 million
Medicare recipients qualified because of age.4 Of the four “plans” that
compose Medicare, parts A and B are relevant to our proposed refor-
mation of the American public health insurance system. Part A, the
Hospital Insurance Program, relies on backing from payroll taxes and
covers inpatient hospital, hospice, skilled nursing, and home healthcare.
Part B is bankrolled by beneficiaries’ premiums and general revenues,
and relates to physician and outpatient health care.5
Medicaid insures America’s poorest citizens, regardless of age. In
addition to meeting financial criteria, an individual must be a member
of at least one of several eligible groups—such as low-income families
with children or those with certain disabilities—to qualify for state
funding.6 Overall, Medicaid insures over 52 million Americans, in-
cluding 13 million elderly citizens with long-term disabilities, 14 mil-
lion low-income working parents, and 25 million children.7
Though nearly half of Medicaid’s recipients are children, many
children live in households whose incomes exceed the Medicaid eligi-
bility threshold yet are insufficient to afford private health insurance.
For these children, the federal government created the State Children’s
Health Insurance Program (SCHIP) in 1997. SCHIP provides rough-
ly 5 million children across the country with many of the same services
provided by Medicaid.8 Like Medicaid, SCHIP is funded by the states
in collaboration with the federal government, the latter of which uses
a formula to cap state allocations. If states do not fully use their federal
funds within three years, the U.S. Department of Health and Human
Services redistributes these unused funds to states that have exhausted
their grants.
Together, Medicare, Medicaid, SCHIP provide healthcare cover-
age to one-quarter of the American population. Though these programs
have achieved a great deal of success, additional reforms are urgently
needed in order to improve access to aid and raise levels of health
throughout the country.
W HAT IS W RONG WITH P UBLIC H EALTH C ARE ?

Existing public healthcare programs are rife with inadequacies. With
regards to healthcare for the elderly, Medicare faces a major crisis: ex-
penditures are increasing at an alarming rate, meaning that Medicare’s
financial future is uncertain. Despite these rising costs, benefit packages
are increasingly insufficient to support the healthcare needs of many el-
derly people. About 90 percent of Medicare beneficiaries must purchase
supplemental coverage to provide for their medical needs.9
Medicaid has its problems, too. Its daunting enrollment process
discourages many eligible Americans from applying, and the general
public is largely ignorant of how the program operates and who is eli-
gible to enroll.10 Data from the 1999 National Survey of America’s
Families (NSAF) suggests that while 88 percent of low-income parents
with uninsured children were somewhat familiar with Medicare and
SCHIP, only 38 percent understood that their children could partici-
pate in the program even if their families did not receive welfare. Nearly
half did not even understand the basic rules.11
This confusion varied by state—in Massachusetts, for instance, 73
percent of low-income families understood Medicaid’s basic rules, in
contrast to only 54 percent of Texans.12 To rectify the general public’s
lack of understanding, our government must proactively provide infor-
mation about Medicaid and SCHIP to low-income families in an at-
tempt to ease access and bolster participation. Further, our government
must simplify application processes—a practical and cost-effective way
of providing medical coverage to greater numbers of impoverished
children.
Seeking cost-effective solutions is crucial to repairing both Medic-
aid and SCHIP. Since these programs function under state jurisdiction,
they are susceptible to local budget cuts, which in turn reduce federal
matching of funding, creating a negative feedback loop. This problem
hits SCHIP—which has a limited amount of federal financing—the
hardest. Though caps on federal funds allocated to states for SCHIP
were initially meant to be beneficial, they now threaten the program: 19
state programs are expected to face federal SCHIP funding shortfalls
by 2007.13
A F ACELIFT FOR F EDERAL H EALTHCARE
The American public healthcare system clearly has its flaws, chief among
them an inability to provide adequate healthcare for all children. To rem-
edy this, our government should reevaluate the unequal distribution of
benefits between the young and the old, the wealthy and the poor. Our
government should, ultimately, restructure Medicare to eliminate the
program’s bias toward affluent individuals. This renovation would limit
spending, generating funds that could be used to increase enrollment of
eligible children in Medicaid and SCHIP.
In order to reduce the number of uninsured American children,
we propose cross- enrollment between Medicaid, SCHIP, the National
School Lunch Program (NSLP), and the Special Supplemental Nutri-
tion Program for Women, Infants, and Children (WIC). NSLP reaches
60 percent of uninsured, low-income Americans between ages six and
17, while WIC provides supplemental nutrition benefits a majority of
eligible children under age six.14 Together, the two programs reach a
large chunk of America’s uninsured children.
Our proposal is a form of “express lane eligibility” (ELE), a con-
cept created by The Children’s Partnership to locate and enroll uninsured
children within state budgetary parameters.15 Currently, the Senate Fi-
nance Committee is reviewing the Children’s Express Lane to Health
Coverage Act of 2003 (S. 1083), which would “reduce bureaucracy by
streamlining enrollment processes for the Medicaid and State Children’s
Health Insurance Programs through better links with programs provid-
ing nutrition and related assistance to low-income families.”16 If passed,
this bill could serve as an important first step toward a multilayered
policy including: targeted outreach that piggybacks on public services
to identify eligible children effectively, simplified application processes
which increase efficiency by eliminating application redundancies (en-
suring that parents would not have to fill out similar forms for separate
programs), and automatic enrollment during the period of application
processing to ensure that the maximum number of children are insured
in the shortest amount of time.
Based on successful case studies in California, Ohio, and Vermont,
we propose requiring all states to adhere to an ELE plan involving NSLP
and WIC.17 Because the income requirements for these nutrition pro-
grams are more stringent than either Medicaid’s or SCHIP’s—below
185 percent of the federal poverty line (FPL)—children who qualify
for NSLP or WIC also automatically satisfy Medicaid or SCHIP eli-
gibility criteria. NSLP divides child participants into those with a total
household income less than or equal to 130 percent FPL, who receive
free lunches, and those whose household income lies between 130 per-
cent and 185 percent FPL, who receive reduced-cost lunches.18 We
propose using the higher income cutoff in order to reach as many chil-
dren as possible.
ELE implementation procedures must follow regular, systematic
patterns that maximize efficiency, incurring the fewest administration
costs without jeopardizing accessibility and convenience. To that end,
parents would receive a supplemental insert along with the NSLP or
WIC application. This document would ask for parental consent to share
basic information, such as date of birth and family income, between pro-
grams. After processing the NSLP or WIC application, agencies would
enter necessary information into a database connected to state comput-
ers. State outreach personnel would access this computer system and
then contact the applicant for follow-up appointments. These personnel
would also collect the child’s Social Security number and immigration
status, additional criteria not necessary for NSLP or WIC participa-
tion.19
During the interim period when applications undergo secondary
review, children would receive temporary Medicaid cards. Providing
Medicaid benefits rather than SCHIP benefits is logical in light of the
2003 census report, which noted that 62 percent of uninsured children
live below the FPL, and are thus fully eligible for Medicaid coverage.20
A child’s insurance status would be reevaluated once her application is
officially processed. Unfortunately, this form of presumptive eligibility
may increase government spending since children who apply but do not
qualify for either program will receive insurance while their applications
are being evaluated. We believe, however, that the benefits of extending
insurance to millions of children outweigh these costs.
Though simple in theory, ELE faces several challenges. Most prom-
inent among these is the question of how to calculate income eligibility,
as public programs do not have a single, standard method of determin-
ing income. Both NSLP and WIC calculate household income, which
includes both related and unrelated individuals living under the same
roof, while Medicaid and SCHIP rely on family income, which is lim-
ited to financial guardians who live in the same home as the child.21 By
these inconsistent standards, children who do not qualify for NSLP or
WIC may actually be eligible for medical coverage. Amending publicly
funded health program eligibility criteria to align with the Medicaid
and SCHIP income calculation standard would remedy these inconsis-
tencies.
A second problem involves equity and immigration status. Medic-
aid and SCHIP cover only citizens and legal immigrants, while NSLP
and WIC have no such requirements.22 This discrepancy may discour-
age immigrant families from enrolling their children in social services
because parents do not want government agencies sharing information
about their citizenship status. Because no family—regardless of citizen-
ship status—should be denied prenatal nutritional counseling or food for
a growing child, it is crucial that our government respect families’ privacy
and make it clear that eligibility for one program does not impact eligi-
bility for another. In any event, tying programs like NSLP and WIC to
insurance through ELE does not appear to negatively affect enrollment.
Trials of ELE in five California school districts with high numbers of
recent immigrants resulted in an increase in school lunch program en-
rollment of two and eight percent in two districts, and a decrease of one
and two percent in two others—statistics consistent with these districts’
annual fluctuations in enrollment.23 These findings indicate that immi-
gration issues may not have a significant impact on participation in ELE
programs. Despite these optimistic figures, it will be critical to prioritize
families’ privacy when implementing ELE nationwide.
Information sharing, too, could prove difficult. While some states
integrate Medicaid and SCHIP, others separate the two programs. For
ELE to work successfully in states with segregated insurance programs,
there must be an efficient flow of information from one program to
the next so that children with family income above Medicaid criteria
but below SCHIP requirements can be matched with the appropriate
plan.24 Also, any system needs to ensure that states receive the proper
federal matching rates for children enrolled in each program. One way
of facilitating a productive working relationship between SCHIP and
Medicaid would involve a federally funded centralized computer sys-
tem that would use database information from enrollment in NSLP and
WIC to match children with the appropriate insurance policy.
Establishing the infrastructure necessary to implement ELE will
be costly. But by restructuring Medicare to adhere to a progressive, slid-
ing-scale model—and thus require less funding—our government could
lessen the cost of enrolling children in public insurance programs like
Medicaid and SCHIP. Decreasing Medicare benefits for senior citizens
with liquid assets amounting to $250,000 or more and diverting these
funds to states’ Medicaid and SCHIP programs would limit budgetary
strain.
This change to Medicare involves both parts A and B of the current
system. Currently, Part A recipients pay an $840 deductible, while the
federal government pays for hospital stays up to 60 days and nursing
home care for 20 days.25 Under our proposal, individuals with private
assets exceeding $250,000 will be obligated to pay for the first fourteen
days of a hospital stay. After this period, Medicare will assume all bills
in accordance with the present regulations. These beneficiaries can theo-
retically afford a complementary Medigap or private insurance plan, so
the government saves money without limiting health care to those who
cannot afford private coverage.
Coinsurance under Part B requires senior citizens to pay for 20 per-
cent of outpatient care: Medicare assumes 80 percent of costs for doctor
visits, home health care, ambulance service, x-rays, etc.26 We propose
that individuals with $250,000 or more in liquid assets pay for 40 per-
cent of Part B services. This proposal assumes that supplemental health-
care plans will fill this gap and provide insurance packages especially
tailored to these Medicare revisions.
This proposal uses private rather than net assets to establish wealth
because this figure more accurately reflects affluence. Private assets con-
sist of money from mutual funds, stocks, bonds, and personal bank ac-
counts and exclude retirement funds and real estate investments. The
assessment of net assets is an unwieldy process that requires a tremen-
dous amount of paperwork as well as administrative time and effort.
Calculating liquid assets should both more accurately reflect wealth and
cut down on organizational costs.
F ISCAL B ENEFITS , E THICAL O BLIGATIONS

Lower organizational costs are not the only fiscal advantage of imple-
menting ELE programs. From a strictly economic perspective, the mar-
ginal benefits associated with insuring children exceed those of insuring
senior citizens. According to the Kaiser Family Foundation, in fiscal year
2000, children aged zero to 18 (who composed 55 percent of Medicaid
recipients) cost an average of $1227 each in Medicaid expenditures. In
contrast, mean expenses per Medicare enrollee were $5506 in 1998 (most
recent data).27 On average, children’s coverage through Medicaid costs less
than one-fifth that of a Medicare beneficiary; a child insured by SCHIP
costs somewhere between these two figures depending on the state. On an
absolute scale, it is cheaper to insure children than senior citizens. Simply
put, children give us more bang for our buck. And because children even-
tually grow up, securing their health today will produce healthier adults
and seniors tomorrow, driving down costs both now and in the future.
In addition to reducing spending, our proposal remedies un-
ethical distribution of benefits—both within Medicare and among
Medicare, Medicaid, and SCHIP. Today’s Medicare system is by
no means fiscally robust and must be reshaped in order to allocate
resources more equitably. Since Medicare’s inception, the vast ma-
jority of senior citizens have qualified for the program. This uni-
versality distinguishes Medicare from Medicaid and private insur-
ance programs, many of which employ strict screening procedures.
Despite this universality, the current Medicare system allows for
discrepancies in the benefits received by different socioeconomic
classes. Studies conducted by researchers at Dartmouth, Stanford
and the National Bureau of Economic Research (NBER) conclude
that the amount of Medicare funding directed towards elderly indi-
viduals directly correlates with their respective income levels—the
higher the percentile in earnings during their working years, the
more money spent on medical services during their senior years. In
fact, the wealthiest ten percent of beneficiaries claimed an average
of $1000 more in net Medicare benefits over their lifetimes than
did the poorest ten percent.28 Moreover, wealthy beneficiaries of-
ten purchase supplemental insurance to cover the gaps in Medicare.
Not only are they receiving additional Medicare funds, but they also
have complementary coverage. While these studies do not present
comprehensive investigations of Medicare’s effectiveness as a whole,
they highlight the inequalities present among recipients. By cur-
tailing benefits for affluent seniors, we could dedicate Medicare re-
sources solely to poorer individuals who cannot afford to pay for
their own health services. Our proposal attempts to shift funding
towards those who need it most.
Not only are there financial disparities among elderly benefi-
ciaries, but children receive disproportionately low federal funding.
President George W. Bush’s budget for fiscal year 2006 allocates
$340 billion dollars to Medicare, yet grants only $1 billion over the
next two years to expand SCHIP coverage.29
And though Medicaid’s projected funding, $338 billion, is com-
parable to that of Medicare, children’s services account for only 16
percent of the Medicaid’s budget.30 It is ethically irresponsible not
to allocate resources equitably in order to assist parents who cannot
provide their children with health coverage, a central element of a
family’s well-being. In the words of one Kentucky parent, “Last year
for several months, we were without health insurance...I was con-
stantly worried—what if my daughter breaks her arm, or was in a car
accident, or just got really sick—how would I pay for that with no
health insurance? It’s a frightening position to be in.”31
O PPOSITION , F EASIBILITY , AND R ESPONSIBILITY

Despite fiscal and moral arguments for redistributing Medicare re-
sources to ensure access to Medicaid and SCHIP, numerous criticisms
can be raised against such redistribution. Opponents might claim that
it is not our government’s duty to walk parents through the application
process, or that it is not our government’s fault if American citizens do
not take advantage of their eligibility for public health care. But apply-
ing to Medicaid or SCHIP is by no means a simple process—enroll-
ment requires considerable amounts of paperwork, intricate financial
information, and multiple face-to-face interviews. More importantly,
arguments about our “government’s duty” divert attention away from
children. The question becomes whether or not it is socially acceptable
to penalize children for their parents’ lack of information about govern-
ment bureaucracy—completely sidestepping our obligation to ensure
that all children have access to reliable healthcare.
Beyond arguments involving responsibility, issues of political feasi-
bility surround efforts to amend Medicare, Medicaid, and SCHIP. It is
likely that a sliding-scale Medicare system will anger seniors in higher
socioeconomic brackets, while gaining favor with those from poorer
backgrounds. Overcoming mobilization bias may be difficult since the
wealthiest seniors—the small portion of the population which will be
the most affected—have the resources to express their opinions and in-
fluence policy.
Pressuring pharmaceutical companies into reducing prices is one
possible way to appease affluent seniors and ease the transition to a pro-
gressive Medicare system. Currently, drug prices in the United States
are not competitive in comparison to those of other industrial countries.
Canadian prices, for instance, are 40 percent lower than American raw
fees and 33 percent lower when adjusted for discounts.32 The factor
entirely responsible for this difference is the Canadian government’s
willingness to negotiate drug prices on behalf of its citizens. Our gov-
ernment, unlike the government of nearly every other country in the
western world, will not represent the interests of its citizens to the drug
industry—leaving Americans unable to effectively negotiate drug costs.
But according to Pfizer vice-president Peter Rost, companies can turn a
profit while reducing drug costs—sales doubled when Pfizer decreased
charges in Northern Europe.33 Our government must step in and ne-
gotiate costs for all citizens in order to limit price gouging and thereby
alleviate the financial burden for seniors affected by reduced Medicare
benefits.
In the hopes of countering political opposition, advertisement cam-
paigns that highlight the plight of uninsured children could be used to
evoke sympathy from the American public. Such ads would likely be
countered by organized groups of wealthy senior citizens, and possibly
the American Association of Retired Persons (AARP). In response to
these critics, efforts must be made to emphasize measures to reduce
drug costs for seniors. Even if this method does not completely placate
those negatively affected, the plan should gain popularity among the
families of uninsured children who receive augmented benefits and have
easier access to federally provided healthcare.
T HE E QUITABLE E XPRESS L ANE : H EALTHCARE FOR

A LL A MERICANS
Our government should provide a combination of express lane eligi-
bility, progressive health insurance based on socioeconomic status, and
reduction in prescription drug costs in an attempt to enhance children’s
access to public insurance policies. By amending Medicare, Washington
could redirect funds to SCHIP and Medicaid while keeping expen-
ditures in check. Further, because our proposal would transfer money
from an affluent population that can afford first-rate services to needy
children, it would elevate pediatric care without sacrificing geriatric
care, ensuring that all individuals, regardless of age, receive adequate
coverage. Though our proposal may seem controversial, it is necessitated
by the grave shortfalls of the nation’s healthcare system—a system that
can only be fixed by an approach that accounts for problems of access,
cost, and quality. Such an approach is the best way of addressing the
nation’s health care shortfalls, the best way of providing for America’s
8.5 million uninsured children.
1. “People With or Without Health Coverage by Selected Characteristics: 2002 and

