To celebrate its May Release, the Stanford China Program hosted a virtual book launch event for Fateful Decisions: Choices That Will Shape China’s Future (Stanford University Press) on June 2^nd. Joining co-authors Thomas Fingar (Shorenstein APARC Fellow, Stanford University) and Jean C. Oi (Director, Stanford China Program; William Haas Professor of Chinese Politics, Stanford University) were contributors Karen Eggleston (Senior Fellow at FSI; Director of the Asia Health Policy Program, Shorenstein APARC, Stanford University), Barry Naughton (Sokwanlok Chair of Chinese International Affairs, School of Global Policy and Strategy, UC San Diego), and Andrew Walder (Senior Fellow at FSI; Denise O'Leary and Kent Thiry Professor, Stanford University). As Fingar and Oi point out in their volume, despite China’s extraordinary growth over the past 40 years, the country’s future is uncertain. China has enjoyed optimal conditions for development since the 1980s, but new hurdles including an aging populace, the loss of comparative economic advantage, a politically entrenched elite, and a population with rising expectations will test the country’s leaders. With each focusing on a different facet of China’s challenges, the panelists gathered to share their expertise and provide the audience with a glimpse into what the future might hold for this important country.

Available Now: Fateful Decisions: Choices That Will Shape China’s Future

Following an introduction from Professor Jean Oi, the program kicked off with Professor Barry Naughton of University of California, San Diego, who discussed his chapter entitled “Grand Steerage.” Professor Naughton argued that, as it plans for the future, China’s policymaking is becoming increasingly technology-focused, particularly in the realm of economic policy. Naughton further notes that China’s economy is becoming simultaneously more state-guided and more centered around technology. This decision is a gamble, though: China is investing heavily in high-tech industries, advancing massive, centrally steered projects like the Greater Bay Area initiative and the Xiong’an New District. If they are successful, says Naughton, this will indeed be an incredible success. But, if they are not, China’s losses will be major: “There’s not really a middle ground.”

After Professor Naughton was Professor Karen Eggleston, an expert on health policy in Asia. Professor Eggleston’s chapter, “Demographic and Healthcare Challenges,” deals with emerging obstacles for China’s healthcare system, including population aging and the problems that come with it, like chronic diseases and elder care. Although China’s healthcare system has improved dramatically in recent decades, it has done so unevenly, notes Eggleston: life expectancy has greatly increased, but with disparities according to income, region, and urban vs. rural status; universal healthcare is available, but the benefit level is low, effectively limiting the standard of care many can receive. The ratio of health spending to GDP is also increasing, yet it is still modest compared to high-income countries. The COVID-19 crisis has, of course, introduced even more challenges: Will China be able to distribute future vaccines equitably? Will this crisis negatively affect young people’s decisions to choose healthcare as a career? Will telemedicine, which has seen a surge under the pandemic, improve or exacerbate existing disparities? China faces a multitude of constraints and choices going forward if it hopes to meet its population’s healthcare needs.

The audience then had a chance to hear from co-editor Thomas Fingar, speaking on his chapter, “Sources and Shapers of China’s Foreign Policy.” Fingar noted three key takeaways from both his chapter and his talk: Firstly, China’s foreign policy is a fundamental part of its national policy. Secondly, the global political environment plays an important role in shaping both foreign and domestic policy which, thirdly, plays an important role in shaping foreign policy. The conditions that allowed China to flourish over the past 40 years, emphasized Fingar, are very different from those of the present. In the 1970s and 80s, China was able to take advantage of Cold War bipolarity, globalization was in its infancy, and “China was the only significant developing country willing to embark, at that time, on the export-led path of development.” In recent years, though, China’s behavior internationally has alienated other countries; there are many competitors pursuing its style of development; and its needs and aspirations have changed, requiring more raw materials and depending upon multi-national economic agreements. Fingar suggests two potential foreign policy options: China could continue with its wolf warrior diplomacy, which has “alienated essentially all China’s neighbors to some degree,” or it could return to a style more similar to that of the 1980s and 90s Reform and Opening era. It remains to be seen which style will win out.

