Non-communicable diseases such as heart and respiratory disease, cancer, obesity and diabetes are now responsible for some two-thirds of premature deaths around the world. And most of those are in low- and middle-income countries.

The United Nations has estimated that on top of the social and psychological burdens of chronic disease, the cumulative loss to the global economy could reach $47 trillion by 2030 if things remain status quo.

“That was a big whopper of a number and got a lot of attention, and that was good because it raised awareness,” said Rachel Nugent, vice president for global non-communicable diseases (NDCs) at the research institute RTI International.

“It’s an issue that is driven by a lot of different factors, “ she said. “And understanding how the larger social and economic factors affect NDCs, at a policy level, very little progress has been made — there’s been very little collaboration.”

Nugent was addressing the fourth annual Global Health Economics Colloquium at University of California San Francisco, with health experts, policymakers, students and researchers from Stanford, Berkeley and UCSF who gather every year to take a deep dive into the economics of a global health issue. More than 200 experts from 10 universities and public health departments attended the conference.

The daylong gathering focused on recent developments in the economics of NDCs, looking at case studies from around the world, and new guidelines for cost-effectiveness analysis and the role of economics in reducing health inequality.

“The donors are not convinced that there are cost-effective things that we can do in these countries; a lot of them are very skeptical that this is affecting the poor,” said Nugent, a member of the World Health Organization’s expert advisory panel on the management of NCDs.

In India, for example, much of the population still defecates outdoors, contaminating water sources and agricultural products, which can lead to malnutrition and physical and cognitive disorders. Many donors would rather see funds go to building latrines as they can see tangible results; NDC prevention is a long-term slog.

“But I don’t think we should necessarily think of NDCs as either-or,” said Nugent.  “I think that integration of services and programming is very much at the forefront of what is the right way to go.”

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Cost-effectiveness Analyses

Nugent’s research has shown five cost-effective interventions would avert more than 5 million premature deaths from NCDs by 2030, or a reduction of 28.5 percent in projected mortality from chronic disease around the world. And the average benefit-cost ratio is 9:1, at a global cost of $8.5 billion a year.

The interventions are raising the price of tobacco products by 125 percent through taxation; providing aspirin to 75 percent of those suffering from acute myocardial infarction; reducing salt intake by 30 percent; reducing the prevalence of high blood pressure with low-cost hypertension medication; and providing preventive drug therapy to 70 percent of those at high risk of heart disease.

Gillian Sanders-Schmidler, a professor of medicine at Duke University Medical Center and former assistant professor of medicine at Stanford Health Policy’s Center for Primary Care and Outcomes Research, addressed the colloquium about recommendations of the Second Panel on Cost-Effectiveness in Health and Medicine.

“There is a continued emphasis on transparency and comparability across analyses,” said Sanders-Schmidler. “And of course the big changes are that we’re now asking for a second reference case and using an ‘impact inventory’ table to clarify the scope of the findings.”

The independent panel of non-government scientists and scholars, which also included Stanford Health Policy’s Douglas K. Owens, focused on new ways to deliver health care effectively, yet with a focus on efficiency, as health care spending in the United States has reached 18 percent of GDP, much greater than the global average of 10 percent.

The first panel that convened in 1996 recommended that all cost-effectiveness analyses of health interventions include a reference case that uses standard methodological practices to improve comparability and quality. The second panel, which published its findings in September, now recommends that in addition to the societal perspective recommended by the original panel, that CEAs include a second reference case that looks at the health-care sector impact of an intervention. Additional guidance was given on what to include in the societal perspective reference case.

The panel wrote in its JAMA “special communication” that these societal reference cases should include medical costs “borne by third-party payers and paid out-of-pocket by patients, time costs of patients in seeking and receiving care, time costs of informal (unpaid) caregivers, transportation costs, effects on future productivity and consumption, and other costs and effects outside the health-care sector.”

They found most countries, including the United States, give greater weight to clinical evidence in their cost-effectiveness analyses. The panel now recommends an “impact inventory” that helps analysts and end-users of cost effectiveness analyses look at the impact of interventions beyond the formal health-care sector.

“We’re trying to ask people to be explicit,” said Owens, director of the Center of Primary Care and Outcomes Research and Center for Health Policy at Stanford.

“We want them to look at how to value outcomes in a societal perspective, not just the health-care sector, to look at all these other sectors such as productivity consumption, criminal justice, education, housing and the environment,” he said.

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Case Studies

Several case studies presented at the colloquium indicated that policy changes, government intervention and social factors are key to preventing obesity and diabetes and other NCDs.

Kristine Madsen, an associate professor of public health at UC Berkeley who focuses on childhood obesity, spoke about the nation’s first “soda tax” on sugar-sweetened beverages, which was implemented in Berkeley in March 2015.

