The Korean Peninsula stands at a perilous crossroads. Recent missile tests and provocations, coupled with historical trends, paint a worrisome picture of the current state of affairs, prompting some analysts to warn of a looming conflict. The Korea Program at Shorenstein APARC recently hosted two events to analyze these escalating tensions that have sparked global concern.

On February 21, the seminar “Slow Boil: What to Expect from North Korea in 2024,” featured Victor Cha, D.S. Song-KF Chair, Professor of Government at Georgetown University, and Senior Vice President for Asia and Korea Chair at the Center for Strategic and International Studies. Cha discussed historical behavioral patterns of North Korean missile tests, military provocations, and weapons demonstrations, and what all these might mean for security on the Korean peninsula.

The following week, on March 7, at the seminar  “Is North Korea Preparing for War?,” we were joined by Robert Carlin, a non-resident scholar at the James Martin Center for Nonproliferation Studies, Middlebury Institute of International Studies at Monterey and Siegfried Hecker, a professor of practice at the James Martin Center for Nonproliferation Studies, Middlebury Institute of International Studies at Monterey, and in the Department of Nuclear Engineering at Texas A&M University. Carlin and Hecker, both formerly our colleagues at the Stanford Center for International Security and Cooperation, discussed their recent 38 North article, “Is Kim Jong Un Preparing for War?,” which posits that Pyongyang has already made the strategic decision to go to war. 

The speakers at both events delved into the various rationales behind North Korea's actions and provided contrasting viewpoints on the trajectory of the situation. While Carlin and Hecker painted a grim picture of North Korea's intentions to engage in warfare and advocated for robust security measures, Cha argued that, while 2024 will be a challenging year, established approaches such as diplomacy and deterrence will remain effective in managing relations with Pyongyang. 

Rhetorical Preparations for Conflict

Carlin and Hecker provided a grave assessment, suggesting that “Kim Jong Un has made a strategic decision to go to war,” akin to his grandfather's stance in 1950. Hecker provided historical context, indicating that despite attempts at normalization with the United States, each North Korean leader has simultaneously explored the development of its nuclear weapons arsenal and accumulation of its conventional armaments. Hecker argued, "The Korean War was never settled, it was an armistice, and so, more or less, North Korea has been preparing for war, but this is different and we are really concerned.”

Carlin noted a shift that occurred at the Workers’ Party plenum at the end of 2022, in which “Pyongyang announced new measures that demonstrated that the old policy with the U.S. was over and that they were going to move much more towards the Russians.” The plenum also marked a rhetorical shift where Kim Jong Un introduced the phrase “war preparations.” “Some people say, ‘Oh that's normal North Korean rhetoric’ — it's not normal. They had not been talking at that level to their own people about war preparations […] they talked a lot about deterrence which meant building up, but not war preparations,” said Carlin.

According to Carlin, Pyongyang has “primed the pan for a clash in the Yellow Sea […] everything we have seen in the last year suggests very strongly that this is a decision the regime has made, and that it will patiently move in this direction.”

The speakers both argued that Kim's shift stems from a perceived failure of past diplomatic endeavors and a traumatic setback at the 2019 Hanoi summit, when, as Hecker indicated, the North Koreans decided to abandon the 30-year policy of seeking normalization with the United States. “This is a more dangerous time than any time since the start of the Korean War,” Hecker warned.
 

The Inevitable Tensions of Deterrence

In contrast, Cha’s assessment of the situation is more cautiously optimistic, anticipating a surge in North Korean provocations in 2024 but attributing it to historical patterns rather than a definitive strategic shift. According to Cha, we should  expect North Korean belligerence to increase in 2024, while dialogue looks unlikely.” He highlighted North Korea's tendency to ramp up provocations during U.S. election years, produced data on the increasing number of provocations since the 1990s, and emphasized Kim's repeated rejections of dialogue with the Biden administration.

Cha also provided four reasons why he does not expect a war with North Korea in 2024: “First, Pyongyang is not confident enough in its capability to deter U.S. and South Korean retaliation […] Second, the uptempo in U.S.-ROK and U.S.-ROK-Japan exercising […] Third, if North Korea were ready to go to war, they would not be selling all their ammunition to Russia […] and fourth, if North Korea were really ready to go to war, they would not be decoupling from South Korea.”

