Family planning programs in developing countries that offer contraceptives and reproductive health advice apparently do more than prevent pregnancies — they can keep girls in primary school for up to a year longer, even before the youngsters start to think about marriage and babies.

New research by Stanford Health Policy’s Grant Miller and Kim Singer Babiarz indicates that the availability of modern contraceptives alone can keep young girls in the classroom longer, likely because their parents develop greater expectations for their daughters’ long-term health outcomes and economic opportunities.

“What we find is that family planning exposure at a young age is linked to greater opportunities later in life – including economic empowerment,” said Babiarz, an SHP research scholar with a PhD in agricultural economics who focuses on women and children in development. “The fertility effects were modest; the most striking findings were the incentives created to keep girls in school and improvements in the types of jobs women have later in life.”

Babiarz and Miller, a senior fellow at the Freeman Spogli Institute for International Studies and director of the Stanford Center on Global Poverty and Development, unveiled their study at the annual meeting of the Center for Global Development in Washington, D.C. on Dec. 7.

They conducted research with Christine Valente, an associate professor in the department of economics at the University of Bristol and Tey Nai Peng, the principal investigator for the Malaysia Family Life Survey. The Southeast Asia nation was one of the first low-income countries to provide modern contraceptives on a large scale, first in 1954 and then establishing a National Family Planning Board in 1966.

The government then scaled up its national program between 1966 and 1974 and conducted robust surveys with retrospective life histories and detailed community-level information about the timing of family planning availability. The use of contraceptives such as the pill, condoms and IUDs, went from 3 percent in 1961 to 39 percent in 1975. The country also experienced a decrease in the fertility rate of 6.2 children to 4.3 during the same period.

The researchers were able to compare what happened to Malaysian girls who were very young when contraceptives became available in their communities to those who were adolescents when they first gained access to modern contraception. They were not surprised by the effects on fertility; that has generally been the case in countries that adopt large-scale family planning programs.

But they also found unintended incentives: that girls in communities with family planning clinics stayed in school six months longer, increasing to more than an additional year for the girls who were born after the family planning programs began. And it didn’t matter if the girls had fewer younger siblings at home.

Other benefits later in life included better jobs when they became adults. When the Malaysian girls were grown, they were more likely to take in their own elderly parents (relative to their husbands’ parents), a signal of increased status in their households. In fact, they found that the incentives for investing in girls created by family planning may actually outweigh its direct effects, which work through reductions in fertility and changes in birth timing.

“The existence of family planning and contraceptives may lead parents to believe their daughters can participate in the labor force and that more schooling will therefore benefit them,” Miller said. “In other words, it can change their expectations about the world their daughter will live in one day.”

Few studies explicitly distinguish the incentive effects of family planning on women’s education from its direct effects on fertility. Miller said he hoped the new findings might lead policymakers to consider the broader beneficial consequences of family planning beyond those that work directly through changes in pregnancy and fertility.

“A central contribution of this working paper is that it studies the possible incentive effects of family planning programs for human capital investment in girls,” the authors wrote,” which could then translate into improvements in women’s economic status throughout their lives.”

There is plenty of research on how the rapid warming of the planet is going to have growing adverse impacts on global economies, health, food supplies and natural disasters.

A new study now suggests that as temperatures continue to rise — particularly with more and more 90-plus-degree days — more fetuses and infants will experience economic loss by age 30.

“There is a growing body of evidence that finds that shocks to the fetus and young child — whether nutritional, environmental, economic or stress-related — have long-term consequences on health, education and economic outcomes throughout the life cycle,” said Maya Rossin-Slater, an assistant professor of health research and policy at Stanford Medicine and a faculty fellow at the Stanford Institute for Economic Policy Research.

Rossin-Slater published her study Dec. 4 in the Proceedings of the National Academy of Sciences, indicating early-life exposure to extreme temperatures is linked to potential losses in human capital. Her co-authors are Adam Isen, an economist with the U.S. Department of Treasury, and Reed Walker, an assistant professor at University of California, Berkeley.

