Hotpot for one, please.
Want to know what it's like to spend a quarter in China? Check out a blog post from a Ford Dorsey Master's in International Policy (MIP) student.
Want to know what it's like to spend a quarter in China? Check out a blog post from a Ford Dorsey Master's in International Policy (MIP) student.
People who are acquainted with the work of Shorenstein APARC’s Asia Health Policy Program (AHPP) may be aware of the Innovation for Healthy Aging collaborative research project led by APARC Deputy Director and AHPP Director Karen Eggleston. This project, which identifies and analyzes productive public-private partnerships advancing healthy aging solutions in East Asia and other regions, encompasses an upcoming volume, co-authored by Eggleston with Harvard University professors Richard Zeckhauser and John Donohue, about public and private roles in governance of multiple sectors in China and the United States, including health care and elderly care. This volume, however, is not the first collaboration between Eggleston and Zeckhauser.
Zeckhauser, the Frank P. Ramsey Professor of Political Economy at Harvard University’s Kennedy School, is known for his many policy investigations that explore ways to promote the health of human beings, to help markets work more effectively, and to foster informed and appropriate choices by individuals and government agencies. In 2006, Eggleston and Zeckhauser co-wrote a paper about antibiotic resistance as a global threat, an issue that has since received much attention as it has become a critical public health and public policy challenge. Zeckhauser was a pioneer in framing antibiotic resistance as a global threat.
On October 20, 2018, Eggleston was among some 150 colleagues, students, and friends who participated in a special symposium at the Kennedy School to celebrate Zeckhauser’s 50th anniversary of teaching and research, and to anticipate what the next 50 years might bring in the multiple fields he has influenced throughout his long career.
Eggleston joined the first of two panels in that symposium, where she spoke about Zeckhauser’s impact on health policy and about what academics and policymakers should be tackling next on the path to addressing the global threat of antibiotic resistance.
The panel was moderated by Harvard Professor Edward Glaeser. In addition to Eggleston, it included Jeffrey Liebman, Daniel Schrag, and Cass Sunstein.
A video recording of the panel is made available by the Kennedy School. Listen to Eggleston’s remarks (beginning at the 8:42 and 36:20 time marks):
As Stanford’s fall quarter draws to a close, the first cohort of students who are participating in Freeman Spogli Institute’s (FSI) inaugural overseas program in Beijing embarked on their final field excursion. The 8 students and 4 Stanford faculty traveled first to Jinan city (济南) (capital of Shandong province), then to Zouping county (邹平), both located in China’s eastern region of Shandong (山东).
Stanford China Studies in Beijing students and faculty being greeted by their hosts in Jinan, Shandong
Three Stanford Master’s in International Policy students and 5 undergraduate students are participating in this pilot program in Beijing at the Stanford Center at Peking University (SCPKU). The pilot program is being offered by FSl in cooperation with Peking University. Details regarding student activities, reflections and earlier travels can be found here.
This third and final trip was significant not only for the wide-ranging sites that the students saw, but also because Zouping County has a storied connection to the wider community of China scholars in the U.S. and to Stanford. Zouping county was the first rural site in China where foreign scholars were given official access to conduct field research in the 1980’s after Deng Xiaoping’s Opening and Reform in 1978. The late Professor Michel Oksenberg (1938-2001), senior fellow at Shorenstein APARC and FSl, who also served as a key member of the U.S. National Security Council under President Jimmy Carter, spearheaded this effort, which brought over eighty U.S. academics to the area between 1984 and 1991 (For more details re. that history, please see here).
The students’ field trip included visits with those at the top of the official pyramid to the village grassroots, including meetings with the Mayor and Vice Mayor of Jinan (pop: 6.8 million) and City Planning officials there; plus local city officials in Zouping County. Students and faculty viewed urban plans for the Jinan International Medical and Science Center and toured the corporate conglomerate, Shandong Weiqiao Pioneer Group (山东魏橋创业集团有限公司) that owns the largest textile factory in the world; and Xiwang Group, Ltd. (西王集团有限公司) whose main lines of business are corn oil production and structural steel. In some ways, the site visits reminded one of China’s economic rise as the manufacturing hub of the world; and its beckoning future as a science and technology giant.
China Studies in Beijing students and faculty viewing plans for the Jinan International Medical and Science Center
(From left to right): Students -- Drew Hasson (MIP second year student); Lucas Hornsby (sophomore); Isaac Kipust (junior); Jenn Hu (sophomore); and Cathy Dao (sophomore) – and Stanford faculty meeting with Mayor and Vice Mayor of Jinan city
(From front, left to back, right): Profs. Jean Oi, Andrew Walder, Scott Rozelle, Tom Fingar stop by at the company store inside Xiwang Group
A highlight of the trip also included the village of Wangjing, Linchi Township, also in Zouping County. Surrounded by village children, mixing with residents and exchanging high-fives with “the kids [and] the grandmothers, ” Stanford students got a chance to enter ordinary homes and see what village life is like in one (albeit affluent and well-developed) township of Linchi.
