April was Health Month on SSRN, and in our latest author interview we spoke with Professor Paul Spiegel, MD, Director of the Center for Humanitarian Health at Johns Hopkins University. He is recognised for his research on preventing and responding to complex humanitarian emergencies. We spoke to him about refugees, mental health and the challenges of using technology to assist in dealing with humanitarian crises…

Q: The UCL Lancet Commission article you co-wrote back in 2018 opens by talking about migration in terms of a billion people on the move. I imagine that number has only grown with the war in Yemen, with Ukraine, Sudan. How would you estimate current migration pressures? They seem to be getting worse…

PS: Yes, migration pressures have become significantly worse, but that was also sadly expected because of what’s happening with the climate emergency, or climate change. And then, of course, the more unexpected occurrence of something like what happened with Ukraine. There are so many issues when we’re looking at migration. We’ve often concentrated on forced migration, which is understandable because it hits the press. But there are so many other issues, particularly those in the realm of economic migration, and undocumented migration, that we’re seeing across the board everywhere, but of course both Europe and the United States are really being affected by this as well.

Q: Do you think the climate emergency is driving these big tidal movements of populations?

PS: I think it’s a mixture of things. It’s a mixture of governance, and in many cases, poor governance. We’re seeing that, for example, in Venezuela and in Turkey, with the incredible amount of inflation, which means people are moving. Climate change is clearly causing an issue, in terms of natural disasters; it’s always a bit more difficult to attribute movement directly to climate change, but there’s no question we’re seeing that. We’re also seeing migration due to the political system, the increase in populism, the changes from a unipolar world, that is one where the United States is up in front, to looking at what’s happening now with China, and where many of the unaligned countries are being forced to choose sides. All of these political pressures are increasing which is making people feel unsettled and so a tremendous amount of movement is occurring.

Q: It does seem as though the scale of those flows are asking questions that our current global political structures don’t seem to be able to answer. Do you see any governments or any international organisations that are showing the way? Do you see any kind of beacons of hope politically?

PS: Yes, and no. I would say some people and many organisations are showing the way by perhaps documenting and stating that this is not just a future problem, it’s a current problem and therefore calling on governments and the United Nations, to act. But I think that’s where we’re falling down after that. It takes an incredible political will, and in the case of the United Nations, it requires many, many governments to actually agree on what to do, and that’s clearly not happening. In terms of migration and migration policy, it’s a very emotive issue, a very divisive issue. Here in the United States now we’re seeing finally what was called Title 42 being ended, which was a public health title barring people from coming over due to COVID-19, which was a complete abuse of public health masquerading as a migration policy. I think just like with climate change itself, and all of the concerns and the issues that are coming up in terms of how your governments act, and how they react, it’s the same with migration. But I think it may even be more divisive because of the political climate as well, for example when you look at Britain, and what’s happened there, and what’s currently happening. The population of the world is divided, and I think it’s going to make it much more difficult to actually address in a productive and constructive manner, how to deal with migration, both economic and forced.

Q: Yes, and I’m sure you’re aware of our current home secretary’s dream of supporting illegal migrants from the UK to Rwanda. What would your response be to that policy idea? I know it echoes some of the tactics used by previous Australian governments.

PS: Right. It’s against at least the principle, or let’s say the spirit of refugee law, that’s number one. Number two is that it’s very unclear if there will be a safe environment, both in Rwanda and the other countries that have been willing to accept refugees. This sets an incredibly dangerous precedent of once again, the wealthier countries buying their way out of their responsibilities under refugee law, in order to send refugees to another country that certainly don’t have the capacity, and in some cases, the security to be able to welcome these people in the long term.

This current political climate is much worse than it was a couple decades ago, in terms of anti-migrant, anti-foreign, sentiment and we are now seeing governments resort to methods that really have not been accepted before. Many of us are very concerned that the norms are shifting, and that this may even come to seem acceptable in the future. It’s completely unacceptable.

Q: In the last 10 years, in the UK, there’s been an increasing interest in openness and talking about mental health issues in the media. Politicians and celebrities are talking about depression and burnout in ways that wouldn’t have happened in the past. I noticed you often emphasise the need to think about the mental health challenge of displaced peoples. How should we think about that, and does it often get missed out during humanitarian crises?

