Eyeglasses boosted the standardized test scores of rural Chinese schoolchildren as much as 18 percent in just six months, according to a large-scale, ongoing study led by Stanford researchers.

"The evidence is overwhelming," said Scott Rozelle, co-director of the Rural Education Action Program (REAP), a coalition of Chinese universities and Stanford's Freeman Spogli Institute for International Studies that works to improve education and health in rural China.

The initial test scores for nearsighted students hovered around 68 percent. After receiving glasses, average scores soared to 86 percent. "You do these simple interventions and a child's whole life changes," Rozelle said. "It's fantastic."

REAP scholars partnered with Chinese ophthalmologists and scores of graduate students to orchestrate the massive project, the first to examine vision problems in rural China.

In 2012 and 2013, the team screened the vision of approximately 20,000 fourth and fifth graders in rural Shaanxi and Gansu provinces and doled out more than 4,000 pairs of eyeglasses. They discovered that 25 percent of the students were nearsighted, but only one in seven of those nearsighted students had the glasses they needed.

"There's a huge amount of unmet need," said Matthew Boswell, a REAP project manager based at Stanford.

The results may seem intuitive. Yet, helping the millions of nearsighted children in rural China is anything but easy, the REAP team discovered. Few of these rural children (and adults) know they are nearsighted – the world, to them, is naturally blurry. In addition, eye doctors are concentrated in the populous coastal corridors or regional "county towns," often dozens of miles by bus from the homes of rural Chinese families, Boswell said.

Basic eyeglasses cost between 200 and 500 yuan ($30 to $80), a price out of reach for many, he said.

The researchers also struggled to counter pervasive superstitions about eyeglasses.

For example, many rural Chinese residents believe that glasses make children's' vision deteriorate, relying on the observation that vision generally worsens with age, Boswell said. In addition, many Chinese do "eye exercises" by rubbing their eyes, cheeks and temples each morning, a practice they believe improves vision, he said.

They also face political struggles: China's rural health care program doesn't pay for vision care. "We could tell health or education officials until we were blue in the face there was a high level of need for vision care in rural communities," Boswell said. "But if your findings are not attached to something they care about, it's hard to make them listen."

Hence the connection to the test scores, a highly valued measurement by Chinese policymakers. The REAP team taps its large network of Chinese academic collaborators to translate its research results into policy reform, a process that is often successful, Rozelle said.

REAP is currently analyzing alternative ways to boost the delivery and acceptance of eye care, Boswell said. The original study assigned nearsighted students into six groups.  Researchers gave one-third of the students glasses; one-third received a voucher to purchase glasses; and another third remained untreated. Then, half of the students in each group received training about the causes and treatments for vision problems.

The training failed to significantly affect whether students wore the glasses, Boswell said.  The students who had to invest time to acquire glasses using a voucher demonstrated similar usage rates as students who received free glasses, he said.

Among a variety of other initiatives currently underway, the REAP team is training Chinese teachers to conduct simple vision tests, Boswell said.

"It's an extreme feel–good example," Rozelle said. "You put the first pair of glasses on a kid … and then a huge smile lights up their face."

Becky Bach is a writer for the Stanford News Service.

The favelas of Rio de Janeiro are some of the most dangerous places in the world. Havens for drug lords and their booming narcotics businesses, the urban slums that are home to 20 percent of the city’s population are notorious for soaring murder rates and a dearth of public services. Police often have little or no presence in most of Rio’s 800 favelas. And when they do, their conflicts with criminals frequently result in the killing of bystanders.

Brazilian officials have tried to bring order to the favelas with a set of policies and initiatives launched in 2008. A so-called pacification program has trained special teams of police to take a more targeted approach to fighting crime. The program has increased stability and reduced violence in about 30 favelas.

But Stanford researchers have found a hitch: When criminals are put out of business in one favela, they relocate to another. And that can lead to an increase in violence in the non-pacified slums.

“The cost of violence is disproportionately felt by the poor,” said Beatriz Magaloni, an associate professor of political science and senior fellow at Stanford’s Freeman Spogli Institute for International Studies. “Where there is violence, there is no investment. We are working with the government and the police and the community on ways to make these places safer and reduce that poverty by improving the quality of the police and devising ways to reduce the level of lethality they tend to use.”

