The panel was moderated by Susan Dentzer, Editor-in-Chief of Health Affairs, and included representatives from USAID and several global health R&D partners from the public and private sectors (representing Product Development Partnerships – or PDPs).

• Hugh Chang, Director of Special Initiatives, PATH
• Rick King, PhD, Vice President, Vaccine Design, IAVI
• Emily Moore, Vice President for Business Development, Temptime Corp.
• Wendy Taylor, Senior Advisor for Innovative Finance and Public Private Partnerships, Bureau of Global Health, USA

On Monday, Nov. 21^st 9:30am EST, Research!America will be webcasting a briefing on USAID and the agency’s impact on global health research and development.  The panel will be moderated by Susan Dentzer, Editor-in-Chief of Health Affairs, and will include representatives from USAID and several global health R&D partners from the public and private sectors (representing Product Development Partnerships – or PDPs).  Panelists include:

• Hugh Chang, Director of Special Initiatives, PATH
• Rick King, PhD, Vice President, Vaccine Design, IAVI
• Emily Moore, Vice President for Business Development, Temptime Corp.
• Wendy Taylor, Senior Advisor for Innovative Finance and Public Private Partnerships, Bureau of Global Health, USAI

The U.S. Agency for International Development (USAID) is marking its 50th anniversary as the main U.S. humanitarian relief and international development agency. This conversation regarding USAID and its global partenrs will shed insight into instrumental partnerships in global health work.

This important event will be webcast live at http://bit.ly/vWwx9o where you can also submit questions. You can also join the conversation on Twitter under the hashtag #GHPDP.

Amie Batson on Why Americans Should Care about Global Health Research:

FDA Commissioner, Margaret Hamburg:

Representative Ed Markey (D-Mass):

Whoopi Goldberg:

Stay tuned to Global Pulse Blog for more views on this monumental speech and its implications.

Yesterday, Secretary of State Hillary Rodham Clinton declared the U.S. government’s intent to create an “AIDS-free generation.” Secretary Clinton outlined a bold plan to reduce new HIV-infections, globally, including the eradication of pediatric HIV by 2015. This new strategy builds upon the success of the President’s Emergency Plan for AIDS Relief (PEPFAR), the U.S. program that addresses HIV/AIDS in resource-limited settings.

A notable feature of Secretary Clinton’s “AIDS-free generation” initiative is to strengthen healthcare systems in sub-Saharan Africa. Clinton stated:

“We know we can’t create an AIDS-free generation by dictating solutions from Washington. Our in-country partners — including governments, NGOs, and faith-based organizations — need to own and lead their nation’s response. So we are working with ministries of health and local organizations to strengthen their health systems so they can take on an even broader range of health problems.”

Strengthening African healthcare systems is a view echoed by many eminent voices in the global health community. Last year, the Institute of Medicine (IOM) of the National Academy of Sciences authored a report entitled: “Preparing for the Future of HIV/AIDS in Africa: A Shared Responsibility.” The IOM report recommended the urgent need to increase African healthcare workforce capacity to address the HIV epidemic.

I offer Secretary Clinton a solution to assist African healthcare workforces and ensure the success of the “AIDS-free generation” initiative. Last year, in an editorial in The New England Journal of Medicine, Vanessa Kerry, Sara Auld, and Paul Farmer reintroduced the idea of enacting a Global Health Service Corp (GHSC). The GHSC, compromised of U.S. healthcare professionals, would provide medical education and technical assistance to enhance the healthcare workforces in low-income countries. The GHSC’s goal would “go beyond that of filling a human resource void to focus on infrastructure development, knowledge transfer, and capacity building.” The GHSC could also offer partial student loan forgiveness for U.S. corps members who engage in service abroad for a specified time period similar to the loan forgiveness offered by the National Health Service Corp.

To address the African healthcare workforce shortage, I encourage Secretary Clinton to adopt the principles of the GHSC. The success of the “AIDS-free generation” initiative depends on the availability of skilled healthcare workers in African resource limited settings. Additionally, the eventual transition from a U.S. to African led HIV/AIDS response requires the U.S. to teach and train healthcare personnel in recipient countries through collaborative partnerships that eventually lead to African ownership of their domestic healthcare needs.

