Stanford University

Health and Medicine

FSI’s researchers assess health and medicine through the lenses of economics, nutrition and politics. They’re studying and influencing public health policies of local and national governments and the roles that corporations and nongovernmental organizations play in providing health care around the world. Scholars look at how governance affects citizens’ health, how children’s health care access affects the aging process and how to improve children’s health in Guatemala and rural China. They want to know what it will take for people to cook more safely and breathe more easily in developing countries.

FSI professors investigate how lifestyles affect health. What good does gardening do for older Americans? What are the benefits of eating organic food or growing genetically modified rice in China? They study cost-effectiveness by examining programs like those aimed at preventing the spread of tuberculosis in Russian prisons. Policies that impact obesity and undernutrition are examined; as are the public health implications of limiting salt in processed foods and the role of smoking among men who work in Chinese factories. FSI health research looks at sweeping domestic policies like the Affordable Care Act and the role of foreign aid in affecting the price of HIV drugs in Africa.

Public Health Preparedness and the Unthinkable: Reflections on Nuclear Terrorism and Pandemic Influenza

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Abstract:  In this era of catastrophic terrorism and heightened concerns about pandemic influenza and other emerging diseases, unprecedented resources have been allocated to improving medical and public health emergency preparedness.  Investments in such preparedness, however, can impose significant opportunity costs, particularly when the investments are focused on improving consequence management capabilities.  Enhancing preparedness and response capabilities in economically efficient, proportionate, and politically sustainable ways thus becomes a critical component of any longterm effort to address the threats we face.  Dr. Hatchett will speak about the challenges of developing medical countermeasure for CBRN threats and preparing communities for infectious disease emergencies, using these examples to raise more general issues about the relative benefits of specific v. "broad-spectrum" strategies and countermeasures, decision-making under conditions of uncertainty, and our efforts to "get ready" for nuclear terrorism and pandemic influenza.

Dr. Hatchett is Associate Director for Radiation Countermeasures Research and Emergency Preparedness at the National Institute for Allergy and Infectious Disease, overseeing a program that develops drugs and devices to prevent or mitigate the effects of radiation exposure. 

In 2005-06, he served as Director for Biodefense Policy at the White House Homeland Security Council, where he was a principal author of the Implementation Plan for the National Strategy for Pandemic Influenza and helped set policy and devise strategies to mitigate the consequences of a pandemic.  Dr. Hatchett previously served as Senior Medical Adviser in the U.S. Department of Health and Human Services (HHS) Office of Public Health Emergency Preparedness, where he worked on a wide range of biodefense issues, including the delivery of mass prophylaxis to urban populations, the development of disease containment strategies, and the role of modeling in the formulation of public health policy. 

Dr. Hatchett completed his undergraduate and medical educations at Vanderbilt University, an internship and residency in Internal Medicine at New York Hospital - Cornell Medical Center, and a fellowship in Medical Oncology at the Duke University Medical Center.

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Richard Hatchett Associate Director for Radiation Countermeasures Research and Emergency Preparedness, National Institute of Allergy and Infectious Diseases Speaker
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Transitions 2009 conference to focus on action plan for President-elect Obama

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America's standing in the world has been damaged by eight years of unilateralism and it must cooperate with rising powers to tackle emerging transnational threats, according to a major research project to be unveiled Thursday, Nov. 13, at a conference hosted by Stanford's Freeman Spogli Institute for International Studies (FSI).

The directors of "Managing Global Insecurity Project (MGI)" (MGI) from Stanford's Center for International Security and Cooperation (CISAC), New York University and the Brookings Institution will use the conference to present their "plan for action" for the next U.S. president.

"President-elect Obama should take advantage of the current financial crisis and the goodwill engendered by his election to reestablish American leadership, and use it to rebuild international order," said CISAC's Stephen J. Stedman. "Part of that is to recalibrate international institutions to reflect today's distribution of power. If you could find a way for constructive engagement between the G-7 and Russia, China, India, Brazil and South Africa-that reflects the reality of world power today-you could actually animate a lot of cooperation."

