Eyeglasses boosted the standardized test scores of rural Chinese schoolchildren as much as 18 percent in just six months, according to a large-scale, ongoing study led by Stanford researchers.

"The evidence is overwhelming," said Scott Rozelle, co-director of the Rural Education Action Program (REAP), a coalition of Chinese universities and Stanford's Freeman Spogli Institute for International Studies that works to improve education and health in rural China.

The initial test scores for nearsighted students hovered around 68 percent. After receiving glasses, average scores soared to 86 percent. "You do these simple interventions and a child's whole life changes," Rozelle said. "It's fantastic."

REAP scholars partnered with Chinese ophthalmologists and scores of graduate students to orchestrate the massive project, the first to examine vision problems in rural China.

In 2012 and 2013, the team screened the vision of approximately 20,000 fourth and fifth graders in rural Shaanxi and Gansu provinces and doled out more than 4,000 pairs of eyeglasses. They discovered that 25 percent of the students were nearsighted, but only one in seven of those nearsighted students had the glasses they needed.

"There's a huge amount of unmet need," said Matthew Boswell, a REAP project manager based at Stanford.

The results may seem intuitive. Yet, helping the millions of nearsighted children in rural China is anything but easy, the REAP team discovered. Few of these rural children (and adults) know they are nearsighted – the world, to them, is naturally blurry. In addition, eye doctors are concentrated in the populous coastal corridors or regional "county towns," often dozens of miles by bus from the homes of rural Chinese families, Boswell said.

Basic eyeglasses cost between 200 and 500 yuan ($30 to $80), a price out of reach for many, he said.

The researchers also struggled to counter pervasive superstitions about eyeglasses.

For example, many rural Chinese residents believe that glasses make children's' vision deteriorate, relying on the observation that vision generally worsens with age, Boswell said. In addition, many Chinese do "eye exercises" by rubbing their eyes, cheeks and temples each morning, a practice they believe improves vision, he said.

They also face political struggles: China's rural health care program doesn't pay for vision care. "We could tell health or education officials until we were blue in the face there was a high level of need for vision care in rural communities," Boswell said. "But if your findings are not attached to something they care about, it's hard to make them listen."

Hence the connection to the test scores, a highly valued measurement by Chinese policymakers. The REAP team taps its large network of Chinese academic collaborators to translate its research results into policy reform, a process that is often successful, Rozelle said.

REAP is currently analyzing alternative ways to boost the delivery and acceptance of eye care, Boswell said. The original study assigned nearsighted students into six groups.  Researchers gave one-third of the students glasses; one-third received a voucher to purchase glasses; and another third remained untreated. Then, half of the students in each group received training about the causes and treatments for vision problems.

The training failed to significantly affect whether students wore the glasses, Boswell said.  The students who had to invest time to acquire glasses using a voucher demonstrated similar usage rates as students who received free glasses, he said.

Among a variety of other initiatives currently underway, the REAP team is training Chinese teachers to conduct simple vision tests, Boswell said.

"It's an extreme feel–good example," Rozelle said. "You put the first pair of glasses on a kid … and then a huge smile lights up their face."

Becky Bach is a writer for the Stanford News Service.

Children in rural Kenya are more susceptible to disease and death the farther away they live from clean drinking water, according to Stanford researchers.

In a survey of families in Asembo – a small farming community at the edge of Lake Victoria that has high rates of chronic diarrhea, child malnutrition and child death – a research team from the Center on Food Security and the Environment found that most people live just over a quarter-mile from clean water sources. About 200 feet closer to home are ponds and springs contaminated with E. coli bacteria. Sixty-six percent of families primarily use this contaminated surface water for drinking.

A child in Asembo, Kenya sits next to her family's water storage containers.

A child in Asembo, Kenya sits next to her family's water storage containers. Photo Credit: Amy Pickering

While water is essential for farming, collecting it is time-consuming and physically exhausting in remote places like Asembo. Previous research has shown that when families must travel long distances for water, child health suffers. The harder it is to collect, the less of it a family will use. A shortage of water for cooking and drinking compromises children’s nutrition and hydration. And it limits hand washing and bathing, making children more susceptible to disease. Quality and availability of water also varies widely from source to source, and the time required to collect water can force families to use dirtier, unimproved water sources that are closer to home. 