Professor Scott Rozelle, joined by Isaac Kipust, Lucas Hornsy and Prof. Tom Fingar, engage with village residents of Wangjing
Drew Hasson exchanging high-fives with the residents of Wangjing village
Students and faculty crowded into a village's home
Isaac Kipust playing with the villager's son
Three boys from Wangjing village with Isaac Kipust and Prof. Scott Rozelle
By the village square, Professor Scott Rozelle even took the opportunity to challenge two village boys to strive for not only a college degree, but a graduate degree; and not just an M.A. but a Ph.D. – and not just at any university, but at Stanford University! One day, perhaps – who knows? – Stanford may find itself conferring a doctoral degree to a student who calls Wangjing village his home.
What’s an M.A.? Not higher than a Ph.D.! Prof. Scott Rozelle in conversation with two village boys in the town square at Wangjing
And the laughing continues . . .
Scott Rozelle in conversation with the boys as Profs. Jean Oi and Andrew Walder look on
All the students, faculty and residents of Wangjing village, Zouping county, gather for the final photo
Students have gone on three field trips during the course of this overseas program – an excursion to the Great Wall at Jinshanling and to Chengde, a “mountain resort” of the Qing Dynasty court; China’s Northeast region, including to the cities of Dalian, Dandong and Jinzhou (see report here); and, now, Shandong province to China’s east. In addition to these field trips, students have also had unparalleled access to speakers from China’s National Development and Reform Commission, which operates directly under China’s State Council; prominent venture capitalistsand start-up entrepreneurs; and executives from large Chinese multinationals. Students have also enjoyed visits to China’s Foreign Ministry for discussions with experts on U.S.-China relations; as well as to the U.S. Embassy, engaging in discussions with its staff on U.S.-China trade tensions and geopolitical relations. Students have not only accessed the halls of power in China, however, but have also visited peri-urban migrant communities and schools for children of migrant workers.
The China Studies in Beijing Program lasts the length of an academic quarterat Stanford – i.e., a mere eleven weeks – and yet it provided diverse opportunities for students to explore multiple facets of this complex and kaleidoscopic nation – from officialdom to ordinary villages; Beijing’s high-tech entrepreneurs to migrant children; international relations experts to corporate executives at China’s MNCs. Even while taking intensive courses taught by leading Stanford scholars on China’s economy, society, international relations and politics, students also enjoyed weekly brown-bag seminars led by guest speakers who spoke on the current state of U.S.-China relations; China-North Korea trade; U.S.-China military competition; China’s growing middle class; and the country’s severe urban-rural divide.
Pending final university approval, the application page for China Studies in Beijing’s Fall 2019 program will open soon. Please stay tuned for more information here or email Patrick Laboon, FSI’s Academic Program Manager, at plaboon@stanford.edu for updates. We anticipate the due date for candidate statement of interest and application to be set for the end of January.
Last month, He Jiankui, a Chinese researcher, announced the birth of the world’s first gene-edited babies, whose DNA had been edited to reduce the risk of HIV infection. While the claim has not yet been verified, Chinese authorities have launched an investigation and ordered this researcher’s work to stop. In the discussion that follows, Stanford Law Professor Hank Greely, an expert in the ethical, legal, and social implications of new biomedical technologies, and a Stanford Health Policy Fellow, discusses the legal and ethical questions surrounding the new world of gene-editing.
First, can you explain what the Chinese researcher, He Jiankui, did?
I’ll try but, first, we don’t know whether He Jiankui** did anything except make YouTube videos and give a talk. There has been no independent verification that these babies exist, let alone that he edited their genes. It would be a very bold fraud, but bold frauds have been carried out before in bioscience, including, notably, Hwang Woo-Suk’s false claim in 2004-05 that he had successfully cloned human embryos.
Assuming He Jiankui did what he said he did, he used a fantastic new DNA editing tool called CRISPR (“Clustered Regularly Interspaced Short Palindromic Repeats”) in human embryos very shortly after the eggs were fertilized. His goal was to change a gene called CCR5. This gene makes a protein that sits on the outside of some our white blood cells, crucial to the immune system, called T cells. There is good evidence that T cells that lack CCR5 cannot be (or cannot easily be) infected with HIV; about 1% of Northern Europeans (and a smaller percentage of people elsewhere) have a particular change in their CCR5 gene that deleted 32 base pairs (“letters”) in the DNA sequence and they do not seem to get HIV infections. So, his stated goal was to provide these embryos (and the babies, teenagers, and adults they turn into) with immunity from HIV infection. The data he released, however, shows that one of the twins only had half of her cells modified. If half of her T cells have CCR5, she could still be HIV infected. The other twin had all of her cells changed but not in the way He Jiankui intended, and not in the way found in people. We have no idea whether she will be immune, wholly or partially, from HIV infection.