2003,” U.S. Census Bureau 8 Feb 2005. http://www.census.gov/hhes/www/hlthins/
hlthin03/hi03t5.pdf.
2. Newacheck, P et al. “The Role of Medicaid in Ensuring Children’s Access to
Care.” JAMA 290(20) (1998): 1789-1793. http://jama.ama-assn.org/cgi/re-
print/280/20/1789.pdf.
3. “CMS/HFCA History” 22 Dec 2004. Centers for Medicare & Medicaid Services 12
Feb 2005 http://www.cms.hhs.gov/about/history/default.asp?.
4. “CMS/HFCA History.”
5. “Medicare at a Glance” Mar 2004. The Henry J. Kaiser Family Foundation. 12 Feb.
2005. http://www.kff.org/medicare/loader.cfm?url=/commonspot/security/getfile.
cfm&PageID=33319.
6. “The Medicaid Program at a Glance.” Jan. 2005. The Henry J. Kaiser Family Founda-
tion, 12 Feb. 2005. http://www.kff.org/medicare/loader.cfm?url=/commonspot/se-
curity/getfile.cfm&PageID=33319.
7. “The Medicaid Program at a Glance.”
8. “Medicaid/SCHIP” Feb. 2005. The Henry J. Kaiser Family Foundation, 12 Feb.
2005. http://www.kff.org/medicare/loader.cfm?url=/commonspot/security/getfile.
cfm&PageID=33319.
9. Moon, M. “Medicare.” The New England Journal of Medicine 22 Mar. 2001, 12 Feb.
2005 http://content.nejm.org/cgi/content/full/344/12/928.
10. Perry, Michael; et al. “Medicaid and Children: Overcoming Barriers to Enrollment:
Findings from a National Survey.” Washington, D.C.: Kaiser Commission on Med-
icaid and the Uninsured 2000.
11. Kenney, G; Haley, J; Dubay, L. “How Familiar are Low-Income Parents with
Medicaid and SCHIP?” New Federalism: National Survey of America’s Families,
Urban Institute B-34 (May 2001), 2 Feb 2005 http://www.urban.org/template.
cfm?Template=/TaggedContent/ ViewPublication.cfm&PublicationID=7232&Na
vMenuID=95.
12. Kenney; Haley; Dubay.
13. “Kaiser Commission on Medicaid and the Uninsured,” 2 Feb. 2005, The Henry
J. Kaiser Family Foundation, 12 Feb. 2005 http://www.kff.org/medicaid/loader.
cfm?url=/ commonspot/security/getfile.cfm&PageID=50856.
14. “School Lunch Plan: Implementations Strategies,” Express Lane Eligibility, The
Children’s Partnership, Feb. 10 2005 http://www.childrenspartnership.org/express-
lane/sl-implement.html.
15. Homer, D; Lazarus, W; Marrow, B. “Express Lane Eligibility.” The Future of Chil-
dren 13(1) (2003): 229, 13 Jan 2005 http://www.futureofchildren.org/usr_doc/
tfoc13-1_iig.pdf.
16. “Children’s Express Lane to Health Coverage Act of 2003 (Introduced in Senate)
S1083 IS.” Thomas: Legislative Information on the Internet, The Library of Con-
gress, Jan 20 2005. http://thomas.loc.gov/cgi-bin/query/z?c108:S.1083:.
17. “School Lunch Plan: Implementation Strategies.”
18. “School Lunch Plan: Implementation Strategies.”
19. “Express Lane Eligibility” 226-7.
20. Bhandari, S; Gifford, E. “Children with Health Insurance: 2001.” U.S. Census Bu-
reau, Aug 2003, 30 Jan 2005. http://www.census.gov/prod/2003pubs/p60-224.pdf.
21. Horner, D; Lazarus, W; Morrow, B. “Building an On-ramp to Children’s Health
Coverage: a Report on California’s Express Lane Eligibility Program” Sept. 2004.
The Henry J. Kaiser Family Foundation, 20 Jan 2005. http://www.childrenspartner-
ship.org/expresslane/ele-CA.pdf.
22. Horner; Lazarus; Morrow. “Building Health Coverage: a Report on California’s
Express Lane Eligibility Program.”
23. “Building an On-ramp to Children’s Health Coverage: a Report on California’s
Express Lane Eligibility Program.”
24. “Express Lane Eligibility” 228.
25. “Original Medicare: Getting Care in a Hospital, Nursing Home, at Home and with
Hospice.” AARP, 5 Feb. 2005 http://www.aarp.org/healthcoverage/medicare/Ar-
ticles/a2003-04-28-orginalmedicareA.html.
26. “Original Medicare: Getting Doctor, Home Health and Preventive Care.” AARP,
5 Feb. 2005 http://www.aarp.org/healthcoverage/medicare/Articles/a2003-04-28-
originalmedicareB.html.
27. “Distribution of Medicaid Spending per Enrollee by Enrollment Group, FY2000.”
Statehealthfacts.org, The Henry J. Kaiser Family Foundation, 3 Feb. 2005 http://
www.statehealthfacts.kff.org/cgi-bin/healthfacts.cgi?action=compare&category=M
edicaid+%26+SCHIP&subcategory=Medicaid+Spending&topic=Spending+per+E
nrollee+by+Group%2c+FY2000.
28. McClellan, Mark; Skinner, Jonathan. “The Incidence of Medicare.” NBER Working
Paper No. 6013, Apr 1997: 32.
29. “FY06: Department of Health and Human Services.” Office of Management and
Budget, Feb. 2005, http://www.whitehouse.gov/omb/budget/fy2006/hhs.html.
30. “Distribution of Medicaid Spending by Enrollment Group, FY2000.” Statehealth-
facts.org, The Henry J. Kaiser Family Foundation, 3 Feb. 2005 http://www.state-
healthfacts.kff.org/cgi-bin/healthfacts.cgi?action=compare&category=Medicaid
+%26+SCHIP&subcategory=Medicaid+Spending&topic=Spending+by+Enrol
lment+Group%2c+FY2000.
31. DeParle, Nancy-Ann Min. “Celebrating 35 Years of Medicare and Medicaid,”
Health Care Financing Review 22(1) (2000): 3, 10 Feb. 2005 http://www.cms.hhs.
gov/review/00fall/00Fallpg1.pdf.
32. Danzon, P; Furukawa, M. “Prices and Availability of Pharmaceuticals: Evidence
from Nine Countries.” Health Affairs W3-524 (29 Oct 2003): 7. http://entrepre-
neurship.mit.edu/forum/Prices%20and%20Availability%20of%20Pharmaceuticals
_9Countries%20HA%20Oct2003.pdf?type=topNews&storyID=5653226
33. Rost, P. “Saving lives, not bottom line must drive drug companies.” SFGate.com.
9 Jan 2005, 3 Feb 2005 http://sfgate.com/cgi-bin/article.cgi?file=/c/a/2005/01/09/
EDGE2AMLSQ1.DTL.
A BOUT THE A UTHORS
Amelia Hausauer, Jermaine Archie, Craig Boge, Anthony Ortega, and

Sarah Pratt, all Human Biology majors at Stanford University, wrote
this policy proposal for “The Human Predicament,” an introductory
Human Biology course.
Hausauer, a rising junior, concentrates is in Pathophysiology and Dis-
ease Mechanisms. Her interests include viral epidemiology and global
health. Hausauer is a member of SCOPE, a premedical program plac-
ing students in local emergency rooms; and she has researched the
gene Nkx 2.5 in Ciona Intestinalis in Dr. Michael Levine’s molecular
biology lab at the University of California at Berkeley. She is also an
intern at the HEAL pediatric obesity and diabetes clinic at Children’s
Hospital Oakland. In 2004, Hausauer received the President’s Award
for Academic Excellence. After graduating from Stanford, she plans on
attending medical school.
Archie, a rising senior, is originally from Motha-Effingham County,

Georgia. He is currently conducting neuroscience research at Stan-
ford.
Boge, a rising junior, concentrates is in Epidemiology and Infectious

Diseases. He is originally from Prosser, a small town in eastern Wash-
ington.
Ortega, a rising junior, concentrates is in Race, Health Policy, and the

Disadvantaged. He is passionate about a variety of political issues,
including immigration policy, race and ethnicity studies, and public
health. Ortega works at Stanford’s Center for Career Development,
where he coordinates the Stanford Immersion in Medicine Series
(SIMS), a shadowing program administered in conjunction with the
Stanford Hospital. He also volunteers as a translator for EPA.net, an
organization that aims to bring internet access and technology to low-
er-income neighborhoods in the Stanford area. In addition to majoring
in Human Biology, Ortega is pursuing a minor in Italian, and hopes to
attend medical school after Stanford.
Pratt, a rising junior, concentrates is in Comparative Health Policy. Her

interests include intersections between policy and reproductive and
sexual health, infectious disease, and health in the developing world.
She recently worked at the U.S. Department of Agriculture, where she
studied the impact of federal programming on education, health, and
infrastructure development on Native American reservations; and at
the U.K. Medical Research Council Unit in the Gambia, Africa, where
she researched the impact of HIV/AIDS serostatus disclosure on anti-
retroviral adherence, cumulating in a policy proposal that was presented
to the Gambian National AIDS Secretariat. Pratt also recently received
a grant to research the use of non-prescription hormonal contraception
among teenagers in England. She is interested in pursuing a master’s
degree in public health and a Ph.D., and would like to eventually work
in academia and teaching.
For correspondence, please email Amelia Hausauer at hausauer@stanford.edu.
Current Research: Public Health
Innocent Until
Proven Guilty:
Military Use of Depleted Uranium
Rachel Saltzman
Since the 1991 Persian Gulf War, debate about the effects of de-
pleted uranium (DU) on the environment and on the human body
has gained momentum. The U.S. Department of Defense has al-
ways claimed that DU is an indispensable component of muni-
tions, and that any negative toxicological and radiological effects
are negligible. Scientists in the private sector, however, have con-
tended not only that an absence of sufficient evidence undermines
the Defense Department’s claims of no risk, but that DU in all
likelihood causes a variety of adverse health effects. Until conclu-
sive research has been gathered and evaluated by multiple interest
groups, the United States should establish a moratorium on mili-
tary use of DU.
DU is a byproduct of the uranium enrichment process, when
fissionable U-235 and U-234 are separated from natural uranium.1
A heavy metal made from uranium hexafluoride, DU has about 60
percent of the radioactivity of natural uranium and a half-life of
4.468 billion years.2 Although DU has been used for decades in
medical and industrial contexts (e.g. radiation shielding and coun-
terbalance weights in aircrafts), it has more recently been used as a
component of munitions by the U.S. military.3 DU’s high density
makes it ideal for use both in “penetrators” against armored targets
and as armor plate for military vehicles.4 According to the United
States Army, it offers a significant performance advantage over
other materials, such as tungsten, used for these purposes.5 DU
S A LT Z M A N | 55
may also be attractive for the financial advantage it offers to munitions
companies. A waste product of U.S. nuclear weapons and energy facili-
ties,6 DU is stored by the U.S. Department of Energy, which allegedly
gives it free-of-charge to U.S. armaments companies and sells it to more
than twenty other countries.7 In addition to the estimated 320 tons that
were deployed by the Army during the Persian Gulf War, DU has been
used in operations in Bosnia, Kosovo, Serbia, Montenegro, and recently
in Iraq.8
The most likely victims of DU exposure are the crews of vehicles car-
rying DU ammunition or fitted with DU armor. Civilians returning to
live in conflict areas are also at risk for exposure from contaminated food
and water supplies.9 The extent of environmental contamination from
DU particles and penetrator fragments left in the soil depends on corro-
sion rates, the amount of soil resuspension, the depth of DU penetrators
buried in the soil, and the water sources that feed into local water sup-
plies—which may also influence the extent of DU uptake by plants and
animals.10 However, uncertainties in estimates about inhalation intakes,
as well as exposure from food and water after a conflict, result from a lack
of knowledge about local soil conditions and human behavior,11 and a
lack of empirical information on human DU exposure.
Humans can be exposed to DU through inhalation, ingestion, and
dermal contact.12 The heavy metal has both chemical and radiological
toxicity, and is thought to be especially dangerous to the kidneys and
lungs. DU, which is weakly radioactive, emits alpha particles, beta par-
ticles, and photons (x-rays and gamma rays).13 If it enters the body, the
worst cell damage occurs from alpha particles.14 The greatest risk of in-
halation is thought to be increased risk of lung cancer, while there is less
estimated risk of contracting leukemia or other cancers.15 DU may also
cause hepatic, hematological, respiratory, and cardiac toxic effects, and
may even directly damage DNA because of the enhancement of chemi-
cal effects by alpha-particle radiation.16 Laboratory research performed
over the last few years has shown that cells exposed to DU experience
chromosome breaks, DNA cleavage, and cell death—effects that are all
commonly accepted precursors to cancer, leukemia, lymphoma, and ge-
netic disturbances, including sterility and birth defects.17
Inhalation is the most likely route of exposure to DU during a mili-
tary conflict, when the impact of a DU penetrator against its target pro-
duces a cloud of fine dust that can be inhaled immediately by anyone
within about 25 meters of the destroyed equipment.18 After a conflict,
DU dust continues to present a hazard as it travels by wind through-
out the surrounding environment.19 This dust is made up of particles
of ceramic uranium oxide, over 60 percent of which are smaller than
five microns in diameter.20 The small particles are easily inhaled and
are likely to be retained in the lungs. After inhalation, some of the par-
ticles are cleared in mucus and swallowed, while some are absorbed into
the blood.21 Other particles remain in the lungs, possibly for years, and
are slowly absorbed into the bloodstream, cleared by the bronchial tree,
or passed to nearby lymph nodes.22 When uranium is absorbed by the
blood, most is passed out of the body through urine, while about ten
percent goes to the kidneys and is lost within weeks, and another ten
percent deposits in bone, where it remains for many years.23 The Brit-
ish Royal Society, an independent scientific academy, suggests that after
large inhalation intakes, health effects might include short-term respira-
tory effects or, in case of heavy exposure, fibrosis of the lung or increased
risk of lung cancer.24
In 2002, The Royal Society released a report on the health effects
of DU munitions. Using information from animal studies considered
alongside limited evidence from human exposure, the Royal Society
reported that the kidney is the most susceptible organ to the toxic ef-
fects of uranium. There have been substantial difficulties, however, in
assessing the nephrological health of exposed veterans. Adverse effects
of uranium concentrations in human kidneys are not well documented,
and the few existing epidemiological studies have been less than con-
clusive. The only measurements of uranium isotopes in veterans’ urine
referenced by the Royal Society report came from a Canadian study
which cited uncertainty about the reliability of its measurements.25
The Royal Society maintains that except in extreme circumstances,
an increased risk of developing fatal cancers from exposure to DU on
the battlefield, or from returning to live the area after a conflict, is un-
detectable.26 Yet uncertainties in research on battlefield intake have
made estimation of general radiological effects difficult.27 Similarly,
while exposure to DU may result in short-term kidney dysfunction,
speculation about long-term effects has been impossible because of a
lack of studies devoted to long-term monitoring of exposed individu-
als.28 Despite a failure to present conclusive findings, the Royal Society
report did show that claims about lack of health risk from DU should
be regarded as suspect. Assessments of risk resulting from DU expo-
sure are largely based on poor data for concentrations and properties
of DU oxides released during test firings.29 Furthermore, predictions
of resulting concentrations in tissues and organs, as well as radiological
and toxicological risks, have been based on modeling procedures rather
than on actual data.30
S A LT Z M A N | 57
In a presentation to the Royal Society on July 19th, 2000—two years
before the Society’s report was published—radiation expert Chris Busby
challenged the deductive method that has been used both to set legal ex-
posure levels and to maintain that exposure to DU is safe for human be-
ings.31 He argued that the physics-based, “nuclear establishment” model
for analyzing the health threats of DU is antiquated and reductionist.32
Most problematically, the model uses data from high level, acute, ex-
ternal exposure to predict health effects for low-level, chronic, internal
exposure.33 Busby, along with other scientists concerned about the risks
associated with the use of fissile materials, recommends that risk evalu-
ation for DU should instead be based on an inductive analytical method
that would involve using specific epidemiological information to look at
the way in which doses from isotopes directly react with cells in various
stages of biological development.34 This type of research, in addition to
being more conclusive and scientifically sound, would allow scientists to
explore legitimately the dose-response relationship of DU with human
cells.
The difficulties of finding reliable research methods that can produce
conclusive data to describe the effects of DU exposure is compounded
by an artificially limited flow of information. A 1994 report to Congress
by the U.S. Army Environmental Policy Institute provides an example
of the way in which concerns regarding DU’s adverse effects have been
downplayed. The report states, “It is highly unlikely that DU is a contrib-
uting factor to the unexplained illnesses currently being reported by vet-
erans of Desert Storm. This conclusion is based on assessment that there
was little or no internal DU exposure by most Desert Storm soldiers.”35
However, according to a 1991 to 1995 survey of 10,051 Persian Gulf War
veterans, 82 percent of veterans reported having entered captured Iraqi
vehicles—suggesting that about 123,000 soldiers were directly exposed
to DU during that conflict.36
In addition to the claim that U.S. soldiers probably were not exposed
during the Persian Gulf War, the Environmental Policy Institute report
frequently uses the lack of conclusive data about risk as evidence of no
risk: “While there are no data that can be used directly to establish the
human cancer and hereditary risks from low-level, low-dose radiation,
there is general agreement that the models currently in use do not un-
derestimate either the cancer or hereditary risks.”37 The claim that there
is no appreciable risk associated with DU is based on “general agree-
ment”—yet the report does not specify who exactly is included in this
consensus. At the same time, it contains an admission that all evaluation
of risk has been based on empirically unsupported estimation, for the
simple reason that there are no data available. Certainly it is the responsi-
bility of the U.S. Army to achieve “maximum battlefield advantage.”38 It
should not follow, however, that the adverse health effects of DU should
be regarded as “minimal” simply because the long-term effects are not
“well-defined.”39 For the health of our soldiers, we cannot afford to em-
ploy an innocent-until-proven-guilty approach with respect to poten-
tially dangerous materials.
Whereas the U.S. Army and Defense Department have treated DU
as an issue of tactical advantage and not as a potential health threat,
scientists and physicians in the private sector have attempted to discover
the full effects of DU on the human body. Doug Rokke, the former head
of the Pentagon’s Depleted Uranium Project, released an independent
paper in November of 2002 on the uses and hazards of DU. During the
Persian Gulf War, Rokke left his research job with the University of Illi-
nois Physics Department when he was recalled to active duty in the U.S.
Army and assigned to the Depleted Uranium Assessment Team.40 “As
the team health physicist and medic,” he explained in a November 2000
address to Vietnam and Desert Storm veterans, “I was responsible for
planning and implementing DU (Uranium 238) contaminated equip-
ment and terrain clean-up and for providing medical care recommenda-
tions for exposed personnel.”41 Rokke’s work contradicts official claims
about the risk associated with DU, maintaining that it poses a significant
threat to human health. He lists twelve effects of DU that have been
verified by his own personal experience, the observations of physicians,
and personal reports from individuals with known DU exposure. The ef-
fects include reactive airway disease, neurological abnormalities, kidney
stones and chronic kidney pain, rashes, vision degradation and night vi-
sion losses, gum tissue problems, lymphoma, various forms of skin and
organ cancer, neuro-psychological disorders, uranium in semen, sexual
dysfunction, and birth defects in offspring.42 The likelihood that these
effects have been caused by DU exposure is supported by the similar ef-
fects experienced by residents of several cities in the United States where
DU is manufactured and tested for use in munitions.43 Iraqi and other
humanitarian agency physicians have similarly reported adverse health
effects in populations that were exposed to DU.44 Rejecting the offi-
cial claims of the U.S. Army, Rokke suggests that one reason no adverse
health effects of DU have been definitively proven is that U.S. authorities
have engaged in “deliberate denial and delay of medical screening and
consequent medical care” for U.S. soldiers exposed to DU.45 The small
number of exposed soldiers that have been monitored typically were not
approached for testing, or even informed of potential health threats, until
S A LT Z M A N | 59
years after their last contact with DU. Yet according to health physics
guidelines, testing should be completed within thirty days—not several
years—of exposure.46
Not only have exposed individuals faced difficulties in receiving medi-
cal assessments, but they have also encountered an impeded flow of infor-
mation surrounding DU data. Rokke writes that in 1994 and 1995, “United
States Department of Defense medical personnel at a U.S. Army instal-
lation hospital removed, separated, and hid documented diagnoses from
affected individuals and other physicians.”47 These confiscations occurred
around the same time that the Army Environmental Policy Institute made
its report to Congress repudiating the notion of health threats associated
with DU. The juxtaposition of the Army’s official report and the actions
of the Defense Department seems contradictory. It appears that the mili-
tary has long been aware of a correlation between DU and adverse health
effects. Physicians and exposed individuals, however, have found it diffi-
cult to pursue treatment once the patients’ problems were associated with
DU exposure. Rokke confirms this censorship by U.S. authorities with his
reference to a memorandum sent to his team in Saudi Arabia in March
1991. “This memo,” he writes, “told us to be sure no matter what we did
or reported that we should only report information so DU could always
be used.”48 The Depleted Uranium Assessment Team, it seems, was not
used to compile legitimate research to protect U.S. soldiers. In the absence
of such research, the Army was able to claim that investigation into DU’s
effects had taken place and that members of the U.S. Army were safe.
Documented evidence shows that U.S. authorities have known about
the hazards of DU for a significant length of time but have not widely
publicized this information. A letter sent to General Leslie R. Groves on
October 30, 1943, by the Subcommittee of the S-1 Executive Committee
on the Use of Radioactive Materials as a Military Weapon, suggested that
uranium could be used as an air and terrain contaminant.49 The memo
stated:
Areas so contaminated by radioactive material would be danger-

