The threat of a pandemic claiming millions of lives and devastating economies around the world is as serious as the potential perils of global climate change, renowned economist Larry Summers told a Stanford audience during a recent visit to campus.

The world is taking dramatic and costly steps to prevent the calamitous impact of climate change on the economies and national security of most countries. Yet preparations for a worldwide pandemic on the scale of the 1918 flu are vastly underfunded and ill-formed.

“My biggest fear is that the world is way short of focus on all the issues associated with pandemic,” said Summers, former treasury secretary in the Clinton administration and Harvard president emeritus, who in recent years has focused on the economics of global health care.

“We are talking about something that could kill surely tens of millions and perhaps 100 million people, and the Stanford football program is substantially more expensive than the WHO budget for pandemic flu,” he said. “It’s just crazy that we are so underinvested and underprepared.”

Summers, the Charles W. Eliot University Professor at Harvard, also served as director of the White House National Economic Council in the Obama administration. He was in conversation with Stanford Health Policy’s Paul Wise for the March 8 event co-sponsored by the Stanford Institute of Economic Policy Research for faculty and students.

The World Health Organization budget for outbreaks and crisis response has been reduced by nearly 50 percent from 2012 to 2015. Some global health experts blame these cuts in part for its slow response to the Ebola outbreak in West Africa and the ongoing Zika crisis in Brazil.

In Brazil, Zika has been linked to a spike in cases of microcephaly, a birth defect marked by small head size and underdeveloped brains. Brazil has confirmed more than 640 cases of microcephaly and is investigating an additional 4,200 suspected cases. Puerto Rico is now preparing for an expected outbreak there.

Summers said the mortality rate from the great flu pandemic was far greater than the recent Ebola outbreak in West Africa, which killed some 11,300 people mostly in Sierra Leone, Liberia and Guinea. Some 50 million people died worldwide during the 1918-1919 flu pandemic.

‘I don’t want to minimize in any way the significance of Ebola, but there are things to worry about that are vastly larger,” said Summers, who gave the keynote address for the January unveiling of the National Academy of Medicine’s report on global health risks.

That report by the Commission on a Global Health Risks Framework for the Future found that, compared with other major threats to global security, the world has “grossly underinvested” in efforts to prevent and prepare for the spread of infectious diseases. The commissioners — some 250 independent experts in health, governance and research and development — estimate $60 billion in annualized expected losses from pandemics.

“Pandemics cause devastation to human lives and livelihoods much as do wars, financial crises and climate change,” the report said. “Pandemic prevention and response, therefore, should be treated as an essential tenet of both national and global security — not just a matter of health.”

Summers estimates that pandemic flu risk is in the same range of global climate change in terms of expected costs over the next century. Yet a potential pandemic is getting only 2 percent of the attention and resources that global climate change has today.

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Summers also chaired the Lancet Commission on Investing in Health, an independent group of 25 leading economists and global health experts from around the world. Their landmark report, Global Health 2035, provides a specific roadmap for this achieving “a grand convergence” in health within our lifetimes. Ahead of the U.N. General Assembly last fall, Summers led a joint declaration together with economists from 44 countries calling on world leaders to prioritize investments in health.

Wise, in the Department of Pediatrics at Stanford and senior fellow at the Freeman Spogli Institute for International Studies, asked Summers how one plans for pandemics when faced with so many failed governments and conflicts around the world.

“One of the central challenges that I worry about a lot in the deliberations of pandemic control is that many of the (regions) of greatest concern are characterized by chronic political instability, conflict and very weak governance,” said Wise, who for more than 30 years has been traveling to rural Guatemala to provide medical care to children there for his Children in Crisis project.

Summers said the world has been fortunate that there are so many brave and devoted medical workers who are trained to go into these conflict regions to try and contain outbreaks.

“But I think it would be disingenuous of me to say that you can solve these problems without in some way containing the failed state,” he said.

Wise then asked Summers what sort of advice he would give to the Stanford students who were trying to decide between a career in which one might use economics to make a fortune on Wall Street, or use economics for the greater good.

“I have always believed that you can count — and you can care,” Summers said. “There is nothing about counting and using numbers and analyzing the math that means you don’t care in a moral way.”

When a physician works with a patient and saves her life, he said, that has a profound and direct impact on both the patient and physician. But working on a vaccination program that has the potential of saving thousands of lives one day comes with delayed gratification.

“But the impact of making the world a better place and enabling people to survive and avoid grieving the loss of of a family member is as great — or greater,” he said.

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My daughter, Emily, was teaching English at a middle school in Asahi City, Chiba Prefecture, on the Japan Exchange and Teaching (JET) Program when the 2011 Tohoku earthquake struck on March 11, 2011. Tohoku is a region in the northeast portion of the island of Honshu, the largest island in Japan. Though Asahi City, a coastal city, is not in the Tohoku region, it was still heavily damaged by the resulting tsunami. Several of Emily’s students lost their homes. She was emotionally shaken, of course, but was fortunate not to sustain any injuries.

