From genome editing to “hacking” the microbiome, advances in the life sciences and its associated technological revolution have already altered the biosecurity landscape, and will continue to do so. What does this new landscape look like, and how can policymakers and other stakeholders navigate this space? A new report by Stanford scholars David Relman and Megan Palmer along with George Mason University’s Jesse Kirkpatrick and Greg Koblentz assesses this emerging biosecurity landscape to help answer these questions and illustrates gaps in governance and regulation through the use of scenarios.

The report—the product of two years of workshops, issue briefs, and white papers authored by different participants—involved people from different organizations and backgrounds ranging from life sciences and medicine to social science and ethics. “The project process was just as important as the product,” said Palmer. “It was a truly interdisciplinary effort.”

Genome editing, including CRISPR, is disruptive to the biosecurity landscape, and it serves as an illustration of more general trends in the evolving landscape, the authors write. CRISPR technology does not exist in a vacuum—rather, it is enabled by, represents, and gives rise to a suite of technologies with potential benefits and that require new approaches to adaptive policy making and governance.

Scenarios illustrating governance gaps in in the report include:

• A reckless CRISPR user who develops and markets a probiotic created with genome editing that has serious unanticipated effects for consumers;
• An agricultural biotechnology firm conducting dual use genome editing research that lies outside current oversight, but nonetheless could have negative consequences for human health
• An intentional release of a gene drive organism from a lab, that while having limited physical harm, feeds a state-based misinformation campaign with large economic impacts
• An accidental release of a gene drive organism due to lack of awareness and uncertainty about the risk classifications and protocols for handling new technologies
• A terrorist group using commercial firms that lack strong customer and order screening to use genome editing to weaponize a nonpathogenic bacteria
• A state-sponsored program to develop biological weapons for new strategic uses, including covert assassination, using largely publicly available research
   

In each of these examples, the researchers play out a hypothetical situation exposing a number of security and governance gaps for policymakers and other stakeholders to address.

In the report, the authors conclude that genome editing has tremendous potential benefits and economic impacts. The authors note that the market for genome editing is expected to exceed $3.5 billion by 2019, but a security incident, safety lapse, reckless misadventure, or significant regulatory uncertainty could hurt growth. Increased reliance on the “bio-economy,” they write, means biosecurity is increasingly critical to economic security as well as human health.

Other key takeaways:

Genome editing has the potential to improve the human condition. Genome editing is poised to make major beneficial contributions to basic research, medicine, public health, agriculture, and manufacturing that could reduce suffering, strengthen food security, and protect the environment.

Genome editing is disruptive to the biosecurity landscape. The threat landscape has, and continues to expand to include new means of disrupting or manipulating biological systems and processes in humans, plants, and animals. Genome editing could be used to create new types of biological weapons. Further, technical advances will make misuse easier and more widespread.

CRISPR illuminates broader trends and the challenges of an evolving security landscape. An approach to biosecurity that accounts for these trends, and encompasses risks posed by deliberate, accidental, and reckless misuse, can help address the complex and evolving security landscape.

Technology must be taken seriously.  A thorough, informed, and accessible analysis of any emerging technology is crucial to considering the impact that it may have on the security landscape.

Key stakeholders must be engaged. Stakeholders in the genome editing field encompass a more diverse array of actors than those that have been involved so far in biosecurity discussions. These stakeholders range from international organizations to government agencies to universities, companies, lay communities writ large, and scientists.

Applied research is needed to create and implement innovative and effective policies. Applied research is necessary to continue the process of modifying existing governance measures, and testing and adapting new ones, as new genome editing technologies and applications are developed, new stakeholders emerge, and new pathways for misuse are identified.

Download the executive summary and full report at editingbiosecurity.org.

Science moves forward when scientists take risks.

“For example, one of the hottest new ideas in cancer treatment involves using patients’ own immune cells to treat their cancer,” writes Stanford Health Policy’s Jay Bhattacharya in this policy brief. “The researchers who worked on these ideas when they were novel risked failure, but still pursued them.” 

The National Institutes of Health plays an important role in addressing this fail-to-win strategy underlying scientific research, Bhattacharya said. With a $37 billion annual budget, the NIH is the world’s largest funder of biomedical research.

“As a public institution, it can be thought of as ‘patient capital,’ a funding source with a longtime horizon and an understanding that good ideas frequently lead down blind alleys,” Bhattacharya writes with his colleague, Mikko Packalen, a Stanford alumnus and associate professor of economics at the University of Waterloo in Ontario, Canada.

