A revelatory story emerged in China this spring: Bo Xilai, Chongqing’s powerful Communist Party head, was stripped of both his post and party membership and accused of shocking abuses of power, including covering up his wife’s alleged involvement in the death of a shadowy British businessman.

On May 2, the Shorenstein Asia-Pacific Research Center held a special seminar to make sense of what this unusual high-level scandal could mean for the future of China’s current political system, erupting just months ahead of a once-in-a-generation leadership transition.

Minxin Pei, director of the Keck Center for International and Strategic Studies at Claremont McKenna College, said the scandal is a severe test for the Chinese Communist Party (CCP), which balances on a knife’s edge as it prepares to replace the majority of its Politburo members—the highest CCP echelon. The Bo affair has exposed the existence of serious corruption at a very high level of government, calling into question the party’s image and credibility.

“This is the biggest threat to party unity since 1989,” he said.

More potentially damaging still, however, is the negative light it has cast on China’s overall political system. The scandal has revealed weaknesses and loopholes in the power structure, and the government’s poor crisis management skills.

“The Bo Xilai affair is the beginning of the end of the Tiananmen era,” Pei said. “Twenty years from now, historians will make this point.”

Xueguang Zhou, a professor of sociology and Freeman Spogli Institute senior fellow, agreed with Pei’s analysis that Bo’s fall from power has tarnished the party’s image and deeply disrupted the cohesiveness of its upper leadership.He spoke also of the outpouring of criticism on social media sites for the government’s inability to reign in corruption—so much so that censors have not been able to keep up.

“These voices have been so fierce in criticizing the top leadership that it has huge implications for the emergence of China’s civil society,” Zhou said. 

He expressed his concern for the future of local politics after the smoke from the Bo affair has cleared. Although it is widely acknowledged in China that shady political dealings go hand-in-hand with local-level politics, positive innovations in governance also frequently occur at the city and county level.

“I hope that local governments will still have the power to experiment,” he said.

After all is said and done, China’s top leadership is at a major turning point. Only time will tell the full impact of the fall of Bo Xilai, both during this year’s power transition and the evolution of China’s government structure in the coming decades.

A once-a-day pill to help prevent HIV infection could significantly reduce the spread of AIDS, but only makes economic sense if used in select, high-risk groups, Stanford researchers conclude in a new study.

The researchers looked at the cost-effectiveness of the combination drug tenofovir-emtricitabine, which was found in a landmark 2010 trial to reduce an individual’s risk of HIV infection by 44 percent when taken daily. Patients who were particularly faithful about taking the drug reduced their risk to an even greater extent – by 73 percent.

The results generated so much interest that the Stanford researchers decided to see if it would be cost-effective to prescribe the pill daily in large populations, a prevention technique known as pre-exposure prophylaxis, or PrEP.

They created an economic model focused on gay men, as they account for more than half of the estimated 56,000 new infections annually in the United States, according to the Centers for Disease Control and Prevention.

“Promoting PrEP to all men who have sex with men could be prohibitively expensive,” said Jessie Juusola, a PhD candidate in management science and engineering in the School of Engineering and first author of the study. “Adopting it for men who have sex with men at high risk of acquiring HIV, however, is an investment with good value that does not break the bank.”

For instance, using the pill in the general population of gay men would cost $495 billion over 20 years, compared to $85 billion when targeted to those at particularly high risk, the researchers found. The study will be published in the April 17 issue of the Annals of Internal Medicine.

Senior author Eran Bendavid, an affiliate of Stanford Health Policy at the Freeman Spogli Institute, said the results are a departure from a previous study. Earlier research found PrEP was not cost-effective when compared with other commonly accepted prevention programs.

The new Stanford study differs in a few important respects, taking into consideration the decline in transmission rates over time as more individuals take the pill. The Stanford team also assumed individuals would stop taking PrEP after 20 years, not stay on the drug for life, as the previous study had assumed.

The pill combination, marketed under the brand name Truvada, is widely used for treating HIV infection. But it wasn’t until a landmark trial, published in the New England Journal of Medicine in November 2010, that individuals and their doctors began to seriously consider using the drug as a preventive therapy. The drug’s maker, Foster City, Calif.-based Gilead Sciences Inc., has filed a supplemental new drug application to market it for prevention purposes.