With the fifth anniversary of the 2011 Tohoku earthquake and tsunami approaching, I have been reflecting upon the tremendous anxiety that I felt that day about Emily’s safety, my wife’s family in Tohoku, and the people of Japan in general. My reflections deepened last week while observing the interaction of SPICE’s Reischauer Scholars Program (RSP) students (American high school students studying about Japan) with SPICE’s Stanford e-Japan students (Japanese high school students studying about the United States) in an informal online “social hour.” The RSP and Stanford e-Japan are distance-learning courses that are offered by SPICE.

Stanford e-Japan instructor Waka Brown and RSP instructor Naomi Funahashi organized the social hour to help to build bridges between youth in Japan and the United States. During the latter part of the social hour, RSP student, David Jaffe (Mesa, Arizona), posed the question, “How is 3.11 remembered today?” Among the many Stanford e-Japan students who spoke was Minoru Takeuchi (Sakura City, Chiba Prefecture), who stated, “When the earthquake happened, I was an elementary school student (12 years old). I still remember very well… at that time, I was in school. Some students were very afraid and crying… Maybe after the earthquake, many Japanese noticed the importance of working together, the preciousness that they could meet their friends…” The Japanese students’ sharing of their experiences related to 3.11 extended the social hour far beyond the hour, and the gratitude expressed by the American students to their counterparts in Japan flowed for many minutes in a text-chat box.

Observing the students was one of the most rewarding experiences of my career at SPICE. The Japanese students’ remembrances of 3.11 brought back poignant and difficult memories for me but also provided me with hopeful thoughts on the future of the U.S.–Japan relationship as I witnessed students from across the Pacific forming budding friendships and discussing topics of mutual relevance.
 

Resources for the classroom
 

My hope is that teachers will carve out some time in their curriculum to engage their students in a study of 3.11 as well as its legacies. The study of natural hazards ought to be a core part of school curriculum. SPICE has undertaken many curricular projects related to 3.11. I would recommend that teachers show the film, After the Darkness, which was produced by Risa Morimoto and Funahashi. After the Darkness is a documentary film that touches upon the events of the disaster itself but also focuses on the experiences of two survivors in particular. It is accompanied with free curricular lessons that are accessible to students of various ages. I also recommend a lecture by Professor Emeritus Daniel Okimoto, Stanford University, on “Japan’s Geological Factors,” which is accompanied by a free lesson plan. Another recommended curricular unit is SPICE’s Examining Long-term Radiation Effects, which was produced prior to 3.11 but can help students understand the radiation-related concerns following the Fukushima Daiichi nuclear disaster. In addition, the film, Live Your Dream: The Taylor Anderson Story, is about one of two American JET Program teachers who lost their lives during 3.11. SPICE developed a teacher’s guide for the film that can be freely downloaded from the Live Your Dream: The Taylor Anderson Story website. Lastly, I recommend the use of the films from the 113 Project in classrooms. Earlier this week, I moderated a panel discussion that included Wesley Julian (director of the 113 Project), Andy Anderson (father of Taylor Anderson and board member of the Taylor Anderson Memorial Fund) as well as other Americans and Japanese who continue to contribute to relief efforts in the Tohoku region.

Stanford foreign policy experts discussed flashpoints around the world at an OpenXChange event this week.

Three of Stanford's most seasoned international affairs experts discussed foreign policy and diplomacy – and practiced a bit of it on stage, too – as they tackled the topics of refugees, Russia and other politically thorny issues at a campus forum March 1.

The event, "When the World Is Aflame," featured Condoleezza Rice, a Stanford political science professor and former U.S. secretary of state; Michael McFaul, director of Stanford's Freeman Spogli Institute for International Studies and former U.S. ambassador to Russia; and Jeremy Weinstein, a Stanford political science professor and former director for the National Security Council.

Janine Zacharia, a Stanford visiting lecturer in communication and former Jerusalem bureau chief and Middle East correspondent for the Washington Post, was the moderator.

The event was hosted by OpenXChange, a campus initiative to provide a forum for students and community members to focus on today's societal challenges.

"So you were resetting some of my policy?" Rice half-jokingly interjected, as McFaul discussed the objectives behind the U.S. trade talks with Russia a few years ago.

"It was not about making friends with the Russians – I want to make that clear," McFaul continued after the laughter in the audience died down. "And it wasn't that we needed to correct the wrongs from the previous period," he said, casting a quick glance over at Rice. "The Russians had an interest in giving the Iranians a nuclear weapon. Our answer was, no, and let's work with them to prevent that."