ous until the slow natural decay of the material took place ... for
average terrain no decontaminating methods are known. No ef-
fective protective clothing for personnel seems possible of devel-
opment ... Reservoirs or wells would be contaminated [and] food
poisoned.50
The letter stated that inhalation of uranium would result in “bron-

chial irritation coming on in a few hours to a few days.”51 Individuals
exposed to DU dust during Operation Desert Storm experienced exactly
these symptoms, yet were never informed of their exposure to DU or told
to seek medical screening.
Without these medical evaluations, the number of reported medical
problems experienced by people with DU exposure is far lower than it
would otherwise be—thus bolstering the claim that such cases do not
exist. A physician in California reported being trained by the Pentagon,
with other doctors, months before the 2003 Iraq war began—to diagnose
returning soldiers with mental problems only.52 This claim is interesting
in light of a recent Gulf War Review, which reported that as of September
2003, only 262 veterans had been treated for DU poisoning.53 Mean-
while, of nearly 700,000 American veterans of the Persian Gulf War,
240,000 are on permanent medical disability, and over 11,000 are dead.54
Furthermore, statistics suggest that veterans exposed to contamination
during the Persian Gulf War have passed on health problems to their
families. According to a U.S. government study of babies born to 251
Persian Gulf War veterans, 67 percent of the babies had serious illnesses
or birth defects.55 Children of veterans were born without eyes and ears,
had missing organs, fused fingers, and thyroid or other malfunctions.56
Significantly, similar birth defects have been reported in populations in
Iraq, Yugoslavia, and Afghanistan, where DU weapons have been used.57
Using concrete data from the 2003 Iraq war to expand upon previous sta-
tistics is difficult, as compiled information is still fragmentary. However,
many veterans of the current war are already suffering from Gulf War
Syndrome, a disease whose symptoms indicate chemical or radiation
poisoning, which was first experienced by veterans of the Persian Gulf
War.58 It has been reported that in one unit of twenty U.S. soldiers who
were exposed only to DU in 2003, eight developed malignancies within
six months.59 As further data from the current Iraq war is compiled,
reported adverse health effects will likely echo those of previous conflicts
in the Middle East and the Balkans.
DU has come to be regarded as one of the main possibilities for the
cause of Gulf War Syndrome. Asaf Durakovic of the Uranium Medical
Research Center (UMRC) describes Gulf War Syndrome as “a complex,
progressive, incapacitating multiorgan system disorder” whose symptoms
include incapacitating fatigue, musculoskeletal and joint pains, headaches,
neuropsychiatric disorders, affect changes, confusion, visual problems,
changes of gait, loss of memory, lymphadenopathies, respiratory impair-
ment, impotence, and urinary tract morphological and functional altera-
tions.60 Generally, only three possibilities have been regarded as potential
causes for Gulf War Syndrome: Iraqi chemical and biological weapons,
S A LT Z M A N | 61
the cocktail of vaccinations given to coalition soldiers, and DU.61 As
there were no detectable biological agents used during the 2003 Iraq war,
the possibilities for the cause of adverse health effects experienced by U.S
soldiers are likely limited to prewar vaccinations and DU.62 However,
Iraqi children who did not receive vaccinations experienced the same
adverse effects as U.S. veterans.63 DU is thus becoming more widely re-
garded as the most likely culprit of Gulf War Syndrome.
Perhaps the most telling study to date correlating DU exposure with
adverse health effects was begun in 2002 by the Uranium Medical Re-
search Center of Washington D.C., an independent non-profit organiza-
tion founded in 1997 to provide scientific and medical research into the
effects of uranium, transuranium elements, and radionuclides produced
by the process of uranium decay and fission.64 Entering Afghanistan at
the end of Operation Anaconda in March 2002, the UMRC team con-
ducted studies of populations in the Jalalabad, Spin Gar, Tora Bora, and
Kabul regions and identified civilians suffering from the same symptoms
encountered in the Persian Gulf War and the Balkan conflicts.65 These
symptoms included physical weakness, headache, muscular and skeletal
pains, respiratory changes, fever, persistent dry cough, chest pain, gastro-
intestinal problems, neurological symptoms, memory loss, anxiety, and
depression.66 Twenty-four hour urine samples were collected from test
subjects who were present in the area of the bombings, displayed symp-
toms that began relative to the bombing raids, and showed clinical mani-
festations.67 High uranium levels were found in the urine of 100 percent
of the test subjects, averaging 20 times higher than uranium levels in the
urine of the non-exposed population.68 In a subsequent study later in the
year, the UMRC found uranium concentrations up to 200 times higher
than in the control population.69 This study is important to establishing
the correlation between adverse health effects and DU exposure. How-
ever, Durakovic points out that there is still “a conspicuous absence of a
meaningful comprehensive research effort that would correlate [Persian
Gulf War and Balkan Syndromes] with uranium contamination.”70 The
UMRC remains the only organization that has performed sustained re-
search on DU using advanced methodology.71
As DU has begun to receive increasing attention as a possible cause
of Gulf War Syndrome, reliable press coverage of its hazards has faced
difficulties at every step. Investigative reporting about DU has most-
ly appeared in independent publications, such as American Free Press,
rather than in mainstream newspapers. John Hanchette, editor of USA
Today from 1991 to 2001, reports having written several news articles
about the effects of DU on Persian Gulf War veterans, none of which
were published because of pressure from the Pentagon.72 This silencing
of speculation about the dangers of DU has allowed the U.S. Army to
continue using the DU munitions that are strategically effective in the
short run, but that are ultimately damaging both citizens of foreign na-
tions and U.S. veterans in ways that are not yet fully understood. Presi-
dent George W. Bush has repudiated efforts to question the morality of
continued use of DU munitions, referring to the “false claim that the
depleted uranium rounds fired by coalition forces have caused cancers
and birth defects in Iraq.”73 However, as representatives from the United
Nations Environment Program have not been allowed into Iraq to as-
sess DU pollution, no one has even had the opportunity to attempt to
substantiate the president’s claim that the association of health problems
with DU is “false.”74
Keith Baverstock, formerly the top expert on radiation and health
at the World Health Organization (WHO), has experienced first-hand
the type of censorship that impedes both journalistic commentary and
scientific research on DU. Baverstock’s own study on DU’s health effects
was suppressed by WHO, suggesting that the control of certain informa-
tion is not isolated to the United States. In November 2001, Baverstock
composed a paper with two other scientists on the radiological toxicity of
DU that was allegedly blocked from publication by WHO. He believes
that if the article had been published at the time of its completion, the
United States and the United Kingdom would have been compelled to
restrict use of DU in military combat, and to clean up contaminated
sites.75 In February 2004 he told the Sunday Herald, an independent
newspaper in Scotland, “Our study suggests that the widespread use of
depleted uranium weapons in Iraq could pose a unique health hazard to
the civilian population.”76
Baverstock’s study challenged the research of the Royal Society and
WHO with criticism of previous methods of risk evaluation. His paper
suggested that the study of DU’s health effects should include consider-
ation of a “bystander effect,” in which unirradiated cells growing close to
cells exposed to radiation from DU display genetic alteration supposed
to be related to cancer induction.77 The alpha particles emitted by heavy
metals such as DU are known to be a potent cause of bystander effects,
which may be enhanced by combined radio-chemical exposure.78 These
findings cast uncomfortable doubt on the claims of multiple organiza-
tions that the health effects of DU are negligible.
In email correspondence from March 17, 2005, Baverstock wrote
that both the International Commission on Radiological Protection
(ICRP) and the International Atomic Energy Agency (IAEA) have
S A LT Z M A N | 63
“considerable leverage over the WHO, not so much in a formal man-
date sense but through interagency committees and personal contacts.”79
Both of these agencies reaffirmed in 2003 the “establishment”80 posi-
tion that DU dust could be treated as a natural insoluble uranium ox-
ide—meaning that permissible levels would be based on radiotoxicity
rather than chemical toxicity. Yet Baverstock’s research suggests that the
chemical toxicity of DU, especially as it interacts with the radiological
properties, may be more important than previously assumed. Thus, it
may have been more convenient for ICRP and IAEA that Baverstock’s
paper was not formally published. He told the Sunday Herald in 2004,
“I believe our study was censored and suppressed by the WHO because
they didn’t like its conclusions. Previous experience suggests that WHO
officials were bowing to pressure from the IAEA, whose remit is to
promote nuclear power.”81 Baverstock reconfirmed through email cor-
respondence that in the past, “The Geneva Office [of the WHO] has
acted to my certain knowledge on the wishes of IAEA and against the
best interests of public health.”82 This situation, then, may simply be one
of many in which politics trumps human well-being. Whether WHO
publication of the article was prevented by a bureaucratic “turf war”83
within the agency or by pressure, for political reasons, from the IAEA,
its suppression has allowed continued—and largely un-criticized—use
of DU by the United States and the United Kingdom during renewed
conflict in Iraq.
Some of the most immediate victims of censorship have been mem-
bers of the U.S. Armed Forces. Despite the U.S. government’s long-
standing knowledge that exposure to DU causes health problems, U.S.
soldiers participating in military conflicts during the 1990s were never
officially warned about the danger. UMRC’s Durakovic reported that
during his service in Operation Desert Shield as a unit commander, “My
expertise of internal contamination was never used because we were nev-
er informed of the intended use of DU prior to or during the war.”84 As
a member of the Depleted Uranium Assessment team, Rokke was one
of the few soldiers aware of his and others’ exposure. However, after his
1991 stint on the DU assessment team, he was ordered to restrict dis-
cussion of his knowledge of DU hazards to commanders and medical
personnel.85 Under orders to stop informing commanders and troops
about the hazards, Rokke was prohibited from helping U.S. soldiers take
preventative measures to protect themselves, or deal with health conse-
quences after exposure.86 It appears that such active perpetuation of vet-
erans’ ignorance continued long after the end of the conflict. A comment
by Senator Paul Wellstone, before his death in 2002, to Joyce Riley, the
executive director of the American Gulf War Veterans Association, sug-
gests continued secrecy of the type that Rokke describes.87 Wellstone
informed Riley that 95 percent of Persian Gulf War veterans had been
released from military service by 1995.88 Meanwhile, any Desert Storm
veterans remaining in the U.S. military were isolated from each other in
order to prevent information about DU from being transferred to new
troops.89
Members of the U.S. Armed Forces, however, are not the only vic-
tims of DU exposure. Both military personnel and civilians of nations
against whom the United States has used DU weapons suffer from a host
of cancers and developmental problems. In 1990, the United Kingdom
Atomic Energy Authority (UKAEA) released a report that predicted, “If
50 tonnes of residual DU dust remained [in Iraq] there could be half a
million extra cancers by the end of the century.”90 The estimated amount
of DU used during Persian Gulf War ranges from the Pentagon’s admit-
ted 320 tons to estimates of other scientific bodies reaching as high as
900 tons.91 According to the UKAEA’s estimate, the projected number
of cancer cases could reach as high as 9,000,000 from the Persian Gulf
War alone.92
Since the renewal of conflict in 2003, human rights activists have
mobilized against the usage of DU. Leuren Moret, an independent
scientist and radiation specialist, has bluntly described U.S. use of DU
against third world countries as “genocide.”93 Moret believes that the
irreversible pollution of the landscape by a radioactive and chemically
toxic substance will permanently damage the genetic makeup of the third
world populations against which DU has been used.94 The United States
has been further criticized by proponents of international law, who object
to the use of weapons that target civilians as well as military personnel
and have encouraged the United Nations to take a stand on DU. In 1996,
a subcommission of the U.N. Human Rights Commission declared DU
a weapon of mass destruction, concluding that its use violates the Ge-
neva Convention on four counts: “the principle that there is no unlimited
right to choose the means and methods of warfare,” “the ban on causing
unnecessary suffering and superfluous injury,” “indiscriminate warfare,”
and “the use of poison or poisoned weapons.”95 An international ban,
however, has not been officially enacted.
This is not the first time that munitions have been employed without
sufficient knowledge as to their adverse health effects. During the 1960s
and 70s, the Defense Department maintained that Agent Orange did
not cause adverse health effects in humans long after it was proven that
dioxin, a potent carcinogen, was a major contaminant of the herbicide.96
S A LT Z M A N | 65
As a result, eighty million liters of herbicides were spread across the
landscape in South Vietnam between 1961 and 1971.97 People living in
that region now suffer from cancers, nervous system damage, and other
debilitating diseases comparable to the problems now experienced by
populations that have been exposed to DU.
This approach to military conflict should not be allowed to continue.
The United States must act to protect the members of its Armed Forces,
and to spare civilians of other nations from getting caught in the crossfire
of international politics. At least until sufficient epidemiological studies
have been conducted and evaluated by reputable interest groups that are
not associated with the nuclear power industry, the U.S. Department of
Defense, the U.K. Ministry of Defense, or military suppliers, the U.S.
military should stop using DU. While there is still research to be done to
establish the exact scientific relationship between DU exposure and ad-
verse health effects, the wealth of research that points to DU as danger-
ous to human health should be enough to warrant a moratorium on mili-
tary use of this radioactive and chemically toxic heavy metal. In March
2003, Rep. Jim McDermott (D-WA) introduced a bill in the House of
Representatives entitled the Depleted Uranium Munitions Study Act of
2003 (H.R. 1483). McDermott’s bill proposed that a study be conducted
by the Agency for Toxic Substances and Disease Registry (ATSDR)
to establish the effects of exposure to DU on veterans and their chil-
dren. The bill also called for a cleanup effort of contaminated sites in
the United States. In May 2004, Rep. José Serrano (D-NY) introduced
the Depleted Uranium Screening and Testing Act of 2004 (H.R. 4463),
calling for identification and screening of exposed members of the U.S.
Armed Forces. Until the kind of evaluation proposed in these two bills
is undertaken and completed, a moratorium on the use of DU weapons
must be enacted.
It seems unlikely, however, that the federal government will take ac-
tion in the near future as these bills continue to receive little attention.
In the meantime, a secondary solution may be to combat the problem at
the state level. Louisiana and Connecticut, which both recently passed
laws providing for screening of veterans, are the only states thus far to
aid veterans in dealing with DU exposure. Both laws, which go into ef-
fect October 1, 2005, require the adjutant generals of their respective
states to assist members of the National Guard who served in the Persian
Gulf War, Operation Enduring Freedom, or Operation Iraqi Freedom
in obtaining federal treatment services.98 These services include a health
screening test for DU exposure that uses a bioassay procedure able to
detect DU at low levels.99 Although no state funds are to be used,100 the
laws are designed to help veterans receive recognition and access to fed-
eral services. Furthermore, both laws call for research into the feasibility
and cost of adding pre-deployment training for members of the Armed
Forces concerning potential exposure to DU and other toxic substanc-
es,101 and Connecticut’s law calls for a task force dedicated to studying
the health effects of exposure to DU and other hazardous substances in
a military context.102
This united effort, equally supported by Democrats and Republi-
cans in both Louisiana and Connecticut, should encourage officials in
other states to take action on an issue that must remain free of partisan-
ship. State legislatures should continue to pass laws that acknowledge
the health problems of veterans and commit to training soldiers in the
necessary precautions to avoid being exposed to DU in the first place.
The legislative battle, however, cannot end here. The steps taken by the
Connecticut and Louisiana legislatures are more concerned with evalu-
ating the problems associated with DU than with directly improving the
situation. Furthermore, state laws cannot protect civilians around the
world that continue to be exposed to the hazards of DU munitions used
by the U.S. military. State involvement is a good first step. However, until
our federal government bans the use of DU munitions and make efforts
to repair the damage caused by these weapons, the United States will
continue to engage in conduct that both violates the Geneva Convention
and places its own citizens at risk.
1. Rokke, D. “Depleted Uranium: Uses and Hazards” 2000.

2. Ibid.
3. U.S. Army Environmental Policy Institute. “Health and Environmental Consequences of
Depleted Uranium Use by the U.S. Army” 1994.
4. Ibid.
5. Ibid.
6. Bollyn, C. “Depleted Uranium Released During Canadian Plane Crash.” American Free
Press 22 October 2004.
7. Moret, L. “U.S. Nuclear Policy and Depleted Uranium” June 2003.
8. Flatow, I. “Health and environmental hazards posed by depleted uranium exposure.” NPR
Science Friday 2003.
9. The Royal Society. “The health effects of depleted uranium munitions: Summary” 2002: 4.
10. Ibid.
11. Ibid.
12. World Health Organization. “Depleted uranium: sources, exposure and health effects:
Executive summary” 2001: 2.
13. Murray, V. “Depleted Uranium: A New Battlefield Hazard.” The Lancet 360, no. 1 (2002):
s31-s32.
S A LT Z M A N | 67
14. Ibid.
15. Ibid.
16. Ibid.
17. Bishop, D. “IDUST Report to Parliament on DU.” Letter to the Environmental Audit
Committee. 2004.
18. Rokke. “Depleted Uranium: Uses and Hazards.”
19. Ibid.
20. Bishop. “IDUST Report to Parliament on DU.”
21. Murray. “Depleted Uranium: A New Battlefield Hazard.”
22. Ibid.
23. Ibid.
24. The Royal Society. “The health effects of depleted uranium munitions: Summary”: 3.
27. Ibid.
28. Ibid.
29. Murray, “Depleted Uranium: A New Battlefield Hazard.”
30. Ibid.
31. Busby, C. “Science on Trial.” Invited Presentation to the Royal Society, 19 July
2000.
32. Ibid.
33. Ibid.
34. Ibid.
35. U.S. Army Environmental Policy Institute. “Health and Environmental Consequences
of Depleted Uranium Use By the U.S. Army.”
36. Bollyn, C. “Cancer Epidemic Caused by U.S. WMD.” American Free Press 13 August
2004.
37. U.S. Army Environmental Policy Institute. “Health and Environmental Consequences
of Depleted Uranium Use By the U.S. Army.”
38. Ibid.
39. Ibid.
40. Rokke, D. “Address on Depleted Uranium.” True Democracy 2, no. 2 (2002).
41. Rokke. “Address on Depleted Uranium.”
42. Ibid.
43. Rokke. “Depleted Uranium: Uses and Hazards.”
44. Ibid.
45. Ibid.
46. Ibid.
47. Ibid.
48. Ibid.
49. Ibid.
50. Moret, L. “Depleted Uranium: Dirty bombs, dirty missiles, dirty bullets.” San Francisco
Bay View 16 March 2005.
51. Ibid.
52. Ibid.
53. Bollyn, C. “DU Syndrome Stricken Vets Denied Care.” American Free Press 20 August
2004.
54. Ibid.
55. Ibid.
56. Moret, L. “Depleted Uranium: The Trojan Horse of Nuclear War.” World Affairs—The
Journal of International Affairs 8, no. 2 (2004).
57. Ibid.
58. Busby. “Science on Trial.”
59. Moret. “Depleted Uranium: Dirty bombs, dirty missiles, dirty bullets.”
60. Durakovic, A. “Undiagnosed Illnesses and Radioactive Warfare.”: 520.
61. Bollyn. “Cancer Epidemic Caused by U.S. WMD.”
62. Ibid.
63. Busby. “Science on Trial.”
64. www.umrc.net
65. Durakovic, A. “Undiagnosed Illnesses and Radioactive Warfare.” Croatian Medical
Journal 44, no. 5 (2003): 527.
66. Ibid.
67. Ibid.
68. Durakovic. “Undiagnosed Illnesses and Radioactive Warfare”: 528.
69. Ibid.
70. Durakovic. “Undiagnosed Illnesses and Radioactive Warfare”: 526.
71. Ibid.
72. Bollyn. “DU Syndrome Stricken Vets Denied Care.”
73. Moret. “Depleted Uranium: The Trojan Horse of Nuclear War.”
74. Ibid.
75. Edwards, R. “WHO ‘suppressed’ scientific study into depleted uranium cancer fears in
Iraq.” Sunday Herald. Scotland, 22 Februrary 2004.
76. Ibid.
77. Baverstock, K. “Radiological toxicity of DU.” 2001.
78. Ibid.
79. Keith Baverstock, Personal Correspondence, keith.baverstock@uku.fi, 17 March 2005.
80. Ibid.
81. Edwards. “WHO ‘suppressed’ scientific study into depleted uranium cancer fears in
Iraq.”
82. Baverstock. Personal Correspondence.
83. Baverstock. Personal Correspondence.
84. Bollyn, C. “Depleted Uranium Blamed for Cancer Clusters Among Iraq War Vets.”
WagingPeace.org. 15 August 2004.
85. Rokke. “Address on Depleted Uranium.”
86. Ibid.
87. Moret. “Depleted uranium: Dirty bombs, dirty missiles, dirty bullets.”
88. Ibid.
89. Ibid.
90. Moret. “Depleted Uranium: The Trojan Horse of Nuclear War.”
91. Ibid.
S A LT Z M A N | 69
92. Ibid.
93. Ibid.
94. Ibid.
95. Ibid.
96. Bishop. “IDUST Report to Parliament on DU.”
97. “Vietnam: ‘The Biggest Chemical War’ in History,” Truthout.org. 14 March 2004.
98. Connecticut House of Representatives. “File No. 840.” approved by the Legislative
Commissioner 4 June 2005; Louisiana House of Representatives, “Act No. 69.” signed
by the Governor 16 June 2005.
99. Ibid.
100. Ibid.
101. Ibid.
102. CT House of Representatives. “File No. 840.”
ABOUT THE AUTHOR
Rachel Saltzman is a rising sophomore at Yale. A prospective English

major from Evansville, Indiana, Saltzman graduated cum laude from
Choate Rosemary Hall in 2004. Her interests include social justice and
environmental concerns as they relate to global policy. She hopes to com-
bine her study of literature and the cultural politics imbedded in texts
with her concern for environmental politics. After graduating from Yale,
Saltzman plans to attend law school.
For correspondence, please email Rachel Saltzman at rachel.saltzman@yale.edu.
Current Research: International Development
Voices From Rural