The CDC issued interim guidelines on the drug’s use in January 2011, suggesting that if practitioners prescribe it as a preventive measure, they regularly monitor patients for side effects and counsel them about adherence, condom use and other methods to reduce their risk of infection.

In developing their model, the Stanford researchers took into account the cost of the drug – about $26 a day, or almost $10,000 a year – as well as the expenses for physician visits, periodic monitoring of kidney function affected by the drug, and regular testing for HIV and sexually transmitted diseases.

“We’re talking about giving uninfected people a drug that has some toxicities, so it’s crucial to have them monitored regularly,” said Bendavid, who is an assistant professor of medicine in Stanford’s School of Medicine.

Without PrEP, the researchers calculated there would be more than 490,000 new infections among gay men in the United States in the next 20 years. If just 20 percent of these men took the pill daily, there would be nearly 63,000 fewer infections.

However, the costs are substantial. Use of the drug by 20 percent of gay men would cost $98 billion over 20 years; if every man in this group took PrEP for 20 years, the costs would be a staggering $495 billion.

Given these figures, the researchers looked at the option of giving PrEP only to men who are at high risk – those who have five or more sexual partners in a year. If just 20 percent of these high-risk individuals took the drug, 41,000 new infections would be prevented over 20 years at a cost of about $16.6 billion.

At less than $50,000 per quality-adjusted life year gained (a measure of how long people live and their quality of life), that strategy represents relatively good value, according to Juusola.

“However, even though it provides good value, it is still very expensive,” she said. “In the current health care climate, PrEP’s costs may become prohibitive, especially given the other competing priorities for HIV resources, such as providing treatment for infected individuals.”

She said the costs could be significantly reduced if the pill is found to be effective when used intermittently, rather than on a daily basis. Current trials are examining the effectiveness of the drug when used less often.

Other co-authors are Margaret L. Brandeau, the Coleman F. Fung Professor of Engineering, and Douglas K. Owens, the Henry J. Kaiser, Jr. Professor at Stanford and senior investigator at the Veterans Affairs Palo Alto Health Care System. Owens also is director of Stanford’s Center for Health Policy and Center for Primary Care and Outcomes Research.

The study was funded by the National Institutes of Health and the Department of Veterans Affairs and supported by Stanford’s departments of Medicine and Management Science and Engineering.

From the Arab Spring to the Occupy Wall Street movement, young people have emerged at the helm of citizen-led change, opposing and challenging the status quo. Recognizing their local and global impact, youth are increasingly stepping up to fulfill Gandhi's famous maxim: "Be the change you want to see in the world." In turn, they are encouraging other members of their generation to answer this call to duty. In the aftermath of revolutions across the Middle East and North Africa (MENA), youth have never been more engaged and active in the future development of their communities.

Inspired by these events, a group of young Stanford students launched a forum to unite leaders from the MENA region with their Western counterparts to build a bridge towards greater understanding, collaboration, and partnership. Nothing of this scale had ever been done on the Stanford campus, and there was a clear demand from the student body for deeper engagement with the region.

It was in this spirit that the American Middle Eastern Network for Dialogue at Stanford (AMENDS) was born, which will host its inaugural conference at Stanford University April 10 to 14, 2012 to convene exceptional young leaders together to share their ideas, seed potential collaborations and inspire the world. The AMENDS team represents a diverse group of students of various nationalities, faiths, and persuasions, but the common thread that connects them all is a desire to interact with the future generation of leaders who are writing a new chapter in the history of the Middle East.

