Controversies over the lack of diagnostic testing for the COVID-19 virus have dominated U.S headlines for weeks. Technical challenges with the first test developed by the Centers for Disease Control and Prevention (CDC) left the nation with minimal diagnostic capacity during the first few weeks of the epidemic, according to a new paper published today in the Journal of the American Medical Association by Michelle Mello, a professor of medicine at Stanford Health Policy and professor of law at Stanford Law School.

On February 29, the Food and Drug Administration (FDA) began allowing high-complexity labs across the country to use tests they developed in-house. On March 5, the Stanford Clinical Virology Lab deployed its own test for patients at Stanford Health Care and Stanford Children’s Health.

We asked Mello to answer some questions about the federal rollout of diagnostic testing.

You write that in the early stages, COVID-19 “spread beyond the nation’s ability to detect it.” Is there anything the U.S. government could or should have done weeks ago to get out ahead of the spread?

Adopting broader testing criteria and allowing use of a wider range of tests would have been helpful in identifying the first U.S. cases and containing the spread. Manufacturing problems like the one that arose with CDC’s test are always a risk, but the fact that CDC put all its eggs in that one basket made the manufacturing snafu highly consequential.

Also, the public messaging from Washington about the seriousness of the problem has been neither consistent nor accurate, and I worry it may have led Americans to take fewer steps to prevent community transmission than we should have. Containment was not “pretty close to airtight.” A vaccine was never going to be ready in “three to four months,” as the Trump administration claimed. The case fatality rate is not “way under 1 percent.” Part of the problem here is that as the stock market continues to plunge, the president and the task force he appointed appear to be more concerned about calming investors than stopping the virus.

We seem to be between a rock and a hard place: You write that remedying gaps in testing is imperative, yet “more testing is not always better.” How do we determine the happy middle ground?

First, the testing criteria have to be calibrated to our actual testing capacity. You can’t announce that any American who wants a coronavirus test can get one and then, within hours, announce that there aren’t enough test kits to make that possible. High priorities for testing include patients with serious, unexplained respiratory illness and contacts of known cases. From there, testing can be expanded, beginning with other high-risk groups, as capacity permits.

Second, we should consider unintended side effects of mass testing. The problem with this virus is that it doesn’t have signature symptoms. It looks like the common cold or the flu. If everyone with a cough or fever, or who has been around someone with a cough or fever, shows up in their doctor’s office demanding a test, it will quickly overwhelm care facilities that should be focusing on patients with a higher likelihood of being infected or and those who are infected and are seriously ill. It may also work against the social distancing measures that public health officials are trying to encourage, because crowded waiting rooms may spread the virus.

The CDC announced Monday it now has the testing capacity in 78 state and local public health labs across 50 states to test for the virus. There are now 75,000 lab kits cumulatively to test for COVID-19 with more coming on board by mid-March. But is there anything we could have done to roll this out earlier?

The alternative would have been to allow laboratories to deploy their own tests from the beginning, using the primers and protocols made publicly available by the World Health Organization. That’s what other countries have done. RT-PCR is a mature technology and high-complexity labs around the country are well-qualified to conduct this type of testing.

There is a public health argument for not going that route: perhaps those labs wouldn’t have done as good a job as CDC’s own lab and the state labs that it handpicked early in the outbreak. What if there were erroneous test results? We could miss cases, or we could put people into isolation, with huge social consequences, based on false-positive results. There is also a worry that some labs aren’t consistent about reporting positive test results to CDC, and underreporting could compromise disease surveillance efforts.

The counterargument is that high-complexity labs have that certification for a reason—they’re good at what they do. And of course, surveillance is also compromised when you miss cases because you don’t test.

You write in your paper that testing for COVID-19 “highlights a controversial area of public policy—the regulation of laboratory-developed tests—in which there has long been tension between the goals of access and quality.” Who should be in charge of regulating these tests?

Laboratory-developed tests are largely unregulated outside of emergencies. The FDA proposed draft guidance in 2014 that, if implemented, would have required labs to make certain showings to FDA about tests they developed in-house, with the particular evidence calibrated to the risks involved in having a wrong test result. Contrary to President Trump’s claim that an Obama-era policy constrained coronavirus testing, the guidance did not relate to emergency situations. During declared emergencies, another statute and set of regulations apply, and the FDA has broad discretion to allow or disallow use of novel diagnostics and therapies as emergency countermeasures.

