International Development
Beth Duff-Brown
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A new calculation that combines health and economic well-being at the population level could help to better measure progress toward the U.N. Sustainable Development Goals and illuminate major disparities in health and living standards across countries, and between men and women, according to a new study by Stanford and Harvard researchers.

In a study released this month in The Lancet Global HealthJoshua Salomon, a professor of medicine and core faculty member at Stanford Health Policy, finds there are startling differences between countries in the number of years people can expect to survive free from poverty, much greater than the differences observed in life expectancy alone, and that women surrender more years of life to poverty than men in much of the world.

At the U.N. Sustainable Development Summit in 2015, world leaders adopted the Sustainable Development Goals (SDGs) as the embodiment of the global agenda for development through 2030. One of the 17 goals calls for universal health coverage, including financial risk protection, which highlights the explicit link between economic and health development policies.

“Despite this link, and despite the multitude of targets and indicators established through the SDGs and other global initiatives, most monitoring and benchmarking efforts rely on metrics that are highly specific to a single dimension of interest,” Salomon and his colleagues from the Harvard T.H. Chan School of Public Health wrote in the Lancet study.

Such an approach misses opportunities to understand the broader impact of development policies as they affect the well-being of populations in multiple ways.

So, the researchers developed a population-level measure of poverty-free life expectancy (PFLE) and computed the measurements for 90 countries with available data. They used Sullivan's method to incorporate the prevalence of poverty by age and sex from household economic surveys into demographic life tables based on mortality rates that are routinely estimated for all countries. Poverty-free life expectancy for each country is the average number of years people could expect to survive with adequate income to meet their basic needs, given current mortality rates and poverty prevalence in that country.

The authors found that PFLE varies widely between countries, ranging from less than 10 years in Malawi to more than 80 years in countries such as Iceland.  In 67 of 90 countries, the difference between life expectancy and PFLE was greater for females than for males, indicating that women generally surrender more years of life to poverty than men do. 

In some African countries, people can expect to live more than half of the total lifespan in poverty.

“This new indicator can aid in monitoring progress toward the linked global agendas of health improvement and poverty elimination and can strengthen accountability for development policies,” the authors wrote.

Despite general improvements in survival in most regions of the world in the past decades, the focus in the Sustainable Development Goals era on ending poverty “brings into sharp relief the importance of ensuring that years of added life are lived with at least a minimum standard of economic well-being.”

Salomon said the researchers hope the development of a new, simple measure that summarizes overall health and economic welfare in a single number can do two things.

“One is to help encourage leaders to be transparent and accountable to the populations they serve through regular tracking and reporting on overall progress toward longer and better lives,” he said. “The other is to bring measurement out of the silos of individual sectors, to highlight both the need for multisectoral action to improve health and welfare and the connections between health and economic consequences of public policy.”

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The rising level of carbon dioxide in the atmosphere means that crops are becoming less nutritious, and that change could lead to higher rates of malnutrition that predispose people to various diseases.

That conclusion comes from an analysis published Tuesday in the journal PLOS Medicine, which also examined how the risk could be alleviated. In the end, cutting emissions, and not public health initiatives, may be the best response, according to the paper's authors, which includes Stanford Health Policy's Eran Bendavid and Sanjay Basu.

Research has already shown that crops like wheat and rice produce lower levels of essential nutrients when exposed to higher levels of carbon dioxide, thanks to experiments that artificially increased CO2 concentrations in agricultural fields. While plants grew bigger, they also had lower concentrations of minerals like iron and zinc.


Read the story at NPR



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The Stanford Center for Innovation in Global Health invites you to a private screening of The New Barbarianism followed by a panel discussion with the film's executive producer and director Stephen Morrison, co-director and writer Justin Kenny and Stanford scholars Michele Barry, Paul Wise and Ertharin Cousin.

The New Barbarianism is a highly acclaimed CSIS Global Health Policy Center original feature documentary (58 minutes) that examines the crisis, its causes, the limited international response and possible ways forward through dozens of interviews and original footage obtained from inside Syria, Yemen and Afghanistan. It builds on several years of prior work on the intersection of health and security, the role of militaries, and the human tragedies seen in Syria and Yemen.

