International Development

FSI researchers consider international development from a variety of angles. They analyze ideas such as how public action and good governance are cornerstones of economic prosperity in Mexico and how investments in high school education will improve China’s economy.

They are looking at novel technological interventions to improve rural livelihoods, like the development implications of solar power-generated crop growing in Northern Benin.

FSI academics also assess which political processes yield better access to public services, particularly in developing countries. With a focus on health care, researchers have studied the political incentives to embrace UNICEF’s child survival efforts and how a well-run anti-alcohol policy in Russia affected mortality rates.

FSI’s work on international development also includes training the next generation of leaders through pre- and post-doctoral fellowships as well as the Draper Hills Summer Fellows Program.

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Background

Cardiovascular diseases represent an increasing share of the global disease burden. There is concern that increased consumption of palm oil could exacerbate mortality from ischemic heart disease (IHD) and stroke, particularly in developing countries where it represents a major nutritional source of saturated fat.

Methods

The study analyzed country-level data from 1980-1997 derived from the World Health Organization's Mortality Database, U.S. Department of Agriculture international estimates, and the World Bank (234 annual observations; 23 countries). Outcomes included mortality from IHD and stroke for adults aged 50 and older. Predictors included per-capita consumption of palm oil and cigarettes and per-capita Gross Domestic Product as well as time trends and an interaction between palm oil consumption and country economic development level. Analyses examined changes in country-level outcomes over time employing linear panel regressions with country-level fixed effects, population weighting, and robust standard errors clustered by country. Sensitivity analyses included further adjustment for other major dietary sources of saturated fat.

Results

In developing countries, for every additional kilogram of palm oil consumed per-capita annually, IHD mortality rates increased by 68 deaths per 100,000 (95% CI [21-115]), whereas, in similar settings, stroke mortality rates increased by 19 deaths per 100,000 (95% CI [-12-49]) but were not significant. For historically high-income countries, changes in IHD and stroke mortality rates from palm oil consumption were smaller (IHD: 17 deaths per 100,000 (95% CI [5.3-29]); stroke: 5.1 deaths per 100,000 (95% CI [-1.2-11.0])). Inclusion of other major saturated fat sources including beef, pork, chicken, coconut oil, milk cheese, and butter did not substantially change the differentially higher relationship between palm oil and IHD mortality in developing countries.

Conclusions

Increased palm oil consumption is related to higher IHD mortality rates in developing countries. Palm oil consumption represents a saturated fat source relevant for policies aimed at reducing cardiovascular disease burdens.

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Globalization and Health
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CISAC
Stanford University
Encina Hall, E209
Stanford, CA 94305-6165

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Senior Fellow at the Freeman Spogli Institute for International Studies
Thomas C. and Joan M. Merigan Professor
Professor of Medicine
Professor of Microbiology and Immunology
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David A. Relman, M.D., is the Thomas C. and Joan M. Merigan Professor in the Departments of Medicine, and of Microbiology and Immunology at Stanford University, and Chief of Infectious Diseases at the Veterans Affairs Palo Alto Health Care System in Palo Alto, California. He is also Senior Fellow at the Freeman Spogli Institute for International Studies (FSI) at Stanford, and served as science co-director at the Center for International Security and Cooperation at Stanford from 2013-2017. He is currently director of a new Biosecurity Initiative at FSI.

Relman was an early pioneer in the modern study of the human indigenous microbiota. Most recently, his work has focused on human microbial community assembly, and community stability and resilience in the face of disturbance. Ecological theory and predictions are tested in clinical studies with multiple approaches for characterizing the human microbiome. Previous work included the development of molecular methods for identifying novel microbial pathogens, and the subsequent identification of several historically important microbial disease agents. One of his papers was selected as “one of the 50 most important publications of the past century” by the American Society for Microbiology.

Dr. Relman received an S.B. (Biology) from MIT, M.D. from Harvard Medical School, and joined the faculty at Stanford in 1994. He served as vice-chair of the NAS Committee that reviewed the science performed as part of the FBI investigation of the 2001 Anthrax Letters, as a member of the National Science Advisory Board on Biosecurity, and as President of the Infectious Diseases Society of America. He is currently a member of the Intelligence Community Studies Board and the Committee on Science, Technology and the Law, both at the National Academies of Science. He has received an NIH Pioneer Award, an NIH Transformative Research Award, and was elected a member of the National Academy of Medicine in 2011.

