Please note: the start time for this event has been moved from 3:00 to 3:15pm.

Join FSI Director Michael McFaul in conversation with Richard Stengel, Under Secretary of State for Public Diplomacy and Public Affairs. They will address the role of entrepreneurship in creating stable, prosperous societies around the world.

Richard Stengel Undersecretary of State for Public Diplomacy and Public Affairs Special Guest United States Department of State
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Sharon Beckstrand
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Slavery victimizes tens of millions of people worldwide. In 2016, 40 million people were identified as slaves, an estimated 25% percent of them children. Given a broader definition of slavery that includes child labor and child servitude, 152 million children between the ages of 5 and 17 were child laborers as of 2016, and many millions more were involved in some form of slavery-like practice.

Stanford PhD candidate Vincent Jappah, MD, notes in his new article published in the journal Medicine, Conflict and Survival, that the gray area surrounding the acceptance of child servitude in many cultures makes formulating the correct number of victims difficult. Call it servitude or slavery, the practice diminishes the health and social well-being of children and causes harmful ripple effects in their communities as well as to the rest of the world.

Jappah notes that policies to address child servitude and other slavery-like practices are fundamental to global health policy and development. Using a health equity framework can help mitigate the negative impacts of child servitude, in that it requires addressing the diverse factors that impact a person’s ability to meet key health milestones. Irrespective of a person’s race, socio-economic status, financial and physical ability, all global citizens have the right to a healthy life.

The study, “The political economy of child service in Liberia, West Africa,” co-authored by Jappah and Danielle Taana Smith, a professor of African American Studies at Syracuse University, notes that modern slavery is often centered around alleviating one’s own personal poverty and gaining power, even if that means exploiting the children of your own community.

Both Liberian natives, the researchers note that Liberians — like those of other countries including the United States — will often target those from low socioeconomic backgrounds and indigenous peoples.

This often takes place “within groups that in many instances share similar racial identities and physical features,” Jappah said. “Today, the child next door in a neighbor’s home may be deprived of going to school and coerced into performing endless hours of chores, with poor food and living conditions, the inability to leave the house, and the constant fear of violence.”

Jappah notes child servitude can potentially have devastating health consequences, and poses a major health challenge for individuals and their communities. Many victims typically live in unsuitable and unsanitary environments often littered with mosquitos, flies, lice, and other transmitters of disease. These children may also face poor mental health outcomes such as depression, social anxiety and social dysfunction, low self-esteem and failure to meet critical developmental milestones.

These children, as all children do, internalize and, to some extent, normalize their living conditions, and society becomes more acquiescent to such practices, despite their detrimental effects.
Vincent Jappah, MD, MPH
PhD Candidate, Stanford Heath Policy

Liberia is one of the poorest countries in the world, having suffered years of civil war and regional conflict. Its human development indicators rank 175 out of 189 countries on the 2019 Human Development Index. The child malnutrition rate is 15% among 5-year-olds and younger and many Liberians lack access to basic needs such as food, water, shelter, education, and health care.

In fact, the authors note, nearly 63% of the people in the West African nation established by freed American slaves live in poverty; 69% of the country’s 5 million people live on less than $3.20 a day.

“A functional economy that ensures that most citizens can earn a living wage does not exist,” the authors wrote. “Extreme poverty in some families, high levels of illiteracy and unemployment, and suboptimal economic activities contribute to child servitude and other forms of child exploitation.”

The children of Liberia are not alone. In societies with inherent instability and ongoing conflict, the practice of child servitude can become accepted as a normal way to make money and centralize power when opportunity and resources are scarce.

Jappah notes that for young children and adolescents, this is the period of forming personality, critical reasoning and developing relationships outside of the home, as well as forming opinions about the world around them. Living in such dehumanizing conditions can result in shame and trauma and often have intergenerational effects. They also have lower levels of education and higher dropout rates, contributing to an ongoing cycle of intergenerational poverty.

“These children, as all children do, internalize and, to some extent, normalize their living conditions, and society becomes more acquiescent to such practices, despite their detrimental effects,” Jappah said.  “These practices are widespread in places where laws are not adequate to address them, or if there are laws, few enforcement mechanisms are in place, or they are not enforced.”

Jappah said Liberians must address their cultural history of exploitation if they want to abolish the practice of child servitude. In addition, addressing the larger issues of inequity and the exclusion of marginalized groups is necessary.

“Throughout human history, we have witnessed clashes among social classes and groups,” Jappah said. “The more inequitable a society is, the more likely it is to be rife with social tensions.”

