Our Leadership Academy for Development (LAD) recently visited Tunis, Tunisia in partnership with the Center for International Private Enterprise (CIPE) to conduct a workshop for a group of Tunisian business, government and civil society leaders. Read more here. 

"While it is folly to underestimate the severity of the crisis in Iran, it is no less dangerous to underestimate the regime’s capacity for brutality. There are hundreds of thousands of Revolutionary Guard and militia forces whose perks of power and privilege are tethered to the survival of the regime, and it is hard to imagine they would give up wealth and status beyond their wildest dreams without a fight." - writes Abbas Milani, Director of Iranian Studies and CDDRL affiliated faculty on latest protest in Iran. Read the article here.

On November 17, 2017, FSI and CISAC senior fellow Martha Crenshaw spoke to the United Nations about how civil wars affect terrorism. In response to her discussion, Politically Speaking published the following Q&A.

The international response to civil wars and conflicts involving armed or insurgent groups was the subject of discussion as the Department of Political Affairs recently hosted the contributors to a special issue of Dædalus, produced as part of the American Academy of Arts and Sciences’ Civil Wars, Violence, and International Responses project.

Martha Crenshaw, Senior Fellow at the Center for International Security and Cooperation (CISAC) at Stanford; Tanisha M. Fazal, Associate Professor of Political Science at the University of Minnesota; and Stathis Kalyvas, Arnold Wolfers Professor of Political Science at Yale, spoke about the evolving profile of armed groups, particularly those ostensibly motivated by religion. Following the 17 November discussion, Politically Speaking spoke to the researchers, whose work aims not only to contribute to current policy-making but also to contextualize current trends by building a larger conceptual understanding of the threats posed by the collapse of state authority associated with civil wars and insurgencies.

Politically Speaking: At the UN we often talk about the internationalization of civil wars, the mobilization of outside support, the involvement of foreign fighters and spillover effects. Can these phenomena be prevented?

Martha Crenshaw: It is not possible to contain civil wars within national boundaries or prevent linkages and spillovers, especially when conflicts involve parties motivated by transnational ideologies such as jihadism and its accompanying sectarianism. Outside actors, whether states or non-states, are drawn into or even instigate these conflicts because they have an affinity for local players and/or because they see support for specific factions as useful in pursuing their own self-interests and rivalries. Due particularly to the prevalence of social media and the ease of internet communication, civil wars in which jihadist or violent Islamist factions are fighting will attract volunteers and inspire individual terrorist attacks against the countries perceived as opposing the global Islamist cause, be they neighbors or physically distant from the battlefield. The difficulty of prevention in such complex scenarios does not mean, however, that nothing can be done.  It is essential not to approach the problem piecemeal; today’s complex and messy conflicts should be considered comprehensively as wholes that may be greater than the sum of their parts. Policies for countering terrorism, insurgency, and “violent extremism” should not be compartmentalized. For example, military efforts to quell violent oppositions may succeed in eliminating the threat on the ground but in the long run stimulate support for the cause and thus perpetuate or even widen the struggle. Military victories do not automatically create stable political orders or solve the political grievances and disputes that led to war in the first place.

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Family planning programs in developing countries that offer contraceptives and reproductive health advice apparently do more than prevent pregnancies — they can keep girls in primary school for up to a year longer, even before the youngsters start to think about marriage and babies.

New research by Stanford Health Policy’s Grant Miller and Kim Singer Babiarz indicates that the availability of modern contraceptives alone can keep young girls in the classroom longer, likely because their parents develop greater expectations for their daughters’ long-term health outcomes and economic opportunities.

“What we find is that family planning exposure at a young age is linked to greater opportunities later in life – including economic empowerment,” said Babiarz, an SHP research scholar with a PhD in agricultural economics who focuses on women and children in development. “The fertility effects were modest; the most striking findings were the incentives created to keep girls in school and improvements in the types of jobs women have later in life.”

Babiarz and Miller, a senior fellow at the Freeman Spogli Institute for International Studies and director of the Stanford Center on Global Poverty and Development, unveiled their study at the annual meeting of the Center for Global Development in Washington, D.C. on Dec. 7.

They conducted research with Christine Valente, an associate professor in the department of economics at the University of Bristol and Tey Nai Peng, the principal investigator for the Malaysia Family Life Survey. The Southeast Asia nation was one of the first low-income countries to provide modern contraceptives on a large scale, first in 1954 and then establishing a National Family Planning Board in 1966.

