India celebrates the 10th anniversary of its Emergency Management and Research Institute (EMRI), the world's largest ambulance service that is saving the lives of the poorest Indian residents free of charge. Stanford Medicine experts, who trained responders in emergency medical procedures, joined EMRI to celebrate the program's success. Read More

Medical researchers must work together across disciplines to provide better health care to those who need it most, according to panelists at Stanford Medicine’s Annual Population Health Sciences Colloquium.

The symposium, hosted by the Stanford Center for Population Health Sciences, brought together working groups from across the Stanford campus to showcase the latest findings in population health research.

“Population health science at Stanford is likely to make the most important contributions when we cross traditional intellectual expertise disciplines,” said Paul H. Wise, a core faculty member at the Center for Health Policy/Center for Primary Care and Outcomes Research (CHP/PCOR).

Many of the scholars at the daylong conference on Tuesday stressed that an interdisciplinary approach to health care is crucial to understanding and aiding underserved populations.

“To deal with life-course questions we need to create-life course observational windows,” said Mark Cullen, chief of the Division of General Medical Disciplines and director of the Stanford Center for Population Health Sciences.

Instead of trying to create an all-encompassing care plan for the human population as a whole, panelists demonstrated that studying the needs of particular groups, or smaller populations, can better serve individuals within populations that may not receive the best care.

Douglas K. Owens, director of CHP/PCOR, said the U.S.  Preventive Services Task Force, of which he is a member, has “often faced a real paucity of data trying to develop prediction guidelines for both the very young and the old.”

The Task Force, a panel of experts that makes recommendations for medical prevention services, is generally able to make guidelines for large populations like adults, but suggestions for specialized groups like children and the elderly are more challenging. Though Stanford researchers like Wise are working to improve care for particular sectors like children, more study is needed.

Several speakers at the conference said the underserved population of poor children could benefit from research targeted toward their population group.

“We don’t really understand the biology of the life-course, why things taking place in gestation and early life actually affect healthy aging and adult onset disease,” said Wise, adding, “We have a very poor understanding of how to translate this understanding into effective interventions for communities in need.”

Panelists agreed that big data can help them understand smaller, poorly served populations, such as young children in impoverished communities. By collecting large amounts of data from the general population, researchers will increase the amount of data available for more specific groups. This allows researchers to study these populations more closely and help create better outcomes.

Abby King, a professor of health research and policy and of medicine, and Jason Wang, director of the Center for Policy, Outcomes and Prevention (CPOP) and a CHP/PCOR core faculty member, believe life-course digital applications can provide individualized care while collecting data on a large-scale.

According to King, a life-course app, or a device to track health and provide care throughout one’s life, would grow with the user and help them through important developmental stages.

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Health-care techniques using mobile devices, known as mHealth, could be particularly useful in underserved populations. King notes that even low-income populations have cell phones, so using phones as health-care tools could help decrease the gap between higher- and lower-income populations.

“I think for us one of the major challenges of the century is to really close that health-disparities gap and mHealth can help.”

However, each app must be tailored to the user.

“There’s no reason to believe that an African-American 16-year-old is going to be motivated the same way as a 45-year-old white man,” said Wang. “You need to involve patients in the design of the app.” When the app fits the specific patient’s needs, they are more likely to use it regularly, and knowing the needs of their population helps determine their preferences.

As the world continues to become more connected, the panelists said that reaching across disciplines and incorporating technology may hold the key to effective health care in the 21^st century.

As more physicians move from solo and small practices, a dozen common medical procedures are becoming more expensive in areas where physicians are clustered into large medical practices, according to a new study.

The October study in Health Affairs assessed the relationships between physician competition and prices paid by private organizations in 2010 for 15 common, high-cost procedures to determine whether high concentrations of physician practices and accompanying increased market power were associated with higher prices for services.

They found that prices were indeed 8 to 26 percent higher in the thousands of counties analyzed, with the highest average physician concentration compared to counties with the lowest. This was for 12 of the 15 procedures they examined, including colonoscopy with lesion removal, vasectomy, laparoscopic appendectomy and knee replacement surgery.

“Our findings are consistent with the hypothesis that greater market power allows physicians to bargain for higher prices from insurers,” wrote Dan Austin, a graduate of the Stanford University School of Medicine and a resident physician at the University of California, San Francisco, and Laurence C. Baker, chair of Health Research and Policy at Stanford and a core faculty member at CHP/PCOR.

“We concluded that physician competition is frequently associated with prices,” they said. “Policies that would influence physician practice organization should take this into consideration.”

