Those who live and die behind prison walls don’t usually get much public attention. Incarceration is, after all, meant to remove criminals from society. But contagious and potentially deadly diseases can’t be locked and left in a penitentiary, especially when infected inmates are eventually released.

The problem of prisoners and ex-convicts transmitting diseases to the general population is especially bad in the countries of the former Soviet Union, where rates of tuberculosis and drug-resistant strains of TB are among the world’s highest.

But Stanford researchers have identified solutions that could help curb tuberculosis in Russia, Latvia, Tajikistan and the 12 other countries in the region. Led by Jeremy Goldhaber-Fiebert, an assistant professor of medicine, the team has shown that a genetic TB and drug resistance screening tool called GeneXpert is more cost effective and better at reducing the spread of the disease than other methods currently recommended by the World Health Organization. Their findings were published online Nov. 27 in PLoS Medicine.

“Tuberculosis doesn’t stop at any border or any locked gate,” said Goldhaber-Fiebert, who is also a faculty member at Stanford Health Policy, a research center at the university’s Freeman Spogli Institute for International Studies.

“Drug-resistant TB is rampant in prisons,” he said. “When infected prisoners get out, they are thought to drive the TB epidemic in the general population. We are looking to find better ways to deal with that.”

About 400,000 cases of TB were diagnosed last year in the 15 former Soviet Union states – 40 times the number reported in the United States. Nearly 80,000 of the sick had drug-resistant TB. According to several studies, the prevalence of TB among the region’s prisoners is 10 times greater than that of the general population.

The WHO suggests three ways to screen for TB in prisons: relying on inmates to report symptoms, actively interviewing prisoners about their health, and administering chest X-rays. The organization doesn’t recommend one method over another, and currently, prisoners in the former Soviet Union are screened annually with miniature chest X-rays.

While X-rays can show whether a lung looks healthy, they don’t always catch TB. And when they do, they cannot differentiate between a TB that can be cured with standard medications and its drug-resistant cousins that require more expensive and extensive treatments.

That’s where GeneXpert has an upper hand.

Since it was introduced in 2005, the diagnostic has been hailed as a potentially powerful tool that can help to cut TB and drug-resistance rates by more accurately diagnosing people and getting them treated. With just a small sample of mucous analyzed by a machine, the GeneXpert system can instantly detect TB and its drug-resistant genetic mutations, well suited to mass screening within the prison systems of the former Soviet Union.

But the GeneXpert test is more expensive than alternative screening methods. And while it promises to be more effective, its impact on total costs had not been quantified in the former Soviet Union region until Goldhaber-Fiebert and his colleagues began their work nearly three years ago.

By developing computer models of the former Soviet Union’s prison populations, the team predicted that using GeneXpert can cut the prevalence of TB among inmates by about 20 percent within four years – provided the screening is combined with standard regimens of drug treatment for infected patients and for those with drug-resistant TB.

“For this to make sense, you need to have the right drugs to cure those individuals you identify,” Goldhaber-Fiebert said.

The additional cost of screening with GeneXpert averages to $71 per prisoner compared to the next best alternative approach, he said.

When compared to the decreases in illness and increases in survival, and factoring the financial and societal costs of TB in the broader population, the method makes good economic sense, he said.

“There is a large, direct value to using this technology for screening in prison settings, and there are potentially substantial secondary benefits to the general population of the former Soviet Union and to the world,” Goldhaber-Fiebert said.

Douglas K. Owens, a professor of medicine who is one of the paper’s co-authors and director of Stanford Health Policy, said the findings could give governments and medical experts the evidence they need to change the way they tackle TB.

“This is the kind of work we hope will inform policymaking about TB control,” Owens said. “We’ve shown there’s a more effective approach for trying to catch TB in prisons, and that means a better chance for preventing the disease from spreading.”

Co-authors on the PLoS Medicine paper also include former Stanford medical student Daniel Winetsky and current Stanford doctoral student in Management Science and Engineering, Diana Negoescu.

The researchers collaborated with the AIDS Foundation East-West. Funding for the study came from Äids Fonds, the International Research & Exchanges Board, the Department of Veterans Affairs, the National Institutes of Health, and Stanford.

