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Melissa Morgan
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Following the deaths of George Floyd, Breonna Taylor and Elijah McClain, the effectiveness of policing and police reform have reemerged as a prominent topic of debate both in the United States and in communities around the world. One popular method of police reform is community policing, defined generally as law enforcement systems where officers build and maintain active, reinforcing relationships with local stakeholders, including citizens and community leaders.

The principle underpinning this philosophy is simple; when law enforcement officers create a personal, responsive presence in a community, they are better able to do their job, benefit from citizens’ cooperation, and overall safety improves. But gauging the actual effectiveness of these practices has proven challenging to study in a controlled and rigorous way.

In a first-of-its-kind study led by Graeme Blair (Dept. of Political Science, University of California–Los Angeles), Jeremy Weinstein (Dept. of Political Science, Stanford and FSI Senior Fellow at the Center on Democracy, Development and the Rule of Law) and Fotini Christia (Dept. of Political Science, Massachusetts Institute of Technology), a group of intercollegiate researchers have published new research examining the effectiveness of community policing in the Global South.

To mark the publication of the new findings in the journal Science this week, Blair, Christia and Weinstein spoke to us about what their findings reveal about the usefulness of community policing practices in a global context, and what more needs to be done to implement police reform in diverse systems.



Let’s start by defining what community policing is. Can you give some context on where this style of intervention comes from and why it has become a popular model in so many places?

Weinstein: Community policing is perhaps the most celebrated policing reform in recent decades. The idea is pretty simple in theory: the police should involve regular citizens directly in their work by building channels of dialogue and improving police-citizen collaboration. In practice, community policing takes lots of different forms including frequent beat patrols, decentralized decision-making, community engagement programs, and problem-oriented policing.

After compelling evidence emerged about the efficacy of community policing in Chicago in the 1990s, the approach took off around the United States. By 2015, nearly all U.S. cities identified community policing as a core element of their mission. Increasingly, advocates have promoted the export of community policing to countries in the Global South where issues of insecurity and mistrust in the police are significant. We wanted to figure out whether these practices work in a wholly different context.

Advocates have promoted the export of community policing to countries in the Global South where issues of insecurity and mistrust in the police are significant. We wanted to figure out whether these practices work in a wholly different context.
Jeremy Weinstein
Professor of Political Science and FSI Senior Fellow at CDDRL

There’s a great deal of support for community policing, but not a lot of concrete data on whether it works. What makes this a challenging issue to study?

Christia: Building trust between police and the citizens they are tasked to protect is at the core of community policing. As such, an important challenge lies with identifying the right measures to capture this often-complex police-citizen interaction. This was even more of a pronounced challenge in our study as we conducted six coordinated experiments across a diverse set of sites in the Global South in Brazil, Colombia, Liberia, Pakistan, the Philippines and Uganda.

To make progress in understanding the impacts of community policing, we needed to develop a set of common strategies for the police to implement that made sense in each national context, which we call locally appropriate community policing interventions. We also needed to agree upon a shared research design across countries and to introduce common outcome measures to ensure that we were looking at the impacts of these programs in similar ways. This approach to launching coordinated, multi-site, randomized controlled trials across contexts has been pioneered by the organization that sponsored this work, Evidence in Governance and Politics (EGAP).

Researchers from Evidence in Governance and Politics (EGAP) meet with law enforcement officers in the Philippines.
Researchers from Evidence in Governance and Politics (EGAP) meet with law enforcement officers in the Philippines. | Researchers from Evidence in Governance and Politics

Your team partnered with six communities across the Global South in Brazil, Colombia, Liberia, Pakistan, the Philippines and Uganda. Based on your research, what evidence did you find for or against the use of community policing practices?

Blair: We find that community policing doesn’t live up to its promise when implemented in the Global South. Community policing doesn’t build trust between citizens and police, it doesn’t lead to citizens to share the kinds of tips and information with police that might improve police efficiency, and, perhaps not surprisingly then, it does not lead to lower crime. This disappointing result was apparent across all six contexts and for all of the primary outcomes we measured.

Community policing doesn’t build trust between citizens and police, it doesn’t lead to citizens to share the kinds of tips and information with police that might improve police efficiency, and, perhaps not surprisingly then, it does not lead to lower crime.
Graeme Blair
Assistant Professor of Political Science, UCLA

Is there an alternative to community policing, or ways to reform these systems, that would make them more efficacious at creating the desired outcomes?

Weinstein: We carefully examined each of the six contexts, including through interviews with the police agencies and the research teams, to make sense of this null result. We identified three primary constraints that may have impeded the implementation of community policing: (a) a lack of prioritization of these new practices by police leadership (b) the rotation to new posts of police officers who had championed the effort and were trained to implement it and (c) limited resources to follow up on the concerns raised by citizens.

The bottom line is that community policing isn’t positioned to deliver increased trust and collaboration in environments with limited incentives and resources to enable police to change their behavior. Our conclusion is that community policing should be seen as an incremental reform that can make a difference in well-resourced police departments with strong incentives to be responsive to citizen concerns. But when those conditions are absent, an incremental approach can’t deliver. More systemic reforms are required.

Community members in Uganda fill out survey questions about community policing as part of a research project by Evidence in Governance and Politics (EGAP).
Community members in Uganda fill out survey questions about community policing as part of a research project by Evidence in Governance and Politics (EGAP). | Evidence in Governance and Politics

How does the data from your work fit into broader issues of equity, just representation, and racism that communities across the world continue to grapple with?

