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.
When is the last time you took a good, hard look at your health insurance options? Do you know what changes were made to your plan last year?
If the answer is “no,” you are not alone.
According to a new study by Maria Polyakova, assistant professor of health research and policy and Stanford Health Policy core faculty member, most Medicare Part D enrollees do not change their plans from year to year — even though plans can change drastically.
The study, recently published in the American Economic Journal: Applied, asserts that nudging consumers to re-evaluate their coverage could save them around $500 per year in out of pocket spending and premiums.
What is Medicare Part D?
Implemented in 2006, Part D allows Medicare users to purchase prescription drug coverage. Plans are administered by private insurance companies, but are heavily subsidized and regulated by the federal government. Consumers choose from more than 30 plans in their home state and are able to switch during a yearly open-enrollment period.
About 40 million people in the United States are enrolled in a Part D plan.
But Polyakova finds that “people do not seem to be switching contracts very often. At the same time, the contracts are changing quite dramatically every year.”
Though the study does not examine why consumers failed to switch, the data suggests that changing plans can be costly. Not necessarily a financial cost, but likely one of time or energy.
Thoroughly examining more than 30 plans on a yearly basis can be a burden, and changes are not always easy to detect.
“There are many other features of Part D plans that may change, so even if premiums appear the same, insurers may have changed other parts of coverage, such as deductible levels, co-pays and co-insurance, as well as which drugs are included,” said Polyakova.
Because the Part D market as a whole is dynamic, consumers can lose money even when their plan is stable.
“Even if your specific plan doesn’t change much, it is possible that it is not the best plan anymore because other plans change.”
Consumers tend to stick with the plan they picked when they first signed up. As a result, the study observes that individuals with similar needs may find themselves enrolled in very different plans if they made their first enrollment choices in different years.
This suggests that while most people likely try to pick the best coverage initially, they do not tend to re-evaluate their coverage each year in a way that fits their needs.
How can we improve coverage choices?
Polyakova believes that if the U.S. government were to more actively remind people to re-examine their plans during open enrollment, they could save consumers 20 to 30 percent.
Some researchers worry that improving individual choices and encouraging consumers to update their coverage could negatively affect the insurance market through “adverse selection.”
For example, individuals who are fairly healthy might tend to choose less generous plans than those who are relatively sick. If all those in poorer health end up in one plan, and there are no relatively low-spending enrollees to counteract the risk, the generous plan can become unsustainable.
However, the study finds evidence suggesting that for Part D, reminders to re-examine plans are unlikely to cause issues from adverse selection.
The federal government has implemented risk adjustment policies, or ways to combat the negative effects of adverse selection, that work to keep the market from unraveling. The government provides higher subsidies for sicker patients, pays the majority of patient costs and caps insurers’ profits and losses.
“From the point of view of the government, it seems that it is worthwhile to remind people who are already enrolled to reconsider their choices and potentially explain the differences across plans,” said Polyakova.
As the Affordable Care Act (ACA) changes coverage for Part D plans, reminding enrollees to re-examine their choices will become even more important. The ACA will substantially increase coverage, and plans could change considerably as a result.
What does this mean for the health insurance market?
While the study focuses specifically on Medicare Part D, Polyakova believes these findings likely translate to other areas of health insurance, particularly coverage under the ACA, which has many similar policies.
“The idea that we should remind consumers to re-evaluate plans has already been quite influential in the ACA policy debate,” said Polyakova. “Policymakers are tracking whether consumers are switching plans from one year to the next.”
She argues that in a consumer-driven economy, people must be able to easily make choices between products, in this case health insurance plans, for the market to function. But because choosing takes so much time and plan features are not always transparent, the forces driving the market may become weak.
Educating people about the financial benefits of switching plans could help the insurance market get back on track.
“People should try to reconsider their health risk and their insurance choices during every enrollment period,” Polyakova said. “Because if they don’t, it could have serious financial implications.”