He concluded that those tensions are evident in developing countries as well as the industrialized nations such as the United States, a Western harbor of child trafficking and slavery. According to the Global Slavery Index, on any given day in 2016 there were 403,000 people living in conditions of modern slavery in the United States — or 1.3 victims of slavery for every thousand people in this country.

 “This phenomenon is universal; Liberia is not an exception,” Jappah said.



Vincent Jappah Photo

Vincent Jappah, MD, MPH

PhD Candidate
He focuses on public policy, economics, global child and maternal health.
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A new article co-authored by Health Policy PhD candidate Vincent Jappah reveals that the modern drivers of child servitude in Liberia are largely social vulnerability and cultural acceptance of the practice, rather than traditional factors based on race and ethnicity.


In addition to her role as Director of Strategic Partnerships for the Human Trafficking Data Lab, Jessie Brunner serves as Deputy Director of Strategy and Program Development at the Center for Human Rights and International Justice at Stanford University. In this capacity she manages the Center's main interdisciplinary collaborations and research activities, in addition to advising on overall Center strategy. Jessie currently researches issues relevant to data collection and ethical data use in the human trafficking field, with a focus on Brazil and Southeast Asia. Furthermore, in her role as co-Principal Investigator of the Re:Structure Lab, Jessie is investigating how supply chains and business models can be re-imagined to promote equitable labor standards, worker rights, and abolish forced labor. Brunner earned a MA in International Policy from Stanford University and a BA in Mass Communications and a Spanish minor from the University of California, Berkeley.

Director of Strategic Partnerships, Human Trafficking Data Lab
Deputy Director of Strategy and Program Development, Center for Human Rights and International Justice

Nearly 120 million children in 37 countries are at risk of missing their measlescontaining vaccine (MCV) shots this year, as preventive and public health campaigns take a back seat to policies put in place to contain coronavirus disease 2019 (COVID-19). In March, the World Health Organization (WHO) issued guidelines indicating that mass vaccination campaigns should be put on hold to maintain physical distancing and minimize COVID-19 transmission. The disruption of immunization services, even for short periods, will lead to more susceptible individuals, more communities with less than the 95% MCV coverage needed for herd immunity, and therefore more measles outbreaks globally. A mere 15% decrease in routine measles vaccinations—a plausible result of lockdowns and disruption of health services—could raise the burden of childhood deaths by nearly a quarter of a million in poorer countries. Solutions for COVID-19, especially among the global poor, cannot include forgoing vaccinations.

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Deparati Guha-Sapir
Maria Moitinho de Almeida
Mory Keita
Gregg Greenough
Eran Bendavid
Beth Duff-Brown
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The U.S. government's global hunger and food security initiative, Feed the Future, has prevented 2.2 million children from experiencing malnutrition in sub-Saharan Africa, according to new research led by Stanford Health Policy's PhD candidate Tess Ryckman.

The researchers compared children’s health in 33 low- and middle-income countries in sub-Saharan Africa. In 12 of those countries, Feed the Future provided services such as agricultural assistance and financial services for farmers, as well as direct nutrition support, such as nutrient supplementation. 

The study, published online Dec. 11 in The BMJ, found a 3.9 percentage point decrease in chronic malnutrition among children served by Feed the Future, leading to 2.2 million fewer children whose development has been harmed by malnourishment.

“What we see with stunting rates is striking,” Ryckman said. “I would argue that 2 million fewer children stunted over seven years is major progress and puts a substantial dent in total stunting levels. And that’s 2 million children who will now have the levels of physical and cognitive development to allow them to reach their full potential.”

Stunting, or having a low height for a particular age, is a key indicator of child malnutrition. Children who aren’t properly nourished in their first 1,000 days are more likely to get sick more often, to perform poorly in school, grow up to be economically disadvantaged and suffer from chronic diseases, according to the World Health Organization.

A Controlled Study

Feed the Future is thought to be the world’s largest agricultural and nutrition program, with around $6 billion in funding from USAID (plus more from other federal agencies) between 2010 and 2015. Despite its size, much remains unknown about the effectiveness of the program.

The researchers analyzed survey data on almost 900,000 children younger than 5 in sub-Saharan Africa from 2000 to 2017. They compared children from the Feed the Future countries with those in countries that are not participants in the program, both before and after the program’s implementation in 2011.

The researchers found the results were even more pronounced — a 4.6 percentage point decline in stunting — when they restricted their sample to populations most likely to have been reached by program. These included children who were younger when the program began, rural areas where Feed the Future operated more intensively, and in countries where the program had greater geographic coverage.

