Health and Medicine

FSI’s researchers assess health and medicine through the lenses of economics, nutrition and politics. They’re studying and influencing public health policies of local and national governments and the roles that corporations and nongovernmental organizations play in providing health care around the world. Scholars look at how governance affects citizens’ health, how children’s health care access affects the aging process and how to improve children’s health in Guatemala and rural China. They want to know what it will take for people to cook more safely and breathe more easily in developing countries.

FSI professors investigate how lifestyles affect health. What good does gardening do for older Americans? What are the benefits of eating organic food or growing genetically modified rice in China? They study cost-effectiveness by examining programs like those aimed at preventing the spread of tuberculosis in Russian prisons. Policies that impact obesity and undernutrition are examined; as are the public health implications of limiting salt in processed foods and the role of smoking among men who work in Chinese factories. FSI health research looks at sweeping domestic policies like the Affordable Care Act and the role of foreign aid in affecting the price of HIV drugs in Africa.

Paragraphs

Proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors substantially reduce low-density lipoprotein cholesterol, but it is presently unclear whether they also reduce mortality. The list prices of PCSK9 inhibitors in the United States (>$14,500 per year) are >100× higher than generic statins, and only a small fraction of their higher cost is likely to be recovered by prevention of cardiovascular events. The projected cost effectiveness of PCSK9 inhibitors does not meet generally accepted benchmarks for good value in the United States, but their value would be improved by substantial price reductions. For individual patients, the high out-of-pocket costs of PCSK9 inhibitors may impede access and reduce long-term adherence. The budgetary impact of PCSK9 inhibitors would be very large if all potentially eligible patients were treated, which poses dilemmas for policymakers, payers, and society.

All Publications button
1
Publication Type
Journal Articles
Publication Date
Journal Publisher
Journal of the American College of Cardiology
Authors
Mark A. Hlatky
Authors
Beth Duff-Brown
News Type
News
Date
Paragraphs

At least 91 Americans die every day from an opioid overdose. The epidemic has claimed more than 300,000 lives since 2000 and is expected kill another half million over the next decade.

So perhaps it’s time to step up lawsuits against the drug manufacturers that sell the opioids to the tune of $13 billion per year, Stanford Health Policy’s Michelle Mello argues in a commentary in the current issue of The New England Journal of Medicine.

Mello, a professor of law and of health research and policy, and co-author Rebecca L. Haffajee, an assistant professor of health management and policy at University of Michigan School of Public Health, note that although heroin and illicitly manufactured fentanyl account for an increasing proportion of opioid overdoses, the majority of people who are addicted to opioids get hooked on prescribed painkillers.

While clinicians and health-care providers are trying to prescribe fewer opioids, Mello and Haffajee believe litigation is another crucial method to fight the crisis.

“The search for solutions has spread in many directions, and one tentacle is probing the legal accountability of companies that supply opioids to the prescription market,” the authors write.

The final report of President Trump’s Commission on Combating Drug Addiction and the Opioid Crisis details decades of aggressive marketing of oxycodone from 1997-2002 that led to a tenfold rise in prescriptions to treat moderate to severe pain. “To this day, the opioid pharmaceutical industry influences the nation’s response to the crisis,” the report said, noting the industry had sponsored some 20,000 conferences for physicians on managing pain with opioids while claiming their potential for addiction was low.

Mello and Haffajee argue that similar to the early cigarette promotions by Big Tobacco, opioid manufacturers have failed to adequately warn patients about addition risks on drug packaging and in their marketing campaigns.

“Some recent claims allege that opioid manufacturers deliberately withheld information about their products’ dangers, misrepresenting them as safer than alternatives,” they write.

Early attempts to bring class-action suits against opioid manufacturers have encountered procedural barriers. Judges typically find that proposed class members lack sufficiently common claims because of different circumstances surrounding opioid use and clinical conditions.

But the tide may be turning. There has been an uptick in litigation against Big Pharma since Purdue Pharma, the maker of the blockbuster painkiller, OxyContin, agreed in 2007 to pay $600 million to settle charges that it misled federal regulators, doctors, and patients about the drug’s risk of addiction and its potential to be abused.

