Key Findings

The results were striking - and they matter for policymakers, health leaders, and the public alike.

🌍 2,419 citizens across six middle-income countries participated
📈 43 out of 45 policy proposals saw increased support after deliberation
✅ The most popular proposals were those relating to infection prevention
🌐 Regional differences emerged — particularly around attitudes to restricting antibiotic use in food production.

Antimicrobial resistance is not only a scientific challenge but a societal one. This project shows that when citizens are given balanced information, diverse perspectives, and the opportunity to deliberate, they can engage meaningfully with the complexity of AMR and support the action it requires. Building public trust and community engagement is essential to reducing the global impact of AMR. We hope these findings and resources will help advance public engagement on AMR and strengthen deliberative approaches across global health.

From Understanding to Action

This study demonstrates something important: when citizens are given the chance to engage seriously with a complex global health challenge, they rise to it.

Across all six countries, deliberation moved public opinion towards greater support for ambitious AMR action — on prescription practices, agricultural use, access to medicines, and prevention. The 2024 UN Political Declaration set out what governments have committed to. This research shows that the public, when informed, is ready to support it.

The findings have direct relevance for:

• Policymakers designing national AMR action plans, particularly in middle-income countries
• Health communicators seeking evidence-based approaches to public engagement on AMR
• Researchers building the evidence base for deliberative approaches in global health
• Civil society organizations advocating for community-level AMR action
   

We are committed to sharing these findings as widely as possible — with governments, health bodies, and the communities that took part.

Thanks to our funders

With thanks to the Novo Nordisk Foundation and Wellcome.

Contact and Media

For media inquiries and further information about the research, please contact Louise Gough (Chief Operating Officer) at info@thetrinitychallenge.org.

Read our press release.

Argument and Contribution

At the national level, the United States struggled to effectively respond to the COVID-19 pandemic: federal policy was delayed and inconsistent, supply shortages were widespread, and political pressure undermined accurate public health guidance. At the state and local levels, however, there was a great deal of variation in terms of the capacity to respond to COVID. While indicators of state capacity often focus on “formal” indicators like institutional resources, staffing, and finances, translating formal capacities into effectively implemented policies is neither a simple nor an automatic process. 

In “Building the Plane While Flying,” Didi Kuo and Andrew S. Kelly draw our attention to the importance of informal indicators of public health capacity. These include strong relationships within and across government agencies, the embeddedness of health officers in local communities, and prior experience with responding to disasters, among other factors. The authors argue that local governments with strong informal capacity were better able to communicate with and learn from one another, as well as to gain the trust of community members, during the pandemic. Conversely, localities with otherwise strong formal capacities often failed to respond to the challenges at hand. This is because they were unable to effectively leverage their relationships and organizational networks.
 

Kuo and Kelly’s paper is informed by qualitative analysis of California’s public health institutions as well as in-depth interviews with health officers across seventeen Northern, Central, and Southern California counties. The interviews illuminate the concrete processes by which local governments responded (or struggled to respond) to the COVID-19 pandemic. One of the paper’s key contributions is to push us to conceptualize state capacity more broadly and to focus on the factors that drive not just policy development, but policy implementation. 

The Importance of Informal Capacity

The bulk of the paper disaggregates informal capacity into its various mechanisms and processes. Each of these proves to be crucial in explaining different pandemic outcomes at the local level. One such mechanism is coordination within local governments. To illustrate this, consider public health officers, who enjoy broad legal powers to protect public health as well as financial resources and personnel at their disposal. By law, officers possess significant capacities to mitigate health crises. Yet across the interviews, health officers reported that effectively implementing COVID-19 policy required their cooperation and communication with a host of actors, including the County Counsel (the county’s top lawyer), Chief Administrative Officer, and Board of Supervisors, which is charged with appointing health officers.
 

Closely related to intra-governmental coordination is the importance of autonomy, particularly in the face of political pressure. For example, boards of supervisors sometimes undermined the public guidance provided by health officers. (This guidance could range from the need to close schools to officers simply communicating truthfully with localities about COVID-19 risks.) Overcoming efforts by board members to ignore or muzzle officers required coordination between those actors who were more insulated from political pressure.

Another key component of informal capacity was prior experience responding to emergencies and California’s myriad of natural disasters, such as fires, floods, or mudslides. Health officers from more experienced counties noted their ability to draw upon established emergency procedures and partnerships. For example, some counties had previously cooperated with each other, as well as with independent agencies like the Red Cross, to provide aid and shelter to those affected by wildfires. These experiences — for which no amount of financial resources or personnel can substitute — served as templates to help coordinate COVID-19 policy responses.

