China has a large and growing elderly population, but to be old in China-particularly in the countryside-is to be vulnerable. In the country's rural areas there are few clinics and hospitals, and health insurance is virtually nonexistent. Compared with elderly Chinese living in urban areas, those in rural areas have a shorter life expectancy and a poorer quality of life.

Further, little academic research has focused on the health needs and health status of China's elderly. It is with the goal of addressing this deficit that Pengqian Fang, a trainee with CHP/PCOR's China-U.S. Health and Aging Research Fellowship, recently returned to China from Stanford. Fang is seeking to document the health disparities between China's rural and urban elderly population, and to use his findings to propose healthcare assistance programs for the elderly in rural areas of China.

Fang spent a year at Stanford studying health-services research concepts and methods and developing his research project.

In the project, which Fang refined with guidance from CHP/PCOR faculty, Fang will conduct a detailed survey of the health status, health needs, and healthcare utilization of elderly people in rural and urban areas of China, through in-home interviews in three Chinese provinces with different geographic and socioeconomic characteristics: Guizhou (in southwest China), Hubei (in central China), and Guangdong (in the southeast).

He will conduct the project in collaboration with the health departments of the

three provinces, and with support from Tongji Medical College in Wuhan, where he

is director and associate professor of healthcare management.

Fang's study will be among the first of its kind in China. Such research is needed, Fang explained, because China's elderly population (of whom 70 percent reside in rural areas) is growing steadily, and in the coming years its members will require medical services at increasing rates. According to the country's 2000 census, China has 132 million people over age 65, making up more than 10 percent of the population; the over-80 population, which numbers 10 million people, is increasing by 5.4 percent a year; and about 20 percent of all elderly people in the world live in China.

The elderly in China's rural areas face particular challenges in getting high-quality, affordable healthcare services, Fang explained. There are few clinics and hospitals in rural areas, and there is no government-sponsored health coverage for the elderly (like the United States' Medicare program) anywhere in China. All of these factors put China's rural elderly in a vulnerable position, especially those with disabilities or serious illnesses.

"This research will show the disparities that exist, and it will encourage a dialogue about policies to help rural elderly people in China," Fang said.

Fang plans to conduct his survey in the first half of 2005, analyze the data in the summer and fall, and return to Stanford in November 2005 to present the results. In each of the three provinces studied, the research team will recruit 500 households and will conduct interviews with all individuals age 65 and over who reside there, for an estimated final sample of 2,500 people.

The respondents will be asked for a variety of information, including their income and education, insurance status, health status, daily activities, social activity, mental health, utilization of healthcare services, and accessibility and affordability of medical care. The researchers will also interview community healthcare workers-including physicians, nurses, and administrative staff-to seek information on the health needs of the elderly and the barriers they and their healthcare providers face.

The China-U.S. Health and Aging Research Fellowship, administered jointly by

CHP/PCOR and the China Health Economics Institute (Beijing), aims to improve

healthcare quality and efficiency in China through an exchange program in which

selected Chinese health services researchers come to Stanford to study for six months to a year, and then return to China to conduct an original research project. The fellowship is funded by the National Institutes of Health's Fogarty International Center.

"I have learned very much from Stanford and this program," Fang said. "The classes I attended have given me very useful ideas." He noted that since health services research is still a young field in China-about ten years old-"we learn a lot from the United States, like how to ask the research question, how to get a grant, how to design a study."

One aspect of Stanford that particularly impressed Fang was its emphasis on interdisciplinary collaboration.

"This is a very good feature-the close relationship between different fields," he said. "In my country we are more focused on one narrow field."

Fang said he is interested in establishing research collaborations between Stanford and Tongji Medical College-an idea that he and CHP/PCOR's leadership will be exploring in the coming months.

There is much to admire about the U.S. healthcare system's emphasis on innovation and technology, Fang said. Still, he said, "I don't hope for China to follow the U.S. health system," with its heavy reliance on free-market principles. For one thing, "medicine here is very costly." He cited a personal example of how he fractured his arm in a minor bicycle accident, and how his emergency room visit for the injury, along with a follow-up physician appointment, cost more than $1,000. "I was surprised it cost so much," he said.

A review of the fellowship program conducted by officials at the China Health Economics Institute last fall concluded that it has been successful and valuable. Leaders at the institute said the trainees' Stanford experience has enhanced their intellectual abilities, their knowledge of research methodology, their leadership capacity, and their ability to collaborate internationally.

As the conflict in Iraq reminds us, nation building confounds its architects' designs with almost predictable regularity. Investments of time, resources, and specialized knowledge have not enabled large-scale political engineering. Instead, would-be nation builders have been frustrated by a proliferation of unintended consequences and their inability to elicit societal participation in their projects. Results depend more upon initial conditions prior to an intervention than the nation builder's exertions upon arrival.

Hence, the U.S. has performed most poorly when its mission required the most work (e.g., Somalia, Haiti, Iraq). Conversely, it has done best where it did less (Germany, Japan), deferring to old-regime civil servants and upgrading already functional institutions. Given the humbling record of Western powers at navigating the perils of macro-level political planning, the "how" of nation-building should be considered, in the formulation of Defense Secretary Donald Rumsfeld, a known unknown.

