Stanford University’s Center on Democracy, Development and the Rule of Law (CDDRL) is proud to announce our four incoming fellows who will be joining us in the 2016-2017 academic year to develop their research, engage with faculty and tap into our diverse scholarly community. 

The pre- and postdoctoral program will provide fellows the time to focus on research and data analysis as they work to finalize and publish their dissertation research, while connecting with resident faculty and research staff at CDDRL. 

Fellows will present their research during our weekly research seminar series and an array of scholarly events and conferences.

Topics of the incoming cohort include electoral fraud in Russia, how the elite class impacts state power in China, the role of emotions in support for democracy in Zimbabwe, and market institutions in Nigeria. 

Learn more in the Q&A below.

Hometown: Tomsk, Russia

Academic Institution: Northwestern University

Discipline and expected date of graduation: Sociology, April 2017

Research Interests: authoritarianism, state capacity, social policy, civil society, trust, Russia and post-communist countries

Dissertation Title: The State that Betrays the Trust: Infrastructural State Power, Public Sector Organizations, and Authoritarian Resilience in Putin's Russia

What attracted you to the CDDRL Pre/post-doctoral program? I study the connection between state capacity and political regimes - the topic that is at the core of many research initiatives at CDDRL. Learning more about this work and receiving feedback for my dissertation will enrich and sharpen my analysis, while helping me to place it into a comparative context. I am looking forward to discussing my work with the faculty who study the post-Soviet region. I also will explore policy implications of my work with the help of policy experts at CDDRL.

What do you hope to accomplish during your nine-month residency at the CDDRL? Besides finishing writing my dissertation, I will workshop three working papers to prepare them for publication. The first one argues that Putin's regime used the school system to administer a large-scale electoral fraud in 2012 presidential elections; the second one shows how the networks of social organizations were used by subnational autocrats to strengthen the regime; and the third one will look at the factors that make the abuse of such organizations more difficult in some regions. In addition to these papers I will continue developing my post-graduation research project exploring the relationship between social trust and distrust, institutions, political competition, and democratization.

Fun fact: I have spent 25 years of my life in Siberia, and I can tell you: Chicago winters are worse!

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Shelby Grossman

CDDRL Postdoctoral Fellow

Hometown: Reading, MA

Academic Institution: Harvard University

Discipline & Graduation Date:  Government, Summer 2016

Research interests: political economy of development, private governance, market institutions, Sub-Saharan Africa, survey methods

Dissertation Title: The Politics of Order in Informal Markets: Evidence from Lagos

What attracted you to the CDDRL post-doctoral program? I was attracted to CDDRL largely for its community of scholars. Affiliated faculty work on the political economy of development and medieval and modern market institutions, topics that are tied to my own interests.

What do you hope to accomplish during your nine-month residency at the CDDRL? I plan to prepare a book manuscript based on my dissertation, a project that explains variation in the provision of pro-trade institutions in private market organizations through the study of physical marketplaces in Nigeria. In addition, I will continue to remotely manage an on-going project in Nigeria (with Meredith Startz) investigating whether reputation alleviates contracting frictions. I also plan to work on submitting to journals a few working papers, including one on the politics of non-compliance with polio vaccination in Nigeria (with Jonathan Phillips and Leah Rosenzweig). 

Fun fact: Contrary to popular belief, not all cheese is vegetarian. I have a website to help people determine if a cheese is vegetarian or not: IsThisCheeseVegetarian.com. 

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Daniel Mattingly

CDDRL Postdoctoral Fellow

Hometown: Oakland, California

Academic Institution: University of California, Berkeley

Discipline & Graduation Date: Political Science, Summer 2016

Research Interests: Governance, rule of law, state building, authoritarian politics, Chinese politics

Dissertation Title: The Social Origins of State Power: Democratic Institutions and Local Elites in China

What attracted you to CDDRL?  The Center has a fantastic community of scholars and practitioners who work on the areas that I'm interested in, including governance and the rule of law. I'm excited to learn from the CDDRL community and participate in the Center's events. The fellowship also provides me with valuable time to finish my book manuscript before I start teaching.