Is it legal in the U.S.—or anywhere? If not, why?
It is not legal in the U.S. The FDA takes the position, which I think courts would most likely uphold, that genetically altered human embryos are either drugs or biological products (or both) and so under its jurisdiction. It is illegal—a federal crime—to distribute a new drug without FDA approval. The FDA has not approved genome editing for embryos for clinical use. For research uses only, you can get FDA permission more easily. You need to submit an application to the FDA for what’s called an Investigation New Drug (IND) exemption. You need to show the FDA that there is good reason, based on non-human research, that this will not be too risky for the research participants and that there is a reasonable chance it will be effective. His work would not satisfy either side of this and so would not get an IND.
But that’s not relevant right now because since December 2015 Congress has regularly added an amendment to the FDA’s funding bill, prohibiting it from even considering any application, of any kind, for human germline editing. So, if you did this in the US now, you’d be doing it without FDA approval, which would make your use an illegal distribution of a new drug.
In many other countries, particularly in Europe, any germline human genome editing is illegal by specific statute (which it is not in the U.S.). In most countries there is no law on this—many poor countries have other things to worry about—so it is legal (at least, not specifically illegal) in most countries.
What are the dangers? What are the potential benefits?
One danger to the children is that CRISPR might have caused damage to other parts of their DNA. These so-called off-target effects are fairly common when CRISPR is used. In addition to changes in other parts of the genome, we know that He Jiankui did not accurately make the changes he aimed for in the CCR5 gene; it’s possible that the He Jiankui-modified gene would not only be ineffective at preventing HIV but affirmatively harmful.
A second danger is that life without a working CCR5 gene may have its own problems. The Northern Europeans without it include adults and appear healthy but they haven’t been closely followed to see if they are at higher risk for other problems. There is some early evidence, for example, that they might be more susceptible to West Nile Virus and influenza.
The potential benefit to the babies is HIV immunity but it is of very little weight. One twin cannot be immune because half of her cells have CCR5. The other may not be immune. And both are “saved” from the possibility, probably small, that they would become infected after being exposed to HIV (probably several decades in the future). HIV is already a manageable disease (though certainly not fun); we have no idea how easily preventable or treatable it may be in 20 years.
The potential benefit to science/medicine is showing that CRISPR’d babies can be born but if that is worth establishing, it could and should be done in a different setting, with an embryo with a very serious disease for which no good alternative exists.
When might it become legal?
It could become legal any time Congress lets the appropriations rider lapse (next fall) and FDA decided there was enough safety information to allow it to proceed. I expect that neither of those will happen anytime soon.
When/if it does, would it be governed or overseen by an international organization? How might it be regulated?
Highly unlikely. In the U.S. it will be overseen by FDA and local IRBs. Not perfect but not terrible.
What are the ethical challenges we’ll face when it does become legal?
For me, really not much. The safety issues for the kids are key. Apart from that, based on our current knowledge of human genetics, there are very few situations where gene editing in embryos will be better than embryo selection. We don’t know enough to make super babies and are unlikely to anytime soon. For some people doing any genetic editing that could pass down to future generations is itself a major ethical issue, a “line in the sand” we should not pass. As I have written elsewhere, I don’t think that’s right. See https://leapsmag.com/much-ado-about-nothing-much-crispr-for-human-embryo-editing/
What legal issues do you anticipate?
If this is tried before it is legal, I would expect federal criminal charges against the clinics/scientists. That might raise the question of whether a gene-modified human embryo really is a drug or biological device for purposes of FDA law. If this is tried after it is legal and it goes wrong, big malpractice suits. If it gets used under appropriate regulation, not much.
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Hank Greely is the Deane F. and Kate Edelman Johnson Professor of Law at Stanford Law School, Director of the Center for Law and the Biosciences, Professor (by courtesy) of Genetics, Stanford School of Medicine, Chair of the Steering Committee of the Center for Biomedical Ethics. And Director of the Stanford Program in Neuroscience and Society.
** He Jiankui was a postdoctoral scholar at Stanford in the laboratory of Prof. Stephen Quake from January 2011 to January 2012. His work in the Quake lab focused on computational analysis and was in no way related to gene-editing.
Co-sponsored by the Southeast Asia Program and
the Center on Democracy, Development and the Rule of Law
Indonesia features Southeast Asia’s most vibrant and dynamic democracy, but debilitating institutional dysfunctions persist. Age-old patronage-style practices remain commonplace, despite voter demands for governance reform. In effect, two mutually incompatible systems operate simultaneously: the rule of law on the one hand—“Ruler’s Law” on the other. The disarray provides space for mafias and Islamist fringe groups to wield clout. The contradiction tends to deter investment that Indonesia sorely needs in order to escape a “middle-income trap.” What are the prospects for change in the April 2019 national elections? Join the Indonesia political analyst Kevin O’Rourke for a presentation and discussion of poll data, political trends, and potential post-2019 scenarios in the world’s fourth most populous country.
