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This book is part of a wider project that aims to propose a model GATT that makes good economic sense without undoing its current basic structure. It asks: What does the historical record indicate about the aims and objectives of the framers of the GATT? To what extent does the historical record provide support for one or more of the economic rationales for the GATT? The book supports that the two main framers of the GATT were the United Kingdom and the United States; developing countries' influence was noticeable only after the mid-1950s. The framers understood the GATT as a pro-peace instrument; however, they were mindful of the costs of achieving such a far-reaching objective and were not willing to allocate them disproportionately. This may explain why their negotiations were based on reciprocal market access commitments so that the terms of trade were not unevenly distributed or affected through the GATT.

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World Trade Review
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Background.  The net value of increased health care spending remains unclear, especially for chronic diseases.

Objective. To assess value for money spent on medical care for patients with type 2 diabetes, using a “cost-of-living” approach.

Setting. Mayo Clinic Rochester, a not-for-profit integrated health care delivery system. 

Patients. 613 patients with type 2 diabetes: 36 diagnosed before 1985; 186 in 1985-96; 181 in 1997-99; and 210 in 2000-02.

Design. We compare the increase in inflation-adjusted annual health care spending with the value of changes in health status between 1997 and 2005.

Measurements. Measures of health status are (1) cardiovascular risk based on the United Kingdom Prospective Diabetes Study (UKPDS) equations, holding age and diabetes duration constant (“modifiable risk”); and (2) simulated outcomes for all diabetes complications using the UKPDS Outcomes Model. The present discounted value of improved survival and avoided treatment spending for coronary heart disease (CHD), net of the increase in annual spending per patient, yields net value.

Results. We estimate a total value of $20,824 per patient for quality improvement ($17,392 from reduction in modifiable risk of fatal CHD and fatal stroke, $3,432 from avoided CHD treatment spending), and a value net of cost of $10,911 per patient (95% confidence interval -$8,480, $33,402). A second approach to assessing value, using the UKPDS Outcomes Model, yields a net value of $6,931 per patient.

Conclusions. Our estimates of net value are positive, indicating that value for money has improved, although confidence intervals bracket zero. The increase in spending thus appears “worth it” on average, but there remains considerable room for enhancing value for money in care for patients with diabetes.

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Annals of Internal Medicine
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Karen Eggleston
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BACKGROUND: Genetic variability among patients plays an important role in determining the dose of warfarin that should be used when oral anticoagulation is initiated, but practical methods of using genetic information have not been evaluated in a diverse and large population. We developed and used an algorithm for estimating the appropriate warfarin dose that is based on both clinical and genetic data from a broad population base. METHODS: Clinical and genetic data from 4043 patients were used to create a dose algorithm that was based on clinical variables only and an algorithm in which genetic information was added to the clinical variables. In a validation cohort of 1009 subjects, we evaluated the potential clinical value of each algorithm by calculating the percentage of patients whose predicted dose of warfarin was within 20% of the actual stable therapeutic dose; we also evaluated other clinically relevant indicators. RESULTS: In the validation cohort, the pharmacogenetic algorithm accurately identified larger proportions of patients who required 21 mg of warfarin or less per week and of those who required 49 mg or more per week to achieve the target international normalized ratio than did the clinical algorithm (49.4% vs. 33.3%, P<0.001, among patients requiring < or = 21 mg per week; and 24.8% vs. 7.2%, P<0.001, among those requiring > or = 49 mg per week). CONCLUSIONS: The use of a pharmacogenetic algorithm for estimating the appropriate initial dose of warfarin produces recommendations that are significantly closer to the required stable therapeutic dose than those derived from a clinical algorithm or a fixed-dose approach. The greatest benefits were observed in the 46.2% of the population that required 21 mg or less of warfarin per week or 49 mg or more per week for therapeutic anticoagulation.

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Thitinan Pongsudhirak, an International Visitor in 2009-10, is a high-profile expert on contemporary political, economic, and foreign-policy issues in Thailand today. Pongsudhirak is not senior in years, but he is in stature.  His career path has been meteoric since he earned his BA in political science with distinction at UC Santa Barbara only ten years ago. In 2001, he received the United Kingdom’s Best Dissertation Prize for his doctoral thesis at the London School of Economics on the political economy of the Thai economic crisis in 1997.

