Coal is the leading energy-related cause of climate change and creates serious local air pollution; it also remains, for now, an essential energy source for many growing economies. PESD's new volume studies key coal producing and exporting countries--China, India, Indonesia, Australia, South Africa, and the United States--for insights into how coal production, transport, and consumption will evolve in the future, and what this may mean for the environment.

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Foreign aid to the public health sectors of developing countries often appears to be allocated backwards: The global burden of non-communicable diseases such as diabetes or heart disease is enormous – yet they receive little health aid. 

By comparison, the global burden of HIV is much smaller, yet it receives more health aid than any other single disease.

So will a wholesale reversal in health aid priorities improve global health? The answer, according to a new study by Stanford researchers, is that if the goal is to maximize the health benefits from each donor dollar, health aid is actually allocated pretty well.

Still, reallocating foreign aid to step up the fight against malaria and TB could lead to greater overall health improvements in developing nations. And it could be done without spending more money, the researchers have found.

Eran Bendavid, an assistant professor in the Department of Medicine and a core faculty member at the Center for Health Policy and Center for Primary Care and Outcomes Research, and three Stanford research assistants write in the July issue of Health Affairs that more health aid is going to disease categories with more cost-effective interventions.

"What we found, somewhat to our surprise, is that in nearly all countries, more aid was flowing to finance priorities with more cost-effective options,” Bendavid said in an interview. “That is partly because more aid was flowing to the treatment and prevention of infectious diseases such as HIV and malaria, and their management can be relatively inexpensive, even if the burden of these diseases is lower than that of non-communicable diseases.”

Bendavid, an infectious disease physician, added: “Conversely, even though the burden of non-communicable diseases is high and growing, addressing these chronic conditions such as diabetes and heart disease is, broadly, more costly than the unfinished infectious disease agenda.”

The authors also show that just because health aid is broadly allocated toward better cost-effectiveness does not mean that it cannot be better allocated.

The biggest gains would come from taking some of the foreign aid earmarked for HIV or maternal, newborn or child health, and putting it toward programs to treat malaria and tuberculosis, they write.

The Stanford research team reviewed the literature for cost-effectiveness of interventions targeting five disease categories: HIV, malaria, tuberculosis, non-communicable disease and maternal, newborn and child health.

What they found was that aid from wealthy nations to developing ones might be allocated efficiently, but that the money is not always spent in the best interest of curbing the communicable diseases that would improve the overall health of a nation.

It is crucial, therefore, to further study the consequences of realignment of donor funds.

Public health aid is critical to most developing countries. Development assistance from high-income countries to public health sectors of low- and middle-income countries amounts to nearly 40 percent of public health spending in countries with a per capita GDP of less than $2,000.

The researchers focused on 20 countries that received the greatest total amount of aid between 2008 and 2011, a period of historically unprecedented growth in health aid. Development assistance has since flattened, however, so the authors believe it’s increasingly important to consider best value when investing limited resources.

The 20 countries studied ­– from Afghanistan to Zambia – received $58 billion out of the total $103.2 billion in recorded health aid disbursements to 170 countries between 2001 and 2011.

“Over the period of 2001-2011, a greater amount of disbursements flowed to HIV programs than any other disease category,” the authors write. “On average, interventions addressing malaria and had the lowest incremental cost-effectiveness ratio (ICER), which indicates that malaria interventions could yield greater health improvements from each dollar compared with the interventions having a higher ICER.”

The authors analyzed the data and determined that the alignment improves if up to 61 percent of HIV aid is reallocated for TB control and up to 80 percent is reallocated for malaria control.

“Our evidence suggests that the greatest improvements in the efficiency of global health dollars could result from reallocating funds to malaria and TB control programs,” the authors write.

“This study shows, for the first time, that the current allocation of health aid is generally aligned with the cost-effectiveness of targeted interventions. Contrary to common views that advocate for reprioritization toward non-communicable diseases, our data suggest that the alignment could best be improved by focusing on malaria and TB, especially where addressing those diseases is highly cost effective.”

The other authors of the study are Andrew Duong and Gillian Raikes, both research assistants in the Program of Human Biology; and Charlotte Sagan, a RA in the School of Medicine.

Bioengineering researchers have recently constructed the final steps required to engineer yeast to manufacture opiates, including morphine and other medical drugs, from glucose, drawing significant interest, and concern, from the media and academics in the science and policy fields, including at the Center for International Security and Cooperation (CISAC).  

“Researchers are getting better at building biology based platforms to create a wide variety of compounds that are difficult, inefficient, or sometimes impossible to create by other means,” Dr. Megan J. Palmer told National Public Radio in the weekly Science Friday segment.

She highlighted how these platforms can enable production of potentially safer, cheaper and more effective drugs. “But one significant concern is if we create the full pathway to go from glucose to this intermediate and then all the way to things like morphine, this could feed into illicit markets and bolster new illicit markets.”

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The media this week has focused on comments by researchers who pointed out that the modified yeast could be used to manufacture heroin, a synthesized version of morphine. The prospect of “home-brewed heroin” has been prominently featured in news coverage.

There are significant concerns, says Palmer, but she cautioned that focusing solely on that possibility could lead to bad policy outcomes.

“There is a big opportunity for researchers, policy makers, and industry to work together to figure out what controls they can put in,” she said in a separate interview. “We have time to get ahead of this problem. We now have choices in how we build and regulate the technology. The challenge for regulatory and technical communities will be to avoid reactive quick fixes. It’s encouraging to see researchers engaging in these issues early on.”

