As he explained during the recent Rosenkranz Prize Symposium, Stefano M. Bertozzi used this slogan to promote health reform in the Mexico City prison system. By encouraging inmates to step up and get themselves tested for HIV and other chronic illnesses, Bertozzi, dean and professor of health policy and management at the UC Berkeley School of Public Health, was able to decrease the spread of illnesses in Mexican prisons and the surrounding communities.
The Rosenkranz Prize Symposium celebrated research projects that—like Bertozzi’s—address the health care needs of the world’s most vulnerable populations. With support from the Rosenkranz Prize for Health Care Research in Developing Countries, Stanford scholars have stepped up to tackle health issues in regions in need.
Since 2010, the award has funded six young Stanford researchers who aim to improve health in developing countries. The symposium celebrated their achievements.
The award honors the work of Dr. George Rosenkranz who spent his career reducing health disparities around the globe. Rosenkranz, who was the first to synthesize cortisone and the active ingredient in the first oral contraceptive, also celebrated his 100th birthday at the symposium.
Producing research that will increase care for vulnerable populations globally is the ultimate goal of the Rosenkranz Prize.
Andrés Moreno-Estrada, the 2012 winner, has used the award to study genetics in Latin American and Caribbean populations, aiming to increase knowledge of potential genetic illnesses. He said, “The Rosenkranz Prize is a clear, important step forward to demonstrate that we can do cutting edge science in developing countries that is of international relevance.”
Other winners include Eran Bendavid, Sanjay Basu, Marcella Alsan, Jason Andrews and Ami Bhatt. Their projects range from the effect of AIDS relief efforts on health care delivery to the treatment of diabetes in India to low-cost diagnostic tools for regions lacking infrastructure.
“I can’t think of a better way to celebrate (my father’s) birthday than listening to the bright future of science,” said Ricardo T. Rosenkranz, son of Dr. George Rosenkranz and a prize donor. “We can’t wait to hear what the next Rosenkranz Prize winners tell us.”
Dr. George Rosenkranz celebrated his 100th birthday at the symposium. The first to synthesize cortisone as well as the active ingredient in the first oral contraceptive, Rosenkranz spent his life reducing health disparities around the globe.
Sex differences in mortality vary over time and place as a function of social, health, and medical circumstances. The magnitude of these variations, and their response to large socioeconomic changes, suggest that biological differences cannot fully account for sex differences in survival. Drawing on a wide swath of mortality data across countries and over time, we develop a set of empiric observations with which any theory about excess male mortality and its correlates will have to contend. We show that as societies develop, M/F survival first declines and then increases, a “sex difference in mortality transition” embedded within the demographic and epidemiologic transitions. After the onset of this transition, cross-sectional variation in excess male mortality exhibits a consistent pattern of greater female resilience to mortality under socio-economic adversity. The causal mechanisms underlying these associations merit further research.
This event has reached capacity. Please join us to watch the live-stream at this link.
The symposium will focus on the key questions that impact health through the year 2020. How could the 2016 election affect health care in the U.S.? How will payment reform affect health systems, physicians and patients? Are the insurance exchanges viable? What challenges pose the biggest threat to global health? Experts from Stanford and beyond address these topics and more as they discuss the future of health policy.
Lloyd Minor, Dean, Stanford University School of Medicine
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Minor, MD, is a scientist, surgeon and academic leader. He is the Carl and Elizabeth Naumann Dean of the Stanford University School of Medicine, a position he has held since December 2012. Minor leads more than 1,500 faculty and 1,000 students at the oldest medical school in the West and has made precision health — the prevention of disease before it strikes — a hallmark of research, education and patient care at Stanford Medicine.
Bob Kocher,a partner at the Silicon Valley venture capital firm, Venrock
Bob Kocher
Kocher, MD, is a partner at Venrock who focuses on healthcare IT and services investments and is a consulting professor at Stanford University School of Medicine. He served in the Obama Administration as special assistant to the president for health care and economic policy and was one of the key shapers of the Affordable Care Act.
David Entwistle, President and CEO, Stanford Health Care
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Entwistle joined Stanford Health Care as its President and CEO in July, bringing extensive executive experience at leading academic medical centers. Most recently he served as CEO of the University of Utah Hospitals & Clinics, the only academic medical center in the Intermountain West region. While serving at UUHC, Entwistle received the Modern Healthcare “Up and Comers Award,” for significant contributions in health-care administration, management or policy.
Chris Dawes, President and CEO, Lucile Packard Children’s Hospital
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Christopher G. Dawes became President and Chief Executive Officer of Lucile Packard Children’s Hospital Stanford in 1997 after five years of service as Chief Operating Officer. Under his guidance, the hospital, research center and regional medical network has been ranked as one of the best in the nation, as an industry leader in patient safety and innovation in providing a full complement of services for children and expectant mothers.
