Representation and Governance in International Organizations

What does representation mean when applied to international organizations? While many scholars working on normative questions related to global governance often make use of the concept of representation, few have addressed specifics of applying the concept to the rules and practices by which IOs operate. This article examines representation as a fundamental, albeit often neglected, norm of governance which, if perceived to be deficient or unfair, can interfere with other components of governance, as well as with performance of an organization’s core tasks by undermining legitimacy. We argue that the concept of representation has been neglected in the ongoing debates about good governance and democratic deficits within IOs. We aim to correct this by drawing on insights from normative political theory considerations of representation. The article then applies theoretical aspects of representation to the governance of the International Monetary Fund. We determine that subjecting IOs to this kind of conceptual scrutiny highlights important deficiencies in representational practices in global politics. Finally, our conclusion argues scholars of global governance need to address the normative and empirical implications of conceptualizing representation at the supranational level

Representation and Governance in International Organizations

What does representation mean when applied to international organizations? While many scholars working on normative questions related to global governance often make use of the concept of representation, few have addressed specifics of applying the concept to the rules and practices by which IOs operate. This article examines representation as a fundamental, albeit often neglected, norm of governance which, if perceived to be deficient or unfair, can interfere with other components of governance, as well as with performance of an organization’s core tasks by undermining legitimacy. We argue that the concept of representation has been neglected in the ongoing debates about good governance and democratic deficits within IOs. We aim to correct this by drawing on insights from normative political theory considerations of representation. The article then applies theoretical aspects of representation to the governance of the International Monetary Fund. We determine that subjecting IOs to this kind of conceptual scrutiny highlights important deficiencies in representational practices in global politics. Finally, our conclusion argues scholars of global governance need to address the normative and empirical implications of conceptualizing representation at the supranational level

China's Leadership in Global Economic Governance and the Creation of the Asian Infrastructure Investment Bank

Abstract Are we witnessing a restructuring of the global economic order, akin to the period immediately after World War Two; or is China's leadership in global economic governance ancillary -even complimentary -to the existing order? To assess how China's role in global economic governance has transformed, we examine China's engagement with the World Bank (WB) and Asian Development Bank (AsDB). We analyze how the governance systems of these legacy intergovernmental organizations (IOs) have adjusted to the rise of China. We then turn to an inspection of China's leadership within the Asian Infrastructure Investment Bank (AIIB) to determine whether it parallels or diverges from governance arrangements in legacy IOs. Our findings indicate that the AsDB and WB have failed to adjust to suitably account for the increased influence of China. Our conclusion suggests the creation of the AIIB was the result of frustration with the glacial pace of governance change in American-dominated global institutions. At the same time, we conclude the AIIB should not be seen as a direct challenge to legacy IOs and American dominance of global economic governance. We expect the continued widespread dissatisfaction of China and other rising powers within the American global order unless legacy IOs undertake significant adjustments to their internal governance mechanisms

Representation and Governance in International Organizations

What does representation mean when applied to international organizations? While many scholars working on normative questions related to global governance often make use of the concept of representation, few have addressed specifics of applying the concept to the rules and practices by which IOs operate. This article examines representation as a fundamental, albeit often neglected, norm of governance which, if perceived to be deficient or unfair, can interfere with other components of governance, as well as with performance of an organization’s core tasks by undermining legitimacy. We argue that the concept of representation has been neglected in the ongoing debates about good governance and democratic deficits within IOs. We aim to correct this by drawing on insights from normative political theory considerations of representation. The article then applies theoretical aspects of representation to the governance of the International Monetary Fund. We determine that subjecting IOs to this kind of conceptual scrutiny highlights important deficiencies in representational practices in global politics. Finally, our conclusion argues scholars of global governance need to address the normative and empirical implications of conceptualizing representation at the supranational level. (author's abstract

A prescription for clinical immunology: the pills are available and ready for testing. A review

