Dr. George Rosenkranz —a world-renowned scientist who devoted his life to improving global health and established a prize to foster innovative research among emerging Stanford scholars — leaves behind an extraordinary legacy of science and humanitarianism.

Rosenkranz was 102 when he died Sunday after a prolific scientific career, one that would forever change the course of women’s reproductive lives.

A Hungarian Jew who fled the Nazis during World War II and eventually emigrated to Mexico, Rosenkranz was one of three scientists who pioneered the chemical compounds that led to the birth control pill. He was also instrumental in developing medicines to fight venereal diseases.

His family established The Dr. George Rosenkranz Prize in 2010 at the Freeman Spogli Institute for International Studies; the prize is administered by Stanford Health Policy. The $100,000 award goes to researchers working to improve health care in the developing world.

The beloved figure often made it to the campus symposiums that honored the prize winners.

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The first Rosenkranz Prize was awarded in 2010 to SHP’s Eran Bendavid, an infectious disease physician and associate professor of medicine. He used his award to study whether U.S. money spent on malaria and HIV programs in sub-Saharan Africa translated into better health outcomes for women and their children.

“George has galvanized a community of global health researchers at Stanford,” said Bendavid. “We now have a community of scholars whose focus on critical issues in other countries has been powerfully enabled by George's legacy. He and his family have been an inspiration for us and, by extension, our students. The spirit of promoting promising young researchers is something we all benefit from. His is a wonderful name and a legacy to be attached to.”

Other Rosenkranz Prize winners honor his legacy with remembrances:

“There are very few people who have changed the world as much as Dr. Rosenkranz; his work in synthesizing and bringing oral contraception to market changed how people form families, and empowered women around the world.” — Mike Baiocchi, a Stanford statistician and the 2017 winner.

“The Rosenkranz Prize helped our young lab take risks where we might not have been able to; risks that have paid off intellectually,” said Baiocchi, whose team is conducting the largest-ever randomized trial to measure the impact of No Means No Worldwide project, which is training 300,000 boys and girls in Kenya and Malawi to prevent rape and teen pregnancy.

“The prize money allowed us to bring two of our statistics PhD students to Kenya to visit the communities they have been working with, to present their work to the stakeholders. This has built a passion for in these students, who have each launched their own Kenya-based study to examine means for reducing gender-based violence.”

“Dr. Rosenkranz's professional and personal legacy are closely intertwined. By his example, I and many other Rosenkranz scholars have been enabled to marry what sometimes feel like dueling passions: social justice and rigorous scholarship. I feel so fortunate to have met Dr. Rosenkranz and hope that many others will continue to be inspired by his message of equity, global fellowship, and excellence.” — Ami Bhatt, the 2016 winner who is building the first multi-country microbiome research project focused on noncommunicable disease risk in Africa.

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“As a Mexican awardee of the Rosenkranz prize it is a privilege to be part of the legacy of one of the most prominent Mexican scientists, whose generous support was a vital seed to create my research laboratory on Human Genomics in Mexico.” — Andrés Moreno Estrada, the 2012 winner who is analyzing the DNA of indigenous groups in Latin American, one of the most underrepresented populations in the field of genetics.

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“The prize was a huge boost to my career as an early stage researcher. It allowed me to do work in India on antimicrobial resistance (AMR) at a time when the topic was not a high priority for global funding agencies. The project led to a series of a collaborations with a large public hospital in India. There were several publications as a result of this partnership, and the studies we performed were innovative and informative on the prevalence on AMR in community-dwelling individuals.” — Marcella Alsan, one of two 2015 prize winners.

Mariam Noorulhuda has seen health disparities up close in the developing world, particularly in Afghanistan, where she interned at a hospital in Kabul last summer.

“There was a shortage of trained health-care professionals, especially women, poor facility conditions, and insecurity,” she said. “Our hospital was minutes away from multiple bombings.”

Noorulhuda is a rising senior and one of six Stanford undergraduates chosen for the inaugural class of Stanford Health Policy Undergraduate Research Fellows. From a variety of disciplines, they will spend this summer partnered with SHP faculty to work on research projects. The students were chosen for their desire to blend health policy with their own undergraduate studies.

Noorulhuda’s Story

Mariam Noorulhuda

That is when she lost another brother, as health-care infrastructure was demolished after much of the capital was destroyed in bombings. When the Taliban targeted her father for his resistance efforts, they fled again and were granted asylum in the United States in 1997. Though raised in the Bay Area, many family members remain in Afghanistan.

“Much of my family has been affected by the brutal impact that war has on health — not entirely through bombs and bullets per say — but through indirect effects like displacement and virtually nonexistent health systems,” said Noorulhuda, a history major with a minor in human rights.

She will work with SHP’s Eran Bendavid, an infectious diseases physician and associate professor of medicine who focuses on the impact of health policies and outcomes in developing countries. He is the fellowship coordinator for this inaugural summer program.

Impact of Health Policy

"There is a growing recognition that health policy impacts just about every facet of human experience and well-being, and we see students picking up on that earlier and earlier,” said Bendavid. “The scholarship at SHP — from the effects of gun ownership or armed conflict to quality of care and guideline development — is an exceptional environment for gaining experience and a deep-dive into health policy research."