As a general matter, it makes good sense to require labs to submit evidence that their in-house tests work. It’s odd that laboratory-developed tests are carved out of requirements that apply to other kinds of medical devices. It’s also sensible that our legal framework allows FDA’s regular rules to be relaxed during emergencies so we can tailor our response to the difficult and changing circumstances.

You write that diagnostic testing is critical to an effective response to the novel coronavirus. What sort of policies and guidelines should be put into place to prevent such a sluggish rollout during an emerging epidemic the next time one comes around?

The legal framework for an effective emergency response is in place. Because giving agency heads the discretion to act as potentially unforeseeable circumstances require is a linchpin of this legal framework, it only works if leaders make smart choices. Every emergency is different, and there is a danger of Monday-morning quarterbacking. But we should learn from every misstep we make, and I think the lesson here is to make better use of already developed networks of highly qualified labs to make sure we have adequate testing capacity to isolate cases and trace their contacts very early in an outbreak.

What are some innovative approaches we could be taking to speed up testing for those who really need it?

The South Koreans have set up drive-through testing stations in parking lots to avoid concentrating crowds of people indoors. Of course, that requires that you have plenty of test kits, which we don’t yet – but we should also be thinking about creative ways to address the epidemic. For example, how could video calls be used to monitor the health of people confined at home after being exposed to the virus? How can social media be used to connect neighbors to help one another when some are isolated at home? Hopefully we can find new ways for technology to bring us together when pathogens drive us apart.

A task force of national health experts recommends clinicians screen all adults 18 to 79 for the hepatitis C virus (HCV), noting that the viral infection is now associated with more deaths in the United States than the top 60 reportable infectious diseases combined.

Many people are unaware they are carrying the viral infection.

“People with hepatitis C do not always feel sick and may not know they have it,” says chair of the U.S. Preventive Services Task Force Douglas K. Owens, M.D, M.S. “Screening is key to finding this infection early, when it’s easier to treat and cure, helping reduce illnesses and deaths.”

Screening involves testing a blood sample to see whether it contains antibodies (disease-fighting proteins) that react specifically to the hepatitis C virus. This test is followed by a second test that determines the level of virus in the blood. When used together, these two tests accurately identify whether a person has hepatitis C infection, according to the Task Force.

An estimated 4.1 million people in the United States are carrying HCV antibodies; about 2.4 million are living with the virus, according to the Task Force. The HCV infection becomes chronic in 75% to 85% of cases and some of those people develop symptoms such as chronic fatigue and depression, and liver diseases that can range from cirrhosis to liver cancer.

Approximately one-third of people ages 18 to 30 who inject drugs are infected with the virus; 70% to 90% of older injection-drug users are infected.

Owens, who is the director of Stanford Health Policy and the Henry J. Kaiser, Jr., Professor of Medicine, said the opioid epidemic now plays an important role in the prevalence of HCV. There are more than three times the number of acute HCV cases than a decade ago, particularly among young, white, injection drug users who live in rural areas. Women aged 15 to 44 have also been hit hard by the virus that is spread through contaminated blood.

“The opioid epidemic has added fuel to the HCV fire, substantially increasing transmission,” said Owens. “HCV is now an enormous public health problem, affecting a much broader age range of people than before. Fortunately, we have the tools to identify people and treatment is now successful in the vast majority of patients, so screening can prevent the mortality and morbidity from HCV.”

The U.S. Preventive Services Task Force is an independent panel of national experts in prevention and evidence-based medicine whose recommendations are followed by primary care clinicians nationwide. It has recommended people who are at high risk be tested for hepatitis C, as well as “baby boomers” born between 1945 and 1965, but now recommends screening all adults age 18 to 79, and younger or older patients if they are at high risk of acquiring HCV.

