China has a large and growing elderly population, but to be old in China-particularly in the countryside-is to be vulnerable. In the country's rural areas there are few clinics and hospitals, and health insurance is virtually nonexistent. Compared with elderly Chinese living in urban areas, those in rural areas have a shorter life expectancy and a poorer quality of life.

Further, little academic research has focused on the health needs and health status of China's elderly. It is with the goal of addressing this deficit that Pengqian Fang, a trainee with CHP/PCOR's China-U.S. Health and Aging Research Fellowship, recently returned to China from Stanford. Fang is seeking to document the health disparities between China's rural and urban elderly population, and to use his findings to propose healthcare assistance programs for the elderly in rural areas of China.

Fang spent a year at Stanford studying health-services research concepts and methods and developing his research project.

In the project, which Fang refined with guidance from CHP/PCOR faculty, Fang will conduct a detailed survey of the health status, health needs, and healthcare utilization of elderly people in rural and urban areas of China, through in-home interviews in three Chinese provinces with different geographic and socioeconomic characteristics: Guizhou (in southwest China), Hubei (in central China), and Guangdong (in the southeast).

He will conduct the project in collaboration with the health departments of the

three provinces, and with support from Tongji Medical College in Wuhan, where he

is director and associate professor of healthcare management.

Fang's study will be among the first of its kind in China. Such research is needed, Fang explained, because China's elderly population (of whom 70 percent reside in rural areas) is growing steadily, and in the coming years its members will require medical services at increasing rates. According to the country's 2000 census, China has 132 million people over age 65, making up more than 10 percent of the population; the over-80 population, which numbers 10 million people, is increasing by 5.4 percent a year; and about 20 percent of all elderly people in the world live in China.

The elderly in China's rural areas face particular challenges in getting high-quality, affordable healthcare services, Fang explained. There are few clinics and hospitals in rural areas, and there is no government-sponsored health coverage for the elderly (like the United States' Medicare program) anywhere in China. All of these factors put China's rural elderly in a vulnerable position, especially those with disabilities or serious illnesses.

"This research will show the disparities that exist, and it will encourage a dialogue about policies to help rural elderly people in China," Fang said.

Fang plans to conduct his survey in the first half of 2005, analyze the data in the summer and fall, and return to Stanford in November 2005 to present the results. In each of the three provinces studied, the research team will recruit 500 households and will conduct interviews with all individuals age 65 and over who reside there, for an estimated final sample of 2,500 people.

The respondents will be asked for a variety of information, including their income and education, insurance status, health status, daily activities, social activity, mental health, utilization of healthcare services, and accessibility and affordability of medical care. The researchers will also interview community healthcare workers-including physicians, nurses, and administrative staff-to seek information on the health needs of the elderly and the barriers they and their healthcare providers face.

The China-U.S. Health and Aging Research Fellowship, administered jointly by

CHP/PCOR and the China Health Economics Institute (Beijing), aims to improve

healthcare quality and efficiency in China through an exchange program in which

selected Chinese health services researchers come to Stanford to study for six months to a year, and then return to China to conduct an original research project. The fellowship is funded by the National Institutes of Health's Fogarty International Center.

"I have learned very much from Stanford and this program," Fang said. "The classes I attended have given me very useful ideas." He noted that since health services research is still a young field in China-about ten years old-"we learn a lot from the United States, like how to ask the research question, how to get a grant, how to design a study."

One aspect of Stanford that particularly impressed Fang was its emphasis on interdisciplinary collaboration.

"This is a very good feature-the close relationship between different fields," he said. "In my country we are more focused on one narrow field."

Fang said he is interested in establishing research collaborations between Stanford and Tongji Medical College-an idea that he and CHP/PCOR's leadership will be exploring in the coming months.

There is much to admire about the U.S. healthcare system's emphasis on innovation and technology, Fang said. Still, he said, "I don't hope for China to follow the U.S. health system," with its heavy reliance on free-market principles. For one thing, "medicine here is very costly." He cited a personal example of how he fractured his arm in a minor bicycle accident, and how his emergency room visit for the injury, along with a follow-up physician appointment, cost more than $1,000. "I was surprised it cost so much," he said.

A review of the fellowship program conducted by officials at the China Health Economics Institute last fall concluded that it has been successful and valuable. Leaders at the institute said the trainees' Stanford experience has enhanced their intellectual abilities, their knowledge of research methodology, their leadership capacity, and their ability to collaborate internationally.

A new united nations report recommending the most sweeping reform in the institution's history offers a global vision of collective security for the 21st century that is as committed to development in poor nations as it is to prevention of nuclear terrorism in rich ones.

The point is, according to the report's research director, Stephen Stedman, a threat to one is a threat to all in today's world. "Globalization means that a major terrorist attack anywhere in the industrial world would have devastating consequences for the well-being of millions around the developing world," the document states. The report's value lies in putting forward a comparative framework of collective security that addresses all the compelling threats of the day, Stedman explained. "The recommendations really are the most important possible makeover of the institution in 60 years," he said. "I think something is going to come out of it." Stedman, a senior fellow at the Center for International Security and Cooperation (CISAC) at the Stanford Institute for International Studies (SIIS), was recruited a year ago by U.N. Secretary General Kofi Annan to direct research for the High-Level Panel on Threats, Challenges, and Change. Stedman is an expert on civil wars, mediation, conflict prevention, and peacekeeping.

Annan created the 16-member blue-ribbon panel, made up mostly of former government leaders and ministers, in the wake of widespread heated criticism of the United Nations following the U.S.-led war in Iraq. In Annan's annual report to the General Assembly in 2003, he said, "Rarely have such dire forecasts been made about the U.N. ... We have reached a fork in the road ... a moment no less decisive than 1945 itself, when the U.N. was founded." The panel was charged with analyzing global security threats and proposing far-reaching reforms to the international system.