Some may argue that enacting the GHSC, especially in the era of U.S. government austerity measures, is not prudent. However, the funding for the GHSC already exists. In addition to HIV/AIDS prevention and treatment, PEPFAR’s congressional mandate requires the program to “strengthen partner government [healthcare] capacity to lead the response to this epidemic and other health demands.” Last year alone, PEPFAR committed over $734 million in healthcare capacity building initiatives.

Global health is the moral litmus test of our time. As Secretary Clinton asserted: “An AIDS-free generation would be one of the greatest gifts the United States could give to our collective future.” The U.S. should enact the GHSC to ensure the success and sustainability of the “AIDS-free generation” initiative.

-Anand Reddi, The Huffington Post

If you are interested in supporting the Global Health Service Corp please sign the petition to show your support. http://www.globalhealthservicecorps.org/index.php/petition/

Additionally, the Medical Student Section of the American Medical Association is considering a resolution endorsing the GHSC at its 2011 Interim Meeting in New Orleans, Louisiana.

• Beth Tritter, Managing Director, The Glover Park Group; Former Legislative Director for Congresswoman Nita Lowey, Ranking Member of the House Appropriations Subcommittee on State and Foreign Operations.
• Todd Summers, Senior Advisor for Global Health, ONE Campaign.
• Allen Moore, Senior Advisor for Global Health Security Program, Stimson Center, and Adjunct Professor in Global Health, George Washington University; Former Deputy Chief of Staff and Policy Director for Former Senate Majority Leader Bill Frist.
• Jennifer Kates, Moderator, Vice President and Director, Global Health & HIV Policy, Kaiser Family Foundation.

They will examine the new legislative landscape of the 112th Congress and the ways in which recent changes will impact global health programs and foreign assistance.

You can watch the live studio webcast on kff.org. Viewers can also email questions before or during the live webcast at infocus@kff.org.

Kaiser Family Foundation recently held a webcast on “The Future of US Multilateral Engagement on Global Health“ as part of the Foundation’s US Global Health Policy: In Focus live webcast series. This question and answer format webcast featured an expert panel including Mark Abdoo the director for Global Health and Food Security, Natasha Bilimoria the president of Friends of the Global Fight Against AIDS, Tuberculosis, and Malaria, and Jennifer Kates the vice president and director of Global Health Policy & HIV for the Kaiser Family Foundation, moderated by senior analyst Josh Michaud.

This discussion explores the approach taken by the United States to address Global Health funding historically and looking into the future. Discussions on global health funding often involve a division between bilateral approaches to funding versus multilateral funding engagement. Bilateral funding involves the provision of direct assistance from one government to, or for the benefit of, one or more other countries, with the donor having significant control over the target, approach and content of assistance. On the other hand, multilateral organizations such as the World Health Organization, the United Nations and the Global Fund, bring together global stakeholders to develop and collaborate on global health targets.

Historically, the US has commonly supported global health priorities via bilateral funding and programs but the focus on promoting multilateral organizations is growing. For example, the US was the first and is currently the largest donor to the Global Fund to Fight AIDS, Tuberculosis and Malaria, and a key component of the Obama Administration’s Global Health Initiative includes a renewed and increased commitment to multilateral engagement. The shifting approach has led to questions regarding the appropriate focus for US global health engagement, the proper balance between multilateral and bilateral funding efforts and the appropriate role of the US government and other organizations in international treaties and other collaborative agreements.

Check out this and more global health-related webcasts and other valuable resources on global health policy at the http://www.kff.org/ website. A more detailed discussion on the US Government’s Global Health Policy Architecture is also available.

A related webcast and fact sheets on maternal and child health and family planning are also available.

Check out their website to register and access related materials.

It can be argued that health care providers who neglect to report illegal immigrants under their care will violate the law and be considered criminals. The bill provides physicians with no guidance as to what constitutes “reasonable grounds” to suspect that somebody is in the country illegally, leaving the particulars of such scrutiny to anyone’s imagination (although the fact that Arizona shares a border with Mexico rather than a European country suggests that whites will not be “reasonable” suspects).

Dr. Restrepo and colleagues also published a letter in the Arizona Republic earlier:

As physicians, we are concerned about the immigration bill signed by Gov. Jan Brewer. We care for many patients who may appear foreign based on superficial impressions. It is unclear whether health-care professionals like ourselves will infringe on the law if we don’t report patients or their families to the police or immigration authorities based on a vague suspicion of illegality. . . . Senate Bill 1070 tacitly prescribes a break with one of the oldest traditions of medicine: Physicians shall protect patients regardless of nationality or race [emph. added].

