Stanford University

Health policy

February 2010 Dispatch - Strict Liability for Medical Injuries? The Impact of Increasing Malpractice Liability on Obstetrician Behavior in Taiwan

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Brian Chen
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Malpractice liability, along with medical technology and payment system distortions, regularly figures among the most-cited reasons for escalating health-care spending in the United States. On the one hand, Harvard economist Amitabh Chandra conservatively estimates that upwards of $60 billion, or 3 percent of total health care costs ($1.8 trillion), is spent annually as a result of direct litigation and indirect defensive medicine costs. On the other hand, tort reform advocates place the figure at $200 billion by extrapolating, to the entire U.S. population, the results of research conducted by Stanford professor Dan Kessler and Mark McClellan. Their 1996 study shows that tort reforms reduced provider liability costs for Medicare heart patients by 5 to 9 percent.

At the heart of these debates is the following question. Does medical malpractice liability achieve its dual goal of compensating victims of medical injuries and deterring medical errors, or does it merely encourage wasteful defensive medicine without improving patient health? Despite considerable empirical research, there is little evidence that malpractice litigation deters medical negligence. The evidence is much stronger—though still hotly debated—that malpractice fears actually encourage physicians to engage in defensive medicine. My work at Shorenstein APARC explores whether malpractice pressures affect physician behavior, patient health, and health care costs in Asia. Studying physicians’ response to legal changes in Taiwan, I find that greater malpractice liability may, under certain circumstances, prompt physicians to perform more services without necessarily improving patient health.

In particular, I focus on how increased medical malpractice liability affects physicians in Taiwan who provide treatment to pregnant women. I have studied how a series of court rulings as well as an amendment to Taiwanese law between 1997 and 2004 impacted physicians’ test-ordering behavior and decisions to perform Caesarian sections. Traditionally, Taiwanese doctors are held accountable for medical malpractice under two bodies of law: tort law in the Civil Code, and criminal law for harm resulting from negligent acts in the course of professional operations. The latter, prosecutorial approach is rare among industrialized nations.

In January 1998, a Taipei District Court decision in favor of plaintiffs in a civil suit for damages sent shockwaves through the medical community. The district court judge disregarded the traditional tort requirement of proving the defendant’s negligence (or fault), and applied the “strict liability” doctrine of the Consumer Protection Law to impose liability on a medical provider without any showing of wrongdoing. The court decision—subsequently affirmed by the Taipei High Court on September 1, 1999 and by the Supreme Court on May 10, 2001—sparked resentment among medical professionals. Passions flared in heated debates between medical and legal scholars about whether medical services should be considered a covered “service” under the Consumer Protection Law. Economists and legal academics questioned whether the traditional justifications for imposing strict liability apply in the highly unpredictable practice of medicine, especially in obstetrics. The saga concluded in April 2004, when the legislature amended the Medical Law to require negligence or fault in medical malpractice cases.

My research considers the effect of these court rulings and legal amendments on physicians’ test-ordering behavior and their propensity to perform Caesarean sections. I identify two sources of variation in perceived risks of malpractice liability: (1) the differences between the level of exposure to malpractice risks due to the ownership structure and size of the physicians’ place of practice; and (2) the differences in perceived risks based on the physicians’ geographical location.

My results are consistent with the existence of defensive medicine. First, with respect to their propensity to increase laboratory tests and reduce Caesarean sections, physicians who own their clinics (“physician-owners”) in Taiwan reacted more strongly to the legal changes than did physicians who are salaried employees at larger hospitals (“nonowners”). Physician-owners’ behavior did not change, however, in discretionary expenditures that were not associated with defensive medicine. Second, physician-owners working in areas under the jurisdiction of the Taipei District Court reacted more strongly to legal change than did those practicing in Kaohsiung, Taiwan’s second largest city, at the opposite end of the island.

The negative connection between the likelihood of Caesarean deliveries and increased malpractice liability deserves special mention, since most published studies find a positive association between malpractice liability risks and Caesarean rates. However, economists Janet Currie and Bentley MacLeod at Columbia University suggest that reforms in which liability is closely aligned with defendant’s actual levels of care may produce the opposite effect. In the Taiwan context, increased medical malpractice liability accrues directly to the physician-owners. Since Caesarean sections are generally riskier than natural deliveries, it seems logical that higher tort liability in Taiwan may actually decrease the likelihood of deliveries by Caesarean sections. In this sense, my study confirms Currie and MacLeod’s predictions and empirical results.

My work contributes to our understanding of health law and policy in several concrete ways. First, I add support to the existence of defensive medicine, even in a non-Common Law jurisdiction. Since I focus on Taiwan—an environment that lacks malpractice insurance, in which physicians are either owners or employees at providers of varying sizes—my research isolates the pure effect of malpractice liability to a greater extent than do many current studies. Second, I show that interaction between the payment and legal systems may either enhance or mitigate the hypothetical pure effects of legal policies. In a fee-for-service system, physicians subject to higher malpractice risks appear much more willing to increase laboratory tests than to reduce profitable Caesarean sections. Third, my research indicates that, by altering physicians’ exposure to risks, different organizational forms and ownership structures of health care provision may affect defensive medicine at differing rates.