AMENDS seeks to take a step forward towards greater partnership with a post-Arab Spring generation of leaders in the Middle East.                                -AMENDS co-founders Elliot Stoller and Khaled AlShawi

Co-founders Elliot Stoller (BA '13) and Khaled AlShawi (BA '13), hailing from Chicago and Bahrain respectively, were inspired to start a project devoted to U.S.-MENA relations largely in response to events surrounding the Arab Spring, “The problems addressed through the uprisings transcend a single country or region. They affect us all and require global collaboration to solve. AMENDS seeks to take a step forward towards greater partnership with a post-Arab Spring generation of leaders in the Middle East. ”

Within a year of launching the initiative, the AMENDS team received applications from over 300 promising delegates, organized a four-day summit, and launched an ambitious fundraising campaign to cover the costs of such an endeavor. Described by AMENDS senior leadership as a "full-time job" on top of their demanding academic schedules, this grassroots operation is fueled by the entrepreneurial energy of a band of passionate and dedicated student volunteers. AMENDS has benefited from the consultation of a board of advisors comprised of Stanford faculty and staff from the Center on Democracy, Development, and the Rule of Law (CDDRL), the Freeman Spogli Institute for International Studies, and the Hamid and Christina Moghadam Program in Iranian Studies.

According to Larry Diamond, CDDRL director and member of the AMENDS advisory board, "It has been a pleasure working with the AMENDS team on the design and implementation of this innovative project — the first of its kind — to convene a new generation of leaders in the U.S. and the Middle East at Stanford University."

AMENDS delegates hail from 17 countries and together represent students and young professionals leading projects driven by the ingenuity of the new Middle East. 

AMENDS delegates hail from 17 countries and together represent students and young professionals leading projects driven by the ingenuity of the new Middle East. While many of their projects are still in their initial stages of development, the AMENDS conference and network is intended to provide leadership training and peer support to help scale-up these initiatives. A mentorship program pairs delegates with professionals, development practitioners, and industry leaders for tailored advice and support.

AMENDS delegates are as diverse as the issues they are confronting in the Middle East, North America, and the United Kingdom. Several AMENDS delegates are leveraging the use of new technology and social media to unite civil society, stimulate public debate, introduce alternative energy resources, and promote citizen-led journalism. In Egypt, Morocco, and Palestine, delegates are members of youth movements at the forefront of the Arab Spring revolutions and are championing new approaches for political change. Others are working in their local communities to defend the rights of HIV/AIDS patients in Egypt, support children with disabilities in Canada, and empower uninsured MENA immigrants in the U.S. Many projects share the common goal of getting more youth engaged and active in their local communities to achieve broader societal goals.

Over a five-day period, delegates will deliver ten-minute "AMENDS Talks" styled after TEDTalks^TM, where they will introduce their initiatives to the larger Stanford community. The videos will be recorded and available through an online forum — in both Arabic and English — giving delegates’ a global platform to share their ideas, inspiring others to take action. Delegates will also participate in leadership development workshops at the Stanford Graduate School for Business and networking events sponsored by AMENDS strategic partner TechWadi, a Silicon Valley-based organization fostering high-tech entrepreneurial development in the Arab world.

Notable scholars and practitioners from the U.S. and the MENA region will provide unique insight and analysis to some of the timeliest topics emerging from the region. Speakers include Sami Ben Gharbia, Tunisian political activist and a Foreign Policy Top 100 Thinker; Thomas T. Riley, former U.S. ambassador to Morocco; and Rami Khouri, director of the Issam Fares Institute for Public Policy and International Affairs at the American University of Beirut.

CDDRL faculty and staff will also be leading sessions and addressing the AMENDS delegates at the summit, including CDDRL Director Larry Diamond, CDDRL Consulting Professor and AMENDS Advisory Board Member Prince Hicham Ben Abdallah, Arab Reform and Democracy Program Manager Lina Khatib, and Moroccan journalist and CDDRL Visiting Scholar Ahmed Benchemsi.

Most AMENDS Talks and sessions are open to the Stanford community and general public. For more information on AMENDS, to read about the 2012 delegates, and to view the conference agenda, please visit: amends.stanford.edu.

What are the right questions the president should ask — and we as his employers should ask — when deciding whether going to war is (a) justified and (b) worth it, asks Bill Keller in the <i>New York Times</i>. Karl Eikenberry, who served in Afghanistan both as a military commander and as ambassador, put it this way: “If we do not in the future better align ends, ways and means, historians may find that in the aftermath of the wars in Iraq and Afghanistan the United States was compelled to contract its global posture similar to the British when they announced their ‘East of Suez’ policy in the late 1960s.”

