Stringent social-distancing rules and other restrictions aimed at addressing the Covid-19 pandemic have brought a large part of the world to a screeching halt and dramatically changed current daily life for millions of people around the globe. In the U.S. alone, the economic toll was underscored this week when the U.S. Labor Department reported that another 6.6 million people filed for unemployment last week, bringing the total number of job losses to more than 16 million over the last month.
How long can a nation of 327 million people endure with work and schools closed, lost jobs, and people still dying from a pandemic with no proven treatment? And, as the number of new infections starts to level off, will Americans be willing to continue to adhere to such strict measures?
In a perspective published in the April 9, 2020, issue of the New England Journal of Medicine, David Studdert, professor in both Stanford’s law and medical schools, and Mark Hall, professor of law at Wake Forest Law School, analyze the tension between disease control priorities and basic social and economic freedoms.
“Resistance to drastic disease-control measures is already evident. Rising infection rates and mortality, coupled with scientific uncertainty about Covid-19, should keep resentment at bay — for a while. But the status quo isn’t sustainable for months on end; public unrest will eventually become too great,” writes Studdert and Hall.
In ordinary times, a comprehensive program of testing, certification, and retesting would be beyond the pale. Today, it seems like a fair price to pay for safely and fairly resuming a semblance of normal life.
David M. Studdert is a leading expert in the fields of health law and empirical legal research. He 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.
David Studdert addresses the tradeoff between basic liberties and societal health in the current coronavirus pandemic in a New England Journal of Medicine perspective.
Most studies that look at whether democracy improves global health rely on measurements of life expectancy at birth and infant mortality rates. Yet those measures disproportionately reflect progress on infectious diseases — such as malaria, diarrheal illnesses and pneumonia — which relies heavily on foreign aid.
A new study led by Stanford Health Policy's Tara Templin and the Council on Foreign Relations suggests that a better way to measure the role of democracy in public health is to examine the causes of adult mortality, such as noncommunicable diseases, HIV, cardiovascular disease and transportation injuries. Little international assistance targets these noncommunicable diseases.
When the researchers measured improvements in those particular areas of public health, the results proved dramatic.
“The results of this study suggest that elections and the health of the people are increasingly inseparable,” the authors wrote.
“Democratic institutions and processes, and particularly free and fair elections, can be an important catalyst for improving population health, with the largest health gains possible for cardiovascular and other noncommunicable diseases,” the authors wrote.
Templin said the study brings new data to the question of how governance and health inform global health policy debates, particularly as global health funding stagnates.
“As more cases of cardiovascular diseases, diabetes and cancers occur in low- and middle-income countries, there will be a need for greater health-care infrastructure and resources to provide chronic care that weren’t as critical in providing childhood vaccines or acute care,” Templin said.
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Free and fair elections for better health
In 2016, the four mortality causes most ameliorated by democracy — cardiovascular disease, tuberculosis, transportation injuries and other noncommunicable diseases — were responsible for 25 percent of total death and disability in people younger than 70 in low- and middle-income countries. That same year, cardiovascular diseases accounted for 14 million deaths in those countries, 42 percent of which occurred in individuals younger than 70.
Over the past 20 years, the increase in democratic experience reduced mortality in these countries from cardiovascular disease, other noncommunicable diseases and tuberculosis between 8-10 percent, the authors wrote.
“Free and fair elections appear important for improving adult health and noncommunicable disease outcomes, most likely by increasing government accountability and responsiveness,” the study said.
What Templin and her co-authors found was democracy was associated with better noncommunicable disease outcomes. They hypothesize that democracies may give higher priority to health-care investments.
HIV-free life expectancy at age 15, for example, improved significantly — on average by 3 percent every 10 years during the study period — after countries transitioned to democracy. Democratic experience also explains significant improvements in mortality from cardiovascular disease, tuberculosis, transportation injuries, cancers, cirrhosis and other noncommunicable diseases, the study said.
Watch: Some of the authors of the study discuss the significant their findings:
What Templin and her co-authors found was democracy was associated with better noncommunicable disease outcomes. They hypothesize that democracies may give higher priority to health-care investments.
HIV-free life expectancy at age 15, for example, improved significantly — on average by 3 percent every 10 years during the study period — after countries transitioned to democracy. Democratic experience also explains significant improvements in mortality from cardiovascular disease, tuberculosis, transportation injuries, cancers, cirrhosis and other noncommunicable diseases, the study said.
Foreign aid often misdirected
And yet, this connection between fair elections and global health is little understood.
“Democratic government has not been a driving force in global health,” the researchers wrote. “Many of the countries that have had the greatest improvements in life expectancy and child mortality over the past 15 years are electoral autocracies that achieved their health successes with the heavy contribution of foreign aid.”
