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Stanford scholars debate whether the Iran nuclear deal can withstand U.S. withdrawal, if a revitalized nuclear program is possible and what a new deal would look like.

Following the announcement of the U.S. withdrawal from the Iran deal, three Stanford scholars consider what it means for American foreign policy and diplomacy.

Stanford scholars debate how the Trump administration’s decision on Iran will affect foreign relations. (Image credit: ruskpp / Getty Images)

In 2015, the Joint Comprehensive Plan of Action – known as the Iran nuclear deal, or JCPOA – was agreed between Iran and the U.S., United Kingdom, France, Germany, China and Russia. The international agreement limited Iran’s nuclear activities in exchange for a reprieve from international sanctions.

What happens next remains unclear. What does withdrawal signal about American foreign policy? What would a new agreement look like – and is it even possible? To answer some of these questions, Stanford News Service talked to three scholars about the issues:

• Siegfried Hecker is a top nuclear security scholar, former Los Alamos National Laboratory director and senior fellow at the Center for International Security and Cooperation. Hecker’s research interests include plutonium science, nuclear weapons policy and international security, nuclear security (including nonproliferation and counter terrorism) and cooperative nuclear threat reduction.
• Abbas Milani is the Hamid and Christina Moghadam Director of Iranian Studiesand affiliate at FSI’s Center on Democracy Development and the Rule of Law. He has been one of the founding co-directors of the Iran Democracy Project and a research fellow at the Hoover Institution. In 2016, he launched the Iran2040 Project that produces research on the future of the Iranian economy, population, energy, water, agriculture and the financial system.
• Allen Weiner is a senior lecturer of law, director of the Stanford Program in International and Comparative Law and co-director of the Stanford Center on International Conflict and Negotiation. His scholarship focuses on international law and the response to the contemporary security threats of international terrorism, the proliferation of weapons of mass destruction and situations of widespread humanitarian atrocities.

What does withdrawal from the Iran deal signal about American foreign policy?

Milani: It signifies that U.S. foreign policy is dependent on the views, even whims, of one person – the president – and the rhetoric he used during the campaign. Views of U.S. government experts or allies has I think never counted for less.

Weiner: The withdrawal from the JCPOA signals a departure from the notion that the U.S. places high value on the benefits of stability, predictability and consistency in its foreign relations. It also reflects the Trump administration’s belief that the U.S. has the ability to persuade other countries to accommodate American interests through coercive mechanisms.

How will withdrawal from the Iran nuclear deal be viewed from inside Iran?

Milani: Iran is a country divided. The people, suffering from a profound – even existential – economic crisis, are worried about their future. Bickering political factions in the regime are playing the blame game: first blame the U.S., and then opposing factions.

Can the Iran nuclear deal withstand U.S. withdrawal? What options are available – both politically and legally?

Hecker: I don’t see Iran making a mad dash for nuclear weapons to respond to the U.S. withdrawal. The country has too much to lose. Tehran could decide to keep the essence of the deal with the other countries and isolate the U.S. It may find that it will get adequate sanctions relief from the other countries in spite of U.S. pressure. That may be sufficient for Iran to continue to honor its nuclear deal commitments for now.

Milani: I would be surprised if the deal does not survive. It was never a U.S. deal.  The U.S. was simply a key player. Europe, U.K., China, Russia, the UN, and International Atomic Energy Agency (IAEA) want it to continue – Iran, too.

Weiner: In a sense, yes. Iran is free to continue to comply with the restraints on its nuclear activities negotiated in the JCPOA and to accept IAEA inspections. The other signatories to the JCPOA are free not to re-impose on Iran the sanctions that were lifted under the JCPOA. Because of the reach of U.S. sanctions, however, European companies in particular will face significant risks in doing business in Iran, which means Iran will be deprived of many of the commercial benefits it sought in negotiating the JCPOA. It is far from clear that the remaining, much more limited benefits available under the JCPOA will be appealing enough for Iran to continue to suspend those aspects of its nuclear program that are covered by the JCPOA.

What are reasons to oppose the Iran nuclear deal?

Hecker: The deal was able to get more Iranian nuclear concessions than I had ever thought possible. Apparently, the Trump administration objected primarily that the deal did not include Iran’s other activities, such as missile tests and Iran’s role in the region that it views as unacceptable. However, some of President Trump’s claims about the nuclear deal were simply incorrect.

Milani: The deal surely had flaws. It did not address such critical issues as Iran’s missile program, the regime’s role in places like Syria and Iraq, and human right abuses at home. It surely was not the worst deal in history. It was the least bad option at the time.

Weiner: The key objection voiced by many critics of the JCPOA concerns the “sunset provisions” in the deal, under which many key restrictions in the JCPOA on Iranian nuclear activities last only for 10 or 15 years (depending on the particular restriction). This potentially allows Iran to benefit from sanctions relief now and to merely postpone its pursuit of a nuclear weapon. Other objections concern the failure of the JCPOA adequately to address Iran’s missile development programs or its destabilizing regional activities more generally.