You’re in the supermarket eyeing a basket of sweet, juicy plums. You reach for the conventionally grown stone fruit, then decide to spring the extra dollar per pound for its organic cousin. You figure you’ve just made the healthier decision by choosing the organic product — but new findings from Stanford University cast some doubt on your thinking.

“There isn’t much difference between organic and conventional foods, if you’re an adult and making a decision based solely on your health,” said Dena M. Bravata, the senior author of a paper comparing the nutrition of organic and non-organic foods, in the Annals of Internal Medicine.

A team led by Bravata, a senior affiliate with Stanford’s Center for Health Policy, and Crystal Smith-Spangler, a Veterans Affairs physician fellow at the center, did the most comprehensive meta-analysis to date of existing studies comparing organic and conventional foods. They did not find strong evidence that organic foods are more nutritious or carry fewer health risks than conventional alternatives, though consumption of organic foods can reduce the risk of pesticide exposure.

The popularity of organic products, which are generally grown without synthetic pesticides or fertilizers or routine use of antibiotics or growth hormones, is skyrocketing in the United States. Between 1997 and 2011, U.S. sales of organic foods increased from $3.6 billion to $24.4 billion, and many consumers are willing to pay a premium for these products. Organic foods are often twice as expensive as their conventionally grown counterparts.

Although there is a common perception — perhaps based on price alone — that organic foods are better for you than non-organic ones, it remains an open question as to the health benefits. In fact, the Stanford study stemmed from Bravata’s patients asking her again and again about the benefits of organic products. She didn’t know how to advise them.

So Bravata, who is also chief medical officer at the health-care transparency company Castlight Health, did a literature search, uncovering what she called a “confusing body of studies, including some that were not very rigorous, appearing in trade publications.” There wasn’t a comprehensive synthesis of the evidence that included both benefits and harms, she said.

“This was a ripe area in which to do a systematic review,” said first author Smith-Spangler, who jumped on board to conduct the meta-analysis with Bravata and other Stanford colleagues.

For their study, the researchers sifted through thousands of papers and identified 237 of the most relevant to analyze. Those included 17 studies (six of which were randomized clinical trials) of populations consuming organic and conventional diets, and 223 studies that compared either the nutrient levels or the bacterial, fungal or pesticide contamination of various products (fruits, vegetables, grains, meats, milk, poultry, and eggs) grown organically and conventionally. There were no long-term studies of health outcomes of people consuming organic versus conventionally produced food; the duration of the studies involving human subjects ranged from two days to two years.

After analyzing the data, the researchers found little significant difference in health benefits between organic and conventional foods. No consistent differences were seen in the vitamin content of organic products, and only one nutrient — phosphorus — was significantly higher in organic versus conventionally grown produce (and the researchers note that because few people have phosphorous deficiency, this has little clinical significance). There was also no difference in protein or fat content between organic and conventional milk, though evidence from a limited number of studies suggested that organic milk may contain significantly higher levels of omega-3 fatty acids.

The researchers were also unable to identify specific fruits and vegetables for which organic appeared the consistently healthier choice, despite running what Bravata called “tons of analyses.”

“Some believe that organic food is always healthier and more nutritious,” said Smith-Spangler, who is also an instructor of medicine at the School of Medicine. “We were a little surprised that we didn’t find that.”

The review yielded scant evidence that conventional foods posed greater health risks than organic products. While researchers found that organic produce is 30 percent less likely to be contaminated with pesticides than conventional fruits and vegetables, organic foods are not necessarily 100 percent free of pesticides.

What’s more, as the researchers noted, the pesticide levels of all foods fell within the allowable safety limits. Two studies of children consuming organic and conventional diets did find lower levels of pesticide residues in the urine of children on organic diets, though the levels of urinary pesticides in both groups of children were below the allowable safety thresholds. Also, organic chicken and pork appeared to reduce exposure to antibiotic-resistant bacteria, but the clinical significance of this is unclear.

As for what the findings mean for consumers, the researchers said their aim is to educate people, not to discourage them from making organic purchases. “If you look beyond health effects, there are plenty of other reasons to buy organic instead of conventional,” noted Bravata. She listed taste preferences and concerns about the effects of conventional farming practices on the environment and animal welfare as some of the reasons people choose organic products.

“Our goal was to shed light on what the evidence is,” said Smith-Spangler. “This is information that people can use to make their own decisions based on their level of concern about pesticides, their budget and other considerations.”