The researchers used data from the U.S. Census Bureau’s Longitudinal Employer Household Dynamic Files, which contain information on adult labor market outcomes linked to county and exact date of birth. They looked at weather in counties in 24 states on any given day, and then measured how many days with average temperatures above 90 degrees a child born on that day in that county would have experienced during gestation and during the first year of life. They then compared the earnings of individuals who were exposed to different numbers of such hot days, but who were of the same race and gender, and born in the same county and on the same day of the year (but in different years).

Each day a fetus or infant experiences 90-plus-degree temperatures, Rossin-Slater and her co-authors found that he made $30 less a year on average, or $430 over the course of his lifetime. While that may not seem like a huge loss of income, the authors point out that their study is best understood from a population-level perspective rather than from an individual one.

“There is a lot of research already showing that extreme heat has immediate effects on labor market productivity and GDP,” she said. “What we are saying is that there is another wrinkle to this — that there can be consequences many years later, on cohorts who are still in the womb.”

Most Americans today only experience one day a year that is 90 degrees or hotter. But the Climate Impact Lab has indicated that if countries continue to take only moderate action on climate change, by the end of this century there will be about 43 such days a year.

So, if you multiple a $30 annual loss a day by 43 days, you come up with an average $1,290 a year — and compounded in large populations of pregnant women in hot climates.

“Prior research shows that exposure to extreme heat in utero leads to lower birth weight and increases infant mortality,” said Rossin-Slater, who is also a core faculty member at Stanford Health Policy. She said poor fetal and infant health could impact adult earnings in three ways: cognitive impairment, poor health that causes people to miss school or work, and less non-cognitive skill development such as self-control.

“With regard to exposure to heat specifically, fetuses and infants are especially sensitive because their thermoregulatory systems are not fully developed and they have less capacity to self-regulate when their bodies are exposed to extreme temperatures,” Rossin-Slater said.

Hot Zones and Air Conditioners

The obvious questions that arise from such research: What happens to the babies of women who already live in very high temperatures? And why not just ensure that all pregnant women have air conditioners, at least in the developed world where it would be more affordable?

Women in warm zones such as parts of Africa and South Asia, as well as U.S. cities like Phoenix and Washington, D.C., shouldn’t worry too much. The loss of income is relatively little and people living in hot climates may actually adapt over time to exposure to extreme heat.

“Our study is not saying that individual people should be doing something differently to avoid exposure to extreme heat,” Rossin-Slater said. “Instead, we think we are providing additional evidence for the possible population-level consequences of climate change and the projected increase in the number of days with extreme temperatures.”

And what about those air conditioners? The cohorts in the study are actually born in the 1970s, during a period of rapid expansion in air conditioning across American households. The researchers found the earning losses went away in areas where most people got air conditioners installed.

“If we think that there is something biological going on as a result of the fetus being overheated, then it makes sense that AC, which prevents the overheating, can mitigate this negative effect,” Rossin-Slater said.

But it’s important to recognize, she said, that air conditioners come with costs, both financial from the perspective of individuals and households who can and can’t afford such systems, and environmental from the perspective of the country or planet as a whole.

“So this is not a `free’ solution and any cost-benefit calculations related to climate change should take into account this adaption response,” Rossin-Slater said. “But we ought to think about what these results imply at the global level — in many countries that are much hotter than the United States and still don’t have AC. So if we are trying to understand global inequality and the impacts of climate change on developing countries, our results suggest that climate change could play a role in perpetuating global inequality across generations.”

