Upon seeing the printed agenda for the “Inaugural Stanford e-Tottori Day” on August 23, 2019, Silicon Valley entrepreneur Takeshi Homma, whose hometown is in Tottori Prefecture, remarked that he never thought that he would see Tottori high school students at a ceremony at Stanford University. This prompted me to recall the initiative that Homma took several years ago to introduce me to Tottori Prefecture, the least populated in all of Japan. His vision was to bridge his ancestral home with his current home, the United States, through the establishment of an online class on U.S. society and culture for high school students in Tottori. Through Homma’s vision and the support of Tottori Governor Shinji Hirai and the Tottori Prefectural Board of Education, Stanford e-Tottori was established over three years ago. Jonas Edman has been the Instructor of Stanford e-Tottori since its inception.

The inaugural Stanford e-Tottori Day honored Ayaka Ikei of Seishokaichi High School and Yua Kodani of Tottori Nishi High School for achieving at the highest levels in the course. It began with remarks by Takuya Fukushima, Office Director of the English Education Advancement Office, Tottori Prefectural Board of Education. Fukushima commented on the significance of Stanford e-Tottori to the students who have participated, noting their growth not only in terms of their English communication skills but also their understanding of U.S. society and culture. Fukushima, as a graduate of Hiroshima University and also someone who has studied at the University of California, Santa Barbara, and Ohio State University, knows well the significance of the U.S.–Japan relationship. During his remarks and much to the delight of the audience, he shared a television news program that featured a class that Edman taught in person in Tottori in July.

Rie Kusakiyo makes opening remarks at Stanford e-Tottori Day. She is Advisor for Educational Affairs at the Consulate General of Japan in San Francisco.

The highlight of the program was Edman’s introduction of his student honorees, Ayaka and Yua, and their heartfelt presentations, which included their aspirations for the future. During the question and answer period, their passion for helping others surfaced. Ayaka would like to go into the field of education and Yua into the field of medicine. Edman expressed how proud he is of their accomplishments and presented them with plaques.

Visiting Scholar Kenichirou Oyama, Shorenstein Asia-Pacific Research Center, noted, “I was very impressed by the presentations of the two young high school students. In addition, as I am from a provincial town myself, I feel strongly that this program offers hope for young students who live in provincial areas.” By “hope,” Oyama was referring to the fact that students in more rural areas generally have fewer educational opportunities than students in metropolitan areas like Tokyo.

Edman shares a similar sentiment. “The fact that Tottori is quite isolated is what makes the teaching of Stanford e-Tottori so rewarding for me. Making Stanford scholarship accessible to them really captures the heart of SPICE’s mission.” Earlier this year, Edman facilitated a joint online class between his students in Tottori and Japanese language students at Nueva School in Hillsborough, California, whose teacher is Yoko Sase. It was remarkable for Edman to observe how much the students shared and learned from each other. During their trip to the San Francisco Bay Area, Ayaka, Yua, and Fukushima had the chance to visit Nueva and met several of the students with whom they had previously met only virtually. Through Stanford e-Tottori, more students, entrepreneurs, and scholars in the United States are also learning about Tottori.

The fourth Stanford e-Tottori course will commence this fall with the highest enrollment to date.

To stay informed of SPICE-related news, join our email list and follow SPICE on Facebook or Twitter.

• Honoring Stanford e-Tottori students
• From Sand Dunes to Detective Conan
• Seeing the World Beyond a Grain of Sand: SPICE's Online Course for Tottori Prefecture
• High School Students in Tottori Prefecture Spreading Their Wings

"There’s a better way for the American people to grapple in depth with the issues we face at the start of the primary season. Furthermore, we think that, despite their sharp differences of party and ideology, Americans can have serious and respectful conversations across our deep divides. A surprisingly simple innovation can help cut through the poisonous fog of our political polarization. It is an experiment in democracy to show what the whole electorate would think, if it could be similarly engaged," write Larry Diamond, FSI (CDDRL) and Hoover Senior Fellow and James Fishkin, Director of the Center for Deliberative Democracy at Stanford University. Read here.

SPICE is proud to announce a new partnership with Oita Prefecture in Japan to develop an online course for high school students in Oita Prefecture. The new program, called Stanford e-Oita, will launch in the fall of 2019 and will introduce Japanese high school students to U.S. culture and society. The students will also have an opportunity to improve their English language skills, as the course will be conducted entirely in English.

