Former U.S. Ambassador to Afghanistan Karl Eikenberry has been awarded a William J. Perry Fellowship in International Security at Stanford’s Center for International Security and Cooperation (CISAC), where he will continue to address emerging security challenges facing the United States.

Ambassador Eikenberry has an ambitious agenda for the coming academic year, which includes teaching and mentoring students, public speaking and working closely with former Secretary of Defense William Perry. He also will take part in activities at the Walter H. Shorenstein Asia-Pacific Research Center (APARC), such as the new China and the World research initiative.

“It’s a lifetime honor to receive the Perry Fellowship,” says Eikenberry. “I can’t think of an American in modern times who has better exemplified inspirational commitment to public service than Dr. William Perry. And I can’t think of a better institute of higher learning to be associated with than Stanford University.”

Ambassador Eikenberry has been at Stanford since September 2011 as the Frank E. and Arthur W. Payne Distinguished Lecturer and is an affiliated faculty member for CISAC, APARC and the Center on Democracy, Development and the Rule of Law (CDDRL), as well as research affiliate at the Europe Center – all policy research centers within Stanford’s Freeman Spogli Institute of International Studies.

Before coming to Stanford, Ambassador Eikenberry led the civilian surge directed by President Obama from 2009 to 2011 in an effort to reverse the momentum gained by insurgents, and set the conditions for a transition to Afghanistan sovereignty. He retired from his 35-year military career in April 2009 with the rank of U.S. Army Lieutenant General after posts including commander and staff officer with mechanized, light, airborne and ranger infantry units in the United States, as well as Korea, Italy and as the Commander of the American-led Coalition Forces from 2005-2007.

"Karl Eikenberry's record of public service amply demonstrates his unique qualities, not only as a leader of the American military at a challenging time, but as a strategic thinker and an insightful diplomat,” says CISAC Co-Director Mariano-Florentino Cuéllar. “He has a rare understanding of the profound challenges facing our world, and has been a tremendous asset to CISAC and Stanford.”

Ambassador Eikenberry’s research areas include U.S. strategy in the Asia-Pacific region; China’s evolving security strategy; the United States and NATO; the future of the U.S. military; Washington’s policies in Central and South Asia; and assessing the risks of military intervention.

The fellowship was established to honor Perry, the 19^th U.S. secretary of defense and former CISAC co-director, and to recognize his leadership in the cause of peace. Perry is co-director of the Preventive Defense Project and the Nuclear Risk Reduction Initiative at CISAC and is an expert on U.S. foreign policy, national security and arms control. Perry Fellows spend a year at CISAC conducting policy-relevant research on international security issues. They join other distinguished scientists, social and political scientists and engineers who work together on problems that cannot be solved within a single field of study.

Ambassador Eikenberry is a graduate of the U.S. Military Academy, has master’s degrees from Harvard University in East Asian Studies and Stanford University in Political Science, and was a National Security Fellow at the Kennedy School of Government at Harvard. He earned an Interpreter’s Certificate in Mandarin Chinese from the British Foreign Commonwealth Office while studying at the United Kingdom Ministry of Defense Chinese Language School in Hong Kong, and has an Advanced Degree in Chinese History from Nanjing University in the People’s Republic of China.

Preparing a meal in some of the world’s poorest rural areas can turn an ordinary activity into a deadly chore. Animal dung and crop scraps often fuel the indoor fires used for cooking. And before any food fills a hungry belly, thick black smoke fills a family’s lungs.

Pneumonia and other acute respiratory infections kill about 1 million people a year in low-income countries, making them the top cause of death in the developing world and the greatest threat to children’s lives. Makeshift stoves belch much of the polluted air leading to those illnesses. About 75 percent of South Asians and nearly half the world’s population use open-fire stoves inside their homes.

“The smoke is asphyxiating,” said Grant Miller, an associate professor of medicine at Stanford working on ways to get people to buy – and use – cleaner, safer stoves. “It burns your eyes and you can’t stop coughing.”

Governments and humanitarian organizations have urged people to trade their traditional stoves for safer models, many of which have chimneys that funnel smoke out of a home. But the switch from dangerous stoves has been slow to come, even though most people using them know they’re harmful.