"The problems with our democracy—ever-deepening polarization, incivility, gridlock, dysfunction, conflicts of interest, and disregard for democratic norms—are not just problems of political culture and behavior. Politicians are driven by incentives, especially the desire to get re-elected. Institutions heavily shape these incentives, and our institutions are in need of reform. Unless we reform our democracy, we will be increasingly hard-pressed to improve the health of democracy globally." Listen to Larry Diamond, Senior Fellow at the Freeman Spogli Institute for International Studies, explains in this podcast what are the options from here, by Hoover Institution. 

Paul Wise watched as children ran around a playground attached to a health clinic at a displaced persons camp on the outskirts of Mosul — the northern city in Iraq once controlled by the Islamic State but now back in the hands of the Iraqi government.

The children had survived the Battle of Mosul, which had fallen to ISIS in 2014 but was retaken by the government forces and allied militias during a nine-month military campaign that ended in July. Many of the children suffer from physical and mental wounds and Wise wondered how they would recover with so little medical infrastructure.

Wise was part of a small delegation of physician-academics asked to evaluate a World Health Organization-led system to treat civilians injured in the Mosul fighting. Wise and his colleagues recently slipped into Mosul to visit field hospitals, review health care on the ground and determine whether there is a better way to distribute medical aid during armed conflict.

The visit left the Stanford Medicine professor of pediatrics and senior fellow at the Freeman Spogli Institute for International Studies with questions about health care, humanitarian ethics, and conduct of war: Are there better ways to deliver emergency medical care during the height of battle? How do relief workers maintain neutrality when embedded with government security forces? Has the system of financing humanitarian interventions — one that was essentially created during the Cold War — become dangerously outdated?

Answering these questions is the mission of a new health-and-security initiative at Stanford led by Wise, a core faculty member at Stanford Health Policy who has spent 40 years working to improve the health of children impacted by conflict. Much of his work has been in Guatemala through his Children in Crisis project, the first university-based program to address the needs of children in areas of unstable governance and civil war.

“In talking with the groups that are running these humanitarian efforts in Mosul, there was this uneasiness, this kind of disorientation with the way things are now,” said Wise. “It was a kind of recognition that humanitarian norms are changing, the health personnel and facilities are at greater risk; the financial gap between humanitarian need and humanitarian capability is growing; and the old way of financing humanitarian intervention is inadequate, archaic.”

An Interdisciplinary Approach

Wise believes academics are well suited to help resolve these humanitarian conundrums.

“So we are going to move ahead and try to bring all the players together to reconsider this global challenge. Here at Stanford, we have the capacity to draw upon remarkable resources,” he said.

The new biosecurity initiative led by Stanford Medicine physician and FSI senior fellow, David Relman, together with world-renowned political scientists, security specialists, computer scientists and health policy experts will “attempt to craft new strategies for the provision of critical services to populations affected by conflict and political stability.”

The initiative will collaborate with other institutions such as Johns Hopkins, UCSF, Harvard, and the American Academy of Arts and Sciences. It will also seek the engagement of partners committed to providing humanitarian services, including WHO, the U.N. High Commissioner for Refugees, Doctors Without Borders and the International Committee of the Red Cross.

“The voice of communities impacted by war should also be an essential element in this ambitious effort,” Wise said. “To break new ground, we’re going to have to do things differently; the health strategies need to take into consideration fundamental understanding of the political dynamics. But we have a special opportunity here at Stanford because we take an interdisciplinary approach.”

Children of War

Most of the children Wise saw will never be the same, he said, nor the humanitarian workers who risked their lives to treat them, their families, and fighters from all sides of the battle to oust the Islamic extremists from the city on the Tigris River.

“I look at these little kids with horrendous emotional trauma and PTSD, and I think to myself, it’s the collision of all these questions playing out within a 50-square-meter little playground,” he said. “It’s these broader, strategic and ethical questions that are really profound. And as a pediatrician who is dedicating the last phase of my career to these questions of security and the political dimensions — I have to engage on all of these levels. That’s not easy.”