Hepatitis C is primarily spread when blood from an infected person enters the body of someone who is not infected. There currently is no vaccine for hepatitis C although research in the development of a vaccine is underway. But there are effective oral direct-acting antiviral (DAA) medications that can clear the virus from the body, particularly if caught early.

“Hepatitis C affects millions of people across the country,” says Task Force member Michael J. Barry, M.D. “We recommend screening all adults regardless of their risk because new evidence shows that more people can benefit from this service than even before.”

The Task Force’s final recommendation statement and corresponding evidence summary have been published online in the Journal of the American Medical Association, as well as on the Task Force website at http://www.uspreventiveservicestaskforce.org. 

This is the first installment in a series leading up to the publication of Fateful Decisions.

China has tremendous resources, both human and financial, but it may now be facing a perfect storm of challenges. Its future is neither inevitable nor immutable, and its further evolution will be highly contingent on the content and efficacy of complex policy choices.

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One of these challenges — how China must soon achieve economic growth as it grapples with the realities of a rapidly aging population and a shrinking workforce — is the subject of a chapter authored by Karen Eggleston, the deputy director of APARC and director of the Center’s Asia Health Policy Program. In the following interview, Eggleston shares perspectives from her chapter, “Demographic Challenges.”

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Q: What are some of the fateful decisions China is facing regarding the responsibilities of caring for a large, aging population?

A: China has achieved impressive improvements in health and longevity. It has implemented universal health coverage and is experimenting with financial support for long-term care for older adults. Yet significant gaps between the most- and least-privileged Chinese citizens persist, and in some cases are growing. As I have written elsewhere, it is not surprising that there are wide disparities in health and healthcare between different population subgroups in a country as populous, expansive, and diverse as China. How effectively and efficiently China meets these and other health- and aging-related issues will have a major impact on its ability to manage other social and economic challenges.

In the chapter I contributed to the volume Fateful Decisions, I note that China’s current population and demographic trends — including relatively rapid aging — reflect the success of earlier investments in infectious disease control, public health measures, and other contributors to mortality reduction. The lingering effects of family planning policies, historic preferences for sons, and rapid economic development are also major considerations. Together, these factors have produced a shrinking working-age population, a growing number of elderly, a gender imbalance, and hurdles for inclusive urbanization. An urgent question for China’s future is to what extent policies will ameliorate disparities in health, healthcare use, and the burden of medical spending.

The unfolding COVID-2019 outbreak is a powerful illustration of just how fateful decisions about health systems can be. Compared to the SARS outbreak almost two decades ago, China has been better prepared for this situation. SARS raised health system reform to the top of the political agenda and, many argue, played a direct role in China’s achieving universal health coverage and vastly strengthening the public health system.

But as China has become a middle-income global economic powerhouse in the years since SARS and the ensuing wave of health policy reforms, the expectations of its citizens about their health system have also risen. Has the health system, including public health and medical care, been strengthened to the same degree as other parts of the economy and public services? The impact of and lasting response to COVID-2019 may prove a litmus test.

Q: Why do these decisions about health carry such importance for China’s future development?

Through the last four decades, China has benefitted from a demographic dividend caused by the large bulge in the working-age population. But to achieve future economic growth and productivity, investments in human capital — particularly in health and education —need to be made. This higher productivity will, in turn, be the means by which a smaller workforce can support China’s large and growing cohort of retirees.

As we’ve already seen, health expenditures have increased rapidly as China has developed its system of universal health coverage. Double-digit health spending growth surpassed the rate of economic growth, and as a result, health spending absorbs an increasingly larger share of the total economy. China needs to make sure additional spending on health and elderly care is efficient and effective, while also addressing the nonmedical determinants of health and promoting healthy aging. The health system needs to be reengineered to emphasize prevention, provide coordinated health care for people with multiple chronic diseases, assure equitable access to rapidly changing medical technologies, and ensure long-term care for frail elderly, all without unsustainable increases in opportunity costs for China’s future generations.

Q: What is the Chinese government doing to improve healthcare quality and delivery, and what more could it do to affect meaningful change in its systems?

China’s current policies seek to balance individual responsibility, community support, and taxpayer redistribution through safety-net coverage funded by central and local governments. Like many countries, China would benefit from improved coordination across multiple agencies and structure incentives to avoid or mitigate unintended consequences that undermine the goals of its health system. Recent governance reforms, such as the creation of the National Healthcare Security Administration, aim to address these challenges.

