Stanford foreign policy experts discussed flashpoints around the world at an OpenXChange event this week.

Three of Stanford's most seasoned international affairs experts discussed foreign policy and diplomacy – and practiced a bit of it on stage, too – as they tackled the topics of refugees, Russia and other politically thorny issues at a campus forum March 1.

The event, "When the World Is Aflame," featured Condoleezza Rice, a Stanford political science professor and former U.S. secretary of state; Michael McFaul, director of Stanford's Freeman Spogli Institute for International Studies and former U.S. ambassador to Russia; and Jeremy Weinstein, a Stanford political science professor and former director for the National Security Council.

Janine Zacharia, a Stanford visiting lecturer in communication and former Jerusalem bureau chief and Middle East correspondent for the Washington Post, was the moderator.

The event was hosted by OpenXChange, a campus initiative to provide a forum for students and community members to focus on today's societal challenges.

"So you were resetting some of my policy?" Rice half-jokingly interjected, as McFaul discussed the objectives behind the U.S. trade talks with Russia a few years ago.

"It was not about making friends with the Russians – I want to make that clear," McFaul continued after the laughter in the audience died down. "And it wasn't that we needed to correct the wrongs from the previous period," he said, casting a quick glance over at Rice. "The Russians had an interest in giving the Iranians a nuclear weapon. Our answer was, no, and let's work with them to prevent that."

A series of trade sanctions with Russia were eventually accomplished, but as it turns out, McFaul noted, the political environment has since changed with Russia's aggression in Crimea, Ukraine and Syria.

Today's conflict in Syria was laid about four years ago, the panelists agreed, when the United States decided to aid the rebels and not overtly attack the current regime.

"There were reasons our president and others did not go down that path, but it was an invitation to others to play games in that environment," Weinstein said. "What their endgame is, we don't know."

Rice added that Russian President Vladimir Putin "does not mind countries that basically don't function." As such, "a stable, functioning Syria was never his definition of success."

Zacharia asked, "Are you saying we have yielded the endgame to the Russians in Syria? There is nothing we can do? And we're playing defense?"

"Yes," Rice answered.

"Wait, there is no endgame," McFaul said. "It's not that we yielded the endgame."

"Right," Rice replied.

Though the panelists' opinions differed at times, the trio of political science professors agreed on many points, including that international order is being tested, and that the refugee crisis is an overwhelming problem – one that the United States should help resolve.

"I'm a firm believer that America has a moral obligation to take [refugees]," Rice said. "But let's remember that we have to have a way to take them that is actually going to work within the system."

"We have a humanitarian architecture that simply isn't up to the task," Weinstein said. Securing congressional funding to reform the system will be a challenge.

What's more problematic, McFaul added, is that the current political rhetoric about how the United States should handle refugees is "based on fear."

"We're not having a rational debate about this in my opinion," McFaul said. "We have to fill the debate with empirical facts instead."

Public fears will continue as long as extreme Islamic State terrorist groups remain influential, "inspiring lone wolves like [those] in San Bernardino," Rice said, referring to the December 2015 terrorist attack there that killed 14 and injured 22 people.

"Somebody has got to defeat ISIS in its crib," Rice said. "They march in columns; they don't hide in caves like al-Qaeda. If CBS News can find them, then the American military can find them."

The tougher challenge, however, will be the task of influencing sectarian politics and creating a more stable state in the long term, Weinstein said.

Stanford – with its cache of expertise – should strive to shape the national dialogue with concrete facts and analyses, McFaul said. Inspiring students and giving them the foundational tools to become the new generation of policy leaders is also part of that, he said. Adding a course on Russian politics would also be an improvement, he said.

Weinstein is a senior fellow at the Freeman Spogli Institute. Rice, a former Stanford provost, is the Denning Professor in Global Business and the Economy at Stanford Graduate School of Business and the Thomas and Barbara Stephenson Senior Fellow at the Hoover Institution.

The panelists urged students to gain a deep knowledge of the areas and issues they care about.

"Know your facts," Rice emphasized.