The government then scaled up its national program between 1966 and 1974 and conducted robust surveys with retrospective life histories and detailed community-level information about the timing of family planning availability. The use of contraceptives such as the pill, condoms and IUDs, went from 3 percent in 1961 to 39 percent in 1975. The country also experienced a decrease in the fertility rate of 6.2 children to 4.3 during the same period.

The researchers were able to compare what happened to Malaysian girls who were very young when contraceptives became available in their communities to those who were adolescents when they first gained access to modern contraception. They were not surprised by the effects on fertility; that has generally been the case in countries that adopt large-scale family planning programs.

But they also found unintended incentives: that girls in communities with family planning clinics stayed in school six months longer, increasing to more than an additional year for the girls who were born after the family planning programs began. And it didn’t matter if the girls had fewer younger siblings at home.

Other benefits later in life included better jobs when they became adults. When the Malaysian girls were grown, they were more likely to take in their own elderly parents (relative to their husbands’ parents), a signal of increased status in their households. In fact, they found that the incentives for investing in girls created by family planning may actually outweigh its direct effects, which work through reductions in fertility and changes in birth timing.

“The existence of family planning and contraceptives may lead parents to believe their daughters can participate in the labor force and that more schooling will therefore benefit them,” Miller said. “In other words, it can change their expectations about the world their daughter will live in one day.”

Few studies explicitly distinguish the incentive effects of family planning on women’s education from its direct effects on fertility. Miller said he hoped the new findings might lead policymakers to consider the broader beneficial consequences of family planning beyond those that work directly through changes in pregnancy and fertility.

“A central contribution of this working paper is that it studies the possible incentive effects of family planning programs for human capital investment in girls,” the authors wrote,” which could then translate into improvements in women’s economic status throughout their lives.”

There is plenty of research on how the rapid warming of the planet is going to have growing adverse impacts on global economies, health, food supplies and natural disasters.

A new study now suggests that as temperatures continue to rise — particularly with more and more 90-plus-degree days — more fetuses and infants will experience economic loss by age 30.

“There is a growing body of evidence that finds that shocks to the fetus and young child — whether nutritional, environmental, economic or stress-related — have long-term consequences on health, education and economic outcomes throughout the life cycle,” said Maya Rossin-Slater, an assistant professor of health research and policy at Stanford Medicine and a faculty fellow at the Stanford Institute for Economic Policy Research.

Rossin-Slater published her study Dec. 4 in the Proceedings of the National Academy of Sciences, indicating early-life exposure to extreme temperatures is linked to potential losses in human capital. Her co-authors are Adam Isen, an economist with the U.S. Department of Treasury, and Reed Walker, an assistant professor at University of California, Berkeley.

The researchers used data from the U.S. Census Bureau’s Longitudinal Employer Household Dynamic Files, which contain information on adult labor market outcomes linked to county and exact date of birth. They looked at weather in counties in 24 states on any given day, and then measured how many days with average temperatures above 90 degrees a child born on that day in that county would have experienced during gestation and during the first year of life. They then compared the earnings of individuals who were exposed to different numbers of such hot days, but who were of the same race and gender, and born in the same county and on the same day of the year (but in different years).

Each day a fetus or infant experiences 90-plus-degree temperatures, Rossin-Slater and her co-authors found that he made $30 less a year on average, or $430 over the course of his lifetime. While that may not seem like a huge loss of income, the authors point out that their study is best understood from a population-level perspective rather than from an individual one.

“There is a lot of research already showing that extreme heat has immediate effects on labor market productivity and GDP,” she said. “What we are saying is that there is another wrinkle to this — that there can be consequences many years later, on cohorts who are still in the womb.”

Most Americans today only experience one day a year that is 90 degrees or hotter. But the Climate Impact Lab has indicated that if countries continue to take only moderate action on climate change, by the end of this century there will be about 43 such days a year.

So, if you multiple a $30 annual loss a day by 43 days, you come up with an average $1,290 a year — and compounded in large populations of pregnant women in hot climates.

“Prior research shows that exposure to extreme heat in utero leads to lower birth weight and increases infant mortality,” said Rossin-Slater, who is also a core faculty member at Stanford Health Policy. She said poor fetal and infant health could impact adult earnings in three ways: cognitive impairment, poor health that causes people to miss school or work, and less non-cognitive skill development such as self-control.

“With regard to exposure to heat specifically, fetuses and infants are especially sensitive because their thermoregulatory systems are not fully developed and they have less capacity to self-regulate when their bodies are exposed to extreme temperatures,” Rossin-Slater said.

