REAP co-director Scott Rozelle builds on a ten-part series for Caixin Magazine titled, "Inequality 2030: Glimmering Hope in China in a Future Facing Extreme Despair." In his sixth column, Rozelle asks why rural China continues to be plagued by poor vision and intestinal worms.

To read the column in Chinese, click here.

> To read Column 1: Why We Need to Worry About Inequality, click here. 

> To read Column 2: China's Inequality Starts During the First 1,000 Days, click here. 

> To read Column 3: Behind Before They Start - The Preschool Years (Part 1), click here. 

> To read Column 4: Behind Before They Start - The Preschool Years (Part 2), click here.  

> To read Column 5: How to Cure China's Largest Epidemic, click here. 

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Inequality 2030:

Glimmering Hope in China in a Future Facing Extreme Despair

Caixin Column 6: A Tale of Two Travesties

Travesty One: China’s Intestinal Worms Epidemic

Our group, the Rural Education Action Project (REAP), did a study in 2010. We discovered that 40% of students in Guizhou rural elementary schools were infected with intestinal worms. Invisible to the naked eye, intestinal worms quietly sap valuable nutrients from their host, leading to stunted growth and malnutrition. Moreover, intestinal roundworm infection is associated with poorer academic performance, lower scores on memory and intelligence tests, and lower school attendance rates. So let me just make sure that this is clear: As late as 2010, 4 out of 10 rural Chinese children in our sample were attending school … and living life … with worms in their stomachs.

At that time, we wrote a policy brief to the State Council, informing the top leadership of the severity of the situation. The reaction was swift. China’s top leaders stated that this was unacceptable. They promised to address this problem as soon as possible. They pushed relevant agencies to investigate and explore effective ways to eliminate this alarming health problem. We were left hopeful.

Three years later, in May 2013, we repeated the same study. And to our dismay, this time we found that nearly 50% of children had intestinal worms. If our study is representative and half of the school-aged children in Guizhou—and most likely similar shares in other southern Chinese provinces—have worms, then this means that millions of kids are still infected with worms and are still suffering the consequences for their nutrition, health, and ability to learn. 

To put it simply: This is a travesty.

Why? In part, because this is a disease that is typically found in the poorest developing countries – not in a modernizing, increasingly wealthy superpower like China. Even more to the point, this is a travesty because this disease is very easy to control: a child infected with worms can be cured for a full six months simply by taking two deworming pills. These pills are super safe (medically, one of the safest medicines in the world) and super effective (worms are almost completely eliminated within one to two days). The medicine is also extremely inexpensive: the highest quality deworming tablets in China cost only 2 yuan per tablet. So 2 tablets, for 2 yuan each, will keep a child worm-free for a full six months. Yup, you read that right: for a total of 8 yuan per child per year, China could be entirely worm-free. This devastating health problem could be averted for only 200 million yuan per year (if every student in every poor county – all 25 million of them – took their deworming medicine). That is what we call a travesty. 

Travesty Two: The Vision Disaster

We discovered Travesty Two after one of Scott’s former grad students did a study in one of the poorest Tibetan autonomous counties in Gansu in the early 2000s. He showed that when rural elementary school students were given eyeglasses when they were nearsighted, their educational performance improved significantly.

After seeing this study, we met with the only group of academic eye doctors in China that was working on this issue with any degree of long-term commitment—a small group of opthamologists at the Zhongshan Optometry Center (ZOC) at Zhongshan University. We were told that, by their estimates, around 30% of 10 to 12 year olds in grade 5 and grade 6 were nearsighted and needed glasses. No one knew for sure, but the ZOC group had worked a lot in China’s urban schools and schools in the rural areas of their own Guangdong province and they thought these would be plausible rates for vision problems—even in the poor rural areas of Central and Western China. 

Armed with this information, we started to do our own informal census of vision problems in rural China as we went about our other research activities. At first, we were puzzled. Over the course of several years, we visited hundreds of elementary schools throughout rural China—in Ningxia, Shaanxi, Shanxi, Sichuan, Henan, Hebei and more. And in all these visits, we almost never saw elementary school students wearing glasses. At most, in a school of 100 or more, there were one or two kids wearing glasses. What was going on?

In collaboration with ZOC and our partners from Renmin University and Shaanxi Normal University, we set out to find out. We asked three questions: How many of these rural elementary school students had poor vision? Of the students with poor vision, how many were wearing glasses and how many were not? And what would happen if kids with poor vision that were not wearing glasses had a pair to put on?