Since 2006 he has held an associate professorship in international relations at Thailand’s premier institution of higher education, Chulalongkorn University, while simultaneously heading the Institute of Security and International Studies, the country’s leading think tank on foreign affairs. 

His publications include: “After the Red Uprising” in Far East Economic Review, May 2009; “Why Thais Are Angry” in The New York Times, 18 April 2009; “Thailand Since the Coup” in Journal of Democracy, October-December 2008; “Thaksin: Competitive Authoritarian and Flawed Dissident” in John Kane, Haig Patapan and Benjamin Wong (eds), Dissident Democrats: The Challenge of Democratic Leadership in Asia, New York, NY: Palgrave Macmillan, 2008. He was Salzburg Global Seminar Faculty Member in June 2009, Japan Foundation’s Cultural Leader in 2008, Visiting Research Fellow at ISEAS in Singapore in 2005.

For ten years, in tandem with his academic career, he worked as an analyst for The Economist’s Intelligence Unit.  He has written on bilateral free-trade areas in Asia, co-authored a book on Thailand’s trade policy, and is admired by Southeast Asianist historians for having insightfully revisited, in a 2007 essay, the sensitive matter of Thailand’s role during World War II.


The international visitors seminar series provides an opportunity for the Humanities Center's international scholars in residence to engage with the Stanford community by presenting and discussing their recent work in a congenial environment. Stanford faculty, students, and affiliates meet over lunch to hear a brief, informal presentation and engage in vigorous discussion. The series seeks to foster the exchange of ideas across borders and across disciplines, with the particular goal of enhancing interactions between researchers in the humanities and the social scientists.

Levinthal Hall

Thitinan Pongsudhirak Professor, International Political Economy, Chulalongkorn University, Thailand; FSI-Humanities Center International Visitor, 2009-2010 Speaker
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Global health disparities were the topic of a special event November 11th co-sponsored by the Asia Health Policy Program of the Shorenstein Asia-Pacific Research Center and the Center for Health Policy / Primary Care and Outcomes Research.

Sir Michael Marmot, internationally renowned Principal Investigator of the Whitehall Studies of British civil servants (investigating explanations for the striking inverse social gradient in morbidity and mortality), spoke about research on the social determinants of health and taking action to promote policy change. Pointing out the extreme disparities in life expectancy for peoples in different parts of the world – including the “haves” and “have-nots” within the high-income world – he presented an overview of “Closing the gap in a generation: Health equity through action on the social determinants of health” (http://www.who.int/social_determinants/en/). That report was commissioned by the World Health Organization (WHO) and released last year; Sir Marmot served as the Chair of the Commission on Social Determinants of Health.

Criticizing those who justify initiatives in global health solely on economic grounds, Sir Marmot argued that addressing the social determinants of health is a matter of social justice.

He presented data and discussed the report’s three primary recommendations: 1. Improve daily living conditions; 2. Tackle the inequitable distribution of power, money, and resources; and 3. Measure and understand the problem and assess the impact of action.
Stating that the World Health Assembly resolution on the social determinants of health was only meaningful as a first “baby step,” Marmot urged the audience to consider how research and policy advocacy can address the social determinants of health so that all individuals can lead flourishing lives.

Examples from Asia include

  • the high risk of maternal mortality (1 in 8) in Afghanistan;
  • the steep gradient in under-5 mortality in India (with the rate almost three times higher for the poorest quintile than for the wealthiest quintile);
  • less than half of women in Bangladesh have a say in decision-making about their own health care;
  • a large share of the world’s population living on less than US$2 a day reside in Asia;
  • social protection systems like pensions are possible in lower and middle-income countries, with Thailand as an example;
  • more can be done to address the millions impoverished by catastrophic health expenditures, such as in southeast Asia; and
  • conflict-ridden areas and internally displaced people, such as in Pakistan and Myanmar, are among the most vulnerable.