What do you hope to accomplish during your nine-month residency at the CDDRL? While at CDDRL, I plan to prepare my book manuscript and to work on some related projects on local elites and state power in China and elsewhere. 

Fun fact: I grew up on an organic farm in Vermont.

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Lauren E. Young

CDDRL Postdoctoral Fellow

Hometown: Saratoga, CA

Academic Institution: Columbia University 

Discipline & Graduation Date: Political Science (Comparative Politics, Methods), May 2016 (defense), Oct 2016 (degree conferral)

Research Interests: political violence, political economy of development, autocratic persistence, democratization, protest, electoral violence

Dissertation Title: The Psychology of Repression and Dissent in Autocracy

What attracted you to the CDDRL post-doctoral program? As a graduate of the CISAC honors program when I was an undergraduate at Stanford, I have seen first-hand how intellectually stimulating, collaborative, and plugged into policy CDDRL is. While at the center I will be revising my dissertation work on the political psychology of participation in pro-democracy movements in Zimbabwe for submission as a book manuscript, and moving forward new projects that similarly seek to understand how different forms of violence by non-state actors affects citizens' preferences and decision-making. Because of its deep bench of experts on autocracy, narco-trafficking, and insurgency, CDDRL will add enormous value to these projects.

What do you hope to accomplish during your nine-month residency at the CDDRL?  During my fellowship year, my primary goal is to revise my research on Zimbabwe into a book manuscript. I defended my dissertation as three stand-alone articles, including two experiments showing that emotions influence whether opposition supporters in Zimbabwe express their pro-democracy preferences and a descriptive paper showing that repression has a larger effect on the behavior of the poor. To prepare the book manuscript during my fellowship, I will bring in additional quantitative and qualitative descriptive evidence and tie the three papers together into a cohesive argument about how opposition supporters make decisions about participation in protest, why emotions have such a large effect on these decisions, and how this affects variation across individuals and the strategic choices of autocrats and activists.

Fun fact: During my fieldwork I took an overnight train from Victoria Falls to a southern city in Zimbabwe and hitch-hiked into a national park. It got a little nerve-wracking when night started to fall, but ended with  an invitation to a barbecue! 

A key concern weighing heavily on those attending this week’s global conference on AIDS is the diminishing donor support to fight the communicable disease, which has claimed an estimated 35 million lives since the beginning of the epidemic.

“That’s on everybody’s mind now — how to continue facing the epidemic with the shrinking resources,” said Eran Bendavid, a core faculty member at Stanford Health Policy and assistant professor at Stanford Medicine attending the conference in Durban, South Africa.

Donor government funding to support HIV efforts in low- and middle-income countries fell for the first time in 2015, decreasing from $8.6 billion in 2014 to $7.5 billion last year, according to a new report by the Kaiser Family Foundation and UNAIDS.

Funding for HIV treatment declined for 13 of 14 major donor governments, with the U.S. continuing to provide more donor funding for HIV than any other country or organization.

“There’s a sense of panic about how we’re going to fill the shortfall in funding,” Bendavid said. “All the major donors are here, PEPFAR, the Global Fund, and everyone is saying `We need more to continue the fight.’

“But, in my mind,” Bendavid continued, “the conversation that is mostly missing is the one between the organizations on the front lines and the national ministries of health and finance. See what they can do to get domestic resources to fill the gap.”

PEPFAR — the President’s Emergency Plan for AIDS Release — is the U.S. government initiative to help those suffering from HIV/AIDS.

Bendavid, an infectious disease physician, joins 18,000 global leaders, researchers, activists and front-line health workers attending the conference July 18-22.

The U.N. General Assembly last month pledged to end the AIDS epidemic by 2030. But more than half of the nearly 37 million people around the world infected with HIV still have no access to the antiretroviral therapy that is saving so many lives.

U.S. Secretary-General Ban Ki-moon said on the opening day of AIDS2016 that when the conference was last held in Durban 16 years ago, less than 1 percent of all people living with HIV in developing countries had access to treatment.

“Today, the world has proven that when we come together, we can transform lives,” Ban said, noting that of the 36.7 million people living with HIV today, about 46 percent of infected adults have access to antiretroviral treatment.