Steve Hilton, senior advisor to British Prime Minister David Cameron, will join Stanford as a visiting scholar at the university’s Freeman Spogli Institute for International Studies.

Hilton, who will also be a visiting fellow at Stanford’s Hoover Institution, will arrive in May and spend his year on campus teaching, researching and writing.

“We look forward to having Steve Hilton in residence at FSI starting later this spring,” said Coit Blacker, FSI’s director. “Lively and engaging, Steve is certain to bring a fresh perspective to many of the issues and challenges that are of ongoing concern to our faculty, fellows and students.”

As Cameron’s top advisor, Hilton’s primary responsibility is the development and implementation of domestic policy. He specializes in the promotion of enterprise and economic growth, public service reform, family policy, decentralization, and government transparency and accountability.

Hilton will focus on innovation in government, public services and communities around the world while at Stanford. He will work with a wide range of centers and organizations across the university, including FSI’s Center on Democracy, Development and the Rule of Law and The Europe Center; the Graduate School of Business' Center for Social Innovation; the Center on Philanthropy and Civil Society; and the Hasso Plattner Institute of Design.

"I'm delighted to be joining the academic community at Stanford and greatly look forward to an exhilarating and productive year,” Hilton said. “It will be a huge pleasure to be able to focus on our most pressing social and governmental challenges."

Before Cameron’s election as prime minister in 2010, Hilton served as his chief strategist and developed the ideas associated with the modernization of the British Conservative Party.

Hilton previously ran Good Business, a corporate responsibility consulting firm, and is the author of Good Business: Your World Needs You. The book makes the case for businesses to play a more direct and active role in advancing social progress.

Ford Dorsey Program in International Policy (IPS) 2003 alum Sharmeen Obaid-Chinoy has been nominated for an Academy Award in the Best Documentary, Short Subject Category for her film "Saving Face." The film is about the work of Dr. Mohammad Jawad, a British-Pakistani plastic surgeon who traveled to Pakistan to perform reconstructive surgery on women who have been victims of acid throwing.  Sharmeen is the first Pakistani to be nominated for an Oscar.

Newly printed “no smoking” signs went up across China when the government rolled out a nationwide public indoor smoking ban in May 2011. A sticky gray layer of smoke residue now coats many signs, representing the challenges China’s growing tobacco-control movement faces against a multibillion-dollar government-run industry and deeply embedded social practices.

How has the cigarette become so integrated into the fabric of everyday life across the People’s Republic of China (PRC)?

To get to the heart of this question, historians, health policy specialists, sociologists, anthropologists, business scholars, and other experts met Mar. 26 and 27 in Beijing for a conference organized by Stanford’s Asia Health Policy Program. They examined connections intricately woven over the past 60 years between marketing and cigarette gifting, production and consumer demand, government policy and economic profit, and many other dimensions of China’s cigarette culture.

Anthropologist Matthew Kohrman, a specialist on tobacco in China, led the conference, which was held at the new Stanford Center at Peking University. In an interview, he spoke about the history of China’s cigarette industry, cigarettes and society, and the tobacco-control movement.

The early years

Tobacco first entered China through missionary contact in the 1600s, says Kohrman, but it was not until the early 20th century when cigarettes began gaining popularity. The first cigarette advertising was a “confused tapestry” of messages as marketers figured out what spoke to the public. “There were just as many images of neo-Confucian filial piety as there were of cosmopolitan ‘modern women,’” says Kohrman.

Through improved marketing and aggressive factory building, British American Tobacco and Nanyang Brothers, China’s two largest pre-war firms, helped increase the demand for cigarettes. The Sino-Japanese War (1937–1945) disrupted the cigarette supply, but their popularity had taken hold. Some cigarette firms shifted during the war to the relative safety of southwest China, where tobacco production has remained concentrated ever since.

Post-1949

After the founding of the PRC in 1949, the tobacco industry was nationalized and strong relationships between the central government and cigarette manufacturers in the provinces were formed. Cigarettes also began to be viewed as a part of everyday life. “Ration coupons for cigarettes were issued alongside grain, sugar, and bicycle coupons,” says Kohman. “The Maoist regime legitimized cigarettes as the right of every citizen."