To support the research she’s doing and the relationships she’s building in Brazil, Magaloni is working with FSI’s International Policy Implementation Lab, a new initiative that will bolster impact-oriented international research, problem-based teaching and long-term engagement with urgent policy implementation problems around the world.

Collaborating with a team of Stanford students, Magaloni is working with community groups, police organizations, government officials and other scholars to study existing policies and training procedures that could broaden the pacification program and make it more effective. The relationships have paid off with access to high-level government data, exclusive research findings and a pipeline between academics and policymakers that can improve living conditions for some of Rio’s poorest and most vulnerable people.

Her project is an example of the work being supported by the International Policy Implementation Lab, which recently awarded Magaloni’s project and those led by five other researchers a total of $210,000.

The lab, which is being supported in part by an initial $2 million gift from two anonymous donors, will grant another round of funding later this fiscal year to support projects led by Stanford faculty.

Recognizing that many Stanford scholars are engaged in international policy analysis, the Implementation Lab will help researchers who want to better understand policy implementation – a process often stymied by bureaucracy, politicking and budget constraints, but also often reflecting deliberation and experimentation by people across different countries, organizations, and cultures.

“The Implementation Lab will help us better understand health, security, poverty and governance challenges in an evolving world,” said FSI Director Mariano-Florentino Cuéllar.  “It will serve as a resource to foster communication across projects, so we can learn more about how implementation plays out in different settings and regions. Through the Implementation Lab, we can better engage faculty and students in understanding how policymakers and organizations change longstanding practices and actually execute policy.”

The Implementation Lab will support long-term projects grounded in policy-oriented research on a specific international topic. The projects must strive to connect scholarly research to interdisciplinary teaching, and will often involve long-term engagement with particular problems or international settings to better understand and inform the implementation of policy.

The first round of funding from the Implementation Lab will help shore up projects aimed at bolstering rural education in China, improving health care in India, curbing violence in Mexico and Brazil, and training government officials and business leaders in developing countries to improve economic growth and development.

And it will support a project led by political scientist Scott Sagan that uses online polling to better gauge the public’s tolerance for the use of nuclear weapons under certain scenarios – work that will lead to the collection of data that can inform how government officials craft military and diplomatic strategy.

“I can imagine two big benefits of the Implementation Lab,” said Sagan, a senior fellow at FSI and the institute’s Center for International Security and Cooperation.

“It will help pay for specific tasks that are sometimes not adequately funded elsewhere, especially in terms of student involvement,” he said. “And it will create a greater focus on policy implementation work that allows us to present our research results and see whether those results will have an impact on change.”

To encourage and support these ventures, the Implementation Lab will provide targeted funding, space for research projects and teaching, and a variety of support functions, including connections to on-campus resources that can assist with data visualization, locating interested students, and other tasks.  Those activities will be phased in during the next year based on the advice and feedback of faculty and others who are early participants.

The Implementation Lab is poised to be different from – but complementary to – other Stanford initiatives like the Hasso Plattner Institute of Design. FSI’s Implementation Lab is specifically focused on supporting long-term relationships and engaging students and faculty in the study of policy implementation in different national, organizational, and cultural settings.

Image

FSI Senior Fellow Grant Miller is working on improving health care in India.

“The Stanford International Policy Lab is creating an exciting new community that will catapult our ability to have meaningful and sustained policy engagement and impact through common learning and sharing of experiences with like-minded scholars from all corners of campus,” said Grant Miller, an associate professor of medicine and FSI senior fellow whose project on improving health care in India is being supported by the Implementation Lab.

Ann Arvin, Stanford’s vice provost and dean of research, said the International Policy Implementation Lab will help and encourage faculty to make their scholarship more relevant to pressing problems.

Demands for specialized resources, narrowly focused engagement of students, the ability to consider a long-term horizon, and an understanding of the often opaque processes of policy formulation and implementation pose considerable challenges for researchers seeking to enhance the potential of their policy-oriented research to achieve real impact.