In a statement released on May 18, the National Physicians Alliance and CIR/SEIU-Healthcare condemn the law as “an affront to human rights and a devastating step backwards for the health and well being of the entire nation,” and warn that it will “create new obstacles to obtaining needed health care.”

More on Arizona SB 1070:

• Some 50,000 protesters gather in Phoenix on May 29 to demonstrate against the law
• Immigrant groups and workers’ organizations (Hispanic and not) urge a boycott of Arizona
• The Sound Strike, a group of musicians and performers headed by Zach de la Rocha, boycotts AZ

Does Arizona’s law go too far? Do you think it is likely to affect the practice of medicine in the state? Do doctors have a role to play in this debate? Join the discussion by leaving a comment!

In the face of this expanding pool of people in need, US government funding seems to be staying stable. For example, at the same time that the Obama administration has announced plans to expand HIV treatment to at least 4 million by 2013, they have also signaled no increases in funding budgets through fiscal 2011. Defending the administrations commitment to fight the global pandemic, Eric Goosby, the President’s AIDS czar, stated that “our commitment to universal coverage hasn’t wavered.”

For more on the global fight on AIDS and particularly the fight in Uganda, check out the Wall Street Journal’s January 30th article and slideshow.

“To some, human trafficking may seem like a problem limited to other parts of the world. In fact, it occurs in every country, including the United States, and we have a responsibility to fight it just as others do. ” - Secretary of State, Hillary Rodham Clinton (full article here)

Good afternoon, Global!

Today is National Global Human Trafficking Awareness day, and for those who are unfamiliar, human trafficking is “the recruitment, transportation, transfer, harbouring or receipt of persons, by means of threat or use of force or other forms of coercion, of abduction, of fraud, of deception, of the abuse of power or of a position of vulnerability or of the giving or receiving of payments or benefits to achieve the consent of a person having control over another person, for the purpose of exploitation.” (UN Protocol to Prevent, Suppress, and Punish Trafficking in Persons)

It is one of several forms of slavery that exist today (click here to learn about modern slavery), and as our Secretary of State stated so clearly, it is not just an international issue, but a domestic one as well.

Here are some quick facts from freetheslaves.net and the US DOJ:

• there are more slaves now than ever before in human history – approximately 27 million around the world
• the cost of a slave has decreased from $40,000 in 1850, to $90 in 2008
• it would cost $40 per family to buy all bonded laborers in the world – Americans spend this much on chocolate each Valentine’s Day
• 17,500 slaves are brought into the United States every year
• sexual exploitation of minors is lawfully considered human trafficking – approximately 325,000 children in the United States are subjected to sexual exploitation every year
• the average age of entry into the commercial sex industry within the United States is 11-12 years old

So for those of you who want to learn/do more, here are a few things for today:

statement in the Global Pulse by our Hana Akselrod:
http://www.globalpulsejournal.com/blog/index.php/2009/10/27/human-trafficking-part-i-introduction/

some local events:
http://humantrafficking.change.org/blog/view/national_human_trafficking_awareness_day_events_near_you

a poster to share:
http://www.bridgetofreedomfoundation.org/NGHTAD_Letter-1.pdf

a Facebook group:
http://www.facebook.com/group.php?gid=209640181028&ref=mf

powerful article regarding chocolate slavery in the ivory coast: http://vision.ucsd.edu/~kbranson/stopchocolateslavery/atasteofslavery.html

Department of State 2009 Trafficking in Persons Report:
http://www.state.gov/g/tip/rls/tiprpt/2009/index.htm

an article on modern slavery:
http://www1.voanews.com/english/news/a-13-2009-08-21-voa49-68706537.html

an organization working to end slavery:
http://www.freetheslaves.net

a great list of links/resources:
http://traffickfree.org/educate.html

Medical students from the University of Michigan gathered yesterday for World AIDS Day to rally Representative John Dingell’s support regarding several key issues surrounding global health and health care reform. Students sang modified versions of Christmas carols, whose words were replaced with language describing the necessity of: 1) accessible and affordable essential medicines for HIV/AIDS patients worldwide and 2) continued backing of PEPFAR, which currently only has $366 million of the $48 billion as promised by former President George W. Bush in 2008.