During the Deng Xiaoping era (1978–1997), China’s cigarette industry really took off as manufacturers competed with one another for foreign currency to purchase cutting-edge European equipment and newer varieties of tobacco seed stock. Increased production and the return of full-scale advertising fueled greater consumer demand, and manufacturers began producing more and more varieties of cigarette. Vendors displayed glass cases filled with a colorful patchwork of cigarette packs bearing names like Panda, Double Happiness, and Red Pagoda.

The tobacco industry remained under government control as other industries privatized in the 1980s and 1990s. Party-state management of the cigarette became even more centralized in the early 1980s with the creation of the China Tobacco Monopoly Administration and its parallel external counterpart, the China Tobacco Corporation.

Since 1949, provincial protectionism has marked the cigarette market. It is now possible to purchase Beijing cigarettes in Kunming, Chengdu brands in Shanghai, and so on, but to distribute cigarettes in another province, a manufacturer must cut a deal with provincial government officials. Provincial administrations are loath to cut such deals because central government policy dictates that the portion of cigarette sales tax which does not go to the central government always is channeled to the finance bureau of the province of original production. China’s 2001 entry into the World Trade Organization opened the market ever so slightly to international brands like Marlboro and Kent, but domestic brands continue to dominate because of fierce protectionism.

...If it chooses to do so, China is in a position to lead and change the landscape in a very profound way.
-Matthew Kohrman, Professor of Anthropology, Stanford
A new era

In 2003, the World Health Organization established the first global health treaty, the Framework Convention on Tobacco Control (FCTC). Although the United States still has not yet ratified the FCTC, China signed the treaty in 2003 and ratified it in 2005. Kohrman says China’s tobacco industry giants fear competition from international cigarette brands more than they worry about tobacco-control measures related to the FCTC.

Nonetheless, the FCTC ushered in a new era of public health research about tobacco and has helped increase public awareness about the dangers of smoking. New restrictions have been imposed on print and television advertising for cigarettes, and international organizations, such as the Bloomberg Family Foundation, have begun funding anti-tobacco work in China.

A big challenge to tobacco-control campaigns, says Kohrman, is the sheer amount of money that tobacco companies have available for marketing. “In 2010, China’s tobacco industry posted profits in excess of U.S. $90 billion—that’s huge. Tobacco control research and advocacy now annually receive a few million dollars, and much of that is coming through outside funders, which have very specific projects in mind.”

China’s tobacco advertisers have adapted to the new restrictions that prevent them from openly promoting cigarettes in the media. They have instead moved to point-of-sale and soft-marketing tactics, including misinformation campaigns about the “dangers” of quitting smoking. “The actual expenditure on marketing probably hasn’t dropped very much,” says Kohrman.

Cigarettes and society

Strong marketing and the legitimization of cigarettes as a part of everyday life have led to the deep integration of cigarettes into Chinese society. While only 3 to 4 percent of women in China smoke, cigarettes are an important part of male identity and social mobility. The wide range of cigarette brands has led to the growth of high-end varieties favored by businessmen and politicians, with some brands costing as much as $50 a pack. The custom of cigarette gifting has existed in China for decades, and it is difficult for a young man to turn down a package of cigarettes from a senior colleague or supervisor.

There is also the fact that nicotine is highly addictive, and quitting is difficult in an environment where smoking cigarettes is socially sanctioned. Kohrman says, “When you take an incredibly addictive substance like nicotine and throw it into the mix of all of these norms and customs, it creates a pretty toxic brew.”

The future?

Tobacco control presents a formidable challenge in China, one that requires understanding the historical context and complex dimensions of the cigarette industry. “Cigarettes have been insinuated into so many aspects of daily life across China, and the market for this product has now become so closely enmeshed with matters of government finance and operations,” says Kohrman.

What happens in China could have implications for the entire world. “There’s a tobacco-induced human annihilation unfolding right now in almost every country and questions about how society and Big Tobacco are enmeshed, and how cigarette culture and government finance have become mutually supportive are pivotal,” says Kohrman. “Every country except Bhutan has legalized cigarette sales and is subject to many of the same general issues as China—only in China they’re on a much larger scale. But if it chooses to do so, China is in a position to lead and change the landscape in a very profound way.”