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.

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Jeremy Goldhaber-Fiebert, PhD, is a Professor of Health Policy, a Core Faculty Member at the Center for Health Policy and the Department of Health Policy, and a Faculty Affiliate of the Stanford Center on Longevity and Stanford Center for International Development. His research focuses on complex policy decisions surrounding the prevention and management of increasingly common, chronic diseases and the life course impact of exposure to their risk factors. In the context of both developing and developed countries including the US, India, China, and South Africa, he has examined chronic conditions including type 2 diabetes and cardiovascular diseases, human papillomavirus and cervical cancer, tuberculosis, and hepatitis C and on risk factors including smoking, physical activity, obesity, malnutrition, and other diseases themselves. He combines simulation modeling methods and cost-effectiveness analyses with econometric approaches and behavioral economic studies to address these issues. Dr. Goldhaber-Fiebert graduated magna cum laude from Harvard College in 1997, with an A.B. in the History and Literature of America. After working as a software engineer and consultant, he conducted a year-long public health research program in Costa Rica with his wife in 2001. Winner of the Lee B. Lusted Prize for Outstanding Student Research from the Society for Medical Decision Making in 2006 and in 2008, he completed his PhD in Health Policy concentrating in Decision Science at Harvard University in 2008. He was elected as a Trustee of the Society for Medical Decision Making in 2011.

Past and current research topics:

  1. Type 2 diabetes and cardiovascular risk factors: Randomized and observational studies in Costa Rica examining the impact of community-based lifestyle interventions and the relationship of gender, risk factors, and care utilization.
  2. Cervical cancer: Model-based cost-effectiveness analyses and costing methods studies that examine policy issues relating to cervical cancer screening and human papillomavirus vaccination in countries including the United States, Brazil, India, Kenya, Peru, South Africa, Tanzania, and Thailand.
  3. Measles, haemophilus influenzae type b, and other childhood infectious diseases: Longitudinal regression analyses of country-level data from middle and upper income countries that examine the link between vaccination, sustained reductions in mortality, and evidence of herd immunity.
  4. Patient adherence: Studies in both developing and developed countries of the costs and effectiveness of measures to increase successful adherence. Adherence to cervical cancer screening as well as to disease management programs targeting depression and obesity is examined from both a decision-analytic and a behavioral economics perspective.
  5. Simulation modeling methods: Research examining model calibration and validation, the appropriate representation of uncertainty in projected outcomes, the use of models to examine plausible counterfactuals at the biological and epidemiological level, and the reflection of population and spatial heterogeneity.
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During the eighteen months after January 2007, cereal prices doubled, setting off a world food crisis. In the United States, rising food prices have been a pocketbook annoyance. Most Americans can opt to buy lower-priced sources of calories and proteins and eat out less frequently. But for nearly half of the world’s population—the 2.5 billion people who live on less than $2 per day—rising costs mean fewer meals, smaller portions, stunted children, and higher infant mortality rates. The price explosion has produced, in short, a crisis of food security, defined by the Food and Agriculture Organization (FAO) as the physical and economic access to the food necessary for a healthy and productive life. And it has meant a sharp setback to decades-long efforts to reduce poverty in poor countries.

The current situation is quite unlike the food crises of 1966 and 1973. It is not the result of a significant drop in food supply caused by bad weather, pests, or policy changes in the former Soviet Union. Rather, it is fundamentally a demand-driven story of “success.” Rising incomes, especially in China, India, Indonesia, and Brazil, have increased demand for diversified diets that include more meat and vegetable oils. Against this background of growing income and demand, increased global consumption of biofuels and the American and European quest for energy self-sufficiency have added further strains to the agricultural system. At the same time, neglected investments in productivity-improving agricultural technology—along with a weak U.S. dollar, excessive speculation, and misguided government policies in both developed and developing countries—have exacerbated the situation. Climate change also looms ominously over the entire global food system.

In short, an array of agricultural, economic, and political connections among commodities and across nations are now working together to the detriment of the world’s food-insecure people...

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FSI senior fellow Stephen Stedman reviews John Bolton's book, Surrender Is not an Option, in the July/August issue of the Boston Review. "The memoir reads like an international relations primer done in the style of a modern morality tale," he writes. "Imagine Kenneth Waltz's classic Man, the State, and War as written by Ayn Rand."

One of the more remarkable underreported stories of 2008 was a speech in which the State department’s legal adviser John Bellinger admitted that there “are also realities about the International Criminal Court that the United States must accept.” He also stated that the Bush administration would work with the Court to maximize its chances of success in Darfur. Bellinger did not say that the United States might actually join the Court, but acknowledged that it enjoyed widespread international support and legitimacy, and that the United States could fruitfully cooperate with it on areas of mutual benefit.

Neither mea culpa nor volte-face, the speech nonetheless indicates the distance the administration has traveled in seven years. While Bellinger’s oratory went largely unnoticed by foreign policy wonks and the attentive public alike, it did not escape the scrutiny of John Bolton, who dismissed it as Clinton-era “pabulum” and reflective of “the yearning the Rice State Department has for acceptance” by academics and foreign intellectuals. He added ominously, “the fight resumes after Jan. 20.”

Bolton has been a powerful influence on Republican foreign policy for the last twenty years. Before his appointment as ambassador to the United Nations in 2005—which was achieved without Senate confirmation—Bolton dominated arms-control policy in the first Bush term. He killed the Anti-Ballistic Missile (ABM) Treaty, negotiations with North Korea, and the Biological Weapons Convention verification protocol. During the Clinton years, he campaigned tirelessly from his Heritage Foundation perch for missile defense and against global governance, which he seems to equate with global government. In 1998, when then-Secretary-General of the United Nations Kofi Annan released a report critical of both the United Nations secretariat and member states for the failure to prevent genocide in Srebrenica, Bolton chastized Annan for having the temerity to criticize governments for what they did or did not do in the former Yugoslavia. He added menacingly: “I think if he continues down this road, ultimately it means war, at least with the Republican Party.”

Bolton came of age politically during Barry Goldwater’s presidential campaign. The future policy heavyweight was a high schooler in Baltimore at the time. He honed his conservatism at Yale College and Yale Law School, ducked Vietnam through a National Guard posting (“looking back, I am not terribly proud of this calculation”), and got his first taste of Washington as an intern to Spiro Agnew. During the Bush Sr. presidency, Bolton was Assistant Secretary for International Organization Affairs in James Baker’s State Department, and was one of the first people who Baker called when he needed a posse of chad-disputing lawyers in Florida in November 2000. Bolton’s name keeps showing up in various articles about the fight inside the Republican Party for the soul of John McCain’s foreign policy.

All of this makes it imperative to read his memoirs, which clarify the stakes in the forthcoming election. Although it is hard to imagine Bolton in a McCain administration—his memoirs offend so many within his party, across the aisle, and overseas, that Bolton could not win Senate confirmation for capitol dog-catcher—Bolton will be plotting, pressing, and pushing to force McCain’s foreign policy back to the unilateralism of George Bush’s first term, when the war on terror meant never having to say you’re sorry. And there are important national security posts that do not require Senate approval.

The memoir reads like an international relations primer done in the style of a modern morality tale—imagine Kenneth Waltz's classic Man, the State, and War as written by Ayn Rand.

