This article originally appeared in the American Ambassadors Review (Spring 2019).

For nearly five decades, Washington and Moscow have engaged in negotiations to manage their nuclear competition. Those negotiations produced a string of acronyms—SALT, INF, START—for arms control agreements that strengthened strategic stability, reduced bloated nuclear arsenals and had a positive impact on the broader bilateral relationship.

That is changing. The Intermediate-range Nuclear Forces (INF) Treaty is headed for demise. The New Strategic Arms Reduction Treaty (New START) has less than two years to run, and the administration of Donald Trump has yet to engage on Russian suggestions to extend it. Bilateral strategic stability talks have not been held in 18 months.

On its current path, the U.S.-Russia nuclear arms control regime likely will come to an end in 2021. That will make for a strategic relationship that is less stable, less secure and less predictable and will further complicate an already troubled bilateral relationship.

Fifty Years of Arms Control

Bilateral nuclear arms control talks between Washington and Moscow began in 1969 with the Strategic Arms Limitation Talks (SALT). They resulted from a growing understanding that negotiated limits on the superpowers’ nuclear arms competition served the interests of both. Over the next five decades, arms control treaties and unilateral force decisions led the sides to reduce their active arsenals to 4,000-4,500 nuclear weapons each—down from a U.S. peak of more than 30,000 in the 1960s and a Soviet/Russian peak that exceeded 40,000 in the 1970s.

Early treaties such as the 1972 Interim Offensive Agreement and the 1979 SALT II Treaty (which never entered into force but whose limits were observed into the mid-1980s) merely slowed the growth of nuclear arsenals. Later treaties had a more dramatic impact. The 1987 INF Treaty banned the entire class of U.S. and Soviet land-based missiles with ranges between 500 and 5,500 kilometers. The 1991 START Treaty required the sides to reduce their accountable strategic nuclear warheads by some 40 percent while cutting strategic missile launchers and bombers by about 30 percent.

Arms control agreements often had a beneficial impact on the broader relationship. SALT helped advance détente in the early 1970s; progress on INF and START spurred an improvement in the overall U.S.-Soviet relationship in the late 1980s; and the relatively quick conclusion of New START gave a positive impulse to the Obama administration’s reset with Russia, even though the reset proved short-lived.

Today, the U.S.-Russian relationship has hit its lowest point since the end of the Cold War. Arms control, or the looming collapse of arms control, rather than helping, may contribute to a further deterioration of relations.

The Demise of the INF Treaty

The INF Treaty is on a death course. Russia violated the treaty by developing and deploying the 9M729, a prohibited intermediate-range cruise missile. Neither the Obama nor the Trump administration employed an effective strategy to persuade Moscow to return to compliance.

On October 20, 2018, President Trump announced that the United States would terminate the treaty, surprising allies and administration officials alike. NATO subsequently backed the U.S. decision, though European officials privately grumbled about a fait accompli. In early February, U.S. officials stated that they had suspended U.S. treaty obligations and given Russia the required six months’ notice of the U.S. intention to withdraw from the agreement. Russia then suspended its treaty obligations.

The United States could not remain forever in a treaty that Russia has violated. However, the way the Trump administration handled its departure amounted to diplomatic malpractice. Washington will get blamed for the treaty’s end.

There was a smarter way. First, U.S. officials should have informed their European counterparts in early 2018 that the United States would have no choice in 12–24 months but to leave the treaty if Russia did not correct its violation and urge them to apply political heat on the Kremlin, including at the highest level. Russia’s intermediate-range missiles cannot reach the United States; they threaten Europe and Asia.

Second, the U.S. military should have deployed conventionally armed air- and sea-launched cruise missiles to the European region to show that the Russian violation would not go unchallenged.

Third, NATO should have begun a study of long-term countermeasures, with one option being deployment in Europe of a conventionally armed U.S. intermediate-range ballistic missile. While the Alliance likely could not have found consensus to adopt that option, discussing it would have reminded military leaders in Moscow how much they disliked the U.S. Pershing II, whose deployment in West Germany in the 1980s proved key to securing the INF Treaty.

Fourth, U.S. officials should have indicated to their Russian counterparts that, if they addressed U.S. concerns about the 9M729 violation, the United States would consider ways to address Russian concerns that the Aegis Ashore missile defense facility in Romania could launch offensive missiles.

Would such steps have brought Russia back into compliance? Perhaps not, but they certainly would have increased the odds. Even if they did not succeed, they would have positioned Washington far better with its allies and put it in a stronger position to lay blame for the treaty’s end where it belonged—on Russia.