Blair: In many ways community policing appears to be the ideal policy for this moment, where so many are demanding that police abuse be reduced while also reducing crime victimization. Community policing is meant to do both, constructing a virtuous cycle between citizen-police cooperation, trust, and crime reduction. Our null results sound a note of caution: it may not be so simple. We observed big barriers to implementing this shift in policing, and barriers that likely affect other incremental policies. To address equity in the way governments enforce the law, we may need more systematic changes to how we organize the police and hold them accountable.   

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A law enforcement officer meets with community members in Brazil.
A law enforcement officer meets with community members in Brazil.
Evidence in Governance and Politics
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A first-of-its-kind study from Jeremy M. Weinstein, Graeme Blair and Fotini Christia shows that the celebrated practice of community policing may have few, if any, positive impacts on communities in the Global South.

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Jamie O’Connell is a Lecturer in Residence at Stanford Law School. He teaches and writes on political and legal development and has particular expertise in law and development, transitional justice, democratization, post-conflict reconstruction, and business and human rights. Until 2018, he was a Senior Fellow of the Honorable G. William and Ariadna Miller Institute for Global Challenges and the Law at the University of California, Berkeley, School of Law, as well as a Lecturer in Residence, teaching both law and undergraduate students.

O’Connell has worked on human rights and development in over a dozen countries in Africa, the Americas, Asia, and Europe, under the auspices of the United Nations, local and international non-governmental organizations, and academic institutions. He co-founded International Professional Partnerships for Sierra Leone, a non-governmental organization that worked with the government of Sierra Leone to enhance the performance of its agencies and civil servants. Earlier in his career, O’Connell studied international business as a researcher at Harvard Business School, publishing numerous case studies. He has directed the Human Rights Clinic at the University of Sierra Leone and taught as a visitor at Harvard Law School and Columbia Law School. O’Connell clerked for the Honorable James R. Browning on the U.S. Court of Appeals for the Ninth Circuit and is admitted to practice in California (inactive status) and New York. In 2016-17, he was a visiting professor and Fulbright Senior Scholar at the University of Valencia (Spain) Faculty of Law.

O’Connell’s scholarship includes “Representation, Paternalism, and Exclusion: The Divergent Impacts of the AKP’s Populism on Human Rights In Turkey” in Human Rights in a Time of Populism: Challenges and Responses (2020); “When Prosecution Is Not Enough: How the International Criminal Court Can Prevent Atrocity and Advance Accountability by Emulating Regional Human Rights Institutions” (with James L. Cavallaro, Yale Journal of International Law, 2020); “Common Interests, Closer Allies: How Democracy in Arab States Can Benefit the West” (Stanford Journal of International Law, 2012); “Empowering the Disadvantaged after Dictatorship and Conflict: Legal Empowerment, Transitions and Transitional Justice,” in Legal Empowerment: Practitioners’ Perspectives (2010); “East Timor 1999,” in The Responsibility to Protect: Moving the Campaign Forward (2007); “Gambling with the Psyche: Does Prosecuting Human Rights Violators Console Their Victims?” (Harvard International Law Journal, 2005); “Here Interest Meets Humanity: How to End the War and Support Reconstruction in Liberia, and the Case for Modest American Leadership” (Harvard Human Rights Journal, 2004); and Sierra Leone’s Truth and Reconciliation Commission and Special Court: A Citizen’s Handbook (with Paul James-Allen and Sheku B.S. Lahai, 2003).

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What are the effects of international intervention on the rule of law after civil war? Rule of law requires not only that state authorities abide by legal limits on their power, but also that citizens rely on state laws and institutions to adjudicate disputes. Using an original survey and list experiment in Liberia, I show that exposure to the UN Mission in Liberia (UNMIL) increased citizens’ reliance on state over nonstate authorities to resolve the most serious incidents of crime and violence, and increased nonstate authorities’ reliance on legal over illegal mechanisms of dispute resolution. I use multiple identification strategies to support a causal interpretation of these results, including an instrumental variables strategy that leverages plausibly exogenous variation in the distribution of UNMIL personnel induced by the killing of seven peacekeepers in neighboring Côte d'Ivoire. My results are still detectable two years later, even in communities that report no further exposure to peacekeepers. I also find that exposure to UNMIL did not mitigate and may in fact have exacerbated citizens’ perceptions of state corruption and bias in the short term, but that these apparently adverse effects dissipated over time. I conclude by discussing implications of these complex but overall beneficial effects.

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Stanford University’s Center on Democracy, Development and the Rule of Law (CDDRL) is proud to announce our four incoming fellows who will be joining us in the 2016-2017 academic year to develop their research, engage with faculty and tap into our diverse scholarly community. 

The pre- and postdoctoral program will provide fellows the time to focus on research and data analysis as they work to finalize and publish their dissertation research, while connecting with resident faculty and research staff at CDDRL. 

Fellows will present their research during our weekly research seminar series and an array of scholarly events and conferences.

Topics of the incoming cohort include electoral fraud in Russia, how the elite class impacts state power in China, the role of emotions in support for democracy in Zimbabwe, and market institutions in Nigeria. 

Learn more in the Q&A below.


