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Foreign Aid

Health care aid for developing countries boosts life expectancy, study finds

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Foreign aid for health care is directly linked to an increase in life expectancy and a decrease in child mortality in developing countries, according to a new study by Stanford researchers.

The researchers examined both public and private health-aid programs between 1974 and 2010 in 140 countries and found that, contrary to common perceptions about the waste and ineffectiveness of aid, these health-aid grants led to significant health improvements with lasting effects over time.

Countries receiving more health aid witnessed a more rapid rise in life expectancy and saw measurably larger declines in mortality among children under the age of 5 than countries that received less health aid, said Eran Bendavid, MD, an assistant professor in Stanford Medical School's Division of General Medical Disciplines and lead author of the study. If these trends continue, he said, an increase in health aid of just 4 percent, or $1 billion, could have major implications for child mortality.

“If health aid continues to be as effective as it has been, we estimate there will be 364,800 fewer deaths in children under 5,” he said. “We are talking about $1 billion, which is a relatively small commitment for developed countries.”

The study was published online April 21 in JAMA Internal Medicine. The study’s co-author, Jay Bhattacharya, MD, PhD, is an associate professor of medicine.

Bendavid and Bhattacharya are core faculty members at Stanford’s Center for Health Policy and Center for Primary Care and Outcomes Research at the university's Freeman Spogli Institute for International Studies.

Does it work?

Bendavid noted that there is much debate around foreign aid. Critics question whether it’s used effectively and reaches its intended recipients. They often argue that it discourages local development and displaces domestic resources that might otherwise be devoted to health. So the researchers devised a statistical tool to address the basic unanswered question: Do investments in health really lead to health improvements?

Bendavid said there are many reasons to suspect the answer would be no, though the findings proved just the contrary, with health-related aid leading to direct, beneficial outcomes.

“I think for many people, that will be surprising,” he said. “But for me, it fits with other evidence of the incredible success of public health promotion in developing countries.” In a previous study, for instance, he found that hundreds of thousands of lives were saved through the U.S. President’s Emergency Plan for AIDS Relief, or PEPFAR, in which the U.S. government invested billions of dollars in antiretroviral treatment and other AIDS-related prevention and treatment initiatives.

In the latest study, the two investigators used data from the Creditor Reporting System of the Organization for Economic Cooperation and Development, the world’s most extensive source of information on foreign aid. While aid programs for health grew during the 36-year study period, the largest period of growth occurred between 2000 and 2010, they found.

Stepped-up investments

It was during this decade that many governments and private groups stepped up their investments in health, including PEPFAR; the World Bank; the Global Fund to Fight AIDS, Tuberculosis and Malaria; the Gates Foundation; and the GAVI Alliance, among others, he said.

As a result, while health aid in 1990 accounted for 4 percent of total foreign aid, it now amounts to 15 percent of all aid, he said. And it’s become an important part of health budgets in recipient countries, accounting for 25-30 percent of all health-care spending in low-income countries, Bendavid said.

The researchers found that these funds were used effectively, largely because of the targeting of aid to disease priorities where improved technologies — such as new vaccines, insecticide-treated bed nets for malarial prevention and antiretroviral drugs for HIV — could make a real difference.

They observed the greatest health impacts between 2000 and 2010, when donor investments were at their peak. During the decade, under-5 child mortality declined from a mean of 109.2 to 72.4 deaths per 1,000, or 36.8 fewer deaths among those children in the countries that received the most health aid, the researchers found (a 34 percent reduction). In the countries receiving the least, under-5 mortality fell from 31.6 to 23.2 deaths per 1,000, or 8.4 fewer deaths per 1,000 live births (a 26 percent reduction), the researchers reported.

Life expectancy increases

During that period, life-expectancy figures also grew faster in countries with a greater infusion of health aid, Bendavid said. Life expectancy rose from 57.5 to 62.3 — an increase of 4.8 years — among the countries receiving the most aid. Among the countries receiving the least health aid, life expectancy increased by 2.7 years, from 69.8 to 72.5 years.