What did we find? Just as ZOC had predicted so many years before, nearly 30 percent of elementary school students (in grades 4 to 6) in rural areas have poor vision. But then we found the really troubling part. Of those with poor vision, only one in six (15%) were wearing glasses. The rest had never even been prescribed a pair. How much did this oversight matter? Well, when we gave glasses to students with poor vision, we found that their academic performance improved enormously (relative to students with poor vision that did not wear glasses). Were we surprised? Well, no! Teachers in rural areas today still use the blackboard for most of their classes. So, if these students can’t see, how can they ever hope to learn?

Our study revealed that when you put a pair of glasses on a student with vision problem, a student that was barely passing (scoring, say, 65 on a test), suddenly  becomes a student in the middle of the pack, scoring 75. Ten points is a huge rise in performance – for an investment of only about 300 yuan for a proper pair of glasses. Assuming these glasses can last a rural child for about 2 years, the investment is only half that much on an annual basis. Thus, if there are 5 million children in grades 4, 5 and 6 in China’s poor rural areas, and if 30 percent of them need glasses, then Travesty Two could be averted for an investment of only 5 million * 30% * 150 yuan per year = 225 million yuan per year.

Again, a serious and wide-ranging impediment to rural Chinese children’s learning and healthy development is being allowed to persist in this modernizing superpower when effective, low-cost solutions are available and easy to put into place. And so we say again, this is a travesty.

How is that China can’t find a solution to such simple social problems, social problems that are endangering the entire nation’s future?

If we were to digress, we could give you even more examples. Did you read last month’s column? In the face of a crippling anemia epidemic among young rural students, we have shown that for only 8 yuan per day, all of these students could receive a nutritious lunch that would give them nearly half of their daily nutritional needs. Such a program would reduce micronutrient deficiencies and improve the educational performance of not only the children that were malnourished (and, indeed, up to 30 percent of students in poor rural areas are not getting enough nutrients in their diets), but also improve the test scores of the rest of the class—most likely because in classes where all children are healthy, there is more focus (and hence more learning) for all.

And the most frustrating part of all is that we know the money is there to spend. Build one less freeway. Open one less sports stadium. Slow down the construction of the high-speed rail network (build it, but, build it at a slower pace). And all of this could be paid for. Eliminating worms, fighting malnutrition and reducing poor vision are all concrete, cost effective steps that would have a huge and immediate impact on educational performance. Travesties!

If not being able to fix such a simple problem is a travesty, what do we call the situation that has allowed the problem to emerge in the first place? A travesty’s travesty.

In this case, the blame lies in two places: with the parents of the children and with the system in which they are going to school and seeking health care.

First, we believe the blame lies in part with rural parents and other family members. Why? To put it bluntly, our research has taught us that parents—and especially grandparents, who are often rural children’s day-to-day caregivers—are often ignorant and misinformed. When you ask a person in rural Guizhou why they don’t deworm their children, they frequently state right out: “Worms are not bad for you. You need them to digest your food.” Most moms do not know that worms are passed on through human night soil. Grandma still rarely washes her hands before cooking. No one tells their children or grandchildren that they should always wear shoes outside. 

In a recent project we worked with local doctors to deworm children. We gave them two high-quality, super safe deworming tablets with the simple instructions: “Take these two tablets before you go to bed tonight.” In no small number of our households, Grandpa or Dad had the child take one and throw the other away. Why? “Too many worms is not good, but, everyone needs some of them,” they said. Of course, without completing the deworming process, the worms almost immediately reproduce in the child’s stomach and intestines. Hence, in this very real way, Mom and Dad and Grandma and Grandpa are to blame.

The myths about eyeglasses are even more formidable. We worked with some high quality optometrists on a project last year and identified the students in each class that had poor vision and needed glasses. Armed with this information, we asked the parents and grandparents of children identified to have poor vision if their children had vision problems. More than 80% said they did not. But, that is not all. It is not only that they did not know. They also did not seem to care. We asked the same parents—more than 2000 of them—whether they would get their children glasses if their vision was bad enough that they could not see the board and it was affecting their grades. More than half of the parents said that even under these circumstances children who are younger than 12 years old should not get glasses. “Glasses hurt the eyes of children,” they said. “Not wearing glasses make the eyes tougher and they get better on their own.” Of course, none of this is true. Parents are not paying attention and even if they were, they are incapable of responding because they do not know. Again, Mom and Dad and Grandma and Grandpa are to blame.