Panelists:
Marcella Alsan, Assistant Professor of Medicine, Stanford University
Marcella Alsan’s research focuses on the relationship between health and socioeconomic disparities with a focus on infectious disease. Another vein of research focuses on the microfoundations of antibiotic overuse and resistance. She received a BA degree in cognitive neuroscience from Harvard University, a master’s degree in international public health from Harvard School of Public Health, a medical degree from Loyola University, and a PhD in economics from Harvard University. She is board-certified in both internal medicine and infectious disease. She trained at Brigham and Women’s Hospital, completing the Hiatt Global Health Equity Residency Fellowship in internal medicine. She combined her PhD with an Infectious Disease Fellowship at Massachusetts General Hospital. She currently is an infectious disease specialist at the Department of Veterans Affairs, Palo Alto.
Laurence Baker, Chair of Health Research and Policy, Stanford University
Laurence Baker is an economist interested in the organization and economic performance of the U.S. health-care system, and his research has investigated a range of topics including financial incentives in health care, competition in health-care markets, health insurance and managed care and health-care technology adoption. Baker is a past recipient of the ASHE medal from ASHEcon and the Alice Hersch Award from AcademyHealth. He received his BA from Calvin College, and his MA and PhD in economics from Princeton University.
Eran Bendavid, Assistant Professor of Medicine, Stanford University
Eran Bendavid is an infectious diseases physician. His research interests involve understanding the relationship between policies and health outcomes in developing countries. He explores how decisions about foreign assistance for health are made, and how those decisions affect the health of those whom assistance aims to serve. Dr. Bendavid is also a disease modeler, and uses that skill to explore issues of resource allocation in low and middle-income countries with cost-effectiveness analyses. His recent research projects include an impact evaluation of the US assistance program for HIV in Africa, and an exploration of the association between drug prices, aid and health outcomes in countries heavily affected by HIV.
Jay Bhattacharya, Professor of Medicine, Stanford University
Jay Bhattacharya’s research focuses on the constraints that vulnerable populations face in making decisions that affect their health status, as well as the effects of government policies and programs designed to benefit vulnerable populations. He has published empirical economics and health services research on the elderly, adolescents, HIV/AIDS and managed care. Most recently, he has researched the regulation of the viatical-settlements market (a secondary life-insurance market that often targets HIV patients) and summer/winter differences in nutritional outcomes for low-income American families. He is also working on a project examining the labor-market conditions that help determine why some U.S. employers do not provide health insurance.
M. Kate Bundorf, Associate Professor of Medicine, Stanford University
M. Kate Bundorf is a Faculty Research Fellow at the National Bureau of Economic Research. She received her M.B.A. and M.P.H. degrees from The University of California at Berkeley and her Ph.D. from The Wharton School. She was a Fulbright Lecturer and Visiting Professor at Fudan School of Public Health in Shanghai, China in 2009 and 2010. Her research, which focuses on health insurance markets, has been published in leading economics and health policy journals and has received funding from the U.S. National Institutes of Health, the Agency for Health Care Research and Quality and the Robert Wood Johnson Foundation. She received the 13th Annual Health Care Research Award from The National Institute for Health Care Management in 2007.
David Chan, Assistant Professor of Medicine, Stanford University
David Chan is a physician and economist whose research focuses on productivity in US health care. His research draws on insights from labor and organizational economics. He is particularly interested in studying what drives physician behavior, how this explains differences in productivity in health care delivery, and what the implications are for the design of health care. He is the recipient of the 2014 NIH Director’s High-Risk, High-Reward Early Independence Award to study the optimal balance of information in health information technology for patient care. David Chan is also an investigator at the Department of Veterans Affairs and a Faculty Research Fellow at the National Bureau of Economic Research.
Kathryn M. McDonald, Executive Director of the Center for Health Policy and the Center for Primary Care and Outcomes Research, Stanford University
Kathryn McDonald, MM, is the Executive Director of the Center for Health Policy (CHP) and Center for Primary Care and Outcomes Research (PCOR) and a senior scholar at the Centers. She is also Associate Director of the Stanford-UCSF Evidence-based Practice Center (under RAND). Her work focuses on measures and interventions to achieve evidence-based patient-centered healthcare quality and patient safety. Mrs. McDonald has served as a project director and principal investigator on a number of research projects at the Stanford School of Medicine, including the development and ongoing enhancement of the Quality and Patient Safety Indicators for the Agency for Healthcare Research and Quality. She has authored numerous peer reviewed articles and government reports, including several with wide enough followership to merit recent updates: Care Coordination Measures Atlas, Closing the Quality Gap, and Patient Safety Practices.