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“In addition, medicines are more effective and less toxic, technology allows diagnosis in 20 minutes or less, generic medicines reduced the cost of treatment to just a dollar a day and great international finance has been made available,” Ban said.

Still, the secretary-general warned, “the gains are inadequate — and fragile,” when you consider that more than half of all people living with HIV still lack access to treatment.

Bendavid, who spoke by telephone from Durban, gave a symposium at the conference on Tuesday that summarizes his research and provides his conclusions on the most effective approaches to use donor resources.

He said the while the global burden of noncommunicable diseases, such as heart disease and cancer, is greater than HIV, malaria, or TB, the interventions available to combat infectious diseases are more cost-effective. 

“Basically, the resource constraints are forcing us to think carefully about what to invest in, and we want to invest in what works,” Bendavid said, adding that donor funding typically goes straight to the disease rather than the local health system infrastructure.

“The scarce donor resources should not be directed towards interventions that are either inefficacious or costly,” he argued. “The opportunity cost of investing in costly or ineffective interventions is very high when you consider the millions who could benefit from inexpensive, simple interventions such as bed nets and drugs for TB.”

He conceded that he typically gets push back on this line of reasoning.

“But when you’re talking about what you can do with very limited resources, investing in noncommunicable diseases, in my mind, jeopardizes the premise of donor funding: There are many people who would be happy to shut down PEPFAR and the Global Fund if they were shown to be ineffective.”

He published a paper earlier this year that found the U.S. government has invested $1.4 billion in HIV prevention programs that promote sexual abstinence and marital fidelity. But there is no evidence that the programs have been effective at changing sexual behavior and reducing HIV Risk.

Bendavid said his presentation at the symposium was received with a mix of understanding and concern.

“People mentioned that funding health systems could have averted Ebola, and that the fight against HIV needs to address health systems,” he said. “I agree, but also think governments should step up and help fill some of those gaps.”

The Asia Health Policy Program at Stanford’s Shorenstein Asia-Pacific Research Center, in collaboration with scholars from Stanford Health Policy's Center on Demography and Economics of Health and Aging, the Stanford Institute for Economic Policy Research, and the Next World Program, is soliciting papers for the third annual workshop on the economics of ageing titled Financing Longevity: The Economics of Pensions, Health Insurance, Long-term Care and Disability Insurance held at Stanford from April 24-25, 2017, and for a related special issue of the Journal of the Economics of Ageing.

The triumph of longevity can pose a challenge to the fiscal integrity of public and private pension systems and other social support programs disproportionately used by older adults. High-income countries offer lessons – frequently cautionary tales – for low- and middle-income countries about how to design social protection programs to be sustainable in the face of population ageing. Technological change and income inequality interact with population ageing to threaten the sustainability and perceived fairness of conventional financing for many social programs. Promoting longer working lives and savings for retirement are obvious policy priorities; but in many cases the fiscal challenges are even more acute for other social programs, such as insurance systems for medical care, long-term care, and disability. Reform of entitlement programs is also often politically difficult, further highlighting how important it is for developing countries putting in place comprehensive social security systems to take account of the macroeconomic implications of population ageing.

The objective of the workshop is to explore the economics of ageing from the perspective of sustainable financing for longer lives. The workshop will bring together researchers to present recent empirical and theoretical research on the economics of ageing with special (yet not exclusive) foci on the following topics:

• Public and private roles in savings and retirement security
• Living and working in an Age of Longevity: Lessons for Finance
• Defined benefit, defined contribution, and innovations in design of pension programs
• Intergenerational and equity implications of different financing mechanisms for pensions and social insurance
• The impact of population aging on health insurance financing
• Economic incentives of long-term care insurance and disability insurance systems
• Precautionary savings and social protection system generosity
• Elderly cognitive function and financial planning
• Evaluation of policies aimed at increasing health and productivity of older adults
• Population ageing and financing economic growth
• Tax policies’ implications for capital deepening and investment in human capital
• The relationship between population age structure and capital market returns
• Evidence on policies designed to address disparities – gender, ethnic/racial, inter-regional, urban/rural – in old-age support
• The political economy of reforming pension systems as well as health, long-term care and disability insurance programs

Submission for the workshop

Interested authors are invited to submit a 1-page abstract by Sept. 30, 2016, to Karen Eggleston at karene@stanford.edu. The authors of accepted abstracts will be notified by Oct. 15, 2016, and completed draft papers will be expected by April 1, 2017.