The authors studied 15 high-cost, high-volume procedures that generated 7,000 total bills in 2010 and had a mean price of at least $500. They identified nine surgical and medical specialties: dermatology, cardiology, radiation oncology, gastroenterology, otolaryngology, urology, ophthalmology, orthopedics, and general surgery.

Average prices for the procedures studied varied. Total knee replacement surgery and insertion of intracoronary stent were the two most expensive, at  $2,301 and $1,282, respectively. Vasectomy and colonoscopy were the least expensive, at  $576 and $586.

The authors found there was also considerable variation across counties within each specialty. The mean price in the 90th-percentile county was 1.8 to 2.7 times higher than in the 10th-percentile county. The 75th-percentile county was commonly $200 to $300 more expensive than the 25th-percentile county, and in some cases more.

This study adds to the growing body of research that demonstrates wide variation in medical prices for the same procedure or test based on a number of factors, including where a procedure is performed and who performs it.

“We know from some good examples that larger, well-run practices can provide high- quality care," Baker said in an interview. “And many of our current policies are built around the notion that we should encourage the formation of larger organizations in the hope of improving the quality of care and fostering improvements in value."

But, adds Baker: “It is also important that we factor in these kinds of effects on prices and the downstream impacts this can have on our health-care costs.”

Matt Sheehan
China Correspondent, The WorldPost
October 12th, 2015

Simply giving nearsighted children glasses can dramatically boost their school performance. Convincing teachers and parents is harder.

This article is the second in a What’s Working series that looks at innovative policy solutions pioneered by the Rural Education Action Program. REAP brings together researchers from Stanford University and China to devise new ways to improve rural education and alleviate poverty. You can read the first article in the series here.  

QIN'AN COUNTY, China -- Wei Wentai can barely be heard over the crescendo of cackles coming from the hallway. Fourth graders everywhere cane be boisterousness, but today the presence of two foreigners, an exotic breed in the rugged hills of western China, has driven these kids into a frenzy.

You could try to reason with the children: tell them they need to quiet down because Dr. Wei is here to train their teachers in how to perform vision tests. Those tests will give some kids free glasses so they can see the blackboard, dramatically improving their grades and chances of graduating high school.

But yeah, that’d be about as effective here in rural Gansu, in China's northwest, as it would be in Alabama, and it takes the lunch bell to drag the mob away from the classroom window. 

With relative peace restored, Wei continues to tutor the 12 village schoolteachers in the basics of eyesight and education. Having grown up nearby, he knows what superstitions to dispel (“No, glasses do not make your eyes worse”) and what points to drive home (“Yes, glasses dramatically improve grades for nearsighted students”). Despite receiving his medical training in Shanghai, Wei returned home after graduating and always speaks in the local dialect when training the teachers to perform this basic eye exam and write referrals.

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It’s a simple presentation tailored to this county, but one predicated on years of trust building and scientific trials by researchers on both sides of the Pacific Ocean.

Driving the project, called Seeing is Learning, are researchers from Stanford University’s Rural Education Action Plan (REAP) and Shaanxi Normal University’s Center for Experimental Economics in Education (CEEE). These groups operate in an emerging field of development economics that prizes rigorous experimentation over theory. Concrete interventions, randomized controlled trials and impact analysis are what drive their research and policy recommendations. Randomized controlled trials compare a randomly assigned group of participants receiving a particular treatment being studied with one not receiving the treatments. These trials are often called the gold standard of scientific research. 

REAP and CEEE have spent almost five years accruing the political capital and research results that they hope will overcome one of the biggest obstacles standing between rural Chinese kids and a high school diploma: most of them can’t even see the writing on the blackboard. 

Like many of their peers around East Asia, rural Chinese children suffer high rates of myopia. Around 57 percent are nearsighted by middle school, according to one REAP study. Unlike schoolchildren in Singapore or in China’s cities, most kids growing up in the Chinese countryside are ignorant of and isolated from vision care. 

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In hundreds of visits to rural Chinese classrooms, REAP program director Matt Boswell has rarely seen a bespectacled face. A patchy and inadequate rural medical system, the high cost of glasses and cultural preferences for eye exercises over glasses (what one researcher calls “voodoo health”) mean that most children growing up in townships and villages never take a vision test. 

“There is no eye care at the township level in China,” said Boswell. “Period.”

That void has a huge impact on education. In a study published in the British Medical Journal, REAP and Chinese researchers showed that giving myopic kids free glasses improved their math test scores by about as much as reducing class sizes. Those improvements came despite the fact that only 41 percent of students who were prescribed glasses actually wore them regularly. According to Boswell, when results were limited to the students who actually wore the glasses they were given, the impact proved enormous: it roughly halved the achievement gap between these rural students and their urban peers in just nine months.