Bendavid said previous experience has shown that, on average, life expectancy has increased by nearly one year every four years in developed countries. But health-aid programs literally cut in half the time it took to reach this goal in developing countries. “In that same four-year span, they increased life expectancy by two years, rather than one year,” he said.

He said the results are not surprising if one considers some of the new health technologies made available to developing nations as a result of foreign aid. Childhood vaccines, including those for diphtheria, tetanus, polio and measles, have all but wiped out what used to be among the top killers of young children in the developing world. Health aid directed to providing insecticide-treated malarial bed nets also has been credited in recent studies with reducing malarial deaths among young children, he noted.

Among both adults and children, aid that has expanded the availability of antiretroviral drugs in the developing world has had a major impact on reducing deaths and improving overall life expectancies, he said. For instance, in a study published in 2012, Bendavid and colleagues found that PEPFAR’s health aid resulted in more than 740,000 lives saved between 2004 and 2008 in nine countries.

The researchers also found that the benefits of aid have a lasting effect: The telltale signs of aid’s relationship to reducing under-5 mortality were detectable for three years following the distribution of aid. The correlation between health aid and longer life expectancy overall was detectable for five years after the aid was distributed.

With aid commitments flattening amid the economic downturn, Bendavid said donors will have to be that much smarter in how they invest future dollars, focusing on the most cost-effective interventions and technologies.

“To date, there has been little consideration of how to use development aid in the most cost-effective manner,” he said. “That will have to change now that the funding level has reached a plateau.”

The study was funded by the George Rosenkranz Fellowship for Health Policy Research in Developing Countries and by the National Institutes of Health (grant K01AI084582).

Information about Stanford’s Department of Medicine, which also supported the work, is available at http://medicine.stanford.edu.

Ruthann Richter is the director of media relations at the Stanford School of Medicine.

 

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New FSI initiative expands global research opportunities for students

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Zack Bonzell came to Stanford with a strong interest in human biology and political science. Last summer, the undergraduate had the chance to fuse his interests while doing field research with faculty at the university’s Freeman Spogli Institute for International Studies (FSI). 

During a two-week internship, he travelled to Guatemala with FSI senior fellows Paul Wise, Beatriz Magaloni, Alberto Díaz-Cayeros and Scott Rozelle to learn about the country’s rural health care system by shadowing doctors and interviewing mothers in an impoverished area about the issues leading to the area’s high rates of child malnutrition.

“That experience was an ideal way to blend my interests and gave me a better idea of how to craft my course of study at Stanford,” said Bonzell, who is now a junior. “One of the things that really struck me was when Paul Wise said the health outcomes we were seeing are the result of extreme material deprivation. These people are sick because they are poor. That gave me more of an interest in political economy.”

Students conduct interviews about nutrition with REAP in China. Photo Credit: Matt Boswell

FSI is now expanding its educational opportunities for students, like Bonzell, who want to do research on global issues in Asia, Latin America, Europe and Africa.

The Stanford Global Student Fellows program (SGSF) is being funded in large part through a $1.25 million anonymous gift that will help grow existing programs and create new offerings for graduates and undergraduates.

“This program deepens FSI’s commitment to its mission of educating the next generation of leaders in international affairs,” said FSI Director Mariano-Florentino Cuéllar. “It also offers outstanding opportunities for Stanford students to work closely with the leading thinkers on global policy issues.”

The program, which is part of FSI’s efforts to expand student opportunities, will build on the institute’s undergraduate mentorship programs that allow students to work on faculty research projects each quarter. Those positions will now be available during the summer. Some of the positions will be connected to projects in FSI’s new International Policy Implementation Lab, an initiative that gives students a close-up view of how academics and policy influencers can address some of the world’s thorniest issues.

PoliSci 114S students work together in a UN conflict simulation. Photo Credit: Rod Searcey

Building on FSI’s experience placing students in research opportunities, the program will create and expand summer field research internships. The two- to six-week internships this summer will give undergraduates the opportunity to work with FSI senior fellows in China, Guatemala, India and Mexico who study global health, conflict resolution, governance and poverty reduction.  In coming years, the program will likely include additional fieldwork projects in Rwanda, Tanzania and Brazil. The SGSF program covers all travel expenses for students and provides students with an opportunity to work closely with a faculty member and a team of other students on an ongoing research project addressing real-world problems in a specific region. 

