The Economist quotes REAP's research on China's rural healthcare system. The full article can be read here.

Following the formulation of the UN’s “sustainable development” goals in 2015, governments worldwide have committed to expanding access to primary care services. Experts believe that primary care can address about 90% of health problems and it has been found to be related to higher life expectancy and lower child mortality rates. However, experts are concerned that a lack of access to primary care and the poor quality of health services will be incapable of meeting the growing burden of chronic illness in poor countries. 

The WHO calculated that about 400 million people globally are unable to access “essential health services,” such as antenatal care and treatment for tuberculosis. However, this figure does not take into account the global burden of non-communicable diseases, such as diabetes or cardiovascular disease. Non-communicable diseases are expected to account for over 70% of deaths in developing countries by 2020, but findings from the World Bank and WHO demonstrate that access to treatments for these diseases are severely deficient. For example, it is estimated that more than half of individuals in developing countries with hypertension are not aware they have this condition, and between 24% and 62% of individuals with diabetes do not receive treatment.

In addition to access and utilization of primary care services, there are concerns that the quality of medical care is poor in developing countries and regions and, therefore, cannot meet the needs of patients. To demonstrate deficiencies in the quality of medical care, the Economist cited research conducted by Sean Sylvia, a professor at Renmin University of China and REAP collaborator, that sent standardized patients to township health centers in Shaanxi province. This research found that health workers spent less than two minutes with patients on average, gave correct diagnoses only 26% of the time, and provided a wrong diagnoses in 41% of the study cases. 

Findings such as these demonstrate the need for improvements in primary care systems across the world. In order to see that these improvements are realized, further research is necessary to develop evidence that can help leaders understand why many individuals do not receive the medical care that they need. 

The Asia Health Policy Program, established in 2007, promotes a comparative understanding of health and health policy in the Asia-Pacific region through research and collaboration with regional scholars, a colloquium series on health and demographic change, and conferences and publications on comparative health policy topics. The program is committed to supporting young researchers through its Asia Health Policy Postdoctoral Fellowship. Every year, the program director, Karen Eggleston, mentors recent doctoral graduates invited to come to Stanford to undertake original research on contemporary health policy of relevance to the Asia-Pacific region. The Program recently organized the Workshop of Young Leaders in Asia Health Policy in Beijing to celebrate its 10th anniversary.

Asia Health Policy Program alumni have been expanding around the globe. Young Kyung Do, from South Korea, was the first Asia Health Policy Postdoctoral Fellow in 2008-09. He earned his doctorate in health policy and management from the University of North Carolina at Chapel Hill, and is currently an associate professor in the Department of Health Policy and Management at Seoul National University in South Korea. His research interests include aging and long-term care, the interplay of health, education and labor, health behavior, sleep and time use, risk literacy and risk communication, value of medical interventions, and quality assessment from the patient's perspective. Working papers: 

The Effect of Informal Caregiving on Labor Market Outcomes in South Korea

The Effect of Coresidence with an Adult Child on Depressive Symptoms among Older Widowed Women in South Korea: An Instrumental Variable Estimation

The Effect of Sleep Duration on Body Weight in Adolescents: Evidence from a Natural Experiment

Brian K. Chen, from the United States, was the 2009-10 Asia Health Policy Postdoctoral Fellow. He earned his doctorate in business administration from the Haas Business School at the University of California, Berkeley. He is currently an associate professor in the Department of Health Services Policy and Management at the Arnold School of Public Health, University of South Carolina in the United States.  He is also the associate director of Taiwan Doctoral Program housed in the Department of Health Services Policy and Management.  He has a unique combination of legal and economic expertise. He received a Juris Doctor from Stanford Law School in 1997. His research focuses on health policy, particularly with respect to health disparities, the burden of chronic illnesses and aging as well as the impact of incentives in health care organizations on provider and patient behavior.  Working papers: 

Strict Liability for Medical Injuries? The Impact of Increasing Malpractice Liability on Obstetrician Behavior: Evidence from Taiwan

Patient Copayments, Provider Incentives and Income Effects: Theory and Evidence from China’s Essential Medications List Policy

Qiulin Chen, from China, was the 2010-11 Asia Health Policy Postdoctoral Fellow. He earned his doctorate in economics from Peking University. He is currently an associate professor and director of the Social Security Research Division of the Institute of Population and Labor Economics, and deputy director of the Research Center of Health Industry Development at the Chinese Academy of Social Sciences in Beijing. His research interests are health economics and health policy, aging and social security, and public finance.