The city has seen a 21 percent decline in the drinking of soda and other sugary drinks in low-income neighborhoods after the city levied a penny-per-ounce tax on sodas and sugary drinks. At the same time, according to a study in the American Journal of Public Health, neighboring San Francisco — where a similar soda-tax measure was defeated — and Oakland saw a 4 percent increase in the purchase of sweetened beverages.

“This decline of 21 percent in Berkeley represents the largest public health impact in an intervention that I have ever seen,” said Madsen.

Sergio Bautista of the Mexico National Institute of Public Health and UC Berkeley, said that Mexico’s sugary drinks tax implemented in January 2014 is expected to lead to a 10 percent reduction in sugary drinks consumption and prevent an estimated 189,300 cases of diabetes in a country famed for its sugary bottled cola.

William Dow, a professor of health policy management at UC Berkeley, shared his research on Costa Rica, where on average people live longer than Americans, despite the several times higher income and 10 times higher health expenditures in the United States.

Costa Rican men have a life expectancy of 77 and the women typically live until age 82; in Americans the numbers are 76 and 81, respectively. Obesity is low among Costa Rican men and few of their women smoke. Lung cancer mortality in the United States is four times higher among men and six times higher among women.

“It’s remarkable in so many ways,” Dow said, noting that deaths in the Central American country are due predominantly to infectious disease. “Does Costa Rica have any unique effective programs to emulate, or is there something going on upstream driving those health outcomes?”

He believes Costa Rica’s national health insurance and excellent access to primary care for nearly all its people are key. Having this guaranteed lifetime access to health care also reduces the stress and depression that can so badly harm physical health.

“And I would argue that probably diet is one of the most important things going on here,” said Dow, noting their diets are healthy.

Costa Ricans eat mostly unprocessed foods such as rice and black beans, corn tortilla, yam and squash, with little meat and plenty of fresh fruit.

“They also have the highest remaining life expectancy at age 80 of any country in the world, he said. “What we have learned in Costa Rica would be helpful in many other countries.”

When governments and scholars work together on data security, society benefits from better safeguards and protections, a U.S. intelligence expert said Wednesday.

The difficulty is keeping up with technology and societal trends, Admiral Bobby R. Inman said at the Center for International Security and Cooperation's annual Drell Lecture for 2017. His talk was titled, “The Challenges of Providing Data Security.”

Inman, whose U.S. Navy career spanned 31 years, served as the director of the National Security Agency, deputy director of the Central Intelligence Agency, and held other influential positions in the U.S. intelligence community. After retiring from the Navy, Inman worked on start-ups in the private sector, in higher education, and as chairman of the Federal Reserve Bank of Dallas. He is currently the Lyndon B. Johnson Centennial Chair in National Policy at the University of Texas, Austin.

'9/11 changed everything'

During his talk, Inman recounted the early days of cryptography and the dialogue between government officials like himself and scholars at universities such as Stanford and UC Berkeley. Cryptography or cryptology is the practice and study of techniques for secure communication in the presence of third parties typically known as adversaries.

Inman was a key driver behind establishing the United States Foreign Intelligence Surveillance Court in 1978. The purpose of the “FISA” court was to oversee requests for surveillance warrants against foreign spies inside the United States by federal law enforcement and intelligence agencies.

Today, technology has overwhelmed many issues regarding how the government tracks the communications of foreign entities, Inman said. And events have ushered in a different orientation on what type of information and from whom is sought by U.S. intelligence. “9/11 changed everything,” he added.

After 9/11, U.S. intelligence began to focus on foreign individuals in addition to the traditional foreign state actors, Inman said. He pointed out the value of such data collection, as penetrating small groups with human agents is extraordinarily difficult and dangerous.

“The only way you’re likely to get a lead on them (terrorists or narcotic traffickers) is through their communications,” he said.

The Internet, especially social media, has exploded in usage and made data security efforts even more complex, Inman said. “A vastly different world.” As a result, serious privacy, commercial usages and intellectual property issues need to be resolved more than ever. He noted that the rule of law is important to follow when the governmnt or other entities collect and examine communications data.

Inman is particularly worried about how “basic issues of ethics and morality” have eroded in society, which results in people scheming to sell private data for profit that puts others at risk. Another issue involves how to prevent terrorist groups from preying upon mentally weak people and recruiting them over the Internet.

A key reason Inman was invited to be the Drell speaker this year was his connection to Martin Hellman and Whitfield Diffie, two pioneering cryptographers from CISAC who drew Inman’s attention in the mid-1970s when they wrote a groundbreaking paper in their field of study. The three later established long-running friendships that produced strong cryptography frameworks.