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Improvements of that size represent some of the juiciest low-hanging fruit in Chinese education. Sixty percent of children in the countryside will drop out before high school, many due to failed grades and entrance exams. These tens of millions of dropouts threaten to throw a wrench in the Chinese government's plan to transition to a service- and innovation-based economy.

But when dealing with China’s bureaucracies, having a simple solution to a vexing problem isn’t enough to start harvesting that low-hanging fruit. The real art and science of the project came in aligning bureaucratic interests to get it off the ground.

“Every issue has its own little ecosystem,” Boswell said. 

For Seeing is Learning, that ecosystem involved education officials committed to the eye exercise regime, schools that closely guard access to their students, families who are deeply suspicious of the effect of eyeglasses and hospitals that saw no reason to screen rural kids.

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To break the impasse, the researchers had to first get local education bureaucrats on board. Randomized controlled trials proved the effectiveness of glasses and debunked the myth of eye exercises. They caught the eye of a powerful official in the nearby city of Tianshui, whose backing opened the doors to local schools. With REAP’s pledge to subsidize glasses, the hospitals suddenly saw large new markets materialize.

As a kicker, one trial found that when teachers were offered an iPad if their students were wearing glasses during random inspections, usage rates jumped from 9 to 80 percent.

“Hospitals love it because they get in the schools. Principals love it because of the impact on scores,” said Boswell. “We love it because the kids are learning.”

Turning that newfound excitement into a working program required the creation of two “Model Vision Counties” in which nurses and doctors like Wei Wentai receive accelerated optometry training.  In order to expand that reach from the county seat down to the village,  REAP ran another trial to see if teachers could conduct accurate eye exams after just a half-day training (answer: yes). So the newly trained doctors now rotate through the village schools, training teachers who then refer students to the hospital vision centers for proper prescriptions.

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Now the researchers are looking to scale up the program to six counties and at the same time turn the vision centers into sustainable social enterprises. Using their privileged access to schools, the vision centers can sell glasses to urban children with the resources to pay. Those profits then subsidize the first pair of glasses for rural kids, and repay REAP's initial loan, which REAP can then reinvest in creating further Model Vision Counties.

It’s a new model for REAP and one that prompts many new research questions. Can the vision centers earn enough revenue to both subsidize glasses and keep the hospitals happy? Will teachers enforce wearing eyeglasses if given a simple mandate rather than an iPad? Will the impact of the first pair of glasses convince rural parents to purchase the second pair?

Those questions will be investigated and answered when the project scales up. But as this van winds its way back down from the village to the county hospital, Wei Wentai reflects on the work they’ve done.

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A child takes an eye exam administered by REAP and CEEE.

Health economics expert Laurence C. Baker has been appointed chair of the Department of Health Research and Policy (HRP) in the Stanford School of Medicine. He said he intends to encourage students and faculty within the department to expand the use of emerging data and analytic tools in their health-care research and policy recommendations.

Baker, a professor of health research and policy and a core faculty member at the Center for Health Policy/Center for Primary Care and Outcomes Research, succeeds Philip W. Lavori, who becomes vice chair of the newly established Department of Biomedical Data Science.

“Laurence is a natural and excellent choice for the HRP chair position,” said Stanford Dean of Medicine Lloyd Minor. “Well-respected, trusted, and admired by his peers, Laurence has been chief of Health Services Research within HRP since 2001, during which time the division has grown in strength and reputation.”

Minor called Baker one of the top health economic experts in the world with a strong policy focus, saying he would “bring the unique perspective, energy, and thoughtful guidance needed during this time of change for the department.”

The Health Research and Policy department houses the divisions of Health Services Research and Epidemiology, and provides the analytical foundation for research conducted at the Stanford School of Medicine, offering expertise, research and training on collecting and interpreting the scientific evidence essential to improving human health.

“It’s an exciting time for health policy and the Division of Health Services Research,” Baker said. “The country is facing important challenges in our health-care system, and countries around the globe are looking for insights and new ideas that can improve health care. So  there are real opportunities for Stanford to be a leader and make a difference.”

Baker, who is also a research associate at the National Bureau of Economic Research, said that in his new role he intends to strengthen the epidemiology and the health services research groups at HRP. He will build on Lavori’s efforts to recruit diverse junior and senior faculty, train and retain graduate students and post-MD physician scientists, and make significant contributions to the Stanford Cancer Institute and Population Health Sciences.

“I’ve learned a lot from Phil and have really appreciated his steady and thoughtful leadership of HRP, as well as his insightful approaches to seeking excellence at a time of great change,"  Baker said. “We already have a strong history of making important contributions, and I think we are in an excellent position to make the most of new opportunities — like bigger and better emerging data and analytic tools and new settings for research — to do outstanding work.”