More likely, it is a known unknowable. The extent of unintended consequences and contingency in largescale political engineering makes disappointment certain and disaster likely.

Twentieth-century experiences belie the notion that nation-building successes will solve the problem of state failures. Forces trying to impose regime change and raise new state structures immediately grapple with societal inertia and their own deficit in understanding local politics.

This dilemma pushes would-be nation builders down one of two undesirable paths. Either they recognize their inability to restructure indigenous political arrangements or they attempt to do so in vain. Despite plans of change at the outset of nation building, those executing the project soon embrace a change of plans.

Thus, even the most committed states have been hampered by an inability to develop political capacity on the ground and improve upon the initial endowments of the country being occupied. Institutional value-added has been minimal, reflecting the problem of state instability back upon those who expected to solve it.

These patterns raise serious doubts about the chances of success in even the most well-intentioned of regimechange missions. They demarcate the limits of projecting state power abroad, whether for humanitarian or security purposes. The failures of imposed regime change lead to the conclusion that indigenous gradual political development-with all of its potential for authoritarianism and civil unrest-may be the optimal path for sustainable democratization and state building.

When comparing the uneven history of post-colonial development with the poor record of nation building we are left paraphrasing Churchill's endorsement of democracy as the worst kind of government except for the alternatives: Sovereign political development may be the worst form of government except for all those kinds of nation building that have been tried.

Infrastructural weakness is not a technical problem surmountable through systematic review of prior experiences. Indeed, the notion of "learning past lessons" deceptively implies that the current generation of academics and policymakers can succeed where their predecessors failed. The idea that nation building is a flawed but salvageable project prejudges its fundamental viability.

Once we have set our sights on rescuing an enterprise that has repeatedly frustrated its architects and their subjects, we screen out alternatives that more effectively serve the same development goals. We also risk funneling research down an intellectual cul-de-sac, at great cost in time, resources, and lives lost for those participating in failed regime-change missions. Therefore, a more productive direction for contemporary interest in nation building may mean backing up and reassessing the core problem of weak states, on one hand, and the limits of foreign intervention, on the other. Ensuring a positive impact on the country considered for intervention requires orienting the enterprise away from the takeover of state functions and toward the short-term provision of aid to local communities.

Apart from the futile pursuit of infrastructural power or the doomed deployment of despotic power (coercion), one can envision a third kind of influence, "regenerative power," which is exercised during relief efforts, such as emergency assistance following natural disasters.

Regenerative power involves neither the adoption of domestic state functions nor physical coercion. It denotes the ability of a state to develop infrastructure under the direction of the local population. For example, it means rebuilding a post office, but not delivering the mail. It is typified by the U.S. response to natural disaster relief within its own borders and abroad.

Regenerative power turns nation building on its head. Rather than imposing a blueprint from outside, participants respond to the needs of the affected community. It is restorative rather than transformative. There is no preexisting master plan for what the "final product" will be, but rather an organically evolving process in which the assisting group serves at the direction of the people being assisted.

The exercise of regenerative power is inherently limited in scale since it depends on local engagement rather than elite planning. It is inimical to macro-level ambitions but it also acquires a bounded effectiveness that imposed regime change lacks. Where nation building attempts to overwrite existing organization and only belatedly incorporates local understanding, disaster relief efforts and regenerative projects begin from the assumption that local communities know best their own needs. Existing social networks and patterns of authority are an asset, not a hindrance, and local know-how offers the principal tool for resolving local crises.

Rather than pursuing the often destructive delusion of interventionist state transformation, regenerative power starts from an interest in using state power for constructive purposes and a sober assessment of the limits of that aim. The assisting foreign groups serve under the direction of indigenous political leaders toward the achievement of physical reconstruction and emergency service provision.

With remarkable prescience Rumsfeld commented in October 2001, "I don't know people who are smart enough from other countries to tell other countries the kind of arrangements they ought to have to govern themselves."

The experience of twentieth century U.S. interventions and ongoing operations in Iraq supports his insight. Proponents of nation building or shared sovereignty arrangements have exaggerated the ability of powerful states to foster institutions in developing countries. The empirical record, from successful outcomes in Germany and Japan to dismal failures across the global south, shows the societies alleged to be most in need of strong institutions have proven the least tractable for foreign administration. Rather than transmitting new modes of organization, would-be nation builders have relied upon existing structures for governance.

This dependence on the very context that was intended for change reveals how little infrastructural power nation builders wield. They are consistently unable to implement political decisions through the local groups. Contrary to recent arguments that sustained effort and area expertise can enable success, nation building has foundered despite such investments.

Understanding that nation building is a "known unknowable" is crucial for redirecting intervention where it can be more effective. Advocates of humanitarian assistance should consider the merits of smaller, regenerative projects that can respond better to uncertainty and avoid the perils of large-scale political engineering.

The Walter H. Shorenstein Asia-Pacific Research Center (Shorenstein APARC) at the Freeman Spogli Institute for International Studies at Stanford University invites applications to receive funding grants for activities or programs focusing on health care policy in Asia. Shorenstein APARC welcomes research proposals on a wide range of topics from diverse disciplines, but has particular interest in international studies of demography; the effects of an aging population on social, economic, and political systems; and the causes and prevention of epidemics such as AIDS and Avian Influenza in Asian countries.