In a recent perspective published by the New England Journal of Medicine (NEJM), Stanford Law student Alexandra Daniels analyzed a growing body of federal litigation brought by prisoners with the hepatitis C virus (HCV) who are seeking access to treatment for their condition. With co-author and mentor, Law Professor David Studdert — also a professor of medicine at Stanford Health Policy — Daniels documented the dire public health problem of HCV in prisons.
“People incarcerated in prisons account for approximately one third of HCV cases in the United States” the authors wrote, and nearly one in five prisoners are infected, compared with 1 percent of the general population.
HCV is a slow-moving disease, but left untreated it eventually leads to cirrhosis, cancer, liver failure, and death.
A new wave of “miracle” drugs for treating HCV appeared in 2014. Direct-acting antivirals–or DAAs–are far more effective than anything previously known. The catch–they are extremely expensive, upwards of $50,000 for a course of treatment. This creates a far higher price tag for universal treatment than most prison systems can afford. The result is that, even though prisons are the epicenter of the HCV epidemic, only a small minority of prisoners have gained access to DAAs.
Owning Handgun Associated With Dramatically Higher Risk of Suicide
Men who own handguns are eight times more likely to die of suicide by handgun than men who don’t have one — and women who own handguns are 35 times more likely than women who don’t, according to startling new research led by SHP's David Studdert.
Stanford Works With California Prisons to Test and Prevent COVID-19
A $1 million gift from the Horowitz Family Foundation allows Stanford researchers to work on reducing the spread of COVID-19 among the incarcerated and inform mitigation strategies in other high-density living situations.
Partitioning the Curve — Interstate Travel Restrictions During the Covid-19 Pandemic
Many jurisdictions have responded to the unevenness of the COVID-19 pandemic by battening down their borders. SHP's David Studdert and Michelle Mello take a deep dive into the legalities of attempting to prevent people from crossing state lines in this New England Journal of Medicine perspective.
The U.S. Supreme Court has interpreted the 8th Amendment of the Constitution, which prohibits cruel and unusual punishment, to guarantee prisoners a minimum basic level of health care. Yet even though prisons are the epicenter of the hepatitis C epidemic, only a small minority of prisoners have gained access to new "miracle" drugs to treat HCV.
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.
As we watch President Trump tell the states they have to do more to find their own personal protective equipment for their health-care workers, governors lash back with demands for a national leader who will unlock the emergency powers of the federal government.
The response to the COVID-19 pandemic has exposed major weaknesses in the federalist system of public health governance, which divides powers among the federal, state and local governments, argues SHP’s Michelle Mello in this New England Journal of Medicinecommentary.
The coronavirus, she writes, “is exactly the type of infectious disease for which federal public health powers and emergencies were conceived: it is highly transmissible, crosses borders efficiently, and threatens our national infrastructure and economy.”
“Strong, decisive national action is therefore imperative,” writes Mello, a professor of medicine and a professor of law, and Rebecca L. Haffajee, a policy researcher at the RAND Corporation. “Yet the federal response has been alarmingly slow to develop, fostering confusion about the nature of the virus and necessary steps to address it.”
The authors warn this “lack of interjurisdictional coordination has and will cost lives.”
Though states must respect constitutionally protected individual rights — such as due process, equal protection and freedom of travel and association — the Constitution puts primary responsibility for public health with the states, cities and counties. It gives them the right to exercise broad police powers to protect their citizens’ health during ordinary times.
In extraordinary times — like the one we’re experiencing now — states and the federal government can activate emergency powers to expand their abilities to act swiftly and protect human life and health. All 50 states and dozens of localities and the federal government have declared emergencies.
“The resulting executive powers are sweeping: they can range from halting business operations, to restricting freedom of movement, to limiting civil rights and liberties, to commandeering property,” Mello and Haffajee write in the NEJM Perspective.
This emergency legal framework has led to too few checks-and-balances on poor decisions—historically, in the direction of being overly aggressive, write the authors. They note a good example is when New Jersey’s governor ordered a nurse returning from Sierra Leone during the 2014 Ebola outbreak into quarantine, contrary to Centers for Disease Control and Prevention guidelines.
Too Little Too Late?
“Today, we find ourselves in the opposite situation: the federal government has done too little,” the authors write. “Perhaps because of misleading early statements from federal officials about the gravity of the COVID-19 threat, public sentiment has weighed against taking steps that would impose hardships on families and businesses.”
