Team:Paris Bettencourt/Human Practice/Technology Transfer

   As we began working on tuberculosis, we started to raise some concerns on the possible impact of our project “outside” the iGEM community. Since part of our work consisted in designing a bacterial vector for treating tuberculosis, we started wondering how this new item of technology could be possibly translated into an actual therapy. Besides ordinary safety concerns, we had to take into account the fact that tuberculosis epidemics are particularly widespread in the so-called “developing” and “emergent” countries, whereas they are relatively rare in the “developed” ones. According to the WHO sponsored Global Plan to Stop TB, whereas tuberculosis affects all countries around the world, 85% of cases occur in Africa (30%) and Asia (55%), while India and China alone represent 35%. This means that thinking about possible applications of our genetically engineered bio-machine consists precisely in raising the question of how synthetic biology could be subject to “technology transfer” from developed countries to developing ones.

   Moreover, as Allison S. Rhines points out in an excellent review article,
the global TB epidemic is characterized by significant differences in prevalence between men and women. That rates of TB are much higher among men than women in large areas of the world has been extensively documented. Nevertheless, some scholars believe that these differences are in part, if not wholly, due to the effects of confounding variables such as differential access to care, which would bias case reporting (Rhines 2013)

   This observation highlights the fact that any technology transfer to developing countries targeting tuberculosis diagnosis and treatment cannot be “gender insensitive”. Women living in countries plagued by tuberculosis epidemics have specific needs and problems, which are to be explicitly addressed. This paper is therefore a modest contribution to a discussion on the problems raised by biotechnology transfer in the broader context of development policies and gender inequality.

   As it is widely known, a Millennium Summit was held under the aegis of the United Nations in 2000. The main achievement of this meeting has consisted in setting a global agenda for improving living standards worldwide through cooperation between developed and developing countries. Such agenda entails eight goals, ranging from eradicating extreme poverty and hunger to establishing a global partnership for development. Notably, the third of these goals aims at “promoting gender equality and empowering women” by “eliminating gender disparity in all levels of education no later than 2015”.

   In order to set a general framework for action and to identify the best strategies for helping developing countries achieve the “Millennium goals”, then UN Secretary-General Kofi Annan charged ten task forces with issuing a report each. All those task forces were meant to address one main area of concern, by representing different points of view (various UN agencies, universities and research centres, NGOs and other private or public groups). In particular, one task force was charged with tackling the question of gender equality in education and society. The task of empowering women has therefore been investigated in tight association with the one of ensuring high-level primary and secondary education to all children. This mere fact, in our opinion, highlights the importance of engaging women in participating actively to any cooperation program targeting their own countries. Furthermore, it highlights the importance that the suggestions advanced by the UN task force on gender equality bear for the synthetic biology community in order for it to better understand the issue of technology transfer.

   The intimate connection between gender inequality and the constraints undermining “the potential to reduce poverty and achieve high levels of well-being in societies around the world” is clearly stated by the report’s authors in their executive summary. However, as they argue further, gender inequality lies within the very fabric of society (“entrenched attitudes, societal institutions and market forces”), since the “norms” establishing both obligations and rights of women and men are very basic social norms, built on the innate biological distinction between females and males. Gender inequality is thus rooted not only in education, but in all other facets of society as well.

   As a result, such problem must be tackled in in its full scope, i.e. within a broad “operational framework”. The UN taskforce adopted therefore a “multidimensional” approach, which consisted in working on three big “domains”: providing access to resources and opportunities for all women, ensuring their psychological, as well as physical, security and fostering their capabilities. These three domains, observe the authors, are inextricably intertwined and progress must be accomplished in all of them in order for the third Millennium Goal to be reached. However, the concept of “capability” plays a central role in their conceptual scheme for analysing gender inequality. This concept is tightly linked to the one of “empowerment”, that is the “capacity of someone to control its own destiny”. More precisely, the authors define capabilities as
basic human abilities as measured by education, health and nutrition. These capabilities are fundamental to individual well-being and are the means through which individuals access other forms of well-being. (Grown 2005, page 2)
“Capabilities” are thus to be interpreted as consisting in the “basic human abilities” that allow an individual to acquire all the “tools” it needs to steer its own life.

   However, such “capabilities approach” was not a novelty by the time this report was written. Indeed, it dated back to the studies of economist Amartya J. Sen on the definition of living standards. Working on the welfare of populations in developing countries, Sen attempted a classification of various nations on the basis of such parameters as life expectancy, infant mortality, and age-specific death rates. He found out that classifications according to one or more of these parameters were sensibly different from the “usual” classification based on the Gross National Product per capita, which prompted him to define a new framework for analysing the welfare of individuals in a given population. This framework stresses the importance of a person’s “achievements” in defining its well-being, i.e. the importance of what it is “capable” of doing and being (is it in good health? Is it well sheltered? Did it have the chance to get a good education?...). Sen then defines “capabilities” as the “achievements” one person could possibly reach under its present conditions. Therefore, one person’s capabilities constrain its freedom to choose among different “ways of living”.