In 2011, the FSE researchers partnered with the Centers for Disease Control Kenya Medical Research Institute (CDC-KEMRI), which was already conducting an extensive survey of household-level health indicators in the region. Combining resources with CDC-KEMRI allowed the team – led by FSE Director Rosamond Naylor, a professor of environmental earth system science, and Jenna Davis, an assistant professor of civil and environmental engineering – to use a robust set of data. The information covered about 3,000 households in a five kilometer radius and was collected on a bi-weekly basis for six months. In exploring the links between water, food and health in Asembo, FSE researchers first expanded the definition of water “access” to account for both physical distance and the quality of water sources.

Researchers take a child's measurements in Asembo, Kenya.

Researchers take a child's measurements in Asembo, Kenya. Photo Credit: Amy Pickering

Researchers then mapped the distance of each household from its nearest water source, and recorded whether the source was improved (such as a deep borewell) or unimproved (surface water like a pond, spring or shallow well). To get the most precise possible data on local water quality, the research team collected samples from each household’s water source and sent them to a local hospital lab for testing. Surveyors then collected data on each household’s water management practices, including water treatment. They measured agricultural output, dietary diversity, and perceived food insecurity, then recorded the weight and height measurements of each child in the household. Respondents also reported the frequency of recent cases of diarrheal disease among children of the household.

Results of the initial survey highlight sobering realities about water access in Asembo. Households in the survey reported average per capita water consumption of only 31 liters per day, including water used for cooking, drinking, hygiene and agriculture. The average walk time to the nearest water source was approximately 15 minutes. The average distance to the nearest improved source was 428 meters, whereas the average distance to unimproved surface water was 374 meters. Water quality tests confirmed that these sources, used by the majority of families, were highly contaminated with E. coli bacteria, while improved water sources were significantly cleaner. Thirty percent of children showed stunted growth, and 11 percent were underweight for their age.

A researcher collects a sample of stored water at a household in Asembo, Kenya.

A researcher collects a sample of stored water at a household in Asembo, Kenya. Photo Credit: Amy Pickering

Researchers found that close proximity to an abundant water source, regardless of quality, correlated with an increase in food production and diversity, as well as a lower hunger score. Having enough extra water for crop irrigation clearly improves children’s diets – particularly their access to the micronutrients essential for normal physical and cognitive development – and helps them resist disease. Households further from water sources reported lower and less diverse crop yields, as well as poorer child health indicators. Quality was also an important factor, as households with access to clean, improved water reported better child health outcomes than those relying on contaminated surface water.

The ultimate goal of the project, “Rural health and development at the food-water nexus” is to design interventions and policy incentives that help people absorb nutrients in environments where food and water are limited and disease is prevalent. In the next stage of the project, researchers will focus on links between water access and the progression of HIV, and will also investigate how improved diets from better water access can impact household income.

About the Stanford Research Team:

Jenna Davis is Associate Professor of Civil and Environmental Engineering, Higgins-Magid Faculty Senior Fellow at the Stanford Woods Institute for the Environment, and an affiliate of the Center on Food Security and the Environment.
Rosamond Naylor is the Director of the Center on Food Security and the Environment, Professor of Environmental Earth System Science, and the William Wrigley Senior Fellow at the Stanford Woods Institute.
Eran Bendavid is an infectious diseases physician and Assistant Professor of Medicine in the Division of General Internal Medicine, as well as an affiliate of the Center on Food Security and the Environment and the Stanford Health Policy center.
Amy Pickering is a lecturer in the School of Earth Sciences, and a research associate in Civil and Environmental Engineering, the Woods Institute for the Environment, and the Center on Food Security and the Environment.
Glwadys Gbetibouo is a postdoctoral scholar at the Center on Food Security and the Environment.
Katrina ole-MoiYoi is a Ph.D. student at the Center on Food Security and the Environment.

