Can AI help create “smart borders” between countries?
A refugee in Uganda’s Oruchinga settlement uses an iris scan to claim food assistance.
In 2016, border patrols in Greece, Latvia and Hungary received a prototype for an AI-powered lie detector to help screen asylum seekers. The detector, called iBorderCtrl, was funded by the European Commission in hopes to eventually mitigate refugee crises like the one sparked by the Syrian civil war a year prior.
iBorderCtrl, which analyzes micro expressions in the face, received but one slice of the Commission’s €34.9 billion border control and migration management budget. Still in development is the more ambitious EuMigraTool, a predictive AI system that will process internet news and social media posts to estimate not only the number of migrants heading for a particular country, but also the “risks of tensions between migrants and EU citizens.”
Both iBorderCtrl and EuMigraTool are part of a broader trend: the growing digitization of migration-related technologies. Outside of the EU, in refugee camps in Jordan, the United Nations introduced iris scanning software to distribute humanitarian aid, including food and medicine. And in the United States, Customs and Border Protection has attempted to automate its services through an app called CBP One, which both travelers and asylum seekers can use to apply for I-94 forms, the arrival-departure record cards for people who are not U.S. citizens or permanent residents.
According to Koen Leurs, professor of gender, media and migration studies at Utrecht University in the Netherlands, we have arrived at a point where migration management has become so reliant on digital technology that the former can no longer be studied in isolation from the latter. Investigating this reliance for his new book, Digital Migration, Leurs came to the conclusion that applications like those mentioned above are more often than not a double-edged sword, presenting both benefits and drawbacks.
There has been “a huge acceleration” in the way digital technologies “dehumanize people,” says Koen Leurs, professor of gender, media and migration studies at Utrecht University in the Netherlands. Governments treat asylum seekers as test subjects for new inventions, all along the borders of the developed world.
On the one hand, digital technology can make migration management more efficient and less labor intensive, enabling countries to process larger numbers of people in a time when global movement is on the rise due to globalization and political instability. Leurs also discovered that informal knowledge networks such as Informed Immigrant, an online resource that connects migrants to social workers and community organizers, have positively impacted the lives of their users. The same, Leurs notes, is true of platforms like Twitter, Facebook, and WhatsApp, all of which migrants use to stay in touch with each other as well as their families back home. “The emotional support you receive through social media is something we all came to appreciate during the COVID pandemic,” Leurs says. “For refugees, this had already been common knowledge for years.”
On the flipside, automatization of migration management – particularly through the use of AI – has spawned extensive criticism from human rights activists. Sharing their sentiment, Leurs attests that many so-called innovations are making life harder for migrants, not easier. He also says there has been “a huge acceleration” in the way digital technologies “dehumanize people,” and that governments treat asylum seekers as test subjects for new inventions, all along the borders of the developed world.
In Jordan, for example, refugees had to scan their irises in order to collect aid, prompting the question of whether such measures are ethical. Speaking to Reuters, Petra Molnar, a fellow at Harvard University’s Berkman Klein Center for Internet and Society, said that she was troubled by the fact that this experiment was done on marginalized people. “The refugees are guinea pigs,” she said. “Imagine what would happen at your local grocery store if all of a sudden iris scanning became a thing,” she pointed out. “People would be up in arms. But somehow it is OK to do it in a refugee camp.”
Artificial intelligence programs have been scrutinized for their unreliability, their complex processing, thwarted by the race and gender biases picked up from training data. In 2019, a female reporter from The Intercept tested iBorderCtrl and, despite answering all questions truthfully, was accused by the machine of lying four out of 16 times. Had she been waiting at checkpoint on the Greek or Latvian border, she would have been flagged for additional screening – a measure that could jeopardize her chance of entry. Because of its biases, and the negative press that this attracted, iBorderCtrl did not move past its test phase.
While facial recognition caused problems on the European border, it was helpful in Ukraine, where programs like those developed by software company Clearview AI are used to spot Russian spies, identify dead soldiers, and check movement in and out of war zones.