6:30pm Doors Open | 7pm Screening | 8pm Panel Discussion


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485 Lasuen Mall
Stanford, CA 94305

Richard E. Behrman Professor of Child Health and Society
Senior Fellow, Freeman Spogli Institute for International Studies

Dr. Wise is the Richard E. Behrman Professor of Child Health and Society and Professor of Pediatrics and Health Policy at Stanford University School of Medicine.  Dr. Wise is also a Senior Fellow in the Center for Democracy, Development and the Rule of Law and the Center for International Security and Cooperation, in the Freeman-Spogli Institute for International Studies, Stanford University. He is also co-Director of the March of Dimes Center for Prematurity Research at Stanford University.

Dr. Wise received his A.B. degree summa cum laude in Latin American Studies and his M.D. degree from Cornell University, a Master of Public Health degree from the Harvard School of Public Health and did his pediatric training at the Children’s Hospital in Boston.  His former positions include Director of Emergency and Primary Care Services at Boston Children’s Hospital, Director of the Harvard Institute for Reproductive and Child Health, and Vice-Chief of the Division of Social Medicine and Health Inequalities at the Brigham and Women’s Hospital and Harvard Medical School.  He served as Special Assistant to the U.S. Surgeon General, Chair of the Steering Committee of the NIH Global Network for Women’s and Children’s Health Research, and currently is a member of the Advisory Council of the National Institute of Child Health and Human Development, NIH. 

Dr. Wise’s research focuses on health inequalities, child health policy, and global child health.   He leads a multidisciplinary initiative, Children in Crisis, which is directed at integrating expertise in political science, security, and health services in areas of civil conflict and unstable governance.

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Affiliated faculty at the Center for International Security and Cooperation
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Beth Duff-Brown
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Stanford Health Policy's Paul Wise — the Richard E. Behrman Professor of Child Health and Society — traveled to Iraq last year with a small delegation of physician-academics to evaluate the World Health Organization's system to treat civilians injured in the battle for Mosul. The northern city controlled by the Islamic State in 2014 was retaken by government forces last year and the team visited field hospitals to review health care on the ground and determine whether there is a better way to distribute medical aid during armed conflict.

We wrote about their visit in November.

Now, the team members have published their findings in an in-depth report put out by Johns Hopkins University's Center for Humanitarian Health.

The Lancet also has published an editorial about their research to coincide with the release of the report.

"The Battle of Mosul provides an important case study for what might be to come," the editorial board wrote. "Above all, this should be a very rare occurrence, and The Lancet echoes the evaluation's recommendation that governments, and possibly their allies, must ensure their militaries can fulfill the obligations of protection and care for wounded citizens under the Geneva Conventions. However, in modern warfare, access to the injured may increasingly be one-sided when fighting against warring factions that see health workers and civilians as acceptable targets of war. Governments should be prepared to face this eventuality. To be able to continue providing the best standards of care and saving lives, a high-level meeting must urgently be organized to examine and answer this question: are the humanitarian principles as they are defined today still relevant for this changing warfare?"

Some of the key findings of the report include: 

  • Between 1500-1800 lives, both military and civilian, may have been saved through this trauma response.
  • By attempting to apply Western military standards of trauma care and ‘moving forward’ towards the frontline to save civilians lives, WHO and its partners challenged existing humanitarian principles, particularly those of neutrality and independence.
  • The Iraqi government and its military did not have medical capacity to fulfill their obligations to protect and care for wounded civilians on the Mosul battlefield, and the U.S.-led coalition did not provide substantial medical care for wounded civilians.
  • WHO-supported field hospitals filled important gaps in trauma surgical care, while post-operative and rehabilitative care warranted greater support.
  • Successful coordination among local leaders, partners, and civilian and military officials occurred, but field coordination could have been better resourced.


pablo buffer horizontal

And some of the key recommendations:

  • Warring factions, and those supporting them, need to enhance the former’s medical capacities to ensure they can fulfill their obligations under the Geneva Conventions and Additional Protocols.
  • Deliberation is needed regarding the benefits to and the moral obligations of governments who support such warring factions, like the U.S.-led coalition in the Mosul battle.
  • Humanitarians must take care to avoid being instrumentalized by governments or military in future conflicts.
  • Medical teams operating directly with a combatant force should not be identified as humanitarian;
  • Frontline medical services could be provided by specialized groups explicitly trained to work directly with combatant forces, possibly contracted as military support services focusing on providing frontline medical services for both injured soldiers and civilians.
  • Using private medical organizations (i.e., contractors) to provide humanitarian services in conflict settings needs further study. 
  • How humanitarian actors can apply standards of trauma care that compel them to move towards the frontline to save lives, and still adhere to longstanding humanitarian principles, needs debate at senior levels such as at the Inter Agency Standing Committee or at the intergovernmental level.