The fellowships were made possible with generous support from Stanford political scientist Scott Sagan, and his wife Sujitpan Bao Lamsam, vice chairman of Kasikornbank in Thailand. Sagan is a senior fellow at the Center for International Security and Cooperation who focuses on nuclear strategy, the ethics of war and the safety of hazardous technology.

“One of the great strengths of Stanford is the opportunity for undergraduates to get deeply involved in faculty research projects,” said Sagan, whose daughter Charlotte Sagan (BA, `15) was a research assistant in health policy while at Stanford. “We wanted to help create such opportunities for future students.”

Tiffany Liu

Tiffany Liu just finished her freshman year and has yet to declare her major, though she’s thinking symbolic systems, the study of human-computer interaction.

“Both fields incorporate so many diverging perspectives and methods in order to solve salient issues,” said Liu, who will work with Jason Wang, an associate professor of pediatrics who looks at the use of innovative technology to improve quality of care and health outcomes.

“I’m eager to engage in health policy research through a mix of technical and non-technical methods — we can process and analyze data in so many more interesting ways using computers, and yet we can’t ever lose the humanistic aspect of health initiatives,” Liu said.

Nikhil Shankar, also a rising senior, is an economics major. He jumped at the health policy fellowships because he believes applied economics can have “real-world impact.”

He will be working with SHP’s Grant Miller, a senior fellow at the Freeman Spogli Institute for International Studies and director of the Stanford King Center on Global Development. They will examine the impact of population policy on child health outcomes by gender in China.

Nikhil Shankar

Health-care inequality driven by factors beyond the control of individuals is something that troubles Andrea Banuet, a human biology major and another a rising senior.

“Factors such as socioeconomic status, age, ethnic and racial backgrounds should not determine the type of care an individual can attain — but the really sad reality is that in many parts of our country, it does.”

She believes that policy informed by research has the power to combat institutional biases and promote change in health-care accessibility. She will be working Kathryn M. McDonald, executive director of CHP/PCOR, an expert on health-care quality and patient safety.

Conrad Milhaupt is another rising senior with a double major in economics and public policy.

“I have a passion for the intersection of economics, politics and policy, with a particular focus on health and environmental policy,” said Milhaupt, who will work with SHP’s Jay Bhattacharya, a professor of medicine and economics.

Milhaupt took Bhattacharya’s health economics class in his sophomore year and became intrigued by the discrepancies in costs for health services with only marginal differences in outcomes. He is particularly interested in health care in rural America and ways that changes to our public-private insurance mix may improve access to care and help manage costs.

“Ultimately, I am driven to study this topic by my belief that health care is a human right and that health is an integral aspect of every individual’s life,” he said.

Conrad Milhaupt

Calvin Tolbert, with funding from the Office of the Vice Provost for Teaching and Learning, will work with Eric Sun, an economist and assistant professor of anesthesiology who researches consolidation in physician markets and the economics of pain treatments.

Tolbert is a rising junior majoring in economics and classics, with a minor in mathematics.

“The thing that initially drew me to economics was the fact that it was both math-intensive and pertinent to public policy, which is a keen interest of mine,” he said.

He will be working on a project that looks at physician compensation across countries and the wide gap in costs and access to medical care and drugs.

“This is an area that first caught my eye, when I read accounts of medical tourism in the news, including both people from developing countries who come to America for serious procedures and Americans who visit other countries to receive treatment due to the expense of medical care in this country.”

The United States has more people with new HIV diagnoses each year than any high-income nation. There is this widespread misconception out there that we’ve got it under control; that the drug cocktails are so effective that HIV is no longer a leading threat.

“Unfortunately, HIV remains a major public health problem in the U.S.,” said Stanford Health Policy’s Douglas K. Owens. He is chair of the U.S. Preventive Services Task Force, which issued two influential recommendations Tuesday for the prevention and treatment of HIV.

“Each year, almost 40,000 people acquire HIV, he said. “It’s not acceptable and requires our urgent attention.”

Owens, the Henry J. Kaiser, Jr., professor at Stanford Medicine, said an estimated 1.1 million people are currently living with HIV in this country — and more than 700,000 people have died of AIDS since the first cases were reported in 1981. Of the 38,281 new diagnoses of HIV reported in 2017, 81% were among men and 19% among women.

“There are highly effective preventive interventions that can help us toward the goal of ending the HIV epidemic in the U.S.,” said Owens, who is also an investigator at VA Palo Alto Health Care System “However, we know not enough people receive these interventions.”

The task force recommends clinicians screen everyone aged 15 to 65 and all pregnant women for HIV and offer pre-exposure prophylaxis (PrEP) — a pill that helps prevent HIV — to people at high risk of contracting the potentially fatal infection.

It released its recommendations with a series of articles and editorials in the Journal of the American Medical Association (JAMA), calling for dramatic action to end the AIDS epidemic in the United States once and for all. 

The task force is an independent, volunteer panel of national experts in prevention and evidence-based medicine who work to improve the health of all Americans by making recommendations. They typically give letter grades to its recommendations, and this time issued its highest grade, an A.

The draft recommendations were made last year and then put out for review and public comment. The recommendations made Tuesday are final.

The benefit of this endorsement could be substantial, according to one of the accompanying editorials in JAMA, because under the Affordable Care Act, Grade A and B recommendations made by the USPSTF should be covered by private insurance without patient cost-sharing.

