Using agricultural and economic characteristics in African nations as test cases, new research by David Lobell and Marshall Burke demonstrates the use of satellite data to address the long-standing problem of accurate data collection in developing countries. An often cited challenge in achieving development goals aimed at poverty and hunger reduction is the lack of reliable on-the-ground data. Limited or insuffiient data makes it difficult to establish baseline conditions and to assess effectiveness of various aid programs. In the past, researchers and policymakers had to rely on ground surveys, which are expensive, time-consuming, and rarely conducted. This has led to large data gaps in mapping sustainable development goal progress, such as in agricultural and poverty statistics.
Stanford Health Policy’s newest faculty member, Joshua Salomon, believes that one urgent need in global health research is to improve forecasts of the patterns and trends that are the major causes of death and disease.
Salomon, who is leaving leaving his position as professor of global health at the Harvard T.H. Chan School of Public Health to join Stanford on Aug. 1, works on modeling of infectious and chronic diseases and their associated intervention strategies, as well as methods for economic evaluation of public health programs and ways to measure the global burden of disease.
And he looks at the potential impact and cost effectiveness of new health technologies.
“Projections of future trends in health are crucial to formulating policy,” said Salomon, who has a PhD from Harvard. “To think strategically about the technologies and policies that would make the biggest impact on health over the next 20 to 50 years, we really need to start by understanding the range of likely trends in major health challenges over the coming decades.”
Stanford, he said, offers him a “rich collaborative environment” to better learn from advances in forecasting across a range of other disciplines, such as economics, political science, and environmental science.
“With a better picture of what the world is likely to look like over the next 50 years — and what are going to be the most pressing health problems — we can invest wisely and put ourselves in a position to respond more effectively.”
Salomon is also the director of the Prevention Policy Modeling Lab, which is funded by a five-year award from the Centers for Disease Control and Prevention. The consortium represents the collaborative research of experts from Massachusetts General Hospital, Boston Medical Center, Dana Farber Cancer Institute, Yale School of Public Health, Brown University School of Public Health, and the Massachusetts Department of Public Health and.
He will continue directing the lab from Stanford and intends to bring in new research threads from his colleagues here on the Farm. The lab works on a wide range of projects dealing with policy analysis for hepatitis, sexually transmitted infections and diseases such as HIV, and tuberculosis.
“It’s a rewarding grant for me to work on because, unlike a lot of modeling projects, the work that we do really starts from urgent public health questions that policymakers have,” he said. “All of the questions that we are working on are questions that originated directly from discussions with CDC and other public health partners.”
With Salomon’s move to Stanford, the university gains a dynamic duo.
Grace Lee joins Stanford as the Associate Chief Medical Officer at Lucile Packard Children's Hospital in the fall, 2017.
His wife, Grace Lee, MD, MPH, joins in the fall as the Associate Chief Medical Officer at Lucile Packard Children’s Hospital. As a professor of population medicine at Harvard Pilgrim Health Care Institute & Harvard Medical School, Lee has led research in vaccine safety in the FDA-funded Post-licensure Rapid Immunization Safety Monitoring (PRISM) program and the CDC-funded Vaccine Safety Datalink, which monitors the safety of vaccines and studies rare and adverse reactions from immunizations.
She has also examined the impact of financial penalties on rates of healthcare-associated infections, as the principal investigator of an AHRQ-funded study, as well as developed novel surveillance definitions for ventilator-related events in neonates and children.
While at Stanford, Lee said, she intends “to find opportunities to enhance the learning health system approach to improve patient outcomes and population health.”
Salomon has spent his entire career as a collaborator on the Global Burden of Disease project, the world’s most comprehensive epidemiological study commissioned by the World Bank in 1990, which tracks mortality and morbidity from major diseases, injuries and risks factors.
“The study has made a major contribution to global public health because before this study we just didn’t have a comprehensive, systematic understanding of the things that cause death and disability in low- and middle-income countries. But now we do,” he said. “It’s hugely ambitious and very sweeping in scope — and a lot of my work is around providing the evidence we need to inform policy.”