“The International Policy Implementation Lab will help our faculty and students address these obstacles,” Arvin said. “We anticipate that this novel program will bring together Stanford scholars who seek solutions to different policy-related problems at various places around the world, but whose work is linked by the underlying similarities of these challenges. The Implementation Lab will give them the opportunity to learn from each other and share ideas and experiences about what succeeds and what is likely to fail when it comes to putting policy into practice.”

That’s what attracts Stephen Luby to the lab.

“The mistake that researchers often make is that they work in isolation,” said Luby, whose work on reducing pollution caused by the brick making industry in Bangladesh is being supported by the Implementation Lab. “Then they think they’re ready to engage in the implementation process, and realize they haven’t engaged with all the stakeholders. Policy implementation is an iterative process. You need feedback from all the right people along the way.”

Luby, a professor of medicine and senior fellow at FSI and the Stanford Woods Institute for the Environment, is working with brick makers and suppliers, as well as anthropologists and government regulators, to identify better ways to curb the pollution created by the coal-burning kilns throughout Bangladesh.

“Pneumonia is the leading cause of death among kids in Bangladesh,” Luby said. “And the brick kiln pollution is largely responsible for that. They’re using a 150-year-old technology to bake bricks, and there are better, cleaner ways to do it.”

But swapping coal-burning kilns for ones that are fired with cleaner natural gas is expensive, and there is little incentive for brick makers to change.

The government has passed regulations aimed at reducing pollution, but corruption, toothless laws and poor enforcement continue to undermine those policies.

"The country is caught in an equilibrium where people are getting cheap bricks but at a high cost to health and the environment,” Luby said. “We need to disrupt that equilibrium, and I look to the Implementation Lab to help us think this through. There’s a community of scholars who want to transform their work into implementation, and the lab will help convene them." 

The favelas of Rio de Janeiro are some of the most dangerous places in the world. Havens for drug lords and their booming narcotics businesses, the urban slums that are home to 20 percent of the city’s population are notorious for soaring murder rates and a dearth of public services. Police often have little or no presence in most of Rio’s 800 favelas. And when they do, their conflicts with criminals frequently result in the killing of bystanders.

Brazilian officials have tried to bring order to the favelas with a set of policies and initiatives launched in 2008. A so-called pacification program has trained special teams of police to take a more targeted approach to fighting crime. The program has increased stability and reduced violence in about 30 favelas.

But Stanford researchers have found a hitch: When criminals are put out of business in one favela, they relocate to another. And that can lead to an increase in violence in the non-pacified slums.

“The cost of violence is disproportionately felt by the poor,” said Beatriz Magaloni, an associate professor of political science and senior fellow at Stanford’s Freeman Spogli Institute for International Studies. “Where there is violence, there is no investment. We are working with the government and the police and the community on ways to make these places safer and reduce that poverty by improving the quality of the police and devising ways to reduce the level of lethality they tend to use.”

To support the research she’s doing and the relationships she’s building in Brazil, Magaloni is working with FSI’s International Policy Implementation Lab, a new initiative that will bolster impact-oriented international research, problem-based teaching and long-term engagement with urgent policy implementation problems around the world.

Collaborating with a team of Stanford students, Magaloni is working with community groups, police organizations, government officials and other scholars to study existing policies and training procedures that could broaden the pacification program and make it more effective. The relationships have paid off with access to high-level government data, exclusive research findings and a pipeline between academics and policymakers that can improve living conditions for some of Rio’s poorest and most vulnerable people.

Her project is an example of the work being supported by the International Policy Implementation Lab, which recently awarded Magaloni’s project and those led by five other researchers a total of $210,000.

The lab, which is being supported in part by an initial $2 million gift from two anonymous donors, will grant another round of funding later this fiscal year to support projects led by Stanford faculty.

Recognizing that many Stanford scholars are engaged in international policy analysis, the Implementation Lab will help researchers who want to better understand policy implementation – a process often stymied by bureaucracy, politicking and budget constraints, but also often reflecting deliberation and experimentation by people across different countries, organizations, and cultures.

“The Implementation Lab will help us better understand health, security, poverty and governance challenges in an evolving world,” said FSI Director Mariano-Florentino Cuéllar.  “It will serve as a resource to foster communication across projects, so we can learn more about how implementation plays out in different settings and regions. Through the Implementation Lab, we can better engage faculty and students in understanding how policymakers and organizations change longstanding practices and actually execute policy.”