“How this recommendation will be implemented is of critical importance because cost is a major barrier for people both to start and to stay on PrEP,” wrote Diane V. Havlir, MD, and Susan P. Buchbinder, MD, in their editorial. At present, they wrote, the average monthly retail cost for PrEP without insurance is nearly $2,000.

The task force members concluded “with high certainty” that while there are some small harms associated with PreP, the magnitude of benefit with oral tenofovir disoproxil fumarate-based therapy to reduce the risk of HIV infection in people at high risk is substantial.

“Clinicians can make a real difference toward reducing the burden of HIV in the United States, Owens said in the task force statement. “HIV screening and HIV prevention work to reduce new HIV infections and ultimately save lives.”

Fewer than half of all adults have ever been tested for HIV in the U.S. and many of those requiring more frequent testing are not receiving it. The task force emphasized that clinicians should make testing routine and ensure patients are given an environment that is free of judgment during discussions of sexual health.

Screening is the only way to know if a person has been infected with HIV because, after initial flu-like symptoms, HIV does not cause any signs of symptoms for several years. So the task force recommends HIV screening for everyone between of 15 and 65 and for pregnant women.

In addition to screening, people need to prevent getting HIV by using condoms during sex, the task force said, for those who inject drugs, using clean needles and syringes.

People at high risk for HIV have an additional strategy for prevention in taking PrEP, the task force said in its statement. “For people at high risk of getting HIV, the benefits of PrEP far outweigh the harms, which can include kidney problems and nausea.”

Read the full task force statement and accompanying articles and editorials in JAMA.  

A new study by Stanford economists shows that giving fathers flexibility to take time off work in the months after their children are born improves the postpartum health and mental well-being of mothers.

In the study, slated for release by the National Bureau of Economic Research on June 3, Petra Persson and Maya Rossin-Slater examined the effects of a reform in Sweden that introduced more flexibility into the parental leave system. The 2012 law removed a prior restriction preventing a child’s mother and father from taking paid leave at the same time. And it allowed fathers to use up to 30 days of paid leave on an intermittent basis within a year of their child’s birth while the mothers were still on leave.

The policy change resulted in some clear benefits toward the mother’s health, including reductions in childbirth-related complications and postpartum anxiety, according to their empirical analysis.

“A lot of the discussion around how to support mothers is about mothers being able to take leave, but we often don’t think about the other part of the equation — fathers,” says Rossin-Slater, an assistant professor of health research and policy.

“Our study underscores that the father’s presence in the household shortly after childbirth can have important consequences for the new mother's physical and mental health,” says Persson, an assistant professor of economics.

Rossin-Slater and Persson are both faculty fellows at the Stanford Institute for Economic Policy Research.

Among their main findings of effects following the reform: Mothers are 14 percent less likely to need a specialist or be admitted to a hospital for childbirth-related complications — such as mastitis or other infections — within the first six months of childbirth. And they are 11 percent less likely to get an antibiotic prescription within that first half-year of their baby’s life.

There is also an overall 26 percent drop in the likelihood of any anti-anxiety prescriptions during that six-month postpartum period — with reductions in prescriptions being most pronounced during the first three months after childbirth.

What’s more, the study found that the average new father used paid leave for only a few days following the reform — far less than the maximum 30 days allowed — indicating how strong of a difference a couple of days of extra support for the mother could make.

“The key here is that families are granted the flexibility to decide, on a day-to-day basis, exactly when to have the dad stay home,” said Persson. “If, for example, the mom gets early symptoms of mastitis while breastfeeding, the dad can take one or two days off from work so that the mom can rest, which may avoid complications from the infection or the need for antibiotics.”

These indirect benefits from giving fathers workplace flexibility are not trivial matters when you consider the health issues mothers often face after childbirth and after they get home from the hospital, says Rossin-Slater, who is also a faculty member of Stanford Health Policy.

Infections and childbirth complications lead to one out of 100 women getting readmitted to the hospital within 30 days in the United States, according to the study.

Meanwhile, postpartum depression occurs for about one out of nine women, and maternal mortality has also been a rising trend over the past 25 years in the U.S.

The study comes as a growing number of lawmakers in the United States vocalize support for paid family leave but have failed to pass federal legislation.

Washington, D.C., and six states have adopted various paid family leave laws, but the U.S. remains the only industrialized nation in the world that does not have a national mandate guaranteeing a certain amount of paid parental leave.

Some federal lawmakers are working on family leave measures and have proposed such legislation over the past few years — including The Family Act, The New Parents Act — but none of them have ever gained enough traction to proceed in Congress.

This new study can help broaden the policy discussions, the researchers say.

The larger context around paid family leave policies is often framed today as a way to help narrow the gender wage gap by giving women more workplace flexibility and fewer career setbacks.

This study, however, shines a light on maternal health costs and how a policy on paid family leave — that includes workplace flexibility for the father — offers more benefits than previously thought, Rossin-Slater says.

“It's important to think not only about giving families access to some leave, but also about letting them have agency over how they use it,” she says.

And when it comes to concerns that fathers might use paid parental leave to goof off instead of spending the time as intended, the researchers say their study should assuage those worries.

“It's not like fathers are going to end up using a whole month to just stay home and watch TV. We don't find any evidence of that,” Rossin-Slater says. “Instead they only use a limited number of days precisely when the timing for that seems most beneficial for the family.”