Much of Salomon’s work is global in nature. He’s most recently focused on older adults in one rural South African community, which has a high prevalence of HIV and one of the world’s highest levels of hypertension. His research there aims to inform urgent prevention initiatives tailored to older adults where HIV and cardiovascular risks are moderate or high, as in similar communities in sub-Saharan Africa.
“People don’t expect a high level of ongoing HIV transmission in older adults,” he said. “The double burden that we find, with a very high level of HIV, as well as the high prevalence of diabetes and heart disease, creates enormous strains on the health-care system.”
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Stanford Health Policy's Joshua Salomon believes forecasting new patterns and trends in global health is an urgent need.
Fewer girls in low-and-middle-income countries finish secondary school, resulting in poorer health and economic outcomes for their own children — and perpetuating the vicious cycle of gender inequality worldwide.
According to The World Bank, in Sub-Saharan and South Asia, boys are 1.5 times more likely to complete secondary education than girls. Many are forced to stay at home and help their mothers with housework and childcare, particularly if a younger sibling is sick.
Yet the potential gains from increased participation of women in the global workforce over the next decade are estimated at $12 trillion. Studies show that women’s equal participation in the workforce could boost some countries’ GDP by up to 20 percent.
Stanford Health Policy’s Marcella Alsan, a physician and economist, argues in a new study in the journal Pediatrics, that identifying contributors to education disparities and making investments in early childhood health could significantly advance global health and development.
“There are so many advantages to girls staying in school,” Alsan, an assistant professor of medicine at Stanford Medicine, said in an interview. “For one thing, the longer they’re in school, the less likely they are to become young mothers or contract HIV. And the more educated the mother, their own children have better chances of survival.”
So what are some of the biggest barriers to girls completing secondary school in less developed countries?
Alsan and her co-authors found the gender gap is compounded by illness among young children in the household since adolescent girls are often tasked with childcare and domestic chores. The problem is exacerbated if the mother works outside the household.
Follow the Numbers
Along with SHP research data analyst Anlu Xing, Alsan and her team used Demographic and Health Surveys on 41,821 households in 38 low-and-middle-income countries. The surveys asked about illnesses in children under 5 in the last two weeks, and then asked the adolescent boys and girls if they had been in school in the same period.
As expected, more girls remained at home than boys. When no young children in the household are ill, adolescent girls are on average 6 percent less likely to attend school than adolescent boys within the same household.
But the gap increases to 7.8 percent if the household reports one illness episode among an under-5 child, and up to 8.5 percent if there are two or more episodes of illness.
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In other words, the authors write, “The gender gap in adolescent school attendance increased by around 50 percent when young children in the household became ill.”
The education gap between adolescent boys and girls jumps to 10.06 percent if the younger child has two or more episodes of illness — and the mother is working outside the home or in the fields.
“Policies that strengthen family and community supports for challenges such as sick child care will prove essential,” the authors write, “particularly as women move increasingly into the workforce outside the home.”
Alsan’s co-authors are Eran Bendavid, assistant professor of medicine and core faculty member at Stanford Health Policy; Gary Darmstadt, a professor of pediatrics and associate dean for maternal and child health at Stanford Medicine; and Paul Wise, another core faculty member at SHP and professor of pediatrics.
Vaccines Also Key
Alsan and her team also examined data on the gender gap in adolescent education in association with national vaccine rates, using the same country-year surveys.
They found that in countries where about 70 percent of all the boys and girls had the same series of eight vaccines — including polio, diphtheria, tetanus and measles — the gender gap in education approaches zero.
“We hypothesize that countries with high rates of childhood vaccination will experience lower rates of young child illness, thereby decreasing the need for adolescent girls’ to devote time to caring for sick children,” the authors write.
Given the long-term benefits of secondary school for women’s health and economic outcomes, the authors believe their study underscores the societal benefits of keeping girls in school. A combination of vaccines and early childhood interventions to keep toddlers healthy and their older sisters in school are paramount.
“The international community agrees that educating girls through secondary school has plenty of societal benefits — we show that health interventions targeting young kids are an important way to do just that,” says Alsan. “Not only the targeted little kids benefit but also their older sisters — a double dividend.”
