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.

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.

For Matthew Kohrman and his students, the war against tobacco needs a new communications strategy.

After all, he noted, three times as many cigarettes are currently manufactured and sold worldwide than were in the 1960s. And the global cigarette industry is the greatest cause of preventable death on the planet today.

That’s why the Stanford associate professor of anthropology decided to teach an introductory seminar this spring, Anthro 182N, titled Smoke and Mirrors in Global Health. Kohrman led his 10 students on a journey into the “strange optics” that the global tobacco industry uses – and what to do about them.

As noted in the syllabus, “entrenched challenges” to global health require society to develop “new methods” to communicate the real truth about tobacco.

Just what are those “new methods?” At the culmination of the class, the students presented some variations on that theme. Their end-of-the-quarter projects were web-based efforts profiling various features of global tobacco. They included exposés on how academicians in China assist the industry in that country, humorous parodies and critiques of Philip Morris, and flawed approaches to tobacco control in South Korea.

They tackled big-picture questions, Kohrman said. For example, they asked what exactly constitutes cigarette manufacturing and how new strategies could help slow the spread of tobacco-related diseases worldwide.

Kohrman, the director of Stanford’s Cigarette Citadels project, envisioned his class as a way for students to offer some thought-provoking and original ideas grounded in solid data. After viewing the student projects, he was astounded – and proud.

“My overall impression has been a feeling of awe,” he said. “Mostly freshmen and sophomores, the students who enrolled in this new course quickly synthesized complex intellectual concepts introduced early in the quarter, conceived their own innovative project ideas, collected relevant data, generously worked with each other, designed apt strategies for evocatively visualizing their messages, and chose and implemented strong interactive media tools – most of which were utterly new to me.”

One of those students was Minkee Sohn, a communication major, who created a video, “Fresh Recruits,” to highlight what he believes is the hypocrisy in the language of some cigarette manufacturers’ recruitment efforts.

“While cigarette manufacturers,” Sohn said, “often frame smoking as an act of free choice, that choice is just an illusion. Free choice is denied to people in all stages of cigarette manufacturing and consumption.”

For example, he explained that children in the African country of Malawi are coerced to work with their families in tobacco fields. “It’s deeply disturbing to hear companies associate freedom with high-paying jobs in cigarette manufacturing.”

For biology major Annabel Chen, the most important thing she learned was to analyze information skeptically. “Industries like big tobacco have influences in unexpected places, so you always need to do sleuthing to find out the truth,” she said.

She chose to examine the links between tobacco and academic research in China. “Seeing as China is the biggest tobacco market in the world, this was a problem we needed to address.”

Kohrman appreciates how students like Sohn and Chen were willing to try an experimental course, never taught before, and which for many was outside of their comfort zone. He said the course will be taught again in 2015-16.

“Looking back, it was the perfect-size group for all the work and one-on-one teaching we did,” he said.

The course was a classic collaboration, according to Kohrman, who also credits Claudia Engel, a lecturer in the Anthropology Department who helped with the technology and his own experiences mentoring undergraduate research, all of which proved instrumental to designing Smoke and Mirrors in Global Health.

“It was a great success today,” he said after seeing the student projects on the last day of class. Tom Glynn, a top adviser to the American Cancer Society, was on hand to see the presentations.

Kohrman added, “Students got tremendous feedback, and there was lots of enthusiasm about how this experimental course unfolded.”

Clifton Parker is a writer for the Stanford News Service.

“I am the first child of my parents. I have a small brother at home. If the first child were a son, my parents might be happy ... but I am a daughter. I complete all the household tasks, go to school, again do the household activities in the evening … my parents do not give value or recognition to me.”

Stanford Assistant Professor of Medicine Marcella Alsan often refers to this comment by a 15-year-old girl from Nepal when she talks about how the division of labor among men and women starts at a young age in the developing world.

“Anecdotally, girls must sacrifice their education to help out with domestic tasks, including taking care of children, a job that becomes more onerous if their younger siblings are ill,” said, Alsan, a core faculty member at the Center for Health Policy/Center for Primary Care and Outcomes Research (CHP/PCOR) within the Freeman Spogli Institute of International Studies, and the Department of Medicine.

More than 100 million girls worldwide fail to complete secondary school, despite research that shows a mother’s literacy is the most robust predictor of child survival. So Alsan is analyzing whether medical interventions in children under 5 tend to lead their older sisters back to school.