In April 2021, not long after iBorderCtrl was shut down, the European Commission proposed the world’s first-ever legal framework for AI regulation: the Artificial Intelligence Act. The act, which is still being developed, promises to prevent potentially “harmful” AI practices from being used in migration management. In the most recent draft, approved by the European Parliament’s Liberties and Internal Market committees, the ban included emotion recognition systems (like iBorderCtrl), predictive policing systems (like EUMigraTool), and biometric categorization systems (like iris scanners). The act also stipulates that AI must be subject to strict oversight and accountability measures.
While some worry the AI Act is not comprehensive enough, others wonder if it is in fact going too far. Indeed, many proponents of machine learning argue that, by placing a categorical ban on certain systems, governments will thwart the development of potentially useful technology. While facial recognition caused problems on the European border, it was helpful in Ukraine, where programs like those developed by software company Clearview AI are used to spot Russian spies, identify dead soldiers, and check movement in and out of war zones.
Instead of flat-out banning AI, why not strive to make it more reliable? “One of the most compelling arguments against AI is that it is inherently biased,” says Vera Raposo, an assistant professor of law at NOVA University in Lisbon specializing in digital law. “In truth, AI itself is not biased; it becomes biased due to human influence. It seems that complete eradication of biases is unattainable, but mitigation is possible. We can strive to reduce biases by employing more comprehensive and unbiased data in AI training and encompassing a wider range of individuals. We can also work on developing less biased algorithms, although this is challenging given that coders, being human, inherently possess biases of their own.”
AI is most effective when it enhances human performance rather than replacing it.
Accessibility is another obstacle that needs to be overcome. Leurs points out that, in migration management, AI often functions as a “black box” because the migration officers operating it are unable to comprehend its complex decision-making process and thus unable to scrutinize its results. One solution to this problem is to have law enforcement work closely with AI experts. Alternatively, machine learning could be limited to gathering and summarizing information, leaving evaluation of that information to actual people.
Raposo agrees AI is most effective when it enhances human performance rather than replacing it. On the topic of transparency, she does note that making an AI that is both sophisticated and easy to understand is a little bit like having your cake and eating it too. “In numerous domains,” she explains, “we might need to accept a reduced level of explainability in exchange for a high degree of accuracy (assuming we cannot have both).” Using healthcare as an analogy, she adds that “some medications work in ways not fully understood by either doctors or pharma companies, yet persist due to demonstrated efficacy in clinical trials.”
Leurs believes digital technologies used in migration management can be improved through a push for more conscientious research. “Technology is a poison and a medicine for that poison,” he argues, which is why new tech should be developed with its potential applications in mind. “Ethics has become a major concern in recent years. Increasingly, and particularly in the study of forced migration, researchers are posing critical questions like ‘what happens with the data that is gathered?’ and ‘who will this harm?’” In some cases, Leurs thinks, that last question may need to be reversed: we should be thinking about how we can actively disarm oppressive structures. “After all, our work should align with the interests of the communities it is going to affect.”
Breakthrough therapies are breaking patients' banks. Key changes could improve access, experts say.
Single-treatment therapies are revolutionizing medicine. But insurers and patients wonder whether they can afford treatment and, if they can, whether the high costs are worthwhile.
CSL Behring’s new gene therapy for hemophilia, Hemgenix, costs $3.5 million for one treatment, but helps the body create substances that allow blood to clot. It appears to be a cure, eliminating the need for other treatments for many years at least.
Likewise, Novartis’s Kymriah mobilizes the body’s immune system to fight B-cell lymphoma, but at a cost $475,000. For patients who respond, it seems to offer years of life without the cancer progressing.
These single-treatment therapies are at the forefront of a new, bold era of medicine. Unfortunately, they also come with new, bold prices that leave insurers and patients wondering whether they can afford treatment and, if they can, whether the high costs are worthwhile.
“Most pharmaceutical leaders are there to improve and save people’s lives,” says Jeremy Levin, chairman and CEO of Ovid Therapeutics, and immediate past chairman of the Biotechnology Innovation Organization. If the therapeutics they develop are too expensive for payers to authorize, patients aren’t helped.