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Secondary school girls responding to a speech at Jamhuri High School in Nairobi, Kenya.
In the slums of Nairobi, where sexual assault is as commonplace as it is taboo to discuss, a team of Kenyan counselors is teaching kids that no means no.
The girls learn to shout — “Hands off my body!” — and throw an elbow jab or good kick to the groin. The boys are encouraged to stand up for the girls and fight against the social traditions that have normalized rape.
Perhaps most effectively, the children learn how to talk themselves out of precarious situations, use clever diversions and speak loudly when faced with potential attackers, through a series of role-playing exercises that promote healthy gender norms.
The behavioral intervention appears to be working. Observational studies have inferred that the incidence of rape has dropped dramatically — perhaps even by half.
But how do those who are devoted to protecting these girls from sexual violence prove to themselves and their donors that their efforts and dollars are making a difference?
This is where Mike Baiocchi comes in. The Stanford statistician and his team of researchers and students are conducting the largest-ever randomized trial of its kind in an effort to place rare, high-quality quantitative proof alongside the more common observational evidence.
“That’s what I specialize in: messy, real-world data where you try and prove the cause-and-effect relationship,” said Baiocchi, PhD, an assistant professor of medicine at the Stanford Prevention Research Center in the School of Medicine.
Rosenkranz Prize 2017 winner Mike Baiocchi and his partner, Clea Sarnquist, both of Stanford Medicine, conduct research on the ground in Nairobi, Kenya, to determine whether a rape prevention program is truly making a difference.
Rosenkranz Prize 2017 winner Mike Baiocchi and his partner, Clea Sarnquist, both of Stanford Medicine, conduct research on the ground in Nairobi, Kenya, to determine whether a rape prevention program is truly making a difference.
Baiocchi and his team have designed a closed-cohort study that will track the behavior of about 5,000 girls and 1,000 boys enrolled in the No Means No Worldwide project, which is training 300,000 girls and boys in Kenya and Malawi to prevent rape and teen pregnancy.
“The entire Rosenkranz selection committee was highly impressed both with the rigor of Mike’s work — which he publishes in top journals in the field of statistics — as well as his unconventional and potentially very impactful work on the prevention of gender-based violence in illegal settlements around Nairobi,” said Grant Miller, PhD, an associate professor of medicine and core faculty member at Stanford Health Policy.
Miller chairs the committee that selects the winners of Stanford Health Policy’s annual $100,000 prize, which goes to promising young Stanford researchers who are investigating ways to improve health care and health policy in developing countries.
In Kenya, national surveys reveal that as many as 46 percent of Kenyan women experience sexual assault as children.
“In the roughest part of the Nairobi slums, 20 to 25 percent of high school girls will be raped this year,” said Baiocchi. “This program, however, looks like it is having the ability to cut that in about half. Our job is to tease out the evidence through careful measurement and design of experiment.”
To do this, Baiocchi and other members of the Stanford Gender-Based Violence Collaborative have traveled to Nairobi to collect baseline data. His partner is Clea Sarnquist, DrPH, a senior research scholar for the Global Child Health Program in the Stanford Department of Pediatrics.
Several pilot evaluations of the program, published in 2014 in Pediatrics, found that more than half of 2,000 high school girls who had completed the self-defense course had used their newfound skills to fend off sexual harassment or rape.
But Lee Paiva, the San Francisco-based founder of No Means No Worldwide, wanted proof. She told Stanford Medicine magazine last year that since establishing training in 2010, she often wondered about the true effectiveness of the program.
“A little voice inside me said, `What did you teach them?’” she said. “What did those kids actually get? What is that money really going to do?”
She determined that she wasn’t going to move forward on the program until she could answer those questions. That is when she turned to Stanford.
Expanding on their initial work, Baiocchi and Sarnquist spent several months last year, working with their Kenyan partners, Ujamaa-Africa and the African Institute for Health and Development, in 90 schools in the poorest parts of Nairobi to establish the largest randomized trial of its kind.