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Natalia Forrat

CDDRL Pre-Doctoral Fellow

Hometown: Tomsk, Russia

Academic Institution: Northwestern University

Discipline and expected date of graduation: Sociology, April 2017

Research Interests: authoritarianism, state capacity, social policy, civil society, trust, Russia and post-communist countries

Dissertation Title: The State that Betrays the Trust: Infrastructural State Power, Public Sector Organizations, and Authoritarian Resilience in Putin's Russia

What attracted you to the CDDRL Pre/post-doctoral program? I study the connection between state capacity and political regimes - the topic that is at the core of many research initiatives at CDDRL. Learning more about this work and receiving feedback for my dissertation will enrich and sharpen my analysis, while helping me to place it into a comparative context. I am looking forward to discussing my work with the faculty who study the post-Soviet region. I also will explore policy implications of my work with the help of policy experts at CDDRL.

What do you hope to accomplish during your nine-month residency at the CDDRL? Besides finishing writing my dissertation, I will workshop three working papers to prepare them for publication. The first one argues that Putin's regime used the school system to administer a large-scale electoral fraud in 2012 presidential elections; the second one shows how the networks of social organizations were used by subnational autocrats to strengthen the regime; and the third one will look at the factors that make the abuse of such organizations more difficult in some regions. In addition to these papers I will continue developing my post-graduation research project exploring the relationship between social trust and distrust, institutions, political competition, and democratization.

Fun fact: I have spent 25 years of my life in Siberia, and I can tell you: Chicago winters are worse!

 

 

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Shelby Grossman

CDDRL Postdoctoral Fellow

Hometown: Reading, MA

Academic Institution: Harvard University

Discipline & Graduation Date:  Government, Summer 2016

Research interests: political economy of development, private governance, market institutions, Sub-Saharan Africa, survey methods

Dissertation Title: The Politics of Order in Informal Markets: Evidence from Lagos

What attracted you to the CDDRL post-doctoral program? I was attracted to CDDRL largely for its community of scholars. Affiliated faculty work on the political economy of development and medieval and modern market institutions, topics that are tied to my own interests.

What do you hope to accomplish during your nine-month residency at the CDDRL? I plan to prepare a book manuscript based on my dissertation, a project that explains variation in the provision of pro-trade institutions in private market organizations through the study of physical marketplaces in Nigeria. In addition, I will continue to remotely manage an on-going project in Nigeria (with Meredith Startz) investigating whether reputation alleviates contracting frictions. I also plan to work on submitting to journals a few working papers, including one on the politics of non-compliance with polio vaccination in Nigeria (with Jonathan Phillips and Leah Rosenzweig). 

Fun fact: Contrary to popular belief, not all cheese is vegetarian. I have a website to help people determine if a cheese is vegetarian or not: IsThisCheeseVegetarian.com. 

 

 

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Daniel Mattingly

CDDRL Postdoctoral Fellow

Hometown: Oakland, California

Academic Institution: University of California, Berkeley

Discipline & Graduation Date: Political Science, Summer 2016

Research Interests: Governance, rule of law, state building, authoritarian politics, Chinese politics

Dissertation Title: The Social Origins of State Power: Democratic Institutions and Local Elites in China

What attracted you to CDDRL?  The Center has a fantastic community of scholars and practitioners who work on the areas that I'm interested in, including governance and the rule of law. I'm excited to learn from the CDDRL community and participate in the Center's events. The fellowship also provides me with valuable time to finish my book manuscript before I start teaching.

What do you hope to accomplish during your nine-month residency at the CDDRL? While at CDDRL, I plan to prepare my book manuscript and to work on some related projects on local elites and state power in China and elsewhere. 

Fun fact: I grew up on an organic farm in Vermont.

 

 

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Lauren E. Young

CDDRL Postdoctoral Fellow

Hometown: Saratoga, CA

Academic Institution: Columbia University 

Discipline & Graduation Date: Political Science (Comparative Politics, Methods), May 2016 (defense), Oct 2016 (degree conferral)

Research Interests: political violence, political economy of development, autocratic persistence, democratization, protest, electoral violence

Dissertation Title: The Psychology of Repression and Dissent in Autocracy

What attracted you to the CDDRL post-doctoral program? As a graduate of the CISAC honors program when I was an undergraduate at Stanford, I have seen first-hand how intellectually stimulating, collaborative, and plugged into policy CDDRL is. While at the center I will be revising my dissertation work on the political psychology of participation in pro-democracy movements in Zimbabwe for submission as a book manuscript, and moving forward new projects that similarly seek to understand how different forms of violence by non-state actors affects citizens' preferences and decision-making. Because of its deep bench of experts on autocracy, narco-trafficking, and insurgency, CDDRL will add enormous value to these projects.

What do you hope to accomplish during your nine-month residency at the CDDRL?  During my fellowship year, my primary goal is to revise my research on Zimbabwe into a book manuscript. I defended my dissertation as three stand-alone articles, including two experiments showing that emotions influence whether opposition supporters in Zimbabwe express their pro-democracy preferences and a descriptive paper showing that repression has a larger effect on the behavior of the poor. To prepare the book manuscript during my fellowship, I will bring in additional quantitative and qualitative descriptive evidence and tie the three papers together into a cohesive argument about how opposition supporters make decisions about participation in protest, why emotions have such a large effect on these decisions, and how this affects variation across individuals and the strategic choices of autocrats and activists.