“Our findings are certainly encouraging because it has been difficult for other programs and interventions to demonstrate impact on stunting, and this program has received a lot of funding, so it’s good to see that it’s having an impact,” Ryckman said.

Multifaceted Approach to Nutrition

Experts are divided about the best way to help the world’s 149 million malnourished children: Is assistance that directly targets nutrition, such as breastfeeding promotion or nutrient supplementation, more effective? Or is it also beneficial to tackle the problem at its root by supporting agriculture and confronting household poverty?

The authors, including Stanford Health Policy’s Eran Bendavid, MD, associate professor of medicine, and Jay Bhattacharya, MD, PhD, professor of medicine, a senior fellow (by courtesy) at the Freeman Spogli Institute of International Studies and a senior fellow senior fellow at the Stanford Institute for Economic Policy Research, said their analysis supports the value of a multifaceted approach to combating malnutrition among children, namely leveraging agriculture and food security interventions.

“Independent evaluations of large health policy programs such as Feed the Future help build the evidence base needed to tackle persistent patterns of undernutrition,” said Bendavid, an epidemiologist. “The widespread prevalence of stunting and chronic undernutrition is among the most common and yet most stubborn cause of underdevelopment in the world, and learning what works in this space is sorely needed.”

The researchers, including Stanford medical students Margot Robinson and Courtney Pederson, speculated that possible drivers of the program’s effectiveness include three features of Feed the Future’s design: its country-tailored approach; its focus on underlying drivers of nutrition, such as empowering female farmers; and its large scale and adequate funding.

The authors hope their independent evaluation of the program might lead to more funding and support for it. At the very least, they said, it should demonstrate to people working on Feed the Future and the broader global nutrition program community that programs focused mostly on agriculture and food security — indirect contributors to malnutrition — can lead to success.

Value Unknown

Feed the Future has been scaled back in recent years — it once served 19 countries and now reaches only 12. The program’s budget also remains somewhat murky.

“While there isn’t much data on the program’s funding under the Trump administration, the program appears to have been scaled back, at least in terms of the countries where it operates,” Ryckman said. “It’s possible that some of these gains could be lost, absent longer-term intervention from Feed the Future.”


The researchers also did not look at whether the program provided high value for the money spent.

“While we find that it has been effective, it hasn’t led to drastic declines in stunting and it is unclear whether it is good value for money,” she said.

Ryckman also noted that USAID’s own evaluation of its program is tenuous because it looked only at before-and-after stunting levels in Feed the Future countries without comparing the results to a control group or adjusting for other sources of bias, which is problematic because stunting is slowly declining in most countries.

“These types of evaluations are misleading,” Ryckman said. “The U.S. government really needs to prioritize having their programs independently evaluated using more robust methods. That was part of our motivation for doing this study.”

Support for the study was provided by the National Institutes of Health (grant P20-AG17253), the National Science Foundation and the Doris Duke Charitable Foundation.


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Beth Duff-Brown
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Armed conflict continues its brutal march in Syria, Yemen, Southeast Asia and South Sudan — to name a few of the international hotspots that contributed to an 11% increase in political violence around the world in 2018.

Nearly 10 million Yemenis are facing famine this year; Syria was the deadliest place on earth for civilians last year, with more than 7,100 fatalities.

Many of those killed — and even more who face starvation — are children. And that’s when Stanford professor of pediatrics Paul Wise finds it hard to stand on the sidelines. Wise, who has traveled to Guatemala annually for the last 40 years to treat children in rural communities, also travels to the frontlines of global calamities.

As part of a small team of physicians, Wise went to Mosul, the northern city in Iraq once controlled by ISIS, in 2017 to evaluate the World Health Organization-led system to treat civilians injured in the brutal battle for the city. 

Working with colleagues at the Freeman Spogli Institute for International Studies, Wise has collaborated with the U.S. military, non-governmental organizations and the United Nations on the interaction of humanitarian and security challenges.

So, it should come as no surprise that the American Academy of Arts & Sciences — of which he is a member — recently appointed him and two other global health experts to lead a new initiative to develop new strategies to protect civilians, health care and cultural heritage in areas of extreme violence. 

The initiative, Rethinking the Humanitarian Health Response to Violence Conflict, will be a collaboration among political scientists, international human rights lawyers, physicians, academics and even the curators of major museums. They will develop strategies to prevent civilian harm and deliver critical health services in areas plagued by violent conflict, most notably in the Middle East, central and north Africa and parts of Asia. 