China’s achievements and remaining challenges can be illustrated with the Healthcare Access and Quality Index (HAQ), which measures premature mortality from causes that should not occur if the individual had access to high-quality healthcare: among 195 countries and territories, China achieved the highest absolute increase in the HAQ Index from 2000 to 2016. However, the 43-point regional disparity in HAQ within China is the equivalent of the difference between Iceland (the highest HAQ in the world) and North Korea.

Q: The subject of your chapter, China’s demographic challenges, is one of the issues you investigate in your upcoming book, Healthy Aging in Asia. As you show in this volume, challenges at the intersection of aging, economics, demographic transition, and healthcare policy are not unique to China. How are other countries in Asia responding to them and what lessons could benefit China?

 As I note in the introduction of Healthy Aging in Asia, the demographic transition from high to low fertility and mortality has been more rapid in much of Asia than in Europe and North America. That means social institutions, such as retirement, living arrangements, and intergenerational support, have to adapt quickly. For example, extending work-lives (as is happening in Japan) will be necessary but feasible only if the added years are healthy ones and equitable only if the least advantaged also benefit from healthy aging. The blessings of longevity dim when clouded by pain, disability, and loss of dignity.

 Investment strategies in insurance and managing chronic conditions are also important considerations. Japan and Korea have adopted insurance systems for financing long-term care for frail elderly, while places like Hong Kong have good empirical research on chronic condition management.

 No country or system has a “magic pill” to address these challenges, but the empirical evidence and rich policy experience documented in Healthy Aging from health systems as diverse as those in the cities of Singapore and Hong Kong to large economies such as Japan, India, and China can certainly be instructive.

More evidence-based research is needed before the U.S. Preventive Services Task Force can recommend that clinicians screen their older patients for cognitive impairment such as dementia and Alzheimer’s disease.

Cognitive impairment is a growing public health dilemma that affects millions of Americans as they age. The Global Burden of Disease study shows that Alzheimer’s rose from the 12th most burdensome disease or injury in the United States in 1990 to the 6th in 2016.

Medical experts who were commissioned to conduct an evidence report for the Task Force projected that the burden of Alzheimer’s disease is expected to grow to 13.8 million U.S. residents by 2050 — or nearly 3.3% of the projected U.S. population by that year.

Their findings, the Task Force recommendation statement and several accompanying editorials were all published Tuesday in the Journal of the American Medical Association.

The symptoms of cognitive impairment can range from problems with memory and language, to learning new things or making decisions that affect everyday life. 

“Early identification of cognitive impairment through screening would ideally allow patients and their families to receive care at an earlier stage in the disease process, potentially facilitating discussions regarding health, financial, and legal decision-making while the patient still retains decision-making capacity,” the authors of the Task Force evidence report wrote.

But after reviewing some 287 studies including more than 285,000 older adults, the Task Force determined there wasn’t sufficient evidence about the benefits or harms of screening adults 65 and older who do not have signs or symptoms. The Task Force also did not find adequate evidence that screening for cognitive impairment improves decision-making or planning by patients, caregivers or doctors.

At the same time, there is little evidence on potential harms of screening, such as depression, anxiety or lower quality of life.

“Given the burden of dementia and the intense public interest in preventing cognitive impairment, the lack of progress is disheartening,” Carol Brayne, MD, with the Department of Public Health and Primary Care at the University of Cambridge in the UK, wrote in an accompanying JAMA editorial to the Task Force evidence report.

But, she added, “Political considerations and pressure from commercial interests and patient advocacy groups notwithstanding, public policies for dementia screening should be supported by evidence.”

The Task Force — an independent panel of national experts in prevention and evidence-based medicine — encourages clinicians to remain alert for early signs of symptoms of cognitive impairment, while calling for more research on the detection of dementia.

“Research is especially needed on whether screening and early detection of cognitive impairment helps patients, caregivers, and doctors make decisions about health care or plan for the future,” said Douglas K. Owens, chair of the Task Force and the director of Stanford Health Policy.  “We share the frustration of clinicians who want to offer something that could help patients prevent cognitive impairment. We hope that additional research will enable us to know whether that’s possible.”