Finally, Professor Andrew Walder concluded the program with his discussion of China’s political future at large. His chapter, “China’s National Trajectory,” follows China’s remarkable advancement in recent years and “tr[ies] to divine what a lower growth era will mean for China’s political future.” The last 40 years of rapid growth have generated support for China’s political system, more patriotism, the near eradication of democracy movements, and an elite unity not seen in the 1970s and 80s. However, low growth rates could mean a reversal for many of these trends, says Walder. While the aforementioned support for and stability of the Chinese government was maintained by ever-improving living standards and upward mobility, a low growth period (coupled with an aging population) means the government will no longer be able to rely on these trends for popular support. Rather, it will need to improve its provision of public services to address present-day challenges. Regardless, argues Walder, the low growth era will undoubtedly lead to “dynamic changes underneath the façade of stability of Chinese politics….”

For more insights on the modern obstacles China faces and what they mean for the country’s future, check out Fateful Decisions: Choices That Will Shape China's Future, available for purchase now.

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This is the third installment in our series, “Stories in a Time of Pandemic,” in which APARC alumni across Asia share their perspectives on the responses to and implications of COVID-19 in their communities. In part 1 and part 2 of the series, we feature observations from our alumni in China, Mongolia, Myanmar, and Singapore.

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The first case of COVID-19 in the Philippines was reported on January 30, 2020, and local transmission was confirmed on March 7, 2020. As of May 21, the number of cases of COVID-19 has risen to 13,434 and the number of deaths attributed to the virus increased to 846, according to the Philippine Department of Health COVID-19 Case Tracker. It is quite alarming that among the ASEAN countries, the Philippines had the second-highest mortality due to COVID-19, next to Indonesia (as per May 5 date by the WHO COVID-19 Dashboard). This could be attributed to several factors, including whether the country’s health system can handle the overwhelming demand for health care due to the COVID-19 crisis and how effective the government’s response is in stemming the spread of this new pathogen. Inherent in the death statistics is the capacity of a country to conduct COVID-19 tests, which means that there should be a sufficient number of test kits available and that the health workers are properly trained to conduct the tests, trace the contacts, and isolate identified individuals.

The President of the Philippines imposed a total lockdown called enhanced community quarantine (ECQ) for the entire island of Luzon, which encompasses eight administrative regions, including the national capital region, from March 15 to April 30. Other parts of the country have also been under some degree of quarantine at different periods since the appearance of local transmission. Executive Order 112, signed on April 30, 2020, was issued to further extend the ECQ in identified high-risk areas and a general community quarantine (GCQ) in the rest of the country. The inter-agency task force for the management of emerging infectious diseases defines ECQ as the implementation of temporary restrictions on the mobility of people, strict regulations of industries, and a heightened presence of uniformed personnel. GCQ is, in a nutshell, a less strict version of ECQ.

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Image captured from the Center for Strategic and International Studies, Southeast Asia COVID-19 Tracker, May 21, 2020.

The Philippines has faced a lot of challenges during this crisis. First, the health system lacks adequate surge capacity to safely handle a nationwide outbreak of COVID-19 due to shortages of personal protective equipment (PPE), mechanical ventilators, and hospitals with ICUs and isolation beds (see this World Bank report and this Rappler article). More importantly, the insufficient number of health workers, especially in areas outside the metropolitan, is a major concern. Nonetheless, the Department of Health has worked hard to meet the surge in demand due to COVID-19, including partnering with the private sector to repurpose structures and providing data to the public to ensure transparency and accountability. As in other countries, the health workers and those with frontline responsibilities have truly been the new heroes or “bayani” with their tireless efforts and sacrifices. 

Another challenge pertains to the adverse economic impact of COVID-19. The Philippines has a relatively large informal sector and the income of many families depends on daily transactions with no formal job or social security. This has prompted the government to extend cash or in-kind support to vulnerable populations – a response that has posed several challenges, particularly related to the who/what/how framework. First, the Philippine government had to properly identify those in need (who). Second, it had to ensure that sufficient resources can be allocated to the identified groups (what). And third, it had to distribute aid in an efficient, timely, and equitable way (how). The government's social welfare efforts to provide for the vulnerable groups have mixed results: at times, the distribution of aid is organized and efficient, at other times insufficient and disorderly (see these CNN Philippines reports of April 7 and April 30).