Informal capacity also depended upon health departments effectively communicating with the public. Many departments initially lacked the infrastructure to do this, and therefore relied on cooperation with other actors like school superintendents, sheriffs, and community leaders. Some counties created toolkits to improve their community’s understanding of personal protective equipment (PPE) or even produced local TV shows. Still others scheduled conference calls with local hospitals, faith leaders, and nursing homes. Given that many of these communication efforts were improvised, public health officers stressed the importance of formalizing coordination between state and nonstate actors so as to improve emergency preparedness in the future.
 

In addition to coordination within local governments, effective policy-making and communication required coordination across governments. One such institution was the Association of Bay Area Health Officers (ABAHO), founded in the 1980s during the HIV/AIDS epidemic. ABAHO members had also coordinated policy responses to the H1N1 outbreak. These cross-county partnerships enabled early, rapid, and unified responses to the COVID-19 pandemic. By contrast, the authors find that regions without such networks faced greater challenges in developing and implementing public policy.

A final aspect of informal capacity is the social embeddedness of health officials in their communities. This includes partnerships with leaders of businesses and faith groups, teachers, and restaurant owners. Not only did these partnerships increase the scope of outreach, but they also often established relationships that had not existed beforehand. Gaining a foothold in local communities thus increased the likelihood that community members would support policies and enabled local governments to access hard-to-reach populations.
 

Kuo and Kelly’s analysis of informal capacity should give us pause when considering existing indices of public health preparedness; some of these have ranked the United States quite high despite its often ineffective responses to the COVID-19 pandemic. That this mismatch occurs is arguably a function of observers prioritizing formal capacities. For federal, decentralized countries like the US, informal capacities and relationships are essential not only for delivering services but for generating legitimacy and trust among those receiving services.

*Research-in-Brief prepared by Adam Fefer.

Stanford University’s Center on Democracy, Development and the Rule of Law (CDDRL) is proud to announce our four incoming fellows who will be joining us in the 2016-2017 academic year to develop their research, engage with faculty and tap into our diverse scholarly community. 

The pre- and postdoctoral program will provide fellows the time to focus on research and data analysis as they work to finalize and publish their dissertation research, while connecting with resident faculty and research staff at CDDRL. 

Fellows will present their research during our weekly research seminar series and an array of scholarly events and conferences.

Topics of the incoming cohort include electoral fraud in Russia, how the elite class impacts state power in China, the role of emotions in support for democracy in Zimbabwe, and market institutions in Nigeria. 

Learn more in the Q&A below.

Hometown: Tomsk, Russia

Academic Institution: Northwestern University

Discipline and expected date of graduation: Sociology, April 2017

Research Interests: authoritarianism, state capacity, social policy, civil society, trust, Russia and post-communist countries

Dissertation Title: The State that Betrays the Trust: Infrastructural State Power, Public Sector Organizations, and Authoritarian Resilience in Putin's Russia

What attracted you to the CDDRL Pre/post-doctoral program? I study the connection between state capacity and political regimes - the topic that is at the core of many research initiatives at CDDRL. Learning more about this work and receiving feedback for my dissertation will enrich and sharpen my analysis, while helping me to place it into a comparative context. I am looking forward to discussing my work with the faculty who study the post-Soviet region. I also will explore policy implications of my work with the help of policy experts at CDDRL.

What do you hope to accomplish during your nine-month residency at the CDDRL? Besides finishing writing my dissertation, I will workshop three working papers to prepare them for publication. The first one argues that Putin's regime used the school system to administer a large-scale electoral fraud in 2012 presidential elections; the second one shows how the networks of social organizations were used by subnational autocrats to strengthen the regime; and the third one will look at the factors that make the abuse of such organizations more difficult in some regions. In addition to these papers I will continue developing my post-graduation research project exploring the relationship between social trust and distrust, institutions, political competition, and democratization.

Fun fact: I have spent 25 years of my life in Siberia, and I can tell you: Chicago winters are worse!

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Shelby Grossman

CDDRL Postdoctoral Fellow

Hometown: Reading, MA

Academic Institution: Harvard University

Discipline & Graduation Date:  Government, Summer 2016

Research interests: political economy of development, private governance, market institutions, Sub-Saharan Africa, survey methods

Dissertation Title: The Politics of Order in Informal Markets: Evidence from Lagos

What attracted you to the CDDRL post-doctoral program? I was attracted to CDDRL largely for its community of scholars. Affiliated faculty work on the political economy of development and medieval and modern market institutions, topics that are tied to my own interests.