Cha suggested that, while war is unlikely, “coercion, particularly against South Korea, and North Korea-Russia relations are only going to grow.” He described North Korea’s transfer of armaments from Najin to Dunai in Russia to three munition storage facilities near the Ukrainian front. Cha sees a possible change in the U.S. North Korea policy approach from focusing on denuclearization to curtailing and disincentivizing this behavior.

An Uncertain Year Ahead

Whether or not the escalating tensions since the 2019 Hanoi Summit mean that Pyongyang is headed to war, its increased belligerence is a clear signal that Kim’s government has shifted its efforts. North Korea is now pursuing its security and economic agendas without any indication of attempting to normalize relations with the United States or South Korea. Furthermore, it continues to strengthen its partnership with the China-Russia bloc. The assessment of continued tensions on the Korean Peninsula is undisputed.

Ultimately, both perspectives shared by the speakers highlight the need for vigilance, strategic coordination, and innovative policy solutions to address the escalating tensions in the region.
 

Dr. Daniel Greene has been accepted as a 2022 Emerging Leaders in Biosecurity fellow from the Center for Health Security at John Hopkins University.

The Emerging Leaders in Biosecurity program supports talented career professionals in deepening their expertise, expanding their network, and building their leadership skills through a series of events coordinated by the center. The highly competitive program inspires and connects the next generation of leaders and innovators in the biosecurity community.

Dr. Daniel Greene received his Ph.D. in Education from Stanford University, and continues research focused on the societal risks and potential of the life sciences using a combination of data science, survey research, policy and analysis, and qualitative methods to help us understand our collective options for regulating life-science research. He has been a Postdoctoral Researcher in Biosecurity and Project Fellow for CISAC since 2019.

Center for Health Security Announcement

As biological research and its applications rapidly evolve, new attempts at the governance of biology are emerging, challenging traditional assumptions about how science works and who is responsible for governing. However, these governance approaches often are not evaluated, analyzed, or compared. This hinders the building of a cumulative base of experience and opportunities for learning. Consider “biosecurity governance,” a term with no internationally agreed definition, here defined as the processes that influence behavior to prevent or deter misuse of biological science and technology. Changes in technical, social, and political environments, coupled with the emergence of natural diseases such as coronavirus disease 2019 (COVID-19), are testing existing governance processes. This has led some communities to look beyond existing biosecurity models, policies, and procedures. But without systematic analysis and learning across them, it is hard to know what works. We suggest that activities focused on rethinking biosecurity governance present opportunities to “experiment” with new sets of assumptions about the relationship among biology, security, and society, leading to the development, assessment, and iteration of governance hypotheses.

Read the rest at Science

Taiwan is only 81 miles off the coast of mainland China and was expected to be hard hit by the coronavirus, due to its proximity and the number of flights between the island nation and its massive neighbor to the west.

Yet it has so far managed to prevent the coronavirus from heavily impacting its 23 million citizens, despite hundreds of thousands of them working and residing in China.

According to the Johns Hopkins Coronavirus COVID-19 Global Cases map, as of Tuesday there were only 42 cases and one death in Taiwan, far behind China, with more than 80,000 cases and more than 2,900 deaths. The country also lags far behind its other Asian neighbors and ranks 17^th in the world for the number of global cases. As of this writing, South Korea was second, with 5,186 cases; followed by Iran with 2,336 and Italy with 2,036 people infected with the virus.

The United States currently stands at 107 known cases and six deaths.

The viral outbreak in China occurred just before the Lunar New Year, during which time millions of Chinese and Taiwanese were expected to travel for the holidays.

So what steps did Taiwan take to protect its people? And could those steps be replicated here at home?

Stanford Health Policy’s Jason Wang, MD, PhD, an associate professor of pediatrics at Stanford Medicine who also has a PhD in policy analysis, credits his native Taiwan with using new technology and a robust pandemic prevention plan put into place at the 2003 SARS outbreak.

“The Taiwan government established the National Health Command Center (NHCC) after SARS and it’s become part of a disaster management center that focuses on large-outbreak responses and acts as the operational command point for direct communications,” said Wang, a pediatrician and the director of the Center for Policy, Outcomes, and Prevention at Stanford. The NHCC also established the Central Epidemic Command Center, which was activated in early January.