“The right to receive care and the right of pharmaceuticals developers to profit should never be at odds,” Levin stresses. And yet, sometimes they are.
Leigh Turner, executive director of the bioethics program, University of California, Irvine, notes this same tension between drug developers that are “seeking to maximize profits by charging as much as the market will bear for cell and gene therapy products and other medical interventions, and payers trying to control costs while also attempting to provide access to medical products with promising safety and efficacy profiles.”
Why Payers Balk
Health insurers can become skittish around extremely high prices, yet these therapies often accompany significant overall savings. For perspective, the estimated annual treatment cost for hemophilia exceeds $300,000. With Hemgenix, payers would break even after about 12 years.
But, in 12 years, will the patient still have that insurer? Therein lies the rub. U.S. payers, are used to a “pay-as-you-go” model, in which the lifetime costs of therapies typically are shared by multiple payers over many years, as patients change jobs. Single treatment therapeutics eliminate that cost-sharing ability.
"As long as formularies are based on profits to middlemen…Americans’ healthcare costs will continue to skyrocket,” says Patricia Goldsmith, the CEO of CancerCare.
“There is a phenomenally complex, bureaucratic reimbursement system that has grown, layer upon layer, during several decades,” Levin says. As medicine has innovated, payment systems haven’t kept up.
Therefore, biopharma companies begin working with insurance companies and their pharmacy benefit managers (PBMs), which act on an insurer’s behalf to decide which drugs to cover and by how much, early in the drug approval process. Their goal is to make sophisticated new drugs available while still earning a return on their investment.
New Payment Models
Pay-for-performance is one increasingly popular strategy, Turner says. “These models typically link payments to evidence generation and clinically significant outcomes.”
A biotech company called bluebird bio, for example, offers value-based pricing for Zynteglo, a $2.8 million possible cure for the rare blood disorder known as beta thalassaemia. It generally eliminates patients’ need for blood transfusions. The company is so sure it works that it will refund 80 percent of the cost of the therapy if patients need blood transfusions related to that condition within five years of being treated with Zynteglo.
In his February 2023 State of the Union speech, President Biden proposed three pilot programs to reduce drug costs. One of them, the Cell and Gene Therapy Access Model calls on the federal Centers for Medicare & Medicaid Services to establish outcomes-based agreements with manufacturers for certain cell and gene therapies.
A mortgage-style payment system is another, albeit rare, approach. Amortized payments spread the cost of treatments over decades, and let people change employers without losing their healthcare benefits.
Only about 14 percent of all drugs that enter clinical trials are approved by the FDA. Pharma companies, therefore, have an exigent need to earn a profit.
The new payment models that are being discussed aren’t solutions to high prices, says Bill Kramer, senior advisor for health policy at Purchaser Business Group on Health (PBGH), a nonprofit that seeks to lower health care costs. He points out that innovative pricing models, although well-intended, may distract from the real problem of high prices. They are attempts to “soften the blow. The best thing would be to charge a reasonable price to begin with,” he says.
Instead, he proposes making better use of research on cost and clinical effectiveness. The Institute for Clinical and Economic Review (ICER) conducts such research in the U.S., determining whether the benefits of specific drugs justify their proposed prices. ICER is an independent non-profit research institute. Its reports typically assess the degrees of improvement new therapies offer and suggest prices that would reflect that. “Publicizing that data is very important,” Kramer says. “Their results aren’t used to the extent they could and should be.” Pharmaceutical companies tend to price their therapies higher than ICER’s recommendations.
Drug Development Costs Soar
Drug developers have long pointed to the onerous costs of drug development as a reason for high prices.
A 2020 study found the average cost to bring a drug to market exceeded $1.1 billion, while other studies have estimated overall costs as high as $2.6 billion. The development timeframe is about 10 years. That’s because modern therapeutics target precise mechanisms to create better outcomes, but also have high failure rates. Only about 14 percent of all drugs that enter clinical trials are approved by the FDA. Pharma companies, therefore, have an exigent need to earn a profit.