In sum, the practice of “defensive medicine” appears not to be a uniquely American phenomenon. Indeed, it may also play a role in health care cost escalations in Asia, especially under heightened physician liability regimes.

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Shorenstein APARC Dispatches are regular bulletins designed exclusively for our friends and supporters. Written by center faculty and scholars, Shorenstein APARC Dispatches deliver timely, succinct analysis on current events and trends in Asia, often discussing their potential implications for business.

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With the rapid growth of the Chinese economy and transition from central planning to a more market-oriented structure since the 1980s, private health care providers have gained market share, especially in provision of primary health care, despite legal and administrative obstacles.  To reach the goals for universal health care coverage, access and quality announced in April 2009 as part of China’s new health reforms, effective government stewardship of non-state health care providers will be crucial. This presentation will give an overview of private providers in the grass roots health delivery system in urban and rural China, as well as evidence from field study. Policy trends in stewardship, contracting out and how private providers can better participate in universe health insurance are discussed.

Yan Wang is deputy director of the Disease Control Division for the Shandong Province Health Department, China, and a visiting scholar with the Asia Health Policy Program at the Shorenstein Asia Pacific Research Center at Stanford University in 2009-2010. She received her Ph.D. in public health from Shandong University and has been in charge of managing rural and urban community health services for Shandong’s 90 million residents for 10 years. Her research interests focus on evidence to improve policies for primary health care, health insurance, and health promotion.

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Shorenstein APARC
Stanford University
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AHPP Visiting Scholar, 2009-2010
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Dr. Yan Wang is a visiting scholar at Shorenstein Asia-Pacific Research Center for 2009-2010. Her research focuses on tobacco control, primary health care system, health education and health promotion, and health insurance. She is currently also the group manager of Division of Grass-Root Health Services, Shandong Provincial Health Department, P.R.China, and is in charge of urban community health services, health education and health promotion. She has an MA in public health from Shandong Medical University and PhD in Social Medicine and Health Management from Shandong University. Dr. Yan Wang has been an adjunct professor at Weifang Medical University since 2008. She also engaged in academic association and public organizations related to health affair.

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Better Governance for Better Health: Harnessing applied methods to advance the study of the political determinants of health

On April 26 and 27, the Center for Democracy, Development and Rule of Law (CDDRL) and the Center for Health Policy (CHP-PCOR) at Stanford University will hold a two-day conference on Governance and Health. The conference aims to bring together political scientists, economists, medical doctors, and health policy experts seeking to provide better answers as to how governance may hinder or improve health in developing countries. There will be a focus on highlighting empirical tools and research strategies such as surveys, randomized control trials, Geographic Information Systems (GIS), and behavioral experiments to allow researchers to share expertise and exchange ideas about new approaches to studying the links between governance and health. Understanding the mechanisms linking governance to health will help move us toward meaningful policy recommendations to save lives and improve wellbeing.

 

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Claire Adida

Encina Hall
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Senior Fellow, Freeman Spogli Institute for International Studies
Professor (by courtesy) of Political Science
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Claire Adida is Senior Fellow at FSI (CDDRL), Professor (by courtesy) of Political Science, and faculty co-director at the Immigration Policy Lab at Stanford University. She is also a faculty affiliate with the Center for Effective Global Action (CEGA), the Evidence in Governance and Politics (EGAP) group, the Policy Design and Evaluation Lab (PDEL), and the Future of Democracy Initiative at the UC Institute on Global Conflict and Cooperation (IGCC). She is an invited researcher with J-PAL’s Humanitarian Protection and Displaced Livelihoods Initiatives and an international advisory board member with CFREF’s Bridging Divides research program.

Adida uses quantitative and field methods to investigate how countries manage new and existing forms of diversity, what exacerbates or alleviates outgroup prejudice and discrimination, and how vulnerable groups navigate discriminatory environments. She has published two books on immigrant integration and exclusion: Immigrant exclusion and insecurity in Africa; Coethnic strangers (Cambridge University Press, 2014); and Why Muslim integration fails in Christian-heritage societies (with David Laitin and Marie-Anne Valfort, Harvard University Press, 2016). Her articles are published in the American Political Science Review, Science Advances, the Proceedings of the National Academy of Sciences, the Quarterly Journal of Political Science, Comparative Political Studies, the Journal of Population Economics, the Journal of Experimental Political Science, and Political Science Research & Methods, among others.

Prior to joining Stanford, she was Assistant Professor (2010-2016), Associate Professor (2016-2022), and Professor of Political Science at UC San Diego, where she also served as the co-Director and Director of the Center for Comparative Immigration Studies (2018-2024). In 2021-2022, she served as Research Advisor to the Director of the Office of Refugee Resettlement in the U.S. Government’s Department of Health & Human Services. She received her Ph.D. in political science from Stanford University in 2010, her Master's in International Affairs from Columbia University’s School of International and Public Affairs (2003), and her Bachelor's in political science and communication studies from Northwestern University (2000).