Stedman, Bruce Jones from New York University's Center on International Cooperation and Carlos Pascual from Brookings will discuss concrete actions for the incoming administration to restore American credibility, galvanize action against transnational threats ranging from global warming to nuclear proliferation and rejuvenate international institutions such as the United Nations.

"You find in American foreign policy a blanket dismissal of international institutions, especially regarding security," Stedman said. "But if you eliminate them, you don't have a prayer of recreating the kind of cooperation that exists in the U.N. There actually is a pretty good basis of cooperation on which to build."

The nonpartisan project also will be presented Nov. 20 at a high-profile event at the Brookings Institution that will feature leaders such as former Secretary of State Madeleine Albright and Brookings President Strobe Talbott. That in turn will take place on the heels of the upcoming G-20 emergency summit to discuss measures to stave off a global recession and give a greater voice to developing nations. MGI's "plan for action" includes a series of policy papers on hot-button topics such as economic security.

"The big thing we talk about is if you institutionalize cooperation with the existing and rising powers you can hope to build a common understanding of shared long-term interests," Jones said. "If you approach issues only through the lens of the hottest crises, you will find different interests in the very short term on how [problems] are handled."

Transitions 2009

The 20-month-long project, which incorporated feedback and direction from nonpartisan U.S. and international advisory boards, dovetails closely with the theme of FSI's fourth annual conference: "Transitions 2009."

"There has rarely been a moment more fraught with danger and opportunity, as new administrations in the United States and abroad face the interlocking challenges of terrorism, nuclear proliferation, climate change, hunger, soaring food prices, pandemic disease, energy security, an assertive Russia and the grave implications of failed and failing states," FSI Director Coit D. Blacker said. "This conference will examine what we need to do to prepare our own citizens for the formidable challenges we face and America's own evolving role in the world."

Timothy Garton Ash, an Oxford professor and Hoover Institution senior fellow, will deliver the conference's keynote address, titled, "Beyond the West? New Administrations in the United States and Europe Face the Challenge of a Multi-Polar World."

Blacker, who served in the first Clinton administration; Stephen D. Krasner, who worked in the current Bush administration; medical Professor Alan M. Garber; and Stanford President Emeritus Gerhard Casper will open the conference with a reflection on the past and future and the watershed moment presented by Obama's presidency. The conference also will include breakout sessions with FSI faculty such as "Rethinking the War on Terror," led by Martha Crenshaw of CISAC; "Toward Regional Security in Northeast Asia," chaired by former Ambassador Michael J. Armacost, acting director of the Shorenstein Asia-Pacific Research Center; and "Is African Society in Transition?" led by economist Roz Naylor of the Program on Food Security and the Environment.

Long-term security

For MGI project leaders Stedman, Jones and Pascual, the zeitgeist of the moment is America's relationship with the emerging powers. "The good news from an American perspective is, despite the financial crisis, despite everything else, sober leadership in China, India, Brazil and elsewhere understand, in the immediate term, there is no alternative to American leadership, as long as [it] is geared toward cooperation and not 'do as you please-ism,'" Jones said. "On the other side, the financial crisis highlights that U.S. foreign policy has to come to terms with the fact that it does not have the power to dictate outcomes. It has to build cooperation with emerging powers, with international institutions, into the front burner of American foreign policy." More broadly, international cooperation must be built on what Stedman calls the principle of "responsible sovereignty," the notion that sovereignty entails obligations and duties toward other states as well as to one's own citizens.

In addition to MGI's "plan for action," the three men have coauthored Power and Responsibility: International Order in an Era of Transnational Threats, to be published in 2009. The book criticizes both the Bush and Clinton administrations for failing to take advantage of the moment of U.S. dominance after the fall of the Soviet Union to build enduring cooperative structures. "We're in a much tougher position than we were five years ago and 10 years ago," Jones said. "There still is an opportunity, but time is getting away from us."