Wise traveled with WHO officials, as well as Paul Spiegel, a physician who leads the Center for Humanitarian Health at Johns Hopkins Bloomberg School of Public Health; Adam Kushner, a trauma surgeon affiliated with Johns Hopkins; and Kent Garber, a surgical resident at UCLA and research associate at Johns Hopkins.

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Spiegel also believes academics are uniquely positioned to help assess the current system of responding to medical crises during conflict.

“I believe that we can bring objectivity and rigor to analyzing and evaluating important and innovative responses, such as the trauma response by WHO and others in Mosul,” Spiegel said. “Humanitarian organizations are often busy responding quickly to rapidly changing situations; they don’t always have the luxury of time to do what academic humanitarians can do.”

Making the two-hour drive from Erbil to Mosul in armored, bulletproof SUVs provided by the United Nations, they slipped into field hospitals to meet with Iraqi physicians and medical teams with the humanitarian agencies.

Wise, who was able to take a few photos and video on his smartphone, described the devastation on the ground, noting that not since the siege of Leningrad has a city of this size experienced such street-by-street fighting. In large parts of the city, virtually every building was bombed or bulleted. It will take years to clear the rubble and rebuild.

“It’s just a remarkable story of tragedy and resilience,” he said.

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Since the city was not long ago controlled by ISIS, the field hospitals are still surrounded by massive concrete barricades and tactical trucks stationed outside with mounted machine guns.

The team found that at the height of the battle for Mosul, there was tremendous pressure to treat injured civilians and discharge patients very quickly, due to the lack of medical infrastructure and personnel and the continuous wave of new injuries coming in.

“The charge for us was to evaluate the system and how well it worked, what ways could it be improved, how many lives that it saved,” Wise said. “One of the concerns, for example, was that in order to put in medical people that close to the frontline, you have to give them some kind of security. This raised issues among the humanitarians about their need for independence and neutrality, since you’re essentially embedding them with Iraqi security forces.”

Epidemiology and Ethics

“We are looking at the technical issues and the epidemiologic issues, but also dealing with the ethical issues and their implications,” he said.

They intend to write an internal report and then publish their findings in a major medical journal, to get the word out about the issue and gain support for ongoing collaborative work. They’re looking to partners like the American Academy of Arts and Sciences, which recently devoted an entire issue of its journal, Daedalus, to the factors and influences of contemporary civil war. One of the essays in that issue by Wise and his Stanford colleague, Dr. Michele Barry, who directs the Center for Innovation in Global Health, talks about the threat of a global pandemic as a potential byproduct of the 30 ongoing civil wars around the world.

“We’re trying to get the report completed quickly because the model of trauma care for civilians in Mosul is a new model and could be implemented in other combat areas, like the fighting in Syria and other places in Iraq,” Wise said.

Wise worries some see Stanford University as an insulated Silicon Valley institution in a beautiful setting and not always engaged in the real world.

“Well, this is about as engaged in the real world as you can get — this is Stanford moving and doing things out there, not just sitting around in seminar rooms. Sometimes you need to get close to the front lines to save lives,” he said.

When asked what surprised him during this trip to Mosul, Wise smiled.

“I’m sort of old and I’ve seen a lot of the world and not a lot surprises me anymore,” he said. “But it was a reminder of how desperate are the lives of millions of people — that we could do so much more. It’s a reminder of just how fragile physical security really is in this world."

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The Center for International Security and Cooperation now has more than 46 podcasts, dating all the way back to Oct. 19, 2016. Listen to them on the CISAC page on the iTunes website. Simply mouse over the title and click play. Open iTunes to download and subscribe to CISAC podcasts. Seminars and events at CISAC are routinely audiotaped for use as podcasts. Also, the Freeman Spogli Institute for International Relations offers the World Class podcast series, featuring scholars and experts from FSI, CISAC and beyond.