The Implementation Lab will support long-term projects grounded in policy-oriented research on a specific international topic. The projects must strive to connect scholarly research to interdisciplinary teaching, and will often involve long-term engagement with particular problems or international settings to better understand and inform the implementation of policy.

The first round of funding from the Implementation Lab will help shore up projects aimed at bolstering rural education in China, improving health care in India, curbing violence in Mexico and Brazil, and training government officials and business leaders in developing countries to improve economic growth and development.

And it will support a project led by political scientist Scott Sagan that uses online polling to better gauge the public’s tolerance for the use of nuclear weapons under certain scenarios – work that will lead to the collection of data that can inform how government officials craft military and diplomatic strategy.

“I can imagine two big benefits of the Implementation Lab,” said Sagan, a senior fellow at FSI and the institute’s Center for International Security and Cooperation.

“It will help pay for specific tasks that are sometimes not adequately funded elsewhere, especially in terms of student involvement,” he said. “And it will create a greater focus on policy implementation work that allows us to present our research results and see whether those results will have an impact on change.”

To encourage and support these ventures, the Implementation Lab will provide targeted funding, space for research projects and teaching, and a variety of support functions, including connections to on-campus resources that can assist with data visualization, locating interested students, and other tasks.  Those activities will be phased in during the next year based on the advice and feedback of faculty and others who are early participants.

The Implementation Lab is poised to be different from – but complementary to – other Stanford initiatives like the Hasso Plattner Institute of Design. FSI’s Implementation Lab is specifically focused on supporting long-term relationships and engaging students and faculty in the study of policy implementation in different national, organizational, and cultural settings.

Image

FSI Senior Fellow Grant Miller is working on improving health care in India.

“The Stanford International Policy Lab is creating an exciting new community that will catapult our ability to have meaningful and sustained policy engagement and impact through common learning and sharing of experiences with like-minded scholars from all corners of campus,” said Grant Miller, an associate professor of medicine and FSI senior fellow whose project on improving health care in India is being supported by the Implementation Lab.

Ann Arvin, Stanford’s vice provost and dean of research, said the International Policy Implementation Lab will help and encourage faculty to make their scholarship more relevant to pressing problems.

Demands for specialized resources, narrowly focused engagement of students, the ability to consider a long-term horizon, and an understanding of the often opaque processes of policy formulation and implementation pose considerable challenges for researchers seeking to enhance the potential of their policy-oriented research to achieve real impact.

“The International Policy Implementation Lab will help our faculty and students address these obstacles,” Arvin said. “We anticipate that this novel program will bring together Stanford scholars who seek solutions to different policy-related problems at various places around the world, but whose work is linked by the underlying similarities of these challenges. The Implementation Lab will give them the opportunity to learn from each other and share ideas and experiences about what succeeds and what is likely to fail when it comes to putting policy into practice.”

That’s what attracts Stephen Luby to the lab.

“The mistake that researchers often make is that they work in isolation,” said Luby, whose work on reducing pollution caused by the brick making industry in Bangladesh is being supported by the Implementation Lab. “Then they think they’re ready to engage in the implementation process, and realize they haven’t engaged with all the stakeholders. Policy implementation is an iterative process. You need feedback from all the right people along the way.”

Luby, a professor of medicine and senior fellow at FSI and the Stanford Woods Institute for the Environment, is working with brick makers and suppliers, as well as anthropologists and government regulators, to identify better ways to curb the pollution created by the coal-burning kilns throughout Bangladesh.

“Pneumonia is the leading cause of death among kids in Bangladesh,” Luby said. “And the brick kiln pollution is largely responsible for that. They’re using a 150-year-old technology to bake bricks, and there are better, cleaner ways to do it.”

But swapping coal-burning kilns for ones that are fired with cleaner natural gas is expensive, and there is little incentive for brick makers to change.

The government has passed regulations aimed at reducing pollution, but corruption, toothless laws and poor enforcement continue to undermine those policies.