PS: Luckily in the UK and in other places, mental health is becoming more of an accepted issue and there is less stigma. That’s certainly the same in humanitarian settings. It is clearly recognised by humanitarians as an important issue that needs to be addressed. In the past I think it was certainly not given as much emphasis, so that’s positive. But there are quite some differences, I would say. In terms of refugees, or internally displaced persons or others that are forcibly displaced, one aspect is losing everything that they have, which they have to deal with. Another aspect is the loss that may have occurred, particularly if there was a conflict or as we’ve seen in earthquakes like those that happened in Turkey and Syria. Then there’s a whole other area that we need to deal with, which is more a lack of livelihoods, feeling a lack of productivity in many of these refugee camps. People are being warehoused and they’re not really able to work. They’re restricted. There are a couple different ways to try to address mental health here. One is by trying to have as much normalcy as possible. Having child friendly spaces and making sure children go to school is the obvious point, but other ways are to try to work with host governments and allow refugees to work. There have been more and more studies showing that ultimately refugees, whether it be in in high-income countries or low-income countries, are often very beneficial to the local economy where they are. They don’t actually take money or have a negative effect on the economy. Depending on the refugees’ profile, some people within the national population will benefit and others will not. But overall, refugees have a positive effect on most economies, and so we should figure out a way to be able to allow them to work, which probably will address many of their mental health issues. The next component is from a medical point of view, that in large scale displacement it’s going to be very difficult to be able to get a psychologist or a psychiatrist to work individually, for individual people. So we need to work on different ways of doing cognitive behavioural therapy, or training people, perhaps community workers, to be able to address this, at least at the beginning, so that more people can receive and understand how to do some simple cognitive behavioural therapy that will improve their situation.

Q: You have to find mental health solutions that can scale…

PS: Yes, definitely. And that’s difficult. For example, most recently, I was leading the emergency refugee response. And mental health was a big, big issue, of course, and you had many, many problems. One was, of course, language and cultural issues when you’re displaced into another country. But on top of that, in many countries, including all of our countries, generally there are not enough mental health experts to address the national populations, and then you also have a huge influx. And on top of that, many times, mental health is not necessarily covered as part of the basic packages in terms of health insurance. That’s another big area that needs to be addressed.

Q: What is your opinion are on the rising tide of online mental health solutions, like eCBT apps or Woebot, which can talk back to you and talk you through a problem. How do you see that playing out in terms of the refugee crisis? Would that be a potential solution?

PS: Yeah, that’s a good point, certainly, online solutions can help dealing with people’s issues, particularly if they can speak the language, and understand the culture. I don’t think I’m sufficiently knowledgeable in terms of the apps, but I think it’s something to consider, certainly with AI. But I don’t know the science behind it. We did talk about using the Ukrainian diaspora to try to support Ukrainians in terms of mental health. And the same thing has happened in the Syrian crisis. Certainly, with technology there have been very many interesting and positive consequences of COVID, and one of them is dealing with online medical care.

Q: I was struck by a piece in The Washington Post in which you were talking about how people were using Facebook data to track the movements of the social media refugees. Social media and refugees – you don’t think of those in the same mental box, but these platforms may have data and technology that might help us to address this issue.

