Those who live and die behind prison walls don’t usually get much public attention. Incarceration is, after all, meant to remove criminals from society. But contagious and potentially deadly diseases can’t be locked and left in a penitentiary, especially when infected inmates are eventually released.

The problem of prisoners and ex-convicts transmitting diseases to the general population is especially bad in the countries of the former Soviet Union, where rates of tuberculosis and drug-resistant strains of TB are among the world’s highest.

But Stanford researchers have identified solutions that could help curb tuberculosis in Russia, Latvia, Tajikistan and the 12 other countries in the region. Led by Jeremy Goldhaber-Fiebert, an assistant professor of medicine, the team has shown that a genetic TB and drug resistance screening tool called GeneXpert is more cost effective and better at reducing the spread of the disease than other methods currently recommended by the World Health Organization. Their findings were published online Nov. 27 in PLoS Medicine.

“Tuberculosis doesn’t stop at any border or any locked gate,” said Goldhaber-Fiebert, who is also a faculty member at Stanford Health Policy, a research center at the university’s Freeman Spogli Institute for International Studies.

“Drug-resistant TB is rampant in prisons,” he said. “When infected prisoners get out, they are thought to drive the TB epidemic in the general population. We are looking to find better ways to deal with that.”

About 400,000 cases of TB were diagnosed last year in the 15 former Soviet Union states – 40 times the number reported in the United States. Nearly 80,000 of the sick had drug-resistant TB. According to several studies, the prevalence of TB among the region’s prisoners is 10 times greater than that of the general population.

The WHO suggests three ways to screen for TB in prisons: relying on inmates to report symptoms, actively interviewing prisoners about their health, and administering chest X-rays. The organization doesn’t recommend one method over another, and currently, prisoners in the former Soviet Union are screened annually with miniature chest X-rays.

While X-rays can show whether a lung looks healthy, they don’t always catch TB. And when they do, they cannot differentiate between a TB that can be cured with standard medications and its drug-resistant cousins that require more expensive and extensive treatments.

That’s where GeneXpert has an upper hand.

Since it was introduced in 2005, the diagnostic has been hailed as a potentially powerful tool that can help to cut TB and drug-resistance rates by more accurately diagnosing people and getting them treated. With just a small sample of mucous analyzed by a machine, the GeneXpert system can instantly detect TB and its drug-resistant genetic mutations, well suited to mass screening within the prison systems of the former Soviet Union.

But the GeneXpert test is more expensive than alternative screening methods. And while it promises to be more effective, its impact on total costs had not been quantified in the former Soviet Union region until Goldhaber-Fiebert and his colleagues began their work nearly three years ago.

By developing computer models of the former Soviet Union’s prison populations, the team predicted that using GeneXpert can cut the prevalence of TB among inmates by about 20 percent within four years – provided the screening is combined with standard regimens of drug treatment for infected patients and for those with drug-resistant TB.

“For this to make sense, you need to have the right drugs to cure those individuals you identify,” Goldhaber-Fiebert said.

The additional cost of screening with GeneXpert averages to $71 per prisoner compared to the next best alternative approach, he said.

When compared to the decreases in illness and increases in survival, and factoring the financial and societal costs of TB in the broader population, the method makes good economic sense, he said.

“There is a large, direct value to using this technology for screening in prison settings, and there are potentially substantial secondary benefits to the general population of the former Soviet Union and to the world,” Goldhaber-Fiebert said.

Douglas K. Owens, a professor of medicine who is one of the paper’s co-authors and director of Stanford Health Policy, said the findings could give governments and medical experts the evidence they need to change the way they tackle TB.

“This is the kind of work we hope will inform policymaking about TB control,” Owens said. “We’ve shown there’s a more effective approach for trying to catch TB in prisons, and that means a better chance for preventing the disease from spreading.”

Co-authors on the PLoS Medicine paper also include former Stanford medical student Daniel Winetsky and current Stanford doctoral student in Management Science and Engineering, Diana Negoescu.

The researchers collaborated with the AIDS Foundation East-West. Funding for the study came from Äids Fonds, the International Research & Exchanges Board, the Department of Veterans Affairs, the National Institutes of Health, and Stanford.

On October 30, the Program on Human Rights (PHR) at Stanford's Center on Democracy, Development and the Rule of Law (CDDRL) held a day-long conference to examine health and human rights. The conference was held to discuss how a rights-based approach to health services can impact the delivery of effective health interventions and advance other socio-economic and cultural rights in developing regions. The conference titled, “Why We Should Care: Health and Human Rights” was divided into five panels with presenters from diverse backgrounds and professions including lawyers, doctors, public health experts, students and activists.