COVID-19 in the Philippines – How Filipinos Have Coped

There has been a strong spirit of “bayanihan” or collectivism in the country amidst the COVID-19 crisis. People are volunteering, distributing goods to vulnerable groups, or donating PPE to those with frontline duties. Some enterprises also rose to the occasion by repurposing their businesses to meet the local demand for medical products and PPE.

Different individuals have coped differently: some have welcomed the work hiatus that the quarantine has afforded them, some connected more with friends and family, others become more productive working from home. Staying healthy and being mindful are also factors that contribute to remaining calm and rational in this time of national distress.

Despite the challenges, we will continue to face, especially once the quarantine has eased and the new normal is in effect, we can say that Filipinos have also learned some valuable lessons amid this crisis. For one, Filipinos have become more mindful of the importance of good sanitation and non-pharmaceutical public health measures in mitigating the transmission of the virus. Most Filipinos have also become more proactive in their approach, keeping social distance, wearing masks, and practicing proper handwashing, among others. Furthermore, this crisis has redefined and created new heroes who rose to the challenge – from those staying at home to avoid the further spread of the virus to those on the frontline who have dedicated their time and effort to combat the pandemic, to government and business leaders who have served the country sincerely during this crisis.

Perhaps there really is a silver lining in every cloud.

Mongolia, a nation bordered by China and Russia, does not usually attract much public attention. Its success so far in containing COVID-19, however, is well worth considering.

Any of several factors could make Mongolia highly vulnerable to COVID-19: its weak healthcare system, its proximity to China, the first epicenter of the coronavirus, and its close ties to South Korea, which experienced one of the largest initial outbreaks of COVID-19 outside China and which is home to a relatively large population of Mongolian migrant workers. Yet Mongolia’s strategy in fighting the pandemic seems to have worked well thus far for its 3.2 million people.

In the following post, Dr. Gendengarjaa Baigalimaa, a gynecological oncologist at the Mungun Guur Hospital in Ulaanbaatar, Mongolia’s capital, discusses the country’s response to the pandemic and its implications. Baigalimaa was a 2013-14 postdoctoral fellow on developing Asia health policy with APARC’s Asia Health Policy Program.

This is the second installment in our series, “Stories in a Time of Pandemic,” in which APARC alumni across Asia share their perspectives on the responses to and implications of COVID-19 in their communities. You can read the first part in the series, featuring reflections by several former Global Affiliates Program Fellows.

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Dr. Gendengarjaa Baigalimaa

As of May 17, 2020, the number of new coronavirus infections in Mongolia has reached 136. All of them are imported cases, including four foreigners and 132 Mongolians who came from abroad. They have been treated by the National Center for Communicable Diseases and some have been discharged as totally recovered. Most notably, there have been no reports of community transmission.

Following the World Health Organization's recommendation of January 22 that countries begin considering containment measures, Mongolia immediately activated its inter-agency State Emergency Commission in support of the Ministry of Health as a lead agency in the response against the coronavirus outbreak. The Mongolian government made an unprecedented decision to close all schools and kindergartens starting January 25. All classes are now being conducting via TV and the internet.

Already in mid-February, with the pandemic's spreading in China, the Mongolian government’s strategy was to adopt decisive preventative measures, including the cancelation of the national holiday Tsagaan Sar, the Mongolian lunar new year, and closure of all travel between Ulaanbaatar and provinces outside the capital. Mongolia also closed its borders with China and Russia, stopping the inflow and outflow of people, and banned international flights from all airlines. The government has been mobilizing its citizens to return home from countries like South Korea, Japan, Turkey, and Russia. Those arriving are quarantined for an extended 21-day period, with multiple coronavirus screenings.