If revitalizing international cooperation fails, Jones said, transnational threats will gain the upper hand. "We will not be able to come to terms with climate change, transnational terrorism, spreading nuclear proliferation," he said. "U.S. national security and global security will deteriorate. [We] have a moment of opportunity to do this now."

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Presidential Leadership, Illness, and Decision Making

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Rose McDermott is a Professor of Political Science at Brown University.  She is currently a fellow at the Center for Advanced Studies in the Behavioral Sciences at Stanford University.  She holds a Ph.D. in Political Science and an M.A. in Experimental Social Psychology, both from Stanford University. She held a National Institute on Drug Abuse Post Doctoral Fellowship in Substance Abuse Treatment Outcome Research at the San Francisco VA through the University of San Francisco Psychiatry Department.  Professor McDermott has also held fellowships at the John M. Olin Institute for Strategic Studies and the Women and Public Policy Program, both at Harvard University. Professor McDermott's main area of research concerns political psychology in international relations. She is the author of Risk Taking in International Relations: Prospect Theory in American Foreign Policy (University of Michigan Press, 1998), Political Psychology in International Relations (University of Michigan Press, 2004), and Presidential Illness, Leadership and Decision Making (Cambridge University Press, 2007). She is co-editor of Measuring Identity: A Guide for Social Science Research, with Rawi Abdelal, Yoshiko Herrera, and Alastair Iain Johnson (Cambridge University Press, forthcoming).

She has written numerous articles and book chapters on experimentation, the impact of emotion on decision making, social identity, and evolutionary and neuroscientific models of political science.  She is currently involved in a series of projects investigating the endogenous sources of aggression, and a book project on pandemic disease.

Herbert Abrams is a professor of radiology, emeritus, at the Stanford School of Medicine and a member-in-residence at CISAC, where he directs the Project on Disabled Leadership. He was Professor and Director of Diagnostic Radiology at Stanford from 1960 to 1967, and was then appointed and served as Philip H. Cook Professor and Chairman of Radiology at Harvard University from 1967 to 1985. He returned to Stanford in 1985 as Professor of Radiology in order to spend most of his time in research in CISAC. Dr. Abrams' present focus is on presidential disability and its potential impact on decision making.

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Rose McDermott Visiting Fellow, Center for Advanced Study in the Behavioral Sciences, Stanford University; Professor of Political Science, University of California, Santa Barbara Speaker
Herbert Abrams Professor of Radiology, Emeritus and CISAC Member-in-Residence Commentator
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The Health Effects of Air Pollution: Evidence from Forest Fires

This study examined the link between exposure to particulate matter—a form of air pollution in which fine particles are suspended in the air—and adverse health outcomes for the elderly, who are hypothesized to be affected disproportionately.  In order to continue to determine environmental standards for pollution and to design effective public health warnings about pollution, an understanding of the health effects is needed. Such policies are particularly pertinent to the elderly, who might be socially isolated and less able to leave an area during a high-pollution episode.

Systematic Review: The Health Benefits and Harms of Gardening Among the Elderly

This meta-analysis evaluated the extent to which gardening among elderly adults is associated with specific health outcomes, including exercise capacity, body weight, serum lipids, fasting serum glucose and insulin, blood pressure, mental status, and gardening-related orthopedic injuries and exposure to infectious diseases. Searches of eight databases, including: PubMed, PsychInfo, AgeLine, ToxLine, Ovid, ERIC, CAB, and Cinhal resulted in identification of over 6,000 articles.

Stress, Genes, and Decision-Making in Older Adults

Immunosenescence, the age-related decline of the immune system, may be affected by environmental or psychological stressors which, combined with endocrinosenescence, may accelerate the decline of immune-related health. Because making critical decisions, especially those related to health and medicine, is a common source of stress, it may have unforeseen and particularly deleterious effects on the immune system in elderly populations.