Fun fact: During my fieldwork I took an overnight train from Victoria Falls to a southern city in Zimbabwe and hitch-hiked into a national park. It got a little nerve-wracking when night started to fall, but ended with  an invitation to a barbecue! 

 

 
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Shelby Grossman was a research scholar at the Cyber Policy Center. Her research focuses on online safety. Shelby's research has been published in Comparative Political Studies, PNAS Nexus, Political Communication, The Journal of Politics, World Development, and World Politics. Her book, "The Politics of Order in Informal Markets," was published by Cambridge University Press. She is co-editor of the Journal of Online Trust and Safety, and teaches classes at Stanford on open source investigation and online trust and safety issues. 

Shelby was an assistant professor of political science at the University of Memphis from 2017-2019, and a postdoctoral fellow at Stanford University’s Center on Democracy, Development, and the Rule of Law from 2016-17. She earned her Ph.D. in Government from Harvard University in 2016.

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Panelists

Michele Barry, MD: Medicine and Tropical Diseases; Center for Innovation in Global Health

Doug Owens, MD: Medicine; Center for Health Policy/Primary Care Outcomes Research

David Relman, MD: Medicine, Microbiology & Immunology; Center for International Security and Cooperation

Stephen J. Stedman: Center on Democracy, Development and the Rule of Law

Paul Wise, MD: Pediatrics; Center for Health Policy/Primary Care Outcomes Research

 

Co-sponsors:

Freeman Spogli Institute for International Studies

Stanford University School of Medicine

Center for African Studies

Center for Health Policy/Center for Primary Care and Outcomes Research

Center for Innovation in Global Health

Center for International Security and Cooperation

Center on Democracy, Development, and the Rule of Law

McCoy Family Center for Ethics in Society

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Michele Barry Panelist

Encina Commons, Room 201 
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Executive Assistant: Soomin Li, soominli@stanford.edu
Phone: (650) 725-9911

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Henry J. Kaiser, Jr. Professor
Professor, Health Policy
Senior Fellow, Freeman Spogli Institute for International Studies
Professor, Management Science & Engineering (by courtesy)
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Douglas K. Owens is the Henry J. Kaiser, Jr. Professor, Chair of the Department of Health Policy in the Stanford University School of Medicine and Director of the Center for Health Policy (CHP) in the Freeman Spogli Institute for International Studies (FSI). He is a general internist, a Professor of Management Science and Engineering (by courtesy), at Stanford University; and a Senior Fellow at the Freeman Spogli Institute for International Studies.

Owens' research includes the application of decision theory to clinical and health policy problems; clinical decision making; methods for developing clinical guidelines; decision support; comparative effectiveness; modeling substance use and infectious diseases; cardiovascular disease; patient-centered decision making; assessing the value of health care services, including cost-effectiveness analysis; quality of care; and evidence synthesis.

Owens chaired the Clinical Guidelines Committee of the American College of Physicians for four years. The guideline committee develops clinical guidelines that are used widely and are published regularly in the Annals of Internal Medicine. He was a member and then Vice-Chair and Chair of the U.S. Preventive Services Task Force, which develops national guidelines on preventive care, including guidelines for screening for breast, colorectal, prostate, and lung cancer. He has helped lead the development of more than 50 national guidelines on treatment and prevention. He also was a member of the Second Panel on Cost Effectiveness in Health and Medicine, which developed guidelines for the conduct of cost-effectiveness analyses.

Owens also directed the Stanford-UCSF Evidence-based Practice Center. He co-directs the Stanford Health Services Research Program, and previously directed the VA Physician Fellowship in Health Services Research, and the VA Postdoctoral Informatics Fellowship Program.

Owens received a BS and an MS from Stanford University, and an MD from the University of California-San Francisco. He completed a residency in internal medicine at the University of Pennsylvania and a fellowship in health research and policy at Stanford. Owens is a past-President of the Society for Medical Decision Making. He received the VA Undersecretary’s Award for Outstanding Achievement in Health Services Research, and the Eisenberg Award for Leadership in Medical Decision Making from the Society for Medical Decision Making. Owens also received a MERIT award from the National Institutes on Drug Abuse to study HIV, HCV, and the opioid epidemic. He was elected to the American Society for Clinical Investigation (ASCI) and the Association of American Physicians (AAP.)

Chair, Department of Health Policy, School of Medicine
Director, Center for Health Policy, Freeman Spogli Institute for International Studies
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Thomas C. and Joan M. Merigan Professor
Professor of Medicine
Professor of Microbiology and Immunology
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David A. Relman, M.D., is the Thomas C. and Joan M. Merigan Professor in the Departments of Medicine, and of Microbiology and Immunology at Stanford University, and Chief of Infectious Diseases at the Veterans Affairs Palo Alto Health Care System in Palo Alto, California. He is also Senior Fellow at the Freeman Spogli Institute for International Studies (FSI) at Stanford, and served as science co-director at the Center for International Security and Cooperation at Stanford from 2013-2017. He is currently director of a new Biosecurity Initiative at FSI.

Relman was an early pioneer in the modern study of the human indigenous microbiota. Most recently, his work has focused on human microbial community assembly, and community stability and resilience in the face of disturbance. Ecological theory and predictions are tested in clinical studies with multiple approaches for characterizing the human microbiome. Previous work included the development of molecular methods for identifying novel microbial pathogens, and the subsequent identification of several historically important microbial disease agents. One of his papers was selected as “one of the 50 most important publications of the past century” by the American Society for Microbiology.

