A panel of experts has released a draft recommendation that men aged 55 to 69 with no sign of prostate cancer should still talk to their physicians about whether they should be screened for the second leading cause of cancer deaths in American men.

The U.S. Preventive Services Task Force issued a contentious recommendation in 2012 leaning against screening among men of average risk because of the substantial potential harms associated with screening and treatment.

Prostate cancer screenings are done using a blood test that measures the amount of a prostate-specific antigen, a type of protein, in a man’s blood. When a man has elevated PSA, it may be caused by prostate cancer, but it could also be caused by other conditions such as inflammation of the prostate.

One of the challenges of prostate cancer is that a substantial proportion of prostate cancer grows so slowly that it would not harm the patient.  The task force found that detecting prostate cancer early might not reduce the chance of dying from the disease and that treatment often caused impotence and urinary incontinence.

But now the task force members, using new data from a European trial and evidence about current treatment practices, believe there is more evidence to suggest the benefits of the screening might outweigh the harms for certain men — and that the choice should be one made with their physicians.

“The benefits and harms of prostate cancer screening are closely balanced and our new draft guideline suggests that men discuss screening with their physicians,” said Stanford Health Policy’s Douglas K. Owens, who was a member of the task force during the development of the guideline.

“We now have a long-term follow-up from clinical trials that show modest benefits and more men are being treated with active surveillance which may mitigate some of the harms of overtreatment,” said Owens.

Some 181,000 men in the United States are diagnosed with prostate cancer each year. Of those, an estimated 26,000 men die from the disease.

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The task force changed its draft recommendation for screening from a D to a C for men aged 55 to 69, but continues to recommend against men 70 and older being screened. The draft recommendation is open for public comment through May 8 on its new prostate cancer screening website.

“Prostate cancer is one of the most common cancers to affect men, and the decision about screening using PSA-based testing is complex,” said Task Force Member Alex H. Krist, MD, MPH. “In the end, men who are considering screening deserve to be aware of what the science says, so they can make the best choice for themselves, together with their doctor.”

The Task Force is an independent, volunteer panel of national experts in prevention and evidence-based medicine that works to improve the health of all Americans by making evidence-based recommendations about clinical preventive serves such as screenings, counseling services, and preventive medications.

Task Force Chair Kirsten Bibbins-Domingo, PhD, MD, said members reviewed evidence on the benefits and harms of screening for men at higher risk for prostate cancer, such as African-American men and those with a family history.

“Clinicians should speak with their African-American patients about their increased risk of developing and dying from prostate cancer, as well as the potential benefits and harms of screening,” said Bibbins-Domingo.

She noted that there remains a “striking absence” of evidence to guide high-risk men as they make their decisions about screening: “Additional research on prostate cancer in African-American men should be a national priority.”

Many national medical associations are aligned with the task force’s new recommendations, including the American Urological Association, the American Cancer Society and the American College of Physicians.

Some critics continue to have concerns about screening.

“In my mind, the greatest misconception about the test is that we say it ‘saves lives,’ when that is uncertain,” writes Vinay Prasad, an oncologist, in the popular medical blog, STAT News. “PSA testing reduces the risk of dying of prostate cancer, but there is no evidence it reduces the risk of dying,”

In Nikkei Shimbun, Takeo Hoshi gave his analysis of the border adjustment tax and its potential impact on domestic and international economic policies.

The article was republished with permission and is available in English and Japanese below.

Two months have passed since Donald Trump entered the White House, and the direction of his international economic policies is gradually becoming clearer. On his first full day in office, he signed a presidential order pulling the United States out of the Trans-Pacific Partnership, strategically steering the country away from multinational trade agreements—through which the United States had led the way in writing the rules of international commerce—and toward bilateral pacts with the aim of giving the country an advantage over foreign competitors.

