After going in for a routine procedure, a man ends up with a punctured lung and a medical emergency. A woman's surgery goes well until her stomach is stitched up with a sponge inside. Most of us feel safe going to the doctor, but the road to high-quality care was not straightforward. In this FSI World Class Podcast, Stanford Health Policy's Kathryn McDonald tells us how the safe, high-quality care we expect got where it is today and what we can do to maintain it. Kathryn McDonald is the Executive Director of the Center for Health Policy/Primary Care and Outcomes Research at Stanford University.

And in this Q&A posted on Medium, McDonald responds to the age-old question: How can we improve the quality of health care?

"One of the lead agencies that’s responsible for generating evidence and moving it into practice is the Agency for Healthcare Research and Quality (AHRQ). They’re under Health and Human Services. They have a major program called AHRQ’s Evidence Now aimed at improving heart health in America. Lots of people are on aspirin to prevent heart attacks, but there are also lots of people who could benefit from it who aren’t on it. They’re working with the health-care delivery system to figure out how to get patients who need to be on aspirin to use it. These are driven by reforms to make the delivery system accountable for patients’ health. If you can change behavior — either of patients or of physicians — you can save more lives."

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Stanford Health Policy’s newest faculty member, Joshua Salomon, believes that one urgent need in global health research is to improve forecasts of the patterns and trends that are the major causes of death and disease.

Salomon, who is leaving leaving his position as professor of global health at the Harvard T.H. Chan School of Public Health to join Stanford on Aug. 1, works on modeling of infectious and chronic diseases and their associated intervention strategies, as well as methods for economic evaluation of public health programs and ways to measure the global burden of disease.

And he looks at the potential impact and cost effectiveness of new health technologies.

“Projections of future trends in health are crucial to formulating policy,” said Salomon, who has a PhD from Harvard. “To think strategically about the technologies and policies that would make the biggest impact on health over the next 20 to 50 years, we really need to start by understanding the range of likely trends in major health challenges over the coming decades.”

Stanford, he said, offers him a “rich collaborative environment” to better learn from advances in forecasting across a range of other disciplines, such as economics, political science, and environmental science.

“With a better picture of what the world is likely to look like over the next 50 years — and what are going to be the most pressing health problems — we can invest wisely and put ourselves in a position to respond more effectively.”

Salomon is also the director of the Prevention Policy Modeling Lab, which is funded by a five-year award from the Centers for Disease Control and Prevention. The consortium represents the collaborative research of experts from Massachusetts General Hospital, Boston Medical Center, Dana Farber Cancer Institute, Yale School of Public Health, Brown University School of Public Health, and the Massachusetts Department of Public Health and.

He will continue directing the lab from Stanford and intends to bring in new research threads from his colleagues here on the Farm. The lab works on a wide range of projects dealing with policy analysis for hepatitis, sexually transmitted infections and diseases such as HIV, and tuberculosis.

“It’s a rewarding grant for me to work on because, unlike a lot of modeling projects, the work that we do really starts from urgent public health questions that policymakers have,” he said. “All of the questions that we are working on are questions that originated directly from discussions with CDC and other public health partners.”

With Salomon’s move to Stanford, the university gains a dynamic duo.

Grace Lee joins Stanford as the Associate Chief Medical Officer at Lucile Packard Children's Hospital in the fall, 2017.

His wife, Grace Lee, MD, MPH, joins in the fall as the Associate Chief Medical Officer at Lucile Packard Children’s Hospital. As a professor of population medicine at Harvard Pilgrim Health Care Institute & Harvard Medical School, Lee has led research in vaccine safety in the FDA-funded Post-licensure Rapid Immunization Safety Monitoring (PRISM) program and the CDC-funded Vaccine Safety Datalink, which monitors the safety of vaccines and studies rare and adverse reactions from immunizations.