What nuclear facilities remain in place in Iran, and how easily might they be repurposed to create weapons?

Hecker: Iran has dramatically reduced its inventories of enriched uranium in compliance with the deal. It has enrichment facilities that could be restarted rather easily to enrich uranium to weapons grade, but not without withdrawing from the deal. It could also begin construction of a new plutonium-producing reactor, but that would be rather costly since it made the one under construction inoperative in compliance with the deal. The bottom line is that it would take quite some time to get back to the material inventories and facilities Iran had before the deal went into effect.

Milani: Iran’s enrichment facilities remain but much of their capacity has been mothballed. Ninety-eight percent of the country’s low enrichment uranium has been shipped out of the country. The Arak heavy water reactor has been virtually dismantled. All known facilities are under constant surveillance by the IAEA. The regime’s missile program has, however, continued.

What effect could withdrawal have on anticipated talks with North Korea?

Hecker: That’s quite uncertain. North Korea may still want a deal, but it would likely ask for greater assurances from the U.S. about potential withdrawal, just as the U.S. is pressing North Korea about its past history of compliance.

Weiner: Commentators have observed that withdrawal from the JCPOA raises questions about U.S. credibility and its willingness to keep its word. Some suggest that this will make North Korea less likely to move actively in the direction of complete, verifiable, irreversible nuclear disarmament for fear that once it has given up its nuclear program, the U.S. might simply re-impose sanctions or pursue other hostile policies towards it. On the other hand, President Trump has emphasized that he would keep any commitments he makes in negotiations with North Korea; it was only the commitments of the prior U.S. administration that he did not feel obliged to honor. Whether this would provide enough confidence to the North Koreans to trust the United States is, of course, far from clear.

What would a new deal look like?

Hecker: I don’t see a new deal involving this administration as a possibility.

Milani: I think the U.S. could have had more impact on a possible revamped deal had it stayed in the agreement. It remains to be seen whether Europeans will continue to try to coordinate with the U.S. and will try to forge a different agreement with the regime.

Weiner: A new agreement, to be acceptable to the U.S., would have to eliminate (or at least significantly extend) the sunset clauses and address Iran’s missile program. From Iran’s side, a revised deal would have to involve more than just lifting sanctions against Iran. It would also have to more emphatically embrace the prospect of American companies doing business in Iran. With respect to commercial relations, Iran argues that even though the United States formally lifted sanctions against Iran after the JCPOA took effect, the ongoing threat that U.S. sanctions would be re-imposed has effectively dissuaded many businesses in both the U.S. and Europe from pursuing long-term business arrangements in Iran.

Prostate cancer is the second leading cause of death among American men, after heart disease.

Yet ever since the prostate-specific antigen (PSA) screening was approved by the FDA in 1986, there has been a debate in the health-care community about the efficacy of the test. The American Urological Association had until 2013 recommended routine testing but did an about-face not long after the U.S. Preventive Services Task Force recommended against regular screening.

The Task Force — and independent, volunteer panel of national experts in prevention and evidence-based medicine — concluded in 2012 that there was “moderate certainty” the benefits of the screening did not outweigh the potential harms. The biggest risks included a false positive that leads to a biopsy that could cause infection, pain and bleeding, as well as surgery and radiation that can provoke impotence or problems with the bladder or bowels.

But the Task Force is now recommending that men aged 55 to 69 talk to their physicians about whether to get the test. New evidence indicates screening in this age group can reduce the risk of metastatic cancer and the chance of dying from prostate cancer.

“Prostate cancer is one of the most common cancers to affect men and the decision whether to be screened is complex,” said Task Force vice chair Alex H. Krist, MD. “Men should discuss the benefits and harms of screening with their doctor, so they can make the best choice for themselves based on their values and individual circumstances.”

Stanford Health Policy’s Douglas K. Owens, director of the Center for Health Policy and the Center for Primary Care Outcomes and Research, said there is also new information on active surveillance — a way of monitoring prostate cancer that may allow some men with low-risk prostate cancers to delay or, in some cases, avoid treatment with radiation or surgery.

Active surveillance, he said, has become a more common choice for men with lower-risk prostate cancer over the past several years and may reduce the chance of overtreatment.

“For men who are more interested in the small potential benefit and willing to accept the potential harms, screening may be the right choice for them,” said Owens, MD, a professor at Stanford Medicine and another vice chair of the Task Force. “Men who place more value on avoiding the potential harms may choose not to be screened.”

The Task Force still recommends men 70 and older do not get the test as a matter of routine.

The panel released its recommendation on the Task Force website on May 8. The final recommendation and evidence reviews were published in the Journal of the American Medical Association (JAMA), along with several editorials.

The guidelines issued by the 16-member Task Force impact virtually every primary care patient and practice in the United States. They make letter grade recommendations and have now bumped the “D” against screening up to a “C,” which recommends screening decisions for prostate cancer be based on professional judgment and patient preference. 