Most of the buzz in health care reform revolves around insurance and patient coverage. An equally important aspect of health reform that may not be receiving as much clout, however, is the issue of biogeneric drugs. Biogeneric drugs–refer to earlier posts of two videos–are the generic version of expensive biologic drugs. Biologic drugs are created from live cells and treat diseases such as Rheumatoid Arthritis, Breast Cancer, Multiple Sclerosis and Alzheimer’s. The cost of these drug regimens are very expensive; the drug called Herceptin used to treat breast cancer may run a bill of $45,000 per year. If law does not pass that allows generic production of an equally effective biogeneric drug, patient access to life saving medicines will be extremely limited to those with good insurance coverage  (sometimes not even the case) and/or financial cushioning (a significant chunk of the global patient population is crowded out from treatment in face of these drug prices).

Please support the passage of biogeneric drugs by limiting data exclusivity to 5 years, not the proposed 12 years. In addition to the 12 year data exclusivity of biologics, Pharma wants to reel in more profits and continue their monopoly reign through a process called ‘evergreening.’ Evergreening occurs when a drug is slightly modified–changing from thrice a day to once a day pill–and allows Pharma to retain their monopoly of a biologic, essentially crowding out market competition, drug innovation and patient access to care. If Pharma gets their way with biologic drugs, they will have 12 + 12 years on top of their 20 year patent, and will exclude an entire generation from important medicines.

If you would like to get involved, and change the course of biogeneric history, please:

+ email Congress

+ call your representative

+ tell your friends

Thanks for reading.  Happy WAD.

The ban was enacted in 1987 at a time of widespread fear that HIV could be transmitted by casual contact and was further strengthened by Congress in 1993 as an amendment offered by Senator Jesse Helms. The ban covered both visiting tourists and foreigners seeking to live in this country. In 2008, President George W. Bush signed legislation, passed by Congress in July 2008, that repealed the statute on which the ban was based, although the ban remained in effect.

One of the results of the restriction has been that no major international conference on HIV/AIDS has been held in the United States since 1990, limiting collaboration and visibility of HIV/AIDS related research and issues in the United States media coverage. Many believe that lifting the ban would end the inconsistency in United States health policy, where the US has led efforts towards AIDS prevention internationally while upholding restrictions that prevented international AIDS researchers and activists from gathering at conferences in the US.

President Obama stated, “If we want to be a global leader in combating H.I.V./AIDS, we need to act like it. Now, we talk about reducing the stigma of this disease, yet we’ve treated a visitor living with it as a threat.”

For more information:
Mahto M, Ponnusamy K, Schuhwerk M, Richens J, Lambert N, Wilkins E, Churchill DR, Miller RF, Behrens RH. “Knowledge, attitudes and health outcomes in HIV-infected travellers to the USA”. HIV Medicine 2006; 7: 201–204.

Human trafficking is a subject that elicits strong visceral reactions when it chances into the spotlight. For good reason. Stomach-churning stories of children sold into forced labor, of young girls and boys entrapped into lives of rape and violence that the word “prostitution” doesn’t quite cover, and of adult men and women smuggled across borders to become indentured servants — they are found on the uncomfortable, dark underside of the global flow in trade, money, and labor, that underpins modern economics and society itself. They resonate as a nightmare version of the more familiar logic of supply and demand, legality and illegality. They constitute infuriating human rights abuses, and violate any number of laws and treaties — and because they happen to people whose very existence is undocumented, whose bodies are uncounted and whose faces and voices are hidden, they go on and are not discussed in polite company. It is the twenty-first century, and the trade in human beings accounts for the world’s third largest illegal market¹. It is probably small news that the United States is a big consumer. It is news to most people that the US is also a source of victims.

Human trafficking is defined as the crime of using force, coercion, or fraud to procure or detain another person for involuntary servitude or for commercial sex work². It often involves travel across borders, but doesn’t have to. The best available estimates pin the number of people trafficked across national borders for sexual or labor exploitation at 800,000 each year — and the number of people brought into the US for these purposes for 15,000 to 18,000 per year^3,4. Immigrants and refugees are particularly vulnerable to exploitation, and being an internally displaced person (IDP) has been shown to be an additional risk factor for becoming a victim of trafficking^2,5.