“By that standard, NIH ought to be putting money into novel ideas that cannot get funding from private sources,” they write.

But that doesn’t appear to be the case.

Bhattacharya, a professor of medicine with a PhD in economics, and Packalen conducted a quantitative analysis to measure the extent to which NIH funds novel ideas. They looked at 24 million biomedical research articles in the MEDLINE database published between 1950 and 2017 with an American first author.

“An article was considered novel if the newest idea on which it was built upon was relatively recent in the sense that the idea had first appeared in any biomedical research paper at most a few years prior,” they said in the policy brief for the Stanford Institute for Economic Policy Research, where Bhattacharya is a senior fellow.

They found that from 2010 to 2016, the NIH disproportionately funded biomedical research based neither on the most recent ideas nor on the most longstanding ideas, but rather on those of intermediate vintage introduced into the literature between 1990 and 2005.

“Specifically, NIH funded research based on 10- to 25-year-old ideas at a 55 percent rate, compared with a 45 percent funding rate for more recent or older idea,” they write. “By contrast, from 1990 to 1999, NIH funded research based on new ideas at a higher rate than it funded research drawing on well-established ideas.

“This indicates that NIH has become less likely to support edge science over the past two decades,” the researchers concluded. “These results are disheartening and consistent with a growing body of scholarship that finds NIH review panels becoming more conservative and risk-averse.” 

Policy Reforms

The authors note the NIH recognizes the danger of underfunding high-risk ideas and has taken steps to counter “a creeping conservative bias” by increasing the number of training awards, paying bonuses to young researchers and developing methods for identifying high-risk ideas.

But more needs to be done, they said, recommending that the NIH:

1. Reform the review process and rethink how review panel members are selected;
2. Change the way it measures success to increase tolerance of failure;
3. Develop ways to directly measure the novelty of ideas;
4. Find additional ways to reward scientists working on novel ideas by taking steps to advance their careers.

“If the world’s foremost supporter of biomedical research has indeed become less open to edge science, as our analysis indicates, it bodes poorly for science.” 

Read the Full Policy Brief

The Trump administration has proposed a new rule that would require direct-to-consumer TV advertisements for prescription drugs to disclose the price of their products.

The Centers for Medicare & Medicaid Services (CMS) said the disclosures would help consumers “make informed decisions that minimize not only their out-of-pocket costs, but also expenditures borne by Medicare and Medicaid, both of which are significant problems.”

The idea enjoys broad public support, since medical care and drug costs continue to skyrocket.  A U.S. Senate report earlier this year revealed that the cost of the 20 most commonly prescribed brand-name drugs have risen tenfold in the past five years.

In a June 2018 poll, 76 percent of Americans favored required drug advertisements to include a statement about how much the drugs cost.

But Michelle Mello, a Stanford Law School professor and Stanford Medicine professor of health research and policy, writes in this New England Journal of Medicine perspective that the proposed rule raises substantial public health and legal concerns.

A potential unintended consequence of price disclosure may be to dissuade patients from seeking care, writes Mello and her co-author, Stacie B. Dusetzina of Vanderbilt University School of Medicine, because of the perception that they cannot afford treatment. For example, Trulicity, a widely advertised drug for type 2 diabetes has a list price of $730 a month.

“Patients who could benefit from diabetes treatment may assume that they cannot afford it, when in fact insured patients’ costs for Trulicity may be much lower, and cheaper treatment options available,” they write. Metformin, for instance, costs $4 per month for patients who pay cash.

CMS would demand drug makers use the list prices from the Wholesale Acquisition Cost (WAC) in their television ads, including that costs “may be different” for those who are insured.

“This wording doesn’t communicate that costs to patients are probably much lower than the WAC,” writes Mello, a core faculty member at Stanford Health Policy.

This could have important legal implications as well, as compelled disclosures in advertising impinge on commercial speech protected by the First Amendment. Furthermore, they write, “disagreement about whether the WAC accurately represents a drug’s price could affect how courts assess the rule when constitutional challenges are inevitably filed.”

The researchers say three aspects of the proposed rule undercut the government’s ability to argue that it would improve patient decision-making and reduce drug spending: 

1. Price information does little to inform consumer decisions if it inaccurately represents actual cost.
2. Consumers can already obtain information on cash prices online and their own cost from their insurer.
3. The rule contains no meaningful enforcement mechanism; CMS plans only to list violators on its website, calling into question whether companies will comply.