Yuhei is a Research Scholar (post-doc) at the Japan Program of the Asia-Pacific Research Center (APARC) at Stanford University for the academic year of 2018-2019. His broad research interest centers around understanding how firms and people interact over a social and geographic space, and how such interactions shape the socio-economic space in turn. Currently, he is working on projects that elucidate how Japanese firms form firm-to-firm trade linkages and what it implies for Japanese economies. Yuhei obtained his Ph.D in Economics from MIT in 2018. From 2019, Yuhei will join the Department of Economics at Boston University as an assistant professor.
The following report was originally published by the Hoover Institution.
Scholars from the Hoover Institution, the Freeman Spogli Institute for International Studies, and other organizations today issued a report that examines China’s efforts to influence US institutions and calls for protecting American values, norms, and laws from such interference, while also warning against “demonizing” any group of people.
According to the 192-page document, which was unveiled today (Nov. 29) at a Hoover DC press event, China is attempting on a wide scale to manipulate state and local governments, universities, think tanks, media, corporations, and the Chinese American community. (Click here to read the report, titled “Chinese Influence & American Interests: Promoting Constructive Vigilance.”)
The document was produced by researchers convened by the Hoover Institution and the Asia Society’s Center on US-China Relations, along with support from The Annenberg Foundation Trust at Sunnylands. The working group included leading China scholars who researched the issue for more than a year and a half. Project cochairs are Larry Diamond, senior fellow at the Freeman Spogli Institute for International Studies and the Hoover Institution, and Orville Schell, the Arthur Ross Director at Asia Society Center on US-China Relations.
The objective of the Chinese entities is to promote sympathetic views of China, especially its government, policies, society and culture, the report concludes. The work is described as a “summons to greater awareness of the challenges our country faces and greater vigilance in defending our institutions,” and explicitly not intended to cause unfairness or recklessness towards any group of Americans.
On this point, Diamond and Schell wrote in the afterword, “At the same time that we fortify ourselves against harmful outside interference, we must also be mindful to do no harm. In particular, we must guard against having this report used unfairly to cast aspersions on Chinese, whether Chinese American immigrants who have become (or are becoming) United States citizens, Chinese students, Chinese businesspeople, or other kinds of Chinese visitors, whose contributions to America’s progress over the past century have been enormous.”
The report’s findings include the following:
Policy principles
Looking to the future, the scholars offer a set of policy principles for guiding American relationships with Chinese entities. These include:
For example, the report urges that the US media should undertake careful, fact-based investigative reporting of Chinese influence activities, and it should enhance its knowledge base for undertaking responsible reporting. Also, Congress should perform its constitutional role by continuing to investigate, report on, and recommend appropriate action concerning Chinese influence activities in the United States.
However, the report should not be viewed as an invitation to a McCarthy era-like reaction against Chinese in America, the researchers noted.
“We reiterate: it is absolutely crucial that whatever measures are taken to counteract harmful forms of Chinese influence seeking not end up demonizing any group of Americans, or even visitors to America, in ways that are unfair or reckless,” wrote Diamond and Schell.
Clifton B. Parker, Hoover Institution: 650-498-5204, cbparker@stanford.edu
My reply to the frequently asked question if Kim Jong Un will ever give up North Korea’s nuclear weapons is, “I don’t know, and most likely he doesn’t know either. But it is time to find out.” However, insisting that Kim Jong Un give a full declaration of his nuclear program up front will not work. It will breed more suspicion instead of building the trust necessary for the North to denuclearize, a process that will extend beyond the 2020 US presidential election.
However, the time it will take to get to the endpoint should not obscure the progress that has already been made. Since this spring, Kim Jong Un has taken significant steps to reduce the nuclear threat North Korea poses. He has declared an end to nuclear testing and closed the nuclear test tunnels by setting off explosive charges inside the test tunnel complex. He also declared an end to testing intermediate- and long-range missiles including intercontinental ballistic missiles (ICBMs). I consider these as two of the most important steps toward reducing the threat North Korea poses and as significant steps on the path to denuclearization.
Whereas the North still poses a nuclear threat to Japan and South Korea as well as US military forces and citizens in the region, the threat to the United States has been markedly reduced. In my opinion, North Korea needs more nuclear and ICBM tests to be able to reach the United States with a nuclear-tipped missile. Freezing the sophistication of the program is a necessary precursor to rolling it back in a step-by-step process.