Inman said, “We were privileged to start the dialogue. That’s where you begin to solve problems,” as fears and misperceptions can be resolved through discussions and openness. “I think what we need is a repeat of pulling together people” from academia and government to deal with today’s security threats. “We need to assess where we are.”

His concern is who would convene such a dialogue. “We’re in a pretty bumpy time, nationally,” said Inman, who urges a neutral party to be such a convener. On broader security fronts, Inman said he is most apprehensive about a possible nuclear exchange between Pakistan and India.

Legacy of Drell

The event included a tribute to Sidney Drell, who passed away last December at the age of 90. Drell co-founded CISAC, and jointly directed it from 1983 to 1989. The Drell Lecture, which is named after him, is an annual public event sponsored by CISAC. By tradition, the lecturer addresses a current and critical national or international security issue that has important scientific or technical dimensions.

In her opening remarks, Amy Zegart, co-director of CISAC, described Drell as a “true giant in the field of theoretical physics” who devoted his life’s work to reducing the threat of nuclear catastrophe. One trademarks of the Drell lecture was that its namesake had the opportunity to ask the first question of the speaker. “He had a unique way of asking penetrating questions" with gentle decency and fairness, she added.

CISAC’s William Perry, also on hand to discuss Drell’s legacy, said, “Sid Drell was truly a man for all seasons” who excelled in various fields of academic and policy. Perry first met Drell 55 years ago when he was beginning his own career in nuclear arms control. “Sid’s deep interest in arms control led to him teaming up with John Lewis” to launch CISAC, he noted.

“He was an extraordinary man,” Perry said, “and we shall never see his like again.”

Drell was a fan of classical music, especially the St. Lawrence String Quartet, a chamber music group whose music was piped in to the Bechtel Conference Room before the event began.

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The populist backlash against globalization is being felt acutely across Europe as well as here in the US. And yet whether you look at it from an economic, political or military perspective, transnational cooperation has become an integral part of our global landscape. Hear CDDRL Mosbacher Director Francis Fukuyama on the future of globalization for World Affairs. 

In a shack that now sits below sea level, a mother in Bangladesh struggles to grow vegetables in soil inundated by salt water. In Malawi, a toddler joins thousands of other children perishing from drought-induced malnutrition. And in China, more than one million people died from air pollution in 2012 alone.

Around the world, climate change is already having an effect on human health.

In a recent paper, Katherine Burke and Michele Barry from the Stanford Center for Innovation in Global Health, along with former Wellesley College President Diana Walsh, described climate change as “the ultimate global health crisis.” They offered recommendations to the new United States president to address the urgently arising health risks associated with climate change.

Bangladeshi children make their way through flood waters.

The authors, along with Stanford researchers Marshall Burke, Eran Bendavid and Amy Pickering who also study climate change, are concerned by how little has been done to mitigate its effects on health.

“I think it’s likely that health impacts could be the most important impact of climate change,” said Marshall Burke, an assistant professor of earth system science and a fellow at the Freeman-Spogli Institute for International Studies.

There is still time to ease — though not eliminate — the worst effects on health, but as the average global temperature continues to creep upward, time appears to be running short.

“I think we are at a critical point right now in terms of mitigating the effects of climate change on health,” said Amy Pickering, a research engineer at the Woods Institute for the Environment. “And I don’t think that’s a priority of the new administration at all.”

Health effects of climate change

Even in countries like the United States that are well-equipped to adapt to climate change, health impacts will be significant.

“Extremes of temperature have a very observable direct effect,” said Eran Bendavid, an assistant professor of medicine and Stanford Health Policy core faculty member.

“We see mortality rates increase when temperatures are very low, and especially when they are very high.”

Bendavid also has seen air pollutants cause respiratory problems in people from Beijing to Los Angeles to villages in Sub-Saharan Africa.

“Hotter temperatures make it such that particulate matter and dust and pollutants stick around longer,” he said.

In addition to respiratory issues, air pollution can have long-term cognitive effects. A study in Chile found that children who are exposed to high amounts of air pollution in utero score lower on math tests by the fourth grade.

“I think we’re only starting to understand the true costs of dirty air,” said Marshall Burke. “Even short-term exposure to low levels can have life-long effects.”

Low-income countries like Bangladesh already suffer widespread, direct health effects from rising sea levels. Salt water flooding has crept through homes and crops, threatening food sources and drinking water for millions of people.

“I think that flooding is one of the most pressing issues in low-income and densely populated countries,” said Pickering. “There’s no infrastructure there to handle it.”

Standing water left over from flooding is also a breeding ground for diseases like cholera, diarrhea and mosquito-borne illnesses, all of which are likely to become more prevalent as the planet warms.

