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.”

View the photo gallery by clicking here or on the arrows below:

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.

Doctors, nurses and other medical staff in Myanmar are wearing black ribbons to protest the appointments of military personnel in the Ministry of Health.

“The Black Ribbon Movement Myanmar 2015,” which began on Facebook in early August, quickly amassed over 42,000 followers, and on Aug. 12, led the minister for health to drop plans to appoint military personnel to over 300 management positions within the ministry.

Writing for The Diplomat, Stanford visiting scholar Phyu Phyu Thin Zaw said the movement shows the dissatisfaction shared among her fellow doctors about the incursion of the military in the healthcare sector. She said it's also representative of greater injustices seen across Myanmar. 

Four years have passed since the country transitioned from military rule toward democratization, and the Ministry of Health among other civic organizations still see the military exert influence over its operations.

Thin Zaw said she remains optimistic, though, and views the movement as a sign of the reemergence of a proactive civil society. The movement continues on this Facebook page.

The article published in The Diplomat can be found by clicking here.

Video of A career in Economics...it's much more than you think

Marcella Alsan, an assistant professor of Medicine and CHP/PCOR core faculty member, shows how economics is a broader field than most people realize in this video produced by the American Economic Association (AEA).  Along with other top economists, she discusses the interdisciplinary nature of economics, specifically as it relates to global health.  Alsan states that "without understanding economic principals and economic forces, [there is] a real gaping hole in actually practicing medicine."  Understanding economics can help us to understand policy decisions and to tackle the broad problems of society.

Although the expansion of Medicaid under the Affordable Care Act has made millions of low-income and rural Americans eligible for health insurance, many states don’t provide dental coverage for adults under their Medicaid programs.

Paying for dental insurance on the individual market or paying for dental services out of pocket is cost-prohibitive for Medicaid beneficiaries, many of whom are at or beneath the federal poverty level.

So many have turned to emergency rooms for such care.

More than 2 percent of all emergency department visits are now related to nontraumatic dental conditions, according to a study by researchers at Stanford University, the University of California-San Francisco, Truven Health Analytics and the federal Agency for Healthcare Research and Quality.

The researchers said Medicaid dental coverage could help reduce the need for many low-income Americans to visit emergency departments for dental conditions that may have otherwise been prevented with adequate access to basic dental care.

“It is likely that EDs will continue to provide care to individuals without adequate access to community-based dental care unless new dental service delivery models are developed to expand access in underserved areas, and unless more dental providers begin to accept Medicaid under the ACA,” the researchers wrote in their study, which was published today in Health Affairs.

Read full article

Despite potential legal and enforcement challenges, California’s new vaccination law may set a precedent for other states, according to Stanford scholars.

The law, SB 277, ends exceptions to vaccination mandates based on religious and philosophical beliefs, leaving only medical exemptions as a path to avoid the vaccinations children are required to have before entering school.

David Studdert, a core faculty member at the Center for Health Policy/Center for Primary Care and Outcomes Research, and Michelle Mello, a core faculty member of Health Research and Policy, authored a report on the new law along with Northwestern Law School’s Wendy Parmet, which appears today in the New England Journal of Medicine. Studdert and Mello are both professors of law and medicine at Stanford.

Studdert, Mello, and Parmet discuss four factors that led to passage of the law. Strong advocacy by several members of the California legislature was one factor.  Another was the state’s efforts to publicize data showing that personal belief exemptions have doubled since 2007, enough to endanger the community. In addition, there is mounting evidence that the recent measles outbreak at Disneyland could have been prevented by better vaccination compliance. Finally, supporters of SB 277 highlighted the risks unvaccinated school children pose to vulnerable classmates. According to the report, “the bill’s proponents focused on the specific threat to schoolchildren who are too medically fragile to receive vaccinations, effectively framing vaccine refusal as a decision that endangers others rather than a purely ‘personal’ one.”

SB 277 could place pressure on other states to tighten their exemptions for school-entry vaccination requirements. At this time, only West Virginia and Mississippi have legislation that prevents personal belief exemptions for vaccination. Adding California may give such laws national attention, and Studdert said that this development may be an “indication that politics are starting to shift.”