“As the population harmed by opioids grows and more information about the population is documented, it becomes easier to identify subgroups with similar factual circumstances and legal claims — for example, newborns with neonatal abstinence syndrome,” they said.

Perhaps most promising, the authors write, is the “advent of suits brought against drug makers and distributors by the federal government and dozens of states, counties, cities, and Native American tribes.

“Because the government itself is claiming injury and seeking restitution so that it can repair social systems debilitated by opioid addiction, these suits avoid defenses that blame opioid consumers or prescribers,” they said. “They also garner substantial publicity.”

The government is borrowing from the playbooks used to sue tobacco and firearms companies, relying on four strategies:

  • Focus on the “public scourge” created by the opioid manufacturers due to their oversaturation of the market, arguing that opioids constitutes a public nuisance;
  • Paint the opioid companies’ business practices as deceptive;
  • Call out the manufacturers’ lax monitoring of suspicious opioid orders; and
  • Ask courts to make companies disgorge the “unjust enrichment” they have reaped at the government’s expense through their unfair business practices.

Two large settlements have occurred in state cases that included unjust enrichment claims, the authors note, although the pharmaceutical companies avoided admitting fault. The Commonwealth of Kentucky settled with Purdue Pharma for $24 million in 2015 over allegations that it had profited while Kentucky was left paying associated medical and drug costs of those who became addicted.

Earlier this year, drug wholesaler Cardinal Health Inc. agreed to pay $20 million to settle a lawsuit brought by West Virginia’s attorney general over accusations that it flooded the market with opioids in a state that now has the highest opioid overdose rate in the nation.

Such lawsuits have garnered a lot of media attention and contributed to pressure on the U.S. government to take action against the abusive practices of drug manufacturers and distributors.

“Win or lose, lawsuits that very publicly paint the opioid industry as contributing to the worst drug crisis in American history put wind in the sails of agencies and legislatures seeking stronger oversight,” Mello and Haffajee write. “Together, litigation and its spillover effects hold real hope for arresting the opioid epidemic.”

 

Listen to a podcast with Haffajee talking about the opioid crisis.

 

 

Hero Image
heroin boy
Five-year-old Derrick Slaughter attends a march through the streets of Norwalk, Ohio, against the epidemic of heroin with his grandmother on July 14, 2017. Both of Derrick's parents are heroin addicts and he is now being raised by his grandparents. At least 4,149 Ohioans died from drug overdoses in 2016, a 36 percent leap from just the previous year.
Spencer Platt/Getty Images
All News button
1
Authors
News Type
News
Date
Paragraphs

As a recipient of a Stanford Center at Peking University (SCPKU) Team Innovation Faculty Fellowship, Judith Prochaska, an associate professor of medicine, and her colleagues from the Stanford Prevention Research Center, had an opportunity to teach a graduate seminar in Beijing in summer of 2016.  In addition to teaching, the fellowship allowed her to connect with in-country scholars and explore new research opportunities.  Read more.

Hero Image
peking symposium
Students from Peking University and Stanford attended an SCPKU seminar led by Michael Baiocchi (front, far left), Randall Stafford (front, second from right) and Judith Prochaska (front, far right).
Kenny Fu
All News button
1
Authors
Beth Duff-Brown
News Type
News
Date
Paragraphs

Family planning programs in developing countries that offer contraceptives and reproductive health advice apparently do more than prevent pregnancies — they can keep girls in primary school for up to a year longer, even before the youngsters start to think about marriage and babies.

New research by Stanford Health Policy’s Grant Miller and Kim Singer Babiarz indicates that the availability of modern contraceptives alone can keep young girls in the classroom longer, likely because their parents develop greater expectations for their daughters’ long-term health outcomes and economic opportunities.

“What we find is that family planning exposure at a young age is linked to greater opportunities later in life – including economic empowerment,” said Babiarz, an SHP research scholar with a PhD in agricultural economics who focuses on women and children in development. “The fertility effects were modest; the most striking findings were the incentives created to keep girls in school and improvements in the types of jobs women have later in life.”

Babiarz and Miller, a senior fellow at the Freeman Spogli Institute for International Studies and director of the Stanford Center on Global Poverty and Development, unveiled their study at the annual meeting of the Center for Global Development in Washington, D.C. on Dec. 7.