She also said that people should aim for healthier diets overall. She emphasized the importance of eating of fruits and vegetables, “however they are grown,” noting that most Americans don’t consume the recommended amount.

In discussing limitations of their work, the researchers noted the heterogeneity of the studies they reviewed due to differences in testing methods; physical factors affecting the food, such as weather and soil type; and great variation among organic farming methods. With regard to the latter, there may be specific organic practices (for example, the way that manure fertilizer, a risk for bacterial contamination, is used and handled) that could yield a safer product of higher nutritional quality.

“What I learned is there’s a lot of variation between farming practices,” said Smith-Spangler. “It appears there are a lot of different factors that are important in predicting nutritional quality and harms.”

Other Stanford co-authors are Margaret Brandeau, the Coleman F. Fung Professor in the School of Engineering; medical students Grace Hunter, J. Clay Bavinger and Maren Pearson; research assistant Paul Eschbach; Vandana Sundaram, assistant director for research at CHP/PCOR; Hau Liu, clinical assistant professor of medicine at Stanford and senior director at Castlight Health; Patricia Schirmer, infectious disease physician with the Veterans Affairs Palo Alto Health Care System; medical librarian Christopher Stave; and Ingram Olkin, professor emeritus of statistics and of education.

The authors received no external funding for the study.

Michelle Brandt is the associate director of digital communications and media relations at the Stanford School of Medicine.

From Shanghai to São Paulo, people around the world are living longer than ever, challenging long-held ideas about retirement and well-established national retirement systems. Stanford health economists Karen Eggleston and Victor R. Fuchs offer an innovative view of the global aging phenomenon in an article published recently in the Journal of Economic Perspectives.

Drawing on a century of demographic data from 17 countries, Eggleston and Fuchs show that the share of increases in life expectancy realized after age 65 was only about 20 percent at the beginning of the 20th century but close to 80 percent by the dawn of the 21st century. Expected lifetime labor force participation as a percent of life expectancy is now declining. Eggleston and Fuchs share four interrelated responses to the economic and social challenges posed by this “new demographic transition:”

• Increase the retirement age.
• Encourage savings.
• Strengthen education.
• Emphasize healthy lifestyles early to ensure productivity in old age.

Eggleston is director of the Asia Health Policy Program at the Shorenstein Asia-Pacific Research Center. Fuchs is Henry J. Kaiser, Jr., Professor Emeritus, in Stanford’s Department of Economics and Department of Health Research and Policy, and a senior fellow at FSI and SIEPR.

Of the four policy responses the article proposes, is one especially critical?

Fuchs: The most important solution in terms of its potential impact would be people changing their attitudes toward retirement. This would mean people postponing retirement and saving more during their working years. If you work five years longer, for example, you would have greater savings and a shorter period of time when you would need the money.

Eggleston: We tend to think of the solutions as being interrelated. To address this longstanding and inevitable global demographic transition, organizations and policy structures need to support changes in individual behavior. In the case of the retirement age in the United States and European countries, policymakers need to change the many incentives that encourage people to retire younger.

What do you most hope policymakers will take away from the article?

Fuchs: We hope they will recognize the absolute need for individuals and organizations to plan for later retirement.

What are the special challenges faced by China and India, the world’s largest populations?

Eggleston: Longer lives in China and India contribute to improved human development, yet population aging also brings special challenges. China’s population is aging more rapidly than India’s and both countries need to invest more in the education and health of their young people, especially in poor rural areas.

In India, nutrition and education will help to reap a one-time boost to economic growth if the large cohorts of the working age population can be productively employed, while building a foundation for sustained improvement of living standards. China’s youth need to be as productive as possible to support the elderly while continuing to improve the national living standard.

The coming decade will be crucial in China, as the country transitions into a new economic phase and expands its fledging social protection system. The goal should be to ameliorate disparities and protect the vulnerable, while maintaining a financially sustainable and culturally appropriate balance of government and family responsibility for old-age support.

Preparing a meal in some of the world’s poorest rural areas can turn an ordinary activity into a deadly chore. Animal dung and crop scraps often fuel the indoor fires used for cooking. And before any food fills a hungry belly, thick black smoke fills a family’s lungs.

