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Front cover of the book "Who Shall Live?"

Since the first edition of Who Shall Live? (1974), over 100,000 students, teachers, physicians, and general readers from more than a dozen fields have found this book to be a reader-friendly, authoritative introduction to economic concepts applied to health and medical care.

Health care is by far the largest industry in the United States. It is three times larger than education and five times as large as national defense. In 2001, Americans spent over 12,500 per person for hospitals, physicians, drugs and other health care services and goods. Other high-income democracies spend one third less, enjoy three more years of life expectancy, and have more equal access to medical care.

In this book, each of the chapters of the original edition is followed by supplementary readings on such subjects as: "Social Determinants of Health: Caveats and Nuances", "The Structure of Medical Education — It's Time for a Change", and "How to Save 1 Trillion Out of Health Care".

The ten years following publication of the 2nd expanded edition in 2011 were arguably more turbulent for US health and health care than any other ten-year period since World War II. They span the implementation of the Affordable Care Act, the deepening opioid epidemic, and the physical, psychological, and socio-economic traumas of the COVID-19 pandemic.

An important new contribution to this book is to describe and analyze the changes in five sections: "The Affordable Care Act and the Uninsured", "Health Care Expenditures", "Health Outcomes", "The COVID-19 Pandemic", and "Health and Politics". This part includes 24 tables and figures.

This book will be welcomed by students, professionals, and life-long learners to gain increased understanding of the relation between health, economics, and social choice.

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Health, Economics and Social Choice

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Karen Eggleston
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APARC Predoctoral Fellow, 2023-2024, Fall 2024
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Marie Wako joined the Walter H. Shorenstein Asia-Pacific Research Center (APARC) as the 2023-2024 APARC Predoctoral Fellow, as well as for the 2024 fall quarter. She is a JSD (Ph.D. equivalent) candidate at Stanford Law School. She holds an LL.M. from Stanford Law School and a J.D. and LL.B. from the University of Tokyo. Her research interests include empirical analysis of human rights, law and gender, international trade law, and international public law.
 
Marie’s current research project focuses on the impact of female judges in Japanese criminal cases. Concerned about the persistently low gender equality in Japan, Marie seeks to understand how the presence of female judges can potentially challenge the male-dominated judiciary and influence sentencing outcomes.
 
The research utilizes a rare situation in Japan where criminal cases are randomly assigned to a group of judges, which enables us to study the pure causal impact of female judges on the judicial panel. The study conducts statistical analyses on a dataset of approximately 620 cases of criminal cases. Preliminary results indicate on average a statistically significant increase of 7.8 percentage points in sentencing severity for sexual offenses per one female judge, while no significant difference is observed for non-sexual offenses. Since the three judges in the panel must come to a unanimous conclusion in deciding the sentencing, this gap implies that, for better or for worse, these female judges are influencing the views of the male judges in the same judicial panel.
 
As an APARC pre-doctoral fellow, Marie aimed to advancing her research by conducting further qualitative analysis and conducting a comprehensive content analysis of published judgments to delve deeper into the reasons behind heavier sentencing in sexual offenses when a female judge is involved. Her study seeks to contribute to the broader interdisciplinary conversation surrounding equitable representation of women in deliberative forums.
 
Before commencing her studies at Stanford, Marie gained practical experience as a qualified lawyer, aiding private companies and government agencies on various aspects of international trade law, including export control and economic sanctions, treaty negotiation, and international public law matters. In addition to her research on gender in the judiciary, Marie is concurrently developing a project examining the influence of labor provisions in trade agreements and their potential to improve working conditions in exporting industries across different countries.
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Yuya Ouchi joined the Walter H. Shorenstein Asia-Pacific Research Center (APARC) as a visiting postdoctoral scholar for the 2023-2024 academic year. Ouchi is a postdoctoral fellow with the Japan Society for the Promotion of Science. While at APARC, he conducted research with Professor Kiyoteru Tsutsui on international human rights.