Often considered part of this more protectionist approach is the administration’s push to introduce what is known as a border adjustment tax, which the Republican Party has been advocating. Trump himself initially rejected the tax as being too complex but has recently begun to support it. Because the tax is applied to imports but not to exports, some see it as a mercantilist tool to promote sales of domestic goods and services in overseas markets while keeping out imports. Should Washington embrace such a tax, other governments may be prompted to reciprocate with protectionist policies of their own, raising the specter of shrinking global trade.

Is It Really Protectionist?

On closer inspection, though, the border adjustment tax is actually not a trade-distorting mechanism but part of fundamental tax reform. This article will examine the implications of this tax using a number of simple, hypothetical examples. The impetus for such an examination was provided by a series of articles authored by members of the Tokyo Foundation’s Tax and Social Security Policy Committee (Japanese only), led by Senior Fellow Shigeki Morinobu.

The border adjustment tax, properly speaking, is part of a “destination-based cash flow tax” (DBCFT). As the name suggests, there are two basic components to the DBCFT.

The first is the “destination-based” element, meaning that the tax is levied in the country of consumption rather than of origin. Japan’s consumption tax and other forms of value added taxes all follow this principle, as exports are untaxed, while imports are taxed. The tax now being debated in the United States is an attempt to apply the destination-based idea to corporate taxes.

The other is the “cash flow” element, which taxes the profits defined as actual receipts minus actual payments. One important difference of this approach from current corporate tax practices is that companies would be able to deduct the full amount spent on capital investment during that year, instead of depreciating it over the useful life of a tangible asset. By providing immediate relief, the DBCFT is likely to encourage corporate investment. Here, though, I will concentrate my discussion on the impact of the destination-based element of the tax.

The destination-based element, as noted above, leads to “border adjustment,” inasmuch as the tax is applied to domestic consumption and excludes goods or services produced at home but are consumed abroad. To elucidate what this entails, let us see how the DBCFT would affect the after-tax income using a simple example of a vertically integrated corporate group with three stages of production, depicted in the table. We will first assume that the corporate tax rate is 20%.

(1) The material supply producer sells raw materials for $5 million, of which $3 million is paid as labor, leaving a profit of $2 million.

(2) The intermediate goods producer purchases the raw materials for $5 million and processes them into intermediate inputs worth $8 million. Workers are paid $1.8 million for a profit of $1.2 million.

(3) The final goods producer purchases the intermediate inputs for $8 million and assembles them into final goods, which are sold to consumers at $10 million, paying workers $1 million and registering a profit of $1 million.

Group Profit after Border Adjustment Tax ($ million)

Note: No border adjustment for overseas production.

Let us first look at what this corporate group would owe the tax authorities under the current corporate tax system. When all three stages of production take place domestically, the three companies would be required to pay 20% of their profits as corporate tax. Together, the three companies earn $4.2 million ($2 million + $1.2 million +$1 million) in profits. After paying 20%, they would be left with after-tax income of $3.36 ($4.2 million × 0.8).

Current System Encourages Multinationals to Move Offshore

How would the amount the group pays in taxes change if it chose to relocate its intermediate goods production to a country with a corporate tax rate of, say, 10%? The lower taxes would mean that the after-tax income of the group as a whole would now rise to $3.48 million ([$2 million +$1 million] × 0.8 + $1.2 million × 0.9). The group would thus have an incentive to move its operations overseas. In other words, the current US tax system has a distorting effect in encouraging multinationals to move to countries offering lower corporate tax rates.

The border adjustment tax can rectify the distortion by eliminating this incentive, as shown in the right-hand column of the table. If the group ships raw materials to the intermediate goods company located in a different country, the group’s tax base, adjusted at the border, would decline by $5 million (exports are not included in taxable revenue) and correspondingly rise by $8 million (imports are taxed) as the offshore affiliate ships the intermediate goods to be assembled and sold as final products. With a corporate tax rate of 20%, the group as a whole would see its after-tax income decline to $2.88 million ([$2 million + $1 million] ×0.8 – [$8 million − $5 million] × 0.2 + $1.2 million × 0.9) despite a lower corporate rate for the intermediate goods company. Note that the second term of the equation represents the border adjustment tax.