There were two Asia Health Policy Postdoctoral Fellows from 2011until 2012. Ang Sun, from China, earned her doctorate in economics from Brown University in the United States. She is currently an associate professor at Central University of Finance and Economics in Beijing, China. Her research focuses on household and marriage, development, demography and health. The second fellow, Siyan Yi from Cambodia, was the first recipient of the Developing Asia Health Policy Fellowship for citizens of low-income countries in Asia. Dr. Yi earned his doctorate in international health sciences from the University of Tokyo. He is currently a director of KHANA Center for Population Health Research in Cambodia and adjunct associate professor at Center for Global Health Research of Touro University California in the United States. His research projects are in population health, including clinical epidemiology, social and behavioral determinants of health, health promotion, health system strengthening, and health policy in both developed and developing countries.

Marjorie Pajaron, from the Philippines, was the 2012-13 Asia Health Policy Postdoctoral Fellow. She earned her doctorate in economics from the University of Hawaii at Manoa. She is currently an assistant professor at the School of Economics, University of the Philippines. Her research lies at the intersection of applied microeconomics and health policy, with a focus on gender, health, development and labor economics.  Working papers: 

Remittances, Informal Loans, and Assets as Risk-Coping Mechanisms: Evidence from Agricultural Households in Rural Philippines

The Roles of Gender and Education on the Intrahousehold Allocations of Remittances of Filipino Migrant Workers

Margaret Triyana, from Indonesia, was the 2013-14 Asia Health Policy Postdoctoral Fellow. She earned her doctorate in public policy from the Harris School of Public Policy at the University of Chicago. She is currently a visiting assistant professor at the Keough School of Global Affairs at the University of Notre dame, in the United States. Prior to joining the Asia Health Policy Program, she was an Indonesia research fellow at the Harvard Kennedy School. She is particularly interested in how social policies affect health outcomes for the poor, early health investments, and health-seeking behavior in limited-resource settings.

Gendendarjaa Baigalimaa, from Mongolia, was the 2013-14 Visiting Scholar for Developing Asia Health Policy. A medical doctor by training, she studied cancer prevention and the impact of the National Cervical Cancer Program in Mongolia. Upon completion of her fellowship with the Asia Health Policy Program, she became a gynecological oncologist at Mungun Guur Hospital in Mongolia.

There were two Asia Health Policy postdoctoral fellows from 2014 until 2015. Pham Ngoc Minh, from Vietnam, who earned his doctorate in medical science from Kyushu University in Japan, is currently a visiting research fellow at Curtin University in Australia. His main research interests include the epidemiology and prevention of metabolic diseases, particularly diabetes, and depression in Asian adults. He also works on systematic reviews and meta-analyses of observational and clinical studies to inform health policy. The second postdoctoral fellow was Phyu Phyu Thin Zaw, from Myanmar, who completed her doctorate in epidemiology from the Prince of Songkla University in Thailand. She is a research scientist at the Department of Medical Research in the Pyin Oo Lwin branch of the Ministry of Health and Sport in Myanmar. Currently, she is on leave to attend a master of public policy at Oxford University, in the United Kingdom.  Her current research work involves equitable allocation of healthcare resources, the current health system transformations, and the democratization process in Myanmar.

Darika Saingam, from Thailand, was the 2015-16 Asia Health Policy Postdoctoral Fellow. She earned her doctorate in epidemiology from the Prince of Songkla University in Thailand. Her research interests are public health, substance abuse and drug policy. She seeks to identify potentially effective policy directions suitable for Thailand. Before she joined the Asia Health Policy Program, she served as a researcher at Songkla University’s Epidemiology Unit. She has since continued her work on substance abuse research.

Kim Ngan Do, from Vietnam, was the 2016-17 Asia Health Policy Postdoctoral Fellow. She earned her doctorate in health policy and management from the College of Medicine at Seoul National University, South Korea. She has a strong interest in health system-related issues, especially health financing, human resources for health, and health care service delivery. She implemented comparative studies at the regional level and completed fieldwork in Cambodia, Laos, Philippines, South Korea and Vietnam.

