Center on Democracy, Development and the Rule of Law is part of the Freeman Spogli Institute for International Studies
Steve Luby draws on years of classroom debate to examine why some global health projects succeed and others fail, often in ways he didn’t expect.
The pandemic of antimicrobial resistance (AMR) will only be mitigated by policy action and innovation and importantly, supported by local and community action. With the United Nations General Assembly high level meeting on AMR taking place in September 2024, we decided to ascertain citizens’ understanding of the issues and prioritisation for action.
From June to August 2024, while intergovernmental negotiations on the outcome document were taking place, we used Deliberative Polling®, a methodology founded on deliberative democratic theory, in six middle income countries across three continents to explore people’s understanding and support for 45 policies that were likely to feature in the political declaration.
In total 2419 participants were randomised to deliberation intervention (written and video information, facilitated online small group discussions, and expert plenary sessions) or control groups who only completed the pre- and post-deliberation surveys. Support increased significantly through deliberation for 3/4 of the proposals (>90% for 2/3), as well as on knowledge about AMR and internal political efficacy. Proposals relating to infection prevention were most heavily supported across all six countries. We found regional variation in support for proposals relating to informal antibiotic access and the use of antibiotics in food production, with less support for selected proposals from South America.
Deliberative polling is a powerful method of large scale community engagement and this is new for AMR helping us to understand the views of the public relating to policies that will require their support to enact.
[version 2; peer review: 2 approved, 3 approved with reservations]
For the second time in history, UN Member States adopted a Political Declaration on AMR in 2024. This declaration outlines ambitious commitments to tackle one of the most pressing health challenges of our time. These commitments will only be successful if the public understands, supports, and ultimately changes behavior to make them work.
Ahead of UNGA, we asked citizens in six countries what they thought about different policy proposals across six themes: Equity, Access and Stewardship; Infection Prevention; Food Security; Awareness and Education; Target setting; and Surveillance.
Working with the Trinity Challenge, we brought together 2,419 citizens from Brazil, Colombia, Nigeria, Tanzania, India, and Indonesia using Deliberative Polling®, a method that assesses what a representative and informed sample would think about policy proposals after extended, evidence-based discussions. Deliberations took place on the innovative Artificial Intelligence (AI)-assisted Stanford University Online Deliberation Platform across two days.
Citizens left the process not just more informed, but more engaged with the solutions required.
Deliberative Polling® is a research methodology developed by Professor James Fishkin at Stanford University's Deliberative Democracy Lab. Unlike standard opinion polling, it measures not just initial public opinion but informed public opinion - what people think after genuine engagement with the issues, trade-offs, and expert perspectives.
It has been applied in over 160 cases around the world, from national referendums to climate policy.
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.
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:
We are committed to sharing these findings as widely as possible — with governments, health bodies, and the communities that took part.
With thanks to the Novo Nordisk Foundation and Wellcome.
For media inquiries and further information about the research, please contact Louise Gough (Chief Operating Officer) at info@thetrinitychallenge.org.
The Deliberative Democracy Lab and the Trinity Challenge asked 2419 people in six countries through the first-ever deliberative poll on AMR.
This research evaluates methodologies to mitigate misreporting in intimate partner violence (IPV) data collection in a middle-income country. We conducted surveys in Russia involving three list experiments, a self-administered tablet questionnaire, a self-administered online survey, and conventional face-to-face interviews. Results show that list experiments yield lower disclosure rates for the complex IPV definitions suggested by the UN. The tablet-based self-administered questionnaire, conducted with an interviewer present, also did not increase IPV reporting. Conversely, the self-administered online survey increased lifetime IPV disclosures by 51% (physical) and 26% (psychological) compared to face-to-face interviews. Women showed greater sensitivity to the online survey mode. This increase is linked to the absence of interviewer bias, enhanced safety by minimizing potential perpetrators’ presence, and reduced cognitive burden. We argue that self-administered online surveys—using sampling bias mitigation—may thus be an optimal, low-cost method for surveying the general population in middle- and high-income countries.
This brief is part of the Democracy Action Lab's "The Case for Democracy" series, which curates academic scholarship on democracy’s impacts across various domains of governance and development. Drawing from an exhaustive review of the literature, this analysis presents selected works that encompass significant findings and illustrate how the academic conversation has unfolded.
While national wealth has long been considered a primary determinant of population health, democratic governance independently improves health outcomes through distinct political mechanisms. Democracies consistently outperform autocracies on metrics including infant mortality, life expectancy, and disease control—with particularly strong effects for conditions requiring sustained policy commitment and equitable service delivery. These benefits materialize primarily through long-term democratic experience rather than short-term regime change, as electoral accountability and responsive institutions require time to develop.