However, opponents of the law are likely to challenge it in court. Challengers may argue that the law impinges on their First Amendment rights to free exercise of religious beliefs or that it violates unvaccinated children’s right to access public schools.  However, Studdert “would be very surprised if SB 277 ends up being struck down as a result of such challenges.”  In the past, courts have ruled in favor of public health agencies in similar cases. “For over a century, appellate courts accepted arguments that mass vaccination is crucial to the well-being of the community.”

A more difficult challenge is enforcement of the law. Unvaccinated children can still attend school as long as their parents pledge to complete the children’s required vaccinations, and schools are not penalized for failing to follow up. The authors argue that “state laws should instead task health departments with enforcement responsibility for vaccination mandates” in order to boost compliance. “Willing providers,” or doctors who sympathize with vaccination opponents, may also undermine enforcement if they choose a broad interpretation of the medical exemption criteria. Other ways around the stricter requirements include home-schooling and nannies. This would not affect school safety but could have implications for the larger community.

Foreign aid to the public health sectors of developing countries often appears to be allocated backwards: The global burden of non-communicable diseases such as diabetes or heart disease is enormous – yet they receive little health aid. 

By comparison, the global burden of HIV is much smaller, yet it receives more health aid than any other single disease.

So will a wholesale reversal in health aid priorities improve global health? The answer, according to a new study by Stanford researchers, is that if the goal is to maximize the health benefits from each donor dollar, health aid is actually allocated pretty well.

Still, reallocating foreign aid to step up the fight against malaria and TB could lead to greater overall health improvements in developing nations. And it could be done without spending more money, the researchers have found.

Eran Bendavid, an assistant professor in the Department of Medicine and a core faculty member at the Center for Health Policy and Center for Primary Care and Outcomes Research, and three Stanford research assistants write in the July issue of Health Affairs that more health aid is going to disease categories with more cost-effective interventions.

"What we found, somewhat to our surprise, is that in nearly all countries, more aid was flowing to finance priorities with more cost-effective options,” Bendavid said in an interview. “That is partly because more aid was flowing to the treatment and prevention of infectious diseases such as HIV and malaria, and their management can be relatively inexpensive, even if the burden of these diseases is lower than that of non-communicable diseases.”

Bendavid, an infectious disease physician, added: “Conversely, even though the burden of non-communicable diseases is high and growing, addressing these chronic conditions such as diabetes and heart disease is, broadly, more costly than the unfinished infectious disease agenda.”

The authors also show that just because health aid is broadly allocated toward better cost-effectiveness does not mean that it cannot be better allocated.

The biggest gains would come from taking some of the foreign aid earmarked for HIV or maternal, newborn or child health, and putting it toward programs to treat malaria and tuberculosis, they write.

The Stanford research team reviewed the literature for cost-effectiveness of interventions targeting five disease categories: HIV, malaria, tuberculosis, non-communicable disease and maternal, newborn and child health.

What they found was that aid from wealthy nations to developing ones might be allocated efficiently, but that the money is not always spent in the best interest of curbing the communicable diseases that would improve the overall health of a nation.

It is crucial, therefore, to further study the consequences of realignment of donor funds.

Public health aid is critical to most developing countries. Development assistance from high-income countries to public health sectors of low- and middle-income countries amounts to nearly 40 percent of public health spending in countries with a per capita GDP of less than $2,000.

The researchers focused on 20 countries that received the greatest total amount of aid between 2008 and 2011, a period of historically unprecedented growth in health aid. Development assistance has since flattened, however, so the authors believe it’s increasingly important to consider best value when investing limited resources.

The 20 countries studied ­– from Afghanistan to Zambia – received $58 billion out of the total $103.2 billion in recorded health aid disbursements to 170 countries between 2001 and 2011.

“Over the period of 2001-2011, a greater amount of disbursements flowed to HIV programs than any other disease category,” the authors write. “On average, interventions addressing malaria and had the lowest incremental cost-effectiveness ratio (ICER), which indicates that malaria interventions could yield greater health improvements from each dollar compared with the interventions having a higher ICER.”

The authors analyzed the data and determined that the alignment improves if up to 61 percent of HIV aid is reallocated for TB control and up to 80 percent is reallocated for malaria control.

“Our evidence suggests that the greatest improvements in the efficiency of global health dollars could result from reallocating funds to malaria and TB control programs,” the authors write.

“This study shows, for the first time, that the current allocation of health aid is generally aligned with the cost-effectiveness of targeted interventions. Contrary to common views that advocate for reprioritization toward non-communicable diseases, our data suggest that the alignment could best be improved by focusing on malaria and TB, especially where addressing those diseases is highly cost effective.”

