Measles came back with a vengeance in 2019, with cases quadrupling globally and 1,276 cases reported in the United States since the beginning of the year — the largest increase in 27 years.

Most of those cases worldwide were among people who weren't vaccinated against the preventable infection. Anti-vaccinations movements have gained ground in the industrialized nations while gaps of immunization coverage or lack of access to health care facilities plague Africa and developing nations around the globe.

But there's some good news in California. 

A new study by researchers at Stanford and the University of California, San Francisco shows the vaccination rate for measles is approaching 95% in nearly all counties of the Golden State. That auspicious number promotes herd immunity, protecting vulnerable unvaccinated people, such as newborns.

The co-authors of the study, which appears in PLOS Medicine, believe this hike in the state's vaccination rate is due to a contentious 2016 law that did away with the personal belief and religious exemptions following the 2014-2015 measles outbreak that began in Disneyland.

The new vaccine policy is associated with a 3% increase in statewide MMR (measles, mumps and rubella) vaccine coverage since the law was adopted, the researchers found, and a 2% decrease in non-medical religious and philosophical exemptions.

That jump may put the state above the critical 95% vaccinated point, which is needed for effective herd immunity against measles. "That would be very meaningful," said Stanford Health Policy's Eran Bendavid, MD, an associate professor of medicine and a co-author of the study.

The policy debates surrounding vaccine hesitancy in the United States have focused on vaccine exemptions, which provide an option for parents to waive current vaccination requirements for entry into school or daycare centers. Currently, 18 states allow nonmedical exemptions based on philosophical, personal or other beliefs.

"The factors driving vaccine hesitancy are complex and include misconceptions and misinformation about vaccine safety, low perceived risk of infectious disease, and lack of trust in health care providers," the authors write. 

The California experiment, however, could serve as an example to state legislatures and public health departments, as well as the federal government, the researchers say. 

"While we did see a small increase in medical exemptions, the much larger increase in MMR coverage suggests that the policy worked as expected," said Sindiso Nyathi, a graduate student in epidemiology, and one of the paper's first authors. "This is good news for states considering similar policies."

Sindiso said evaluating the efficacy of vaccine policies can be difficult due to lack of controls to use as comparisons, which limits the conclusions that can be drawn. To address that gap, their work used a hypothetical control group and estimated how many Californian children would have received the MMR vaccine if the law had not gone into effect. They then compared that to how many kids were vaccinated following the law's enactment in 2016.

The researchers also broke the data down by county. 

"Our county-level analysis found that greater increases in coverage were observed in counties with low coverage levels before the policy," Nyathi said. "This is good news, as it suggests that the policy was more effective in areas that had lower coverage. Similar policies may be an effective tool to bring vaccine coverage levels above herd immunity thresholds." 

While the researchers found the law work as intended, there was a small, 0.4% increase in the number of medical exemptions. 

Under the current California law, parents can request vaccination waivers for children whose medical condition might be impacted by the vaccine.

In September, Gov. Gavin Newsom signed into law another vaccination bill that will go into effect on Jan. 1. It will give the California Department of Public Health the power to revoke medical exemptions if it determines they are not medically sound. The department will also have the power to review exemptions from doctors who write more than five in one year.

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.’”

On August 26, Judge Thad Balkman delivered a $572 million judgment against pharmaceutical giant Johnson & Johnson for the company’s role in fueling the opioid epidemic in Oklahoma. In the discussion that follows, Stanford Law Professors Michelle Mello and Nora Freeman Engstrom discuss the decision and how other cases tied to the national opioid crisis are developing.

The Oklahoma decision took many onlookers by surprise. How did the case unfold? And what did Judge Balkman find? On Monday, Cleveland County District Judge Thad Balkman of Oklahoma issued a judgment that capped off a long and closely-scrutinized trial wherein the Oklahoma Attorney General faced off against Johnson & Johnson (J&J), claiming that J&J contributed to the opioid epidemic that has devastated the state of Oklahoma.