To commemorate the new online course and partnership between Stanford University and Oita Prefecture, SPICE hosted a ceremony on Stanford campus last week with Oita Governor Katsusada Hirose and a large contingent of Japanese businessmen and government workers from Oita Prefecture, including representatives from the Development Bank of Japan and Japan Semiconductor. Also in attendance was Dr. Michael Armacost, former U.S. Ambassador to Japan and an old friend of Governor Hirose.

“I am so honored to be here at the ceremony with my old schoolmate Ambassador Armacost,” commented Governor Hirose during his formal remarks. “I also extend my sincere gratitude to SPICE Director Dr. Mukai for your generous and continued support on this. It is a dream for our students to be able to take classes from Stanford University even in Oita, a regional city in Japan. I hope the agreement this time will be a great opportunity for students of both countries to learn from each other.”

Planning for the Stanford e-Oita online course is still at an early stage, but the main course topics are now being decided. Dr. Mukai moderated a discussion on possible topics for the new course, and several of those in attendance enthusiastically contributed suggestions for consideration. The SPICE staff shared their experiences teaching other online courses such as Stanford e-Japan, Stanford e-Tottori, Stanford e-Hiroshima, and the Reischauer Scholars Program (a course on Japan for U.S. high school students). Oita Prefectural Board of Education’s Keisuke Toyoda, who oversees the Stanford e-Oita online course, also offered his high-priority topics for the program, which includes entrepreneurship, Japan–U.S. relations, region-to-region partnerships, and the UN’s Sustainable Development Goals. Several others offered their suggestions, as well.

Ambassador Armacost also made formal remarks, commenting especially on the strong and natural modern partnership between the United States and Japan, but also how U.S.–Japan relations at the governmental level have evolved over time to become a more balanced relationship.

“Back in my days—in the late ‘80s, early ‘90s—the United States used to approach U.S.–Japan relations with a kind of instructional mindset. ‘How can we teach Japan to be more like us?’ I always disagreed with that approach,” shared Ambassador Armacost. “Nowadays, it seems to be much better—a more reciprocal mindset. ‘What can we learn from each other to build a better future?’”

Fittingly, it is in that same spirit of mutual respect, reciprocity, and hope for the future that SPICE and Oita Prefecture launch our new Stanford–Oita partnership and online course.

“I have a lot of expectations for the future,” commented Governor Hirose. “Thank you so much.”

To stay informed of SPICE-related news, join our email list and follow SPICE on Facebook or Twitter.

I always find it hard to believe so many people are living in poverty: some 39.7 million Americans, or 12.3% of the population. It’s such a wealthy country, yet so many are poor.

In a twist that could be interpreted as good news — it doesn’t seem fair to say there is anything positive about living in poverty — I recently learned that older, low-income Americans tend to be healthier if they live in more affluent areas of the country.

Not only are they healthier, but their physical well-being is better across the board with a lower prevalence of dozens of chronic conditions, particularly if they live in rural communities. This, despite their income having less purchasing power in those better-resourced neighborhoods.

This was the key finding in new research published by Stanford Health Policy’s Maria Polyakova in the Annals of Internal Medicine.

While recent studies have reported that low-income adults living in more affluent areas of the United States have longer life expectancies, less has been known about the relationship between the affluence of a geographic area and morbidity of the low-income population.

“I was interested in figuring out whether the same relationship holds for morbidity: Are poorer people less sick in richer areas?” Polyakova told me. “And if so, are there any specific conditions that drive these differences that could be the target for policy-making?”

So Polyakova, a faculty fellow at the Stanford Institute for Economic Policy Research, and her co-author, Lynn M. Hua at the University of Pennsylvania, set out to evaluate the association between chronic conditions among low-income, older adults and the economic affluence of a local area. 

They focused on nearly 6.4 million Medicare beneficiaries in 2015 aged 66 to 100 years old who received low-income support under Medicare Part D, a prescription drug program for Medicare enrollees. They investigated the prevalence of 48 chronic conditions among these patients, including common chronic conditions such as hypertension, depression, diabetes and Alzheimer’s disease. They found the presence of all conditions is highly correlated: places, where the poor tend to have a high prevalence of one disease, are likely to have a high prevalence of all 48 conditions.

