Stanford Health Policy is a joint effort of the Freeman Spogli Institute for International Studies and the Stanford School of Medicine
Context The effect of global health initiatives on population health is uncertain. Between 2003 and 2008, the US President's Emergency Plan for AIDS Relief (PEPFAR), the largest initiative ever devoted to a single disease, operated intensively in 12 African focus countries. The initiative's effect on all-cause adult mortality is unknown.
Objective To determine whether PEPFAR was associated with relative changes in adult mortality in the countries and districts where it operated most intensively.
Design, Setting, and Participants Using person-level data from the Demographic and Health Surveys, we conducted cross-country and within-country analyses of adult mortality (annual probability of death per 1000 adults between 15 and 59 years old) and PEPFAR's activities. Across countries, we compared adult mortality in 9 African focus countries (Ethiopia, Kenya, Mozambique, Namibia, Nigeria, Rwanda, Tanzania, Uganda, and Zambia) with 18 African nonfocus countries from 1998 to 2008. We performed subnational analyses using information on PEPFAR's programmatic intensity in Tanzania and Rwanda. We employed difference-in-difference analyses with fixed effects for countries and years as well as personal and time-varying area characteristics.
Main Outcome Measure Adult all-cause mortality.
Results We analyzed information on 1 538 612 adults, including 60 303 deaths, from 41 surveys in 27 countries, 9 of them focus countries. In 2003, age-adjusted adult mortality was 8.3 per 1000 adults in the focus countries (95% CI, 8.0-8.6) and 8.5 per 1000 adults (95% CI, 8.3-8.7) in the nonfocus countries. In 2008, mortality was 4.1 per 1000 (95% CI, 3.6-4.6) in the focus countries and 6.9 per 1000 (95% CI, 6.3-7.5) in the nonfocus countries. The adjusted odds ratio of mortality among adults living in focus countries compared with nonfocus countries between 2004 and 2008 was 0.84 (95% CI, 0.72-0.99; P = .03). Within Tanzania and Rwanda, the adjusted odds ratio of mortality for adults living in districts where PEPFAR operated more intensively was 0.83 (95% CI, 0.72-0.97; P = .02) and 0.75 (95% CI, 0.56-0.99; P = .04), respectively, compared with districts where it operated less intensively.
Conclusions Between 2004 and 2008, all-cause adult mortality declined more in PEPFAR focus countries relative to nonfocus countries. It was not possible to determine whether PEPFAR was associated with mortality effects separate from reductions in HIV-specific deaths.
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Prof. Stephen Luby studied philosophy and earned a Bachelor of Arts summa cum laude from Creighton University. He then earned his medical degree from the University of Texas Southwestern Medical School at Dallas and completed his residency in internal medicine at the University of Rochester-Strong Memorial Hospital. He studied epidemiology and preventive medicine at the Centers for Disease Control and Prevention.
Prof. Luby's former positions include leading the Epidemiology Unit of the Community Health Sciences Department at the Aga Khan University in Karachi, Pakistan, for five years and working as a Medical Epidemiologist in the Foodborne and Diarrheal Diseases Branch of the U.S. Centers for Disease Control and Prevention (CDC) exploring causes and prevention of diarrheal disease in settings where diarrhea is a leading cause of childhood death. Immediately prior to joining the Stanford faculty, Prof. Luby served for eight years at the International Centre for Diarrhoeal Diseases Research, Bangladesh (icddr,b), where he directed the Centre for Communicable Diseases. He was also the Country Director for CDC in Bangladesh.
During his over 25 years of public health work in low-income countries, Prof. Luby frequently encountered political and governance difficulties undermining efforts to improve public health. His work within the Center on Democracy, Development, and the Rule of Law (CDDRL) connects him with a community of scholars who provide ideas and approaches to understand and address these critical barriers.
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Dr. Lee Sanders is a general pediatrician and Professor of Pediatrics at the Stanford University School of Medicine, where he is Chief of the Division of General Pediatrics. He holds a joint appointment in the Center for Health Policy in the Freeman Spogli Institute for International Studies, where he is a co-director of the Center for Policy, Outcomes and Prevention (CPOP).
An author of numerous peer-reviewed articles addressing child health disparities, Dr. Sanders is a nationally recognized scholar in the fields of health literacy and child chronic-illness care. Dr. Sanders was named a Robert Wood Johnson Foundation Generalist Physician Faculty Scholar for his leadership on the role of maternal health literacy and English-language proficiency in addressing child health disparities. Aiming to make the US health system more navigable for the one in 4 families with limited health literacy, he has served as an advisor to the Institute of Medicine, the Centers for Disease Control and Prevention, the Food and Drug Administration, the American Academy of Pediatrics, the Academic Pediatric Association, and the American Cancer Society. Dr. Sanders leads a multi-disciplinary CPOP research team that provides analytic guidance to national and state policies affecting children with complex chronic illness – with a focus on the special health-system requirements that arise from the unique epidemiology, care-use patterns, and health-care costs for this population. He leads another CPOP/PCOR-based research team that applies family-centered approaches to new technologies that aim to improve care coordination for children with medical complexity. Dr. Sanders is also principal investigator on two NIH-funded studies that address health literacy in the pediatric context: one aims to assess the efficacy of a low-literacy, early-childhood intervention designed to prevent early childhood obesity; the other aims to provide the FDA with guidance on improved labeling of pediatric liquid medication. Research settings for this work include state and regional health departments, primary-care and subspecialty-care clinics, community-health centers, WIC offices, federally subsidized child-care centers, and family advocacy centers.