CDDRL Visiting Scholar, Summer 2016
CDDRL Hewlett Fellow, 2008-09
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Beatriz Magaloni

Dept. of Political Science
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Senior Fellow at the Freeman Spogli Institute for International Studies
Graham H. Stuart Professor of International Relations
Professor of Political Science
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Beatriz Magaloni Magaloni is the Graham Stuart Professor of International Relations at the Department of Political Science. Magaloni is also a Senior Fellow at the Freeman Spogli Institute, where she holds affiliations with the Center on Democracy, Development and the Rule of Law (CDDRL) and the Center for International Security and Cooperation (CISAC). She is also a Stanford’s King Center for Global Development faculty affiliate. Magaloni has taught at Stanford University for over two decades.

She leads the Poverty, Violence, and Governance Lab (Povgov). Founded by Magaloni in 2010, Povgov is one of Stanford University’s leading impact-driven knowledge production laboratories in the social sciences. Under her leadership, Povgov has innovated and advanced a host of cutting-edge research agendas to reduce violence and poverty and promote peace, security, and human rights.

Magaloni’s work has contributed to the study of authoritarian politics, poverty alleviation, indigenous governance, and, more recently, violence, crime, security institutions, and human rights. Her first book, Voting for Autocracy: Hegemonic Party Survival and its Demise in Mexico (Cambridge University Press, 2006) is widely recognized as a seminal study in the field of comparative politics. It received the 2007 Leon Epstein Award for the Best Book published in the previous two years in the area of political parties and organizations, as well as the Best Book Award from the American Political Science Association’s Comparative Democratization Section. Her second book The Politics of Poverty Relief: Strategies of Vote Buying and Social Policies in Mexico (with Alberto Diaz-Cayeros and Federico Estevez) (Cambridge University Press, 2016) explores how politics shapes poverty alleviation.

Magaloni’s work was published in leading journals, including the American Political Science Review, American Journal of Political Science, Criminology & Public Policy, World Development, Comparative Political Studies, Annual Review of Political Science, Cambridge Journal of Evidence-Based Policing, Latin American Research Review, and others.

Magaloni received wide international acclaim for identifying innovative solutions for salient societal problems through impact-driven research. In 2023, she was named winner of the world-renowned Stockholm Prize in Criminology, considered an equivalent of the Nobel Prize in the field of criminology. The award recognized her extensive research on crime, policing, and human rights in Mexico and Brazil. Magaloni’s research production in this area was also recognized by the American Political Science Association, which named her recipient of the 2021 Heinz I. Eulau Award for the best article published in the American Political Science Review, the leading journal in the discipline.

She received her Ph.D. in political science from Duke University and holds a law degree from the Instituto Tecnológico Autónomo de México.

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Grant Miller

Encina Commons Room 101,
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Henry J. Kaiser, Jr. Professor
Professor, Health Policy
Senior Fellow at the Freeman Spogli Institute for International Studies
Senior Fellow at the Stanford Institute for Economic Policy Research
Professor, Economics (by courtesy)
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As a health and development economist based at the Stanford School of Medicine, Dr. Miller's overarching focus is research and teaching aimed at developing more effective health improvement strategies for developing countries.

His agenda addresses three major interrelated themes: First, what are the major causes of population health improvement around the world and over time? His projects addressing this question are retrospective observational studies that focus both on historical health improvement and the determinants of population health in developing countries today. Second, what are the behavioral underpinnings of the major determinants of population health improvement? Policy relevance and generalizability require knowing not only which factors have contributed most to population health gains, but also why. Third, how can programs and policies use these behavioral insights to improve population health more effectively? The ultimate test of policy relevance is the ability to help formulate new strategies using these insights that are effective.

Faculty Fellow, Stanford Center on Global Poverty and Development
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Lisa Blaydes

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Senior Fellow at the Freeman Spogli Institute for International Studies
Professor of Political Science
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Lisa Blaydes is a Professor of Political Science at Stanford University. She is the author of State of Repression: Iraq under Saddam Hussein (Princeton University Press, 2018) and Elections and Distributive Politics in Mubarak’s Egypt (Cambridge University Press, 2011). Professor Blaydes received the 2009 Gabriel Almond Award for best dissertation in the field of comparative politics from the American Political Science Association for this project.  Her articles have appeared in the American Political Science Review, International Studies Quarterly, International Organization, Journal of Theoretical Politics, Middle East Journal, and World Politics. During the 2008-2009 and 2009-2010 academic years, Professor Blaydes was an Academy Scholar at the Harvard Academy for International and Area Studies. She holds degrees in Political Science (PhD) from the University of California, Los Angeles, and International Relations (BA, MA) from Johns Hopkins University.