“While we cannot ascertain a causal relationship, our results clearly point towards the importance of further understanding why the socioeconomic environment of low-income, older adults is so tightly linked to such a broad measure of health,” the researchers wrote. 

The results, they said, were broadly consistent with the extensive literature on the social determinants of health. But their work takes that literature even further.

“Our study extends this research by providing measures of the prevalence of chronic conditions among low-income, older adults for a large national sample of the U.S. population,” Polyakova said. 

The researchers used clinical, rather than self-reported measures of diagnoses and reported this group’s variation in morbidity across local areas of the country, rather than nationally. 

“Our results raise the bar for researchers who are trying to find out what factors drive health disparities in the U.S.; these factors would have to be able to explain the differences in nearly 50 condition,” Polyakova said.

The study supported by the National Institute on Aging came to three key conclusions:

1. The health of low-income, older adults in the United States varies substantially across local geographic regions, and this variation cannot be attributed to one specific disease or a narrow set of conditions. 
2. Consistent with their original hypothesis, they found that more affluent local areas of the country have a lower prevalence of chronic conditions in the low-income, older adult population.
3. The researchers found that low-income, older adults have better health in rural areas of the country.

I wondered why these poor, older adults do particularly well in rural communities, as those regions often lack easy access to high-quality health care and state-of-the-art hospitals.

“We don’t know the exact answer, but there is a general sense that differences in the social fabric and lifestyle in rural areas — could contribute to this pattern,” Polyakova told me. “It appears that better health in these areas persists, despite challenges of accessing formal care.”

On August 26, Judge Thad Balkman delivered a $572 million judgment against pharmaceutical giant Johnson & Johnson for the company’s role in fueling the opioid epidemic in Oklahoma. In the discussion that follows, Stanford Law Professors Michelle Mello and Nora Freeman Engstrom discuss the decision and how other cases tied to the national opioid crisis are developing.

The Oklahoma decision took many onlookers by surprise. How did the case unfold? And what did Judge Balkman find? On Monday, Cleveland County District Judge Thad Balkman of Oklahoma issued a judgment that capped off a long and closely-scrutinized trial wherein the Oklahoma Attorney General faced off against Johnson & Johnson (J&J), claiming that J&J contributed to the opioid epidemic that has devastated the state of Oklahoma.

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Stanford Law Professors Michelle Mello and Nora Freeman Engstrom

To understand the verdict, a bit of background is helpful. When Oklahoma initially sued, it cast the net broadly, asserting claims against several defendants under several causes of action.  Certain defendants (namely, Purdue and Teva) chose to settle rather than roll the dice at trial. (Purdue, the maker of OxyContin, agreed to pay Oklahoma $270 million and Teva, one of the world’s leading providers of generic drugs, $85 million; neither admitted wrongdoing.)  Further, over time, Oklahoma’s various causes of action got winnowed down to the singular claim that J&J had created a public nuisance by aggressively and deceptively marketing opioid products to Oklahoma’s doctors and patients.  This posture meant that Oklahoma’s victory at trial was far from a foregone conclusion, as public nuisance claims can be very hard to prove, particularly in cases that relate to dangerous products.

With that table set, the trial began on May 28, 2019.  In a crowded courtroom in Cleveland County, it stretched on for nearly seven weeks and featured dozens of witnesses and more than 800 exhibits. The trial was a bench trial, meaning there was no jury, but there was a written opinion explaining the judge’s decision.  Judge Balkman’s 42-page opinion offers a cogent summary of the evidence and governing law and, broadly, vindicates Oklahoma’s litigation strategy. The opinion finds that J&J engaged in a deceptive marketing campaign designed to convince Oklahoma doctors and the public that opioids were safe and effective for the long-term treatment of chronic, non-malignant pain. Further, this “false, misleading, and dangerous marketing” caused “exponentially increasing rates of addiction [and] overdose death,” which ravaged the Sooner State. The picture Judge Balkman draws is stark and, for J&J, devastating.

Are individuals suing drug companies too? Are there class action cases that are relevant?