South Africa
Married Women and AIDS
Vulnerability: Moving Toward
Female-Controlled Prevention
Jenny Tolan
South Africa, Africa’s wealthiest nation, faces one of the fastest

growing rates of HIV/AIDS infection in the world. In the past
fifteen years the nation has seen a huge jump in HIV prevalence,
from one percent of the population in 1990 to 20 percent in
2001.1 In 2004 these figures reached over 26 percent, making
South Africa the nation with the world’s highest rate of HIV/
AIDS infection.2 But HIV/AIDS does not affect all popula-
tions equally. As in most of sub-Saharan Africa, women in South
Africa are 30 percent more likely to be HIV positive than men.3
Even more surprising, AIDS does not target all women consis-
tently. Research has found that married women and women in
long-term monogamous relationships run a greater risk of con-
tracting HIV than non-married women.4 Because most cultures
and policies encourage monogamy and commitment in the face
of AIDS, these statistics are shocking. Why are women in South
Africa, and particularly married women, more susceptible to
HIV/AIDS than men? What conditions of South African mar-
riage make women more vulnerable to the effects of this global
pandemic?
Married women in rural South Africa have specific vulner-
abilities to HIV/AIDS as a result of three major factors: migrant
TOLAN | 71
labor, lobola, and gendered economic inequality. These three factors
lead to heightened AIDS vulnerability in two ways: they lower the
agency of women and they increase sexual risk behavior. Women expe-
rience lowered agency in that they have virtually no ability to refuse sex
or demand the use of condoms. They experience increased sexual risk
behavior in that they have higher coital frequency, decreased condom
use, and exposure to partners with higher rates of infection. Although
women are also twice as biologically vulnerable to HIV as men, it is
their lack of power and high-risk behavior that make them most vul-
nerable to HIV infection.5 The danger of this vulnerability lies not
only in its impact on women, but also on the population at large as
women pass the disease onto their children.6 Despite this danger, cur-
rent AIDS prevention policies prove largely ineffective when applied
to married women.a Effective policy must abandon current trends and
put greater resources into female-controlled prevention, specifically,
microbicide.
Up to this point little research has focused specifically on married
women and HIV/AIDS. But one study focusing on marriage and HIV
risk was published in September of 2004 by Shelley Clark, an HIV/
AIDS researcher at the Irving B. Harris Graduate School of Public
Policy Studies. The study looked at adolescent girls and concluded that
married girls aged fifteen to nineteen were 75 percent more likely to
be HIV-positive than sexually-active unmarried girls.b This statistic
illustrates the urgent need for further research on married women and
AIDS.
In the summer of 2004, I spent eight weeks at the Masoyi Home
Based Care Project in Mpumalanga, South Africa. The Masoyi tribal
area is a rural district home to 220,000 black Africans, most of whom
live in extreme poverty. The unemployment rate is nearly 75 percent,
and approximately 32 percent of the adult population—an estimated
132,000 people—are HIV positive.7
During my stay, I interviewed ten women and two men who work
with the Masoyi program. Each of my subjects was either married or in
long-term relationships. Though the interviews did not reveal the HIV
status of my subjects, the common themes that arose from their stories
a
This set of arguments is not exclusive to South Africa. South Africa as a nation shares many
cultural and historical commonalities with neighboring countries, and the majority of my find-
ings apply to regions throughout southern Africa. In this paper I look at some factors specific to
South Africa as well as many broader topics that apply to married women across the region.
b
For a review of past research mentioning married women and HIV see: Clark, Shelley. “Early
Marriage and HIV Risks in Sub-Saharan Africa.” Studies in Family Planning. 35(3) (Sept
2004): 150.
expose this group’s particular vulnerabilities to HIV/AIDS and lead to
a broader discussion of gender, marriage, and disease in South Africa.
T HE F ACTORS OF V ULNERABILITY
The system of migrant labor leads to high sexual risk behavior for wom-
en by increasing their exposure to partners with high rates of infec-
tion.8 The migrant labor system is a consequence of overwhelming un-
employment in rural areas where men seeking jobs are forced to travel
to the mines or cities. Jabulile, Orphan Coordinator of Masoyi Home
Based Care Project, describes the situation: “My husband is working in
Witbank, welding some broken things. He is working in a workshop.
He has been there a long time––he got this job in 1987––when I got
the first child. He comes home month end. He says he’s not enjoying
working there, but because there is no work here, he is working there.”
While men are away from home, it is common for them to have mul-
tiple sexual partners.9 This is a result of the conditions of their work
as well as the cultural acceptance of male infidelity. Workers’ housing
in the mining and urban industries is often unbearable. Men live in
single-sex barracks, often 12 to 16 per room, with little space and no
privacy.10 Studies show that men say they cannot stay celibate while
separated from their wives for such long periods of time.11 Jabulile de-
scribes the norm of separation from her husband, “Since I was married
to him––we didn’t stay together for a long time. He stay for three days
and go––stay for three days and go. If there was work here for him to
work every day and come home, he would stay. But there is none––and
he’s not somebody who is educated so he can find any job.”
The practice of male polygamy is also culturally accepted by most
men and women in South Africa. In a 2003 study conducted by re-
searchers Claudia C. Da Cruz and Bermudes Ribeiro about HIV and
condom use in South Africa, the male participants described having
multiple partners as acceptable and even desirable.12 Of the subjects
interviewed, 59 percent of males had more than one sexual partner, and
22 percent had three or more sexual partners.13 Most of my subjects
were aware of this risk. As Jabulile said, “About sickness––I’m worried
about that. Because I know my husband––he is not someone who is
faithful. Ah, I’m really worried.” Migrant men can be sexually involved
with women at work in several ways: engagement with prostitutes,
short-term casual relationships, and long-term relationships with “sec-
ond wives.”14 The greatest risk comes with prostitution. Commercial
TOLAN | 73
sex industries are rampant in mining and industrial areas. As John C.
Caldwell, John K. Anarfi, and Pat Caldwell put it in a 1997 paper re-
lating migration to risk of HIV/AIDS, “[in] most of Africa it is rural
migrants to the city who are most likely to be found in the slum and
shanty town bars where the commercial sex workers are more likely to
have uncured STDs and are probably more likely to have many dif-
ferent customers and be HIV positive.”15 The culture of poverty and
prostitution leads men to high exposure to STDs and HIV.
In 1993 it was already estimated that nearly half of the minework-
ers returning to rural areas after work were infecting their wives and
other women.16 Since then, AIDS rates in South Africa have skyrock-
eted, and so have the levels of infection of migrant workers. According
to Caldwell et al., “With the exception of [mother to child and infected
blood transmission,] the HIV levels in rural areas may be almost entirely
the result of persistent reinfection brought back from the towns by re-
turning migrants.”17 Because migrant workers generate income, they are
more likely to be able to afford brides and are therefore more likely to be
married.18
Lobola, the custom of paying a bride’s family in exchange for mar-
riage is a lingering element of traditional patriarchy, and further exac-
erbates vulnerability of HIV/AIDS among married women. Lobola, or
“bride price,” is a tradition that dates back to the founding of the Zulu
nation. In the past century, however, it has shifted from traditional sym-
bolism to a commercial practice often paid in cash.19 As the marriage
transaction has grown more commercial, the woman has become more
like the property of the man.20 Today, the payment of lobola is extremely
widespread. Likhapha Mbatha, of the Gender Research Project at the
Centre for Applied Legal Studies (CALS), University of Witwatersrand,
studied women in three South African provinces and found that bride
price had been paid for 98 percent of the wives.21
The tradition of lobola lowers female agency by creating a sense of
male ownership that leaves the wife subject to her husband’s demands.
Author Uli von Kapff writes: “No wife will dare to oppose her husband
as she would be sent home, and her father would have to return most of
the cattle.”22 Though divorce is accepted in South Africa today, a woman
is responsible for repayment of the lobola to her ex-husband. Repayment
is nearly impossible in poor areas; oftentimes, the woman’s family has
already eaten the lobola.23
Lobola gives the husband full rights over his wife’s productive and
reproductive capabilities.24 According to Barbara Klugman, director of
the Women’s Health Project at the University of Witwatersrand, “[if ] a
husband initiates sex, his wife may not refuse him.”25 This standard also
applies to condom use. According to customs of traditional marriage, a
woman may not use contraceptives without the consent of her husband.26
Unfortunately, studies have shown that women have a greater desire for
condom use than their male counterparts.27 For men in South Africa, a
deep stigma surrounds the use of condoms. One subject in Da Cruz and
Ribeiro’s study stated: “My boyfriend says using a condom is like eating
a sweet with the wrapper on it.”28 Because husbands do not like to use
condoms, the women are forced to comply. Jabulile said:
At one time I didn’t want my husband to come to me without a

condom. In that moment he saw that I was cross, so he accept the
condom––he accept it. But as time goes on he say, “I’m tired. I’m
tired––I’ve paid lobola for you––you’re my wife.” And––there was
a fight. In the end––he wins the fight. We don’t use the condom.
At the moment––I’m just afraid––I don’t know my status.
As Jabulile’s story illustrates, lobola can reaffirm male sexual domi-

nance and deny women the right to request condoms. A shocking study
from Zambia found that only 11 percent of women believed they had
the right to ask their husbands to use a condom—even if he had proven
himself to be unfaithful and was HIV-positive.29
In addition to lowering a woman’s agency, lobola also contributes
to HIV risk by increasing the sexual risk behavior of women. The first
example of this is higher coital frequency. A study in Kenya and Zam-
bia found that married girls have unprotected sex much more often and
have been engaged in sexual activity for a longer period of their lives
than have unmarried girls.30 Considering that many partners are HIV
positive, the mere reality of coital frequency is a sexual risk behavior. A
second instance of sexual risk behavior involves condom use. HIV/AIDS
researcher Agathe Latre-Gato Lawson writes: “In rural communities so-
cial control, particularly over the sexual behavior of women, is strong be-
cause women are regarded as childbearers, whose duty it is to perpetuate
the lineage of the husband’s family.”31 With this high emphasis placed
on producing children, Brooke Grundfest Schoepf writes: “[couples] that
have not reached their desired family size will reject condoms, even when
one spouse is HIV positive.”32 This reality compounds the HIV risk for
married women.
A final factor of sexual risk behavior stemming from lobola is the
tendency for women to be ‘bought’ and married by men who are signifi-
cantly older and therefore able to pay. At least two studies have shown
TOLAN | 75
that the age of a woman’s partner is a major risk factor, and that having an
older partner substantially raises HIV rates among adolescent girls.33
Despite the connections between lobola, gender inequality, and AIDS,
a contrasting viewpoint argues that lobola can actually benefit women.
Thanduxolo, a 13-year-old Masoyi girl, told me in an interview that
she did not like men having ownership over their wives. When I asked
her why the community did not end the practice of lobola, however,
her response was strong: “We cannot get rid of lobola! If there was no
lobola, men could just go from wife to wife. Once the man pays lobola he
has given his money so he will stay with that wife. He has paid for her,
so he must stay. Without lobola, men would never stay with one wife.
They could just go.” In this way, the tradition of lobola may actually give
women some social power. Von Kapff writes: “The more cattle paid, the
better the marriage seems to work in the long-term, as the bridegroom
frequently has to save over several years for the lobola and therefore
chooses his bride carefully.”34 For these reasons, many South African
women want to keep the custom alive.
The paradox created by lobola creates an extremely difficult situ-
ation. A policy solution would have to confront the gendered norms
while somehow preserving the positive components of lobola that are
part of African cultural tradition.
The final way that married women are at high risk is through their
economic dependence on men. Rural African women form the major-
ity of the poorest of the poor in South Africa with an average income
of between 400 and 700 rand [$64 to $112] per month.35 In an area
like Masoyi, where the majority of those employed are migrant work-
ers, women are unlikely to find employment. The mining industry, for
example, employs 97 percent men and only 3 percent women.36 Fur-
thermore, while men are away for long periods of time, it is the wom-
an’s duty to stay at home to care for the family. Busisiwe, a preschool
teacher and Masoyi Home Based Care volunteer, speaks of her lack of
money and subsequent reliance on her husband: “I need money. I want
enough money to send my children to school. I get 280 rand [$45] for
volunteering. My husband he is working at Kinrose mine. Do you know
this mine? It is a gold mine. I think he is getting 1000 rand [$160] a
month.”
This economic reality leaves women little agency to stand up to
men in fear of losing financial support. Catherine Albertyn, Director
of CALS, writes: “The prevalence of women seeking sexual relation-
ships to ensure food and shelter for themselves and their families is a
widespread consequence of gendered poverty and inequality in South
Africa.”37 This situation is common for the women of Masoyi. Mumsy,
a childcare worker for Masoyi Home Based Care Project, said:
In my family I was suffering. My husband—he was at Joburg

since March—not coming back. No money to give me to buy
some food. So my children are suffering. My husband is work-
ing at Kinrose mine. Since 1988 until today—it’s a long time.
He is making good money there, but he gives me little money.
He is getting 1200 or 1300 rand [approximately $210] and he is
giving me 400 rand [approximately $66]—is a little money—to
buy some food.
Mumsy’s words present a classic case of a migrant husband who

refuses to give his wife a fair share of income. If Mumsy’s husband does
not want to use condoms, she has little power to demand otherwise.
She said: “My husband doesn’t like the condom. He doesn’t like! So I’m
scared about this. I advise him long time, but he say condom is a plastic.
He doesn’t like, he doesn’t use. I say use a condom, he say no. I don’t know
what I can do.” Ezekiel Kalipeni, Susan Craddock, and Jayati Ghosh
confirm that “[women] are not always in the economic position to say
no to partners who will not assent to using condoms.”38 This is true
regardless of women’s knowledge of HIV risk. The women of Masoyi
were all aware of the risk of AIDS, but they were more concerned with
the immediate necessity of feeding their children. The most common
question surrounding married women and AIDS was the following:
“If it’s a choice between leaving a man to lower the risk of AIDS and
putting food on the table for your children, what would you choose?”39
The answer for most women was simple: stay with your husband, accept
his demands, and pray you do not fall victim to AIDS.
IMPLICATIONS FOR POLICY AND FEMALE-CONTROLLED PREVENTION

In view of the conditions facing women in South Africa, the current
policies addressing HIV/AIDS prevention prove widely ineffective
for married women. Dominant global strategies emphasize increased
education with messages to abstain from sex, stay faithful, or use con-
doms.40 For married women, all of these methods are impractical or
fall beyond their control. Today’s high relative AIDS rates for married
women may in fact be a sign that prevention methods have been ef-
fective for single women. To target the larger population of married
TOLAN | 77
women, however, an innovative solution must bypass the control of the
husband and give the woman agency. The most promising prospect for
female-controlled prevention is the use of microbicide.41
C URRENT P OLICY S HORTCOMINGS