 

Affiliated faculty at the Center on Democracy, Development and the Rule of Law
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Alberto Díaz-Cayeros

Encina Hall, C149
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(650) 725-0500
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Senior Fellow, Freeman Spogli Institute for International Studies
Professor, by courtesy, of Political Science
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Alberto Díaz-Cayeros is a Senior Fellow at Stanford University's Freeman Spogli Institute for International Studies (FSI), and co-director of the Democracy Action Lab (DAL), based at FSI's Center on Democracy, Development and Rule of Law (CDDRL). His research interests include federalism, poverty relief, indigenous governance, political economy of health, violence, and citizen security in Mexico and Latin America.

He is the author of Federalism, Fiscal Authority and Centralization in Latin America (Cambridge, reedited 2016), coauthored with Federico Estévez and Beatriz Magaloni, of The Political Logic of Poverty Relief (Cambridge, 2016), and of numerous journal articles and book chapters.

He is currently working on a project on cartography and the developmental legacies of colonial rule and governance in indigenous communities in Mexico.

From 2016 to 2023, he was the Director of the Center for Latin American Studies at Stanford University, and from 2009 to 2013, Director of the Center for US-Mexican Studies at UCSD, the University of California, San Diego.

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Director of the Center for Latin American Studies (2016 - 2023)
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Larry Diamond

CDDRL
Stanford University
Encina Hall, C147
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Mosbacher Senior Fellow in Global Democracy at the Freeman Spogli Institute for International Studies
William L. Clayton Senior Fellow at the Hoover Institution
Professor, by courtesy, of Political Science and Sociology
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Larry Diamond is the William L. Clayton Senior Fellow at the Hoover Institution, the Mosbacher Senior Fellow in Global Democracy at the Freeman Spogli Institute for International Studies (FSI), and a Bass University Fellow in Undergraduate Education at Stanford University. He is also professor by courtesy of Political Science and Sociology at Stanford, where he lectures and teaches courses on democracy (including an online course on EdX). At the Hoover Institution, he co-leads the Project on Taiwan in the Indo-Pacific Region and participates in the Project on the U.S., China, and the World. At FSI, he is among the core faculty of the Center on Democracy, Development and the Rule of Law, which he directed for six and a half years. He leads FSI’s Israel Studies Program and is a member of the Program on Arab Reform and Development. He also co-leads the Global Digital Policy Incubator, based at FSI’s Cyber Policy Center. He served for 32 years as founding co-editor of the Journal of Democracy.

Diamond’s research focuses on global trends affecting freedom and democracy and on U.S. and international policies to defend and advance democracy. His book, Ill Winds: Saving Democracy from Russian Rage, Chinese Ambition, and American Complacency, analyzes the challenges confronting liberal democracy in the United States and around the world at this potential “hinge in history,” and offers an agenda for strengthening and defending democracy at home and abroad.  A paperback edition with a new preface was released by Penguin in April 2020. His other books include: In Search of Democracy (2016), The Spirit of Democracy (2008), Developing Democracy: Toward Consolidation (1999), Promoting Democracy in the 1990s (1995), and Class, Ethnicity, and Democracy in Nigeria (1989). He has edited or coedited more than fifty books, including China’s Influence and American Interests (2019, with Orville Schell), Silicon Triangle: The United States, China, Taiwan the Global Semiconductor Security (2023, with James O. Ellis Jr. and Orville Schell), and The Troubling State of India’s Democracy (2024, with Sumit Ganguly and Dinsha Mistree).

During 2002–03, Diamond served as a consultant to the US Agency for International Development (USAID) and was a contributing author of its report, Foreign Aid in the National Interest. He has advised and lectured to universities and think tanks around the world, and to the World Bank, the United Nations, the State Department, and other organizations dealing with governance and development. During the first three months of 2004, Diamond served as a senior adviser on governance to the Coalition Provisional Authority in Baghdad. His 2005 book, Squandered Victory: The American Occupation and the Bungled Effort to Bring Democracy to Iraq, was one of the first books to critically analyze America's postwar engagement in Iraq.

Among Diamond’s other edited books are Democracy in Decline?; Democratization and Authoritarianism in the Arab World; Will China Democratize?; and Liberation Technology: Social Media and the Struggle for Democracy, all edited with Marc F. Plattner; and Politics and Culture in Contemporary Iran, with Abbas Milani. With Juan J. Linz and Seymour Martin Lipset, he edited the series, Democracy in Developing Countries, which helped to shape a new generation of comparative study of democratic development.

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Former Director of the Center on Democracy, Development and the Rule of Law
Faculty Chair, Jan Koum Israel Studies Program
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Seema Jayachandran

Landau Economics Bldg, Room 230
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Assistant Professor of Economics
CHP/PCOR Affiliate
CDDRL Affiliated Faculty

Seema Jayachandran is an assistant professor in the Department of Economics at Stanford University. She is also a Faculty Research Fellow at the National Bureau of Economic Research (NBER) and a Research Affiliate of the Bureau for Research and Economic Analysis of Development (BREAD), Centre for Economic Policy Research (CEPR), and Stanford Center for International Development (SCID).