The most commonly used screening tests include the Mini-Mental State Examination as well as the clock-drawing test. Screening tests involve asking patients to perform a series of tasks that asses one or more aspects of cognitive functions. The USPSTF concluded that more research is needed to know whether such screening tests can lead to interventions that help prevent or improve cognitive impairment. 

Elderly patients hospitalized with congestive heart failure have a poor prognosis and high risk of death and hospital readmission. So, their post-discharge care can strongly influence their outcomes.

Yet despite data showing that transitional care interventions, such as home visits by nurses, can reduce death rates and hospital readmission by more than 30%, many health systems have not implemented such programs. Health policy experts say this is due in part to cost concerns and doubts about the effectiveness of these delivery services.

 Now, a team of Stanford Medicine and Veterans Affairs researchers has sought to assess whether transitional care interventions provide good value and better outcomes, as there are 5 million people living with congestive heart failure in the United States and 500,000 new cases diagnosed each year. CHF is the stage of chronic heart disease in which fluids build up around the heart, causing it to pump inefficiently.

The researchers updated a 2017 study on the impact of transitional care intervention with four years of additional data. They then used it to compare standard post-discharge management with three post-discharge regimes for patients 75 or older that they found to be most effective: disease management clinics, nurse home visits and nurse case management.

All three transitional care interventions delivered appreciable health benefits to the patient population, said Jeremy Goldhaber-Fiebert, PhD, associate professor of medicine at the Stanford School of Medicine and core faculty member of Stanford Health Policy.

The findings were published in the Annals of International Medicine. Goldhaber-Fiebert is the senior author. The lead authors are Manuel R. Blum, MD, MS in Epidemiology & Clinical Research at Stanford in 2019 and now at the Department of General Internal Medicine at the University Hospital of Bern; Henning Øien, PhD, Norwegian Institute of Public Health, Oslo; and Harris L. Carmichael, MD, a Stanford/Intermountain Fellow in Population Health, Delivery Science, and Primary Care

“Transitional care interventions for older individuals with congestive heart failure — particularly nurse home visits — offer a high-value care alternative that could improve the health and longevity of millions of Americans,” he said.

The researchers said these transitional care services should become the standard of care for post-discharge management of patients with heart failure.

Heart failure causes 1 in 8 deaths nationwide

The prevalence of heart failure is estimated to be 26 million people worldwide and growing. In the United states, heart 5.7 million adults have been diagnosed with HF, with an estimated annual direct cost of $39.2 billion to $60 billion. Total heart failure costs in the United States are expected to exceed $70 billion by 2030, the authors wrote. According to the Centers for Disease Control and Prevention, heart disease costs the United States about $219 billion each year from health-care services, medicines and lost productivity.

Of the 15 million Americans in their mid-70s to 80s today, about 1 million suffer heart failure.

“So population gains from more effective post-discharge care would be hundreds of thousands of life years,” Goldhaber-Fiebert said. “Likewise, tens of thousands of costly rehospitalizations could be prevented each year if these interventions were delivered successfully.”

Heart failure primarily affects older people and is the second-most common inpatient diagnosis billed to Medicare. Yet the authors cite a recent study of 18 million Medicaid charges which found that only 7% of eligible patients at risk of rehospitalization received transitional services.

The standard post-hospital care for those patients includes sending them home with some advice and scheduling follow-up visits for them with cardiologists within 14 days of discharge. The researchers found that patients who received this standard post-hospitalization care with an average age of 75 had an average life expectancy of 2.9 years and 2.9 hospitalizations during their remaining lifetime. In comparison, nurse home visits decreased the number of hospitalizations by 10 readmissions per 100 patients and increased life expectancy by approximately four months, the study found.

“If these interventions were successfully implemented at scale, they could provide important substantial benefits with very good value,” said co-author Douglas Owens, MD, the Henry J. Kaiser Jr. Professor and professor of medicine at Stanford.