It’s always great to see the work of one of our researchers shouted out in the New York Times. It’s even better when it becomes the scientific basis of an argument thrown into the mix of a presidential campaign.
Nicholas Kristof asserted in his column on Sunday that when women are involved in the political process and given the capacity to shape public policy, everyone benefits, particularly when it comes to health.
Kristof, who covers human rights, women’s rights, health and global affairs for the Times, wrote in his column:
Put aside your feelings about Hillary Clinton: I understand that many Americans distrust her and would welcome a woman in the White House if it were someone else. But whatever one thinks of Clinton, her nomination is a milestone, and a lesson of history is that when women advance, humanity advances.
Grant Miller of Stanford University found that when states, one by one, gave women the right to vote at the local level in the 19th and early 20th centuries, politicians scrambled to find favor with female voters and allocated more funds to public health and child health. The upshot was that child mortality rates dropped sharply and 20,000 children’s lives were saved each year.
Many of those whose lives were saved were boys. Today, some are still alive, elderly men perhaps disgruntled by the cavalcade of women at the podium in Philadelphia. But they should remember that when women gained power at the voting booth, they used it to benefit boys as well as girls.
Miller, an associate professor of medicine and core faculty member of Stanford Health Policy, first wrote about this issue in the Quarterly Journal of Economics in 2008, arguing that women’s choices appear to emphasize child welfare more than those of men.
He presented evidence on how state-to-state suffrage rights for U.S. women from 1869 to the adoption of the 19th Amendment in 1920, which gave all women the right to vote, helped children benefit from scientific breakthroughs.
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Simple hygienic practices — including hand and food washing, boiling water and milk, refrigerating meat and the renewed emphasis on breastfeeding — were among the most important innovations in the 19th and early 20th centuries to help protect children from often-fatal diseases such typhoid fever, smallpox, measles and scarlet fever.
As women became more and more involved in state and federal politics, Miller found, child mortality declined by 8 to 15 percent, or 20,000 fewer child deaths each year.
“Public health historians clearly link the success of hygiene campaigns to the rising influence of women,” Miller wrote, citing examples with data and graphs.
That women have been — and can be — so influential seems like a no-brainer, but it’s nice to have the science to back it up.
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.
The Supreme Court struck down parts of a Texas law that imposed standards on abortion providers that had the effect of reducing the number of abortion facilities in the state by at least half. In a 5-3 ruling in which Justice Anthony Kennedy joined the liberal wing of the Court, the justices said the restrictions placed an undue burden on a woman’s constitutional right to seek an abortion. The 2013 law required all abortion facilities to meet state standards for ambulatory surgical centers (ASCs) and required doctors performing abortions to have admitting privileges at a nearby hospital.
Justice Stephen G. Breyer wrote in the majority opinion, “We conclude that neither of these provisions offers medical benefits sufficient to justify the burdens upon access that each imposes. Each places a substantial obstacle in the path of women seeking a pre-viability abortion, each constitutes an undue burden on abortion access, and each violates the Federal Constitution.”
Michelle Mello, a professor of health research and policy at the Stanford School of Medicine and professor of law at Stanford Law School, as well a core faculty member of Stanford Health Policy, was a signatory to a brief submitted to the Supreme Court by public health academics and the American Public Health Association in support of the abortion providers’ challenge.
What was the main argument of the amici curiae brief submitted to the Supreme Court by public health academics and organizations?
There were two critical factual points that had to be made. First, although the Texas law’s provisions were putatively adopted to benefit women’s health, they actually had no medical benefit. Second, the law had a rapid, dramatic effect on access to abortion in Texas. Particularly because in Texas several other restrictions already limited access to abortion and funding for family planning services was scant, this poses a real threat to public health.
Can you say more about why the provisions of the law did not protect women’s health?
The standards were completely unnecessary. Abortion is an extremely safe procedure; complications rarely occur. The facilities already had protocols in place to ensure safe transfer to hospitals in the event of an emergency. But when complications do occur, they usually arise after the woman returns home, so transfer from the facility to the hospital isn’t an issue. And there’s no reason a woman needs to receive emergency care from the same doctor who performed the abortion.