The other authors of the study are Andrew Duong and Gillian Raikes, both research assistants in the Program of Human Biology; and Charlotte Sagan, a RA in the School of Medicine.

The increasing resistance to antimicrobial drugs is a growing public health concern, particularly in low- and middle-income countries that require high out-of-pocket payments for prescription drugs.

“Understanding the drivers of antibiotic resistance in low- to middle-income countries is important for wealthier nations because antibiotic-resistant pathogens, similar to other communicable diseases, do not respect national boundaries,” said Marcella Alsan, MD, PhD, MPH, the lead author of the study, which was published July 9 in The Lancet Infectious Disease.

Alsan is an assistant professor of medicine at Stanford, an investigator at the Veterans Affairs Palo Alto Health Care System and a core faculty member at the Center for Health Policy/Center for Primary Care and Outcomes Research.

“Out-of-pocket health expenditures are a major source of health-care financing in the developing world,” said Jay Bhattacharya, MD, PhD, senior author of the study and a professor of medicine, a senior fellow at the Freeman Spogli Institute for International Studies and another core faculty member at CHP/PCOR.

Read the full article here.

Rates of obesity in the United States remain extremely high. New statistics show that nearly two-thirds of adults are at an unhealthy weight and that – for the first time ever – obese Americans now outnumber those who are merely overweight.

Two Stanford public health law experts say one of biggest culprits of the obesity epidemic – on top of fast foods and our sedentary lifestyle – are sugary drinks.

And they believe the sweet spot for public health law in curbing the adverse effects of sugar-sweetened beverages (SSBs) lies in the strategic use of measures such as higher SSB taxes, limits on advertisements targeting kids, and restrictions on soft drinks and sugar-sweetened teas and sports drinks in government institutions, such as public schools.

“It’s always possible to get more and better evidence about the effectiveness of public health laws,” says David Studdert, a professor of medicine at the Stanford School of Medicine, professor at the Stanford Law School and core faculty member at the Center for Health Policy/Center for Primary Care and Outcomes Research.

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“But enough is already known about the promise of some legal interventions to curb SSB consumption – significant tax hikes and advertising restrictions are two good examples – to be fairly confident that they would make a difference.”

Studdert is the lead author of a review paper published July 7 in PLoS Medicine, entitled, “Searching for Public Health Law’s Sweet Spot: The Regulation of Sugar-Sweetened Beverages.”

Studdert and senior author Michelle Mello, professor of law and professor of health research and policy at the School of Medicine, and co-author Jordan Flanders, a former Stanford Law School student, argue that sugary drinks are a substantial, yet preventable contributor to the global burden of obesity and associated health conditions.

A new study published June 29 in the American Heart Association journal Circulation linked the consumption of sugary drinks to an estimated 184,000 adult deaths each year, with more than 25,000 of those Americans. The study, conducted by researchers from Tufts University, found that the beverages are responsible for an estimated 133,000 of those deaths from diabetes, 45,000 from cardiovascular disease and 6,450 from cancer.

While Americans’ consumption of sugary drinks has plateaued, according to the Tufts study, about three-fourths of the deaths due to SSBs are now in developing countries. Mexico leads with 24,000 total deaths. The United States still ranks fourth, however, just behind South Africa and Morocco.

The Stanford researchers say the evidence shows that sugary drinks are contributors to the global obesity epidemic, but the appropriate reach of regulation to curtail SSB consumptions remains highly contested.

The main regulatory approaches to SSBs are higher taxes, restrictions on the availability of the sugar-sweetened drinks in schools, restrictions on advertising and marketing, labeling requirements and government procurement and benefits standards.

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“Finding public health law’s sweet spot requires regulatory approaches that are capable both of achieving measurable improvements to public health and of winning victories in courts of law and public opinion,” the researchers write.

Over the last decade, many national, state, and local governments have introduced laws aimed at curbing consumption of sugar-sweetened beverages (SSBs), especially by children. The main regulatory approaches have been taxes, restrictions on the availability of SSBs in schools, calls for controls on advertising and marketing, labeling requirements, and government procurement and benefits standards.

But efforts to regulate the drinks often encounter stiff opposition, including claims that the laws are inequitable, do not achieve their goals, and have negative economic effects.