Some numbers from the Human Trafficking Reporting System set up by the US Department of Justice in 2007⁶:
- 83% of 1,200+ human trafficking incidents reported in the US involved sex trafficking
- Two-thirds of all victims were under age 24, and 27% of all victims were children and teens under age 17.
- Over 90% of victims in all reported trafficking incidents, and 99% of victims in sex exploitation cases, were female.
- Hispanic immigrants made up 37% of sex trafficking victims and 56% of labor trafficking victims in the US in 2007-2008
- More than half of all victims, and 63% of sex trafficking victims, were US citizens.

What does all this have to do with human rights or global health? Are you kidding?

No art or movie clips this time. Just incredibly depressing statistics and some imagination. Medical- and public-health-side interpretations coming next time.

In upcoming installments:
Part II: Guest post from AMSA Global’s Health and Human Rights coordinator.
Part III: Trafficking and the medical provider: What you need to know, what you can do to help.
Part IV: Guest post from the field.

Sources / Further Reading:
[1] Orhant M. Trafficking In Persons. Population Reference Bureau. 2002. Link.
[2] Logan TK, Walker R, and Hunt G. Understanding Human Trafficking in the United States. Trauma, Violence, and Abuse. 2009. 10(1): 3-30.
[3] U.S. Department of State. Trafficking in Persons Report. 2006. Link.
[4] Polaris Project. Human Trafficking Statistics. 2009. Link.
[5] Feller E. UNHCR’s role in IDP protection: Opportunities and challenges- Forced Migration Review. 2006. Link.
[6] U.S. Department of Justice (DOJ) Bureau of Justice Programs. More than 1,200 alleged incidents of human trafficking reported in the U.S. Press release. 15 Jan. 2009. Link.

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In our previous themed series, Jennifer Weinberg writes about health care, HIV, and teledermatology in Botswana, where she spent the summer of 2009. Check out “Blogging from Botswana”, parts I, II, III, and IV, from this summer.

In a recent Economist article, the clever authors offered cogent commentary related to the fiery health care debates taking place within the US and what the Obama administration will have to do to navigate the storm and unfavorable winds.  For the most part, the authors diagram where and when Mr. Obama begins to vacillate and also recommend how he should proceed with a promising give-and-take strategy.  Although this literary dialogue devoted to policy compromise (aimed to directly please the centrists, while indirectly enraging the head and tail of the political spectrum) is certainly relevant to the title of this piece, I do not intend to dwell on it.  Frankly, others have done it well enough.

However, I believe another, and equally important, lesson in moderation  is encapsulated by the US health care debates of the past 15 years.  This lesson has to do with the process of bill creation rather than content.

The Clintons’ attempt at health reform received nothing more than a frosty shoulder from Congress once the President and First Lady unleashed their chimeric beast.  Part of this was because Congress did not care for “Hillarycare” (no pun intended, well perhaps a slight intention), and a lot of it was because Congress felt it had been excluded from the process.  The Obama team believed they could rectify this issue with ease.  For them, it was only a matter of unloading all of the legislative burden onto Congress.  All that was required of the Executive branch was a show of support and a calendar of due-dates.  In my opinion, this was the largest planning failure and impetus for legislative impasse that the administration could have created at such a critical and vulnerable time.

Instead of foolishly believing that a diametric approach would facilitate the process, the administration should have partnered with Congress but still assumed the necessary (and otherwise vacant) roles.  Although Congressional men and women can do a great many things, there is a key thing they never do: assume accountability to all American voters.  I am not implying that they are indifferent toward the greater interests of the country, but no matter how pragmatic they are, they are still elected by their constituents, which are always bound by state borders.  The US President is a bit unique in this regard.  The President is elected by the nation of voters (at least those that exercise their right and through an admittedly obscure process, the Electoral College) and has commensurate priority and perspective shifts.  Mr. Obama should not make light of this, and better yet, he should articulate his appreciation of this fact.  Without this pivotal revelation and subsequent action, no meaningful legislation will be put forward.

To date, the War on Health Care is taking place merely in the abstract.  We are not deliberating over any one bill.  There are many floating in the Capital Building breeze.  Each crafted by legislators with personalized ideas and voting blocks.  This simply will not do.  The appropriate action for the Obama team is to decide what exactly it wants and then clearly describe it to Congress and the American people.  It is fine to outsource the writing and even details to the Legislative branch, but for legislation of this magnitude, the bill’s outline must come from the President.  His insistent reinforcement of “less expensive, more quality/quantity” does nothing to bolster the public’s faith nor silence the critics (even if some oppositional claims are fallacious…and occasionally comical).  Waging a battle against those presumably advocating for “more expensive, lower quality” care is likely not fruitful.  I suspect their numbers are small and political influence nominal.  Better to explain to the public and policy detractors WHAT are the specific aims of the legislation and WHY we need them.  Follow that with the HOW, and the administration may just find its efforts back on track.