In the actual event, the Trump administration hardly tried. In January, Russian officials offered to exhibit the 9M729 to U.S. experts. U.S. officials could have taken that proposal and insisted on procedures for a meaningful exhibition. Instead, they flat out turned it down.

Much of the problem on the American side may lie with National Security Advisor John Bolton. He generally disdains arms control agreements as constraining U.S. capabilities and options (which is true, but they also constrain Russian capabilities and options). He had previously called for U.S. withdrawal from the INF Treaty.

Exhibitions of the 9M729 and Aegis Ashore facility could have opened a path to resolve each side’s compliance concerns, but Moscow and Washington have not shown the needed political will. It looks like the treaty will meet its demise in August.

Questions about the Future of New START

In contrast to the INF Treaty, Russia has complied with the limits of the 2010 New START Treaty, which required reductions by each country to no more than 1,550 deployed strategic warheads and no more than 700 deployed strategic missiles and bombers by February 2018. The United States also met the limits, though Russian officials question the adequacy of measures the U.S. military took to remove some strategic systems from treaty accountability.

New START by its terms will expire in February 2021, though the treaty allows extension for up to five years. Russian officials have proposed discussion of extension. In 2017, Trump administration officials said they would first have to complete the new nuclear posture review and see whether Russia met the February 2018 limits. Both of those boxes were checked more than a year ago. U.S. officials now say they are studying the question and see no rush.

New START extension should be a no-brainer. First, it would extend to 2026 the limits on Russian strategic forces and provide a mechanism to address new nuclear systems that the Russian military has under development. Second, extension would not affect U.S. strategic modernization plans, which the Pentagon designed to fit within New START’s limits. Third, extension would continue the flow of information that the U.S. military and intelligence community receive about Russian strategic forces from data exchanges, notifications and on-site inspections. That information lets the U.S. military make smarter decisions about how to equip and operate U.S. strategic forces.

When asked about extension, however, Bolton has raised two alternatives: renegotiation of New START or a treaty modeled on the 2002 Strategic Offensive Reductions Treaty (SORT). Neither holds much promise.

Renegotiation would allow Washington to try to improve New START, perhaps with additional verification measures or expanded limits to capture nuclear weapons not now covered by the treaty. But Moscow would seek changes as well, starting with limits on missile defense and conventional strike systems, both of which are anathema to the Trump administration. Renegotiation would take a long time and have, at best, an uncertain prospect of success.

As for the SORT model, SORT limited just warheads (though with no verification measures); it did not constrain strategic missiles and bombers. While Moscow accepted such an agreement in 2002, Russian officials since 2008 have made clear that a strategic arms control agreement must limit missiles and bombers, as does New START.

Bolton opposed New START when the Senate discussed its ratification back in 2010. Neither Secretary of State Mike Pompeo nor Acting Secretary of Defense Patrick Shanahan seem to be advocates for the treaty. Although extension would be very much in the U.S. interest, the Trump administration appears inclined to let it expire.

No Strategic Stability Talks

U.S. and Russian officials in the past have held strategic stability talks to take a broad look at developments that affect their strategic relationship. Such talks are useful, particularly when new developments, such as those in the cyber and space domains, emerge and when Russian nuclear doctrine has provoked concern in Washington and led to changes in the U.S. nuclear posture. Even if strategic stability talks do not spin off specific negotiations, they provide a venue for the sides to exchange views and better understand the concerns of the other.

During the Trump administration, a one-day session of strategic stability talks took place in September 2017. As of March 2019, it has not agreed to a second meeting.

An Unsettling Future

For most of the five decades of U.S.-Soviet/Russian arms control negotiations, the American side took the lead. Moscow often struck a pose not of disinterest, but of less interest—likely for bargaining purposes. That is no longer the case. The Kremlin now faces a White House that attaches as little priority to reducing arms as it does—perhaps less. The U.S. President evinces no understanding of arms control, while his national security advisor apparently seeks to end it.

With the INF Treaty all but dead, New START’s fate uncertain after 2021 and no sign of new initiatives on either side, arms control as practiced for some 50 years may be coming to an end or, at a minimum, to a pause. That occurs at a time when Russia and the United States have significant nuclear modernization programs underway. While the bulk of those programs aim primarily to replace old weapons with new ones, the sides are also developing nuclear capabilities that neither previously had in its arsenal. Economic constraints may limit an all-out arms race, but the strategic nuclear relationship seems headed for uncharted territory.