“For all these reasons,” Persson says, “giving households flexibility in how to use paternity leave makes a lot of sense.”

People today can generally expect to live longer and, in some parts of the world, healthier lives. The substantial increases in life expectancy underlying these global demographic shifts represent a human triumph over disease, hunger, and deprivation, but also pose difficult challenges across multiple sectors. Population aging will have dramatic effects on labor supply, patterns of work and retirement, family and social structures, healthcare services, savings, and, of course, pension systems and other social support programs used by older adults. Individuals, communities, and nations around the world must adapt quickly to the demographic reality facing us and design new approaches to financing the many needs that come with longer lives.

This imperative is the focus of a newly published special issue of The Journal of the Economics of Ageing, entitled Financing Longevity: The Economics of Pensions, Health and Long-term Care. The special issue collects articles originally written for and discussed at a conference that was dedicated to the same topic and held at Stanford in April 2017 to mark the tenth anniversary of APARC’s Asia Health Policy Program (AHPP). The conference convened top experts in health economics and policy to examine empirical and theoretical research on a range of problems pertinent to the economics of aging from the perspective of sustainable financing for long lives. The economics of the demographic transition is one of the research areas that Karen Eggleston, APARC’s deputy director and AHPP director, studies. She co-edited the special issue with Anita Mukherjee, a Stanford graduate now assistant professor in the Department of Risk and Insurance at the Wisconsin School of Business, University of Wisconsin-Madison.

The Financing Longevity conference was organized by The Next World Program, a Consortium composed of partners from Harvard University, Fudan University, Stanford University, and the World Demographic and Aging Forum, and was cosponsored by AHPP, the Stanford Institute for Economic Policy Research, and the Stanford Center on the Demography and Economics of Aging.

The contributions that originated from the conference and are collected in the Journal’s special issue cover comparative research on more than 30 European countries and 17 Latin American countries, as well as studies on Australia, the United States, India, China, and Japan. They analyze a variety of questions pertinent to financing longevity, including how pension structures may exacerbate existing social inequalities; how formal and informal insurance interact in securing long-term care needs; the ways in which the elderly cope with caregiving and cognitive decline; and what new approaches might help extend old-age financial security to those working outside the formal sector, which is a major concern in low-income countries.

Another challenge of utmost importance is the global pension crisis, caused due to committed payments that far exceed the saved resources. It is a problem that Eggleston and Mukherjee highlight in their introduction to the special issue. By 2050, they note, the pension gap facing the world’s eight largest pension systems is expected to reach nearly US $400 trillion. The problem cannot be ignored, as “the financial security of people leading longer lives is in serious jeopardy.” Indeed four of the eight research papers in the special issue shed light on pensions and inequality in income support for older adults. The other four research papers focus on health and its interaction with labor force participation, savings, and long-term care.

The issue also features two special contributions. The first is an interview with Olivia S. Mitchell, a professor at the University of Pennsylvania’s Wharton School and worldwide expert on pensions and ageing. Mitchell explains the areas offering the most promise and excitement in her field; discusses ways to encourage delayed retirement and spur more saving; and suggests several priority areas for future research. The latter include applying behavioral insights to questions about retirement planning, improving financial literacy, and advancing innovations to help people imagine themselves at older ages and save more for their future selves.

The second unique contribution is a perspective on the challenges of financing longevity in Japan, based on the keynote address delivered at the 2017 Stanford conference by Mr. Hirotaka Unami, then senior Director for policy planning and research of the Minister’s secretariat of the Japan Ministry of Finance and currently deputy director general with the Ministry’s Budget Bureau.

In Japan, decades of improving life expectancy and falling birth rates have produced a rapidly aging and now shrinking population. Data released by Japan’s Statistics Bureau ahead of Children's Day on May 5, 2019 reveal that Japan’s child population (those younger than 15) ranks lowest among countries with a total population exceeding 40 million. In his piece, Unami focuses on the difficult tradeoffs Japan faces in responding to the increase in oldest-old population (people aged 75 and over) and the overall population decline. Japan aspires to do so through policies that are designed to restore financial sustainability for the country’s social security system, including the medical care and long-term care insurance systems.

Unami argues that Japan must simultaneously pursue a combination of increased tax revenues, reduced benefit growth, and accelerated economic growth. He notes that these three-pronged efforts require action in five areas: review Japan’s pension policies; reduce the scope of insurance coverage in low-risk areas; increase the effectiveness of health service providers; increase a beneficiary’s burden according to their means; and enhance policies for preventive health care for the elderly.

The aging of our world’s population is a defining issue of our time and there is pressing need for research to inform policies intended to improve the financial well-being of present and future generations. The articles collected in the Financing Longevity special issue and the ongoing work by APARC’s Asia Health Policy Program point to multiple areas ripe for such future research.

View the complete special issue >>

Learn more about Dr. Karen Eggleston’s work in the area of innovation for healthy aging >>

U.S. government aid for treating children and adults with HIV and malaria in developing countries has done more than expand access to lifesaving interventions: It has changed how people around the world view the United States, according to a new study by researchers at the School of Medicine.

Compared with other types of foreign aid, investing in health is uniquely associated with a better opinion of the United States, improving its “soft power” and standing in the world, the study said.  

Favorability ratings of the United States increased in proportion to health aid from 2002 to 2016 and rose sharply after the implementation of the President’s Emergency Plan for AIDS Relief in 2003 and the launch of the President’s Malaria Initiative in 2005, the researchers report.