PS: I’m glad you brought that up, because it’s something that many of us are very, very interested in – but we’re running into a lot of roadblocks. I would say there are a couple different aspects. One is can I use public data to be able to both track where people may be moving, but also try to get signals in terms of potential diseases of epidemic potential? There are things that already exist, for example data scraping, you can start looking at both on the Web and local newspapers, all of that exists. But probably the most important data are private data, or at least companies that have this data. So definitely Facebook and Meta, Twitter, and cell phone data would be hugely, hugely important to be able to follow people as they move. And that’s been done in some situations. Google Maps is really interesting. Google did some really interesting work in quarantine during COVID-19, using Google Maps. But there are two major problems and I don’t want to underestimate them. Many of the social media companies are understandably very concerned, as they have a reputational risk that they’re lending user data be used in nefarious ways. So, they’re becoming more careful now, in terms of how this data would be used, even if people have given consent. although admittedly, many are not aware of that they may have given that consent. But then there are other data that would be really interesting to us, and could be possible, there are a lot of regulatory issues. And there are a lot of data privacy and security issues. I think many of us believe that there should be ways to get around that when you have exceptional circumstances, but that really requires a regulatory environment that doesn’t exist now. And so, I’ll just give some examples. One would be looking at what we call personal health or personal medical records. One of the biggest problems we run into is when people move, even within a country, but certainly outside of a country, and we lose continuity of care. Maintaining continuity of care is is very difficult for children’s vaccinations, non-communicable chronic diseases, what medicine people are taking, what are the protocols for TB, or other diseases compared to where they are now. We could save a tremendous amount of money and we would help people much, much more, if people had access to their own records. It’s their agency, they should own those records. Then they could decide to use biometrics in the cloud, the usual blockchain that everyone talks about, and the technology exists where we could have that. But it’s complicated in terms of data privacy and so it’s not happening yet. It can be frustrating when we have the technology, we know it can work, but we’re not able to actually do that. It would be so much more cost effective, it would save millions and millions of Euros, and we would reduce antibiotic resistance, and other drug resistance. And then finally, we would be able to provide people with continuity of care so there would be less morbidity and mortality.

Q: It’s almost if you imagine a kind of global USB medical dog tag. So whatever country you end up in, you can plug in their health system. 

PS: And you don’t even need the dog tag – it can all be done in the cloud, and then we just use biometrics. And it exists. And, in my understanding there’s even those at Google and in other places working on some of the frameworks. Because I think we recognise that it’s clear there won’t be one system globally, it never works like that. But if there can be a framework where if you have multiple systems, it can move on to that framework…When we start looking into the details about how this can happen, and then particularly in some of the countries where we work, where you don’t have electronic medical records to begin with, and even at the clinics, the health care workers don’t have the capacity to do their job. And then in most of the world, you know, health records generally stay, whether it be written or even online, they stay part of that organisation, or part of the government. And this would be a complete shift. So, there’s a whole set of power and autonomy issues to address.

Q: In terms of your role and work, how does your of academic research work sit within what you do – because you clearly do a lot of policy and advocacy?

PS: I’m a bit of an odd duck, I’m called a Professor of Practice, and I’ve always been connected to academia, but much of my work has always been practice. So previously, it was within NGOs and then with the UN. I did my residency at Johns Hopkins many, many years ago, and coming back it’s actually been really enjoyable to be able to try to work with academics in a multi-sectoral environment. Not just sticking with public health, but trying to work with the political scientists, the engineers, so trying to look at things in a multidisciplinary way. To take it to that next step of not just publishing articles, but actually trying to advocate using evidence to ensure that what we’re doing has an effect in the field. That’s been, I would say, both the challenge and what’s become quite enjoyable. We do some bread-and-butter things like everyone, in terms of looking at health information systems, looking at monitoring and evaluation to try to improve existing systems. But what I’d like to do is to push the envelope on areas from my practice days – I still do practice, I still respond to emergencies – as there are so many gaps. I think that it’s incumbent upon us to try, even if we can’t make a change – although I hope that we can make a change, at least to advocate for those changes using clear evidence. So, technology is one. Another one that I am really excited about is, it’s a new name and an old concept, which is now called the Humanitarian Development Peace Nexus, but in essence, we’re working and doing a bunch of studies to look at how the Humanitarians and the Development people work or do not work together. Not surprisingly, they don’t work together very well, there’s such division and just like with the issue of medical records, there’s so much waste in the long term, even within the same government. You have your development people focusing on one area, humanitarian people maybe even in the same area, and they’re not working together, they’re not looking at sustainability. There’s a lot that can be done. I do hope that our research will not just be in published journals, but actually will change practice.

Q: How does the working paper, the preprint and SSRN, sit within your kind of publishing?

PS: Yeah, so it’s interesting, I’ve been thinking a lot about that, too. I think that preprints are important in certain areas, particularly when you’re publishing something like in the COVID-19 era that needs to get out there so that either research or policymakers need to know about it. My concern is that in some situations it’s still being reviewed, and so it hasn’t necessarily gone through the full peer review process. And I would have concerns at times. And I’ve seen this both in COVID-19 and the media particularly, that people latch on – I’m less concerned about researchers latching on to something that actually hasn’t gone through a full review. And in the end, it could be rejected or there could be a major revision. So, I think that it’s a very important point when the data that we are discussing where the conclusions need more immediate response. Otherwise, if it’s something that is longer term, I’m not convinced that we need to move there until everything has been finalised through peer review. There does need to be some sort of thinking on this. There needs to be some sort of decision tree to say, should we do preprints? Or when it when is it appropriate to release preprints when research hasn’t yet been finalised?