At the September 2018 inter-Korean summit in Pyongyang, Kim also told President Moon that he would commit to dismantling the Yongbyon nuclear complex if the US takes commensurate measures—unspecified, at least in public. The Yongbyon complex is the heart of North Korea’s nuclear program. Shutting it down and dismantling it would be a very big deal because it would stop plutonium and tritium production (for hydrogen bombs) and significantly disrupt highly enriched uranium production.
Yet, Kim’s actions have been widely dismissed as insignificant or insincere by both the left and the right of the American political spectrum. In many of these quarters, the sincerity of Kim’s denuclearization promise is judged by whether or not he is willing to provide a full and complete declaration and to agree on adequate verification measures. But Kim’s willingness to provide a full declaration at this early stage tells us little about his willingness to denuclearize. Moreover, I maintain that insisting on this approach is a dead end, certainly as long as Washington continues to apply “maximum pressure” instead of moving to implement the steps on normalizing relations that President Trump agreed to in the June Singapore statement.
A full declaration is a dead end because it is tantamount to surrender, and Kim has not surrendered, nor will he. A complete account of North Korea’s nuclear weapons, materials, and facilities would, in Kim’s view, likely be far too risky in that it would essentially provide a targeting list for US military planners and seal the inevitable end of the nuclear program and possibly his regime.
Furthermore, a declaration must be accompanied by a robust verification protocol. That, in turn, must allow inspections and a full accounting of all past activities such as production and procurement records as well as export activities. And, once all these activities are complete, an inspection protocol must provide assurances that activities that could support a weapons program are not being reconstituted. This would be a contentious and drawn-out affair.
It is inconceivable that the North would declare all of its nuclear weapons, their location, and allow inspections of the weapons or of their disassembly up front. But in addition to the weapons themselves, a nuclear weapon program consists of three interlocking elements: 1) the nuclear bomb fuel, which depending on the type of bomb includes plutonium, highly enriched uranium (HEU), and forms of heavy hydrogen—deuterium and tritium; 2) weaponization—that is, designing, building and testing weapons, and; 3) delivery systems, which in the case of North Korea appear to be missiles, although airplane or ship delivery cannot be ruled out. Each of these elements involves dozens of sites, hundreds of buildings, and several thousand people.
Let me give an example of what is involved just for verification of plutonium inventories and means of production. Plutonium is produced in reactors by the fission of uranium fuel. We estimate that most of the North’s plutonium has been produced in its 5 MWe (electric) gas-graphite reactor at the Yongbyon complex. A complete declaration must provide for the entire operations history (along with its design and operational characteristics) going back to its initial operation in 1986 to correctly estimate how much plutonium was produced.
In addition, North Korea has operated the Soviet-supplied IRT-2000 research reactor at the Yongbyon site since 1967. Although little plutonium has likely been produced there, this would have to be verified by providing the complete operating history along with performance characteristics since its initial operation. North Korea has also constructed an experimental light water reactor (ELWR) that is likely not yet operational. Its status would have to be checked to see if it was configured to favor weapon-grade plutonium production. Finally, North Korea began to build but never completed 50 MWe and 200 MWe gas-graphite reactors, whose construction operations were stopped by the Agreed Framework in 1994. Their status would have to be verified.
The 5 MWe reactor fuel consists of natural uranium metal alloy fuel elements. Tracking the entire history of fuel fabrication would be an important verification step for plutonium production. It starts with uranium ore mining, milling and conversion to uranium oxide. This is followed by a few additional steps to produce the uranium metal that is formed into fuel elements for the reactor to produce plutonium. Some of these same steps would also be used, but then complemented by turning the uranium into a compound that serves as the precursor gas (uranium hexafluoride) for centrifuge enrichment to produce low enriched uranium for light water reactors or highly enriched uranium for bombs.
A complete and accurate accounting of fuel produced would also likely show a discrepancy that indicates that more fuel was produced at Yongbyon than was consumed. The difference could be accounted for by the fuel that North Korea produced for the gas-graphite reactor it built in Syria, a project that was terminated by Israel’s air raid on the Al Kibar site in September 2007. North Korea is unlikely to acknowledge the illicit construction of the Syrian reactor as part of its own plutonium declaration.
Once produced in the reactor, plutonium has to be extracted from the used or spent fuel after a sufficient period of time that allows the spent fuel to cool thermally and radioactively. The extraction or separations process is accomplished in a reprocessing facility using mechanical and chemical methods. The North’s reprocessing facility became operational in the early 1990s. All of its operations records would have to be examined and verified. In addition, it is likely that some small amount of plutonium that may have been produced in the IRT-2000 reactor was separated in the hot cell facilities in that complex. Its records would have to be examined and verified.
