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Douglas K. Owens
Jeremy Goldhaber-Fiebert
Joshua Salomon
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Stanford health law experts Michelle Mello and David Studdert discuss the ongoing pandemic, proof of vaccination “passports” at the state and federal levels, and a July 19 ruling that Indiana University could require that its students be vaccinated.
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David Studdert
Michelle Mello
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China’s national health reforms over the past two decades have brought the system closer to the modern, safe, reliable, and accessible health system that is commensurate with China’s dramatic economic growth, improvement in living standards, and high hopes for the next generation.

China’s national health reforms of 2009—continuing many reforms undertaken since SARS (2003)—consolidated a system of social health insurance covering the entire population for basic health services, contributing to a surge in healthcare utilization while reducing out-of-pocket costs to patients – which declined from 56% to 28% of total health expenditures between 2003 and 2017. An expanded basic public health service package, funded by per capita government budget allocations that include a higher central government subsidy for lower-income provinces, provides basic population health services to all Chinese. Now the governance structure consolidates the purchaser role for social health insurance schemes under the National Healthcare Security Administration, with most other health sector functions under the National Health Commission. China’s world-leading technological prowess in multiple fields spanning digital commerce to artificial intelligence—and accompanying innovative business models such as WeDoctor that have not yet been fully integrated into the health system—hold promise for supporting higher quality and more convenient healthcare for China’s 1.4 billion.

However, many challenges remain, from dealing with COVID-19 and its aftermath to other lingering challenges, from promoting healthy aging to the political economy of addressing patient-provider tensions, changing provider payment to promote “value” rather than volume, and deciding which new medical therapies qualify as “basic” for the basic medical insurance schemes. To make China’s investments in universal health coverage and the accompanying rapid medical spending growth sustainable in the longer run, policies need to help the most vulnerable avoid illness-induced poverty, increase health system efficiency, strengthen primary care, and reform provider payment systems.

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Testimony before the U.S.-China Economic and Security Review Commission
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Karen Eggleston
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Purpose: This study aims to bridge the gaps in the existing literature by studying the links between children's development and the subjective well-being of the caregivers using first-hand data collected in rural China. Design/methodology/approach: Although the broad array of literature has examined the effects of child development on the subjective well-being of caregivers, the relationship between early childhood development and caregiver subjective well-being has not been well-studied using sample families with potential developmental delay in rural China. Also, existing research has relied on maternal reports to evaluate the developmental status of children. The study used data collected from 32 townships in seven nationally designated poverty counties in the Qinling mountainous area in 2016. The authors measure child development using the social-emotional module of the Ages & Stages Questionnaire and Bayley Scales of Infant and Toddler Development–Third Edition. Findings: The authors find that child development indicators are correlated with caregiver subjective well-being. In particular, social-emotional skills are positively associated with life evaluations and positive emotion. However, we do not find any significant correlation between child development and negative emotion or depression, anxiety and stress scores. Originality/value: The value of this study is to report the indicators of child development in rural China and examines the correlation between child development and caregivers' subjective well-being.
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China Agricultural Economic Review
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Scott Rozelle
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Stanley Perlman, who has been studying coronaviruses for 39 years, got a nasty email June 4: “Dr. Frankenstein just wants more public money and wants to research things he shouldn’t be messing with. THANKS A LOT FOR CORONA LOSER.”

Perlman, a mild-mannered, grandfatherly virologist at the University of Iowa, didn’t know the author of the dyspeptic email and had nothing to do with the emergence of the coronavirus. But he had co-signed a letter to the Lancet in February 2020 saying SARS-CoV-2 was not a bioengineered virus and condemning “conspiracy theories suggesting that COVID-19 does not have a natural origin.”

Read the rest at The Washington Post

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Stanford University microbiologist David A. Relman said the political climate last year made many scientists hesitant to express openness to the lab-leak idea. They did not want to align themselves with a theory closely associated with Trump and his allies, who referred to the coronavirus as “the China virus.”

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This interview by Bruce Goldman was originally published by the Stanford School of Medicine.


On May 13, the journal Science published a letter, signed by 18 scientists, stating that it was still unclear whether the virus that causes COVID-19 emerged naturally or was the result of a laboratory accident, but that neither cause could be ruled out. David Relman, MD, the Thomas C. and Joan M. Merigan Professor and professor of microbiology and immunology, spearheaded the effort.