They conducted research with Christine Valente, an associate professor in the department of economics at the University of Bristol and Tey Nai Peng, the principal investigator for the Malaysia Family Life Survey. The Southeast Asia nation was one of the first low-income countries to provide modern contraceptives on a large scale, first in 1954 and then establishing a National Family Planning Board in 1966.

The government then scaled up its national program between 1966 and 1974 and conducted robust surveys with retrospective life histories and detailed community-level information about the timing of family planning availability. The use of contraceptives such as the pill, condoms and IUDs, went from 3 percent in 1961 to 39 percent in 1975. The country also experienced a decrease in the fertility rate of 6.2 children to 4.3 during the same period.

The researchers were able to compare what happened to Malaysian girls who were very young when contraceptives became available in their communities to those who were adolescents when they first gained access to modern contraception. They were not surprised by the effects on fertility; that has generally been the case in countries that adopt large-scale family planning programs.

But they also found unintended incentives: that girls in communities with family planning clinics stayed in school six months longer, increasing to more than an additional year for the girls who were born after the family planning programs began. And it didn’t matter if the girls had fewer younger siblings at home.

Other benefits later in life included better jobs when they became adults. When the Malaysian girls were grown, they were more likely to take in their own elderly parents (relative to their husbands’ parents), a signal of increased status in their households. In fact, they found that the incentives for investing in girls created by family planning may actually outweigh its direct effects, which work through reductions in fertility and changes in birth timing.

“The existence of family planning and contraceptives may lead parents to believe their daughters can participate in the labor force and that more schooling will therefore benefit them,” Miller said. “In other words, it can change their expectations about the world their daughter will live in one day.”

Few studies explicitly distinguish the incentive effects of family planning on women’s education from its direct effects on fertility. Miller said he hoped the new findings might lead policymakers to consider the broader beneficial consequences of family planning beyond those that work directly through changes in pregnancy and fertility.

“A central contribution of this working paper is that it studies the possible incentive effects of family planning programs for human capital investment in girls,” the authors wrote,” which could then translate into improvements in women’s economic status throughout their lives.”

Hero Image
malaysian schoolgirls
Indian, Malay, and Chinese school girls learn side by side in the Wisma Dharma Candra school in Kuala Lumpur, Malaysia.
Chris Hondros/Getty Images
All News button
1
-

Summary

 

Axonopathy is a typical early characteristic of neurodegenerative diseases in central nervous system (CNS), which leads to axon degeneration and retrograde neuronal cell death. It is critical to decipher the upstream signals that trigger the neurodegeneration cascade to minimize the severe consequences of progressive CNS dysfunction. It is also upmost interest to promote CNS axon regeneration for neural repair. Optic neuropathies are a group of retinal ganglion cell (RGC) diseases with features of axonopathy: they are initiated by optic nerve (ON) injury and that produces secondary RGC death. Prof. Hu’s study of three in vivo mouse models of optic neuropathies (traumatic optic nerve injury, glaucoma and EAE/optic neuritis) revealed that both acute traumatic injury and chronic insult of ON induce endoplasmic reticulum (ER) stress and activate the unfolded protein response (UPR) signal transduction pathways in RGCs. Modulation of two key downstream pathways of ER stress synergistically promote survival of both RGC somata and axons in all three optic neuropathy models, suggest that neuronal ER stress is a general upstream mechanism for both events in CNS axonopathies, and that axon injury-induced ER stress is the link between the sequential events of axon injury and neuronal soma death. Using the same model, we also revealed a complex neuron-intrinsic balancing mechanism involving AKT as the nodal point of PI3K, mTORC1/2 and GSK3β that coordinates both positive and negative cues to regulate adult CNS axon regeneration.

Speaker - Professor Hu Yang

 

Prof. Hu, Assistant Professor of Ophthalmology at Stanford

University School of Medicine, is also member of Bio-X

and of Stanford Neurosciences Institute. He received the

Doughlas Johnson Award for Glaucoma Research (2013)

and the Knight Templar Eye Foundation Travel Fellowship

Award (2016). Prof. Hu received his Ph.D in Neuroscience

at Weill Medical College of Cornell University and MD from

Beijing Medical University.