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Baker said that the department successes have also included growing its faculty, establishing  new PhD programs and working on interdisciplinary research projects at the School of Medicine and in collaborations with CHP/PCOR.

“I want to continue looking for opportunities to grow and strengthen the research and education that we offer, in the hope that we can strengthen the overall contribution to national and international health policy that Stanford can make,” he said.

Baker’s research examines the impact of financial incentives, regulations and organizational structures in health care. He also looks at the impact of managed care and related insurance arrangements on health care costs, the pricing of physician services, prices for health insurance and the availability and utilization of medical technologies.

Baker completed his doctoral degree in Economics at Princeton in 1994, and joined the faculty at Stanford in HRP soon after. His research focuses on the way that changes in health-care delivery systems influence the cost and quality of care, with a particular interest in the growth of large, multi-specialty, and hospital-affiliated medical practices.

In addition to his position in HRP, Baker is a professor of economics (by courtesy) at Stanford, a fellow of the Center for Health Policy, and a senior fellow of the Stanford Institute for Economic Policy Research.

He also leads the School of Medicine’s Scholarly Concentration and Medical Scholars programs. Baker has received multiple honors and awards, including the ASHE medal from the American Society of Health Economists, and has helped lead key professional groups, serving on the boards of directors of the International Health Economics Association, AcademyHealth, and the American Society of Health Economists.

“There is growing recognition of the need for well-crafted health policies that can help us deliver quality care and real value,” Baker said. “More and more people are on the lookout for ways to improve population health in the United States and around the world, so I think we’re going to see more interest in the kind of work we do.”

Most Americans will get at least one faulty diagnosis in their lifetime, sometimes with devastating consequences and “urgent change is warranted to address this challenge,” a panel of medical experts said Tuesday.

In a landmark report by the Institute of Medicine, the medical arm of the National Academies of Sciences, Engineering and Medicine, the experts said that despite dramatic improvements in patient safety over the last 15 years, diagnostic errors have been the critical blind spot of health-care providers.

Exact figures on diagnostic errors are hard to come by, as reporting is not required. Some medical experts have estimated that more than 12 million adults are misdiagnosed every year.

“Despite the pervasiveness of diagnostic error and the risk for patient harm, they have been largely unappreciated within the quality-safety movement in healthcare — and this cannot and must not continue,” said Dr. Victor Dzau, president of the Institute of Medicine, an independent organization of the country’s leading medical and health policy researchers.

“Diagnostic errors are a significant contributor to patient harm and have received too little attention until now,” he said at a public briefing in Washington, D.C., about the report, “Improving Diagnosis in Health Care.”

To address the challenge, the IOM convened the committee comprised of medical and health policy researchers to improve diagnosis in medicine. The Committee on Diagnostic Error in Health Care members include experts from Stanford, Harvard, Drexel, Tufts, the Memorial-Sloan Kettering Cancer Center, Kaiser Permanente and more than a dozen other universities and national medical organizations.

“We defined diagnostic error from a patient's perspective, and brought together the research so far that clearly shows the opportunity and grave need to improve the current situation,” said Kathryn M. McDonald executive director of Stanford’s Center for Health Policy/Center for Primary Care and Outcomes Research, and a member of the IOM committee.

“The report is packed with reasons and directions for action from all, in ways that support what patients deserve from the health-care system: freedom from worry about inattention to diagnostic errors,” McDonald said. “That's been the status quo for too long.”

The committee issued a set of goals to reduce diagnostic errors and improve medical outcomes. They recommend that the health-care community:

1. Facilitate more effective teamwork in the diagnostic process among health-care professionals, patients and their families.

2. Enhance health-care professional education and training in the diagnostic process.

3. Ensure that health information technologies support patients and health-care professionals in the diagnostic process.

4. Develop and deploy approaches to identify, learn from and reduce diagnostic errors and near misses in clinical practice.

5. Establish a work system and culture that supports the diagnostic process and improvements in diagnostic performances.

6. Develop a reporting environment and medical liability system that facilitates improved diagnosis through learning from diagnostic errors and near misses.

7. Design a payment and care delivery environment that supports the diagnostic process.

8. And provide dedicated funding for research on the diagnostic process and diagnostic errors.

The experts emphasized that medical education must include more of an emphasis on the diagnostic process. And new technologies, such as electronic health records, should be built on better collaboration among the IT vendors, users and the Office of the National Coordinator for Health Information Technology.