The challenge will be to find ways for researchers, law enforcers, and policy experts to work together to build safeguards into the biology itself as well as into organizations and institutions. 

“We really need to think about security as a design principle,” Palmer said. She hopes to foster thoughtful and rigorous analysis of how the design of biotechnology impacts future governance options.

“This issue highlights beautifully the nexus between public policy and science and technology, which is where CISAC has already, and will continue to make important contributions,” said CISAC Co-Director David Relman. Dr. Relman is also the Thomas C. and Joan M. Merigan Professor in the Departments of Medicine, and of Microbiology and Immunology at Stanford University. 

CISAC recently hosted a seminar led by Stanford’s Dr. Christina Smolke that discussed technology advances that are resulting in alternative supply chains for drugs, with particular attention to opiates.

Dr. Smolke is also troubled by the over-emphasis of the risks associated with the potential technology. “I believe it’s inflammatory, biased, and not grounded in an accurate representation of the technology. However, the commentary focuses on the risks of the supply chain and proposes regulations/governance for such a technology, without implementing a process to engage various parties in discussions to thoughtfully assess risks, opportunities, and regulatory needs in this context.”

“I think we need to frame this issue in the context of the larger systemic challenges involving the rearrangements of supply chains enabled through bio-manufacturing and how we spread responsible norms and practices,” Palmer said. “We need to think about governance options in terms of human capacities and technical capacities. What safeguards can we engineer into our technologies, and in turn what safeguards can we build into our organizations and institutions?”

What is it about terrorism that makes it so difficult to study and counteract through U.S. government policy? That’s the central question CISAC Senior Fellow Martha Crenshaw hopes to answer in an upcoming book she is co-authoring with Gary LaFree, Director of the National Center for the Study of Terrorism and Responses to Terrorism (START), where Crenshaw serves as lead investigator. at the University of Maryland. 

The idea for the book stems from Crenshaw’s long career in grappling with terrorism and observing how governments struggle to combat it. She has been writing and thinking about terrorism since the 1970s and is currently conducting a multi-year project mapping the evolution of violent extremist groups. However, the difficulties inherent in the topic have not much changed for academics and policymakers.

The problems start with defining terrorism, something that has bedeviled both researchers and policymakers for decades, Crenshaw told a Stanford audience in CISAC. 

“We are still arguing about what terrorism means. But even if you agree on a definition, then applying it to the real world remains difficult,” she said.

Beyond semantics, the study of terrorism faces a series of hurdles inherent to the topic. An overarching social theory of the causes of terrorism remains elusive, and there is no agreement on whether terrorism actually works. 

Additionally, academics have used many different levels of analyses–individual, organizational, cultural, economic, and others–but have yet to agree on which analyses bear more fruit.

Despite what you might gather from what’s said in the media, terrorism events are actually very rare. Terrorist attacks that kill large amounts of people are even more rare. “9/11 was a black swan, a highly consequential event but only a one-of-a-kind. We show why it’s the case that terrorism is very rare and therefore makes it very hard to predict any kind of trends,” Crenshaw said.

Most of the information available is about attacks that actually happened. But there are many more plots, about ten times more, than actual attacks. Crenshaw said she and her research assistants have used news media and government documents to identify failed and foiled plots against the United States, European Union, and NATO countries plus Australia and New Zealand. The plots have been coded in a dataset that she will analyze.  

There are additional obstacles in the way of researchers and policymakers. 

Attributing responsibility for attacks is difficult, which hampers research and government responses. “How do you know who to respond against? The concept of terrorism is mixed in with insurgency. It’s hard to think of a policy that targets one but not the other,” Crenshaw said. Terrorist organizations are very small and the boundaries between groups are extremely porous. Yet, there is not a preponderance of lone wolves.

Sometimes, the U.S. government obstructs research. Crenshaw lamented the over-classification of government documents, and drew particular attention to the designation “For Official Use Only”, which is not a classification but a designation that seems to depend on the agency using it. 

“If you are analyzing illegal forms of violence there are three sources of information: governments, victims, and terrorists. Victims are difficult to find. Self-reporting is even harder and usually unfeasible. And governments are very secretive. We would like to see more transparency and openness on their part,” she said.

“I think what is being done here is really important when it comes to the question of why it’s so hard to find policy solutions for terrorism,” said Betsy Cooper, a Law and International Security Postdoctoral Fellow at CISAC, who offered commentary on the book draft to the seminar. “A lot of what is in the chapter about the state of counter-terrorism research is very important.” 

“I learned a lot especially about the automation in the global terrorism database and it poses some interesting questions. Is something terrorism because we say it is or can we use objective criteria regardless of whether you see it as something else?” 

In this talk sponsored by the Stanford Institute for Economic Policy Research, three CISAC scholars discuss the Islamic State, Iran and the Taliban and the threats they impose to American security. The talk is moderated by Brad Kapnick, a Partner at Katten & Temple, LLP, and SIEPR Advisory Board member. Joining him are Martha Crenshaw, a senior fellow at CISAC and the Freeman Spogli Institute for International Studies and professor, by courtesy, of political science; CISAC Senior Fellow Scott Sagan, the Caroline S.G. Munro Professor of Political Science; former U.S. Ambassador to Afghanistan Karl Eikenberry, the William J. Perry Fellow at CISAC and a consulting professor at the Freeman Spogli Institute.

This is an abbreviated version of the talk below. The full talk can be found here.