In fact, though rural children’s caregivers may be an immediate cause of persistent poor health, their ignorance is likely not their fault. Parents and their children may well be victims of China’s rapid development. It is our hypothesis that China has simply developed too fast. In one generation, China moved up the income ladder a distance that took four or five generations in other countries. In those countries, there was time during the development process for ordinary citizens to learn about nutrition … and health … and parenting … and how to educate their children for a new higher-wage economy. However, China’s families—especially those in poor remote areas—did not have the same chance to catch up. When Grandma was raising her own children—not so many years ago—she thought she was raising subsistence farmers. To be successful, all her children had to do was to survive childhood and grow up to learn how to follow a bullock around their paddy land. Such an upbringing was also sufficient for an unskilled worker working on a construction site hauling bricks or in a factory assembling widgets. Now, however, these same grandmas are raising grandkids who need to be nurtured in a way that allows them to develop to a point in which they can go to high school and college and learn algebra and calculus and English and Chinese literature and go on to take more demanding jobs. Having anemia or worms or being a bit nearsighted did not matter in the past. Now, in a newly competitive and demanding economy, it may mean the difference between success and failure.

So if it is not really the parents’ fault, whose fault is it? Why are rural children still growing up without treatment for their basic health needs? Why do Mom and Dad and Grandma and Grandpa not know what they should do to take care of their kids? When there is a market failure or an information breakdown it is the role of the government to step in and correct the failure. And in this case we must place the blame—the ultimate blame—on the government. They are not playing their proper role and it is costing China very dearly.

The problem here is actually very similar to that of parents: it is a problem of ignorance and misinformation—either due to absence of knowledge or due to purposeful neglect. When the top leadership directed the Ministry of Finance to fund a deworming program in Guizhou, the top officials at the Center for Disease Control did not support it. Most top Center for Disease Control officials do not even know that intestinal worm rates are nearly 50% in rural schools in Southwest China. Or, maybe they do know but just do not care. Out of sight, out of mind. The budget for high profile “urban-oriented, rich-man” diseases, like diabetes, cancer and heart disease expands every year. Meanwhile, it seems that no one is interested in the unseen infections in poor rural schools.  In fact, if one looks for data on any disease that primarily affects poor rural areas—anemia or myopia or intestinal worms—it is almost always difficult (if not impossible) to find.

Government officials are also simultaneously territorial and deathly afraid of taking responsibility, even when the potential gains are large. In most of the rest of the world, a lot of health care takes place in schools. And when you think about it, what a great place to do so! When you’re trying to reach kids in a school, all of the target population is together in one place. The returns to conducting health and nutrition interventions in schools are high because the students are both concentrated and easily monitored. However, because of the fear of taking responsibility, there are currently rules in China against carrying out any health care activities in schools. China used to conduct these activities and did so with great efficiency and effectiveness. Every older Chinese remembers eating “bao-ta” candy, a sweetened deworming tablet, on an annual or semi-annual basis. At that early stage, China nearly wiped out intestinal worms. But, today, for some reason, they simply don’t do it anymore. Our team—even when accompanied by doctors—was not allowed to give the students deworming medicine. They had to take their medicine home to take it. Once they got there, they had to convince their illiterate grandmas that the doctor wanted them to take two tablets because worms were no good. The state—that should have known better—pushed its responsibility off onto Grandma and Grandpa. And we know how that worked out. 

The same happens in eye care. Schools regularly would not allow us in—even though we were giving high quality eye exams and free glasses to students who desperately needed them. Principals and teachers are just as misinformed as parents. “Eyeglasses are no good for grade 4 and grade 5 students,” they said. “Eye exercises are enough. Eyeglasses will make your eyes worse.” Even when the local town doctors came to give eye exams, principals invariably took the list they were given of those with potentially poor vision and filed it away without taking action. If schools are so misinformed and inactive, how can we expect parents to become informed enough to help their children become healthy?

Travesty, Travesty, Travesty. This country has spent billions on new facilities and teacher salaries. And they claim that they are committed to investing as much as it takes to significantly improve rural educational outcomes. But after all this investment and all this talk, China’s rural children are still sick. They are malnourished. They can’t see. And most of all, they can’t learn.

Today, these huge investments may be wasted. And China is missing an opportunity to spend less money in smarter ways so as to ensure that they are actually educating their young people in a way in which they can learn and thrive. When intestinal worms are eradicated, when glasses are prescribed, when kids get nutritious food, they learn, they grow and they thrive. But when they don’t, as they they are not in so many rural schools today, it is nothing less than a TRAVESTY. The time has come for change.

In the post-9/11 world, forging a successful grand strategy in U.S. foreign policy is unlikely and dangerous, according to a Stanford scholar.