Striving for Good Feelings or Averting Bad Ones? The Role of Affective Goals in Health Care Decisions across the Life Span

Previous research suggests that the emotions people value ("ideal affect") can help explain cultural differences in health care preferences. For example, those valuing excitement tend to prefer physicians who promote excitement and medications that induce feelings of excitement. However, the emotions people want to avoid ("avoided affect") may be just as influential, particularly among older adults and East Asian Americans who tend to be motivated more by avoiding (versus approaching) certain outcomes.

Disease Emergence from Global Climate and Land Use Change

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Climate change and land use change can affect multiple infectious diseases of humans, acting either independently or synergistically. Expanded efforts in empiric and future scenario-based risk assessment are required to anticipate problems. Moreover, the many health impacts of climate and land use change must be examined in the context of the myriad other environmental and behavioral determinants of disease. To optimize prevention capabilities, upstream environmental approaches must be part of any intervention, rather than assaults on single agents of disease. Clinicians must develop stronger ties, not only to public health officials and scientists, but also to earth and environmental scientists and policy makers. Without such efforts, we will inevitably benefit our current generation at the cost of generations to come.

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Gender imbalance in China

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On October 2, 2008, Dr. Marcus Feldman of Stanford's Biology department delivered the first colloquium in the series on "The Implications of Demographic Change in China," co-sponsored by the Asia Health Policy Program and the Stanford China Program. Dr. Feldman discussed the sex-ratio imbalance and gender studies in China.

As Dr. Feldman noted, the total fertility rate in China has dropped dramatically in recent years, due in large part to the Chinese government's One Child Policy, which was introduced in 1979. In the early 1970s, the fertility rate averaged almost 6 births per woman, dropping to about 1.6 after the year 2000. China's sex ratio of males to females at birth (SRB), meanwhile, has risen. In 1975, the SRB was about 106 male births per 100 female births, and in 2005 had climbed to over 120 male births per 100 female births. When parity (birth order) is taken into account, the ratio becomes even more startling; for the first birth, the ratio is close to even (about 108 in the year 2005), but exceeded 145 in 2005 for the second birth and even higher for the third birth (almost163 in 2005). Research indicates that the imbalanced SRB is largely concentrated in the lower coastal regions of mainland China, where the population is predominantly Han. Shaanxi, Anhui and Jiangxi Province have the highest ratio of male to female births.

Evidence of gender imbalance is not merely limited to the ratio at birth; high ratios of male to female children are seen through ages 0-4, indicating that son preference affects not only which children survive birth, but also the survival rate of females in early childhood. In fact, research indicates that while excess girl child mortality (EGCM) has decreased for infants less than a year old in the period between 1973 and 2000, it has become increasingly pronounced for children between the ages of 0-4 and 5-9, with EGCM rates increasing every year.

Two Studies

Two studies were carried out in 1997 and 2000 by the Institute for Population and Development Studies of Xi'an Jiaotong University to investigate the causes of gender imbalance. The 1997 study focused on the cultural transmission of son preference, and the 2000 study on marriage form and old age support.

Three counties were chosen as sites, and the studies were a combination of surveys, in-depth interviews and focus group discussions. The first county, Sanyuan () in Shaanxi province, is a medium-developed region whose principal agricultural product is wheat. Fertility is high in Sanyuan, which is characterized by the dominance of virilocal marriage (in which the bride joins the family of her husband) and strict patrilineal family systems. The second county, Lueyang () in Shaanxi province is an underdeveloped mountainous region in which the patrilineal family system is more relaxed, fertility is lower than in Sanyuan, and there are diversified forms of marriage. The third site, Songzi () in Hubei province, is a well-developed rice- and cotton-producing plains region, with low fertility, relaxed family systems and diversified marriage. The results of household surveys showed a strong preference among parents in both Sanyuan and Lueyang to live with their sons in old age, which was not surprising, but a surprising result was found when parents were asked about the primary benefits of having a son. The most-reported reason was for carrying on the family name, which shows that traditional (Confucian) values played a bigger role in son preference than practical considerations such as labor or old age support. Overall, Lueyang was shown to have a much higher rate for transmitting no son-preference than Sanyuan, with older women slightly more likely to transmit no son-preference.