As the example shows, a border adjustment tax will eliminate the financial benefits of relocating abroad, as companies will gain nothing from the lower tax rates in other countries.

The same goes for countries where lower wage levels prevail. To see this, let us consider a case where the corporate group can benefit from lower labor costs overseas. Suppose that producing intermediate goods domestically costs $1.8 million in labor but that this cost is reduced to $1.3 million at an offshore plant. For simplicity’s sake, we will assume that the $500,000 in lower expenses boosts profit at the intermediate goods company to $1.7 million.

In the absence of border adjustment, a business would have an incentive to relocate to a country with lower wages even if the corporate tax rate were the same. Such advantages disappear, though, in the face of border adjustment; in the above example, the group would see its after-tax income fall to $3.16 million ([$2 million + $1 million] ×0.8 – [$8 million − $5 million] × 0.2 + $1.7 million × 0.8). Here we are assuming that the corporate tax rate in the foreign country is the same 20%. The after-tax income with border adjustment is less than the $3.36 million the business would have earned had it kept production at home.

Destination-Based Principle

These calculations are premised on the foreign country using the origin-based approach to corporate taxation, rather than the destination-based principle. If the offshore plant, too, is subject to border adjustment, then its sales (exports) would be untaxed and only its purchases (imports) taxed. In such a situation, its after-tax income would rise to $1.96 ($1.7 × 0.8 – [$5 million − $8 million] × 0.2) even with a corporate tax rate of 20%, boosting the income of the group as a whole to $3.76 million.

Should the Trump administration embrace the destination-based approach, therefore, other governments would have an incentive to follow suit. In fact, most proponents of the border adjustment tax in the United States argue that the lack of such a tax puts the country at an unfair disadvantage vis-à-vis markets that have value-added taxes.

I hope these examples will help show that the border adjustment tax is not a protectionist measure. It can be considered part of the Trump administration’s efforts to maintain US competitiveness as the world increasingly turns from origin-based tax systems to destination-based systems.

As the failed Obamacare repeal effort suggests, though, the White House’s ability to push policies through Congress appears dubious. That said, the global trend toward the destination-based tax systems is undeniable, and the introduction of a border adjustment tax will continue to be a topic of political debate in the United States. Japan has a value-added tax in the form of the 8% consumption tax, but its corporate tax has no border adjustments. Tokyo, too, needs to review the current tax system critically, including the possibility of introducing border adjustments to its corporate tax, as the day Washington goes forward with tax reform may not be far off.

(Translated from “Kokkyo-chosei-zei, kakkoku zeisei ni eikyo,” Keizai Kyoshitsu, Nihon Keizai Shimbun, March 30, 2017.)

トランポノミクスの行方（上）国境調整税、各国税制に影響―海外移転促すゆがみ是正

   トランプ米政権の発足から２カ月が過ぎた。経済政策に関して一つ明確になったのは国際経済政策だろう。環太平洋経済連携協定（ＴＰＰ）など多国間での国際経済活動に関する包括的なルールを構築するために指導的な役割を果たそうとする政策から、２国間で米国が有利になるような国際経済交渉を戦略的に進める政策へと移行した。

   保護貿易政策の一つとして取り上げられるのが国境調整税だ。もともと共和党が推していた政策で、トランプ大統領自身は複雑すぎるとして当初難色を示していたが、最近ではホワイトハウスも支持し始めたようだ。輸入品に課税する一方、輸出品は課税対象にならないので、輸出を促進し、輸入を抑える重商主義的な政策とされる。もし米国がそうした政策をとるなら、他国もそれに対抗して保護貿易的な政策をとり、世界貿易は収縮のスパイラルに陥ってしまう。これは由々しきことだ。  