Their findings were published this week in the American Journal of Public Health. The lead author is postdoctoral scholar Aleksandra Jakubowski, PhD, MPH. The senior author is Eran Bendavid, MD, associate professor of medicine and a core faculty member at Stanford Health Policy.

“Using data on aid and opinions of the United States, we found that investments in health offer a unique opportunity to promote the perceptions of the United States abroad, in addition to disease burden relief,” the authors wrote. “Our study provides new evidence to support the notion that health diplomacy is a net win for the United States and recipient countries alike.”

The Trump administration, however, has proposed a 23% cut in foreign aid in its 2020 budget, including large reductions to programs that fight AIDS and malaria overseas.

The Stanford researchers believe their study is the first to add heft to the argument that U.S. health aid boosts the “soft power” that wins the hearts and minds of foreign friends and foes.

“Our study shows that investing in health aid improves our nation’s standing abroad, which could have important downstream diplomatic benefits to the United States,” Jakubowskisaid. “Investments in health aid help the United States accumulate soft power. Allowing the U.S. reputation to falter would be contrary to our own interests.” 

A Policy Debate

Many politicians and economists consider spending U.S. tax dollars on foreign aid as an ineffective, and possibly harmful, enterprise that goes unappreciated and leads to accusations of American meddling in other countries’ national affairs.

The U.S. government, for the past 15 years, has contributed more foreign health aid than any other country, significantly reducing disease burden, increasing life expectancy and improving employment in recipient countries, the authors wrote. Still, this generosity has historically constituted less than 1% of the U.S. gross domestic product.

“Our results suggest that the dollars invested in health aid offer good value for money,” the researchers wrote. “That is, the relatively low investment in health aid (in terms of GDP) has provided the United States with large returns in the form of improved public perceptions, which may advance the U.S. government’s ability to negotiate international policies that are aligned with American priorities and preferences.”

The researchers used 258 Global Attitudes Surveys, based on interviews with more than 260,000 respondents, conducted by the Pew Research Center in 45 low- to middle-income countries between 2002 and 2016.

Their analysis focused on the health sector, which includes several large programs for infectious disease control, but also support for nutrition, child health and reproductive health programs. They compared health aid to other major areas of U.S. investment: governance, infrastructure, humanitarian aid and military aid. They also constructed a database of news stories that mentioned the President’s Emergency Plan for AIDS Relief or the President’s Malaria Initiative by crawling through the online archives of the top three newspapers by circulation in each of the 45 countries.

They found that the probability of populations holding a very favorable opinion of the United States was 19 percentage points higher in the countries where and years when U.S. donations for health care were highest, compared with countries where and years when health aid donations were lowest. Using another metric, the researchers found that every additional $100 million in health aid was associated with a nearly 6 percentage-point increase in the probability of respondents indicating they had a “very favorable” opinion of the United States. 

In contrast, the researchers found, aid for governance, infrastructure, humanitarian and military purposes was not associated with a better opinion of the United States.

Bendavid, an infectious diseases physician and core faculty member of Stanford Health Policy, said that when he set out to conduct this research, he believed it would result “in a resounding thud” — that the “soft power” of health aid would have no impact on public opinion.

“For me, the notion that this program — hatched and headquartered in D.C. — would have impacts among millions in Nairobi and Dakar, seemed farfetched,” Bendavid said. “I was incredulous until all the pieces were in place.”

The ‘America First’ Agenda

The Trump administration’s “America First” agenda is calling for significant cuts to global health aid, particularly to the highly successful AIDS relief program, which was established by President George W. Bush. The administration’s budget, released in March, proposed a $860 million cut to the program; the President’s Malaria Initiative is facing a $331 million reduction in federal funding. That’s a decline of 18% and 44%, respectively.

The U.S. contribution to the Global Fund to Fight AIDS, Tuberculosis and Malaria would also decline by 17%, or $225 million, according to the Kaiser Family Foundation.

Yet beyond the reputational damage to the United States, such cuts could be a major setback to improving health outcomes in developing countries, the researchers said. After all, HIV knows no borders, and having more resilient health care systems is instrumental when facing public health crises, such as the Ebola outbreak in the Democratic Republic of Congo, Jakubowski said.

“The most direct impact of cutting the United States’ health aid allocations is the potential to undermine or reverse the progress that has been enabled by U.S. aid in curbing mortality and the spread of disease,” Bendavid said. “However, this study suggests there are also repercussions to the United States: the relationships the U.S. has built with recipient nations could also be undermined.”            

Other Stanford co-authors are Steven Asch, MD, MPH, professor of medicine, and former graduate student Don Mai.

Stanford’s Department of Medicine supported the work.

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Fourteen years ago, Stanford Health Policy’s Douglas K. Owens and colleagues published a cost-effectiveness analysis that would change the face of HIV prevention. Their landmark study in The New England Journal of Medicine showed that expanding HIV screening would increase life expectancy and curb transmission of the disease — and was cost effective in virtually all health-care settings.

Not long after their model-based results were published, their findings became key evidence in the decision to expand screening by the Centers for Disease Control and Prevention. Their work has been used in HIV screening guidelines from the U.S. Preventive Services Task Force — which Owens now chairs — the American College of Physicians and the Department of Veterans Affairs, among others.

