FSI researchers strive to understand how countries relate to one another, and what policies are needed to achieve global stability and prosperity. International relations experts focus on the challenging U.S.-Russian relationship, the alliance between the U.S. and Japan and the limitations of America’s counterinsurgency strategy in Afghanistan.
Foreign aid is also examined by scholars trying to understand whether money earmarked for health improvements reaches those who need it most. And FSI’s Walter H. Shorenstein Asia-Pacific Research Center has published on the need for strong South Korean leadership in dealing with its northern neighbor.
FSI researchers also look at the citizens who drive international relations, studying the effects of migration and how borders shape people’s lives. Meanwhile FSI students are very much involved in this area, working with the United Nations in Ethiopia to rethink refugee communities.
Trade is also a key component of international relations, with FSI approaching the topic from a slew of angles and states. The economy of trade is rife for study, with an APARC event on the implications of more open trade policies in Japan, and FSI researchers making sense of who would benefit from a free trade zone between the European Union and the United States.
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
About the Event: Dean Winslow describes the challenges facing the US during the COVID-19 pandemic emphasizing the importance of diagnostic testing in responding to the pandemic. He discusses the critical role of the US government in procuring and stockpiling tests and providing them to areas experiencing hot spots and to schools, communities of high social vulnerability and other congregate settings. In the second part of the talk Winslow describes how the CDC supported the care and resettlement in the US of more than 124,000 Afghan refugees who fled the country in August 2021 following the fall of Afghanistan to Taliban forces. He also describes the CDC response and support of undocumented immigrants arriving at the Southwest Border.
About the Speaker: Dean Winslow, MD is Professor of Medicine with appointments in the Divisions of Hospital Medicine and Infectious Diseases and is a Senior Fellow (courtesy) at CISAC/Freeman Spogli Institute. He has served on the Stanford faculty since 1998 and served from 2003-2008 as Co-Director of Stanford's Infectious Diseases Fellowship Training Program. He was in private practice in Wilmington, Delaware where he started the state’s first multidisciplinary clinic for HIV patients in 1985. In 1988 he joined the DuPont Company where he worked both as a bench scientist on HIV drug resistance then later designed the clinical trials supporting FDA approval of efavirenz. In 1999 he became Vice President of Regulatory Affairs at Visible Genetics Inc. and led the FDA clearance of the TRUGENE HIV-1 drug resistance test. Dr. Winslow joined the staff at Santa Clara Valley Medical Center in 2003, where he served as Chief of the Division of AIDS Medicine and later as Chair of the Department of Medicine. In 2015 he was appointed Academic Physician-In-Chief at Stanford/ValleyCare and Vice Chair of the Department of Medicine. He was a Resident Fellow in Robinson House 2013-2017 and was visiting faculty at Oxford University in 2017. He was Lead Physician for the US Antarctic Program of the National Science Foundation 2019-2020 based at McMurdo Station, Antarctica. In 2021 he took leave from Stanford to lead the US COVID-19 Testing and Diagnostic Working Group. He served as CDC Senior Advisor to Operation ALLIES WELCOME and Chief Medical Officer for the Southwest Border Migrant Health Task Force before returning to Stanford in July 2022.
Dr. Winslow is a Master of the American College of Physicians, Fellow of the Royal College of Physicians, the Infectious Diseases Society of America, and the Pediatric Infectious Diseases Society. He is the author of 87 papers. He is,a member of the IDSA Sepsis Task Force, and previously served as Chair of the Standards and Practice Guidelines Committee.