Reduced hospitalizations for congestive heart failure, according to the research, produces substantial cost savings that partially offset the costs of delivering the interventions. Though nurse home visits increase lifetime health care costs by $4,622, the substantial health benefits that they deliver justify their costs: $19,570 quality adjusted life years gained, which is considered highly cost-effective.

Hospital and insurance administrators take note

“Our results have important implications for decision-makers in hospital administration as well as in insurance and policy settings,” the authors wrote. They concluded:

• Transitional care services should become the standard of care for post-discharge management of patients with heart failure;
• The increasing reimbursement restrictions and regulations affecting HF hospital readmissions, through such programs as the Centers for Medicare & Medicaid Services Hospital Readmission Reduction Program, makes this research particularly informative to decision-makers;
• Hospital administrators could use the research to determine which transitional services are most cost-effective for its rural population, overall patient base and hospital system.

The other Stanford researcher on the study was Paul Heidenreich, MD, a professor of medicine and health research and policy at the Stanford University School of Medicine and, by courtesy, professor of health research and policy at the Palo Alto Veterans Affairs Health Care System.

Updated January 24
Millions of residents in China are under lockdown measures as the number of reported deaths from the coronavirus outbreak rises to 26. In the United States, dozens of people are being monitored for the virus. The World Health Organization on January 23 said at a press conference the outbreak did not yet constitute a global public health emergency.

The outbreak of a novel coronavirus that began in December 2019 in Wuhan, China “is evolving and complex,” said the head of the World Health Organization (WHO) after its emergency committee convened on Wednesday, January 22, and decided that more information was needed before the WHO declares whether or not the outbreak is a public health emergency of international concern. The new virus, known as 2019-nCoV, causes respiratory illness and continues to spread across China. Chinese health authorities, reports the Washington Post, announced that at least 17 people have now died as a result of infection and confirmed cases have been reported in Japan, Thailand, South Korea, Hong Kong, and Macao, with one travel-related case detected in the United States, in the State of Washington. The WHO decision was made as the city of Wuhan shut down all air and train traffic to try to contain the spread of the virus.

With concern over and coverage of the situation rapidly developing, Karen Eggleston, APARC Deputy Director and the Asia Health Policy Program Director at the Shorenstein Asia-Pacific Research Center, offered her insights on the outbreak and its impact on both Asian and international healthcare systems.

Q: Why has this outbreak raised so much concern in China and internationally, and how worried should people be about it?

Infectious disease outbreaks can challenge any health system. Events such as SARS, Ebola, and MERS outbreaks, and even the devastating flu pandemic a century ago, remind us of the frightening power that infectious diseases with high-case fatality can have. The global burden of mortality and morbidity is mostly from non-communicable chronic diseases, but no country or society is immune to old, newly emerging, and re-emerging infectious diseases. And although health systems are generally stronger now and have more technologies to trace and contain outbreaks, there are also deep and complicated challenges that make swift, coordinated disease response difficult even in the modern era.

Any government leadership or healthcare responders who have tried to manage an outbreak situation before are hyper-aware of the need to prepare for and manage future incidents, but we are living in a moment of very complicated social dynamics surrounding public health and healthcare. Distrust in drug companies and government agencies, controversies over vaccines, and increasing skepticism in science, even if only from vocal minorities, all make it more difficult to manage a cohesive international response to an outbreak situation and protect vulnerable people.

Q: As you’ve mentioned, many people looking at this situation with the memory of outbreaks such as SARS or H1N1 in mind. How is the Chinese government addressing this crisis and how does its reaction compare with China’s history of emergency health responses?

China’s health system is much more prepared now, compared to the SARS crisis 17 years ago. More training and investment in primary health care, disease surveillance and technology systems for tracking and monitoring outbreaks, and the achievement of universal health coverage with improving catastrophic coverage even for the rural population, all suggest a health system that is much better prepared to handle a situation like this. Top-level leadership in China had already begun to publicly address the situation within days of the outbreak to assure the public that strict prevention measures will be taken and to urge local officials to take responsibility and share full information. Until more information is gained and more is understood about the nature of this virus, it’s been categorized as a “Grade B infectious disease” but will be managed as if it is a "Grade A infectious disease," which requires the strictest prevention and control measures, including mandatory quarantine of patients and medical observation for those who have had close contact with patients, according to the commission. China currently only classifies two other diseases as Grade A infection diseases—bubonic plague and cholera—and so that tells you something about how seriously this is being treated by those in leadership positions.