A series of trade sanctions with Russia were eventually accomplished, but as it turns out, McFaul noted, the political environment has since changed with Russia's aggression in Crimea, Ukraine and Syria.

Today's conflict in Syria was laid about four years ago, the panelists agreed, when the United States decided to aid the rebels and not overtly attack the current regime.

"There were reasons our president and others did not go down that path, but it was an invitation to others to play games in that environment," Weinstein said. "What their endgame is, we don't know."

Rice added that Russian President Vladimir Putin "does not mind countries that basically don't function." As such, "a stable, functioning Syria was never his definition of success."

Zacharia asked, "Are you saying we have yielded the endgame to the Russians in Syria? There is nothing we can do? And we're playing defense?"

"Yes," Rice answered.

"Wait, there is no endgame," McFaul said. "It's not that we yielded the endgame."

"Right," Rice replied.

Though the panelists' opinions differed at times, the trio of political science professors agreed on many points, including that international order is being tested, and that the refugee crisis is an overwhelming problem – one that the United States should help resolve.

"I'm a firm believer that America has a moral obligation to take [refugees]," Rice said. "But let's remember that we have to have a way to take them that is actually going to work within the system."

"We have a humanitarian architecture that simply isn't up to the task," Weinstein said. Securing congressional funding to reform the system will be a challenge.

What's more problematic, McFaul added, is that the current political rhetoric about how the United States should handle refugees is "based on fear."

"We're not having a rational debate about this in my opinion," McFaul said. "We have to fill the debate with empirical facts instead."

Public fears will continue as long as extreme Islamic State terrorist groups remain influential, "inspiring lone wolves like [those] in San Bernardino," Rice said, referring to the December 2015 terrorist attack there that killed 14 and injured 22 people.

"Somebody has got to defeat ISIS in its crib," Rice said. "They march in columns; they don't hide in caves like al-Qaeda. If CBS News can find them, then the American military can find them."

The tougher challenge, however, will be the task of influencing sectarian politics and creating a more stable state in the long term, Weinstein said.

Stanford – with its cache of expertise – should strive to shape the national dialogue with concrete facts and analyses, McFaul said. Inspiring students and giving them the foundational tools to become the new generation of policy leaders is also part of that, he said. Adding a course on Russian politics would also be an improvement, he said.

Weinstein is a senior fellow at the Freeman Spogli Institute. Rice, a former Stanford provost, is the Denning Professor in Global Business and the Economy at Stanford Graduate School of Business and the Thomas and Barbara Stephenson Senior Fellow at the Hoover Institution.

The panelists urged students to gain a deep knowledge of the areas and issues they care about.

"Know your facts," Rice emphasized.

"When you're making policy decisions at the table, the people who understand these places and understand the political dynamics – those are the people whose voices are second to none around the table," Weinstein said.

"And we need to get you prepared for that in a more robust way," McFaul said, inviting students to pass any ideas about this to him.

In terms of career choices, "there's nothing greater" than public service, he said. "Sometimes I would get goose pimples when I could stand in front of Russians with the American flag behind me, representing the United States of America."

Infant deaths in Massachusetts for much of the 1800s accounted for more than 20 percent of all deaths, many due to diarrhea, cholera and other gastrointestinal disorders.

But from 1870 to 1930, the infant mortality rate plummeted from around 1 in 5 white infants to 1 in 16 for both Massachusetts and the entire United States.

Studies have shown that the dramatic decline was due to the impact of a clean-water system in Boston and other major U.S. cities at that turn of the 20^th century.

Now, new research by Stanford Health Policy’s Marcella Alsan indicates that effective sewage systems installed in Boston and surrounding municipalities complemented the water treatment plants and had a significant role in protecting the lives of children.

“We were motivated to investigate this because there was a watershed moment when infant mortality began to decline in the U.S. and Massachusetts that we wanted to understand,” said Alsan, an assistant professor in the Department of Medicine, and the country’s only physician who is a tropical disease expert and economist.

“In retrospect, the daunting challenges these engineers and medical professionals faced in designing, financing and executing such a massive project is incredible,” Alsan said in an interview. “It was really inspiring to read the history of how it all came together.”

She and co-author, Claudia Goldin of Harvard University’s Department of Economics, analyzed about 200,000 of infant death certificates in Boston and 54 other Massachusetts municipalities spanning the years 1880 to 1915.

The impetus behind the creation of the Metropolitan Sewerage District was complaints regarding the stench of sewage among Boston’s upper-class citizens.

“The first of a series of hearings was given by the sewerage commission at the City Hall on Friday night,” read a story in an 1875 edition of the Boston Medical and Surgical Journal. “From the statements made it would appear in various parts of the district including most of the finest streets, the stench is terrible, often causing much sickness.”

A joint engineering and medical commission was appointed in 1875 to devise a remedy and a massive drainage project got underway.