The Program:

The conference started with a welcoming address by Helen Stacy, director of the Program on Human Rights. CDDRL Director Larry Diamond introduced the keynote speaker Paul H. Wise, professor of child health and society and pediatrics at Stanford University’s School of Medicine, and director of the Center for Policy, Outcomes and Prevention. Wise's opening remarks began on a somber note, “The language of rights means very little to a child stillborn, an infant dying in pain from pneumonia or a child desiccated by famine.” In his address, Wise emphasized the need for an aligned and integrated rights-based approach that does not undermine effective and efficient medical interventions. “We need to fill the gap between the worlds of child health and child rights so that our programs and policies are both effective and just,” he stressed.

Following the keynote address, the conference presenters shared their work according to a geographic or thematic focus. The first panel brought together three generations of speakers from Stanford - a faculty member, a pre-doctoral fellow and a recent graduate - in a unique opportunity to share ideas and discuss possibilities of health work in Africa. Rebecca Walker, clinical instructor in emergency medicine at Stanford School of Medicine, presented her impressions and reactions on Mindy Roseman’s study of forced sterilization in Namibia. Roseman, academic director of the Human Rights Program and lecturer on law at Harvard Law School, was unable to attend due to flight complications after hurricane Sandy hit the East Coast.

Eric Kramon, 2011-2012 pre-doctoral fellow at CDDRL, spoke about the political sources of ethnic inequality in health outcomes in Africa.  Kramon’s work in Kenya illustrated how politics plays a determinant role in ethnic inequalities and consequently in access to health and health outcomes. Jeffrey Tran, a 2011 Stanford graduate in human biology, described the vision behind the launch of the Project of Emergency First Aid Responder in Western Cape Province, South Africa that he helped implement. Tran explained, “Individuals and communities are an integral part of the solution and we work with the communities to develop first aid training programs that are taught and eventually run by community members.”

Panel two was dedicated to the health impact of drones in Pakistan and in Gaza. Based on research by the Stanford International Clinic on Human Rights and Conflict Negotiation in Pakistan, Professor James Cavallaro and Stanford law school student Omar Shakir, explained that drones are not only responsible for deaths of civilians but also constitute a constant disturbance to social life and mental health of ordinary people, including their relations with children and the elderly. Drones impact other rights as well - such as the right to education - as children are prevented from attending schools for fear of drone strikes. Rajaie S. Batniji, resident physician in internal medicine at Stanford and a CDDRL affiliate, explained the clinical diagnosis of traumatic disorders that result from constant surveillance and insecurity. He cited the work of Jonathan Mann in defining dignity and the devastating effects on physical, mental, and social well-being when these senses are violated. Batniji explained that populations in Gaza are prevented from living life with dignity and respect because they live under constant threat to their security and intrusion into their homes and communications.

Vivek Srinivasan, manager of the Program on Liberation Technology at CDDRL, presented his experience on the Right to Food Campaign in India. He believes that this campaign has led to the mobilization for rights and the provision of services. “Not all demands are confrontational. Communities begin demanding something that is perceived as small in scope but have ramifications that extend to other rights such as the right to education, the right to housing and the right to work.” According to Srinivasan, the Right to Food Campaign in India has had a tremendous impact in putting hunger on the policy agenda. Suchi Pande, an activist-researcher who worked on the Right to Information Campaign in India for over seven years and was the secretary for the National Campaign for People’s Right to Information from 2006 to 2008, supported Srinivasan’s argument of strong correlation in achievements and right-based mobilization. However, Pande pointed out that despite successes in the Right to Food Campaign, other economic and social rights including the right to health in India continues to be a non-issue for politicians and the government. She is optimistic and believes that rural public hearings, the role of the right to information and its supporting mechanisms will facilitate access to public health in rural India.

In panel four, Sarah MacCarthy showed results that suggest that counseling and testing services for HIV-positive pregnant women remain limited, insufficient or lacking in quality in Salvador, Brazil. “While Brazil’s HIV/AIDS program has been internationally acclaimed, national practice still fails to meet national and global guidelines,” she explained. Calling attention to the regional discrepancies in the HIV/AIDS policy and program implementation in Brazil, Nadejda Marques, manager of the Program on Human Rights at CDDRL,, expressed concerns about the implementation of an HIV/AIDS program in a context of limited resources. “In Angola, counseling and voluntary testing units for HIV/AIDS don’t have drinking water or sanitary conditions to receive patients. They lack basic equipment for testing and data collection, there is a generalized shortage of doctors, and health care providers have no specific training on HIV/AIDS.” Despite this alarming situation, Marques explained that advocating for the rights of persons living with HIV/AIDS in Angola has put in evidence the failure of a heath system unable to provide even the most basic services to its population and has enabled mobilization in a context where human rights are routinely violated.