   The intimate connection between “capabilities” and freedom to steer one’s life was thus already present in the seminal works of Sen. Moreover, this link has been further highlighted and “contextualised” with respect to gender issues in developing countries by philosopher Martha C. Nussbaum. Whereas Sen’s understanding of the concept of “capability” aims at determining the best way in which quality of life assessment are to be made, Nussbaum’s approach is more focused on the “foundational” value of capabilities for the basic political principles underlying a free society. As she put it herself, the way in which Nussbaum applies this concept is philosophically more “exigent” and relies on a twofold intuition:
first, that certain functions are particularly central in human life, in the sense that their presence or absence of human life; and second…that there is something that it is to do these functions in a truly human way, not merely animal way. (Nussbaum 2000, pages 71-72)

   According to this interpretation, “capabilities” coincide with what makes human life “truly human”, so that depriving any human being of the chance to develop its own capabilities is tantamount to depriving it of its very “humanness”. A life that is truly human, as Nussbaum argues, is not merely shaped from the outside (by society, by the “physical world” itself) as a passive object, but it is capable of “fulfil itself” through specific human “powers”, such as those that are described by different form of capabilities. Central human capabilities, according to Nussbaum, are for example: the ability of living to the end a human life of normal length; the ability of having good health (being adequately nourished, having adequate shelter); the ability of preserving one’s bodily integrity against any form of violence; the ability of freely using one’s senses in order to “imagine, think and reason” in a proper human way (developing its own creativity through experience and education), and so on (page 78-79). According to Nussbaum, capabilities matter enormously for human dignity. In a sense, human rights are a matter of capabilities. This is all the more true for women, whose life options are considerably more limited than men’s ones.

   One of the main burden limiting women’s access to education and active participation to society in developing countries is obviously childcare. Yet, this is far from being the only problem. As we can read in the Women and Health Report of the WHO
at every age, women in high-income countries live longer and are less likely to suffer from ill-health and premature mortality than those in low-income countries. In richer countries, death rates for children and young women are very low, and most deaths occur after 60 years of age. In poorer countries, the picture is quite different: the population is on average younger, death rates among children are higher, and most female deaths occur among girls, adolescents and younger adult women. The most striking difference between rich and poor countries is in maternal mortality – 99% of the more than half million maternal deaths every year happen in developing countries. Not surprisingly, the highest burden of morbidity and mortality…is concentrated in the poorest and often the institutionally weakest countries, particularly those facing humanitarian crises. (Please follow)

Such impressing data raise the question of what international cooperation can actually do to improve women situation worldwide. Economist Jeffrey Sachs, one of the architects of the UN Millennium campaign, is very optimistic about the potentialities of foreign aids. In his essay The End of Poverty, Sachs maintains that
a large number of the extreme poor are caught in a poverty trap, unable on their own to escape from extreme material deprivation. They are trapped by disease, physical isolation, climate stress, environmental degradation, and by extreme poverty itself. Even though life-saving solutions exist to increase their chance for survival…these families and their governments simply lack the financial means to make these crucial investments. (Sachs 2005, page 19)

   In his opinion, some nations in the world cannot climb up the “ladder of development” because their inhabitants are trapped in a self-reinforcing mechanism that allows poverty to persist: families start up with a very poor amount of capital (not only financial, but also cultural, health, natural capital, etc.), which dooms their offspring to cope with even more extreme poverty. Those families simply lack an adequate “basis” for all successive accumulation cycles, which, as a result, cannot keep pace with the demographic growth. On such bases, Sachs advocates strategic investments in developing countries from international aid associations, venture capitalists and start up companies. He maintains that poverty could be eradicated by 2025 if only rich countries “followed through on their repeated promises to deliver more help”, in the framework of a “global compact” between the rich and the poor.

   However, other cooperation experts have taken very different stances on the effectiveness of international aids. Development economist William Easterly, for instance, has being arguing against all the policies advocated by Sachs. In books The Elusive Quest for Growth, Easterly affirms that the “aid-financed fetish” has done more harm than good to developing countries in the last fifty years. Based on the concept of “financing gap” – i.e. the gap between the investment rate, as estimated through statistical modelling, that a given country needs to attain a certain target growth and its own savings – foreign aids have been pouring money into developing countries according to standards and goals set “from the outside” (by developed countries). For this reason, foreign aids have eventually prevented the poor they were meant to aid from finding solutions that were really suited to their own problems. Moreover, they have also hampered the efficiency of local institution, by feeding corrupted officers and creating a lobby of humanitarian agencies whose only goal is to perpetuate themselves. Giving money to developing countries on the basis of their alleged “financing gap”, writes Easterly,
creates perverse incentives for the recipient, as was recognized long ago. The financing gap is larger, and aid larger, the lower the saving of the recipient. This creates incentives against the recipient’s marshalling its own resources for development.(Easterly 2002, page 44)

   Those two competing standpoints on foreign aids also apply to “technology transfer” in the domain of health and biological technologies. Are we sure that people suffering from hunger and diseases in developing countries do really need a technology designed in Europe or in the USA? Do we know how to successfully “transfer” such technology without incurring in the “fallacies” highlighted by Easterly?