Q: Is there any current work that you’ve published recently that you think people should focus on?

PS: We just published something last week on the BMJ, looking at migration and detention, issues, and processes. And so, we tried to do this broadly, we weren’t there yet. This is an example of unfunded research, but everyone was just passionate about it. We were working with three countries in Europe, and then the United States here. We were trying to look at detention standards in these countries and so what we published two weeks ago was looking at, in the US, you have three different agencies, the Immigration and Customs Enforcement, the Customs and Border Protection and Office of Refugee Resettlement. But the bottom line is, you have people coming into the country, and they are detained for 72 hours in theory, although it’s often longer, but it’s supposed to be 72. And then they go to different areas We developed a framework to evaluate the existing standard standards, both in terms of protection, gender-based violence, health, and mental health. Perhaps not surprisingly we found them lacking in complementarity. Certain assumptions were made, but they were not followed up, such as people should be moved out within 72 hours, but often they stay much longer, and therefore their care is different. And so I am hopeful that this can start this discussion, one about detention itself, because I think many of us feel that detention should be a last resort, and it’s often not necessary. There are many other ways that we can deal with migrants outside of detaining them. If the government do decide they’re going to detain certain migrants, we need to ensure that there are complementary standards, and that they actually are enforced.

Here are some recent papers from Paul Spiegel:

Evaluation of the US detention standards to protect the health and dignity of migrants: a systematic review of national health standards (BMJ)

HIV Infection and Engagement in the Care Continuum Among Venezuelan Migrants and Refugees: Results of a Biobehavioral Survey in Colombia

Meeting the Health Challenges of Displaced Populations from Ukraine

COVID-19: Projecting the Impact in Rohingya Refugee Camps and Beyond

You can check out his SSRN author profile here

In our latest author interview we chat with David Gamage, Law Professor and Whistler Faculty Fellow at Indiana University Maurer School of Law. He’s spent time outside academia, working with the US Treasury Department as an advisor during the Obama Administration on the Affordable Care Act, and also happens to be one of topmost downloaded Law authors on SSRN. We spoke about wealth, fairness and the challenges of taxing global corporations…

Q: Tax is in the news this month as the UK Prime Minister has finally released his tax return, which revealed that on his income of £4.8m over the last three years he paid just over £1m in tax over the course of the three years. This gave him an effective tax rate of 22%, which is lower than many people who earn far less. The issue is that tax earnings from work in both the UK and the US tend to be taxed at a far higher rate than earnings from wealth such as shares and investments – why is that?

In the US, and in most parts of the world, it turns out it’s very hard to tax really wealthy people. We talk about the strategy of ‘Buy, borrow, die…’ If you are wealthy, you want to get your income treated within the tax system as an investment return. Then when you need money, you borrow from those returns, and as that borrowing isn’t treated as income you aren’t taxed on it. Then you have a lot of money you can do stuff with. The final step, ‘Die’ is that in the US you aren’t taxed on investment gains at death. Most taxpayers don’t play all these games, but a lot of very rich taxpayers do play these games to a very substantial extent. As a result, taxpayers with many millions of dollars in wealth can often end up paying an effective tax rate on their true income of something like 8% or less in the US, and unlike in the UK we don’t have any Value Added Tax (VAT) on consumption. Overall, the very wealthy who do this type of tax planning just don’t pay much tax compared to ordinary people.