Many of the standards for ASCs are simply irrelevant to providing safe abortions. Many abortions aren’t surgical, they’re medical (chemical). And standards relating to things like providing general anesthesia, avoiding infections to open wounds, having an advanced heating and air condition system, and having a particular traffic pattern from the operating room to the recovery room just don’t apply. The state’s argument about protecting women’s health was just a pretext.
It was a dangerous pretext, in fact, because these were standards that most abortion facilities clearly were not going to be able to meet. Many hospitals require doctors to admit a minimum number of patients in order to maintain admitting privileges, but abortion is so safe that abortion providers generally can’t do that. And fitting out a clinic to meet ASCs is prohibitively expensive. ASCs can afford it because they charge for expensive operations like cosmetic surgeries, hysterectomies, and hernia repairs; abortion providers can’t.
Why do you and the other signatories consider this a public health issue?
More than 60,000 Texas women per year obtain legal abortions. While we’d all like to see this number go down, you can’t restrict access to abortion while also failing to provide adequate support for other methods of family planning. History makes it abundantly clear that the result will be greater numbers of women resorting to illegal, unsafe abortions or facing the mental and physical health risks of carrying unwanted pregnancies to term.
Does the Supreme Court’s holding have implications beyond this case?
Yes, because the Court clarified how it will apply the “undue burden” standard of Planned Parenthood v. Casey in future cases. The majority said that courts must balance “the burdens a law imposes on abortion access” against “the benefits those laws confer.” The justices also clarified that appellate courts can take a deep dive into the factual evidence about a law’s effects presented earlier in the case. These holdings collectively make it harder for states to adopt abortion restrictions based on flimsy arguments about how they will benefit women.
Colorectal cancer is the second leading cause of death from cancer in the United States, after lung cancer, yet many Americans are still loathe to be screened for the disease.
The U.S. Preventive Services Task Force strongly recommended adults ages 50 to 75 to be screened for colon cancer and suggested adults 76 to 85 make individual decisions about whether to be screened, depending on their overall health and prior screening history. The recommendation and several accompanying editorials were published Wednesay in the Journal of the American Medical Association (JAMA).
The independent body of national experts in prevention and evidence-based medicine emphasized colonoscopy is not the only valid test out there. There are multiple screening options available to the one-third of Americans over 50 who have never been screened.
What is the most significant finding of this final recommendation?
Colorectal cancer is the second leading cause of death from cancer in the United States. The good news is that evidence convincingly shows screening for colorectal cancer works. The Task Force strongly recommends screening adults 50 to 75 for colorectal cancer, as it reduces the risk of dying from the disease. Unfortunately, one-third of people 50 to 75 have never been screened, so we are missing an important opportunity to prevent deaths from colorectal cancer.
There are multiple screening options for colorectal cancer. What are they and how should individuals decide which is best for them?
What really matters is that people get screened. There are several options that are effective, so we recommend that people discuss the options with their clinician. There are direct visualization tests, like colonoscopy, and stool-based tests, like fecal immunochemical testing (FIT). Each test has different strengths and limitations, and people may prefer one approach over another. For example, colonoscopy can be done every 10 years, but FIT testing should be done every year. But the real message is, choose an approach in consultation with your clinician and get screened.
The Task Force found that once adults reach 76 years old, the benefits of screening become smaller and the potential for harm is greater. Why is this and how should older Americans determine which test is best for them?
We recommend individual decision making for patients 76 to 85. The benefits are smaller because a person’s chance of dying of other causes goes up as they get older. The harms are still small but increase with age, primarily because the risks of the potential complications of colonoscopy (bleeding, perforation, and infection) go up with age. Still, some people in this age group will benefit from screening. People most likely to benefit are those who have not been screened before, people who are healthy enough to undergo treatment for CRC should it be found, and people who do not have other diseases or conditions that limit their life expectancy substantially.
