Education is widely considered one of the greatest investments a government can make into its citizens and economic prosperity. At the United States Agency for International Development (USAID), government officials are working with partner countries to improve the quality and reach of their education systems. The agency recently stood up the Center for Education, charged with achieving sustained, measurable improvements in students’ learning outcomes and skills development. In addition, education teams are embedded within regional bureaus and are responsible for assisting with country-level education programming. 

Over the summer, I had the opportunity to intern with USAID’s Africa Bureau, where I learned how the U.S. Government (USG) foreign assistance is programmed to support children and youth’s educational development. During my internship, I participated in numerous working groups that deepened my understanding of what education has the power to do for children and youth, particularly the most vulnerable and marginalized.

One of my most meaningful assignments was helping to lead the USG’s Working Group on Education in Crisis and Conflict Settings. Through this experience, I learned that schooling is important for a myriad of reasons beyond learning outcomes and job placement. In conflict and crises zones, for instance, schools can provide children with physical and emotional protection as well as a greater sense of normalcy. 

For this group, I was responsible for encouraging participant engagement and organizing monthly meetings. I secured additional members, solicited member feedback, and crafted agendas based on participant input and events on the ground. Through this group, I was able to see first-hand how the USG is ensuring the continuity of education programming in some of the most difficult humanitarian crises zones—from Haiti to Afghanistan.

I was also able to take part in several joint research projects that USAID funded in collaboration with external partners. These research projects included: 1) a review of social and emotional learning outcomes for students in Africa, 2) an analysis of how education contributes to resiliency in Africa (and vice-versa), and 3) an examination of how violence against children is perpetrated within school systems and recommendations for prevention. I coordinated workflow between USAID and external partners for these research projects, compiled feedback, participated in working sessions on key findings, and observed field interviews. 

Most significantly, I distilled each of the final research papers into three two-page summary sheets for ease of reference for our team and future collaborators. Of the three research topics, I found the insight into social and emotional learning outcomes to be the most interesting. While I had conceptualized learning outcomes solely in terms of curriculum content, schooling is also paramount for developing students’ social and emotional competencies – from peer-to-peer dynamics to emotional self-regulation. These competencies, which schools, directly and indirectly, teach their students, are critical for helping individuals to manage shocks and stressors into adulthood.

Lastly, I helped to roll out two new initiatives within my team for USAID writ large. First, I helped launch a new USAID working group on promoting resiliency within the education system in Africa.  I worked with the lead organizer to finalize the participant list, develop the kickoff meeting agenda, and review the group’s statement of work and overall mission. Second, I assisted with developing an online training module designed to assist officers with safeguarding and protecting children’s rights within education programs. I coordinated with external partners to organize a two-week pilot testing of the training module – securing expert USAID officers to help pilot, creating and reviewing feedback forms, and taking the training myself.

From this training, I learned that schools are not always safe spaces that positively impact the lives of children.  At times, schools are the site of violence and abuse, particularly in crisis and conflict-affected areas and among the most marginalized. The training taught me how to identify signs of abuse and respond to and report situations of abuse. 

At the conclusion of my internship, I not only gained greater insight into education programming but also into my future career trajectory. I applied to the Ford Dorsey Master’s in International Program (MIP) at the the Freeman Spogli Institute with the intention to focus on international security from a humanitarian, development, and human rights perspective. I envision my next job within USAID, the U.S. Department of State, or the United States Institute of Peace. Now that I have interned with USAID, I am certain that this is still the path I see for myself. Following my internship, I plan to apply to the Presidential Management Fellows Program, as well as directly to USG hiring agencies. I am confident that my time spent at USAID has prepared me well for this new chapter.

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The Role of the Special Envoy

As the Biden administration begins to review policy towards North Korea in earnest, King’s book and perspectives are particularly timely. Drawing on over a decade of experience, King explains how the role of the special envoy provides a unique opportunity to influence the policy agenda on human rights. As a senior member within the U.S. State Department, the envoy is in a position to both elevate the importance of rights violations to policymakers in Washington and provide feedback on how policy decisions impact the situation on the ground.     

King outlines several avenues where U.S. policymakers can increase pressure on North Korea to address the ongoing human rights crisis in the country. Predominantly among them is the recommendation to support the work on human rights already done by the UN and UN agencies, such as the reporting of Special Rapporteur Tomás Quintana.

“North Korea is very sensitive about its international legitimacy,” King notes. “Working through the UN and with UN agencies gives greater validity and acceptability to the human rights issues and puts greater pressure on North Korea to follow international norms.”

King’s other recommendations center more directly on the people of North Korea. He urges ongoing support for initiatives and agreements that foster access to information and proper distribution of resources and aid for North Koreans within the country along with freedom of movement for those who are attempting to leave and face crossing hostile borders into China. 