On December 2 the panel, chaired by former Thai prime minister Anand Panyarachun, issued its 95-page report: "A More Secure World: Our Shared Responsibility." The document identifies six major threats to global security:

-War between states;

-Violence within states, including civil wars, large-scale human rights abuses, and genocide;

-Poverty, infectious disease, and environmental degradation;

-Nuclear, radiological, chemical, and biological weapons;

-Terrorism; and

-Transnational organized crime.

Although states do not face these threats equally, a collective security system must take all member states' threats seriously and deal with them equitably, the report noted. It specifically mentioned the world's appallingly slow response to AIDS.

The report makes 101 recommendations for collective prevention and response to the threats, including ways to reform the United Nations. Annan described these in a December 3 editorial in the International Herald Tribune as "the most comprehensive and coherent set of proposals for forging a common response to common threats that I have seen."

The document also reaffirms the right of states to defend themselves-even preemptively-when an attack is imminent, and it offers guidelines to help the Security Council decide when to authorize the use of force. Stedman said other significant proposals involve improving biosecurity, strengthening nuclear nonproliferation, and defining terrorism. Panel members agreed that any politically motivated violence against civilians should be regarded as terrorism and condemned.

The panel was very critical of the Human Rights Commission, a body that has often harmed the United Nations' reputation by permitting the membership of some of the worst human-rights violators, including Cuba, Libya, and Sudan. The report also discussed the need for new institutions, such as a peace-building commission, that would support countries emerging from conflict.

Scott Sagan, co-director of CISAC, described the report as hard-hitting, although he said he would have tried to extend the withdrawal clause of the nonproliferation treaty from three months to a year. "I think it's the beginning of some major changes that will be helpful," he said. "We need to get states to work together to reform the U.N. rather than sniping at it."

CISAC was closely involved in the panel's work and was named in a cover letter accompanying the report from Panyarachun to Annan. Co-director Chris Chyba served on the panel's 30-member resource group, providing expertise on nuclear nonproliferation and bioterrorism. Bruce Jones, a former CISAC Hamburg Fellow, acted as Stedman's deputy, and Tarun Chhabra, a graduate of CISAC's undergraduate honors program and recent Marshall Scholarship recipient, worked as a research officer. Political science Professors David Laitin and James Fearon, and SIIS Senior Fellow David Victor, provided, respectively, expertise on terrorism, civil wars, and the environment, Stedman said. "There is an immense amount of Stanford influence in the report," he added.

CISAC also hosted a nuclear nonproliferation workshop for the panel on campus last March and helped organize a meeting during the summer in Bangkok. SIIS co-hosted a conference on governance and sovereignty on campus in April and a meeting at Oxford University in June. CISAC provided workspace to give the research team a quiet place to focus on writing the report's first draft in August.

The report has attracted intense international media interest in part because it calls for expanding the U.N. Security Council, its top decision-making group, from 15 to 24 members. The panel was unable to agree on one proposal and offers two options that would make the council more representative and democratic. "I believe either formula would strengthen the legitimacy in the eyes of the world, by bringing its membership closer to the realities of the 21st century-as opposed to those of 1945, when the U.N. Charter was drafted," Annan wrote in the International Herald Tribune.

According to Stedman, the media has highlighted the Security Council's proposed expansion because so many nations have a stake in it. "But in the absence of a new consensus on international peace and security, expansion of the council will not be effective," he explained.

In March, Annan will use the report to inform a series of proposals he will present to the 191 U.N. member states. These, in turn, will be submitted to a summit of world leaders before the General Assembly convenes next September in New York. Stedman said he has been asked to stay on for another year as a special advisor to the secretary general to keep the United Nations "on message" during negotiations.

Engagement by the United States, which has openly questioned the institution's relevance, will be critical to implementing the report's recommendations, said Stedman, who added that the superpower can benefit from a revamped United Nations. "Putting threats to the United States into a global framework makes it more secure," he said.

Stedman noted that one of the most disturbing aspects of the panel's consultations was listening to government representatives from civil-society organizations dismiss the seriousness of bio- and nuclear terror threats against the United States. "They were essentially denying this as a real threat to American security," he said. "I said it's as real a threat to the U.S. as other threats are to you."

When Stedman accepted the job, he thought he would spend 80 percent of his time on research and writing and 20 percent on consultations and negotiating. In fact, he said, it was the other way around. "It's unlike anything I've ever done," he said. "It's been a blast." In contrast to academia, where a researcher presents his or her best findings and defends them, Stedman was faced with 16 people who would push back, reject, or accept his work. "I had to work to change language to include their concerns," he said. "My biggest concern at the beginning was that the report would be based on the lowest common denominator. It's not."

Stedman said the panel members remained open-minded throughout the year. "They showed flexibility, listened to arguments, and changed their minds," he said. "Our job was to be as persuasive, rigorous, and comprehensive in our analysis as we were able to achieve."

In the end, Stedman said, the report belongs to the panel. "Parts of what the exercise shows is that access to those making policy is really important," he said. "If you do really good work and you have access, you have a chance of being heard. Kofi Annan gave me that opportunity."

The Walter H. Shorenstein Asia-Pacific Research Center (Shorenstein APARC) at the Freeman Spogli Institute for International Studies at Stanford University invites applications to receive funding grants for activities or programs focusing on health care policy in Asia. Shorenstein APARC welcomes research proposals on a wide range of topics from diverse disciplines, but has particular interest in international studies of demography; the effects of an aging population on social, economic, and political systems; and the causes and prevention of epidemics such as AIDS and Avian Influenza in Asian countries.