"The country is caught in an equilibrium where people are getting cheap bricks but at a high cost to health and the environment,” Luby said. “We need to disrupt that equilibrium, and I look to the Implementation Lab to help us think this through. There’s a community of scholars who want to transform their work into implementation, and the lab will help convene them.”

For more information about FSI's International Policy Implementation Lab, please refer to this Concept Note or contact Elizabeth Gardner.

REAP co-director Scott Rozelle builds on a ten-part series for Caixin Magazine titled, "Inequality 2030: Glimmering Hope in China in a Future Facing Extreme Despair." In his sixth column, Rozelle asks why rural China continues to be plagued by poor vision and intestinal worms.

To read the column in Chinese, click here.

> To read Column 1: Why We Need to Worry About Inequality, click here. 

> To read Column 2: China's Inequality Starts During the First 1,000 Days, click here. 

> To read Column 3: Behind Before They Start - The Preschool Years (Part 1), click here. 

> To read Column 4: Behind Before They Start - The Preschool Years (Part 2), click here.  

> To read Column 5: How to Cure China's Largest Epidemic, click here. 

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Inequality 2030:

Glimmering Hope in China in a Future Facing Extreme Despair

Caixin Column 6: A Tale of Two Travesties

Travesty One: China’s Intestinal Worms Epidemic

Our group, the Rural Education Action Project (REAP), did a study in 2010. We discovered that 40% of students in Guizhou rural elementary schools were infected with intestinal worms. Invisible to the naked eye, intestinal worms quietly sap valuable nutrients from their host, leading to stunted growth and malnutrition. Moreover, intestinal roundworm infection is associated with poorer academic performance, lower scores on memory and intelligence tests, and lower school attendance rates. So let me just make sure that this is clear: As late as 2010, 4 out of 10 rural Chinese children in our sample were attending school … and living life … with worms in their stomachs.

At that time, we wrote a policy brief to the State Council, informing the top leadership of the severity of the situation. The reaction was swift. China’s top leaders stated that this was unacceptable. They promised to address this problem as soon as possible. They pushed relevant agencies to investigate and explore effective ways to eliminate this alarming health problem. We were left hopeful.

Three years later, in May 2013, we repeated the same study. And to our dismay, this time we found that nearly 50% of children had intestinal worms. If our study is representative and half of the school-aged children in Guizhou—and most likely similar shares in other southern Chinese provinces—have worms, then this means that millions of kids are still infected with worms and are still suffering the consequences for their nutrition, health, and ability to learn. 

To put it simply: This is a travesty.

Why? In part, because this is a disease that is typically found in the poorest developing countries – not in a modernizing, increasingly wealthy superpower like China. Even more to the point, this is a travesty because this disease is very easy to control: a child infected with worms can be cured for a full six months simply by taking two deworming pills. These pills are super safe (medically, one of the safest medicines in the world) and super effective (worms are almost completely eliminated within one to two days). The medicine is also extremely inexpensive: the highest quality deworming tablets in China cost only 2 yuan per tablet. So 2 tablets, for 2 yuan each, will keep a child worm-free for a full six months. Yup, you read that right: for a total of 8 yuan per child per year, China could be entirely worm-free. This devastating health problem could be averted for only 200 million yuan per year (if every student in every poor county – all 25 million of them – took their deworming medicine). That is what we call a travesty. 

Travesty Two: The Vision Disaster

We discovered Travesty Two after one of Scott’s former grad students did a study in one of the poorest Tibetan autonomous counties in Gansu in the early 2000s. He showed that when rural elementary school students were given eyeglasses when they were nearsighted, their educational performance improved significantly.

After seeing this study, we met with the only group of academic eye doctors in China that was working on this issue with any degree of long-term commitment—a small group of opthamologists at the Zhongshan Optometry Center (ZOC) at Zhongshan University. We were told that, by their estimates, around 30% of 10 to 12 year olds in grade 5 and grade 6 were nearsighted and needed glasses. No one knew for sure, but the ZOC group had worked a lot in China’s urban schools and schools in the rural areas of their own Guangdong province and they thought these would be plausible rates for vision problems—even in the poor rural areas of Central and Western China. 