 

 

 

Registration

 

Lunch box option provided

 

 

Coming to SCPKU

 

The nearest Peking University entrance to the Center is

the Northeast Gate on Zhongguancun Beidajie. Please

make sure to bring your ID or passport for registration at

the gate. We will send you a reminder and map of the

Center once you have successfully registered. For

inquiries, please call (86) 10 62744170.

Stanford Center at Peking University
Langrun Yuan, Peking University

Lectures
Authors
Beth Duff-Brown
News Type
News
Date
Paragraphs

There is no denying the Affordable Care Act has significantly increased the number of Americans with health insurance. Yet many policymakers and consumers question the value of Marketplace plan coverage under the ACA because cost-sharing can get pretty high.

A survey by the Kaiser Family Foundation and The New York Times last year found that 22 percent of people who purchased health insurance through an ACA Marketplace plan had trouble paying their medical bills due to copayments, high deductibles, and co-insurance payments.

Out-of-pocket costs under a typical silver plan, for example, can be twice as high as they are in the average plan provided by employers.

So Stanford health policy researchers conducted a study, published online in Health Affairs, in which they simulated out-of-pocket spending for bronze, silver and gold Marketplace plans — those having actuarial values of 60 percent, 70 percent and 80 percent, respectively.

They found that while Marketplace plans significantly reduce exposure to the financial risk of a catastrophic illness, the use of actuarial values can be misleading. For the vast majority of consumers, the proportion of covered spending is likely to be far less than their actuarial values.

“Many Americans may find themselves not using their health insurance plan in a given year because they didn't get sick,” said Maria Polyakova, an assistant professor of health research and policy at Stanford Medicine and lead author of the paper.

In fact, only when annual health-care spending exceeds $16,500 for bronze plans, $19,500 for silver plans, and $21,500 for gold plans do plans in these metal tiers cover the proportion of costs matching their actuarial values. These metal levels are intended to provide standardized information on coverage generosity to help consumers choose among plans.

Marketplace plans provide relatively comprehensive coverage for the small proportion of people who experience extremely high health-care spending, the authors wrote. But the vast majority of enrollees experience relatively little direct benefit from their coverage in any given year because most of their services out of pocket because their expenses fall below the deductible limits.

But Polyakova, who is also a faculty research fellow at the National Bureau of Economic Research, said it’s important not to conclude that purchasing health insurance is a waste of money for the young and healthy.

“Indeed, most working-age adults do not use much health care,” she said. “The idea of health insurance, however, is to protect household finances in those cases when someone does get sick and needs expensive care. In this paper, we find that for many consumers, Marketplace plans are likely to provide valuable risk protection.”

The mismatch between expected and experienced coverage for the majority of people who have low health-care expenditures is one factor that may have inhibited enrollment in Marketplace plans among relatively healthy people, the authors wrote, a phenomenon that could have contributed to Marketplace instability.

“More generally, a weakness of using actuarial value is that doing so distracts consumers from the key purpose of insurance, which is financial risk protection,” said Polyakova and co-author Kate Bundorf, an associate professor of health research and policy and chief of the Division of Health Services Research at the Stanford School of Medicine.

“Policymakers should consider alternative ways of communicating plan generosity that more accurately convey to consumers their likely out-of-pocket spending in a plan and how much risk protection plans provide,” they wrote. “Moreover, it may be important and valuable to emphasize the risk protection value of plans in the public debate.”

One fairly easy fix, Polyakova said, would be for healthcare.gov to show consumers their expected spending under different “sick” and “healthy” scenarios. Currently, the health site asks consumers whether they expect to be sick or healthy and then shows which out-of-pocket costs would result. But it doesn't show people who expect to be healthy what would happen to their spending if they did get sick.