Hot Zones and Air Conditioners

The obvious questions that arise from such research: What happens to the babies of women who already live in very high temperatures? And why not just ensure that all pregnant women have air conditioners, at least in the developed world where it would be more affordable?

Women in warm zones such as parts of Africa and South Asia, as well as U.S. cities like Phoenix and Washington, D.C., shouldn’t worry too much. The loss of income is relatively little and people living in hot climates may actually adapt over time to exposure to extreme heat.

“Our study is not saying that individual people should be doing something differently to avoid exposure to extreme heat,” Rossin-Slater said. “Instead, we think we are providing additional evidence for the possible population-level consequences of climate change and the projected increase in the number of days with extreme temperatures.”

And what about those air conditioners? The cohorts in the study are actually born in the 1970s, during a period of rapid expansion in air conditioning across American households. The researchers found the earning losses went away in areas where most people got air conditioners installed.

“If we think that there is something biological going on as a result of the fetus being overheated, then it makes sense that AC, which prevents the overheating, can mitigate this negative effect,” Rossin-Slater said.

But it’s important to recognize, she said, that air conditioners come with costs, both financial from the perspective of individuals and households who can and can’t afford such systems, and environmental from the perspective of the country or planet as a whole.

“So this is not a `free’ solution and any cost-benefit calculations related to climate change should take into account this adaption response,” Rossin-Slater said. “But we ought to think about what these results imply at the global level — in many countries that are much hotter than the United States and still don’t have AC. So if we are trying to understand global inequality and the impacts of climate change on developing countries, our results suggest that climate change could play a role in perpetuating global inequality across generations.”

"The problems with our democracy—ever-deepening polarization, incivility, gridlock, dysfunction, conflicts of interest, and disregard for democratic norms—are not just problems of political culture and behavior. Politicians are driven by incentives, especially the desire to get re-elected. Institutions heavily shape these incentives, and our institutions are in need of reform. Unless we reform our democracy, we will be increasingly hard-pressed to improve the health of democracy globally." Listen to Larry Diamond, Senior Fellow at the Freeman Spogli Institute for International Studies, explains in this podcast what are the options from here, by Hoover Institution. 

Paul Wise watched as children ran around a playground attached to a health clinic at a displaced persons camp on the outskirts of Mosul — the northern city in Iraq once controlled by the Islamic State but now back in the hands of the Iraqi government.

The children had survived the Battle of Mosul, which had fallen to ISIS in 2014 but was retaken by the government forces and allied militias during a nine-month military campaign that ended in July. Many of the children suffer from physical and mental wounds and Wise wondered how they would recover with so little medical infrastructure.

Wise was part of a small delegation of physician-academics asked to evaluate a World Health Organization-led system to treat civilians injured in the Mosul fighting. Wise and his colleagues recently slipped into Mosul to visit field hospitals, review health care on the ground and determine whether there is a better way to distribute medical aid during armed conflict.

The visit left the Stanford Medicine professor of pediatrics and senior fellow at the Freeman Spogli Institute for International Studies with questions about health care, humanitarian ethics, and conduct of war: Are there better ways to deliver emergency medical care during the height of battle? How do relief workers maintain neutrality when embedded with government security forces? Has the system of financing humanitarian interventions — one that was essentially created during the Cold War — become dangerously outdated?

Answering these questions is the mission of a new health-and-security initiative at Stanford led by Wise, a core faculty member at Stanford Health Policy who has spent 40 years working to improve the health of children impacted by conflict. Much of his work has been in Guatemala through his Children in Crisis project, the first university-based program to address the needs of children in areas of unstable governance and civil war.

“In talking with the groups that are running these humanitarian efforts in Mosul, there was this uneasiness, this kind of disorientation with the way things are now,” said Wise. “It was a kind of recognition that humanitarian norms are changing, the health personnel and facilities are at greater risk; the financial gap between humanitarian need and humanitarian capability is growing; and the old way of financing humanitarian intervention is inadequate, archaic.”

An Interdisciplinary Approach

Wise believes academics are well suited to help resolve these humanitarian conundrums.

“So we are going to move ahead and try to bring all the players together to reconsider this global challenge. Here at Stanford, we have the capacity to draw upon remarkable resources,” he said.

The new biosecurity initiative led by Stanford Medicine physician and FSI senior fellow, David Relman, together with world-renowned political scientists, security specialists, computer scientists and health policy experts will “attempt to craft new strategies for the provision of critical services to populations affected by conflict and political stability.”