Owens and his Stanford colleague Margaret Brandeau, professor of management science and engineering, have led this team of decision scientists who have been at the forefront of developing scientific models for the screening and prevention of HIV for two decades now. This modeling team — which also includes colleagues from UCSF and Yale — has published nearly 250 peer-reviewed studies and is one of the most experienced and respected in the world.

But today, the opioid epidemic is threatening the hard-fought gains in the prevention and control of HIV and hepatitis C virus (HCV). In support of their continued work to address the opioid epidemic, Owens received a highly prestigious MERIT award from the National Institute on Drug Abuse (NIDA),which provides up to 10 years of funding for the team.

“We are extremely grateful to NIDA for this support and to our colleague at NIDA, Dr. Peter Hartsock, who has worked with us for over 20 years to mitigate the harms from HIV and HCV,” said Owens.

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The team will now turn its sights on the complex interplay of the opioid epidemic, and HIV and hepatitis C virus (HCV) transmission. The transmission of HCV has been fueled by the opioid epidemic, and HCV now kills more Americans than all other infectious diseases combined.  

“The unfolding opioid epidemic is a defining challenge for the public health and medical systems in the United States,” Owens, the principal investigator of the team, and his colleagues wrote in their grant proposal. “The reversal of life expectancy growth in the demographic groups most affected by the opioid epidemic represents the aggregation of a complex web of harmful public health and population trends, including a rise in overdoses, suicides, mental health afflictions, economic disadvantages, and infectious disease outbreaks.”

Indeed, for the first time since the 1960s, the U.S. life expectancy has contracted for the second year in a row; drug overdoses have been the leading cause of death for Americans under age 50, with an estimated two-thirds of those deaths resulting from opioids.

Since the last renewal of their NIDA-funding grant in 2013, the team has watched the dramatic rise of opioid overuse, injection drug use, and overdose become a national public health crisis, with more than 60,000 drug overdose deaths in the United States reported by the CDC.

“The growing use of needle-based opioids increases the likelihood of accelerating HIV and HCV transmission,” said co-investigator Jeremy Goldhaber-Fiebert, an associate professor of medicine and core faculty at Stanford Health Policy. “Identifying the best combination of approaches to reduce HIV and HCV transmissions stemming from the opioid epidemic is of critical public health importance.”

The other co-investigators on the team of the project, “Making Better Decisions: Policy Modeling for AIDS and Drug Abuse,” are:

1. Eran Bendavid, an infectious diseases physician and associate professor of medicine at Stanford who is another a seasoned HIV modeler and outcomes expert;

2. Keith Humphreys, professor of psychiatry and behavioral sciences at Stanford and a former senior policy advisor in the White House Office of National Drug Control Policy; 

3. David Paltiel, a Yale School of Public Health professor who pioneered policy options for mitigating the impact of HIV in the United States and abroad;

4. Gregg Gonsalves, an assistant professor of epidemiology at Yale and a 2018 MacArthur Foundation Fellow who will focus on developing new algorithms to detect and predict opioid-related outbreaks of HIV and HCV;

5. James Kahn of the Institute for Health Policy Studies at UCSF, professor of epidemiology and biostatistics and an expert on the individual and population impact of prevention and treatment for HIV, HCV and opioid use.

The End of AIDS? 

Toward 2012, a series of scientific advances led to calls for “the end of AIDS.” The two big factors were the cost of the “triple cocktail” of antiretrovirals plunging in developing countries and then huge donations from wealthy countries began pouring in to fight the disease.

Yet the researchers say successes have been too few and that the incidence of HIV remains far too high. About 40 million people were living with HIV around the world in 2017; an estimated 940,000 people died from AIDS-related illnesses that same year.

The year 2015 marked the first time in two decades that the number of HIV diagnoses tied to opioids increased.

"Although it was started by prescription opioid overprescribing, the epidemic has evolved to include significant injection opioid use which is now threatening to significantly increase the spread of infectious diseases like HIV and Hepatitis C,” said Humphreys.

The most visible example of an opioid-related HIV outbreak took place in Scott County, IN, in 2014-2015. A single infection introduced into the community resulted in nearly 200 new HIV cases within six months, largely related to oxymorphone injections. In 2017 and again in March 2018, two additional substantial outbreaks occurred in Scott County, likely linked to both risky sex and needle sharing. 

In addition, the CDC has identified 220 counties in 26 states that are uniquely vulnerable to HIV and HCV outbreaks related to opioid injections.

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“Developing models that forecast high-risk areas for HIV and HCV is essential for aligning surveillance and public health interventions with risk,” said Brandeau, a leader in designing models for the prevention of HIV and hepatitis, especially in drug abuse disorders.

There have also been striking increases in the injection of opioids and heroin that are closely linked to the spread of viral hepatitis. In the demographic areas most affected by opioids, the researchers found, diagnoses of acute hepatitis have more than quadrupled — reversing trends of the previous decade. And in the country as a whole, the number of new HCV cases has nearly tripled since 2010. 

“For any type of contact with an infected source such as a dirty needle, or even cocaine straws, HCV is by far the most rapidly transmissible of the blood-borne infections,” said Bendavid. “One of the challenging issues with hepatitis C is that its major health manifestations do not appear for many years after infection."

What’s the Plan? 