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

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

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

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

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

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

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

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

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

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

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

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

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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.


mosul bike


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.


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."

mosul old woman


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Professor, Health Policy
Senior Fellow, Freeman Spogli Institute for International Studies

Joshua Salomon is a Professor of Health Policy in the Stanford University School of Medicine and a Senior Fellow at the Center for Health Policy in the Freeman Spogli Institute for International Studies. His research focuses on priority-setting in global health, within three main substantive areas: (1) measurement and valuation of health outcomes; (2) modeling patterns and trends in major causes of global mortality and disease burden; and (3) evaluation of health interventions and policies.

Dr. Salomon is an investigator on projects funded by the Centers for Disease Control, National Institutes of Health and the Bill & Melinda Gates Foundation, relating to modeling of infectious and chronic diseases and associated intervention strategies; methods for economic evaluation of public health programs; measurement of the global burden of disease; and assessment of the potential impact and cost effectiveness of new health technologies.

He is Director of the Prevention Policy Modeling Lab, which is a multi-institution research consortium that conducts health and economic modeling relating to infectious disease. Prior to joining the Stanford faculty, Dr. Salomon was Professor of Global Health at Harvard T.H. Chan School of Public Health.

Beth Duff-Brown
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Fewer girls in low-and-middle-income countries finish secondary school, resulting in poorer health and economic outcomes for their own children — and perpetuating the vicious cycle of gender inequality worldwide.

According to The World Bank, in Sub-Saharan and South Asia, boys are 1.5 times more likely to complete secondary education than girls. Many are forced to stay at home and help their mothers with housework and childcare, particularly if a younger sibling is sick.

Yet the potential gains from increased participation of women in the global workforce over the next decade are estimated at $12 trillion. Studies show that women’s equal participation in the workforce could boost some countries’ GDP by up to 20 percent.

Stanford Health Policy’s Marcella Alsan, a physician and economist, argues in a new study in the journal Pediatrics, that identifying contributors to education disparities and making investments in early childhood health could significantly advance global health and development.

“There are so many advantages to girls staying in school,” Alsan, an assistant professor of medicine at Stanford Medicine, said in an interview. “For one thing, the longer they’re in school, the less likely they are to become young mothers or contract HIV. And the more educated the mother, their own children have better chances of survival.”

So what are some of the biggest barriers to girls completing secondary school in less developed countries?

Alsan and her co-authors found the gender gap is compounded by illness among young children in the household since adolescent girls are often tasked with childcare and domestic chores. The problem is exacerbated if the mother works outside the household.

Follow the Numbers

Along with SHP research data analyst Anlu Xing, Alsan and her team used Demographic and Health Surveys on 41,821 households in 38 low-and-middle-income countries. The surveys asked about illnesses in children under 5 in the last two weeks, and then asked the adolescent boys and girls if they had been in school in the same period.

As expected, more girls remained at home than boys. When no young children in the household are ill, adolescent girls are on average 6 percent less likely to attend school than adolescent boys within the same household.

But the gap increases to 7.8 percent if the household reports one illness episode among an under-5 child, and up to 8.5 percent if there are two or more episodes of illness.

mongolian children study

In other words, the authors write, “The gender gap in adolescent school attendance increased by around 50 percent when young children in the household became ill.”

The education gap between adolescent boys and girls jumps to 10.06 percent if the younger child has two or more episodes of illness — and the mother is working outside the home or in the fields.

“Policies that strengthen family and community supports for challenges such as sick child care will prove essential,” the authors write, “particularly as women move increasingly into the workforce outside the home.”

Alsan’s co-authors are Eran Bendavid, assistant professor of medicine and core faculty member at Stanford Health Policy; Gary Darmstadt, a professor of pediatrics and associate dean for maternal and child health at Stanford Medicine; and Paul Wise, another core faculty member at SHP and professor of pediatrics.