Economy-class travel and accommodation costs for one author of each accepted paper will be covered by the organizers.

Invited authors are expected to submit their paper to the Journal of the Economics of Ageing. A selection of these papers will (assuming successful completion of the review process) be published in a special issue.

Submission to the special issue

Authors (also those interested who are not attending the workshop) are invited to submit papers for the special issue in the Journal of the Economics of Ageing by Aug. 1, 2017. Submissions should be made online. Please select article type “SI Financing Longevity.”

About the Next World Program

The Next World Program is a joint initiative of Harvard University’s Program on the Global Demography of Aging, the WDA Forum, Stanford’s Asia Health Policy Program, and Fudan University’s Working Group on Comparative Ageing Societies. These institutions organize an annual workshop and a special issue in the Journal of the Economics of Ageing on an important economic theme related to ageing societies.

More information can be found in the PDF below.

Studying the microorganisms that live in our gut is a relatively new field, one that has only really taken off in the last decade. In fact, it is estimated that half of the microbes that live in and around our GI track have yet to be discovered.

“This means there is a huge amount of this dark matter within us,” said Ami S. Bhatt, an assistant professor of medicine and genetics who runs the Bhatt Lab at the Stanford School of Medicine. The lab is devoted to exploiting disease vulnerabilities by cataloguing the human microbiome, the trillions of microbes living in and on our bodies.

“I think if we fast-forward to the impact of some these findings in 10 years, we’re going to learn that modifying the microbiota is a potent way to modulate health,” Bhatt said. “Humans are not only made up of human cells, but are a complex mixture of human cells and the microbes that live within us and among us — and these microorganisms are as critical to our well-being as we are to theirs.”

Bhatt, along with key collaborators at the University of Witwatersrand in Johannesburg, and the INDEPTH research consortium, now intends to take this research to Africa.

She is this year’s winner of the of the Rosenkranz Prize for Health Care Research in Developing Countries, awarded by Stanford Health Policy to promising young Stanford researchers who are investigating ways to improve health care in developing countries.

The $100,000 prize is targeted at Stanford’s emerging researchers who are dedicated to improving health care in poorer parts of the world, but may lack the financial resources.

Bhatt, MD, PhD, intends to take the prize money to execute the first multi-country microbiome research project focused on non-communicable disease risk in Africa. The project intends to explore the relationship between the gut microbiome composition and body mass index (BMI) in patients who are either severely malnourished or obese.

“As a rapidly developing continent with extremes of resource access, Africa is simultaneously faced with challenges relating to the extremes of metabolic status,” Bhatt wrote in her Rosenkranz project proposal. The Bay Area native, who is also the director of global oncology at Stanford, came to the School of Medicine in 2014 to focus on how changes in the microbiome are associated with cancer.

In this new project, Bhatt and members of her lab will team up with colleagues in Africa, first in South Africa, and then in Ghana, Burkina Faso, and Kenya. They will leverage the infrastructure already in place at the INDEPTH Network of researchers, using an existing cohort of 12,000 patients at within those four countries. The patients have already consented to be involved in DNA testing and have given blood and urine specimens.

Identifying alterations of the microbiome that are associated with severe malnutrition or obesity could pave the way for interventions that may mitigate the severity or prevalence of these disorders, Bhatt said.

“These organisms are critical to our health in that they are in a delicate balance with one another and their human hosts,” she said. “Alterations in the microbiome are associated with various diseases — but have mostly been studied in Western populations. Unfortunately, little is known about the generalizability of these findings to low- and middle-income countries – where most of the world’s population lives.”

Bhatt said that as Africa rapidly continues to develop, the continent is simultaneous faced with challenges relating to extreme weight gain and loss. While the wealthy are facing obesity and its associated disease such as stroke, heart failure and diabetes, many people are still faced with issues related to food insecurity, hunger and malnutrition.

The research, she hopes, could lead to aggressive behavioral, dietary and lifestyle modifications targeted at maintaining healthy BMI in at-risk individuals.