The marriage study found that rates of uxorilocal marriage (in which the groom joins the family of his wife) have, for the most part, been dropping in both Lueyang and Songzi since the 1970's. In Sanyuan, where uxorilocal marriage has been traditionally uncommon, the rates have remained steady at around 5 percent since the 1950's. The researchers calculated children's odds ratios of providing financial help to parents based on marriage form, and found the net ratios highest for women in virilocal marriages and sons in uxorilocal marriages.

Mechanisms of gender imbalance

There are several likely factors for the imbalanced sex ratio at birth in China. Underreporting of female births, infanticide, and sex-selective abortion (post-pre-natal gender testing) all contribute to this syndrome. Furthermore, poor nutritional and medical care for girls in their younger years can further skew the gender balance by exacerbating excess female child mortality. At the basic source of this issue, however, remains a fundamental gender bias that dates back historically and philosophically through Confucian culture and traditional patriarchal structures.

If the SRB, EFCM, TFR (total fertility rate) were all to remain at their early 2000s levels, then by 2030 the total population of China would be 84.2% of what would normally be expected at the current fertility rate (potentially causing economic welfare issues for the elderly, along with a work force deficiency). Moreover, there would be an excess in the male population of 20-21% (relative to females), essentially making it mathematically impossible for this proportion of the male population to marry. Needless to say, the possibility of such a severe "marriage squeeze", and the general top-heavy ratio of aging population to young working population are very problematic prospects for China's population and for the government's endeavors to promote both economic growth and social stability.

Examples of government efforts

The government is considering several policy options to try to avert this potential crisis. Stronger punishments were suggested at the 2008 National People's Congress (NPC) and Chinese People's Political Consultative Conference (CPPCC) for non-medical sex identification and sex-selection abortions (both of which can be obtained for relatively cheap rates within the country, despite being illegal). More proactively, an experimental program called "Care For Girls" was implemented in 2000 in Chaohu (a city in Anhui province). This program includes: financial help for 1- and 2-daughter families; sponsoring of girls' educational fees and increased pensions to families with daughters; and the promotion of uxorilocal marital structures. Since the introduction of the program, the local SRB went from 125 in 1999 to 114 in 2002. In response to this apparent success, the government expanded the "Care For Girls" program to 24 counties with high SRB rates in 2003-2004, and saw the average SRB in those counties drop from 133.8 in 2000 to 119.6 in 2005. Stipulation and initiation of a national "Care For Girls" campaign occurred in January 2006 - July 2006, with the goal of bringing the national SRB average to normal levels within 15 years. In January 2008, the government expanded on this effort by launching the "Care For Girls Youth Volunteer Action", beginning with more than 1000 students (mostly at the university level) directed at engaging in promotional activities and data collection (under the Chinese Communist Youth League). These policies are part of a comprehensive aspiration on the part of the PRC government towards the "construction of a new reproductive culture."

Son preference among migrant workers in Shenzhen

With the Chinese economic reform of the early 1980s, millions of laborers have been migrating from rural to urban areas. After migration, rural-urban laborers have to familiarize themselves with the rules and customs of their new locations, rebuilding their social networks in the process of adapting to their new occupations and habitation. But how do individual characteristics (i.e. gender, education level and the time of residency), restructured social networks, and the experiences of migration influence migrants' attitudes and behaviors regarding son preference? These questions were examined in a 2005 study conducted in Shenzhen.