Dr. Relman received an S.B. (Biology) from MIT, M.D. from Harvard Medical School, and joined the faculty at Stanford in 1994. He served as vice-chair of the NAS Committee that reviewed the science performed as part of the FBI investigation of the 2001 Anthrax Letters, as a member of the National Science Advisory Board on Biosecurity, and as President of the Infectious Diseases Society of America. He is currently a member of the Intelligence Community Studies Board and the Committee on Science, Technology and the Law, both at the National Academies of Science. He has received an NIH Pioneer Award, an NIH Transformative Research Award, and was elected a member of the National Academy of Medicine in 2011.

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Senior Fellow at the Freeman Spogli Institute for International Studies
Professor, by courtesy, of Political Science
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Stephen Stedman is a Senior Fellow at the Freeman Spogli Institute for International Studies (FSI) and the Center on Democracy, Development and the Rule of Law (CDDRL), an affiliated faculty member at CISAC, and professor of political science (by courtesy) at Stanford University. He is director of CDDRL's Fisher Family Honors Program in Democracy, Development and Rule of Law, and will be faculty director of the Program on International Relations in the School of Humanities and Sciences effective Fall 2025.

In 2011-12 Professor Stedman served as the Director for the Global Commission on Elections, Democracy, and Security, a body of eminent persons tasked with developing recommendations on promoting and protecting the integrity of elections and international electoral assistance. The Commission is a joint project of the Kofi Annan Foundation and International IDEA, an intergovernmental organization that works on international democracy and electoral assistance.

In 2003-04 Professor Stedman was Research Director of the United Nations High-level Panel on Threats, Challenges and Change and was a principal drafter of the Panel’s report, A More Secure World: Our Shared Responsibility.

In 2005 he served as Assistant Secretary-General and Special Advisor to the Secretary- General of the United Nations, with responsibility for working with governments to adopt the Panel’s recommendations for strengthening collective security and for implementing changes within the United Nations Secretariat, including the creation of a Peacebuilding Support Office, a Counter Terrorism Task Force, and a Policy Committee to act as a cabinet to the Secretary-General.

His most recent book, with Bruce Jones and Carlos Pascual, is Power and Responsibility: Creating International Order in an Era of Transnational Threats (Washington DC: Brookings Institution, 2009).

Director, Fisher Family Honors Program in Democracy, Development and Rule of Law
Director, Program in International Relations
Affiliated faculty at the Center for International Security and Cooperation
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Richard E. Behrman Professor of Child Health and Society
Senior Fellow, Freeman Spogli Institute for International Studies
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Dr. Paul Wise is dedicated to bridging the fields of child health equity, public policy, and international security studies. He is the Richard E. Behrman Professor of Child Health and Society and Professor of Pediatrics, Division of Neonatology and Developmental Medicine, and Health Policy at Stanford University. He is also co-Director, Stanford Center for Prematurity Research and a Senior Fellow in the Center on Democracy, Development, and the Rule of Law, and the Center for International Security and Cooperation, Freeman Spogli Institute for International Studies, Stanford University. Wise is a fellow of the American Academy of Arts and Sciences and has been working as the Juvenile Care Monitor for the U.S. Federal Court overseeing the treatment of migrant children in U.S. border detention facilities.

Wise received his A.B. degree summa cum laude in Latin American Studies and his M.D. degree from Cornell University, a Master of Public Health degree from the Harvard School of Public Health and did his pediatric training at the Children’s Hospital in Boston. His former positions include Director of Emergency and Primary Care Services at Boston Children’s Hospital, Director of the Harvard Institute for Reproductive and Child Health, Vice-Chief of the Division of Social Medicine and Health Inequalities at the Brigham and Women’s Hospital and Harvard Medical School and was the founding Director or the Center for Policy, Outcomes and Prevention, Stanford University School of Medicine. He has served in a variety of professional and consultative roles, including Special Assistant to the U.S. Surgeon General, Chair of the Steering Committee of the NIH Global Network for Women’s and Children’s Health Research, Chair of the Strategic Planning Task Force of the Secretary’s Committee on Genetics, Health and Society, a member of the Advisory Council of the National Institute of Child Health and Human Development, NIH, and the Health and Human Secretary’s Advisory Committee on Infant and Maternal Mortality.

Wise’s most recent U.S.-focused work has addressed disparities in birth outcomes, regionalized specialty care for children, and Medicaid. His international work has focused on women’s and child health in violent and politically complex environments, including Ukraine, Gaza, Central America, Venezuela, and children in detention on the U.S.-Mexico border.  

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(Updated Nov. 7, 2014)

The Centers for Disease Control and Prevention reported on Nov. 4 that the death toll from the Ebola outbreak in West Africa has risen to above 4,960 and that an estimated 8,168 people, mostly in Liberia, Sierra Leone and Guinea, have contracted the virus since March. It is the largest and most severe outbreak of the Ebola virus since it was first detected four decades ago. All but nine of the deaths were in those three countries; eight were in Nigeria and one patient died in the United States.

The CDC in October proclaimed that in the worst-case scenario, Sierra Leone and Liberia could have 1.4 million cases by Jan. 20, 2015, if the disease keeps spreading without immediate and immense intervention to contain the virus.