Colonel Winslow entered the Air National Guard in 1980 and was a Distinguished Graduate of the USAF School of Aerospace Medicine. He served as Commander of the 159th Medical Group 1992-1995 and was State Air Surgeon, Delaware Air National Guard 1995-2011. He served as ANG Assistant to the Commander, 59th Medical Wing, Joint Base San Antonio 2011-2014. Colonel Winslow deployed to the Middle East six times from 2003-2011 as a flight surgeon supporting combat operations in Iraq and Afghanistan. From Jan-April 2003 Colonel Winslow was the flight surgeon responsible for combat rescue operations from Tikrit to northern Iraq. In 2005 he coordinated military public health in Louisiana in the aftermath of Hurricane Katrina. In 2006 Colonel Winslow served as an ER physician at the United States Air Force 447th EMEDS (combat hospital) in Baghdad and in 2008 he served as hospital commander during the Iraq surge. He is a 2007 graduate of Air War College. He served as an infectious disease consultant to the USAF Surgeon General. In 2017 Dr. Winslow was nominated by the President to serve as Assistant Secretary of Defense for Health Affairs. He has 1150 military flying hours including 431 combat hours and 263 combat sorties. He has extensive operational experience in fighter, tactical airlift, and combat rescue missions. He holds an FAA Airline Transport Pilot license.
Since 2006 Dr. Winslow has arranged medical care in the U.S. for 28 Iraqi children who have complicated medical conditions for which care is not available in Iraq. In 2015, Dr. Winslow and his wife, Dr. Julie Parsonnet, created The Eagle Fund of the Silicon Valley Community Foundation, which provides aid to middle eastern and central American refugees. In 2018 he co-founded Scrubs Addressing the Firearms Epidemic (SAFE), which unites health care professionals to address gun violence in the US as a public health issue and to advocate for education, research, and evidence-backed policy to reduce gun violence.
All CISAC events are scheduled using the Pacific Time Zone.
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
During the severe acute respiratory syndrome (SARS) outbreak in 2003, Taiwan reported 346 confirmed cases and 73 deaths. Of all known infections, 94% were transmitted inside hospitals. Nine major hospitals were fully or partially shut down, and many doctors and nurses quit for fear of becoming infected. The Taipei Municipal Ho-Ping Hospital was most severely affected. Its index patient, a 42-year-old undocumented hospital laundry worker who interacted with staff and patients for 6 days before being hospitalized, became a superspreader, infecting at least 20 other patients and 10 staff members. The entire 450-bed hospital was ordered to shut down, and all 930 staff and 240 patients were quarantined within the hospital. The central government appointed the previous Minister of Health as head of the Anti-SARS Taskforce. Ultimately the hospital was evacuated; the outbreak resulted in 26 deaths. Events surrounding the hospital’s evacuation offer important lessons for hospitals struggling to cope with the COVID-19 pandemic, which has been caused by spread of a similar coronavirus.
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.
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.”
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.
“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.
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:
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;
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;
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.
Conversations in Global Health: Providing Healthcare in Conflict Zones Dr. Tom Catena Chair of the Aurora Humanitarian Initiative
Tom Catena, MD, is a surgeon, veteran, globally recognized humanitarian, and inaugural Chair of the Aurora Humanitarian Initiative. He founded the Mother of Mercy Hospital in Sudan's war-ravaged Nuba Mountains and has dedicated the last decade of his life to provide medical care in this conflict zone.
Stanford School of Medicine Senior Communications Strategist, Paul Costello, will interview Dr. Catena about how he operates in a low-resources, conflict setting to improve the well-being of the most vulnerable populations. We will also learn about his remarkable life journey that drove him to work in this area.
Following the Conversation, please join us for a screening of "The Heart of Nuba" (6:30pm), a film that tells the story of Dr. Catena's work in the Nuba Mountains.
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.
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 workshop,” observed Martha Crenshaw (shown above), a Senior Fellow at FSI, “was a unique opportunity to exchange views with Chinese colleagues on the subject of civil conflict in the contemporary world. A valuable learning experience for all of us."
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.
The Trump administration's immigration crackdown may be leading to an unintended consequence: a drop-off in benefits enrollment among legal Hispanic immigrants, according to new research by Stanford Health Policy's Marcella Alsan.
