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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

CHRONIC HUNGER IN A TIME OF PROSPERITY

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

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

FOOD DIVERSIFICATION AND INTENSIFICATION

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

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

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

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

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

LOOKING AHEAD

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

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

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

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

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

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

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

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

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

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

Two planning grants were also awarded, as follows:

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

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