An estimated 210,000 girls may have “gone missing” due to China’s “Later, Longer, Fewer” campaign, a birth planning policy predating the One Child Policy, according to a new study led by Stanford Health Policy researchers published by the Center for Global Development.

The study looked at hundreds of thousands of births occurring before and during the “Later, Longer, Fewer” policy to measure its effect on marriage, fertility, and sex selection behavior. The policy, which began in the 1970s and preceded China's One-Child Policy, promoted later marriage, longer gaps between successive children, and having fewer children to cut the country's population. The study emphasizes that because this policy existed before ultrasound technology was widely available — and therefore before selective abortion was an option — these missing girls must have been due to postnatal neglect of infant girls, or in the extreme, infanticide.

The authors of the new study are Grant Miller, director of the Stanford Center on Global Poverty and Development, a core faculty member at Stanford Health Policy and senior fellow at the Freeman Spogli Institute for International Studies; Kimberly Babiarz, a research scholar at Stanford Health Policy; Paul Ma and Shige Song.

The researchers found that China’s “Longer, Later, Fewer” population control policy reduced total fertility rates by 0.9 births per woman and was directly responsible for an estimated 210,000 missing girls countrywide. The phenomenon of “missing girls” widely recognized in later years under the One Child Policy is largely thought due to sex-selective abortion after ultrasound technology spread across China.

“Prior research has shown that sex ratios rose dramatically under China's One-Child Policy, leading to stark imbalances in the numbers of men and women. But we’re finding that girls went missing earlier than previously thought, which can in part be directly attributed to birth planning policy that predates the One-Child Policy,” said Grant Miller, a senior fellow at the Stanford Institute for Economic Policy Research and a non-resident fellow at the Center for Global Development.

The top findings of the study include:

• The birth planning policy reduced fertility by 0.9 births per woman, explaining 28 percent of the overall decline during this period.

• The Later, Longer, Fewer policy is responsible for a roughly twofold increase in the use of “fertility stopping rules,” the practice of continuing to have children until the desired number of sons is achieved.

• The Later, Longer, Fewer policy is also responsible for an increase in postnatal neglect, from none to 0.3 percent of all female births in China during this period.

• Sex selection behavior was concentrated among couples with the highest demand for sons (couples that have more children but no sons), with sex ratios reaching 117 males per 100 female births among these couples.

“Population control strategies can have unforeseen consequences and human costs,” Miller said. “At the same time, as China debates the future of birth planning policies, it’s also important to note that family planning policy does not appear to be the largest driver of fertility.”

Watch Francis Fukuyama's lecture he gave in Vienna in March, 2019 on Identity and the Nation State’s Future as part of The ERSTE Foundation Tipping Point Talks 2019. Full video here.

In September 2018, Shinzo Abe won a party election, thereby securing his third consecutive term as president of Japan’s Liberal Democratic Party and getting closer to becoming the longest-serving prime minister in the country’s postwar history. With his current administration now in its seventh year, Abe looks likely to continue implementing the economic policies he started in 2012, dubbed "Abenomics” and based upon “three arrows” of bold monetary policy, flexible fiscal policy, and structural reform to promote private investment.

Seven years in, with growth visible in many measures of the Japanese economy, has Abenomics truly succeeded? Are there, in fact, shortcomings that the administration needs to address before taking the proverbial victory lap, as Abe is considering the legacy he will leave behind? What are the most important challenges facing the Japanese economy in the near future?

These questions were the focus of an expert panel that APARC’s Japan Program recently hosted at Stanford. The event gathered five experts to go beyond the readily apparent successes of Abenomics in order to examine some of its potential shortfalls.

Takeo Hoshi, director of the Japan Program and moderator for the panel, opened the session by recounting many of the acheivements made by Abenomics: the country’s economy was experiencing its longest expansion in the postwar period—73 months and counting; real GDP was increasing; and the unmployment rate had fallen below 2.5%, with significant growth in female workforce participation.