President Barack Obama’s 2014 budget proposal promises significant food aid reform that will enable the United States to feed about 4 million more people without a significant increase of the current $1.8 billion spent on feeding the world's most hungry. Since the food aid program's inception in 1954, the U.S. has helped feed more than 1 billion people in more than 150 countries, and remains the largest provider of international food aid.

The intention of the reform is to make food aid more efficient, cost effective, and flexible. It aims to use local and regional markets to lower the cost of food and speed its delivery, and calls for the use of cash transfers and electronic food vouchers.

The proposed reforms would also end monetization—the sale of U.S. food abroad to be sold by local NGOs for cash. This practice has been criticized for hurting vulnerable communities by depriving local farmers of the incentives and opportunities to develop their own livelihoods. Several studies, including one by the Government Accountability Office, found monetization to be costly and inefficient—an average of 25 cents per taxpayer dollar spent on food aid is lost.

Barry Riley, a food aid expert and visiting fellow at the Center on Food Security and the Environment, discusses his perspective on the importance of these new reforms, their chances of passage, and the country's current role in international food aid.

Why is local procurement such an important addition to food aid reform?

An increase of funding for local and regional procurement is the most important programmatic element of the proposed reforms. It would help managers working in food security-related development programs to determine for each emergency what commodities are most appropriate and where they can be procured most quickly and inexpensively. Some studies have shown local and regional procurement of food and other cash-based programs can get food to people in critical need 11 to 15 weeks faster at a savings of 25-50 percent. Equally important, local procurement is less likely to disrupt local economic conditions, but rather promote self-sufficiency by increasing demand (often for preferred local staples) and incomes of local producers. The move to 45 percent local (and 55 percent tied) procurement is a BIG step, and one to face strong opposition from American commodity interests and U.S.-flag shippers. 

How difficult is it to ensure vouchers and electronic cash transfers are getting into the hands of people that really need the aid?

Vouchers (and similar urban coupon shops) have been used many times over the past decades as a food transfer mechanism (also sometimes used in food for work programs) enabling the recipient to trade the voucher(s) for foodstuffs when it is most convenient or when they are most needed. Electronic vouchers are new, and how well they work depends on local situations. In places like urban Latin America, Africa and India, it probably could be made to work quite well; the technology is evolving quickly that would enable this sort of transfer mechanism.  

Rural Ethiopia, Burkina Faso, Central African Republic, Malawi – probably not so well. I’m admittedly skeptical that electronic transfers of purchasing power to remote areas would be sufficient in most cases to motivate traders to move food to these hungry areas. Their risks are extremely high and, in my experience in Africa, traders will only deliver food to remote rural areas (inevitably over very bad roads) if they can command prices considerably higher than costs plus a high risk premium.

Why aren’t international food aid organizations more in favor of direct dollar support for local operating costs?

There is (and has long been) opposition among many of the NGOs to the President’s proposal to replace “monetization” with a promise of on-going direct dollar support for the local operating costs of NGO food security-related projects. They believe it will continue to be easier to get Congress to approve money to buy American food commodities to ship overseas than to get approval for dollars to ship overseas, particularly in light of tightening budgets. These NGOs have tended, over the years, to receive a sympathetic ear from Congress.

The proposal shifts oversight of the food aid program from the Agriculture Committees within the U.S. Department of Agriculture (USDA) to the Foreign Affairs/Relations Committees of the State Department’s U.S. Agency for International Development (USAID). What is the likelihood of Congress approving this transfer?

The chance of that happening, in this of all Congresses, is about the same as winning the Power Ball Lottery. Crusty committee chair-people are extremely sensitive to reductions in their empires and the agriculture committees – especially in the Senate – are powerful committees. On top of that, there are so many elements in the overall 2014 federal budget creating heartburn on the Hill that food aid considerations are far, far, far down the line. The best the President is likely to get in the present divided Congress are hearings and a continuing resolution of some sort.

What did you wish to see in the food aid reform proposal that was not addressed in this budget?