With some variation, prevention programs across southern Africa have
focused on educational outreach and increased condom availability.42
Kalipeni et al. write: “These strategies, while constituting a necessary
first step in AIDS prevention, have proven to be of limited value in
diminishing transmission of HIV in most regions.”43 Education and
greater awareness do not necessarily equal the ability to change risk
behaviors. This certainly holds true for married women. Though the
women I interviewed had a great knowledge of AIDS from their work
in home-based care, they were unable to change the risk behaviors
in their marriages. Kalipeni et al. discuss a National Research Coun-
cil study that found that “[knowledge] of AIDS and its transmission
routes is rarely a predictor of less risky behavior.”44 This is also true for
men. The husbands of the women I interviewed received HIV/AIDS
education at their jobs, but did not choose to change their behavior.
The issue, then, does not come from a lack of knowledge, but from
cultural standards that override that knowledge.
The method of condom distribution has also proven ineffective
for married women. As of 1995, 98 million condoms had been dis-
tributed nationally to all the provinces in South Africa.45 Still, mar-
ried women have little ability to demand the use of condoms from
their husbands. Norms of male dominance and stigma surrounding
condoms are more powerful than condom availability or education to
prevent HIV/AIDS.
A policy that seemed successful in Uganda and that has been ad-
opted by the United States for the Bush Administration’s global AIDS
effort is called the “ABC Strategy.”46 ABC stands for “Abstain, Be
Faithful, Condomize,” and, in that order, the mantra dictates policy for
a majority of AIDS projects. Unfortunately, this policy collapses with
respect to married women. Married women do not have the choice to
abstain from sex, they can be faithful but cannot control their husbands’
behavior, and they cannot demand condoms. Dr. Kathleen Cravero,
deputy director of UNAIDS, believes the ABC method is a good start,
but realizes it is not enough, “We tell women to be faithful to their
partners, but we know that their partners are unfaithful to them,” she
said at a conference at the Woodrow Wilson International Center for
Scholars on November 10, 2004. “We tell women to use condoms, but
we know that their partners will refuse. If we are going to help protect
women, and help them protect themselves, we have to acknowledge
the realities in which they live.”47 The realities for married women
are especially binding. While single women have some potential to
abstain from sex or demand condoms—to employ the education avail-
able to them—married women do not have these options. Because
gender norms will not change rapidly, the best current strategy to de-
crease women’s HIV risk is female-controlled prevention.48
T HE M ICROBICIDE
The most promising method of female-controlled prevention currently
under development is microbicide. A microbicide is a spermicide-like
gel that women can apply before intercourse to protect against HIV
and other STDs.49 This method could revolutionize a woman’s agency
over her HIV risk because she could use the gel without consulting
her partner.50
Today there are approximately 60 candidate microbicides under
development, but none has reached the market.51 This is due to a
severe lack of resources devoted to microbicide research and develop-
ment. Small biopharmaceutical companies, nonprofit organizations,
and smaller public companies are the only groups currently inves-
tigating microbicide products.52 Large pharmaceutical and biotech
companies have not sponsored microbicides because a first generation
product may not be highly profitable. In the short-term, microbicide
funding must therefore come from governments and philanthropic
donors of the public sector.53
The U.S. government currently invests approximately $88.8 million a
year in microbicide research.54 The Rockefeller Foundation estimates that
roughly $775 million over five years is needed to guarantee a successful
product by 2010.55 The three federal agencies with significant research
and development for microbicides are the U.S. Agency for International
Development (USAID), the Center for Disease Control (CDC), and the
National Institute of Health (NIH).56 Though spending on microbicides
in all three agencies has increased in the past five years, it is still less than
two percent of total AIDS spending.57 There is also a problem of coordi-
nation between the agencies, as no official mechanism exists to regulate
overall microbicide research and development.
TOLAN | 79
Certain policy makers have made a bold effort towards microbicide
legislation. In 2001, Representative Connie A. Morella (R-MD) and
Senator Jon S. Corzine (D-NJ) introduced the first Microbicide De-
velopment Acts to Congress.58 On March 8, 2005, Corzine, joined by
Senator Barack Obama (D-IL), Senator Olympia Snowe (R-ME), and
others introduced a revised version of the earlier legislation (S. 550).
The bill, which currently has 19 cosponsors, was referred to the Senate
Committee on Health, Education, Labor and Pensions, but no further
action has occurred.59
The Microbicide Development Act would expand investments
for microbicide research at NIH, CDC, and USAID; expedite the
implementation of the NIH’s five-year strategic plan for microbicide
research; and expand coordination among the three federal agencies.60
The legislation would also establish a Microbicide Research and De-
velopment Branch within the National Institute of Allergy and Infec-
tious Diseases that would be essential to providing appropriate staff
and funding for microbicide development.61 Today the general public
is largely unaware of the existing research on microbicides and the po-
tential they have for HIV prevention.62 People must become familiar
with microbicides so they can pressure the government to pass this
legislation.
A final challenge to the success of the microbicide is effective dis-
tribution. If microbicides are to reach the most vulnerable women, they
must be widely available, affordable, user friendly, and culturally ac-
cepted.63 The Rockefeller Foundation funded a report entitled “Prepar-
ing for Microbicide Access and Use,” which outlined specific priori-
ties such as investment focused on distribution and access; as well as
research and development; an international working group to specify
policy, legal, fiscal, and monetary measures needed for accessibility; and
pilot initiatives between three and five countries to establish a frame-
work for “microbicides preparedness.”64 Resources must be devoted to
a plan for microbicide distribution as well as scientific development.
Despite the obstacles, the potential of a successful microbicide is
tremendous. Conservative estimates suggest that the introduction of
even a partially effective microbicide could result in 2.5 million averted
cases of HIV over three years.65 Further, the estimated cost savings to
governments of developing countries from the introduction of a micro-
bicide are $3.7 billion.66 The microbicide is the single most promising
strategy to combat the gender inequity of AIDS. To assure women’s
empowerment in the fight against HIV/AIDS, microbicides must be
put on the global agenda.
1. UNAIDS / UNICEF / USAIDS Report. Children on the Brink 2002: A Joint Report
on Orphan Estimates and Program Strategies. July 2002.
2. Avert.org Adverting HIV & AIDS http://www.avert.org/safricastats.htm
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http://www.fightglobalaids.org/files/phatfile/New%20AIDS%20Statistics%20from
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4. International Women’s Health Coalition. Women and HIV/AIDS Fact Sheet. http://
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5. Albertyn, C. “Contesting Democracy: HIV/AIDS and the Achievement of Gender
Equality in South Africa.” Feminist Studies 29(3) (Fall 2003), 597. (Women are
said to be two times more likely than men to contract HIV from a single act of
unprotected sex.)
6. Lawson, A. “Women and AIDS in Africa: sociocultural dimensions of the HIV/AIDS
epidemic.” UNESCO, Blackwell Publishers, Oxford and MA, 1999. 393.
7. Masoyi HBC. History of the Organization. www.masoyi.org
8. Sexual Cultures and Migration in the Era of AIDS: Anthropological and Demo-
graphic Perspectives. Ed. Gilbert Herdt. Oxford: Clarendon Press, 1997. 48.
9. Caldwell, J; Anarfi, J; Caldwell, P. “Mobility, Migration, Sex, STDs, and AIDS: An
Essay on Sub-Saharan Africa with Other Parallels.” Sexual Cultures and Migration
in the Era of AIDS: Anthropological and Demographic Perspectives. Ed. Gilbert
Herdt. Oxford: Clarendon Press, 1997. 44.
10. Campbell, C. “Migrancy, Masculine Identities, and AIDS: The Psychosocial Context
of HIV Transmission on the South African Gold Mines.” HIV and AIDS in Africa:
Beyond Epidemiology. Eds. Kalipeni, Ezekiel, Susan Craddock, Joseph R. Oppong,
and Jayati Ghosh. Malden, MA: Blackwell Publishing, 2004. 144.
11. Jochelson, K; Mothibeli, M; Leger, J.P. “Human Immunodeficiency Virus and Mi-
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13. Ibid, 152.
14. Jochelson et al., op. cit, 165.
15. Caldwell et al., op. cit, 45.
16. Kalipeni E; Craddock, S; Ghosh, J. “Mapping the AIDS Pandemic in Eastern and
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Malden, MA: Blackwell Publishing, 2004. 60.
17. Caldwell et al., op. cit, 48. My emphasis.
18. Lobola: Its implications for women’s reproductive rights. Harare, Zimbabwe; Women
and Law in Southern Africa Research Trust: Weaver Press [distributor], 2002.
19. Ibid, 12.
20. Ibid, 28.
TOLAN | 81
21. “South African Wimmin.” The Economist, 341(1986) (5 Oct. 1996): 79.
22. Von Kapff, U. Zulu: “People of Heaven.” South Africa: Holiday Africa Publications,
1997. 37.
23. Discussion with Thanduxolo, home of Florence, August 2004.
24. Women and law in Southern Africa Research Trust, op. cit, 25.
25. Klugman, B. “Sexual Rights in Southern Africa: A Beijing Discourse or a Strategic
Necessity?” Health and Human Rights 4(2) (2000).
26. Women and law in Southern Africa Research Trust, op. cit, 40.
27. Da Cruz, op. cit, 157.
28. Ibid, 139.
29. UNAIDS 2004 Report on “Women and AIDS.” http://www.unaids.org/wad2004/
EPIupdate2004_html_en/Epi04_04_en.htm#P28_3962
30. Clark, op. cit, 154.
31. Lawson, op. cit, 394.
32. Schoepf, B. “AIDS in Africa: Structure, Agency, and Risk.” HIV and AIDS in Africa:
Beyond Epidemiology. Eds. Kalipeni, Ezekiel, Susan Craddock, Joseph R. Oppong,
and Jayati Ghosh. Malden, MA: Blackwell Publishing, 2004. 127.
33. Gregson, S;Nyamukapa, C; Garnett, G; Mason, P; Zhuwau, T; Carael, M; Chandi-
wana, S; Anderson, R. “Sexual mixing patterns and sex differentials in teenage ex-
posure to HIV infection in rural Zimbabwe.” Lancet 359(9,321) (2002): 903. Kelly,
R; Gray, R; Sewankambo, N; Serwadda, D; Wabwire-Mangen, F; Lutalo, T; Wawer,
M. “Age differences in sexual partners and risk of HIV-1 infection in rural Uganda.”
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34. Von Kapff, op. cit, 37.
35. Maharaj, Z. “Gender Inequality and the Economy: Empowering Women in the new
South Africa.” Keynote speech at Professional Women’s League of KwaZuluNatal, 9
Aug. 1999. www.africaaction.org/docs99/gen9908.htm
36. Moleke, P. “The state of the labor market in contemporary South Africa.” State of the
Nation: South Africa 2003-2004. Eds. John Daniel, Adam Habib and Roger South-
all. Cape Town, South Africa: Human Sciences Research Council, 2003.
37. Albertyn, op. cit, 598.
38. Kalipeni et al., op. cit, 65.
39. Participant Observation, Masoyi area, August 2004.
40. UNAIDS 2004 Report on “Women and AIDS” op. cit.
42. Kalipeni et al., op. cit, 65.
43. Ibid.
44. Ibid, 66.
45. Da Cruz, op. cit, 136.
46. Loconte, J. “The White House Initiative to Combat AIDS: Learning from Uganda.”
September 29, 2003. The Heritage Foundation. http://www.heritage.org/Research/
Africa/BG1692.cfm
47. Harter, E. “Women’s Vulnerability to AIDS Key Element in UNAIDS Agenda.”
Washington DC. Allafrica.com/stories/200411160799.html
49. “Microbicides, Women and AIDS.” UNAIDS The Global Coalition on Women and
AIDS.
www.unaids.org/html/pub/una-docs/GCWA_Microbicides_02Feb04_en_pdf/GCW...
51. “About Microbicides.” MAS: Microbicides As an Alternative Solution. http://www.
mas-health.org/microbicides.htm
52. The Body – The Complete HIV/AIDS Resource http://www.thebody.com/aac/bro-
chures/microbicides.html
53. Global Campaign for Microbicides
http://www.global-campaign.org/about_microbicides.htm
54. Senator Corzine, J. “Microbicide Development Act Introductory Statement.” 8
March 2005.
www.amsa.org/legislativecenter/MDA109testimony.doc
55. “Microbicides, Women and AIDS.” Op. cit.
56. Alliance for Microbicide Development http://www.microbicide.org/microbicidein-
fo/legislation.shtml
57. Ibid.
58. Office of Legislative Policy and Analysis: Linking the National Institutes of Health
and Congress
http://olpa.od.nih.gov/legislation/109/pendinglegislation/microbicide.asp
59. Ibid.
60. Senator Corzine, op. cit.
61. Ibid.
62. The Body, op. cit.
63. “Preparing for Microbicide Access and Use” A Report by the Access Working Group
of the Microbicide Initiative funded by the Rockefeller Foundation. http://www.
microbicide.org/microbicideinfo/rockefeller/access.and.use.rockfound.pdf
64. Ibid.
66. International Partnership for Microbicides.
http://www.ipm-microbicides.org/about_microbicides.cfm
67. Ibid.
A BOUT THE A UTHOR

Jenny Tolan graduated from Stanford in June 2005 with a B.A. in In-
ternational Relations and a minor in Spanish. Her academic interests
include African and Latin American Studies, human rights, and in-
ternational development. While at Stanford, Tolan was the founder
of Bursting the Bubble, a group that hosts current events discussion
panels for students living in the “Stanford bubble”; a coordinator of
Ravenswood Reads, a tutoring and mentoring program for youth in
East Palo Alto; and co-president of Students for Kerry. Tolan spent her
junior fall studying abroad in Spain at the University of Sevilla. Tolan is
TOLAN | 83
currently working at Partners for Democratic Change, an international
organization committed to building sustainable local capacity and a
culture of conflict management worldwide.
For correspondence, please email Jenny Tolan at jenny.tolan@gmail.com.
Current Research: International Development
Globalization and
Education:
A Case Study in Papua New Guinea
Hammad Ahmed
Many new sites of corporate growth and economic development

have emerged as a result of political and economic restructuring
under globalization. Such sites are marked by inflows of knowl-
edge and capital from the developed world, and by changes to
infrastructure and institutions, especially educational systems.
Proponents of traditional economic development models often
cite these institutional changes as evidence of a new world in
which capitalism brings prosperity, a world in which multina-
tional corporations lead the charge to modernize undeveloped
sectors of the globe. In reality, the entry of multinational corpo-
rations and extractive industries has different consequences in
different countries. Scholarship has increasingly monitored the
effects of globalization on the developing world; and education,
as an intersection of cultural, economic, and political change, is
an apt lens through which to examine these effects.
Globalization’s influence on education in Papua New Guinea
makes that country an ideal case study. Papua and New Guinea—
formerly colonies under the successive rule of the Netherlands,
Germany, England, and Australia—achieved independence in
1975, merging into modern Papua New Guinea.1
Since achieving independence, the state has depended on aid
grants from Australia. The geographic characteristics of Papua
New Guinea deterred developers throughout the early part of the
20th century, but the discovery of substantial copper and gold in
1968 made multinational corporations eager to begin operations
AHMED | 85
in the country.2 Ever since, the development of infrastructure in Papua
New Guinea—including education—has increasingly been driven by
these multinational corporations.
In this proposal, I will broadly chart the course of scholastic ed-
ucation in Papua New Guinea from the earliest colonial systems to
contemporary models. Beginning with history, I will examine various
colonial rationales for education. I will then discuss contemporary
curricula, focusing on the political privileging of certain knowledge,
linking education in Papua New Guinea to larger forces of corporate
economic growth, and making a preliminary inquiry into the social
and ecological consequences of an educational system that is subser-
vient to globalization. I conclude by recommending that policymak-
ers scrutinize the purpose, implementation and effects of education in
postcolonial settings, and strive to reinvigorate existing systems by fos-
tering healthy political and intellectual communities. Ultimately, our
government should encourage multinational corporations to abdicate
the political agency they are given under globalization, and pressure
them to genuinely empower natives of developing countries to control
their own educational and economic fates.
C OLONIALISM , E DUCATION , AND C ONTROL

In many ways, colonialism and missionary work were the antecedents
of contemporary economic development. Under globalization, how-
ever, the actors have changed from imperial and religious powers to
global corporations. One important difference drawn between cultural
imperialism and globalization is that the latter lacks a center or state-
oriented character.3 But both contemporary and colonial educational
systems ultimately serve a global economy. A more careful look at the
first globalized educational institutions in Papua New Guinea—colo-
nial systems, that is—will clarify just how “modern” the modern ver-
sions are.
At the end of the 19th century, missionaries increased activity in
Papua New Guinea and began operating the country’s first schools. All
the schools were religious in nature; instructors hoped to civilize the
natives through Christianity.4 A major emphasis was put on literacy,
in order to put the Gospel in the hands of the people. The missionaries’
religious goals were not shared by most of the indigenous population.5
By the early 1900s, both colonial administrators and the indigenous
population began to realize the usefulness of education as a form of
power. Some enthusiasts of German colonialism argued that educating
the natives was necessary to make them good assistants and laborers,
which would allow colonists to better exploit indigenous labor.6 Other
colonialists maintained that the natives must become industrious and
could, through education, become self-sufficient. Such were the mo-
tives behind the policies of Sir J.H.P. Murray, a colonial administrator
for 35 years beginning in 1908 who preached the merits of “habits of
industry.”7 Murray suggested that by working for white settlers, black
natives would become stronger and better equipped to help their own
villages. For the natives of Papua and New Guinea, education began to
be seen as a way of acquiring some of the material goods that colonizers
brought with them.8 The schools were seen as an access point to the
colonizers’ power, because manual labor and theft had proven not to be
particularly effective. In the 1960s, transitions from colonial occupation
to postcolonial independence saw the entry of multinational corpora-
tions. This coincided with the reform of education to orient natives for
careers in public service and government and the subsequent stratifica-
tion of native society. At the same time, community-based education
started taking its place as the model of choice.9
Education in Papua New Guinea has served shifting functions,
including “civilizing” native people, creating more productive laborers,
transitioning to agricultural self-sufficiency, and strengthening com-
munity. But, throughout all this, education has predominantly been a
vehicle for natives to get jobs.
With the increase in the number of secular schools relative to mis-
sion schools, villagers acknowledged the potential usefulness of educa-
tion—the “true knowledge” that would bring them the high status jobs
and way of life of Europeans.10 This view of education is decidedly op-
timistic, and some have even compared it to a “cargo cult” in which the
mere imitation of the colonizer brings the material riches of his kind.11
Attitudes like this one, though perhaps naïve, persist today, suggesting
that colonial legacies are still a strong force in Papua New Guinea’s
globalized educational system.
C URRICULUM D ESIGN
Though the education of Papua New Guinea islanders is widely cited
as a prerequisite to economic development, the content of this educa-
tion is highly contested. In many ways, debates over the composition
of school curricula represent one front where the larger debate over
AHMED | 87
economic opportunity and capitalism is staged. Because any school
curriculum will necessarily teach some things and omit others, we
must ask what knowledge is privileged,12 and whether these choices
reflect the forces of globalization.
A common criticism leveled against postcolonial educational sys-
tems cites the “irrelevance” of teaching material—for example, teach-
ing algebra to someone who will most likely be involved in local agri-
culture as an adult. Despite this alleged irrelevance, many parents and
children in Papua New Guinea prize this technical education as a pri-
mary route to employment and social mobility.13 In fact, schools with
rural-biased syllabi, such as Vunamami in 1959, incite the disapproval
of parents. Agriculture, they argue, is something necessarily learned at
home and in the village, while education is something they still have
not received.14
These complaints evince the different understandings of the pur-
pose of education among developers and locals, but they also point
to the disparity between job aspirations and job realities perpetuated
by globalization. As more villagers receive education—as the pool
of potential employees becomes more skilled—employers raise their
standards for hiring. If the primary goal of education in developing
countries is to provide natives with “good” jobs, then competitive la-
bor markets controlled by foreigners work against that goal, attracting
laborers who would otherwise be working in industries like agricul-
ture with the mirage of the colonizers’ wealth. Thus, debates over the
relevance of school curricula reflect the difficulty of implementing a
rural-based curriculum while the society offers higher rewards in the
urban, non-agricultural sector.15
While recognizing that debates over curricula often point to prob-
lems beyond the teaching material, it is important to look at what is
being taught. Curricula differ from school to school, but one wide-
spread model is the Primary and Secondary Teacher Education Proj-
ect (PASTEP), cosponsored by Papua New Guinea Department of
Education, Australian Agency for International Aid, and GRM In-
ternational (a resource and development management company based
in Brisbane).16 PASTEP, a product of global collaboration, consists
of modules which represent “appropriate” subjects for village students:
Agriculture and Resource Science, Community Development, Expres-
sive Arts, Gender Equity, Health, Information Communication Tech-
nology, Language Development, Mathematics, Professional Studies,
Science, Social Science, Special Education, Spiritual and Moral Edu-
cation, Technology, and Vernacular to English Transition Strategies
Training.17 Even at a quick glance, this list embodies all of the afore-
mentioned tensions between rural relevance and global demand. What
is more interesting is the content of some of the modules themselves.
The module on Spiritual and Moral Education, for example, is a
cosmopolitan caricature of the “shrinking world.” Though a small por-
tion is devoted to indigenous religions of Papua New Guinea, most of
the chapter is an outline of other world religions such as Islam, Hindu-
ism, and Christianity.18 This sort of multiculturalism appears more and
more often in texts produced in contemporary globalized systems.19
Such multicultural syllabi deploy a narrow and essentialist discourse
in which particular groups are described in terms of their nationalist
histories, their unique knowledge, and their key figures. Hidden from
view are highly unequal political economies and the oppression of sub-
altern groups and their practices. In such a flattened world, resentment
pops up among students working through representations with which
they do not identify.20 Both perceptions of cultural death and surges
of fierce nationalism become more likely,21 but one can expect nothing
less from such a narrow model of education.
With globalization, economic considerations and political identi-
ties have turned school syllabi into arenas in which sweeping cultural
battles are waged. As the economic and political ties of the world have
changed, so too have the demographics of the educated in Papua New
Guinea. Whether individuals obtain the results they expected when
they began schooling depends as much on the curricula as it does on
the structures of economic globalization.
M ULTINATIONALS AND D EVELOPMENT