   筆者もそう考えていたが、国境調整税の中身を検討すると、本質は貿易政策ではなく、根本的な税制改革の一部であり、その観点からとらえる必要があることが分かる。本稿では国境調整税の仕組みを簡単な例を使いながら考える。東京財団の税・社会保障調査会の森信茂樹・中央大教授、田近栄治・成城大特任教授、佐藤主光・一橋大教授による一連の論考が契機となった。
 

   そもそも国境調整税は正確には「仕向け地主義キャッシュフロー課税」の一部だ。名前の通り、こうした課税の仕方には２つの特徴がある。 　

   一つは「仕向け地主義」だ。財が消費される場所（国）で課税対象が決まることで、生産の場所で課税対象が決まる「源泉地主義」と区別される。日本の消費税も含めて付加価値税は仕向け地主義の税制の分かりやすい一例だ。実際、付加価値税に関しては国境調整が行われている。輸出は課税されず、輸入は課税される。そうした仕向け地主義を法人税に適用しようとするのが現在の米国での議論だ。 　

   もう一つは「キャッシュフロー課税」だ。実際に手元に入る売り上げから実際に支払われた費用を引いたキャッシュフローに課税する。例えば現在の法人税では設備投資の際に、その減耗分だけを何年かにわたり控除するが、キャッシュフロー課税では投資した年に投資額をすべて控除できるようになる。これは投資を促進する効果を持つが、本稿では仕向け地主義の国境調整の方に議論を集中する。 　

   国境調整の意味を理解するため、次のような３段階の生産過程を垂直に統合した企業の例を考える。法人税率は２０％で、最終消費財はすべて国内で消費されると仮定する。 　
   ①材料部門は労働を投入して５００万ドルの価値の原材料を作り出す。３００万ドルを労働者に支払い、２００万ドルの利益が生まれる。 　
   ②中間財部門は原材料を５００万ドルで仕入れて加工し、８００万ドルの中間財を生産する。１８０万ドルを労働者に払い、利益は１２０万ドルだ。 　
   ③消費財部門は中間財を８００万ドルで仕入れて加工し生産物を消費者に１千万ドルで売る。１００万ドルを労働者に払い、利益は１００万ドルになる。 この例を使って、国境調整を含まない米国の現行税制では企業が生産過程の一部を法人税率の低い外国に移転するインセンティブ（誘因）があることを示せる。  

   まず３つの生産過程すべてが国内で行われる場合には、法人税率は２０％なので、企業全体の税引き後利益は（２００万＋１２０万＋１００万）×０・８＝３３６万ドルになる。 　

   企業が中間財部門を海外に移転すれば、原材料部門は原材料を海外法人の中間財部門に輸出し、消費財部門は中間財を海外法人から輸入する。これを示したのが表の最初の４列で、４列目が各部門の税引き前の利益だ。法人税率が海外の方が安ければ、企業は海外に移転するインセンティブを持つ。例えば海外の法人税率が１０％なら、中間財生産を海外に移すことで企業全体の税引き後利益は（２００万＋１００万）×０・８＋１２０万×０・９＝３４８万ドルに増える。  　

   つまり現在の米国の法人税は多国籍企業に、法人税率の低い国に生産を移すインセンティブを与えているという意味でゆがみがあるといえる。 　国境調整を導入すると、このゆがみを是正できる。表の最後の列は国境調整の値を示す。原材料部門はすべてを輸出するので国境調整はマイナス５００万ドルに、消費財部門の仕入れは輸入なので国境調整は８００万ドルになる。この国境調整に税率２０％をかけたものが国境調整額（以下の数式の第２項）になる。中間財生産の海外移転時の税引き後利益は（２００万＋１００万）×０・８―（８００万―５００万）×０・２＋１２０万×０・９＝２８８万ドルで、国内にとどまる場合を下回る。 　
  