Change, if it ever comes, will likely be incremental and halting. I’ll be happy to see any step, however small, in the right direction. The total end of tied procurement would be at the top of my wish list. Even more important, perhaps, iron-clad, multi-year commitments of funding to food security programs intended to overcome long-term institutional impediments to achieving enduring food security in low income food deficit situations…and sticking with such commitments for 15 years.

What role does food aid play in advancing American foreign policy goals?

Most importantly, by being the single largest source of food commodities to the World Food Program in confronting disaster and emergency situations. Food support to American NGOs has been under-evaluated over the past 40 years. I’ll be talking about this later in the book I am writing, but these small projects were all that kept agricultural development (and early food security efforts) going in many small countries during the “dark decades” when international finance institutions and bilateral donors were not financing agricultural development. There are valuable on-the-ground lessons in that NGO food-assisted experience still waiting to be assessed.

Let me add, given what we know about the onset of serious climate change in the decades to come, the need to supply large amounts of food to populations suffering severe food deprivation will probably grow in the future. Where will the food come from and who will pay for those future transfers?

While the U.S. remains the largest provider of food aid, what can the EU and Canada teach the U.S. about food aid policy?

Donors hate to think that other donors have something to teach them. But, of course, they always do. The Canadian and European experience with food aid is best summed up in the way their objective has come to be restated over the past 15 or so years: not “food aid” but “aid for food.” The purpose of assistance intended to improve food security is to improve either, or both, availability and access over the long term (leave nutrition aside for a moment).

European and Canadian assistance can be much more flexible in choosing the instruments – food, cash, technical assistance, training, institutional strengthening, public policy, public-private cooperation, etc. – required to achieve a realistic food security goal which I would describe as pretty good assurance that most people can get their hands on the food they need most of the time. Commodity food aid, in some form – or the promise of its ready availability when needed – will probably need to be part of the total array of inputs required for the several years needed in particular food insecure countries to achieve that “pretty good assurance.” Europe and Canada are closer to understanding this and have become appropriately flexible in concerting resources to get it done. That’s the lesson.

China’s commitment to agricultural development over the last thirty years has dramatically transformed the country’s economy. Rural income per capita has risen an astounding 20 times after 30 prior years of stagnation. Its poverty rate (US$1.25/day) has dropped from 40 percent to less than five, and 350 million rural people between the ages of 18-65 are now working in the industrial or service sector, enjoying rising wages and new economic opportunities.

This rapid transformation is largely the result of three key agricultural policy decisions: putting land in the hands of farmers, market deregulation, and major public investment in the agricultural sector. Although China must now contend with extreme inequality, high levels of pollution, and an aging farming sector there are still lessons to draw from China’s experience that could hasten the transformation of other developing countries.

China expert and agricultural economist Scott Rozelle broke these lessons down at FSE’s fourteenth Global Food Policy and Food Security Symposium Series last week, opening with an underlying theme of the series.

“Growth and development starts with agriculture,” said Rozelle. “Agriculture provides the basis for sound, sustained economic growth needed to build housing, invest in education for kids, start self-employed enterprises, and finance moves off the farm.”

To prove this point he referenced China’s ‘lost decades’ (1950s-1970s) when 80 percent of the population lived in the rural sector and relied on communal, subsistence agriculture. Poor land rights, weak incentives, incomplete markets and inappropriate investments left the average rural farmer poorer at the end of 70s than they were in the 50s with almost no off-farm employment growth.

So what changed? Incentives, market deregulation and strategic investments by the state were key.

Creating the right incentives

In 1978 the Chinese government broke the communes down into small “family farms” such that every rural resident was allocated a small parcel of land. A family of five farmed an area the size of a football field. While they did not own nor could sell the land, they had the right to choose what crops and inputs they used and the right to the income generated from their land.

“Incentives are important, and can be enough in the short run,” said Rozelle. “Hard work led to money in the pockets of farmers and China was off.”

“Every two and half years China added another California in term of agriculture,” said Rozelle.

Between 1979 and 1985 productivity for wheat, maize, and rice went up 50 percent using the same amount of labor, land and inputs. Agriculture across the spectrum has grown at an astounding rate of 5 percent since 1988 (about four times the population growth rate). Livestock and fisheries have grown even faster – accounting for most of the output of the agricultural sector by 2005.