In the next five years, the team intends to evaluate how strategies to prevent and mitigate the harms of opioid use can decrease the spread of HIV and HCV and thereby reduce morbidity and mortality from opioid use. They have four specific goals: 

1. Model the effect of the opioid epidemic on transmission of HIV and HCV.

2. Model the epidemiological and population impacts of individual strategies to prevent and mitigate the harms of opioids and drug injection on HIV and HCV outcomes by evaluating prevention strategies;

3. Model the epidemiologic and population impact of portfoliosof strategies to mitigate the harms of opioid use and drug injection on HIV and HCV outcomes;

4. And model the impact of barriers to implementation of effective strategies to reduce the harms of opioid use on HIV and HCV.

“We will perform novel analyses assessing intervention impacts singly and in combination assessing outcomes for HIV, HCV and opioid use disorder,” the researchers wrote in their grant proposal.

Then, the researcher will model new methods for building complex multi-intervention and multi-disease models and developing adaptive testing algorithms for identifying outbreaks.

Finally, the team intends to assess the barriers and intervention approaches “that more realistically reflect implementation issues than current models and hence identify resource needs for system planning.”

Medicare made $70 billion in payments to physicians in 2017 for care they provided to the 44 million Americans covered by the federal health-care program.

Who decides how much a physician should be reimbursed from Medicare for their services?

Medicare has depended on a committee convened by the American Medical Association known as the Relative Value Scale Update Committee (RUC) since 1992. The RUC has been called the most important health care committee you’ve never heard of.

The RUC has 31 members, most of whom come from the major specialty societies, such as the American Academy of Orthopedic Surgeons and American Association of Neurological Surgeons. By estimating the time and effort physicians take to perform thousands of different services, the RUC assigns “values” to each service that determine how much physicians are paid for delivering it. 

The RUC has come under heavy criticism in health policy circles for its influential role in setting payment levels. But its performance and methods have never been closely studied.

So Stanford researchers David C. Chan and David Studdert — both core faculty members at Stanford Health Policy — set out to evaluate how well the RUC was doing. The researchers analyzed one critical ingredient of the valuation process: how long services take to perform.  They compared the RUC’s estimates of the duration of 293 common operations to “benchmark” times for the same operations, obtained from actual surgical cases recorded in a large national database.

The study, published in The New England Journal of Medicine, found substantial discrepancies between the RUC’s time estimates and the benchmark times. But Chan and Studdert also found that the RUC did not show a systematic bias; times were as likely to be overestimated as they were to be underestimated.  

The research team, which also included Johnny Huynh, a PhD student in economics at UCLA, then characterized inaccuracies, quantified their effect on physician revenue, and examined whether re-review by the RUC corrected them.

“The inaccuracy of the RUC’s estimates for some procedures times was quite large,” said Chan, a faculty fellow at the Stanford Institute for Economic Policy Research and staff physician at the Veterans Affairs Palo Alto Health Care System. “The best way we could think of to indicate how large was to convert them into clinical revenue, and see how the inaccuracies affected different specialties.”

The study estimated that orthopedic surgeons and urologists received higher payments than they would have if benchmark times had been used — $160 million and $40 million more, respectively, in Medicare reimbursements over a five year period. Whereas cardiothoracic surgeons, neurosurgeons and vascular surgeons received lower payments — $130 million, $60 million, and $30 million less, respectively — during the same period.

Yet the researchers did not find evidence that inaccuracies stemmed from systematic bias.

“There was already an awareness that the RUC was missing the mark on some of its time estimates. Our study reinforces that inaccuracy story,” said Studdert, a professor of medicine and law. “But the prevailing view is that RUC uses times that are systematically longer than the truth, and we just don’t see that.” 

The study concludes nonetheless that reform is still needed, because the time discrepancies are large and have substantial effects on payment allocations. It points to two policy reforms that have the potential to improve the accuracy of service valuations by the RUC: 

1. Use larger and more reliable sources of data for the time estimates;
2. Enhance the real-time accuracy of the valuations by monitoring such data sources for substantial changes in the duration of procedures and using this information to prioritize procedures for re-review.

“I believe that the RUC has moved in this direction recently, and I suspect that there would be a fairly general agreement that the process could be improved by going further and using more and better data,” Chan said.

The researchers now intend to turn their sights on another aspect of physician payment policy: the perception that the RUC methods lead to underpayment of primary care physicians.

“The biggest criticism of the RUC over the years is the allegation that it systematically undervalues the work of primary care physicians, relative to surgeons,” Studdert said. “Now that we have developed method for benchmarking the RUC’s accuracy, we’d like to redeploy it on this primary care versus surgical care issue.”

Drug companies and medical device manufacturers have long cultivated ties with physicians and hospitals in an effort to promote their wares. This has led to some suspicion that patients may end up with prescriptions for drugs they don’t need or devices they don’t want.

So the federal Centers for Medicare & Medicaid Services established the Open Payments database — required under the Affordable Care Act — which allows patients to discover whether their physicians or hospitals have any financial ties with drug or device companies.

It is designed to give the public a more transparent health-care system, though as the website notes, all information on the Open Payments database is open to personal interpretation.

"Transparency has become a very vogue strategy in U.S. health policy,” said Stanford Health Policy’s Michelle Mello. “Information disclosure requirements are being used to do everything from curbing overeating to helping patients decide where to have their heart surgery.”