She has also examined the impact of financial penalties on rates of healthcare-associated infections, as the principal investigator of an AHRQ-funded study, as well as developed novel surveillance definitions for ventilator-related events in neonates and children.

While at Stanford, Lee said, she intends “to find opportunities to enhance the learning health system approach to improve patient outcomes and population health.”

Salomon has spent his entire career as a collaborator on the Global Burden of Disease project, the world’s most comprehensive epidemiological study commissioned by the World Bank in 1990, which tracks mortality and morbidity from major diseases, injuries and risks factors.

“The study has made a major contribution to global public health because before this study we just didn’t have a comprehensive, systematic understanding of the things that cause death and disability in low- and middle-income countries. But now we do,” he said. “It’s hugely ambitious and very sweeping in scope — and a lot of my work is around providing the evidence we need to inform policy.”

Much of Salomon’s work is global in nature. He’s most recently focused on older adults in one rural South African community, which has a high prevalence of HIV and one of the world’s highest levels of hypertension. His research there aims to inform urgent prevention initiatives tailored to older adults where HIV and cardiovascular risks are moderate or high, as in similar communities in sub-Saharan Africa.

“People don’t expect a high level of ongoing HIV transmission in older adults,” he said. “The double burden that we find, with a very high level of HIV, as well as the high prevalence of diabetes and heart disease, creates enormous strains on the health-care system.”

The Asia Health Policy Program at the Shorenstein Asia-Pacific Research Center, in conjunction with The Next World Program, is soliciting papers for a workshop, “Inequality & Aging,” held at the University of Hohenheim from May 4-5, 2018. The workshop will result in a special issue of the Journal of the Economics of Ageing, and aims to address topics such as:

• Population dynamics and income distribution
• The evolution of inequality over time and with respect to age
• Health inequality in old age
• The effects of social security systems and pension schemes on inequality
• Policies to cope with demographic challenges and the challenges posed by inequality
• Family backgrounds and equality of opportunities
• Demographically induced poverty traps
• Effects of automation and the digital economy in ageing societies
• Flexible working time and careers, and their long-term implications
• The dynamics of inheritances, etc.

Researchers who seek to attend the workshop are invited to submit a full paper or at least a 1-page extended abstract directly to Klaus Prettner and Alfonso Sousa-Poza by Sept. 30, 2017.

Authors of accepted papers will be notified by the end of October and completed draft papers will be expected by Jan. 31, 2018. Economy airfare and accommodation will be provided to one author associated with each accepted paper. A selection of the presented papers will be published in the special issue; the best paper by an author below the age of 35 will receive an award and be made available online as a working paper.

Researchers who do not seek to attend the workshop are also invited to submit papers for the special issue. Those papers can be submitted directly online under “SI Inequality & Ageing” by May 31, 2018.

For complete details, please click on the link below to view the PDF.

Stanford Health Policy’s Michelle Mello is calling for reforms to the practice of overlapping surgery, a practice in which surgeons juggle multiple operations at the same time.

Primary surgeons who run multiple operating rooms delegate “non-critical” parts of the operations to trainees or physician assistants. Overlapping scheduling is considered an important means of giving surgical trainees hands-on experience before they enter the profession with a license to operate. But patients are often unaware about the prospect that their surgeon may be double-booked.

“As patients at a teaching hospital, we know that surgery is a team sport and trainees will be involved,” Mello said in an interview. “But learning that the surgeon we’ve entrusted ourselves to may be out of the room for extended periods while we’re under anesthesia comes as a surprise to many patients. Like other aspects of surgical care, policies and procedures need to be in place to make sure this can be done safely.”

Mello, who is a professor of health research and policy at Stanford Medicine and a professor of law at Stanford Law School, wrote in this JAMA editorial that the practice has dented patient trust in the surgical profession and that better research is needed to determine how patients are impacted by double booking. Mello wrote with co-author Edward H. Livingston, MD, of the Department of Surgery at the UT Southwestern School of Medicine in Dallas. Livingston is also deputy editor of JAMA.