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Global Affiliate Visiting Scholar, 2024-2025
Parallel, Inc.
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Daisuke Asahara joins the Walter H. Shorenstein Asia-Pacific Research Center (APARC) as a visiting scholar for 2023-2024 and a global affiliate visiting scholar for 2024-25. Asahara has experience as CFO and COO of HEROZ, Inc. (listed on the Tokyo Stock Exchange Prime Market) and, prior to that, as an investment banker at Goldman Sachs. During this time at APARC, he will conduct research with Professor Kiyoteru Tsutui on finance, innovation, and startups in Japan. He holds a Doctor of Business Administration from Hitotsubashi University, an MBA from The Wharton School, University of Pennsylvania – where he was honored as one of the Class of 2013 graduation speakers – and both a Master's and Bachelor's degree in Informatics and Engineering from Kyoto University.

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mastro testimony

Chairman Gallagher, Ranking Member Krishnamoorthi, and members of the Select Committee:

Thank you for the opportunity to present my views on how to enhance near-term deterrence and our our own resilience against the PRC’s attempts to take Taiwan by force. The growth in Chinese military capabilities is well-documented, so I will not take time to summarize it in this testimony. Moreover, this committee has demonstrated an understanding that there is a possibility that China will attempt to take Taiwan by force. My article, “The Taiwan Temptation,” provides more concrete evidence to that fact if it is of interest. Instead, in this testimony, I want to focus on the challenges we face in countering (and thus deterring) China, including some fallacies; my recommendations for how to mitigate US defense challenges in deterring China from attempting a fait accompli; and my four rules for deterrence.

China does not want to fight a protracted war against the United States at this stage of development. The only situation in which it will initiate a war over Taiwan is if the leadership believes it can move quickly and take the island before the United States has time to respond (I’ll address some caveats to this later on).

The main vulnerabilities the United States experiences in its military power in Asia stem from the fact that it is not a resident power in Asia and thus is attempting to project power across vast distances. The emerging U.S. way of war exhibits several dependencies that China’s A2AD strategy targets. First and foremost, the United States relies on other countries for base access, while China can rely on home bases. This is problematic for several reasons. The number of bases the United States has access to in the first island chain has atrophied since the end of the Cold War, while China has infinite possibilities for basing options on its massive soil. In practice, the result is that the United States has one air base, Kadena Air Base in Okinawa, within combat range of Taiwan, while China has thirty-nine. Each air base can only support so many aircraft (Kadena can house about eighty aircraft, only fifty-four of which are fighters. And even here, the U.S. Air Force has also started to pull many of these aging aircraft out of the base, replacing them only with a temporary unit of more modern F-22s), which translates into China being able to generate far more sorties than the United States.

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Oriana Skylar Mastro
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This commentary originally appeared in Shukan Toyokeizai.



Military tensions between China and Taiwan rise, and the U.S. government informs the Japanese government that it wants to deploy U.S. forces in Japan to defend Taiwan. At the same time, China sends a message through various channels that it will not touch Japan at all if it does not cooperate with the U.S. military and remains neutral.

In the event of a Taiwan contingency, It is highly likely that military conflict between China and Taiwan will lead to a decision by the U.S. military to intervene, followed by the deployment of fighter jets and naval vessels from U.S. military bases in Japan. In the process, Japan will be forced to make a major choice. 

If U.S. forces are deployed to the area around Taiwan, U.S. bases located in Japan, including Okinawa, will serve as bases. Under the so-called “Far East Clause” of Article 6 of the Japan-U.S. Security Treaty, U.S. forces can use Japanese facilities and areas “to contribute to the maintenance of international peace and security in the Far East.” However, the deployment of U.S. forces under the Far East Clause requires prior consultation with the Japanese side. Nevertheless, there is little chance that the Japanese government will turn the US down for fear of a confrontation with China. If Japan were to refuse at the last minute, the trust between Japan and the U.S. would be damaged, and the Japan-U.S. Security Treaty regime would effectively collapse. As a result, Japan would have no choice but to confront China alone. This would be a bad move that would only be a temporary fix. 