Q: And what about the response from the international health communities?

As with any major healthcare crisis, health systems around the globe must also respond with alacrity and integrity, including effective surveillance, monitoring, and infection control. Individuals also play a crucial role in supporting the instructions and recommendations made by established healthcare professionals. For example, the individual with the confirmed case in Washington State proactively told medical personnel about his recent visit to the Wuhan area. His medical providers then exercised appropriate levels of caution, given the unknown nature of the virus, and isolated him while his symptoms developed. He is currently combatting an infection similar in severity to that of mild pneumonia, and so far no other cases have been reported in the United States, though some may arise in the coming days and weeks.

There is always a fine balance between safeguarding public health while still respecting individual rights, civil liberties, and undertaking a prudent, scientific response. The aim is to remain clear and transparent in communications and actions without reverting to disproportionate or overly aggressive responses which lead to panic, distortion, and misinformation about the situation. Some countries, like the Democratic People’s Republic of Korea, may choose to seal their international borders until more is understood about the nature of this virus, but most nations will use tried-and-tested methods of monitoring travelers and alerting population health systems so that information about cases is widely available to health authorities and medical researchers trying to understand the cause and develop a potential cure.

Q: As this situation continues to develop, and with inevitable future disease outbreaks around the globe, what would you hope people keep in mind about the role we all play in healthcare crises and in public health?

One issue this outbreak reminds us of in a visceral and intimate way is how closely people are linked together across the world. Globalization and air travel almost instantaneously link continents, countries, and regions. The timing of this outbreak is particularly fraught, because it’s the beginning of the Lunar New Year, when there is a vast migration of people both within China, throughout greater Asia, and across the globe as massive populations go home to celebrate the holidays with family. The potential for a contagious disease to spread easily through crowds and across borders in circumstances like this is very high, and highlights the need for the international communities to share information, scientific expertise, and understanding.

We need to remember that this is not just a problem in a remote part of the world that has no impact on those of us who live in relative comfort in high-income countries. Rather, this is something that could easily impact anyone. Perhaps this latest outbreak and response will showcase how vital additional, ongoing investments in both domestic and international healthcare systems, technologies, and people are.

The toll from gun violence at schools has only escalated in the 20 years since the jolting, horrific massacre at Columbine High.

By December 2019, at least 245 primary and secondary schools in the United States had experienced a shooting, killing 146 people and injuring 310, according to The Washington Post.

At least 245 primary and secondary schools in the United States have experienced a shooting — killing 146 people and injuring 310 — since the country's first mass school shooting at Columbine High School in April 1999.

Now, new Stanford-led research sounds an alarm to what was once a silent reckoning: the mental health impact to tens of thousands of surviving students who were attending schools where gunshots rang out.

A study has found that local exposure to fatal school shootings increased antidepressant use among youths.

Specifically, the average rate of antidepressant use among youths under age 20 rose by 21 percent in the local communities where fatal school shootings occurred, according to the study. And the rate increase – based on comparisons two years before the incident and two years after – persisted even in the third year out.

“There are articles that suggest school shootings are the new norm – they’re happening so frequently that we’re getting desensitized to them – and that maybe for the people who survive, they just go back to normal life because this is just life in America. But what our study shows is that does not appear to be the case,” said Maya Rossin-Slater, a core faculty member at Stanford Health Policy and faculty fellow at the Stanford Institute for Economic Policy Research (SIEPR). “There are real consequences on an important marker of mental health.”

The study is detailed in a working paper published Monday by the National Bureau of Economic Research. It was co-authored by Rossin-Slater, an assistant professor of health policy in the Stanford School of Medicine; Molly Schnell, a former postdoctoral fellow at SIEPR now an assistant professor at Northwestern University; Hannes Schwandt, an assistant professor at Northwestern and former visiting fellow at SIEPR; Sam Trejo, a Stanford doctoral candidate in economics and education; and Lindsey Uniat, a former predoctoral research fellow at SIEPR now a PhD student at Yale University.