The use of masks, especially from early November, when flu season starts and air pollution worsens, is already familiar to Mongolians. This season, the government has enforced mask-wearing in public places. In the capital city of Ulaanbaatar, the requirement that all employees at government offices, banks, shops, and markets wear masks was imposed as early as January 25. The State Emergency Commission would issue fines of 150,000₮ (54 USD) for violating the order. At the same time, health professionals and community leaders conveyed the importance of mask-wearing and handwashing and worked to increase sanitation at all public places.    

These steps have helped immensely to contain the spread of COVID-19. They have also had the added benefit of sharply reducing the number of flu infections. At the start of the flu season last year, almost 12.7 percent of all hospital visits were flu-related, compared to 1.8 percent this year. Another unexpected benefit was the drop in gastrointestinal infections among children. Children were staying home and washing their hands properly. As a result, there have been no cases of gastrointestinal infections registered this year so far.

“Not only did Mongolia close its borders early and move promptly, but also did a great job at quarantining evacuees from overseas immediately upon arrival and taking safety measures,” said Mr. Sergey Diorditsa, the WHO representative to Mongolia. He praised the country’s economic stimulus measures and noted that prolonged restrictions may adversely affect its social and economic sectors and that WHO Mongolia is conducting a study on the in-country impacts of COVID-19. Indeed, data provided by the National Statistical Office shows that the country’s economy is expected to decline sharply due to the adverse effects of the pandemic.

Mongolia’s urgent response to COVID-19 offers lessons for vulnerable communities on containment of the coronavirus and prevention of its spread. The country is also a relevant case study for the economic repercussions of the pandemic.

COVID-19, combined with the effects of ongoing civil conflicts, hotter and drier weather in many areas, and an unfolding locust invasion in Africa and the Middle East, could cut off access to food for tens of millions of people. The world is “on the brink of a hunger pandemic,” according to World Food Program (WFP) Executive Director David Beasley, who warned the United Nations Security Council recently of the urgent need for action to avert “multiple famines of biblical proportions.”

(Watch Beasley’s conversation on food insecurity as a national security threat with his WFP predecessor, Ertharin Cousin, a visiting scholar with Stanford’s Center of Food Security and the Environment.)

Understanding how these conditions – alone or in combination – might affect crop harvests and food supply chains is essential to finding solutions, according to David Lobell, the Gloria and Richard Kushel Director of the Center on Food Security and the Environment. Below, Lobell discusses the connection between immigration and U.S. food security, a counter-intuitive effect of COVID-19 and more.

How could COVID-19 affect global food security?

I think the biggest effects will probably be related to lost incomes for many low-income people. Even if food prices don’t change, potentially hundreds of millions could be pushed into a much more precarious food situation. I’d be especially worried about remittances – the money immigrants in wealthy nations send home to developing nations – falling, since these are a surprisingly large source of stability for many poor people. Beyond the income effects, there are definitely prospects for reduced supply of foods, but I think these are secondary, especially because global stocks right now are quite large.

Another counter-intuitive effect is that the drop in gasoline demand due to social distancing may be a big driver of changes in food prices. A lot of corn demand is for use in ethanol fuel, and corn prices can affect the prices of many other crops. The price of corn has dropped by about 20 percent since February.

What are the biggest risks in terms of food supply?

Three things come to mind. First, for crops that require a lot of labor, there are some indications that planting and harvest activities are being affected. Even though these are usually included as essential activities, they often rely on migrant populations that can no longer cross state or national borders. California is going to be a prime case study in this.

Second, some countries, like Russia, have started to restrict food exports in an effort to calm domestic consumers worried about food shortages. Even if there is enough global supply, there is a risk that supply for importing countries could be curtailed. This was a big part of the food price spikes a decade ago. Now, we have the added potential that exports will be limited by a lack of mobility to get products to the port – for instance, there are reports from South America that towns won’t let trucks through for fear of the virus.

Third, COVID-19 could really limit the ability of governments and international groups to address other crises that emerge. Nearly every year there are at least a few surprises around the world affecting food that are usually handled before they make big news. Things like livestock diseases and crop pest outbreaks, for example. But without the ability to deploy people to assess and fix problems, there is more scope for issues to go unchecked. Right now, the biggest example of this is the desert locust outbreak in Eastern Africa.