“We think that a better alternative would be making patient-specific cost information accessible at the point of prescribing, “ the authors write. 

The cost of prescription drugs should become a routine part of clinician-patient discussions, although they acknowledge that this would put more time constraints on medical practices.

“Providing salient cost information at the right time could help reduce drug spending while preserving patient choice, but we believe that direct-to-consumer advertising is the wrong vehicle,” they write.

A national panel of medical experts is recommending for the first time that clinicians offer daily preventive medication to patients who are at high risk of acquiring HIV/AIDS.

The U.S. Preventive Services Task Force estimates that 1.1 million Americans are currently living with HIV. More than 700,000 people have died from AIDS in the United States since the first cases were reported in 1981 and some 40,000 Americans are diagnosed with the virus each year.

Though HIV is treatable, there is still no vaccine and it has significant health consequences.

But the Task Force said in a published draft recommendation on Tuesday that it found “convincing evidence” that taking a daily pre-exposure prophylaxis, known as PrEP, provides a substantial benefit in decreasing the risk of HIV infection in people at high risk. 

PrEP is a combination of two drugs, tenofovir disoproxil fumarate and emtricitabine, taken in one daily pill. The Centers for Disease Control and Prevention says that PrEP reduces the risk of getting HIV from sex by more than 90 percent and by 70 percent for intravenous drug users.

“Unfortunately, HIV is still a major problem in the United States,” said Stanford Health Policy’s Douglas K. Owens, vice-chairman of the Task Force, an independent, voluntary panel of experts in prevention and evidence-based medicine. “But the evidence on this daily treatment is that, if you take it properly, it’s very effective.”

The Task Force, whose recommendations are followed by primary care physicians and clinical practices across the country, gave the recommendation its highest grade, an A. But it noted that PrEP currently is not being used in many persons at high risk of HIV infection. 

“We hope our recommendation will bring attention to a very effective preventative service,” Owens said. “We want clinicians to be aware that for patients at high risk of HIV, PrEP is an important preventive strategy to discuss.”

The global AIDS epidemic has slowed in recent year. AIDS-related deaths have been reduced by more than 50 percent since the peak of the AIDS crisis in 2004. In 2017, 940,000 people died from AIDS-related illnesses worldwide, compared to 1.4 million in 2010 and 1.9 million in 2004.

But many people remain at risk, including sex workers and people who have been trafficked.

The Task Force recommendation is only for those Americans who remain at high risk for contracting the virus, including:

1. Sexually active men whose male partners are already living with HIV, or have a recent sexually transmitted infection (STI) such as syphilis, gonorrhea, or chlamydia;
2. Heterosexual women and men who are sexually active and have an STI or partner living with HIV or who are inconsistent in their use of condoms with a partner at high risk of HIV;
3. People who inject drugs and either share drug injection equipment.

The Task Force reaffirmed its 2013 recommendation that people ages 15 to 65 and all pregnant women also be screened for HIV in an additional draft recommendation. Both recommendations are open for public comment until December 26.

Preeclampsia is a serious complication of pregnancy that affects 5 to 10 percent of all pregnancies — over 8 million a year worldwide — and claims the lives of 76,000 mothers and half a million babies each year.

The condition causes hypertension and abnormal protein in the urine, and has few effective preventive or therapeutic strategies. The clinical abnormalities usually resolve completely after delivery, but recent research shows that women who have had preeclampsia have higher rates of heart disease later in life, for reasons that are poorly understood.

That’s where Mark Hlatky, Virginia Winn, and their Stanford Medicine research team come in. They were recently awarded a 4-year, $6 million NIH grant from the National Heart, Lung and Blood Institute to study the links between preeclampsia and the subsequent risk of atherosclerotic cardiovascular disease (ASCVD) as women grow older.

“The goal of this study is to improve cardiovascular health in women, by learning how pregnancy affects heart disease later in life,” said Hlatky, a Stanford Health Policy fellow. “We hope that shedding new light on these links can lead to better prevention and treatment.”

The interdisciplinary study called EPOCH — Effect of Preeclampsia On Cardiovascular Health — could eventually help millions of women and their clinicians worldwide.

“Since about 85 percent of women become pregnant at some point during their lives, and heart disease is the leading cause of death in women, determining how pregnancy complications might increase the risk of heart disease later in life could be very important,” said Hlatky, a professor of health research and policy and of cardiovascular medicine. “If there is a specific biomarker ‘signature’ of heart disease risk in women who have had preeclampsia, it would open up new possibilities for risk assessment and better treatment to prevent heart attacks and strokes.”