However, some officials from the Ministry of Defense and the Self-Defense Forces are concerned about how the public would react. From China's point of view, this is a point to take advantage of, and by communicating that "Japan will be safe if it declares its neutrality," it may be able to divide Japan, the U.S., and Taiwan. 

The phrase "a Taiwan contingency is a Japan contingency" was introduced by former Prime Minister Shinzo Abe at a symposium sponsored by a Taiwanese think tank in 2006. This comment was followed by the statement, "It is also a contingency for the Japan-U.S. alliance." How will Japanese public opinion react to the "ultimate choice" in the face of a Taiwan contingency? 

An interesting study, part of the Stanford Japan Barometer, conducted by Stanford University sociologist Kiyoteru Tsutsui and his colleagues examined this issue using a method called conjoint experiments. 

The subjects were presented with two scenarios: "In the event of an emergency in Taiwan, under what circumstances would you be more likely to support military involvement by the Self-Defense Forces?" The subjects were presented with two scenarios and asked to choose the one in which they would be more likely to support Japan's military involvement. 

In the event of a Taiwan contingency, the researchers presented three options in each of five categories: "Chinese actions," "U.S. actions," "Chinese actions toward Japan," "U.S. actions toward Japan," and "international community reaction. In an experiment in which each of more than 7,000 subjects was asked to answer which of two scenarios in which they were randomly combined would support Japan's military involvement in the event of an emergency in Taiwan. The series of scenarios reflect the opinions of security experts who participated in simulations of a Taiwan contingency conducted by various agencies in the United States. The results show whether support for Japan's military involvement strengthened or weakened when each scenario was presented.

The survey results indicate that Japan is hesitant to fight China but would respond to a request from the U.S. military for logistical support.

One of these scenarios is precisely related to the aforementioned issue. When China promised Japan that it would not touch Japanese territory, including the Senkaku Islands, support for Japan's military involvement weakened. On the other hand, if China landed on and occupied the Senkaku Islands at the same time as its invasion of Taiwan, support for Japan's military involvement increased. The result is clear: "Japanese people place the highest priority on the impact on Japanese territory," said Professor Tsutsui. 

The survey results indicate that Japan is hesitant to fight China but would respond to a request from the U.S. military for logistical support. How will Japan be involved in a Taiwan contingency? Public opinion is not yet settled. 

In reality, many experts believe that if U.S. forces deployed from bases in Japan clash with Chinese forces, the next request will be for cover by the Self-Defense Forces. It is quite a narrow pass to say that they will not participate in combat and only provide logistical support. 

As for why Japan should get involved in a Taiwan contingency, the debate tends to settle on supply chain issues, particularly in the area of semiconductors, or geopolitical importance. Many Japanese, however, may feel that such reasons alone are not sufficient to make a decision to put the lives of Self-Defense Force personnel on the line and the residents of the Nansei Islands at risk. 
The supply chains that Japanese firms have built in East Asia, including China, would also be severely damaged. In addition, Chinese nationalism would flare up violently if it were to fight Japan again. The cost of fighting China as a neighbor is extremely high for Japan. 

Where Did You Get the Money To Pay for the Succession?
 

The issue of money is also unavoidable. In order to prepare for contingencies, we must also consider financing the cost of war. 

If the armed conflict with China is prolonged, huge fiscal outlays will be required not only for the continuation of the war but also for the repair of domestic infrastructure. In addition to supplementary budgets, it will be necessary to issue government bonds. 

However, Japanese financial institutions alone may not be able to digest the Japanese Government Bonds. For this reason, a simulation by the Japan Strategy Research Forum this year called for the direct underwriting of Japanese Government Bonds by the Bank of Japan. 