On the flip side, many regions of Sub-Saharan Africa — where clean water is already hard to access — are likely to experience severe droughts. The United Nations warned last year that more than 36 million people across southern and eastern Africa face hunger due to drought and record-high temperatures.

Residents may have to walk farther to find water, and local sources could become contaminated more easily. Pickering fears that losing access to nearby, clean water will make maintaining proper hygiene and growing nutritious foods a challenge.

Climate change will affect health in all sectors of society.

All of these effects and more can also damage mental health, said Katherine Burke and her colleagues in their paper. The aftermath of extreme weather events and the hardships of living in long-term drought or flood can cause anxiety, depression, grief and trauma.

Climate change will affect health in every sector of society, but as Katherine Burke and her colleagues said, “….climate disruption is inflicting the greatest suffering on those least responsible for causing it, least equipped to adapt, least able to resist the powerful forces of the status quo.

“If we fail to act now,” they said, “the survival of our species may hang in the balance.”

What can the new administration do to ease health effects?

If the Paris Agreement’s emissions standards are met, scientists predict that the world’s temperature will increase about 2.7 degrees Celsius – still significant but less hazardous than the 4-degree increase projected from current emissions.

The United States plays a critical role in the Paris Agreement. Apart from the significance of cutting its own emissions, failing to live up to its end of the bargain — as the Trump administration has suggested — could have a significant impact on the morale of the other countries involved.

“The reason that Paris is going to work is because we’re in this together,” said Marshall Burke. “If you don’t meet your target, you’re going to be publicly shamed.”

The Trump administration has also discussed repealing the Clean Power Plan, Obama-era legislation to decrease the use of coal, which has been shown to contribute to respiratory disease.

“Withdrawing from either of those will likely have negative short- and long-run health impacts, both in the U.S. and abroad,” said Marshall Burke.

Scott Pruitt, who was confirmed today as the head of the Environmental Protection Agency (EPA), is expected to carry out Trump’s promise to dismantle environment regulations.

Despite the Trump administration’s apparent doubts about climate change, a few prominent Republicans do support addressing its effects.

Secretary of State Rex Tillerson, the former chairman and CEO of Exxon Mobile, supports a carbon tax, which would create a financial incentive to turn to renewable energy sources. He also has expressed support for the Paris Agreement. It is possible that as secretary of state, Tillerson could help maintain U.S. obligations from the Paris Agreement, though it is far from certain whether he would choose to do so or how Trump would react.

More promising is a recent proposal from the Climate Leadership Council. Authored by eight leading Republicans — including two former secretaries of state, two former secretaries of the treasury and Rob Walton, Walmart’s former chairman of the board — the plan seeks to reduce emissions considerably through a carbon dividends plan.

Already an issue, malnutrition will increase with droughts in Sub-Saharan Africa.

Their proposal would gradually increase taxes on carbon emissions but would return the proceeds directly to the American people. Americans would receive a regular check with their portion of the proceeds, similar to receiving a social security check. According to the authors, 70 percent of Americans would come out ahead financially, keeping the tax from being a burden on low- and middle-income Americans while still incentivizing lower emissions.

“A tax on carbon is exactly what we need to provide the right incentives and induce the sort of technological and infrastructure change needed to reduce long-term emissions,” said Marshall Burke.

Pickering added, “This policy is a ray of hope for meaningful action on climate.”

It remains to be seen whether the new administration and congress would consider such a program.

What can academics do to help?

Meanwhile, academics can promote health by researching the effects of climate change and finding ways to adapt to them.

“I think it’s fascinating that there’s just so little data right now on how climate change is going to impact health,” said Pickering.

Studying the effects of warming on the world challenges traditional methods of research.

“You can’t create any sort of experiment,” said Bendavid. “There’s only one climate and one planet.”

The scholars agree that interdisciplinary study is a critical part of adapting to climate change and that more research is needed.

“If ever there was an issue worthy of a leader’s best effort, this is the moment, this is the issue,” said Katherine Burke and her colleagues. “Time is short, but it may not be too late to make all the difference.”

Stanford University has expressed its views on the recent executive order on immigration, and is offering resources for students who could be affected. News accounts indicate that as many as 17,000 students across the country fall into this category. On Jan. 27, President Trump signed an executive order restricting travel to the United States of people from seven largely Muslim countries -- Syria, Iran, Iraq, Libya, Somalia, Sudan and Yemen.

Amy Zegart, co-director of the Center for International Security and Cooperation, said CISAC's "mission is generating knowledge to build a safer world. We bring scholars, ideas from everywhere. And always will."

Looking ahead, Stanford is planning campus events and initiatives on this issue. Some information already to note: 

• Stanford launched a new website on immigration issues for students and scholars. This includes centralized campus information about international travel guidance and other information. Stanford will continue to add content to this site.