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Stanford Law Professors Michelle Mello and Nora Freeman Engstrom

To understand the verdict, a bit of background is helpful. When Oklahoma initially sued, it cast the net broadly, asserting claims against several defendants under several causes of action.  Certain defendants (namely, Purdue and Teva) chose to settle rather than roll the dice at trial. (Purdue, the maker of OxyContin, agreed to pay Oklahoma $270 million and Teva, one of the world’s leading providers of generic drugs, $85 million; neither admitted wrongdoing.)  Further, over time, Oklahoma’s various causes of action got winnowed down to the singular claim that J&J had created a public nuisance by aggressively and deceptively marketing opioid products to Oklahoma’s doctors and patients.  This posture meant that Oklahoma’s victory at trial was far from a foregone conclusion, as public nuisance claims can be very hard to prove, particularly in cases that relate to dangerous products.

With that table set, the trial began on May 28, 2019.  In a crowded courtroom in Cleveland County, it stretched on for nearly seven weeks and featured dozens of witnesses and more than 800 exhibits. The trial was a bench trial, meaning there was no jury, but there was a written opinion explaining the judge’s decision.  Judge Balkman’s 42-page opinion offers a cogent summary of the evidence and governing law and, broadly, vindicates Oklahoma’s litigation strategy. The opinion finds that J&J engaged in a deceptive marketing campaign designed to convince Oklahoma doctors and the public that opioids were safe and effective for the long-term treatment of chronic, non-malignant pain. Further, this “false, misleading, and dangerous marketing” caused “exponentially increasing rates of addiction [and] overdose death,” which ravaged the Sooner State. The picture Judge Balkman draws is stark and, for J&J, devastating.

Are individuals suing drug companies too? Are there class action cases that are relevant?

There are some suits by individuals, but we don’t believe that’s where the big money damages—and the real social impact of the litigation—will be.  More important is the pending federal multi-district litigation (MDL), which consolidates nearly 2,000 individual federal lawsuits brought by cities, counties, municipalities, and tribal governments in a single action before Judge Dan Polster in Cleveland, Ohio. Additionally, 48 states have initiated separate litigation, with a lineup of claims and defendants similar to the MDL.

Does this win for Oklahoma mean these other plaintiffs have an easy road ahead?

Not easy, but potentially easier. The Oklahoma case is what we call a bellwether. Like the ram that leads the other sheep this way or that, the bellwether trial doesn’t control the path of future litigation. But it does go first, and it helps to indicate trends.

As a bellwether, the big verdict here is very reassuring to the many states, counties, municipalities, and tribes suing opioid makers, distributors, and retailers, and it is, correspondingly, very disturbing for those who made and sold opioids to the American public.  The verdict suggests that this litigation has legs, and that judges and juries may be willing to pin blame not just on Purdue, the maker of OxyContin, but on others who played an arguably less central role in fueling this public health crisis.

What is striking is how damning Judge Balkman’s factual conclusions about J&J’s conduct are, and how similar they are to the allegations made against other opioid manufacturers in other cases.  All the things he objected to regarding J&J’s marketing practices are things that others, too, allegedly have done. Some of them are things that multiple companies banded together to do. Plaintiffs’ attorneys should be feeling pretty confident about their chances of persuading other courts that those practices are problematic.

Is Oklahoma free to use the award as it wishes? Will the state share some of the award with the people who died or suffered in the opioid crisis (if the decision is upheld on appeal)?

The damages, in this case, are intended to fund Oklahoma’s “nuisance abatement plan.”  That’s the remedy in a public nuisance case: The defendant has to pay to clean up the mess it made. In this case, Oklahoma provided a detailed plan laying out what would be needed to abate the opioid problem in the state. The costs added up to $572 million for the first year, and that’s what the judge awarded—not the $17 billion Oklahoma sought for a multi-year abatement effort.

The plan specifies that the money will be used for opioid use disorder screening, prevention and treatment ($292 million), housing and other services for those in recovery ($32 million), continuing medical education programs ($108 million), a pain management benefit program ($103 million), treatment of neonatal abstinence syndrome ($21 million), and other services.  Individuals won’t be direct recipients of the funds, though they may receive the services funded.