What do you hope to accomplish during your nine-month residency at the CDDRL? I plan to prepare a book manuscript based on my dissertation, a project that explains variation in the provision of pro-trade institutions in private market organizations through the study of physical marketplaces in Nigeria. In addition, I will continue to remotely manage an on-going project in Nigeria (with Meredith Startz) investigating whether reputation alleviates contracting frictions. I also plan to work on submitting to journals a few working papers, including one on the politics of non-compliance with polio vaccination in Nigeria (with Jonathan Phillips and Leah Rosenzweig). 

Fun fact: Contrary to popular belief, not all cheese is vegetarian. I have a website to help people determine if a cheese is vegetarian or not: IsThisCheeseVegetarian.com. 

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Daniel Mattingly

CDDRL Postdoctoral Fellow

Hometown: Oakland, California

Academic Institution: University of California, Berkeley

Discipline & Graduation Date: Political Science, Summer 2016

Research Interests: Governance, rule of law, state building, authoritarian politics, Chinese politics

Dissertation Title: The Social Origins of State Power: Democratic Institutions and Local Elites in China

What attracted you to CDDRL?  The Center has a fantastic community of scholars and practitioners who work on the areas that I'm interested in, including governance and the rule of law. I'm excited to learn from the CDDRL community and participate in the Center's events. The fellowship also provides me with valuable time to finish my book manuscript before I start teaching.

What do you hope to accomplish during your nine-month residency at the CDDRL? While at CDDRL, I plan to prepare my book manuscript and to work on some related projects on local elites and state power in China and elsewhere. 

Fun fact: I grew up on an organic farm in Vermont.

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Lauren E. Young

CDDRL Postdoctoral Fellow

Hometown: Saratoga, CA

Academic Institution: Columbia University 

Discipline & Graduation Date: Political Science (Comparative Politics, Methods), May 2016 (defense), Oct 2016 (degree conferral)

Research Interests: political violence, political economy of development, autocratic persistence, democratization, protest, electoral violence

Dissertation Title: The Psychology of Repression and Dissent in Autocracy

What attracted you to the CDDRL post-doctoral program? As a graduate of the CISAC honors program when I was an undergraduate at Stanford, I have seen first-hand how intellectually stimulating, collaborative, and plugged into policy CDDRL is. While at the center I will be revising my dissertation work on the political psychology of participation in pro-democracy movements in Zimbabwe for submission as a book manuscript, and moving forward new projects that similarly seek to understand how different forms of violence by non-state actors affects citizens' preferences and decision-making. Because of its deep bench of experts on autocracy, narco-trafficking, and insurgency, CDDRL will add enormous value to these projects.

What do you hope to accomplish during your nine-month residency at the CDDRL?  During my fellowship year, my primary goal is to revise my research on Zimbabwe into a book manuscript. I defended my dissertation as three stand-alone articles, including two experiments showing that emotions influence whether opposition supporters in Zimbabwe express their pro-democracy preferences and a descriptive paper showing that repression has a larger effect on the behavior of the poor. To prepare the book manuscript during my fellowship, I will bring in additional quantitative and qualitative descriptive evidence and tie the three papers together into a cohesive argument about how opposition supporters make decisions about participation in protest, why emotions have such a large effect on these decisions, and how this affects variation across individuals and the strategic choices of autocrats and activists.

Fun fact: During my fieldwork I took an overnight train from Victoria Falls to a southern city in Zimbabwe and hitch-hiked into a national park. It got a little nerve-wracking when night started to fall, but ended with  an invitation to a barbecue! 

Stanford students belong to the first generation that could witness the end of extreme global poverty — in what would be one of humankind's greatest achievements — the head of the World Bank said during a recent talk on campus.

But their generation, he said, is also likely to experience the first global pandemic since the 1918 influenza that killed more than 50 million people.

Jim Yong Kim, president of the World Bank, said innovations in health, education and finance are behind the World Bank's twin goals of ending extreme poverty and boosting shared prosperity for the bottom 40 percent of the global population.

Speaking at the inaugural conference of the Stanford Global Development and Poverty Initiative on Oct. 29, Kim lauded faculty and students for their multidisciplinary approach in tackling poverty and improving public health. He is an infectious disease physician who oversaw World Health Organization initiatives on HIV/AIDS.