Their collaborative research – accelerated by their simultaneous stints at SIEPR – is the largest study to date on the effects of school shootings on youth mental health.

The study comes as the issue of gun safety continues to stoke political wrangling and public debate. And the researchers say their findings suggest policymakers should take a wide lens to their decision-making process.

“When we think about the cost of school shootings, they’re often quantified in terms of the cost to the individuals who die or are injured, and their families,” Rossin-Slater noted. “Those costs are unfathomable and undeniable. But the reality is that there are many more students exposed to school shootings who survive. And the broad implication is to think about the cost not just to the direct victims but to those who are indirectly affected.”

A Driver for Antidepressant Use

More than 240,000 students have been exposed to school shootings in America since the mass shooting in Columbine in April 1999, according to The Washington Post  data used in the study. And the number of school shootings per year has been trending up since 2015.

Yet despite this “uniquely American phenomenon” – since 2009, over 50 times more school shootings have occurred in the U.S. than in Canada, Japan, Germany, Italy, France and the United Kingdom combined – little is known about the effects of such gun violence on the mental health of the nation’s youth, the study stated.

“We know that poor mental health in childhood can have negative consequences throughout life,” Schwandt said. “At the same time, children are known to show significant levels of resilience, so it really wasn’t clear what we would find as we started this project.”

The researchers examined 44 shootings at schools across the country between January 2008 and April 2013. They used a database that covered the near universe of prescriptions filled at U.S. retail pharmacies along with information on the address of the medical provider who prescribed each drug. They compared the antidepressant prescription rates of providers practicing in areas within a 5-mile radius of a school shooting to those practicing in areas 10-to-15 miles away, looking at two years prior and two to three years after the incident.

Of those 44 school shootings, 15 of them involved at least one death. The 44 shootings occurred in 10 states: Alabama, California, Connecticut, Florida, Nebraska, North Carolina, Ohio, South Carolina, Tennessee and Texas.

Researchers found a marked increase in the rate of antidepressant prescriptions for youths nearby, but only for the shootings that were fatal. They did not see a significant effect on prescriptions for youths exposed to non-fatal school shootings.

“The immediate impact on antidepressant use that we find, and its remarkable persistence over two, and even three years, certainly constitutes a stronger effect pattern than what we would have expected,” Schwandt said.

Meanwhile, adult antidepressant use did not appear to be significantly impacted by local exposure to school shootings.

Layers of Costs, More Unknowns

The researchers also analyzed whether the concentration of child mental health providers in areas affected by fatal school shootings made a difference in the antidepressant rates, and they drilled a further comparison between the prevalence of those who can prescribe drugs, such as psychiatrists and other medical doctors, and those who cannot prescribe drugs, such as psychologists and licensed social workers.

Increases in antidepressant rates were the same across areas with both high and low concentrations of prescribing doctors, the researchers found. But in areas with higher concentrations of non-prescribing mental health providers, the increases in antidepressant use were significantly smaller – indicating perhaps a greater reliance on non-pharmacological treatments or therapy for shooting-related trauma.

The researchers also found no evidence that the rise in antidepressant usage stemmed from mental health conditions that were previously undiagnosed prior to the shootings.

In totality, the researchers say the results in the study clearly pointed to an adverse impact from a fatal shooting on the mental health of youths in the local community. Furthermore, the results capture only a portion of the mental health consequences: Non-drug related treatments could have been undertaken as well.

“Increased incidence of poor mental health is at least part of the story,” Schnell said.

Though their analysis included only 44 schools and 15 fatal school shootings, Rossin-Slater noted how the trend of school shootings is growing. She believes the mental health impact found on the local communities they studied “can be generalizable to other communities’ experiences.”

That’s all the more reason why policymakers should consider the overall negative effects of school shootings, and how further research will be needed to gauge other societal consequences, the researchers said.

“Think of it as layers of costs,” Rossin-Slater said. And when it comes to evaluating gun violence at schools, “we think our numbers say, ‘Hey, these are costly things, and it’s costlier than we previously thought.’”