   国境調整が多国籍企業の海外移転を防ぐという結論は、海外移転の魅力の根元に左右されない。法人税率の低さを利用する海外移転も、賃金の安さを利用する海外移転も、国境調整があれば起きない。 　例えば中間財生産で、国内生産ならば１８０万ドル分の労働が必要だが、海外生産ならば労働投入が１３０万ドルで済む場合を考える。ここでは簡単化のために、すべて中間財部門の利益を押し上げると仮定する。中間財部門の利益は表の場合よりも５０万ドル増えて１７０万ドルになる。 　
  
   国境調整がない場合、海外の法人税率が国内と一緒だったとしても、生産費が低い地域に中間財生産を移すことで全体の利益を増やせるので、企業は海外移転を決める。 　

   しかし国境調整があると、税引き後の利益は（２００万＋１００万）×０・８―（８００万―５００万）×０・２＋１７０万×０・８＝３１６万ドルにしかならない。国内にとどまる場合の税引き後利益（３３６万ドル）より低くなるので、企業は海外移転しない。   

   こうした一見効率的にみえる海外移転も妨げられてしまうのは、海外の法人税の制度が源泉地主義をとっているからだ。もし海外の法人税も仕向け地主義に変更され国境調整が行われるなら、中間財部門の売上高はすべて輸出で、仕入れはすべて輸入なので、その税引き後所得は１７０万×０・８―（５００万―８００万）×０・２＝１９６万ドルとなり、企業全体の税引き後所得は３７６万ドルになる。 　

   つまり法人税を仕向け地主義に変えると、海外の政府にもまた仕向け地主義に変更するインセンティブが生じる。米国で法人税の仕向け地主義への変更を主張する論者は、他国が付加価値税を課して国境調整を行っているのに、米国の法人税には国境調整がないので、米国が国際競争上不利になっていると指摘する。 　

   国境調整税の本質は貿易政策ではない。源泉地主義課税から仕向け地主義課税への移行という世界的な流れの中で、米国の国際競争力を保とうとする税制改革の一部だ。 　

   医療保険制度改革法（オバマケア）代替法案を撤回せざるを得なかったことに象徴されるように、トランプ政権の政策実行能力は大いに疑問視される。国境調整が導入されるか否かも確かではない。しかし仕向け地主義への世界的な方向性が変わらない限り、国境調整などの法人税の改革は繰り返し議題にのぼるだろう。日本には消費税という仕向け地主義の税が既に存在するが、法人税の国境調整はない。米国が国境調整を導入するとき、日本の税制度は現状のままでよいのか、今のうちに見直しておくべきだろう。

(2017年3月30日付『日本経済新聞』「経済教室」より転載）

Jonathan Chen has a doctorate in computer science and could have his pick of lucrative jobs here in Silicon Valley today.

Instead, he pursued his medical degree and is working on ways to help physicians quickly mine clinical data to reach better diagnoses for their patients.

“I walked away from higher paying jobs because I was looking for a greater purpose in my work and a rewarding career,” said Chen, a physician-scientist at Stanford who was a VA Medical Informatics Fellow at Stanford Health Policy.

Future works like his — supported by a five-year grant from the National Institutes of Health — may be on the chopping block.

The Trump administration’s proposed budget intends to cut NIH funding by $7 billion over the next 18 months, which could severely compromise research grants that lead to major biomedical breakthroughs.

Chen is currently building OrderRex, a digital platform that data-mines electronic medical records that show clinical practice patterns and outcomes to inform medical decisions. He hopes it will one day be the Amazon of electronic medical records.

After more than 20 years of hard work — a college freshman when he was only 13  — Chen is finally poised to become a junior faculty member. But now he has to wonder whether he made the right choice.

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“Seeing the proposed research budget cuts gives me pause,” Chen said. “And I’m considering whether it is foolish for me to even be joining the academic ranks now, chasing down grants that will be increasingly difficult to come by, amidst a political climate that does not seem to care for science.”

The administration has said it respects and would support the work of the NIH, which Secretary of Health and Human Services Tom Price recently called “very important.” But, he added, the American taxpayers should be getting “a bigger bang for the buck.”