• A letter to the campus community from Stanford president Marc Tessier-Lavigne, provost John Etchemendy, and incoming provost Persis Drell affirming the university's support for international students. "As events unfold, the university intends to continue vigorously advocating before Congress, the Executive Branch, and beyond for policies consistent with its commitment to members of our community who are international, undocumented and those who are impacted by the recent executive order."

Syria's civil war has taken a devastating toll on children.

Stanford freshman Emma Abdullah puts a young human face on that tragedy with her book, The Blue Box, which details the plights of Syrian children during the country’s six-year civil war. Published in 2014, the work is a collection of short stories and poems, and all proceeds go to charity. Abdullah estimates she’s raised $80,000 for the cause. Abdullah, who was raised in Kuwait, has relatives and friends from her father’s side of the family in Syria who have died or gone missing.

As many as 470,000 people and 10,000 children have been killed in the war, according to published accounts and the United Nations.

“My goal is to raise awareness about what these children are going through,” said Abdullah, who spoke at a recent staff meeting at Stanford's Center for International Security and Cooperation. “It’s important for me to bring this situation to light.”

She’s found receptive minds among her fellow classmates, though many of them were not aware of the scope of horror in Syria. “Other students have been good, and people are willing to listen once you talk to them about it. It’s been very positive at Stanford, and there is a lot to do on campus.”

Her 86-page book includes a child who writes stories about people in Syria. “She feeds the box with her thoughts; she puts in everything she has. She doesn't know it but her box becomes powerful. It takes up every word, every smile and every heartbeat and slowly, quietly, it grows. It grows into something so much bigger and more profound than she is. She’s just a child. She’s just a child who promised she’d save another but who doesn't know how. But one day, she looks at her box and she understands,” writes Abdullah, who will major in political science.

'It's a sad picture'

The Syrian civil war began in March 2011; the politics involved were not understandable to Abdullah. Would things return to normal? They did not, and have not since. She soon began losing friends – she estimates at least 20 people -- as thousands of children were tortured and killed.  She wanted to do something and make a difference, and not just be a bystander staying silent. So Abdullah began expressing her thoughts and feelings in story form.

Regarding the book’s front cover, Abdullah recalled that when she told the child who drew it how beautiful it was, the child replied, “Don’t lie, it’s a sad picture.” Despite the bright colors, one sees children in that drawing crying and a military airplane flying overhead dropping bombs. And, one of the girls pictured, Nour, is lost forever, likely dead, noted Abdullah. 

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In one story, “Call of the Jasmine,” a little boy named Karim writes an early letter to Santa Claus, worried that he may not be alive come December. “I know where I live is not very pretty and I know there’s not much in it for you, but mama says we’re beautiful where it counts.”

In another account, a child is given an injection of lethal poison. “Everything subsequently goes dark but I close my eyes anyway. The darkness will protect me.”

Some quotes from the book include, “When you write something down, it stays forever. It's like a little part of you that you're giving to the universe.” Abdullah also writes, “We live in a world where some people have already lost the game before having begun.”

As she describes the experience of war on children, “There is no Richter scale to measure pain; it leaves you vulnerable. It's not pain you can get used to, not sorrow that you can tame. It leaves you broken, broken but alive.”

Ultimately, one of her characters said, “Maybe life just wants to be noticed, like a sulking toddler, so it will keep throwing things our way until we finally give it the attention it deserves.”

Disconnected world

Abdullah says literature and art allow us to connect with each other in ways that any other medium would really struggle to match.

“We tend to think of refugees as statistics; death tolls in faraway lands we will never live in. We see children of war and never picture our own for we assume that we will never find ourselves packing up our lives and everything we know only to cross oceans for new homes that do not want us,” she said.

That disconnect is the greatest part of the problem. “We allow ourselves to feel distanced from these events and these people. I wonder how many people stop to think ‘this could be me,’” she said.

Abdullah said that when people read a story or watch a play, they are able to think beyond their own lives and feel what another’s pain is like.

“If stories and theater allow us all to live the harrowing life of a refugee, if only for just an hour, maybe we could all carry a little part of them inside of us and maybe then we’d want to push for change,” she added.

‘Community and unity’

President Trump’s recent travel ban for Muslims from seven different Middle Eastern countries has focused attention on Syrian refugees, Abdullah said. Now, media outlets are interviewing refugees and doing in-depth stories on them. She believes the protests and activism around the country and on campus reflects the desire by many to take a closer look at the victims of the Syrian war.

“We see a greater sense of community and unity, and people who might not have cared about these issues are starting to do so now. People are saying, ‘this is not right’ There is a sense of hope,” she said.