Junichi Kanda, a Bank of Japan alumnus in the House of Representatives who served as finance minister, opposed this proposal, saying, "It would cause a sudden loss of confidence in Japan's finances and the yen, leading to a significant depreciation of the yen to over 300 yen to the dollar and an increase in interest rates to over 10%. Such an extreme depreciation of the yen would also hinder the purchase of equipment and materials in foreign currency. 

Instead, Kanda suggested issuing foreign currency-denominated government bonds for foreigners. However, since there has been no such issuance since 1988, it is necessary to gradually issue these bonds from normal times to develop investors, he said. 

The prerequisite is that confidence in Japan's finances is secured. Japan needs to maintain fiscal discipline on a regular basis in case of emergency," said Kanda. Even in peacetime, there is a strong argument in Japan for using government bonds as a source of funds for increased defense spending. If the government cannot even raise taxes, China will question its seriousness. More open and substantive discussions are needed if the Japanese people are to be convinced to accept the costs of a Taiwan contingency.

Headshot of Kiyoteru Tsutsui

Kiyoteru Tsutsui

Senior Fellow at FSI; Professor of Sociology; Henri H. and Tomoye Takahashi Professor and Senior Fellow in Japanese Studies at APARC; Director of the Japan Program; Deputy Director, APARC
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The ultimate choice that must be made.

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This is an English translation of an article originally published by The Asahi Shimbun


Stanford University Professor of Sociology Kiyoteru Tsutsui is a recipient of the Suntory Prize for Arts and Sciences and the Ishibashi Tanzan Prize for his book Human Rights and the State (Iwanami Shinsho, 2022). Although he has published many works in English, this was his first publication in Japanese. After earning a master's degree at Kyoto University, he moved to the United States. Before Stanford, he served as a professor at the University of Michigan. “I wanted to make a difference in the United States first,” he says. “I had not thought about publishing in Japanese.”

However, since he joined Stanford in 2020 and has undertaken the role of director of the Japan Program at the University's Asia-Pacific Research Center (APARC), Tsutsui has become increasingly aware of the importance of Japanese studies and publishing in Japanese. He recognizes the decline of Japanese studies and the necessity of revitalizing the field and connecting Japan and the United States. Tsutsui is currently the only professor of Japanese studies at APARC. In the 1990s, there were three or four faculty experts in Japanese studies at the center.

With the popularity of Japanese anime, manga, video games, and other forms of Japanese culture, the number of Japanese-language students in the United States is not decreasing," notes Tsutsui. However, “the departure from Japan in the social sciences is severe.” The reason for this, according to Tsutsui, is that area studies are declining, and there is an increasing emphasis on theories and models. “But Chinese studies are growing, and the subjects of German, French, and other area studies maintain interest.” In 2019, a session titled "The Death of Japanese Studies" was held at the North American Association for Asian Studies, attracting much attention.

Tsutsui worries that the declining interest in Japanese studies could negatively impact public opinion and policymaking toward Japan in the United States. For example, during the Japan-U.S. trade friction of the 1980s, the Japan-U.S. relationship was hardly a focus of Japanese studies scholars in the United States.

Tsutsui works to advance U.S.-Japan dialogue, promote Japanese studies research, and clear up misunderstandings about Japanese affairs. Last year, he launched the Stanford Japan Barometer (SJB), a periodic public opinion survey on political, economic, and social issues concerning contemporary Japan — a project he started in hopes of fostering young researchers’ interest in Japan.

“We have already researched gender and policy and the Taiwan contingency and security,” he says. “In the future, we will continue to cover a wide range of topics in Japanese politics, economy, and society, including techno-media, artificial intelligence, Japan’s declining birthrate, and its Constitution.” Unlike a typical public opinion survey, SJB focuses on types of questions that move people’s opinions. Therefore, SJB asks questions on different issues with different assumptions, comparing people’s responses.