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Hlatky and his co-principal investigator, Stanford high-risk obstetrician Winn, note that a history of preeclampsia doubles the woman’s risk of future heart disease and stroke, and triples her risk of hypertension. And these adverse consequences occur at younger ages than in women who never developed the condition during pregnancy.

"The dramatic physiologic changes that happen during pregnancy are indeed remarkable," said Winn, the Arline and Pete Harman faculty scholar in the Department of Obstetrics and Gynecology. "This study highlights how complications that occur in pregnancy impact women's health beyond pregnancy." 

The pathogenic links between preeclampsia early in life and ASCVD late in life have been difficult to investigate because the process develops over decades, the authors said. And few clinicians are aware of the link between the condition and late ASCVD risk and there are no validated biomarkers for this process.

Preliminary data that contributed to the application of the project was a direct result of Winn’s endowed Arline and Pete Harman Faculty Scholar award and funding from the Stanford Maternal and Child Health Research Institute and the Stanford Cardiovascular Institute.

The 4-year grant will support a multi-disciplinary research team in taking a life-course approach. The EPOCH study will enroll three cohorts of women at distinct points in the natural history of the disorder: during pregnancy in their reproductive years; during the long, asymptomatic period in mid-life; and the ultimate development of ASCVD in later life.

“It’s very difficult to study the effects of early life events on the development of diseases late in life, since they are separated by 40 years or more,” Hlatky said. “We don’t have reliable health records in the United States from 40 or more years ago, so it’s a challenge for American researchers.” This is why, he said, the EPOCH study includes researchers from Denmark, which has a national health system, complete medical data of their citizens since the 1970’s, and a national biobank that will allow study of later life events.

The first cohort of women will include some of those who are already part of the Stanford March of Dimes Prematurity Research Center. The center, led by David Stevenson began recruiting women in 2011 to study pregnancy from the first trimester through delivery. The study has collected a wide array of “omics” measures at multiple time points: metabolomics, proteomics, cell-free RNA, the microbiome and immune cells for analysis, as well as collection of amniotic fluid, cord blood, and the placenta. The pregnancy cohort will enroll additional women who are cared for at Lucile Packard Children’s Hospital for treatment of preeclampsia, about 100 in all, plus a matched group with uncomplicated pregnancies.

This is where it gets pretty technical — but also pretty cool

The researchers will collect high-dimensional “omic” biomarker data to assess the pathophysiology of preeclampsia and its relationship to cardiovascular function and disease. They’ll assess cell signaling pathways using single-cell immune profiling (CyTOF) methods in the lab of Brice Gaudilliere, an assistant professor of anesthesia.

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They will then analyze the cell-free RNA profiles using methods developed by co-investigator Stephen Quake, a professor of bioengineering and applied physics, and co-president of the Chan Zuckerberg Biohub. They will assess metabolomics using novel methods also developed at Stanford by co-investigator Michael Snyder,  professor and chair of genetics.

Stanford data scientists, including co-investigators, Robert Tibshirani and Nima Aghaeepour, have been at the forefront of developing and applying novel statistical and bioinformatic approaches, which the team will use to analyze the torrents of data that can now be collected by modern “omics” technologies from individual clinical research subjects.

“The EPOCH study is truly interdisciplinary — we are bringing together faculty from eight different departments to study a major problem in women’s health.”

The second, mid-life cohort will be recruited from women who had a pregnancy complicated by preeclampsia. Marcia Stefanick, professor of medicine in the Stanford Prevention Research Center, will use the Stanford Medicine Research Data Repository (STARR), which contains electronic records from more than 1.6 million patients since 1995, to identify eligible women. Stefanick and the EPOCH team will recruit 200 pre-menopausal women who had either a pregnancy complicated by preeclampsia or an uncomplicated pregnancy.

The third, late-life cohort of women will be identified in the Danish National Biobank by Stanford visiting professor Mads Melbye. Samples will be retrieved from women who had preeclampsia early in life and ASCD later in life, as well as a set of matched control subjects, and analyzed in Stanford laboratories.

“We’re not quite sure whether the physiologic challenges of pregnancy that result in preeclampsia simply reveal underlying cardiovascular risk, or causes change that leads to the increased risk in later life,” Winn said. “The EPOCH study will identify unique aspects of preeclampsia that links it to later ASCVD, opening potential novel approaches to improve women’s health.”