Q: That sounds like something people might want to change…

Right, so the question is why can’t we just fix this? The reality is that there is no straightforward easy fix, so what I have tried to do in much of my work and my research is to devise better systems. The Canadian system doesn’t have the die step, for example, but there are still a whole variety of things the very wealthy can do to forever defer paying taxes. Another promising reform strategy is to adopt some form of wealth tax, like in Switzerland. In the United States, Senators Warren and Sanders, among others, have proposed wealth tax reforms. I was heavily involved in consulting on Senator Warren’s proposed wealth tax reforms, and I have also been heavily involved in a number of similar state-level reform efforts. As another approach for reform, President Biden has proposed a Billionaires Minimum Income Tax reform proposal. I helped develop this reform proposal and co-drafted the legislation to enact this reform. The basic idea is to end deferral for most extremely wealth taxpayers by measuring their investment gains annually without waiting for sale transactions, for purposes of levying an alternative minimum tax. In other words, the idea is to try to tax very wealthy peoples’ income as it accrues, as their wealth accumulates.

Q: I’m interested in this idea about taxing wealth being all about timing – if you bring in a wealth tax that the wealthy don’t like, they postpone realising gains until a new regime appears that taxes them less. Is this why an annual wealth tax would be so powerful?

The fact that wealthy taxpayers can take planning steps to defer their tax liabilities until some future date, and then later take steps to completely escape taxation, has long been understood as the Achilles’ Heel of a realization-based tax system. For that reason, I have argued in my scholarship that some sort of accrual-based measurement system that limits deferral is needed in order to effectively tax extremely wealthy taxpayers. Among other reasons, this is because both history and theory suggest that if you don’t tax now, you will never successfully tax ever. The odds that a political environment supporting robust and comprehensive taxation will last long enough to effectively tax these deferred tax liabilities on the back end, are just low! 

Q: In the paper you wrote recently on SSRN with Darien Shanske, you made the case for an Alternative Minimum Tax (AMT) at the state level, to deal with Corporates using profit shifting to avoid tax. I’m fascinated by the idea of profit shifting, can you talk a bit about what corporations are doing and how an AMT could help?

Many large corporations, especially most large US Tech and Pharma corporations, set up subsidiaries in low-tax or no-tax jurisdictions, such as Ireland, or more aggressively in places such as the Caymans.

So then, once a corporate taxpayer has a subsidiary in a low-tax or a zero-tax country, they then find a way to have that subsidiary charge very high charges to the US parent, such as for interest on a loan or rent for intellectual property or the like. This is the problem of transfer pricing. If the US parent and a subsidiary in a low-tax country are engaged in a transaction wherein the subsidiary is charging the parent for something, how should we treat this transaction for tax purposes? There isn’t a real market transaction, because it’s in a sense just one hand talking to the other hand –  so if my right hand charged my left hand high rents, all of a sudden it looks like my hand being charged high rents doesn’t have much profit –  and so the reported profits for tax purposes go to the hand charging the high rents where it turns out taxes just happened to be low…

The truth is that there is no perfect solution to global profit shifting. Instead, there are two different sets of approaches, one is “Let’s tax global income of our corporations.” The US income tax system used to do that in theory, but it was pretty easy to get out of it. Under that approach, the problem is that if you do tax these corporations more, they might just leave the US. 

The other set of approaches is to just tax just the domestic income of the corporations, but the problem there is profit shifting. The corporations can play accounting games to move the profits to low or no-tax countries. 

The new US federal Corporate Alternative Minimum Tax is designed to combat profit shifting by adopting the approach of partially taxing the global income of corporations, but only to a limited degree as a form of alternative minimum tax. The CAMT only applies to very large corporations who are doing a lot of profit shifting, so it’s pretty far from going to a complete world-wide tax system. My article with Darien Shanske argues that profit shifting is also a problem at the US State level, and that the US states should consider conforming to the new federal CAMT in order to combat this profit shifting as it affects state-level corporate taxes.

Q: What do think is the single most inefficient aspect of the US Tax code?

I would say that is the realization rule for the income tax. Or more broadly, I would cite to buy/borrow/die. That is: the ability of wealthy taxpayers to accrue their income in the form of asset appreciation that is not currently taxed, then to access that income tax-free by borrowing, and finally to erase all of those deferred tax liabilities when they die, so as to ultimately escape the tax entirely. This is a giant open door to tax avoidance. It distorts the economy through all the wasteful transactions taxpayers engage in to move their money through this gaping wound to escape tax.

Q: What do think is the single most unfair aspect of the US Tax code?

I think it’s that billionaires and mega-millionaires can have such extremely low effective tax rates. Somebody has to pay for government, so the middle class and working class are paying for government, and we are running very large budget deficits – but the very wealthy are benefiting from the legal system, the military and the security apparatus that keeps them and their wealth secure.