CISAC's Siegfried Hecker this week won the Dwight D. Eisenhower award from the American Nuclear Society. He received the honor, along with former Senator Richard Lugar (R-IN) and former Senator Sam Nunn (D-GA), for his "historic achievements in the advancement of nuclear nonproliferation, arms control, and peaceful uses of nuclear energy." The annoucement from the American Nuclear Society noted:

"Dr. Siegfried Hecker, an international expert in plutonium metallurgy, is being recognized for his nuclear non–proliferation efforts during and following his tenure as the Director of the Los Alamos National Laboratory. Dr. Hecker was part of a historic visit by a U.S. delegation to Sarov, Russia, known as Arazamas-16 during the Cold War.  This was the first visit to the closed city by the U.S., and it laid the foundation for a series of programs aimed at securing nuclear materials in Russia and all of its former republics. Dr. Hecker’s current research at Stanford University’s Center for International Security and Cooperation is focused on reducing the risks of nuclear terrorism worldwide, the nuclear challenges in India, North Korea, Pakistan, and the nuclear aspirations of Iran."

CISAC co-director Amy Zegart wrote the following essay in the Oct. 25 online edition of The Atlantic:

Pity the professionals. In the past month, President Trump has sideswiped certification of the Iran nuclear deal, sandbagged his own secretary of state’s diplomatic efforts with North Korea, and even provoked the ever-careful Senate Foreign Relations Committee Chairman, Bob Corker, to uncork his deepest fears in a series of bombshell interviews. “The volatility, is you know, to anyone who has been around, is to a degree alarming,” Corker told the Times earlier this month, revealing that many in the administration were working overtime to keep the president from “the path to World War III.” He doubled down on those comments a few weeks later, declaring that Trump, among other things, was “taking us on a path to combat” with North Korea and should “leave it to the professionals for a while.”

The professionals sure have their hands full. So far, the Trump Doctrine in foreign policy appears to consist of three elements: baiting adversaries, rattling allies, and scaring the crap out of Congress. The administration has injected strategic instability into world politics, undermining alliances and institutions, hastening bad trends, and igniting festering crises across the globe. “America first” looks increasingly like “America alone.” The indispensable nation is becoming the unreliable one. Even without a nuclear disaster, the damage inflicted by the Trump presidency won’t be undone for years, if ever.

But it’s also important to understand that today’s foreign-policy challenges— whether it’s Iran’s hegemonic ambitions in the Middle East, North Korea’s breakneck nuclear breakout, China’s rise, Russia’s nihilism, Europe’s populism and fragmentation, Syria’s civil war, or transnational terrorism and cyber threats—did not start with Trump. This is the most challenging foreign-policy environment any White House has confronted in modern history.

Three swirling complexities explain why.

Threat complexity

Take a look at any of the annual threat assessments issued by the Director of National Intelligence over the past few years. They will make your head spin. They are filled with rising states, declining states, weak states, rogue states, terrorists, hackers, and more. Bad actors don’t just threaten physical space these days. Adversaries are working on ways to cripple America in cyberspace and even outer space—by compromising all those satellite systems on which its digital society depends. In this threat landscape, the number, identity, magnitude, and velocity of dangers facing America are all wildly uncertain. Exactly how many principal adversaries does the United States have? Who are they and what do they want? What could they do to us? How are these threats changing and how can we keep up without spending ourselves into oblivion or leaving ourselves vulnerable to other nasty surprises? These are fundamental questions. There are no consensus answers. Uncertainty is what fuels America’s foreign-policy anxieties today.

The Cold War was different. Then, certainty was what fueled American foreign-policy anxieties. It was clear to all that the U.S. faced a single principal adversary. The Soviet Union had territory on a map and soldiers in uniforms. Thanks to U.S. intelligence, Soviet intentions and capabilities were fairly well understood. The threat landscape was deadly but slower-moving: Communists never met a five-year plan they didn’t like. And while superpower nuclear dangers were terrifying, they were also constraining in a helpful but insane sort of way. In 1961, President Kennedy invoked the specter of a “nuclear sword of Damocles, hanging by the slenderest of threads” over the earth. Every American foreign-policy decision had to consider the question: What would Moscow think of that? Today, the nuclear sword of Damocles is still hanging—indeed, China, India, Pakistan, and North Korea have all successfully tested nuclear devices since 1961—but no singular threat guides U.S. foreign policy as the Soviet Union once did.