To Bolton, the United Nations is a “target rich environment,” and I had a front row seat to watch his gunslinging. In 2005 I served as Special Adviser to UN Secretary-General Kofi Annan. I was responsible for developing member-state support for his efforts to overhaul the United Nations. In that capacity, I was in Brussels in March 2005 when President Bush nominated Bolton as Ambassador to the United Nations. One high-ranking EU official recoiled in horror, and, to share his agita, repeated two of Bolton’s more famous lines: that “UN headquarters could lose ten floors and no one would know the difference,” and that “there was no United Nations.” How in the world, the official asked, could such a man be Ambassador to the United Nations?

Amidst nodding heads and shared pained looks, I offered that if I could pick the ten floors, I would agree with Bolton. Moreover, I said, any sentient being who spends time in Turtle Bay—the Manhattan site of the United Nations—will at some point in frustration say to themselves that there is no United Nations. Bolton’s sin was to say it publicly. Finally, I suggested that John Bolton was irrelevant: “If the President of the United States and the Secretary of State want a strong, effective United Nations, then Bolton will have to deliver. If they don’t, you could have John Kerry as the U.S. ambassador, and nothing will happen.”

Oh well; win some, lose some. Which is what Condoleeza Rice is rumored to have told a friend who asked how John Bolton could have possibly been nominated for the position under her watch.

Or more accurately, I was half right, half wrong. Reading this book, one can almost feel sorry for how unsuited Bolton was for his new job. For four years he had been the point man for breaking American commitments abroad, insulting allies and enemies alike, ditching the ABM Treaty, and unsigning the Rome Statute, which established the International Criminal Court (“my happiest moment at State”). In the heady days of the first Bush administration, when it believed the United States was so powerful it could get anything that it wanted without friends, partners, or institutions, Bolton was the “say no” guy, a job he performed with great brio. How could he know that in 2005 his big boss, the President, and his nominal boss, the Secretary of State, would actually decide that international cooperation was necessary, and that maybe we should start worrying about America’s free fall in world opinion? A pit bull in the first term, Bolton would be a yap dog in the second, grating on the Secretary of State, the President, and most American allies.

Almost sorry, for whatever else you say about John Bolton, he is not of the “we can disagree without being disagreeable” school of American politics. This is one of the nastiest, pettiest memoirs in the annals of American diplomatic history. Among the many targets of insults and catty remarks are former and present U.K. ambassadors to the United Nations Emyr Jones Parry, Adam Thomson (“I could never look at or listen to Thomson without immediately thinking of Harry [Potter] and all his little friends”), and John Sawers; recent U.K. foreign ministers; just about every UN civil servant mentioned; indeed, just about every U.S. civil servant mentioned, along with countless journalists and politicians.

The memoir reads like an international relations primer done in the style of a modern morality tale—imagine Kenneth Waltz’s classic Man, the State, and War as written by Ayn Rand. Bolton, usually singlehandedly, takes on what he calls the High Minded, the Normers (those who create international norms of behavior or try to “[whip] the United States into line with leftist views of the way the world should look”), the EAPeasers (career State Department officials who advocate negotiations with North Korea), the Risen Bureaucracy, the Crusaders of Compromise, the Arms Control True Believers, and the EUroids.

The book has the formulaic allegories typical of the genre—the young, innocent female (Kristen Silverberg, Assistant Secretary for International Organization Affairs) driven to tears after being berated by the cold-hearted career bureaucrat (Nicholas Burns); the noble knight (Bolton himself) fighting against the political higher ups who care only about “positioning themselves” (Rice) or their legacy (Colin Powell). And of course Bolton’s plaintive cries that the 2005-06 changes in administration policy occurred against the will of the President. One sees the peasants now: ‘If only the King knew what was happening, this would never go on.’

Now add a heaping dose of xenophobia. Foreigners, appeasing foreigners, foreigners claiming to know us better than we know ourselves: all loom large in Bolton’s memoirs. He insults the former Swedish foreign minister and President of the General Assembly Jan Eliasson as not only having “an ethereal Hammarskjöldian vision problem, but also a Gunnar Myrdal problem, yet another foreigner who ‘understood’ us better than we did ourselves.” (This is the Myrdal who shared the 1974 Nobel Prize in Economics with Friedrich Hayek, and whose classic book on race, An American Dilemma: The Negro Problem and Modern Democracy, was cited in Brown v. Board of Education.) At one point in his belittlement of a Bush political appointee, a special assistant to Condoleeza Rice, no less, Bolton adds that she was “a naturalized citizen originally from Pakistan,” in case we wondered why she could not possibly understand America’s real foreign policy interests. In Bolton’s worldview Zbigniew Brzezinski is probably a naturalized American citizen originally from Poland; Henry Kissinger, a naturalized American citizen originally from Germany.

In the Bolton universe, you want Iran and North Korea to be referred to the Security Council, so that when it fails to unite behind a resolute strategy, the United States is then free to take the tough action it needs to take. And in the case of North Korea, Bolton is clear about what that would be: “unilateralist, interventionist, and preemptive.” Is it any wonder that when it came to Iran and North Korea, our allies and adversaries were loathe to refer them anywhere near Bolton?

Richard Hofstadter’s 1964 article “The Paranoid Style in American Politics” was prompted by the supporters of the Goldwater campaign. Bolton strides right off the pages of Hofstadter’s essay:

He is always manning the barricades of civilization . . . he does not see social conflict as something to be mediated and compromised, in the manner of the working politician. Since what is at stake is always a conflict between absolute good and absolute evil, what is necessary is not compromise but the will to fight things out to a finish. Since the enemy is thought of as being totally evil and totally unappeasable, he must be totally eliminated—if not from the world, at least from the theatre of operations to which the paranoid directs his attention. This demand for total triumph leads to the formulation of hopelessly unrealistic goals, and since these goals are not even remotely attainable, failure constantly heightens the paranoid’s sense of frustration. Even partial success leaves him with the same feeling of powerlessness with which he began, and this in turn only strengthens his awareness of the vast and terrifying quality of the enemy he opposes.

According to Bolton, we do not need diplomats who negotiate, seek common ground, and strive for cooperative solutions. We need litigators who will go to the wall defending American interests, who will understand that when others say no, they mean no, and that therefore compromise is illusion. But in a world where the United States needs international cooperation for its own peace and prosperity, what comes next? Bolton’s answers are laughable—we stick with our “closest friends in the United Nations”—Israel, Palau and the Marshall Islands. Or we forge a new alliance with Japan, South Korea, Australia, Canada, and New Zealand to overcome the parasitic and paralytic EU. The road to global primacy runs through . . . Wellington?

There are, of course, some glaring contradictions in the memoirs. Bolton is known as a sovereignty hawk and he spells out the content of that doctrine as “greater independence and fewer unnecessary restraints.” The job of civil servants, politically appointed or career, is “to implement the president’s policies.” So it comes as a double shock when we find Bolton handing a draft Security Council resolution to the Israeli ambassador, in case the ambassador wants to ask his Prime Minister to appeal directly to Bush or Rice to change President Bush’s policy on Lebanon.

Another example concerns Bolton’s recurring beratement of UN officials for forgetting that they work for the member states. He then describes how one Under-Secretary-General, American appointee Christopher Burnham, surreptitiously showed him budget documents that put the United States at an advantage in budget negotiations. It is hard to see how you can have it both ways. Either UN officials serve all member states equally or the organization is up for grabs to the most powerful state.