After plutonium is separated, it must be purified, alloyed, cast and machined into final bomb components. Each of these steps generates residue and waste streams that must be monitored and assessed for their plutonium content. Based on my visits to Yongbyon and discussions with the North’s technical staff, I believe that the steps beginning with delivery of yellowcake to Yongbyon (from the uranium mining and milling sites), plus all steps for fuel fabrication, reactor production of plutonium, spent fuel cooling, reprocessing, plutonium purification and alloying into metal ingots are conducted at Yongbyon.
During my visits to Yongbyon, I was told that the plutonium ingots are then taken off site (of an undeclared location) in which the plutonium is cast into bomb components—which would then be followed by machining and assembling into pits, the plutonium cores of the weapons. In 2010, I was also told that all plutonium residues and wastes from reprocessing and plutonium metal preparation were still stored at Yongbyon (under questionable safety conditions). Very little had been done to prepare the spent fuel waste for final disposition. This is likely still the case and, hence, most of the reprocessing facility must remain operational after the rest of Yongbyon is shut down in order to prepare the hazardous waste for safe, long-term disposition. This will also complicate the plutonium inventory verification.
A complete declaration must also include how much plutonium was used during underground testing. In addition to the six known tests at Punggye-ri, North Korea also claims to have conducted “subcritical” experiments (stopping just short of a nuclear detonation), which I consider to be unlikely. If it did, however, North Korea would have to declare the amount of plutonium used and its current state, particularly since such experiments could leave plutonium in a usable form unlike the case for nuclear detonations. To verify the nuclear test history of plutonium, as well as for highly enriched uranium, it would be necessary to provide information or allow drill-back inspections into the test tunnels at Punggye-ri to ascertain the type and amount of nuclear material used in the test.
To complicate matters even further, if one or more of the North’s test devices failed to produce a nuclear explosion, then plutonium (or HEU) could still be resident in the tunnels. Both the United States and Russia experienced such test failures. This is also possibly the case for North Korea because there is still some uncertainty as to whether or not a nuclear test was conducted in May 2010 when a faint seismic signal was observed from the test area. For the most part, the jury is still out on that event, but the North would now have to allow inspections and verification.
It should be apparent that the declaration plus commensurate verification of the amount of plutonium North Korea possesses, which I believe is only between 20 and 40 kilograms, will be an enormous job. I cannot see it being accomplished in the current adversarial environment and certainly not within the timeframe that has been specified by the US government.
A similar sequence of declarations, inspections, and verification measures would have to be developed for the other bomb fuels, namely HEU and the hydrogen isotopes, deuterium and tritium. Verification of HEU inventories and means of production will be particularly contentious because very little is known about the centrifuge facility at the Yongbyon site. As far as we know, my Stanford colleagues and I are the only foreigners to have seen that facility, and then only in a hurried walk-through in 2010. In addition, there exists at least one other covert centrifuge site.
The situation is even more problematic for the second element of the North’s nuclear program, that of weaponization, which includes bomb design, production, and testing because we know nothing about these activities or where they are performed. Although we have some information regarding the nuclear test site at which six nuclear tests were conducted, we do not know if there are other tunnel complexes that have been prepared for testing.
The third element includes all of the North’s missiles and its production, storage and launch sites and complexes. These will also represent a major challenge for complete and correct declarations, inspections and verification.
Once all of the elements have been declared and the dismantling begins, then the focus will have to change to verifying the dismantlement and assessing the potential reversibility of these actions—a challenge that is not only difficult, but one that must be ongoing.
Verification was one of the sticking points during the 2007-2008 diplomatic initiative pursued late in the George W. Bush administration. In 2008, the North turned over copies of 18,000 pages of operating records of the reactor and reprocessing facilities in Yongbyon. The veracity of that disclosure has never been established because diplomatic efforts fell apart when the United States insisted on more declarations up front and North Korea accused Washington of having moved the goal posts. That declaration constituted only a small part of what I outlined above as being necessary for a full accounting of plutonium, not to mention the other components of North Korea’s nuclear program. That was 10 years ago, and much has happened since to make future declarations and verification much more problematic.
At this time, the level of trust between Pyongyang and Washington required for North Korea to agree to a full, verifiable declaration up front does not exist. Hence, my colleagues Robert Carlin and Elliot Serbin and I have suggested a different approach. Negotiations should begin with an agreed end state: North Korea without nuclear weapons or a nuclear weapon program. Civilian nuclear and space programs would remain open for negotiation and possible cooperation. But all facilities and activities that have direct nuclear weapons applicability must eventually be eliminated.
Rather than insisting on a full declaration up front, the two sides should first agree to have the North take significant steps that reduce the nuclear threat it poses in return for commensurate movements toward normalization—the details of which would have to be worked out during negotiations. A good next step for the North would be the destruction of the 5 MWe plutonium production reactor, which would be part of the package that Kim proposed to Moon at the Pyongyang Summit. If these actions are matched by US steps toward normalization as pledged in the Singapore statement, they will serve to build the trust required for the North to initiate a phased declaration process that initially covers operations in Yongbyon and eventually includes the entire nuclear program discussed above.