He also responded to questions about the role of freedom and liberty in social development – contrasting India and China – and commented on the peculiar contours of the US health reform debate.

Professor Marmot closed by noting that, in exhorting everyone to strive for social justice and close the gaps in health inequalities all too apparent in our 21st century world, he hoped he was not too much like Don Quixote, going around “doing good deeds but with people all laughing at him.” 
Professor Sir Michael Marmot MBBS, MPH, PhD, FRCP, FFPHM, FMedSci, is Director of the International Institute for Society and Health and MRC Research Professor of Epidemiology and Public Health at University College, London. In 2000 he was knighted by Her Majesty The Queen for services to Epidemiology and understanding health inequalities.

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Edited by SEAF Director Don Emmerson and co-published in 2008-09 by APARC at Stanford and ISEAS in Singapore, Hard Choices: Security, Democracy, and Regionalism in Southeast Asia continues to attract attention. Excerpted below are two differing but equally thoughtful recent reviews:

Noel M. Morada is a professor of political science at the University of the Philippines-Diliman and director of the Philippines Progamme in the Asia Pacific Centre for the Responsibility to Protect (R2P) at the University Queensland in Brisbane, Australia.

Writing in Kasarinlan: Philippine Journal of Third World Studies, 23: 2 (2008), pp. 119-122, Prof. Morada found the title of Hard Choices “apt” because its authors “ask hard questions—including philosophical ones—on the merits and demerits of pushing for a more ‘people-centered’ ASEAN, the challenges and constraints in implementing Responsibility to Protect (R2P) principles in the region, as well as the possible directions that ASEAN may take in the near future.”

A “good thing” about the book, in his view, “is that the reader is left to make his or her own conclusions” about “the issues and arguments” that it presents. He notes the variety of backgrounds of the authors: from scholars based far from Southeast Asia, through local analysts on Track II, to an official from inside the ASEAN secretariat itself. Their chapters, in his judgment, contribute significantly to current debates about what balance that ASEAN should strike between “state-centered and society-centered conceptions of security,” including “the dilemmas and constraints” that state and societal actors face in pursuing a more “participatory” kind of regionalism in Southeast Asia.

Among the issues featured in Hard Choices, Morada cites “the thorny problem of intervention in the domestic affairs of [ASEAN] members,” including the challenge to regionalism posed by Myanmar’s rulers, and whether or not the ASEAN Charter can facilitate a response or may itself be an obstacle to reform. While highlighting the relative optimism of Mely Caballero-Anthony’s chapter on non-traditional security, he finds a consensus among the book’s authors that “ASEAN’s traditional norms—i.e., state sovereignty and non-interference—still rule.”

Prof. Morada ends his review thus: “This should be a required reading for graduate students specializing in Southeast Asia and a must have for ASEAN specialists and observers. More importantly, civil society groups would benefit immensely from reading this volume as part of their education about ASEAN, on which many remain uninformed. Many of my friends in the academic community in the region have in fact been quite disappointed with many civil society groups who simply want to push their agenda but have not done their homework on the workings of ASEAN. This book should help enlighten them further.”

Lee Jones is a lecturer in the Department of Politics at the College of Queen Mary, University of London.

Writing for a future issue of the ASEASUK Newsletter, a publication of the Association of Southeast Asian Studies in the United Kingdom, Dr. Jones, unlike Prof. Morada, misses a firmer editorial hand. “Theoretical engagement is relatively sparse,” writes Jones, “and the book would have benefited from an overarching framework to help structure and guide the contributions. Particularly given many contributors’ focus on Myanmar, ASEAN’s policies towards it, and ASEAN’s recent institutional evolution, an early chapter agreeing [to] a collective account of these matters would have left more space for analysis and argumentation.”

Jones singles out the chapter by “veteran official Termsak Chalermpalanupap” as “a highly informative overview of ASEAN’s institutional development which will be useful for all students of ASEAN.” Chapters by Simon Tay (on air pollution) and Michael Malley (on nuclear energy) are also praised by Jones as demonstrating that “democratisation does not (as other contributors imply) automatically produce either more liberal policies or enhanced regional cooperation.” On the contrary, writes Jones, “democratisation can give vent to illiberal, nationalist and uncooperative sentiments, particularly when dominated (as ASEAN polities are) by cynical oligarchs. It is disappointing, therefore, that none of the chapters engages in systematic analysis of the domestic social forces at work in ASEAN states.”