Pneumonia and other acute respiratory infections kill about 1 million people a year in low-income countries, making them the top cause of death in the developing world and the greatest threat to children’s lives. Makeshift stoves belch much of the polluted air leading to those illnesses. About 75 percent of South Asians and nearly half the world’s population use open-fire stoves inside their homes.

“The smoke is asphyxiating,” said Grant Miller, an associate professor of medicine at Stanford working on ways to get people to buy – and use – cleaner, safer stoves. “It burns your eyes and you can’t stop coughing.”

Governments and humanitarian organizations have urged people to trade their traditional stoves for safer models, many of which have chimneys that funnel smoke out of a home. But the switch from dangerous stoves has been slow to come, even though most people using them know they’re harmful.

Miller and his colleagues are studying what’s behind the reluctance and what can be done about it. They suspect much of the problem rests with the widespread approach to clean cookstove conversion, which focuses on educating people about the appliances’ health hazards and offering new models at a low cost.

Their most recent findings, published in the Proceedings of the National Academy of Sciences, boil down to this: Clean and modern cookstoves don’t have features people want. And until they’re redesigned, people are unlikely to bother with them.

“People don’t think of cookstoves as health technologies,” said Miller, an associate professor of medicine and a Stanford Health Policy faculty member at the university’s Freeman Spogli Institute for International Studies. Miller is the senior author of the PNAS paper, which published online June 11.

“They don’t think respiratory illness is the biggest health problem that they have,” he said. “And when you ask them what they want from a stove, they talk about saving time and having better fuel efficiency. They’re not talking about smoke emissions.”

In the first of two studies, Miller – joined by Yale researchers and Lynn Hildemann, a Stanford engineering professor affiliated with the Stanford Woods Institute for the Environment – surveyed about 2,500 women who cook for their families in rural Bangladesh. 

Nearly all of the women use traditional stoves, and 94 percent of them said they know the smoke from their stoves can make them sick. But 76 percent said the smoke is less harmful than polluted water, and 66 percent said it wasn’t as dangerous as rotten food.

“People know their cookstoves are bad, but they don’t think cookstoves are the most important problem they face,” Miller said. “They’d rather spend their money fixing those things and getting their kids into a good school than buying a new cookstove.”

When asked what features are most important in a stove, the women talked about things that could save fuel costs, cooking time and the hassle that goes into collecting fuel.

“A very small percent said reducing pollution was important,” Miller said.

The researchers then tried to assess more directly how Bangladeshis value new stoves. They offered 2,200 customers across 42 rural villages the opportunity to buy one of two models – one boasted improved fuel efficiency; the other had a chimney to reduce exposure to indoor smoke.

At the market prices of $5.80 for an efficient stove and $10.90 for the chimney stove, less than a third of customers ordered either model. And when the stoves were delivered a few weeks after the orders were taken, a very small number of families actually went through with the purchase of either model.  Large randomized discounts increased customer interest in fuel-efficient stoves, but did little to raise purchase rates of chimney stoves.

“A big implication is that the health education and social marketing approaches aren’t going to work,” Miller said. “You need to get inside the heads of the users and figure out what they really want and value – even if unrelated to smoke and health – and then give it to them.”

The lead author of the PNAS paper was Ahmed Mushfiq Mobarak, an economist at Yale. It was co-authored by Yale researchers Puneet Dwivedi and Robert Bailis. Their work was supported by the Freeman Spogli Institute’s Walter H. Shorenstein Asia-Pacific Research Center, Stanford’s Woods Institute for the Environment, and the International Growth Centre.

The government’s far-reaching health care foreign aid program has contributed to a significant decline in adult death rates in Africa, according to a new study by Stanford researchers. 

Between 2004 and 2008, the U.S. President’s Emergency Plan for AIDS Relief was associated with a reduction in the odds of death of nearly 20 percent in the countries where it operated. The researchers found that more than 740,000 lives were saved during this period in nine countries targeted by the program, known by its acronym, PEPFAR.

“We were surprised and impressed to find these mortality reductions,” said Eran Bendavid, an affiliate at Stanford Health Policy, part of the university’s Freeman Spogli Institute for International Studies.

“While many assume that foreign aid works, most evaluations of aid suggest it does not work or even causes harm,” said Bendavid, an assistant professor of medicine at Stanford’s School of Medicine. “Despite all the challenges to making aid work and to implementing HIV treatment in Africa, the benefits of PEPFAR were large and measurable across many African countries.”