Michelle Mello, Professor of Law and of Health Research and Policy, Stanford University
Michelle Mello is Professor of Law at Stanford Law School and Professor of Health Research and Policy at Stanford University School of Medicine. She conducts empirical research into issues at the intersection of law, ethics, and health policy. She is the author of more than 150 articles and book chapters on the medical malpractice system, medical errors and patient safety, public health law, research ethics, the obesity epidemic, pharmaceuticals, and other topics. From 2000 to 2014, Dr. Mello was a professor at the Harvard School of Public Health, where she directed the School’s Program in Law and Public Health. In 2013-14 she completed a Lab Fellowship at Harvard University’s Edmond J. Safra Center for Ethics. Dr. Mello teaches courses in torts and public health law. She holds a J.D. from the Yale Law School, a Ph.D. in Health Policy and Administration from the University of North Carolina at Chapel Hill, an M.Phil. from Oxford University, where she was a Marshall Scholar, and a B.A. from Stanford University. In 2013, she was elected to the National Academy of Medicine (formerly known as the Institute of Medicine).
Grant Miller, Associate Professor of Medicine, Stanford University
Grant Miller is Director of the Stanford Center for International Development, an Associate Professor of Medicine at the Stanford University School of Medicine, a Core Faculty Member at the Center for Health Policy/Primary Care and Outcomes Research, a Senior Fellow at the Freeman Spogli Institute for International Studies (FSI) and the Stanford Institute for Economic Policy Research (SIEPR), and a Research Associate at the National Bureau of Economic Research (NBER). His primary interests are health economics, development economics, and economic demography. As a health and development economist based at the Stanford Medical School, Dr. Miller’s overarching focus is research and teaching aimed at developing more effective health improvement strategies for developing countries. His agenda addresses three major interrelated themes. (1) First, what are the major causes of population health improvement around the world and over time? (2) Second, what are the behavioral underpinnings of the major determinants of population health improvement? (3) Third, how can programs and policies use these behavioral insights to improve population health more effectively?
Douglas K. Owens, Director of the Center for Health Policy and the Center for Primary Care and Outcomes Research, Stanford University
Douglas K. Owens, MD, MS, is the Henry J. Kaiser, Jr., Professor at Stanford University, where he is a professor of medicine. He is director of the Center for Health Policy in the Freeman Spogli Institute for International Studies and director of the Center for Primary Care and Outcomes Research (PCOR) in the Department of Medicine. He is a general internist and associate director of the Center for Innovation to Implementation at the Veterans Affairs Palo Alto Health Care System. A past member of the U.S. Preventive Services Task Force, he has helped lead the development of national U.S. guidelines on screening for HIV, hepatitis C, hepatitis B, lung cancer, colorectal cancer, breast cancer, and use of aspirin and statins to prevent cardiovascular disease.
Maria Polyakova, Assistant Professor of Health Research and Policy, Stanford University
Maria Polyakova, PhD, is an Assistant Professor of Health Research and Policy at the Stanford University School of Medicine. Her research investigates questions surrounding the role of government in the design and financing of health insurance systems. She is especially interested in the relationships between public policies and individuals’ decision-making in health care and health insurance, as well as in the risk protection and re-distributive aspects of health insurance systems. She received a BA degree in Economics and Mathematics from Yale University and a PhD in Economics from MIT.
David M. Studdert, Professor of Medicine and of Law, Stanford University
David M. Studdert is a leading expert in the fields of health law and empirical legal research. His scholarship explores how the legal system influences the health and well-being of populations. A prolific scholar, he has authored more than 150 articles and book chapters, and his work appears frequently in leading international medical, law and health policy publications. Professor Studdert has received the Alice S. Hersh New Investigator Award from AcademyHealth, the leading organization for health services and health policy research in the United States. He was awarded a Federation Fellowship (2006) and a Laureate Fellowship (2011) by the Australian Research Council. He holds a law degree from University of Melbourne and a doctoral degree in health policy and public health from the Harvard School of Public Health.
A key concern weighing heavily on those attending this week’s global conference on AIDS is the diminishing donor support to fight the communicable disease, which has claimed an estimated 35 million lives since the beginning of the epidemic.
“That’s on everybody’s mind now — how to continue facing the epidemic with the shrinking resources,” said Eran Bendavid, a core faculty member at Stanford Health Policy and assistant professor at Stanford Medicine attending the conference in Durban, South Africa.
Donor government funding to support HIV efforts in low- and middle-income countries fell for the first time in 2015, decreasing from $8.6 billion in 2014 to $7.5 billion last year, according to a new report by the Kaiser Family Foundation and UNAIDS.
Funding for HIV treatment declined for 13 of 14 major donor governments, with the U.S. continuing to provide more donor funding for HIV than any other country or organization.
“There’s a sense of panic about how we’re going to fill the shortfall in funding,” Bendavid said. “All the major donors are here, PEPFAR, the Global Fund, and everyone is saying `We need more to continue the fight.’