The Visiting Fellows in Israel Studies program at CDDRL and the Environmental Social Sciences department of the Doerr School of Sustainability
present a two-day conference
Los Angeles and Tel Aviv-Yafo are vibrant cultural and cosmopolitan centers characterized by significant demographic diversity. They are also home to disparate ethnic, religious, and cultural groups and are marked by stark contrasts in wealth and poverty. Despite their differences in size and geography, both cities face similar challenges in fashioning their responses to the anticipated adverse impacts of rapid climate change. To enhance climate resilience and ensure the effective implementation of climate policies, it is essential to consider not only the technical integrity of adaptation programs but also the socio-economic and cultural diversity unique to each city.
Studying these two cities side by side can shed light on how climate strategies can be adapted across scales and contexts. It can provide insights into navigating the complex interactions between central and local governments in designing climate adaptation programs. It can aid in prioritizing resource utilization to achieve the greatest possible reduction in climate-related risks. And, it can foster creative thinking about how equity-focused climate actions can be tailored to the unique needs, capacities, and values of diverse communities within each city.
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Chair: Gordon Bloom, Director, Social Entrepreneurship and Innovation Lab (SE Lab)- Human & Planetary Health; Founder, Social Entrepreneurship Collaboratory (SE Labs), Stanford University
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We are grateful to Tel Aviv University, The Diane and Guilford Glazer Foundation, the Jewish Climate Trust, and Hillel@Stanford for their support in making this conference possible.
The conference was held at Paul Brest Hall on Stanford's campus. Two-hundred people attended. Read about it in the news.
Protecting the lives of children in Gaza and other conflicts requires changes to the rules of engagement and global responses to all conflicts affecting civilian populations, argue Zulfiqar Bhutta, Georgia Dominguez, and Paul Wise.
Major: Economics
Hometown: Allen, TX
Thesis Advisor: José Ignacio Cuesta
Tentative Thesis Title: Big Pharma Mergers and Their Effects on Medicare Drug Prices
Future aspirations post-Stanford: Taking a gap year after graduation to teach English abroad, then coming back to go to law school.
A fun fact about yourself: I’m an avid rock climber, and I’m working on my pilot’s license, even though I’m afraid of heights.
When you think of the climate crisis and the major impact it will have upon all corners of the world, one nation stands out as the epicenter of the unfolding cataclysmic changes: Bangladesh.
When Stephen Luby, MD, began working there two decades ago, the South Asian country was facing tremendous climate stress brought on by intermittent floods, extreme heat, cyclones and drought that threatened human life.
Stephen Luby is among a growing number of Stanford Medicine community members dedicated to finding solutions to urgent problems of planetary and human health.
Please join us in congratulating Didi Kuo, Center Fellow at the Freeman Spogli Institute for International Studies (FS), and co-author Andrew S. Kelly, Assistant Professor in the Department of Health Sciences at California State University, East Bay, on being awarded the 2023 Leonard S. Robins Award for the Best Paper on Health Politics and Policy by the American Political Science Association (APSA)!
The Robins Award is named in honor of Leonard S. Robins, who, through his presence and gentle questioning at virtually every health politics panel, graciously nurtured the scholarship of both junior and senior scholars. The award recognizes the best paper on any subject that fits under the rubric of Health Politics and Policy presented at the previous annual APSA meeting.
Kuo and Kelly's award-winning paper, "State Capacity and Public Health: California and COVID-19," investigates the comparative COVID-19 policy response across counties and regions within California. In the description of the 2022 APSA panel "The Politics of Pandemic Response and the Opportunities for Health Policy Reform," during which they presented their paper, it notes that "In moving beyond a consideration of formal state and public health capacity, Kuo and Kelly argue that the more robust policy response of the Bay Area was, in part, a product of partnerships between state and community-based actors. Drawing on the concept of 'embedded autonomy,' Kuo and Kelly reconceptualize public health capacity and consider it within broader issues of state capacity and democracy."
An abstract of the paper can be found below:
On March 17, 2020, six counties in the Bay Area jointly issued the nation’s first shelter-in-place orders in response to the COVID-19 crisis. Cities and states across the United States quickly followed suit, with varying degrees of success. Public health officials have been critical in setting policies, enforcing behavioral and non-pharmaceutical interventions, and communicating with the public. This paper explores the determinants of public health capacity, distinguishing between formal institutional capacity (ie budget, staff) and informal embedded capacity (ie community ties, insulation from political pressures). It argues that informal embedded capacity is critical to public health capacity, but difficult to measure empirically. It concludes by relating public health capacity to broader issues of state capacity and democracy.
The award recognizes Kuo and Kelly's paper, “State Capacity and Public Health: California and COVID-19,” as the best paper on health politics and policy presented at the 2022 American Political Science Association (APSA) conference.