Vaccines Also Key

Alsan and her team also examined data on the gender gap in adolescent education in association with national vaccine rates, using the same country-year surveys.

They found that in countries where about 70 percent of all the boys and girls had the same series of eight vaccines — including polio, diphtheria, tetanus and measles — the gender gap in education approaches zero.

“We hypothesize that countries with high rates of childhood vaccination will experience lower rates of young child illness, thereby decreasing the need for adolescent girls’ to devote time to caring for sick children,” the authors write.

Given the long-term benefits of secondary school for women’s health and economic outcomes, the authors believe their study underscores the societal benefits of keeping girls in school. A combination of vaccines and early childhood interventions to keep toddlers healthy and their older sisters in school are paramount.

“The international community agrees that educating girls through secondary school has plenty of societal benefits — we show that health interventions targeting young kids are an important way to do just that,” says Alsan. “Not only the targeted little kids benefit but also their older sisters — a double dividend.”

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In a shack that now sits below sea level, a mother in Bangladesh struggles to grow vegetables in soil inundated by salt water. In Malawi, a toddler joins thousands of other children perishing from drought-induced malnutrition. And in China, more than one million people died from air pollution in 2012 alone.

Around the world, climate change is already having an effect on human health.

In a recent paper, Katherine Burke and Michele Barry from the Stanford Center for Innovation in Global Health, along with former Wellesley College President Diana Walsh, described climate change as “the ultimate global health crisis.” They offered recommendations to the new United States president to address the urgently arising health risks associated with climate change.

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Bangladeshi children make their way through flood waters.

The authors, along with Stanford researchers Marshall Burke, Eran Bendavid and Amy Pickering who also study climate change, are concerned by how little has been done to mitigate its effects on health.

“I think it’s likely that health impacts could be the most important impact of climate change,” said Marshall Burke, an assistant professor of earth system science and a fellow at the Freeman-Spogli Institute for International Studies.

There is still time to ease — though not eliminate — the worst effects on health, but as the average global temperature continues to creep upward, time appears to be running short.

“I think we are at a critical point right now in terms of mitigating the effects of climate change on health,” said Amy Pickering, a research engineer at the Woods Institute for the Environment. “And I don’t think that’s a priority of the new administration at all.”

Health effects of climate change

Even in countries like the United States that are well-equipped to adapt to climate change, health impacts will be significant.

“Extremes of temperature have a very observable direct effect,” said Eran Bendavid, an assistant professor of medicine and Stanford Health Policy core faculty member.

“We see mortality rates increase when temperatures are very low, and especially when they are very high.”

Bendavid also has seen air pollutants cause respiratory problems in people from Beijing to Los Angeles to villages in Sub-Saharan Africa.

“Hotter temperatures make it such that particulate matter and dust and pollutants stick around longer,” he said.

In addition to respiratory issues, air pollution can have long-term cognitive effects. A study in Chile found that children who are exposed to high amounts of air pollution in utero score lower on math tests by the fourth grade.

“I think we’re only starting to understand the true costs of dirty air,” said Marshall Burke. “Even short-term exposure to low levels can have life-long effects.”

Low-income countries like Bangladesh already suffer widespread, direct health effects from rising sea levels. Salt water flooding has crept through homes and crops, threatening food sources and drinking water for millions of people.

“I think that flooding is one of the most pressing issues in low-income and densely populated countries,” said Pickering. “There’s no infrastructure there to handle it.”

Standing water left over from flooding is also a breeding ground for diseases like cholera, diarrhea and mosquito-borne illnesses, all of which are likely to become more prevalent as the planet warms.

On the flip side, many regions of Sub-Saharan Africa — where clean water is already hard to access — are likely to experience severe droughts. The United Nations warned last year that more than 36 million people across southern and eastern Africa face hunger due to drought and record-high temperatures.

Residents may have to walk farther to find water, and local sources could become contaminated more easily. Pickering fears that losing access to nearby, clean water will make maintaining proper hygiene and growing nutritious foods a challenge.

Flow Chart detailing how Climate CHnage Affects Your Health
Climate change will affect health in all sectors of society.