“But, in my mind,” Bendavid continued, “the conversation that is mostly missing is the one between the organizations on the front lines and the national ministries of health and finance. See what they can do to get domestic resources to fill the gap.”
PEPFAR — the President’s Emergency Plan for AIDS Release — is the U.S. government initiative to help those suffering from HIV/AIDS.
Bendavid, an infectious disease physician, joins 18,000 global leaders, researchers, activists and front-line health workers attending the conference July 18-22.
The U.N. General Assembly last month pledged to end the AIDS epidemic by 2030. But more than half of the nearly 37 million people around the world infected with HIV still have no access to the antiretroviral therapy that is saving so many lives.
U.S. Secretary-General Ban Ki-moon said on the opening day of AIDS2016 that when the conference was last held in Durban 16 years ago, less than 1 percent of all people living with HIV in developing countries had access to treatment.
“Today, the world has proven that when we come together, we can transform lives,” Ban said, noting that of the 36.7 million people living with HIV today, about 46 percent of infected adults have access to antiretroviral treatment.
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“In addition, medicines are more effective and less toxic, technology allows diagnosis in 20 minutes or less, generic medicines reduced the cost of treatment to just a dollar a day and great international finance has been made available,” Ban said.
Still, the secretary-general warned, “the gains are inadequate — and fragile,” when you consider that more than half of all people living with HIV still lack access to treatment.
Bendavid, who spoke by telephone from Durban, gave a symposium at the conference on Tuesday that summarizes his research and provides his conclusions on the most effective approaches to use donor resources.
He said the while the global burden of noncommunicable diseases, such as heart disease and cancer, is greater than HIV, malaria, or TB, the interventions available to combat infectious diseases are more cost-effective.
“Basically, the resource constraints are forcing us to think carefully about what to invest in, and we want to invest in what works,” Bendavid said, adding that donor funding typically goes straight to the disease rather than the local health system infrastructure.
“The scarce donor resources should not be directed towards interventions that are either inefficacious or costly,” he argued. “The opportunity cost of investing in costly or ineffective interventions is very high when you consider the millions who could benefit from inexpensive, simple interventions such as bed nets and drugs for TB.”
He conceded that he typically gets push back on this line of reasoning.
“But when you’re talking about what you can do with very limited resources, investing in noncommunicable diseases, in my mind, jeopardizes the premise of donor funding: There are many people who would be happy to shut down PEPFAR and the Global Fund if they were shown to be ineffective.”
He published a paper earlier this year that found the U.S. government has invested $1.4 billion in HIV prevention programs that promote sexual abstinence and marital fidelity. But there is no evidence that the programs have been effective at changing sexual behavior and reducing HIV Risk.
Bendavid said his presentation at the symposium was received with a mix of understanding and concern.
“People mentioned that funding health systems could have averted Ebola, and that the fight against HIV needs to address health systems,” he said. “I agree, but also think governments should step up and help fill some of those gaps.”
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21st International AIDS Conference (AIDS 2016), Durban, South Africa
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 theJournal 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.
Studying the microorganisms that live in our gut is a relatively new field, one that has only really taken off in the last decade. In fact, it is estimated that half of the microbes that live in and around our GI track have yet to be discovered.
“This means there is a huge amount of this dark matter within us,” said Ami S. Bhatt, an assistant professor of medicine and genetics who runs the Bhatt Lab at the Stanford School of Medicine. The lab is devoted to exploiting disease vulnerabilities by cataloguing the human microbiome, the trillions of microbes living in and on our bodies.
“I think if we fast-forward to the impact of some these findings in 10 years, we’re going to learn that modifying the microbiota is a potent way to modulate health,” Bhatt said. “Humans are not only made up of human cells, but are a complex mixture of human cells and the microbes that live within us and among us — and these microorganisms are as critical to our well-being as we are to theirs.”
Bhatt, along with key collaborators at the University of Witwatersrand in Johannesburg, and the INDEPTH research consortium, now intends to take this research to Africa.
The $100,000 prize is targeted at Stanford’s emerging researchers who are dedicated to improving health care in poorer parts of the world, but may lack the financial resources.
Bhatt, MD, PhD, intends to take the prize money to execute the first multi-country microbiome research project focused on non-communicable disease risk in Africa. The project intends to explore the relationship between the gut microbiome composition and body mass index (BMI) in patients who are either severely malnourished or obese.
“As a rapidly developing continent with extremes of resource access, Africa is simultaneously faced with challenges relating to the extremes of metabolic status,” Bhatt wrote in her Rosenkranz project proposal. The Bay Area native, who is also the director of global oncology at Stanford, came to the School of Medicine in 2014 to focus on how changes in the microbiome are associated with cancer.