Mello, a professor of health research and policy at the School of Medicine and professor of law at Stanford Law School, and her colleagues wanted to understand whether the Open Payments system is achieving its goal of helping patients make more informed decisions.

In a new study published by JAMA Network Open, the researchers found an unintended consequence of the public disclosure system: It may have diminished trust in even those physicians who never received payments from drug or medical device firms.

Lack of Public Trust

The authors’ survey of 3,500 respondents found that public disclosure of payments was associated with a 2.7% decline in trust in one’s own physician regardless of whether the respondents knew their physicians had received payments. In fact, the authors note, fewer than 5% of U.S. adults report knowing about their physicians’ industry payments or using the Open Payment website.

“Doctors might consider that unfair because people reported diminished trust even though most of them had no idea whether their doctor took industry payments or not,” Mello said. “About two-thirds of physicians receive industry payments, so what we’re seeing is a kind of spillover reputational damage to the one-third who don’t.”

Mello said she and her co-authors — Genevieve P. Kanter of the University of Pennsylvania, Daniel Carpenter of Harvard University and Lisa Lehmann of the National Center for Ethics in Health Care in the Veterans Health Administration — were surprised by their findings.

“Why would trust go down if few people are using the Open Payments data?” Mello asked. “We think that the large amount of media publicity about the Open Payments law — which has described drug companies’ financial influence as pervasive and highlighted extreme cases of physicians taking very large payments — may have changed how people think about the trustworthiness of the medical profession as a whole.” 

Pharmaceutical companies for decades have engaged physicians through a variety of kinds of financial relationships. Grants for company-sponsored research constitute the largest expenditure, but consulting fees, honoraria for giving lectures, providing meals, covering travel expenses, and giving small gifts are also common activities. Physicians may also have investment interests in drug and device companies.

“However, the nature of these relationships and the magnitude of the dollars flowing from companies to physicians have largely been opaque to the public,” the authors wrote.

The Policy Implications

Trust is a crucial element of the physician-patient relationship affecting many aspects of patient behavior and sentiment that ultimately affect health, the authors said. For example, trust in one’s physician is associated with “whether patients follow treatment recommendations, how well they self-manage chronic conditions, and whether they seek preventive care.” Further, the authors wrote, “Trust in the medical profession may affect the public’s views of scientific authority and medical research, which may influence patient adherence and health-promoting behaviors,” they wrote.

The researchers suggested institutional policies should be implemented by hospitals and physicians to help patients understand what these payments represent. Some kinds of payments, such as an honorariumfor serving as a paid speaker for a drug company, are more concerning than, say, research grants. But many patients may not be able to distinguish between the two.

“Pharma-free physicians might consider advertising that status to current and prospective patients, or health plans could include a marker for that on their `Find a Physician’ websites,” Mello said.

Finally, she said, patients should look up their doctor and if they see any payments they find concerning, ask their doctors about them.

“Seeing whether the payments pass the `red-faced test’ in these conversations should be illuminating,” Mello said.

Marcella Alsan and Marianne Wanamaker are recipients of this year’s prestigious Arrow Award from the International Health Economics Association for research that shows the health of African-American men was adversely impacted by the Tuskegee syphilis study of the early 20th century.

The annual award recognizes excellence in the field of health economics and is named after the late Kenneth J. Arrow, a Nobel Prize-winning economist and mathematician. He was a Stanford Health Policy fellow and senior fellow by courtesy at the Freeman Spogli Institute for International Studies (FSI). He was also a senior fellow, emeritus, at the Stanford Institute for Economic Policy Research (SIEPR).

The IHEA awarded the 27th annual Arrow Award to Alsan, a core faculty member at Stanford Health Policy, a senior fellow at FSI and SIEPR, and co-author Wanamaker of the University of Tennessee for their paper, “Tuskegee and the Health of Black Men” published in the Quarterly Journal of Economics.

The infamous Tuskegee study began in 1932 when the U.S. Public Health Service began following approximately 600 African-American men, some of whom had syphilis, for the stated purpose of understanding the natural history of the disease. The government willingly withheld treatment even after penicillin became an established magic bullet for treating the illness. 

The medical doctors and staff of the CDC followed the men for four decades, until ultimately the study was halted in 1972 when it was brought to the attention of the media by law student Peter Buxtun.

As noted in this story about the research, Alsan and Wanamaker found that the public disclosure of the study in 1972 was associated with an increase in medical mistrust and mortality among African-American men in the immediate aftermath of the revelation.

“The award is an immense honor for both Marianne and me. First, it sheds light on the importance of history for understanding health disparities. Second, it reaffirms the “expected behavior of the physician” that Professor Arrow eloquently described in his seminal 1963 paper on the distinctive features of the market for medical care and the externalities associated with deviating from those expectations.”

African-American men today have the worst health outcomes of all major ethnic, racial and demographic groups in the United States. Life expectancy for black men at age 45 is three years less than their white male peers, and five years less than for black women.

When their working paper was first published by the National Bureau of Economic Research, it became part of the national discussion about the lasting impact of the Tuskegee study.

“The story that Alsan and Wanamaker uncovered is even deeper than the direct effects of the Tuskegee Study,” wrote Vann R. Newkirk II in The Atlantic. “Their research helps validate the anecdotal experiences of physicians, historians, and public health workers in black communities and gives new power to them.”