The end of the U.S.-Russian nuclear arms control regime would have wider impacts. If the two nuclear superpowers no longer are reducing—and no longer limiting—their nuclear arms, what credibility will they have to insist that other countries, such as North Korea, forgo nuclear weapons or that third countries sanction proliferating states? Will China decide to adjust its nuclear posture and move from its current modest stockpile of under 300 weapons toward a larger and more diverse arsenal?

The current course will lead to a less stable and secure world. The United States and Russia will be less able to predict future developments on the other side and thus will have to make expensive worst-case assumptions. It will make for a more complex and dangerous relationship. Perhaps then they will recall the lessons of the 1960s and 1980s that arms control, however imperfect, can offer a useful tool for managing great power competition.

The Stanford University Scholars Program for Japanese High School Students or “Stanford e-Japan” is an online course sponsored by the Yanai Tadashi Foundation and the Stanford Program on International and Cross-Cultural Education (SPICE), Stanford University. This online course teaches Japanese high school students about U.S. society and underscores the importance of U.S.–Japan relations. Through Stanford e-Japan, ambassadors, top scholars, and experts throughout the United States provide web-based lectures and engage Japanese high school students in live discussion sessions called “virtual classes.” Stanford e-Japan is now in its 5th year and 8th session overall.

On March 15, 2019, 29 high school students across Japan were notified of their acceptance to the Spring 2019 Stanford e-Japan Program. The online course kicks off today and runs until August 23, and will include students representing Aichi, Chiba, Fukuoka, Gunma, Hiroshima, Hokkaido, Hyogo, Kanagawa, Nagano, Niigata, Okinawa, Osaka, Saitama, Shizuoka, Tokyo, and Toyama. In addition to a diverse geographical representation within Japan, the students themselves bring a diverse set of experiences to the program, many having lived overseas in places such as Canada, China, the Philippines, and the United States.

The selected Stanford e-Japan high school students will listen to lectures by renowned experts in the field including Professors Emeritus Daniel Okimoto and Peter Duus, and Professors Katherine Gin Lum, Phillip Lipscy, and Kenji Kushida (Stanford University) on topics such as “Baseball Diplomacy,” “The Atomic Bombings of Japan,” “The Attack on Pearl Harbor,” “Religion in the U.S.,” “U.S.–Japan Relations,” and “Silicon Valley and Entrepreneurship.” Live virtual classes include guest speakers such as Ms. Suzanne Basalla (Toyota Research Institute), Ms. Maiko Cagno (U.S. Consulate, Fukuoka), and Mr. Andrew Ogawa (Quest Venture Partners).

Many Stanford e-Japan students in the current cohort (as well as past ones) have mentioned their desire to study in the United States. The Stanford e-Japan Program equips many students with the motivation and confidence to do so, in addition to many of the skills they will need to study at U.S. universities and colleges. In addition to weekly lectures, assignments, discussion board posts, and virtual classes, the program participants will complete a final research paper on a topic concerning U.S. society or the U.S.–Japan relationship.

“Through this course, we’ve raised Japanese students’ interest in U.S. society and U.S.–Japan relations, which is fantastic,” commented Brown. “I’ve encouraged them to seriously consider undergraduate studies in the United States and to look into opportunities like the Yanai Tadashi Foundation Scholarships.”

Stanford e-Japan is one of several online courses for high school students offered by SPICE, including the Reischauer Scholars Program, the China Scholars Program, and the Sejong Korean Scholars Program. For more information about Stanford e-Japan, please visit stanfordejapan.org.

To be notified when the next Stanford e-Japan application period opens, join our email list or follow us on Facebook and Twitter.

Related articles:

• Yanai Tadashi Foundation and SPICE/Stanford University
• Winners announced for the Fall 2018 Stanford e-Japan Award
• Spring 2019 Stanford e-Japan online course now accepting applications

Medicare made $70 billion in payments to physicians in 2017 for care they provided to the 44 million Americans covered by the federal health-care program.

Who decides how much a physician should be reimbursed from Medicare for their services?

Medicare has depended on a committee convened by the American Medical Association known as the Relative Value Scale Update Committee (RUC) since 1992. The RUC has been called the most important health care committee you’ve never heard of.

The RUC has 31 members, most of whom come from the major specialty societies, such as the American Academy of Orthopedic Surgeons and American Association of Neurological Surgeons. By estimating the time and effort physicians take to perform thousands of different services, the RUC assigns “values” to each service that determine how much physicians are paid for delivering it. 

The RUC has come under heavy criticism in health policy circles for its influential role in setting payment levels. But its performance and methods have never been closely studied.

So Stanford researchers David C. Chan and David Studdert — both core faculty members at Stanford Health Policy — set out to evaluate how well the RUC was doing. The researchers analyzed one critical ingredient of the valuation process: how long services take to perform.  They compared the RUC’s estimates of the duration of 293 common operations to “benchmark” times for the same operations, obtained from actual surgical cases recorded in a large national database.