Legally, what happens next?

J&J has vowed to appeal the “flawed” Oklahoma judgment, and we expect that the judgment will be appealed, first to Oklahoma’s intermediate, and then, likely, to its supreme, court.  More immediately, though, attention will turn from Oklahoma to Ohio.  The first bellwether trial in the MDL, involving claims from Ohio’s Cuyahoga and Summit counties, is scheduled to begin on October 21.

Even as they prepare for trial, however, lawyers for both plaintiffs and defendants are also, no doubt, continuing to work toward reaching a broad and encompassing settlement.  When Judge Polster was first assigned the MDL back in January 2018, he made no bones about his desire to do “something meaningful to abate this crisis”—and to do it quickly.  It hasn’t been easy to execute on that, which isn’t surprising given the unprecedented magnitude and complexity of the litigation.

Still, we expect that, sooner or later, the opioid litigation will settle.  Indeed, even as we write, news is breaking that Purdue and the Sacklers may be in the midst of a negotiation whereby Purdue would declare bankruptcy and the Sacklers would contribute a cash payment of roughly $4.5 billion-plus relinquish ownership of the company, in return for peace with plaintiffs.

But even forging a settlement involving just those two entities is tricky—and forging a broader settlement will be exponentially harder for a number of reasons.  One is that any truly global agreement needs to pass muster with a range of defendants, some of whom have comparatively shallow pockets, and all of whom sold (or made or distributed) different products, at different times, in different quantities, in different states.  And, on the other side of the table, any settlement agreement needs to get buy-in from both those plaintiffs in the MDL and also state attorneys’ general, who have their own distinct set of priorities and interests relating to their separate lawsuits.  Further, because only a small proportion of eligible cities and counties have joined the MDL to date, any global settlement needs to somehow—equitably but firmly—close the courthouse door on those potential future plaintiffs.  None of this will be easy to accomplish.  But whenever new information reduces uncertainty about how courts would resolve a legal dispute, settlement becomes more likely—and, here, the Oklahoma verdict makes a significant contribution.

 

Nora Freeman Engstrom, Professor of Law and Deane F. Johnson Faculty Scholar, is a nationally-recognized expert in tort law, legal ethics, and complex litigation. Her work explores the day-to-day operation of the tort system—particularly its interaction with alternative compensation mechanisms. Michelle Mello, Professor of Law and Professor of Health Research and Policy (School of Medicine), is a leading empirical health scholar and the author of more than 150 book chapters and articles, including “Drug Companies’ Liability for the Opioid Epidemic,” recently published in the New England Journal of Medicine.  

Americans have witnessed repeated mass shootings. The carnage in Texas and Ohio last weekend claimed another 31 lives and has left the nation stunned and angry.

Many are demanding that members of Congress pass tougher gun-control laws; others blame mental health and violent video games for the rampant shootings.

Stanford Health Policy’s David Studdert — an expert on the public health epidemic of firearms violence — acknowledges that mass shootings are on the rise in the United States.

“It’s been a horrific weekend,” said Studdert, a professor of law at Stanford Law School and professor of medicine at Stanford School of Medicine. “Experts now generally agree that mass shootings are becoming more common — and that a common thread is disaffected young men who have access to high-caliber, high-capacity weapons.”

Both suspects in the Dayton and El Paso shootings fit this profile.

Studdert notes, however, that while mass shootings have become the public face of gun violence, they account for less than 1% of the 40,000 firearm deaths each year.

“So as a public health researcher, I do care about mass shootings and I am interested in understanding and their causes — but the focus of my ongoing research is the other 99 percent.”

Largest investment in firearms research in two decades

It’s that focus the Studdert will be pursuing in a recently-awarded $668,000 grant from the National Collaboration on Gun Violence Research. The private collaborative’s mission is to fund nonpartisan, scientific research that offers the public and policymakers a factual basis for developing fair and effective gun policies.