And yet by other measures, Abenomics could be viewed as having missed several of its major goals. Inflation remains around 0.5%, and even after extending the target date from 2020 to 2025, it appears unlikely that the Japanese government can achieve primary balance. Additionally, and even though the government changed the way it calculated nominal GDP (leading to a possibly-inflated bump), the economy was still unlikely to reach the target goals of 600 trillion yen GDP along with 3% nominal growth and 2% real growth as set by Abenomics.

Joshua Hausman, assistant professor of public policy and of economics at the University of Michigan, discussed Abenomics targets for inflation. Hausman explained to the audience that Abenomics expressed goal of raising inflation was meant to achieve three benefits. First, GDP would see growth due to increased domestic spending ahead of inflation. Second, by raising nominal interest rates above 0%, the Bank of Japan would have more leeway to lower rates during a recession. And third, raising the rate of inflation would help erode Japan’s substantial government debt.

However, argued Hausman, while the Bank of Japan was hopeful that their actions would encourage businesses to raise prices, there has yet to be a significant change in the inflation figure. And while there has been growth in the GDP, the amount of change mirrors that of the period between 1993 and 2007, well before Abenomics. The Bank of Japan, concluded Hausman, desserves credit for what it has achieved, but should consider alternative courses of action.

Takatoshi Ito, professor of international and public affairs at Columbia University, noted that the Abe administration was also unlikely to achieve its goal of a primary balance in the next six years. Even after raising the consumption tax in 2014 (and with indications that another tax hike would occur in October of this year), the mark was unlikely to be achieved, because even as tax revenue were increasing, so too were expenditures made by the Abe government.

Another impact area of Abenomics, and focus of previous events by the Japan Program, is “womenomics,” or the economic policies’s influence on women’s presence and roles in the workforce. Nobuko Nagase, professor of labor economics and social policy at Ochanomizu University, Japan, shared several of the ways in which the administration appeared to be successfully addressing gender inequality in the economy. One big achievement has been the increase in the number of female university graduates who have children and are able to obtain better-paying jobs. Previously, as little as 30% of the female workforce in Japan remained employed following either marrage or a first child; the present figure has risen to 48%. And while across all management levels the growth of women has been relatively flat, among the middle and lowest tier management positions, there have been modest improvements in female representation.

Nagase noted, however, that there was still much to be done. Abenomics has not been successful in increasing the participation of fathers in childcare. Additionally, while both men and women had seen reductions in the long work hours for which Japan is notorious, improvement in narrowing the gender pay gap has been slow, especially in large-size firms. The most important challenges, said Nagase, are reforming the japanese labor practice of long-term employment and the seniority-based pay system, changing household models from full-time working husband and dependent housewives to double income households with children, and re-regulating labor rules to protect non-standard employees.

Panelist Steven Vogel, professor of Asian studies and of political science at the University of California, Berkeley, considered the extent to which the third arrow of Abenomics has hit the mark. He suggested that the Japanese government had succumbed to the ideological trap that regulations were a hindrance to the markets. Before Abe, explained Vogel, deregulation models had led to increases in non-regular work, expansion in inequality, and lower overall consumption. And while under Abe there was a continuation of appetite for deregulation—for example, the establishment of 10 dereguation zones over several cities—there is some evidence, albeit mixed, of it having a positive impact: profits are up, but capital investment and labor’s share of income are both down.

“Don’t expect huge economic impact from deregulation per se,” noted Vogel. Japan needs to improve its model of corporate governance, and it needs labor market reform, he concluded.

The panel was cohosted by the Japan Society for the Promotion of Science and the Japan Foundation Center for Global Partnership. For related information, as well as published reports, see the Japan Program’s research project The Political Economy of Japan under the Abe Government.

Most studies that look at whether democracy improves global health rely on measurements of life expectancy at birth and infant mortality rates. Yet those measures disproportionately reflect progress on infectious diseases — such as malaria, diarrheal illnesses and pneumonia — which relies heavily on foreign aid.