The study, published in The New England Journal of Medicine, found substantial discrepancies between the RUC’s time estimates and the benchmark times. But Chan and Studdert also found that the RUC did not show a systematic bias; times were as likely to be overestimated as they were to be underestimated.  

The research team, which also included Johnny Huynh, a PhD student in economics at UCLA, then characterized inaccuracies, quantified their effect on physician revenue, and examined whether re-review by the RUC corrected them.

“The inaccuracy of the RUC’s estimates for some procedures times was quite large,” said Chan, a faculty fellow at the Stanford Institute for Economic Policy Research and staff physician at the Veterans Affairs Palo Alto Health Care System. “The best way we could think of to indicate how large was to convert them into clinical revenue, and see how the inaccuracies affected different specialties.”

The study estimated that orthopedic surgeons and urologists received higher payments than they would have if benchmark times had been used — $160 million and $40 million more, respectively, in Medicare reimbursements over a five year period. Whereas cardiothoracic surgeons, neurosurgeons and vascular surgeons received lower payments — $130 million, $60 million, and $30 million less, respectively — during the same period.

Yet the researchers did not find evidence that inaccuracies stemmed from systematic bias.

“There was already an awareness that the RUC was missing the mark on some of its time estimates. Our study reinforces that inaccuracy story,” said Studdert, a professor of medicine and law. “But the prevailing view is that RUC uses times that are systematically longer than the truth, and we just don’t see that.” 

The study concludes nonetheless that reform is still needed, because the time discrepancies are large and have substantial effects on payment allocations. It points to two policy reforms that have the potential to improve the accuracy of service valuations by the RUC: 

1. Use larger and more reliable sources of data for the time estimates;
2. Enhance the real-time accuracy of the valuations by monitoring such data sources for substantial changes in the duration of procedures and using this information to prioritize procedures for re-review.

“I believe that the RUC has moved in this direction recently, and I suspect that there would be a fairly general agreement that the process could be improved by going further and using more and better data,” Chan said.

The researchers now intend to turn their sights on another aspect of physician payment policy: the perception that the RUC methods lead to underpayment of primary care physicians.

“The biggest criticism of the RUC over the years is the allegation that it systematically undervalues the work of primary care physicians, relative to surgeons,” Studdert said. “Now that we have developed method for benchmarking the RUC’s accuracy, we’d like to redeploy it on this primary care versus surgical care issue.”

Applications opened yesterday for the China Scholars Program, an intensive, college-level online course on contemporary China for U.S. high school students. The China Scholars Program is offered by the Stanford Program on International and Cross-Cultural Education (SPICE), Stanford University, and is open to rising 10th, 11th, and 12th graders. The Fall 2019 online course will run from late August through December. Applications are due June 15, 2019.

Stanford University China Scholars Program for high school students
Fall 2019 session (late August through December)
Application period: April 15 to June 15, 2019
 

Accepted applicants will engage in a rigorous academic exploration of key issues in China, spanning politics, economics, social issues, culture, and the arts, with an emphasis on the relationship between the United States and China. In real-time conversations with leading scholars, experts, and diplomats from Stanford University and other institutions, participants will be exposed to the cutting edge of U.S.–China relations and scholarship. Students who complete the online course will be equipped with a rare degree of expertise about China and international relations that may have a significant impact on their choice of study and future career.

As in previous sessions of the China Scholars Program, the Fall 2019 cohort will comprise high school students from across the United States. Participants in the current cohort represent states across the nation, including New York, New Jersey, Massachusetts, Missouri, Indiana, Pennsylvania, Illinois, Arizona, California, and Hawaii. The immense diversity of student backgrounds and experiences within each online course allows for an especially rich exchange of ideas and perspectives among the young scholars—a crucial and invaluable component of the learning experience.

“It’s been one of the most fascinating, valuable, and formative classes I have ever taken,” says Rebecca Qiu, a recent alum of the program. “Every week, you discuss pressing topics—from technology censorship to the urban-rural divide—with your motivated peers. During virtual classes, you have the opportunity to ask questions and speak with some of the most influential experts and researchers on modern China—I cannot emphasize how valuable this is. [The China Scholars Program] provides you with a huge breadth and depth of knowledge on China and U.S.–China relations that you cannot find in any typical high school class.”

More information on the China Scholars Program is available at http://chinascholars.org. Interested high school students can apply now at https://spicestanford.smapply.io/prog/china_scholars_program/. The deadline to apply is June 15, 2019.