Though we sometimes talk of globalization as a set of changes in a
broad structure, emphasis must certainly be placed on the agents that
act upon and within that structure. This is where multinational corpo-
rations and foreign capital investors enter the discussion.
Because Papua New Guinea possesses incredible mineral and nat-
ural resources, it is home to a large number of multinational corpora-
tions and other publicly owned extractive industries. Finding a com-
plete list of these groups is nearly impossible, so I limited my research
to three specific groups: Freeport-McMoRan, Ok Tedi Mining, and
Lihir Gold. Other multinationals in Papua New Guinea certainly do
exist, but their activities are less visible.
These companies see themselves as “community partners” and the
AHMED | 89
bringers of development, but they sometimes bring development in
overtly imperialist ways.a 22 Statistics on their corporate websites boast
their employment figures, donations, and local involvement. These sta-
tistics are classically misleading. For example, Lihir Gold cites the per-
centage of its employees who are natives of Papua New Guinea (53
percent) without stating the absolute number, what sorts of positions
they hold, or what percentage of the local population works for the
company.23 And though the companies trumpet their donations to the
government to increase educational spending, little mention is made
of the huge sums donated by international investors and export credit
agencies to the companies themselves. Lihir received a $250 million
(USD) guarantee of commercial bank finance from Australian Export
Finance Insurance Corporation (interestingly, the U.S. Overseas Pri-
vate Investment Corporation turned down the project on environmen-
tal grounds).24 A $2.8 million corporate charitable donation by Lihir
in 2004 pales in comparison.25
These are all signs that the relationship between the corporations
and the people is a distorted one. In many ways, multinational corpo-
rations obscure their tracks by publicizing their charitable activities,
while failing to acknowledge that their presence owes much to the
prior history of marginalization during the colonial period. At times,
companies even do violence to the historical record. For instance, the
Ok Tedi website claims that “Prior to...1968, people lived off the land
as they had for centuries...with virtually no contact with the outside
world.”26 The absolute erasure of seventy years of colonial domination
is stark evidence that the corporations operate in a world of their own
construction—a world in which primitive, undeveloped, untouched
people desperately desire the coming of modernity.
Corporations, as powerful agents of globalization, have wide-rang-
ing effects on the economy, just as colonial powers did before them.
These effects include a spike in the demand for educated labor, and
therefore a demand for institutions of education. It should come as no
surprise that secondary schools always appear on the map alongside
the operations of multinational corporations.b But when these schools
do appear, an increase in the number of educated indigenous people
does not necessarily translate to a higher proportion with jobs in the
a
Moffett J.B., CEO claimed that Freeport would “thrust a spear of economic development
into the heart of Irian Jaya.”
b
See the websites of the three multinational corporations (http://www.fcx.com; http://www.
oktedi.com; http://lihir.com.pg).
company. Instead, we find more competition for scarce jobs. Education
may bring some workers a higher income—but when the operations
close, the jobs will likely disappear. Ok Tedi will cease operations in
Papua New Guinea in 2012.27 What will be the value of education
then?
S OCIO -E COLOGICAL C ONSEQUENCES

Because education built around global corporate presence severely de-
stabilizes the labor market, it also has an array of social and environ-
mental consequences. Though Papua New Guineans may see education
as the road to a higher standard of living, this view takes for granted
many existing inequalities and barriers. Given that corporations like
Freeport-McMoRan provide comparatively high salaries to the nar-
row set of local people whom they employ, there is strong incentive
for individuals to acquire an education that prepares them to work for
companies like Freeport-McMoRan. But many of these graduates are
simply not hired and are forced to choose between going back to the
village, where they will work off the debt they owe to the financiers of
their education (typically parents and family members), or staying in
the urban centers and finding other means of employment and sur-
vival. Herein lies one of the major sources of urban slums.28 Graduates
who are hired enjoy positions of community leadership and a modern
lifestyle,29 creating a sense of “deserved privilege” that exacerbates so-
cial tensions and centralizes wealth. The presence of global corpora-
tions enables this situation.
Inequalities between rural and urban sectors have environmental
consequences as well. When a sizeable portion of students migrates
to the city, the agricultural work is left to fewer people. This decrease
in labor can increase the dependence of those left behind on farm-
ing technology like pesticide and fertilizer. Fields may be planted with
less diverse and simpler crops, which exhaust the soil,30 and falling
rural incomes may contribute to a desperate environmental degrada-
tion. Furthermore, the often overlooked field of political ecology has
demonstrated that as much as poverty, affluence is a source of environ-
mental destruction.31 The increased burden in the cities and the rising
wealth of the educated class can put extra stress on the environment
as a whole.
Education, like many other national institutions, benefits people
and regions in different manners and to different degrees. Schools
AHMED | 91
in Papua New Guinea exist in a highly unequal distribution. Many
localities simply did not have access to schools until corporations en-
tered their lands, as was the case with Ok Tedi.32 Thus, when a school
is built, the decision of where to place it can determine whether or
not a generation of a village will receive education. This can be an
intensely political moment.
P OLICY R ECOMMENDATIONS
In Papua New Guinea, as in much of the developing world, these poli-
tics must be reemphasized when talking about institutions like educa-
tion. As with the curriculum debate, it is not sufficient to assert that
development problems are the result of economic inefficiencies. The
point is not whether certain subjects are being taught too much or not
enough. More important to a discussion of development is the location
of political power—who decides where schools are placed and what is
taught.33 Under the present system, this political power rests squarely
with multinational corporations. The local people who live with these
corporations in their backyards are robbed of this power, and thus face
choices under globalization that are little better than the choices they
faced under colonialism.
Although education can benefit some members of developing
communities, it should not be seen as the primary development solu-
tion for poor countries. With increasing money being spent on insti-
tutional education in postcolonial settings, we must critically examine
the purpose of this education, how it is implemented, and what its
consequences are.
For educational policymakers, there are several immediate steps
to be taken. If anything is to be taught, reading should be the prior-
ity. Estimates from 2002 show that only 64.6 percent of Papua New
Guinea’s population is literate (71.1 percent of males and 57.7 percent
of females).34 Without access to written communication, people do
not have access to the instruments of widely organized politics. Both
inside and outside the classroom, engagement with the curricula should
be encouraged, as disagreement can be quite constructive in fostering
intellectual and political community. Educational exchanges between
Papua New Guinea and countries like Australia, New Zealand, the
United States, and the European nations should be used to reinvigo-
rate the schooling experience for all children. Policymakers should also
encourage a more complicated and democratic representation of the
world than is currently available in the curricula.
In addition to working with the global community to push for
each of these reforms, our government should consider requiring U.S.-
based multinational corporations to reserve high-level positions for
locals. More than just submitting annual sustainable development re-
ports, these companies must prioritize the needs of their native hosts.
Ultimately, the control of resources should be in the hands of the
people most closely affected by their extraction. Moving forward will
mean putting political power back in the hands of the people whose
lives and livelihoods are at stake.
1. Swatridge, C. Delivering the Goods: Education as Cargo in Papua New Guinea. Manchester
University Press, 1985. 12.
2. Pintz, S. “Education and Cultural Transition in Papua New Guinea.” Occasional Papers in
Social Foundations of Education (7) (March 1985): 4.
3. Burbules; Torres. “Globalization and Education: Critical Perspectives”. Social Theory, Educa-
tion, and Cultural Change. Routledge, 2000. 208.
4. Smith, P. Education and Colonial Control in Papua New Guinea: A Documentary History.
Longman Cheshire Printery, 1987. 2.
5. Smith, G. “Education in Papua New Guinea.” The Second Century in Australian Education
no. 11. Melbourne University Press, 1975.
6. Smith, P. 30.
7. Smith, P. 61.
8. Swatridge, C. 13.
9. Pintz, S.:18.
10. Smith, P. 245.
11. Swatridge, C. 4.
12. Burbules; Torres. 243
13. Smith, G. 42.
14. Ibid. 46.
15. Ibid 52.
16. GRM – Leading Resources and Development Management Company http://www.grm.
com.au/
17. “Pastep Curriculum Materials.” Teacher Education in Papua New Guinea. http://www.
PNGteachereducation.com/pastep/curriculummaterials.php
18. “Social and Spiritual Development Strand: Spiritual and Moral Education.” Teacher Edu-
cation in Papua New Guinea. http://www.PNGteachereducation.com/filestore/sme1.2sp
iritualityinmelanesia.pdf
19. Burbules; Torres. 188.
20. Ibid 193.
21. Smith, G. 268.
22. Freeport in Indonesia: Mining the Earth in the face of ecological devastation and human
rights violations. A Project Underground Fact-Sheet. Berkeley, CA. (course website).
AHMED | 93
23. “2003 Report to the Community, Part 1.” Lihir Gold Limited. http://www.lihir.com.pg/
community/2004/comrep2003_part1.pdf
24. “Australian Firms Plunder Papua New Guinea.” Mines and Communities. http://www.
minesandcommunities.org/Country/png3.htm
25. “2003 Report to the Community, Part 2.” Lihir Gold Limited. http://www.lihir.com.pg/
community/2004/comrep2003_part2.pdf
26. “Community.” Ok Tedi Mining Limited. http://www.oktedi.com/community/community.
php
27. Ok Tedi Mining Limited. http://www.oktedi.com
28. Smith, P. 263.
29. Ibid 261.
30. Watts; Peet. “Liberating Political Ecology.” Liberation Ecologies: Environment, Develop-
ment, Social Movements. London: Routledge, 2004. 27.
31. Ibid 32.
32. Pintz, S: 12.
33. Smith, G. 51.
34. “Field Listings - Literacy.” CIA World Factbook. June 2005. http://www.cia.gov/cia/publi-
cations/factbook/fields/2103.html
A BOUT THE A UTHOR

Hammad Ahmed is a rising junior at Stanford University majoring in
International Relations and hoping to minor in Cultural and Social
Anthropology. Originally from Pakistan, he is interested in the cul-
tural politics of globalization, the environment, and social movements.
Ahmed has worked with CARE, the Immigration and Refugee Servic-
es of America, and the Stanford LGBT Community Resources Center.
Since 2002, he has been an affiliate of the Telluride Association. His
future plans are uncertain, but law and academia are possibilities.
For correspondence, please email Hammad Ahmed at hammad@stanford.edu.
Surveys: Policy and Social Perspectives from
Community, Political, and Corporate Leaders
Three Models of
Corporate Social
Responsibility:
Implications for Public Policy
Elizabeth Redman
Less than a year ago in The Miami Herald, Henry Miller wrote,
“Businesses do not have social responsibilities; only people do.”1
The Economist also recently offered a skeptical view of corporate
benevolence; the feature article in the January 22, 2005 issue criti-
cizes companies contributing to the tsunami relief effort for spend-
ing “other people’s money” and concludes, “All things considered,
there is much to be said for leaving social and economic policy to
governments.”2 The rejection of a “social conscience of business”
is nothing new; in fact, the sentiment dates back to at least 1970
when Milton Friedman declared, “There is one and only one so-
cial responsibility of business—to use its resources and engage in
activities designed to increase its profits.” But what happens when
governments fail in the arena of social and economic policy? And
where do companies who believe in the philosophy of “doing well
by doing good” fit into the picture?
While groups like Business for Social Responsibility (BSR)
tirelessly promote the value added from socially responsible behav-
ior, scholars and practitioners debate whether increasing expendi-
tures on social or environmental obligations can boost the bottom
line. For example, while Michael Porter and Class van der Linde
REDMAN | 95
believe that strict environmental regulations can stimulate innovation
and enhance competitiveness, others dismiss the possibility of “virtually
costless environmental regulation” and argue that increasing the strin-
gency of environmental laws necessarily results in reduced profits for the
firm.”3
The ongoing philosophical debate and contradictory anecdotal evi-
dence require explanations for the varying relationships between social
responsibility and profit that could have profound impacts on the struc-
ture of government policies toward corporate social responsibility (CSR).
As thousands of CEOs worldwide make substantial investments in their
workforces, their communities, and the environment, it is important that
we understand the perceptions that executives have of the relationship
between their firms’ social and financial goals. Interviews with corporate
executives and case studies reveal three models of thinking about CSR,
though firm decisions are often based on some combination of the mod-
els. While these models do not offer one “right” way to conceptualize
CSR, they do provide a framework for considerations about public policy
and the future of socially responsible business behavior. The three models
offer policymakers a more effective way of organizing thinking about the
often elusive and multifaceted concept of CSR.
M ODEL O NE : T HE T RADITIONAL C ONFLICT

In the traditional neoclassical model, tradeoffs between social and en-
vironmental goals and profits are inevitable. Since firms only consider
private marginal costs when making production decisions, firms overpro-
duce products or services, and operate at less than the socially optimum
market equilibrium when social costs exceed firms’ private costs. These
decisions create negative externalities and require government policies
or other market-correcting interventions to restore the socially optimal
equilibrium.
Consistent with Friedman’s views, private expenditures on envi-
ronmental or social objectives represent dollars stolen from either em-
ployees or stockholders. More stringent environmental protections limit
firms’ ability to use “free” receptacles—such as rivers, open land, and the
air—for their production waste. Many companies rely on a strategy of
“built-in obsolescence,” thereby increasing production inefficiencies (e.g.
pollution) and adding to the growing piles of junk in landfills. As The
Economist points out, donations of time or money to natural disaster vic-
tims or impoverished communities represent dollars stolen from equity
owners. Firms with this mindset consider only short-run private costs and
benefits, leading them to overproduce public bads and undervalue socially
beneficial decisions.
The view of social responsibility and profits as mutually exclusive
objectives has been well documented. In Cradle to Cradle, McDonough
and Braungart define the longstanding problem: “We are accustomed to
thinking of industry and the environment as being at odds with each oth-
er, because conventional methods of extraction, manufacture, and disposal
are destructive to the natural world. Environmentalists often characterize
business as bad and industry itself (and the growth it demands) as inevita-
bly destructive. On the other hand, industrialists often view environmen-
talism as an obstacle to production and growth.... It appears these two
systems cannot thrive in the same world.”4
Indigo Teiwes, Research Analyst for the Portland-based socially
responsible investment fund Portfolio 21, believes a majority of today’s
firms follow this ideology.5 She cites the example of Scottish and South-
ern Energy, a firm she initially considered a great potential investment.
Seeking to diversify its mix of generation plants to increase capacity and
boost earnings, the company made a strategic business decision to buy
two coal-fired power stations in July 2004.6 The acquisition of the coal
plants, which represent two of the United Kingdom’s top four worst coal-
fired stations with respect to greenhouse gas emissions,7 represents a clear
conflict between financial gains and environmental integrity.
When business externalities create social and environmental prob-
lems, traditional market-correction policies may be necessary. In Cor-
porate Responsibility in the Global Village: The Role of Public Policy, Susan
Ariel Aaronson and James T. Reeves explain, “Although market forces
are increasingly pressing companies to act responsibly, markets have not
succeeded in prodding corporations to ‘do the right thing’ everywhere
they operate. To some degree, public policies to promote CSR arise from
market failures.”8 To encourage socially responsible behavior the govern-
ment should give tax breaks or rebates to companies that meet certain
requirements, give out awards or recognition for good behavior, and the
development of social or eco-labels that companies can obtain by meet-
ing relevant standards. Legislation to encourage particular components
of corporate responsibility can take many forms, from minimum-wage
laws to command-and-control strategies to reduce pollution. While Dan
Bross, Microsoft’s Director of Community Outreach, believes competi-
tion brings about better results than government regulation and claims
that “firms bristle at more government mandates,”9 other companies,
such as the energy provider PacifiCorp, prefer the clear messages and
REDMAN | 97
straightforward detail that mandatory requirements provide.10 Regard-
less of whether governments impose harsher regulations or create more
incentives to spur voluntary business programs to solve social and envi-
ronmental problems, outside forces are necessary to restore the socially
optimal market equilibrium when firms view other societal goals as an
impediment to profit-seeking.
M ODEL T WO : C ORPORATE S OCIAL R ESPONSIBILITY

B RINGS IN THE C ASH
While the traditional view of conflict between industrial and social goals
is far from obsolete, many companies are redefining the relationship be-
tween financial, social, and environmental performance. Executives from
these companies view environmental integrity and healthy communities
as means to achieve greater profits. Model two represents the ideology of
the majority of companies that make it into socially responsible invest-
ment (SRI) portfolios.
These companies choose to be socially responsible for a variety of
profit-oriented reasons: increased sales, greater innovation, decreased
production inefficiencies, decreased future risks, and greater access to
capital. Many indicators suggest that 21st century businesses view social
and environmental excellence as strategic business tools: from 1995 to
2003, assets put into in social investments grew 40 percent faster than all
professionally managed investment assets in the United States.11 In re-
sponse, companies are developing CSR departments, rewriting their mis-
sion statements to include ethical goals, and developing codes of conduct
that extend to employees and contractors worldwide, to the point that by
the end of 2003, more than 2,000 companies had issued CSR reports.12
While publicly held companies are still slaves to the numbers on their
quarterly SEC filings, many have found ways to turn social responsibility
into economic success.
One major reason CSR is on the rise is that executives believe it can
help them attract new customers or boost sales. Whether they use CSR
as a strategic marketing tool to capture a niche market or believe their
good works will be recognized and rewarded later, CEOs often cite repu-
tation as their most valuable intangible asset.13 Kara Hartnett of BSR
explains, “Brand differentiation is important for known companies. Social
responsibility can set them apart.”14 Companies with direct consumer
interaction want a reputation for good corporate citizenship, though their
definitions of citizenship vary. US Bank tracks the number of Community
Reinvestment Act (CRA) accounts opened and tries to quantify gains
from investing in disenfranchised segments of the population. While US
Bank does not specifically market its community outreach, executive Lin-
da Wright asserts that, “when you give back to the community, it comes
back to you. Accounts have been opened with US Bank because of the
respect people have for the company.”15 At Microsoft, where CSR is “all
about the bottom line,” the company places emphasis on achieving the
greatest market share possible and becoming a market leader.16 Real-
izing the number of potential Xbox customers concerned about labor and
environmental issues, Microsoft decided to push compliance with vendor
codes and reexamine the environmental rules of the countries where their
manufacturers are located.
In addition to helping businesses that sell directly to consumers, CSR
can also increase demand for business-to-business transactions. While
Levi’s has found that vendors are resistant to embrace its codes of con-
duct, the demand from purchasers for safe, healthy, and compliant facto-
ries has created a new marketing strategy for many offshore production
sites. According to Levi’s executive Suzanne Beck, many factories now
tout their “Levi’s certification” to attract contracts with other big name
purchasers.17
CSR programs also build connections within the community. Dun-
can Wyse, President of the Oregon Business Council, explains, “A lot of
business is connections. Companies are not islands, they are not isolated
from the world; their business depends on their engagement in networks.
When a company strengthens its relationship with the community, this is
part of its mission.”18 In “The Business Case for Corporate Citizenship,”
Arthur D. Little elaborates, “The perceptions that stakeholders have of
a company’s corporate citizenship performance can significantly affect
the business’s license to operate. Companies with a poor reputation in
this area can find themselves continually responding to criticism of their
approach to a whole range of environmental and social issues.”19 Com-
munity involvement and activism help companies garner the good will of
politicians and regulators in ways that may help the business later.
Model two businesses believe that by enhancing their reputation,
they also bolster recruitment and retention of quality employees. Numer-
ous psychological studies have found that job satisfaction correlates with
greater commitment to a company and greater business success. A 2004
survey reveals that more than three-fourths of MBA graduates would
forgo financial benefits to work for an organization with a better reputa-
tion CSR and ethics.20 In fact, the business case between CSR and hu-
man resources is often so clear that many companies fail to acknowledge
REDMAN | 99
excellent treatment of employees as a social responsibility. When asked
about the company’s high wages and presence at community events, the
Human Resources Director of fast-food chain, In-N-Out, remarked:
Efficiency wages are self-serving. Our store managers may make