New York City’s attempt to ban the sale of jumbo-sized sugary drinks sold in city restaurants, theaters and food carts triggered international headlines and a firestorm of opposition. The soft drink industry embarked on a multimillion-dollar campaign to block the proposal championed by former Mayor Michael Bloomberg.

The proposal died last year when the New York State Court of Appeals ruled that the city’s Board of Health had “exceeded the scope of its regulatory authority.”

Taxes on SSBs, the most commonly adopted measure, vary widely, the authors write. A few countries, most notably several South Pacific island nations, where obesity rates are among the highest in the world, have introduced very high taxes on sugary drinks.

But most sugar-sweetened beverage taxes add between 5 and 9 cents per liter. This is well short of the level that experts argue is needed to significantly affect consumption and weight outcomes: a sales tax of at least 20 percent of the container’s price or a specific excise tax of 1 cent per ounce.

“In the United States, there have been many government proposals to introduce or raise taxes – most unsuccessful,” the authors write. “The beverage industry has invested heavily in public relations firms and `grassroots’ organizations to oppose the initiatives.”

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Berkeley, Calif., recently became the first U.S. city to pass an SSB tax, a penny-per-ounce excise on soda distributors, but a similar ballot measure in nearby San Francisco failed. At least 22 states have proposed SSB taxes since 2010, but only one state, Washington, passed a measure at the level recommended by economists – and it was repealed the following year in a voter referendum.

Yet U.S. childhood obesity has more than doubled in children and quadrupled in adolescents in the past 30 years, according to the Centers for Disease Control and Prevention. More than one-third of children and adolescents are overweight or obese.

“There is broad consensus in the public health community that reducing the influence of advertising is a critical step in addressing the spread of childhood obesity,” the authors say.

The United States and Canada have sought to regulate advertisers through a soft approach — mainly via voluntary guidelines and pressure to self-regulate, the authors write.

“These appear to have had only a modest impact on marketing practices,” they said. “U.S. regulators face considerable legal barriers in going further, including courts’ increasingly expansive interpretations of the scope of protected commercial speech under the First Amendment. Unless judicial currents shift, it will remain extremely difficult to impose restrictions on SSB advertising.”

Mello said low- and middle-income countries should anticipate that SSB companies will increasingly target them as promising markets, and that those developing countries should start crafting their regulatory responses now.

“Our experience with tobacco control teaches us that lower- and middle-income countries need to become wary when product regulation in the U.S. tightens,” Mello said. “Like squeezing a balloon, it pushes companies to intensify their marketing efforts overseas, and our public health problems get exported."

And, the authors note, while policy nudges have become fashionable, “there are dangers in treading too lightly.” “Strategies such as calorie labels, portion caps, and small beverage taxes preserve consumer freedom but are typically too modest to affect consumer behavior – and such modesty can be recast as arbitrariness. Industry opposition will come whether the intervention is modest or aggressive but should be easier to combat if officials can show their policy is effective,” they wrote.

“One somewhat surprising message that comes from reviewing how courts have handled challenges to SSB laws is that regulators can run greater risks of having their laws struck down if they are too timid,” Studdert said.

“Courts weigh effectiveness, and modest attempts to change behavior are often ineffective,” he said. “So one piece of advice regulators in this area should consider is to ‘go big or go home’.”

Demographic change is fast becoming one of the most globally significant trends of the 21st century. Declining fertility rates and rising life expectancy -- two of the patterns triggering demographic change -- will cause vast socioeconomic strains, especially in the Asia-Pacific region, which has some of the world's most populous countries. Stanford health researcher Karen Eggleston says comparison and cross-collaboration are needed to induce creative solutions.

In an interview with the Office of International Affairs, Eggleston discusses her research approaches and partnerships in the study of healthcare systems and health policy in the Asia-Pacific region. She leads a multiyear research initative that examines comparative policy responses to demographic change in East Asia. Eggleston says the goal is to help move global health policy to a place where everyone has an "equal opportunity for a healthier and longer life."

The Q&A may be viewed in full by clicking here.

Analyzing demographic change in China, Japan and South Korea is the focus of the book Aging Asia, an outcome of a conference between the Walter H. Shorenstein Asia-Pacific Research Center and the Stanford Center on Longevity.

Eggleston also coedited a special issue of the Journal of the Economics of Ageing with David Bloom, a professor at Harvard University, looking at a range of economic issues related to population change in China and India.