What current and/or likely future weather conditions might have significant impacts on food production?

As the globe warms, we continue to see more “surprises” in most years in terms of record hot or dry growing seasons. It’s a bit too soon to say if and where those will emerge this year. Since global food stocks are high, we have some ability to cope with a shock, but if governments are already nervous it may take less to induce export bans and all of the negative effects those entail.

Ahead of the summer harvest, what is the prospect for controlling locust swarms in threatened countries, and how might the swarms further complicate the global food security picture?

If not for COVID-19, this would likely be the biggest development related to food this year. My understanding is that they are spreading fast in Africa and the Middle East, and while they haven’t yet had big effects in the main production regions, the next couple of months will be critical. The hope is that the winds change and drive them back toward the desert areas they came from. If not, there are at least 20 million people at risk of major food security impacts in the region.

Could we see locust swarms in the U.S.? What can we do to prevent them?

Locusts can occur anywhere. A few years back there was a major outbreak in Israel. They haven’t been a big issue in the U.S. because control methods are available, such as widespread spraying. But again, in a time of COVID-19, these types of responses are harder.

What does history teach us about the situation we are in with multiple threats to food security, and how to deal with it?

I think it comes down to a combination of investing in science-based solutions to avoid problems to begin with, and then having good social safety nets for when problems arise. At that level, it’s not really any different than dealing with infectious disease. The absence of any problems is our goal. At the same time, that absence always seems to breed complacency and neglect. Hopefully, the experiences of 2020 will help strengthen support for a society based on facts, science and compassion.

Media Contacts

David Lobell, Center on Food Security and the Environment: (650) 721-6207; dlobell@stanford.edu

Rob Jordan, Stanford Woods Institute for the Environment: (650) 721-1881; rjordan@stanford.edu

Most of the stillbirths that occur around the world are among women who live in low- and middle-income countries. Some 2.5 million women suffer the heartbreaking loss each year.

Yet determining the causes and prevention of stillbirths has largely been ignored as a global health priority — the incidence not even included in the WHO Millennium Development Goals.

Stanford Health Policy’s Rosenkranz Prize Winner, Ashley Styczynski, MD, MPH, discovered the alarmingly high level of stillbirths while working in Bangladesh as a 2019-2020 Fogarty Fellow, studying antimicrobial resistance in newborns in the hospitals there.

The $100,000 Rosenkranz Prize is awarded to a Stanford researcher who is doing innovative work to improve health in the developing world.

“I was surprised to learn that the rates of stillbirths were comparable to sub-Saharan Africa and that in many cases they had no idea of the cause,” Styczynski said in a Skype call from Dhaka, where she has been living for eight months while conducting her antimicrobial resistance research.

Rosenkranz Prize Winner Ashley Styczynski takes specimen samples with women in Dhaka, Bangladesh, for her research on antimicrobial resistance in newborns. This research led to her prize-winning proposal to investigate the alarmingly high rate of stillbirths in the South Asian nation.

The South Asian nation is among the top 10 countries with the highest number of stillbirths, with an average of 25.4 stillbirths per 1,000 births. Studies have implicated maternal infections as the cause; one ongoing study in Bangladesh has recovered bacteria from blood samples in stillborn babies in whom no prior maternal infection was suspected.

Styczynski believes intrauterine infections may be an underrecognized factor contributing to the excess stillbirths in Bangladesh. She intends to perform metagenomic sequencing on placental tissues of stillborn babies, a process that will allow her to examine the genes in the organisms of those tissues and evaluate the bacterial diversity.

“The alternative hypothesis would be that stillbirths are caused by non-infectious etiologies, which I will be assessing through interviews,” Styczynski wrote in her Rosenkranz application.

Those interviews will be with mothers to evaluate for frequency of infectious symptoms during pregnancy, including fever, rash, cough, dysuria and diarrhea, as well as possible toxin exposures. She will compare the findings with the metagenomic sequencing results to determine how frequently potential pathogens may be presenting as subclinical infections.

“By applying advanced technologies and software platforms, this research will not only enhance our understanding of causes of stillbirths in Bangladesh, but it may also provide insights into causes of early neonatal deaths," Styczynski said.