For example, Mello and Livingston noted that The Seattle Times reported in February about the unusually high volume of neurosurgical operations “and reportedly poor outcomes” at the Swedish Neuroscience Institute. The top two neurosurgeons each billed more than $75 million in 2015, and clinical staffers who raised concerns were ignored. The news reports prompted federal and state investigations and the resignations of the hospital’s neurosurgery chief and chief executive officer.

Medicare regulations applicable to teaching hospitals allow surgeries to overlap, but primary surgeons can’t bill the government for an operation unless they personally perform the “critical or key portions.”

The Senate Committee on Finance, which oversees Medicare, issued a report last year that said patient safety and informed consent were key concerns raised by overlapping surgery. But they also found scant research on the consequences for patients.

Mello and Livingston write that six peer-reviewed studies have been published about the safety of overlaps, but note that they were all retrospective, single-institution studies.

“These studies suggest that overlapping surgery is not associated with increased risk of patient harm, but these observational studies have important limitations,” they said. 

For example, some studies lumped cases with just one second of overlap together with cases that overlapped significantly longer, making it hard to measure the relationship between the amount of overlap and surgical outcomes. They added that the generalizability of findings beyond the small number of institutions and surgeons studied is unknown.

In ongoing work with other Stanford Health Policy faculty, Mello plans to examine data from a large number of teaching hospitals. One issue requiring further investigation, she said, is whether the longer procedure times documented for overlapping cases mean more time under anesthesia, which elevates the risk of postoperative complications.

Citing a public opinion survey showing that 69 percent of Americans oppose the practice, the JAMA authors concluded, “Overall, the modest evidence base does not suggest that overlapping surgery is unsafe, but rather that the practice is not trusted.”

They believe patients and regulators may distrust it because of the possibility of harm to patients, lack of transparency about what is going on, and surgeons’ conflict of interest in determining on their own what aspects of operations they must personally perform.

Mello and Livingston believe restoring public trust in the surgical system requires stronger proof that overlapping scheduling is safe, including evidence from randomized studies, and better informed consent practices which ensure that patients are given full information about scheduling practices well ahead of surgery.

“The disclosure should include the likelihood that the operation will involve an overlap, a description of who will perform which parts of the operation and what their qualifications are, and the patient’s option if he or she objects to the scheduling,” they said.

Finally, hospitals have an obligation to ensure that their surgeons are performing the critical parts of an operation.

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"The robots aren't going to take over, or even destroy jobs," says CDDRL's Jerry Kaplan. Read the article here.

What happens when rising countries like China, India and Brazil collide with international organizations still operating from a post-World War II landscape?

That’s the question Phillip Lipscy, assistant professor of political science at Stanford University, addresses in his new book, Renegotiating the World Order. Lipscy analyzes how influential global organizations like the U.N. Security Council and International Monetary Fund react, or, in some cases, don’t react to pressures exerted by rising nations. While the influence of these international organizations has increased stability and peace, Lipscy details the hurdles rising countries must overcome to have a seat at the global table. He also discusses how established countries like the United States exert their influence in these matters.

The Stanford News Service interviewed Lipscy, who is also the Thomas Rohlen Center Fellow at Stanford’s Freeman Spogli Institute for International Studies, about his new book:

What is the major takeaway from your book?

My book examines how countries renegotiate their position in the world order. I specifically look at international institutions like the United Nations Security Council, International Monetary Fund (IMF), and European Union (EU). These institutions play important roles in the international system and they are often contested by countries that seek greater influence. I show that renegotiation plays out differently depending on the institution’s policy area: institutions in competitive policy areas tend to adjust flexibly or collapse as states exit, while institutions in noncompetitive policy areas can remain relevant even while resisting change.

Why is understanding institutional change in international relations important?