A new study led by Stanford Health Policy's Tara Templin and the Council on Foreign Relations suggests that a better way to measure the role of democracy in public health is to examine the causes of adult mortality, such as noncommunicable diseases, HIV, cardiovascular disease and transportation injuries. Little international assistance targets these noncommunicable diseases. 

When the researchers measured improvements in those particular areas of public health, the results proved dramatic.

“The results of this study suggest that elections and the health of the people are increasingly inseparable,” the authors wrote.

A paper describing the findings was published today in The Lancet. Templin, a graduate student in the Department of Health Research and Policy, shares lead authorship with Thomas Bollyky, JD, director of the Global Health Program at the Council on Foreign Relations.

“Democratic institutions and processes, and particularly free and fair elections, can be an important catalyst for improving population health, with the largest health gains possible for cardiovascular and other noncommunicable diseases,” the authors wrote.

Templin said the study brings new data to the question of how governance and health inform global health policy debates, particularly as global health funding stagnates.

“As more cases of cardiovascular diseases, diabetes and cancers occur in low- and middle-income countries, there will be a need for greater health-care infrastructure and resources to provide chronic care that weren’t as critical in providing childhood vaccines or acute care,” Templin said.

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Free and fair elections for better health

In 2016, the four mortality causes most ameliorated by democracy — cardiovascular disease, tuberculosis, transportation injuries and other noncommunicable diseases — were responsible for 25 percent of total death and disability in people younger than 70 in low- and middle-income countries. That same year, cardiovascular diseases accounted for 14 million deaths in those countries, 42 percent of which occurred in individuals younger than 70.

Over the past 20 years, the increase in democratic experience reduced mortality in these countries from cardiovascular disease, other noncommunicable diseases and tuberculosis between 8-10 percent, the authors wrote.

“Free and fair elections appear important for improving adult health and noncommunicable disease outcomes, most likely by increasing government accountability and responsiveness,” the study said.

The researchers used data from the Global Burden of Diseases, Injuries, and Risk Factors Study; V-Dem; and Financing Global Health databases. The data cover 170 countries from 1970 to 2015.

What Templin and her co-authors found was democracy was associated with better noncommunicable disease outcomes. They hypothesize that democracies may give higher priority to health-care investments.

HIV-free life expectancy at age 15, for example, improved significantly — on average by 3 percent every 10 years during the study period — after countries transitioned to democracy. Democratic experience also explains significant improvements in mortality from cardiovascular disease, tuberculosis, transportation injuries, cancers, cirrhosis and other noncommunicable diseases, the study said.

Watch: Some of the authors of the study discuss the significant their findings: 

What Templin and her co-authors found was democracy was associated with better noncommunicable disease outcomes. They hypothesize that democracies may give higher priority to health-care investments.

HIV-free life expectancy at age 15, for example, improved significantly — on average by 3 percent every 10 years during the study period — after countries transitioned to democracy. Democratic experience also explains significant improvements in mortality from cardiovascular disease, tuberculosis, transportation injuries, cancers, cirrhosis and other noncommunicable diseases, the study said.

Foreign aid often misdirected

And yet, this connection between fair elections and global health is little understood.

“Democratic government has not been a driving force in global health,” the researchers wrote.  “Many of the countries that have had the greatest improvements in life expectancy and child mortality over the past 15 years are electoral autocracies that achieved their health successes with the heavy contribution of foreign aid.”

They note that Ethiopia, Myanmar, Rwanda and Uganda all extended their life expectancy by 10 years or more between 1996 and 2016. The governments of these countries were elected, however, in multiparty elections designed so the opposition could only lose, making them among the least democratic nations in the world.

Yet these nations were among the top two-dozen recipients of foreign assistance for health.

Only 2 percent of the total development assistance for health in 2016 was devoted to noncommunicable diseases, which was the cause of 58 percent of the death and disability in low-income and middle-income countries that same year, the researchers found.

“Although many bilateral aid agencies emphasize the importance of democratic governance in their policy statements,” the authors wrote, “most studies of development assistance have found no correlation between foreign aid and democratic governance and, in some instance, a negative correlation.”