She said that living in constant fear of being hurt by others for what you believe in and in fear of being told you can no longer enter a country like the U.S. is something no one should have to experience.

“Nobody chooses where they are born,” Abdullah said.

“My friends in the Middle East are afraid that all the years they have spent working hard will amount to nothing if their education is interrupted. Those studying in the U.S. wonder whether they will be able to visit their families for the holidays and those in other countries are afraid that maybe the ban will spread to where they are, too.”

Power of writing

Abdullah said she’s always enjoyed writing; she started publishing when she was 13, and has written for student newspapers and magazines in her home country. “I saw that people were being touched, and thought it could have an effect.”

Emma Abdullah

Abdullah went to high school at the New English School in Kuwait. Her book has been adapted as a play by Alison Shan Price. Titled, “The Blue Box: The Memories of Children of War,” it premiered in Kuwait in 2015 and then internationally at the Edinburgh Festival Fringe in Scotland last year. 

For those seeking to help, Abdullah suggests making donations to the Syrian American Medical Society, which has helped with evacuations and humanitarian relief for children and others caught up in the crisis.

“The most important thing is not to forget them and not to allow anyone else to either. It is too easy to become indifferent, she said.

The Syrian war has dragged on for six years now, Abdullah said, and children continue to suffer and die every day.

“On a very small scale, the best thing you can do is talk about them and make sure your friends do, too. Learn more about the war and the refugee crisis so that you can spread the word,” she said.

People can donate to charities and NGOs that work with refugees, volunteer at charities, or even start their own fundraisers.

“Advocacy is crucial,” Abdullah said. “Protest, email or call your representatives and urge your government to increase their assistance to Syrian refugees, and encourage your friends to do the same.”

Follow CISAC at @StanfordCISAC and www.facebook.com/StanfordCISAC.

MEDIA CONTACTS

Clifton B. Parker, Center for International Security and Cooperation: (650) 725-6488, cbparker@stanford.edu

Today, the Bulletin of Atomic Scientists’ “doomsday clock” moved 30 seconds forward to 2 and a half minutes to midnight. The closer the minute hand gets to midnight, the closer the bulletin predicts humankind is to destroying itself. The symbolic clock was created in 1947 when Albert Einstein and Robert Oppenheimer (the father of the U.S. nuclear program) founded the publication.

The following experts from the Center for International Security and Cooperation and the Freeman Spogli Institute for International Studies offered these perspectives:

William J. Perry, a former U.S. Secretary of Defense and senior fellow at the Center for International Security and Cooperation (CISAC), said: "Last year the Doomsday clock was set at 3 minutes to midnight, the closest it has been to global 'midnight' since the iciest days of the Cold War. This ominous pronouncement reflected my own fears that we were now in greater danger of nuclear catastrophe than we were during the Cold War, with the growing threat of nuclear terrorism, the continued risk of accidents and miscalculation, and the possibility of regional nuclear war and continued nuclear proliferation around the world."

He added, "Today the Bulletin of Atomic Scientists announced that we have moved closer to global catastrophe, for the first time setting the clock 30 seconds ahead to 2 and a half minutes to midnight, approaching a time not seen since the United States and Soviet Russia first developed the H-bomb. We must heed this dire warning as a call to action. There are concrete steps that we can take to reduce the risk of nuclear annihilation, but we must start today."

Siegfried Hecker, the former director of the Los Alamos National Laboratory and senior fellow at CISAC, said, "The bulletin’s keepers of the clock made the correct call to move the clock 30 seconds closer to midnight. The disregard for fact-based analysis of issues such as global climate change during the recent presidential campaign is truly alarming. However, my immediate concerns focus on the world having become a more dangerous nuclear place."

He said, "Developments in North Korea top the list: 2016 was a very bad year as Pyongyang greatly expanded its nuclear complex to increase the size of its arsenal to perhaps as many as 20 to 25 weapons, conducted two more nuclear tests to enhance the sophistication of its weapons, and launched two dozen missile tests. All of this while Washington cut all communications with a regime about which we know so little, while continuing the failed policies of sanctions and leaning on China to solve the problem."

"Confrontation," Hecker said, "has replaced cooperation between Russia and the United States. For the first time since the end of the Cold War the specter of a nuclear arms race was raised in 2016. President Putin put the finishing touches on suspending or terminating most of the cooperative nuclear threat reduction programs with the United States. Nuclear safety and security concerns appear to have taken a back seat to nuclear saber rattling and cyber attacks."

He noted, "Tensions between China and the United States have increased substantially over Beijing’s more muscular role in international affairs, particularly with its actions in the South China Sea. Moreover, tensions over Taiwan prompted by President Trump’s comments about the One-China policy renew the possibility of conflict."