The study is the first to show a decline in all causes of death related to the program. It appears in the May 16 issue of the Journal of the American Medical Association.

Bendavid is the lead author of the study. It was co-authored by Grant Miller and Jay Bhattacharya, who are both core faculty members of Stanford Health Policy and associate professors of medicine. The study was funded by the National Institutes of Health and the Dr. George Rosenkranz Prize for Health Care Research in Developing Countries.

PEPFAR began in 2003 under the Bush administration with a five-year, $15 billion investment in fighting AIDS around the world and a focus on treatment and prevention in 15 countries. It was reauthorized by Congress in 2008 and has expanded its reach to 31 countries.

To measure the impact of the program, Bendavid and his colleagues analyzed health and survival information for more than 1.5 million adults in 27 African countries, including nine countries where PEPFAR has focused its efforts. The researchers examined data available in the Demographic and Health Surveys, a USAID-funded project that involves a representative sampling of in-person interviews among women in which they discuss their health and the health of their family members. These surveys form the foundation of many health measurements in developing countries.

They found the odds of death from any cause among adults were 16 to 20 percent lower in the PEPFAR-targeted countries.

To bolster the results, the scientists did a separate analysis using specific data on PEPFAR programs in Rwanda and Tanzania. They compared regions of the two countries where PEPFAR’s investments led to widespread increases in the number and size of sites providing antiretroviral therapy, with areas where PEPFAR had fewer services available.



“We observed a similar reduction in mortality when exploring PEPFAR’s effects using a different lens,” Bendavid said.

In Tanzania, the odds of death were found to be 17 percent lower and in Rwanda 25 percent lower in the districts with greater support from PEPFAR.

Bendavid speculates that the program’s commitment to building an infrastructure that includes drug distribution systems, clinics, pharmacies, laboratories and testing facilities has been an important factor for its success.

“The scale of PEPFAR’s investment was unprecedented,” Bendavid said. “People working in PEPFAR’s focus countries describe working supply chains, stocked pharmacies and staffed clinics.”



Although the program was targeted to address HIV, these services could have benefitted patients with a variety of other health concerns. For example, one study found that some uninfected, pregnant women in Ethiopia, Rwanda and Tanzania chose to deliver their babies in facilities supported by PEPFAR, Bendavid said.

Some have argued that focusing resources on a specific disease, such as AIDS, may detract efforts from other diseases and activities, undermining some of the benefits of such programs. But the latest study does not support this argument. Rather, it suggests that PEPFAR helped prevent additional deaths from causes other than HIV/AIDS.

“Whether disease-specific programs like PEPFAR have synergies with other health improvement efforts – or instead undermine them, as some have worried – is really an open question,” Miller said. “There are reasons to think either scenario is possible, and more research is needed. We don’t find much evidence of PEPFAR undercutting other initiatives. If anything, we see hints of synergies.”



Bendavid said the program managed to accomplish the reduction in mortality in the face of enormous challenges – from persuading people to go for HIV testing and treatment to dealing with problems of drug shortages and drug resistance.

Historically, few other large-scale health initiatives have succeeded to such an extent. Smallpox, which was eradicated by 1979, is among the rare and more notable examples.

“PEPFAR’s success with HIV … may be considered the clearest demonstration of aid’s effectiveness in recent years,” the researchers concluded.

In 2009, PEPFAR was folded into a new Global Health Initiative that calls for a broader agenda, with some resources redistributed to other programs, such as maternal and child health.

Its budget, which rose dramatically in the early years, has remained relatively flat or declined slightly since then. It peaked at $6.8 billion in fiscal year 2010, then declined to $6.7 billion and $6.6 billion in fiscal years 2011 and 2012, respectively, according to figures from the Kaiser Family Foundation. The Obama administration’s budget request for the 2013 fiscal year is $6.4 billion.

While the program appears to have had an impact within a few years of its implementation, Bendavid noted that reduced investments in fighting AIDS, both through PEPFAR and other international aid programs, could have implications for the future of the epidemic.

“We are transforming the face of the epidemic but funding shortfalls will change the road ahead,” he said.



Ruthann Richter is Director of Media Relations for the Stanford School of Medicine.