Shorenstein Asia-Pacific Research Center faculty and scholars have published a variety of publications in early 2014, covering topics from the Japanese fiscal condition to disability policy in North Korea. 

Publications are often products of long-standing research projects led by Center affiliates. New Challenges for Maturing Democracies in Korea and Taiwan, coedited by Shorenstein APARC Director Gi-Wook Shin and Center on Democracy, Development and Rule of Law Director Larry Diamond, emerged from the Stanford Korea Democracy Project, which seeks to understand social movements in South Korea.

Postdoctoral fellows who reside at Shorenstein APARC for a year of vigorous study and engagement in Center activities also support research publications. Former visiting scholar Dominik Müller, now at Goethe-University Frankfurt, published Islam, Politics and Youth in Malaysia: The Pop-Islamist Reinvention of PAS. Müller examined the religious bureaucracy of Malaysia at Shorenstein APARC in 2013.

Shorenstein APARC manages an active publishing program with Stanford University Press and the Brookings Institution Press. Center affiliates also publish extensively in external peer-reviewed academic journals and books, as well as in a working paper series led by the Asia Health Policy Program.

Publications released in recent months include: 

Comparative Institutional Analysis: Theory, Corporations and East Asia. Selected Papers of Masahiko Aoki, Masahiko Aoki, Edward Elgar Publishing, 2014

The volume is a collection of 22 articles that span the course of Aoki’s 45-year academic career. The essays cover a wide range of topics from the comparative perspective including corporate governance, institutional change and mechanism design in Japan, China and South Korea. The articles suggest policy responses for industry and governments.

Confronting Memories of World War II: European and Asian Legacies, Eds. Daniel Chirot, Gi-Wook Shin, Daniel C. Sneider, University of Washington Press, 2014

Comparing the European and Asian legacies, the book provides insight into the influence that World War II continues to have on contemporary politics and attitudes. The collection gathers a variety of perspectives that compare how Europe and Asia handle memories and reflections of guilt, and how wartime experiences are reinterpreted and used for domestic and international purposes.

“Defying Gravity: How Long Will Japanese Government Bond Prices Remain High?” Takeo Hoshi, Takatoshi Ito, Economic Policy, January 2014

The article examines the fiscal regime of Japan and considers if the country can withstand its high debt to GDP ratio. The paper shows that Japan’s fiscal situation is unsustainable through various simulations, and suggests that sufficiently large tax increases and/or expenditure cuts would put government debt on a sustainable path.

“Facts, Minds, and Formats: Scholarship and Political Change in Indonesia,” Donald K. Emmerson, Cornell University Press, March 2014

Indonesia has changed dramatically in recent decades, and a wealth of literature highlights divergent interpretations and perspectives surrounding those dynamics. The article considers the demise of liberal democracy, the rise of President Sukarno in 1959, and the latter’s replacement by General Suharto in 1965. The essay is part of the larger volume, Producing Indonesia: The State of the Field of Indonesian Studies.

“The Fukushima Nuclear Disaster and the DPJ: Leadership, Structures, and Information Challenges During the Crisis,” Kenji E. Kushida, Japanese Political Economy, Spring 2014

The Fukushima nuclear disaster was a critical event that shook Japan’s political economy, society and national psyche, as well as the world’s perspectives on nuclear energy policy. The article examines how the nuclear disaster unfolded and analyzes the response undertaken by the Democratic Party of Japan under Prime Minister Naoto Kan. Kushida is the Takahashi Research Associate at Shorenstein APARC.

“Japan-Korea Relations: Time for U.S. Intervention?” Daniel C. Sneider, National Bureau of Asian Research, January 2014

The paper describes current relations between South Korea and Japan, recognizing that their relationship has noticeably deteriorated in recent months. While the United States has attempted to promote dialogue, its hesitant intervention is unlikely to change the overall dynamic of the Japan-Korea relationship. Sneider suggests that a more active U.S. mediation role could encourage reconciliation and normalization of relations.