Ami Laws, adjunct associate professor of medicine at Stanford, described how a physician can provide services in collaboration with the judicial system to advance human rights. Laws is an expert witness on cases of torture survivors that require asylum status in the U.S. and has worked mainly with victims of torture in the Punjab region in India. Everaldo Lamprea, a JSD candidate at Stanford Law School and an assistant professor at Los Andes Law School in Bogotá, Colombia, spoke about his recent comparative study on health litigation in low and middle-income countries. The escalation of right-to-health litigation in these countries can have unexpected and harmful consequences to healthcare reforms and the enforceability of the right to health. In part, this is because significant financial resources are allocated to the litigation processes and not to the health system. In addition, while litigation can highlight gaps that exist in the health system that need regulation, countries have been very slow to adapt and adjust to these signals.

Next Steps:

A number of key ideas, questions and insights emerged from the conference including:

. How to identify an effective intervention that will also mobilize communities to advocate for its implementation?

. How to provide services to the more vulnerable populations without alienating a contingent that has access to basic health care services?

. What instruments can be used to share best practices among national healthcare systems?

. How do global priorities adapt to contexts of limited financial resources and human capital?

. How can punctual achievements in rights that guarantee access to health be expanded for the achievement of other social, economic and cultural rights?

The Program on Human Rights at CDDRL will continue to pursue a research agenda examining health and human rights following the conference and announced that it will be the thematic focus of the Sanela Diana Jenkins Speakers Series in 2014. The PHR is also actively seeking support for research projects that include a right to health component at the core of its academic investigation for the 2012-2013 academic year.

Fresh off his re-election victory, Barack Obama—the “Pacific President”—became the first president to visit Myanmar and Cambodia when he traveled to the Southeast Asian countries in November.

The trip highlights the region’s importance to the United States and signals that Obama’s second term will significantly focus on Asian trade, security and governance issues.

Eight Walter H. Shorenstein Asia-Pacific Research Center scholars sat down to discuss reactions to the election in Asia, and possible directions for U.S.-Asia relations and foreign policy during the second Obama administration.

How do you think countries in Asia view the outcome of the U.S. presidential election?

Karl Eikenberry: Overall, I think the countries of Asia will view President Obama’s reelection as positive, including because of the likely continuity in American policy toward the region.

Thomas Fingar: Beijing is troubled by Obama’s policies toward Asia because it sees them as directed against China and detrimental to its interests. But it was more troubled by Romney’s rhetoric during the campaign and probably interprets the election outcome as portending more continuity than change in U.S. policy. On balance, Beijing would rather deal with a devil it knows than cope with the uncertainties of a new U.S. administration.

Gi-Wook Shin: There was some concern in South Korea that Mitt Romney would have reverted to the hardline North Korea policy of George W. Bush’s first term. It would have created a bit of tension between the United States and South Korea, so in that context many Koreans are relieved that Obama was re-elected.

David Straub: Interestingly, President Obama personally is overwhelmingly popular in South Korea, but opinion polls show that most South Koreans continue to have complex, even critical views of American foreign policy under him.

Is President Obama likely to make major changes to Asia policy in his second term?

Eikenberry: Some of the people in key positions in the second Obama administration will change, including Secretary of State Hillary Clinton, but President Obama will of course be in office for four more years. He has been in Asia and knows the players. He has a clear strategy, so overall I expect continuity in his administration’s Asia policy. 

Michael H. Armacost: Events are really what shape foreign policy, and developments can occur that are hard to predict.

Henry S. Rowen: We tend to assume there is a continuity or gradual evolution to events, but there are also discontinuities. Something could happen in North Korea, for example. Unexpected events do happen from time to time, and the question is to try to figure out what they might be.

How could U.S. China policy develop?

Fingar: If President Obama has a clear plan for his second term, its goals and priorities are not yet clear to the Chinese. They worry that he may continue, or ratchet up, efforts they see as designed to constrain China’s rise. That said, they know that steady relations with the United States are essential for their own continued economic success and will respond positively to U.S. efforts to reduce distrust and enhance strategic stability. They will be troubled, however, by likely—and overdue—U.S. pressure to secure enforcement of China’s intellectual property and other trade-related commitments, and by likely U.S. efforts to deepen trade relations with other countries.

How could the possible election of a more conservative Japanese government during the second term of the Obama administration affect U.S.-Japan relations?