Stanford Health Policy Affiliate
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Abstract

Although the past few decades have seen rising incomes and increased government attention to rural development, many children in rural China still lack regular access to micronutrient-rich diets. Insufficient diets and poor knowledge of nutrition among the poor result in nutritional problems, including irondeficiency anaemia, which adversely affect attention and learning of students in school. Little research has been conducted in China documenting the prevalence of nutritional problems among vulnerable populations, such as school-age children, in rural areas. The absence of programmes to combat anaemia among students might be interpreted as a sign that the Government does not recognize its severity. The goals of this paper were to measure the prevalence of anaemia among school-age children in poor regions of Qinghai and Ningxia, to identify individual-, household- and school-based factors that correlate with anaemia in this region, and to report on the correlation between the anaemic status and the physical, psychological and cognitive outcomes. The results of a cross-sectional survey are reported here. The survey involved over 4,000 fourth and fifth grade students from 76 randomly-selected elementary schools in 10 poor counties in rural Qinghai province and Ningxia Hui Autonomous Region, located in the northwest region of China. Data were collected using a structured questionnaire and standardized tests. Trained professional nurses administered haemoglobin (Hb) tests (using Hemocue finger prick kits) and measured heights and weights of children. The baseline data showed that the overall anaemia rate was 24.9%, using the World Health Organization's blood Hb cut-offs of 120 g/L for children aged 12 years and older and 115 g/L for children aged 11 years and under. Children who lived and ate at school had higher rates of anaemia, as did children whose parents worked in farms or were away from home. Children with parents who had lower levels of education were more likely to be anaemic. The anaemic status correlated with the adverse physical, cognitive and psychological outcomes among the students. Such findings are consistent with findings of other recent studies in poor, northwest areas of China and led to conclude that anaemia remains a serious health problem among children in parts of China. © International Centre For Diarrhoeal Disease Research, Bangladesh.

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Journal of Health, Population and Nutrition
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Grant Miller

Encina Commons Room 180,
615 Crothers Way,
Stanford, CA 94305-6006

(650) 736-0403 (650) 723-1919
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LCY: Tan Lan Lee Professor
Professor, Health Policy
Professor Pediatrics (General Pediatrics)
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C. Jason Wang, M.D., Ph.D. is a Professor of Pediatrics and Health Policy and director of the Center for Policy, Outcomes, and Prevention at Stanford University.  He received his B.S. from MIT, M.D. from Harvard, and Ph.D. in policy analysis from RAND.  After completing his pediatric residency training at UCSF, he worked in Greater China with McKinsey and Company, during which time he performed multiple studies in the Asian healthcare market. In 2000, he was recruited to serve as the project manager for the Taskforce on Reforming Taiwan's National Health Insurance System. His fellowship training in health services research included the Robert Wood Johnson Clinical Scholars Program and the National Research Service Award Fellowship at UCLA. Prior to coming to Stanford in 2011, he was an Assistant Professor of Pediatrics and Public Health (2006-2010) and Associate Professor (2010-2011) at Boston University and Boston Medical Center. 

Among his accomplishments, he was selected as the student speaker for Harvard Medical School Commencement (1996).  He received the Overseas Chinese Outstanding Achievement Medal (1996), the Robert Wood Johnson Physician Faculty Scholars Career Development Award (2007), the CIMIT Young Clinician Research Award for Transformative Innovation in Healthcare Research (2010), and the NIH Director’s New Innovator Award (2011). He was recently named a “Viewpoints” editor and a regular contributor for the Journal of the American Medical Association (JAMA).  He served as an external reviewer for the 2011 IOM Report “Child and Adolescent Health and Health Care Quality: Measuring What Matters” and as a reviewer for AHRQ study sections.

Dr. Wang has written two bestselling Chinese books published in Taiwan and co-authored an English book “Analysis of Healthcare Interventions that Change Patient Trajectories”.  His essay, "Time is Ripe for Increased U.S.-China Cooperation in Health," was selected as the first-place American essay in the 2003 A. Doak Barnett Memorial Essay Contest sponsored by the National Committee on United States-China Relations.

Currently he is the principal investigator on a number of quality improvement and quality assessment projects funded by the Robert Wood Johnson Foundation, the National Institutes of Health (USA), Health Resources and Services Administration (HRSA), and the Andrew T. Huang Medical Education Promotion Fund (Taiwan).

Dr. Wang’s research interests include: 1) developing tools for assessing and improving the quality of healthcare; 2) facilitating the use of innovative consumer technology in improving quality of care and health outcomes; 3) studying competency-based medical education curriculum, and 4) improving health systems performance.

Director, Center for Policy, Outcomes & Prevention (CPOP)
Co-Director, PCHA-UHA Research & Learning Collaborative
Co-Chair, Mobile Health & Other Technologies, Stanford Center for Population Health Sciences
Co-Director, Academic General Pediatrics Fellowship

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Chief of Ophthalmology for the VA Palo Alto Health Care System
Assistant Professor, VA
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Dr. Pershing is on the ophthalmology faculty at Stanford University School of Medicine and serves as Chief of Ophthalmology for the VA Palo Alto Health Care System, with an academic career blending clinical practice, teaching, research, and administration.