Before the early 20th century, renegotiating the world order often meant acquiring a strong military and fighting or coercing other countries. As I argue in the book, several transformations have made peaceful renegotiation more viable. Military confrontation has become more costly with the advent of nuclear weapons, and several factors – like joint democracy and economic interdependence – have made conflict less likely. At the same time, the rise of international institutions gives countries mechanisms to gradually and peacefully elevate their influence in the international system.

What motivates countries to pursue institutional change?

The motivations vary. The common theme is a sense of unfairness. For example, Japan’s economy grew rapidly after the conclusion of World War II in 1945. Japanese leaders felt that their country deserved international recognition and respect, but they were frustrated that their status in international institutions lagged behind.  Japan has never been a permanent member of the U.N. Security Council, and Japan ranked fifth in IMF voting power in 1980 despite having the world’s second-largest economy. Japanese nationals remain underrepresented in most international organizations, particularly in leadership posts. More recently, policymakers in countries like China and India have expressed similar frustrations.

Is this an important aspect of U.S. foreign policy as well?

Institutional change is not just a foreign policy priority for rising states. The United States has also sought institutional change on numerous occasions. For example, the U.S. has been critical of U.N. agencies that give only one vote to each member state while assessing financial contributions according to economic size. This creates situations where the U.S. pays the largest share of an agency’s budget but gets routinely outvoted by countries paying much less. The U.S. has pulled out of several international organizations over this type of concern. The U.S. withdrew membership from the United Nations Educational, Scientific and Cultural Organization (UNESCO) in 1985 after accusing the institution of over-representing Soviet interests. In the International Fund for Agricultural Development, the U.S. renegotiated voting rules in its favor by threatening to withdraw funding.

Can you talk about the role policy areas, both competitive and noncompetitive, play in international institutions? 

One of the key theoretical insights of the book is that characteristics of policy areas have predictable effects on political institutions, just like markets affect private firms. International institutions sometimes operate in policy areas where competition is fierce, like development aid. In these policy areas, it is easy to create alternative institutions or bargain for better outcomes by threatening exit. On the other hand, creating competition in the policy area of the IMF is challenging: to address international financial crises, you need adequate resources, access to sensitive information, and political cover provided by broad membership. It is very difficult to create a successful competitor to the IMF from scratch. This limits the bargaining power of dissatisfied states and effectively locks them in, even if they believe the institution is fundamentally unfair.

Your book points out that the composition of some of the world’s most important organizations – U.N. Security Council, IMF – are based on the world order in the immediate aftermath of WWII. What does it say that the makeup of these notable organizations hasn’t changed significantly in more than 70 years?

There has been some change. For example, the U.N. Security Council added some nonpermanent members in 1965 and the IMF has redistributed voting power on several occasions. However, it is also true that these institutions reflect what I call a “World War II effect.” The permanent five members of the U.N. Security Council are essentially the major Allied Powers of World War II, excluding important countries like Japan, Germany, India, and Brazil. Similarly, I show that the Axis Powers from World War II remain underrepresented in important areas like IMF voting shares and leadership positions in major international organizations. It is remarkable that some institutions are able to maintain these types of imbalances for many decades despite fundamental shifts in the international system: this is one of the puzzles that motivated me to write the book.

Recently, Harvard political scientist Graham Allison has argued that the U.S. and China may be “destined for war” because of China’s rising power. Do you agree with this?

China is vested in the international status quo to a much larger degree than historical rising powers. China’s economic rise in part has been fueled by economic openness promoted by the U.S. and major international organizations like the IMF and World Trade Organization. There are some exceptions, like development aid institutions, where Chinese dissatisfaction has led to the creation of alternative institutions. In my view, China’s new institutions, like the Asian Infrastructure Investment Bank, illustrate how China can increase its international influence and prestige without resorting to violence or coercion. Rather than seeing these institutions as threats, the U.S. should welcome them and cooperate with China to shape their trajectory.

Does your book have any implications for President Trump’s policies toward international institutions? 