In this new project, Bhatt and members of her lab will team up with colleagues in Africa, first in South Africa, and then in Ghana, Burkina Faso, and Kenya. They will leverage the infrastructure already in place at the INDEPTH Network of researchers, using an existing cohort of 12,000 patients at within those four countries. The patients have already consented to be involved in DNA testing and have given blood and urine specimens.
Identifying alterations of the microbiome that are associated with severe malnutrition or obesity could pave the way for interventions that may mitigate the severity or prevalence of these disorders, Bhatt said.
“These organisms are critical to our health in that they are in a delicate balance with one another and their human hosts,” she said. “Alterations in the microbiome are associated with various diseases — but have mostly been studied in Western populations. Unfortunately, little is known about the generalizability of these findings to low- and middle-income countries – where most of the world’s population lives.”
Bhatt said that as Africa rapidly continues to develop, the continent is simultaneous faced with challenges relating to extreme weight gain and loss. While the wealthy are facing obesity and its associated disease such as stroke, heart failure and diabetes, many people are still faced with issues related to food insecurity, hunger and malnutrition.
The research, she hopes, could lead to aggressive behavioral, dietary and lifestyle modifications targeted at maintaining healthy BMI in at-risk individuals.
Grant Miller, an associate professor of medicine and core faculty member at Stanford Health Policy who chaired the Rosenkranz Prize committee this year, believes Bhatt’s research could eventually break new ground.
“The entire Rosenkranz Prize selection committee was highly impressed with Ami and the innovation of her project,” Miller said. “Ami’s work on the human microbiome in the extremes of nutritional status in developing countries — including its potential link to obesity, an emerging challenge in low income countries — is potentially path-breaking.”
The award’s namesake, George Rosenkranz, first synthesized cortisone in 1951, and later progestin, the active ingredient in oral birth control pills. He went on to establish the Mexican National Institute for Genomic Medicine, and his family created the Rosenkranz Prize in 2009.
The award embodies Dr. Rosenkranz’s belief that young scientists hold the curiosity and drive necessary to find alternative solutions to longstanding health-care dilemmas.
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Ami S. Bhatt with Ricky Rosenkranz (Stanford '85, son of George Rosenkranz) celebrate her winning the 2016 Rosenkranz Prize for emerging research in the developing world. The prize will help Bhatt launch a microbiome research project in Africa.
“Vic-TOR-ia!” Fátima cried, a grin lighting up her face. The 5-year-old had become fast friends with Stanford medical student Tori Bawel almost instantly after Bawel arrived in San Lucas Tolimán. After giving piggy-back rides to Fátima, a career in global pediatrics changed from a distant wish to a developing reality for Bawel.
Bawel is one of a few lucky medical students to travel with Stanford pediatrician Paul Wise, MD, MPH, to San Lucas Tolimán, a town in the mountains of rural Guatemala that serves as a base for his work to improve nutrition for local children. Once she completes her medical training, Bawel plans to devote her life to improving health in underserved areas.
“As an elementary school student, I was really compelled by issues of social justice,” she said. “I hope that over the course of my lifetime, I’m able to make a difference like physicians have done here in Guatemala and around the world.”
Every summer, Wise, a professor of pediatrics and a Stanford Health Policy core faculty member, takes a handful of undergraduates to the communities around San Lucas to learn about the Rural Guatemala Child Health and Nutrition Program. A collaboration between Stanford and a group of local health promoters, the program uses nutritional supplements and health education to save the lives of children under five. The students follow the promoters on house visits, help them measure the weight and height of children and gain an understanding of how the program helps the rural communities.
“We feel it is part of our educational mission,” said Wise. “We want to grow people who will make a difference, and part of that is providing them opportunities to do so.”
Bawel’s experience reinforced her desire to engage in global health work: “It’s inspired me and motivated me to want to give my life, like Wise, to… serving in areas of the world with the greatest need.”
Meeting Guatemalan students who overcame economic difficulties to study medicine — like Flor Julajuj — was also deeply moving for Bawel. Very few in rural Guatemala have the opportunity to pursue higher education or good health care. But with some help from Wise, Julajuj was able to attend medical school; just this month, she graduated from the University of San Carlos in Guatemala City.
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“It’s been a great opportunity,” said Julajuj. “It’s changed my life.”
Most, though, are not so lucky; Bawel also encountered two young women who dream of becoming physicians but cannot afford medical school. Meeting the young, ambitious women “makes me want to empower them with the education and opportunities I have had,” said Bawel.
Wise, meanwhile, will continue to each Stanford students about ways to help these communities.
“They see the poverty, but they also begin to understand why being a great doctor or a great diplomat or a great economist will serve the interests of people down here if done well,” he said. “We want them to go back to whatever field they’re interested in, committed to gaining skills and then using them to serve the needs and the rights of people in places like San Lucas.”
Stanford pediatrician Paul Wise stooped below the black tarp roof of a cinderblock house in Guatemala to offer his condolences to a mother who had just lost her child.