“What makes FSI such an incredible institution is that it attracts faculty who have very pragmatic interests,” Bonzell said. “It seeks to wed academic work with a more direct impact, and there’s a lot of potential for more students to think along similar lines.”

The Stanford Global Student Fellows will also allow FSI to work closely with its partners, including the Program in International Relations, the Haas Center for Public Service, and Stanford in Government to provide opportunities for graduate and undergraduate students. 

Mexican Ambassador Eduardo Medina Mora and Jorge Olarte, '13, speaking with students at the US-Mex FoCUS event. Photo Credit: Rod Searcey

One of the program’s new initiatives geared toward undergraduates is the Global Policy Summer Fellowships. The fellowships help secure placement and a $6,000 stipend for students interested in interning at international policy and international affairs organizations. This summer,The Europe Center at FSI is placing students at the Center for European Policy Studies and Bruegel, two Brussels-based think tanks. Future positions will be created with six offerings abroad and two based in the United States.including the Program in International Relations, the Haas Center for Public Service, and Stanford in Government to provide opportunities for graduate and undergraduate students. 

The Stanford Global Student Fellows program will also commit $400,000 to create a Mentored Global Research Fellowship that will provide research opportunities for students to conduct their own overseas research under the close mentorship of a faculty member. The program will award stipends of $6,000 for summer undergraduate projects and $9,000 for summer graduate projects, and $1,500 for smaller projects executed during the school year.

Thomas Hendee '13 chatting with children in rural Guatemala. Photo Credit: Maria Contreras

The faculty advisory committee overseeing the development and implementation of these new programs includes Scott Rozelle, the Helen F. Farnsworth Senior Fellow and the co-director of FSI’s Rural Education Action Program; Stephen Stedman, a senior fellow at FSI and the deputy director of CDDRL; and Lisa Blaydes, assistant professor of political science.

The application deadline for all summer programs is Feb. 28, 2015. The deadline to apply for academic quarterly programs is the end of the first week of each quarter, beginning in the fall of 2014. 

For more information, students should contact Elena Cryst at ecryst@stanford.edu and watch for postings on FSI’s student program Facebook page. Students can also sign up for the program’s distribution and announcement list.

 

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State Building Outside-In

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There is no consensus in the policy or academic worlds about what kind of interventions are most effective in promoting governance in badly governed polities.   The three major approaches to understanding state development — modernization theory, institutional capacity, and rational choice institutionalism suggest very different approaches.   While modernization theory is most expansive about the possibilities for external action, its record over time is the most problematic.   Rational choice institutionalism, in contrast, suggests that in rent-seeking exclusive orders the opportunities for external actors are limited.  Rational choice institutionalism, however, does not provide a clear mapping of mixed order polities, ones in which the interests of political elites are torn between open access and rent-seeking.
 
Speaker Bio:
 
Stephen Krasner is the Graham H. Stuart Professor of International Relations, the Senior Associate Dean for the Social Sciences, School of Humanities & Sciences, and the deputy director of FSI. A former director of CDDRL, Krasner is also an FSI senior fellow, and a fellow of the Hoover Institution. From February 2005 to April 2007 he served as the Director of Policy Planning at the US State Department. While at the State Department, Krasner was a driving force behind foreign assistance reform designed to more effectively target American foreign aid. He was also involved in activities related to the promotion of good governance and democratic institutions around the world.

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Stephen D. Krasner

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Stanford University
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Senior Fellow at the Freeman Spogli Institute for International Studies, Emeritus
Graham H. Stuart Professor of International Relations
Senior Fellow at the Hoover Institution, Emeritus
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Stephen Krasner is the Graham H. Stuart Professor of International Relations. A former director of CDDRL, Krasner is also an FSI senior fellow, and a fellow of the Hoover Institution.

From February 2005 to April 2007 he served as the Director of Policy Planning at the US State Department. While at the State Department, Krasner was a driving force behind foreign assistance reform designed to more effectively target American foreign aid. He was also involved in activities related to the promotion of good governance and democratic institutions around the world.