Miller and his colleagues are studying what’s behind the reluctance and what can be done about it. They suspect much of the problem rests with the widespread approach to clean cookstove conversion, which focuses on educating people about the appliances’ health hazards and offering new models at a low cost.

Their most recent findings, published in the Proceedings of the National Academy of Sciences, boil down to this: Clean and modern cookstoves don’t have features people want. And until they’re redesigned, people are unlikely to bother with them.

“People don’t think of cookstoves as health technologies,” said Miller, an associate professor of medicine and a Stanford Health Policy faculty member at the university’s Freeman Spogli Institute for International Studies. Miller is the senior author of the PNAS paper, which published online June 11.

“They don’t think respiratory illness is the biggest health problem that they have,” he said. “And when you ask them what they want from a stove, they talk about saving time and having better fuel efficiency. They’re not talking about smoke emissions.”

In the first of two studies, Miller – joined by Yale researchers and Lynn Hildemann, a Stanford engineering professor affiliated with the Stanford Woods Institute for the Environment – surveyed about 2,500 women who cook for their families in rural Bangladesh. 

Nearly all of the women use traditional stoves, and 94 percent of them said they know the smoke from their stoves can make them sick. But 76 percent said the smoke is less harmful than polluted water, and 66 percent said it wasn’t as dangerous as rotten food.

“People know their cookstoves are bad, but they don’t think cookstoves are the most important problem they face,” Miller said. “They’d rather spend their money fixing those things and getting their kids into a good school than buying a new cookstove.”

When asked what features are most important in a stove, the women talked about things that could save fuel costs, cooking time and the hassle that goes into collecting fuel.

“A very small percent said reducing pollution was important,” Miller said.

The researchers then tried to assess more directly how Bangladeshis value new stoves. They offered 2,200 customers across 42 rural villages the opportunity to buy one of two models – one boasted improved fuel efficiency; the other had a chimney to reduce exposure to indoor smoke.

At the market prices of $5.80 for an efficient stove and $10.90 for the chimney stove, less than a third of customers ordered either model. And when the stoves were delivered a few weeks after the orders were taken, a very small number of families actually went through with the purchase of either model.  Large randomized discounts increased customer interest in fuel-efficient stoves, but did little to raise purchase rates of chimney stoves.

“A big implication is that the health education and social marketing approaches aren’t going to work,” Miller said. “You need to get inside the heads of the users and figure out what they really want and value – even if unrelated to smoke and health – and then give it to them.”

The lead author of the PNAS paper was Ahmed Mushfiq Mobarak, an economist at Yale. It was co-authored by Yale researchers Puneet Dwivedi and Robert Bailis. Their work was supported by the Freeman Spogli Institute’s Walter H. Shorenstein Asia-Pacific Research Center, Stanford’s Woods Institute for the Environment, and the International Growth Centre.

Scarborough Shoal, a tiny rocky outcropping and lagoon off the west coast of the Philippines, sits at the center of the latest South China Sea tug-of-war. Protesters took to the streets in Manila on May 11 to criticize China’s support of fishermen who entered the disputed territory a month ago and sparked a yet unresolved naval standoff between the Philippines and China. On May 9, while ships from both sides maneuvered in the area, Manila's secretary of defense assured Filipinos that if Beijing attacked, Washington would come to the country’s defense.  

That expectation had been strengthened in Manila in November 2011 when the visiting American secretary of state, Hillary Clinton, referred to the South China Sea as the “West Philippine Sea.” Clinton’s slip of the tongue was not a major diplomatic incident. But some Flipinos saw it as a sign of U.S. support for their government's maritime claims.

Washington’s refusal to side with any of the claimant states had not changed. What had changed was the level of American concern. In the November 2011 issue of Foreign Policy Clinton had defended the idea of a “pivot” toward Asia, meaning a renewed U.S. focus on Asia after a decade of intense military activity in Afghanistan and Iraq.

The term “pivot” has fallen out of favor in Washington, but the Obama administration’s heightened interest in Asia is real and ongoing, says Donald K. Emmerson, director of Stanford’s Southeast Asia Forum. He recently discussed the nuances of what he describes as an important but “lopsided pivot.”