Organizational complexity

As threats have grown more complex, organizational arrangements to deal with them have, too. Coordinating Soviet policy was one thing. Developing coherent U.S. foreign policy in the face of so much uncertainty across so many issues is quite another. Little wonder special advisers, envoys, commissions, boards, initiatives, czars, and new agencies have been growing like mushrooms. This may not sound so bad. But it is. Every new agency or czar or special arrangement says, “the regular process here ain’t working.” The crux of the problem is that bureaucracies are notoriously hard to kill or change. Ronald Reagan famously quipped that bureaucracy is the closest thing to immortal life on earth. Whenever a crisis hits, the natural response is to add a new organization and stir. But if today’s chief challenge is developing coherent, coordinated policy in the face of complexity, creating more organizations to coordinate doesn’t get you very far. Over time, the whole bureaucratic universe just keeps growing bigger, filled with obsolete organizations alongside new organizations; fragmented jurisdictions, overlapping jurisdictions, and unclear jurisdictions; and silos so specialized that nobody can see across all the key issues easily.

Cognitive complexity

Humans are not superhuman. Research finds that most people can remember at most seven items at a time, fewer as they grow older. Even the biggest brains have limits. In 2001, Peter Pronovost of Johns Hopkins noticed that highly trained medical teams at the university’s medical center were screwing up insertions of central line catheters, causing infections in critically ill patients at alarming rates. Why? Because they often forgot one of just five simple steps (like washing their hands) before starting the procedure. (Pronovost instituted a checklist that has since become widely used and is credited with saving thousands of lives.)

In foreign policy, too, the stakes are high and humans are frequently overloaded by complexity, resulting in catastrophic errors that nobody ever intended. One of the chief findings of the 9/11 Commission, for example, was that many inside the FBI simply didn’t know or couldn’t remember all the legal requirements and rules for sharing intelligence and law-enforcement information. Even the Bureau’s own 1995 guidelines were “almost immediately misunderstood and misapplied,” the commission concluded. As a result, clues to the terror plot emerged weeks before 9/11 but were marooned in different parts of the bureaucracy.

In 1935, an advanced bomber nicknamed “the Flying Fortress” crashed during a test flight. The Army Air Corps investigation found that the machine worked fine. The problem was the human. The airplane was so sophisticated, flying required the pilot to remember too many things, and he forgot one of them: unlocking the rudder and elevator controls during takeoff. It was “too much airplane for one man to fly,” one reporter later wrote. That crash sparked the invention of pilot checklists which have been used for nearly a century, transforming global aviation.

U.S. foreign policy is becoming too much airplane for one person to fly. “The professionals” surrounding Trump—Secretaries James Mattis and Rex Tillerson, Chief of Staff John Kelly, National-Security Adviser H.R. McMaster, and others—are trying to keep the whole thing from crashing with a pilot who has never flown before. Let’s hope they can.

America’s approach to the world is a complicated mess, for reasons that predate the current president.

Amy Zegart is co-director of the Center for International Security and Cooperation and professor of political science, by courtesy. She is also the Davies Family Senior Fellow at the Hoover Institution and directs the Cyber Policy Program. She wrote this essay as a contributing editor to The Atlantic.

There are 30 civil wars underway around the globe, where civilians are dealing with death and destruction as well as public health emergencies exacerbated by the deadly march of conflict.

Yemen is battling an unprecedented cholera outbreak which has killed more than 2,150 people this year, with another 700,000 suspected cases of the water-borne disease. The government and a rival faction have been fighting for control of the country, taking 10,000 lives since 2015.