"South Asia has inched closer to potential nuclear confrontation between India and Pakistan. India’s expanding economy and its concerns about Chinese military expansion has prompted it to strengthening its nuclear arsenal by moving toward a full triad – land, air and sea-based nuclear weapons. Pakistan, its much smaller and weaker neighbor, feels increasingly threatened by India’s expanding military. It has moved to what is called a posture of full-spectrum nuclear deterrence, which includes very dangerous tactical battlefield nuclear weapons that lower the nuclear threshold," Hecker said.

"Preventing and responding to potential acts of nuclear terrorism require close international cooperation. Unfortunately, all signs point in the opposite direction at a time when the atrocities perpetrated by terrorists are increasing. Greatest among these pullbacks was President Putin’s decision not to participate in the 2016 Nuclear Security Summit held in Washington, DC. With President Obama’s tenure having ended, this very effective collaborative international effort is now in limbo," he said.

MEDIA CONTACTS

Clifton B. Parker, Center for International Security and Cooperation: (650) 725-6488, cbparker@stanford.edu

Chaney Kourouniotis, Freeman Spogli Institute for International Relations: (6650) 724-9842, chaney.kourouniotis@stanford.edu

Space is more important than ever for the security of the United States, but it’s almost like the Wild West in terms of behavior, a top general said today.

Air Force Gen. John Hyten, commander of the U.S. Strategic Command, spoke Jan. 24 at Stanford’s Center for International Security and Cooperation. His talk was titled, “U.S. Strategic Command Perspectives on Deterrence and Assurance.”

Hyten said, “Space is fundamental to every single military operation that occurs on the planet today.” He added that “there is no such thing as a war in space,” because it would affect all realms of human existence, due to the satellite systems. Hyten advocates “strategic deterrence” and “norms of behavior” across space as well as land, water and cyberspace.

Otherwise, rivals like China and Russia will only threaten U.S. interests in space and wreak havoc for humanity below, he said. Most of contemporary life depends on systems connected to space.

Hyten also addressed other topics, including recent proposals by some to upgrade the country’s missile defense systems.

“You just don’t snap your fingers and build a state-of-the-art anything overnight,” Hyten said, adding that he has not yet spoken to Trump administration officials about the issue. “We need a powerful military,” but a severe budget crunch makes “reasonable solutions” more likely than expensive and unrealistic ones.

On the upgrade front, Hyten said he favors a long-range strike missile system to replace existing cruise missiles; a better air-to-air missile for the Air Force; and an improved missile defense ground base interceptor.

‘Critically dependent’

From satellites to global-positioning systems (GPS), space has transformed human life – and the military – in the 21st century, Hyten said. In terms of defining "space," the U.S. designates people who travel above an altitude of 50 miles as astronauts.

As the commander of the U.S. Strategic Command, Hyten oversees the control of U.S. strategic forces, providing options for the president and secretary of defense. In particular, this command is charged with space operations (such as military satellites), information operations (such as information warfare), missile defense, global command and control, intelligence, surveillance, and reconnaissance, global strike and strategic deterrence (the U.S. nuclear arsenal), and combating weapons of mass destruction.

Hyten explained that every drone, fighter jet, bomber, ship and soldier is “critically dependent” on space to conduct their own operations. All cell phones use space, and the GPS command systems overall are managed at Strategic Command, he said.

“No soldier has to worry about what’s over the next hill,” he said, describing GPS capabilities, which have fundamentally transformed humanity’s way of life.

Space needs to be available for exploration, he said.

“I watch what goes on in space, and I worry about us destroying that environment for future generations.” He said that too many drifting objects and debris exist – about 22,000 right now. A recent Chinese satellite interception created a couple thousand more debris objects that now circle about the Earth at various altitudes and pose the risk of striking satellites.

“We track every object in space” now, Hyten said, urging “international norms of behavior in space.”

He added, “We have to deter bad behavior on space. We have to deter war in space. It’s bad for everybody. We could trash that forever.”

But now rivals like China and Russia are building weapons to deploy in the lower levels of space. “How do we prevent this? It’s bigger than a space problem,” he said.

Deterring conflict in the cyber, nuclear and space realms is the strategic deterrence goal of the 21st century, Hyten said.

“The best way to prevent war is to be prepared for war,” he said.

Hyten believes the U.S. needs a fundamentally different debate about deterrence. And it all starts with nuclear weapons.

“In my deepest heart, I wish I didn’t have to worry about nuclear weapons,” he said. Hyten described his job as “pretty sobering, it’s not easy.”