Hero Image
obamacare enrollment
Miami residents work with a UniVista Insurance company advisor as they sign up for the Affordable Care Act, also known as Obamacare on Feb. 5, 2015.
Joe Raedle/Getty Images
All News button
1

"Prospects for Tuberculosis Elimination in the US and Globally"

 

Elimination of tuberculosis in the United States has been an explicit public health policy goal since the 1980s. Globally, the World Health Organization has established ambitious targets to reduce deaths from tuberculosis by 95% before 2035. In this seminar we will explore results from TB epidemic simulation models to shed light on the potential short-term and long-term trajectories of TB in the US under a range of different policy scenarios, and will consider relevant epidemiological and policy trends in global TB control. We will describe ongoing work to translate models into decision tools for US state-level TB planners, and to model key interdependencies between US and global TB control. 

 

Please note: All research in progress seminars are off-the-record unless otherwise noted. Any information about methodology and/or results are embargoed until publication.

Encina Commons Room 114, 615 Crothers Way, Stanford, CA 94305-6006
(650) 736-9477
0
Professor, Health Policy
Senior Fellow, Freeman Spogli Institute for International Studies
josh_salomon-headshot_2023.jpg PhD

Joshua Salomon is a Professor of Health Policy in the Department of Health Policy at Stanford School of Medicine, Senior Fellow in the Freeman Spogli Institute for International Studies, and founding Director of the Prevention Policy Modeling Lab. Trained in health policy and decision science, Dr. Salomon leads multidisciplinary research teams dedicated to producing rigorous, actionable evidence to improve the public’s health and reduce health disparities. His work — supported by the National Institutes of Health, Centers for Disease Control and Prevention, and the Bill & Melinda Gates Foundation — combines data synthesis and mathematical modeling to measure and forecast health outcomes and evaluate public health programs and strategies, with particular emphasis on infectious diseases. He has spearheaded methodological innovation in measurement and valuation of health, infectious disease modeling and forecasting, and cost-effectiveness analysis. His applied modeling work on HIV/AIDS, tuberculosis, viral hepatitis, COVID-19 and other major health challenges informs local, state, national and international policies to improve health and wellbeing, particularly among under-served populations in the United States and around the world.  

Dr. Salomon established the multi-institution Prevention Policy Modeling Lab in 2014 to conduct health and economic modeling that guides reasoned public health decision-making relating to infectious disease. He has co-authored more than three hundred original peer-reviewed research articles and mentored dozens of graduate and post-graduate trainees in health policy, medicine and public health. Prior to joining the Stanford Faculty, Dr. Salomon served as a policy analyst in the Department of Evidence and Information for Policy at the World Health Organization in Geneva, and as Professor of Global Health at Harvard T.H. Chan School of Public Health. As Associate Chair for Academic Affairs and Strategy in the Department of Health Policy at Stanford, he works on faculty recruitment and development, and leads strategic initiatives to promote interdisciplinary collaborative research, practice partnerships and policy translation.

Collaboration

In this recent Stanford Report article, Salomon talks about how he helped gather faculty, trainees, and other researchers from Stanford and elsewhere to lend expertise in infectious disease modeling and data analytics in hopes of informing the public health response to the COVID-19 pandemic locally and nationwide. This quickly-assembled unit used county data to build models that were updated in real-time and shared with county epidemiologists to track the impact of the epidemic, underlying transmission trends, and potential effectiveness of public health measures.

The unit also advised county epidemiologists on developing their own models for planning and envisioning different scenarios. “In the early weeks especially, we were learning more about the virus every day,” Salomon explained, “but we hadn’t yet seen the first peak of what would eventually turn into multiple waves, so there was a lot of uncertainty about when that peak might arrive, how high it could be, and what would happen next.”

Read Stanford Report Article

Seminars
-

This seminar exploits longitudinal claims data and a cost-sharing subsidy that has exempted copayment and coinsurance of healthcare service for children under the age of 3 in Taiwan.  We conduct a regression discontinuity design by comparing the use of healthcare for children just before and just after their third birthdays. Our results show that lower level of cost sharing increases outpatient visits and discourages patients’ price-shopping behavior. In contrast, the utilization of inpatient care for children is price insensitive. Finally, we find little evidence on the impact of the cost-sharing subsidy on children’s short-run or long-run health.