They note that Ethiopia, Myanmar, Rwanda and Uganda all extended their life expectancy by 10 years or more between 1996 and 2016. The governments of these countries were elected, however, in multiparty elections designed so the opposition could only lose, making them among the least democratic nations in the world.
Yet these nations were among the top two-dozen recipients of foreign assistance for health.
Only 2 percent of the total development assistance for health in 2016 was devoted to noncommunicable diseases, which was the cause of 58 percent of the death and disability in low-income and middle-income countries that same year, the researchers found.
“Although many bilateral aid agencies emphasize the importance of democratic governance in their policy statements,” the authors wrote, “most studies of development assistance have found no correlation between foreign aid and democratic governance and, in some instance, a negative correlation.”
Autocracies such as Cuba and China, known for providing good health care at low cost, have not always been as successful when their populations’ health needs shifted to treating and preventing noncommunicable diseases. A 2017 assessment, for example, found that true life expectancy in China was lower than its expected life expectancy at birth from 1980 to 2000 and has only improved over the past decade with increased government health spending. In Cuba, the degree to which its observed life expectancy has exceeded expectations has decreased, from four-to-seven years higher than expected in 1970 to three-to-five years higher than expected in 2016.
“There is good reason to believe that the role that democracy plays in child health and infectious diseases may not be generalizable to the diseases that disproportionately affect adults,” Bollyky said. Cardiovascular diseases, cancers and other noncommunicable diseases, according to Bollyky, are largely chronic, costlier to treat than most infectious diseases, and require more health care infrastructure and skilled medical personnel.
The researchers hypothesize that democracy improves population health because:
When enforced through regular, free and fair elections, democracies should have a greater incentive than autocracies to provide health-promoting resources and services to a larger proportion of the population;
Democracies are more open to feedback from a broader range of interest groups, more protective of media freedom and might be more willing to use that feedback to improve their public health programs;
Autocracies reduce political competition and access to information, which might deter constituent feedback and responsive governance.
Various studies have concluded that democratic rule is better for population health, but almost all of them have focused on infant and child mortality or life expectancy at birth.
Over the past 20 years, the average country’s increase in democracy reduced mortality from cardiovascular disease by roughly 10 percent, the authors wrote. They estimate that more than 16 million cardiovascular deaths may have been averted due to an increase in democracy globally from 1995 to 2015. They also found improvements in other health burdens in the countries where democracy has taken hold: an 8.9 percent reduction in deaths from tuberculosis, a 9.5 percent drop in deaths from transportation injuries and a 9.1 percent mortality reduction in other noncommunicable disease, such as congenital heart disease and congenital birth defects.
“This study suggests that democratic governance and its promotion, along with other government accountability measures, might further enhance efforts to improve population health,” the study said. “Pretending otherwise is akin to believing that the solution to a nation’s crumbling roads and infrastructure is just a technical schematic and cheaper materials.”
The other researchers who contributed to the study are Matthew Cohen, Diana Schoder, Joseph Dieleman and Simon Wigley, from CFR, the University of Washington-Seattle and Bilkent University in Turkey, respectively.
Funding for the research came from Bloomberg Philanthropies and the Bill & Melinda Gates Foundation. Stanford’s Department of Health Research and Policy also supported the work.
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Election officials count the votes at a polling station on February 24, 2019 in Dakar, Senegal.
The United States spends over 17 percent of GDP on health care; the next six highest countries spend over 11 percent. This six percent differential indicates an excess spending of approximately one trillion dollars per year. Depending on the benefit from the extra spending, this suggests the possibility of a huge misallocation of resources. Also, because the federal government funds almost half of total health care spending, there are significant effects on the deficit and the debt. The main reasons for the excess are (1) the U.S. pays higher prices for drugs, devices, and equipment and higher fees to specialists and sub-specialists; (2) higher administrative costs; and (3) a more expensive mix of medical care. The seminar will focus on institutional and political explanations for the three proximate reasons.
Speaker Bio:
Victor R. Fuchs is the Henry J. Kaiser Jr Professor Emeritus at Stanford University, in the Departments of Economics and Health Research and Policy. He is also a Research Associate of the National Bureau of Economic Research and a Senior Fellow at SIEPR. He applies economic analysis to social problems of national concern, with special emphasis on health and medical care. He is author of nine books, the editor of six others, and has published over two hundred papers and shorter pieces. His current research focuses on male-female differences in mortality, reform of medical education, and the future of U.S. health care.