All of these effects and more can also damage mental health, said Katherine Burke and her colleagues in their paper. The aftermath of extreme weather events and the hardships of living in long-term drought or flood can cause anxiety, depression, grief and trauma.

Climate change will affect health in every sector of society, but as Katherine Burke and her colleagues said, “….climate disruption is inflicting the greatest suffering on those least responsible for causing it, least equipped to adapt, least able to resist the powerful forces of the status quo.

“If we fail to act now,” they said, “the survival of our species may hang in the balance.”

What can the new administration do to ease health effects?

If the Paris Agreement’s emissions standards are met, scientists predict that the world’s temperature will increase about 2.7 degrees Celsius – still significant but less hazardous than the 4-degree increase projected from current emissions.

The United States plays a critical role in the Paris Agreement. Apart from the significance of cutting its own emissions, failing to live up to its end of the bargain — as the Trump administration has suggested — could have a significant impact on the morale of the other countries involved.

“The reason that Paris is going to work is because we’re in this together,” said Marshall Burke. “If you don’t meet your target, you’re going to be publicly shamed.”

The Trump administration has also discussed repealing the Clean Power Plan, Obama-era legislation to decrease the use of coal, which has been shown to contribute to respiratory disease.

“Withdrawing from either of those will likely have negative short- and long-run health impacts, both in the U.S. and abroad,” said Marshall Burke.

Scott Pruitt, who was confirmed today as the head of the Environmental Protection Agency (EPA), is expected to carry out Trump’s promise to dismantle environment regulations.

Despite the Trump administration’s apparent doubts about climate change, a few prominent Republicans do support addressing its effects.

Secretary of State Rex Tillerson, the former chairman and CEO of Exxon Mobile, supports a carbon tax, which would create a financial incentive to turn to renewable energy sources. He also has expressed support for the Paris Agreement. It is possible that as secretary of state, Tillerson could help maintain U.S. obligations from the Paris Agreement, though it is far from certain whether he would choose to do so or how Trump would react.

More promising is a recent proposal from the Climate Leadership Council. Authored by eight leading Republicans — including two former secretaries of state, two former secretaries of the treasury and Rob Walton, Walmart’s former chairman of the board — the plan seeks to reduce emissions considerably through a carbon dividends plan.

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Already an issue, malnutrition will increase with droughts in Sub-Saharan Africa.

Their proposal would gradually increase taxes on carbon emissions but would return the proceeds directly to the American people. Americans would receive a regular check with their portion of the proceeds, similar to receiving a social security check. According to the authors, 70 percent of Americans would come out ahead financially, keeping the tax from being a burden on low- and middle-income Americans while still incentivizing lower emissions.

“A tax on carbon is exactly what we need to provide the right incentives and induce the sort of technological and infrastructure change needed to reduce long-term emissions,” said Marshall Burke.

Pickering added, “This policy is a ray of hope for meaningful action on climate.”

It remains to be seen whether the new administration and congress would consider such a program.

What can academics do to help?

Meanwhile, academics can promote health by researching the effects of climate change and finding ways to adapt to them.

“I think it’s fascinating that there’s just so little data right now on how climate change is going to impact health,” said Pickering.

Studying the effects of warming on the world challenges traditional methods of research.

“You can’t create any sort of experiment,” said Bendavid. “There’s only one climate and one planet.”

The scholars agree that interdisciplinary study is a critical part of adapting to climate change and that more research is needed.

“If ever there was an issue worthy of a leader’s best effort, this is the moment, this is the issue,” said Katherine Burke and her colleagues. “Time is short, but it may not be too late to make all the difference.”

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"Most civilian casualties in war are not the result of direct exposure to bombs and bullets; they are due to the destruction of the essentials of daily living, including food, water, shelter, and health care."


So begins the abstract for an essay in the Winter 2017 edition of Daedalus by Stanford Health Policy’s Paul Wise, the Richard E. Behrman Professor of Child Health and Society and professor of pediatrics at the Stanford School of Medicine.

Wise argues in his essay, “The Epidemiologic Challenge to the Conduct of Just War: Confronting Indirect Civilian Casualties of War," that the death of any child is always a tragedy. But the death of a child from preventable causes is particularly unjust.