"When you're making policy decisions at the table, the people who understand these places and understand the political dynamics – those are the people whose voices are second to none around the table," Weinstein said.

"And we need to get you prepared for that in a more robust way," McFaul said, inviting students to pass any ideas about this to him.

In terms of career choices, "there's nothing greater" than public service, he said. "Sometimes I would get goose pimples when I could stand in front of Russians with the American flag behind me, representing the United States of America."

Infant deaths in Massachusetts for much of the 1800s accounted for more than 20 percent of all deaths, many due to diarrhea, cholera and other gastrointestinal disorders.

But from 1870 to 1930, the infant mortality rate plummeted from around 1 in 5 white infants to 1 in 16 for both Massachusetts and the entire United States.

Studies have shown that the dramatic decline was due to the impact of a clean-water system in Boston and other major U.S. cities at that turn of the 20^th century.

Now, new research by Stanford Health Policy’s Marcella Alsan indicates that effective sewage systems installed in Boston and surrounding municipalities complemented the water treatment plants and had a significant role in protecting the lives of children.

“We were motivated to investigate this because there was a watershed moment when infant mortality began to decline in the U.S. and Massachusetts that we wanted to understand,” said Alsan, an assistant professor in the Department of Medicine, and the country’s only physician who is a tropical disease expert and economist.

“In retrospect, the daunting challenges these engineers and medical professionals faced in designing, financing and executing such a massive project is incredible,” Alsan said in an interview. “It was really inspiring to read the history of how it all came together.”

She and co-author, Claudia Goldin of Harvard University’s Department of Economics, analyzed about 200,000 of infant death certificates in Boston and 54 other Massachusetts municipalities spanning the years 1880 to 1915.

The impetus behind the creation of the Metropolitan Sewerage District was complaints regarding the stench of sewage among Boston’s upper-class citizens.

“The first of a series of hearings was given by the sewerage commission at the City Hall on Friday night,” read a story in an 1875 edition of the Boston Medical and Surgical Journal. “From the statements made it would appear in various parts of the district including most of the finest streets, the stench is terrible, often causing much sickness.”

A joint engineering and medical commission was appointed in 1875 to devise a remedy and a massive drainage project got underway.

Alsan and Goldin found that an overwhelming number of deaths in the greater metropolitan area were due to gastrointestinal disorders, but that this improved significantly when sanitation canals became part of the overall water systems.

“We find robust evidence that the pure water and sewerage treatments pioneered by far-sighted public servants and engineers in the Commonwealth saved many babies,” they write in a working paper. “It must also have enhanced the quality of life for the citizens of the Greater Boston area even if it did not reduce the non-child death rate by much.”

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They acknowledge that the interpretation of their results is intuitive. But it’s an important one to promote because many developing countries today have yet to heed the lesson of combining safe drinking water and improved sanitation systems.

“Without proper disposal of fecal material, the benefits of clean water technologies for the health of children are likely limited,” they write. “Such a result has relevance for today’s low-and middle- income countries.”

The Millennium Development Goal Target 7.C — to halve by 2015 the proportion of the population without sustainable access to safe drinking water and basic sanitation —was only met for water, but not sanitation. Between 1990 and 2015, 2.6 billion people gained access to improved drinking water sources.

Yet despite that progress, one-third of the global population is still using unimproved sanitation facilities, including nearly 1 billion people who are still forced to defecate in the open. This often leads to cholera, typhoid, hepatitis, polio, and worm infestation.

Diarrhea is the third-largest killer of children under 5 in sub-Saharan Africa, and 44 million pregnant women are infected with worms each year due to open defecation, according to the United Nations. Every minute, 1.1 million liters of human excrement enters the Ganges River in India.

The problem of waste disposal likely will be compounded by rapid urbanization occurring in the developing world, said Alsan, and lack of sanitation and the practice of open defecation costs the world’s poorest countries $260 billion a year.

“We think our findings underscore how complementary these infrastructure investments are, and hope that holds lessons for the developing world,” said Alsan. “In all practicality, it’s very hard to ensure the municipal water supply is not contaminated if the sewage infrastructure is neglected.”