Shenzhen is the first Special Economic Zone in China to implement economic reform and has since developed from a small fishing village into a modern coastal city. According to the 2000 Population Census, the total population of Shenzhen is 7,008,800, and the ratio of migrants to permanent urban residents is 4.77:1.

The Shenzhen study seemed to indicate initially that only a small minority of migrants (7% of total respondents) expressed a strong attitude towards son preference. However, the actual childbearing behavior of rural-urban migrants was remarkably different compared to their reported attitudes. The sex ratio of migrant children is as high as 163 male births per 100 female births, and the later in the birth order, the higher the sex ratio for the child, i.e., the sex ratio is 1.52 for the first birth and rises steeply to 1.80 for the second birth, peaking at 1.94 for the third and above birth. Thus the results suggest that migrants' childbearing behaviors actually suggest a strong son preference.

The Shenzhen study also found that three major determinants, namely social networks, migration history, and individual factors, all have significant effects on son preference among rural-urban migrants.

First, weak ties (formed by friends, bosses, and fellow workers) in social networks affect the attitude of son preference among rural-urban migrants. That is, the risk of having son-preference tends to decrease when the overall influence of network members is positive (without son preference). Moreover, increasing social contacts with network members will reduce the dependence upon strong ties (formed by family members and kin) and thus decrease the traditional culture of "rearing a son to support parents in their old age" and familial pressures to have more children.

Second, the duraction of residency in an urban area has a significant effect on the attitude of son preference among rural-urban migrations. The longer the migrants live in an urban area, the more likely that their attitudes of son-preference will adapt to urban reproductive norms. For example, the data indicated that ratio of male and female birth is more balanced among those living in urban areas for 8 years or longer. However, rural-urban migrants still exhibit a strong overall behavior of son preference. In other words, the change in childbearing behavior in terms of birth patterns still lags far behind the apparent change of attitudes.

Age and education are identified as factors affecting son preference among rural-urban migrants. For instance, an increase in age relative to initial migration will often decrease the imbalance in the sex ratio.

An additional study on rural-urban migrants examined the relationship between the gender of married migrants and their provision of financial support to parents and parents-in-law post-migration. The results showed, in fact, that female migrants are more likely to give financial support to their parents-in-law after migration.

Even today, the patrilineal conception of support for elderly family members is still very prevalent in rural China. Sons are expected to provide fundamental support to their parents, while daughters tend to provide supplementary and emotional support. This traditional old-age support pattern of reliance on sons can often intensify the syndrome of son bias among rural or traditional Chinese. However, the results here proved that if aging parents are more likely to receive sustenance from married daughters compared to married sons, the dominant son-preference in rural China could be logically undercut and eventually the traditional patrilineal conception of old-age support, and resulting gender bias, could be ameliorated and even eliminated.

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Private Providers and Public-Private Partnerships in Health: Asia in Comparative Perspective

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Dr. Forsberg will present findings from studies in China and Vietnam and put those findings into a broader comparative perspective regarding the future role of the private sector in improving health service delivery and population health.

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Birger Carl Forsberg is a public health specialist and lecturer in International Health at the Karolinska Institute in Stockholm, Sweden from where he holds an MD and a PhD. He is also trained in economics and has health economics as one of his areas of work. Dr Forsberg has more than 20 years experience from international health from around 25 low- and middle-income countries as an adviser to bilateral donors and international organisations. Since 2002 he has been a consultant to the World Bank on public private sector collaboration in health. He is also coordinator since 2002 of a joint Harvard-Karolinska research programme called Private Sector Programme in Health (PSP). The programme has coordinated studies of the private health sector in five countries in Asia and Africa. In his talk Dr Forsberg will present findings from PSP studies in China and Vietnam and put those findings into a broader perspective on the future role of the private sector in health service delivery for increased access to health services and improved health.

Philippines Conference Room

Birger Carl Forsberg, MD Private Sector Program in Health Coordinator Speaker Karolinska Institutet, Sweden
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