I have also written on how this all builds on historical forms of disadvantage and oppression. For instance, the black descendants of slavery didn’t historically have the opportunities to build wealth and take advantage of the many ways that the government supports wealth building. And now these historically disadvantaged taxpayers end up paying much higher effective rates of tax because of the flaws in the tax system.

Q: What is the one thing we could to increase the transparency of the US tax code?

This is difficult. Transparency is an inherently complex issue. I have written about salience and transparency, and it is often not clear what sort of information about taxation should be provided and in what manner in order to foster the philosophical ideals underlying transparency goals. For instance, some have claimed that a Value Added Tax is not transparent, because you don’t see the price of that tax on the register when purchases are made, by contrast to sales taxes in the United States. But taxpayers don’t see the ways that the government spends the funds raised by a VAT, and how this spending supports the economy, when they make purchases at the register either. 

You could imagine a hypothetical world in which, when you bought an apple, you got a complete report of all the services the government gave you that enabled that apple sale along with all of the costs of all taxes that affect the price of that apple. But this hypothetical is of course absurd. In a world of limited attention spans, limited time, and limited information, we cannot provide complete information about all aspects of taxation at the time when every purchase or transaction is made. 

There are lots of government reports analyzing the tax system and its impacts, and these reports are generally made publicly available – as they should be. What more beyond this should be done to further transparency goals is a difficult set of questions.

I think in the US we currently have an excessively cumbersome tax filing return system, that people hate. Some conservatives think that making people suffer through a painful approach for filing taxes is important for transparency. The UK has a much better system in my view, certainly much less painful in terms of tax filing. I think people in the UK are aware that their tax system exists and are aware they pay taxes, and that no meaningful transparency goals would be furthered by requiring UK taxpayers to jump through more tax filing hoops, painfully, as in the US, forcing them to do paperwork every year which could be done more easily by government computers.

Q: You had some experience working in the Treasury Department under the Obama administration: what’s it like going from an academic discussion about tax policy to actually working on tax policy advice? Did anything about that transition surprise you?

In my prior government position, I was primarily working on the tax provisions of the Affordable Care Act—the major health care reform enacted under former President Obama. The Affordable Care Act was the largest healthcare reform in the US in over 30 years and was substantially enacted through the tax code.

Being in government for a time was a fun, interesting experience which I think has really helped my understanding of the world. But the skill set of being an effective actor in Government is quite different from being an academic, even though the issues are similar. At the end of my time in government, I was quite happy to return to my scholarship and teaching.

Q. What role have preprints in general and SSRN in particular played in your particular academic work?

First, I’m going to tell you one of my pet peeves about SSRN. SSRN doesn’t track legal citations very well, at least US legal citations, because most legal publications use footnotes instead of end notes. As a result, for myself and for other prominent American legal scholars, the number of citations shown on SSRN is embarrassingly and erroneously low. I’d much rather SSRN not count citations at all than falsely undercount citations for legal scholars.

{SSRN writes: Noted! We are painfully aware of this issue, which is caused by technical challenge of extracting that metadata from PDF footnotes that we’ve so far been unable to solve…we will definitely pass on that feedback.}

Today, there are lots of places that people can post their work online to make it accessible, which has been transformative. In my view, it is important for the marketplace of ideas for academic drafts and working papers, as well as final publications, to be accessible and available.

SSRN is my preferred place to put academic work online. One big reason is that SSRN doesn’t charge anyone for access – if it did charge, I would go somewhere else, it’s just great that people don’t have to pay to access research. It’s also critically important that my work is under my control. Universities often create systems for posting papers that have a lot of bureaucracy; I spent eight years at UC Berkeley at the beginning of my career, but my SSRN posted papers move with me and remain under my control.

Here are some recent papers from David Gamage on SSRN:

Why States Should Conform to the New Corporate AMT

Amicus Curiae Brief of Law Professors

Tax Base Diversification as an Enforcement Tool

Phased Mark-to-Market for Billionaire Income Tax Reforms

Billionaire Mark-to-Market Reforms: Response to Susswein and Brown

You can check out David Gamage’s Author Profile here