The president wants to cut U.S. budgetary contributions toward international institutions like the United Nations. This has been something of a partisan issue for many years with Republican administrations pushing for similar policies: it is rooted in suspicion toward big government and unaccountable bureaucracies. It is true that international organizations can become inefficient and wasteful, so maintaining accountability is helpful and necessary. However, I worry that President Trump’s approach will be blunt and ineffectual. Combined with understaffing at the State Department, arbitrary budget cuts could put the U.S. at a serious diplomatic disadvantage as other countries seek to expand their international influence: precisely the type of international renegotiation that my book highlights.

Milenko Martinovich is a writer for the Stanford News Service.

Published in the journal Bulletin of Atomic Scientists, this new article by Siegfried Hecker and Paul C. White below is based on content in Hecker's 2016 book, Doomed to Cooperate: How American and Russian Scientists Joined Forces to Avert Some of the Greatest Post-Cold War Nuclear Dangers:

“Nuclear weapons stink when taken apart,” a Russian nuclear weapons engineer told his audience. The year was 2000, and he spoke to a group of Russian and American experts who were attending a workshop in Sarov, the Russian Los Alamos, on how to safely dismantle nuclear weapons. The engineer was right: Nuclear weapons being disassembled smell like rotten eggs or a high-school chemistry lab gone bad. They can contain high explosives, organic substances, uranium, plutonium, and many other materials. Over the years, these materials interact, outgas, corrode, and are subject to irradiation, producing a foul smell. Hardly anyone outside the room would have had any reason to be aware of this, so the engineer’s words inspired knowing nods, and acted like a wink or a secret handshake: The Russian and American nuclear scientists in the room shared a common bond.

It was a strange phenomenon. Until just 10 years previously, the experts’ respective governments had been adversaries. But Russian and American nuclear scientists shared ties that no one else in the world could appreciate. Working far apart, they and their forebears had ushered into existence the world’s most destructive weapon, the atom bomb. They had worked to improve it, manage it, and make sure it was reliable. Now, they were trying to keep nuclear weapons safe from accidents and secure against theft and sabotage as the two superpowers downsized their arsenals. The scientists and engineers knew something that few others understood: That the most dangerous time in a typical nuclear weapon’s life cycle is not when it is being created, transported, or readied for launch. Rather, it is when it is being taken apart. Corrosion, changes in the sensitivity of chemical high explosives, outgassing of various compounds, radiation damage, and dimensional changes all challenge the skills of weapons engineers and scientists. The experts in the room might once have been one another’s opponents in some sense, but many on each side had intimate knowledge of weapons disassembly—who else could better understand what their counterparts were going through? 

An urgent problem

The story of how the United States and Russia worked together to address weapons safety had begun years before, and represents a remarkable tale of once-mortal-adversaries cooperating on matters that took them right to the edges of their respective countries’ most sensitive nuclear secrets.

It started with the disastrous Chernobyl nuclear reactor accident in April 1986. After briefly denying it had occurred, Moscow reached out to the international nuclear community for help mitigating the tragic consequences. Washington assisted quickly and effectively. Years later, Russian nuclear weapon scientists told their American counterparts (including the authors of this column) that the Chernobyl accident had happened because the Soviet Union was isolated. That is, Russian nuclear reactor designers, engineers, and operators had not had the opportunity to learn from their international peers. The weapon scientists assured us that the safety of nuclear bombs had always been much more rigorous. Yet the memory of the Chernobyl tragedy, and the enormous increase in the number of weapons being moved and disassembled, made Russian nuclear scientists keen to discuss concerns and safety practices with American counterparts.

The end of the Cold War all but eliminated immediate fears of a nuclear war. In an ironic twist of fate, though, it dramatically increased the risk of nuclear accidents and the potential for theft or diversion of nuclear weapons and materials. When the Soviet Union collapsed, Russia had to transport unprecedented numbers of weapons from former Soviet republics to Russia for dismantlement. No one was as sharply aware of the risks as Russia’s nuclear weapons personnel.