“People with Disabilities in a Changing North Korea,” Katharina Zellweger, Shorenstein APARC, 2014 

The working paper details the environment that people with disabilities face in the Democratic People’s Republic of North Korea. Despite its reputation as a repressive, closed society where human rights are routinely abused, there are in fact a number of institutions that work to address the needs of the disabled. Zellweger writes from a perspective of a senior aid worker with over thirty years of experience in Asia; she was the Pantech Fellow at Shorenstein APARC from 2011­–13.

To view the full listing of publications, as well as reviews and purchasing information, please consult the Publications page on Shorenstein APARC's website.

In regions of rural China where health education is limited, parents know more about the nutritional needs of their pigs than of their own children. And while piglets are raised to be robust and ready to command high market prices, infants in this part of the world suffer from high rates of anemia and cognitive delays that put them – and the country’s economy – at risk, according to Stanford researchers.

Those researchers are now experimenting with ways to encourage parents to feed their children more nutritious food. And they’re hoping their results will push the Chinese government to implement policies to curb malnutrition, especially anemia.

“Anemia acts like an invisible drag on the Chinese economy,” says Scott Rozelle, director of the Rural Education Action Program (REAP) at Stanford’s Freeman Spogli Institute for International Studies (FSI). REAP is a part of FSI's Center on Food Security and the Environment.

Rozelle and his colleagues spearheaded a survey of 1,800 babies in Shaanxi province that shows the scope and impact of malnutrition throughout the region. Their findings will soon be published.

A map of Shaanxi province, where the REAP survey was carried out. Photo Credit: Wikipedia

Despite China’s rapid economic growth in recent decades, anemia among rural populations remains widespread. Left untreated, anemia decreases oxygen to the brain and can hurt cognitive and physical development. The World Health Organization estimates that effective treatment of anemia can improve national economic productivity by up to 20 percent. Other research has shown that the long-term effects can be even greater.

But poor nutrition is only partially to blame for the high rates of cognitive delays that the researchers discovered. Rozelle and his team also found that most parents don’t spend enough time playing and talking with their babies. In general, parenting practices in the region do not involve providing babies with mental stimulation, which is also an important part of cognitive development.

Testing and treating 1,800 babies

Rozelle and his colleagues first set out to understand the scope of the problem by measuring anemia rates among rural Chinese babies. Between April and October, 2013, REAP administered the largest survey of rural baby nutrition ever conducted in China. Over the course of four weeks, a team of around 120 surveyors tested 1,824 babies in 351 poor, rural villages across Shaanxi Province.

The researchers found that in the region, where pig farming is one of the main industries, more than three times as many parents had accurate information about pig nutrition than about baby nutrition. When asked whether micronutrients are necessary for the healthy growth of baby pigs, over 70 percent of caretakers responded “yes”. But only 21 percent of caretakers believed that micronutrients are also important for human babies.

The researchers also found that 49 percent of the children in the survey had anemia, an additional 28 percent were "near-anemic" and 40 percent showed significant cognitive or motor delays. These rates exceed the global average for children and indicate widespread deficiencies in child nutrition in the region.

A REAP surveyor tests how a baby reacts to his own reflection. Photo Credit: REAP

The REAP team then set up an experiment. One third of households were given a free daily supply of nutritional supplements for their children. Another third were given the same free supplements, and were enrolled in a text message reminder program. A final third of households served as a control group. The study is ongoing through April, 2015, but 12 months into the program, the researchers have found that the supplements have reduced anemia rates by 28 percent, although cognitive delays have persisted.

Anemia linked to poor diets

In contrast with their children, the parents who participated in the survey seemed to be well-fed and showed relatively low levels of anemia (19 percent). Many also reported purchasing expensive baby formula for their children, indicating a willingness to spend financial resources on child nutrition. The problem therefore seems to be not one of poverty, but rather one of information: parents are unknowingly feeding their children food that is lacking in iron and other micronutrients.

The nutrients missing from the babies’ diets are plentiful in solid foods such as fruits, vegetables, and lean meat. International standards for child nutrition advise that complementary foods be introduced to infants at around six months of age. By one year of age, solids should make up more than half of a child’s diet.