100 to 120 percent over industry norms, but the money spent on
salaries is seen as an investment. Our wages not only broaden the
applicant pool from which we can choose employees, but increase
performance levels and retention rates.... Although you can never
know for sure why people stay with a company, I certainly believe
it may influence why people like their job here.21
Resources devoted to employees also contribute to health and pro-

ductivity. The International Labour Organization (ILO) estimates that
“on the job accidents and illnesses annually take some two million lives
and cost the global economy an estimated 1.25 trillion, or four percent of
annual global GDP.”22 Overall, fewer accidents and sickness translate to
more productive employees.
Furthermore, studies have shown that corporate community service
programs, common at many companies touting their social responsibil-
ity, can help spur financially valuable innovation by “developing a variety
of competencies, including teamwork, planning and implementation,
communication, project management, listening skills, and customer
focus.”23 And while NGOs and watchdog groups may in some cases
be out to fight the “rise of the corporation,” in others, they collaborate
with companies to provide new sources of information or strategies for
management.
Risk avoidance is another area where NGOs can be useful to busi-
nesses, and an additional reason why many company executives believe
CSR can improve financial performance. In Conversations with Disbe-
lievers, Simon Zadek writes:
Advocates advance two primary arguments for how CE [Corpo-

rate Engagement] can help a company manage its risks. The first
claim is that engaging in CE can help avoid harms associated
with socially irresponsible or illegal behavior perpetrated by em-
ployees, and to mitigate the harms to the corporation created by
accidents or mistakes.... The second, more complex claim, is that
engaging in increased CE will help companies better understand
and manage risks that come from new and unfamiliar sources.24
GAP, Starbucks, Patagonia, and Adidas are just a few companies
whose partnerships with NGOs help them acquire knowledge about
production sites, working conditions, environmental damages, and other
core components of their business.
Early strategic investments in CSR can improve product and ser-
vice quality, defray future lawsuits, and prevent or at least mitigate the
effects of negative media coverage. Sourcing guidelines and ethical codes
help companies avoid the future costs of shoddy workmanship, unreli-
able business relationships, financial mismanagement, and disruptions
of operations by improving the quality of products and services. At Oc-
cidental Petroleum, community involvement and their environmental
precautions have everything to do with risk avoidance. Vice President
of Communications and Public Affairs, Lawrence Meriage, explains:
In the indigenous communities where we operate in Ecuador,

we have a long-standing relationship with the people. Having
them look at us as friends, instead of enemies, means our opera-
tions will not be disrupted and we will be able to negotiate new
agreements later on. Building these relationships helps us avoid
protests, strikes, or other disruptions such as people blocking
roads.”25
After unveiling plans to build pipelines through land belonging to

the U’wa community in Colombia, Meriage spent time responding to
over 40,000 protestors’ postcards and letters. The negative publicity led
to a “time sink” for the company and has forced them to take fiscal and
moral obligations into account when making company decisions about
where to operate.26 Now, before entering into new contracts, Occiden-
tal asks a series of questions about many types of risks, ranging from
geological to political. If any of these outweigh the potential rewards,
Occidental may choose not to operate even if the deal appears profitable
in the short run.
Being the first company to act in an area of CSR can also create a
competitive advantage by helping the company anticipate future legis-
lation. Sidney Espinosa of Hewlett Packard (HP) explains, “It is im-
portant for a company to identify policy issues that are hot and take
a stance/find a position before laws are passed.”27 In an interview in
2003, Espinosa discussed how the company was already addressing the
issues of product take-backs and computer recycling through its own
private recycling program and by pushing for national legislation that
the company could reasonably accommodate. New directives requiring
REDMAN | 101
manufacturers to take back and recycle electrical products show that
HP correctly predicted the trend, and the company will no doubt have
an easier time dealing with the new rules than will its less forward-
thinking competitors. PacifiCorp uses a similar strategy: the company
continues to increase its use of renewables while simultaneously pushing
government policies that give incentives for using wind power and man-
date renewable portfolio standards.28 By accurately anticipating future
policy trends and responding with the appropriate social or environ-
mental programs, companies believe they can become market leaders.
Finally, many model two companies may view CSR as a way to
increase their access to capital. As early as 1971, the development of
(SRI) funds created a new market for capital. From “green funds” which
focus on environmentally beneficial practices, to investors who push for
living wages at Responsible Wealth, SRI funds use a variety of strat-
egies to select companies that are qualified under their definition of
“socially responsible.” As would be expected, these targeted investments
have convinced some companies to adopt CSR practices—Portfolio 21’s
Teiwes recalls a few cases where companies initially rejected from the
investment fund reapplied after adopting more environmentally friendly
policies—and while most companies have not developed CSR programs
or reevaluated their business strategy solely to attract SRI capital, it is
certainly another incentive for good works.
As companies make strategic ventures into the social and environ-
mental arena, little government involvement seems necessary to promote
business considerations of more than just profit margins and investors’
pocketbooks. However, business involvement in social and environmen-
tal affairs alone is not a recipe for success and does not guarantee that all
stakeholder groups will be considered fairly. In model two cases, rather
than promoting general CSR, public policy should focus on increasing
transparency about companies’ CSR practices by encouraging compa-
rable, comprehensive reporting standards or disclosure laws, and fos-
tering collaborations between businesses, governments, and NGOs to
tackle specific issues. Though debate continues over the effectiveness of
mandatory CSR reporting (often called “triple bottom line reporting”)
due to costs and the risk of stifling creativity and leading to “lowest
common denominator” practices,29 there is something to be said for
greater transparency about companies’ social and environmental inter-
ventions. Reporting can be an effective tool for companies to reevaluate
their programs in a number of areas, as well as a way for outsiders to
monitor their progress. Further, while groups like BSR in the United
States foster communication and collaboration between business and
NGOs, and while many companies have strategically aligned with non-
profits or charities to work on particular issue areas, governments could
play a greater role in the development of such partnerships by offering
funding and education, and by showing an active interest in promoting
the dialogue between organizations and sectors with different ways of
thinking.
M ODEL T HREE : M ULTIPLE F IRM G OALS , A LL C REATED E QUAL

Though model two companies predominate among SRI portfolios, Teiwes
believes it is model three businesses that we should really strive to encourage.
Model three explains the ideology of firms that have made commitments
to environmental and social goals without evidence that corporate citizen-
ship leads to tangible financial gains. The owners or managers have decided
that social and environmental achievements are independently worthy of
attainment and should be pursued with equal enthusiasm to profits. Wyse
explains, “A large part of CSR is the individuals involved in senior ranks.
CEOs like to be involved in policy and service; it helps them to lead a ful-
filling life. Just like others, executives feel good about giving back to their
community and consider it part of their responsibility as a professional.”30
While uncommon in a society that measures success by GDP per cap-
ita or by the amount of economic activity generated regardless of its source
or deleterious effects, there are companies who view their business in terms
of its social and environmental contributions. Generally privately run by
social entrepreneurs, philanthropists or environmentalists, these companies
often have CEOs or owners with deep personal convictions. Their compa-
nies make profits but financial goals do not trump social or environmental
considerations.
This ideology functions on the idea that businesses, like people, have
moral obligations and responsibilities that extend beyond the financial
world. Adidas’s Social and Environmental Affairs Manager, Gregg Nebel,
scoffs at the idea of using CSR is as a marketing strategy. He explains,
“Why market what you are doing if you are simply doing what is right?
The feeling here is that there is an expectation that a company will do the
right thing, and there is no reason to advertise that we are fulfilling this
obligation.”
Newman’s Own is one example of a company with a social purpose.
Owner Paul Newman donates all of the company’s profits and royalties
after taxes to educational and charitable causes, ensuring that the company
will only increase profit margins to increase the firm’s ability to contribute
REDMAN | 103
to social welfare. Lighting fixture manufacturer Rejuvenation and forest
products provider Collins Companies also exemplify businesses with deep-
rooted commitments to the environment and their community. While each
of these companies runs a business with traditional financial goals, they
do not view their commitment to sustainable environmental practices as a
strategy for business, but rather as an important end in and of itself.
However, the degree to which such socially oriented firms can succeed
is unclear. Although BSR reports that a “2001 Hill & Knowlton/Harris
Interactive poll showed that 79 percent of Americans take corporate citi-
zenship into account when deciding whether to buy a particular company’s
product [and] 36 percent consider corporate citizenship an important fac-
tor when making purchasing decisions,”31 the evidence often is not there to
support this, in either their buying patterns or shareholder votes. There are
consumers willing to pay higher prices for peace of mind over the produc-
tion methods of the goods they buy, but their limited numbers create niche
markets for socially responsible brands rather than pushing the business
community to evaluate the triple bottom line in all scenarios or markets.
To encourage companies to follow model three, policymakers should
reconsider current indexes for business success, accounting practices, and
the valuation of intangible assets. Model-three thinking requires more
than teaching business owners and managers how to be responsible corpo-
rate citizens; it requires transforming average citizens’ understanding about
value creation and expanding definitions of success to include social and
environmental triumphs.
Tools to place dollar values on intangibles like these social and en-
vironmental triumphs are already underway. By working within the old
framework, many hope to quantify the financial returns on intangible
investments and to translate intangible successes into tangible results.32
Some organizations, such as the New Economics Foundation (NEF) in
London offer even more radical approaches to measuring firm success.
Challenging the traditional national accounts of material wealth—GDP or
GNP—NEF created the Index of Sustainable Economic Welfare (ISEW)
which measures well-being by factoring in “goods” which are not captured
by GNP (e.g. household labor), and deducting “bads” such as long-term en-
vironmental damage and the costs of crime.33 Policies to promote socially
responsible behavior from a model-three perspective need to encourage
further research, education, and discussions of societal value creation.
M ERGING THE M ODELS
Though executives often structure their thinking around one of the
three models, businesses have many top executives, each with differ-
ent feelings about the interaction between profits and CSR. To avoid
giving off contradictory messages, they present themselves as a com-
bination of the three models. The fact that Patagonia’s founder, Yvon
Chouinard is famous for saying, “Every time I’ve done the right thing
for the environment, I’ve made a profit”34 makes Patagonia appear to
be the perfect example of a model-two business. Yet Patagonia’s Social
Audit Coordinator, Huntley Dornan, believes that Chouinard and his
wife are so committed to their principles that they would probably be
more likely to let the company go bankrupt than change the company’s
core values, and maintains that in reality, the firm’s decisions reflect of a
combination of models two and three.35 Though Qualcomm’s invest-
ments in the community are strategic, Vice President Dan Sullivan
adds, “You make investments in your community because you live in
it. Employees live in the area, they go to the library, they breathe the
air. A good company knows it needs to do more than time and motion
studies.”36
Even with these blurred distinctions, the three models provide a
useful framework for developing appropriate policies toward CSR. In
all cases, government can play a proactive role in supporting policies
promoting an awareness and emphasis on sustainable development.
The European Commission has taken steps to learn more about the
“knowledge economy and the importance of intangibles as competi-
tiveness factors,” study the links between intangible investments and
performance across companies and sectors, outline strategies for future
financial reporting in Europe, and hold forums to discuss intangible
assets as well as methods and practices of measuring and reporting.37
Efforts like that of the European Commission further the discussion
of CSR without assuming that all companies embrace CSR in the
same way.
M OVING F ORWARD
While the field of CSR and public comprehension of its significance have
expanded tremendously in the last decade, the broad range of motivations,
programs, and policy suggestions suggest that there is no one solution that
will encourage sustainable business practices among all U.S. companies.
REDMAN | 105
There will always be companies that see any government policy as more
“red tape” and to whom CSR will just be window dressing. And there
always will be companies that follow ethical standards and consider the
social consequences of their actions, not because consumers demand it
or government encourages it, but because someone in the business be-
lieves it is the right thing to do. But there are also many middle-ground
companies that are trying to decide not only how far their social and en-
vironmental commitments should extend, but also how to conceptualize
the interaction between their social, environmental, and financial perfor-
mance. Given the pressure placed on companies by various stakeholder
groups and the many groups trying to define socially responsible behavior,
it is no surprise the debate continues over the existence of “true CSR.”
The three models presented here simplify the discussion in a way that
makes it possible to identify the interactions among social, environmental,
and financial goals across a variety of situations: a necessary first step in
paving the way for a discussion about how to proceed. Plans to promote
CSR—and thus sustainable economic development—must be tailored to
fit the prevailing business models for CSR. Trying to encourage CSR
without first understanding the motivations for corporate citizenship is
a lot like trying to design a building before you know what the ground is
made of. Using the three models, we can come to a better understanding
of the surface we have to build on.
1. Miller, H. “Businesses don’t have social responsibilities; people do.” The Miami Her-
ald 21 July 2004.
2. “The Good Company.” The Economist. 22-28 Jan. 2005: 11.
3. Porter, M; van der Linde, C. “Toward a New Conception of the Environment-Com-
petitiveness Relationship.” & Palmer, K, Oates, W; Portney, P. “Tightening En-
vironmental Standards: The Benefit-Cost or the No-Cost Paradigm?” Journal of
Economic Perspectives 9(4) (Fall 1995).
4. Braungart, M; McDonough, W. Cradle to Cradle. New York: North Point Press,
2002.
5. Teiwes, I. Portfolio 21 Research Analyst. Personal Interview. 21 Jan. 2005.
6. “Scottish and Southern buys AEP’s UK power plants.” Reuters, 30 July 2004. http://
www.planetark.com/dailynewsstory.cfm/newsid/26375/newsDate/3-Aug-2004/
story.htm
7. “UK’s worst climate polluters named” Friends of the Earth, 10 Aug. 2003 http://www.
foe-scotland.org.uk/press/pr20030803.html
8. Aaronson, S; Reeves, J. Corporate Responsibility in the Global Village: The Role of
Public Policy. Washington, DC: National Policy Association, 2002.
9. Bross, D. Director, Community Outreach, US Legal-Community Affairs. Microsoft
Corporation. Personal Interview. 23 June 2003.
10. Singh, V. PacifiCorp. Telephone Interview. 25 March 2004.
11. Social Investment Forum. “2003 Report on Socially Responsible Investing Trends
in the United States.” December 2003. http://www.socialinvest.org/areas/research/
trends/SRI_Trends_Report_2003.pdf
12. The Center for Corporate Citizenship at Boston College http://www.onphilanthro-
py.com/tren_comm/tc2003-12-31a.html
13. Aaronson; Reeves.
14. Hartnett. K. Senior Manager, Business for Social Responsibility. Personal Interview.
June 2003.
15. Wright, L. Vice President, Community Relations. US Bank. Personal Interview.
25 June 2003.
16. Bross, D.
17. Beck, S. Manager, Worldwide Government Affairs & Public Policy. Levi-Strauss &
Co. Personal Interview. 17 June 2003.
18. Wyse, D. President. Oregon Business Council. Personal Interview. June 2003.
19. Little, A. “The Business Case for Corporate Citizenship.” Distributed at the World
Economic Forum Annual Meeting. 31 Jan.- 4 Feb. 2002.
20. Roner, L. “MBA graduates want jobs with ethical companies.” Ethical Corporation
Online. 2 Aug. 2004.
21. Iriart, K. Vice President of Human Resources. In-N-Out Burger. July 2003.
22. International Labour Organization. “ILO: Work hazards kill millions, cost billions.”
World of Work Magazine. ILO Online, 23 May 2003.
23. “Overview of Business and the Community.” www.bsr.org
24. Zadek, S. Conversations with Disbelievers. The Ford Foundation, 2000.
25. Meriage, L. Vice President of Communications and Public Affairs, Occidental Pe-
troleum. Personal Interview. July 2003.
26. Meriage, Larry. July 2003.
27. Espinosa, S. Manager of Public Affairs, Hewlett-Packard Company. Personal Inter-
view. 30 June 2003.
28. Edmonds, B. Director, Environmental Policy, Pacificorp. Personal Interview. 24 June
2003.
29. Beck, S. Manager, Worldwide Government Affairs & Public Policy. Levi-Strauss &
Co. Personal Interview. 17 June 2003. & “Is it time to make CSR reporting com-
pulsory?” EU Business, 2003. www.eubusiness.com
30. Wyse, D.
31. “Overview of Corporate Social Responsibility.” Issue Briefs. Business for Social
Responsibility. www.bsr.org
32. Keen, J. “Don’t Ignore the Intangibles; Even benefits that are hard to quantify can
be an important part of a successful business case.” CIO 16(22). Framingham: 1
Sept. 2003.
33. “nef ’s well-being programme.” New Economics Foundation, http://www.neweco-
nomics.org/gen/well-being_current.aspx
34. http://www.onepercentfortheplanet.org/whyjoin.htm
35. Dornan, H. Social Audit Coordinator, Patagonia. Personal Interview. 11 July
2003.
REDMAN | 107
36. Sullivan, D. Executive Vice President, Human Resources. Personal Interview. July,
2003.
37. “European Commission Work on Intangible Assets” http://www.ll-a.fr/intangibles/
ec_work.htm
A BOUT THE A UTHOR
Elizabeth Redman graduated summa cum laude from Pomona College