In the wake of the Presidential Nuclear Initiatives launched by George H.W. Bush and Mikhail S. Gorbachev in September and October of 1991, which promised transparency and dialogue on safe warhead transportation and storage, the Russians gave voice to their concerns. In Washington in November 1991, Viktor N. Mikhailov, later Russia’s minister of atomic energy, specifically requested help with weapon safety and security, as well as help storing the huge excess of fissile material that would result from the accelerated dismantlement of his country’s nuclear stockpile. The US Congress responded to these requests promptly by way of the Nunn-Lugar cooperative threat reduction legislation.

The scope and timing of the Nunn-Lugar efforts matched the urgency of Russian requests. To deal with security concerns related to the surge in warhead transportation, the United States cooperated to develop accident-resistant transportation containers. It provided armored Kevlar blankets to shield warheads and warhead containers from terrorist bullets, and smart rail cars that enabled secure monitoring of warhead shipments. Washington also helped meet the new storage requirements (resulting from increased dismantlement rates) by providing containers and technical and financial support for the construction of a state-of-the-art fissile material storage facility at the Mayak site in Russia.

These Nunn-Lugar-sponsored efforts, managed by the US Defense Department and supported by the US national nuclear labs, were a good beginning, but the Russian nuclear weapons experts wanted to do more to mitigate the dangers. The extraordinary number of nuclear weapons returning from the field and waiting to be disassembled included some past their certified lifetime. During one of the first meetings of Russian and American nuclear experts at Los Alamos in December 1992, Rady I. Ilkaev, the deputy scientific director of the Russian national nuclear lab VNIIEF, proposed direct, unclassified consultations on nuclear weapon safety.

The Russians not only sought bilateral technical cooperation, but also believed that Russian-American teamwork would demonstrate an unparalleled level of transparency about nuclear safety, which would help reassure their own citizens and a worried world that remembered the Chernobyl tragedy all too well.

Ilkaev and his Russian colleagues took advantage of the lab-to-lab scientific collaborations that blossomed during the early 1990s to explore much closer cooperation on safety—an approach that resonated strongly with their US lab counterparts. Yet no government agreements were in place to allow such cooperation. So two tracks were pursued in parallel: The governments prepared for formal negotiations, while simultaneously allowing the labs to exchange sensitive but unclassified nuclear-weapon safety and security concerns and practices. This sharing took the form of symposia called the Security Technology Exchanges. 

Four such symposia were held between October 1993 and March 1994, two in each country, at which American and Russian scientists, engineers, and government officials compared experiences on a range of topics. Subjects included analyzing nuclear risk; mitigating risks posed by hazardous materials; understanding the response of engineered systems to abnormal environments; and communicating the content of technical documents. 

One of the most important topics discussed in these symposia and later exchanges was human reliability. The economic and political crisis resulting from the collapse of the Soviet Union severely strained one of the foundations of nuclear weapon safety: people. One of the authors of this piece (Paul C. White) recalls that at a July 1993 planning meeting in Ekaterinburg, his Russian counterpart asked, “What do you do when you can no longer count on people to do what they’re supposed to do—to obey the rules?” Although the Russians’ confidence in the loyalty and patriotism of their nuclear workers remained high, they expressed concern that the fraying of the decades-old system of authority could give rise to insider threats.

A mutual strategic interest

These symposia opened doors, established a foundation for building trust, and nurtured professional and personal friendships that endure to this day. They also helped pave the way for government negotiations on the Weapons Safety and Security Exchange agreement, or WSSX, which the US energy secretary and Russian minister of atomic energy signed in December 1994. It entered into force in June 1995. 