Video by Ankur Bhatt

Grant Miller, an associate professor of medicine and core faculty member at Stanford Health Policy who chaired the Rosenkranz Prize committee this year, believes Bhatt’s research could eventually break new ground.

“The entire Rosenkranz Prize selection committee was highly impressed with Ami and the innovation of her project,” Miller said. “Ami’s work on the human microbiome in the extremes of nutritional status in developing countries — including its potential link to obesity, an emerging challenge in low income countries — is potentially path-breaking.”

The award’s namesake, George Rosenkranz, 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 Dr. Rosenkranz’s belief that young scientists hold the curiosity and drive necessary to find alternative solutions to longstanding health-care dilemmas.

“Vic-TOR-ia!” Fátima cried, a grin lighting up her face. The 5-year-old had become fast friends with Stanford medical student Tori Bawel almost instantly after Bawel arrived in San Lucas Tolimán. After giving piggy-back rides to Fátima, a career in global pediatrics changed from a distant wish to a developing reality for Bawel.

Bawel is one of a few lucky medical students to travel with Stanford pediatrician Paul Wise, MD, MPH, to San Lucas Tolimán, a town in the mountains of rural Guatemala that serves as a base for his work to improve nutrition for local children. Once she completes her medical training, Bawel plans to devote her life to improving health in underserved areas.

“As an elementary school student, I was really compelled by issues of social justice,” she said. “I hope that over the course of my lifetime, I’m able to make a difference like physicians have done here in Guatemala and around the world.”

Every summer, Wise, a professor of pediatrics and a Stanford Health Policy core faculty member, takes a handful of undergraduates to the communities around San Lucas to learn about the Rural Guatemala Child Health and Nutrition Program. A collaboration between Stanford and a group of local health promoters, the program uses nutritional supplements and health education to save the lives of children under five. The students follow the promoters on house visits, help them measure the weight and height of children and gain an understanding of how the program helps the rural communities.

“We feel it is part of our educational mission,” said Wise. “We want to grow people who will make a difference, and part of that is providing them opportunities to do so.”

Bawel’s experience reinforced her desire to engage in global health work: “It’s inspired me and motivated me to want to give my life, like Wise, to… serving in areas of the world with the greatest need.”

Meeting Guatemalan students who overcame economic difficulties to study medicine — like Flor Julajuj — was also deeply moving for Bawel. Very few in rural Guatemala have the opportunity to pursue higher education or good health care. But with some help from Wise, Julajuj was able to attend medical school; just this month, she graduated from the University of San Carlos in Guatemala City.

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“It’s been a great opportunity,” said Julajuj. “It’s changed my life.”

Most, though, are not so lucky; Bawel also encountered two young women who dream of becoming physicians but cannot afford medical school. Meeting the young, ambitious women “makes me want to empower them with the education and opportunities I have had,” said Bawel.

Wise, meanwhile, will continue to each Stanford students about ways to help these communities.

“They see the poverty, but they also begin to understand why being a great doctor or a great diplomat or a great economist will serve the interests of people down here if done well,” he said. “We want them to go back to whatever field they’re interested in, committed to gaining skills and then using them to serve the needs and the rights of people in places like San Lucas.”

The boy’s genetic disorder would have been terminal anywhere, but thanks to Wise and local health promoters, the boy’s family had years with him instead of months.

They found the doctor through the Guatemala Rural Child Health and Nutrition Program, a collaboration between Wise and the health promoters to eliminate death by malnutrition for children under 5.

While Wise spoke to the heartbroken mother, his Stanford research assistant Alejandro Chavez helped the promoters set up inside a local community center to measure the weight and height of local kids to determine their nutrition level.

Chavez and the promoters had worked together for months to create an app for tablets that will make it easier to find malnourished children.

The app they designed will decrease training time for new health promoters and allow the program to expand. The goal is to distribute the app globally to help programs in other countries tackle malnutrition.

Children in crisis

As recently as 2005, about one of every 20 children in this rural area of Guatemala died before their 5th birthday. Almost half the deaths were associated with severe malnutrition.

“The death of any child is always a tragedy, but the death of any child from preventable causes is always unjust,” said Wise, a Stanford Health Policy core faculty member.