Relman is no stranger to complicated microbial threat scenarios and illness of unclear origin. He has advised the U.S. government on emerging infectious diseases and potential biological threats. He served as vice chair of a National Academy of Sciences committee reviewing the FBI investigation of letters containing anthrax that were sent in 2001. Recently, he chaired another academy committee that assessed a cluster of poorly explained illnesses in U.S. embassy employees. He is a past president of the Infectious Diseases Society of America.

Stanford Medicine science writer Bruce Goldman asked Relman to explain what remains unknown about the coronavirus’s emergence, what we may learn and what’s at stake.

1. How might SARS-CoV-2, which causes COVID-19, have first infected humans?

Relman: We know very little about its origins. The virus’s closest known relatives were discovered in bats in Yunnan Province, China, yet the first known cases of COVID-19 were detected in Wuhan, about 1,000 miles away.

There are two general scenarios by which this virus could have made the jump to humans. First, the jump, or “spillover,” might have happened directly from an animal to a human, by means of an encounter that took place within, say, a bat-inhabited cave or mine, or closer to human dwellings — say, at an animal market. Or it could have happened indirectly, through a human encounter with some other animal to which the primary host, presumably a bat, had transmitted the virus.

Bats and other potential SARS-CoV-2 hosts are known to be shipped across China, including to Wuhan. But if there were any infected animals near or in Wuhan, they haven’t been publicly identified.

Maybe someone became infected after contact with an infected animal in or near Yunnan, and moved on to Wuhan. But then, because of the high transmissibility of this virus, you’d have expected to see other infected people at or near the site of this initial encounter, whether through similar animal exposure or because of transmission from this person.

2. What’s the other scenario?

Relman: SARS-CoV-2 could have spent some time in a laboratory before encountering humans. We know that some of the largest collections of bat coronaviruses in the world — and a vigorous research program involving the creation of “chimeric” bat coronaviruses by integrating unfamiliar coronavirus genomic sequences into other, known coronaviruses — are located in downtown Wuhan. And we know that laboratory accidents happen everywhere there are laboratories.

Humans are fallible, and laboratory accidents happen — far more often than we care to admit.
David Relman
Senior Fellow, CISAC

All scientists need to acknowledge a simple fact: Humans are fallible, and laboratory accidents happen — far more often than we care to admit. Several years ago, an investigative reporter uncovered evidence of hundreds of lab accidents across the United States involving dangerous, disease-causing microbes in academic institutions and government centers of excellence alike — including the Centers for Disease Control and Prevention and the National Institutes of Health.

SARS-CoV-2 might have been lurking in a sample collected from a bat or other infected animal, brought to a laboratory, perhaps stored in a freezer, then propagated in the laboratory as part of an effort to resurrect and study bat-associated viruses. The materials might have been discarded as a failed experiment. Or SARS-CoV-2 could have been created through commonly used laboratory techniques to study novel viruses, starting with closely related coronaviruses that have not yet been revealed to the public. Either way, SARS-CoV-2 could have easily infected an unsuspecting lab worker and then caused a mild or asymptomatic infection that was carried out of the laboratory.

3. Why is it important to understand SARS-CoV-2’s origins?

Relman: Some argue that we would be best served by focusing on countering the dire impacts of the pandemic and not diverting resources to ascertaining its origins. I agree that addressing the pandemic’s calamitous effects deserves high priority. But it’s possible and important for us to pursue both. Greater clarity about the origins will help guide efforts to prevent a next pandemic. Such prevention efforts would look very different depending on which of these scenarios proves to be the most likely.

Evidence favoring a natural spillover should prompt a wide variety of measures to minimize human contact with high-risk animal hosts. Evidence favoring a laboratory spillover should prompt intensified review and oversight of high-risk laboratory work and should strengthen efforts to improve laboratory safety. Both kinds of risk-mitigation efforts will be resource intensive, so it’s worth knowing which scenario is most likely.

4. What attempts at investigating SARS-CoV-2’s origin have been made so far, with what outcomes?

Relman: There’s a glaring paucity of data. The SARS-CoV-2 genome sequence, and those of a handful of not-so-closely-related bat coronaviruses, have been analyzed ad nauseam. But the near ancestors of SARS-CoV-2 remain missing in action. Absent that knowledge, it’s impossible to discern the origins of this virus from its genome sequence alone. SARS-CoV-2 hasn’t been reliably detected anywhere prior to the first reported cases of disease in humans in Wuhan at the end of 2019. The whole enterprise has been made even more difficult by the Chinese national authorities’ efforts to control and limit the release of public health records and data pertaining to laboratory research on coronaviruses.