At CDDRL, Krasner was the coordinator of the Program on Sovereignty. His work has dealt primarily with sovereignty, American foreign policy, and the political determinants of international economic relations. Before coming to Stanford in 1981 he taught at Harvard University and UCLA. At Stanford, he was chair of the political science department from 1984 to 1991, and he served as the editor of International Organization from 1986 to 1992.

He has been a fellow at the Center for Advanced Studies in the Behavioral Sciences (1987-88) and at the Wissenschaftskolleg zu Berlin (2000-2001). In 2002 he served as director for governance and development at the National Security Council. He is a fellow of the American Academy of Arts and Sciences and a member of the Council on Foreign Relations.

His major publications include Defending the National Interest: Raw Materials Investment and American Foreign Policy (1978), Structural Conflict: The Third World Against Global Liberalism (1985), Sovereignty: Organized Hypocrisy (1999), and How to Make Love to a Despot (2020). Publications he has edited include International Regimes (1983), Exploration and Contestation in the Study of World Politics (co-editor, 1999),  Problematic Sovereignty: Contested Rules and Political Possibilities (2001), and Power, the State, and Sovereignty: Essays on International Relations (2009). He received a BA in history from Cornell University, an MA in international affairs from Columbia University and a PhD in political science from Harvard.

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The Geography of Governance: Evidence from Slums, Satellites and Foreign Aid

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It is almost too obvious to state, but access to public services and the nature of governance varies hugely within countries, regions and cities. Nevertheless, most work on the “quality of government”, rule of law, corruption, etc. focuses on between-country comparisons. After providing some evidence that within-country variation belies any notion of a national “quality of government”, I lay out a framework for explaining why outcomes vary so much across localities within countries. I explore the usefulness of the framework by providing evidence from three ongoing projects. The first relies on surveys designed to examine the role of slum-level social and political networks in conditioning access to basic public services in Udaipur, India. The second project relies on four post-civil war settings to understand why authorities target some localities with electrification projects but not others.  The third project involves a field experiment embedded in an aid program that compares alternative means of improving accountability in Ghana’s district governments. I will conclude with some reflections on the costs and benefits of working with donors on governance programming.

Speaker Bio: 

Erik Wibbels is an Associate Professor of Political Science at Duke University. His research focuses on development, decentralized governance and other areas of political economy. He has also spent considerable time working with USAID's Center of Excellence on Democracy, Human Rights and Governance in an effort to improve the quality of aid programs aimed at decentralized governance and service provision.

 

 

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Erik Wibbels Associate Professor of Political Science Speaker Duke University
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Imagining Xi Jinping's China in 2023: Is a New Type of Great Power Relationship Possible Between the U.S. and China

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Mr. Rudd served as Australia’s 26th Prime Minister from 2007 to 2010, then as Foreign Minister from 2010 to 2012, before returning to the Prime Ministership in 2013. As Prime Minister, Mr. Rudd led Australia’s response during the Global Financial Crisis. Australia's fiscal response to the crisis was reviewed by the IMF as the most effective stimulus strategy of all member states. Australia was the only major advanced economy not to go into recession. Mr. Rudd is also internationally recognized as one of the founders of the G20 which drove the global response to the crisis, and which in 2009 helped prevent the crisis from spiraling into a second global depression.

As Prime Minister and Foreign Minister, Mr. Rudd was active in global and regional foreign policy leadership. He was a driving force in expanding the East Asia Summit to include both the US and Russia in 2010. He also initiated the concept of transforming the EAS into a wider Asia Pacific Community to help manage deep-routed tensions in Asia by building over time the institutions and culture of common security in Asia. On climate change, Mr. Rudd ratified the Kyoto Protocol in 2007 and legislated in 2008 for a 20% mandatory renewable energy target for Australia. Mr. Rudd launched Australia's challenge in the International Court of Justice with the object of stopping Japanese whaling in the Southern Ocean. Mr Rudd drove Australia’s successful bid for its current non-permanent seat on the United Nation’s Security Council and the near doubling of Australia's foreign aid budget.