Autocracies such as Cuba and China, known for providing good health care at low cost, have not always been as successful when their populations’ health needs shifted to treating and preventing noncommunicable diseases. A 2017 assessment, for example, found that true life expectancy in China was lower than its expected life expectancy at birth from 1980 to 2000 and has only improved over the past decade with increased government health spending. In Cuba, the degree to which its observed life expectancy has exceeded expectations has decreased, from four-to-seven years higher than expected in 1970 to three-to-five years higher than expected in 2016.

“There is good reason to believe that the role that democracy plays in child health and infectious diseases may not be generalizable to the diseases that disproportionately affect adults,” Bollyky said. Cardiovascular diseases, cancers and other noncommunicable diseases, according to Bollyky, are largely chronic, costlier to treat than most infectious diseases, and require more health care infrastructure and skilled medical personnel.  

The researchers hypothesize that democracy improves population health because:

1. When enforced through regular, free and fair elections, democracies should have a greater incentive than autocracies to provide health-promoting resources and services to a larger proportion of the population;
2. Democracies are more open to feedback from a broader range of interest groups, more protective of media freedom and might be more willing to use that feedback to improve their public health programs;
3. Autocracies reduce political competition and access to information, which might deter constituent feedback and responsive governance.

Various studies have concluded that democratic rule is better for population health, but almost all of them have focused on infant and child mortality or life expectancy at birth.

Over the past 20 years, the average country’s increase in democracy reduced mortality from cardiovascular disease by roughly 10 percent, the authors wrote. They estimate that more than 16 million cardiovascular deaths may have been averted due to an increase in democracy globally from 1995 to 2015. They also found improvements in other health burdens in the countries where democracy has taken hold: an 8.9 percent reduction in deaths from tuberculosis, a 9.5 percent drop in deaths from transportation injuries and a 9.1 percent mortality reduction in other noncommunicable disease, such as congenital heart disease and congenital birth defects.

“This study suggests that democratic governance and its promotion, along with other government accountability measures, might further enhance efforts to improve population health,” the study said. “Pretending otherwise is akin to believing that the solution to a nation’s crumbling roads and infrastructure is just a technical schematic and cheaper materials.”

The other researchers who contributed to the study are Matthew Cohen, Diana Schoder, Joseph Dieleman and Simon Wigley, from CFR, the University of Washington-Seattle and Bilkent University in Turkey, respectively.

Funding for the research came from Bloomberg Philanthropies and the Bill & Melinda Gates Foundation. Stanford’s Department of Health Research and Policy also supported the work.

Stanford e-Japan is an online course that teaches Japanese high school students about American society and culture and U.S.–Japan relations. The course introduces students to both American and Japanese perspectives on many historical and contemporary issues. It is offered biannually by the Stanford Program on International and Cross-Cultural Education (SPICE). The Fall 2018 cohort was the seventh group of students to complete Stanford e-Japan.

In August 2019, three of the top students of the Fall 2018 Stanford e-Japan distance-learning course will be honored at an event at Stanford University. The three Stanford e-Japan Day honorees—Sakura Hayakawa (Katoh Gakuen Gyoshu Senior High School), Ryotaro Homma (Kaisei Senior High School), and Taiki Yamamoto (Ritsumeikan Uji Senior High School)—will be recognized for their coursework and exceptional research essays that focused respectively on “Importance of Youth Political Participation and Citizenship Education,” “The Abolition of the Electoral College: A Synthesis of the Positive Aspects,” and “The U.S.-Japan Alliance: Is a New Framework Necessary?”

Mayu Fujinami (Keio Girls Senior High School) and Tatsuya Sugiyama (Saitama Prefectural Urawa High School) received Honorable Mentions for their research papers on “The Importance of Paternity Leave for Gender Equality” and “Design Thinking: Lessons from the U.S.,” respectively.

Applications for the next session of Stanford e-Japan (Spring 2019) are currently being accepted through February 24, 2019. More information is available at stanfordejapan.org.

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