Stanford Health Policy is a joint effort of the Freeman Spogli Institute for International Studies and the Stanford School of Medicine
FSI’s researchers assess health and medicine through the lenses of economics, nutrition and politics. They’re studying and influencing public health policies of local and national governments and the roles that corporations and nongovernmental organizations play in providing health care around the world. Scholars look at how governance affects citizens’ health, how children’s health care access affects the aging process and how to improve children’s health in Guatemala and rural China. They want to know what it will take for people to cook more safely and breathe more easily in developing countries.
FSI professors investigate how lifestyles affect health. What good does gardening do for older Americans? What are the benefits of eating organic food or growing genetically modified rice in China? They study cost-effectiveness by examining programs like those aimed at preventing the spread of tuberculosis in Russian prisons. Policies that impact obesity and undernutrition are examined; as are the public health implications of limiting salt in processed foods and the role of smoking among men who work in Chinese factories. FSI health research looks at sweeping domestic policies like the Affordable Care Act and the role of foreign aid in affecting the price of HIV drugs in Africa.
Based on a nationwide field survey of “a thousand villages” in 30 Chinese provinces, this study employs the SF-8 global health status measure and the extended model of Grossman and its sequential probability regression to analyze the effects of public health, the access of basic medical services and the new rural cooperative medical system on the health of residents. The results show that the diagnostic and treatment level of village clinics has a marked effect on residents’ physiological health but no effect on their mental health; the distance from the nearest medical institution and the sewage discharge system have a fairly noticeable effect on all health indicators; drinking tap water has a positive effect on health; and the fund-raising level of the new rural cooperative medical system has little effect on the health of residents, with its effect typically seen in reducing the individual economic risks of patients with serious diseases and promoting social harmony. Age, educational level and other individual factors have a remarkable effect on health. Our research supports the government’s development policy of placing the emphasis of rural health expenditure on grassroots medical services and public health, and verifies that the goal of the new cooperative scheme is to eliminate the economic risks of catastrophic diseases.
117 Encina Commons, Room 116
Stanford, CA 94305-6006
Elena Lucchese is a Ph.D. student in Economics at the University of Bologna (Italy). She is currently doing research at Stanford University in the Center for Health Policy and the Center for Primary Care and Outcomes Research (CHP/PCOR). Her research interests are applied micro-economics, health economics and economics of education. In 2016, she was awarded a "Young Researcher Best Paper Award" by the Italian Health Economics Association for her work on the Effect of Ambulance Response Time on Cardiovascular Severity. In 2014, she also received a 14,000 euros grant from Eurizon Capital SGR as a Principal Investigator for her research project on the Efficiency of Public Spending in Europe. She is the president of the association "L'Osteria Volante", funded by the University of Padova, which promotes debates on economics, politics, and environmental issues (www.losteriavolante.it).
"Most civilian casualties in war are not the result of direct exposure to bombs and bullets; they are due to the destruction of the essentials of daily living, including food, water, shelter, and health care."
So begins the abstract for an essay in the Winter 2017 edition of Daedalus by Stanford Health Policy’s Paul Wise, the Richard E. Behrman Professor of Child Health and Society and professor of pediatrics at the Stanford School of Medicine.
Wise argues in his essay, “The Epidemiologic Challenge to the Conduct of Just War: Confronting Indirect Civilian Casualties of War," that the death of any child is always a tragedy. But the death of a child from preventable causes is particularly unjust.
“This is, of course, as true in peacetime as it is in war,” he writes. “My argument is that the dramatic growth in our ability to prevent death and disability from the indirect effects of war generates not only humanitarian impulses, but also just war demands for the provision of this capability to populations affected by war.”
The American Academy of Arts & Sciences devoted its Fall 2016 and Winter 2017 issues of its journal, Daedalus, to the theory of Just War. It held its 204th annual meeting at Stanford University in November, with Wise reviewing the main points of his essay. Other speakers included Stanford President Marc Tessier-Lavigne and FSI's Scott Sagan and Joe Felter.
(Videos of all their talks can be found on this page. And you can listen to their conversations in this World Class podcast, "Ethics in War," by the Freeman Spogli Institute for International Studies.)
Just War is a theory dating back to the early Christian theologians, who called on warring parties to justify their use of force and to protect noncombatants and innocent civilians.
The statisticians of war and genocide typically look at the total number of deaths due to combat or murder: 5 to 6 million Jews were exterminated in the Holocaust; the Second Congo War from 1998-2003 is estimated to have claimed more than 3 million civilian lives in direct combat.
More recently, the nonprofit organization, I Am Syria, estimates that 450,000 civilians, 50,000 of whom were children, have been killed in the Syrian civil war that erupted up March 2011. But how many will have died in the eventual aftermath due to lack of medical care, food and shelter?