The new study was an extension of two benchmark reports by the institute released 15 years ago, which revealed the startling statistic that 100,000 Americans die in hospitals every year due to medical errors.

“These landmark reports from IOM reverberated throughout the healthcare community and were the impetus for system-wide improvement in patient safety and quality,” Dzau said.

The Department of Health and Human Services reported in December that there was a decline from 2010 to 2013 in hospital-acquired infections, which translated to 1.3 million patients and $12 billion in health spending avoided.

“You can see we have come a long way,” Dzau said. But, he added: “The critical element that has been absent from patient safety and quality is diagnostic error.”

In a video released at the public briefing, two patients talk about their own misdiagnosis and that of a loved one, and how those errors forever changed their lives. They were told they were overreacting and not to question their doctor. One said she was embarrassed at having wasted the valuable time of the hospital doctors and nurses.

“The video has two patients for whom things went poorly and one who had a first-class diagnostic experience because of excellent teamwork,” McDonald said. “And this is one of the key messages of the report. We need less of the old model of diagnosis from one expert to more of a teamwork approach to the diagnostic process.”

Dr. John Ball, chair of the committee and executive vice president emeritus of the American College of Physicians, said clinicians must work toward a culture where patients are central to the solution.

“Patients and families are first; diagnostics are second and those who support it, third,” said Ball. “This is an issue that matters to patients, and we’re shining a light on it.”

Ball said getting the right diagnosis is critical because it impacts every other health care decision that follows, as well as the quality of life for the patient.

The committee members were asked during the briefing why they were not recommending that misdiagnosis reporting be mandatory, something that likely will lead to controversy.

“The committee believes that given the lack of agreement on what constitutes a diagnostic error, given the complexity of hard data and the lack of valid measurement approaches, the time was not right to call for mandatory reporting,” Ball said. “Instead it was appropriate at this time to leverage the intrinsic motivation of health-care professionals to improve the diagnostic performance and to treat diagnostic error in the same way we treat other quality improvement efforts by health-care organizations.”

The three women who are the first doctoral candidates in the School of Medicine’s new PhD in Health Policy program have one guiding belief:  economics, decision science and data are now key to improving health care.

Stanford Health Policy, through the Department of Health Research and Policy at the School of Medicine, launched the PhD program to educate the next generation of scholarly leaders in the field of health policy.

And the first crop of candidates is taking their backgrounds in science and economics to pursue health policy careers based on medical information technology, data and analytics.

“We live in an era where information in health care is more rapidly and readily available than ever before,” said Catherine Lei, who will focus on the industrial organization of health care, the effects of insurance costs and the impact of regulation on health insurance markets.

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“Whether it be the digitization of medical records, the aggregation of pharmaceutical companies’ research into electronic databases, or the increased transparency of the health-care sector as a whole — stakeholders from every corner of the industry recognize that this is a critical turning point in health care,” said Lei.

Kyu Eun Lee, who worked as a research assistant at the Harvard Center for Health Decision Science before joining Stanford, intends to develop mathematical models for health interventions in Asia and other parts of the developing world.

“I am seeking advanced training in quantitative methodology and the application of those skills to support decision-making in a global health context,” said Lee, who graduated from Pohang University of Science and Technology in South Korea and then got her master’s of science at the University of Minnesota.

“I am particularly interested in model-based, cost-effectiveness analysis of cancer interventions in South or Southeast Asia, where the risks of communicable and noncommunicable diseases compete under limited resources,” she said.

The new program offers coursework in two tracks: Health Economics, including the economic behavior of individuals, providers, insurers and governments and how their actions affect health and medical care; and Decision Sciences, which uses quantitative techniques to assess the effectiveness and value of medical treatments.

“The new PhD program really developed because of our aim to offer premier educational programs that will train the next generation of health policy leaders,” said Laurence Baker, professor of Health Research and Policy and chief of Health Services Research in the department of Health Research and Policy.

“One of the real strengths of the program is its context at Stanford, with a rich set of opportunities for health policy students to interact with the clinicians and scientists from around the school of medicine and the university,” said Baker, who is also an affiliated faculty member at the Center for Health Policy/Center for Primary Care and Outcomes Research (CHP/PCOR).

Yiqun Chen, who will focus on the supply and demand of health care both in the United States and China, said her double major in economics and medicine at Peking University made her aware of the integral role that economics plays in providing an analytic framework for studying the meaty issues in health care today.Chen, who went on to get her master’s in economics at Duke University, has published several papers and intends to investigate whether Medicaid payment increases to nursing homes result in cost offsets.

“The utilization of hospital services is high among nursing home residents; yet a large proportion of stays are documented to be avoidable through provision of better quality of nursing home care,” Chen said.