To be notified when the next China Scholars Program application period opens, join our email list or follow us on Facebook and Twitter.

The China Scholars Program is one of several online courses for high school students offered by SPICE, Stanford University, including the Reischauer Scholars Program (on Japan), the Sejong Scholars Program (on Korea), and the Stanford e-Japan Program (on U.S. society, offered to high school students in Japan).

Related article:

• The China Scholars Program: Continuing a 45-year tradition of bridging Stanford and schools

To thwart the effects of ‘Putinism,’ the American people must first understand the nature of the threat, Michael McFaul told the House Intelligence Committee.

What is “Putinism,” and what threat does it pose to U.S. national security? What steps can the U.S. take to confront it? These are the questions that former U.S. Ambassador to Russia and Freeman Spogli Institute (FSI) Director Michael McFaul sought to answer in his testimony before the House Intelligence Committee on March 28, 2019.

Sign up for the FSI newsletter to receive more stories like this directly to your email inbox.

The committee’s hearing, “Putin’s Playbook: The Kremlin’s Use of Oligarchs, Money and Intelligence in 2016 and Beyond,” focused on the complex web of political and economic forces within Russia, and how they are leveraged abroad to advance Putin’s foreign policy agenda.

Chaired by Representative Adam Schiff, the committee listened as McFaul emphasized the need for foreign policy decision making to be based on the latest data-based research and evidence.

“To contain and thwart the malicious effects of ‘Putinism,’ said McFaul, “the United States government and the American people must first understand the nature of the threat.”

There Goes the Neighborhood

Since Putin’s first term as president in 2000, McFaul explained, the Russian economy has experienced a radical redistribution of property rights, increasing public ownership at the expense of the private sector, and further weakening property protection laws. Strengthened state ownership to support political aims has entrenched Putin’s leadership over the country but not fostered vibrant or sustainable economic growth.

Now You See it, Now You Don’t

To distract from domestic corruption, economic inefficiency and overall inequality, said McFaul, the Kremlin has drawn the public’s attention toward its foreign adversaries, particularly the United States. A fabricated narrative claims that sanctions are a foreign ploy to cause economic stagnation, rather than a diplomatic response to Russian violations of international law.

Putinism On The Move

According to McFaul, Putin leverages several powerful methods of influence, many of which parallel those used within Russia, to further disrupt and weaken the international order:

1. Heavy investment in international media, such as RT and Sputnik International
2. The creation of organizations, fake identities and bots to influence public opinion on non-Russian social media platforms, particularly in the West
3. “Doxing” — the theft of information by digital means with the aim of weakening perceived adversaries
4. The cultivation of direct contacts and financial support with sympathetic non-governmental organizations and individual politicians
5. Strategic business engagements with foreign entities to establish political influence and leverage
6. Mobilization of coercive actors, such as soldiers, mercenaries and even assassins

Although lifting sanctions is a high priority for the Kremlin, noted McFaul, Putin has sought to develop relationships with sympathetic figures in foreign governments and wait for a favorable change in power rather than addressing the primary reasons that sanctions were enacted in the first place.

Defining the U.S. Response

In response to these so-called rules of ‘Putin’s Playbook,’ McFaul has already partnered with Congressman Ro Khanna and Alex Stamos, the Director of the Stanford Internet Observatory, to define and advocate for the specific actions that will protect the United States’ national security, beginning with reforms to deter doxing operations and enhance the cybersecurity of voting infrastructure.

“National security is not a partisan issue,” said McFaul in his testimony before the House Intelligence Committee. “When it comes to national security, if the Russians attack us, they’re not going to just attack the Republicans and leave the Democrats to the side… I want us to get back to the national security threats that threaten all of us together.”

Read Michael McFaul’s complete written testimony.

Drug companies and medical device manufacturers have long cultivated ties with physicians and hospitals in an effort to promote their wares. This has led to some suspicion that patients may end up with prescriptions for drugs they don’t need or devices they don’t want.

So the federal Centers for Medicare & Medicaid Services established the Open Payments database — required under the Affordable Care Act — which allows patients to discover whether their physicians or hospitals have any financial ties with drug or device companies.

It is designed to give the public a more transparent health-care system, though as the website notes, all information on the Open Payments database is open to personal interpretation.

"Transparency has become a very vogue strategy in U.S. health policy,” said Stanford Health Policy’s Michelle Mello. “Information disclosure requirements are being used to do everything from curbing overeating to helping patients decide where to have their heart surgery.”

Mello, a professor of health research and policy at the School of Medicine and professor of law at Stanford Law School, and her colleagues wanted to understand whether the Open Payments system is achieving its goal of helping patients make more informed decisions.