During the Cold War, American leaders understood that the Soviet Union was their primary adversary, writes political scientist Amy Zegart in an essay for the Hoover Institution's Foreign Policy Working Group, a new two-year initiative that brings together Stanford scholars to examine key U.S. foreign policy challenges.

Zegart, co-director of the Center for International Security and Cooperation, notes that the Soviet threat – one of nuclear annihilation – brought a singular focus to U.S. foreign policy for the second half of the 20th century.

Successful grand strategies, she writes, depend on knowing the number and identities of one's enemies, what they want, how they operate and what damage they can unleash.

That is no longer the case in 2014 and for the foreseeable future, she suggests.

"The post-9/11 threat environment is vastly different," notes Zegart. Today, the number, identity and magnitude of dangers threatening American interests are all "wildly uncertain."

Exactly how many principal adversaries does the United States face at any given time? Who are they and what do they want? What could they do to America? Is China a rising threat or a responsible stakeholder? How likely is a "digital Pearl Harbor" that cripples U.S. strategic forces or financial institutions?

The answer to all these questions, she writes, is that nobody really knows: "Each day, it seems, we are told to be very afraid about something different and vaguely sinister."

On top of this, grand strategy requires dynamic international collaboration. But organizations like NATO, the International Monetary Fund and the United Nations Security Council are "out of whack with current power realities," writes Zegart. Gaps exist between the "aspirations and capabilities" of international organizations that typically forge partnerships with America.

A new approach

If grand strategy is outdated – and even dangerous – what can be done?

The first step is to give up on notions of grand strategy, Zegart advises. Instead, the United States should strive for what FSI Senior Fellow and working group co-chair Stephen Krasner calls "orienting principles." These are policy ideas that lie between ad hoc reactions to arising situations and grand visions of how the future should unfold.

"Orienting principles aren't glamorous," Zegart writes, "but they hold out the prospect of something better than foreign policy a la carte or a grand strategy that mis-estimates the threat environment and misunderstands the organizational requirements for success."

When grand strategies work well, they are truly grand, says Zegart. "That is, they must be able to anticipate and articulate a compelling future state of the world and galvanize the development of policies, institutions and capabilities at the domestic and international level to get us there. That's hard enough."

A second challenge, she adds, is the strategic interaction part of grand strategy, which requires thwarting and adjusting to the countermoves of principal adversaries.

"Grand strategy is not a game of solitaire, where we come up with all the moves and the cards just sit there. It's not all about us and our big ideas," she notes.

Instead, grand strategy is a multi-player game with powerful adversaries seeking to impose their national wills on the world to serve their own interests, Zegart observes.

"The sorry truth is that American grand strategies are usually alluring but elusive," she concludes. "The Cold War this isn't. We live in a hazy threat du jour world. This is too much complexity and uncertainty for grand strategy to handle."

Masahiko Aoki has been engaged with Stanford University for over four decades. He has witnessed the roots of Silicon Valley grow and seen the many successes of students who formerly passed through his classroom. Selected academic papers written over his 40-year academic career have recently been published.

Aoki is the Henri and Tomoye Takahashi professor emeritus of Japanese Studies in the department of economics and a senior fellow at the Stanford Institute for Economic Policy Research (SIEPR) and the Freeman Spogli Institute for International Studies (FSI), in residence at Shorenstein APARC.

You have been at Stanford since 1967 in different capacities – what has changed since then? Can you share some memories with us? 

I first came to Stanford as an assistant professor in 1967. Campus and the surrounding environment were different then – there were series of apricot orchards along El Camino to the south and my office was located in a wooden building – the old president’s house where the engineering buildings stand today. Changes at the university and in Silicon Valley have been fascinating to witness. I was away from Stanford in the 1970s, but when I came back in the 1980s, I had over 200 students at a time in my classes. This was because of widespread interest in Japan’s economic performance, which was then challenging American industries. Now students are inclined to be more interested in the rise of China. I share the same interest.

What has been most interesting for me is collaboration with graduate students and faculty to develop institutional studies. In the 1990s, I worked with Paul Milgrom, Avner Greif and Marcel Fafchamps among others, to initiate the field of comparative institutional analysis in the economics department. Greif and Fafchamps now have appointments in FSI like myself. Our research worked to understand why and how institutions matter to economic performance. However, my interests have expanded since then. I aim to understand relations between economic and demographic variables as well as institutional complementarities between economic institutions, social norms and political governance. As for my former students, many of them can now be found in important academic, government and private sector roles across the world.

What particular “lens” do you use to conduct your research?

Some influential economists understand that the nature of polity determines economic performance. They say this correlation is obvious if we compare the exploitative political regime like North Korea with that of a democratic political regime like South Korea. But this “lens” is a bit too simplistic for me. Why do ‘bad’ political regimes persist in some countries?  The relationship between political governance and economic performance is more complex than “the former simply causes the latter.”