Her research focuses on microeconomic issues in developing countries, including health, education, labor markets, and political economy. Her work has been published in the American Economic Review ("Odious Debt," on sovereign debt incurred by dictators), Journal of Political Economy ("Selling Labor Low," on labor market risk in India), and the Quarterly Journal of Economics ("Life Expectancy and Human Capital Investments," on increased education caused by declines in maternal mortality in Sri Lanka), and other journals. Her current projects are based in India, Nepal, and Zimbabwe.

She also works on social issues in the United States. Previously she was a Robert Wood Johnson Scholar in Health Policy Research at the University of California, Berkeley. She also worked as a management consultant with McKinsey & Company in San Francisco. She earned a PhD and master's degree from Harvard University, a master's degree from the University of Oxford where she was a Marshall Scholar, and a bachelor's degree from MIT.

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Kim Dionne Speaker University of California, Los Angeles
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Kathryn Stoner

FSI
Stanford University
Encina Hall C140
Stanford, CA 94305-6055

(650) 736-1820 (650) 724-2996
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Satre Family Senior Fellow, Freeman Spogli Institute for International Studies
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Kathryn Stoner is the Mosbacher Director of the Center on Democracy, Development, and the Rule of Law (CDDRL), and a Senior Fellow at CDDRL and the Center on International Security and Cooperation at FSI. From 2017 to 2021, she served as FSI's Deputy Director. She is Professor of Political Science (by courtesy) at Stanford and she teaches in the Department of Political Science, and in the Program on International Relations, as well as in the Ford Dorsey Master's in International Policy Program. She is also a Senior Fellow (by courtesy) at the Hoover Institution.

Prior to coming to Stanford in 2004, she was on the faculty at Princeton University for nine years, jointly appointed to the Department of Politics and the Princeton School for International and Public Affairs (formerly the Woodrow Wilson School). At Princeton she received the Ralph O. Glendinning Preceptorship awarded to outstanding junior faculty. She also served as a Visiting Associate Professor of Political Science at Columbia University, and an Assistant Professor of Political Science at McGill University. She has held fellowships at Harvard University as well as the Woodrow Wilson Center in Washington, DC. 

In addition to many articles and book chapters on contemporary Russia, she is the author or co-editor of six books: "Transitions to Democracy: A Comparative Perspective," written and edited with Michael A. McFaul (Johns Hopkins 2013);  "Autocracy and Democracy in the Post-Communist World," co-edited with Valerie Bunce and Michael A. McFaul (Cambridge, 2010);  "Resisting the State: Reform and Retrenchment in Post-Soviet Russia" (Cambridge, 2006); "After the Collapse of Communism: Comparative Lessons of Transitions" (Cambridge, 2004), coedited with Michael McFaul; and "Local Heroes: The Political Economy of Russian Regional" Governance (Princeton, 1997); and "Russia Resurrected: Its Power and Purpose in a New Global Order" (Oxford University Press, 2021).

She received a BA (1988) and MA (1989) in Political Science from the University of Toronto, and a PhD in Government from Harvard University (1995). In 2016 she was awarded an honorary doctorate from Iliad State University, Tbilisi, Republic of Georgia.

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Mosbacher Director, Center on Democracy, Development and the Rule of Law
Professor of Political Science (by courtesy), Stanford University
Senior Fellow (by courtesy), Hoover Institution
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Paul H. Wise

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Richard E. Behrman Professor of Child Health and Society
Senior Fellow, Freeman Spogli Institute for International Studies
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Dr. Paul Wise is dedicated to bridging the fields of child health equity, public policy, and international security studies. He is the Richard E. Behrman Professor of Child Health and Society and Professor of Pediatrics, Division of Neonatology and Developmental Medicine, and Health Policy at Stanford University. He is also co-Director, Stanford Center for Prematurity Research and a Senior Fellow in the Center on Democracy, Development, and the Rule of Law, and the Center for International Security and Cooperation, Freeman Spogli Institute for International Studies, Stanford University. Wise is a fellow of the American Academy of Arts and Sciences and has been working as the Juvenile Care Monitor for the U.S. Federal Court overseeing the treatment of migrant children in U.S. border detention facilities.

Wise received his A.B. degree summa cum laude in Latin American Studies and his M.D. degree from Cornell University, a Master of Public Health degree from the Harvard School of Public Health and did his pediatric training at the Children’s Hospital in Boston. His former positions include Director of Emergency and Primary Care Services at Boston Children’s Hospital, Director of the Harvard Institute for Reproductive and Child Health, Vice-Chief of the Division of Social Medicine and Health Inequalities at the Brigham and Women’s Hospital and Harvard Medical School and was the founding Director or the Center for Policy, Outcomes and Prevention, Stanford University School of Medicine. He has served in a variety of professional and consultative roles, including Special Assistant to the U.S. Surgeon General, Chair of the Steering Committee of the NIH Global Network for Women’s and Children’s Health Research, Chair of the Strategic Planning Task Force of the Secretary’s Committee on Genetics, Health and Society, a member of the Advisory Council of the National Institute of Child Health and Human Development, NIH, and the Health and Human Secretary’s Advisory Committee on Infant and Maternal Mortality.