“Doctor Pablo,” as he is known in the communities around San Lucas Tolimán, talked softly as he relayed his sympathies to the mother, whose 9-year-old son had been a patient of his.
Stanford’s Children in Crisis Initiative seeks to save the lives of children in areas of poor governance. In Guatemala, their efforts work toward eliminating death by malnutrition for children under 5.
The boy’s genetic disorder would have been terminal anywhere, but thanks to Wise and local health promoters, the boy’s family had years with him instead of months.
While Wise spoke to the heartbroken mother, his Stanford research assistant Alejandro Chavez helped the promoters set up inside a local community center to measure the weight and height of local kids to determine their nutrition level.
Chavez and the promoters had worked together for months to create an app for tablets that will make it easier to find malnourished children.
The app they designed will decrease training time for new health promoters and allow the program to expand. The goal is to distribute the app globally to help programs in other countries tackle malnutrition.
Children in crisis
As recently as 2005, about one of every 20 children in this rural area of Guatemala died before their 5th birthday. Almost half the deaths were associated with severe malnutrition.
“The death of any child is always a tragedy, but the death of any child from preventable causes is always unjust,” said Wise, a Stanford Health Policy core faculty member.
Along with other faculty from the Freeman Spogli Institute for International Studies (FSI) and the School of Medicine, Wise created the Children in Crisis Initiative to save the lives of children in areas of poor governance. The program brings together Stanford researchers and students across disciplines.
Nowhere are their efforts better illustrated than in the rural communities around San Lucas Tolimán, in the central mountains of Guatemala.
The program’s effectiveness rests on a deep respect for the local communities merged with innovation by Stanford researchers.
“It’s absolutely essential to any program that the people in need be part of the solution,” said Wise. Unlike many nongovernmental organizations and health programs, Wise believes the way to create a sustainable health system is for the locals to run it, so the health promoters manage the program’s day-to-day activities.
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This leaves the Stanford team free to focus on innovation – such as the new app. They believe the technology could change child health programs around the world. Wise’s team has partnered with Medic Mobile – a nonprofit that creates open-source software for health care workers – which plans to distribute the app to other areas suffering from malnutrition.
The six Android tablets purchased by Children in Crisis are enough to monitor the program’s 1,500 kids through the app.
Role of nutrition
When done well, nutrition surveillance is very effective at decreasing child mortality in poor countries.
“Nutrition contributes enormously to health and well-being,” Wise said as he walked through Tierra Santa, a small community near San Lucas, making house calls. “So the focus of our work turned to improving young child nutrition. It’s not an easy thing to do in a place that’s extremely poor.”
Wise and his colleagues – Stanford medical student Tori Bawel and Stanford professor of pediatrics Lisa Chamberlain – made their rounds during their visit in March. Evidence of poverty was everywhere.
Here, clean tap water is a dream and even the sturdier homes often lack four walls or paned windows, though the children were neatly dressed in T-shirts or colorful traje, traditional Mayan clothing.
It’s hard to provide proper nutrition when most families can’t find enough work to buy adequate food. But a little help can make a big difference.
Bawel, a first-year medical student who plans a career improving health in areas of poverty, was struck by the impact the promoter program has had on the community.
“There are children who need supplements and nutrition to stay alive,” she said. “Without this program, that infrastructure does not exist.”
With FSI’s assistance, the nutrition program distributes Incaparina, a supplement of cornmeal, soy and essential nutrients. The sweet, mealy drink helps the program’s most malnourished children get back on track.
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Every two months, the promoters gather each community’s children to measure their weight and height. Children and their mothers sit patiently, waiting for their turn. The children enjoy a cup of Incaparina, and their mothers eagerly listen to the promoters’ tips for keeping their children healthy.
“It’s very important to me,” said Elsira Rosibel Samayoa, who brought her 2-year-old to be measured. “There are mothers who don’t understand the importance of monitoring their children’s weight, but I do.”
Since its implementation in 2009, the Stanford program has slashed nutrition-based mortality in the participating communities by about 80 percent and decreased severe malnutrition by more than 60 percent – saving hundreds of children’s lives.
However, nutrition surveillance and intervention isn’t easy. Tracking nutrition takes training and expertise, and when the local population rarely exceeds a fourth-grade education, learning these skills is especially challenging. Detailed graphs on a standard growth chart are essential to identifying malnourished children.
“The community health workers are extremely capable and smart, but some have never seen a graph before,” said Wise. “Think about what it is to try to explain a graph to someone for the first time.”
It takes the health workers about three years to learn to graph and then interpret the results for intervention.
Wise said, “So we all got together and said, ‘How do we make this easier to do?’”
The app was the answer.
‘Let’s create an app’
Enter Alejandro Chavez, a recent Stanford computer science graduate and Stanford Health Policy research assistant. He developed the app to collect child health data, then determine the child’s degree of malnutrition and suggest intervention.