Since its inception, the Asia Health Policy Program has supported numerous fellows to develop their expertise. They continue to pursue their academic and research interests, and have become experts in their fields. Alumni hold various academic, research and professional positions around the world, and are part of a vital community that promotes deeper understanding of comparative health policy through education, training and implementation of best healthcare practice.

A new biosecurity initiative at the Freeman Spogli Institute for International Studies (FSI) aims to identify and mitigate biological risks, both natural and man-made, and safeguard the future of the life sciences and associated technologies.

The initiative will be led by David A. Relman, a senior fellow at the Center for International Security and Cooperation and FSI. Relman, the Thomas C. and Joan M. Merigan Professor in the Departments of Medicine, and Microbiology & Immunology, has served as the science co-director at CISAC for the past four years. He will leave this position on Aug. 31 to lead the new initiative.

Michael McFaul, director and senior fellow at FSI, said, “With exceptional leadership skills, valuable experience and abundant energy, David Relman is ideally positioned to work with scholars from across campus who offer critical expertise in biosecurity. This is an exciting, challenging and important new initiative for FSI that is designed to protect public health from the many new risks now accelerating.”

Relman said the biosecurity initiative will seek to advance the beneficial applications of the life sciences while reducing the risks of misuse by promoting research, education and policy outreach in biological security. His CISAC leadership gives him the know-how to lead such a wide-ranging effort across diverse disciplines and communities.

Relman said, “The opportunity to serve as co-director at CISAC has been a wonderful experience, one that has afforded me the chance to get to know outstanding faculty and staff, their scholarship, and critical policy-relevant work, all of which I had not fully appreciated sitting across campus. This experience has made clear the unusual qualities of Stanford University, and the great people that work here. I am now greatly looking forward to this new opportunity at FSI.”

Biosecurity collaborations

During Relman’s term as CISAC’s science co-director from 2013-2017, he led an expansion of the transdisciplinary work in science and security to include biology, biological and other areas of engineering, medicine, and earth and environmental sciences.

The foundations for work in biological science, technology and security were established at CISAC, especially in the hiring of Megan Palmer, a senior research scholar at CISAC and FSI. Both Relman and Palmer worked together on engagements and discussions with a growing network of more than 20 faculty involved in biosecurity across Stanford.

Palmer said, “Stanford has an opportunity and imperative to advance security strategies for biological science and technology in a global age. Our faculty bring together expertise in areas including technology, policy, and ethics, and are deeply engaged in shaping future of biotechnology policy and practices.”

New insights, new risks

In his new post, Relman said he intends to build on this foundation by creating an initiative that consolidates and focuses activity in biosecurity, develops research and educational programs, attracts new resources, and looks outward at opportunities for policy impact and changing practices across the globe.

Relman said that “new capabilities and insights are reshaping important aspects of the life sciences and associated technologies, and are accompanied by a host of new risks.” If misused, whether by malice or accident, “they pose the potential for large-scale harm,” he noted.

Relman added that the initiative will bring together interest and expertise across the centers and programs of FSI in partnership with Schools and Departments across the university.

At FSI, CISAC will co-sponsor the biological security initiative, which will leverage Stanford expertise in the life sciences, engineering, law and policy.  Key partners will include Tim Stearns (biology), Drew Endy (bioengineering), Mildred Cho (bioethics), and Hank Greely (law), according to Relman. The biosecurity group will also partner with another new program at FSI in global health and conflict, which is led by Paul Wise, Frank Fukuyama, Steve Stedman, Steve Krasner, and others, he added.

Stanford’s School of Medicine and Department of Medicine will also co-sponsor the initiative, thanks to leadership from Lloyd Minor, Michele Barry and Robert Harrington. Relman looks forward to establishing similar relationships with other schools and departments, he said.

 “These partnerships are critical. I’m excited to work with a growing community both within and beyond Stanford towards the goal of a peaceful and prosperous world in the century of biology,” he said.