How does the pivot fit into the larger global picture?

In the continuing debate as to whether the United States is in decline, the key question is: relative to what? Certainly, if we compare the situation now with the period immediately after World War II, the United States is less powerful relative to the power of other states. But 1945 ushered in a uniquely unipolar moment in American history. Americans had escaped the physical devastation wreaked on Europe and much of Asia. Germany and Japan lay in ruins. Twenty million Russians were dead. China’s long-running civil war would soon resume. Suddenly America had no credible competitors for global power.

Today? Conventional wisdom holds that Asia has become the center of gravity in the global economy. Yet even if we use purchasing power parity rather than exchange rates to measure the American share of world GDP, that share has only modestly decreased. Meanwhile, China’s remarkable rise may be leveling off. The evidence is less that the United States is in secular decline than that the world is changing in ways to which Americans need to adapt if they are to regain economic health. If the pivot facilitates that adaptation, it will have been a success.

Do you interpret the pivot to the Asia-Pacific as more hype or reality?

The pivot is definitely a reality, but the reality is partly about symbolism and atmospherics. The pivot conveys reassurance, particularly to Southeast Asia, that the United States cares about the Asia-Pacific region and that it is willing to cooperate more than before with the Association of Southeast Asian Nations (ASEAN). Part of that is simply “showing up”—a willingness to attend ASEAN regional meetings. Another part of the pivot, however, involves raising the American security profile in the region, which has so far strengthened ASEAN’s diplomatic hand in dealing with China’s sweeping claim to the South China Sea.

How has the pivot been received and interpreted in Asia?

Generally speaking, the pivot has been welcomed in Southeast Asia, despite worries that if it becomes an effort to contain China, a Sino-American cold war could result. The specific responses of Southeast Asian governments have differed, however, on a spectrum from passive acquiescence to active support.

In Japan, the rotation of prime ministers in and out of office has understandably focused that country’s politics more on domestic concerns, and the still not fully resolved disposition of U.S. forces on Okinawa has drawn energy from the bilateral relationship.

As a “middle power,” South Korea has been supportive of multilateral frameworks and solutions. Seoul is pleased to see a renewed American interest in working with Asians in multilateral settings such as ASEAN and the East Asia Summit.

China’s response has varied between cool and hostile. The foreign ministry has treated the pivot with some equanimity compared with the hostility of those in the People’s Liberation Army who view increased American involvement in Asia as a threat to Chinese aims and claims, especially regarding the South China Sea. China’s foreign policy is the outcome of contestation between various groups inside the country that do not necessarily see eye to eye on how best to handle the United States.

What do you see as the main implications, repercussions, and complications of the pivot?

The pivot, as Hillary Clinton advertised it in her Foreign Policy article, signals a shift in U.S. priorities away from Iraq and Afghanistan. For a time following the 9/11 attacks on America in 2001, the United States tended either to neglect Southeast Asia or to treat it as a second front in the “war on terror.” Economically, the pivot implies an acknowledgment that if America is to prosper in this century it will have to pay closer attention to Asia as an engine of global economic growth. Diplomatically, the pivot implies that with regard to Asian states, Washington cannot merely manage its relations bilaterally as the hub where their spokes meet, but must cultivate multilateral diplomacy as well. Militarily, the pivot implies that even while the American global force posture is drawn down in some parts of the world, it needs to be upgraded in Asia in response to Asian and American concerns over the terms on which China’s rise will take place.

A major constructive repercussion of the pivot has been the evolution of China’s own diplomacy in Southeast Asia. Previously China had disavowed multilateral diplomacy with Southeast Asians over claims to the South China Sea—a bilateralist strategy that in Southeast Asian eyes resembled an effort to “divide and rule.” America’s willingness to reach out to ASEAN and take part in ASEAN events has helped diplomats in any one Southeast Asian country to resist having to face China alone. Multilateral discussions, involving China and meant to prepare the way toward an eventual Code of Conduct, are now underway.

But as we saw recently during Hillary Clinton’s visit to the Philippines, it is important for Washington to maintain its independence and impartiality while facilitating peace in the region.