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She will also research the recent consolidation of health insurers and of health care providers and how that is impacting the consumer.

“As a result of such consolidation, not only is there a potential loss of consumer choice, but it gives the pricing power to insurers and health-care service suppliers,” Chen said. And those who argue health-care and insurance consolidation results in greater efficiencies have yet to document these gains or losses — something she intends to do.

Faculty belonging to the health policy centers will advise the PhD candidates. The students will take courses in health economics, health insurance and government program operations, health financing, international health policy and economic development, as well as the cost-effectiveness analysis of new medical technologies.

“The PhD program enables us to train clinicians and non-clinicians in state-of-the-art methods of health policy analysis,” said Douglas K. Owens, director of CHP/PCOR within the Freeman Spogli Institute of International Studies.

Coursework in the new program will also cover relevant statistical and methodological approaches to public health concerns such as obesity and chronic disease.

"Our PhD students will learn from faculty across the University who bring perspectives from economics, medicine, law, decision science, business and other disciplines," said Michelle Mello, a professor of law and professor of health research and policy at the School of Medicine. "They will become truly cross-disciplinary thinkers and problem solvers."

Learn more here. 

MUMBAI, India –  India’s colors, crowd and noises can overpower a newcomer. And the unfathomable wealth and crushing poverty that are both on display reinforce the sense that this is a country of extremes.

Four Stanford students embraced this savory sensory overload while navigating the labyrinthine Indian health-care system during seven weeks of research in the poor communities outside the financial capital, Mumbai, this summer.

“I think this experience has just hammered into me that it’s a very diverse country with a range of experiences,” said Lina Vadlamani, a Human Biology major just starting her senior year. “As one pharmaceutical owner said to us, ‘India might be poor — but the Indian people are not.’ There’s just so much going on here.”

One day they whizzed by bright Bollywood movie posters in belching auto-rickshaws and gaped up at Antilia, the 27-story mansion of a business tycoon considered the world’s most expensive home after Buckingham Palace.

The next, the students were talking to mothers of one Dalit community — members of the so-called “untouchable” Hindu caste — in the slums on the outskirts of Mumbai. They sat on the floor of a one-room community center taking notes as the women told them about their struggles to get access to medicine and doctors.

And yet another day, the students and their Indian colleagues and translators crouched in a small stucco pharmacy in the heat and humidity of the monsoon season while talking to a doctor about the procurement of traditional medicines.

The three Stanford seniors and one School of Medicine student were tracking access to health care, the quality of that care, and the way pharmaceutical networks impact medical practices in India. The Stanford India Health Policy Initiative fellows saw for themselves that the world’s largest democracy has become a microcosm of humanity’s bustling economic prosperity and yawning stretches of poverty.

“I think Mumbai is the place to see the extremes of inequality,” says Mark Walsh, an Economics major starting his senior year and a coterm who already has a Master’s in Public Policy with a focus on international development. “I’m just trying to think about how some of this great prosperity can be applied to the health problems that are affecting some of the most disadvantaged members of Indian society.”

Hadley Reid, another HumBio senior, and Pooja Makhijani, who just began her second year at the Stanford School of Medicine, are the other fellows. The students spent six days a week in the field for seven weeks and then would debrief one another every night back in their rooms on what they had learned that day.

“I’ve always thought I might be interested in doing international field work,” said Reid. “And I thought this fellowship would be a good way to experience that and see what’s really happening on the ground versus what you learn in the classroom.”

Navigating the three medical practices in India

Grant Miller, an associate professor of medicine and core faculty member at the Center for Health Policy/Center for Primary Care and Outcomes Research, directs the India Health Policy Initiative. The program, now in its third year, aims to work on the ground to identify obstacles to health-care delivery in the South Asian nation.

Miller gave the four fellows a mission: Spend your summer investigating the pharmaceutical networks that cater to the three main branches of Indian medicine:

1. The more mainstream Western practice of allopathy; 

2. The traditional AYUSH system of medicine: ayurveda, yoga, unani, siddha and homeopathy.

3. And the large network of providers who have no formal medical training.

“The fellowship has two objectives,” said Miller, also a senior fellow at the Freeman Spogli Institute for International Studies. “One is to develop a nuanced, on-the-ground understanding of the practical realities that often cause otherwise promising health programs in India to fail. The other is to provide in-depth, non-clinical field experience to Stanford students interested in global health.”

Nomita Divi, program manager of the initiative, said the fellowship is designed to be demanding.  During the preparatory spring quarter, the students brainstormed with a design-thinking expert about how to formulate their research and work toward specific goals. When the students return to Stanford later this month, they will focus on unpacking and analyzing the data and then writing a full report.