Responsibilities in Seoul

Speaking as King’s counterpart and colleague in South Korea, Jung-Hoon Lee echoed the need for visibility and accountability — both globally and in South Korea — for the DPRK's human rights crisis. “In the public eye and the global context, the human rights condition in North Korea is not very familiar. Why? There’s no access. The North Korean society is completely cocooned. There are terrible human rights conditions in other parts of the world, but there is access in those cases to see what is going on. In North Korea, there are only testimonials. There are no pictures or documentaries of the gulags and atrocities. That’s why it is so important that we keep raising this issue.”

For Lee, this means working with and through many of the same channels that King points to, such as the UN, and recognizing as a global community the scale of the crimes against humanity being committed.

But it also means accepting responsibilities closer to home. Lee firmly rejects the opinion raised by the South Korean Foreign Minister that refocusing on North Korean human rights and reappointing an ambassador to fill Lee’s now-vacant position is “useless.” Such indifference towards human rights issues in North Korea is damaging, warns Lee, citing the scrutiny South Korea suffered during the recent Tom Lantos Human Rights Commission hearings before the U.S. Congress.

The Road Towards Accountability

Human rights are only one facet of U.S. policy toward North Korea, but we undermine the overall relationship with the North if the United States abandons human rights in pursuit of security or economic goals, writes King in his book. "Policy toward North Korea involves interrelated issues that we frequently separate for analytical purposes or because they are dealt with in different ways or by different means. But these issues are interconnected, and they are not really separable."

Ultimately, any meaningful action to address North Korea's human rights violations will require coordinated efforts from international organizations, national governments, and civic organizations. In the third and final part of the Korea Program’s spring 2021 series on human rights in North Korea, forthcoming on May 20, leaders from the private sector will discuss the challenges of bringing together independent actors and organizations to raise awareness and call for accountability in North Korea. Registration for the event is open to the public.  

A U.S. foreign policy that cuts money to nongovernmental organizations performing or promoting abortions abroad has actually led to an increase in abortions, according to Stanford researchers who have conducted the most comprehensive academic study of the policy’s impact.

Eran Bendavid and Grant Miller — both associate professors at Stanford University School of Medicine and core faculty members at Stanford Health Policy — and doctoral candidate Nina Brooks find that abortions increased among women living in African countries where NGOs, such as the International Planned Parenthood Federation, were most vulnerable to the policy’s requirements.

The policy, widely known as the Mexico City Policy, explicitly prohibits U.S. foreign aid from flowing to any NGO that will not abide by the policy’s main condition: no performing or discussing abortion as a method of family planning, even if just in the form of education or counseling.

The policy has been a political hot potato since its inception. Enacted under Ronald Reagan in 1984, it’s been enforced by subsequent Republican administrations while Democrats in the White House revoked the policy within days of taking office.

The study by Brooks, Bendavid and Miller, published June 27 in The Lancet Global Health, looked at the policy’s effects in more than two dozen African countries over a span of 20 years under three presidents: Bill Clinton, George W. Bush and Barack Obama. It finds that, when the policy was in place during the Bush years, abortions were 40 percent higher relative to the Clinton and Obama administrations.

When the policy was suspended during Obama’s two terms, the research shows that the upward trend in abortion rates reversed.

“Our research suggests that a policy that is supported by taxpayers ostensibly wishing to drive down abortion rates worldwide does the opposite,” said Bendavid, a faculty affiliate of the Stanford King Center on Global Development, which is part of the Stanford Institute for Economic Policy Research (SIEPR).

A key reason for the uptick in abortions is that many NGOs affected by the policy also provide contraceptives – and funding cuts mean birth control is harder to get, said Brooks.

“By undercutting the ability to supply modern contraceptives, the unintended consequence is that abortion rates increase,” she said.

And the policy’s scope has expanded under the Trump administration. While it originally restricted aid directed only toward providing family planning and reproductive health services, President Trump has extended the policy to cover any group engaged in global health, including organizations providing services for HIV or child health – not just family planning.

Groundbreaking Research

The stakes are high. America is the world’s largest provider of development assistance and spent about $7 billion on international health aid in 2017. Many women in sub-Saharan Africa depend on this aid for contraceptives.

In sub-Saharan Africa, NGOs are often primary providers of family planning services. Two of the world’s largest family planning organizations – International Planned Parenthood Federation and Marie Stopes International – have forfeited large sums of U.S. cash for refusing to comply with the policy, according to news reports.