They interviewed the girls who have taken part in the six-week empowerment and self-defense program taught by Kenyans who grew up in the same neighborhoods and are familiar with the local culture.
“It’s hard not to be extraordinarily excited when you watch these girls; they’re play-acting and just being kids, but you are also watching them evolving and creating new ways to deal with these situations,” said Baiocchi.The team is now tracking a fixed group of 5,000 girls and 1,000 boys, ages 10 to 16, over two years. This will give the researchers a better understanding of just how the girls are adopting the training and readapting to societal demands.
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“Doing a randomized trial is slow, expensive, and — if I’m being totally honest — anxiety-inducing because everything is laid so bare and you put things in motion today that won’t be resolved for another two years,” Baiocchi said. “But the reward is extraordinarily high-quality data that helps you understand what’s really going on. We need this level of evidence if we’re going to take on such a difficult problem.”
Since using math to measure the benefits of gender-based violence prevention interventions is a relatively new science, Baiocchi said the team is adopting the highest level of rigor, equivalent to what it would take to get their results through the FDA.
Baiocchi notes both his parents are nurses, his brother is a nurse who is married to a nurse. Public health and service runs through the family DNA.
“So, when I came out as being a math person, I knew that I also had to do good.”
Since receiving his PhD in statistics from The Wharton School at the University of Pennsylvania in 2011, Baiocchi has worked on ways to improve high-risk infant deliveries, school-based earthquake risk reduction in Nepal, bail reform in the United States, improving cardiothoracic surgical care, as well as cancer and cardiovascular disease prevention in China.
The Kenya project team, which includes eight Stanford undergraduate and graduate students, intends to share their results, putting out open-source tutorials that will explain their statistical methods and provide sample code and data.
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“We want to make it really easy for people in this area to start having a similar language so we can better communicate and build on this science,” he said.
The Rosenkranz funding will help to build this open-source site and support the Stanford team in their research and travel to Kenya and other countries.
The award’s namesake, George Rosenkranz, who holds a doctorate in chemistry, first synthesized cortisone in 1951, and later progestin, the active ingredient in oral birth control pills. He went on to establish the Mexican National Institute for Genomic Medicine, and his family created the Rosenkranz Prize in 2009.The award embodies Rosenkranz’s belief that young scientists hold the curiosity and drive necessary to find alternative solutions to longstanding health-care dilemmas.
Baiocchi called Rosenkranz’s work to help women take control of their reproductive health “revolutionary,” and is humbled to now be on the list of the other prizewinners, Eran Bendavid, Sanjay Basu, Marcella Alsan, Jason Andrews and Ami Bhatt.
“Our work is a continuation of the powerful changes Dr. Rosenkranz set in motion,” he said.
And what really matters, Baiocchi said, are the end results.
“There are a number of girls who are not going to get raped this year because of what we are doing,” he said. “And we know that if someone doesn’t get assaulted, that leads them to having a better life — it’s an extraordinarily virtuous cycle.”
Most civilian casualties in war are not the result of direct exposure to bombs and bullets; they are due to the destruction of the essentials of daily living, including food, water, shelter, and health care. These “indirect” effects are too often invisible and not adequately assessed nor addressed by just war principles or global humanitarian response. This essay suggests that while the neglect of indirect effects has been longstanding, recent technical advances make such neglect increasingly unacceptable: 1) our ability to measure indirect effects has improved dramatically and 2) our ability to prevent or mitigate the indirect human toll of war has made unprecedented progress. Together, these advances underscore the importance of addressing more fully the challenge of indirect effects both in the application of just war principles as well as their tragic human cost in areas of conflict around the world.
Historically, improvements in the quality of municipal drinking water made important contributions to mortality decline in wealthy countries. However, water disinfection often does not produce equivalent benefits in developing countries today. We investigate this puzzle by analyzing an abrupt, large-scale municipal water disinfection program in Mexico in 1991 that increased the share of Mexico’s population receiving chlorinated water from 55% to 85% within six months. We find that on average, the program was associated with a 37 to 48% decline in diarrheal disease deaths among children (over 23,000 averted deaths per year) and was highly cost-effective (about $1,310 per life year saved). However, we also find evidence that age (degradation) of water pipes and lack of complementary sanitation infrastructure play important roles in attenuating these benefits. Countervailing behavioral responses, although present, appear to be less important.
