A new calculation that combines health and economic well-being at the population level could help to better measure progress toward the U.N. Sustainable Development Goals and illuminate major disparities in health and living standards across countries, and between men and women, according to a new study by Stanford and Harvard researchers.

In a study released this month in The Lancet Global Health, Joshua Salomon, a professor of medicine and core faculty member at Stanford Health Policy, finds there are startling differences between countries in the number of years people can expect to survive free from poverty, much greater than the differences observed in life expectancy alone, and that women surrender more years of life to poverty than men in much of the world.

At the U.N. Sustainable Development Summit in 2015, world leaders adopted the Sustainable Development Goals (SDGs) as the embodiment of the global agenda for development through 2030. One of the 17 goals calls for universal health coverage, including financial risk protection, which highlights the explicit link between economic and health development policies.

“Despite this link, and despite the multitude of targets and indicators established through the SDGs and other global initiatives, most monitoring and benchmarking efforts rely on metrics that are highly specific to a single dimension of interest,” Salomon and his colleagues from the Harvard T.H. Chan School of Public Health wrote in the Lancet study.

Such an approach misses opportunities to understand the broader impact of development policies as they affect the well-being of populations in multiple ways.

So, the researchers developed a population-level measure of poverty-free life expectancy (PFLE) and computed the measurements for 90 countries with available data. They used Sullivan's method to incorporate the prevalence of poverty by age and sex from household economic surveys into demographic life tables based on mortality rates that are routinely estimated for all countries. Poverty-free life expectancy for each country is the average number of years people could expect to survive with adequate income to meet their basic needs, given current mortality rates and poverty prevalence in that country.

The authors found that PFLE varies widely between countries, ranging from less than 10 years in Malawi to more than 80 years in countries such as Iceland.  In 67 of 90 countries, the difference between life expectancy and PFLE was greater for females than for males, indicating that women generally surrender more years of life to poverty than men do. 

In some African countries, people can expect to live more than half of the total lifespan in poverty.

“This new indicator can aid in monitoring progress toward the linked global agendas of health improvement and poverty elimination and can strengthen accountability for development policies,” the authors wrote.

Despite general improvements in survival in most regions of the world in the past decades, the focus in the Sustainable Development Goals era on ending poverty “brings into sharp relief the importance of ensuring that years of added life are lived with at least a minimum standard of economic well-being.”

Salomon said the researchers hope the development of a new, simple measure that summarizes overall health and economic welfare in a single number can do two things.

“One is to help encourage leaders to be transparent and accountable to the populations they serve through regular tracking and reporting on overall progress toward longer and better lives,” he said. “The other is to bring measurement out of the silos of individual sectors, to highlight both the need for multisectoral action to improve health and welfare and the connections between health and economic consequences of public policy.”

As millions marched against gun violence across the country on Saturday, research by Stanford Health Policy experts about the impact of gun ownership on public health was also in the spotlight.

The Washington Post published an in-depth story about how the work of gun researchers is finally getting attention — an unfortunate consequence of the recent mass shootings in the United States.

David Studdert — a professor of medicine and law — and Yifan Zhang, a biostatics and data analyst with Stanford Health Policy, along with seasoned gun researcher Garen Wintemute of UC Davis’s Violence Prevention Research Program, are trying to answer the question: Are you more or less likely to die if you own a firearm?

“The explosion of national interest in the problem of gun violence since the Parkland shooting has been remarkable,” said Studdert, who is also a core faculty member at Stanford Health Policy.  “And it is inspiring to hear students’ voices — that is definitely a new twist in the politics around this issue. I think there is momentum for change, but I remain pessimistic that we will see the enactment of any substantial reforms at the federal level.”

The Post wrote:

Studdert’s group is using a data set unique to California because of the state’s strict gun laws. Every time a gun is sold in California, a background check logs the purchase and purchaser with California authorities, who also have been unique in their willingness to share such politically fraught data with academic researchers.

Using a sample of 25 million people (taken from California’s voter registration records), Studdert’s team plans to identify handgun owners with the firearm sales records, then compare that against state death records.

The resulting data in theory will help them determine the relationship — whether good or bad — between gun ownership and death.

They call the project LongSHOT, a nod to the project’s scale and ambition.

Academic researchers who were studying the impact of gun violence on public health were dealt a huge financial and political blow in 1996, when the so-called Dickey Amendment was passed by Congress under pressure from gun lobbyists. The law forbids the Centers for Disease Control and Prevention to fund research that might be seen as advocating for gun control. This choked off federal grant money and essential data-gathering on gun violence.