“On balance,” for Jones, “the evidence in Hard Choices seems to favour the pessimist viewpoint. The basis for concluding that civil society has shattered elites’ monopoly on policymaking is rather weak. None of the pro-intervention authors sufficiently counter[s] the pragmatist challenge that ASEAN coherence could not withstand the adoption of a more liberal-interventionist posture. However, this is a contingent judgment which should not lead us simply to endorse the status quo. … [T] he fate of individual countries and the overall direction and content of ASEAN regionalism depends ultimately on the struggles of ASEAN’s own citizens.

Concludes Jones: “A clear-sighted analysis of the respective strengths and weaknesses of the force of movement and reaction, without succumbing to the defeatism of endorsing authoritarianism or the romanticism of believing that democratic institutions alone imply the victory of civil society (or that ASEAN can do much to create such institutions), is therefore vital for understanding the region’s prospects.”

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BACKGROUND: It is unclear whether functional status before dialysis is maintained after the initiation of this therapy in elderly patients with end-stage renal disease (ESRD). METHODS: Using a national registry of patients undergoing dialysis, which was linked to a national registry of nursing home residents, we identified all 3702 nursing home residents in the United States who were starting treatment with dialysis between June 1998 and October 2000 and for whom at least one measurement of functional status was available before the initiation of dialysis. Functional status was measured by assessing the degree of dependence in seven activities of daily living (on the Minimum Data Set-Activities of Daily Living [MDS-ADL] scale of 0 to 28 points, with higher scores indicating greater functional difficulty). RESULTS: The median MDS-ADL score increased from 12 during the 3 months before the initiation of dialysis to 16 during the 3 months after the initiation of dialysis. Three months after the initiation of dialysis, functional status had been maintained in 39% of nursing home residents, but by 12 months after the initiation of dialysis, 58% had died and predialysis functional status had been maintained in only 13%. In a random-effects model, the initiation of dialysis was associated with a sharp decline in functional status, indicated by an increase of 2.8 points in the MDS-ADL score (95% confidence interval [CI], 2.5 to 3.0); this decline was independent of age, sex, race, and functional-status trajectory before the initiation of dialysis. The decline in functional status associated with the initiation of dialysis remained substantial (1.7 points; 95% CI, 1.4 to 2.1), even after adjustment for the presence or absence of an accelerated functional decline during the 3-month period before the initiation of dialysis. CONCLUSIONS: Among nursing home residents with ESRD, the initiation of dialysis is associated with a substantial and sustained decline in functional status. 2009 Massachusetts Medical Society

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What ails the Pakistani polity? Since its emergence from the detritus of the British Indian Empire in 1947, it has witnessed four military coups (1958, 1969, 1978 and 1999), long periods of political instability and a persistent inability to consolidate democratic institutions. It also witnessed the loss of a significant portion of its territory (East Pakistan) in 1971 following the brutal suppression of an indigenous uprising in the aftermath of which some ten million individuals sough refuge in India. The flight of the refugees to India and the failure to reach a political resolution to the crisis precipitated Indian military intervention and culminated in the creation of the new state of Bangladesh.

Pakistan's inability to sustain a transition to democracy is especially puzzling given that India too emerged from the collapse of British rule in South Asia. In marked contrast to Pakistan, it has only experienced a brief bout of authoritarian rule (1975-1977) and has managed to consolidate democracy even though the quality of its democratic institutions and their performance may leave much to be desired.

A number of scholars have proffered important explanations for Pakistan's failure to make a successful transition to democracy. This essay will argue that all the extant explanations are, at best, partial and incomplete. It will then demonstrate that the roots of Pakistan's propensity toward authoritarianism must be sought in the ideology, organization and mobilization strategy of the movement for the creation of Pakistan.

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CDDRL Working Papers
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Šumit Ganguly
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