with a B.A. in Public Policy Analysis and Economics. The recipient of two
undergraduate research grants, Redman spent a year traveling nationally
and internationally to interview business leaders and policymakers about
their views on corporate social responsibility. Her research findings were
compiled in May 2004 in her senior thesis, The Motivations for Corporate
Social Responsibility and the Role of Public Policy in the U.S. Redman’s un-
derstanding of the complex linkages among firms’ social, environmental,
and financial goals led to her selection as a Business Today scholar for the
2003 International Business Conference on the Social Conscience of Busi-
ness, and to scholastic awards from both the Economics and Public Policy
Analysis departments at Pomona College. In 2006, Redman will study the
dynamics of corporate citizenship in Latin America as an Ambassador of
Goodwill for Rotary International. She is currently working in Portland,
Oregon as a policy analyst for the Oregon Business Council and as the
director of the Youth Caucus for the Oregon Bus Project.
For correspondence, please email Elizabeth Redman at liz@busproject.org.
Looking Ahead: Progressive Thinking on Tomorrow’s Issues
Genomic Justice:
Genetic Testing and Health Insurance
in America
Dov Fox
We have long known that all people are not created equal, biologically
speaking. However, new knowledge about which people are bound by
the genetic burdens of ill health threatens to undermine the assumptions
underlying the institution of health insurance. Now that the Human
Genome Project has made it possible to discover previously concealed
hereditary inequalities, how should we, as a society, respond to dispari-
ties among individuals’ genetic risks of ill health?
Advancements in genetic technologies have private insurance pro-
viders clamoring for access to new types of predictive health informa-
tion. Such information would allow for markedly more accurate risk
forecasts, and thus foretell a range of difficulties for health insurance in
the United States. Increasingly precise genetic prognoses may render
risk pools so small that it no longer makes fiscal sense for individuals
to pay for costly insurance policies. Fear of genetic discrimination may
also prevent individuals from reaping the health benefits that can result
from genetic testing. Most alarmingly, genetic risk classification may
be used to deny coverage to those with the worst genetic luck. While
lawmakers have begun to take note of these issues, anti-discrimination
legislation, the current policy solution to these problems, could cripple
private insurance providers. To protect the privacy and wellbeing of
Americans, we should abandon the present scheme of setting health
insurance rates according to individual risk-factors, and, in its place,
adopt a system of roughly equal premiums across communities—a
system that balances the values of free-market liberalism with those
of mutual trust and solidarity.
F OX | 109
C URRENT S TRESSES : H EALTH C ARE AND G ENETIC I NFORMATION
The recent mapping of the human genome holds enormous potential for
beneficial use in personalized clinical health care. The 2003 completion of
Human Genome Project promises to facilitate medical research and genetic
testing to identify at-risk individuals and guide them in strategies for disease
prevention, diagnosis, and treatment. The increasing number and sophistication
of tests resulting from this new genetic information has enabled researchers
to uncover the genetic components of over 5,000 diseases and disorders.a
Mutations in the α-synuclein gene, for instance, increase the risk of Parkinson’s
disease, while single mutations in BRCA and MODY genes increase the risk
of breast cancer and diabetes.b Advances in genetic testing promise to greatly
expand the field of biomedical research, and to enhance lifelong health by
identifying those at-risk of developing debilitating diseases and guiding them
towards reducing any risk-elevating health behaviors. However, such precise
and personalized genetic knowledge also promises to profoundly transform
health insurance in the United States.1
The institution of health insurance relies on the connection between
ignorance and fairness in bringing people together to provide collective se-
curity against their individual risk of ill health. Some people have the good
fortune of being blessed with lifelong health, while others are subject, through
no fault of their own, to disease and disability that limits functioning and
opportunity. Where all are deprived of knowledge about how their health will
play out, all have reason to contribute regular payments as insurance against
the future cost accompanying the unknown risk of individual infirmity. As
risk can be roughly foreseen across large groups, insurance providers can reap
commercial gain by collecting clusters of premiums in exchange for compen-
sating policyholders for the actual medical expenses they encounter.2 The
combination of individual uncertainty and group predictability which existed
up until the genomics era thus gave policyholders and providers incentive
to maintain the present system of health insurance. In the process, health
insurance promotes social values of solidarity and mutual support by encour-
aging citizens—even if unwittingly—to share their fates with one another
a
Examples of genetic testing include: medical examination; family history; chemical, biochemi-
cal, or immunochemical analysis; examination of chromosomes by microscopy; or determina-
tion of DNA composition using molecular genetic techniques that provide carrier or presymp-
tomatic information indicating probable disease or disorder.
b
Genetic research has discovered that monogenic disorders, for example, such as cystic fibrosis,
Duchenne muscular dystrophy, and Huntington Disease, result from defects in a single gene.
Chromosomal disorders, such as Down, Turner, and Klinefelter syndromes, result from too few,
too many, or disorder of chromosomes within an individual’s genes. Multifactorial disorders,
such as schizophrenia, spina bifida, juvenile onset diabetes, and most cancers, result from the
interaction of multiple genes with environmental factors.
by spreading among them the chance that any individual among will suffer
the misfortune of infirmity.
In the United States today, approximately 240 million Americans obtain
health insurance through employer, state, or individual plans, and 40 million
have no health insurance at all. Of those insured, approximately 110 mil-
lion receive group insurance coverage from an employer or Blue Cross/Blue
Shield, 65 million receive publicly-funded coverage from government pro-
grams like Medicare and Medicaid, 40 million receive self-insurance coverage
from an employer, and 25 million receive individual coverage directly from
a provider.
Of those insured, about 50 million Americans receive coverage under
an experience-rated health insurance system that relates premiums to risk
under the principle of actuarial fairness.3 Under such coverage plans, policy-
holders contribute premiums according to the expected cost of their future
claims. Actuarially fair providers engage in a process called underwriting, in
which they determine a policyholder’s expected risk according to the costs
of health care incurred by those with similar risk-related characteristics, such
as age, sex, occupation, height, weight, blood pressure, cholesterol profile,
tobacco and alcohol consumption, and family history. Providers obtain
medical information by requiring the applicant to answer questions on an
insurance proposal form or submit medical examination reports. Individual
premiums are then set in proportion to these risk classifications. With
the completion of the Human Genome Project, private health insurance
providers are now seeking to acquire predictive information about genetic
diseases in order to disaggregate risk along more finely stratified classifica-
tions according to the way in which adverse genes, taken in combination,
contribute to an individual’s risk of ill health. Insurance companies argue
that in order to maintain actuarial fairness, policyholders must submit data
available from genetic testing, so that providers can differentiate premium
levels as accurately as information permits.
However, allowing genetic information to enter into the calculation
of health insurance rates may render the whole institution commercially
self-defeating. More precise predictive information would enable indi-
viduals’ eventual medical costs to be anticipated to a degree never before
possible. If foreseeable risks of personal illness become known, providers
will assign policyholders to sharply defined risk pools, with correspondingly
precise premiums distinguishing the lucky from the unlucky. When pools
become too small, many policyholders will find it cost-effective to save up
their individual earnings for future health expenses than to contribute to
a system of health insurance which offers far less security than it once did.
If enough individuals opt out of the system, providers will no longer be
F OX | 111
able to collect premiums across groups large enough to make it profitable
to cover individuals’ health care expenses.
Aside from fiscal complications, underwriting on the basis of increasingly
accurate genetic information is morally suspect in that it sanctions indirect
racial and ethnic discrimination in health insurance. Some genetic diseases
and disorders are strongly correlated with particular racial or ethnic groups,
such as Tay-Sach’s disease among Ashkenazi Jews of Eastern European de-
scent and sickle cell anemia among individuals of African descent. Extensive
associative studies indicate that Ashkenazi Jews are ten times more likely
than the general American population to carry the genetic mutation for Tay-
Sachs.4 Similar studies show that individuals of African descent are twelve
times more likely than the general American population to carry the patterns
of gene expression associated with sickle cell anemia.5 By charging higher
rates or denying coverage to prospective policyholders who are genetically
predisposed to sickle cell anemia or Tay-Sachs disease, providers would, in
effect, discriminate against those of Jewish or African ancestry.
The use of genetic information by health insurance providers also threatens
to compromise the availability of health insurance for millions of Americans.
Currently, 15 percent of U.S. citizens lack health insurance and 30 percent
of all applicants for individualized coverage are denied on the basis of ap-
proximate risk predictors. Compared to those who have health insurance, the
uninsured get sick more often, heal slower, use emergency rooms with greater
frequency, and die sooner. Genetic information exacerbates the problem of
coverage denial and its attending health problems in that it enables providers
to predict risk with better precision.c The more certainty the provider has
that insuring any particular applicant will not be profitable, the more likely
it becomes that the provider will decline coverage.6
Fear of genetic discrimination and coverage denial will also preclude
society from reaping the full benefits of biomedical research and healthcare
that are predicated on genetic information. For example, one-third of pro-
spective volunteers in a series of recent studies conducted by NIH refused to
undergo testing for genetic disorders out of fear that providers might uncover
risk factors that would lead them to limit the patient’s access to insurance
coverage. Similar fears keep millions of at-risk applicants and policyholders
each year from getting testing for HIV.7
The moral difficulties that accompany underwriting on the basis of genetic
information point to deeper problems that underlie experience-rated systems of
health insurance. The practice of setting premiums according to expected risk
c
Director of the Human Genome Project Francis Collins estimates that the average individual
carries between five and fifty genes that may predispose them to expensive-to-treat disease.
engenders inequalities in coverage and premiums to whatever extent people
experience advantages or disadvantages from morally arbitrary differences,
including but not limited to those arising from genetic chance.8 Actuarial
fairness punishes the most genetically vulnerable members of society on the
basis of conditions they did not choose and cannot control. Blind to broader
social values of solidarity and mutuality, actuarial fairness is an impoverished
way of thinking about institutions like health insurance—institutions that
are geared toward bringing together communities of individuals with the
common goal of achieving security and good health.
A more compassionate alternative to actuarial fairness would guarantee
adequate coverage to genetically susceptible citizens without sacrificing the
variety, choice, competition and responsiveness enjoyed under the current
insurance system. Just as the American government taxes those with the most
highly rewarded talents and skills in a way that helps those lacking such gifts,
society ought likewise in the context of insurance to regulate inequalities in
the distribution of basic social provisions such as nutrition, education and
healthcare in a way that ensures all citizens possess the capacity for genuine
choice from among a meaningful range of life plans.9 We would do well to
share the costs suffered by individual members whose genetic inheritance
predisposes them to adverse health. Such a system must also remain com-
mercially viable.
In the United States, the sole policy response to the issues raised by
genetically informed underwriting has been legislation barring genetically
informed discrimination. Federal laws such as the Health Insurance Portability
and Accountability Act of 1996, the Genetic Information Nondiscrimina-
tion in Health Insurance Act of 2001, the proposed Genetic Information
Nondiscrimination Act of 2003, and statutes passed in over half the states
prohibit health insurance companies from requiring genetic tests as a condi-
tion for coverage or from denying coverage or charging higher rates based
on the results of genetic tests.10
There are, however, important commercial, practical, and ethical reasons
why legislation barring genetic discrimination cannot sufficiently resolve mat-
ters of distributive justice in health care. Where asymmetric information denies
providers access to accurate genetic knowledge, adverse selection threatens the
survival of for-profit private insurance providers. Were underwriters barred
from using genetic information of actuarial significance, high-risk individuals
would buy insurance in greater proportion than low-risk individuals, creating
a spiral of premium raises and low-risk opt-outs. Furthermore, there is little if
any empirical distinction between genetic information and traditional medical
information like family history and health physical. Family history provides
explicit information about an individual’s genetic constitution, while health
F OX | 113
physicals identify conditions which typically implicate specific contributory
genes. Likewise, many “non-genetic” medical tests point directly to underlying
genetic sources of potential disease or disorder. For instance, a positive test
for high cholesterol in the detection of heart disease or for occult fecal blood
in the detection of colon cancer points directly to mutations in the genes
conferring susceptibility to those conditions.
Even were it possible to distinguish between genetic and non-genetic risks,
the two would not differ in any morally relevant way. Except in the few cases
where individuals could be held at least partially responsible for those risks,
it can hardly be said that any diseases or disabilities are chosen, controllable,
or deserved. People cannot be held morally accountable for environmental
circumstances that adversely affect health, such as pollution, malnutrition,
and low socioeconomic status, which are beyond their reasonable control.
Moreover, new genetic information shows that even food, nicotine, and alcohol
addictions, once thought to be purely voluntary behavioral choices, are at least
partly influenced by an individual’s genetic makeup. As such, there is no sound
basis upon which to differentiate rates among similar risks of ill health such
as, say, genetic susceptibility to diabetes and non-genetic susceptibility to the
Lyme disease spirochete. The ethical and economic difficulties generated by
the introduction of genetic information into health insurance markets call
for more substantive solutions than legislation that does nothing more than
prohibit discrimination on the basis of genetic information.11
H EALTH I NSURANCE IN THE G ENOMIC A GE

The answer to these problems is a nuanced system of privatized community
rating. Such a system assigns broadly equal premiums among individual poli-
cyholders across similar “communities.” Though communities are ordinarily
divided along geographic regions (whether a single congested city block or
multiple counties and districts in less heavily populated regions), communities
may be determined by particular interests or affiliations, such as membership in
political or religious groups, so long as the community includes a rough balance
of healthy and unhealthy individuals. Since coverage rates set uniformly across
a given community do not vary along individual risk factors or health status,
the lucky subsidize the unlucky, even when each has genetic knowledge of her
individual health risks. A community rating system would thus preserve the
advantages of free-market pluralism while promoting the cooperation and
camaraderie that lie at the heart of the institution of health insurance.
To be effective, this system must be built around a collective participation,
guaranteed issue, guaranteed renewal, non-cancelable indemnity program that
prevents providers from discriminating against those susceptible to adverse
health, and protects against adverse selection by those with low personal risk
levels. That coverage could not be cancelled would provide individuals with
security against long-term changes in expected risk and expense across the
course of a policyholder’s transition from youth to old age. Guaranteed issue
and renewal would ensure basic health care coverage for even the most at-risk
citizens. Tax-subsidized vouchers for high-risk individuals would spread the
burden of insuring these cases across a broad population base. Meanwhile,
by making genetic tests required as proof of need for a voucher, this system
would keep people from obtaining such vouchers unfairly. Government or self-
regulation could ensure that all providers allow access to at least “basic” health
care coverage, as determined by a balanced committee of ethicists, economists,
politicians, consumer advocates, and insurance representatives.12
Ours is a society unwilling to deny care in cases of medical emergency.
While our current system of optional health insurance is forced to guard against
financially capable free riders, a system of community-rated insurance plans
that provides coverage to all citizens would prevent anyone from using medi-
cal resources without providing their fair share of contributions. Contractual
incentives would maintain an aspect of personal responsibility for individual
health by discouraging potentially damaging lifestyle behaviors to the extent
that people can be said to exercise control over those behaviors. Other in-
centives for appropriate use of medical resources would realign policyholder
interests with social goals and minimize the moral hazard that could encourage
overuse of care. Removing providers’ incentive to seek genetic test results for
purposes of risk classification would help protect confidentiality of sensitive
personal information while curtailing the administrative and transaction costs
incurred in the process of experience-rated underwriting. Without market
competition from self-insurance or experience-rated providers, community-
rated providers could remain profitable and survive in the private sector. By
allowing people their choice of plans, rates, and benefits among providers, this
system would sustain commercial feasibility in the marketplace, while owning
up to society’s ethical duty to help those most vulnerable to ill health.
In the course of genetic advancements, it will soon become necessary for
our nation to dissolve an institution no longer capable of tending to injustices
which we as a society will not permit. Deficiencies inherent in the current sys-
tem leave us ill-equipped to reap the full promise that new genetic knowledge
will yield for medical care in the United States. We need a system of health
insurance that corrects for the deep inequalities borne in the natural lottery.
By restoring the union of ignorance and fairness, cooperative involvement
in a system of community-rated premiums presents the best solution to the
problem of genetic testing and health insurance in America.
F OX | 115
1. Advances in Genetic Information. Eds. Karen Marshall and Stephen Brown. Lexington, KY:
The Council of State Governments, 1993: 55.
2. Knoppers, B. “Who Should Have Access to Genetic Information.” The Genetic Revolution
and Human Rights. Ed. Justine Burley. New York: Oxford University Press, 1999. 47.
3. Greely, Henry T. “Health Insurance, Employment Discrimination, and the Genetics Revolu-
tion.”The Code of Codes: Scientific and Social Issues in the Human Genome Project. Eds.
Leroy Hood and Daniel J. Kevles. Cambridge, MA: Harvard University Press, 1992. 277.
4. Myerowitz, R. “Splice Junction Mutation in Some Ashkenazi Jews with Tay-Sachs Disease.”
Proceedings of the National Academy of Sciences of the United States of America 82(7)
( June 1988): 3955.
5. Pauling, L; et al. “Sickle Cell Anemia, a Molecular Disease.” Science 110(2865) (Nov. 1949)
: 543-548. and Dunda-Belkhodja, O; et al. “Common Haplotype Dependency of High G
γ-globin Gene Expression and High Hb F Levels in β-thalassemia and Sickle Cell Anemia
Patients.” Proceedings of the National Academy of Sciences of the United States of America
82(7) (Apr. 1985): 2111-2113.
6. Cutler, D. “A Guide to Health Care Reform.” The Journal of Economic Perspectives 8(3)
(Summer 1994): 20.
7. Harris, J. Wonderwoman and Superman. New York: Oxford University Press, 1992. 222.
8. Nozick, R. Anarchy, State, and Utopia. New York: Basic Books, 1977. 149-164, 167-182.
9. Rawls, J. A Theory of Justice. Cambridge: Harvard University Press, 1971. 78-79.
10. Friedrich, M.J. “Preserving Privacy, Preventing Discrimination Becomes the Province of
Genetics Experts.” The Journal of the American Medical Association 288(7) (Aug. 2002):
817-818.
11. Beckwith, J; Alper, J.. “Reconsidering Genetic Antidiscrimination Legislation.” The Journal
of Law, Medicine, and Ethics 26(3) (Fall 1998): 207.
12. Pauly, M. “The Welfare Economics of Community Rating.” The Journal of Risk and Insur-
ance 37(3) (Sept. 1970): 409-412.
A BOUT THE A UTHOR

Dov Fox is currently a D. Phil. candidate on a Rhodes Scholarship at Oxford
University and J.D. candidate at Yale Law School. Before this he received
his M.S. from Oxford and a B.A. from Harvard. Fox has researched with
the President’s Council on Bioethics, contributing to reports on the ethics of
stem cell research and genetic enhancement. He recently published “Human
Growth Hormone and the Measure of Man, in The New Atlantis, vol. 1, no.
7 (2004/2005): 75-89.
For correspondence, please email Dov Fox at dov.fox@st-johns.oxford.ac.uk.
policy research & analysis • the nation’s first student think tank
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ROOSEVELT

A Publication of the Roosevelt Institution

E XECUTIVE E DITORS S ELECTION C OORDINATORS

CURRENT RESEARCH: ANALYSES OF PRESENT

19 Extraction vs. Taxation: What to Do with ANWR

41 Medicare, Medicaid, SCHIP, and the Future of America: New

55 Innocent Until Proven Guilty: Military Use of Depleted Uranium

71 Voices From Rural South Africa

85 Globalization and Education: A Case Study in Papua New Guinea

SURVEYS: POLICY AND SOCIAL PERSPECTIVES

LOOKING AHEAD: PROGRESSIVE THINKING ON

By the submission deadline for this issue, we had received hundreds

Danielle Gilbert, Kevin Hilke, Vincent Intersimone, and Jesse Wolfson

KASTNER AND FELIX | 29

Figure 4 Projected consumption for Scenarios I and II

~ 36% Increase from 1970 to 1990

Figure 5 Comparison of historical and projected national average fuel

KASTNER AND FELIX | 31

(US-Y2K$ per driver) 385

Figure 6 Direct cost to the average driver

• Uncertainty. Any research paper of this nature, which attempts

• Environment. In detailing the beneﬁts to not drilling in

Figure 7 Conservation comparison for Scenarios I and II

change. Quantifying these beneﬁts would only further encour-

• Discount Rate and Option Value. A more in-depth analysis of the

• Rebound Eﬀect. Several studies have shown that increasing en-

KASTNER AND FELIX | 33

International Gas Prices

Figure 8 International gas price comparison (USD$)

Figure 9 Consumption and Price data for the past 50 years

KASTNER AND FELIX | 35

600 Consumption/Capita (gallons)

Figure 10 Model veriﬁcation compares actual consumption data to

Total Consumption vs. ANWR Extraction

Figure 11 ANWR in context to current US consumption and

Figure 12 Full JMP output of ﬁnal model regression

KASTNER AND FELIX | 37

Diﬁglio, C; Duleep, K.G. “Cost Eﬀectiveness of Future Fuel Economy Improvements.”

Espey. “Explaining the Variation in Elasticity Estimates of Gasoline Demand in the

Schmalensee; Stoker, M. “Household Gasoline Demand in the United States.”

West, E.; Williams, C. “Estimates from a Consumer Demand System: Implications

Whitford, R.K. “Fuel-Eﬃcient Autos: Progress and Prognosis.” Annual Review of

A BOUT THE A UTHORS

David Felix is a mechanical engineer with B.S. from the University of

KASTNER AND FELIX | 39

For correspondence, please email David Felix at dfelix@bren.ucsb.edu.

Amelia Hausauer, Jermaine

If statistical data is any indication, then the 8.5 million children in

W HAT IS W RONG WITH P UBLIC H EALTH C ARE ?

F ISCAL B ENEFITS , E THICAL O BLIGATIONS

O PPOSITION , F EASIBILITY , AND R ESPONSIBILITY

T HE E QUITABLE E XPRESS L ANE : H EALTHCARE FOR

1. “People With or Without Health Coverage by Selected Characteristics: 2002 and

A BOUT THE A UTHORS

Amelia Hausauer, Jermaine Archie, Craig Boge, Anthony Ortega, and

Archie, a rising senior, is originally from Motha-Eﬃngham County,

Boge, a rising junior, concentrates is in Epidemiology and Infectious

Ortega, a rising junior, concentrates is in Race, Health Policy, and the

Pratt, a rising junior, concentrates is in Comparative Health Policy. Her

For correspondence, please email Amelia Hausauer at hausauer@stanford.edu.

Areas so contaminated by radioactive material would be danger-

The letter stated that inhalation of uranium would result in “bron-

1. Rokke, D. “Depleted Uranium: Uses and Hazards” 2000.