As millions marched against gun violence across the country on Saturday, research by Stanford Health Policy experts about the impact of gun ownership on public health was also in the spotlight.

The Washington Post published an in-depth story about how the work of gun researchers is finally getting attention — an unfortunate consequence of the recent mass shootings in the United States.

David Studdert — a professor of medicine and law — and Yifan Zhang, a biostatics and data analyst with Stanford Health Policy, along with seasoned gun researcher Garen Wintemute of UC Davis’s Violence Prevention Research Program, are trying to answer the question: Are you more or less likely to die if you own a firearm?

“The explosion of national interest in the problem of gun violence since the Parkland shooting has been remarkable,” said Studdert, who is also a core faculty member at Stanford Health Policy.  “And it is inspiring to hear students’ voices — that is definitely a new twist in the politics around this issue. I think there is momentum for change, but I remain pessimistic that we will see the enactment of any substantial reforms at the federal level.”

The Post wrote:

Studdert’s group is using a data set unique to California because of the state’s strict gun laws. Every time a gun is sold in California, a background check logs the purchase and purchaser with California authorities, who also have been unique in their willingness to share such politically fraught data with academic researchers.

Using a sample of 25 million people (taken from California’s voter registration records), Studdert’s team plans to identify handgun owners with the firearm sales records, then compare that against state death records.

The resulting data in theory will help them determine the relationship — whether good or bad — between gun ownership and death.

They call the project LongSHOT, a nod to the project’s scale and ambition.

Academic researchers who were studying the impact of gun violence on public health were dealt a huge financial and political blow in 1996, when the so-called Dickey Amendment was passed by Congress under pressure from gun lobbyists. The law forbids the Centers for Disease Control and Prevention to fund research that might be seen as advocating for gun control. This choked off federal grant money and essential data-gathering on gun violence.

But tucked into the government spending bill in Congress last week was language that indicates the CDC now has the authority to conduct research on the causes and effects of gun violence. Though gun researchers are skeptical that the change in tone will lead to any significant support or funding, some believe that it’s a start. The $1.3 trillion government funding measure also includes efforts to improve state compliance with the national background check system, as well as funding for school counseling and safety programs.

Again, from The Post story:

Yifan Zhang was finishing her PhD in biostatistics at Harvard five years ago when news broke of the Sandy Hook Elementary School shooting.

As a graduate student from China, specializing in highly technical design of clinical drug trials, she had little connection to America’s long-running debate over gun violence. But even now, she said, the anguished faces of those parents she saw on television remain seared in her memory.

So when she heard about a gun-violence research project at Stanford University that could use the statistical skills she had honed on pharmaceuticals, she jumped at the chance.

“I have a son who just turned 1,” said Zhang, 31. “When I think about what I will need to teach him about protecting himself, I think about that school shooting.”

Zhang hopes the Stanford team can one day have an impact.

“I think there are going to be some big decisions that the whole country has to make together, and I’m hoping that our research can help provide evidence and information for the decision making,” she said.

Health care has become the largest sector of the global economy, now accounting for more than 10 percent of Gross World Product, or $7.5 trillion. And it’s only going to get bigger as economists expect that figure to approach $18 trillion in two decades.

And yet, the quality of care and health outcomes are not keeping pace.

Ashish K. Jha — a leading expert on health policy and director of the Harvard Global Health Institute — calls this a “critical moment” in health care as the standard of care increasingly becomes more important than the number of people who have health coverage around the world.

“The point is, coverage is not coverage is not coverage. All health financing schemes are not the same,” said Jha, noting that China and Canada have universal coverage for its citizens, but many still receive inadequate health care or are going broke due to the high cost of special medical needs.

“In many places, the problem is the shallowness of the coverage.  Everyone may be covered — but if you get really sick, shallow coverage gets people into trouble,” said Jha, a keynote speaker at the annual Global Health Economics Colloquium, which brings together health economists and policy experts from University of California San Francisco, UC Berkeley and Stanford Health Policy to discuss recent developments in their fields.

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The fifth colloquium identified the health needs of vulnerable populations and developing cost-effective and scalable interventions to improve the health of socially and economically disadvantaged people here in the United States and in low- and middle-income countries.

“Our hope for the day is that our speakers will remind us why we do what we do, remind us why we support evidence-based policies, and most of all to inspire us at a time of this geopolitical craziness and why we must continue to persist,” Dhruv Kazi, a cardiologist and health economist at UCSF, who opened the daylong event.

Rising cost of global health care

Global health-care spending is so massive due to several key factors, Jha told the audience: the unprecedented rapid expansion of people moving into the middle class and the rise in treatments, drugs and medical technologies.

And while these are all positive movements, he said, as the world becomes more interdependent, it “behooves us to act” quickly so that health coverage and quality keep up.

At the end of 2016 there were 3.2 billion people in the global middle class; on average 160 million will join the middle class annually for the next five years, heavily concentrated in Asia.

So the two goals of universal health care should be financial protection and improved health.

But Jha noted that while 90 percent of China’s 1.4 billion people are covered by its national health care system, some 18 percent of Chinese are still thrown into poverty by the incidence of catastrophic health spending above and beyond what the government provides. That is nearly 8 percent higher than the global incidence of catastrophic spending, which stands at 11.7 percent.