Studdert, Yifan Zhang, a statistician with Stanford Health Policy, and Stanford political scientist Jonathan Rodden are working with colleagues at UC Davis, Northeastern University and Erasmus University Rotterdam on the Study of Handgun Ownership and Transfer, or LongSHOT.

The team is following several million Californians over a 12-year period to better understand the causal relationship between firearm ownership and mortality. They launched in 2016 with the initial goal of assessing the risks and benefits of ownership for firearm owners.

“The implications of firearm ownership for owners is important because they usually are the ones making the decision to purchase and own,” Studdert said. “But we knew from the beginning that this was only part of the picture. The presence of a firearm in the home may also have health implications for the owners’ family members.”

In the new study, the researchers will identify the cohort of adults in California who live with firearm owners but are not themselves gun owners, and then compare their risks of mortality to a group who neither own weapons, nor live with others who do.

Surprisingly little is known about the “secondhand” effects of having guns in the home.

“Existing studies don’t differentiate between owners and non-owners within households, and that is something we have the ability to look at,” Studdert said. “And a very large proportion of non-gun-owners who are living in homes with guns are women — so this is a group that has really been understudied.”

There is already substantial evidence that a gun in the home is associated with increased risks of suicide. But it is not clear how particular subgroups, such as women who don’t own guns, are affected.

“Because our cohort is so large,” Studdert said, “we will also be able to explore whether gun ownership confers certain benefits, as gun-rights advocates often claim, such as enhanced safety in dangerous neighborhoods.”

Studdert said a better accounting of the risks and benefits that firearm ownership poses for non-owners could help inform decisions regarding gun ownership and storage, as well as policies aimed at improving gun safety.

The politics of federal funding for firearms research

The National Collaboration on Gun Violence Research is funded through private philanthropic donations. It was seeded with a $20 million gift from Arnold Ventures and intends to raise another $30 million in private funding for firearms research.

“It’s the biggest investment in firearms research since the late 1990s,” Studdert said.

Research on the impact and causes of firearm violence was dealt a huge blow in 1996 when the so-called Dickey Amendment was passed by Congress. The law has been interpreted as prohibiting the National Institutes of Health and the Centers for Disease Control and Prevention from conducting firearms research.

Studdert said that the growth of research funding from philanthropies like the Arnold Foundation and Joyce Foundation is a welcome development, but that it will take a large and sustained investment to move the science of firearm violence forward.  

“The core funder of large-scale research essentially vacated the space for 20 years,” he said.  “It’s going to take some time to recover. Developing a generation of researchers with expertise will take give to 10 years. But it has to be done — the size of the social problem demands it.”

An estimated 210,000 girls may have “gone missing” due to China’s “Later, Longer, Fewer” campaign, a birth planning policy predating the One Child Policy, according to a new study led by Stanford Health Policy researchers published by the Center for Global Development.

The study looked at hundreds of thousands of births occurring before and during the “Later, Longer, Fewer” policy to measure its effect on marriage, fertility, and sex selection behavior. The policy, which began in the 1970s and preceded China's One-Child Policy, promoted later marriage, longer gaps between successive children, and having fewer children to cut the country's population. The study emphasizes that because this policy existed before ultrasound technology was widely available — and therefore before selective abortion was an option — these missing girls must have been due to postnatal neglect of infant girls, or in the extreme, infanticide.

The authors of the new study are Grant Miller, director of the Stanford Center on Global Poverty and Development, a core faculty member at Stanford Health Policy and senior fellow at the Freeman Spogli Institute for International Studies; Kimberly Babiarz, a research scholar at Stanford Health Policy; Paul Ma and Shige Song.

The researchers found that China’s “Longer, Later, Fewer” population control policy reduced total fertility rates by 0.9 births per woman and was directly responsible for an estimated 210,000 missing girls countrywide. The phenomenon of “missing girls” widely recognized in later years under the One Child Policy is largely thought due to sex-selective abortion after ultrasound technology spread across China.