Armacost: The Trans-Pacific Partnership is an issue where we both have potential constraints on the extent to which Japan can be included, and it is not certain whether that will change very much under a Liberal Democratic Party (LDP) administration. Secondly, there is the longstanding Okinawa base issue. The LDP did not do anything about the base from 1996 onward, and that will probably also be the case if the LDP comes into power again. Finally, the United States will probably push Japan to take more of a stand on the ongoing Senkaku/Diaoyu Islands dispute with China.

After the failure of the United States’ Leap Day agreement with North Korea this year, and especially with the election of a new South Korean government next month, do you think that Obama’s second term could bring a renewed effort in diplomacy with North Korea?

Shin: It will be important to watch the outcome of the South Korean election. If the opposition party wins, they will move very quickly to engage with North Korea and the question then will be how the United States will respond.

Straub: In any event, the United States periodically reaches out to North Korea, to test it or just because time has passed. It may do so again after the election, particularly since there is a still fairly new leadership in North Korea, and also because there are elections or leadership changes in all the countries in the region. A number of the Six Party Talks member states, likely including South Korea, may also push harder for a resumption of those talks, which were never held during President Obama’s first term. But the Obama administration will be cautious because it was burned by North Korea’s breaking of their Leap Day agreement.

What direction might U.S. policy toward South Asia take?

Eikenberry: Our presence in Afghanistan is going to remain an important part of our overall military posture in Central, South, and East Asia. Managing properly the transition to full Afghan responsibility for their internal security will remain very high on President Obama’s agenda. At the same time, it will be important to keep some U.S. counterterrorism capability in Afghanistan, with the permission of the Afghan government.  

The nature of our security dialogue with Pakistan will change in emphasis from one that since 9/11 has mostly been informed by international terrorism. If we continue to make progress against Al Qaida, I expect our conversation with Pakistan will place more emphasis on its nuclear weapons programs and deployments. This is a potentially destabilizing issue and a concern not only to India, but also to China.

There has been a steady appreciation in the current and future importance of India. It will continue to be key in terms of the administration’s broader Asia-Pacific policy, but with a clear understanding of the limits of defense engagement with India.

Will the rebalancing, or “pivot,” toward Asia continue to be a central theme in U.S. foreign policy in Obama’s second term?

Eikenberry: Last year, when President Obama announced the rebalancing to Asia, I think this was done in part to signal to the world that we were putting the decade of costly wars in Iraq and Afghanistan behind us and looking forward—that the U.S. “was back.” I do not believe we will see any short-term major change in the deployment of military capabilities to the Asia-Pacific region, but the rebalancing could have profound consequences in the longer term. It will likely inform the prioritization of our future defense modernization and the development of military doctrine, which in turn drives procurement.

Donald K. Emmerson: Asia will continue to loom large on Washington's policy horizon. Although the pivot was originally all about security, the rebalance has since been "rebalanced" to encompass economic concerns. In July 2012 when Secretary Clinton went to Phnom Penh to attend the security-focused ASEAN Regional Forum, she brought along the largest delegation of American businesspeople ever to visit Southeast Asia. Their presence upgraded the profile of the U.S.-ASEAN Business Forum, which met the following day. The Obama administration has also taken the lead in promoting a Trans-Pacific Partnership to liberalize Asia-Pacific trade. 

President Obama's mid-November trip to Southeast Asia is further evidence of the pivot's continuation. In mid-November he will become the first U.S. president ever to have visited Myanmar and Cambodia. He will stop in Thailand as well. In Phnom Penh he will attend the U.S.-ASEAN Summit and the East Asia Summit. A key issue at these meetings will be the quarrels over sovereignty in the South China Sea between China, Taiwan, the Philippines, Vietnam, Malaysia, and Brunei. To the extent that the United States appears to be intervening against Beijing in these disputes, the "pivot" will be interpreted as a move to check China.

Armacost: There is no doubt that the Asia rebalancing strategy will endure, but the components and the apportionment of resources may change. President Obama may have initially overplayed engagement with China, and now he is probably hedging too much. But it does not change the fact that there is a lot at stake in terms of our relationship with China and that we have to engage the government. So it is a question then of where to strike a balance between hedging and engagement. After the election, there is also the question now of what happens to U.S. trade policy, and whether the Trans-Pacific Partnership will include India, China, and Japan.

Daniel C. Sneider: If you look at the president’s broader message and the one he carried in the campaign, he is very focused on restructuring and moving toward a more innovation-centered U.S. economy to develop new sources of employment. In addition to being concerned about climate change, he is also seriously looking at alternative energy resources as a source of real growth in the U.S. economy and as a way to move away from foreign fossil fuel dependency. Focusing more on the Asia-Pacific region is also quite consistent with these goals.