Dr. Sanders received a BA in History and Science from Harvard University, an MD from Stanford University, and a MPH from the University of California, Berkeley. Between 2006 and 2011, Dr. Sanders served as Medical Director of Children’s Medical Services South Florida, a Florida state agency that coordinates care for more than 10,000 low-income children with special health care needs. He was also Medical Director for Reach Out and Read Florida, a pediatric-clinic-based program that provides books and early-literacy promotion to more than 200,000 underserved children. At the University of Miami, Dr. Sanders directed the Jay Weiss Center for Social Medicine and Health Equity, which fosters a scholarly community committed to addressing global health inequities through community-based participatory research. At Stanford University, Dr. Sanders served as co-medical director of the Family Advocacy Program, which provides free legal assistance to help address social determinants of child health.
Fluent in Spanish, Dr. Sanders is co-director of the Complex Primary Care Clinic at Stanford Children’s Health, which provides multi-disciplinary team care for children with complex chronic conditions. Dr. Sanders is also the father of two daughters, aged 11 and 14 years, who make sure he practices talking less and listening more.
Background. The optimal community-level approach to control pandemic influenza is unknown. Methods. We estimated the health outcomes and costs of combinations of 4 social distancing strategies and 2 antiviral medication strategies to mitigate an influenza pandemic for a demographically typical US community. We used a social network, agent-based model to estimate strategy effectiveness and an economic model to estimate health resource use and costs. We used data from the literature to estimate clinical outcomes and health care utilization. Results. At 1% influenza mortality, moderate infectivity (R(o) of 2.1 or greater), and 60% population compliance, the preferred strategy is adult and child social distancing, school closure, and antiviral treatment and prophylaxis. This strategy reduces the prevalence of cases in the population from 35% to 10%, averts 2480 cases per 10,000 population, costs $2700 per case averted, and costs $31,300 per quality-adjusted life-year gained, compared with the same strategy without school closure. The addition of school closure to adult and child social distancing and antiviral treatment and prophylaxis, if available, is not cost-effective for viral strains with low infectivity (R(o) of 1.6 and below) and low case fatality rates (below 1%). High population compliance lowers costs to society substantially when the pandemic strain is severe (R(o) of 2.1 or greater). Conclusions. Multilayered mitigation strategies that include adult and child social distancing, use of antivirals, and school closure are cost-effective for a moderate to severe pandemic. Choice of strategy should be driven by the severity of the pandemic, as defined by the case fatality rate and infectivity.
As India's middle class has expanded, the nation's public health concerns have shifted. Obesity rates have risen, coinciding with a surge in diabetes. The number of Indians with type 2 diabetes is expected to double by 2030 to nearly 80 million. Meanwhile, 43 percent of children in India are underweight.
BACKGROUND: The optimal community-level approach to control pandemic influenza is unknown. METHODS: We estimated the health outcomes and costs of combinations of 4 social distancing strategies and 2 antiviral medication strategies to mitigate an influenza pandemic for a demographically typical US community. We used a social network, agent-based model to estimate strategy effectiveness and an economic model to estimate health resource use and costs. We used data from the literature to estimate clinical outcomes and health care utilization. RESULTS: At 1% influenza mortality, moderate infectivity (R(o) of 2.1 or greater), and 60% population compliance, the preferred strategy is adult and child social distancing, school closure, and antiviral treatment and prophylaxis. This strategy reduces the prevalence of cases in the population from 35% to 10%, averts 2480 cases per 10,000 population, costs $2700 per case averted, and costs $31,300 per quality-adjusted life-year gained, compared with the same strategy without school closure. The addition of school closure to adult and child social distancing and antiviral treatment and prophylaxis, if available, is not cost-effective for viral strains with low infectivity (R(o) of 1.6 and below) and low case fatality rates (below 1%). High population compliance lowers costs to society substantially when the pandemic strain is severe (R(o) of 2.1 or greater). CONCLUSIONS: Multilayered mitigation strategies that include adult and child social distancing, use of antivirals, and school closure are cost-effective for a moderate to severe pandemic. Choice of strategy should be driven by the severity of the pandemic, as defined by the case fatality rate and infectivity.