Two former U.S. ambassadors to Russia recently shared the stage at the Freeman Spogli Institute, where they discussed the Arab Spring, their mutual respect for former President Barack Obama, and of course, Russian President Vladimir Putin.

William Burns — the Russian ambassador from 2005 to 2008 — told Freeman Spogli Institute Director Michael McFaul — who was in the position from 2012 to 2014 — that Putin is a “combustible combination of grievance and ambition and insecurity all wrapped up together.”

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Standing at about 5 feet and 6 inches tall, Putin is not the most physically intimidating person in the world, but he carries himself with self-assurance, Burns said.

“He told me, ‘You Americans need to listen more — you can’t just have everything your own way,’” Burns said of his first meeting with Putin. “That was vintage Putin…it was not subtle, it was defiantly charmless, but it was quite direct.”

Burns talked about his experience in the Foreign Service, which began at the height of the Cold War in the early ‘80s. Because most of his research in graduate school focused on the Middle East, Burns said he spent two years perfecting the Russian language at the beginning of his career.

“You can’t operate in a place like Russia unless you speak the language well,” Burns said. “Moscow in those days was one of the biggest embassies we had in the world. As creepy as the relationship can be, Russia is still a place that matters.”

Burns said that while former President George H.W. Bush, his Secretary of State James Baker, and his National Security Advisor Brent Scowcroft made their share of mistakes during Bush’s tenure in office, the former president and his team deserve a lot of credit for what they accomplished in Russia and the Middle East.

“In hindsight, Germany’s reunification within less than a year after the end of the Cold War and the fall of the Berlin Wall — and ensuring that the reunification of Germany would remain within NATO — was not a small achievement,” he said. “That took real skill, and it was not inevitable.”

When asked by McFaul whether the U.S. should have been more aggressive in pushing the burgeoning Russian leaders in a more democratic direction after the collapse of the Soviet Union, Burns said he thinks Russia would have been resistant to an “intrusive” American role in their economy at that time.  

“Russians — at the end of the Cold War, and the disintegration of the Soviet Union — had suffered a real crisis in their own confidence,” he said. “I’ve never really bought the argument that a Marshall Plan-scale set of assistance for Russia or the former soviet states in that period would have been that productive. Russia’s future after the end of communism was something that only Russia could shape in the end.”

Shifting focus to the past decade, Burns said that he “always had huge respect for President Obama’s long game in the Middle East,” adding that he thought the former president was unfairly criticized for wanting to disengage the U.S. from the Middle East during his time in office.

“The Arab revolts unfolding in Tunisia, Egypt, Libya and Syria were on a scale and at a pace which would have been hard for any president to adapt to,” Burns said. “On the surface they looked very similar, but they were unfolding in different societies, in different ways … a concern with which I deeply sympathized was not getting dragged into another big military intervention in the Middle East.”

U.S. government aid for treating children and adults with HIV and malaria in developing countries has done more than expand access to lifesaving interventions: It has changed how people around the world view the United States, according to a new study by researchers at the School of Medicine.

Compared with other types of foreign aid, investing in health is uniquely associated with a better opinion of the United States, improving its “soft power” and standing in the world, the study said.  

Favorability ratings of the United States increased in proportion to health aid from 2002 to 2016 and rose sharply after the implementation of the President’s Emergency Plan for AIDS Relief in 2003 and the launch of the President’s Malaria Initiative in 2005, the researchers report.

Their findings were published this week in the American Journal of Public Health. The lead author is postdoctoral scholar Aleksandra Jakubowski, PhD, MPH. The senior author is Eran Bendavid, MD, associate professor of medicine and a core faculty member at Stanford Health Policy.

“Using data on aid and opinions of the United States, we found that investments in health offer a unique opportunity to promote the perceptions of the United States abroad, in addition to disease burden relief,” the authors wrote. “Our study provides new evidence to support the notion that health diplomacy is a net win for the United States and recipient countries alike.”

The Trump administration, however, has proposed a 23% cut in foreign aid in its 2020 budget, including large reductions to programs that fight AIDS and malaria overseas.

The Stanford researchers believe their study is the first to add heft to the argument that U.S. health aid boosts the “soft power” that wins the hearts and minds of foreign friends and foes.

“Our study shows that investing in health aid improves our nation’s standing abroad, which could have important downstream diplomatic benefits to the United States,” Jakubowskisaid. “Investments in health aid help the United States accumulate soft power. Allowing the U.S. reputation to falter would be contrary to our own interests.” 

A Policy Debate

Many politicians and economists consider spending U.S. tax dollars on foreign aid as an ineffective, and possibly harmful, enterprise that goes unappreciated and leads to accusations of American meddling in other countries’ national affairs.

The U.S. government, for the past 15 years, has contributed more foreign health aid than any other country, significantly reducing disease burden, increasing life expectancy and improving employment in recipient countries, the authors wrote. Still, this generosity has historically constituted less than 1% of the U.S. gross domestic product.

“Our results suggest that the dollars invested in health aid offer good value for money,” the researchers wrote. “That is, the relatively low investment in health aid (in terms of GDP) has provided the United States with large returns in the form of improved public perceptions, which may advance the U.S. government’s ability to negotiate international policies that are aligned with American priorities and preferences.”

The researchers used 258 Global Attitudes Surveys, based on interviews with more than 260,000 respondents, conducted by the Pew Research Center in 45 low- to middle-income countries between 2002 and 2016.

Their analysis focused on the health sector, which includes several large programs for infectious disease control, but also support for nutrition, child health and reproductive health programs. They compared health aid to other major areas of U.S. investment: governance, infrastructure, humanitarian aid and military aid. They also constructed a database of news stories that mentioned the President’s Emergency Plan for AIDS Relief or the President’s Malaria Initiative by crawling through the online archives of the top three newspapers by circulation in each of the 45 countries.