To understand the relationship between political governance and the economy, I use game-theoretic concepts. While I am not a game theorist, I still believe that human interaction – whether economic, political or social – is a kind of game. People form beliefs based on how others play societal games. One of the important insights derived from these ideas is that political governance and economic institutions actually co-evolve. Furthermore, we need to look at the historical context to understand the present.

How have you applied these theories to the cases of Japan and the United States?

One of my major research interests has been the comparison of corporate governance across countries. Financial economists view the corporation as the property of stockholders. But we can also view the corporation as a system of distributed cognition. That is, the corporation is a group of people who have different cognitive roles and capabilities. Individuals can be organized to achieve economic value using physical assets as tools for respective cognitions.

By looking at corporations in this reversed way, we can identify different types of organizational architecture and their comparative advantages. In short, my research has found that managers’ cognitive assets are prioritized in U.S. corporate model, while workers’ entrepreneurial cognitive assets are prioritized in Silicon Valley’s model. In contrast, Japan favors a model where manager and workers’ cognitive assets are more interdependent.

You emphasize the connection between economics and demographics. What can be done about Japan and greater Asia’s rising demography problems?

Human capital is very valuable, but cultivating human capital is quite costly. Due to this constraint, the total fertility rate of women has declined as the economy develops. Scholars call this phenomenon the demographic transition. In addition, as economies further develop, people live longer and the working age population in the total population declines. Japan, Singapore and Taiwan are experiencing this phenomenon. Korea will follow this trend soon and at an even faster rate than Japan. Even if China modifies the one-child policy, the demographic dilemma cannot be escaped. And even for California, which is typically considered to be the youngest state in the U.S., a study predicts it will become the oldest state around year 2030.

So, what can be done to cope with this phenomenon? One option to raise the retirement age. Over two decades ago, Japan started this policy and has seen noted, positive effects. Another option is to increase and secure participation of women in the workforce. Across Asia, total populations are still rising due to immigration. Japan should consider liberalizing immigration. It is interesting to note that in the past 1,500 years Japan’s cultural development benefitted greatly from migration and assimilation of people, such as monks, political refugees and artists from Korea and China. 

With the recent execution of Abenomics, what performance can we expect to see from Japan’s economy in year 2014?

Abenomics has only been assessed in terms of short-term effects on the economy. Instead, my view is that Japan is now in the process of longer-term institutional change. Lifetime employment was the core of Japan’s overall institutional arrangement until some twenty years ago. The main banking system and government-industry relationship complemented and mutually reinforced lifetime employment. Though, with the demographic transition, the Japanese government has found it increasingly difficult to sustain. However, Japan’s institutional arrangements are normally very resilient. I think institutional transformation fitting this new demographic phenomena will require the duration of one generation. Institutions cannot be changed overnight by a revolution or government decree.

Of course, Abe could accelerate institutional adaptation by expanding the roles and opportunities for women and young people and creating more open foreign policy. This policy agenda may be related to the so-called “third arrow” of Abenomics, a period of structural reform following monetary easing and fiscal stimulus. But what Abe can do and has the willingness to do has yet to be fully seen. Thus, if we believe that Japan started the process of institutional change in the early 1990s and requires one generation to attain visible outcomes, the next several years are crucial. Tokyo has been chosen as the host city for the 2020 summer Olympics. I hope this event will act as Japan’s opportunity to display its changes to the international audience. 

The Faculty Spotlight Q&A series highlights a different faculty member at Shorenstein APARC each month giving a personal look at his or her teaching approaches and outlook on related topics and upcoming activities.

In an interview with Ars Technica about the visit to the Bay area of North Korean defectors, KSP associate director David Straub criticized their launching of propaganda-carrying balloons into North Korea as irresponsible in light of North Korean threats to retaliate by again attacking South Korea militarily. Although not included in the published interview, Straub prefaced his comments by noting that he "strongly agree[d] on the need to provide the North Korean people with as much information as possible about the outside world and their situation in it," but questioned the effectiveness of the balloon campaign compared to other, less provocative means.

Siegfried Hecker and his research assistant, Peter E. Davis, write that South Korea's nuclear energy program has become model that countries aspiring to obtain nuclear energy should emulate.

CISAC Senior Fellow Siegfried Hecker and his research assistant, Peter E. Davis, write in this Bulletin of the Atomic Scientists article that South Korea's nuclear energy program has become model that countries aspiring to obtain nuclear energy should emulate.