MEDIA CONTACTS:

David Relman, Center for International Security and Cooperation: relman@stanford.edu

Megan Palmer, Center for International Security and Cooperation:  mjpalmer@stanford.edu

Clifton B. Parker, Center for International Security and Cooperation: (650) 725-6488, cbparker@stanford.edu

Siegfried S. Hecker wrote the following essay for Politico Magazine on the subject of the Trump administration's approach to North Korea:

Now that the nuclear crisis on the Korean Peninsula has been at least temporarily defused thanks to Kim Jong Un’s announcement that he would wait and see before launching missiles toward Guam—despite ominous North Korean propaganda as the U.S. and South Korea launch their latest joint military exercises—it’s time to step back and ask ourselves the big questions about just how useful our approach to North Korea’s nuclear program has been so far. 

My answer: Not very useful at all. During the past 15 years, North Korea first built the bomb and then expanded it to a nuclear arsenal that threatens the region, while Washington has continued to deny reality with its call for complete denuclearization. Which is why it’s time to take a long and serious look at the next option: talking with North Korea.

Although a Wall Street Journal op-ed by Secretaries Jim Mattis and Rex Tillerson earlier this month served to lower tensions by stating that the United States was still pursuing peaceful denuclearization, it does not introduce any new elements that could bring the two sides closer to ending the nuclear crisis. The op-ed, which reassured Kim that “the U.S. has no interest in regime change or accelerated reunification of Korea,” is a welcome relief from Mr. Trump’s “fire and fury” warning to Kim. But this approach is likely to fare no better in compelling Pyongyang give up its nuclear weapons than the Obama administration’s “strategic patience.”

So—how can we make real progress?

Washington should drop its preoccupation with North Korea’s intercontinental ballistic missile (ICBM) threat. It is misplaced and dangerous. Instead, Trump administration officials should talk with Pyongyang, face to face, without any preconditions, to avert what I consider the greatest North Korean nuclear threat—that of stumbling into an inadvertent nuclear war on the Korean Peninsula, which may lead to hundreds of thousands deaths including thousands of American citizens.

It’s important to understand why Kim is so obsessed with these weapons: to deter the United States from attacking North Korea and what Pyongyang calls “hostile policies.” Striking the U.S. with a nuclear-tipped missile would be suicide, and there’s no evidence that Kim is suicidal.

What’s more, there’s a lot to indicate that North Korea isn’t close enough to developing ICBM-capable missiles to strike the United States even if it wanted to. The panic over North Korea’s missiles was elevated recently when leaked classified U.S. intelligence estimates were reported to indicate that Pyongyang has already achieved such capabilities, in addition to possessing as many as 60 nuclear weapons in its arsenal. But I don’t concur with those estimates.

Based on my 50 years of experience with nuclear technologies and nuclear weapons, combined with what I saw and learned during my seven visits to North Korea beginning in 2004, I don’t believe Pyongyang has yet mastered the key elements of delivering a nuclear-tipped ICBM to the continental United States. Although North Korea demonstrated significant progress in the missile field with two launches in July, experts have raised serious questions about whether it has demonstrated all the missile and re-entry vehicle technologies that will protect the nuclear warheads during the fiery plunge into the Earth’s atmosphere.

Moreover, the nuclear warhead that must be mounted on the missile is the least developed and least tested part of North Korea’s nuclear ICBM ambitions. It must survive the extreme temperatures and mechanical stresses involved during launch, flight and re-entry into the atmosphere. It must detonate above the target by design, not accidentally explode on launch or burn up during reentry. More missile tests are needed that mirror real ICBM conditions to permit measurements that more accurately define the extreme conditions that the delicate materials such as plutonium, highly enriched uranium and chemical high explosives experience inside the warheads. It is much simpler to detonate a nuclear device in an underground tunnel under controlled conditions than to simulate all of the conditions a warhead experiences on the way to its target. 

What makes matters even more challenging for Pyongyang is that it has very little plutonium and highly enriched uranium. I have estimated that North Korea has 20 to 40 kilograms plutonium and 200 to 450 kilograms highly enriched uranium. My analysis is based on what I saw during my visits to the Yongbyon nuclear complex and on extensive discussions with their nuclear experts. These stocks have to serve multiple uses: They must be shared between experiments required to understand the world’s most complex elements, nuclear tests to certify the design of the weapons and stock for the arsenal. My best estimate, albeit with considerable uncertainty, is that the North’s combined inventories of plutonium and highly enriched uranium suffice for perhaps 20 to 25 nuclear weapons, not the 60 reported in the leaked intelligence estimate.