She is one of two winners of this year’s Rosenkranz Prize for Health Care Research in Developing Countries, awarded by CHP/PCOR to promising young Stanford researchers.

Her Stanford Department of Medicine colleague, Jason Andrews, is the other recipient of the $100,000 prize given to young Stanford researchers to investigate ways to improve access to health care in developing countries.

Andrews is looking at cheap, effective diagnostic tools for infectious diseases, while Alsan is researching how older girls in poorer countries are impacted by the health of their younger siblings.

“My proposed work lays the foundation for a more comprehensive understanding of how illness in households and early child health interventions impact a critical determinant of human development: an older girl’s education,” she said.

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Alsan, the only infectious-disease trained economist in the United States, said Stanford is the ideal place to carry out her interdisciplinary global health research.

“I am humbled and honored to receive this prize, since Dr. Rosenkranz has done so much for women’s health worldwide,” she said.

Alsan – an MD with a specialty in infectious disease who has a PhD in economics from Harvard – said she intends to estimate the impact that illnesses in under-5 children have on older girls’ schooling using econometric tools.

She will compile data from more than 100 Demographic and Health Surveys (DHS) covering nearly 4 million children living in low- and middle-income countries.

The surveys ask about episodes of diarrhea, pneumonia and fever in children under 5 and record data on literacy and school enrollment for every child in the household.

Alsan also intends to collaborate with partners in sub-Saharan Africa to study the gendered effect of household illness on time use, using culturally appropriate questionnaires.

Douglas K. Owens, a Stanford professor of medicine and director of CHP/PCOR, called Alsan’s work “groundbreaking.”

“Although training is critical, more importantly, her work to date shows a degree of innovation, creativity and rigor that led us to conclude she was likely to become one of the top investigators in her field worldwide,” he said.

Low-Cost Diagnostic Tools

Andrews, also an assistant professor of medicine, has been working on ways to bring low-cost diagnostic tools to impoverished communities that bear the brunt of disability and death from infectious disease.

“I began working in rural Nepal as an undergraduate student and as a medical student founded a nonprofit organization that provides free medical services in one of the most remote and impoverished parts of the country,” Andrews said. “As I became a primary physician, and then an infectious diseases specialist, one of the consistent and critical challenges I encountered in this setting was routine diagnosis of infectious disease.”

He said those routine diagnostics were typically hindered by lack of electricity, limited laboratory infrastructure and lack of trained lab personnel.

“In my experiences working throughout rural Nepal – and in India, South Africa, Brazil, Peru and Ethiopia – I found these challenges to be common across rural resource-limited settings,” said Andrews, who founded a nonprofit Nyaya Health – recently renamed Possible Health – which provides modern, low-cost healthcare to rural Nepal.

Andrews has been collaborating with engineers to develop an electricity-free, culture-based incubation and identification system for typhoid; low-cost portable microscopes to detect parasitic worm infections; and most recently an easy-to-use molecular diagnostic tool that does not require electricity.

“The motivation for these projects was not to develop fundamentally new diagnostic approaches, but rather to find simple, low-cost means to make established laboratory techniques affordable and accessible,” he said.

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“We then perform isothermal amplification heated by a reusable, solar-heated, phase-change material,” Andrews said, adding that the entire process is completed in less than 20 minutes and can be performed by anyone with minimal training.

Andrews will enroll 250 patients with suspected cases of cholera in Nepal, using the new diagnostic tools and adapting as many local supplies as possible.

Andrews also intends to establish and curate a website to gather open-source ideas and evidence on diagnostic techniques for use in the developing world.

“Stanford is one of the world’s greatest hubs for innovation and information sharing as pertains to science and technology and is an ideal home for this venture,” he said.

In the current scientific climate, most National Institutes of Health grants go to established researchers. The Rosenkranz Prize aims to stimulate the work of Stanford’s bright young stars – researchers who have the desire to improve health care in the developing world, but lack the resources.

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.

“As in past years, the competition was extremely tough,” said Grant Miller, a senior fellow at the Freeman Spogli Institute and associate professor of medicine who chaired the prize committee this year.

“It’s exciting to see all of the truly innovative global health research being done by junior scholars at Stanford,” he said. “Both Jason and Marcella really exemplify this – and the legacy of George Rosenkranz.”