In a new study published by JAMA Network Open, the researchers found an unintended consequence of the public disclosure system: It may have diminished trust in even those physicians who never received payments from drug or medical device firms.

Lack of Public Trust

The authors’ survey of 3,500 respondents found that public disclosure of payments was associated with a 2.7% decline in trust in one’s own physician regardless of whether the respondents knew their physicians had received payments. In fact, the authors note, fewer than 5% of U.S. adults report knowing about their physicians’ industry payments or using the Open Payment website.

“Doctors might consider that unfair because people reported diminished trust even though most of them had no idea whether their doctor took industry payments or not,” Mello said. “About two-thirds of physicians receive industry payments, so what we’re seeing is a kind of spillover reputational damage to the one-third who don’t.”

Mello said she and her co-authors — Genevieve P. Kanter of the University of Pennsylvania, Daniel Carpenter of Harvard University and Lisa Lehmann of the National Center for Ethics in Health Care in the Veterans Health Administration — were surprised by their findings.

“Why would trust go down if few people are using the Open Payments data?” Mello asked. “We think that the large amount of media publicity about the Open Payments law — which has described drug companies’ financial influence as pervasive and highlighted extreme cases of physicians taking very large payments — may have changed how people think about the trustworthiness of the medical profession as a whole.” 

Pharmaceutical companies for decades have engaged physicians through a variety of kinds of financial relationships. Grants for company-sponsored research constitute the largest expenditure, but consulting fees, honoraria for giving lectures, providing meals, covering travel expenses, and giving small gifts are also common activities. Physicians may also have investment interests in drug and device companies.

“However, the nature of these relationships and the magnitude of the dollars flowing from companies to physicians have largely been opaque to the public,” the authors wrote.

The Policy Implications

Trust is a crucial element of the physician-patient relationship affecting many aspects of patient behavior and sentiment that ultimately affect health, the authors said. For example, trust in one’s physician is associated with “whether patients follow treatment recommendations, how well they self-manage chronic conditions, and whether they seek preventive care.” Further, the authors wrote, “Trust in the medical profession may affect the public’s views of scientific authority and medical research, which may influence patient adherence and health-promoting behaviors,” they wrote.

The researchers suggested institutional policies should be implemented by hospitals and physicians to help patients understand what these payments represent. Some kinds of payments, such as an honorariumfor serving as a paid speaker for a drug company, are more concerning than, say, research grants. But many patients may not be able to distinguish between the two.

“Pharma-free physicians might consider advertising that status to current and prospective patients, or health plans could include a marker for that on their `Find a Physician’ websites,” Mello said.

Finally, she said, patients should look up their doctor and if they see any payments they find concerning, ask their doctors about them.

“Seeing whether the payments pass the `red-faced test’ in these conversations should be illuminating,” Mello said.

Marcella Alsan and Marianne Wanamaker are recipients of this year’s prestigious Arrow Award from the International Health Economics Association for research that shows the health of African-American men was adversely impacted by the Tuskegee syphilis study of the early 20th century.

The annual award recognizes excellence in the field of health economics and is named after the late Kenneth J. Arrow, a Nobel Prize-winning economist and mathematician. He was a Stanford Health Policy fellow and senior fellow by courtesy at the Freeman Spogli Institute for International Studies (FSI). He was also a senior fellow, emeritus, at the Stanford Institute for Economic Policy Research (SIEPR).

The IHEA awarded the 27th annual Arrow Award to Alsan, a core faculty member at Stanford Health Policy, a senior fellow at FSI and SIEPR, and co-author Wanamaker of the University of Tennessee for their paper, “Tuskegee and the Health of Black Men” published in the Quarterly Journal of Economics.

The infamous Tuskegee study began in 1932 when the U.S. Public Health Service began following approximately 600 African-American men, some of whom had syphilis, for the stated purpose of understanding the natural history of the disease. The government willingly withheld treatment even after penicillin became an established magic bullet for treating the illness. 

The medical doctors and staff of the CDC followed the men for four decades, until ultimately the study was halted in 1972 when it was brought to the attention of the media by law student Peter Buxtun.

As noted in this story about the research, Alsan and Wanamaker found that the public disclosure of the study in 1972 was associated with an increase in medical mistrust and mortality among African-American men in the immediate aftermath of the revelation.

“The award is an immense honor for both Marianne and me. First, it sheds light on the importance of history for understanding health disparities. Second, it reaffirms the “expected behavior of the physician” that Professor Arrow eloquently described in his seminal 1963 paper on the distinctive features of the market for medical care and the externalities associated with deviating from those expectations.”