Armed with this information, we started to do our own informal census of vision problems in rural China as we went about our other research activities. At first, we were puzzled. Over the course of several years, we visited hundreds of elementary schools throughout rural China—in Ningxia, Shaanxi, Shanxi, Sichuan, Henan, Hebei and more. And in all these visits, we almost never saw elementary school students wearing glasses. At most, in a school of 100 or more, there were one or two kids wearing glasses. What was going on?

In collaboration with ZOC and our partners from Renmin University and Shaanxi Normal University, we set out to find out. We asked three questions: How many of these rural elementary school students had poor vision? Of the students with poor vision, how many were wearing glasses and how many were not? And what would happen if kids with poor vision that were not wearing glasses had a pair to put on?

What did we find? Just as ZOC had predicted so many years before, nearly 30 percent of elementary school students (in grades 4 to 6) in rural areas have poor vision. But then we found the really troubling part. Of those with poor vision, only one in six (15%) were wearing glasses. The rest had never even been prescribed a pair. How much did this oversight matter? Well, when we gave glasses to students with poor vision, we found that their academic performance improved enormously (relative to students with poor vision that did not wear glasses). Were we surprised? Well, no! Teachers in rural areas today still use the blackboard for most of their classes. So, if these students can’t see, how can they ever hope to learn?

Our study revealed that when you put a pair of glasses on a student with vision problem, a student that was barely passing (scoring, say, 65 on a test), suddenly  becomes a student in the middle of the pack, scoring 75. Ten points is a huge rise in performance – for an investment of only about 300 yuan for a proper pair of glasses. Assuming these glasses can last a rural child for about 2 years, the investment is only half that much on an annual basis. Thus, if there are 5 million children in grades 4, 5 and 6 in China’s poor rural areas, and if 30 percent of them need glasses, then Travesty Two could be averted for an investment of only 5 million * 30% * 150 yuan per year = 225 million yuan per year.

Again, a serious and wide-ranging impediment to rural Chinese children’s learning and healthy development is being allowed to persist in this modernizing superpower when effective, low-cost solutions are available and easy to put into place. And so we say again, this is a travesty.

How is that China can’t find a solution to such simple social problems, social problems that are endangering the entire nation’s future?

If we were to digress, we could give you even more examples. Did you read last month’s column? In the face of a crippling anemia epidemic among young rural students, we have shown that for only 8 yuan per day, all of these students could receive a nutritious lunch that would give them nearly half of their daily nutritional needs. Such a program would reduce micronutrient deficiencies and improve the educational performance of not only the children that were malnourished (and, indeed, up to 30 percent of students in poor rural areas are not getting enough nutrients in their diets), but also improve the test scores of the rest of the class—most likely because in classes where all children are healthy, there is more focus (and hence more learning) for all.

And the most frustrating part of all is that we know the money is there to spend. Build one less freeway. Open one less sports stadium. Slow down the construction of the high-speed rail network (build it, but, build it at a slower pace). And all of this could be paid for. Eliminating worms, fighting malnutrition and reducing poor vision are all concrete, cost effective steps that would have a huge and immediate impact on educational performance. Travesties!

If not being able to fix such a simple problem is a travesty, what do we call the situation that has allowed the problem to emerge in the first place? A travesty’s travesty.

In this case, the blame lies in two places: with the parents of the children and with the system in which they are going to school and seeking health care.

First, we believe the blame lies in part with rural parents and other family members. Why? To put it bluntly, our research has taught us that parents—and especially grandparents, who are often rural children’s day-to-day caregivers—are often ignorant and misinformed. When you ask a person in rural Guizhou why they don’t deworm their children, they frequently state right out: “Worms are not bad for you. You need them to digest your food.” Most moms do not know that worms are passed on through human night soil. Grandma still rarely washes her hands before cooking. No one tells their children or grandchildren that they should always wear shoes outside. 

In a recent project we worked with local doctors to deworm children. We gave them two high-quality, super safe deworming tablets with the simple instructions: “Take these two tablets before you go to bed tonight.” In no small number of our households, Grandpa or Dad had the child take one and throw the other away. Why? “Too many worms is not good, but, everyone needs some of them,” they said. Of course, without completing the deworming process, the worms almost immediately reproduce in the child’s stomach and intestines. Hence, in this very real way, Mom and Dad and Grandma and Grandpa are to blame.