Parents in the REAP study, however, waited until between one year and 18 months to introduce solid foods. Many mothers stopped breastfeeding at six months, switching their babies to diets consisting mostly of rice porridge or wheat-flour based soups.

Many parents said early childhood diets were unimportant for healthy development.

“I don’t think the foods he eats matter since he doesn’t eat that much,” one parent told the researchers.  Another insisted, “Formula and porridge are good enough for my baby. He is always happy after mealtime.”

The “Hidden Hungry”

Sometimes described as “hidden hunger,” micronutrient deficiencies like anemia can go undetected because those afflicted often look healthy. Young children can appear to be well fed or even overweight, but still lack critical nutrients for normal development. In remote places where blood tests are unavailable, it can be impossible to tell that a child is anemic.

A nurse tests a child's blood for signs of anemia. Photo Credit: REAP

But about 25 percent of the world’s population is anemic, making the condition the most common form of malnutrition. About 25 percent of people are anemic worldwide, including half of pregnant women and 40 percent of children under the age of five.

The effects of anemia, however, are most severe among infants and toddlers. The damage it causes is difficult to reverse after the first several years of life.

Nutritional Myths

Rozelle’s team found several misconceptions about infant health and nutrition. One myth was especially common: that babies cannot digest solid food until they can walk.

“I wouldn’t dare give her anything before that,” said one parent. “Soft, clean foods are good for my baby. Hard foods are not healthy.”

Some parents even assumed that soft foods were better for their child’s cognitive development. “A good way to make him smarter is to feed him starches and rice. You can’t feed him hard food,” explained a mother about her young son.

The interviews also highlighted a lack of knowledge about malnutrition, and about the links between nutrition and health. “Genes cause malnutrition,” said one mother. “You’ll know if your skin turns pale and you become really thirsty.”

Another answered, “[Anemia] is caused by not eating enough.” When asked how anemia is treated, answers included drinking sugary water, adding red sauce to food, eating peanuts, getting a blood transfusion at the hospital, and taking traditional Chinese medicine.

In reality, anemia can be treated at home with a daily low-cost iron supplement (like the one being distributed as part of the REAP study), or simply by adding more iron-rich foods to a child’s diet.

 “No one ever told me how to feed my baby”

The pervasiveness of misinformation about baby nutrition stems from a lack of access to health and nutrition education. As one mother explained, “No one ever told me how to feed my baby.” The majority of interviewees reported relying on older family members for guidance on how to feed and care for children.

Local doctors do little to encourage proper child health care. Many prescribe medicines to treat immediate symptoms of malnutrition, such as colds or diarrhea, without addressing underlying issues.

One parent whose baby was found to be anemic reported, “The doctor never said anything to help me understand my child. He just told me to buy some rice powder and medicine.”

A mother participating in the REAP study answers questions about her baby's diet. Photo Credit: REAP

Other parents refuse to see a doctor at all. An interviewee with two young sons admitted to having never taken her children for a check-up for fear that her fertility would be monitored under China’s one-child policy.  Some mothers said they relied on traditional Chinese medicine to treat health problems rather than visit doctors.

Parents also frequently relied on information from local baby formula sales representatives. When asked how she makes decisions about her baby’s health, one mother reported, “I read the booklets at the formula store for information.” Perhaps unsurprisingly, this same mother was late in introducing solid foods to her child, and during the interview fed her 15-month-old child a type of formula that stated clearly on the label that it was suitable only for babies up to 12 months of age.

“The formula salesperson said to ignore that,” she explained.

Nourishing the Future

The REAP team designed an experiment to tackle both problems: infants’ poor diets and parents’ lack of nutritional knowledge. The project, called Nourishing the Future, was funded by the International Initiative for Impact Evaluation, UBS Optimus Foundation, China Medical Board and others.

A NurtureMate nutritional supplement packet, made by Heinz. Photo Credit: REAP

Each household in the study, with the exception of a control group, received a one-year supply of daily supplement packets called NurtureMate, manufactured by Heinz, another partner in the project. The powdered mix of iron, zinc, folic acid, and vitamins can be added to milk or formula, or sprinkled on porridge.