His best known work, Who Shall Live? Health, Economics, and Social Choice (1974; expanded edition 1998, 2nd expanded edition 2011), helps health professionals and policy makers to understand the economic and policy problems in health that have emerged in recent decades. Other books include The Service Economy (1968), How We Live (1983), The Health Economy (1986), Women’s Quest For Economic Equality (1988), and The Future of Health Policy (1993). He is the editor of Individual and Social Responsibility: Child Care, Education, Medical Care, and Long-term Care in America (1996).
Professor Fuchs was elected president of the American Economic Association in 1995. He has also been elected to the American Philosophical Society, the American Academy of Arts and Sciences, the Institute of Medicine of the National Academy of Sciences, and is an Honorary Member of Alpha Omega Alpha. He has received the John R. Commons Award, Emily Mumford Medal for Distinguished Contributions to Social Science in Medicine, Distinguished Investigator Award (Association for Health Services Research), Baxter Foundation Health Services Research Prize, and Madden Distinguished Alumni Award (New York University). ASHE’s (American Society of Health Economists) Career Award for Lifetime Contributions to the Field of Health Economics and the RAND Corporation prize for the Best Paper published in the Forum for Health Economics and Policy are named and awarded in honor of Professor Fuchs.
This event is sponsored by the Stanford Center on Democracy, Development and the Rule of Law and the Center for Health Policy/Center for Primary Care and Outcomes Research.
CISAC Conference Room
Victor Fuchs
the Henry J. Kaiser Jr Professor Emeritus
Speaker
Stanford University
Political and economic transition is often blamed for Russia’s 40% surge in deaths between 1990 and 1994 (the “Russian Mortality Crisis”). Highlighting that increases in mortality occurred primarily among alcohol- related causes and among working-age men (the heaviest drinkers), this paper investigates a different explanation: the demise of the 1985-1988 Gorbachev Anti-Alcohol Campaign. We use archival sources to build a new oblast-year data set spanning 1970-2000 and find that:
The campaign was associated with substantially fewer campaign year deaths,
Oblasts with larger reductions in alcohol consumption and mortality during the campaign experienced larger transition era increases, and
Other former Soviet states and Eastern European countries exhibit similar mortality patterns commensurate with their campaign exposure.
The campaign’s end explains between 32% and 49% of the mortality crisis, suggesting that Russia’s transition to capitalism and democracy was not as lethal as commonly suggested.
Retraction:
In June 2012, Stanford researchers Rajaie Batniji and Eran Bendavid retracted the research findings explained in the following article.
Their findings, presented in the essay, "Does development assistance for health really displace government health spending? Reassessing the evidence," contained errors in statistical model choice and reporting. The essay was published May 8, 2012, by the journal PLoS Medicine.
The researchers erroneously concluded that there was no significant displacement of foreign aid. When they discovered their mistake, they informed editors at PLoS Medicine and moved to correct the record. The editors agreed with the need for the retraction and accepted the authors’ explanation of their error. The retraction can be read at www.plosmedicine.org/article/info%3Adoi%2F10.1371%2Fjournal.pmed.1001214.
When a 2010 study concluded that about half the money given to international governments for providing health care services isn’t used as intended, skeptics who argued that foreign aid is largely wasted were handed a powerful piece of data to bolster their claims.
But Stanford researchers Rajaie S. Batniji and Eran Bendavid say those findings are flawed. In an article featured in the May 8th edition of PLoS Medicine, Batniji and Bendavid say the two-year-old study by researchers at the University of Washington should not be used to guide decisions about how much money to give and who should get it.
“We can’t say that there’s absolutely no displacement of foreign aid, but these earlier findings are too tenuous for the basis of policy,” said Batniji, an affiliate of the Center on Democracy, Development, and the Rule of Law at the Freeman Spogli Institute for International Studies.
Batniji and Bendavid, an affiliate of FSI’s Stanford Health Policy and an assistant professor of medicine, are taking on the 2010 study – which appeared in the Lancet – at a critical time for foreign assistance programs.
The United States, which gives about half of all the world’s health aid, plans to chop its $10 billion budget by about 4 percent in the coming fiscal year. That’s the first cut in more than a decade. And officials have shown no signs of switching their preference of bypassing national governments as recipients of health aid, funneling more than half of U.S. support to non-governmental organizations instead.
Batniji and Bendavid decided to re-analyze the data used by the University of Washington researchers after meeting with policymakers who pointed to the study as a cautionary tale of foreign governments that waste and mismanage money earmarked for health programs.
“People were citing the Lancet piece, saying this was starting to shape how they thought about giving money,” said Batniji, who is also a resident physician at Stanford Medical Center. “But when we started asking questions about what the actual displacement looks like, the answers didn’t seem very compelling or reasonable.”