But it is the big betrayal that is at the heart of the book. Facing a quagmire in Iraq, a faltering coalition in Afghanistan, a nuclear armed North Korea, the possibility of a nuclear Iran, and a war against terror that was creating more, not fewer, terrorists, Condoleeza Rice convinced President Bush that maybe they should stop digging a bigger hole for American foreign policy. And that meant actually trying diplomacy in North Korea, Iran, and the Middle East.

The losers were John Bolton and his acolytes; the winners were the professionals like Nicholas Burns and Christopher Hill. Faced with defeat and repudiation of the failed policies he advocated, Bolton’s response is familiar and tiresome: the professionals had secretly hijacked the president’s policy; the Secretary of State cares more about appeasing foreigners than protecting American interests.

The moment of reckoning for Bolton and for the President that nominated him is not described in the book, but it took place two months after Bolton left the administration. When the United States and North Korea reached a deal in February 2007 that holds the promise of denuclearizing the country, Bolton tried to scuttle it. Asked by reporters whether he was loyal to the President, Bolton answered, “I’m loyal to the original policy.”

What did Bolton achieve at the United Nations? Very little, which was fine by him and fine by the cast of nonaligned Ambassadors who oppose a more effective international organization. I asked one of them in December 2006 if he was happy that Bolton was leaving. He said, “No, we’ve learned how to deal with Mr. Bolton.” When I sought clarification, he said, “Look, Bolton comes in and asks for the sun, the moon, and the stars, and we say ‘no.’ He then says, ‘I told you so’ and leaves. Everybody is happy.”

Which returns us to the question of why anyone would want to wade through these 500 self-serving pages. The best answer: to remind yourself of the stakes of this upcoming election and why the United States needs more old-fashioned diplomacy and less paranoia and arrogance. A McCain presidency might not eschew diplomacy, but in the political free-for-all that is the Republican party, Bolton and his minions are always there, ready to denigrate any agreement or compromise, to sabotage and subvert real diplomacy.

Asked by reporters whether he was loyal to the President, Bolton answered, "I'm loyal to the original policy."

To understand the stakes, consider the little known and even less appreciated record of American negotiations with North Korea since 1994. Between what was called the “Agreed Framework” that brought North Korea back into the Nonproliferation Treaty (NPT) in 1994 and the end of 2000, the United States and North Korea reached twenty agreements on a wide array of issues. Certain of these agreements foundered in implementation, but an objective assessment shows that some of the noncompliance stemmed from constraints placed by American domestic politics.

The Bolton strategy killed the Agreed Framework, hoping through threats, sanctions, and use of force to end the North Korean regime. Unfortunately for Bolton—fortunately for the rest of us—our ally South Korea and our necessary partner China did not want to deal with the consequences: either a war or a collapsed, deadly state on their borders. In the end, they did not have to because North Korea left the NPT, developed a nuclear bomb, and tested it, bankrupting the Bolton policy and producing the sharp change of strategy that has born fruit in recent North Korean steps to end its nuclear program.

Writing about the successes of American negotiators in bringing North Korea and the United States back together in February 2007, former State Department negotiator Robert Carlin and Stanford Professor Emeritus John Lewis have described why Bolton and his crowd loathe diplomacy is loathed by Bolton and his crowd, and why it is so necessary:

Diplomats strive to put down words all of them can swallow and hopefully their superiors in [the] capital can stomach. Written agreements are difficult to reach. The pain often comes not so much in dealing with the other side but in dealing with your own. Unless you are dictating terms to a defeated enemy, you are going to have to compromise on something, probably several somethings, that will make many people unhappy. That was done for the February 13th agreement, and there is no shame to it.

John Bolton did much damage to American interests in the first Bush administration, but he was implementing the president’s policy. President Bush deserves the blame for putting Bolton in a position to continue hardming American interests even when the overall direction of policy changed.

Given that many countries treated the United States as radioactive in 2005; given that trust and confidence in the United States were at all time lows; given that our record was one of a violator of international law and human rights; President Bush, had he truly wanted to start to move the United States out of the hole he had been so assiduously digging, would have had to send to the United Nations an ambassador with extraordinary listening skills, who could work across various international chasms, rebuild respect for American diplomacy, and, yes, advocate agreements that would make a lot of people unhappy. Someone, in fact, a lot like our present Ambassador, Zalmay Khalilzad, a naturalized citizen originally from Afghanistan. Instead he sent . . . Yosemite Sam.

So back to January 20. A new American president will take office with grinding wars in Iraq and Afghanistan, a nuclear-armed North Korea, an Iran headed that way, and crises in Sudan, Israel and Palestine, Lebanon, and Pakistan. Our foreign policy is anathema; our reputation in tatters. Throw in big issues like global warming, non-proliferation, catastrophic terrorism, and a potential pandemic of a deadly new influenza. It is hard to see how any of these crises or issues can be solved without sustained international cooperation and strong international institutions. Take global warming: protecting Americans from its ravages will depend on exercising sovereignty to strike deals with other countries whose domestic behavior threatens us and whose security our domestic behavior threatens. A narrow view of sovereignty as the ability to do as we damned well please will be—quite literally—the death of us all.

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surrender is not an option
Surrender Is not an Option: Defending America at the United Nations and Abroad
by John Bolton. Threshold Editions, $27.00 (hardcover)

 

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The July/August issue of Health Affairs, the leading U.S.-based health policy journal, focuses on China and India. The special issue includes an article on China’s pharmaceutical policy by five contributors to Prescribing Cultures and Pharmaceutical Policy in the Asia-Pacific, a book forthcoming in 2009 from the Shorenstein Asia-Pacific Research Center series with Brookings Institution Press. Chapters on Korea and Japan by Soonman Kwon (Seoul National University) and Toshiaki Iizuka (Aoyama Gakuin University) also appear in Chinese translation in the journal Bijiao (Comparative Studies), along with an overview paper (“Pharmaceutical policy reforms to separate prescribing from dispensing in Japan and South Korea: Possible implications for China”) by Karen Eggleston, Asian Health Policy Program Director.

As Eggleston writes in the introduction to Prescribing Cultures, pharmaceuticals and their regulation play an increasingly important and often contentious role in the health care systems of the Asia Pacific.  For example, some economies such as China have extraordinarily high drug spending as a percentage of total health spending; India and a few others host thriving domestic pharmaceutical industries of global importance, while controversy surrounds patents, trade-related aspects of intellectual property (TRIPS), and pharmaceutical pricing within bilateral trade agreements (Australia-US, Republic of Korea-US); nations throughout the region struggle with appropriate regulation of drugs, from patents to evidence-based purchasing (e.g., Australia’s Pharmaceuticals Benefit Scheme) and direct-to-consumer advertising; deeply-rooted traditions of indigenous medicine are modernizing and integrating into broader health care systems; and policies to separate prescribing and dispensing re-write the professional roles of physicians and pharmacists, with modifications to accommodate cultural norms and strong economic interests. Effective prescribing and pharmaceutical use will be central to controlling infectious diseases, both old and emerging; protecting the global public good of antimicrobial effectiveness; and treating the growing burden of chronic disease in the Asia Pacific.