But tucked into the government spending bill in Congress last week was language that indicates the CDC now has the authority to conduct research on the causes and effects of gun violence. Though gun researchers are skeptical that the change in tone will lead to any significant support or funding, some believe that it’s a start. The $1.3 trillion government funding measure also includes efforts to improve state compliance with the national background check system, as well as funding for school counseling and safety programs.

Again, from The Post story:

Yifan Zhang was finishing her PhD in biostatistics at Harvard five years ago when news broke of the Sandy Hook Elementary School shooting.

As a graduate student from China, specializing in highly technical design of clinical drug trials, she had little connection to America’s long-running debate over gun violence. But even now, she said, the anguished faces of those parents she saw on television remain seared in her memory.

So when she heard about a gun-violence research project at Stanford University that could use the statistical skills she had honed on pharmaceuticals, she jumped at the chance.

“I have a son who just turned 1,” said Zhang, 31. “When I think about what I will need to teach him about protecting himself, I think about that school shooting.”

Zhang hopes the Stanford team can one day have an impact.

“I think there are going to be some big decisions that the whole country has to make together, and I’m hoping that our research can help provide evidence and information for the decision making,” she said.

At least 91 Americans die every day from an opioid overdose. The epidemic has claimed more than 300,000 lives since 2000 and is expected kill another half million over the next decade.

So perhaps it’s time to step up lawsuits against the drug manufacturers that sell the opioids to the tune of $13 billion per year, Stanford Health Policy’s Michelle Mello argues in a commentary in the current issue of The New England Journal of Medicine.

Mello, a professor of law and of health research and policy, and co-author Rebecca L. Haffajee, an assistant professor of health management and policy at University of Michigan School of Public Health, note that although heroin and illicitly manufactured fentanyl account for an increasing proportion of opioid overdoses, the majority of people who are addicted to opioids get hooked on prescribed painkillers.

While clinicians and health-care providers are trying to prescribe fewer opioids, Mello and Haffajee believe litigation is another crucial method to fight the crisis.

“The search for solutions has spread in many directions, and one tentacle is probing the legal accountability of companies that supply opioids to the prescription market,” the authors write.

The final report of President Trump’s Commission on Combating Drug Addiction and the Opioid Crisis details decades of aggressive marketing of oxycodone from 1997-2002 that led to a tenfold rise in prescriptions to treat moderate to severe pain. “To this day, the opioid pharmaceutical industry influences the nation’s response to the crisis,” the report said, noting the industry had sponsored some 20,000 conferences for physicians on managing pain with opioids while claiming their potential for addiction was low.

Mello and Haffajee argue that similar to the early cigarette promotions by Big Tobacco, opioid manufacturers have failed to adequately warn patients about addition risks on drug packaging and in their marketing campaigns.

“Some recent claims allege that opioid manufacturers deliberately withheld information about their products’ dangers, misrepresenting them as safer than alternatives,” they write.

Early attempts to bring class-action suits against opioid manufacturers have encountered procedural barriers. Judges typically find that proposed class members lack sufficiently common claims because of different circumstances surrounding opioid use and clinical conditions.

But the tide may be turning. There has been an uptick in litigation against Big Pharma since Purdue Pharma, the maker of the blockbuster painkiller, OxyContin, agreed in 2007 to pay $600 million to settle charges that it misled federal regulators, doctors, and patients about the drug’s risk of addiction and its potential to be abused.

“As the population harmed by opioids grows and more information about the population is documented, it becomes easier to identify subgroups with similar factual circumstances and legal claims — for example, newborns with neonatal abstinence syndrome,” they said.

Perhaps most promising, the authors write, is the “advent of suits brought against drug makers and distributors by the federal government and dozens of states, counties, cities, and Native American tribes.

“Because the government itself is claiming injury and seeking restitution so that it can repair social systems debilitated by opioid addiction, these suits avoid defenses that blame opioid consumers or prescribers,” they said. “They also garner substantial publicity.”

The government is borrowing from the playbooks used to sue tobacco and firearms companies, relying on four strategies:

• Focus on the “public scourge” created by the opioid manufacturers due to their oversaturation of the market, arguing that opioids constitutes a public nuisance;
• Paint the opioid companies’ business practices as deceptive;
• Call out the manufacturers’ lax monitoring of suspicious opioid orders; and
• Ask courts to make companies disgorge the “unjust enrichment” they have reaped at the government’s expense through their unfair business practices.

