Establishing continental sovereignty in Africa: risk and opportunity in financial integration - lessons for Africa from a legal perspective

This thesis identifies and defines the new African sovereignty. It establishes a modern sovereignty in Africa hatched from the changing nature of sovereignty in which countries come together at various levels or grades of partial surrender of national sovereignty in order to work closer together for their mutual advantage and benefit. To this end, the narrative zooms in on the central issues within the realms of money matters whereby a new model of monetary sovereignty and monetary solutions is designed in an attempt to ease the recurring tensions and challenges of modern national sovereignty in the continent of Africa. As such, this discussion will offer a historical journey through the constitution of sovereignty, to the birth of the nation state and international public law. It develops the theory of the changing nature of sovereignty within the modern state and opens new lines of inquiry for Africa. In this regard, it draws from juxtaposing and mixing elements of regional and global financial integration as well as retaining national financial sovereignty features to form this new design which I dub continental sovereignty. At its core, the thesis will deal with the legal aspects that stem from the co-mingling of legal systems of nation states and communities at the regional and global levels within the context of financial integration. The argument is that the rule of law remains sacrosanct in monetary management. Effective financial integration is the result of properly structured and managed legal frameworks with robust laws and institutions whether at a national, regional or global level. However, the thesis reveals that in order to avoid undermining the progress of Africa’s financial integration project, any solution for Africa must be immersed within a broader global solution where development issues are addressed and resolved and Africa can form a more central part in all relevant international discussion fora. The work will expound these issues by applying them within a regional and global context, with the state of affairs in Africa forming the nucleus. This application consequently presents the six key themes of the thesis which will be considered therein. They are: a.) regional advantage: which exploits the possibilities of deeper and further financial integration between smaller communal arrangements; b.) regional risk and exposure: the extent to which this deeper form of financial integration can spiral out of control if effected too quickly and too ambitiously; c.) global advantage: which considers the merits of global financial integration and the influence exerted by financial laws on the global financial architecture; d.) global risk and exposure: which considers the challenges of global financial integration especially within the background of the Global Financial Crisis 2007-2008; e.) African challenge: which considers the extent to which this analysis impacts the African economic and financial integration agenda; and f.) development challenge: which examines the extent to which global development issues impact the African solution (continental sovereignty) and the need for any solution for the continent to be roped into a broader global solution within which Africa can form an important part. Even though the thesis requests an optimistic undertone on the progress made so far, it unearths the African problem of multiple national sovereignty and multiple overlapping regional sovereignty constituted as the ‘spaghetti bowl’ dilemma. As such, the unique contribution to knowledge on financial integration in Africa can be echoed in these words: Africa‘s financial integration agenda has had little success in authenticating a systematic and dependable legal framework for monetary management. Efforts made have been incomplete, substandard, and not carefully followed through particularly reflected in the impuissant nature of the judicial enforcement mechanisms. Thus, the thesis argues that, any meaningful answer to the problems dogging the continent is inter alia deeply entrenched within a new form of cooperative monetary sovereignty. In other words, the thesis does not prescribe the creation of new laws; rather it advocates the effective enforcement of existing laws.

The role of heart rate as a risk marker for predicting adverse outcomes

Cardiovascular disease is one of the leading causes of death around the world. Resting heart rate has been shown to be a strong and independent risk marker for adverse cardiovascular events and mortality, and yet its role as a predictor of risk is somewhat overlooked in clinical practice. With the aim of highlighting its prognostic value, the role of resting heart rate as a risk marker for death and other adverse outcomes was further examined in a number of different patient populations. A systematic review of studies that previously assessed the prognostic value of resting heart rate for mortality and other adverse cardiovascular outcomes was presented. New analyses of nine clinical trials were carried out. Both the original and extended Cox model that allows for analysis of time-dependent covariates were used to evaluate and compare the predictive value of baseline and time-updated heart rate measurements for adverse outcomes in the CAPRICORN, EUROPA, PROSPER, PERFORM, BEAUTIFUL and SHIFT populations. Pooled individual patient meta-analyses of the CAPRICORN, EPHESUS, OPTIMAAL and VALIANT trials, and the BEAUTIFUL and SHIFT trials, were also performed. The discrimination and calibration of the models applied were evaluated using Harrell’s C-statistic and likelihood ratio tests, respectively. Finally, following on from the systematic review, meta-analyses of the relation between baseline and time-updated heart rate, and the risk of death from any cause and from cardiovascular causes, were conducted. Both elevated baseline and time-updated resting heart rates were found to be associated with an increase in the risk of mortality and other adverse cardiovascular events in all of the populations analysed. In some cases, elevated time-updated heart rate was associated with risk of events where baseline heart rate was not. Time-updated heart rate also contributed additional information about the risk of certain events despite knowledge of baseline heart rate or previous heart rate measurements. The addition of resting heart rate to the models where resting heart rate was found to be associated with risk of outcome improved both discrimination and calibration, and in general, the models including time-updated heart rate along with baseline or the previous heart rate measurement had the highest and similar C-statistics, and thus the greatest discriminative ability. The meta-analyses demonstrated that a 5bpm higher baseline heart rate was associated with a 7.9% and an 8.0% increase in the risk of all-cause and cardiovascular death, respectively (both p less than 0.001). Additionally, a 5bpm higher time-updated heart rate (adjusted for baseline heart rate in eight of the ten studies included in the analyses) was associated with a 12.8% (p less than 0.001) and a 10.9% (p less than 0.001) increase in the risk of all-cause and cardiovascular death, respectively. These findings may motivate health care professionals to routinely assess resting heart rate in order to identify individuals at a higher risk of adverse events. The fact that the addition of time-updated resting heart rate improved the discrimination and calibration of models for certain outcomes, even if only modestly, strengthens the case that it be added to traditional risk models. The findings, however, are of particular importance, and have greater implications for the clinical management of patients with pre-existing disease. An elevated, or increasing heart rate over time could be used as a tool, potentially alongside other established risk scores, to help doctors identify patient deterioration or those at higher risk, who might benefit from more intensive monitoring or treatment re-evaluation. Further exploration of the role of continuous recording of resting heart rate, say, when patients are at home, would be informative. In addition, investigation into the cost-effectiveness and optimal frequency of resting heart rate measurement is required. One of the most vital areas for future research is the definition of an objective cut-off value for the definition of a high resting heart rate.