The forthcoming book will explore these issues in detail, through a multi-disciplinary lens. The first section of the book features chapters on pharmaceutical policy within seven selected health care systems of the Asia Pacific: South Korea, Japan, Thailand, Taiwan, Australia, India, and China. The second section focuses on the cross-cutting themes of prescribing cultures and access versus innovation. Taken as a whole, the contributions aim to provide an evidence base for policy while acknowledging the historical and cultural context that makes policies distinctive.

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Clear evidence suggests the importance of health service provider payment incentives for achieving efficiency, equal access, and quality, including attention to primary, secondary, and tertiary prevention. “Pay for performance” may be on the cusp of significant expansion in Asia, and reform away from fee-for-service has been underway for several years in several economies. Yet despite the policy relevance, the evidence base for evaluating payment reforms in Asia is still very limited.

China in particular has been undertaking significant reforms to its health care system in both rural and urban areas. With the expansion of insurance coverage and need to resolve incentive problems like “supporting medical care through drug sales,” there is an urgent need for evaluating alternative ways of paying health service providers. Evidence from policy reforms in specific regions of China, as well as other economies of the Asia-Pacific, can provide valuable evidence to help inform policy decisions about how to align provider incentives with policy goals of quality care at reasonable cost.

To illuminate these questions, the Asia Health Policy Program and several collaborating institutions are planning to convene a conference on health care provider payment incentives on November 7-8, 2008 in Beijing. The conference will highlight and seek to distill “best-practice” lessons from rigorous and policy-relevant evaluations of recent reforms in China and elsewhere in the Asia Pacific.

The organizing committee – including health economists from Shorenstein APARC, Peking University, Tsinghua University, and Seoul National University – reviewed submissions in June 2008 and accepted sixteen. The conference papers cover payment issues in Korea, Japan, China, Taiwan, Thailand, Tajikistan, the Philippines, and the US, and the disciplines of economics, health services research/health policy, public health, medicine, and ethics. Topics include institutionalized informal payments; the impact of global budget policies on high-cost patients; public-private partnerships; public-sector physicians owning private pharmacies; evidence-informed case payment rates; payment and hospital quality; bonuses and physician satisfaction; physician prescription choice between brand-name and generic drugs; and differences in pharmaceutical utilization across insurance plans that pay providers differently (fee-for-service versus capitation).

Policymakers from China’s National Development and Reform Commission and Ministry of Health will also speak at the conference. Selected research papers will be published through the Shorenstein Asia-Pacific Research Center either in a special volume or in a special issue of an English-language health policy journal.

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“Should the United States promote democracy around the world?” Stanford alumna Kathleen Brown, a former FSI advisory board member, former Treasurer of the State of California, and current head of public finance (Western region) Goldman Sachs

How are democracy, development, and the rule of law in transitioning societies related? How can they be promoted in the world’s most troubled regions? These were among the provocative issues addressed by faculty from the Freeman Spogli Institute’s Center on Democracy, Development, and the Rule of Law, as part of Stanford Day in Los Angeles on January 21, 2006. Panelists included Michael A. McFaul, CDDRL director, associate professor of political science, and senior fellow, the Hoover Institution; Kathryn Stoner, associate director for research and senior research associate at CDDRL; and Larry Diamond, coordinator of CDDRL’s Democracy Program, a Hoover Institution senior fellow, and founding co-editor of the Journal of Democracy.

The capstone of a day devoted to “Addressing Global Issues and Sharing Ideas,” the CDDRL panel was attended by more than 850 alumni, Stanford trustees, and supporters as part of the nationwide “Stanford Matters” series. Moderated by Stanford alumna Kathleen Brown, a former FSI Advisory Board member, former treasurer of the State of California, and current head of public finance (western region) Goldman Sachs, the panel looked at some of the toughest trouble spots in the world, including Iraq, Russia, and other parts of the former Soviet Union.

“Should the United States promote democracy around the world?” Brown began by asking Center Director Michael McFaul. “The President of the United States has said that the United States should put the promotion of liberty and freedom around the world as a fundamental policy proposition,” McFaul responded, noting “it is the central policy question in Washington, D.C., today.” It is not a debate between Democrats and Republicans, he continued, but rather between traditional realists, who look at the balance of power, and Wilsonian liberals, who argue that a country’s conduct of global affairs is profoundly affected by whether or not it is a democracy. The American people, McFaul noted, are divided on the issue. In opinion polls, 55 percent of Republicans say we should promote democracy, while 33 percent say no. Among Democrats, only 13 percent answer unequivocally that the United States should promote democracy.

“The President of the United States has said that the United States should put the promotion of liberty and freedom around the world as a fundamental policy proposition, and it is the central policy question in Washington, D.C., today.” CDDRL Director Michael McFaulAsserting that the United States should promote democracy, McFaul offered three major arguments. First is the moral issue—democracies are demonstrably better at constraining the power of the state and providing better lives for their people. Democracies do not commit genocide, nor do they starve their people. Moreover, most people want democracy, opinion polls show. Second are the economic considerations—we benefit from open societies and an open, liberal world trade system, which allows the free flow of goods and capital. Third is the security dimension. Every country that has attacked the United States has been an autocracy; conversely, no democracy has ever attacked us. The transformation of autocracies, including Japan, Germany, Italy, and the Soviet Union, has made us safer.

It is plausible to believe that the benefits of transformation in the Middle East will make us more secure, McFaul argued. “It would decrease the threats these states pose for each other, their need for weapons, and the need for U.S. intervention in the region,” he stated. Democratic transformation would also address a root cause of terrorism, as the vast majority of terrorists come from autocratic societies. There are, however, short-term problems, McFaul pointed out. Free elections could lead to radical regimes less friendly to the United States, as they have in Egypt, Iran, Iraq, and now in Palestine. U.S. efforts to promote democracy, he noted, can actually produce resistance.

Having advanced a positive case, McFaul asked FSI colleague Stoner-Weiss, “So, how do we promote democracy?” Stoner-Weiss, also an expert on Russia, said it is instructive to see how Russia has fallen off the path to democracy. In 1991, when the Soviet Union collapsed, it seemed to be an exciting time, rife with opportunity. “Here was an enemy, a major nuclear superpower, turning to democracy,” she stated. Despite initial U.S. enthusiasm, the outcome has not been a consolidated democracy. Russia, under Vladimir Putin, is becoming a more authoritarian state, a cause for concern because it is a nuclear state and a broken state—with rising rates of HIV and unable to secure its borders or control the flow of illegal drugs.

“So can we promote democracy?” Stoner-Weiss asked. The answer is a qualified yes, from Serbia to Georgia, and the Ukraine to Kyrgyzstan. But Russia has 89 divisions, 130 ethnicities, 11 time zones, and is the largest landmass in the world, she noted. Moving from a totalitarian state to a democracy and an open economy is enormously complicated. As Boris Yeltsin said in retiring as president on December 31, 1999, “What we thought would be easy turned out to be very difficult.”

Where is Russia today? It ranks below Cuba on the human development index; it is moving backward on corruption; and its economic development is poor, with 30 percent of the public living on subsistence income. Under Putin’s regime, private media have come under pressure, television is totally stated controlled, elections for regional leaders have been canceled, troops have remained in Chechnya, and Putin has supported controversial new legislation to curb civil liberties and NGO’s operating in Russia.