In mid-2020, the World Health Organization organized an investigation into the origins of COVID-19, resulting in a fact-finding trip to Wuhan in January 2021. But the terms of reference laying out the purposes and structure of the visit made no mention of a possible laboratory-based scenario. Each investigating team member had to be individually approved by the Chinese government. And much of the data the investigators got to see was selected prior to the visit and aggregated and presented to the team by their hosts.

The recently released final report from the WHO concluded — despite the absence of dispositive evidence for either scenario — that a natural origin was “likely to very likely” and a laboratory accident “extremely unlikely.” The report dedicated only 4 of its 313 pages to the possibility of a laboratory scenario, much of it under a header entitled “conspiracy theories.” Multiple statements by one of the investigators lambasted any discussion of a laboratory origin as the work of dark conspiracy theorists. (Notably, that investigator — the only American selected to be on the team — has a pronounced conflict of interest.)

Given all this, it’s tough to give this WHO report much credibility. Its lack of objectivity and its failure to follow basic principles of scientific investigation are troubling. Fortunately, WHO’s director-general recognizes some of the shortcomings of the WHO effort and has called for a more robust investigation, as have the governments of the United States, 13 other countries and the European Union.

5. What’s key to an effective investigation of the virus’s origins?

Relman: A credible investigation should address all plausible scenarios in a deliberate manner, involve a wide variety of expertise and disciplines and follow the evidence. In order to critically evaluate other scientists’ conclusions, we must demand their original primary data and the exact methods they used — regardless of how we feel about the topic or about those whose conclusions we seek to assess. Prior assumptions or beliefs, in the absence of supporting evidence, must be set aside.

Investigators should not have any significant conflicts of interest in the outcome of the investigation, such as standing to gain or lose anything of value should the evidence point to any particular scenario.

There are myriad possible sources of valuable data and information, some of them still preserved and protected, that could make greater clarity about the origins feasible. For all of these forms of data and information, one needs proof of place and time of origin, and proof of provenance.

To understand the place and time of the first human cases, we need original records from clinical care facilities and public health institutions as well as archived clinical laboratory data and leftover clinical samples on which new analyses can be performed. One might expect to find samples of wildlife, records of animal die-offs and supply-chain documents.

Efforts to explore possible laboratory origins will require that all laboratories known to be working on coronaviruses, or collecting relevant animal or clinical samples, provide original records of experimental work, internal communications, all forms of data — especially all genetic-sequence data — and all viruses, both natural and recombinant. One might expect to find archived sequence databases and laboratory records.

Needless to say, the politicized nature of the origins issue will make a proper investigation very difficult to pull off. But this doesn’t mean that we shouldn’t try our best. Scientists are inquisitive, capable, clever, determined when motivated, and inclined to share their insights and findings. This should not be a finger-pointing exercise, nor an indictment of one country or an abdication of the important mission to discover biological threats in nature before they cause harm. Scientists are also committed to the pursuit of truth and knowledge. If we have the will, we can and will learn much more about where and how this pandemic arose.  

relman

David Relman

Senior Fellow at the Freeman Spogli Institute for International Studies
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Viral lessons: What a little-known virus could teach us about COVID-19

Stanford epidemiologist Stephen Luby discusses surprising results of a recent study on Nipah virus, a disease with no vaccine and a mortality rate of up to 70 percent.
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Microbiologist David Relman discusses the importance of understanding how the coronavirus emerged.

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This study examines the effects of local and nationwide COVID‐19 disease control measures on the health and economy of China's rural population. We conducted phone surveys with 726 randomly selected village informants across seven rural Chinese provinces in February 2020. Four villages (0.55%) reported infections, and none reported deaths. Disease control measures had been universally implemented in all sample villages. About 74% of informants reported that villagers with wage‐earning jobs outside the village had stopped working due to workplace closures. A higher percentage of rural individuals could not work due to transportation, housing, and other constraints. Local governments had taken measures to reduce the impact of COVID‐19. Although schools in all surveyed villages were closed, 71% of village informants reported that students were attending classes online. Overall, measures to control COVID‐19 appear to have been successful in limiting disease transmission in rural communities outside the main epidemic area. Rural Chinese citizens, however, have experienced significant economic consequences from the disease control measures.
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Agricultural Economics
Authors
Huan Wang
Yue Ma
Matthew Boswell
Alexis Medina
Prashant Loyalka
Scott Rozelle
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