North Korea will need a few more nuclear tests because its experience with either material, plutonium or highly enriched uranium, for warheads is too limited for ICBM use. Nuclear test site preparations appear complete, but Pyongyang is most likely weighing the technical benefits against the political risks of conducting such tests. Whereas I believe North Korea has insufficient test data for ICBM warheads, we must assume it has already learned enough to mount a warhead on its shorter-range missiles that can reach all of South Korea and Japan because these missiles are able to accommodate bigger nuclear warheads and these would experience less stringent operational conditions.

In other words, the North still has a ways to go to pose a serious ICBM threat, but it is clearly working in that direction. The danger is that in his drive to achieve a greater balance with the United States by perfecting a missile capable of delivering a nuclear weapon to the continental U.S., Kim could miscalculate where Trump’s red line actually is, triggering a retaliatory action by Trump that could escalate to a nuclear war on the Korean Peninsula. Our problem is that we know nothing about Kim and the military leaders who control his nuclear arsenal and drive the missile and nuclear development programs. It’s time to talk and find out.

And we have to talk now, without demanding that North Korea agree to any preconditions, such as those suggested by Mattis and Tillerson – namely, an immediate cessation of its provocative threats, nuclear tests, missile launches and other weapons tests. Pyongyang is not about to make unilateral concessions before talks. One should read Kim’s announcement that he will wait with the missile launches as a positive signal, although he added that the U.S. must stop its “arrogant provocations.”

The diplomatic opening created last week on both sides makes such talks possible. President Trump should send a small team of senior military and diplomatic leaders to talk to Pyongyang. These talks would not be negotiations—not yet. Importantly, these talks would not be a reward or a concession to Pyongyang and should not be construed as signaling acceptance of a nuclear-armed North Korea. Talking would, however, be a necessary step toward re-establishing critical links of communication to avoid a nuclear catastrophe. The dialogue should stress the need for mechanisms to avoid misunderstanding, miscalculation or misinterpretation of actions that could quickly bring us over the cliff into a nuclear war.

The talks would provide an opportunity to convey Secretary Tillerson’s message that Washington does not seek regime change face to face in Pyongyang. In simplest terms, the team could underline the message that Washington is deterred from attacking the North, but not from defending the United States and its allies. It should reiterate that any attack on South Korea or Japan, be it with conventional, chemical or nuclear weapons, would bring a devastating retaliatory response upon North Korea.

The team can also impress upon Pyongyang that ensuring the safety and security of nuclear weapons is an awesome responsibility. These two issues are becoming more challenging as North Korea strives to make its nuclear arsenal more combat-ready. A nuclear-weapon accident in the North would be disastrous, as would a struggle to control the North’s nuclear weapons in the case of attempted regime change from within or without. All indications are that such talks would be strongly supported by the North’s two most important neighbors, South Korea and China, particularly if Washington consults them before.

For too long, America’s policy toward North Korea has been based on impractical goals. Complete, verifiable and irreversible denuclearization was a hallmark of the George W. Bush administration’s approach to North Korea and was also pursued by the Obama administration. Whereas complete and verifiable denuclearization might be realistic long-term goals, irreversible is impossible short of the total loss of human memory. The U.S. Manhattan Project produced the bomb in 27 months more than 70 years ago, and that was without knowing with certainty at the outset that it was even possible.

It was under Bush that North Korea first built the bomb and under Obama that it expanded to a threatening nuclear arsenal. Both presidents failed to address the root cause of Pyongyang’s determined effort to build a nuclear weapons arsenal—assuring the Kim regime’s security. Now, Trump faces a North Korea with the ability to inflict unacceptable damage to U.S. allies and U.S. assets in the region, while it also continues its drive to threaten the continental U.S. Perhaps, much as Dwight Eisenhower talked to Nikita Khrushchev, Richard Nixon to China’s Mao Zedong, and Ronald Reagan to Mikhail Gorbachev, Trump can take the next step with North Korea, and talk now to avert a nuclear catastrophe.

Rod Ewing will serve as co-director of the sciences for Stanford’s Center for International Security and Cooperation.