About 80 percent of the federal NIH funding goes to grants for clinical and translational researchers at small businesses and academic institutions.

Here at Stanford Health Policy, the grants have funded research into everything from the epidemic of diagnostic errors to the economic harm of the tsetse fly on African economies; the impact of urbanization on obesity and chronic disease in India, to a global data analysis about whether foreign aid is directly linked to an increase in life expectancy in developing countries.

The National Institutes of Health — which has supported the research of some 148 Nobel Prize winners — has touched the work of nearly every SHP researcher.

“Cutting scientific research budgets could turn a generation of young minds away from the larger purposes of academic medical research and instead send them off into finance, tech, pharma — leaving behind the country’s talent pool in the decades to come,” said Chen.

Eran Bendavid, an assistant professor of medicine and core faculty at Stanford Health Policy, uses political science, economics, and epidemiology to study the prevention and treatment of infectious diseases in developing countries.

The infectious disease physician also depends, in part, on NIH funding.

“There is no substitute for NIH support for basic and applied research,” Bendavid said. “It has been a central actor in the progress of the biomedical fields and made the U.S. the global leader in innovation. It is also good diplomacy, promoting cooperation and partnerships across the globe.”

Bendavid and SHP colleague Grant Miller led the research that showed that declining use of safe contraception led to an increase in abortion rates in sub-Saharan Africa, a region in which family planning services are heavily financed by U.S. foreign aid. Their work was widely cited in news reports as a counterpoint to the Trump administration’s pledge to cut funding to international family planning organizations that also offer abortion.

“Even if many of the budgetary provisions are scaled back, this is an unfortunate place to anchor the negotiations,” Bendavid said of the proposed NIH cuts, which are so severe they are already facing opposition from some members of Congress. “This could signal real changes in what we do as individuals, as a division, and as an institution.”

House Speaker Paul Ryan was asked specifically about President Trump's proposed cuts to the National Institutes of Health. The speaker avoided criticizing the administration for that proposal — but indicated it was unlikely Congress would go along.

“I don’t try to get into making my opinion on this, on specific provisions,” Ryan said. “All I would say is perhaps the most popular domestic funding we have among Republicans is NIH.”

Michele Barry, director of the Center for Innovation in Global Health and senior associate dean for Global Health at Stanford University — as well as one of SHP’s key faculty members — wrote in this editorial on March 28 that such drastic cuts to biomedical research would make us more susceptible to global epidemics.

“We live in a time when pandemics cross borders faster than ever,” Barry wrote. “Yet to the horror of many of us working in global health, President Trump’s budget would completely eliminate the NIH’s Fogarty International Center — one of the most effective tools we have to fight global diseases.”

The GOP’s proposed American Health Care Act may have gone down in flames, but health policy experts say there are plenty of other health-care reforms the Trump administration may attempt.

Michelle Mello and David Studdert, both professors at Stanford University School of Medicine and Stanford Law School and core faculty members at Stanford Health Policy, say medical malpractice reform, for one, is back on the federal policy agenda.

The two write in this New England Journal of Medicine commentary that Secretary of Health and Human Services Tom Price, an orthopedic surgeon and Republican congressman from Georgia before he was appointed to the Trump administration, sponsored several bills aimed at limiting medical liability.

House Speaker Paul Ryan and Price have both said medical malpractice is in crisis, with frivolous lawsuits driving up malpractice insurance premiums and forcing physicians out of business. Hospitals and doctors are so afraid of being sued they overprescribe costly tests and treatments, driving up the cost of health care.

But according to a study published last year, medical errors are the third leading cause of death in the United States. And those who follow medical malpractice insurance say the industry has stabilized in the last decade.

Mello and Studdert write that medical malpractice reform is worth pursuing. The liability system has a host of well-documented problems and its reform was omitted from the Affordable Care Act.  But, they argue, Republican proposals tilt too far towards protecting physicians, with harmful consequences for patients.