“We also want to address the humanitarian and protective frameworks that operate in areas that are extremely violent but wouldn’t necessarily be defined as being in armed conflict, like in the northern triangle of Central America. The human toll in these areas is at least as great as some of these other more traditionally defined areas,” Wise said.

wise guatemala

Another of those areas is Myanmar, where nearly 700,000 ethnic Rohingya Muslims have fled to neighboring Bangladesh amid sectarian violence in the northern Rakhine province, in what the United Nations calls a “textbook example of ethnic cleansing.”

Rethinking is also headed up by global health expert Jaime Sepulvedaof the University of California, San Francisco, and Jennifer M. Welsh, a global governance and security expert at   McGill University in Canada. Their work will result in a series of publications, blog posts, videos, podcasts and op-eds as a means to reach not only a general audience but also local and field-based humanitarian health providers. The initiative will also seek the engagement of those directly victimized by violence in the areas of greatest concern. 

“We will come up with new strategies to protect civilians and deal with their needs when protection fails in the real world,” Wise said. “The goal is to make a difference in the real world. That’s a much more ambitious goal of course, but it’s the only goal that’s worthy of this kind of initiative.” 

A professor of pediatrics in the Medical School and core faculty member at Stanford Health Policy, Wise is also appointed in several international security programs at Stanford, including the Center on Democracy, Development and the Rule of Law,and the Center for International Security and Cooperation,and is a senior fellow at the Freeman Spogli Institute for International Studies.

Wise said he is particularly excited about the prospect of working with those who curate and protect cultural heritage sites and objects.

“The other thing about the American Academy of Arts & Sciences is that we are not just academics, but artists, musicians, novelists — and we expect to take full advantage of breaking out into these disciplines that aren’t normally part of these conversations,” Wise said.

When fire nearly toppled Notre Dame in Paris three months ago, Parisians gathered near the French Gothic cathedral to pray and to sing. When al-Qaida seized control of the North African country of Mali in 2012, a band of librarians undertook a dangerous mission to protect 350,000 centuries-old Arabic texts and smuggled them out of the library in Timbuktu.

At a recent meeting at the Getty Museum in Los Angeles, Wise met with museum directors, archeologists and political scientists about the preservation of cultural heritage.

“It was very clear that there were enormous areas of overlap between the efforts to protect cultural heritage and the efforts to protect people,” he said. “They’re just pragmatically connected because when you start destroying things of cultural importance, it tends to be associated ultimately with atrocities against people.”

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Krysten Crawford
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A U.S. foreign policy that cuts money to nongovernmental organizations performing or promoting abortions abroad has actually led to an increase in abortions, according to Stanford researchers who have conducted the most comprehensive academic study of the policy’s impact.

Eran Bendavid and Grant Miller — both associate professors at Stanford University School of Medicine and core faculty members at Stanford Health Policy — and doctoral candidate Nina Brooks find that abortions increased among women living in African countries where NGOs, such as the International Planned Parenthood Federation, were most vulnerable to the policy’s requirements.

The policy, widely known as the Mexico City Policy, explicitly prohibits U.S. foreign aid from flowing to any NGO that will not abide by the policy’s main condition: no performing or discussing abortion as a method of family planning, even if just in the form of education or counseling.

The policy has been a political hot potato since its inception. Enacted under Ronald Reagan in 1984, it’s been enforced by subsequent Republican administrations while Democrats in the White House revoked the policy within days of taking office.

The study by Brooks, Bendavid and Miller, published June 27 in The Lancet Global Health, looked at the policy’s effects in more than two dozen African countries over a span of 20 years under three presidents: Bill Clinton, George W. Bush and Barack Obama. It finds that, when the policy was in place during the Bush years, abortions were 40 percent higher relative to the Clinton and Obama administrations.

When the policy was suspended during Obama’s two terms, the research shows that the upward trend in abortion rates reversed.

“Our research suggests that a policy that is supported by taxpayers ostensibly wishing to drive down abortion rates worldwide does the opposite,” said Bendavid, a faculty affiliate of the Stanford King Center on Global Development, which is part of the Stanford Institute for Economic Policy Research (SIEPR).

A key reason for the uptick in abortions is that many NGOs affected by the policy also provide contraceptives – and funding cuts mean birth control is harder to get, said Brooks.

“By undercutting the ability to supply modern contraceptives, the unintended consequence is that abortion rates increase,” she said.

And the policy’s scope has expanded under the Trump administration. While it originally restricted aid directed only toward providing family planning and reproductive health services, President Trump has extended the policy to cover any group engaged in global health, including organizations providing services for HIV or child health – not just family planning.

Groundbreaking Research

The stakes are high. America is the world’s largest provider of development assistance and spent about $7 billion on international health aid in 2017. Many women in sub-Saharan Africa depend on this aid for contraceptives.