“How did Russia come to this?” she asked. In retrospect, the power of the president has been too strong. Initial “irrational exuberance” in the United States and Europe about what we could do has given way to apathy. Under Yeltsin, rule was oligarchical and democracy disorganized. Putin came to office promising a “dictatorship of law” to rid the country of corruption. Yet Russia under Putin, who rose through the KGB and never held elective office, has become far less democratic. He has severely curtailed civil liberties. The economy, dependent on oil and natural gas, is not on a path of sustainable growth.

“What can the United States do?” Stoner-Weiss asked. We have emphasized security over democracy, she pointed out, and invested in personal relations with Russia’s leaders, as opposed to investing in political process and institutions. We do have important opportunities, she noted. Russia chairs the G-8 group of major industrial nations this year, providing major opportunities for consultation, and wants to join the World Trade Organization. The United States should advance an institutional framework to help put Russia back on a path to democracy, a rule of law, and more sustainable growth, she argued.

Diamond, an expert on democratic development and regime change, examined U.S. involvement in the Middle East, noting that it is difficult to be optimistic at present. “Democracy is absolutely vital in the battle against terrorism,” he stated. The United States has to drain the swamp of rotten governments, lack of opportunity for participation and the pervasive indignity of human life. “The dilemma we face,” he pointed out, “is getting from here to there in the intractable Middle East.” There is not a single democracy in the Arab Middle East. This is not because of Islam, but rather the authoritarian nature of regimes in the region and the problem of oil.

“Can we promote democracy under these conditions?” Diamond asked. We need to get smart about it, he urged, noting that success depends on the particular context of each country. “If we want to promote democracy, the first rule is to know the country, its language, culture, history, and divisions,” he stated. We need to know, he continued, “who stands to benefit from a democratic transformation and, conversely, who stands to lose?” Rulers of these countries need to allow the space for freedom, for civic and intellectual pluralism, for open societies and meaningful participation. The danger is that there could be one person, one vote, one time. A second rule is that “academic knowledge and political practice must not be compartmentalized.” “To succeed,” Diamond stated, “we need to marry academic theories with concrete knowledge of these countries’ traditions, cultures, practices, and proclivities.”

In the lively question-and-answer session, panelists were asked, “Under what conditions is it appropriate to use force to promote democracy?” McFaul answered that we cannot invade in the name of democracy—we rebuilt Japan in that name but we did not invade that nation. We invaded Iraq in the name of national security. We know how to invade militarily, but still must learn how to build democracy. Effectiveness in the promotion of democracy, Diamond pointed out, requires the exercise of “soft” power—engagement with other societies, linkages with their schools and associations, and offering aid to democratic organizations around the world. Stoner-Weiss concurred, noting that we have used soft power effectively in some parts of the former Soviet Union, notably the Ukraine. People-to-people exchanges definitely help, she added.

To combat Osama bin Laden and the threat of future attacks in the United States, Diamond stated, we must halt the proliferation of nuclear weapons. North Korea and Iran are two of the most important issues on the global agenda. And we have got to improve governance in the Middle East in order to reduce the chances that the states of the region will breed and harbor stateless terrorists. A democratic Iran is in our interest, McFaul emphasized. Saudi Arabia must change as well—the only issue is whether change occurs with evolution or revolution. Democracy, economic development, and the rule of law, McFaul concluded, are inextricably intertwined.

Asked by alumnus and former Stanford trustee Brad Freeman what needs to happen to re-democratize Russia, McFaul pointed out that inequality has been a major issue in Russia—a small portion of the population controls its wealth and resources and, therefore, the political agenda and the use of law. Russia has been ruled by men and needs the rule of institutions, said Stoner-Weiss. We should insist that Putin allow free and fair elections, freedom of the press, and freedom of political expression, and re-focus efforts on developing the institutions of civil society, she stated.

Reform is a generational issue, McFaul emphasized. We need to educate and motivate the young so they can change their country from within. The Stanford Summer Fellows Program, which brought emerging leaders from 28 transitioning countries to Stanford in the program’s inaugural year of 2005, provides an important venue for upcoming generations to meet experienced U.S. leaders and others fighting to build democracies in their own countries. Such exchanges help secure recognition that building support for democracy, sustainable development, and the rule of law is a transnational issue.

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This past autumn, the Freeman Spogli Institute ( FSI ) in conjunction with the Woods Institute for the Environment launched a program on Food Security and the Environment (FSE) to address the deficit in academia and, on a larger scale, the global dialogue surrounding the critical issues of food security, poverty, and environmental degradation.

“Hunger is the silent killer and moral outrage of our time; however, there are few university programs in the United States designed to study and solve the problem of global food insecurity,” states program director Rosamond L. Naylor. “FSE’s dual affiliation with FSI and Stanford’s new Woods Institute for the Environment position it well to make significant steps in this area.”

Through a focused research portfolio and an interdisciplinary team of scholars led by Naylor and Center for Environmental Science and Policy (CESP) co-director Walter P. Falcon, FSE aims to design new approaches to solve these persistent problems, expand higher education on food security and the environment at Stanford, and provide direct policy outreach.

Productive food systems and their environmental consequences form the core of the program. Fundamentally, the FSE program seeks to understand the food security issues that are of paramount interest to poor countries, the food diversification challenges that are a focus of middle-income nations, and the food safety and subsidy concerns prominent in richer nations.

CHRONIC HUNGER IN A TIME OF PROSPERITY

Although the world’s supply of basic foods has doubled over the past century, roughly 850 million people (12 percent of the world’s population) suffer from chronic hunger. Food insecurity deaths during the past 20 years outnumber war deaths by a factor of at least 5 to 1. Food insecurity is particularly widespread in agricultural regions where resource scarcity and environmental degradation constrain productivity and income growth.

FSE is currently assessing the impacts of climate variability on food security in Asian rice economies. This ongoing project combines the expertise of atmospheric scientists, agricultural economists, and policy analysts to understand and mitigate the adverse effects of El Niño-related climate variability on rice production and food security. As a consequence of Falcon and Naylor’s long-standing roles as policy advisors in Indonesia, models developed through this project have already been embedded into analytical units within Indonesia’s Ministries of Agriculture, Planning, and Finance. “With such forecasts in hand, the relevant government agencies are much better equipped to mitigate the negative consequences of El Niño events on incomes and food security in the Indonesian countryside,” explain Falcon and Naylor.

FOOD DIVERSIFICATION AND INTENSIFICATION

With rapid income growth, urbanization, and population growth in developing economies, priorities shift from food security to the diversification of agricultural production and consumption. “Meat production is projected to double by 2020,” states Harold Mooney, CESP senior fellow and an author of the Millennium Ecosystem Assessment. As a result, land once used to provide grains for humans now provides feed for hogs and poultry.

These trends will have major consequences for the global environment—affecting the quality of the atmosphere, water, and soil due to nutrient overloads; impacting marine fisheries both locally and globally through fish meal use; and threatening human health, as, for example, through excessive use of antibiotics.

An FSE project is analyzing the impact of intensive livestock production and assessing the environmental effects to gain a better understanding of the true costs of this resource-intensive system. A product of this work recently appeared as a Policy Forum piece in the December 9, 2005, issue of Science titled "Losing the Links Between Livestock and Land."

Factors contributing to the global growth of livestock systems, lead author Naylor notes, are declining feed-grain prices, relatively inexpensive transportation costs, and trade liberalization. “But many of the true costs remain largely unaccounted for,” she says, including destruction of forests and grasslands to provide farmland for feed crops destined not for humans but for livestock; utilization of large quantities of freshwater; and nitrogen losses from croplands and animal manure.