“The major goal was to lower training requirements and make programs like this simpler to start and maintain,” said Chavez, who now lives and works in Guatemala, where he gets daily feedback from the health promoters.
“I feel like they’ve been very honest with me about things I need to improve,” he said.
Cesia Lizeth Castro Chutá is a senior coordinator for the program who has worked with Chavez to ensure that the app meets the promoters’ needs.
“The tablet automatically generates the information we need to know,” she said. “It becomes easier to confirm that a child is malnourished and needs supplements.”
Looking forward
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With the app’s launch, it looks like training time for the promoters will be reduced from three years to less than six months. That means new communities can be incorporated into the program quickly, creating broader access to care.
Meanwhile, many health programs around the world are waiting to see how well the Stanford app works in Guatemala.
Josh Nesbit, a Stanford alumnus and Medic Mobile CEO, said, “As more health programs recognize the importance of nutrition and implement community-based interventions, screening and surveillance tools will be critical. We must learn from Dr. Wise’s success.”
Could out of pocket drug costs be responsible for pandemics? In this Public Health Perspectives article, Marcella Alsan discusses how copayments for antibiotics can cause people in poor areas to turn to unregulated markets.
On May 26, 2016, researchers at the Walter Reed National Military Medical Center reported the first case of what they called a “truly pan-drug resistant bacteria.” By now, the story has been well-covered in the media: a month earlier, a 49 year old woman walked into a clinic in Pennsylvania with what seemed to be a urinary tract infection. But tests revealed something far scarier—both for her and public health officials. The strain of E. Coli that infiltrated her body has a gene that makes it bulletproof to colistin, the so-called last resort antibiotic.
Most have pinned the blame for the impending doom of a “post-antibiotic world” on the overuse of antibiotics and a lack of new ones in the development pipeline. But there’s another superbug incubator that hasn’t gotten the attention it deserves: poverty.
Last month at the IMF meeting in Washington, D.C., UK Chancellor George Osborne warned about the potentially devastating human and economic cost of antimicrobial resistance. He called for “the world’s governments and industry leaders to work together in radical new ways.” But Gerry Bloom, a physician and economist at the Institute for Development Studies, argued that any measures to stop overuse and concoct new drugs must be “complemented by investments in measures to ensure universal access to effective antibiotic treatment of common infections.”
“In many countries, poor people obtain these drugs in unregulated markets,” Bloom said. “They often take a partial course and the products may be sub-standard. This increases the risk of resistance.”
For at least fifteen years, we’ve known about these socioeconomic origins of antimicrobial resistance. Other studies have revealed problems with mislabeled or expired or counterfeit drugs. But the clearest link between poverty and the rise of antimicrobial resistance is that poor people may not see a qualified health care provider or complete a course of quality antibiotics. Instead, they might turn to unregulated markets for substandard drugs.
But why do people resort to unregulated markets or take drugs that aren’t that great if they are available? Marcella Alsan, an assistant professor of medicine at the Stanford School of Medicine who studies the relationship between socioeconomic disparities and infectious diseases, led a study that answered this question. In last October’s Lancet Infectious Diseases, Alsan and her colleagues showed that it might have a lot to do with requiring copayments in the public sector. To show this, they analyzed the WHO’s 2014 Antibacterial Resistance Global Surveillance report with an eye toward the usual suspects, such as antibiotic consumption and antibiotic-flooded livestock.
The U.S. government has invested $1.4 billion in HIV prevention programs that promote sexual abstinence and marital fidelity, but there is no evidence that these programs have been effective at changing sexual behavior and reducing HIV risk, according to a new Stanford University School of Medicine study.
Since 2004, the U.S. President’s Emergency Fund for AIDS Relief, known as PEPFAR, has supported local initiatives that encourage men and women to limit their number of sexual partners and delay their first sexual experience and, in the process, help to reduce the number of teen pregnancies. However, in a study of nearly 500,000 individuals in 22 countries, the researchers could not find any evidence that these initiatives had an impact on changing individual behavior.
Although PEPFAR has been gradually reducing its support for abstinence and fidelity programs, the researchers suggest that the remaining $50 million or so in annual funding for such programs could have greater health benefits if spent on effective HIV prevention methods. Their findings were published online May 2 and in the May issue of Health Affairs.
“Overall we were not able to detect any population-level benefit from this program,” said Nathan Lo, a Stanford MD/PhD student and lead author of the study. “We did not detect any effect of PEPFAR funding on the number of sexual partners or upon the age of sexual intercourse. And we did not detect any effect on the proportion of teen pregnancy.
“We believe funding should be considered for programs that have a stronger evidence basis,” he added.