In sub-Saharan Africa, NGOs are often primary providers of family planning services. Two of the world’s largest family planning organizations – International Planned Parenthood Federation and Marie Stopes International – have forfeited large sums of U.S. cash for refusing to comply with the policy, according to news reports.

The research findings were based on records of nearly 750,000 women in 26 sub-Saharan African countries from 1995 to 2014. When the policy was in effect under George W. Bush, contraceptive use fell by 14 percent, pregnancies rose by 12 percent and abortions rose by 40 percent relative to the Clinton and subsequent Obama years – an impact sharply timed with the policy and in proportion to the importance of foreign assistance across sub-Saharan Africa.

The paper is the second study of the rule’s impact by Bendavid and Miller, who are both faculty members of Stanford Health Policy. The research is also one of the very few evidence-based analyses of the policy.

Their earlier research, the first quantitative, large-scale effort to examine the policy’s impacts, looked at a smaller set of African countries during the Clinton and Bush administrations and also found an increase in abortion rates when the policy was enacted in 2001.

“Our latest study strengthened our earlier findings because we were able to look at what happens when the rule was turned off, then on, and then off again,” said Bendavid, referring to the policy’s whipsawing under Clinton, Bush and then Obama.

Miller, who is the director of the King Center and a SIEPR senior fellow, says the team’s research reveals a deeply flawed policy.

“We set out to provide the best and most rigorous evidence on the consequences of this policy,” he said. “What we found is a clear-cut case of government action that everyone on all sides of the abortion debate should agree is not desirable.”

Signs of a Global Pushback

Brooks also notes that their findings may underestimate the rule’s full impact.

“The excess abortions performed due to the policy are more likely to be performed unsafely, potentially harming women beyond pregnancy terminations,” she said.

Under Trump, the international response to U.S. funding cuts has shifted. Norway, Canada and several other countries have pledged to increase funding of international NGOs affected by the policy – though not by enough to cover the expected shortfall, says Miller.

“This shows us,” he said, “that despite the intense partisanship in the U.S. over the rule and its implementation, there are ways that policymakers around the world can offset its effects – by ensuring higher levels of family planning funding, for example.”

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May Wong
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A new study by Stanford economists shows that giving fathers flexibility to take time off work in the months after their children are born improves the postpartum health and mental well-being of mothers.

In the study, slated for release by the National Bureau of Economic Research on June 3, Petra Persson and Maya Rossin-Slater examined the effects of a reform in Sweden that introduced more flexibility into the parental leave system. The 2012 law removed a prior restriction preventing a child’s mother and father from taking paid leave at the same time. And it allowed fathers to use up to 30 days of paid leave on an intermittent basis within a year of their child’s birth while the mothers were still on leave.

The policy change resulted in some clear benefits toward the mother’s health, including reductions in childbirth-related complications and postpartum anxiety, according to their empirical analysis.

“A lot of the discussion around how to support mothers is about mothers being able to take leave, but we often don’t think about the other part of the equation — fathers,” says Rossin-Slater, an assistant professor of health research and policy.

“Our study underscores that the father’s presence in the household shortly after childbirth can have important consequences for the new mother's physical and mental health,” says Persson, an assistant professor of economics.

Rossin-Slater and Persson are both faculty fellows at the Stanford Institute for Economic Policy Research.

Among their main findings of effects following the reform: Mothers are 14 percent less likely to need a specialist or be admitted to a hospital for childbirth-related complications — such as mastitis or other infections — within the first six months of childbirth. And they are 11 percent less likely to get an antibiotic prescription within that first half-year of their baby’s life.

There is also an overall 26 percent drop in the likelihood of any anti-anxiety prescriptions during that six-month postpartum period — with reductions in prescriptions being most pronounced during the first three months after childbirth.

What’s more, the study found that the average new father used paid leave for only a few days following the reform — far less than the maximum 30 days allowed — indicating how strong of a difference a couple of days of extra support for the mother could make.

“The key here is that families are granted the flexibility to decide, on a day-to-day basis, exactly when to have the dad stay home,” said Persson. “If, for example, the mom gets early symptoms of mastitis while breastfeeding, the dad can take one or two days off from work so that the mom can rest, which may avoid complications from the infection or the need for antibiotics.”

These indirect benefits from giving fathers workplace flexibility are not trivial matters when you consider the health issues mothers often face after childbirth and after they get home from the hospital, says Rossin-Slater, who is also a faculty member of Stanford Health Policy.

Infections and childbirth complications lead to one out of 100 women getting readmitted to the hospital within 30 days in the United States, according to the study.