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“Two of the key reforms measures on the Republican agenda — ‘safe harbors’ for physicians who comply with clinical practice guidelines and the adjudication of medical injury disputes by expert panels — are promising ideas that have received a good deal of attention in the academic literature over the last 20 years,” Studdert said.

“However, design details matter,” he said. “The versions currently being considered in Congress are quite unconventional; they look more like physician-protection initiatives than reforms designed to improve safety or protect the interests of patients in other ways.” 

The “safe harbors” from liability for providers who adhere to clinical practice guidelines would involve the establishment of tribunals of medical experts who would decide malpractice claims. Price has also proposed “administrative health-care tribunals” that would be presided over by special judges with health care expertise and would issue binding rulings aided by testimony from independent experts.

One worrisome aspect of the Republican proposals is that they would replace ordinary standards of evidence with a requirement that patients prove “gross negligence.” 

“That means that if your physician was merely careless or unskilled, you’re out of luck as a plaintiff,” Mello explained. “You have to show something akin to willful and wanton misconduct — like the case in Boston where the surgeon left in the middle of an operation to deposit money in his bank.”

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Price has claimed that defensive medicine is responsible for a quarter of U.S. health-care spending, about $650 billion, but the authors’ best estimates are closer to $50 billion.

Yet, in their commentary, the authors say this could be an ideal time to pursue reform, which ordinarily rises on the policy agenda only when a “malpractice crisis” occurs and liability insurance costs spike.  “When acutely stressed providers are clamoring for 
immediate relief, cool-headed policy deliberation rarely ensues,” they wrote. 


But, they add, reforms must be fair to patients as well as providers. They note that Price articulated a vision of health system reform that puts patients’ needs front and center.

“Medical liability reform needs the same vision,” they said.

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When a state is “shamed” by outsiders for perceived injustices, it often proves counterproductive, resulting in worse behavior and civil rights violations, a Stanford researcher has found.

Rochelle Terman, a political scientist and postdoctoral fellow at Stanford’s Center for International Security and Cooperation (CISAC), recently spoke about how countries criticized by outsiders on issues like human rights typically respond -- and it's contrary to conventional wisdom. Terman has published findings, “The Relational Politics of Shame: Evidence from the Universal Periodic Review,” on this topic in the Review of International Organizations. She discussed her research in the interview below:

What does your research show about state "shaming"?

Shaming is a ubiquitous strategy to promote international human rights. A key contention in the literature on international norms is that transnational advocacy networks can pressure states into adopting international norms by shaming them – condemning violations and urging reform. The idea is that shaming undermines a state’s legitimacy, which then incentivizes elites into complying with international norms.

In contrast, my work shows that shaming can be counterproductive, encouraging leaders in the target state to persist or “double down” on violations. That is because shaming is seen as illegitimate foreign intervention that threatens a state’s sovereignty and independence.  When viewed in this light, leaders are rewarded for standing up to such pressure and defending the nation against perceived domination. Meanwhile, leaders who “give in” have their political legitimacy undermined at home. The result is that violations tend to persist or even exacerbate.

When and where does it work better to directly confront a country’s leadership about such injustices?

At least two factors moderate the effects of international shaming. The first is the degree to which the norm being promoted is shared between the “shamer” and the target. For instance, the West may shame Uganda or Nigeria for violating LGBT rights. But if Uganda and Nigeria do not accept the “LGBT rights” norm, and refuse to accept that homophobia constitutes bad behavior, then shaming will fail. In this case, it is more likely that shaming will be viewed as illegitimate meddling by foreign powers, and will be met with indignation and defiance.

Second, shaming is quintessentially a relational process. Insofar as it is successful, shaming persuades actors to voluntary change their behavior in order to maintain valued social relationships. In the absence of such relationship, shaming will fail. This is especially so when pressure emanates from a current or historical geopolitical adversary. In this later scenario, not only will shaming fail to work, it will likely provoke defensive hostility and defiance, having a counterproductive effect.