The EPOCH study brings together investigators from eight departments. Additional faculty include Gary Shaw and Seda Tierney (Pediatrics), Martin Angst (Anesthesia), Nicholas Leeper (Surgery) and Heather Boyd (Danish Biobank).

Research by Stanford Health Policy’s Michelle Mello looks at what happens when a group of hospitals started systematically acknowledging adverse outcomes in care by apologizing and proactively offering compensation where substandard care caused serious harm. 

Hospitals have traditionally “crouched in a deny-and-defend posture when things go wrong in medical care,” said Mello, a professor of law at Stanford Law School and a professor of health research and policy. The new approach, called “a communication-and-resolution program,” or CRP, is being adopted by an increasing number of health-care facilities.

“None of the hospitals experienced worsening liability or trends after CRP implementation, which suggests that transparency, apology, and proactive compensation can be pursued without adverse financial consequences,” Mello and her co-authors write in the study published Monday in Health Affairs. However, despite the growing consensus that CRPs are the right thing to do, concerns over liability risks remain.”

Stanford Health Policy asked Mello some questions about the research:

Could this new approach to resolving patient conflict be a thing of the future?

Hospitals that adopt CRPs believe they will help improve patient safety and are consistent with the ethical obligation to disclose medical errors; they also hope they will reduce liability costs. However, there is a lot of uncertainty about their effects on costs. On the one hand, being honest with patients could avoid the anger that prompts patients to sue, and compensating injured patients early on saves on litigation expenses. On the other hand, in the traditional system, very few patients injured by substandard care ever get compensated. Offering up admissions of error and early compensation could mean a lot more patients receive payment, raising total costs. Uncertainty about this issue continues to be a barrier to widespread adoption of the CRP approach.

What were the key findings in your study?

We evaluated the liability effects of CRP implementation at four Massachusetts hospitals by examining before-and-after trends in malpractice claims, volume, cost, and time to resolution. We then compared those to trends among similar hospitals in the state that did not adopt CRPs. We found that CRP implementation was associated with improved trends in the rate of new claims and legal defense costs at the two big hospitals that implemented these programs — favorable developments that were not seen at comparison hospitals with no communication-and-resolution programs in place. CRP implementation was not associated with significant changes upward or downward in trends of new claims receiving compensation, compensation costs, total liability costs, or average compensation per paid claim, nor was it associated with a significant change in time to resolution.

So then why are the findings important?

The study helps resolve uncertainty about the liability effects of admitting and compensating medical errors, especially since the study design was much stronger than that of previous studies. We found that the CRP approach does not expand liability risk and may, in fact, improve some liability outcomes. Therefore, hospitals can “do the right thing” — be honest about errors, apologize, and compensate patients who are injured by negligence — without adverse financial consequences.

Who began the CRP approach and what is the average payment proactively made to patients who did not receive proper care?

The approach dates to the late 1990s and was first publicized by a Veterans Affairs hospital in Kentucky and then by the University of Michigan Health System, both of which reported very positive outcomes.  Stanford was also an early adopter.

The model calls for patients to be compensated at about what the hospital estimates their claim would be worth in traditional litigation. In our study in Massachusetts, the median payment to patients was $75,000. That’s a lot lower than the median payment in the tort system, but the mix of injuries is different. In traditional litigation, 85 percent of claims involve very serious injuries or deaths, because smaller claims aren’t attractive to plaintiff attorneys. They just go uncompensated. In CRPs, it’s easier for patients with moderate-severity injuries to have access to justice.

In Beijing’s bustling Chaoyang District stands a multi-story building known as the Gonghe Senior Apartments: a 400-bed nursing home for middle-income seniors who are disabled or suffer from dementia. Why is Gonghe unique and why is it worth considering? Because Gonghe is a public-private partnership (PPP), a collaborative organizational structure supported by the District Civil Affairs Bureau Welfare Division that donated the land and building and the nonprofit Yuecheng Senior Living that operates the facility. And because PPPs like Gonghe might just be the right model to address the challenges surrounding elderly care in China as well as in other nations that face a looming burden of population aging.

This was a core message shared by Alan Trager, founder and president of the PPP Initiative Ltd., who spoke at a special workshop organized by Shorenstein APARC’s Asia Health Policy Program (AHPP). Focused on PPPs in health and long-term care in China, the workshop was part of a two-day convening related to the Innovation for Healthy Aging project, a collaborative research project led by APARC Deputy Director and AHPP Director Karen Eggleston that identifies and analyzes productive public-private partnerships advancing healthy aging solutions in East Asia and other regions.