“Our aim is to expose students to the realities of field research in India and provide them sufficient time to grasp the realities on the ground, as well as provide them with the tools to assimilate their observations into a final report,” said Divi.

When they arrived in Mumbai in early July, the fellows went through a week of training with Veena Das, the renowned social anthropologist from Johns Hopkins University who is on the executive board of the New Delhi-based Institute of Socio-Economic Research on Development and Democracy (ISERDD). She taught the students how to conduct field research and compose discussion guides before they crossed the thresholds of more than 100 homes of patients and offices of physicians, pharmacists and drug wholesalers.

ISERDD is a nonprofit organization devoted to research on social and economic issues and is the leading partner of the Stanford initiative, providing decades of qualitative and quantitative data sets as well as field researchers who worked alongside the students all summer.

“Primary care in poor parts of India is centered around drugs,” Miller said. “This summer, our fellows focused on the relationship between pharmaceutical suppliers and health providers, many of whom work in the informal sector — that is, they lack formal clinical training of any kind.”

Only 1.3 percent of India’s GDP was devoted to public health in 2014, one of the lowest rates in the world, according to the World Bank. India still accounts for 21 percent of the world’s burden of disease, yet the amount of public funds India invests in health care is quite small compared to other emerging economies.

Most of the cost of health care falls to the patient in India, where 86 percent of the 1.2 billion people must pay for health care and medications on their own. While the private sector caters to Indians who can pay, the poor are left to rely on the often less-than-optimal public health care system and a network of family and friends.

Unproductive spending and corruption also cripple the system.

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In the Field

Jaya Jadhav, a young mother in the Dalit community, explained to the students that they rely on a government nurse who comes once a month to hand out paracetamol. They have no local doctor to treat the more serious cases of typhoid and malaria, so must travel to the next settlement to see a doctor.

The women also turn to poorly trained practitioners who purchase wholesale drugs from small manufacturers and dispense these cheaper, unlabeled and often diluted pills to their patients.

As the students interviewed the women, a dozen children sat on the floor eating government-donated puffed rice and boiled gram from tiffin pots; mothers nursed beneath their saris and politely answered questions. At the end, the women asked shyly if the Stanford students had any medications they could share.

The students explained they were not doctors, but hoped that learning about the women’s daily lives would help them with their findings.

“Well, if it will one day benefit the women in the area, then this exchange of ideas about health is a good thing,” says Jadhav.

But the students weren’t always so sure.

“One of the things that I’m struggling with is the frustration of being able to do so little for these people, who basically have nothing but are ready to give us all their time,” says Makhijani, an American whose parents are from Mumbai. “But I realize I have the potential to be able to do that in the future, so I’m considering coming back to work here one day.”

Hoping for Results

Vadlamani — one of the HumBio majors who this fall also begins the Department of Medicine’s new coterm Master’s Program in Community Health and Prevention Research — applied for the fellowship because of its emphasis on field work.

““It makes us feel like detectives in a way,” said Vadlamani, who was born in the southern India city of Hyderabad and moved to the States with her parents when she was an infant. “I hope we would leave this experience with a couple of concrete areas that need to be focused on that would, down the road, lead to a policy change.”

Reid also believes their summer-long research will yield results.

“I’m not saying we’re painting the broadest, most accurate picture of the situation in India,” she said. “I know we’re taking a very small sample outside of Mumbai. But the hope is our findings will decrease some of the obstacles to effective policymaking for the health care system in India one day.”

Some of the key trends the students observed include the murky government regulations on certain classes of drugs, and the lack of knowledge about the current restrictions of antibiotic and steroid use among AYUSH doctors.

And compounding communicable diseases, such as tuberculosis and HIV/AIDS, Indians are increasingly suffering from non-communicable diseases as well.

“That’s happening across the developing world, these chronic lifestyle diseases such as diabetes and hypertension,” said Walsh. “And these families aren’t used to having to deal with these kinds of chronic diseases.”

The rural poor cannot afford to see a primary care physician who would school them in lifestyle changes to fight a potentially deadly disease such as diabetes.

And those who can afford a doctor in rural India often can’t find one.

India currently has some 840,000 doctors, or about seven physicians for every 10,000 people, according to the World Health Organization. That compares with about 25 in the United States and 16 in India’s economic rival, China.

The doctors the students did meet were generally overworked and struggling to keep up with all their patients and the shifting laws and regulations. But the students were forced to let go of some of their preconceived notions.

“Although there’s definitely a lot of gaps in knowledge, I’ve been surprised at how much doctors do know and how well trained they are,” said Makhijani, who often visits family in Mumbai, but had never ventured out into the poorer communities where her grandfather once ran a government hospital.

