Many little girls imagine being a Disney princess, but few have the chance to live their dream. Josselin is one of the lucky few. She suffers from retinoblastoma and is blind, and what she wanted most for her 14th birthday was a princess party. The Make-A-Wish Foundation made her dream a reality with help from Dr. Lee Sanders, a member of her Stanford medical team and a CHP/PCOR core faculty member. Dressed as her Prince Charming, Sanders escorted the birthday girl, attired in a custom-made Belle ball gown, to her ballroom birthday party and shared her first dance to "Beauty and the Beast."  Says Josselin, "I can’t stop thinking about my big princess party. Now I feel happier than ever."

Despite potential legal and enforcement challenges, California’s new vaccination law may set a precedent for other states, according to Stanford scholars.

The law, SB 277, ends exceptions to vaccination mandates based on religious and philosophical beliefs, leaving only medical exemptions as a path to avoid the vaccinations children are required to have before entering school.

David Studdert, a core faculty member at the Center for Health Policy/Center for Primary Care and Outcomes Research, and Michelle Mello, a core faculty member of Health Research and Policy, authored a report on the new law along with Northwestern Law School’s Wendy Parmet, which appears today in the New England Journal of Medicine. Studdert and Mello are both professors of law and medicine at Stanford.

Studdert, Mello, and Parmet discuss four factors that led to passage of the law. Strong advocacy by several members of the California legislature was one factor.  Another was the state’s efforts to publicize data showing that personal belief exemptions have doubled since 2007, enough to endanger the community. In addition, there is mounting evidence that the recent measles outbreak at Disneyland could have been prevented by better vaccination compliance. Finally, supporters of SB 277 highlighted the risks unvaccinated school children pose to vulnerable classmates. According to the report, “the bill’s proponents focused on the specific threat to schoolchildren who are too medically fragile to receive vaccinations, effectively framing vaccine refusal as a decision that endangers others rather than a purely ‘personal’ one.”

SB 277 could place pressure on other states to tighten their exemptions for school-entry vaccination requirements. At this time, only West Virginia and Mississippi have legislation that prevents personal belief exemptions for vaccination. Adding California may give such laws national attention, and Studdert said that this development may be an “indication that politics are starting to shift.”

However, opponents of the law are likely to challenge it in court. Challengers may argue that the law impinges on their First Amendment rights to free exercise of religious beliefs or that it violates unvaccinated children’s right to access public schools.  However, Studdert “would be very surprised if SB 277 ends up being struck down as a result of such challenges.”  In the past, courts have ruled in favor of public health agencies in similar cases. “For over a century, appellate courts accepted arguments that mass vaccination is crucial to the well-being of the community.”

A more difficult challenge is enforcement of the law. Unvaccinated children can still attend school as long as their parents pledge to complete the children’s required vaccinations, and schools are not penalized for failing to follow up. The authors argue that “state laws should instead task health departments with enforcement responsibility for vaccination mandates” in order to boost compliance. “Willing providers,” or doctors who sympathize with vaccination opponents, may also undermine enforcement if they choose a broad interpretation of the medical exemption criteria. Other ways around the stricter requirements include home-schooling and nannies. This would not affect school safety but could have implications for the larger community.

Andres Moreno is not just unearthing the genetic backgrounds of many Latin Americans and Caribbeans. He’s also making sense of the history of this region, and piecing together a clearer genetic medical history of understudied populations. By looking at the genetic history of Mexicans, Cubans, Puerto Ricans, Dominicans, Hondurans and Colombians, Moreno’s research unearths these populations’ ties to Europe, native tribes and Africans, and serves as a way to understand the waves of migration in these populations.

And he’s able to do much of this work because of the Dr. George Rozenkranz Prize for Health Care Research in Developing Countries, given out by the Center for Health Policy/Center for Primary Care and Outcomes Research (CHP/PCOR) to a promising young researcher.

“The Rosenkranz Prize is such a unique opportunity to promote the work of some of Stanford’s most promising young investigators,” CHP/PCOR Director Douglas K. Owens, also a senior fellow at the Freeman Spogli Institute for International Studies and a professor of medicine, said. “We’ve had researchers from within our centers, and with Andres we have a Rosenkranz recipient who’s thinking about international health from a completely new angle for CHP/PCOR.”

The $100,000 prize is given to young Stanford researchers focusing on how to improve health care access in developing countries. The award’s namesake, George Rozankranz, 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 Rosenkranz Prize has allowed me to build research independence upon original ideas and collaborative efforts initiated in different regions throughout Latin America and the Pacific,” Moreno said. “These efforts are paving the way to conduct population and medical genomics research in populations from developing regions traditionally underrepresented in large-scale genetic projects.”

Moreno continued: “This is only the beginning though. There is much to do to bridge the gap between developed and developing countries in terms of biomedical research, so funding opportunities like the Rosenkranz Award are essential to tackle this problem.”

As part of this work, Moreno published article in PLOS Genetics in November 2013, with two more anticipated in 2014.

“In this publication we especially wanted to focus on people in the Caribbean,” Moreno said. “We felt that this region has been understudied in terms of genetic complexity, and wanted to know which part of Africa, Europe and a Native American tribal genes existed. And its implications for medicine.”

In understanding a person’s genetic history, a doctor can determine whether a patient has gene variants that correlate with a disease. For example, because Ashkenazi Jewish women have an increased likelihood of having breast and ovarian cancer, their health providers are more likely to monitor for these cancers. 

Moreno’s advisor and co-author on the PLOS papers, Stanford Genetics Professor Carlos Bustamente, described Moreno’s work on this project: “Andres was extraordinary in putting the data all together, developing algorithms and doing simulation work,” he said. Moreno would seek to understand the implications of their findings, think through how this would affect their design of the next round of experiments and  “translate it into future genetic studies and interpretation of genomes that come into the clinic.”

The findings also tell a historical story of the region. In the Caribbean, Moreno and his co-authors were able to pinpoint where in Africa particular segments of the population had come from and when they contributed to the genetic pool. The first wave of Africans came from the western tip of Africa (present day Senegal and Gambia), a region that was an original contributor for all African slaves. But another strand of African heritage also emerged in their studies—from Africa’s gold coast (Nigeria and the Gulf of Guinea). Moreno explained, “We can now genetically pinpoint when and where ancestry came from in Africa.”

Moreno said in looking at the populations, a major difference was between the genetic heritage of the island and mainland populations. In the case of the four islands, there were very consistent results of roughly the same date of European genes—about 500 years ago, which, Moreno pointed out, is exactly when colonization happened.

But in the mainland areas, Moreno and colleagues didn’t find European lines until two generations later, meaning Europeans first settled in the islands and then moved to the mainland.

Similarly, the Native American strands are distinct. Moreno and his co-authors believe that the Native American genes among the Caribbean populations are from inland Amazon tribes—a completely different Native American background than what’s typically found among Native American descendants in the United States.

Bustamente said Moreno has great breadth, commanding the whole operation—sampling in the field, collecting the data in the lab, doing the data scrubbing and analysis. Each of these tasks is typically undertaken by a different person. “He does all of this—and it gives him a real edge,” Bustamente said. “He thinks in a very integrated fashion. Plus he’s an MD!”

Kathryn McDonald, executive director for CHP/PCOR, said Moreno’s work represents the essence of the Rosenkranz Prize. “We really wanted this award to reach all angles of the Stanford health policy research community, and Andres embodies this. He’s expanding our understanding of health care and predisposition for diseases in a host of developing countries. It’s exciting—and such important—work.”

Teal Pennebaker is a freelance writer.