There are some suits by individuals, but we don’t believe that’s where the big money damages—and the real social impact of the litigation—will be.  More important is the pending federal multi-district litigation (MDL), which consolidates nearly 2,000 individual federal lawsuits brought by cities, counties, municipalities, and tribal governments in a single action before Judge Dan Polster in Cleveland, Ohio. Additionally, 48 states have initiated separate litigation, with a lineup of claims and defendants similar to the MDL.

Does this win for Oklahoma mean these other plaintiffs have an easy road ahead?

Not easy, but potentially easier. The Oklahoma case is what we call a bellwether. Like the ram that leads the other sheep this way or that, the bellwether trial doesn’t control the path of future litigation. But it does go first, and it helps to indicate trends.

As a bellwether, the big verdict here is very reassuring to the many states, counties, municipalities, and tribes suing opioid makers, distributors, and retailers, and it is, correspondingly, very disturbing for those who made and sold opioids to the American public.  The verdict suggests that this litigation has legs, and that judges and juries may be willing to pin blame not just on Purdue, the maker of OxyContin, but on others who played an arguably less central role in fueling this public health crisis.

What is striking is how damning Judge Balkman’s factual conclusions about J&J’s conduct are, and how similar they are to the allegations made against other opioid manufacturers in other cases.  All the things he objected to regarding J&J’s marketing practices are things that others, too, allegedly have done. Some of them are things that multiple companies banded together to do. Plaintiffs’ attorneys should be feeling pretty confident about their chances of persuading other courts that those practices are problematic.

Is Oklahoma free to use the award as it wishes? Will the state share some of the award with the people who died or suffered in the opioid crisis (if the decision is upheld on appeal)?

The damages, in this case, are intended to fund Oklahoma’s “nuisance abatement plan.”  That’s the remedy in a public nuisance case: The defendant has to pay to clean up the mess it made. In this case, Oklahoma provided a detailed plan laying out what would be needed to abate the opioid problem in the state. The costs added up to $572 million for the first year, and that’s what the judge awarded—not the $17 billion Oklahoma sought for a multi-year abatement effort.

The plan specifies that the money will be used for opioid use disorder screening, prevention and treatment ($292 million), housing and other services for those in recovery ($32 million), continuing medical education programs ($108 million), a pain management benefit program ($103 million), treatment of neonatal abstinence syndrome ($21 million), and other services.  Individuals won’t be direct recipients of the funds, though they may receive the services funded.

Legally, what happens next?

J&J has vowed to appeal the “flawed” Oklahoma judgment, and we expect that the judgment will be appealed, first to Oklahoma’s intermediate, and then, likely, to its supreme, court.  More immediately, though, attention will turn from Oklahoma to Ohio.  The first bellwether trial in the MDL, involving claims from Ohio’s Cuyahoga and Summit counties, is scheduled to begin on October 21.

Even as they prepare for trial, however, lawyers for both plaintiffs and defendants are also, no doubt, continuing to work toward reaching a broad and encompassing settlement.  When Judge Polster was first assigned the MDL back in January 2018, he made no bones about his desire to do “something meaningful to abate this crisis”—and to do it quickly.  It hasn’t been easy to execute on that, which isn’t surprising given the unprecedented magnitude and complexity of the litigation.

Still, we expect that, sooner or later, the opioid litigation will settle.  Indeed, even as we write, news is breaking that Purdue and the Sacklers may be in the midst of a negotiation whereby Purdue would declare bankruptcy and the Sacklers would contribute a cash payment of roughly $4.5 billion-plus relinquish ownership of the company, in return for peace with plaintiffs.

But even forging a settlement involving just those two entities is tricky—and forging a broader settlement will be exponentially harder for a number of reasons.  One is that any truly global agreement needs to pass muster with a range of defendants, some of whom have comparatively shallow pockets, and all of whom sold (or made or distributed) different products, at different times, in different quantities, in different states.  And, on the other side of the table, any settlement agreement needs to get buy-in from both those plaintiffs in the MDL and also state attorneys’ general, who have their own distinct set of priorities and interests relating to their separate lawsuits.  Further, because only a small proportion of eligible cities and counties have joined the MDL to date, any global settlement needs to somehow—equitably but firmly—close the courthouse door on those potential future plaintiffs.  None of this will be easy to accomplish.  But whenever new information reduces uncertainty about how courts would resolve a legal dispute, settlement becomes more likely—and, here, the Oklahoma verdict makes a significant contribution.