“I’ve never had such personal interactions with people living in the slums, with the doctors who are working here,” she said. “It really turns your perspective around, how resilient and creative they are.”

An Honor and Duty

Dr. Masood Ahmed Khan, a physician and pharmacist, spent nearly two hours with the students, with no prior knowledge that they would show up at his door and pepper him with questions about how he runs his unani practice.

When asked why he would give so much of his time, he said it was his “honor and duty” to help the students better understand the ups and downs of his medical community in one of the poor Muslim corners of Mumbai.

Dr. Khan then bid farewell with a cup of masala chai and this advice as they embark on their careers: “Go with empathy, go with humanity — and go with humility.”

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Beth Duff-Brown is the communications manager for the Center for Health Policy/Center for Primary Care and Outcomes Research. She joined the students in Mumbai for a week to blog about their research. You can read the blog postings here. 

The H5N1 strain of the bird flu is a deadly virus that kills more than half of the people who catch it.

Fortunately, it’s not easily spread from person to person, and is usually contracted though close contact with infected birds.

But scientists in the Netherlands have genetically engineered a much more contagious airborne version of the virus that quickly spread among the ferrets they use as an experimental model for how the disease might be transmitted among humans.

And researchers from the University of Wisconsin-Madison used samples from the corpses of birds frozen in the Arctic to recreate a version of the virus similar to the one that killed an estimated 40 million people in the 1918 flu pandemic.

It’s experiments like these that make David Relman, a Stanford microbiologist and co-director of the Center for International Security and Cooperation, say it's time to create a better system for oversight of risky research before a man-made super virus escapes from the lab and causes the next global pandemic.

“The stakes are the health and welfare of much of the earth’s ecosystem,” said Relman.

“We need greater awareness of risk and a greater number of different kinds of tools for regulating the few experiments that are going to pose major risks to large populations of humans and animals and plants.”

Terrorists, rogue states or conventional military powers could also use the published results of experiments like these to create a deadly bioweapon.

“This is an issue of biosecurity, not just biosafety,” he said.

“It’s not simply the production of a new infectious agent, it’s the production of a blueprint for a new infectious agent that’s just as risky as the agent itself.”

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But Relman cited a series of recent lapses at laboratories in the United States as evidence that accidents can and do happen.

“There have been a frightening number of accidents at the best laboratories in the United States with mishandling and escape of dangerous pathogens,” Relman said.

“There is no laboratory, there is no investigator, there is no system that is foolproof, and our best laboratories are not as safe as one would have thought.”

The Centers for Disease Control and Prevention (CDC) admitted last year that it had mishandled samples of Ebola during the recent outbreak, potentially exposing lab workers to the deadly disease.

In the same year, a CDC lab accidentally contaminated a mild strain of the bird flu virus with deadly H5N1 and mailed it to unsuspecting researchers.

And a 60 year-old vial of smallpox (the contagious virus that was effectively eradicated by a worldwide vaccination program) was discovered sitting in an unused storage room at a U.S. Food and Drug Administration lab.

Earlier this year, the U.S. Army accidentally shipped samples of live anthrax to hundreds of labs around the world.

Similar problems have been reported in labs around the world. The United Kingdom has had more than 100 mishaps in its high-containment labs in recent years.

It’s difficult to judge the full scope of the problem, because many lab accidents are underreported.

Studying viruses in the lab does bring important potential benefits, such as the promise of universal vaccines, as well as cheap and effective ways of developing new drugs and other kinds of alternative defenses against naturally occurring diseases.

“It’s a very tricky balancing act,” Relman said.

“We don’t want to simply shut down the work or impede it unnecessarily.”

However, there are safer ways to conduct research, such as using harmless “avirulent” versions of the virus that would not cause widespread death and injury if it infected the general public, Relman said.

Developing better tools for risk-benefit analysis to identify and mitigate potential dangers in the early stages of research would be another important step towards making biological experiments safer.

Closer cooperation among diverse stakeholders (including domain experts, government agencies, funding groups, governing organizations of scientists and the general public) is also needed in order to develop effective rules for oversight and regulation of dangerous experiments, both domestically and abroad.

“We believe that the solutions are going to have to involve a diverse group of actors that has not yet been brought together,” Relman said.

“We need new approaches for governance in the life sciences that allow for these kinds of considerations across the science community and the policy community.”

You can read more about Relman’s views on how to limit the risks of biological engineering in this article he wrote for Foreign Affairs with co-author with Marc Lipsitch, director of Harvard’s Center for Communicable Disease Dynamics.