In the case of the questions on same-sex marriage, the respondents randomly received one of eight explanations, such as “In Japanese society, it is a tradition to see marriage as a heterosexual relationship” and “In Japanese society, there is a tradition of toleration towards same-sex relationships stemming back from the Sengoku Period.” The study examined the difference between respondents who received no explanation and those provided with arguments supportive of same-sex marriages. “Our results showed that respondents tend to become more supportive of same-sex marriage when presented with an argument that not allowing same-sex marriage is unfair from the point of view of human rights and gender equality,” Tsutsui explains.

“I hope that many young scholars will eventually participate in the project and that it will provide an opportunity for the next generation of outstanding researchers to enter Japanese studies and increase their opportunities to work abroad.”
 

Kiyoteru Tsutsui

Kiyoteru Tsutsui

Henri H. and Tomoye Takahashi Professor and Senior Fellow in Japanese Studies at Shorenstein APARC, Director of the Japan Program and Deputy Director at APARC, Senior Fellow at FSI, and Professor of Sociology
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Professor Kiyoteru Tsutsui, a recipient of the Suntory Prize for Arts and Letters and the Ishibashi Tanzan Prize, is a member of the third cohort of the U.S.-Japan Next Generation Network, an exchange program of policy experts from the United States and Japan launched in 2009 by the Mansfield Foundation in the United States in cooperation with the Japan Foundation. As a participant in the network, he explores the state of Japanese studies in the United States.

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Mia Kimura MBA

Mia Kimura is a Curriculum Consultant at the Stanford Program on International and Cross-Cultural Education (SPICE).

Prior to joining SPICE, Mia worked in marketing communications, supporting foreign firms in the Japanese market, and Japanese organizations in the United States. She has also served as Principal at Poppins Active Learning School, an international program for early childhood education in Tokyo. She holds a Bachelor of Arts in Cognitive Science from Brown University, and a Master of Business Administration from The Graduate School of International Corporate Strategy at Hitotsubashi University in Tokyo. She was born in San Francisco and lived in Tokyo for 25 years before returning to the Bay Area.

Mia’s role at SPICE represents the culmination of decades of experience bridging Japanese and American business and social cultures. She also draws from background as an executive coach, defining her role of instructor as an enabler of students’ own curiosity and abilities to question, reflect, and learn.

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View a Japanese version of this announcement.


The Japanese public supports women’s advancement in society, finds the Stanford Japan Barometer, a survey platform launched by the Japan Program at Stanford University’s Walter H. Shorenstein Asia-Pacific Research Center (APARC). This result is somewhat surprising, considering Japan’s poor showing in global gender equality rankings.

Led by Professor of Sociology Kiyoteru Tsutsui, the Henri H. and Tomoye Takahashi Professor and director of the Japan Program at APARC, and Charles Crabtree, an assistant professor in the Department of Government at Dartmouth College and a former visiting assistant professor with the Japan Program, the Stanford Japan Barometer (SJB) is a periodic public opinion survey on political, economic, and social issues concerning contemporary Japan with three main parts: (1) questions about respondents’ demographic background; (2) a stable set of questions about support for policy issues, political parties, public institutions, and international entities; and (3) a thematically focused set of questions and experimental studies on topics of great relevance at the time of the survey. The survey is conducted with a national, quota-based sample of 8,000 Japanese residents.

In the first installation of the survey, conducted in late November 2022, the SJB examined issues concerning gender and sexuality in Japan. It found, among other results, that most Japanese are in favor of recognizing same-sex unions and support a legal change to allow married couples to keep separate surnames. The SJB also examined questions related to women’s advancement in Japanese society, the focus of the following report.