Modern immunology has been extremely successful in elucidating many features of the immune system, but not in stemming pandemics of non-infectious, immune-related disease associated with industrialized populations. These pandemics involve a broad range of allergic, autoimmune, and inflammatory diseases, potentially including neuroinflammatory-associated disorders. It is the purpose of this review to outline the literature pointing toward the causes and potential treatments of these problems

Hydroxyurea for primary stroke prevention in children with sickle cell anaemia in Nigeria (SPRING): a double-blind, multicentre, randomised, phase 3 trial

Background: In high-income countries, standard care for primary stroke prevention in children with sickle cell anaemia and abnormal transcranial Doppler velocities results in a 92% relative risk reduction of strokes but mandates initial monthly blood transfusion. In Africa, where regular blood transfusion is not feasible for most children, we tested the hypothesis that initial moderate-dose compared with low-dose hydroxyurea decreases the incidence of strokes for children with abnormal transcranial Doppler velocities.Methods: SPRING is a double-blind, parallel-group, randomised, controlled, phase 3 trial of children aged 5-12 years with sickle cell anaemia with abnormal transcranial Doppler velocities conducted at three teaching hospitals in Nigeria. For randomisation, we used a permuted block allocation scheme with block sizes of four, stratified by sex and site. Allocation was concealed from all but the pharmacists and statisticians. Participants were assigned in a 1:1 ratio to low-dose (10 mg/kg per day) or moderate-dose (20 mg/kg per day) oral hydroxyurea taken once daily with monthly clinical evaluation and laboratory monitoring. The primary outcome was initial stroke or transient ischaemic attack, centrally adjudicated. The secondary outcome was all-cause hospitalisation. We used the intention-to-treat population for data analysis. The trial was stopped early for futility after a planned minimum follow-up of 3·0 years to follow-up for participants. This trial was registered with ClinicalTrials.gov, number NCT02560935.FINDINGS: Between Aug 2, 2016, and June 14, 2018, 220 participants (median age 7·2 years [IQR 5·5-8·9]; 114 [52%] female) were randomly allocated and followed for a median of 2·4 years (IQR 2·0-2·8). All participants were Nigerian and were from the following ethnic groups: 179 (82%) people were Hausa, 25 (11%) were Fulani, and 16 (7%) identified as another ethnicity. In the low-dose hydroxyurea group, three (3%) of 109 participants had strokes, with an incidence rate of 1·19 per 100 person-years and in the moderate-dose hydroxyurea group five (5%) of 111 had strokes with an incidence rate of 1·92 per 100 person-years (incidence rate ratio 0·62 [95% CI 0·10-3·20], p=0·77). The incidence rate ratio of hospitalisation for any reason was 1·71 (95% CI 1·15-2·57, p=0·0071), with higher incidence rates per 100 person-years in the low-dose group versus the moderate-dose group (27·43 vs 16·08). No participant had hydroxyurea treatment stopped for myelosuppression.Interpretation: Compared with low-dose hydroxyurea therapy, participants treated with moderate-dose hydroxyurea had no difference in the stroke incidence rate. However, secondary analyses suggest that the moderate-dose group could lower incidence rates for all-cause hospitalisations. These findings provide an evidence-based guideline for the use of low-dose hydroxyurea therapy for children with sickle cell anaemia at risk of stroke.Funding: National Institute of Neurological Disorders and Stroke

Randomized controlled trial of fixed low-vs moderate-dose hydroxyurea for primary stroke prevention in Sub-Saharan Africa: Final results of the Spring Trial