Complications? Yes, there is a danger that Washington could be dragged into supporting, or appearing to support, the claims of one of the Southeast Asian parties to the dispute. The Obama administration is aware of this risk, however, and I strongly doubt that an American official will again refer to the “West Philippine Sea.” 

A more serious complication in the longer run may arise from the pivot’s emphasis to date on Asian-Pacific security, and its relative lack of attention to creating and cultivating American economic opportunities in Asia.

China’s economic footprint in Asia is large and growing. It has moved up to become the main trading partner of many countries that used to trade proportionally more with the United States. An unbalanced relationship in which China saves and lends what Americans borrow and spend is unhealthy for both countries, and it cannot last. The pivot should forestall an invidious division of labor whereby Washington through the Seventh Fleet subsidizes the regional peace that enables Asians to prosper doing business with China. A higher priority needs to be placed on promoting American trade and investment in Asia, including China.

The Obama administration is hoping to persuade more Asian economies to join an arrangement called the Trans-Pacific Strategic Economic Partnership (TPP), but the bar that it sets is high. The TPP’s strict protections for the environment, labor, and intellectual property rights and its comprehensive cuts in both tariff and non-tariff barriers to trade have raised its quality but lowered its appeal, especially to the region’s larger economies. Meanwhile, anticipated cuts in American budgets for defense will only intensify the need to refocus the pivot on economic as well as military access to Asia.

Related Resources

Foreign Policy: “America’s Pacific Century”
November 2011 article by Hillary Clinton introducing the concept of the "Asia pivot."

Stanford Daily: "Obama pivots policy toward Asia"
Summary of Donald K. Emmerson's May 1, 2012 talk.

LinkAsia: "Treat Scarborough Shoal Incident as a 'Wake Up Call'"

Thomas Fingar, who has observed developments in U.S.-China relations since "ping-pong diplomacy" in the early 1970s, spoke with China-based Leaders Magazine about the significance of—and hype surrounding—the Obama administration's "Asia pivot." The following is an edited version of the interview transcript.

President Obama recently announced a new military strategy, in which he stated that budget cuts will not weaken the U.S. presence in the Asia-Pacific. How do you interpret this?

The Asia-Pacific is the most economically dynamic region in the world, and it has the largest military forces and the most nuclear powers. U.S. interest has always been there. Our interest, our stake, and our involvement as a Pacific power is very great.

President Obama has been talking about our overall budget deficit and the need to reduce spending, including on defense. Some savings have already come from ending the war in Iraq and winding down the war in Afghanistan, which then increases the relative percentage of the military budget for East Asia. In the process of balancing its budget, the United States is not going to do anything to destabilize the region.

Is this just the policy of the Obama administration, or is it a longer-term strategic shift that could lead to a cold war?

I would distinguish between the rhetoric of "pivoting" toward Asia and the fact that the United States never left Asia. The George W. Bush administration did not send representatives to a number of ASEAN meetings and that troubled people in the region. But U.S. economic and political involvement and military deployments in the region, as well as the alliance structure, have not changed for decades.

American engagement has been important to the threat of nuclear weapons and to the freedom of the seas in the Asia-Pacific. Our allies and China can be confident that this policy is not aimed against anybody—it is not a cold war.

Some experts say that relations between Washington and Beijing are actually doing much better than the media portrays. Do you agree with this perspective?

I do agree with it. I have been involved in U.S.-China relations since "ping-pong diplomacy" in 1972, and we still have ups and downs and swings in our relationship, but the pattern is clear and the magnitude of the swing is much smaller than it used to be. In recent years, we have bumped up against one another in more places around the world, on more issues, because we are both global players. Most issues are handled pretty smoothly, however, and in a pretty routine fashion. The strength of the bilateral relationship—the depth of the interdependence—keeps growing.

From your experience, will there be a big impact on bilateral relations when the new Chinese leadership takes office later this year?

I think it used to be the case that personalities mattered a great deal, but it does not make so much of a difference now in both countries. I do not expect China’s policies and objectives to change, or its perceptions of the United States. In addition, if we elect a new presidential administration, I also do not expect a change in American perceptions of the opportunities and challenges China poses.

Which issue in U.S.-China relations most concerns you?