Pandemics are a growing health concern in the United States and abroad. But as global health specialists are ramping up efforts to prevent them, funding may be slipping away.
President Trump's proposed budget would eliminate the National Institutes of Health's Fogarty International Center, a key player in the fight against diseases worldwide.
According to a USA Today column by Michele Barry, Director of the Center for Innovation in Global Health and a Stanford Health Policy affiliate, and David Yach, a former cabinet director at the World Health Organization, Fogarty's global health research benefits the United States along with other countries. The center has produced insights into Alzheimer's research, is looking into the genetics of obesity and diabetes, and has started developing early warning systems for pandemics.
But its most important accomplishment, according to Barry and Yach, is training scientists in more than 100 low- and middle-income countries. These experts have emerged as leaders in their own countries and around the world.
Their contributions have not only improved health but have influenced the World Health Organization and leading global health donors.
Said Barry and Yach, "To eliminate the Fogarty Center now would undermine progress, erode trust in America’s leadership in global health, and increase the risk of a devastating and preventable epidemic in the U.S. Keeping Fogarty would preserve health, both of Americans and populations all over the world."
Non-communicable diseases such as heart and respiratory disease, cancer, obesity and diabetes are now responsible for some two-thirds of premature deaths around the world. And most of those are in low- and middle-income countries.
The United Nations has estimated that on top of the social and psychological burdens of chronic disease, the cumulative loss to the global economy could reach $47 trillion by 2030 if things remain status quo.
“That was a big whopper of a number and got a lot of attention, and that was good because it raised awareness,” said Rachel Nugent, vice president for global non-communicable diseases (NDCs) at the research institute RTI International.
“It’s an issue that is driven by a lot of different factors, “ she said. “And understanding how the larger social and economic factors affect NDCs, at a policy level, very little progress has been made — there’s been very little collaboration.”
Nugent was addressing the fourth annual Global Health Economics Colloquium at University of California San Francisco, with health experts, policymakers, students and researchers from Stanford, Berkeley and UCSF who gather every year to take a deep dive into the economics of a global health issue. More than 200 experts from 10 universities and public health departments attended the conference.
The daylong gathering focused on recent developments in the economics of NDCs, looking at case studies from around the world, and new guidelines for cost-effectiveness analysis and the role of economics in reducing health inequality.
“The donors are not convinced that there are cost-effective things that we can do in these countries; a lot of them are very skeptical that this is affecting the poor,” said Nugent, a member of the World Health Organization’s expert advisory panel on the management of NCDs.
In India, for example, much of the population still defecates outdoors, contaminating water sources and agricultural products, which can lead to malnutrition and physical and cognitive disorders. Many donors would rather see funds go to building latrines as they can see tangible results; NDC prevention is a long-term slog.
“But I don’t think we should necessarily think of NDCs as either-or,” said Nugent. “I think that integration of services and programming is very much at the forefront of what is the right way to go.”
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Cost-effectiveness Analyses
Nugent’s research has shown five cost-effective interventions would avert more than 5 million premature deaths from NCDs by 2030, or a reduction of 28.5 percent in projected mortality from chronic disease around the world. And the average benefit-cost ratio is 9:1, at a global cost of $8.5 billion a year.
The interventions are raising the price of tobacco products by 125 percent through taxation; providing aspirin to 75 percent of those suffering from acute myocardial infarction; reducing salt intake by 30 percent; reducing the prevalence of high blood pressure with low-cost hypertension medication; and providing preventive drug therapy to 70 percent of those at high risk of heart disease.
“There is a continued emphasis on transparency and comparability across analyses,” said Sanders-Schmidler. “And of course the big changes are that we’re now asking for a second reference case and using an ‘impact inventory’ table to clarify the scope of the findings.”
The independent panel of non-government scientists and scholars, which also included Stanford Health Policy’s Douglas K. Owens, focused on new ways to deliver health care effectively, yet with a focus on efficiency, as health care spending in the United States has reached 18 percent of GDP, much greater than the global average of 10 percent.