In addition to supplements, the treatment group received instruction in the basics of childhood nutrition. At 8:00 every morning, half of the treatment group also received a daily text message reminder to administer the packets: “Have you taken your NurtureMate today? Your baby needs the nutrients to grown strong and stay healthy!”

Text message reminders appear to have been modestly effective in improving program compliance. Caregivers who received the reminders gave their baby the micronutrient supplements, on average, 10 percent more often over the course of the first six months of the study. So far, however, this improved compliance has not led to a corresponding fall in anemia rates.

Other factors influence infant development

Although anemia rates fell among the two treatment groups, Rozelle’s team found no cognitive improvements.

“It’s still early, but it’s becoming clear that nutrition is not the only piece of the puzzle,” says Alexis Medina, the project manager of Nourishing the Future. “Several things affect brain development in young kids. One is nutrition. Another is the mental stimulation that children get through games, toys and face-to-face interaction with adults.”

The babies Medina and her team evaluated had very few toys or books at home, and received minimal attention from their caretakers in terms of playing, singing and talking.

“A lot of parents we talked to didn’t think much about whether they were playing with their kids enough,” Medina said. “But some actually thought it was a waste of time. We had several mothers tell us, ‘Babies don’t remember much when they’re young, so I don’t bother talking or reading to [my baby]. They can’t understand me yet anyway, so what’s the point?’”

Changing policy

With its first high-quality data sets in hand, REAP is now looking for long-term answers to the child malnutrition epidemic in China.

“Sure, we can help the 1,800 babies who are participating in our study now, but what about the other 10 million babies just like them?” asks Rozelle. “To reach all of China’s at-risk babies – that’s our ultimate objective. And to do that, we need an effective government program.”

In fact, the Chinese government has already unveiled a new pilot program that aims to provide every rural baby living in poverty with a free daily nutrient packet. But instead of delivering the packets directly to households, families have to travel several hours to the local county seat to pick up their packets. To date, the pilot has been rolled out in about 350 poor rural counties, with another 300 scheduled for 2014. But the government pilot doesn’t include any baseline research, and thus lacks important data on the health impacts and cost-effectiveness of this type of nutritional intervention.

The scant data available suggests that only a small share of eligible families are actually making the effort to pick up their packets. This is the gap REAP is looking to fill with its studies. Rozelle hopes that REAP’s new data on baby nutrition will help shape the government’s pilot program as it grows.

REAP has a long history of pioneering research and impacting national policy around rural education and health in China. Between 2008 and 2012, REAP surveyed 60,000 rural Chinese school-aged children and found that 30 percent were anemic. That study helped influence the government’s decision to launch a ten-year, nationwide school lunch program funded at more than $20 billion.

“The Chinese government has identified early childhood nutrition as a key policy priority in the coming years,” Rozelle says. “However, we believe they will need help figuring out the best way to implement their policy ideas. This is where REAP can help, by providing evidence-based solutions.”

Updates about the Nourishing the Future program, along with results of the baseline survey, are available on REAP’s website.

Laura Seaman is the Communications and External Relations Manager at Stanford’s Center on Food Security and the Environment. She can be reached at lseaman@stanford.edu

 Research contact: Alexis Medina: amedina5@stanford.edu

Ambassador Kathleen Stephens, the Koret Fellow at the Walter H. Shorenstein Asia-Pacific Research Center in the Freeman Spogli Institute for International Studies, has been named the United States’ chargé d’affaires to India. Stephens was asked to step in to replace retiring Ambassador Nancy Powell at a critical moment, with the formation of a new government in India following the sweeping election victory of the Bharatiya Janata Party led by Narendra Modi.

Stephens will assume the position in June and remain until a new ambassador is nominated and confirmed by the U.S. Senate, the State Department said in a press briefing.

“I look forward to being in India during a momentous and promising time, and to working to deepen the relationship between the United States and India. My time at Stanford allowed me to engage with extraordinary colleagues and students at APARC and beyond, and will stand me in good stead as I take on new challenges in India,” Stephens said.