Wise’s most recent U.S.-focused work has addressed disparities in birth outcomes, regionalized specialty care for children, and Medicaid. His international work has focused on women’s and child health in violent and politically complex environments, including Ukraine, Gaza, Central America, Venezuela, and children in detention on the U.S.-Mexico border.  

Core Faculty, Center on Democracy, Development and the Rule of Law
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James D. Fearon

CISAC
Stanford University
Encina Hall
Stanford, CA 94305-6165

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Senior Fellow at the Freeman Spogli Institute for International Studies
Theodore and Frances Geballe Professor in the School of Humanities and Sciences
Professor of Political Science
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James Fearon is the Theodore and Frances Geballe Professor in the School of Humanities and Sciences and a professor of political science. He is a Senior Fellow at FSI, affiliated with CISAC and CDDRL. His research interests include civil and interstate war, ethnic conflict, the international spread of democracy and the evaluation of foreign aid projects promoting improved governance. Fearon was elected to the National Academy of Sciences in 2012 and the American Academy of Arts and Sciences in 2002. Some of his current research projects include work on the costs of collective and interpersonal violence, democratization and conflict in Myanmar, nuclear weapons and U.S. foreign policy, and the long-run persistence of armed conflict.

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Organized by Stanford Health Policy Director Alan Garber, the Payment Reform Project brings together a group of economists and researchers interested in creating and studying novel approaches to payment for health care. The Project is the combined effort of Stanford Health Policy, FRESH-Thinking and the Stanford Institute for Economic Policy Research. This is a venue for people who have thought deeply about similar issues in other contexts to contribute to a health care discussion.

NGO "Pioneers for Health" promoting tobacco control in Yunnan, PRC

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On December 18, tobacco control was the theme of the 2009 Kunming Health and Development Conference, co-convened by the Yunnan Health and Development Research Association, Pioneers for Health, and ThinkTank Research Center for Health Development. “Pioneers for Health” is a health policy non-governmental organization (NGO) founded in China a year ago with help from AHPP faculty affiliate Matthew Kohrman, Associate Professor of Anthropology. Pioneers for Health also received the good news that Tobacco-Free Kids/Bloomberg Initiative to Reduce Tobacco Use has renewed it for another two-year grant to cover all operational and health advocacy costs.

Article in Translation (Source:  The Economic Daily 经济日报):

More than sixty specialists and academicians from the fields of medicine, economy and sociology convened in Kunming (YunnanProvince) on December 18 for the 2009 Kunming Health and Development Conference, jointly hosted by the Yunnan Health and Development Research Association, Pioneers for Health, and ThinkTank Research Center for Health Development. The theme of the conference was "Tobacco Control for the Creation of a Healthy Lifestyle".  The conference was divided into three parts. For the first part a short film was shown. Titled "Tobacco: From Global Epidemic to Global Control", the film detailed the history of the global tobacco epidemic and its development up to the current day. It looked at the background and significance of the Framework Convention on Tobacco Control. The specialists and academicians present all agreed that a global consensus has been reached regarding the need for tobacco control. As a signatory of the FCTC and as a large nation, China is now responsible for carrying out a huge task. Tobacco control in Yunnan Province will be especially arduous. The second part -- Tobacco Control in Yunnan; Taking the First Step -- focused on the tobacco control effort in Yunnan Province. Topics for discussion included an analysis of ideas and methods to prevent youth from smoking. In the third part -- The Challenges and Opportunities for Tobacco Control in Yunnan Province; a Multi-disciplinary Perspective -- economists, sociologists and health experts engaged in a discussion of issues regarding tobacco control. During the discussion the participants stressed that tobacco control concerns not only public health, but also community development, the domestic economy, the people's livelihood, and the government's image. The most popular topics in this segment were "Tobacco and the Economy", "Tobacco and Health", and "The Influence of Popular Culture on the Behavior of Smoking". A multi-disciplinary approach was used when delving into the issues surrounding tobacco control.

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Reducing the nuclear threat: The argument for public safety

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In this op-ed, CISAC's Richard Rhodes argues that public health, a discipline that organizes science-based systems of surveillance and prevention, has been primarily responsible for controlling the effects of infectious disease. A similar campaign around public safety could help end the existential threat posed by nuclear weapons. Such a push would help create unity in common security and a fundamental transformation in relationships between nations, Rhodes argues.

Today, at the other end of the long trek down the glacier of the Cold War, the nuclear threat has seemingly calved off and fallen into the sea. In 2007, the Pew Research Center's Global Attitudes Project found that 12 countries rated the growing gap between rich and poor as the greatest danger to the world. HIV/AIDS led the list (or tied) in 16 countries, religious and ethnic hatred in another 12. Pollution was identified as the greatest menace in 19 countries, while substantial majorities in 25 countries thought global warming was a "very serious" problem. Only nine countries considered the spread of nuclear weapons to be the greatest danger to the world.

