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.

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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.”

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.”

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.

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.

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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 Study; V-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 Cohen, Diana Schoder, Joseph 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.

The two-day forum, part of a project of the American Academy of Arts and Sciences, led by the Freeman Spogli Institute’s Karl Eikenberry and Stephen Krasner, gathered experts to examine trends in civil wars and solutions moving forward.   

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The Council on Foreign Relations presently tracks six countries in a state of civil war, including three (South Sudan, Afghanistan, and Yemen) where the situation is currently worsening. Furthermore, three states (Central African Republic, Myanmar, and Nigeria) are experiencing sectarian violence with the potential to become larger conflicts. With two months still remaining in 2018, the combined fatalities in Afghanistan, Syria, and Yemen alone is fast approaching 100,000 for the year.

It was against this backdrop that Shorenstein APARC’s U.S.-Asia Security Initiative (USASI), the American Academy of Arts and Sciences (AAAS), and the School for International Studies at Peking University recently co-hosted the security workshop “Civil Wars, Intrastate Violence, and International Responses.” Held in Beijing, on October 22-23, the workshop brought together thirty-five U.S. and international experts to gain a wider perspective on intrastate violence and consider the possibilities for, and limits of, intervention. The workshop is the latest activity of the AAAS project on Civil Wars, Violence, and International Responses, chaired by Ambassador Karl Eikenberry, director of USASI, and by Stephen Krasner, senior fellow at the Freeman Spogli Institute for International Studies (FSI) and professor of international relations.

“Some of the major discussion topics included the appropriate political and economic development models to apply to fragile states recovering from internal conflict, justifications for intervention, and the likely impact of great power competition on the future treatment of civil wars." - Karl Eikenberry

Workshop participants included academics and professionals with expertise in political science, global health, diplomacy, refugee field work, United Nations, and the military. Countries represented at the table included the United States, Ethiopia, France, and China. Throughout the two-day session, they examined three crucial questions: What is the scope of intrastate conflicts and civil wars, and to what extent is it attributable to domestic or international factors? What types of threats to global security emanate from state civil wars? What policy options are available to regional powers and the international community to deal with such threats?

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USASI Director Karl Eikenberry addresses one of the sessions

China’s Emerging Role in Addressing Intrastate Violence

The workshop’s timing and location was prescient. Over the past two decades, China’s global exposure–through trade, investment, and financing–has increased dramatically. Coupled with a growing number of its citizens living abroad, China’s equity in other states has reached the point where it has a direct interest in those experiencing or are at risk of political instability and internal violence. Indeed, through its ambitious Belt and Road Initiative, China has the opportunity to help stabilize fragile states by stimulating economic development.

“The workshop revealed, at least for me, that China is backing away from its absolute defense of sovereignty and non-intervention,” said Stephen Krasner. “As Chinese interests have expanded around the world, and as both its investments and the number of its citizens living abroad have increased, the Chinese have become more concerned with political conditions in weakly governed countries.”

With China’s growing policy and academic interests in addressing civil wars and intrastate violence, as well as its higher international profile in places like United Nations peacekeeping operations, the Beijing event provided an excellent opportunity for Chinese experts to exchange views with their international colleagues.

Paul H. Wise, MD, MPH; Senior Fellow at Stanford Health Policy

Where We are Today, Where We Go Tomorrow

The Beijing workshop was arranged into four sessions, with themes focusing on trends in intrastate violence, the threats it poses to international security, the limits of intervention, and advice to policymakers.

Each panel included presentations of prepared papers, moderator comments, and an open discussion by all participants. A fifth and final session provided an opportunity to summarize the preceding discussions. The workshop then closed out with an open conversation, where participants offered insight and policy recommendations developed over the preceding two days of dialogue.

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The "Civil Wars, Intrastate Violence, and International Responses” workshop marks the second phase of the AAAS project by the same name that launched in 2015. The first phase of the project culminated in the publication of 28 essays across two volumes of the AAAS quarterly journal Dædalus. The ongoing second phase consists of a series of roundtables and workshops in which project participants engage with academics and with government and international organization officials to build a larger conceptual understanding of the threats posed by the collapse of state authority associated with civil wars, and to contribute to current policymaking. Project activities have included meetings with the United Nations leadership and staff; academic activities in the United States; sessions with the U.S. executive and legislative branches; and a visit to Nigeria.

Throughout the workshop, Chatham House Rule of non-attribution applied to all dialogue. A workshop report will be published by the co-hosts in early 2019.

The U.S.-Asia Security Initiative is part of Stanford University’s Walter H. Shorenstein Asia-Pacific Research Center (APARC). Led by former U.S. Ambassador and Lieutenant General (Retired) Karl Eikenberry, USASI seeks to further research, education, and policy relevant dialogues at Stanford University on contemporary Asia-Pacific security issues.

March 1, 2019 update: the workshop report is now available online. Download the report >> 

Participants in the “Civil Wars, Intrastate Violence, and International Responses” workshop