Stephens served as acting under secretary of state for public diplomacy and public affairs in 2012. She was the U.S. ambassador to South Korea from 2008 to 2011, and principal deputy assistant secretary of state for the Bureau of East Asian and Pacific Affairs between 2005 and 2007. Her connection to Asia began in the 1970s when she was a Peace Corps volunteer in South Korea.

She has been in residence at Shorenstein APARC for the academic year, conducting research and participating in projects related to U.S.-Korea relations and greater Asia. Stephens also taught a course for Stanford students while here.

Shorenstein APARC Director Gi-Wook Shin said Stephens’ appointment reinforces the Center’s tradition of scholarship and promotion of bipartisan interaction with governments.

“We’re delighted by the news of Kathy’s appointment. Her long-standing ties with Asia and foreign affairs experience will serve her well in this important position. Kathy’s presence greatly enhanced our Center’s work and research agenda, and we wish her well as she heads to India,” Shin said.

2014 marks the 20^th anniversary of the first continuous connection between China and the internet, established by scientists in Beijing and at Stanford. Also twenty years ago, Victor Koo, Chairman and CEO of Youku Tudou Inc., decided to move to China after graduating with an MBA from Stanford Graduate School of Business.

No one could have foreseen how dramatically the internet would impact business, politics, and society in China over the subsequent 20 years.

On May 6, 2014, Koo returned to Stanford Graduate School of Business to share his own life experiences and to encourage the next generation of entrepreneurial leaders to thrive in their careers.

Below you can find the video of Koo’s talk, “20 Years of China and the Internet: What’s Next?” The event was co-hosted by Stanford Graduate School of Business’s China 2.0 and Global Speaker Series.

Watch Victor Koo's private interview with Stanford Graduate School of Business on "The Future of Online Video in China" here:

The China-U.S. relationship requires the attention of each country’s leadership and can be improved by a shared approach of building new public goods, said Kevin Rudd, Australia’s prime minister (from 2007 to 2010, 2013) and scholar on Chinese relations.

“The future use of Chinese power, either inside or outside the international rules based system, that is either used multilaterally or unilaterally, is the critical question which both presidents Xi Jinping and [Barack] Obama must address for the future,” Rudd said at a lecture delivered on April 16 in the Bechtel Conference Center.

“It is possible to carve out a common future for these countries based on constructing what I describe as new global public goods together,” he said, proposing a relationship focused on mutual advancement of international goals.

Rudd said the United States and China could develop “new rules of the road,” in theory effectively deescalating tensions and adding to the net interests of both countries. He highlighted cybersecurity, climate change and regional security as communal problems they could address together.

Rudd suggested regional tensions in Asia may also be improved by building a culture of common security and changing institutions, including transforming the East Asia Summit into a wider Asia Pacific Community.

The lecture was part of the Asia-Pacific Leaders Forum at the Shorenstein Asia-Pacific Research Center in the Freeman Spogli Institute for International Studies, a series that convenes senior policymakers, business executives and others to share experiences and vision on critical issues facing Asia and the United States.

The full video and written remarks from this event are available below.

Early vaccination could save both lives and money during the next flu pandemic, according to a study led by Stanford medical researchers.

Using lessons learned from the 2009 H1N1 flu pandemic, researchers calculated the costs of waiting to vaccinate, looking at both the price tag to treat sick patients and the number of lives lost. Generally, a new flu vaccine takes at least six months to develop and distribute, but a vaccination campaign at four months after the start of an outbreak would save thousands more lives and millions of dollars in a large metropolitan area, according to the study published in Annals of Internal Medicine.

Additional measures, such as wearing face masks, using cough etiquette, washing hands or closing schools, can limit the virus' spread while a vaccine is in production.

Seasonal flu viruses sicken and kill large numbers of people each year, but the flu becomes a pandemic when it fulfills three criteria: It must be unusually infectious and deadly, it must be a new strain to which humans do not have immunity and it must spread worldwide. The H1N1 strain was a new virus that traveled around the globe at the end of the last decade, but it killed a small percentage of the people infected - less than 0.3 percent. In comparison, the deadly 1918 Spanish flu pandemic killed 2.5 percent of people it infected.