Unfortunately, the strategic opening created by the Singapore and North-South summits has not been followed by such tactical steps to get the negotiation process off the ground. The North and the South are ready to create a commonly acceptable path forward, but we have the worst of environments in Washington. The Trump team claims progress is being made but insists on maintaining maximum pressure. The North’s Foreign Ministry has pointed outthat the “improvement of relations and sanctions are incompatible.” Also, most US North Korea watchers are either wedded to old think that you can’t negotiate with Pyongyang or they are determined to prove President Trump’s claims on North Korea wrong.
With nuclear tensions on the Korean Peninsula dramatically reduced, it is time to find out if Kim’s drive to improve the economy will eventually lead to denuclearization. He may determine that his nuclear arsenal poses a significant hindrance to economic development that outweighs the putative benefits it confers. Washington and Seoul should work together to encourage rather than inhibit this potential shift.
This study focused on an important but often overlooked aspect of safety in medicine: physician safety. In China, patients may violently protest against doctors via disruptive behaviors when facing unsatisfying results, jeopardizing physicians’ security, affecting their diagnostic reasoning, and ultimately harming patient safety. We investigated the relationship between disruptive behaviors, government intervention, and protest results. Statistical analyses reveal that the ‘paying for peace’ mechanism can create distorted incentives for patients and encourage more riots. Efforts should be made to improve service quality and channel medical disputes into the legal framework.
Suhani Jalota was only 20 years old when she established a foundation to help impoverished women in the slums of her native city, Mumbai. She was 23 when Forbes named her one of Asia’s 30-Under-30 Social Entrepreneurs as her foundation was taking off.
Now, at the ripe old age of 24, she is embarking on her pursuit of a PhD in health policy on the econ track at Stanford Medicine’s Department of Health Research and Policy.
As a social entrepreneur, she is hoping to create self-sustaining health organizations managed entirely by the people in the low-income communities they serve.
Last year, Jalota, who is also in the first cohort of Knight-Hennessy Scholars, received the Queen’s Young Leader award from Queen Elizabeth II and attended the royal wedding of Prince Harry and American actress Meghan Markle, who is now Duchess of Sussex.
The Myna Mahila Foundation— which provides affordable sanitary products and promotes employment and empowerment among women in Mumbai’s slums — was the only non-UK charity chosen to receive donations in lieu of gifts for the royal couple.
Stanford Health Policy caught up with Jalota to ask her a few questions about what inspires her and how she became so passionate about sanitary health and empowering women in India.
Who inspired you to become social-entrepreneur at such a young age?
I come from a government family and, growing up, our conversations at home were always about the development of India and the status of women. My father is an Indian civil servant who has worked on water sanitation for the city; my mom works with underprivileged girl children, and my brother creates water filters for the same slum community. My grandparents were in the police. It’s just what we do. It’s our family calling.
As for entrepreneurship, it was Duke University, the Baldwin Scholars Program and the Melissa and Doug Entrepreneurship Fellowship that actually made me believe that all the dreams I had to change the pitiful state of things on the ground in Mumbai could actually be achievable. There I learned to translate the problems I saw to actionable items that the institution was willing to back and support endlessly.
Then in 2011, I met Dr. Jockin Arputham, who spent 40 years working in the slums of Mumbai as the founder of Slum Dwellers International. He became my inspiration, my idol and my mentor. He singlehandedly improved the lives of millions of women.
Dr. Arputham passed away in October. I am here to complete this mission.
What inspired you to establish the Myna Mahila Foundation?
When I started spending more time with women in the slum communities they told me horrific stories about living on the railway tracks, children dying in front of them, and not being able to walk the public toilets without being sexually harassed. Some were taking pills to constipate themselves just so they did not have to go to the public toilet. Others would tell me how they had been married off at 12 and were still living with drunk husbands who beat them every day.
Women were ignoring their own health and it really struck me as how this would lead to such wasted potential for the women, and for India.
The slum community leaders and I began brainstorming — we became very chatty. That’s where the name comes from. Myna from the chatty South Asian bird and Mahila, which means women in Hindi. And we found that their menstrual cycles were physically and mentally exhausting. We found that sanitation and hygiene were clear signals of dignity for women, so we jumped on that.
You see, 320 million women in India do not have access to sanitary pads. And menstruation in India is a taboo health topic; there is a stigma to shopping for sanitary pads. Most women use rags on their periods and these often become dirty, leading to urinary and vaginal infections.
When you are trapped under an aluminum roof where your horizon is the lining of the slum settlement, and you only see limitations ahead of you, it is difficult to see another way of life. After more than six years of working on sanitation and health research with these women, I realized the problems lay deeply entrenched in a woman’s lack of agency, or ability to make decisions. You are brought up to think that what the generations ahead of you have been doing is the only way of life. Hiding your periods, not cooking food or sleeping with the family during your periods, not going to the temple or playing sports — you believe this is the only way to live.