Her research interests focus on analyses of ophthalmic epidemiology and delivery of ophthalmic health care services, as well as improved utilization of evidence-based medicine to determine cost-effectiveness and relative outcomes of ophthalmic treatments. Through this, she aims to provide additional information to policymakers and clinicians in order to optimize treatment choices. She is also interested in health care innovation – technology as well as quality and delivery systems. Dr. Pershing is active in big data initiatives and analysis, including collaborative projects at Stanford and serving on the American Academy of Ophthalmology (AAO) IRIS registry task force and as the AAO representative to the International Consortium for Health Outcomes Measurement (ICHOM).

She graduated from university summa cum laude in 2002, and with high honors from medical school in 2006. During medical school, she was elected to the Alpha Omega Alpha national medical honor society, served as chapter president in her final year, and was honored with the President’s Clinical Science Award, Merck Award for Academic Excellence, and American Medical Women’s Association Commendation. She subsequently completed ophthalmology residency at Stanford University, followed by an AHRQ fellowship in Health Care Research and Health Policy through the Center for Health Policy/Primary Care and Outcomes Research. She presently teaches medical students at Stanford and oversees eye care services at the Palo Alto VA Medical Center.

Dr. Pershing also serves on the national board of directors of the Alpha Omega Alpha medical honor society, with focus on resident initiatives, and mentors both medical students and undergraduate students (through the Stanford Immersion in Medicine series and VA clinical internships in ophthalmology). Dr. Pershing has had an interest in teaching since tutoring fellow students in college and medical school. She is currently co-director for the medical student ophthalmology clerkships, Ophth 300A and 301A and works with students on directed ophthalmology research and MedScholars projects.

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Background: The potential to save money within a short time frame provides a more compelling "business case" for quality improvement than merely demonstrating cost-effectiveness. Our objective was to demonstrate the potential for cost savings from improved control in patients anticoagulated for atrial fibrillation.

Methods and Results: Our population consisted of 67 077 Veterans Health Administration patients anticoagulated for atrial fibrillation between October 1, 2006, and September 30, 2008. We simulated the number of adverse events and their associated costs and utilities, both before and after various degrees of improvement in percent time in therapeutic range (TTR). The simulation had a 2-year time horizon, and costs were calculated from the perspective of the payer. In the base-case analysis, improving TTR by 5% prevented 1114 adverse events, including 662 deaths; it gained 863 quality-adjusted life-years and saved $15.9 million compared with the status quo, not accounting for the cost of the quality improvement program. Improving TTR by 10% prevented 2087 events, gained 1606 quality-adjusted life-years, and saved $29.7 million. In sensitivity analyses, costs were most sensitive to the estimated risk of stroke and the expected stroke reduction from improved TTR. Utilities were most sensitive to the estimated risk of death and the expected mortality benefit from improved TTR.

Conclusions: A quality improvement program to improve anticoagulation control probably would be cost-saving for the payer, even if it were only modestly effective in improving control and even without considering the value of improved health. This study demonstrates how to make a business case for a quality improvement initiative

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Circulation: Cardiovascular Quality and Outcomes
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Jeremy Goldhaber-Fiebert
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Obesity – and its related illnesses – endangers the lives of millions across the world. While healthier, more physically active lifestyles can mitigate this, the question remains of how policymakers can get people to switch from being couch potatoes to keen runner beans. This column presents new evidence suggesting that for many even a nudge may suffice.

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VoxEU
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Jeremy Goldhaber-Fiebert
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Background A growing body of evidence supports the role of type 2 diabetes as an individual-level risk factor for tuberculosis (TB), though evidence from developing countries with the highest TB burdens is lacking. In developing countries, TB is most common among the poor, in whom diabetes may be less common. We assessed the relationship between individual-level risk, social determinants and population health in these settings.

Methods We performed individual-level analyses using the World Health Survey (n = 124 607; 46 countries). We estimated the relationship between TB and diabetes, adjusting for gender, age, body mass index, education, housing quality, crowding and health insurance. We also performed a longitudinal country-level analysis using data on per-capita gross domestic product and TB prevalence and incidence and diabetes prevalence for 1990–95 and 2003–04 (163 countries) to estimate the relationship between increasing diabetes prevalence and TB, identifying countries at risk for disease interactions.

Results In lower income countries, individuals with diabetes are more likely than non-diabetics to have TB [univariable odds ratio (OR): 2.39; 95% confidence interval (CI): 1.84–3.10; multivariable OR: 1.81; 95% CI: 1.37–2.39]. Increases in TB prevalence and incidence over time were more likely to occur when diabetes prevalence also increased (OR: 4.7; 95% CI: 1.0–22.5; OR: 8.6; 95% CI: 1.9–40.4). Large populations, prevalent TB and projected increases in diabetes make countries like India, Peru and the Russia Federation areas of particular concern.

Conclusions Given the association between diabetes and TB and projected increases in diabetes worldwide, multi-disease health policies should be considered.

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International Journal of Epidemiology
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Jeremy Goldhaber-Fiebert
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