The new recommendation now aligns with those of the American Cancer Society and the American Urological Association. Peter R. Carroll, MD, writes in an accompanying editorial in JAMA that the final recommendation by the Task Force “has restarted a national discussion on prostate cancer early detection.”

“The Task Force deserves credit for this more balanced, fairer approach,” said Carroll, a professor and chair of the Department of Urology at the University of California, San Francisco, who opposed the “D” grade the Task Force had given PSA screens in 2012. “The message now is not ‘no screening,’ but ‘smarter screening,’ preserving benefits and reducing harms.”

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The recommendation also addresses men who are at increased risk, particularly African-American men and patients with a family history of prostate cancer.

“For African-American men or those with a family history of prostate cancer, informing these men of their higher risk for developing prostate cancer should be a part of the conversation,” wrote two researchers from the Cleveland Clinic in another accompanying JAMA editorial.

“The U.S. health care delivery system needs a structure that not only allows, but encourages, a space for physicians and patients to engage in meaningful conversations where shared decision making has the opportunity to take place,” wrote Anita D. Misra-Herbert, MD, and Michael W. Kattan, PhD. “What the updated USPSTF recommendations for prostate cancer screening are asking of physicians is to take time to pause, explain what is currently known, understand patient preferences, and make the screening decision together.”

Cuts to Medicaid hurt all children — rich and poor. Because hospitals that deal with serious childhood injuries and illnesses depend on the public funding as much as those poor families who get medical care under the government insurance program.

That’s the message that Stanford Health Policy’s Lisa Chamberlain, Olga Saynina and Paul Wise and will be presenting at the Pediatric Academic Societies meeting in Toronto later this week. The PAS conference is the leading event for academic pediatrics and child health research. Chamberlain and Wise are Stanford Medicine pediatricians and Saynina is a data research analyst with Stanford Health Policy.

New research by the Stanford team shows that proposals to dramatically reduce federal expenditures on Medicaid and CHIP — the Children’s Health Insurance Program — could destabilize current specialty care referral networks for all children. This includes a large subset of privately-insured children in greatest need of high quality, specialized pediatric care.

“Most people think of Medicaid as a safety-net program, and to a certain extent it is,” said Wise, a core faculty member at SHP and the Center on Democracy, Development, and the Rule of Law, as well as a senior fellow at the Freeman Spogli Institute for International Health.

“But it has become so important to child-health systems that rich kids — kids with good commercial insurance — are heavily dependent on specialized care if they really get sick, on facilities that are heavily dependent on Medicaid,” he said.

Nearly one out of every five children live below the poverty line, according to the U.S. Census Bureau, yet few children need extensive health care. But of those who do, about 44 percent rely on Medicaid or other public insurance programs, regardless of their family’s income.

“Caring for seriously ill children requires a wide range of services and specialists, from pediatric surgeons to speech therapists to hospital teachers who make sure kids don’t fall behind,” Chamberlain told SHP for this story last year. “In pediatrics, we work as a team — and cutting Medicaid will reduce our ability to do that.”

The Stanford group analyzed two large datasets: the 2012 national Kids’ Inpatient Databaseand the 2012 California Patient Discharge Database. They found that hospitals caring for children with serious, chronic illnesses — such as congenital heart disease, cancer and severe asthma — are highly dependent on public payers such as Medicaid.

Nationally, major pediatric hospitals reported 55 percent of bed-days were covered by public payers, with the 10-highest volume hospitals ranging from 36 to 100 percent.   Overall, in California for all hospitals, 30 percent of net revenue is derived from Medicaid and for children’s hospitals, Medicaid provides 56 percent of net revenue.

Congratulations to Paul Wise, the Richard E. Behrman Professor of Child Health and Society, professor of pediatrics, and a Senior Fellow in the Freeman Spogli Institute for International Studies - CDDRL affiliated faculty, for being elected as a member of American Academy of Arts and Sciences, one of the country’s oldest and most prestigious honorary learned societies! Dr. Wise is also Stanford Health Policy and Center for International Security and Cooperation (CISAC) faculty.

A new SIEPR policy brief examines the growing life expectancy gap between low-income and high-income Americans. Coauthored by Victor R. Fuchs and APARC Deputy Director Karen Eggleston, the brief shows that life expectancy in the U.S. can be increased if health policy shifts towards preventing the leading causes of death for young people. READ MORE>>

Paul H. Wise, the Richard E. Behrman Professor of Child Health and Society, professor of pediatrics, and a Senior Fellow in the Freeman Spogli Institute for International Studies, is elected to the 2018 membership class of the American Academy of Arts and Sciences. His work focuses on health inequalities, maternal and child health policy, and children's health in areas of violent conflict, political instability and weak governance.

In this video, we ask him about the honor and what he hopes to achieve through membership in the prestigious organization founded in 1780 and devoted to the advancement and study of key societal, scientific and intellectual issues of the day.

"The recognition is important, but I see it as being more important as a platform for continuing to act in the real world; that it provides some semblance of enhanced legitimacy to speak to issues of global importance," says Wise, who is a core faculty member at Stanford Health Policy.