Introduction: In children with sickle cell anemia (SCA) without transcranial Doppler (TCD) screening, the incidence rates of ischemic strokes is approximately the same among children living in low- and high- low-resource settings (Pediatr Neurol. 2019;95:73-78.) with a prevalence of ~ 11%. However, in high-income settings, the standard use of TCD ultrasonography, coupled initially with monthly blood transfusion therapy has dropped the stroke prevalence to < 1%. In a low-income setting, such as Nigeria, where 50% of children in the world with SCA are born (150,000 per year), initial monthly blood transfusion therapy is not practical for most children.In the Stroke Prevention in Nigeria (SPIN) Feasibility Trial (NCT01801423), fixed moderate-dose hydroxyurea was associated with a decreased rate of strokes in children with SCA and abnormal time-averaged mean of the maximum velocity (TAMMV) TCD measurements (≥200cm/sec) when compared to no treatment in the STOP Trial, 0.76 and 10.7 strokes per 100 person-years, repsectively (Am J Hematol. 2020). Based on the success of the SPIN trial, plus the challenges of real-world implementation of a government-supported primary stroke prevention programs for estimated 40,0000 children with SCA in three states in Nigeria, we tested the hypothesis that fixed-moderate dose (~20 mg/kg/day) hydroxyurea therapy for primary stroke prevention results in a 66% relative risk reduction (9 to 3 events per 100 person-years) when compared to fixed low-dose hydroxyurea (~10 mg/kg/day) therapy in a randomized controlled trial (The SPRING Trial; NCT02560935).Methods: In this partial-blind controlled phase III trial, we randomly assigned children between 5 and 12 years of age with SCA and a TCD time-averaged mean of the maximum velocity (TAMMV) ≥ 200 cm/sec measured independently twice or TAMMV ≥220 cm/sec once at study screening to receive fixed low-dose or fixed moderate-dose hydroxyurea. The primary endpoint was a clinical stroke or a transient ischemic attack (TIA). Myelosuppression was assessed with monthly complete blood counts (CBCs). Adherence to hydroxyurea was primarily based on an increase in MCV from baseline and monthly pill count return as a percent of dispensed pills. Hemoglobin F levels were measured at baseline, annually and upon trial exit. To evaluate the safety of hydroxyurea in the trial, children attending the same SCA clinics with TCD (TAMMV) <200 cm/sec at study screening were prospectively followed with biweekly phone calls and annual research visits.Results: A total of 220 children (mean age: 7.5 years, 51.8% female) were randomly assigned to fixed low- (10 mg/kg/day) or moderate- (20 mg/kg/day) dose hydroxyurea, and were followed for a median of 2.4 years (IQR 2.0-2.8). NINDS Clinical Trials leaders stopped the trial early because of futility for the primary outcome. In the fixed low- and moderate-dose hydroxyurea groups, the incidence rates of strokes per 100 person-years were 1.19 and 1.92 respectively, with an incidence rate ratio of 1.60 (95% CI: 0.31-10.34), p = 0.768. The incidence rate ratio of mortality when comparing the children treated with low- and moderate- fixed-dose hydroxyurea to the non-elevated TCD group (no hydroxyurea therapy, n= 211) was 1.97 (95% CI: 0.64-6.02) and 0.47 (95% CI: 0.05-2.38), p = 0.265 and 0.545, respectively. Returned pills during the trial was 5.4% and 4.8% in the fixed low- and moderate-dose groups, respectively, p= 0.144. MCV from baseline to endpoint increased 1.5fl and 7.2 fl in the fixed low- and moderate-dose groups, respectively, p<0.001. Upon exit from the trial 29.4% and 66.7% of the fixed- low and moderate -dose groups, respectively, had either hemoglobin level ≥ 9.0 g/dl, or a fetal hemoglobin level ≥ 20%.Conclusions: For primary stroke prevention in children with SCA, fixed low-dose, when compared to fixed moderate-dose hydroxyurea therapy, demonstrated no difference in the incidence rate of strokes. Both fixed low- and moderate -dose hydroxyurea doses are superior to no treatment for primary stroke prevention with abnormal TCD values. In partnership with Katsina, Kano, and Kaduna health department's leaders in Nigeria, 9 distinct SCA and primary stroke prevention clinics have been established, with the provision of free fixed low-dose hydroxyurea therapy (Bond Chemical, Nigeria; $0.15 per 500 mg) for abnormal TCD values, and biannual CBCs as standard care ,for over 40,000 children with SCA