So we came up with a scheme to sell sanitary pads door-to-door to women who would normally not leave their homes or go to a pharmacy to buy them from male clerks. And we get to know these women; they are opening up and exploring things outside the confines of their husbands’ world. I learned that if women were confident to talk about their periods and menstrual hygiene, it could break the silence surrounding domestic violence or sanitation.
Tell us about the women who work for you and the women you serve.
We employ women from the slum communities we serve, including the accountants, production and sales managers, and the education trainers. We work mostly with Muslim women as that is a representation of the demographics of the communities we are in.
We currently meet about 10,000 women at their doorsteps every month in the 12 slums across Mumbai. It’s not about giving out free pads — a woman gets her period 450 times in her lifetime, so what we’re trying to do is make sure that she understands that it’s a normal health cycle that should not stop her from getting her education and jobs. We have more than 500 girls in our sponsor a girl program, with 100 more girls joining every month. We hold individual counseling and mentorship for these girls along with menstrual hygiene workshops at health camps. We employ 20 women and have partnerships with self-help groups across the city who work with us part-time.
In the words of my mentor Dr. Arputham, it’s not our purpose to tell the women in the slums what to do; you must think about it from their perspective of what they need and help them create their own change. This has been my mission ever since.
We have millions of NGOs in India so you realize that if things are not really improving at a national level, then there’s something that we’re not doing right. We need the civic mindset to marry the efficiency of the business world. This makes people less dependent and more autonomous to be in control of their own situations. And that comes with a sense of pride.
Why focus on health and sanitation?
We are still struggling with the basics in India: basic health, which includes food, housing, potable water and improved sanitation. Numerous research studies have demonstrated that improvements in sanitation have led to dramatic improvements in health, such as life expectancy outcome measures. Unless we have basic health standards achieved, we will remain behind. To add to the problem, health-care is often deprioritized in India. While it accounts for nearly 18 percent of the GDP here in the United States, for example, it only accounts for 1 percent in India. Can you imagine that? With more than 1 billion people. The role of the public sector in India is to get people on the same level playing field with the basics: education, health care so you’re well enough to go to school or work, find food, shelter and water.
India is a true democracy — so if people start to recognize the importance of health and demand better health care, they can get it.
What are your goals for the PhD?
To learn more research techniques to use for conducting experiments on the ground for a variety of topics, including women’s demand for health care, effects of positions of power in seeking health care, and the connection between environment and health. On the supply side, I am becoming increasingly interested in understanding pay-for-performance incentive structures in health institutions and for front-line health workers.
I will also be spending my December breaks and summers in India working at the foundation. After my second year, I hope to continue data collection for my dissertation topic: the effect of environmental changes on health outcomes, such as child stunting levels in the slums. As part of my undergrad thesis, I collected anthropometric data on 880 children to look at the effect of slum redevelopment (when the government forcibly relocates people from slums to government subsidized housing) on child stunting. I learned that when a child has one additional year in the buildings — instead of out in the slums with no toilets and clean water and proper ventilation — they were less likely to be stunted. The effect was even more pronounced (and significant) for children moving from slums without toilets than for children moving from slums with toilets.
Another area of research for me moving forward is how this plays out if a pregnant mother gives birth in the slums or the building. Is that affecting the child’s birth weight? Is water quality, sanitation, population density — have other health outcomes actually improved?
You could have gone anywhere for your PhD. Why Stanford?
The Knight Hennessy Scholars Program — that was a very compelling pull. Further, I think that being at Stanford gives you this additional advantage of having access to really positive technology like Virtual Reality — giving people exposure to a different world. We want people to demand better health care, so if they can experience what it feels like to walk into a hospital and a clean waiting room with a bench and a trash can, it can change their concept of what they deserve. I’m really excited to learn more about how new technologies can be applied in the slums to prompt people to stand up and demand better for themselves.
I took two women who work at Myna Mahila with me to the royal wedding. These are women who come from the slums — and what impressed them most was the cleanliness. They couldn’t believe how people could keep everything so clean. If more women see this through VR, they will start to think that this world should become theirs too. We have access to thousands of women and if we can teach menstrual hygiene education through this technology — well, as an entrepreneur, I get very excited about this. This is just one of the many technologies I want to learn more about and see if they can be applied in the slums.
What did you make of Meghan Markle’s visit to the foundation in January 2017?
When she came to visit she told us she would support us in any way that she could. She kept her word. For us being chosen as one of seven charities for the royal wedding, I thought to myself, oh my God, she really thinks that we’re on to something that could actually change the world for many women. I feel like I have a huge responsibility to live up to their expectations. Now we have to keep our word to them and help women meet their true potential.