Taking a fresh look at the same numbers used for the 2010 study – public financing data culled from the World Health Organization and the International Monetary Fund – the researchers saw a different story emerge about the use of foreign aid in the health sector.
Once Batniji and Bendavid excluded conflicting and outlying data, such as huge discrepancies between WHO and IMF estimates and information about countries that were getting very small amounts of money from other countries, “there was no significant displacement of foreign aid,” Bendavid said.
The Stanford researchers’ findings are poised to influence a debate among policymakers and donors over whether it’s more efficient to give international assistance slated for health spending to government agencies or NGOs.
“We want to free donors of feeling that if they give money directly to governments, the money will be offset and used for an unintended purpose,” Batniji said. “The concern about displacement really amplifies the demands we make on governments for how they use the money. And that is at odds with a recent movement to let foreign governments set their own agendas for how to spend money.”
The research conducted by Batniji and Bendavid was supported by FSI’s Global Underdevelopment Action Fund and the Dr. George Rosenkranz Prize awarded to Bendavid in 2010.
The United Nations High Commissioner for Refugees (UNHCR) establishes and maintains refugee camps to meet the needs of 34.5 million people affected by disaster or war worldwide. Like other international humanitarian organizations, UNHCR maintains central stockpiles which supply these refugee operations. Management at UNHCR seeks to improve the timeliness and quality of its disaster response subject to its budget constraints. We develop an inventory model to analyze the interaction between a stockpile and a downstream refugee camp or relief operation. We consider two inventory decisions: first, how to partition a fixed budget between stockpiling and shipping costs in order to best meet the needs of beneficiaries; and second, given the shipping budget determined by the budget partition, how to ship relief items from the stockpile to a downstream relief operation in an efficient manner. We solve for the shipment policy using dynamic programming, then determine the optimal stockpile size given knowledge of the optimal shipment policy. The optimization balances a key tradeoff: a larger stockpile is costly to procure and maintain, but enhances a humanitarian organization’s ability to respond to relief operation demands. We provide insights into shipment strategies and stockpile size. We also develop a spreadsheet model to help humanitarian organizations in their operational decision-making, leading to improved response to beneficiaries. Humanitarian organizations must use their financial resources wisely to carry out their mandates, and models of this type can help them make the best use of their limited response resources.
Purpose. Mathematical and simulation models are increasingly used to plan for and evaluate health sector responses to disasters, yet no clear consensus exists regarding best practices for the design, conduct, and reporting of such models. The authors examined a large selection of published health sector disaster response models to generate a set of best practice guidelines for such models.
Methods. The authors reviewed a spectrum of published disaster response models addressing public health or health care delivery, focusing in particular on the type of disaster and response decisions considered, decision makers targeted, choice of outcomes evaluated, modeling methodology, and reporting format. They developed initial recommendations for best practices for creating and reporting such models and refined these guidelines after soliciting feedback from response modeling experts and from members of the Society for Medical Decision Making.
Results. The authors propose 6 recommendations for model construction and reporting, inspired by the most exemplary models: health sector disaster response models should address real-world problems, be designed for maximum usability by response planners, strike the appropriate balance between simplicity and complexity, include appropriate outcomes that extend beyond those considered in traditional cost-effectiveness analyses, and be designed to evaluate the many uncertainties inherent in disaster response. Finally, good model reporting is particularly critical for disaster response models.
Conclusions. Quantitative models are critical tools for planning effective health sector responses to disasters. The proposed recommendations can increase the applicability and interpretability of future models, thereby improving strategic, tactical, and operational aspects of preparedness planning and response.
This issue of CHP/PCOR's quarterly newsletter, which covers news from the summer 2006 quarter, includes articles about:
research by CHP/PCOR investigators that influenced the Centers for Disease Control and Prevention to recommend widespread voluntary HIV screening for all Americans ages 13 to 64 -- a significant change from the CDC's previous HIV screening guidelines;
a CHP/PCOR study on patient safety culture in U.S. hospitals -- the largest effort to date to measure hospitals' safety culture and seek to improve it through an intervention that gets hospital executives out of their offices and on to the hospital floors;
an early-stage project in which CHP/PCOR is collaborating with the Center on Democracy, Development and the Rule of Law to study the relationship between health interventions, governance and development;
an evidence report examining the challenges of diagnosing and treating anthrax in children, prepared by the Stanford-UCSF Evidence-based Practice Center; and
a study by CHP/PCOR fellow Kate Bundorf which found that depending on the definition of "affordability" that is used, health insurance is "affordable" to between one-quarter and three-quarters of the uninsured -- and many of those who can't afford insurance purchase it anyway.