African-American men today have the worst health outcomes of all major ethnic, racial and demographic groups in the United States. Life expectancy for black men at age 45 is three years less than their white male peers, and five years less than for black women.

When their working paper was first published by the National Bureau of Economic Research, it became part of the national discussion about the lasting impact of the Tuskegee study.

“The story that Alsan and Wanamaker uncovered is even deeper than the direct effects of the Tuskegee Study,” wrote Vann R. Newkirk II in The Atlantic. “Their research helps validate the anecdotal experiences of physicians, historians, and public health workers in black communities and gives new power to them.”

On March 31, Taiwan’s Ministry of Foreign Affairs reported that two Chinese Air Force (PLAAF) J-11 jets crossed the median line of the Taiwan Strait. This violated the long-held tacit agreement between China and Taiwan that neither side should cross the median line.

Taiwan deemed this “an intentional, reckless & provocative action,” which triggered “a 10-minute standoff” in the air. As Asia security expert Bonnie S. Glaser notes that, if intentional, this would be the first PLAAF crossing of the median line in about 20 years. In this case, it’s likely that Taiwan, not the South China Sea, prompted Beijing’s actions.

An unresolved issue from the Chinese civil war, Taiwan has always been a “core interest” to party leaders in Beijing. Here are some key takeaways from my research on China-Taiwan relations…

Read the full article in The Washington Post.

To hear more from Ketian, don't miss her recently posted video Q&A. In addition, be sure to RSVP for her April 16 seminar "Killing the Chicken to Scare the Monkey: Explaining Coercion by China in the South China Sea."

SPICE is now accepting applications for the 2019 East Asia Summer Institute for High School Teachers. This free three-day institute is SPICE’s premier professional development opportunity for teachers, combining Stanford’s deep content expertise with SPICE’s award-winning lesson plans.

SPICE/NCTA East Asia Summer Institute for High School Teachers
July 8–10, 2019
Stanford University
Application deadline: May 6, 2019

High school teachers of social studies and language arts are especially encouraged to apply.

Participants will learn from Stanford faculty and other experts about the geography, cultures, politics, economics, history, and literature of East Asia, including a special focus on U.S.–Asia relations and the Asian diaspora in the United States. Teachers will also engage in pedagogy-focused discussions and receive training on several SPICE lesson plans on East Asia, in order to help them translate their new content knowledge to the classroom. Teachers who complete the professional development seminar will be eligible for a $250 stipend and three units of credit from Stanford Continuing Studies, and they will leave Stanford with several extensive SPICE curriculum units in hand.

This professional development opportunity will focus largely on China, Japan, and Korea. For example, last year’s speakers included Kathleen Stephens (former U.S. Ambassador to the Republic of Korea), Peter Duus (renowned Stanford scholar of modern Japan), and Clayton Dube (Director of the USC U.S.-China Institute). The institute also featured speakers like author Chun Yu (who grew up in China’s Cultural Revolution) and Joseph Yasutake (who grew up in a Japanese American internment camp), whose rich personal stories brought history to life. SPICE staff led complementary interactive curriculum training sessions on China’s economic development, the atomic bombing of Hiroshima, South Korean pop culture, and East Asia’s “history wars.”

“Every speaker added a new perspective to historical and contemporary events,” remarked participant Kimberly Gavin. “[The] lectures enriched my knowledge base of topics, curriculum demonstrations gave me ideas for effective lessons in the classroom, small group discussions led to rich conversations about primary and secondary sources, and teacher sharing introduced me to new websites. There wasn’t anything that was done that wasn’t valuable to me… I told my administrator yesterday that this was the best conference I have been to as a teacher.”

More information is available at https://spice.fsi.stanford.edu/fellowships/ncta_for_high_school_teachers. Interested high school teachers can apply directly at https://forms.gle/Jd3PP8EowXyPkAyX9. The application deadline is May 6.

The 2019 East Asia Summer Institute for High School Teachers at Stanford University is made possible by the National Consortium for Teaching about Asia.

Stay informed of SPICE news by joining our email list or following us on Facebook and Twitter.

• The Freeman Foundation: Supporting the National Consortium for Teaching about Asia for 20 Years
• Institute highlights the teaching of Asia and the Asian-American experience

This article originally appeared at Brookings.

April 5 marks the 10th anniversary of the speech in which Barack Obama laid out his vision for a world without nuclear weapons. It did not gain traction. Instead, the United States and Russia are developing new nuclear capabilities, while the nuclear arms control regime is on course to expire in 2021. The result will be a world that is less stable, less secure, and less predictable.