“Prior research has shown that sex ratios rose dramatically under China's One-Child Policy, leading to stark imbalances in the numbers of men and women. But we’re finding that girls went missing earlier than previously thought, which can in part be directly attributed to birth planning policy that predates the One-Child Policy,” said Grant Miller, a senior fellow at the Stanford Institute for Economic Policy Research and a non-resident fellow at the Center for Global Development.

The top findings of the study include:

• The birth planning policy reduced fertility by 0.9 births per woman, explaining 28 percent of the overall decline during this period.

• The Later, Longer, Fewer policy is responsible for a roughly twofold increase in the use of “fertility stopping rules,” the practice of continuing to have children until the desired number of sons is achieved.

• The Later, Longer, Fewer policy is also responsible for an increase in postnatal neglect, from none to 0.3 percent of all female births in China during this period.

• Sex selection behavior was concentrated among couples with the highest demand for sons (couples that have more children but no sons), with sex ratios reaching 117 males per 100 female births among these couples.

“Population control strategies can have unforeseen consequences and human costs,” Miller said. “At the same time, as China debates the future of birth planning policies, it’s also important to note that family planning policy does not appear to be the largest driver of fertility.”

Most studies that look at whether democracy improves global health rely on measurements of life expectancy at birth and infant mortality rates. Yet those measures disproportionately reflect progress on infectious diseases — such as malaria, diarrheal illnesses and pneumonia — which relies heavily on foreign aid.

A new study led by Stanford Health Policy's Tara Templin and the Council on Foreign Relations suggests that a better way to measure the role of democracy in public health is to examine the causes of adult mortality, such as noncommunicable diseases, HIV, cardiovascular disease and transportation injuries. Little international assistance targets these noncommunicable diseases. 

When the researchers measured improvements in those particular areas of public health, the results proved dramatic.

“The results of this study suggest that elections and the health of the people are increasingly inseparable,” the authors wrote.

A paper describing the findings was published today in The Lancet. Templin, a graduate student in the Department of Health Research and Policy, shares lead authorship with Thomas Bollyky, JD, director of the Global Health Program at the Council on Foreign Relations.

“Democratic institutions and processes, and particularly free and fair elections, can be an important catalyst for improving population health, with the largest health gains possible for cardiovascular and other noncommunicable diseases,” the authors wrote.

Templin said the study brings new data to the question of how governance and health inform global health policy debates, particularly as global health funding stagnates.

“As more cases of cardiovascular diseases, diabetes and cancers occur in low- and middle-income countries, there will be a need for greater health-care infrastructure and resources to provide chronic care that weren’t as critical in providing childhood vaccines or acute care,” Templin said.

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Free and fair elections for better health

In 2016, the four mortality causes most ameliorated by democracy — cardiovascular disease, tuberculosis, transportation injuries and other noncommunicable diseases — were responsible for 25 percent of total death and disability in people younger than 70 in low- and middle-income countries. That same year, cardiovascular diseases accounted for 14 million deaths in those countries, 42 percent of which occurred in individuals younger than 70.

Over the past 20 years, the increase in democratic experience reduced mortality in these countries from cardiovascular disease, other noncommunicable diseases and tuberculosis between 8-10 percent, the authors wrote.

“Free and fair elections appear important for improving adult health and noncommunicable disease outcomes, most likely by increasing government accountability and responsiveness,” the study said.

The researchers used data from the Global Burden of Diseases, Injuries, and Risk Factors Study; V-Dem; and Financing Global Health databases. The data cover 170 countries from 1970 to 2015.

What Templin and her co-authors found was democracy was associated with better noncommunicable disease outcomes. They hypothesize that democracies may give higher priority to health-care investments.

HIV-free life expectancy at age 15, for example, improved significantly — on average by 3 percent every 10 years during the study period — after countries transitioned to democracy. Democratic experience also explains significant improvements in mortality from cardiovascular disease, tuberculosis, transportation injuries, cancers, cirrhosis and other noncommunicable diseases, the study said.