The research findings were based on records of nearly 750,000 women in 26 sub-Saharan African countries from 1995 to 2014. When the policy was in effect under George W. Bush, contraceptive use fell by 14 percent, pregnancies rose by 12 percent and abortions rose by 40 percent relative to the Clinton and subsequent Obama years – an impact sharply timed with the policy and in proportion to the importance of foreign assistance across sub-Saharan Africa.

The paper is the second study of the rule’s impact by Bendavid and Miller, who are both faculty members of Stanford Health Policy. The research is also one of the very few evidence-based analyses of the policy.

Their earlier research, the first quantitative, large-scale effort to examine the policy’s impacts, looked at a smaller set of African countries during the Clinton and Bush administrations and also found an increase in abortion rates when the policy was enacted in 2001.

“Our latest study strengthened our earlier findings because we were able to look at what happens when the rule was turned off, then on, and then off again,” said Bendavid, referring to the policy’s whipsawing under Clinton, Bush and then Obama.

Miller, who is the director of the King Center and a SIEPR senior fellow, says the team’s research reveals a deeply flawed policy.

“We set out to provide the best and most rigorous evidence on the consequences of this policy,” he said. “What we found is a clear-cut case of government action that everyone on all sides of the abortion debate should agree is not desirable.”

Signs of a Global Pushback

Brooks also notes that their findings may underestimate the rule’s full impact.

“The excess abortions performed due to the policy are more likely to be performed unsafely, potentially harming women beyond pregnancy terminations,” she said.

Under Trump, the international response to U.S. funding cuts has shifted. Norway, Canada and several other countries have pledged to increase funding of international NGOs affected by the policy – though not by enough to cover the expected shortfall, says Miller.

“This shows us,” he said, “that despite the intense partisanship in the U.S. over the rule and its implementation, there are ways that policymakers around the world can offset its effects – by ensuring higher levels of family planning funding, for example.”

By Hal Benton, Seattle Times staff reporter

Karl Eikenberry is a retired Army officer whose two tours of Afghanistan duty — and later service as ambassador to that nation — left him keenly aware of the limits of U.S. military power.

As a soldier, Eikenberry launched the still-ongoing effort to build an Afghan military force capable of fending off the Taliban. As a diplomat, he was stationed at the Kabul embassy during President Barack Obama’s surge that would eventually push American troop strength in Afghanistan to more than 100,000 service members in an attempt to improve security.

“Americans and the world have rightly been disappointed with the results of our costly military campaigns in Iraq and Afghanistan in the 21st century. Hugely expensive, protracted … and damaging to our country’s prestige abroad,” Eikenberry said Thursday to a Town Hall audience in Seattle.

Read the full article in The Seattle Times.

Most studies that look at whether democracy improves global health rely on measurements of life expectancy at birth and infant mortality rates. Yet those measures disproportionately reflect progress on infectious diseases — such as malaria, diarrheal illnesses and pneumonia — which relies heavily on foreign aid.

A new study led by Stanford Health Policy's Tara Templin and the Council on Foreign Relations suggests that a better way to measure the role of democracy in public health is to examine the causes of adult mortality, such as noncommunicable diseases, HIV, cardiovascular disease and transportation injuries. Little international assistance targets these noncommunicable diseases. 

When the researchers measured improvements in those particular areas of public health, the results proved dramatic.

“The results of this study suggest that elections and the health of the people are increasingly inseparable,” the authors wrote.

A paper describing the findings was published today in The Lancet. Templin, a graduate student in the Department of Health Research and Policy, shares lead authorship with Thomas Bollyky, JD, director of the Global Health Program at the Council on Foreign Relations.

“Democratic institutions and processes, and particularly free and fair elections, can be an important catalyst for improving population health, with the largest health gains possible for cardiovascular and other noncommunicable diseases,” the authors wrote.

Templin said the study brings new data to the question of how governance and health inform global health policy debates, particularly as global health funding stagnates.

“As more cases of cardiovascular diseases, diabetes and cancers occur in low- and middle-income countries, there will be a need for greater health-care infrastructure and resources to provide chronic care that weren’t as critical in providing childhood vaccines or acute care,” Templin said.

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Free and fair elections for better health

In 2016, the four mortality causes most ameliorated by democracy — cardiovascular disease, tuberculosis, transportation injuries and other noncommunicable diseases — were responsible for 25 percent of total death and disability in people younger than 70 in low- and middle-income countries. That same year, cardiovascular diseases accounted for 14 million deaths in those countries, 42 percent of which occurred in individuals younger than 70.

Over the past 20 years, the increase in democratic experience reduced mortality in these countries from cardiovascular disease, other noncommunicable diseases and tuberculosis between 8-10 percent, the authors wrote.

“Free and fair elections appear important for improving adult health and noncommunicable disease outcomes, most likely by increasing government accountability and responsiveness,” the study said.