Naylor and her research team are seeking better ways to track all costs of livestock production, especially hidden costs of ecosystem degradation and destruction. “What is needed is a re-coupling of crop and livestock systems,” Naylor says, “if not physically, then through pricing and other policy mechanisms that reflect social costs of resource use and ecological abuse.” Such policies “should not significantly compromise the improving diets of developing countries, nor should they prohibit trade,” Naylor adds. Instead, they should “focus on regulatory and incentive-based tools to encourage livestock and feed producers to internalize pollution costs, minimize nutrient run-off, and pay the true price of water.”

LOOKING AHEAD

The future of the program on Food Security and the Environment looks bright and expansive. Building on existing research at Stanford, researchers are identifying avenues in the world’s least developed countries to enhance orphan crop production— crops with little international trade and investment, but high local value for food and nutrition security. This work seeks to identify advanced genetic and genomic strategies, and natural resource management initiatives, to improve orphan crop yields, enhance crop diversity, and increase rural incomes through orphan crop production.

Another priority research area is development of biofuels. As countries seek energy self-reliance and look for alternatives to food and feed subsidies under World Trade Organization (WTO) rules, the conversion of corn, sugar, and soybeans to ethanol and other energy sources becomes more attractive. New extraction methods are making the technology more efficient, and high crude oil prices are fundamentally changing the economics of biomass energy conversion. A large switch by key export food and feed suppliers, such as the United States and Brazil, to biofuels could fundamentally alter export prices, and hence the world food and feed situation. A team of FSE researchers will assess the true costs of these conversions.

The FSE program recently received a grant through the Presidential Fund for Innovation in International Studies to initiate new research activities. One project links ongoing research at Stanford on the environmental and resource costs of industrial livestock production and trade to assess the extent of Brazil’s rainforest destruction for soybean production. “Tens of millions of hectares of native grassland and rainforest are currently being cleared for soybean production to supply the global industrial livestock sector,” says Naylor. An interdisciplinary team will examine strategies to achieve an appropriate balance between agricultural commodity trade, production practices, and conservation in Brazil’s rainforest states.

“I’m extremely pleased to see the rapid growth of FSE and am encouraged by the recent support provided through the new Presidential Fund,” states Naylor. “It enables the program to engage faculty members from economics, political science, biology, civil and environmental engineering, earth sciences, and medicine—as well as graduate students throughout the university—in a set of collaborative research activities that could significantly improve human well-being and the quality of the environment.”

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The Office of the President and the Stanford International Initiative announced on February 1, 2006, the award of eight new grants totaling $1.05 million to multidisciplinary Stanford faculty teams. The grants are the first to be awarded from Stanford’s new Presidential Fund for Innovation in International Studies (PFIIS) created in 2005.

“The world does not come to us as neat disciplinary problems, but as complex interdisciplinary challenges. The collaborative proposals we have selected for this first round of funding offer great potential to help shed light on some of the most persistent and pressing political issues on the global agenda today—issues acutely important to our common future.” john hennessy, stanford president

The fund supports interdisciplinary research and teaching on three overarching global challenges: pursuing peace and security, improving governance at all levels of society, and advancing human well-being. Priority was given to teams of faculty who did not typically work together, representing multiple fields, and choosing to address issues falling broadly within the three primary research areas of the Initiative. Projects were to be based on collaborative research or teaching, involving faculty from two or more disciplines, and, where possible, from two or more of the University’s seven schools.

“The International Initiative’s Executive Committee was encouraged to receive more than 35 proposals of an impressive caliber and, after careful review, to award the first project and planning grants, totaling $1.05 million, to eight deserving faculty teams.” Coit D. Blacker, director of the Freeman Spogli Institute and chair of the Executive Committee“The International Initiative’s Executive Committee was encouraged to receive more than 35 proposals of an impressive caliber and, after careful review, to award the first project and planning grants, totaling $1.05 million, to eight deserving faculty teams,” stated Coit D. Blacker, director of the Freeman Spogli Institute and chair of the Executive Committee.

The projects qualifying for first-round funding of approximately $1.025 million are the following:

  • Governance Under Authoritarian Rule. Stephen Haber and Beatriz Magaloni, political science; Ian Morris, classics, history; and Jennifer Trimble, classics. Will examine the political economy of authoritarian systems and, by drawing on methods from history, archaeology, political science, and economics, determine why some authoritarian governments are able to transition to democracy, stable economic growth, and functioning political institutions, while others prove predatory and unstable.
  • Addressing Institutional and Interest Conflicts: Project Governance Structures for Global Infrastructure Development. Raymond Levitt, civil and environmental engineering, and Doug McAdam and Richard Scott, sociology. Will examine the challenges of creating effective and efficient public/ private institutions for the provision of low-cost, distributed, and durable infrastructure services to underserved populations in emerging economies, drawing on engineering cost management, organizational and institutional theory, political science, political sociology, and transaction cost analysis.
  • Combating HIV/AIDS in Southern Africa: The Treatment Revolution and Its Impact on Health, Well-Being, and Governance. David Katzenstein, infectious diseases, and Jeremy Weinstein, political science. Based on the 2005 commitment by the Group of 8 donors to put 10 million people infected with HIV/AIDS on treatment within five years, will research the impact of this treatment revolution on health, wellbeing, and governance in Sub-Saharan Africa, with an emphasis on South Africa and Zimbabwe. Seeks to develop a systematic protocol for the collection and analysis of biomedical and social science data.
  • Evaluating Institutional Responses to Market Liberalization: Why Latin America Was Left Behind. Judith Goldstein, political science; Avner Greif, economics; Stephen Haber, political science; Herb Klein, history; Grant Miller, medicine; and Barry Weingast, political science. Will research the dynamic interaction between inequality and Latin American institutions, formal and informal, in explaining the poor performance of Latin American countries over the past two decades, seeking in particular to explain why liberal institutional reforms, such as trade liberalization, have failed to yield expected economic benefits.
  • Feeding the World in the 21st Century: Exploring the Connections Between Food Production, Health, Environmental Resources, and International Security. Rosamond Naylor, FSI/economics; Stephen Stedman, FSI/political science; Peter Vitousek, biological sciences; and Gary Schoolnik, medicine, microbiology and immunology. Launches new research and teaching program at Stanford on Food Security and the Environment (FSE), with an initial priority on two research areas: 1) Food Security, Health, and International Security; 2) Globalization, Agricultural Trade, and the Environment. Seeks to address the problems of global food insecurity and hunger, the “silent killer” of our time, affecting more than 1 billion people globally. Research and teaching will focus on the interconnections between food security, agricultural production, infectious diseases, environmental degradation, and national and international security, with the aim of advancing human well-being by identifying linkages, policy interventions, and new forms of political cooperation.
  • Political Economy of Cultural Diversity. James Fearon, political science, and Romain Wacziarg, Graduate School of Business. Will research the effect of cultural diversity on economic and political performance, examining specifically the role of ethnic, linguistic, and religious diversity on economic growth, the free flow of trade and capital across borders, governance, development of democratic institutions, and political stability. Will develop novel measures of ethnic, linguistic, and religious differences within countries and use these to assess their causal impact on important political and economic outcomes.