Image
hsien ming lien
Hsien-Ming Lien is currently a visiting Fellow at the Center for Advanced Study in the Behavioral Sciences (CASBS) and a Fulbright Scholar at Stanford University. He is also the Director of the Taiwan Study Center, and Professor in the Department of Public Finance, National Chen-Chi University and an adjunct Professor in the Department of Economics at National Taiwan University, where he teaches health systems, health economics, and econometrics. He earned his B.S. from National Taiwan University, and Ph. D. from Boston University.

Prof Lien’s research focuses on 1) physicians’ behavior; 2) the impact of the National Health Insurance program on the health care market; and 3) the impact of copayments on health care use. Prof Lien is a recipient of the Minister Wang Jin Naw Memorial Award for Best Paper in Health Care Management presented by the Kimma Chang Foundation in 2002, and the Golden Paper Award presented by the Chuang Yi-Chou Foundation in 2009. Prof. Lien has published papers in Health Services Research, Journal of Health Economics, Economic Inquiry, and other journals.  

 

Hsien-Ming Lien Visiting Fellow at the Center for Advanced Study in the Behavioral Sciences (CASBS) and a Fulbright Scholar, Stanford University
Seminars
Authors
News Type
News
Date
Paragraphs

The Center for International Security and Cooperation now has more than 46 podcasts, dating all the way back to Oct. 19, 2016. Listen to them on the CISAC page on the iTunes website. Simply mouse over the title and click play. Open iTunes to download and subscribe to CISAC podcasts. Seminars and events at CISAC are routinely audiotaped for use as podcasts. Also, the Freeman Spogli Institute for International Relations offers the World Class podcast series, featuring scholars and experts from FSI, CISAC and beyond.

Hero Image
gettyimages 513740370 Getty Images/Blackzheep
All News button
1
News Type
News
Date
Paragraphs

CISAC co-director Amy Zegart wrote the following essay in the Oct. 25 online edition of The Atlantic:

Pity the professionals. In the past month, President Trump has sideswiped certification of the Iran nuclear deal, sandbagged his own secretary of state’s diplomatic efforts with North Korea, and even provoked the ever-careful Senate Foreign Relations Committee Chairman, Bob Corker, to uncork his deepest fears in a series of bombshell interviews. “The volatility, is you know, to anyone who has been around, is to a degree alarming,” Corker told the Times earlier this month, revealing that many in the administration were working overtime to keep the president from “the path to World War III.” He doubled down on those comments a few weeks later, declaring that Trump, among other things, was “taking us on a path to combat” with North Korea and should “leave it to the professionals for a while.”

The professionals sure have their hands full. So far, the Trump Doctrine in foreign policy appears to consist of three elements: baiting adversaries, rattling allies, and scaring the crap out of Congress. The administration has injected strategic instability into world politics, undermining alliances and institutions, hastening bad trends, and igniting festering crises across the globe. “America first” looks increasingly like “America alone.” The indispensable nation is becoming the unreliable one. Even without a nuclear disaster, the damage inflicted by the Trump presidency won’t be undone for years, if ever.

But it’s also important to understand that today’s foreign-policy challenges— whether it’s Iran’s hegemonic ambitions in the Middle East, North Korea’s breakneck nuclear breakout, China’s rise, Russia’s nihilism, Europe’s populism and fragmentation, Syria’s civil war, or transnational terrorism and cyber threats—did not start with Trump. This is the most challenging foreign-policy environment any White House has confronted in modern history.

Three swirling complexities explain why.

Threat complexity

Take a look at any of the annual threat assessments issued by the Director of National Intelligence over the past few years. They will make your head spin. They are filled with rising states, declining states, weak states, rogue states, terrorists, hackers, and more. Bad actors don’t just threaten physical space these days. Adversaries are working on ways to cripple America in cyberspace and even outer space—by compromising all those satellite systems on which its digital society depends. In this threat landscape, the number, identity, magnitude, and velocity of dangers facing America are all wildly uncertain. Exactly how many principal adversaries does the United States have? Who are they and what do they want? What could they do to us? How are these threats changing and how can we keep up without spending ourselves into oblivion or leaving ourselves vulnerable to other nasty surprises? These are fundamental questions. There are no consensus answers. Uncertainty is what fuels America’s foreign-policy anxieties today.