Mr. Rudd remains engaged in a range of international challenges including global economic management, the rise of China, climate change and sustainable development. He is on the International Advisory Panel of Chatham House. He is a proficient speaker of Mandarin Chinese, a Visiting Professor at Tsinghua University and funded the establishment of the Australian Centre on China in the World at the Australian National University. He was a co-author of the recent report of the UN Secretary General's High Level Panel on Global Sustainability – “Resilient People, Resilient Planet" and chairs the World Economic Forum's Global Agenda Council on Fragile States. He also remains actively engaged in indigenous reconciliation.

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Kevin Rudd 26th Prime Minister of Australia Speaker
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Asia-Pacific Leaders Forum

Scaling Products in Low-Income Markets

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Growing global design expertise and interconnectedness makes it possible for a small organization to address stubborn large-scale social problems. D-Rev is a nonprofit product company that improves the health and increases the income of those living on less than $4 per day.  With its roots in the Stanford design ethos, D-Rev has delivered two products to markets and is redefining what foreign aid is and should be. This talk will focus on five lessons learned from the design, development and now scaling and impact measurement of Brilliance, a phototherapy device for severely jaundiced newborns.

Krista Donaldson is the CEO of D-Rev and has worked in international development, product development and engineering for more than 15 years. She has been recognized by Fast Company as one of the 50 designers shaping the future, and the World Economic Forum as a Technology Pioneer. She did her graduate work at Stanford.

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Krista Donaldson CEO Speaker D-Rev
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Liberation Technology Seminar Series

Petroleum to the People: Africa's Coming Resource Curse and How to Avoid It

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In the coming decade new oil discoveries in Africa will leave fragile democracies vulnerable to corruption, patronage and rent seeking behavior. In a piece co-written in Foreign Affairs, CDDRL Director Larry Diamond and Research Associate Jack Mosbacher advocate a new scheme to directly distribute oil revenue to citizens in the form of taxable income. This oil-to-cash system would strengthen accountability and increase citizens ownership of state resources.

Larry Diamond is a senior fellow at the Hoover Institution and at the Freeman Spogli Institute for International Studies, where he directs the Center on Democracy, Development, and the Rule of Law. Diamond also serves as the Peter E. Haas Faculty Co-Director of the Haas Center for Public Service at Stanford. He is the founding co-editor of the Journal of Democracy and also serves as Senior Consultant (and previously was co-director) at the International Forum for Democratic Studies of the National Endowment for Democracy. During 2002-3, he served as a consultant to the U.S. Agency for International Development (USAID) and was a contributing author of its report Foreign Aid in the National Interest. He has also advised and lectured to the World Bank, the United Nations, the State Department, and other governmental and nongovernmental agencies dealing with governance and development. His latest book, The Spirit of Democracy: The Struggle to Build Free Societies Throughout the World (Times Books, 2008), explores the sources of global democratic progress and stress and the prospects for future democratic expansion.

At Stanford University, Diamond is also professor by courtesy of political science and sociology. He teaches courses on comparative democratic development and post-conflict democracy building, and advises many Stanford students. In May 2007, he was named "Teacher of the Year" by the Associated Students of Stanford University for teaching that "transcends political and ideological barriers." At the June 2007 Commencement ceremony, Diamond was honored by Stanford University with the Dinkelspiel Award for Distinctive Contributions to Undergraduate Education. He was cited, inter alia, for fostering dialogue between Jewish and Muslim students; for "his inspired teaching and commitment to undergraduate education; for the example he sets as a scholar and public intellectual, sharing his passion for democratization, peaceful transitions, and the idea that each of us can contribute to making the world a better place; and for helping make Stanford an ideal place for undergraduates."

Jack Mosbacher is a Research Associate at the Freeman Spogli Institute for International Studies at Stanford University, where he works with Larry Diamond on democratization trends in Africa. A 2012 Stanford graduate, Jack participated in the Undergraduate Honors Program with the Center on Democracy, Development, and the Rule of Law. His thesis, "Bracing for the Boom: Translating Oil into Development in Uganda," won the Departmental Best Thesis Award, and his work has appeared in Foreign Affairs, The Los Angeles Times, and the Washington Quarterly.