Two American aid workers infected with Ebola while working in West Africa were transported to a containment unit at Emory University in Atlanta for treatment, raising public fears about international spread of the highly virulent virus that has no known cure. The two were released from the hospital after being the first humans to receive an experimental Ebola drug called ZMapp. Another man who recently helped an Ebola victim in Liberia traveled to Texas and died in a Dallas hospital. Two of the nurses who treated him caught the virus as well, but have been released from the hospital. Some states have struggled with the moral 

We ask CISAC biosecurity experts David Relman and Megan Palmer to answer several questions about Ebola and the public health concerns and policy implications. Relman is the co-director of the Center for International Security and Cooperation who has served on several federal committees investigating biosecurity matters. He is the Thomas C. and Joan M. Merigan Professor in the Departments of Medicine and of Microbiology and Immunology at Stanford University School of Medicine, and Past-President of the Infectious Diseases Society of America.

Palmer is the William J. Perry Fellow in International Security at CISAC and a Researcher at the UC Berkeley Center for Quantitative Biosciences (QB3), and served as Deputy Director of Policy & Practices for the Multi-University NSF Synthetic Biology Engineering Research Center (SynBERC).

The two of them have answered the questions together.

What is Ebola and how dangerous is it compared to other diseases?

Ebola is an acute viral infectious disease, often associated with severe hemorrhagic fever. While initial symptoms are flu-like, they can rapidly progress, and include vomiting, reduced ability to regulate immune responses and other physiological processes, sometimes leading to internal and external bleeding. The disease has an incubation period that can last up to 21 days, but patients typically become ill four to nine days after infection, and die about seven to ten days later. Fatality rates for the current Ebola outbreak are nearing 60% (according to the CDC), while past outbreaks in the Republic of Congo have seen rates as high as 90%. This outbreak to date has resulted in nearly 1,000 deaths, more than any previous Ebola outbreak.

Ebola virus is believed to reside in animals such as fruit bats where it does not cause disease, but is then transmitted to and among humans and other primates, in whom disease typically does occur. The route by which the virus crosses between species remains largely unknown. People become infectious once they become symptomatic. Ebola is transmitted via blood or bodily fluid, but can persist outside the body for a couple days. Infection can occur through unprotected contact with the sick, but also when contaminated equipment such as needles cut through healthcare workers’ protective gear, and also through contact with infected individuals postmortem.

David Relman
Photo Credit: Rod Searcey

Ebola’s horrific symptoms provoke public fear, and it becomes easy to lose perspective on the relative spread and toll of this outbreak. Ebola is relatively difficult to transmit. This means the latest Ebola outbreak is still small in comparison to the hundreds of thousands of people killed each year via more easily transmitted airborne influenza strains and other diseases such as malaria and tuberculosis. It’s important that we not lose sight of more chronic, but less headline-grabbing diseases that will be pervasive, insidious long-standing challenges for Africa and elsewhere.

Is there a vaccine or cure?

There is no vaccine for Ebola and no tried-and-true cure. Health workers can only give supportive care to patients and try to stop the spread to new victims.

Several experimental therapies for Ebola are under development. One receiving attention is ZMapp, a mix of antibodies produced by mice exposed to the virus that have been adapted to improve their human compatibility. Limited tests in primates show early promise, but the drug had not been tried on humans -- until now. Two Americans transported back to the U.S. from West Africa received the experimental therapy. While the two seem to be improving, it isn’t clear that ZMapp was responsible; another issue is that ZMapp and other potential therapies have not been cleared by the FDA for wider use in humans.

The process for approval, and who gets priority access to such drugs, are complex policy issues. The WHO will be convening leaders and medical ethicists next week to discuss how to develop and distribute experimental therapies. This is not a simple task; many factors need to be taken into consideration and balanced with limited information to guide decisions.

Successful or not, and despite any approval, it’s still uncertain whether enough of such drugs could even be produced quickly enough to respond to this particular outbreak, and if not - whether they’d be effective in a future outbreak.

 

You can listen to Relman in this KQED Public Radio talk show.

Relman joins other experts in a Stanford panel on Ebola

 

Why has this Ebola outbreak involved so many more people, and spread to a wider geographic area,  than previous outbreaks?

This is an evolving investigation and many potential contributing factors are being examined by scientists racing to collect information that can help them get ahead of the outbreak.

One factor is population density. This latest outbreak spread early into denser population areas within Liberia and Sierra Leone, rather than remain confined to isolated villages, as in earlier outbreaks in Central Africa. With a greater number of people being exposed within a smaller geographic area, the likelihood of transmission increases. Of particular concern is the prospect that the virus might take hold in Lagos, Nigeria, where a handful of cases have been recently identified. If this were to spread in Lagos, Africa’s most populous city, the death toll would likely increase dramatically.   

Another factor is the ability of affected regions to mount an effective public health response. This outbreak is occurring in three of the poorest African countries: Sierra Leone, Liberia, and Guinea. Civil wars have likely contributed to degradation of an already relatively poor public health infrastructure. This is also the first Ebola outbreak in the region, and the inexperience of local authorities can delay responses and fuel fearful community responses, undermining the ability to deal with the outbreak early when it’s more easily contained.

Cultural practices around the care of the sick and the dead can also fuel progression of an outbreak. In some parts of Western Africa, washing deceased relatives is commonplace. Customs like these increase the likelihood of the infection spreading through proximity between infected individuals and their family members

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What can be done to curtail the outbreak?