Some 17 children in Syria have been paralyzed from a confirmed polio outbreak in northeastern districts, with 48 cases reported in a country that had not had a case of polio since 1999. The cases are concentrated in areas controlled by opponents of President Bashar al-Assad.

And in the Democratic Republic of Congo — where the civil war officially ended years ago, but thousands of people still suffer from recurrent uprisings and scant infrastructure — a yellow fever outbreak was met last year with a lack of vaccines. The WHO was forced to give inoculations containing a fifth of the normal dose, providing protection for only one year.

And yet today, of the nearly 200 countries on this planet, only six nations — three rich ones and three poor ones — have taken steps to evaluate their ability to withstand a global pandemic.

“The bottom line is that despite the profound global threat of pandemics, there remains no global health mechanism to force parties to act in accordance with global health interests,” write FSI’s Paul Wise and Michele Barry in the Fall 2017 issue of Daedalus.

“There also persists inherent disincentives for countries to report an infectious outbreak early in its course,” the authors write. “The economic impact of such a report can be profound, particularly for countries heavily dependent upon tourism or international trade.”

China, for example, hesitated to report the SARS outbreak in 2002 for fear of instability during political transition and embarrassment over early mishandling of the outbreak. Reporting cases of the 2013 Ebola outbreak in West Africa were slow and the virus killed some 11,300 people in Sierra Leone, Guinea and Liberia before the epidemic was declared over in January 2016.

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“Tragic delays in raising the alarm about the Ebola outbreak in West Africa were laid at the doorstep of the affected national authorities and the regional WHO committees, which were highly concerned about the economic and social implications of reporting an outbreak,” Wise and Barry write in the journal published by the American Academy of Arts and Sciences.

The Daedalus issue, “Civil War & Global Disorder: Threats and Opportunity,” explores the

factors and influences of contemporary civil wars. The 12 essays look at the connection of intrastate strife and transnational terrorism, the limited ambitions of intervening powers, and the many direct and indirect consequences associated with weak states and civil wars.

“Wise and Barry, both medical doctors with extensive field experience in violence-prone developing countries, analyze the relationship between epidemics and intrastate warfare,” write FSI’s Karl Eikenberry and Stephen D. Krasner in their introduction to the issue that includes eight essays by Stanford University faculty.

“Their discussion is premised on the recognition that infectious pandemics can threaten the international order, and that state collapse and civil wars may elevate the risk that pandemics will break out,” they wrote.

Eikenberry and Krasner are hosting a panel discussion about the new volume of Daedalus with FSI senior scholars, including Wise and Barry, on Oct. 23. Members of the Stanford community and the public are invited and can RSVP here. Podcasts with the authors will also be available at FSI’s World Class site over the next few weeks.

Prevention, Detection and Response

Barry and Wise believe there is significant technical capacity to ensure that local infectious outbreaks are not transformed into global pandemics. But those outbreaks require some level of organized and effective governance — and political will.

Prevention, detection, and response are the keys to controlling the risk of a pandemic. Yet it’s almost impossible for these to coincide in areas of conflict.

Prevention includes solid immunization programs and efforts to reduce the risk of animal-to-human spillover associated with exposure to rodents, monkeys and bats.

Then, early detection of an infectious outbreak with pandemic potential is crucial, through a methodical surveillance structure to collect and test samples drawn from domestic and wild animals, a capacity sorely lacking in areas of conflict and weak governance.

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“Civil wars commonly disrupt traditional means of communication,” they write. “The Ebola virus outbreak in West Africa exposed glaring weaknesses in the global strategy to control pandemic outbreaks in areas with minimal public health capacity.”

New strategies that utilize satellite or other technology to link remote or insecure areas to surveillance are urgently needed, they said.

Then there is the response in countries where civil war not only makes it difficult, but politically treacherous.