A WORTHWHILE VISION

Just 10 weeks after his inauguration, President Obama’s first trip to Europe took him to Prague. Speaking in Hradcany Square, Obama voiced his deep interest in reducing nuclear arms, including a “commitment to seek the peace and security of a world without nuclear weapons.” He added that reaching that goal would require time, and that, as long as nuclear arms existed, the United States would maintain a “safe, secure and effective” nuclear arsenal.

Obama’s critics mocked him as naïve and idealistic. Achieving a world without nuclear arms would require, at a minimum, that nations conclude that they could protect their vital interests without nuclear arms; that new and very intrusive verification mechanisms were developed and agreed; and that an enforcement mechanism against any cheating state have real teeth—daunting challenges, to be sure. That said, a world in which nuclear arms were reliably and verifiably eliminated would be very much in the U.S. interest.

Nuclear war today poses the one existential threat to the United States. In a non-nuclear world, America would enjoy the advantages of geography (the protection afforded by two wide oceans and friendly neighbors in Canada and Mexico), the world’s most powerful conventional forces, and an unrivaled network of allies. Deterrence would not end; U.S. conventional forces could threaten enormous costs to any would-be adversary menacing America or its allies.

A big problem arises, however, in trying to persuade other states to accept a non-nuclear world. The balance of advantages and disadvantages that would make such a world so attractive for the United States would seem very different to other countries, such as Russia.

EVENTS TOOK A DIFFERENT COURSE

In any event, matters took a different course than Obama had hoped. Following signature of the New Strategic Arms Reduction Treaty (New START) in April 2010, he called for negotiations with Russia to further reduce strategic nuclear weapons and bring in non-strategic nuclear weapons. That raised the possibility that, for the first time ever, the two countries might negotiate limits on their entire nuclear arsenals.

Moscow chose not to engage in further bilateral negotiations—in part because Washington proved unready to discuss limits on missile defense or conventional strike systems. The Russians also sought a multilateral negotiation, though they have never offered a proposal or explained how one treaty could limit forces as disparate as those of the United States and Russia (4000 to 4500 nuclear weapons each) and China and France (less than 300 each). A Washington Naval Treaty-type agreement assigning unequal limits to its adherents presumably would be unwelcome in Beijing, Paris, and other capitals. 

Today, Russia and the United States have launched major nuclear force modernization programs. These programs focus largely on replacing old systems. Weapons systems age out and need replacement. Both sides, however, also plan to add new capabilities, including exotic strategic weapons and low-yield nuclear arms. One likely and unfortunate result: The threshold for employment of nuclear weapons will be lower.

While U.S. and Russian nuclear modernization proceeds, the regime that limits U.S. and Russian nuclear arms has begun to break down. Russia violated the 1987 Intermediate-range Nuclear Forces (INF) Treaty by deploying a prohibited cruise missile. Neither the Obama nor the Trump administration came up with an effective strategy to bring Moscow back into compliance, and it appears that President Trump barely tried, perhaps reflecting the influence of National Security Advisor John Bolton, who has long expressed skepticism about any agreements that constrain U.S. military forces. The INF Treaty will expire this August when the United States withdraws.

The end of the INF Treaty will leave New START, which caps the sides’ strategic missiles and bombers as well as their deployed strategic warheads, as the sole remaining nuclear arms control agreement. Unlike the INF Treaty, both sides have complied with New START’s limits, but it has less than two years to run before it expires.

New START’s terms allow for an extension of up to five years. Moscow historically has wanted some bounds on U.S. strategic forces. The Russians broached the idea of extension in early 2017 and have raised it several times since then. Extension should be a no-brainer for Washington: It would cap Russian strategic forces until 2026 while forcing no change in U.S. modernization plans, since the Pentagon designed those plans to fit within New START. Extension would also continue the flow of information that the United States receives about Russian strategic forces from New START’s verification measures. Unfortunately, Trump’s grasp of these questions appears weak, and Bolton does not appear a fan of New START.

AN UNCERTAIN FUTURE

The two nuclear superpowers thus will likely find themselves in 2021 in a situation that they have not faced for decades—a world with no constraints on nuclear force numbers. For the United States, that world will prove less stable and less secure as new nuclear capabilities undermine the strategic balance and threaten America. It will prove less predictable, as the data exchanges, notifications, and on-site inspections provided by New START cease. And it will almost certainly prove more costly, as the Pentagon has to make worst-case assumptions.

True, achieving Obama’s vision of a world without nuclear weapons now seems unrealistic. But we could use some presidential commitment to controlling those weapons.