It is estimated that 2 million Congolese, for example, died from starvation and lack of food and medical care in the years following its civil war.
The numbers that make it to the history books often do not reflect the indirect deaths that come on the sidelines and aftermath of war, particularly among children 5 years old and younger. During the periods of intense conflict in the Democratic Republic of Congo and Darfur, direct trauma-related mortality accounted for less than 20 percent of all excess deaths among children. The leading causes of the excess deaths on top of direct conflict were fever and malaria, measles, diarrhea and acute respiratory infections. In Syria, many of those children who have survived likely will have medical and mental repercussions that will be debilitating or deadly.
Wise notes that a report published by the Geneva Declaration Secretariat suggests that for every violent death resulting from combat and conflict between 2004 and 2007, four more died from war-associated elevations in malnutrition and disease. Global health scholars reported that about one-third of all deaths in Iraq were due to indirect causes.
This is why health-care workers are “the ultimate inheritors of failed social order,” said Wise, who is also a senior fellow at the Freeman Spogli Institute for International Studies. “Sooner or later, a breakdown in the bonds that define collective peace, indeed that ensure social justice, will find tragic expression in the clinic, on the ward, or in the morgue.”
That is the extremely bad news. But there is also some good.
Technological advances to prevent conflict and protect civilians have expanded dramatically, such as social media platforms that allow victims of war to communicate instantly and globally, and the crowdsourcing and early-warning SMS systems that take advantage of the more than 2 billion cellphone users around the world.
The United Nations is looking at GPS tracking systems to protect peacekeeping convoys on search-and-rescue missions, according to another article in the Fall 2016 issue of Daedalus. In another example, the International Bar Association created the eyeWitness to Atrocities app for smartphone cameras designed to record and authenticate atrocities.
All this new technology is allowing for advances in epidemiologic and demographic measurement out in the field, Wise said.
“In the context of just war, technical innovation means more than the creation of more powerful and precise munitions,” Wise writes. “It also means an enhanced capacity to measure and reduce the human impact of war.
“Innovation in these two technical domains — measurement and mitigation — has been sufficient to rethink the application of Just War theory to the indirect effects of war.”
Wise runs the Stanford Children in Crisis Initiative, which seeks to save the lives in children who are suffering from conflict and poor governance. Stanford students and local health-care promoters in rural Guatemala have been working with him for decades to try and end death by malnutrition and other causes among young children there.
The initiative last summer launched an app for tablets, which is making it easier to find malnourished children and decrease the training time for new health promoters. The goal is to eventually distribute the application globally.
The international aid community’s growing ability to measure the indirect impact of war, coupled with the ability to prevent or mitigate the indirect human toll of war, is remarkable, Wise said.
“Advances in epidemiology and the technological means of collecting health data have generated a range of new opportunities to assess the immediate and protracted effects of war,” Wise said. “This field is still young and these new technical strategies are creating an unprecedented capacity to assess the impact of war in even remote communities.”
The effect of child poverty and related early life experiences on adult health outcomes and patterns of aging has become a central focus of child health research and advocacy. In this article a critical review of this proliferating literature and its relevance to child health programs and policy are presented. This literature review focused on evidence of the influence of child poverty on the major contributors to adult morbidity and mortality in the United States, the mechanisms by which these associations operate, and the implications for reforming child health programs and policies. Strong and varied evidence base documents the effect of child poverty and related early life experiences and exposures on the major threats to adult health and healthy aging. Studies using a variety of methodologies, including longitudinal and cross-sectional strategies, have reported significant findings regarding cardiovascular disorders, obesity and diabetes, certain cancers, mental health conditions, osteoporosis and fractures, and possibly dementia. These relationships can operate through alterations in fetal and infant development, stress reactivity and inflammation, the development of adverse health behaviors, the conveyance of child chronic illness into adulthood, and inadequate access to effective interventions in childhood. Although the reviewed studies document meaningful relationships between child poverty and adult outcomes, they also reveal that poverty, experiences, and behaviors in adulthood make important contributions to adult health and aging. There is strong evidence that poverty in childhood contributes significantly to adult health. Changes in the content, financing, and advocacy of current child health programs will be required to address the childhood influences on adult health and disease. Policy reforms that reduce child poverty and mitigate its developmental effects must be integrated into broader initiatives and advocacy that also attend to the health and well-being of adults.
Importance
A large-scale review is needed to characterize the rates of airway, respiratory, and cardiovascular complications after pediatric tonsillectomy and adenoidectomy (T&A) for inpatient and ambulatory cohorts.
Objective
To identify risk factors for postoperative complications stratified by age and operative facility type among children undergoing T&A.