“And Taiwan rapidly produced and implemented a list of at least 124 action items in the past five weeks to protect public health,” Wang said. “The policies and actions go beyond border control because they recognized that that wasn’t enough.”

Wang outlines the measures Taiwan took in the last six weeks in an article published Tuesday in the Journal of the American Medical Association.

“Given the continual spread of COVID-19 around the world, understanding the action items that were implemented quickly in Taiwan, and the effectiveness of these actions in preventing a large-scale epidemic, may be instructive for other countries,” Wang and his co-authors wrote.

Within the last five weeks, Wang said, the Taiwan epidemic command center rapidly implemented those 124 action items, including border control from the air and sea, case identification using new data and technology, quarantine of suspicious cases, educating the public while fighting misinformation, negotiating with other countries — and formulating policies for schools and businesses to follow.

Big Data Analytics

The authors note that Taiwan integrated its national health insurance database with its immigration and customs database to begin the creation of big data for analytics. That allowed them case identification by generating real-time alerts during a clinical visit based on travel history and clinical symptoms.

Taipei also used Quick Response (QR) code scanning and online reporting of travel history and health symptoms to classify travelers’ infectious risks based on flight origin and travel history in the last 14 days. People who had not traveled to high-risk areas were sent a health declaration border pass via SMS for faster immigration clearance; those who had traveled to high-risk areas were quarantined at home and tracked through their mobile phones to ensure that they stayed home during the incubation period.

The country also instituted a toll-free hotline for citizens to report suspicious symptoms in themselves or others. As the disease progressed, the government called on major cities to establish their own hotlines so that the main hotline would not become jammed.

Some might say that because Taiwan is such a small country — about 19 times smaller than Texas — it is easier to mobilize during emergencies. Yet Taiwan is particularly challenged by its proximity to China and the fact that 850,000 of its citizens reside on the mainland; another 400,000 work there. Taiwan had 2.71 million visitors from China last year.

So when the WHO was notified on Dec. 31, 2019, of a pneumonia of unknown cause in Wuhan, China, Taiwanese officials began to board planes and assess passengers on direct flights from Wuhan for fever and pneumonia symptoms before passengers could deplane.

As early as Jan. 5, notification was expanded to include any individual who had traveled to Wuhan in the past 14 days and had a fever or symptoms of upper respiratory tract infection at the point of entry. Suspected cases were screened for 26 viruses, including SARS and MERS. Passengers displaying symptoms were quarantined at home and assessed whether medical attention at a hospital was necessary.

What the U.S. Could Learn

One of Wang’s co-authors, Robert H. Brook, M.D., ScD., of the David Geffen School of Medicine at the University of California, Los Angeles, said Washington could learn a great deal from Taiwan’s so-far successful management of the virus.

“In Taiwan, diverse political parties were willing to work together to produce an immediate response to the danger,” said Brook, also of the nonprofit RAND Corporation. “Transparency was critical and frequent communication to the public from a trusted official was paramount to reducing public panic.”

The other co-author of their study is Chun Y. Ng, MBA, MPH, of The New School for Leadership in Health Care, Koo Foundation Sun Yat-Sen Cancer Center, Taipei, Taiwan.

Brook said Taiwan got out ahead of the epidemic by setting up a physical command center to facilitate rapid communications. The command center set the price of masks and used government funds and military personnel to increase mask production. By Jan. 20, the Taiwan CDC announced that it had a stockpile of 44 million surgical masks, 1.9 million N95 masks and 1,100 negative pressure isolation rooms.

“In a country as complex as the United States,” Brook said, “there needs to be a sharing of intelligence on a real-time basis among states and the federal government so that action is not delayed by going through formal channels.”

Please contact Beth Duff-Brown for media requests. 

U.S. government aid for treating children and adults with HIV and malaria in developing countries has done more than expand access to lifesaving interventions: It has changed how people around the world view the United States, according to a new study by researchers at the School of Medicine.

Compared with other types of foreign aid, investing in health is uniquely associated with a better opinion of the United States, improving its “soft power” and standing in the world, the study said.  

Favorability ratings of the United States increased in proportion to health aid from 2002 to 2016 and rose sharply after the implementation of the President’s Emergency Plan for AIDS Relief in 2003 and the launch of the President’s Malaria Initiative in 2005, the researchers report.