Along with other faculty from the Freeman Spogli Institute for International Studies (FSI) and the School of Medicine, Wise created the Children in Crisis Initiative to save the lives of children in areas of poor governance. The program brings together Stanford researchers and students across disciplines.

Nowhere are their efforts better illustrated than in the rural communities around San Lucas Tolimán, in the central mountains of Guatemala.

The program’s effectiveness rests on a deep respect for the local communities merged with innovation by Stanford researchers.

“It’s absolutely essential to any program that the people in need be part of the solution,” said Wise. Unlike many nongovernmental organizations and health programs, Wise believes the way to create a sustainable health system is for the locals to run it, so the health promoters manage the program’s day-to-day activities.

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This leaves the Stanford team free to focus on innovation – such as the new app. They believe the technology could change child health programs around the world. Wise’s team has partnered with Medic Mobile – a nonprofit that creates open-source software for health care workers – which plans to distribute the app to other areas suffering from malnutrition.

The six Android tablets purchased by Children in Crisis are enough to monitor the program’s 1,500 kids through the app.

Role of nutrition

When done well, nutrition surveillance is very effective at decreasing child mortality in poor countries.

“Nutrition contributes enormously to health and well-being,” Wise said as he walked through Tierra Santa, a small community near San Lucas, making house calls. “So the focus of our work turned to improving young child nutrition. It’s not an easy thing to do in a place that’s extremely poor.”

Wise and his colleagues – Stanford medical student Tori Bawel and Stanford professor of pediatrics Lisa Chamberlain – made their rounds during their visit in March. Evidence of poverty was everywhere.

Here, clean tap water is a dream and even the sturdier homes often lack four walls or paned windows, though the children were neatly dressed in T-shirts or colorful traje, traditional Mayan clothing.

It’s hard to provide proper nutrition when most families can’t find enough work to buy adequate food. But a little help can make a big difference.

Bawel, a first-year medical student who plans a career improving health in areas of poverty, was struck by the impact the promoter program has had on the community.

“There are children who need supplements and nutrition to stay alive,” she said. “Without this program, that infrastructure does not exist.”

With FSI’s assistance, the nutrition program distributes Incaparina, a supplement of cornmeal, soy and essential nutrients. The sweet, mealy drink helps the program’s most malnourished children get back on track.

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Every two months, the promoters gather each community’s children to measure their weight and height. Children and their mothers sit patiently, waiting for their turn. The children enjoy a cup of Incaparina, and their mothers eagerly listen to the promoters’ tips for keeping their children healthy.

“It’s very important to me,” said Elsira Rosibel Samayoa, who brought her 2-year-old to be measured. “There are mothers who don’t understand the importance of monitoring their children’s weight, but I do.”

Since its implementation in 2009, the Stanford program has slashed nutrition-based mortality in the participating communities by about 80 percent and decreased severe malnutrition by more than 60 percent – saving hundreds of children’s lives.

However, nutrition surveillance and intervention isn’t easy. Tracking nutrition takes training and expertise, and when the local population rarely exceeds a fourth-grade education, learning these skills is especially challenging. Detailed graphs on a standard growth chart are essential to identifying malnourished children.

“The community health workers are extremely capable and smart, but some have never seen a graph before,” said Wise. “Think about what it is to try to explain a graph to someone for the first time.”

It takes the health workers about three years to learn to graph and then interpret the results for intervention.

Wise said, “So we all got together and said, ‘How do we make this easier to do?’”

The app was the answer.

‘Let’s create an app’

Enter Alejandro Chavez, a recent Stanford computer science graduate and Stanford Health Policy research assistant. He developed the app to collect child health data, then determine the child’s degree of malnutrition and suggest intervention.

“The major goal was to lower training requirements and make programs like this simpler to start and maintain,” said Chavez, who now lives and works in Guatemala, where he gets daily feedback from the health promoters.

“I feel like they’ve been very honest with me about things I need to improve,” he said.

Cesia Lizeth Castro Chutá is a senior coordinator for the program who has worked with Chavez to ensure that the app meets the promoters’ needs.

“The tablet automatically generates the information we need to know,” she said. “It becomes easier to confirm that a child is malnourished and needs supplements.”