The response was very different among nuclear and national security experts when Indiana Republican Sen. Richard Lugar surveyed PDF them in 2005. This group of 85 experts judged that the possibility of a WMD attack against a city or other target somewhere in the world is real and increasing over time. The median estimate of the risk of a nuclear attack somewhere in the world by 2010 was 10 percent. The risk of an attack by 2015 doubled to 20 percent median. There was strong, though not universal, agreement that a nuclear attack is more likely to be carried out by a terrorist organization than by a government. The group was split 45 to 55 percent on whether terrorists were more likely to obtain an intact working nuclear weapon or manufacture one after obtaining weapon-grade nuclear material.

"The proliferation of weapons of mass destruction is not just a security problem," Lugar wrote in the report's introduction. "It is the economic dilemma and the moral challenge of the current age. On September 11, 2001, the world witnessed the destructive potential of international terrorism. But the September 11 attacks do not come close to approximating the destruction that would be unleashed by a nuclear weapon. Weapons of mass destruction have made it possible for a small nation, or even a sub-national group, to kill as many innocent people in a day as national armies killed in months of fighting during World War II.

"The bottom line is this," Lugar concluded: "For the foreseeable future, the United States and other nations will face an existential threat from the intersection of terrorism and weapons of mass destruction."

It's paradoxical that a diminished threat of a superpower nuclear exchange should somehow have resulted in a world where the danger of at least a single nuclear explosion in a major city has increased (and that city is as likely, or likelier, to be Moscow as it is to be Washington or New York). We tend to think that a terrorist nuclear attack would lead us to drive for the elimination of nuclear weapons. I think the opposite case is at least equally likely: A terrorist nuclear attack would almost certainly be followed by a retaliatory nuclear strike on whatever country we believed to be sheltering the perpetrators. That response would surely initiate a new round of nuclear armament and rearmament in the name of deterrence, however illogical. Think of how much 9/11 frightened us; think of how desperate our leaders were to prevent any further such attacks; think of the fact that we invaded and occupied a country, Iraq, that had nothing to do with those attacks in the name of sending a message.

Richard Butler, the former chairman of the Canberra Commission on the Elimination of Nuclear Weapons and the last chairman of UNSCOM, often makes the point that the problem with nuclear weapons is nuclear weapons. People don't always understand what he means. He means that it is the weapons themselves that are the problem, not the values of the entities that control them. U.S. nuclear weapons are just as potentially dangerous to the world as, say, North Korean nuclear weapons. More, I would say, since we have greater numbers of them and have not hesitated to brandish them--even to use them--when we thought it in our interest to do so.

That the problem with nuclear weapons is nuclear weapons may seem counterintuitive, but two centuries ago governments began to think that way about disease, with untold benefits to humanity as a result. Epidemic disease had been conceived in normative terms, as an act of God for which states bore no responsibility. The change that came when disease began to be conceived as a phenomenon of nature without a metaphysical superstructure, a public health problem, a problem for government and a measure of government's success, was revolutionary. More lives were saved, and spared, with public health measures in the twentieth century in the United States alone than were lost throughout the world in all of the twentieth century's wars.

As my Scottish friend Gil Elliot wrote in his seminal book Twentieth Century Book of the Dead, "[These lives] are not saved by accident or goodwill. Human life is daily deliberately protected from nature by accepted practices of hygiene and medical care, by the control of living conditions and the guidance of human relationships. Mortality statistics are constantly examined to see if the causes of death reveal any areas needing special attention. Because of the success of these practices, the area of public death has, in advanced societies, been taken over by man-made death--once an insignificant or 'merged' part of the spectrum, now almost the whole.

"When politicians, in tones of grave wonder, characterize our age as one of vast effort in saving human life, and enormous vigor in destroying it, they seem to feel they are indicating some mysterious paradox of the human spirit. There is no paradox and no mystery. The difference is that one area of public death has been tackled and secured by the forces of reason; the other has not. The pioneers of public health did not change nature, or men, but adjusted the active relationship of men to certain aspects of nature so that the relationship became one of watchful and healthy respect. In doing so they had to contend with and struggle against the suspicious opposition of those who believed that to interfere with nature was sinful, and even that disease and plague were the result of something sinful in the nature of man himself."

Elliot goes on to compare what he calls "public death," meaning biological death, death from disease, to man-made death: "[I do not wish] to claim mystical authority for the comparison I have made between two kinds of public death--that which results from disease and that which we call man-made. The irreducible virtue of the analogy is that the problem of man-made death, like that of disease, can be tackled only by reason. It contains the same elements as the problem of disease--the need to locate the sources of the pest, to devise preventive measures, and to maintain systematic vigilance in their execution. But it is a much wider problem, and for obvious reasons cannot be dealt with by scientific methods to the same extent as can disease."

To advance the cause of public health it was necessary to depoliticize disease, to remove it from the realm of value and install it in the realm of fact. Today we have advanced to the point where international cooperation toward the prevention, control, and even elimination of disease is possible among nations that hardly cooperate with each other in any other way. No one any longer considers disease a political issue, except to the extent that its control measures a nation's quality of life, and only modern primitives consider it a judgment of God.