Isolation and quarantine are key to fighting the spread of Ebola. Isolation involves removing infected individuals from the general population to prevent the spread of disease. Quarantine, however, involves removing uninfected or potentially infected individuals from the general population to limit the spread of disease.

Thus far, the strategy to fight Ebola is dependent on isolating infected patients. Unsurprisingly, isolation efforts have proven hard to enforce. Some families, faced with the prospect of being confined to their homes, have denied the existence of Ebola in their localities, or refuted doctors who claim that one of their family members is sick. This is not unique to Africa; Americans had violent reactions to quarantine during the spread of smallpox. Some regions are now taking more extreme measures: Sierra Leone has deployed its army to enforce isolation at clinics and infected families’ homes, but this also risks civil unrest.

These tensions underscore the necessity of improved education and enforcement mechanisms within public health strategies. Response measures involve fundamental tradeoffs between liberty and safety. Because negotiations occur through complex local, national and international processes, one of the biggest risks is that decisions don’t keep pace with disease spread.

It’s important that we not lose sight of more chronic, but less headline-grabbing diseases that will be pervasive, insidious long-standing challenges for Africa and elsewhere."

How likely is it that the disease will spread into and within the United States?

Currently, airports in Liberia, Sierra Leone, and Guinea are screening all outbound passengers for Ebola symptoms such as fever. This includes asking passengers to complete healthcare questionnaires. However, it is difficult to reliably know who has been infected until they are symptomatic. Individuals could theoretically board a plane before they show symptoms, but develop them upon landing in the United States or elsewhere. This makes containing Ebola difficult, but not impossible.

If the virus were to enter the United States, it would be easier to contain and harder to spread. This virus does not transmit that easily to other humans, especially in settings with good infection control and isolation.

As viruses spread, the chances of genetic variation increase. Yet despite all the concerns from the current outbreak, Ebola is relatively bad at spreading in comparison to respiratory viral diseases such as influenza or measles. The likelihood of a pandemic Ebola virus in the near future seems slim as long as it cannot be transmitted via air.  While it’s possible that the Ebola virus could evolve, there is little evidence to suggest major genetic adaptations at this time.

What are some broader lessons about the dynamics and ecology of emerging infectious diseases that can help prevent or respond to outbreaks now and in the future?

These latest outbreaks remind us that potential pathogens are circulating, replicating and evolving in the environment all the time, and human action can have an immense impact on the emergence and spread of infectious disease.

We are starting to see common factors that may be contributing to the frequency and severity of outbreaks. Increasing human intrusion into zoonotic disease reservoir habitats and natural ecosystems, increasing imbalance and instability at the human-animal-vector interface, and more human population displacement all are likely to increase the chance of outbreaks like Ebola.

Megan Palmer
Photo Credit: Rod Searcey

The epicenter of this latest outbreak was Guéckédou, a village near the Guinean Forest Region. The forest there has been routinely exploited, logged, and neglected over the years, leading to an abysmal ecological status quo. This, in combination with the influx of refugees from conflicts in Guinea, Liberia, Sierra Leone, and Cote d’Ivoire, has compounded the ecological issues in the area, potentially facilitating the spread of Ebola. There seems to be a strong relationship between ecological health and the spread of disease, and this latest outbreak is no exception.

While forensic analyses are ongoing, unregulated food and animal trade in general is also a key factor in the spread of infectious diseases across large geographic regions. Some studies suggest that trade of primates, including great apes, and other animals such as bats, may be responsible for transit of this Ebola strain from Central to Western Africa.

What are some of the other political and security implications of the outbreak and response?

Disease outbreaks can catalyze longer-term political and security issues in addition to more acute tensions.

There are complex international politics involved in emergency response and preparedness. Disease outbreaks often occur in poor regions, and demand help from more wealthy regions. The nature of the response reflects many factors - technical, social, political, legal and economic. Leaders often lack the expertise to take all these factors into account. It is an ongoing challenge to adapt our governance processes to be more reliable and move from damage control to planning. Organizations like the World Health Organization can provide guidance, but more resources and expertise are needed to get ahead of future disasters.

When help is provided, there is often mistrust of non-local workers, who can even be seen as sources of the disease. At a political level, distrust has been fueled by disguising political missions as health interventions, as was the case with the effort that led to the locating of Osama Bin Laden.

There are other security implications of this latest epidemic. This outbreak has led to a dramatic increase in the availability of Ebola virus in unsecured locations across West Africa, as well as to a growing number of labs across the world studying the disease. The immediate need to study the disease and develop beneficial interventions needs to be coupled to considerations of safety and security. From a safety standpoint, a rise in the handling of Ebola samples risks accidental transmission. From a security standpoint, those who wish to cause harm with this virus could acquire it from bodies, graves and other natural sources in the affected region. Both of these risks demand attention and efforts at mitigation.

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Jasper Cummeh III ('07) from Liberia passed away on January 25, 2014 following a brief illness. Cummeh was a good friend to many and worked as an activist, researcher and mentor to young civil society members working on issues of transparency and accountability, policy analysis and advocacy. He was the senior policy director of Actions for Genuine Democratic Alternatives, a civil society organization in Liberia that is working to promote citizen participation, promote good governance and increase transparency in fiscal policy management. 
 
The CDDRL family would like to express our condolences to his family and the broader civil society community in Liberia for this great loss. Please keep Cummeh and his family in your thoughts and prayers during this difficult time.
 