Income growth from farming enabled family members to begin to seek work off the farm. Between 1980 and 2011, off-farm work increased 71 percent with more than 90 percent of households reporting that at least one family member worked off the farm.

Increasing efficiency through liberalization and investment

Another key policy decision was China’s commitment to market liberalization and investment in public goods.

“Markets can be an effective, pro-poor tool of development,” said Rozelle. “A remarkable partnership is formed when you let farmers do production and government do infrastructure…let markets guide decisions.”

The government dismantled state-owned grain trading companies and deregulated trading rules. Prices were set once a week the same day across China to better integrate markets, and eventually prices for major crops closely mirrored those of world prices. Villages began specializing in crops and livestock and incomes of the poor increased. By not providing government input subsidies (e.g, pesticides, fertilizers), traders were incentivized to participate in the market.

“Giving land to farmers and letting the private sector emerge is an easy thing for governments, even without a lot of money, to do,” said Rozelle.

The government provided more indirect market support by publicly investing in better roads, communications, and surface water irrigation. Groundwater was left to the private sector. There were no water or pumping fees nor subsidies for electricity, keeping it completely deregulated. As a result, 50 percent of cultivated land in China is irrigated, compared to 10 percent in the US and only four percent in sub-Saharan Africa.

Finally, China has invested heavily in agricultural research and development (R&D). One percent of China’s agricultural GDP is now invested in agricultural R&D while US investment has fallen over time. US$2 billion alone goes to investments in Chinese biotechnology.

Despite major investment, China only has one major success story to show for so far. The introduction of Bt cotton led to a significant drop in pesticide use (with important health benefits for farmers), and drop in labor and seed price; resulting in a huge 30 percent increase in net income.

“GM technology benefits exist but big policy decisions still need to be made in the face of much resistance both in China and elsewhere in the world on its application,” said Rozelle.

Status of China’s economy

China has largely solved the country’s macro-nutrient food security problem at the household level (>3000 Kcal/day/person) and millions have been lifted out of poverty. Practically all 16-25 years old are now working off the farm.

“This is a real transformation, and one that could not have happened without a major investment in agriculture,” said Rozelle.

While China’s agricultural accomplishments have been major, Rozelle recognizes the system is far from perfect. For starters, there are serious food safety concerns due to lack of traceability. An astounding 98 percent of Beijing consumers think their food is tainted, said Rozelle.

Water is being pumped like crazy and farmers are aging. The younger generation is neither willing nor interested in following in their parents’ farming footsteps. To make up for a labor deficit farmers are applying huge amounts of fertilizer on their land with serious environmental consequences. As a result of changing demographics and an increasing demand for meat, fish, fruits and vegetables, China is likely to be a net importer of food in the long run.

China also faces major urban and rural inequality issues. Even though wages have risen, inequality has not fallen, largely a result of China’s decision not to privatize rural land.

“Rural people have no assets on which to build wealth while urban people were given assets in the form of housing,” said Rozelle. “Housing prices in major cities in China now rival those in the Bay Area!”

The Chinese government fears losing control of the land, but this comes at a price of less individual incentive to invest and inability to build larger farmers. As agricultural growth slows, Rozelle worries high levels of inequality could lead to instability.

Adding fuel to the fire, investment in rural health, nutrition, and education remains far from sufficient. Only 40 percent of the rural poor go to high school resulting in 200 million people who can barely read or write.

“What’s going to happen in 20 years when low skill manufacturing jobs move to other countries?” asked Rozelle. “The rural, uneducated poor are going to become unemployable.”

China’s record leaves room for improvement, but presents a strong case for supporting smallholder agriculture. For those countries emerging out of their own lost decades, smallholder agriculture should remain a primary focus of investment and development.

Mariano-Florentino Cuéllar, a Stanford law professor and expert on administrative law and governance, public organizations, and transnational security, will lead the university’s Freeman Spogli Institute for International Studies.