In a March 1996 directive, US President Bill Clinton stated that cooperation on weapons safety and security was necessary to facilitate other US policy objectives, such as getting Russia to agree and comply with a true zero-yield Comprehensive Nuclear Test Ban Treaty. Clinton authorized lab-to-lab collaboration between the three Russian and three US nuclear weapons labs, with the goal of sustaining the scientific competence of those responsible for the two countries’ respective nuclear stockpiles. His statement was remarkable for declaring that maintaining the expertise of Russian nuclear weapons scientists—America’s Cold War adversaries—was now a US strategic interest.

Although WSSX was an agreement between governments, the nuclear labs provided the driving energy and remained the centers of engagement for all related activities. Over the life of the agreement, which was renewed for five years in 2000, the two sides organized dozens of technical interactions, including symposia, joint studies, workshops, and exchanges of technical papers. The participants completed more than 100 collaborative projects on far-reaching and mutually beneficial topics. Among them were projects on accident response, responding to wildfires near nuclear facilities, and safety during warhead dismantlement. When Americans shared their experience of using a well-known industrial solvent—DMSO, or dimethyl sulfoxide—instead of mechanical methods to remove high explosives that had bonded to metal weapon parts, a Russian participant stood up and declared, “you have just given us a gift!” Such “gifts” were exchanged reciprocally to improve warhead disassembly on both sides.

The discussions on responding to wildfires would also prove mutually beneficial. It wasn’t just technical staff from Los Alamos and Sarov who got to participate in exchange visits. So, too, did the fire departments of the two cities. In May 2000, Los Alamos experienced a devastating fire that burned more than 400 residences and 30 percent of the lab’s real estate, and threatened facilities that housed high explosives, plutonium, and tritium. In 2010, Sarov had to battle a peat fire at the boundary of its nuclear complex. Los Alamos experienced another serious wildfire in 2011. 

The WSSX exchanges allowed experts to learn new ways of looking at similar problems, unquestionably benefiting each country’s handling of the safety and security of its nuclear weaponry. In the book Doomed to Cooperate, one Russian nuclear safety expert said the exchanges led his country to adopt new federal regulations on nuclear weapons safety and emergency response. 

Sadly, the WSSX agreement was not extended in 2005. The end of this remarkable period of cooperation came at the hands of governments, not scientists. Washington imposed more legal and bureaucratic strictures on joint projects, and veered away from prioritizing nuclear safety to promote an agenda of arms control and transparency. Moscow became increasingly resistant to the presence of US technical personnel at its nuclear facilities. During the last three years, as relations between the US and Russian governments have seriously deteriorated, virtually all nuclear cooperation has ended.

Nuclear safety has become more challenging as the designers and engineers who developed the weapons in today’s arsenals retire, and the experience of nuclear testing fades into distant memory. The older generation has passed on as much experience as possible to the younger engineers—particularly the idea that ensuring nuclear safety is a never-ending job. The WSSX projects demonstrated that cooperation has great safety benefits, and can be accomplished without jeopardizing either side’s nuclear secrets. The scientists and engineers on both sides are prepared to resume cooperation. The bonds they forged endure, reflecting a unique like-mindedness, a sort of simpatico professional relationship (or sympatiya in Russian) that helped make scientific engagement such a success and the world a safer place.

CISAC co-director Amy Zegart wrote this July 11 essay in The Atlantic on what the Donald Trump Jr. emails mean:

Line by ugly line, Donald J. Trump Jr.’s emails with British-born former tabloid reporter and Russian intermediary Rob Goldstone are now plastered on The New York Times website. They reveal an astounding set of communications. Goldstone promises incriminating information about Hillary Clinton that could be used in the campaign—with the Kremlin’s backing. Junior’s response should have been to speed dial the FBI. Instead, he writes three little words with big, big consequences: “I love it.”

It’s quite a turn for the First Son. Just a few months ago, The New York Times gave him a fawning spread replete with woodsy photos. Now his association with dirt doesn’t look quite so good.