 

Nora Freeman Engstrom, Professor of Law and Deane F. Johnson Faculty Scholar, is a nationally-recognized expert in tort law, legal ethics, and complex litigation. Her work explores the day-to-day operation of the tort system—particularly its interaction with alternative compensation mechanisms. Michelle Mello, Professor of Law and Professor of Health Research and Policy (School of Medicine), is a leading empirical health scholar and the author of more than 150 book chapters and articles, including “Drug Companies’ Liability for the Opioid Epidemic,” recently published in the New England Journal of Medicine.  

This article originally appeared in the Ukrainian journal Novoye Vremya.

President Volodymyr Zelenskyy may meet President Donald Trump this weekend in Warsaw and is expected to travel to the United States later in the fall.  This gives Mr. Zelenskyy the opportunity to reinforce Kyiv’s relationship with the United States.  It also offers the opportunity to try to establish a connection to Mr. Trump, something that has proven elusive for most foreign leaders.  Here are a few suggestions for Mr. Zelenskyy on dealing with the American president.

Mr. Zelenskyy should bear in mind that Mr. Trump lacks a strong grasp of the U.S. interest in and what is at stake with regard to Ukraine and the conflict that Russia wages against it.  His administration has pursued sensible policies in supporting Kyiv, strengthening NATO and sustaining sanctions on Moscow.  By all appearances, however, Mr. Trump does not instinctively agree with the necessity of his administration’s own policies.  Witness his recent suggestion about inviting Vladimir Putin to join with other G7 leaders when he hosts the G7 summit next year.

Mr. Trump is not detail-oriented.  He reportedly reads little, leading White House staff to resort to graphs and pictures to capture his attention.  The smart way to approach Mr. Trump is to avoid detail, sticking instead with a few clear and easily understood themes.

Flattering the American president would not hurt.  North Korean leader Kim Jong-un appears to have mastered that.  North Korea has reduced none of its nuclear or ballistic missile capabilities—in fact, they have increased—but Mr. Trump swoons over Mr. Kim’s letters and professes not to be bothered by Pyongyang’s shorter range ballistic missile tests.

That said, keep expectations for flattery modest.  No European leader invested more heavily in flattering Mr. Trump than former British Prime Minister Theresa May.  She gave him a state visit in June with all the bells and whistles.  Yet Mr. Trump could not resist sending a series of tweets denigrating her handling of the Brexit conundrum and all but welcoming her replacement.

This underscores the point that, in many foreign policy relationships, Mr. Trump is transactional.  He will be asking what can America get, or what can he get.

Mr. Zelenskyy thus should consider whether there is a topic on which he could offer Mr. Trump a win-win.  Progress toward resolving the Russia-Ukraine conflict in Donbas could provide such an issue.  Real movement toward peace would be a major win for Kyiv, but it could offer Mr. Trump a win as well.  He has repeatedly made clear his desire for improved U.S.-Russia relations, and a genuine settlement in Donbas could lift the biggest obstacle to his goal.

The question is how to shape a proposal to accomplish this.  Bringing Mr. Trump into the current Normandy negotiating format in a way that made it appear as if Mr. Trump sparked a breakthrough would appeal to the Nobel Prize-hungry American president.

However, the key to peace in Donbas lies in Moscow.  The Kremlin seems interested in sustaining a simmering conflict as a means to pressure the government in Kyiv.  Still, aligning interests with Mr. Trump on pressing for peace would be a plus for Mr. Zelenskyy.

While in the United States, the Ukrainian president should not neglect the Congressional leadership.  Both Democrats and Republicans on Capitol Hill support Ukraine and display considerable skepticism toward Russia.  Congress could serve as a check on Mr. Trump should he choose to pursue his less well-thought-out ideas on Russia.

Mr. Zelenskyy’s American interlocutors in Congress want Ukraine to succeed, with success measured by its progress in becoming a normal democratic, market-oriented and prosperous European state.  In the past, developments in Ukraine have disappointed both Ukrainians and the country’s friends in the West.  To the extent that Mr. Zelenskyy can make a persuasive case that this time it is different—that he and the new parliament will take the tough steps to achieve success—he will return home having forged a stronger basis for the U.S.-Ukrainian relationship.  He can bolster his case by coming to Washington with one or two signature reforms under his belt, such as an end to the moratorium on sales of private agricultural land.