Bangladesh, one of the poorest and most densely populated nations in the world, offers a rich variety of emerging and known diseases that go undetected.

“The panoply of infections that could contribute to stillbirths is really unknown,” Styczynski said. “That’s why metagenomics is a great tool here. It just hasn’t been accessible here because of the expense. Now this tool will begin to unpack what’s causing these stillbirths.”

The Rosenkranz Prize was started and endowed by the family of the late Dr. George Rosenkranz, who devoted his career to improving health-care access across the world and helped synthesize the active ingredient for the first oral birth control pill.

“No one is more deserving of the Rosenkranz Prize than Dr. Ashley Styczynski”, said Dr. Ricardo Rosenkranz. “Because of her tenacity, originality and focus, Dr. Styczynski exemplifies the ideal Rosenkranz Prize recipient. She has chosen an often overlooked adverse outcome that may prove to be mitigated by her findings. As a neonatologist interested in health disparities, I fully realize the potential relevance and urgency of her work and am excited to see it come to fruition. As the son of George Rosenkranz, for whom this prize is lovingly named, I know that my father would appreciate Dr. Styczynski’s pioneering spirit as well as her desire to affect global positive change by improving medical outcomes in vulnerable communities. We can’t wait to celebrate her work back at Stanford in the near future."

Sheltering in Place

Styczynski spoke from her flat in Dhaka, where she has been confined for three weeks as the world’s third-most populated city prepares for the onslaught of the coronavirus. The country is on lockdown; no international flights in or out.

As of Thursday, there were 1,572 cases in Bangladesh and 60 deaths, according to the widely used Johns Hopkins Coronavirus Map.

But Styczynski believes that’s about 1% of the actual disease activity in the country because testing was so slow to start. She said there is great stigma in the country over testing — red flags are put on the homes of those who have been diagnosed with COVID-19 — because it breaks up the unity of families and the surrounding community. Health-care workers are being kicked out of apartments by frightened landlords and people are afraid to use the health-care system for fear of infection.

“So, the hospitals are quite empty — more so than they’ve ever been,” she said.

Styczynski likened it to waiting for the tsunami that you know is coming.

“That’s why I wanted to jump in to stave off the morbidity and mortality that will be inundating one of the most populated countries in the world,” she said. Some 165 million people are packed into 50,250 square miles — a land mass about the same size as New York State, which has some 19.5 million people.

Ashley Styczynski goes through a thermoscanner was when I was testing out the triage system at an upazila health complex.

The Centers for Disease Control and Prevention (CDC) has a small team of four people working in Bangladesh. Having spent two years as an Epidemic Intelligence Service Officer at the CDC, Styczynski has now joined its Bangladesh team and is also working with the infection prevention and control team of the International Centre for Diarrhoeal Disease Research, Bangladesh.

“Many people here in Dhaka live in high-density apartments with six to 12 people living in the same room,” she said. “How do you isolate when you have a one-room home?”

Ninety percent of the population are daily wage earners, Styczynski noted, who say they’d rather take their chances with coronavirus than die of starvation.

They take those chances at great risk. There is one ventilator for every 100,000 people in Bangladesh and the district hospitals have maybe one to two days of oxygen supply, Styczynski said.

They started out training military hospitals on medical triage, quarantine and isolation, and infection prevention strategies.

“We’ve also been going to some district hospitals to assess some of the challenges they are facing and to identify some of the gaps in preparedness so that we can communicate back to the Ministry of Health how they can better support these district hospitals,” she said.

Her pandemic travels to the district hospitals and preparedness work has allowed her to gather contextual data for her colleagues back at Stanford who are working to address the lack of personal protective equipment (PPE) in low-resourced countries.

“We hope we can generate some evidence very quickly so that we can share some of this information to better protect health-care workers in other low-resource countries,” she said.

Despite her research being temporarily sidelined, Styczynski is upbeat.

“This is what I signed up for as a Fogarty fellow, to help build local capacity,” she said. “But I am also an infectious disease specialist, and these are the types of situations we run towards rather than away from. We build our career for moments like these.”