Meanwhile, postpartum depression occurs for about one out of nine women, and maternal mortality has also been a rising trend over the past 25 years in the U.S.

The study comes as a growing number of lawmakers in the United States vocalize support for paid family leave but have failed to pass federal legislation.

Washington, D.C., and six states have adopted various paid family leave laws, but the U.S. remains the only industrialized nation in the world that does not have a national mandate guaranteeing a certain amount of paid parental leave.

Some federal lawmakers are working on family leave measures and have proposed such legislation over the past few years — including The Family Act, The New Parents Act — but none of them have ever gained enough traction to proceed in Congress.

This new study can help broaden the policy discussions, the researchers say.

The larger context around paid family leave policies is often framed today as a way to help narrow the gender wage gap by giving women more workplace flexibility and fewer career setbacks.

This study, however, shines a light on maternal health costs and how a policy on paid family leave — that includes workplace flexibility for the father — offers more benefits than previously thought, Rossin-Slater says.

“It's important to think not only about giving families access to some leave, but also about letting them have agency over how they use it,” she says.

And when it comes to concerns that fathers might use paid parental leave to goof off instead of spending the time as intended, the researchers say their study should assuage those worries.

“It's not like fathers are going to end up using a whole month to just stay home and watch TV. We don't find any evidence of that,” Rossin-Slater says. “Instead they only use a limited number of days precisely when the timing for that seems most beneficial for the family.”

“For all these reasons,” Persson says, “giving households flexibility in how to use paternity leave makes a lot of sense.”

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Beth Duff-Brown
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U.S. government aid for treating children and adults with HIV and malaria in developing countries has done more than expand access to lifesaving interventions: It has changed how people around the world view the United States, according to a new study by researchers at the School of Medicine.

Compared with other types of foreign aid, investing in health is uniquely associated with a better opinion of the United States, improving its “soft power” and standing in the world, the study said.  

Favorability ratings of the United States increased in proportion to health aid from 2002 to 2016 and rose sharply after the implementation of the President’s Emergency Plan for AIDS Relief in 2003 and the launch of the President’s Malaria Initiative in 2005, the researchers report.

Their findings were published this week in the American Journal of Public Health. The lead author is postdoctoral scholar Aleksandra Jakubowski, PhD, MPH. The senior author is Eran Bendavid, MD, associate professor of medicine and a core faculty member at Stanford Health Policy.

“Using data on aid and opinions of the United States, we found that investments in health offer a unique opportunity to promote the perceptions of the United States abroad, in addition to disease burden relief,” the authors wrote. “Our study provides new evidence to support the notion that health diplomacy is a net win for the United States and recipient countries alike.”

The Trump administration, however, has proposed a 23% cut in foreign aid in its 2020 budget, including large reductions to programs that fight AIDS and malaria overseas.

The Stanford researchers believe their study is the first to add heft to the argument that U.S. health aid boosts the “soft power” that wins the hearts and minds of foreign friends and foes.

“Our study shows that investing in health aid improves our nation’s standing abroad, which could have important downstream diplomatic benefits to the United States,” Jakubowskisaid. “Investments in health aid help the United States accumulate soft power. Allowing the U.S. reputation to falter would be contrary to our own interests.” 

A Policy Debate

Many politicians and economists consider spending U.S. tax dollars on foreign aid as an ineffective, and possibly harmful, enterprise that goes unappreciated and leads to accusations of American meddling in other countries’ national affairs.

The U.S. government, for the past 15 years, has contributed more foreign health aid than any other country, significantly reducing disease burden, increasing life expectancy and improving employment in recipient countries, the authors wrote. Still, this generosity has historically constituted less than 1% of the U.S. gross domestic product.

“Our results suggest that the dollars invested in health aid offer good value for money,” the researchers wrote. “That is, the relatively low investment in health aid (in terms of GDP) has provided the United States with large returns in the form of improved public perceptions, which may advance the U.S. government’s ability to negotiate international policies that are aligned with American priorities and preferences.”

The researchers used 258 Global Attitudes Surveys, based on interviews with more than 260,000 respondents, conducted by the Pew Research Center in 45 low- to middle-income countries between 2002 and 2016.

Their analysis focused on the health sector, which includes several large programs for infectious disease control, but also support for nutrition, child health and reproductive health programs. They compared health aid to other major areas of U.S. investment: governance, infrastructure, humanitarian aid and military aid. They also constructed a database of news stories that mentioned the President’s Emergency Plan for AIDS Relief or the President’s Malaria Initiative by crawling through the online archives of the top three newspapers by circulation in each of the 45 countries.