The myths about eyeglasses are even more formidable. We worked with some high quality optometrists on a project last year and identified the students in each class that had poor vision and needed glasses. Armed with this information, we asked the parents and grandparents of children identified to have poor vision if their children had vision problems. More than 80% said they did not. But, that is not all. It is not only that they did not know. They also did not seem to care. We asked the same parents—more than 2000 of them—whether they would get their children glasses if their vision was bad enough that they could not see the board and it was affecting their grades. More than half of the parents said that even under these circumstances children who are younger than 12 years old should not get glasses. “Glasses hurt the eyes of children,” they said. “Not wearing glasses make the eyes tougher and they get better on their own.” Of course, none of this is true. Parents are not paying attention and even if they were, they are incapable of responding because they do not know. Again, Mom and Dad and Grandma and Grandpa are to blame.

In fact, though rural children’s caregivers may be an immediate cause of persistent poor health, their ignorance is likely not their fault. Parents and their children may well be victims of China’s rapid development. It is our hypothesis that China has simply developed too fast. In one generation, China moved up the income ladder a distance that took four or five generations in other countries. In those countries, there was time during the development process for ordinary citizens to learn about nutrition … and health … and parenting … and how to educate their children for a new higher-wage economy. However, China’s families—especially those in poor remote areas—did not have the same chance to catch up. When Grandma was raising her own children—not so many years ago—she thought she was raising subsistence farmers. To be successful, all her children had to do was to survive childhood and grow up to learn how to follow a bullock around their paddy land. Such an upbringing was also sufficient for an unskilled worker working on a construction site hauling bricks or in a factory assembling widgets. Now, however, these same grandmas are raising grandkids who need to be nurtured in a way that allows them to develop to a point in which they can go to high school and college and learn algebra and calculus and English and Chinese literature and go on to take more demanding jobs. Having anemia or worms or being a bit nearsighted did not matter in the past. Now, in a newly competitive and demanding economy, it may mean the difference between success and failure.

So if it is not really the parents’ fault, whose fault is it? Why are rural children still growing up without treatment for their basic health needs? Why do Mom and Dad and Grandma and Grandpa not know what they should do to take care of their kids? When there is a market failure or an information breakdown it is the role of the government to step in and correct the failure. And in this case we must place the blame—the ultimate blame—on the government. They are not playing their proper role and it is costing China very dearly.

The problem here is actually very similar to that of parents: it is a problem of ignorance and misinformation—either due to absence of knowledge or due to purposeful neglect. When the top leadership directed the Ministry of Finance to fund a deworming program in Guizhou, the top officials at the Center for Disease Control did not support it. Most top Center for Disease Control officials do not even know that intestinal worm rates are nearly 50% in rural schools in Southwest China. Or, maybe they do know but just do not care. Out of sight, out of mind. The budget for high profile “urban-oriented, rich-man” diseases, like diabetes, cancer and heart disease expands every year. Meanwhile, it seems that no one is interested in the unseen infections in poor rural schools.  In fact, if one looks for data on any disease that primarily affects poor rural areas—anemia or myopia or intestinal worms—it is almost always difficult (if not impossible) to find.

Government officials are also simultaneously territorial and deathly afraid of taking responsibility, even when the potential gains are large. In most of the rest of the world, a lot of health care takes place in schools. And when you think about it, what a great place to do so! When you’re trying to reach kids in a school, all of the target population is together in one place. The returns to conducting health and nutrition interventions in schools are high because the students are both concentrated and easily monitored. However, because of the fear of taking responsibility, there are currently rules in China against carrying out any health care activities in schools. China used to conduct these activities and did so with great efficiency and effectiveness. Every older Chinese remembers eating “bao-ta” candy, a sweetened deworming tablet, on an annual or semi-annual basis. At that early stage, China nearly wiped out intestinal worms. But, today, for some reason, they simply don’t do it anymore. Our team—even when accompanied by doctors—was not allowed to give the students deworming medicine. They had to take their medicine home to take it. Once they got there, they had to convince their illiterate grandmas that the doctor wanted them to take two tablets because worms were no good. The state—that should have known better—pushed its responsibility off onto Grandma and Grandpa. And we know how that worked out. 