Their findings were published this week in the American Journal of Public Health. The lead author is postdoctoral scholar Aleksandra Jakubowski, PhD, MPH. The senior author is Eran Bendavid, MD, associate professor of medicine and a core faculty member at Stanford Health Policy.

“Using data on aid and opinions of the United States, we found that investments in health offer a unique opportunity to promote the perceptions of the United States abroad, in addition to disease burden relief,” the authors wrote. “Our study provides new evidence to support the notion that health diplomacy is a net win for the United States and recipient countries alike.”

The Trump administration, however, has proposed a 23% cut in foreign aid in its 2020 budget, including large reductions to programs that fight AIDS and malaria overseas.

The Stanford researchers believe their study is the first to add heft to the argument that U.S. health aid boosts the “soft power” that wins the hearts and minds of foreign friends and foes.

“Our study shows that investing in health aid improves our nation’s standing abroad, which could have important downstream diplomatic benefits to the United States,” Jakubowskisaid. “Investments in health aid help the United States accumulate soft power. Allowing the U.S. reputation to falter would be contrary to our own interests.” 

A Policy Debate

Many politicians and economists consider spending U.S. tax dollars on foreign aid as an ineffective, and possibly harmful, enterprise that goes unappreciated and leads to accusations of American meddling in other countries’ national affairs.

The U.S. government, for the past 15 years, has contributed more foreign health aid than any other country, significantly reducing disease burden, increasing life expectancy and improving employment in recipient countries, the authors wrote. Still, this generosity has historically constituted less than 1% of the U.S. gross domestic product.

“Our results suggest that the dollars invested in health aid offer good value for money,” the researchers wrote. “That is, the relatively low investment in health aid (in terms of GDP) has provided the United States with large returns in the form of improved public perceptions, which may advance the U.S. government’s ability to negotiate international policies that are aligned with American priorities and preferences.”

The researchers used 258 Global Attitudes Surveys, based on interviews with more than 260,000 respondents, conducted by the Pew Research Center in 45 low- to middle-income countries between 2002 and 2016.

Their analysis focused on the health sector, which includes several large programs for infectious disease control, but also support for nutrition, child health and reproductive health programs. They compared health aid to other major areas of U.S. investment: governance, infrastructure, humanitarian aid and military aid. They also constructed a database of news stories that mentioned the President’s Emergency Plan for AIDS Relief or the President’s Malaria Initiative by crawling through the online archives of the top three newspapers by circulation in each of the 45 countries.

They found that the probability of populations holding a very favorable opinion of the United States was 19 percentage points higher in the countries where and years when U.S. donations for health care were highest, compared with countries where and years when health aid donations were lowest. Using another metric, the researchers found that every additional $100 million in health aid was associated with a nearly 6 percentage-point increase in the probability of respondents indicating they had a “very favorable” opinion of the United States. 

In contrast, the researchers found, aid for governance, infrastructure, humanitarian and military purposes was not associated with a better opinion of the United States.

Bendavid, an infectious diseases physician and core faculty member of Stanford Health Policy, said that when he set out to conduct this research, he believed it would result “in a resounding thud” — that the “soft power” of health aid would have no impact on public opinion.

“For me, the notion that this program — hatched and headquartered in D.C. — would have impacts among millions in Nairobi and Dakar, seemed farfetched,” Bendavid said. “I was incredulous until all the pieces were in place.”

The ‘America First’ Agenda

The Trump administration’s “America First” agenda is calling for significant cuts to global health aid, particularly to the highly successful AIDS relief program, which was established by President George W. Bush. The administration’s budget, released in March, proposed a $860 million cut to the program; the President’s Malaria Initiative is facing a $331 million reduction in federal funding. That’s a decline of 18% and 44%, respectively.

The U.S. contribution to the Global Fund to Fight AIDS, Tuberculosis and Malaria would also decline by 17%, or $225 million, according to the Kaiser Family Foundation.

Yet beyond the reputational damage to the United States, such cuts could be a major setback to improving health outcomes in developing countries, the researchers said. After all, HIV knows no borders, and having more resilient health care systems is instrumental when facing public health crises, such as the Ebola outbreak in the Democratic Republic of Congo, Jakubowski said.