One prominent gender equality issue that often recurs in Japanese public discourse is women’s under-representation in prominent positions, especially in politics and business. According to the latest Global Gender Gap Report released by the World Economic Forum, Japan ranks 116th out of 146 countries in terms of gender equality. Japan fares well in the categories of Education and Health, but in Politics and Economy, it ranks 139th and 121st respectively. In another ranking on women’s role and influence in the workforce, the Glass-Ceiling Index compiled by The Economist, Japan ranks second-worst among the 29 developed countries surveyed. Japan barely avoided the lowest ranking (a dubious distinction taken by South Korea), but indeed ranks lowest in terms of the proportion of women in national parliaments (single or Lower House) among OECD countries, with only 10% of Lower House members being female.

To better understand this striking gender disparity, Tsutsui and Crabtree had respondents complete conjoint experiments that examined what types of candidates the Japanese public is more likely to support for a Diet seat and an external corporate board member. The results show, perhaps surprisingly, that Japanese people prefer women for these positions (52% to 48% for the Diet and 51% to 49% for corporate board). Women support female candidates more than men, but men also prefer female candidates over male ones, averaging across all other candidate characteristics such as education and occupational background. These differences are fairly stable across different ages, educational and family backgrounds, and political party support. Contrary to what gender representation in politics and corporate leadership would indicate, the SJB results suggest that there is robust support for women’s representation in those powerful positions across different spectrums of the Japanese public.

Tsutsui and Crabtree also asked a series of questions about views on gender roles and women’s advancement in Japanese society. Respondents were particularly supportive of more men taking parental leave and helping with childcare, registering 6.3 on a scale of 0-10 (5 being neutral and a number larger than 5 indicating support for the statement). They were not supportive of the statements about traditional gender roles, such as “Men should work outside the home and women should stay home” (3.8), or “Boys should be raised to be manly and girls should be raised to be womanly” (4.3). Interestingly, for all these questions, there is a statistically significant difference between male and female respondents, with men showing greater support for traditional gender roles, although the general trend is a shift away from traditional gender roles even among men.

On questions concerning women’s advancement in Japanese society, the Japanese public demonstrated strong support for the argument that more efforts should be made to increase the number of female politicians (5.8), executives (5.9), and board members (5.8). There is no substantial difference between men and women for these questions, indicating that the support for women’s advancement in politics and business is broadly shared across genders.

When it comes to using a quota to ensure women’s seats in the national Diet, management positions, and board rooms, the opinions are divided across the gender line, with women being significantly more supportive (5.1, 5.2, 5.2) than men (4.8, 4.7, 4.7). This likely indicates that men are threatened by the idea of quota as it would reduce the likelihood of their advancement toward these powerful positions.

Men’s resistance to quotas notwithstanding, overall, the Japanese public supports women’s advancement in society, perhaps recognizing the need for Japan to change in light of the embarrassing showing in global rankings of women’s empowerment. These results suggest that the slow pace of change in women’s advancement in Japan might be attributable to the behavior of gatekeepers, who are mostly older men who come from different socioeconomic backgrounds than the SJB’s average survey respondent, rather than to a lack of public support.


For media inquiries about the survey, please reach out to:
Noa Ronkin
APARC Associate Director for Communications and External Relations
noa.ronkin@stanford.edu

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Video Interview: Kiyoteru Tsutsui Discusses Japan’s Economic Diplomacy in Southeast Asia

Kiyoteru Tsutsui, the Henri H. and Tomoye Takahashi Professor and Senior Fellow in Japanese Studies at Shorenstein APARC, joined Visiting Scholar Gita Wirjawan, host of “Endgame,” a video podcast, to discuss a range of topics, including his work on human rights, the demographic problem in Japan, global democratic decline, and Japan’s approach to Southeast Asia as a projector of soft power.
Video Interview: Kiyoteru Tsutsui Discusses Japan’s Economic Diplomacy in Southeast Asia
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Contrary to current levels of women’s under-representation in leadership positions in Japan, the Stanford Japan Barometer, a new periodic public opinion survey co-developed by Stanford sociologist Kiyoteru Tsutsui and Dartmouth College political scientist Charles Crabtree, finds that the Japanese public favors women for national legislature and corporate board member positions.

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