But he also noted the mass violence of the world prior to 1945 when the first atomic bomb was used. Roughly 80 million people died from 1939 to 1945 during World War II. Consider that in the 10-plus years of the Vietnam War, 58,000 Americans were killed. That’s equivalent to two days of deaths in WWII, he said.

In a world without nuclear weapons, a rise in conventional warfare would produce great numbers of mass casualties, Hyten said. About war, he said, “Once you see it up close, no human will ever want to experience it.”

Though America has “crazy enemies” right now, in many ways the world is more safe than during WWII, Hyten said. The irony is that nuclear weapons deterrence has kept us from the type of mass killings known in events like WWII. But the U.S. must know how to use its nuclear deterrence effectively.

Looking ahead, Hyten said the U.S. needs to think about space as a potential war environment. An attack in space might not mean a response in space, but on the Earth.

Hyten describes space as the domain that people look up at it and still dream about. “I love to look at the stars,” but said he wants to make sure he’s not looking up at junk orbiting in the atmosphere.

‘Space geek’

Hyten has served in the Air Force for 35 years. He originally wanted to be an astronaut, but his eyesight was too bad. He got a waiver, and graduated Harvard in 1981 with an engineering degree on a ROTC scholarship. He entered the Air Force thinking he would only do four years. But then he had a close-up view of what a young Air Force officer could find in the last frontier of space as satellites and military space science were booming.

“God, I love space,” he said.

In introducing Hyten, Amy Zegart, co-director of CISAC, described him as a person of unwavering dedication and profound insights who understands the gravity of situations. “A self-described space geek,” she said.

Hyten lauded CISAC for its research and educational work on national security, and said he enjoyed being around people willing to test out new ideas and discuss potential solutions for vexing problems.

Earlier in the day on campus, Hyten met with William J. Perry, a former U.S. Secretary of Defense and senior fellow at CISAC; George Shultz, a former U.S. Secretary of Defense and senior fellow at the Hoover Institution; and Condoleezza Rice, a senior fellow at the Freeman Spogli Institute for International Studies and Hoover Institution.

General Hyten was nominated for reassignment to head the U.S. Strategic Command on Sept. 8, 2016. He commanded Air Force Space Command from 2014 to 2016.

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Clifton B. Parker, Center for International Security and Cooperation: (650) 725-6488, cbparker@stanford.edu

The Trump administration’s reinstatement of a policy that bans U.S. foreign aid to agencies that provide abortion counseling abroad was a predictable move that could have unintended consequences, Stanford researchers say.

The move freezes funding to nongovernmental organizations that provide abortion services or discuss abortions as a legitimate  family-planning option. It revives what is known as the “Mexico City Policy,” so called because it was announced by President Regan in 1984 during a U.N. population conference in Mexico City. It’s a highly partisan policy, which has been implemented under Republican administrations and suspended by Democratic presidents.

From that standpoint, the move to revive the policy was no surprise, said Grant Miller, PhD, an associate professor of medicine at Stanford and core faculty member at Stanford Health Policy. But Miller’s research has shown that the policy actually appears to have the unintended effect of increasing, not decreasing, abortions in the developing world.

“The bottom line is that it doesn’t matter what you think about abortion and the morality and ethics of it,” Miller told me. “I don’t think either side of the disagreement would think a good policy is one that leads to an increase in abortions. Neither side wants to see more abortions.”

In 2011, Miller published a study with Eran Bendavid, MD, on the impact of the policy between 1994 and 2008 in sub-Saharan Africa, a region in which family planning services are heavily financed by U.S. foreign aid. Family planning agencies provide a range of family planning services, including contraception, so when their funding is cut, the availability of contraception declines, said Bendavid, the study’s lead author and another faculty member at Stanford Health Policy. This results in declining use of safe contraception and an increase in abortion rates, the researchers found.

“Sure enough, where you see this relative decline in use of contraception is where you see this uptick in abortion,” said Bendavid, an assistant professor of medicine. “Our theory of what is underlying this is this notion that when women have more restricted access to modern contraception, they rely on abortion. If the intention was to curb abortion, then what we observe is that cutting support to family planning organizations led to the  opposite effect.”

Miller followed that up with another study published in 2016 that focused on Nepal during the period when the government legalized abortion, making it more widely available. The policy change gave him the opportunity to test the idea of abortion and contraception as substitutes — i.e. that use of one method to limit family size reduces use of the other. In fact, as the number of abortions rose, use of contraception declined, he found.

“What is remarkable is that this is clear evidence on this interchangeable use that women make in use of contraceptives and abortion services,” Miller said.

In other words, women are trying to control the number of children they have and will use one or the other, depending in part upon what is most available. “If contraception is available, they won’t have to resort to abortion,” Bendavid said.

He said these results have subsequently been corroborated in other studies in sub-Saharan Africa.