 
"Jasper Cummeh III, was a dedicated Civil society actor in Liberia, who took interest in fighting corruption in Liberia from an activist point of view. He has written and published several anti-corruption policy briefs. Until his demise Jasper served as Senior Policy Director of the Actions for Genuine Democratic Alternatives, AGENDA and Chairman of the Liberia Freedom of Information Coalition. Jasper's passion for anti-corruption and pro-democracy work in Liberia is demonstrated by the fact that he was doing what he loved doing best when he collapsed and was later pronounced dead. Jasper died on January 25, after he collapsed on January 24th while conducting a policy advocacy training workshop in Monrovia. The Liberian Civil society community will indeed miss Jasper."

- Malcolm W. Joseph ('09)
 

 
"The passing on of Jasper is a sad loss not just to Liberia but to the African Continent as a whole. I had the privilege of working with Jasper at the time he was with CENTAL and the organisation applied to be a contact group for Transparency International, where I am privileged to serve on the Board of Directors. Jasper, had a clear vision of what needed to be done in Liberia to fight the evils of corruption, and promote greater transparency and accountability in the public sector. Jasper was a fearless, and consummate civil activist who was prepared to serve humanity to the best of his abilities. He did not see obstacles in his working environment as insurmountable challenges but rather as opportunities to seek new ways of addressing the many governance issues affecting his country Liberia and in turn, the continent of Africa. We have lost a young visionary and leader, who held so much promise and still had a lot to offer. My sincere condolences to his family, his organisation and country. May His Soul Rest In Eternal Peace."
 
- Rueben L. Lifuka ('11)
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Cummeh during the 2012 regional workshop in Nairobi, Kenya.
Sadaf Minapara
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Zainab Hawa Bangura of Sierra Leone is Special Representative on Sexual Violence in Conflict at the level of Under-Secretary-General at the United Nations.

Prior to this appointment, Ms. Bangura was the Minister of Health and Sanitation for the Government of Sierra Leone, and brings to the position over 20 years of policy, diplomatic and practical experience in the field of governance, conflict resolution and reconciliation in Africa. She was previously the second female Minister of Foreign Affairs and International Cooperation, including Chief Adviser and Spokesperson of the President on bilateral and international issues. Ms. Bangura has been instrumental in developing national programmes on affordable health, advocating for the elimination of genital mutilation, managing the country’s Peace Building Commission and contributing to the multilateral and bilateral relations with the international community. She is experienced in meeting with interlocutors in diverse situations, including rebel groups, and familiar in dealing with State and non-State actors relevant to issues of sexual violence while fighting corruption and impunity.

Ms. Bangura has on-the-ground experience with peacekeeping operations from within the United Nations Mission in Liberia (UNMIL), where she was responsible for the management of the largest civilian component of the Mission, including promoting capacity-building of government institutions and community reconciliation. She is an experienced results-driven civil society, human and women’s rights campaigner and democracy activist, notably as Executive Director of the National Accountability Groups, Chair and Co-founder of the Movement for Progress Party of Sierra Leone, as well as Coordinator and Co-founder of the Campaign for Good Governance.

Ms. Bangura is a former fellow of the Chartered Insurance Institute of London, possessing Diplomas in Insurance Management from the City University Business School of London and Nottingham University. She received her Bachelor of Arts from the Fourah Bay College, University of Sierra Leone.

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Many resource dependent states have to varying degrees, failed to provide for the welfare of their own populations, could threaten global energy markets, and could pose security risks for the United States and other countries.  Many are in Africa, but also Central Asia (Turkmenistan, Kazakhstan, Azerbaijan), Southeast Asia (Cambodia, Burma, East Timor), and South America (Bolivia, Colombia, Ecuador) Some have only recently become – or are about to become – significant resource exporters.  Many have histories of conflict and poor governance.  The recent boom and decline in commodity prices – the largest price shock since the 1970s – will almost certainly cause them special difficulties.  The growing role of India and China, as commodity importers and investors, makes the policy landscape even more challenging.

We believe there is much the new administration can learn from both academic research, and recent global initiatives, about how to address the challenge of poorly governed states that are dependent on oil, gas, and mineral exports.  Over the last eight years there has been a wealth of new research on the special problems that resource dependence can cause in low-income countries – including violent conflict, authoritarian rule, economic volatility, and disappointing growth.  The better we understand the causes of these problems, the more we can learn about how to mitigate them.

There has also been a new set of policy initiatives to address these issues: the Kimberley Process, the Extractive Industries Transparency Initiative, the World Bank’s new “EITI plus plus,” Norway’s Oil for Development initiative, and the incipient Resource Charter.  NGOs have played an important role in most of these initiatives; key players include Global Witness, the Publish What You Pay campaign, the Revenue Watch Institute, Oxfam America, and an extensive network of civil society organizations in the resource-rich countries themselves.

Some of these initiatives have been remarkably successful.  The campaign against ‘blood diamonds,’ through the Kimberley Process, has reduced the trade in illicit diamonds to a fraction of its former level, and may have helped curtail conflicts in Angola, Liberia, and Sierra Leone.  Many other initiatives are so new they have not been have not been carefully evaluated.

This workshop is designed to bring together people in the academic and policy worlds to identify lessons from this research, and from these policy initiatives, that can inform US policy towards resource-dependent poorly states in the new administration.

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