In Syria, there had not been a case of polio reported since 1999. In 2013, health workers began to see children with the kind of paralysis that is associated with a highly contagious polio outbreak.

“However, the government and regional WHO office have been intensely criticized for their slow and uneven response,” the authors note, particularly the government’s resistance to mobilizing immunization efforts in areas sympathetic to opposition forces.

Pressure from international health organizations and neighbors in the region ultimately led to the reinstatement of vaccination campaigns throughout Syria.   

“The Syrian polio outbreak is an important reminder that health interventions, though technical in nature, can be transformed into political currency when certain conditions are met,” they write. “At the most basic level, the destruction or withholding of essential health capabilities can be used to coerce adversaries into political compliance, if not complete submission.”

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Strengthening Global Oversight

The only comprehensive global framework for pandemic detection and control, the authors write, is the International Health Regulations treaty, which was signed in 2005 by 196 member-nations of the World Health Organization to work together for global health security.

The IHR imposed a deadline of 2012 for all states to have in place the necessary capacities to detect, report and respond to local infectious outbreaks. But only a few parties have reported meeting these requirements, and one-third has not even begun the process. There have also been efforts to enhance state reporting of health systems capacities through voluntary assessments of countries working through the Global Health Security Agenda consortium.

But both frameworks, Barry said in an interview, need financial and political support.

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“I see a stronger IHR with more than words — but actual money behind it in order for it to become stronger,” said Barry, noting the Global Health Security Agenda ends in 2018 and she has been asked to sit on a NAAS task force to form its next iteration. “I’m hoping we can move the needle to put money into bio-surveillance and health security, especially in conflict areas.”

Why should Americans care?

“Pathogens know no borders,” Barry said. “And with climate change, we have tremendous movement of vectors; with globalization and billions of people routinely in flight, we have tremendous health threats traveling first class and coach.”

Twenty Countries at High Risk

Meanwhile, some 20 countries are at high risk for pandemic emergence. The two Stanford professors are urgently calling for “new approaches that better integrate the technical and political challenges inherent in preventing pandemics in areas of civil war.”

Wise and Barry note that human factors, such as the expansion of populations into previously forested areas, domesticated animal production practices, food shortages, and alterations in water usage and flows, have been the primary drivers of altered ecological relationships.

So globalization with climate change brews the perfect storm.

“There is substantial evidence that climate change is reshaping ecological interactions and vector prevalence adjacent to human populations,” they said. “Enhanced trade and air transportation have increased the risk that an outbreak will spread widely. While infectious outbreaks can be due to all forms of infectious agents, including bacteria, parasites, and fungi — viruses are of the greatest pandemic concern.”

Science suggests the greatest danger of pandemic lies in tropical and subtropical regions where human and animals are most likely to interact. Most of the estimated 400 emerging infectious diseases that have been identified since 1940 have been zoonoses, or infections that have been transmitted from animals to humans. The human immunodeficiency virus (HIV), for example, is believed to have emerged from a simian host in Central Africa.

Recent analyses have suggested that the “hotspots” for emerging infectious diseases overlap substantially with areas plagued by civil conflict and political instability. 

The U.S. Agency for International Development and the Centers for Disease Control and Prevention have been working on the Emerging Pandemic Threats Program to improve local pandemic detection and response capacities by directing resources and training to countries thought to be at high risk for pandemic. However, it is not clear that this and related programs are addressing the political dynamics at the local level that will determine the essential cooperation of local communities with any imposed global health security response.

“The unpredictability of a serious infectious outbreak, the speed with which it can disseminate, and the fears of domestic political audience can together create a powerful destabilizing force,” Wise and Barry write in their conclusion. “Current discussions regarding global health governance reform have largely been preoccupied by the performance and intricate bureaucratic interaction of global health agencies. However, what may prove far more critical may be the ability of global health governance structures to recognize and engage the complex, political realities on the ground in areas plagued by civil war.”