A Human Cost
Senior author Eran Bendavid, MD, said the ineffective use of these funds has a human cost because it diverts money away from other valuable, risk-reduction efforts, such as male circumcision and methods to prevent transmission from mothers to their children.
“Spending money and having no effect is a pretty costly thing because the money could be used elsewhere to save lives,” said Bendavid, an assistant professor of medicine at Stanford and a core faculty member at Stanford Health Policy.
PEPFAR was launched in 2004 by President George W. Bush with a five-year, $15 billion investment in global AIDS treatment and prevention in 15 countries. The program has had some demonstrated success: A 2012 study by Bendavid showed that it had reduced mortality rates and saved 740,000 lives in nine of the targeted countries between 2004 and 2008.
However, the program’s initial requirement that one-third of the prevention funds be dedicated to abstinence and “be faithful” programs has been highly controversial. Critics questioned whether this approach could work and argued that focusing only on these methods would deprive people of information on other potentially lifesaving options, such as condom use, male circumcision and ways to prevent mother-to-child transmission, and divert resources from these and other proven prevention measures.
Abstinence, Faithfulness Funding Continues
In 2008, when President Barack Obama came into office, the one-third requirement was eliminated, but U.S. funds continued to flow to abstinence and “be faithful” programs, albeit at lower levels. In 2008, $260 million was committed to these programs, but by 2013 by that figure had fallen to $45 million.
Spending money and having no effect is a pretty costly thing because the money could be used elsewhere to save lives.
Although PEPFAR continues to fund abstinence and faithfulness programs as part of its broader behavior-based prevention efforts, there is no routine evaluation of the success of these programs. “We hope our work will emphasize the difficulty in changing sexual behavior and the need to measure the impact of these programs if they are going to continue to be funded,” Lo said.
While many in the medical community were critical of the abstinence-fidelity component, no one had ever analyzed its real-world impact, Lo said. When he presented the results of the study in February at the Conference on Retroviruses and Opportunistic Infection, he received rousing applause from the scientists in the audience, some of whom came to the microphone to congratulate him on the work.
To measure the program’s effectiveness, Lo and his colleagues used data from the Demographic and Health Surveys, a detailed database with individual and household statistics related to population, health, HIV and nutrition. The scientists reviewed the records of nearly 500,000 men and women in 14 of the PEPFAR-targeted countries in sub-Saharan Africa that received funds for abstinence-fidelity programs and eight non-PEPFAR nations in the region. They compared changes in risk behaviors between individuals who were living in countries with U.S.-funded programs and those who were not.
The scientists included data from 1998 through 2013 so they could measure changes before and after the program began. They also controlled for country differences, including gross domestic product, HIV prevalence and contraceptive prevalence, and for individuals’ ages, education, whether they lived in an urban or rural environment, and wealth. All of the individuals in the study were younger than 30.
Number of Sexual Partners
In one measure, the scientists looked at the number of sexual partners reported by individuals in the previous year. Among the 345,000 women studied, they found essentially no difference in the number of sexual partners among those living in PEPFAR-supported countries compared with those living in areas not reached by PEPFAR programs. The same was true for the more than 132,000 men in the study.
Changing sexual behavior is not an easy thing. These are very personal decisions.
The researchers also looked at the age of first sexual intercourse among 178,000 women and more than 71,000 men. Among women, they found a slightly later age of intercourse among women living in PEPFAR countries versus those in non-PEPFAR countries, but the difference was slight — fewer than four months — and not statistically significant. Again, no difference was found among the men.
Finally, they examined teenage pregnancy rates among a total of 27,000 women in both PEPFAR-funded and nonfunded countries and found no difference in rates between the two.
Bendavid noted that, in any setting, it is difficult to change sexual behavior. For instance, a 2012 federal Centers for Disease Control analysis of U.S.-based abstinence programs found they had little impact in altering high-risk sexual practices in this country.
“Changing sexual behavior is not an easy thing,” Bendavid said. “These are very personal decisions. When individuals make decisions about sex, they are not typically thinking about the billboard they may have seen or the guy who came by the village and said they should wait until marriage. Behavioral change is much more complicated than that.”
Level of Education
The one factor that the researchers found to be clearly related to sexual behavior, particularly in women, was education level. Women with at least a primary school education had much lower rates of high-risk sexual behavior than those with no formal education, they found.
“One would expect that women who are educated have more agency and the means to know what behaviors are high-risk,” Bendavid said. “We found a pretty strong association.”
The researchers concluded that the “study contributes to the growing body of evidence that abstinence and faithfulness campaigns may not reduce high-risk sexual behaviors and supports the importance of investing in alternative evidence-based programs for HIV prevention in the developing world.”
The authors noted that PEPFAR representatives have been open to discussing these findings and the implications for funding decisions regarding HIV prevention programs.
Stanford medical student Anita Lowe was also a co-author of the study.
Bob Kocher