Working Paper: Watersheds in Infant Mortality

Non-smoking campaigns that tell teenage boys they will get lung cancer in 30 years if they don’t stop smoking just don’t work.

“But prevention programs that tell them that girls don’t like smokers make them go pale with fear,” says Keith Humphreys, a professor of psychiatry and behavioral sciences.

Humphreys, an affiliated faculty member of Stanford Health Policy, told an audience at the World Economic Forum in Davos, Switzerland, this January that the better approach to public health campaigns are those tailored to the realities of the human brain.

One of those realities is that our brains have evolved to be vulnerable to addiction, especially if we live in the lower-income tiers of society. An understanding of our evolutionary vulnerability to drugs and alcohol can help us to design effective public policies, Humphreys told the Davos audience.

“Primate research indicates that there may be a political and economic dimension to this,” he said. “When lower primates form a hierarchy, those at the bottom undergo a change in their dopamine system. This makes them more likely to consume drugs in an addictive fashion.”

Addiction can happen to anyone at any level of society — the current opiate epidemic is a case in point — but if you look at wealthy societies, those who have less economic and educational resources are more prone to addiction.

“So as inequality worsens, we really have a risk of creating a disempowered underclass of people who are literally sedated by ever more available psychoactive substances.”

Humphreys is on the NeuroChoice team at the Stanford Neurosciences Institute who attended the forum to present their research into the neural basis of decision-making and how these impact public policy.

He says in this video that neuroscience reveals addictive drugs work on precisely the same brain systems that guide our survival decisions. This is compounded by industrial global capitalism, making the exposure to psychoactive substance nearly universal.

“These two combined realities — our evolutionary conserved vulnerability to addiction and the development of a production and transportation system that can deliver substances worldwide — is why one in six deaths on the planet among adults is attributable to psychoactive substance abuse,” says Humphreys.

Stanford researchers are going after the problem in two ways. First is to use neuroscience to unravel the mechanisms of addiction in the brain. Then, they work directly with public policymakers, such as those who regulate the tobacco, alcohol and pharmaceutical industries, as well as those who oversee health-care and criminal justice systems.

“We communicate to our friends in the policy world what science has to teach about addiction and how you can use that information to do a better job at protecting people and promoting public health,” he said.

He said one of their key messages is that psychoactive substances are not ordinary commodities that should not be regulated.

“That’s probably true for broccoli, but it’s not true for psychoactive substances because they impair our brain’s ability to value things,” he said. And that is why public health policies must take into account the evolutionary-conserved circuits in the brain.

“The magnificent decision-making organ that evolution has bequeathed us is vulnerable to addiction, perhaps particularly if we live on the lower tiers of society. This creates a risk for humanity,” Humphreys said. “Karl Marx was worried that religion would become the opiate of the masses. But if we don’t use neuroscience to make better treatments and better policies regarding addiction, the opiate of the masses will be opiates.”

What is the best way to measure returns on investments in health care?

Does the World Health Organization’s approach help developing countries allocate their limited health-care resources wisely?

What are the economic implications of the global rise in non-communicable diseases?

These are just a few of the global challenges taken up by health economics experts at the third annual Global Health Economics Consortium Colloquium at the University of California, San Francisco.

At the core of the conference is the growing field of health economics, and why cost-effectiveness analysis is fast becoming the underpinning of successful health policies.

Not only is the field expanding, so is the collaboration among researchers and faculty at Stanford Health Policy, UCSF Global Health Sciences, and the UC Berkeley School of Public Health, co-sponsors of the Feb. 12 event.

“It’s been great to see the meeting evolve from a show-and-tell to a platform where we can have nuanced discussions about the challenges and controversies in the field,” said Dhruv Kazi, an assistant professor of medicine at UCSF who helped organize and moderate the event.

Some 180 health policy experts, researchers and speakers representing 11 universities, six non-profit organizations and five for-profit outfits attended the daylong conference on the UCSF Mission Bay campus.

“By building bridges between our universities, we create a space where thought-leaders and students alike can engage in discussions to challenge working assumptions and also spearhead innovate strategies and solutions,” said James Kahn, a professor of health policy and epidemiology at UCSF and the director of the consortium.