Two planning grants were also awarded, as follows:

  • Global Health by Design. Geoffrey Gurtner, plastic and reconstructive surgery; David Kelley, mechanical engineering; Thomas Krummel, surgery; Julie Parsonnet, medicine, health research and policy; and Paul Yock, medicine, bioengineering. Will design a project to examine how new technology can be used to develop effective, affordable, and sustainable methods and devices to prevent disease in the world’s poorest countries.
  • Ecological Sanitation in Rural Haiti: An Interdisciplinary Approach to Sanitation and Soil Fertility. Ralph Greco, surgery, and Rodolfo Dirzo, biological sciences. Will develop a plan to test the efficacy of ecological sanitation in decreasing disease and enhancing soil fertility in rural Haiti.

“It is abundantly clear that addressing some of the most significant problems on the global agenda will require imaginative thinking, bold approaches, and interdisciplinary collaboration,” Blacker said. The projects will produce new field research and protocols, conferences, research papers, books, symposia, and courses. Additional annual project awards totaling roughly $1 million each will be made in the fall of 2006 and in 2007.

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Epidemic infectious diseases have shaped many aspects of ancient and modern history. In an interdependent world, well-known pathogens and new, emerging infectious diseases continue to pose a global threat. At the same time, the biomedical and social sciences have been making incredible progress in the diagnosis, prevention, and treatment of communicable diseases.

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Recent events highlight the importance of emerging infectious agents, including HIV/AIDS in the early 1980s, the introduction of West-Nile Virus in the western hemisphere in the late 1990s, and SARS (Severe Acute Respiratory Syndrome) in 2003, and draw attention to the role of increased travel and global connections in facilitating the rapid spread of infectious diseases.

HIV/AIDS is now the world’s greatest pandemic. It has claimed more lives than the Black Plague of the 14th century. With an estimated 16,000 new infections daily, more than 40 million people worldwide are infected with Human Immunodeficiency Virus (HIV). More than seven out of 10 of the world’s HIV-infected people live in sub-Saharan Africa. The impact of HIV/AIDS on local economies, its potential to contribute to regional instability due to loss of human life, and the moral imperative to address the pandemic has brought prevention and treatment of HIV/AIDS to the forefront. Increasingly, it is clear that a multidisciplinary team approach including social scientists, behavioral specialists, clinicians, researchers, and policymakers is essential to address this global pandemic.

Advances in epidemiology, molecular diagnostics, bio-informatics, and genomics have enriched our understanding of ancient and emerging pathogens and offer new avenues for addressing infectious diseases. Vaccines, pharmaceuticals, and new paradigms of public health have increased our ability to control and even eradicate infectious agents. The control of many formerly common childhood diseases has been effectively achieved through the development of vaccines. Smallpox and measles provide examples of diseases that have been eradicated by the culmination of modern innovative public health approaches and widespread vaccination. In the news today, the potential for a viral antigenic shift resulting in a more transmissible form of the deadly H5N1 influenza virus has led to extensive media coverage and disaster planning at local, state, and federal levels of government, as well as international public health bodies.

Teachers and students need a strong foundation in the biologic and social sciences to place these events and responses in context and to allow transfer of vital information and understanding to the community at large. There have been few initiatives to provide high school teachers with accurate, up-to-date knowledge on infectious diseases. U.S. high school students continue to be exposed to global infectious diseases through sensationalized media coverage including popular films and television.

We have been developing a high school curriculum unit with Stanford students Robin Lee, Michelle Silver, Piya Sorcar, and Jessica Zhang and Gary Mukai of SPICE to allow teachers and students to place news concerning infectious diseases in perspective; appreciate diverse social and economic responses to infectious diseases; and understand infectious diseases in the context of a global, interdependent world. The curriculum will also encourage students to consider issues related to epidemic and pandemic infectious diseases and their own personal risk.

The proposed five-module unit is as follows, with the first module having been completed this summer:

I: Introduction to Virology and Infectious Diseases

II: The Epidemiology of HIV/AIDS in the United States and around the World

III: Science, Economics, and Business in Infectious Diseases

IV: Local and International Politics and Policy in Infectious Diseases

V: Community and Personal Health

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On November 16, 2006, FSI convened its annual international conference, A World at Risk, devoted to systemic and human risk confronting the global community. Remarks by Stanford Provost John Etchemendy, FSI Director Coit D. Blacker, former Secretary of State Warren Christopher, former Secretary of Defense William J. Perry, and former Secretary of State George Shultz set the stage for stimulating discussions. Interactive panel sessions encouraged in-depth exploration of major issues with Stanford faculty, outside experts, and policymakers.

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“When I was a child, the world was a simpler place,” stated Stanford Provost John Etchemendy. “What has changed is not the risk, but the number and complexity of problems that face the world today.” The complex challenges of the 21st century require that universities change, as well. The International Initiative, led by FSI, was launched “to identify key challenges of global importance and to contribute to their solutions by leveraging the university’s academic strength and international reach.”

Invoking Jane and Leland Stanford’s desire to educate students to become useful, contributing citizens, Etchemendy said, “We can best serve that mission today by producing graduates well-versed in the complex problems of a world at risk and willing to make the difficult choices that might lead to their solution.”

“It has been acutely apparent to us at FSI that we must actively engage a world at risk,” stated FSI director Coit D. “Chip” Blacker, “risk posed by the growing number of nuclear issues on the international agenda; the insurgency in Iraq; global poverty, hunger, and environmental degradation; the tensions of nationalism versus regionalism in Asia; infectious diseases; terrorism; and the geopolitical, financial, and ecological risks of the West’s current energy policies, especially its voracious appetite for oil.”

Introducing three Stanford luminaries, Blacker said, “One of the remarkable things about Stanford is the privilege of working with some of the outstanding intellects and statesmen of our time. Warren Christopher, William Perry, and George Shultz tower among them.”

“As Stanford University’s primary forum for the consideration of the major international issues of our time, we at FSI are dedicated to interdisciplinary research and teaching on some of the most pressing and complex problems facing the global community today.” – Coit D. “Chip” Blacker, Director, Freeman Spogli Institute“The Middle East has descended into hate, violence, and chaos,” said Warren Christopher, the nation’s 63rd secretary of state. “It really is a dangerous mess.” Discussing the Israeli incursion into Lebanon, the war in Iraq, and Iran’s regional and nuclear ambitions, he said the U.S. has aggravated these threats by “action and inaction.” Nonetheless, the U.S. remains the most influential foreign power in the region. “We must not give up on the Middle East,” he said. “We have to return to old-fashioned diplomacy with all its frustrations and delays.”

“We live in dangerous times,” stated William J. Perry, the nation’s 19th secretary of defense and an FSI senior fellow. “Last month about 1,000 of our service personnel in Iraq were killed, maimed, or wounded; the Taliban is resurging in Afghanistan; North Korea just tested a nuclear bomb; and Iran is not far behind. China’s power is rising and Russia’s democracy is falling.” As Elie Wiesel wrote, he said, “Peace is not God’s gift to its children. Peace is our gift to each other.” Comparing major security issues of 1994 to today, Perry assessed the nuclear arms race, North Korea, Iran, and Iraq. He noted that the Clinton administration had eliminated more than 10,000 nuclear weapons and urged that the work continue, because “the danger of terrorists getting a nuclear bomb is very real.”

