Health care has become the largest sector of the global economy, now accounting for more than 10 percent of Gross World Product, or $7.5 trillion. And it’s only going to get bigger as economists expect that figure to approach $18 trillion in two decades.

And yet, the quality of care and health outcomes are not keeping pace.

Ashish K. Jha — a leading expert on health policy and director of the Harvard Global Health Institute — calls this a “critical moment” in health care as the standard of care increasingly becomes more important than the number of people who have health coverage around the world.

“The point is, coverage is not coverage is not coverage. All health financing schemes are not the same,” said Jha, noting that China and Canada have universal coverage for its citizens, but many still receive inadequate health care or are going broke due to the high cost of special medical needs.

“In many places, the problem is the shallowness of the coverage.  Everyone may be covered — but if you get really sick, shallow coverage gets people into trouble,” said Jha, a keynote speaker at the annual Global Health Economics Colloquium, which brings together health economists and policy experts from University of California San Francisco, UC Berkeley and Stanford Health Policy to discuss recent developments in their fields.

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The fifth colloquium identified the health needs of vulnerable populations and developing cost-effective and scalable interventions to improve the health of socially and economically disadvantaged people here in the United States and in low- and middle-income countries.

“Our hope for the day is that our speakers will remind us why we do what we do, remind us why we support evidence-based policies, and most of all to inspire us at a time of this geopolitical craziness and why we must continue to persist,” Dhruv Kazi, a cardiologist and health economist at UCSF, who opened the daylong event.

Rising cost of global health care

Global health-care spending is so massive due to several key factors, Jha told the audience: the unprecedented rapid expansion of people moving into the middle class and the rise in treatments, drugs and medical technologies.

And while these are all positive movements, he said, as the world becomes more interdependent, it “behooves us to act” quickly so that health coverage and quality keep up.

At the end of 2016 there were 3.2 billion people in the global middle class; on average 160 million will join the middle class annually for the next five years, heavily concentrated in Asia.

So the two goals of universal health care should be financial protection and improved health.

But Jha noted that while 90 percent of China’s 1.4 billion people are covered by its national health care system, some 18 percent of Chinese are still thrown into poverty by the incidence of catastrophic health spending above and beyond what the government provides. That is nearly 8 percent higher than the global incidence of catastrophic spending, which stands at 11.7 percent.

India, by contrast, does not have a universal health-care system and only 20 percent of it 1.3 billion people have some form of health insurance. But it also has a 17-percent incidence of catastrophic health spending.

“Catastrophic payment incidence cannot be inferred from the fraction of the population covered by health insurance schemes or public health services,” Jha said, quoting a recent Lancet study.

It stands to reason that the health outcomes of those in countries with universal health care should have improved. But most studies show that that is not the case; the reason?  The quality just isn’t there.

Unsafe medical care top cause of deaths

Nearly 43 million injuries are caused in hospitals each year around the world, leading to 23 million years of healthy living that is lost among the world’s population.

“Unsafe medical care is probably one of the top 10 causes of death and disability in the world,” Jha said.

Jha wondered if quality of care isn’t a bigger problem than access to care.  For example, in one of India’s poorer rural states, Madhya Pradesh, there are 11 health-care providers within walking distance of every village, a fairly large number of private providers.

“Yet half of them have no formal training, they didn’t go to any school but they call themselves doctors,” Jha said.

And in the capital of India, New Delhi, public-sector physicians who are well trained are so overworked they spend an average of 2.5 minutes and ask one question per patient.

Ideally, universal health care must be effective and consistent with best professional practices while meeting the needs of the individual patient.

“Global health policy leaders have made universal health coverage an overarching priority.  This is a good thing.  But in order for UHC to improve the health of the world’s poor, we need to ensure people get good care. And that is the biggest challenge of all.”

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Under the guidance of the Aspen Institute Congressional Program, thirteen members of Congress convened at Stanford University from March 2-5 to discuss policy options regarding the current North Korea crisis. The representatives deliberated with scholars and practitioners to acquire a better understanding of North Korea and its ruling regime, review the regional actors and their interests, assess the range of potential solutions to the crisis, and determine the role of Congress on this issue.