Mutual suspicion concerns me the most. Some people in China believe the United States will attempt to stop China’s rise or to contain it at some point. In the United States, the things we do not understand about China's intentions and aspirations lead to a similar kind of “worst case” thinking. I think the two countries need to do more to talk directly to one another about their concerns, and to find new approaches. For example, China does not like the bilateral alliance structure the United States has in Northeast Asia. The United States is quite prepared to acknowledge it is an arrangement that was developed for a different time and conditions. What kind of a new collective security arrangement can we have in the region that then? We are a long way from figuring it out, but we need to start talking about it together. 

Original article

"American experts discuss the significance and outcomes of the 'Asia pivot'"
(in Chinese)

China’s demographic landscape is rapidly changing, and the government has responded by launching ambitious social and health service reforms to meet the changing needs of the country’s 1.3 billion people. This week, officials approved a five-year plan to develop a comprehensive nationwide social security network.

Karen Eggleston, the Asia Health Policy Program (AHPP) director and a Stanford Health Policy fellow, discusses the success of China’s health care reforms—including its recently established universal health care system—and the long road still ahead.

Why is the overall health and wellbeing of China’s population important globally?

There are many reasons why the health of China’s citizens matters within a larger global context. On the most basic level, China represents almost 20 percent of humanity. But it is also a major player in the world economy and it depends on having a healthy workforce, especially now that its population is aging more. The government’s ability to meet the needs of its underserved citizens contributes to a more productive and stable China, and works towards closing the huge gaps we see in human wellbeing across the world.

China also potentially offers a model for other developing countries, such as India, that may want to figure out how to make universal health coverage work at a tenth of the income of most of the countries that have put it into place before.

What are some of the biggest changes in China’s health care system since 1949?

One of the most significant changes is that China has achieved very basic universal health insurance coverage in a relatively short period of time.  

Throughout the Mao period (1949–1978) there was a health care system linked to the centrally planned economy, which provided a basic level of coverage via government providers with a lot of regional variation. When economic reform came in 1980, large parts of the system—particularly financing for insurance—collapsed. The majority of China’s citizens were uninsured during the past few decades of very rapid social and economic development.

China’s overall population is changing quite dramatically, which means it has different health care needs, such as treating chronic disease and caring for an increasingly elderly population. The central government is trying to establish a system of accessible primary care—a concept that China’s barefoot doctors helped to pioneer but that fell into disarray—and health services that fit these new needs. 

How does China’s basic health care system work? Are there segments of the population still not receiving adequate coverage and care?

China has had a system where people can select their own doctors. Patients usually want to go to clinics attached to the highest-reputation hospitals, but of course, when you are not insured you almost always by default go to where you can afford the care. “It is difficult to see the doctor, and it is expensive” has been the lament of patients in China, so an explicit goal of the health care reforms has been to address this.

The term “universal coverage” has different definitions. China initially put in place a form of insurance that only covers 20 or 30 percent of medical costs for the previously uninsured population, especially in rural areas. Benefits have expanded, but remain limited. As with the previous system, disparities in coverage still exist across the population. China not only has a huge population with huge economic differences, but within that there is a large migrant worker population. It is a challenge to figure out how to cover these citizens and how to provide them with access to better care. The government is quite aware there are segments of the population not receiving equal coverage, and it continues to strive to resolve the issue.  

What are the greatest innovations in China’s health care system in recent years?

One of the most remarkable things China has achieved is really its new health insurance system. Even if the current coverage is not particularly generous it is nearly universal, and mechanisms are put in place each year to provide more generous coverage. China is also working on strengthening its primary care and population health services, infusing a huge sum of government money into these efforts. It is the only developing country of its per-capita income that has achieved such results so far.

Interestingly, a lot of people assume China achieved its universal coverage by mandate, while in fact the central government did so by subsidizing the cost for local governments and individuals. This reduces the burden, for example, on poorer rural governments and residents, and is one innovative way China is trying to eliminate the disparity in access to care.

Eggleston has recently published a working paper on China’s health care reforms since the Mao era on the AHPP website, as well as an article in the Milken Institute Review.

Gordon Liu, a Chinese government advisor on health care and the executive director of Peking University’s Health Economics and Management Institute, spoke at Stanford on May 29 on the future of China’s health care system.