"Seeking transformative solutions to challenges of development and poverty that are necessarily cross-disciplinary is exactly what a great university should be doing," Kim said in his speech at Stanford.

The World Bank announced last month that the number of people living on less than $1.90 a day is expected to drop to 9.6 percent of the global population by the end of the year. That is down from 36 percent in 1990.

The bank has pledged to cut that rate to 3 percent by 2030.

"We expect the extreme poverty rate to drop below 10 percent for the first time in human history," he said. "This is the best news in the world today. And this is the first generation in human history that has been able to see that potential outcome." 

Promoting prosperity

One of the co-founders of Partners in Health, Kim was the keynote speaker at the daylong conference, "Shared Prosperity and Health," which drew together Stanford faculty and researchers, plus government and NGO officials from around the world.

Stanford's global development and poverty effort is a university-wide initiative of the Stanford Institute for Innovation in Developing Economies, known as Stanford Seed, and the Freeman Spogli Institute for International Studies. The conference was held at Stanford's Graduate School of Business, which was a partner in the event.

Kim's talk was optimistic about the newly adopted U.N. Sustainable Development Goals, with an ambitious agenda to end poverty and hunger, ensure healthy lives, empower women and girls and attain quality education for all children by 2030.

While those goals seem lofty, Kim pointed to the accomplishment of bringing down extreme poverty to 10 percent, a figure many had once said was impossible.

Ninety-one percent of children in developing countries now attend primary school, up from 83 percent in 2000, he said. And the number of people on antiretroviral drugs for treatment of HIV in sub-Saharan Africa has increased eightfold in the last decade.

"But we're humbled by the challenges ahead," Kim said. "Rising global temperatures will have devastating impacts on poor countries and poor people – and, as we saw with Ebola, major pandemics are likely to disproportionately affect the poor."

Pandemic threats

Kim said that most virologists and infectious disease experts are certain a pandemic will sweep the world in the next 30 years. He said that would lead to more than 30 million deaths and anywhere from 5 to 10 percent of lost GDP.

He blasted the global community for taking eight months to respond to the Ebola crisis in West Africa, noting that Guinea, Sierra Leone and Liberia had among the fastest growing economies in Africa before the outbreak killed more than 11,000 people – most of whom were poor.

In an effort to speed up financial aid the next time such an outbreak occurs, the World Bank is developing the Pandemic Emergency Facility, which would disburse funding immediately to national governments and responding agencies.

Rajiv Shah, the administrator for the U.S. Agency for International Development from 2010-2015, spoke earlier at the conference about his work leading the U.S. efforts to contain Ebola.

"Three small countries with total population of maybe 30 million people had such weak health systems with so little domestic investment – in one country $6 per capita health investment per year – that when Ebola became a crisis there was no first-line of defense," he said.

By October 2014, the U.S. was pouring hundreds of millions of dollars into containment efforts, including the establishment of a 2,500-personnel military deployment to hit Ebola on the ground. Shah said President Obama "stayed extraordinarily true to the science" of containment at the source.

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Stunted children 

Moving beyond containment of epidemics, Kim said the most important investment developing countries could make in their people starts when a woman becomes pregnant. Using a combination of health, nutrition and education will have lifelong benefits for each child, as well as for the country in which each prospers.

The World Bank estimates that 26 percent of all children under age 5 in developing countries are stunted, which means they are malnourished and under-stimulated, risking a loss of cognitive abilities that lasts a lifetime. The number climbs to 36 percent in sub-Saharan Africa, giving those children limited prospects in life."This is a disgrace, a global scandal and, in my view, akin to a medical emergency," Kim said. "Children who are stunted by age 5 will not have an equal opportunity in life. If your brain won't let you learn and adapt in a fast-changing world, you won't prosper and, neither will society. All of us lose."

From 2001 to 2013, the World Bank invested $3.3 billion in early childhood development programs in poor countries. Kim said innovative policymaking and financial tools allowed the bank to help Peru cut its rate of child stunting in half to 14 percent in just eight years.

"Progress is possible – and it can happen quickly. But we must do even more,"he said.

Kim said the world set a target in 2012 to reduce stunting in children by 40 percent. But that would still leave 100 million children malnourished and undereducated. The bank and world leaders should pledge to end stunting for all children by 2030, he said.

"With partners like the Global Development and Poverty Initiative and the entire Stanford community, I'm full of hope that we can indeed be the first generation in human history to end extreme poverty and create a more just and prosperous world for everyone on the planet."

Read more here about another innovation to improve health in the developing world.