One last piece of advice.  Mr. Zelenskyy and his team should be wary of former New York mayor Rudy Giuliani’s efforts to drag Ukraine into U.S. domestic politics.  That would risk making Ukraine a partisan political issue in America, which could undermine the bipartisan support that Ukraine has enjoyed since regaining independence in 1991.

* * * * *

Steven Pifer is a William Perry fellow at Stanford University and a former U.S. ambassador to Ukraine.

A task force of national health experts has released a draft recommendation to screen all adults 18 to 79 years for the hepatitis C virus (HCV), noting the opioid epidemic has fueled what has become the most common chronic bloodborne pathogen in the United States.

Cases of acute HCV have increased 3.5-fold over the last decade, particularly among young, white, injection drug users who live in rural areas. Women aged 15 to 44 have also been hit hard by the virus that is spread through contaminated blood.

The U.S. Preventive Services Task Force, which makes recommendations followed by primary care clinicians nationwide, has until now recommended that people who are at high risk be tested for hepatitis C, as well as “baby boomers” born between 1945 and 1965.

“Unfortunately, HCV now affects a broader age range than previously with three times as many new infections per year,” said Stanford Health Policy’s Douglas K. Owens, chair of the independent, voluntary panel of national experts in prevention and evidence-based medicine.

The Task Force now recommends that clinicians encourage all their adult patients, even those with no symptoms or known liver disease, get a blood test for the virus. Pregnant women should also be screened; from 2009 to 2014, the prevalence of HCV infection among women giving birth has nearly doubled.

“The explosive growth in HCV has been fueled by the opioid epidemic, with the spread of HCV into younger populations,” said Owens, director of the Center for Health Policy and the Center for Primary Care and Outcomes Research. “HCV now kills more Americans than all other reportable infectious diseases combined, including HIV.”

An estimated 4.1 million people in the United States are carrying HCV antibodies; about 2.4 million are living with the virus, according to the Task Force. The HCV infection becomes chronic in 75% to 85% of cases and some of those people develop symptoms such as chronic fatigue and depression, and liver diseases that can range from cirrhosis to liver cancer.

Approximately one-third of people ages 18 to 30 who inject drugs are infected with the virus; 70% to 90% of older injection-drug users are infected.

There currently is no vaccine for hepatitis C although research in the development of a vaccine is underway. But there are effective oral direct-acting antiviral (DAA) medications that can clear the virus from the body, particularly if caught early.

“The good news is that treatment for HCV is far better, and far better tolerated than in the past, offering a cure to most people,” Owens said. “Early identification of HCV is important to prevent long-term complications of HCV including liver failure, liver cancer, and death.”

The Task Force said in a release that there are several key research gaps that could inform the benefit of screening for HCV infection:

1. ·     Research is needed on the yield of repeat vs. one-time screening for HCV.
2. ·     Research is needed to identify labor management practices and treatment of HCV infection prior to pregnancy to reduce the risk of mother-to-child transmission.
3. ·     Trials and cohort studies that measure effects on quality of life, function, and extrahepatic effects of HCV infection (such as renal function, cardiovascular effects or diabetes) would be helpful for evaluating the impact of DAA regimens on short-term health outcomes.
4. ·     Additional studies are needed to examine the epidemiology of HCV infection and the effectiveness of DAA regimens in adolescents.

South Korea's decision to end its military agreement with Japan will damage the prospect of continued close security ties among Seoul, Washington and Tokyo because the pact has been a symbol of smooth trilateral military cooperation between them and regarded as a key deterrent against North Korea.

"It is a big mistake," Shin Gi-wook, a Korea studies expert at Stanford University, said in a recent interview adding Seoul's withdrawal from the General Security of Military Information Agreement (GSOMIA) puts the "trilateral security framework at risk."

"The Japan-South Korea relationship may not have hit rock bottom, but it could further deteriorate in the coming months," Shin said. "This is all the more important with the continuing threat of North Korean WMD and the escalating conflict between the U.S. and China in the region. I am concerned that South Korea could be further isolated in the Northeast Asian region—the Moon administration should see the big picture," the professor said…

Read the full article in The Korea Times.