The Consortium — known as GHECon — was awarded a five-year cooperative agreement of up to $8 million by the CDC to conduct economic modeling of disease prevention in five areas: HIV, hepatitis, sexually transmitted diseases, tuberculosis and school health.

Taking a break during the third annual Global Health Economics Consortium Colloquium at UCSF on Feb. 13, 2016. Photo by UCSF/Cindy Chew.

As global economies remain turbulent, Kazi said, governments and donors have become increasingly cost-sensitive and want to better understand the societal returns they are getting for their investments in health.

“That enhances the influence of our work, but also increases the scrutiny it receives, creating an opportunity for the community to have an honest discussion about the challenges and opportunities that lie ahead,” he said. “And that is precisely the platform GHECon sees itself becoming.”

Some of the tough challenges consortium members are undertaking:

1. The World Health Organization recommends using per capita GDP as a benchmark for how much money countries should be willing to spend on health-care interventions. GHECon researchers have shown that this approach is problematic and does not always help countries allocate their limited health-care resources optimally.
2. Economic evaluations have typically only considered health-care costs, overlooking the lost income of patients or caregivers during hospital stays. GHECon researchers are working on ways to value this lost productivity in an effort to estimate the true cost of a disease and, conversely, the benefit of its alleviation. 
3. Cost-effectiveness evaluations traditionally are concerned with how efficiently health-care resources are utilized by asking questions like: How many lives can I save per million dollars invested? But society may care about other benefits that go beyond efficient use of resources, such as reducing disparities by helping the most vulnerable sections of society and alleviating poverty.

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Mark Sculpher, one of the leading health economists in the world, gave the keynote address about his efforts in the UK to use cost-effectiveness analysis to inform decisions at the National Institute for Health and Care Excellence.

He said there are two big challenges today: defining cost-effectiveness thresholds that are meaningful, and determining how policymakers, donors and payers make decisions when there are multiple criteria and perspectives.

“The realities of decision-making inevitably involve a whole host of considerations,” said Sculpher, who is director of the Program on Economics Evaluation and Health Technology Assessment at the University of York. “Ultimately it’s about what is this measure of benefit that we want to maximize — and how do we invest in it.”

Stanford Health Policy’s Douglas K. Owens, director of the Center for Health Policy at the Freeman Spogli Institute for International Studies and the Center for Primary Care and Outcomes Research at the Department of Medicine, presented his influential economic modeling research about the need for routine HIV screening.

“We determined that HIV screening is cost-effective in virtually all health-care settings,” Owens told the audience, noting that the findings became policy at the Centers for Disease Control and Prevention and other national health policy organizations. It has become an example of how economic modeling can inform crucial policy decisions — and help save lives.

There were also robust panel discussions about the challenges of doing cost-effectiveness analysis in developing countries with limited resources; the difficult paths to universal health care; and how economics can help address disparities in health care and financial protection.

“The consortium is particularly valuable because it fosters collaborations among a broad group of global health experts,” Owens said.

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This season, “Downton Abbey's” plot line has health policy wonks on the edge of their seats: a heated debate about hospital consolidation that closely parallels what’s going on in the U.S. health care system today.

If you’re not a Downton fan, here’s a quick plot recap by Kaiser Health News reporter Jenny Gold: It’s 1925 for the lords and ladies at Downton Abbey. Think flapper dresses, cocktail parties and women’s rights. And a big hospital in the nearby city of York is making a play to take over the Downton Cottage Hospital next to the posh estate.

As Maggie Smith’s character, the Dowager Countess of Grantham, sees it, “The Royal Yorkshire county hospital wants to take over our little hospital, which is outrageous!”

Stanford Health Policy’s Kathy McDonald — an unabashed fan of the popular PBS period piece — says things haven’t changed that much today. There has been an uptick in hospital consolidations since 2010, with about 100 taking place each year, she says.

You can listen to McDonald’s interview with Gold, who took the Downton debate to the American Public Media radio show, “Marketplace.”

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