They found that the probability of populations holding a very favorable opinion of the United States was 19 percentage points higher in the countries where and years when U.S. donations for health care were highest, compared with countries where and years when health aid donations were lowest. Using another metric, the researchers found that every additional $100 million in health aid was associated with a nearly 6 percentage-point increase in the probability of respondents indicating they had a “very favorable” opinion of the United States. 

In contrast, the researchers found, aid for governance, infrastructure, humanitarian and military purposes was not associated with a better opinion of the United States.

Bendavid, an infectious diseases physician and core faculty member of Stanford Health Policy, said that when he set out to conduct this research, he believed it would result “in a resounding thud” — that the “soft power” of health aid would have no impact on public opinion.

“For me, the notion that this program — hatched and headquartered in D.C. — would have impacts among millions in Nairobi and Dakar, seemed farfetched,” Bendavid said. “I was incredulous until all the pieces were in place.”

The ‘America First’ Agenda

The Trump administration’s “America First” agenda is calling for significant cuts to global health aid, particularly to the highly successful AIDS relief program, which was established by President George W. Bush. The administration’s budget, released in March, proposed a $860 million cut to the program; the President’s Malaria Initiative is facing a $331 million reduction in federal funding. That’s a decline of 18% and 44%, respectively.

The U.S. contribution to the Global Fund to Fight AIDS, Tuberculosis and Malaria would also decline by 17%, or $225 million, according to the Kaiser Family Foundation.

Yet beyond the reputational damage to the United States, such cuts could be a major setback to improving health outcomes in developing countries, the researchers said. After all, HIV knows no borders, and having more resilient health care systems is instrumental when facing public health crises, such as the Ebola outbreak in the Democratic Republic of Congo, Jakubowski said.

“The most direct impact of cutting the United States’ health aid allocations is the potential to undermine or reverse the progress that has been enabled by U.S. aid in curbing mortality and the spread of disease,” Bendavid said. “However, this study suggests there are also repercussions to the United States: the relationships the U.S. has built with recipient nations could also be undermined.”            

Other Stanford co-authors are Steven Asch, MD, MPH, professor of medicine, and former graduate student Don Mai.

Stanford’s Department of Medicine supported the work.

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Beth Duff-Brown
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Most studies that look at whether democracy improves global health rely on measurements of life expectancy at birth and infant mortality rates. Yet those measures disproportionately reflect progress on infectious diseases — such as malaria, diarrheal illnesses and pneumonia — which relies heavily on foreign aid.

A new study led by Stanford Health Policy's Tara Templin and the Council on Foreign Relations suggests that a better way to measure the role of democracy in public health is to examine the causes of adult mortality, such as noncommunicable diseases, HIV, cardiovascular disease and transportation injuries. Little international assistance targets these noncommunicable diseases. 

When the researchers measured improvements in those particular areas of public health, the results proved dramatic.

“The results of this study suggest that elections and the health of the people are increasingly inseparable,” the authors wrote.

A paper describing the findings was published today in The Lancet. Templin, a graduate student in the Department of Health Research and Policy, shares lead authorship with Thomas Bollyky, JD, director of the Global Health Program at the Council on Foreign Relations.

“Democratic institutions and processes, and particularly free and fair elections, can be an important catalyst for improving population health, with the largest health gains possible for cardiovascular and other noncommunicable diseases,” the authors wrote.

Templin said the study brings new data to the question of how governance and health inform global health policy debates, particularly as global health funding stagnates.

“As more cases of cardiovascular diseases, diabetes and cancers occur in low- and middle-income countries, there will be a need for greater health-care infrastructure and resources to provide chronic care that weren’t as critical in providing childhood vaccines or acute care,” Templin said.


Free and fair elections for better health

In 2016, the four mortality causes most ameliorated by democracy — cardiovascular disease, tuberculosis, transportation injuries and other noncommunicable diseases — were responsible for 25 percent of total death and disability in people younger than 70 in low- and middle-income countries. That same year, cardiovascular diseases accounted for 14 million deaths in those countries, 42 percent of which occurred in individuals younger than 70.

Over the past 20 years, the increase in democratic experience reduced mortality in these countries from cardiovascular disease, other noncommunicable diseases and tuberculosis between 8-10 percent, the authors wrote.

“Free and fair elections appear important for improving adult health and noncommunicable disease outcomes, most likely by increasing government accountability and responsiveness,” the study said.

The researchers used data from the Global Burden of Diseases, Injuries, and Risk Factors StudyV-Dem; and Financing Global Health databases. The data cover 170 countries from 1970 to 2015.