This CBS News story about her work notes that an immigration program called Secure Communities, which was rolled out during the Obama administration, is linked to a lower take-up of benefits such as food stamps and health care enrollment.
In a new paper published by the National Bureau of Economic Research, Alsan and Crystal Yang of Harvard Law School found Hispanic households were particularly hard-hit, even those with legal immigration status.
"We find evidence that our results may be driven by deportation fear rather than lack of benefit information or stigma," the researchers wrote. "Though not at personal risk of deportation, Hispanic citizens may fear their participation could expose non-citizens in their network to immigration authorities. We find significant declines in SNAP and ACA enrollment, particularly among mixed-citizenship status households and in areas where deportation fear is highest."
Paul Wise watched as children ran around a playground attached to a health clinic at a displaced persons camp on the outskirts of Mosul — the northern city in Iraq once controlled by the Islamic State but now back in the hands of the Iraqi government.
The children had survived the Battle of Mosul, which had fallen to ISIS in 2014 but was retaken by the government forces and allied militias during a nine-month military campaign that ended in July. Many of the children suffer from physical and mental wounds and Wise wondered how they would recover with so little medical infrastructure.
Wise was part of a small delegation of physician-academics asked to evaluate a World Health Organization-led system to treat civilians injured in the Mosul fighting. Wise and his colleagues recently slipped into Mosul to visit field hospitals, review health care on the ground and determine whether there is a better way to distribute medical aid during armed conflict.
The visit left the Stanford Medicine professor of pediatrics and senior fellow at the Freeman Spogli Institute for International Studies with questions about health care, humanitarian ethics, and conduct of war: Are there better ways to deliver emergency medical care during the height of battle? How do relief workers maintain neutrality when embedded with government security forces? Has the system of financing humanitarian interventions — one that was essentially created during the Cold War — become dangerously outdated?
Answering these questions is the mission of a new health-and-security initiative at Stanford led by Wise, a core faculty member at Stanford Health Policy who has spent 40 years working to improve the health of children impacted by conflict. Much of his work has been in Guatemala through his Children in Crisis project, the first university-based program to address the needs of children in areas of unstable governance and civil war.
“In talking with the groups that are running these humanitarian efforts in Mosul, there was this uneasiness, this kind of disorientation with the way things are now,” said Wise. “It was a kind of recognition that humanitarian norms are changing, the health personnel and facilities are at greater risk; the financial gap between humanitarian need and humanitarian capability is growing; and the old way of financing humanitarian intervention is inadequate, archaic.”
An Interdisciplinary Approach
Wise believes academics are well suited to help resolve these humanitarian conundrums.
“So we are going to move ahead and try to bring all the players together to reconsider this global challenge. Here at Stanford, we have the capacity to draw upon remarkable resources,” he said.
The new biosecurity initiative led by Stanford Medicine physician and FSI senior fellow, David Relman, together with world-renowned political scientists, security specialists, computer scientists and health policy experts will “attempt to craft new strategies for the provision of critical services to populations affected by conflict and political stability.”
The initiative will collaborate with other institutions such as Johns Hopkins, UCSF, Harvard, and the American Academy of Arts and Sciences. It will also seek the engagement of partners committed to providing humanitarian services, including WHO, the U.N. High Commissioner for Refugees, Doctors Without Borders and the International Committee of the Red Cross.
“The voice of communities impacted by war should also be an essential element in this ambitious effort,” Wise said. “To break new ground, we’re going to have to do things differently; the health strategies need to take into consideration fundamental understanding of the political dynamics. But we have a special opportunity here at Stanford because we take an interdisciplinary approach.”
Children of War
Most of the children Wise saw will never be the same, he said, nor the humanitarian workers who risked their lives to treat them, their families, and fighters from all sides of the battle to oust the Islamic extremists from the city on the Tigris River.