India, by contrast, does not have a universal health-care system and only 20 percent of it 1.3 billion people have some form of health insurance. But it also has a 17-percent incidence of catastrophic health spending.

“Catastrophic payment incidence cannot be inferred from the fraction of the population covered by health insurance schemes or public health services,” Jha said, quoting a recent Lancet study.

It stands to reason that the health outcomes of those in countries with universal health care should have improved. But most studies show that that is not the case; the reason?  The quality just isn’t there.

Unsafe medical care top cause of deaths

Nearly 43 million injuries are caused in hospitals each year around the world, leading to 23 million years of healthy living that is lost among the world’s population.

“Unsafe medical care is probably one of the top 10 causes of death and disability in the world,” Jha said.

Jha wondered if quality of care isn’t a bigger problem than access to care.  For example, in one of India’s poorer rural states, Madhya Pradesh, there are 11 health-care providers within walking distance of every village, a fairly large number of private providers.

“Yet half of them have no formal training, they didn’t go to any school but they call themselves doctors,” Jha said.

And in the capital of India, New Delhi, public-sector physicians who are well trained are so overworked they spend an average of 2.5 minutes and ask one question per patient.

Ideally, universal health care must be effective and consistent with best professional practices while meeting the needs of the individual patient.

“Global health policy leaders have made universal health coverage an overarching priority.  This is a good thing.  But in order for UHC to improve the health of the world’s poor, we need to ensure people get good care. And that is the biggest challenge of all.”

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Stanford Health Policy's Paul Wise — the Richard E. Behrman Professor of Child Health and Society — traveled to Iraq last year with a small delegation of physician-academics to evaluate the World Health Organization's system to treat civilians injured in the battle for Mosul. The northern city controlled by the Islamic State in 2014 was retaken by government forces last year and the team visited field hospitals to review health care on the ground and determine whether there is a better way to distribute medical aid during armed conflict.

We wrote about their visit in November.

Now, the team members have published their findings in an in-depth report put out by Johns Hopkins University's Center for Humanitarian Health.

The Lancet also has published an editorial about their research to coincide with the release of the report.

"The Battle of Mosul provides an important case study for what might be to come," the editorial board wrote. "Above all, this should be a very rare occurrence, and The Lancet echoes the evaluation's recommendation that governments, and possibly their allies, must ensure their militaries can fulfill the obligations of protection and care for wounded citizens under the Geneva Conventions. However, in modern warfare, access to the injured may increasingly be one-sided when fighting against warring factions that see health workers and civilians as acceptable targets of war. Governments should be prepared to face this eventuality. To be able to continue providing the best standards of care and saving lives, a high-level meeting must urgently be organized to examine and answer this question: are the humanitarian principles as they are defined today still relevant for this changing warfare?"

Some of the key findings of the report include: 

• Between 1500-1800 lives, both military and civilian, may have been saved through this trauma response.
• By attempting to apply Western military standards of trauma care and ‘moving forward’ towards the frontline to save civilians lives, WHO and its partners challenged existing humanitarian principles, particularly those of neutrality and independence.
• The Iraqi government and its military did not have medical capacity to fulfill their obligations to protect and care for wounded civilians on the Mosul battlefield, and the U.S.-led coalition did not provide substantial medical care for wounded civilians.
• WHO-supported field hospitals filled important gaps in trauma surgical care, while post-operative and rehabilitative care warranted greater support.
• Successful coordination among local leaders, partners, and civilian and military officials occurred, but field coordination could have been better resourced.

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And some of the key recommendations:

• Warring factions, and those supporting them, need to enhance the former’s medical capacities to ensure they can fulfill their obligations under the Geneva Conventions and Additional Protocols.
• Deliberation is needed regarding the benefits to and the moral obligations of governments who support such warring factions, like the U.S.-led coalition in the Mosul battle.
• Humanitarians must take care to avoid being instrumentalized by governments or military in future conflicts.
• Medical teams operating directly with a combatant force should not be identified as humanitarian;
• Frontline medical services could be provided by specialized groups explicitly trained to work directly with combatant forces, possibly contracted as military support services focusing on providing frontline medical services for both injured soldiers and civilians.
• Using private medical organizations (i.e., contractors) to provide humanitarian services in conflict settings needs further study. 
• How humanitarian actors can apply standards of trauma care that compel them to move towards the frontline to save lives, and still adhere to longstanding humanitarian principles, needs debate at senior levels such as at the Inter Agency Standing Committee or at the intergovernmental level.

Screening all adults for hepatitis C virus infection (HCV) is a cost-effective way to improve clinical outcomes of HCV and identify more infected people compared to current recommendations, according to a new study by SHP’s Joshua Salomon and colleagues.

Using a simulation model, Salomon, a professor of medicine and core faculty member at Stanford Health Policy, and researchers from Boston Medical Center (BMC) and Massachusetts General Hospital (MGH) found that this expanded screening would increase life expectancy and quality of life while remaining cost-effective.