A report summarizing the program’s dialogue is now available for download. In addition to providing non-attributed comments from the proceedings, the document also includes the itinerary for the three days, the names of participants, as well as a collection of relevant publications.

The Aspen Institute Congressional Program was established in 1983 by former U.S. Senator Dick Clark. The program is for members of the United States Congress, and is both nongovernmental and nonpartisan in design. The program gives senators and representatives the opportunity to delve into complex and critical public policy issues with internationally recognized experts. Lawmakers are given the opportunity to explore policy alternatives in off-the-record settings, while simultaneously building relationships crucial to finding solutions.

"Mr. Trump is almost certainly giving authoritarianism a bad name. Support for authoritarian rule declined most among Democrats and young people, while significantly increasing among Republicans. So when it comes to American authoritarianism, perhaps the problem isn’t so much Mr. Trump as it is hyper-partisanship," writes Larry Diamond in The New York Times. Read the full article here.

"Are people merely punishing incumbent parties and politicians, or are they losing faith in democracy itself?" asks Larry Diamond in The American Interest. Read the full article here.

The following remarks were delivered at events memorializing CISAC's late co-founders, Sidney Drell and John Lewis.

Sid Drell Symposium on Fundamental Physics, SLAC, 12 January 2018

• David Holloway: The Friendship of Sidney Drell and Andrei Sakharov

John Lewis Legacy Conference, January 13, 2018

• Remebrance by Thomas Fingar
• Remembrance by David Holloway

The following is a statement by CISAC Affiliate and Professor Emeritus William J. Perry on potential talks between President Donald Trump and Kim Jong Un. It was originally posted on the website of the William J. Perry Project.

I was very encouraged to hear that a summit meeting is being planned for May to deal with the dangerous North Korea nuclear program. This is a major improvement over diplomacy that consisted of shouting insults at each other.

But there are two key questions about this meeting:

First: what will we talk about? That is, what does the U.S. expect to get, and what is the U.S. willing to give?

Second:  what will we and North Korea be doing while we are talking? Are the U.S. and its allies going to sustain the pressure presently on North Korea? And will North Korea continue the development and testing of missiles and nuclear weapons?

Statements from the administration suggest that the U.S. goal is for North Korea to dismantle its nuclear arsenal and become a non-nuclear power. There is every reason to doubt that North Korea would be willing to go that far; but even if they are, there remains a fundamental question: How could we possibly verify such an agreement?

We don’t know how many nuclear weapons they have operational or under construction; we don’t know where all their nuclear facilities are; and we have never implemented a treaty that counts warheads, simply because it is so difficult to verify (and so easy to cheat on). Our nuclear treaties with the Soviet Union and Russia counted missiles, not warheads (the number of operational warheads was assumed based on the number of operational missiles counted). We still do not know how many total nuclear warheads the Russian have, in the field, in their labs, and in their storage facilities, and our estimates may be off by thousands. So it is a fundamental error to think that we could reliably verify a treaty by which North Korea agreed to dismantle all of their nuclear weapons.

We could verify an agreement that banned testing of nuclear weapons and long-range missiles, and such an agreement would be very much in our interest. It would be equally in our interest to have an agreement stopping the proliferation of North Korean nuclear components and technology, although such an agreement would be much harder to verify than a test agreement.

There is good reason to talk, but only if we are talking about something that is worth doing and that could be reasonably verified - otherwise we are setting ourselves up for a major diplomatic failure.

Finally, to hedge against such failure, it would be wise to have a prior agreement that limited objectionable actions such as like nuclear tests while we are talking, as North Korea has suggested that it would. (Before Clinton agreed to begin the diplomatic talks that led to the Agreed Framework, he required North Korea to stop all processing at their nuclear facility at Yongbyon.)

I highly favor talks, but such talks must be based on realistic expectations of what can be negotiated and what can be verified. As I have written before:  “We must deal with North Korea as it is; not as we would wish it to be.” That remains true.

William J. Perry

19th U.S. Secretary of Defense