Fail to do so, and any attempt to eliminate some of our health care inefficiencies and reconcile our groups of uninsured and under-insured will be lost again for at least another two administrations….maybe more.

As the ballooning budget is becoming evermore disconcerting to the administration, the handful of Congressmen still identifying as Republican, and the general public, the actual “reform” might undergo a metamorphosis into a series of small concessions from all major stakeholders.  Perhaps not, but for your weekly dose of skepticism, pick up the recent version of “cap-and-trade”.  After its dilution, the only environmental impact that legislation will have is if they manage to send the bill to the paper-recycling bin.  There is a critical mass of support (going well beyond the walls of the White House) for the premier element of the Obama plan, the government managed health insurance plan.  However, this is also the most contentious reform proposal.  I am not fully aware of how they intend to run this scheme (manage asset, equity, and risk portfolios like private insurance companies?), or most importantly, how they plan to garner the necessary marginal support (at least a few fence dwellers will have to take the decisive step).  So, in these regards, I will be watching this particular drama in anticipation along with much of the rest of the country (and likely world).  But I can make a recommendation for the near-term while they wage battles for the long-term (insurance companies will never go quietly into the night).

One of the strongest criticisms of the private insurance industry is its trepidation vis-a-vis “adverse selection” (the concept that the sickest are the most likely to seek health insurance…and are also the most likely to prove costly for the insurance company and its risk pool).  To hedge against these folks, they actively pursue the statistically healthy and try to screen out those with significant pre-existing  health problems.  Part of the Obama plan’s mission is to offer a health insurance home to these otherwise beneficiary pariahs, as well as attract any others who are looking for a better deal.  Assuming the government scheme desires a risk pool, like other insurance schemes, then I suspect they are hoping that enough relatively healthy, inexpensive shoppers cross the line to dilute the intrinsic risk baggage brought with the least healthy.  Could certainly work, but there are some hang-ups.  For one thing, there will be immense industry push-back (but that is a foregone conclusion, so no need to dwell upon it).  But there may also be some financing issues.  The private companies work the hardest to attract the most healthy, least risky clientele.  Therefore, it might be quite difficult to win enough of this group over, in the near-term.  What may happen is the least healthy are the first to join, followed closely by those able to get insurance but just barely due to their not-so-good statistical health (with a significantly marked up premium).  This does not make for such a promising risk pool and may be quite expensive in the short run.

To avoid this (again in the near-term, the long-term is for the administration and the public to decide), they may decide to operate in the facet they know best: the Payables Department.  If “pre-existing conditions” keep individuals out of private insurance schemes, then make it the ticket into government sponsorship.  In this way, it would now be fashionable to divulge such health problems to demonstrate absolute exclusion from private insurance and then qualify for government protection.  The government can then negotiate fees for their care with given institutions and providers and pick up the tab.  Conversely, if they want such individuals under a traditional  insurance plan, they could accept bids from private insurance companies for this group of patients and then top off the beneficiaries’ (the patients) contributions in order to cover the otherwise unaffordable premiums.  Either way, the government will write checks, which is what they will ultimately do irrespective of their scheme’s details.  This is just one modality that I think could prove useful and not too expensive in the coming few years.  Additionally, the insurance industry may even be amenable to it since it does not make them redundant nor coerce them into accepting their least favorite customers.  Furthermore, it could help those not-so-healthy individuals with coverage but also high premiums that I mentioned before.  Their premiums could actually slide down a bit and/or more of these riskier customers could be offered attractive private plans due to dilution effects: If the riskiest people in the pool are not leaving the insurance company exposed because they are shielded by the government, then the ratio of least risky to risky (but not riskiest) goes up.  Meaning the risky (“not-so-healthy”)  could enjoy swimming around a safer pool with lower costing flotation devices (premiums).

As I said before, I offer this only in the interest of political expedience.  The administration could use something like this, or something fancier if they so choose in the immediate future while still pushing climactic reform for down the road.  However, if their fortitude is not in question and their sense of adventure intact, then good luck soldiers….the war is long and the battles many….but then again, perhaps like never before, the troops are in no short supply.