Combing these insights, we can say that shaming is most likely to work under two conditions: when the target is a strong ally, and the norm is shared.

What are some well-known cases where "shaming" backfired?

The main example I use in my forthcoming paper is on the infamous “anti-homosexuality bill” in Uganda. When Uganda introduced the legislation in 2009 (which in some versions applied capital punishment to offenders) it provoked harsh condemnation among its foreign allies, especially in the West. Western donor countries even suspended aid in attempt to push Yoweri Musaveni’s government to abandon the bill. According to conventional accounts, the onslaught of foreign shaming, coupled with the threat of aid cuts and other material sanctions, should have worked best in the Uganda case.

And yet what we saw was the opposite. The wave of international attention provoked an outraged and defiant reaction among the Ugandan population, turning the bill into a symbol of national sovereignty and self-determination in the face of abusive Western bullying. This reaction energized Ugandan elites to champion the bill in order to reap the political rewards at home. Indeed, the bill was the first to pass unanimously in the Ugandan legislature since the end of military rule in 1999. Museveni – who by all accounts preferred a more moderate solution to the crisis – was backed into a corner.

A Foreign Policy story quoted Ugandan journalist Andrew Mwenda as saying, “the mere fact that Obama threatened Museveni publicly is the very reason he chose to go ahead and sign the bill.” And Museveni did so in a particularly defiant fashion, “with the full witness of the international media to demonstrate Uganda’s independence in the face of Western pressure and provocation.”

Uganda anti-homosexuality law was finally quashed by its constitutional court, which ruled the act invalid because it was not passed with the required quorum. By dismissing the law on procedural grounds, Museveni – widely thought to have control over the court – was able to kill the legislation “without appearing to cave in to foreign pressure.” But by that time, defiance had already transformed Uganda’s normative order, entrenching homophobia into its national identity.

Does this 'doubling down' effect vary in domestic or international contexts?

Probably. States with a significant populist contingent, for instance, are especially hostile to international pressure, especially when it emanates from a historical adversary, like a former colonial power. Ironically, democracies may also be more susceptible to defiance, because elites are more beholden to their constituents, and thus are less able to “give in” to foreign pressure without undermining their own political power. 

The international context matters a great deal as well. States are more likely to resist certain norms if they have allies who feel the same way. For instance, we see significant polarization around LGBT rights at the international level, with most states in Africa and the Muslim world voting against resolutions that push LGBT rights forward. South Africa – originally a pioneer for LGBT rights – has changed its position following criticism from its regional neighbors. 

Does elite reaction drive this response to state "shaming?"

To be quite honest, this is a question I’m still exploring and I don’t have a very clear answer. My hunch at the moment is no. The “defiant” reaction occurs mainly at the level of public audiences, which then incentives elites to violate norms for political gain.  These audiences can be at either the domestic or international level. For instance, if domestic constituents are indignant by foreign shaming, elites are incentivized to “double down,” or at least remain silent, lest they undermine their own political legitimacy.

That said, elites can also strategize and manipulate these expected public reactions for their own political purposes. For instance, if Vladimir Putin knows that the Russian public will grow indignant following Western shaming, he might strategically promote a law that he knows will provoke such a reaction in order to benefit from the ensuing conflict. This is what likely occurred with Russia’s “anti-gay propaganda” law, which (unsurprisingly) provoked harsh condemnation from the West and probably bolstered Putin’s domestic popularity.

Any other important points to highlight?

One important point I’d like to highlight is the long-term effects of defiance. In an effort to resist international pressure, states take action that, in the long term, work to internalize oppositional norms in their national identity. In this way, shaming actually produces deviance, not the other way around.

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

MEDIA CONTACTS:

Rochelle Terman, Center for International Security and Cooperation: (650) 721-1378, rterman@stanford.edu,

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