Former President George W. Bush met with Stanford students for an hourlong conversation that touched on many of the defining moments and policies of his presidency.

In a relaxed and sometimes self-deprecating exchange on May 5, Bush talked about the limits of congressional power and his relationships and personal diplomacy with other world leaders. His tone was more serious when discussing what he described as universal desires for freedom, his military strategies following 9/11, and his commitment to addressing Africa’s HIV/AIDS pandemic.

Mariano-Florentino Cuéllar, director of the university’s Freeman Spogli Institute for International Studies, moderated the session. Stanford President John Hennessy and Condoleezza Rice – Bush’s secretary of state and national security adviser who has returned to teaching political science and business at Stanford – joined the conversation.

"FSI has a terrific track record of convening leaders at Stanford, from the head of the International Monetary Fund to prime ministers and presidents,” Cuéllar said. “On this occasion, we wanted our students to have an opportunity for a candid conversation with one of the key policymakers of the early 21^st century, and we think such experiences will further prepare them for leadership in a complex world."

About 30 students were invited to the session at Encina Hall, but they didn’t know they were meeting Bush until the 43^rd president walked into the room.

“I suspect he misses this sort of engagement,” said Gregory Schweizer, a second-year law school student who was part of the discussion that also covered immigration reform, national education policies and the Edward Snowden affair.

“The media always portrays him as being disengaged from current affairs,” Schweizer said. “But I’m impressed with how interested and engaged he still is.”

Along with representatives from Stanford Law School, other students were invited from the Ford Dorsey Program in International Policy Studies. Honors students from FSI’s Center for International Security and Cooperation and Center on Democracy, Development, and the Rule of Law also joined the conversation.

Bush’s visit was arranged with the help of  Brad Freeman, a former university trustee and Ronald Spogli, who is currently on Stanford's board of trustees. Freeman and Spogli are longtime friends of the former president and philanthropists who donated a naming gift to FSI in 2005. Bush appointed Spogli as ambassador to Italy in 2005 and as ambassador to San Marino a year later. 

Stanford has a tradition of hosting current and former heads of state, including German Chancellor Angela Merkel and former Russian President Dmitry Medvedev – both of whom visited in 2010.

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

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

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

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

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

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

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

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

That’s where GeneXpert has an upper hand.

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

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

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

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

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

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

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

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

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

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

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