   Esther Duflo and Abhijt Banerjee provide a good answer to all these questions in their thoughtful analysis of Poor Economics (Duflo and Banerjee 2011). They argue that the debate on international cooperation has been so far “over-focused” on big theoretical problems, such as the ultimate cause of poverty the importance of democracy for the poor and, precisely, the effectiveness of foreign aid. For this reason, they recommend a radical “focus shift” towards more concrete questions: which is the more effective way to fight malaria in a certain region at a certain time? Does a particular foreign aid program succeed in reaching a particular goal in a particular situation? What should be made to improve children’s education in a given country under given circumstances? Does a poverty trap really exist in a given circumstance?

   Such new perspective relies on two fundamental tenets: on one hand, it implies raising the question of how poor people actually think and make choices; on the other, the shift from abstract dilemmas to concrete problems requires a reliable tool for testing assumptions and verifying facts. As for this second point, Duflo and Banerjee urge economists to adopt randomized control trials, in order to “implement large-scale experiments designed to test if interventions work”. In their essay, they apply this same methodology to a wide range of problems concerning poverty in developing countries. One chapter is devoted to analysing how the poor make decisions on their own health, and particularly why they seem to underexploit very cheap and reachable solutions. The conclusion they reached is that the poor are confronted with the same problems as the inhabitants of rich countries, such the lack of adequate information, weak convictions and procrastination. The real “difference” between those two social groups lies in the fact that the latter live in houses provided with purified tap water, so that they do not have to decide how to disinfect it, they do not have any alternative to having their children vaccinated (otherwise they would be rejected by any public school), they do not have to worry about getting food, and so on.

   In other words, those who live in rich countries are surrounded by invisible “nudges” that prevent them from consuming their limited “stock” of patience, self-control and force of will. On the contrary, the poor, especially those living in developing countries, are constantly called to practice such virtues, due to lack of any social nudge. For this reason, the authors argue that we should get rid of the idea that people are so patient or so well informed that they can take full responsibility for their health choices. This implies accepting that the fundamental goal of health policies in developing countries should consist in fostering as much as possible the access to free preventive care and in regulating the supply of the most expensive treatments. Duflo and Banerjee maintain that health could never improve in developing countries without the active intervention of public authorities, whose investments would later be repaid by the general benefit deriving from a fall in mortality rates and a rise in buying power. The authors concede that such conclusions might sound paternalistic and, to some extent, it is truly so. However, as they argue, it is too easy to denounce paternalism while comfortably sitting in our sofa.

   In conclusion, Duflo and Banerjee’s analyses challenge us to try to understand the real needs and preferences of those at whom our technology is aimed. They also challenge us to “empathise” with them, to “put us in their shoes”. This challenge was all the more appealing to us, since we discovered that another iGEM team was working on tuberculosis. Moreover, this team was based in Indonesia, a country in which tuberculosis infection rates are considerably higher than in France. We had the opportunity to arrange a nice discussion with some members of the team, during which we shared our different backgrounds and our motivations. We also asked their opinion on our project, especially the TBception component, and discussed briefly some concerns. In particular, we discussed about the opportunity of implementing on a wide scale a treatment involving a bacterial vector and not only a given protein. This exchange of opinions was most welcomed, since it enriched our experience of the iGEM competition: synthetic biology is fun and challenging, but we have to always bear in mind that it can serve as a powerful tool for better helping out our fellow human beings.

Guidelines for discussion on biotechnology transfer for global health and environmental problems

1. Trying to get a “big picture” of the problem one wants to address: data, available analyses and previous applications of a given technology to this problem.
2. Trying to understand the social and human impact of this problem. In particular, it is important to identify which areas of the world and which segments of population are affected the most by this problem.
3. Trying to collect information on how international institutions and various aid agencies have been tackling the problem so far. Are there major shortcomings and flaws, or major advancements, to be pointed out? What could the iGEM team learn from the outcome of those humanitarian programs?
4. Trying to focus on the concrete effects, both positive and negative, that the implementation of the team’s project could have on those at whom it is aimed: which are their real needs and the burdens deriving from their condition? How could the team’s project be possibly translated into an appealing solution for them? Are those people suffering from a poverty trap that requires new investments? Do cheap and effective solutions already exist, which should only be fully exploited?
5. Trying to focus on possible gender issues related to the problem the team wants to tackle: how does this problem affect women in particular countries? How could the team’s prospected solutions, in turn, affect those women?
6. Trying to actually discuss with people actually involved in solving the same problem, or people who have good knowledge of the environment in which the team’s project could possibly find an application. Trying also to “design” possible application guidelines and tools for verifying the actual effectiveness of the project.
7. Always empathize with those we work with and those our project is aimed at: science and technology always have a human face!