“I look at these little kids with horrendous emotional trauma and PTSD, and I think to myself, it’s the collision of all these questions playing out within a 50-square-meter little playground,” he said. “It’s these broader, strategic and ethical questions that are really profound. And as a pediatrician who is dedicating the last phase of my career to these questions of security and the political dimensions — I have to engage on all of these levels. That’s not easy.”
Wise traveled with WHO officials, as well as Paul Spiegel, a physician who leads the Center for Humanitarian Health at Johns Hopkins Bloomberg School of Public Health; Adam Kushner, a trauma surgeon affiliated with Johns Hopkins; and Kent Garber, a surgical resident at UCLA and research associate at Johns Hopkins.
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Spiegel also believes academics are uniquely positioned to help assess the current system of responding to medical crises during conflict.
“I believe that we can bring objectivity and rigor to analyzing and evaluating important and innovative responses, such as the trauma response by WHO and others in Mosul,” Spiegel said. “Humanitarian organizations are often busy responding quickly to rapidly changing situations; they don’t always have the luxury of time to do what academic humanitarians can do.”
Making the two-hour drive from Erbil to Mosul in armored, bulletproof SUVs provided by the United Nations, they slipped into field hospitals to meet with Iraqi physicians and medical teams with the humanitarian agencies.
Wise, who was able to take a few photos and video on his smartphone, described the devastation on the ground, noting that not since the siege of Leningrad has a city of this size experienced such street-by-street fighting. In large parts of the city, virtually every building was bombed or bulleted. It will take years to clear the rubble and rebuild.
“It’s just a remarkable story of tragedy and resilience,” he said.
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Since the city was not long ago controlled by ISIS, the field hospitals are still surrounded by massive concrete barricades and tactical trucks stationed outside with mounted machine guns.
The team found that at the height of the battle for Mosul, there was tremendous pressure to treat injured civilians and discharge patients very quickly, due to the lack of medical infrastructure and personnel and the continuous wave of new injuries coming in.
“The charge for us was to evaluate the system and how well it worked, what ways could it be improved, how many lives that it saved,” Wise said. “One of the concerns, for example, was that in order to put in medical people that close to the frontline, you have to give them some kind of security. This raised issues among the humanitarians about their need for independence and neutrality, since you’re essentially embedding them with Iraqi security forces.”
Epidemiology and Ethics
“We are looking at the technical issues and the epidemiologic issues, but also dealing with the ethical issues and their implications,” he said.
They intend to write an internal report and then publish their findings in a major medical journal, to get the word out about the issue and gain support for ongoing collaborative work. They’re looking to partners like the American Academy of Arts and Sciences, which recently devoted an entire issue of its journal, Daedalus, to the factors and influences of contemporary civil war. One of the essays in that issue by Wise and his Stanford colleague, Dr. Michele Barry, who directs the Center for Innovation in Global Health, talks about the threat of a global pandemic as a potential byproduct of the 30 ongoing civil wars around the world.
“We’re trying to get the report completed quickly because the model of trauma care for civilians in Mosul is a new model and could be implemented in other combat areas, like the fighting in Syria and other places in Iraq,” Wise said.
Wise worries some see Stanford University as an insulated Silicon Valley institution in a beautiful setting and not always engaged in the real world.
“Well, this is about as engaged in the real world as you can get — this is Stanford moving and doing things out there, not just sitting around in seminar rooms. Sometimes you need to get close to the front lines to save lives,” he said.
When asked what surprised him during this trip to Mosul, Wise smiled.
“I’m sort of old and I’ve seen a lot of the world and not a lot surprises me anymore,” he said. “But it was a reminder of how desperate are the lives of millions of people — that we could do so much more. It’s a reminder of just how fragile physical security really is in this world."
FSI researchers strive to understand how countries relate to one another, and what policies are needed to achieve global stability and prosperity. International relations experts focus on the challenging U.S.-Russian relationship, the alliance between the U.S. and Japan and the limitations of America’s counterinsurgency strategy in Afghanistan.