"We had a test run of our preparedness in 2009," said Nayer Khazeni, the study’s lead author. Khazeni, an assistant professor of medicine, is also an associate at the Center for Health Policy/Center for Primary Care Outcomes Research (CHP/PCOR) at Stanford’s Freeman Spogli Institute for International Studies (FSI).

"It's great that it happened under a very mild pandemic situation, and I think that's given us a lot of opportunity to learn and revise,” she said. “I hope that recommendations based on our study findings will help make us even more prepared."

Though the World Health Organization declared the H1N1 virus a pandemic in June 2009, large-scale vaccination did not occur until January 2010. By then, many people had already contracted the virus, recovered and developed immunity. The delay spurred the researchers to ask when would be the best time to vaccinate, and how many people should receive the vaccine.

The new study also looked at the economic impacts of the flu, which previous models had not quantified.

The model simulates how a more severe flu virus would spread through a densely populated metropolitan area such as New York City. It considered the deadliness of the virus, whether the population had immunity from a similar strain and how easily the virus spreads between people.

By adding a vaccination campaign into the model at different times, the researchers could predict the best time to vaccinate for a future pandemic. Vaccinating at six months after the start of the outbreak instead of nine (the timing of vaccination for the 2009 H1N1 pandemic) would prevent more than 230,000 infections and almost 6,000 additional deaths in a city of 8.3 million people. The city would also save $51 million in medical bills.

The bottleneck that slows vaccination is the production process. Most doses of flu vaccine are grown in chicken eggs. And when companies must adapt the process to a novel virus, it cuts into the production time for the seasonal flu vaccine. Six months is the least amount of time in which these companies can produce and distribute a sufficient number of doses.

Newer technologies that use cell cultures and DNA manipulation to create vaccines may one day cut down on vaccine-development time. If these technologies could yield enough doses within four months, then a metropolis like New York could save almost twice as many lives and save another $50 million.

"Timing is crucial," said Douglas K. Owens, professor of medicine at Stanford and director of CHP/PCOR. Owens is the senior author on the paper and is a senior investigator at the Veterans Affairs Palo Alto Health Care System.

"Delays of a few weeks or months can make an enormous difference in the number of people who are infected,” he said. “If you had a bad pandemic flu, it can have an enormous impact on the number of people who die."

Before the vaccine becomes available, other strategies can limit the virus' spread. Nonpharmaceutical interventions include hand washing, wearing a face mask, coughing into one's elbow and staying home while sick. In a severe pandemic, schools, businesses and public transit systems could be closed down to reduce exposure, the researchers said.

"I think the most encouraging finding of our study is that nonpharmaceutical interventions can really serve as a bridge to mass-vaccine creation and delivery," said Khazeni. The researchers found that even if a city did not vaccinate until nine months after an outbreak began, by instituting these measures, they could see the same positive effects as if they had vaccinated at four months.

In future studies, the researchers will add more complexity to their model by including additional consideration for young children, who tend to spread flu germs more widely than adults, and people with underlying medical conditions, who are more susceptible to serious illness and death.

Though it's impossible to predict which flu virus will become the next deadly pandemic - and when it will strike - two specific viruses are on epidemiologists' radars: H5N1, a virus in Southeast Asia contracted from birds, and H7N9, a new flu virus strain to which humans have no natural immunity. Both strains have a high mortality rate but cannot yet spread from human to human.

"I don't know that we can predict what the virus is going to be, but I do think it's possible to say that there might be a pandemic," Khazeni said. "There are some similarities in the viruses and the way we prepare that are generalizable. It doesn't actually matter what virus it is."

Researchers from the University of Michigan, Community Health Councils and Harvard University co-authored the study.

The work was supported by the Agency for Healthcare Research, National Institutes of Health, the Veterans Affairs Palo Alto Health Care System, and Stanford’s Department of Medicine. 

Patricia Waldron is a science-writing intern for the Stanford School of Medicine's Office of Communication & Public Affairs.