Looking forward

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With the app’s launch, it looks like training time for the promoters will be reduced from three years to less than six months. That means new communities can be incorporated into the program quickly, creating broader access to care.

Meanwhile, many health programs around the world are waiting to see how well the Stanford app works in Guatemala.

Josh Nesbit, a Stanford alumnus and Medic Mobile CEO, said, “As more health programs recognize the importance of nutrition and implement community-based interventions, screening and surveillance tools will be critical. We must learn from Dr. Wise’s success.”

Could out of pocket drug costs be responsible for pandemics? In this Public Health Perspectives article, Marcella Alsan discusses how copayments for antibiotics can cause people in poor areas to turn to unregulated markets.

On May 26, 2016, researchers at the Walter Reed National Military Medical Center reported the first case of what they called a “truly pan-drug resistant bacteria.” By now, the story has been well-covered in the media: a month earlier, a 49 year old woman walked into a clinic in Pennsylvania with what seemed to be a urinary tract infection. But tests revealed something far scarier—both for her and public health officials. The strain of E. Coli that infiltrated her body has a gene that makes it bulletproof to colistin, the so-called last resort antibiotic.

Most have pinned the blame for the impending doom of a “post-antibiotic world” on the overuse of antibiotics and a lack of new ones in the development pipeline. But there’s another superbug incubator that hasn’t gotten the attention it deserves: poverty.

Last month at the IMF meeting in Washington, D.C., UK Chancellor George Osborne warned about the potentially devastating human and economic cost of antimicrobial resistance. He called for “the world’s governments and industry leaders to work together in radical new ways.” But Gerry Bloom, a physician and economist at the Institute for Development Studies, argued that any measures to stop overuse and concoct new drugs must be “complemented by investments in measures to ensure universal access to effective antibiotic treatment of common infections.”

“In many countries, poor people obtain these drugs in unregulated markets,” Bloom said. “They often take a partial course and the products may be sub-standard. This increases the risk of resistance.”

For at least fifteen years, we’ve known about these socioeconomic origins of antimicrobial resistance. Other studies have revealed problems with mislabeled or expired or counterfeit drugs. But the clearest link between poverty and the rise of antimicrobial resistance is that poor people may not see a qualified health care provider or complete a course of quality antibiotics. Instead, they might turn to unregulated markets for substandard drugs.

But why do people resort to unregulated markets or take drugs that aren’t that great if they are available? Marcella Alsan, an assistant professor of medicine at the Stanford School of Medicine who studies the relationship between socioeconomic disparities and infectious diseases, led a study that answered this question. In last October’s Lancet Infectious Diseases, Alsan and her colleagues showed that it might have a lot to do with requiring copayments in the public sector. To show this, they analyzed the WHO’s 2014 Antibacterial Resistance Global Surveillance report with an eye toward the usual suspects, such as antibiotic consumption and antibiotic-flooded livestock.

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Stanford University's Asian Liver Center (ALC) and the Global Business Group on Health jointly hosted the inaugural JoinJade for China Summit and Awards Ceremony at SCPKU on April 22, 2016.  29 major employers committed to a hepatitis B discrimination-free work environment were recognized at the event.  Lenovo, General Electric and IBM also participated in an employer panel to discuss key strategies for a discrimination-free work environment and next steps.

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JoinJade for China is a joint initiative involving global organizations including the ALC in the U.S. and China, Global Business Group on Health, IBM, General Electric, Intel, Hewlett Packard Enterprise, and HP Inc.  The initiative focuses on building fully inclusive workplaces free from hepatitis B discrimination.  

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The ALC at Stanford University is the first non-profit organization in the U.S. that addresses the disproportionately high rates of chronic hepatitis B infection and liver cancer in Asians and Asian Americans.  Founded in 1996, the center addresses the gap in the fight against hepatitis B through a four-pronged approach of collaboration, advocacy, research, and education and outreach (CARE).  The ultimate goal of the ALC is to eliminate the transmission and stigma of hepatitis B and reduce deaths from liver cancer and liver disease caused by chronic hepatitis B.

Photos courtesy of Stanford University's Asian Liver Center