Ewing, a mineralogist and materials scientist, is the Frank Stanton Professor in Nuclear Security at CISAC and senior fellow at the Freeman Spogli Institute for International Studies. He begins his new position on Sept. 1, following David Relman, the previous co-director for the sciences. Amy Zegart is the CISAC co-director for the social sciences.

Ewing, whose research is focused on the properties of nuclear materials, leads the Reset Nuclear Waste Policy program at CISAC. He describes the center as a unique organization that “explicitly acknowledges” the role of science and the social sciences in formulating policy. 

“CISAC is a rare opportunity for political and social scientists, historians and scientists and engineers to work together on solving pressing problems. The fact that we have two co-directors reflects a serious intent to integrate knowledge from the widest range of perspectives in order to find policy solutions to important problems,” he said.

Scholarship, research

Ewing is the author or co-author of more than 750 research publications and the editor or co-editor of 18 monographs, proceedings volumes or special issues of journals. He has published widely in mineralogy, geochemistry, materials science, nuclear materials, physics and chemistry in more than 100 different journals. Ewing was granted a patent for the development of a highly durable material for the immobilization of excess weapons plutonium. He is also a founding editor of the magazine, Elements. In 2015, he won the Roebling Medal, the highest award of the Mineralogical Society of America for scientific eminence.

“My work on nuclear waste started out with a focus on technical issues, but over several decades, I realized that technical solutions were not enough.  I now focus on trying to understand why institutions – universities, national laboratories and federal agencies – fail to arrive at the technical solutions. I have been surprised to learn how little science has been applied to the nuclear waste problem – and how social issues have dominated the outcome,” Ewing said.

Expertise, policy

In particular, Ewing seeks to understand why so little information from experts rise through an organization and change accepted ‘truths.’

“I first saw this when I was a soldier in Vietnam and continue to see the same problem in many other areas, that a disconnect exists between the on-the-ground reality and policy,” said Ewing who served in the U.S. Army as an interpreter of Vietnamese attached to the 25th Infantry Division from 1969 to 1970.

“At the very highest levels, policies seem to be based on a hunch or a bias rather than an analysis of the problem. I have always wondered why this is so common – as it often leads a country or organization down a wrong and often dangerous path,” he added.

Born in Abilene, Texas, Ewing attended Texas Christian University (B.S., 1968, summa cum laude) and graduate school at Stanford University (M.S., 1972; Ph.D., 1974). He began his academic career as an assistant professor at the University of New Mexico (1974) rising to the rank of Regents’ Professor of Earth & Planetary Sciences in 1993.

From 1997 to 2013, Ewing was a professor at the University of Michigan, and in 2014, he joined Stanford.

MEDIA CONTACTS:

Rod Ewing, Center for International Security and Cooperation: (650) 725-8641, rewing1@stanford.edu

Clifton B. Parker, Center for International Security and Cooperation: (650) 725-6488, cbparker@stanford.edu

When it comes to cybersecurity, Stanford is the hot spot, especially if you work in national security.

On Aug. 18, officials from the U.S. military, National Security Agency, U.S. Cyber Command, Joint Chiefs of Staff, and from countries known as the “Five Eyes,” attended cybersecurity discussions on campus. Most attendees were chief information officers. John Zangardi, the principal deputy chief information officer for the U.S. Department of Defense, led the group.

The "Five Eyes" refers to an alliance comprising the U.S., Australia, Canada, New Zealand, and the United Kingdom. These countries abide by an agreement for joint cooperation in signals intelligence, military intelligence, and human intelligence.

The event was held at the Hoover Institution, a co-sponsor along with Stanford’s Center for International Security and Cooperation, a center in the Freeman Spogli Institute for International Relations. Participants took part in two roundtables – the first one, “Geopolitical Perspectives,” provided a strategic overview of international security with Stanford’s William J. Perry (CISAC and the Hoover Institution), Michael McFaul (FSI and the Hoover Institution), Toomas Henrik Ilves (Hoover Institution), and Francis Fukuyama (the Hoover Institution and FSI's Center on Democracy, Development, and the Rule of Law).

The second discussion, the “Cyber Information Warfare Panel,” focused on cyber challenges with Amy Zegart (CISAC and the Hoover Institution), Herb Lin (CISAC and the Hoover Institution), John Villasenor (CISAC and the Hoover Institution), and Jay Healey (CISAC).