Design, Setting, and Participants
This retrospective review included 115 214 children undergoing T&A in hospitals, hospital-based facilities (HBF), and free-standing facilities (FSF) in California from January 1, 2005, to December 31, 2010. The analysis used the State of California Office of Statewide Health Planning and Development private inpatient data and Emergency Department and Ambulatory Surgery public data. Inpatient (n = 18 622) and ambulatory (n = 96 592) cohorts were identified by codes from the International Classification of Diseases, Ninth Revision, and Current Procedural Terminology. Data were collected from September 2011 to March 2012 and analyzed from March through May 2012.
Main Outcomes and Measures
Rates of airway, respiratory, and cardiovascular complications.
Results
A total of 18 622 inpatients (51% male; 49% female; mean age, 5.4 [range, 0-17] years) and 96 592 ambulatory patients (37% male; 35% female; 28%, masked; mean age, 7.6 [range, 0-17] years) underwent analysis. The ratio of ambulatory to inpatient procedures was 5:1. Inpatients demonstrated more comorbidities (≤8, compared with ≤4 for HBF and ≤3 for FSF patients) and, in general, their complication rates were 2 to 5 times higher (seen in 1% to 12% of patients) than those in HBFs (0.2% to 5%), and more than 10 times higher than those in the FSFs (0% to 0.38%), with rates varying markedly by age range and facility type. Tonsillectomy and adenoidectomy was associated with increased risk for all complication types in both settings, reaching an odds ratio of 8.5 (95% CI, 6.6-11.1) for respiratory complications in the ambulatory setting. Inpatients aged 0 to 9 years experienced higher rates of airway and respiratory complications, peaking at an odds ratio of 7.5 (95% CI, 3.1-18.2) for airway complications in the group aged 0 to 11 months.
Conclusions and Relevance
Large numbers of pediatric patients undergo T&A in ambulatory settings despite higher rates of complications in younger patients and patients with more comorbidities. Fortunately, a high percentage of these patients has been appropriately triaged to the inpatient setting. Further research is needed to elucidate the subgroups that warrant postoperative hospitalization.
Kidney transplant recipients must adhere to their immunosuppressive medication regimen. However, non-adherence remains a major problem.
The aim of this paper is to determine how kidney transplant recipients remember to take their medications, and assess their perception and beliefs about adherence to immunosuppressive medications and barriers to medication adherence. In addition, we aim to assess perception and beliefs about willingness to use a hypothetical, mobile phone app to improve adherence.
We conducted a qualitative study that included an average of three home or workplace visits of kidney transplant recipients (N=16) from a single urban transplant center.
The qualitative study revealed that transplant recipients understood the importance of taking their immunosuppressive medications and this motivated them to take their medications. The visits showed that most participants have incorporated medication use into their daily lives and that any minor deviation from daily routines could result in non-adherence. Participants also reported other barriers to adherence. All participants were interested in using an app to remind them to take their medication; however, they reported potential barriers to using the app.
Although kidney transplant recipients understood the importance of medication adherence, there were significant barriers to maintaining adherence. Participants also reported interest in using a mobile phone app.
Extensive variation exists in the follow-up of positive screens for sickle cell disease. Limited quality indicators exist to measure if the public health goals of screening—early initiation of treatment and enrollment to care—are being achieved. This manuscript focuses on the development of quality indicators related to the follow-up care for individuals identified with sickle cell disease and trait through screening processes. The authors used a modified Delphi method to develop the indicators. The process included a comprehensive literature review with rating of the evidence followed by ratings of draft indicators by an expert panel held in September 2012. The expert panel was nominated by leaders of various professional societies, the Health Resources and Services Administration, and the National Heart, Lung, and Blood Institute and met face to face to discuss and rate each indicator. The panel recommended nine quality indicators focused on key aspects of follow-up care for individuals with positive screens for sickle cell disease and trait. Public health programs and healthcare institutions can use these indicators to assess the quality of follow-up care and provide a basis for improvement efforts to ensure appropriate family education, early initiation of treatment, and appropriate referral to care for individuals identified with sickle cell disease and trait.
For adolescent patients with end-stage hip disease, the choice between total hip arthroplasty (THA) and arthrodesis is complex; the clinical evidence is not definitive, and there are difficult trade-offs between clear short-term benefits from THA and uncertain long-term risks. We surveyed nearly 700 members of the Pediatric Orthopedic Society of North America and the American Association of Hip and Knee Surgeons. Respondents chose between a recommendation of THA or arthrodesis in four clinical vignettes. A clear majority of surgeons recommended THA in two of the vignettes, however opinion was somewhat divided in one vignette (overweight adolescent) and deeply divided in another (adolescent destined for manual labor job). Across all vignettes, recommendations varied systematically according to surgeons' age and their attitudes regarding tradeoffs between life stages.