The announcement was made in Feb. 11 by Provost John Etchemendy and Ann Arvin, Stanford’s vice provost and dean of research.

“Professor Cuéllar brings a remarkable breadth of experience to his new role as FSI director, which is reflected in his many achievements as a legal scholar and his work on diverse federal policy initiatives over the past decade,” Arvin said. “He is deeply committed to enhancing FSI’s academic programs and ensuring that it remains an intellectually rich environment where faculty and students can pursue important interdisciplinary and policy-relevant research.”

Known to colleagues as “Tino,” Cuéllar starts his role as FSI director on July 1.

Cuéllar has been co-director of FSI’s Center for International Security and Cooperation (CISAC) since 2011, and has served in the Clinton and Obama administrations. In his role as FSI director, he’ll oversee 11 research centers and programs – including CISAC – along with a variety of undergraduate and graduate education initiatives on international affairs.  His move to the institute's helm will be marked by a commitment to build on FSI’s interdisciplinary approach to solving some of the world’s biggest problems.

“I am deeply honored to have been asked to lead FSI. The institute is in a unique position to help address some of our most pressing international challenges, in areas such as governance and development, health, technology, and security,” Cuéllar said. “FSI’s culture embodies the best of Stanford – a commitment to rigorous research, training leaders and engaging with the world – and excels at bringing together accomplished scholars from different disciplines.”

Cuéllar, 40, is a senior fellow at FSI and the Stanley Morrison Professor of Law at the law school, where he will continue to teach and conduct research. He succeeds Gerhard Casper, Stanford’s ninth president and a senior fellow at FSI.

“We are deeply indebted to former President Casper for accomplishing so much as FSI director this year and for overseeing the transition to new leadership so effectively,” Arvin said.

Casper was appointed to direct the institute for one year following the departure of Coit D. Blacker, who led FSI from 2003 to 2012 and oversaw significant growth in faculty appointments and research.

Casper, who chaired the search for a new director, said Cuéllar has a “profound understanding of institutions and policy issues, both nationally and internationally.”

“Stanford is very fortunate to have persuaded Tino to become director of the Freeman Spogli Institute for International Studies,” Casper said. “He will not only be an outstanding fiduciary of the institute, but with his considerable imagination, energy, and tenacity will develop collaborative and multidisciplinary approaches to problem-solving.”

Cuéllar – who did undergraduate work at Harvard, earned his law degree from Yale and received his PhD in political science at Stanford in 2000 – has had an extensive public service record since he began teaching at Stanford Law School in 2001.

Taking a leave of absence from Stanford during 2009 and 2010, he worked as special assistant to the president for justice and regulatory policy at the White House, where his responsibilities included justice and public safety, public health policy, borders and immigration, and regulatory reform.  Earlier, he co-chaired the presidential transition team responsible for immigration.

After returning to Stanford, he accepted a presidential appointment to the Council of the Administrative Conference of the United States, a nonpartisan agency charged with recommending improvements in the efficiency and fairness of federal regulatory programs.

Cuéllar also worked in the Treasury Department during the Clinton administration, focusing on fighting financial crime, improving border coordination and enhancing anti-corruption measures.

Since his appointment as co-director of CISAC, Cuéllar worked to expand the center’s agenda while continuing its strong focus on arms control, nuclear security and counterterrorism. During Cuéllar’s tenure, the center launched new projects on cybsersecurity, migration and refugees, as well as violence and governance in Latin America. CISAC also added six fellowships; recruited new faculty affiliates from engineering, medicine, and the social sciences; and forged ties with academic units across campus.

He said his focus as FSI’s director will be to strengthen the institute’s centers and programs and enhance its contributions to graduate education while fostering collaboration among faculty with varying academic backgrounds.

“FSI has much to contribute through its existing research centers and education programs,” he said. “But we will also need to forge new initiatives cutting across existing programs in order to understand more fully the complex risks and relationships shaping our world.”

In addition to Casper, the members of the search committee were Michael H. Armacost, Francis Fukuyama, Philip W. Halperin, David Holloway, Rosamond L. Naylor, Douglas K. Owens, and Elisabeth Paté-Cornell.