 Please click on link to read article that appeared in Foreign Affairs: http://www.foreignaffairs.com/print/136843

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Larry Diamond

CDDRL
Stanford University
Encina Hall, C147
616 Jane Stanford Way
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Mosbacher Senior Fellow in Global Democracy at the Freeman Spogli Institute for International Studies
William L. Clayton Senior Fellow at the Hoover Institution
Professor, by courtesy, of Political Science and Sociology
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MA, PhD

Larry Diamond is the William L. Clayton Senior Fellow at the Hoover Institution, the Mosbacher Senior Fellow in Global Democracy at the Freeman Spogli Institute for International Studies (FSI), and a Bass University Fellow in Undergraduate Education at Stanford University. He is also professor by courtesy of Political Science and Sociology at Stanford, where he lectures and teaches courses on democracy (including an online course on EdX). At the Hoover Institution, he co-leads the Project on Taiwan in the Indo-Pacific Region and participates in the Project on the U.S., China, and the World. At FSI, he is among the core faculty of the Center on Democracy, Development and the Rule of Law, which he directed for six and a half years. He leads FSI’s Israel Studies Program and is a member of the Program on Arab Reform and Development. He also co-leads the Global Digital Policy Incubator, based at FSI’s Cyber Policy Center. He served for 32 years as founding co-editor of the Journal of Democracy.

Diamond’s research focuses on global trends affecting freedom and democracy and on U.S. and international policies to defend and advance democracy. His book, Ill Winds: Saving Democracy from Russian Rage, Chinese Ambition, and American Complacency, analyzes the challenges confronting liberal democracy in the United States and around the world at this potential “hinge in history,” and offers an agenda for strengthening and defending democracy at home and abroad.  A paperback edition with a new preface was released by Penguin in April 2020. His other books include: In Search of Democracy (2016), The Spirit of Democracy (2008), Developing Democracy: Toward Consolidation (1999), Promoting Democracy in the 1990s (1995), and Class, Ethnicity, and Democracy in Nigeria (1989). He has edited or coedited more than fifty books, including China’s Influence and American Interests (2019, with Orville Schell), Silicon Triangle: The United States, China, Taiwan the Global Semiconductor Security (2023, with James O. Ellis Jr. and Orville Schell), and The Troubling State of India’s Democracy (2024, with Sumit Ganguly and Dinsha Mistree).

During 2002–03, Diamond served as a consultant to the US Agency for International Development (USAID) and was a contributing author of its report, Foreign Aid in the National Interest. He has advised and lectured to universities and think tanks around the world, and to the World Bank, the United Nations, the State Department, and other organizations dealing with governance and development. During the first three months of 2004, Diamond served as a senior adviser on governance to the Coalition Provisional Authority in Baghdad. His 2005 book, Squandered Victory: The American Occupation and the Bungled Effort to Bring Democracy to Iraq, was one of the first books to critically analyze America's postwar engagement in Iraq.

Among Diamond’s other edited books are Democracy in Decline?; Democratization and Authoritarianism in the Arab World; Will China Democratize?; and Liberation Technology: Social Media and the Struggle for Democracy, all edited with Marc F. Plattner; and Politics and Culture in Contemporary Iran, with Abbas Milani. With Juan J. Linz and Seymour Martin Lipset, he edited the series, Democracy in Developing Countries, which helped to shape a new generation of comparative study of democratic development.

Download full-resolution headshot; photo credit: Rod Searcey.

Former Director of the Center on Democracy, Development and the Rule of Law
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The Limits of Counterinsurgency Doctrine in Afghanistan

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Counterinsurgency strategy, as applied in Afghanistan, rested on the assumption that it was feasible for the U.S. military to protect the Afghan population, that foreign aid could make the Afghan government more accountable, and that the Karzai administration shared U.S. goals. But all three assumptions turned out to be spectacularly incorrect.

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Karl Eikenberry
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Myopic Solutions to Chronic Problems: The Need for Aid Effectiveness in Yemen

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This paper offers a close analysis of the key challenges facing the foreign aid sector in Yemen, and presents recommendations to the government of Yemen and the international donor community to make aid to Yemen more effective.

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Fatima Abo al-Asrar
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