Two large settlements have occurred in state cases that included unjust enrichment claims, the authors note, although the pharmaceutical companies avoided admitting fault. The Commonwealth of Kentucky settled with Purdue Pharma for $24 million in 2015 over allegations that it had profited while Kentucky was left paying associated medical and drug costs of those who became addicted.

Earlier this year, drug wholesaler Cardinal Health Inc. agreed to pay $20 million to settle a lawsuit brought by West Virginia’s attorney general over accusations that it flooded the market with opioids in a state that now has the highest opioid overdose rate in the nation.

Such lawsuits have garnered a lot of media attention and contributed to pressure on the U.S. government to take action against the abusive practices of drug manufacturers and distributors.

“Win or lose, lawsuits that very publicly paint the opioid industry as contributing to the worst drug crisis in American history put wind in the sails of agencies and legislatures seeking stronger oversight,” Mello and Haffajee write. “Together, litigation and its spillover effects hold real hope for arresting the opioid epidemic.”

Listen to a podcast with Haffajee talking about the opioid crisis.

Maya Rossin-Slater uses her PhD in economics to analyze large-scale data on population health and socioeconomic outcomes to help inform policies targeting families with children, especially those who are disadvantaged or poor.

Rossin-Slater, an assistant professor at the Department of Health Research and Policy at Stanford Medicine, is the newest core faculty member at Stanford Health Policy. Prior to coming to Stanford this summer, she was an assistant professor of economics at the University of California, Santa Barbara for four years after receiving her PhD at Columbia University. Her research centers on public policies and their impacts on the health and well-being of families.She asks complex questions, often finding the answers in large administrative databases. Specializing in using “natural experiment” methods, Rossin-Slater tries to separate causation from correlation.

How do child-support mandates impact the relationship between parents and children? Does high-quality preschool compensate for early life health disadvantages? What are the long-term impacts of early childhood exposure to air pollution once they become adults?

“To me, it’s important to do this kind of research that can inform real-world policies, particularly for less advantaged families,” said Rossin-Slater, who is also a faculty fellow at the Stanford Institute for Economic and Policy Research (SIEPR) and a faculty research fellow at the National Bureau of Economic Research.

“We live in a world with limited resources and we need to understand how to best allocate them,” she said. “So I think there is value in providing rigorous causal evidence on the effectiveness of various tools and policies that impact the less advantaged so that we can get the highest return on public spending as well as the highest potential for improving the outcomes of those at the very bottom.”

In a paper published in the Journal of Public Economics, Rossin-Slater talks about the growing body of evidence that suggests in-utero conditions and health at birth make a difference in later-life well-being. She found that the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) is one of the most cost-effective and successful programs to improve health at birth for children of disadvantaged mothers.

“The estimated effects are the strongest for mothers with a high school education or less, who are most likely eligible for WIC services,” she wrote in the paper, which was cited by the White House blog under President Barack Obama.

Paid Family Leave

When Mark Zuckerberg announced he would take a two-month paternity leave when his daughter was born in 2015, the Facebook co-founder was taking advantage of his own company’s policy, which grants employees up to four months leave for all new parents.

“Studies show that when working parents take time to be with their newborns, outcomes are better for the children and families,” Zuckerberg wrote on his Facebook page.

This prompted many media outlets to turn to a co-authored study with Rossin-Slater, which found that 46 percent more men have taken time off to help take care of their newborns since California made paid family leave (PFL) law in 2004.

“The increase in paternal leave-taking may also have important implications for addressing the gender wage gap,” the authors wrote. “Our results suggest that a gender-neutral PFL policy can increase the amount of time fathers of newborns spend at home—including the time they spend at home while the mothers work—and may therefore be seen as one way to promote gender equality.”

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Here at Stanford, Rossin-Slater is using databases in the United States, Denmark and Sweden to continue her research on public policies (including paid family leave), as well as looking at how prenatal and early childhood factors impact lifelong outcomes. Does inequality and the stress of poverty in pregnancy, for example, get transmitted across generations?

In a forthcoming paper in the American Economic Review Rossin-Slater and her co-author, Stanford economist Petra Persson, found that prenatal exposure to maternal stress due to deaths in the family could have lasting consequences for the mental health of the children.