The same happens in eye care. Schools regularly would not allow us in—even though we were giving high quality eye exams and free glasses to students who desperately needed them. Principals and teachers are just as misinformed as parents. “Eyeglasses are no good for grade 4 and grade 5 students,” they said. “Eye exercises are enough. Eyeglasses will make your eyes worse.” Even when the local town doctors came to give eye exams, principals invariably took the list they were given of those with potentially poor vision and filed it away without taking action. If schools are so misinformed and inactive, how can we expect parents to become informed enough to help their children become healthy?

Travesty, Travesty, Travesty. This country has spent billions on new facilities and teacher salaries. And they claim that they are committed to investing as much as it takes to significantly improve rural educational outcomes. But after all this investment and all this talk, China’s rural children are still sick. They are malnourished. They can’t see. And most of all, they can’t learn.

Today, these huge investments may be wasted. And China is missing an opportunity to spend less money in smarter ways so as to ensure that they are actually educating their young people in a way in which they can learn and thrive. When intestinal worms are eradicated, when glasses are prescribed, when kids get nutritious food, they learn, they grow and they thrive. But when they don’t, as they they are not in so many rural schools today, it is nothing less than a TRAVESTY. The time has come for change.

In the post-9/11 world, forging a successful grand strategy in U.S. foreign policy is unlikely and dangerous, according to a Stanford scholar.

During the Cold War, American leaders understood that the Soviet Union was their primary adversary, writes political scientist Amy Zegart in an essay for the Hoover Institution's Foreign Policy Working Group, a new two-year initiative that brings together Stanford scholars to examine key U.S. foreign policy challenges.

Zegart, co-director of the Center for International Security and Cooperation, notes that the Soviet threat – one of nuclear annihilation – brought a singular focus to U.S. foreign policy for the second half of the 20th century.

Successful grand strategies, she writes, depend on knowing the number and identities of one's enemies, what they want, how they operate and what damage they can unleash.

That is no longer the case in 2014 and for the foreseeable future, she suggests.

"The post-9/11 threat environment is vastly different," notes Zegart. Today, the number, identity and magnitude of dangers threatening American interests are all "wildly uncertain."

Exactly how many principal adversaries does the United States face at any given time? Who are they and what do they want? What could they do to America? Is China a rising threat or a responsible stakeholder? How likely is a "digital Pearl Harbor" that cripples U.S. strategic forces or financial institutions?

The answer to all these questions, she writes, is that nobody really knows: "Each day, it seems, we are told to be very afraid about something different and vaguely sinister."

On top of this, grand strategy requires dynamic international collaboration. But organizations like NATO, the International Monetary Fund and the United Nations Security Council are "out of whack with current power realities," writes Zegart. Gaps exist between the "aspirations and capabilities" of international organizations that typically forge partnerships with America.

A new approach

If grand strategy is outdated – and even dangerous – what can be done?

The first step is to give up on notions of grand strategy, Zegart advises. Instead, the United States should strive for what FSI Senior Fellow and working group co-chair Stephen Krasner calls "orienting principles." These are policy ideas that lie between ad hoc reactions to arising situations and grand visions of how the future should unfold.

"Orienting principles aren't glamorous," Zegart writes, "but they hold out the prospect of something better than foreign policy a la carte or a grand strategy that mis-estimates the threat environment and misunderstands the organizational requirements for success."

When grand strategies work well, they are truly grand, says Zegart. "That is, they must be able to anticipate and articulate a compelling future state of the world and galvanize the development of policies, institutions and capabilities at the domestic and international level to get us there. That's hard enough."

A second challenge, she adds, is the strategic interaction part of grand strategy, which requires thwarting and adjusting to the countermoves of principal adversaries.

"Grand strategy is not a game of solitaire, where we come up with all the moves and the cards just sit there. It's not all about us and our big ideas," she notes.

Instead, grand strategy is a multi-player game with powerful adversaries seeking to impose their national wills on the world to serve their own interests, Zegart observes.

"The sorry truth is that American grand strategies are usually alluring but elusive," she concludes. "The Cold War this isn't. We live in a hazy threat du jour world. This is too much complexity and uncertainty for grand strategy to handle."