What Templin and her co-authors found was democracy was associated with better noncommunicable disease outcomes. They hypothesize that democracies may give higher priority to health-care investments.

HIV-free life expectancy at age 15, for example, improved significantly — on average by 3 percent every 10 years during the study period — after countries transitioned to democracy. Democratic experience also explains significant improvements in mortality from cardiovascular disease, tuberculosis, transportation injuries, cancers, cirrhosis and other noncommunicable diseases, the study said.

Watch: Some of the authors of the study discuss the significant their findings: 


What Templin and her co-authors found was democracy was associated with better noncommunicable disease outcomes. They hypothesize that democracies may give higher priority to health-care investments.

HIV-free life expectancy at age 15, for example, improved significantly — on average by 3 percent every 10 years during the study period — after countries transitioned to democracy. Democratic experience also explains significant improvements in mortality from cardiovascular disease, tuberculosis, transportation injuries, cancers, cirrhosis and other noncommunicable diseases, the study said.

Foreign aid often misdirected

And yet, this connection between fair elections and global health is little understood.

“Democratic government has not been a driving force in global health,” the researchers wrote.  “Many of the countries that have had the greatest improvements in life expectancy and child mortality over the past 15 years are electoral autocracies that achieved their health successes with the heavy contribution of foreign aid.”

They note that Ethiopia, Myanmar, Rwanda and Uganda all extended their life expectancy by 10 years or more between 1996 and 2016. The governments of these countries were elected, however, in multiparty elections designed so the opposition could only lose, making them among the least democratic nations in the world.

Yet these nations were among the top two-dozen recipients of foreign assistance for health.

Only 2 percent of the total development assistance for health in 2016 was devoted to noncommunicable diseases, which was the cause of 58 percent of the death and disability in low-income and middle-income countries that same year, the researchers found.

“Although many bilateral aid agencies emphasize the importance of democratic governance in their policy statements,” the authors wrote, “most studies of development assistance have found no correlation between foreign aid and democratic governance and, in some instance, a negative correlation.”

Autocracies such as Cuba and China, known for providing good health care at low cost, have not always been as successful when their populations’ health needs shifted to treating and preventing noncommunicable diseases. A 2017 assessment, for example, found that true life expectancy in China was lower than its expected life expectancy at birth from 1980 to 2000 and has only improved over the past decade with increased government health spending. In Cuba, the degree to which its observed life expectancy has exceeded expectations has decreased, from four-to-seven years higher than expected in 1970 to three-to-five years higher than expected in 2016.

“There is good reason to believe that the role that democracy plays in child health and infectious diseases may not be generalizable to the diseases that disproportionately affect adults,” Bollyky said. Cardiovascular diseases, cancers and other noncommunicable diseases, according to Bollyky, are largely chronic, costlier to treat than most infectious diseases, and require more health care infrastructure and skilled medical personnel.  

The researchers hypothesize that democracy improves population health because:

  1. When enforced through regular, free and fair elections, democracies should have a greater incentive than autocracies to provide health-promoting resources and services to a larger proportion of the population;
  2. Democracies are more open to feedback from a broader range of interest groups, more protective of media freedom and might be more willing to use that feedback to improve their public health programs;
  3. Autocracies reduce political competition and access to information, which might deter constituent feedback and responsive governance.

Various studies have concluded that democratic rule is better for population health, but almost all of them have focused on infant and child mortality or life expectancy at birth.

Over the past 20 years, the average country’s increase in democracy reduced mortality from cardiovascular disease by roughly 10 percent, the authors wrote. They estimate that more than 16 million cardiovascular deaths may have been averted due to an increase in democracy globally from 1995 to 2015. They also found improvements in other health burdens in the countries where democracy has taken hold: an 8.9 percent reduction in deaths from tuberculosis, a 9.5 percent drop in deaths from transportation injuries and a 9.1 percent mortality reduction in other noncommunicable disease, such as congenital heart disease and congenital birth defects.

“This study suggests that democratic governance and its promotion, along with other government accountability measures, might further enhance efforts to improve population health,” the study said. “Pretending otherwise is akin to believing that the solution to a nation’s crumbling roads and infrastructure is just a technical schematic and cheaper materials.”

The other researchers who contributed to the study are Matthew CohenDiana SchoderJoseph Dieleman and Simon Wigley, from CFR, the University of Washington-Seattle and Bilkent University in Turkey, respectively.

Funding for the research came from Bloomberg Philanthropies and the Bill & Melinda Gates Foundation. Stanford’s Department of Health Research and Policy also supported the work.

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