They examined nearly 300,000 births in Sweden between 1973 and 2011, in which a relative of the mother died either before her due date or in her child’s first year of life. They found that children who were in the womb when a relative died were 25 percent more likely to take medication for ADHD than those who were infants when the relative died. And those children were 13 percent more likely to take prescription drugs for anxiety once they became adults.

Take those results and one can imagine that the stress of living in poverty during pregnancy might be compounded over generations in that same disadvantaged family.

“This would imply that policies aiming to alleviate stress associated with economic disadvantage may help break the cycle of poverty,” Rossin-Slater and Persson told The Washington Post for a story on their research.

In new projects, Rossin-Slater is now studying the effects of reforms in the WIC program in California on maternal and child health, as well as the impacts of paternity leave on maternal mental health and child outcomes in Sweden. She continues using research designs that pay careful attention to establishing causality and working with large administrative databases.

“I believe in and enjoy working with data because it provides an opportunity to learn about how real-world policies actually work,” she said. “I have the privilege of being able to set my own research questions and to use my economic training and newly available data to try to find at least some answers. My hope is that these answers can be useful for creating better and more effective policies.”

The Asia Health Policy Program at Stanford’s Shorenstein Asia-Pacific Research Center, in collaboration with scholars from Stanford Health Policy's Center on Demography and Economics of Health and Aging, the Stanford Institute for Economic Policy Research, and the Next World Program, is soliciting papers for the third annual workshop on the economics of ageing titled Financing Longevity: The Economics of Pensions, Health Insurance, Long-term Care and Disability Insurance held at Stanford from April 24-25, 2017, and for a related special issue of the Journal of the Economics of Ageing.

The triumph of longevity can pose a challenge to the fiscal integrity of public and private pension systems and other social support programs disproportionately used by older adults. High-income countries offer lessons – frequently cautionary tales – for low- and middle-income countries about how to design social protection programs to be sustainable in the face of population ageing. Technological change and income inequality interact with population ageing to threaten the sustainability and perceived fairness of conventional financing for many social programs. Promoting longer working lives and savings for retirement are obvious policy priorities; but in many cases the fiscal challenges are even more acute for other social programs, such as insurance systems for medical care, long-term care, and disability. Reform of entitlement programs is also often politically difficult, further highlighting how important it is for developing countries putting in place comprehensive social security systems to take account of the macroeconomic implications of population ageing.

The objective of the workshop is to explore the economics of ageing from the perspective of sustainable financing for longer lives. The workshop will bring together researchers to present recent empirical and theoretical research on the economics of ageing with special (yet not exclusive) foci on the following topics:

• Public and private roles in savings and retirement security
• Living and working in an Age of Longevity: Lessons for Finance
• Defined benefit, defined contribution, and innovations in design of pension programs
• Intergenerational and equity implications of different financing mechanisms for pensions and social insurance
• The impact of population aging on health insurance financing
• Economic incentives of long-term care insurance and disability insurance systems
• Precautionary savings and social protection system generosity
• Elderly cognitive function and financial planning
• Evaluation of policies aimed at increasing health and productivity of older adults
• Population ageing and financing economic growth
• Tax policies’ implications for capital deepening and investment in human capital
• The relationship between population age structure and capital market returns
• Evidence on policies designed to address disparities – gender, ethnic/racial, inter-regional, urban/rural – in old-age support
• The political economy of reforming pension systems as well as health, long-term care and disability insurance programs

Submission for the workshop

Interested authors are invited to submit a 1-page abstract by Sept. 30, 2016, to Karen Eggleston at karene@stanford.edu. The authors of accepted abstracts will be notified by Oct. 15, 2016, and completed draft papers will be expected by April 1, 2017.

Economy-class travel and accommodation costs for one author of each accepted paper will be covered by the organizers.

Invited authors are expected to submit their paper to the Journal of the Economics of Ageing. A selection of these papers will (assuming successful completion of the review process) be published in a special issue.

Submission to the special issue

Authors (also those interested who are not attending the workshop) are invited to submit papers for the special issue in the Journal of the Economics of Ageing by Aug. 1, 2017. Submissions should be made online. Please select article type “SI Financing Longevity.”

About the Next World Program

The Next World Program is a joint initiative of Harvard University’s Program on the Global Demography of Aging, the WDA Forum, Stanford’s Asia Health Policy Program, and Fudan University’s Working Group on Comparative Ageing Societies. These institutions organize an annual workshop and a special issue in the Journal of the Economics of Ageing on an important economic theme related to ageing societies.

More information can be found in the PDF below.