The tumbling stock market and unprecedented 10 million unemployment claims last month also have created further pressure by the federal government to project a sense of calm.
“The resulting laconic federal response has meant that a precious opportunity to contain COVID-19 through swift, unified national action has been lost — a scenario that mirrors what occurred in Italy,” they write.
So the states had to pick up where the federal government fell short, the authors note. Many jurisdictions issued stay-at-home orders; others did not. As of March 31, more than a dozen governors had yet to issue statewide stay-at-home orders and eight had only ordered partial measures. Yet many jurisdictions turn a blind eye, they note, to noncompliance with social-distancing recommendations issued by the CDC, as evidenced by crowded beaches and children congregating in public parks.
“This is the dark side of federalism: it encourages a patchwork response to epidemics,” the authors write.
“A federal takeover of all public health orders would be out of step with our federalist structure,” the authors state, but there remain three good options:
“The White House must reverse its current trajectory toward prematurely weakening existing federal measures and the resolve of governors who are enforcing stay-at-home orders and school closures.” Trump said last week he wanted the United States “opened up and raring to go by Easter.” A few days later, he heeded the call of medical experts and extended social-distancing guidelines until the end of April, but public health experts believe the crisis will likely be with us longer.
Congress should “use its spending power to further encourage states to follow a uniform playbook for community mitigation that includes measures for effective enforcement of public health orders.” It could threaten to withhold some federal funds from states that do not comply.
“Congress could leverage its interstate-commerce powers to regular economic activities that affect the interstate spread” of COVID-19, such as restricting large businesses from traveling and operating across state lines in ways that expose workers to risk.
The White House could also make further use of the Defense Production Act (DPA) to direct private companies to produce badly needed ventilators and personal protective equipment for health-care workers, the authors write. Trump has ordered General Motors to manufacture ventilators and the $2 trillion stimulus package includes $1 billion for DPA projects.
“Learning is difficult in the midst of an emergency, but one lesson from the COVID-19 epidemic is already clear: when epidemiologists warn that a pathogen has pandemic potential, the time to fly the flag of local freedom is over,” the authors conclude. “Yet national leadership in epidemic response works only if it is evidence-based. It is critical that the U.S. response to COVID-19 going forward be not only national, but rational.”
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.
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
Urbanization and obesity-related chronic diseases are cited as threats to the future health of India's older citizens. With 50% of deaths in adult Indians currently due to chronic diseases, the relationship of urbanization and migration trends to obesity patterns have important population health implications for older Indians. The researchers constructed and calibrated a set of 21 microsimulation models of weight and height of Indian adults. The models separately represented current urban and rural populations of India's major states and were further stratified by sex.
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.
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
Vincenzo Atella is Associate Professor of Economics at the University of Rome "Tor Vergata" where he teaches Macroeconomics and courses in Applied Health Economics at graduate and post graduate level. He is also adjunct associate of the Center for Health Policy at Stanford where he has been visiting professor in different occasions.
Currently, he is CEIS Tor Vergata Director and Scientific Director of the Farmafactoring Foundation, member of SIVEAS (Health Care Services National Evaluation System) of the Ministry of Health, chief economist of the Italian Association of General Practitionners (Società Italiana di Medicina Generale – SIMG) and member and co-founder of the Italian Public Affair Association.
In the recent past he has been member of the International Committee of Experts advising IQWiG (the German Agency for Health Care) for setting national guidelines for Economic Evaluation and member of the Italian Committee for Drug Price appointed by the Ministry of Treasury. He also served as member of the “Strategic Evaluation Committee” of the Italian Drug Agency (AIFA), and has been consultant for the Italian Regional Agency for Health Care Services (http://www.assr.it/), the National Institute of Health (http://www.iss.it/), the WHO and the World Bank. Prof. Atella has been coordinator of a large European Research Network called TECH Europe (http://healthpolicy.fsi.stanford.edu/tech/) which has received financial support by the European Science Foundation. His most recent research activity has focused on poverty, income distribution and health economics. In this last field his research deals with the introduction of new technologies in the health sector, the impact of different co-payment systems on pharmaceutical decision making by physicians and on drug consumption by patients, forecasting health expenditure and with health related income inequalities. The results of this research activity have been published on several international refereed journals as well books.
Director of the Centre for Economic and International Studies (CEIS) at the University of Rome “Tor Vergata”
Adjunct Affiliate at the Center for Health Policy and the Department of Medicine
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.