Watch: Some of the authors of the study discuss the significant their findings: 

What Templin and her co-authors found was democracy was associated with better noncommunicable disease outcomes. They hypothesize that democracies may give higher priority to health-care investments.

HIV-free life expectancy at age 15, for example, improved significantly — on average by 3 percent every 10 years during the study period — after countries transitioned to democracy. Democratic experience also explains significant improvements in mortality from cardiovascular disease, tuberculosis, transportation injuries, cancers, cirrhosis and other noncommunicable diseases, the study said.

Foreign aid often misdirected

And yet, this connection between fair elections and global health is little understood.

“Democratic government has not been a driving force in global health,” the researchers wrote.  “Many of the countries that have had the greatest improvements in life expectancy and child mortality over the past 15 years are electoral autocracies that achieved their health successes with the heavy contribution of foreign aid.”

They note that Ethiopia, Myanmar, Rwanda and Uganda all extended their life expectancy by 10 years or more between 1996 and 2016. The governments of these countries were elected, however, in multiparty elections designed so the opposition could only lose, making them among the least democratic nations in the world.

Yet these nations were among the top two-dozen recipients of foreign assistance for health.

Only 2 percent of the total development assistance for health in 2016 was devoted to noncommunicable diseases, which was the cause of 58 percent of the death and disability in low-income and middle-income countries that same year, the researchers found.

“Although many bilateral aid agencies emphasize the importance of democratic governance in their policy statements,” the authors wrote, “most studies of development assistance have found no correlation between foreign aid and democratic governance and, in some instance, a negative correlation.”

Autocracies such as Cuba and China, known for providing good health care at low cost, have not always been as successful when their populations’ health needs shifted to treating and preventing noncommunicable diseases. A 2017 assessment, for example, found that true life expectancy in China was lower than its expected life expectancy at birth from 1980 to 2000 and has only improved over the past decade with increased government health spending. In Cuba, the degree to which its observed life expectancy has exceeded expectations has decreased, from four-to-seven years higher than expected in 1970 to three-to-five years higher than expected in 2016.

“There is good reason to believe that the role that democracy plays in child health and infectious diseases may not be generalizable to the diseases that disproportionately affect adults,” Bollyky said. Cardiovascular diseases, cancers and other noncommunicable diseases, according to Bollyky, are largely chronic, costlier to treat than most infectious diseases, and require more health care infrastructure and skilled medical personnel.  

The researchers hypothesize that democracy improves population health because:

1. When enforced through regular, free and fair elections, democracies should have a greater incentive than autocracies to provide health-promoting resources and services to a larger proportion of the population;
2. Democracies are more open to feedback from a broader range of interest groups, more protective of media freedom and might be more willing to use that feedback to improve their public health programs;
3. Autocracies reduce political competition and access to information, which might deter constituent feedback and responsive governance.

Various studies have concluded that democratic rule is better for population health, but almost all of them have focused on infant and child mortality or life expectancy at birth.

Over the past 20 years, the average country’s increase in democracy reduced mortality from cardiovascular disease by roughly 10 percent, the authors wrote. They estimate that more than 16 million cardiovascular deaths may have been averted due to an increase in democracy globally from 1995 to 2015. They also found improvements in other health burdens in the countries where democracy has taken hold: an 8.9 percent reduction in deaths from tuberculosis, a 9.5 percent drop in deaths from transportation injuries and a 9.1 percent mortality reduction in other noncommunicable disease, such as congenital heart disease and congenital birth defects.

“This study suggests that democratic governance and its promotion, along with other government accountability measures, might further enhance efforts to improve population health,” the study said. “Pretending otherwise is akin to believing that the solution to a nation’s crumbling roads and infrastructure is just a technical schematic and cheaper materials.”

The other researchers who contributed to the study are Matthew Cohen, Diana Schoder, Joseph Dieleman and Simon Wigley, from CFR, the University of Washington-Seattle and Bilkent University in Turkey, respectively.

Funding for the research came from Bloomberg Philanthropies and the Bill & Melinda Gates Foundation. Stanford’s Department of Health Research and Policy also supported the work.