“The most direct impact of cutting the United States’ health aid allocations is the potential to undermine or reverse the progress that has been enabled by U.S. aid in curbing mortality and the spread of disease,” Bendavid said. “However, this study suggests there are also repercussions to the United States: the relationships the U.S. has built with recipient nations could also be undermined.”            

Other Stanford co-authors are Steven Asch, MD, MPH, professor of medicine, and former graduate student Don Mai.

Stanford’s Department of Medicine supported the work.

From genome editing to “hacking” the microbiome, advances in the life sciences and its associated technological revolution have already altered the biosecurity landscape, and will continue to do so. What does this new landscape look like, and how can policymakers and other stakeholders navigate this space? A new report by Stanford scholars David Relman and Megan Palmer along with George Mason University’s Jesse Kirkpatrick and Greg Koblentz assesses this emerging biosecurity landscape to help answer these questions and illustrates gaps in governance and regulation through the use of scenarios.

The report—the product of two years of workshops, issue briefs, and white papers authored by different participants—involved people from different organizations and backgrounds ranging from life sciences and medicine to social science and ethics. “The project process was just as important as the product,” said Palmer. “It was a truly interdisciplinary effort.”

Genome editing, including CRISPR, is disruptive to the biosecurity landscape, and it serves as an illustration of more general trends in the evolving landscape, the authors write. CRISPR technology does not exist in a vacuum—rather, it is enabled by, represents, and gives rise to a suite of technologies with potential benefits and that require new approaches to adaptive policy making and governance.

Scenarios illustrating governance gaps in in the report include:

• A reckless CRISPR user who develops and markets a probiotic created with genome editing that has serious unanticipated effects for consumers;
• An agricultural biotechnology firm conducting dual use genome editing research that lies outside current oversight, but nonetheless could have negative consequences for human health
• An intentional release of a gene drive organism from a lab, that while having limited physical harm, feeds a state-based misinformation campaign with large economic impacts
• An accidental release of a gene drive organism due to lack of awareness and uncertainty about the risk classifications and protocols for handling new technologies
• A terrorist group using commercial firms that lack strong customer and order screening to use genome editing to weaponize a nonpathogenic bacteria
• A state-sponsored program to develop biological weapons for new strategic uses, including covert assassination, using largely publicly available research
   

In each of these examples, the researchers play out a hypothetical situation exposing a number of security and governance gaps for policymakers and other stakeholders to address.

In the report, the authors conclude that genome editing has tremendous potential benefits and economic impacts. The authors note that the market for genome editing is expected to exceed $3.5 billion by 2019, but a security incident, safety lapse, reckless misadventure, or significant regulatory uncertainty could hurt growth. Increased reliance on the “bio-economy,” they write, means biosecurity is increasingly critical to economic security as well as human health.

Other key takeaways:

Genome editing has the potential to improve the human condition. Genome editing is poised to make major beneficial contributions to basic research, medicine, public health, agriculture, and manufacturing that could reduce suffering, strengthen food security, and protect the environment.

Genome editing is disruptive to the biosecurity landscape. The threat landscape has, and continues to expand to include new means of disrupting or manipulating biological systems and processes in humans, plants, and animals. Genome editing could be used to create new types of biological weapons. Further, technical advances will make misuse easier and more widespread.

CRISPR illuminates broader trends and the challenges of an evolving security landscape. An approach to biosecurity that accounts for these trends, and encompasses risks posed by deliberate, accidental, and reckless misuse, can help address the complex and evolving security landscape.

Technology must be taken seriously.  A thorough, informed, and accessible analysis of any emerging technology is crucial to considering the impact that it may have on the security landscape.

Key stakeholders must be engaged. Stakeholders in the genome editing field encompass a more diverse array of actors than those that have been involved so far in biosecurity discussions. These stakeholders range from international organizations to government agencies to universities, companies, lay communities writ large, and scientists.

Applied research is needed to create and implement innovative and effective policies. Applied research is necessary to continue the process of modifying existing governance measures, and testing and adapting new ones, as new genome editing technologies and applications are developed, new stakeholders emerge, and new pathways for misuse are identified.

Download the executive summary and full report at editingbiosecurity.org.