The Innovation for Healthy Aging project is driven by the imperative to respond to a world that is aging rapidly. This demographic transition, reminded Trager at the opening of his talk, is a defining issue of our time, as aging is a multisectoral issue that increases the demand for health care, long-term care, and a large number of other social services. The aging challenge is exacerbated by its convergence with the rising prevalence of non-communicable diseases (NCDs), also known as chronic diseases. For while NCDs affect all age groups, they account for the highest burden among the elderly.

China: Ground Zero for Global Aging

Alan Trager discusses health and long-term care in China in the GSB's Highly Immersive Classroom

The need to advance healthy aging and NCD prevention is a matter of grave concern in China, whose older population is larger than in any other country. Moreover, the aging challenge in China is interwoven with unique social trends. In particular, filial piety—which, for thousands of years, has been a fundamental family value and a mainstay of health and elder care—is under pressure, as young people strive to balance the demands of careers, fewer children per family, and migrating to cities for school and work, without affordable housing or long-term care financing support for their parents and other elderly relatives, who often stay in rural areas.

China’s health system is yet to adapt to the shift in the disease burden and health care needs driven by the aging population. Its existing health insurance programs are insufficient for outpatient management and care of chronic conditions, and as Trager emphasized, there is a lack of investment in training geriatric medicine professionals and incorporating geriatric principles into clinical practice.

How can China meet the high demand for elder care, increase workforce capacity, and promote healthy aging?

The answer, claims Trager, lies in developing multisector, integrated solutions to the challenges posed by population aging. While system-level efforts, such as building the social protection system and sustaining universal health coverage, continue to be led by the government, PPPs can play a major role in capacity building to ensure the sustainability of such systems through the advancement of technology, human resources, and innovation. Trager shared PPP Initiative Ltd.’s recent efforts to develop PPP solutions for aging populations in China and elsewhere. The workshop was held on October 10 at the Stanford GSB’s Highly Immersive Classroom, which is equipped with advanced video conferencing technology that allows participants in Palo Alto and at the Stanford Center at Peking University to collaborate in real-time. Experts from Beijing joined the discussion and followed Trager’s presentation with comments on how to move from awareness to action.

Private Efforts, Public Value

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Public-private collaborations—or rather collaborative governance–in China as well as in the United States is the subject of an upcoming volume co-authored by Eggleston with Harvard scholars Richard Zeckhauser and John Donahue. Both Zeckhauser and Donahue joined Eggleston the following day, October 11, at an AHPP-hosted seminar to discuss this upcoming publication, titled Private Roles for Public Goals in China and the United States: Contracting, Collaboration, and Delegation.

Eggleston, Donahue, and Zeckhauser define collaborative governance as private engagement in public tasks on terms of shared discretion, where each partner bears responsibilities for certain areas. Their upcoming book explores public-private collaborations in China and the United States, two countries where public needs require solutions that far outstrip the capacities of their governments alone. Beyond considering merely health and elderly care, the book features research into public and private roles in the governance of multiple other sectors, including education, transport infrastructure, affordable housing, social services, and civil society.

At the seminar, the three scholars reviewed different models of private efforts providing public value, outlined the justifications for collaborative governance, and explained some of the conditions that make such collaborative partnerships productive and valuable. They emphasized the need to account for the unique contexts in China and the United States and to steer clear of one-size-fits-all solutions.

Imperative for the Young Generation

One thing, they all agree, applies to both countries: government collaboration with private entities is inevitable if China and the United States are to achieve their articulated goals and meet rapidly increasing demand for high-end public services.

This sentiment echoed a claim Trager made the preceding day: a tidal wave of noncommunicable diseases in an aging world is approaching us quickly and governments cannot handle it alone. Young people must care about advancing creative solutions to this pressing problem because they will be the ones who will pay for the consequences if we get it wrong.

Stanford Health Policy's Paul Wise held a conversation with Dr. Jim Yong Kim, president of the World Bank Group about improving the health of the poorest communities around the world. The two old friends talked about their work and the keys to accomplishing big goals during the Conversation in Global Health event. Wise is a core faculty member at Stanford Health Policy and the Center for Innovation in Global Health, as well as a senior fellow at the Freeman Spogli Institute for International Studies.

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