They found that the probability of populations holding a very favorable opinion of the United States was 19 percentage points higher in the countries where and years when U.S. donations for health care were highest, compared with countries where and years when health aid donations were lowest. Using another metric, the researchers found that every additional $100 million in health aid was associated with a nearly 6 percentage-point increase in the probability of respondents indicating they had a “very favorable” opinion of the United States. 

In contrast, the researchers found, aid for governance, infrastructure, humanitarian and military purposes was not associated with a better opinion of the United States.

Bendavid, an infectious diseases physician and core faculty member of Stanford Health Policy, said that when he set out to conduct this research, he believed it would result “in a resounding thud” — that the “soft power” of health aid would have no impact on public opinion.

“For me, the notion that this program — hatched and headquartered in D.C. — would have impacts among millions in Nairobi and Dakar, seemed farfetched,” Bendavid said. “I was incredulous until all the pieces were in place.”

The ‘America First’ Agenda

The Trump administration’s “America First” agenda is calling for significant cuts to global health aid, particularly to the highly successful AIDS relief program, which was established by President George W. Bush. The administration’s budget, released in March, proposed a $860 million cut to the program; the President’s Malaria Initiative is facing a $331 million reduction in federal funding. That’s a decline of 18% and 44%, respectively.

The U.S. contribution to the Global Fund to Fight AIDS, Tuberculosis and Malaria would also decline by 17%, or $225 million, according to the Kaiser Family Foundation.

Yet beyond the reputational damage to the United States, such cuts could be a major setback to improving health outcomes in developing countries, the researchers said. After all, HIV knows no borders, and having more resilient health care systems is instrumental when facing public health crises, such as the Ebola outbreak in the Democratic Republic of Congo, Jakubowski said.

“The most direct impact of cutting the United States’ health aid allocations is the potential to undermine or reverse the progress that has been enabled by U.S. aid in curbing mortality and the spread of disease,” Bendavid said. “However, this study suggests there are also repercussions to the United States: the relationships the U.S. has built with recipient nations could also be undermined.”            

Other Stanford co-authors are Steven Asch, MD, MPH, professor of medicine, and former graduate student Don Mai.

Stanford’s Department of Medicine supported the work.

China is making a risky bet in the Middle East. By focusing on economic development and adhering to the principle of noninterference in internal affairs, Beijing believes it can deepen relations with countries that are otherwise nearly at war with one another—all the while avoiding any significant role in the political affairs of the region. This is likely to prove naive, particularly if U.S. allies begin to stand up for their interests.

In meetings I attended earlier this month in Beijing on China’s position in the Middle East, sponsored by the Carnegie-Tsinghua Center, Chinese officials, academics, and business leaders expressed a common view that China can avoid political entanglement by promoting development from Tehran to Tel Aviv. China may soon find, however, that its purely transactional approach is unsustainable in this intractable region—placing its own investments at risk and opening new opportunities for the United States.

Over the past three years, China has charted an ambitious future in the Middle East by forging “comprehensive strategic partnerships” with Iran, the United Arab Emirates, Saudi Arabia, and Egypt. This is the highest level of diplomatic relations China can provide, and Beijing believes these four countries anchor a neutral position that will prove more stable over the long term than that of the United States. China has also made massive investments in infrastructure throughout the region, including in Israel, where China is now the second-largest trading partner behind the United States.

China’s interests in the Middle East are both structural and strategic. Structurally, China needs the natural resources of the region, whereas the United States—now the world’s largest oil producer—does not. China is also seeking new markets to absorb its excess industrial capacity, and sees the Middle East poised for growth after decades of wars, woeful infrastructure, and popular discontent. Strategically, together with Russia, China is taking advantage of the uncertainty produced by ever-shifting U.S. policies, including zero-sum prescriptions for Iran and Syria that are unlikely to produce desired outcomes anytime soon. Regional governments in turn have welcomed China’s embrace, and its offer of investment without pressure to politically reform or respect human rights.

China’s President Xi Jinping previewed this more assertive Middle East strategy in a landmark address in Cairo three years ago. There, he declared that China does not seek a “sphere of influence” in the region—even while sinking nearly $100 billion in investments there through ports, roads, and rail projects. He alleged China rejects “proxy” contests—even while concluding a strategic partnership with Iran, the main sponsor of proxies in the region. And he warned against “all forms of discrimination and prejudice against any specific ethnic group and religion”—even while reportedly forcing 1 million Muslims into reeducation camps in China’s Xinjiang province.

Such contradictions can be maintained only so long as traditional U.S. allies in the region now welcoming Chinese investment allow them to be maintained. These U.S. allies do not shy from asserting their broader interests with Washington or expressing disagreement where policies diverge, and it is time they do the same with Beijing.

As the United States questions Chinese investment and intentions, particularly in the areas of technology and ports such as Israel’s Haifa, it can also challenge traditional allies as to whether they are granting China a free ride on what remains a largely U.S.-led security architecture. Such an arrangement should be as unacceptable to American partners in the region as it is to Washington. At the very least, these partners, together with Washington, can demand that Beijing utilize its emerging influence—particularly with Tehran and Damascus—to pursue measures that promote longer-term stability.

Read the rest at The Atlantic.

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.

In this New York Times opinion piece on the global implications of Trump's leadership, columnist Thomas L. Friedman quotes Larry Diamond who points out that Trump's presence in the White House encourages leader's in African countries, such as Museveni in Uganda, to rule as long and as brutally as they want.  

Read it here.

Didi Kuo joins Thomas Carothers<, senior Vice President for studies at the Carnegie Endowment for International Peace, in outlining the ways in which ideas, experiences, and lessons from other countries can magnify reform in the United States.

Read it here.

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.