My three big takeaways from this breaking story:

1) The key word in The New York Times piece is “flurry.” There isn’t one email exchange. There are many. Trump Jr.’s email “dump” will not be the end of the story. Instead, as Churchill once said, it’s just the end of the beginning. Investigators and journalists will be following the email trail.

2) Even the emails released so far paint a damning portrait. The “we didn’t know better, we’re just amateurs” defense with respect to foreign policy—which the White House has been using to this point—will not hold up. Campaign chairman Paul Manafort attended the now-infamous June 9, 2016 meeting with Kremlin-connected lawyer Natalia Veselnitskaya. Manafort is no neophyte in this world. He has worked on multiple Republican presidential campaigns over decades. What’s more, the red line, whether it’s a legal or political one, is: “Thou shalt not work with foreign powers to gain advantage in a U.S. election.” As former FBI director Jim Comey would put it, there is no fuzz on this whatsoever. Even if the foreign power involved were the Brits and not the Russians, meeting with a foreign government to get opposition dirt for a U.S. presidential election is wrong and probably illegal.

3) It is telling that every new piece of hard information major newspapers have reported recently about the Russian meddling in the 2016 election—every single one—supports the Intelligence Community’s conclusions about it. In January, the Office of the Director of National Intelligence released the community's assessment that “Russian president Vladimir Putin ordered an influence campaign in 2016 aimed at the U.S. presidential election,” and that he and his government “aspired to help president-elect Trump's election chances when possible by discrediting Secretary Clinton.” The reporting has yet to implicate Putin himself, but Goldstone’s email citing a Russian official’s offer to “provide the Trump campaign with some official documents and information that would incriminate Hillary and her dealings with Russia,” as part of “Russia and its government’s support for Mr. Trump” is the clearest public evidence yet of the IC’s conclusion. And the emails were released by Trump Jr. himself—right before The New York Times posted them.

We need to stop saying of the intelligence community—as Donald Trump Sr. has encouraged—“These are the people who brought us Iraq WMD” and start saying, “These are the same people who found bin Laden.” In fact, Donald Trump Jr. proudly displays an American flag signed by members of SEAL Team Six—the unit that took out bin Laden—in his office. Junior should have thought harder about the kind of intel that helped the SEALs succeed—and what it might mean for his father.

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 is a contributing editor to The Atlantic.

On July 7, the William J. Perry Project issued the following statement from CISAC's William J. Perry regarding the adoption of the UN Treaty to Prohibit Nuclear Weapons, which was approved by the UN on the same day: 

"The new UN Treaty on the Prohibition of Nuclear Weapons is an important step towards delegitimizing nuclear war as an acceptable risk of modern civilization. Though the treaty will not have the power to eliminate existing nuclear weapons, it provides a vision of a safer world, one that will require great purpose, persistence, and patience to make a reality. Nuclear catastrophe is one of the greatest existential threats facing society today, and we must dream in equal measure in order to imagine a world without these terrible weapons."

The UN treaty places a strong moral imperative against possessing nuclear weapons and gives a voice to some 130 non-nuclear weapons states who are equally affected by the existential risk of nuclear weapons. There is no one solution to this global threat, and there is much more work to be done beyond this treaty to reduce this risk. I call on nuclear-armed states to step up their participation in the fight against the nuclear threat by securing the eight remaining ratifications to enact the Comprehensive Test Ban Treaty, extending the New START agreement, continuing the critical work of the Nuclear Security Summits, and avoiding the unnecessary risk posed by introducing destabilizing new nuclear weapons. My hope is that this treaty will mark a sea change towards global support for the abolition of nuclear weapons. This global threat requires unified global action."

Read more about the treaty here.

William J. Perry, a former U.S. Secretary of Defense, recently joined other nuclear and diplomatic experts in writing a letter to President Trump urging diplomatic talks with North Korea; wrote a Politico op-ed on how to make a deal with North Korea; and delivered the 2017 Barnett-Oksenberg Lecture on issues between China and the United States. Perry is the director of the Preventive Defense Project at CISAC.