The infectious disease primarily attacks the liver. It is believed that one-in-30 Baby Boomers — born between 1945 and 1965 — have HCV, but don’t even know it because it can take years before symptoms emerge. The Centers for Disease Control and Prevention currently recommends HCV testing for boomers, but testing rates in this group remain relatively low, and recent trends show a higher incidence rate of HCV among young people.

“Testing all adults would lead to earlier diagnosis and treatment for many people, which would help to prevent cirrhosis and other long-term complications,” says Salomon, co-senior author of the study published in Clinical Infectious Diseases. “Overall, when you consider both the better health outcomes and the reduced costs of managing long-term liver disease, expanded testing offers excellent value for money.”

To address the potential benefits of changing the testing recommendations, the researchers created simulations to estimate the effectiveness of HCV testing strategies among different age groups. They compared effects of the current testing recommendations; of testing people over 40 years old or over 30 years old, and of testing all adults over 18 years old. All strategies included the current recommendations for targeted testing of high-risk individuals, such as people who inject drugs.

The study found that screening all adults would identify more than 250,000 additional people with HCV, increase cure rates from 41 to 61 percent, and reduce death rates for HCV-attributable diseases more than 20 percent, compared with current recommendations.

“When we expanded testing, the results were compelling,” says Joshua Barocas, lead author on the study and an infectious disease physician at MGH and an instructor in medicine at Harvard Medical School. “Changing the current recommendations could have a major public health impact, improving the quality of life for young people with HCV, and reducing death rates.”

The research team used data from national databases, clinical trials, and observational cohorts to inform their simulation models, which captured the details and dynamics of U.S. population demographics and HCV epidemiology.

All of the age-based strategies decreased costs related to managing chronic HCV and advanced liver disease, but the strategy of testing all adults was most effective. Even in a simulated scenario that required twice as much testing among uninfected people to identify the same number of HCV cases, the testing-all-adults strategy remained cost-effective.

Researchers say these findings should be considered by the CDC for future recommendations on HCV testing.

“Due in part to the opioid epidemic and the increase in injection drug use, the country has seen an increase in cases of HCV among young people,” says Benjamin Linas, MD, co-senior author of the study and infectious disease physician at BMC and an associate professor of medicine at Boston University Medical Center. “The CDC could address this public health concern by recommending all adults receive a one-time HCV test.”

The study was published online in Clinical Infectious Diseases and was funded by the National Institute on Drug Abuse at the National Institutes of Health, the MGH Fund of Medical Delivery and the U.S. Centers for Disease Control and Prevention.

At age 94, with an extensive collection of health policy research and publications under his belt, Victor Fuchs has a lot to say about the health care system.

The high cost. The uninsured. The fragmentation.

During a speech at the Stanford Institute for Economic Policy Research (SIEPR), the pioneering health economist narrowed his gaze to whether a single-payer system is the fix to those problems.

The answer is complicated, and it depends on the questions behind the question, said Fuchs, a SIEPR Senior Fellow and the Henry J. Kaiser, Jr., Professor of Economics and Health Research and Policy, emeritus. He is also a senior fellow at the Freeman Spogli Institute for International Studies and a core faculty member at Stanford Health Policy.

Recent challenges to the Affordable Care Act have rekindled a debate over the merits of a single-payer health care system — where one entity, namely the federal government, would foot the bill for essential services for all — and Fuchs spoke at SIEPR to succinctly explain what a single-payer system could achieve, what would probably never happen, and why.

The problem, Fuchs pointed out, is that the United States spends the most of any high-income country on health care, yet Americans are not achieving better health outcomes. Part of the solution would have to address the nation’s higher administrative costs, higher prices for prescription drugs, and the expensive increasing mix of services and specialists.

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Fuchs contended a single-payer system would lower costs. For one, it would create the bargaining power needed to offset the monopolistic powers of those providing the drugs, medical services and equipment.

To control costs, “we must move to something like a single-payer plan, but that alone will not be sufficient,” Fuchs said. “It will depend on what kind of single-payer plan it is.”

Even as it provides for universal health care insurance coverage, a single-payer system could take on various forms, including a blend of private and public controls.

And to have any chance at success, Fuchs said, the single-payer system would have to be simple, require minimum bureaucracy, and provide choice.

Then comes the rub, of course: The political will has historically tread against single-payer.

Americans are not willing to provide subsidies for those too poor to afford health insurance; neither do they have a compulsion for everyone to acquire coverage and contribute to those subsidies.

“The country as a whole has not been willing to fully embrace these two principles,” he said. “And I feel you need to have a strong majority of both if you’re going to have universal coverage.”

And unfortunately, Fuchs added, he does not believe universal health coverage would necessarily improve health outcomes. Many other socio-economic and environmental factors also play a role there.

In leading a brief discussion with Fuchs, Mark Cullen, a SIEPR Senior Fellow and professor of medicine, asked what makes him think the federal government would work to control costs under a single-payer system — when it has thus far chosen to exert little buying power under the current structure.

“I have not discussed the political feasibility of this, deliberately,” Fuchs quipped.

You can learn more about Fuchs’ viewpoint in The Journal of the American Medical Association.

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