“This is, of course, as true in peacetime as it is in war,” he writes. “My argument is that the dramatic growth in our ability to prevent death and disability from the indirect effects of war generates not only humanitarian impulses, but also just war demands for the provision of this capability to populations affected by war.”

The American Academy of Arts & Sciences devoted its Fall 2016 and Winter 2017 issues of its journal, Daedalus, to the theory of Just War. It held its 204th annual meeting at Stanford University in November, with Wise reviewing the main points of his essay. Other speakers included Stanford President Marc Tessier-Lavigne and FSI's Scott Sagan and Joe Felter.

(Videos of all their talks can be found on this page. And you can listen to their conversations in this World Class podcast, "Ethics in War," by the Freeman Spogli Institute for International Studies.)


Just War is a theory dating back to the early Christian theologians, who called on warring parties to justify their use of force and to protect noncombatants and innocent civilians.

The statisticians of war and genocide typically look at the total number of deaths due to combat or murder: 5 to 6 million Jews were exterminated in the Holocaust; the Second Congo War from 1998-2003 is estimated to have claimed more than 3 million civilian lives in direct combat.

More recently, the nonprofit organization, I Am Syria, estimates that 450,000 civilians, 50,000 of whom were children, have been killed in the Syrian civil war that erupted up March 2011. But how many will have died in the eventual aftermath due to lack of medical care, food and shelter?

It is estimated that 2 million Congolese, for example, died from starvation and lack of food and medical care in the years following its civil war.

The numbers that make it to the history books often do not reflect the indirect deaths that come on the sidelines and aftermath of war, particularly among children 5 years old and younger. During the periods of intense conflict in the Democratic Republic of Congo and Darfur, direct trauma-related mortality accounted for less than 20 percent of all excess deaths among children. The leading causes of the excess deaths on top of direct conflict were fever and malaria, measles, diarrhea and acute respiratory infections. In Syria, many of those children who have survived likely will have medical and mental repercussions that will be debilitating or deadly.

Wise notes that a report published by the Geneva Declaration Secretariat suggests that for every violent death resulting from combat and conflict between 2004 and 2007, four more died from war-associated elevations in malnutrition and disease. Global health scholars reported that about one-third of all deaths in Iraq were due to indirect causes.

This is why health-care workers are “the ultimate inheritors of failed social order,” said Wise, who is also a senior fellow at the Freeman Spogli Institute for International Studies. “Sooner or later, a breakdown in the bonds that define collective peace, indeed that ensure social justice, will find tragic expression in the clinic, on the ward, or in the morgue.”

That is the extremely bad news. But there is also some good.

Technological advances to prevent conflict and protect civilians have expanded dramatically, such as social media platforms that allow victims of war to communicate instantly and globally, and the crowdsourcing and early-warning SMS systems that take advantage of the more than 2 billion cellphone users around the world.

The United Nations is looking at GPS tracking systems to protect peacekeeping convoys on search-and-rescue missions, according to another article in the Fall 2016 issue of Daedalus. In another example, the International Bar Association created the eyeWitness to Atrocities app for smartphone cameras designed to record and authenticate atrocities.

All this new technology is allowing for advances in epidemiologic and demographic measurement out in the field, Wise said.

“In the context of just war, technical innovation means more than the creation of more powerful and precise munitions,” Wise writes. “It also means an enhanced capacity to measure and reduce the human impact of war.

“Innovation in these two technical domains — measurement and mitigation — has been sufficient to rethink the application of Just War theory to the indirect effects of war.”


Wise runs the Stanford Children in Crisis Initiative, which seeks to save the lives in children who are suffering from conflict and poor governance. Stanford students and local health-care promoters in rural Guatemala have been working with him for decades to try and end death by malnutrition and other causes among young children there.

The initiative last summer launched an app for tablets, which is making it easier to find malnourished children and decrease the training time for new health promoters. The goal is to eventually distribute the application globally.

The international aid community’s growing ability to measure the indirect impact of war, coupled with the ability to prevent or mitigate the indirect human toll of war, is remarkable, Wise said.

“Advances in epidemiology and the technological means of collecting health data have generated a range of new opportunities to assess the immediate and protracted effects of war,” Wise said. “This field is still young and these new technical strategies are creating an unprecedented capacity to assess the impact of war in even remote communities.”


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