Alsan and Goldin found that an overwhelming number of deaths in the greater metropolitan area were due to gastrointestinal disorders, but that this improved significantly when sanitation canals became part of the overall water systems.

“We find robust evidence that the pure water and sewerage treatments pioneered by far-sighted public servants and engineers in the Commonwealth saved many babies,” they write in a working paper. “It must also have enhanced the quality of life for the citizens of the Greater Boston area even if it did not reduce the non-child death rate by much.”

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They acknowledge that the interpretation of their results is intuitive. But it’s an important one to promote because many developing countries today have yet to heed the lesson of combining safe drinking water and improved sanitation systems.

“Without proper disposal of fecal material, the benefits of clean water technologies for the health of children are likely limited,” they write. “Such a result has relevance for today’s low-and middle- income countries.”

The Millennium Development Goal Target 7.C — to halve by 2015 the proportion of the population without sustainable access to safe drinking water and basic sanitation —was only met for water, but not sanitation. Between 1990 and 2015, 2.6 billion people gained access to improved drinking water sources.

Yet despite that progress, one-third of the global population is still using unimproved sanitation facilities, including nearly 1 billion people who are still forced to defecate in the open. This often leads to cholera, typhoid, hepatitis, polio, and worm infestation.

Diarrhea is the third-largest killer of children under 5 in sub-Saharan Africa, and 44 million pregnant women are infected with worms each year due to open defecation, according to the United Nations. Every minute, 1.1 million liters of human excrement enters the Ganges River in India.

The problem of waste disposal likely will be compounded by rapid urbanization occurring in the developing world, said Alsan, and lack of sanitation and the practice of open defecation costs the world’s poorest countries $260 billion a year.

“We think our findings underscore how complementary these infrastructure investments are, and hope that holds lessons for the developing world,” said Alsan. “In all practicality, it’s very hard to ensure the municipal water supply is not contaminated if the sewage infrastructure is neglected.”

Working Paper: Watersheds in Infant Mortality

Non-smoking campaigns that tell teenage boys they will get lung cancer in 30 years if they don’t stop smoking just don’t work.

“But prevention programs that tell them that girls don’t like smokers make them go pale with fear,” says Keith Humphreys, a professor of psychiatry and behavioral sciences.

Humphreys, an affiliated faculty member of Stanford Health Policy, told an audience at the World Economic Forum in Davos, Switzerland, this January that the better approach to public health campaigns are those tailored to the realities of the human brain.

One of those realities is that our brains have evolved to be vulnerable to addiction, especially if we live in the lower-income tiers of society. An understanding of our evolutionary vulnerability to drugs and alcohol can help us to design effective public policies, Humphreys told the Davos audience.

“Primate research indicates that there may be a political and economic dimension to this,” he said. “When lower primates form a hierarchy, those at the bottom undergo a change in their dopamine system. This makes them more likely to consume drugs in an addictive fashion.”

Addiction can happen to anyone at any level of society — the current opiate epidemic is a case in point — but if you look at wealthy societies, those who have less economic and educational resources are more prone to addiction.

“So as inequality worsens, we really have a risk of creating a disempowered underclass of people who are literally sedated by ever more available psychoactive substances.”

Humphreys is on the NeuroChoice team at the Stanford Neurosciences Institute who attended the forum to present their research into the neural basis of decision-making and how these impact public policy.

He says in this video that neuroscience reveals addictive drugs work on precisely the same brain systems that guide our survival decisions. This is compounded by industrial global capitalism, making the exposure to psychoactive substance nearly universal.

“These two combined realities — our evolutionary conserved vulnerability to addiction and the development of a production and transportation system that can deliver substances worldwide — is why one in six deaths on the planet among adults is attributable to psychoactive substance abuse,” says Humphreys.

Stanford researchers are going after the problem in two ways. First is to use neuroscience to unravel the mechanisms of addiction in the brain. Then, they work directly with public policymakers, such as those who regulate the tobacco, alcohol and pharmaceutical industries, as well as those who oversee health-care and criminal justice systems.

“We communicate to our friends in the policy world what science has to teach about addiction and how you can use that information to do a better job at protecting people and promoting public health,” he said.

He said one of their key messages is that psychoactive substances are not ordinary commodities that should not be regulated.

“That’s probably true for broccoli, but it’s not true for psychoactive substances because they impair our brain’s ability to value things,” he said. And that is why public health policies must take into account the evolutionary-conserved circuits in the brain.

“The magnificent decision-making organ that evolution has bequeathed us is vulnerable to addiction, perhaps particularly if we live on the lower tiers of society. This creates a risk for humanity,” Humphreys said. “Karl Marx was worried that religion would become the opiate of the masses. But if we don’t use neuroscience to make better treatments and better policies regarding addiction, the opiate of the masses will be opiates.”