Skewed Incentives Increase Costs
Pricing isn’t solely at the discretion of pharma companies, though. “What patients end up paying has much more to do with their PBMs than the actual price of the drug,” Patricia Goldsmith, CEO, CancerCare, says. Transparency is vital.
PBMs control patients’ access to therapies at three levels, through price negotiations, pricing tiers and pharmacy management.
When negotiating with drug manufacturers, Goldsmith says, “PBMs exchange a preferred spot on a formulary (the insurer’s or healthcare provider’s list of acceptable drugs) for cash-base rebates.” Unfortunately, 25 percent of the time, those rebates are not passed to insurers, according to the PBGH report.
Then, PBMs use pricing tiers to steer patients and physicians to certain drugs. For example, Kramer says, “Sometimes PBMs put a high-cost brand name drug in a preferred tier and a lower-cost competitor in a less preferred, higher-cost tier.” As the PBGH report elaborates, “(PBMs) are incentivized to include the highest-priced drugs…since both manufacturing rebates, as well as the administrative fees they charge…are calculated as a percentage of the drug’s price.
Finally, by steering patients to certain pharmacies, PBMs coordinate patients’ access to treatments, control patients’ out-of-pocket costs and receive management fees from the pharmacies.
Therefore, Goldsmith says, “As long as formularies are based on profits to middlemen…Americans’ healthcare costs will continue to skyrocket.”
Transparency into drug pricing will help curb costs, as will new payment strategies. What will make the most impact, however, may well be the development of a new reimbursement system designed to handle dramatic, breakthrough drugs. As Kramer says, “We need a better system to identify drugs that offer dramatic improvements in clinical care.”
In today's podcast episode, law professor Gaia Bernstein talks about the challenges of keeping control over our thoughts and actions, even when some powerful forces are pushing in the other direction.
Each afternoon, kids walk through my neighborhood, on their way back home from school, and almost all of them are walking alone, staring down at their phones. It's a troubling site. This daily parade of the zombie children just can’t bode well for the future.
That’s one reason I felt like Gaia Bernstein’s new book was talking directly to me. A law professor at Seton Hall, Gaia makes a strong argument that people are so addicted to tech at this point, we need some big, system level changes to social media platforms and other addictive technologies, instead of just blaming the individual and expecting them to fix these issues.
Gaia’s book is called Unwired: Gaining Control Over Addictive Technologies. It’s fascinating and I had a chance to talk with her about it for today’s podcast. At its heart, our conversation is really about how and whether we can maintain control over our thoughts and actions, even when some powerful forces are pushing in the other direction.
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We discuss the idea that, in certain situations, maybe it's not reasonable to expect that we’ll be able to enjoy personal freedom and autonomy. We also talk about how to be a good parent when it sometimes seems like our kids prefer to be raised by their iPads; so-called educational video games that actually don’t have anything to do with education; the root causes of tech addictions for people of all ages; and what kinds of changes we should be supporting.
Gaia is Seton’s Hall’s Technology, Privacy and Policy Professor of Law, as well as Co-Director of the Institute for Privacy Protection, and Co-Director of the Gibbons Institute of Law Science and Technology. She’s the founding director of the Institute for Privacy Protection. She created and spearheaded the Institute’s nationally recognized Outreach Program, which educated parents and students about technology overuse and privacy.
Professor Bernstein's scholarship has been published in leading law reviews including the law reviews of Vanderbilt, Boston College, Boston University, and U.C. Davis. Her work has been selected to the Stanford-Yale Junior Faculty Forum and received extensive media coverage. Gaia joined Seton Hall's faculty in 2004. Before that, she was a fellow at the Engelberg Center of Innovation Law & Policy and at the Information Law Institute of the New York University School of Law. She holds a J.S.D. from the New York University School of Law, an LL.M. from Harvard Law School, and a J.D. from Boston University.
Gaia’s work on this topic is groundbreaking I hope you’ll listen to the conversation and then consider pre-ordering her new book. It comes out on March 28.