Owens explains the Task Force's recommendations to JAMA
African-Americans have the highest incidence of and mortality rates from colorectal cancer among all racial and ethnic subgroups. Why are African-Americans more susceptible and does this mean that the screening recommendations differ for them?
The Task Force recognizes the burden that colorectal cancer has on African-Americans, who are at higher risk of being diagnosed with and dying from the disease than other racial/ethnic subgroups. We don’t know why this is — more research is needed in this area. The Task Force did not find enough evidence to conclusively support that making a different recommendation specific to African-Americans would result in a greater net benefit for this population. So our recommendations are intended to apply to all racial/ethnic groups. More robust efforts are needed to ensure that at-risk populations actually receive the screening tests and the follow-up treatments or interventions they need, as people are dying unnecessarily from this disease.
What data did the Task Force use to come to its conclusions?
The Task Force commissioned a comprehensive systematic review of the available evidence on the benefits and harms of colorectal cancer screening. The Task Force also commissioned a modeling study from the Cancer Intervention and Surveillance Modeling Network (CISNET) to help it better understand different screening strategies, such as the optimal age to start or stop screening, and the length of time between screenings. The evidence is convincing that screening reduces the risk of dying from colorectal cancer.
Who is at high risk for colorectal cancer?
The Task Force’s recommendation is for people at average risk of colorectal cancer. People at high risk include those with a history of genetic predisposition to colorectal cancer (including people with Lynch syndrome and familial adenomatous polyposis), and people with a personal history of inflammatory bowel disease, a previous adenomatous polyp, or previous colorectal cancer. Other groups have developed guidelines for people a high risk, including the U.S. Multisociety Task Force and the American Cancer Society.
How can precision health help colorectal cancer prevention?
The Task Force did not address how precision health might play a role in the future. However, we do know that although most cases of colorectal cancer are sporadic, with about 75 percent developing in average risk persons, there are inherited syndromes that increase the risk of colorectal cancer. The inherited familial syndromes, defined by a mutation in a known high-risk cancer susceptibility gene, that increase the risk of colorectal cancer include Lynch syndrome and familial adenomatous polyposis. Family history that is not linked to a known inherited risk syndrome is also a risk factor for colorectal cancer, with an average two- to four-fold increase in risk compared to those people who do not have a family history of colorectal cancer. Understanding more about the causes of this increase in risk is an important area for future research.
What can help reduce one’s risk for colorectal cancer?
The Task Force released a final recommendation in April 2016 on the use of aspirin to prevent colorectal cancer in people with an elevated risk of cardiovascular disease. For adults ages 50 to 59 years with a greater than 10 percent risk of a cardiovascular event, a life expectancy of at least 10 years, who are not at increased risk for bleeding, and who are willing to take a daily aspirin for at least 10 years, the Task Force recommends the daily use of low-dose aspirin. In this group, aspirin reduces both the risk of cardiovascular disease and the risk of colorectal cancer. It’s important to recognize that the Task Force’s recommendation on colorectal cancer screening is a complement to this recommendation, but neither is a replacement for the other. The Task Force is not suggesting that anyone should use aspirin in place of colorectal cancer screening. Colorectal cancer screening is an important, well-proven preventive intervention that reduces the risk of dying from colorectal cancer.
What symptoms usually present for patients with polyps or colorectal cancer?
It’s important to understand that people with colorectal cancer may have no symptoms whatsoever, and the Task Force’s recommendations are for people without symptoms. Symptoms can include blood in the stool or a change in bowel habits. If people have such symptoms, they should discuss them with their clinician.
What treatment options are available for people diagnosed with colorectal cancer? How have these options changed over time?
The Task Force did not examine treatment options in its final recommendations, as its focus is solely on preventive services such as screening. However, based on my professional experience I can attest that treatment depends on the extent of cancer and may involve surgery, chemotherapy, and radiation therapy.
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.
Bob Kocher