Citing North Korea’s 2006 missile and nuclear tests, Perry said he was concerned that a robust North Korean nuclear program will stimulate a “dangerous arms race in the Pacific” and increase “the danger of a terrorist group getting a nuclear bomb.” “Iran is moving inexorably toward becoming a nuclear power,” Perry said. “We are facing new dangers,” he concluded, “and we must adjust our thinking accordingly.”

“The world has never been at a more promising moment than it is today,” said George Shultz, the nation’s 60th secretary of state. “All across the world, economic expansion is taking place. The U.S. is giving fantastic leadership to the global economy.” For Shultz, the imperative is to prevent the security challenges “from aborting all these fantastic opportunities.”

“The Middle East has descended into hate, violence, and chaos. The U.S. remains the most influential foreign power in the region. We have to return to old-fashioned diplomacy with all its frustrations and delays.” – Former Secretary of State Warren ChristopherU.S. leadership should inspire the world, Shultz said, advocating four initiatives. We should aspire to have a world with no nuclear weapons. We should take a different approach to global warning, based on the Montreal Protocols. “This is a gigantic problem we need to do something about and can do something about,” he said. We should build greater understanding of the world of Islam. We must combat rising protectionism. The postwar system reduced tariffs and quotas, promoting trade and growth. “The best defense is a good offense,” Shultz stated. “We need a lot of leadership in that arena.”

Plenary I, chaired by Chip Blacker, examined systemic risk. Elisabeth Paté-Cornell, Burton and Deedee McMurtry Professor and Chair of Management Science and Engineering, discussed how scientists measure risk, asking what can happen, what are the chances it will, and what are the consequences? “The good news is that the worst is not always the most certain,” she noted. Citing challenges of intelligence analysis, she said, “Certainty is rare; signals are imperfect; there is a tendency to focus on one possibility (groupthink) and underestimate others; and it is difficult to assess and communicate uncertainties.” “Success is not guessing in the face of uncertainties,” she said. “It is describing accurately what is known, what is unknown, and what has changed.”

Scott D. Sagan, professor of political science and director of CISAC, examined “Iran and the Collapse of the Global Non-proliferation Regime?” The crux of the issue, Sagan noted, is the emergence of two dangerous beliefs, “deterrence optimism” and “proliferation fatalism.” In Sagan’s view, too little attention has been given to why Iran seeks a nuclear weapon. Arguing that U.N. sanctions are unlikely to work and military options are problematic, Sagan said a negotiated settlement is still possible if the U.S. offers security guarantees to Iran, contingent on Tehran’s agreement to constraints on future nuclear development. As Sagan concluded, “Instead of accepting what appears inevitable, we should work to prevent the unacceptable.”

Siegfried S. Hecker, CISAC co-director, tackled the challenge of “Keeping Fissile Materials out of Terrorist Hands.” Although nuclear terrorism is an old problem, today there is easier access to nuclear materials, greater technological sophistication, and a greater proclivity toward violence. The greatest risk, he said, “is an improvised nuclear device built from stolen or diverted fissile materials.” “Given a few tens of kilograms of fissile material, essentially a grapefruit-sized chunk of plutonium,” he stated, “terrorists will be able to build and detonate an inefficient, but devastating Hiroshima- or Nagasaki-like bomb.” The most likely threat is a so-called “dirty bomb,” he said, which would be a “weapon of mass disruption, not destruction,” but still able to cause panic, contamination, and economic disruption, making risk analysis imperative to mitigate its consequences.

“We are facing new dangers and we must adjust our thinking accordingly. As President Lincoln said, ‘The occasion is piled high with difficulty, and we must rise with the occasion. As our case is new, so we must think anew, and act anew.’” – Former Secretary of Defense William J. PerryTurning to human risk, Michael Osterholm, director of the University of Minnesota’s Center for Infectious Disease Research and Policy, addressed “Pandemic Influenza: Harbinger of Things to Come?” “The risk is one that a pandemic is going to happen,” he told a riveted audience. Comparing the great influenza of 1918 with the pandemics of 1957 and 1968, he noted that pandemics have differed in season of onset, mortality rates, and number of cases. Avian influenza has a 65 percent mortality rate and could affect 30–60 percent of the world’s 6.5 billion people, producing 1.6 billion deaths worldwide and 1.9 million deaths in the U.S. Inevitably, mutation will reduce its lethality.

“It is not a matter of if, just when and where” the pandemic will strike, said Osterholm. Noting that vaccines will not be available in numbers needed, he argued for measures to safeguard families, communities, and essential infrastructure, such as police, firefighters, and health-care workers. Just-in-time inventory practices, he said, have increased vulnerability to disruptions in food supply, transportation, equipment, and communications, making it vital to plan in earnest, now.

Plenary II, chaired by FSI deputy director Michael A. McFaul, assessed risks to humans from “Natural, National, and International Disasters.” Stephen E. Flynn, Jeane J. Kirkpatrick Senior Fellow at the Council on Foreign Relations and a trade and transportation security expert, decried the “artificial firewalls between homeland and national security.” The Hart-Rudman Commission of 1998 warned of a catastrophic attack on U.S. soil, yet we did not rethink national security even after 9/11. We must approach security as a transnational issue, with no clear “domestic” and “international” lines, he urged. More than 65 percent of critical infrastructure is privately owned and has been given inadequate attention by federal authorities. Hurricane Katrina exposed the vulnerabilities. “We face more threats from acts of God than acts of man,” Flynn stated. We need to move from a concept of “security” to one of “resiliency,” he said, greatly improving our ability to withstand a man-made or natural disaster.

David G. Victor, FSI senior fellow and professor of law, addressed three faces of energy security: oil, natural gas, and climate change. Oil prices are volatile, future fields are in places difficult to do business, and the global supply infrastructure is vulnerable, posing the risk of a one- to six-month supply disruption. For Victor, who directs FSI’s Program on Energy and Sustainable Development, the big threat is less supply than a potential demand-side shock, driven by the U.S. and China. Europe relies on an unreliable Russia for 25–30 percent of its natural gas needs, making it imperative to switch to cheaper, more reliable LNG from North Africa and the Middle East. Oil and gas price volatility has driven further dependence on coal-fired plants, with dire consequences for carbon emissions. New coal plant lifetime emissions, Victor said, are equal to all historic coal emissions, making it critical to invest in advanced technology to protect the environment.

“The world has never been at a more promising moment than it is today. All across the world economic expansion is taking place. Poverty is being reduced dramatically as China and India expand, along with Brazil.” – Former Secretary of State George ShultzPeter Bergen, CNN terrorism analyst and producer of Osama bin Laden’s first television interview, offered the dinner keynote, “Successes and Failures of the War on Terrorism Since 9/11.” Assessing negatives, Bergen noted that al Qaeda continues to carry on attacks from its base in Pakistan; Afghanistan is beset by instability; more than 20 million Muslims in Europe remain dangerously un-integrated; bin Laden has not been apprehended and continues to inspire followers through terrorist attacks; Iraq is an unstable breeding ground for jihad; and anti-Americanism is on the rise. Enumerating positives, there has been no follow-on attack on the U.S.; the government has made the country safer; many Muslims have rejected jihad; plots have been foiled and suspects apprehended across the globe. Weighing whether fighting the terrorists abroad has made the U.S. safer here, Bergen was equivocal: The U.S. can identify and eliminate only so many people and cannot stay in Bagdad forever. A network of educated, dedicated terrorists remains, he warned, capable of bringing down commercial aircraft or deploying a radiological bomb.

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