The first panel that convened in 1996 recommended that all cost-effectiveness analyses of health interventions include a reference case that uses standard methodological practices to improve comparability and quality. The second panel, which published its findings in September, now recommends that in addition to the societal perspective recommended by the original panel, that CEAs include a second reference case that looks at the health-care sector impact of an intervention. Additional guidance was given on what to include in the societal perspective reference case.
The panel wrote in its JAMA “special communication” that these societal reference cases should include medical costs “borne by third-party payers and paid out-of-pocket by patients, time costs of patients in seeking and receiving care, time costs of informal (unpaid) caregivers, transportation costs, effects on future productivity and consumption, and other costs and effects outside the health-care sector.”
They found most countries, including the United States, give greater weight to clinical evidence in their cost-effectiveness analyses. The panel now recommends an “impact inventory” that helps analysts and end-users of cost effectiveness analyses look at the impact of interventions beyond the formal health-care sector.
“We’re trying to ask people to be explicit,” said Owens, director of the Center of Primary Care and Outcomes Research and Center for Health Policy at Stanford.
“We want them to look at how to value outcomes in a societal perspective, not just the health-care sector, to look at all these other sectors such as productivity consumption, criminal justice, education, housing and the environment,” he said.
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Case Studies
Several case studies presented at the colloquium indicated that policy changes, government intervention and social factors are key to preventing obesity and diabetes and other NCDs.
Kristine Madsen, an associate professor of public health at UC Berkeley who focuses on childhood obesity, spoke about the nation’s first “soda tax” on sugar-sweetened beverages, which was implemented in Berkeley in March 2015.
The city has seen a 21 percent decline in the drinking of soda and other sugary drinks in low-income neighborhoods after the city levied a penny-per-ounce tax on sodas and sugary drinks. At the same time, according to a study in the American Journal of Public Health, neighboring San Francisco — where a similar soda-tax measure was defeated — and Oakland saw a 4 percent increase in the purchase of sweetened beverages.
“This decline of 21 percent in Berkeley represents the largest public health impact in an intervention that I have ever seen,” said Madsen.
Sergio Bautista of the Mexico National Institute of Public Health and UC Berkeley, said that Mexico’s sugary drinks tax implemented in January 2014 is expected to lead to a 10 percent reduction in sugary drinks consumption and prevent an estimated 189,300 cases of diabetes in a country famed for its sugary bottled cola.
William Dow, a professor of health policy management at UC Berkeley, shared his research on Costa Rica, where on average people live longer than Americans, despite the several times higher income and 10 times higher health expenditures in the United States.
Costa Rican men have a life expectancy of 77 and the women typically live until age 82; in Americans the numbers are 76 and 81, respectively. Obesity is low among Costa Rican men and few of their women smoke. Lung cancer mortality in the United States is four times higher among men and six times higher among women.
“It’s remarkable in so many ways,” Dow said, noting that deaths in the Central American country are due predominantly to infectious disease. “Does Costa Rica have any unique effective programs to emulate, or is there something going on upstream driving those health outcomes?”
He believes Costa Rica’s national health insurance and excellent access to primary care for nearly all its people are key. Having this guaranteed lifetime access to health care also reduces the stress and depression that can so badly harm physical health.
“And I would argue that probably diet is one of the most important things going on here,” said Dow, noting their diets are healthy.
Costa Ricans eat mostly unprocessed foods such as rice and black beans, corn tortilla, yam and squash, with little meat and plenty of fresh fruit.
“They also have the highest remaining life expectancy at age 80 of any country in the world, he said. “What we have learned in Costa Rica would be helpful in many other countries.”
Grace Lee joins Stanford as the Associate Chief Medical Officer at Lucile Packard Children's Hospital in the fall, 2017.
Rosenkranz Prize 2017 winner Mike Baiocchi and his partner, Clea Sarnquist, both of Stanford Medicine, conduct research on the ground in Nairobi, Kenya, to determine whether a rape prevention program is truly making a difference.