In 1999, for the first time in human history, infectious diseases no longer ranked first among causes of death worldwide. Public health, a discipline which organizes science-based systems of surveillance and prevention, was primarily responsible for that millennial change in human mortality. One-half of all the increases in life expectancy in recorded history occurred within the twentieth century. Most of the worldwide increase was accomplished in the first half of the century, and it was almost entirely the result of public health measures directed to primary prevention. Better nutrition, sewage treatment, water purification, the pasteurization of milk, and the immunization of children extended human life--not surgeons cutting or doctors dispensing pills.

Public health is medicine's greatest success story and a powerful model for a parallel discipline, which I propose to call public safety.

Where nuclear weapons--the largest-scale instruments of man-made death--are concerned, the elements of that discipline of public safety have already begun to assemble themselves: materials control and accounting, cooperative threat reduction, security guarantees, agreements and treaties, surveillance and inspection, sanctions, forceful disarming if all else fails.

Reducing and finally eliminating the world's increasingly vestigial nuclear arsenals may be delayed by extremists of the right or the left, as progress was stalled during the George W. Bush administration by rigid Manichaean ideologues who imagined that there might be good nuclear powers and evil nuclear powers and sought to disarm only those they considered evil. Nuclear weapons operate beyond good and evil. They destroy without discrimination or mercy: Whether one lives or dies in their operation is entirely a question of distance from ground zero. In Elliot's eloquent words, they create nations of the dead, and collectively have the capacity to create a world of the dead. But as Niels Bohr, the great Danish physicist and philosopher, was the first to realize, the complement of that utter destructiveness must then be unity in common security, just as it was with smallpox, a fundamental transformation in relationships between nations, nondiscrimination in unity not on the dark side but by the light of day.

Violence originates in vulnerability brutalized: It is vulnerability's corruption, but also its revenge. "Perhaps everything terrible," the poet Rainer Maria Rilke once wrote, "is in its deepest being something helpless that wants help from us." As we extend our commitment to common security, as we work to master man-made death, we will need to recognize that terrible helplessness and relieve it--in others, but also in ourselves.

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Working paper series on health and demographic change in the Asia-Pacific

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Karen Eggleston
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In December 2009, the Asia Health Policy Program celebrates the first anniversary of the launch of the AHPP working paper series on health and demographic change in the Asia-Pacific. The series showcases research by AHPP’s own affiliated faculty, postdoctoral fellows, and visiting scholars, as well as selected works by other scholars from the region.

To date AHPP has released eleven research papers in the series, by authors from China, South Korea, Thailand, Taiwan, Pakistan, and the US, with more on the way from Japan and Vietnam. Topics range from “The Effect of Informal Caregiving on Labor Market Outcomes in South Korea” and “Comparing Public and Private Hospitals in China,” to “Pandemic Influenza and the Globalization of Public Health.”  The working papers are available at the Asia Health Policy website.

AHPP considers quality research papers from leading research universities and think tanks across the Asia-Pacific region for inclusion in the working paper series. If interested, please contact Karen Eggleston.

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The Health Policy Environment in Vietnam: Observations from an Outside Insider

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The health sector's successes in Vietnam have been described as "legendary" by international donors, but there is always the other side of the story. One can question the objectivity of reports from the government of Vietnam, the World Bank, and the World Health Organization. One can wonder in what areas the health sector has failed, who has paid for a "success story" and at what cost, and how much information is well documented and has been made public. Are there "stylized facts" regarding those aspects of health that have been successfully reformed compared with those where reform has lagged? Given these concerns, how can the research community contribute to improving health policy in Vietnam?

Dr. Truong will share his thought on recent socioeconomic development in Vietnam, discuss key health policy issues, and reflect upon his experiences including a research project in which the University of Queensland collaborated with Ministry of Health of Vietnam. Additional evidence will be drawn from a study of the cost-effectiveness of interventions to reduce tobacco use in Vietnam.

Khoa Truong was a visiting faculty member at the Hanoi School of Public Health and a research fellow at the Health Strategy and Policy Institute in 2008-2009.  Prior to that he spent six years as a doctoral fellow at the RAND Corporation.  His research interests include tobacco, alcohol, and illicit drug control policies; the impacts of built environments on health; international health issues; and economic development.

He received his doctorate and master of philosophy in policy analysis from the Pardee RAND Graduate School and earned a master's degree in development economics from Williams College. A native of Vietnam, he began his career working with NGOs in bilateral and multilateral development projects in Southeast Asia. He was awarded a Fulbright scholarship and wrote “most outstanding paper” submitted at an AcademyHealth's Annual Research Meeting (acknowledged as the premier forum for sharing the results of scholarship on health services).

Daniel and Nancy Okimoto Conference Room

Dr. Khoa Truong Assistant Professor of Department of Public Health Sciences Speaker Clemson University
Seminars

The Social Determinants of Health: Application to Developed and Developing Asia

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Karen Eggleston
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Global health disparities were the topic of a special event November 11th co-sponsored by the Asia Health Policy Program of the Shorenstein Asia-Pacific Research Center and the Center for Health Policy / Primary Care and Outcomes Research.

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

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

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

Examples from Asia include

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

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

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

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