The initiative will collaborate with other institutions such as Johns Hopkins, UCSF, Harvard, and the American Academy of Arts and Sciences. It will also seek the engagement of partners committed to providing humanitarian services, including WHO, the U.N. High Commissioner for Refugees, Doctors Without Borders and the International Committee of the Red Cross.

“The voice of communities impacted by war should also be an essential element in this ambitious effort,” Wise said. “To break new ground, we’re going to have to do things differently; the health strategies need to take into consideration fundamental understanding of the political dynamics. But we have a special opportunity here at Stanford because we take an interdisciplinary approach.”

Children of War

Most of the children Wise saw will never be the same, he said, nor the humanitarian workers who risked their lives to treat them, their families, and fighters from all sides of the battle to oust the Islamic extremists from the city on the Tigris River.

“I look at these little kids with horrendous emotional trauma and PTSD, and I think to myself, it’s the collision of all these questions playing out within a 50-square-meter little playground,” he said. “It’s these broader, strategic and ethical questions that are really profound. And as a pediatrician who is dedicating the last phase of my career to these questions of security and the political dimensions — I have to engage on all of these levels. That’s not easy.”

Wise traveled with WHO officials, as well as Paul Spiegel, a physician who leads the Center for Humanitarian Health at Johns Hopkins Bloomberg School of Public Health; Adam Kushner, a trauma surgeon affiliated with Johns Hopkins; and Kent Garber, a surgical resident at UCLA and research associate at Johns Hopkins.

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Spiegel also believes academics are uniquely positioned to help assess the current system of responding to medical crises during conflict.

“I believe that we can bring objectivity and rigor to analyzing and evaluating important and innovative responses, such as the trauma response by WHO and others in Mosul,” Spiegel said. “Humanitarian organizations are often busy responding quickly to rapidly changing situations; they don’t always have the luxury of time to do what academic humanitarians can do.”

Making the two-hour drive from Erbil to Mosul in armored, bulletproof SUVs provided by the United Nations, they slipped into field hospitals to meet with Iraqi physicians and medical teams with the humanitarian agencies.

Wise, who was able to take a few photos and video on his smartphone, described the devastation on the ground, noting that not since the siege of Leningrad has a city of this size experienced such street-by-street fighting. In large parts of the city, virtually every building was bombed or bulleted. It will take years to clear the rubble and rebuild.

“It’s just a remarkable story of tragedy and resilience,” he said.

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Since the city was not long ago controlled by ISIS, the field hospitals are still surrounded by massive concrete barricades and tactical trucks stationed outside with mounted machine guns.

The team found that at the height of the battle for Mosul, there was tremendous pressure to treat injured civilians and discharge patients very quickly, due to the lack of medical infrastructure and personnel and the continuous wave of new injuries coming in.

“The charge for us was to evaluate the system and how well it worked, what ways could it be improved, how many lives that it saved,” Wise said. “One of the concerns, for example, was that in order to put in medical people that close to the frontline, you have to give them some kind of security. This raised issues among the humanitarians about their need for independence and neutrality, since you’re essentially embedding them with Iraqi security forces.”

Epidemiology and Ethics

“We are looking at the technical issues and the epidemiologic issues, but also dealing with the ethical issues and their implications,” he said.

They intend to write an internal report and then publish their findings in a major medical journal, to get the word out about the issue and gain support for ongoing collaborative work. They’re looking to partners like the American Academy of Arts and Sciences, which recently devoted an entire issue of its journal, Daedalus, to the factors and influences of contemporary civil war. One of the essays in that issue by Wise and his Stanford colleague, Dr. Michele Barry, who directs the Center for Innovation in Global Health, talks about the threat of a global pandemic as a potential byproduct of the 30 ongoing civil wars around the world.

“We’re trying to get the report completed quickly because the model of trauma care for civilians in Mosul is a new model and could be implemented in other combat areas, like the fighting in Syria and other places in Iraq,” Wise said.

Wise worries some see Stanford University as an insulated Silicon Valley institution in a beautiful setting and not always engaged in the real world.

“Well, this is about as engaged in the real world as you can get — this is Stanford moving and doing things out there, not just sitting around in seminar rooms. Sometimes you need to get close to the front lines to save lives,” he said.

When asked what surprised him during this trip to Mosul, Wise smiled.

“I’m sort of old and I’ve seen a lot of the world and not a lot surprises me anymore,” he said. “But it was a reminder of how desperate are the lives of millions of people — that we could do so much more. It’s a reminder of just how fragile physical security really is in this world."

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