The Cold War was different. Then, certainty was what fueled American foreign-policy anxieties. It was clear to all that the U.S. faced a single principal adversary. The Soviet Union had territory on a map and soldiers in uniforms. Thanks to U.S. intelligence, Soviet intentions and capabilities were fairly well understood. The threat landscape was deadly but slower-moving: Communists never met a five-year plan they didn’t like. And while superpower nuclear dangers were terrifying, they were also constraining in a helpful but insane sort of way. In 1961, President Kennedy invoked the specter of a “nuclear sword of Damocles, hanging by the slenderest of threads” over the earth. Every American foreign-policy decision had to consider the question: What would Moscow think of that? Today, the nuclear sword of Damocles is still hanging—indeed, China, India, Pakistan, and North Korea have all successfully tested nuclear devices since 1961—but no singular threat guides U.S. foreign policy as the Soviet Union once did.

Organizational complexity

As threats have grown more complex, organizational arrangements to deal with them have, too. Coordinating Soviet policy was one thing. Developing coherent U.S. foreign policy in the face of so much uncertainty across so many issues is quite another. Little wonder special advisers, envoys, commissions, boards, initiatives, czars, and new agencies have been growing like mushrooms. This may not sound so bad. But it is. Every new agency or czar or special arrangement says, “the regular process here ain’t working.” The crux of the problem is that bureaucracies are notoriously hard to kill or change. Ronald Reagan famously quipped that bureaucracy is the closest thing to immortal life on earth. Whenever a crisis hits, the natural response is to add a new organization and stir. But if today’s chief challenge is developing coherent, coordinated policy in the face of complexity, creating more organizations to coordinate doesn’t get you very far. Over time, the whole bureaucratic universe just keeps growing bigger, filled with obsolete organizations alongside new organizations; fragmented jurisdictions, overlapping jurisdictions, and unclear jurisdictions; and silos so specialized that nobody can see across all the key issues easily.

Cognitive complexity

Humans are not superhuman. Research finds that most people can remember at most seven items at a time, fewer as they grow older. Even the biggest brains have limits. In 2001, Peter Pronovost of Johns Hopkins noticed that highly trained medical teams at the university’s medical center were screwing up insertions of central line catheters, causing infections in critically ill patients at alarming rates. Why? Because they often forgot one of just five simple steps (like washing their hands) before starting the procedure. (Pronovost instituted a checklist that has since become widely used and is credited with saving thousands of lives.)

In foreign policy, too, the stakes are high and humans are frequently overloaded by complexity, resulting in catastrophic errors that nobody ever intended. One of the chief findings of the 9/11 Commission, for example, was that many inside the FBI simply didn’t know or couldn’t remember all the legal requirements and rules for sharing intelligence and law-enforcement information. Even the Bureau’s own 1995 guidelines were “almost immediately misunderstood and misapplied,” the commission concluded. As a result, clues to the terror plot emerged weeks before 9/11 but were marooned in different parts of the bureaucracy.

In 1935, an advanced bomber nicknamed “the Flying Fortress” crashed during a test flight. The Army Air Corps investigation found that the machine worked fine. The problem was the human. The airplane was so sophisticated, flying required the pilot to remember too many things, and he forgot one of them: unlocking the rudder and elevator controls during takeoff. It was “too much airplane for one man to fly,” one reporter later wrote. That crash sparked the invention of pilot checklists which have been used for nearly a century, transforming global aviation.

U.S. foreign policy is becoming too much airplane for one person to fly. “The professionals” surrounding Trump—Secretaries James Mattis and Rex Tillerson, Chief of Staff John Kelly, National-Security Adviser H.R. McMaster, and others—are trying to keep the whole thing from crashing with a pilot who has never flown before. Let’s hope they can.

America’s approach to the world is a complicated mess, for reasons that predate the current president.

Amy Zegart is co-director of the Center for International Security and Cooperation and professor of political science, by courtesy. She is also the Davies Family Senior Fellow at the Hoover Institution and directs the Cyber Policy Program. She wrote this essay as a contributing editor to The Atlantic.

 

Hero Image
gettyimages 600691942 Getty Images/tzahiV
All News button
1
Subscribe to Health and Medicine