The researchers used data from the Global Burden of Diseases, Injuries, and Risk Factors Study; V-Dem; and Financing Global Health databases. The data cover 170 countries from 1970 to 2015.

What Templin and her co-authors found was democracy was associated with better noncommunicable disease outcomes. They hypothesize that democracies may give higher priority to health-care investments.

HIV-free life expectancy at age 15, for example, improved significantly — on average by 3 percent every 10 years during the study period — after countries transitioned to democracy. Democratic experience also explains significant improvements in mortality from cardiovascular disease, tuberculosis, transportation injuries, cancers, cirrhosis and other noncommunicable diseases, the study said.

Watch: Some of the authors of the study discuss the significant their findings: 

What Templin and her co-authors found was democracy was associated with better noncommunicable disease outcomes. They hypothesize that democracies may give higher priority to health-care investments.

HIV-free life expectancy at age 15, for example, improved significantly — on average by 3 percent every 10 years during the study period — after countries transitioned to democracy. Democratic experience also explains significant improvements in mortality from cardiovascular disease, tuberculosis, transportation injuries, cancers, cirrhosis and other noncommunicable diseases, the study said.

Foreign aid often misdirected

And yet, this connection between fair elections and global health is little understood.

“Democratic government has not been a driving force in global health,” the researchers wrote.  “Many of the countries that have had the greatest improvements in life expectancy and child mortality over the past 15 years are electoral autocracies that achieved their health successes with the heavy contribution of foreign aid.”

They note that Ethiopia, Myanmar, Rwanda and Uganda all extended their life expectancy by 10 years or more between 1996 and 2016. The governments of these countries were elected, however, in multiparty elections designed so the opposition could only lose, making them among the least democratic nations in the world.

Yet these nations were among the top two-dozen recipients of foreign assistance for health.

Only 2 percent of the total development assistance for health in 2016 was devoted to noncommunicable diseases, which was the cause of 58 percent of the death and disability in low-income and middle-income countries that same year, the researchers found.

“Although many bilateral aid agencies emphasize the importance of democratic governance in their policy statements,” the authors wrote, “most studies of development assistance have found no correlation between foreign aid and democratic governance and, in some instance, a negative correlation.”

Autocracies such as Cuba and China, known for providing good health care at low cost, have not always been as successful when their populations’ health needs shifted to treating and preventing noncommunicable diseases. A 2017 assessment, for example, found that true life expectancy in China was lower than its expected life expectancy at birth from 1980 to 2000 and has only improved over the past decade with increased government health spending. In Cuba, the degree to which its observed life expectancy has exceeded expectations has decreased, from four-to-seven years higher than expected in 1970 to three-to-five years higher than expected in 2016.

“There is good reason to believe that the role that democracy plays in child health and infectious diseases may not be generalizable to the diseases that disproportionately affect adults,” Bollyky said. Cardiovascular diseases, cancers and other noncommunicable diseases, according to Bollyky, are largely chronic, costlier to treat than most infectious diseases, and require more health care infrastructure and skilled medical personnel.  

The researchers hypothesize that democracy improves population health because:

1. When enforced through regular, free and fair elections, democracies should have a greater incentive than autocracies to provide health-promoting resources and services to a larger proportion of the population;
2. Democracies are more open to feedback from a broader range of interest groups, more protective of media freedom and might be more willing to use that feedback to improve their public health programs;
3. Autocracies reduce political competition and access to information, which might deter constituent feedback and responsive governance.

Various studies have concluded that democratic rule is better for population health, but almost all of them have focused on infant and child mortality or life expectancy at birth.

Over the past 20 years, the average country’s increase in democracy reduced mortality from cardiovascular disease by roughly 10 percent, the authors wrote. They estimate that more than 16 million cardiovascular deaths may have been averted due to an increase in democracy globally from 1995 to 2015. They also found improvements in other health burdens in the countries where democracy has taken hold: an 8.9 percent reduction in deaths from tuberculosis, a 9.5 percent drop in deaths from transportation injuries and a 9.1 percent mortality reduction in other noncommunicable disease, such as congenital heart disease and congenital birth defects.

“This study suggests that democratic governance and its promotion, along with other government accountability measures, might further enhance efforts to improve population health,” the study said. “Pretending otherwise is akin to believing that the solution to a nation’s crumbling roads and infrastructure is just a technical schematic and cheaper materials.”

The other researchers who contributed to the study are Matthew Cohen, Diana Schoder, Joseph Dieleman and Simon Wigley, from CFR, the University of Washington-Seattle and Bilkent University in Turkey, respectively.

Funding for the research came from Bloomberg Philanthropies and the Bill & Melinda Gates Foundation. Stanford’s Department of Health Research and Policy also supported the work.