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Bad weather in sub-Saharan Africa increases the spread of HIV, according to a study published in the June 2015 issue of the Economic Journal, co-authored by Stanford professor and FSE fellow Marshall Burke.

When the rains fail, farmers in rural areas often see their incomes fall dramatically and will try to make up for it however they can, including through sex work. Analysing data on more than 200,000 individuals across 19 African countries, the research team finds that by changing sexual behaviour, a year of very low rainfall can increase local infection rates by more than 10%.

The results have important policy implications for fighting the spread of the epidemic, as co-author Erick Gong of Middlebury College notes:

‘Existing approaches to stopping the spread of HIV – such as promoting condom use and the use of anti-retrovirals – remain critically important. But our results suggest that other policy approaches could be very useful too – in particular, approaches that provide safety nets to rural households when the weather turns bad.’

Policies and investments seemingly unrelated to HIV – such as the promotion of rural insurance or household savings schemes, or the development of drought-tolerant crops – might have surprising benefits in slowing the HIV epidemic. Co-author Kelly Jones of the International Food Policy Research Institute says:

‘The HIV/AIDS epidemic remains one of the world’s greatest health challenges, with over a million new infections per year in Africa alone. Our results expand the menu of options for addressing the epidemic, and highlight some surprising options that are not at the forefront of people’s minds.’

The research sheds valuable light on why HIV continues to spread in Africa. Previous studies have documented in limited settings that poor women often alter their sexual behaviour in response to an income shortfall. But until now, there has been little evidence that this response is big enough to affect the trajectory of the HIV epidemic.

To fill this gap, the researchers combined data on the HIV status of thousands of people across sub-Saharan Africa with data on the recent rainfall history in each individual’s location.

Because years of low rainfall can lead to much lower incomes in these locations, particularly in rural areas where people depend more heavily on agriculture for their livelihoods, variation in rainfall provides a way to study how changes in local economic conditions affect infection rates. Co-author Marshall Burke comments:

‘We were surprised by how strong the relationship is between recent rainfall fluctuations and local infection rates. As expected, the relationship is much stronger in rural areas, and particularly for women who report working in agriculture. These are the people who really suffer when the rains fail, and who are forced to turn to more desperate measures to make ends meet.’

Notes for editors: ‘Income Shocks and HIV in Africa’ by Marshall Burke, Erick Gong and Kelly Jones is published in the June 2015 issue of the Economic Journal.

Marshall Burke is an assistant professor of Earth System Science at Stanford University. Erick Gong is an assistant professor of economics at Middlebury College. Kelly Jones is a research fellow at the International Food Policy Research Institute (IFPRI).

For further information: contact Marshall Burke on +1-650-736-8571 (email: mburke@stanford.edu); Erick Gong on +1-802-443-5553 (email: egong@middlebury.edu); Kelly Jones on +1-202-862-4641 (email: k.jones@cgiar.org); or Romesh Vaitilingam on +44-7768-661095 (email: romesh@vaitilingam.com; Twitter: @econromesh).

Maria Polyakova, an assistant professor of health research and policy at the Stanford School of Medicine, is this year’s recipient of the Ernst-Meyer Prize, which recognizes original research about risk and health insurance economics.

Polyakova, who wrote her thesis, “Regulation of Public Health Insurance,” while working on her Ph.D. in economics at MIT, was given the award by The Geneva Association, an international insurance economics think tank based in Switzerland.

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Courbage said the topic not only had considerable academic interest, but also was “an important public policy issue in both the United States and Europe.

“This work makes extremely useful insights about an important area of public policy that has yet to get the attention it needs: the interaction of regulation with important demand and supply-side features of private insurance markets.”

Polyakova said she was honored to receive the award and thanked her thesis committee for their “unbounded support” of her work.

“I am especially grateful to Amy Finkelstein for inspiring my interest in social insurance in general, and health insurance, in particular,” she said. “I hope to continue my work in this area."

A summary of Polyakova’s thesis will be published in the July 2015 issue of The Geneva Association’s Insurance Economics newsletter.

Stanford School of Medicine Dean Lloyd Minor told a distinguished group of visiting physicians, engineers, economists and businessmen from India that it was the perfect time to be collaborating with the world’s largest democracy.

As India’s economy heats up once again and biomedical research scales across the South Asian nation, Stanford intends to remain a key partner in this growth.

“India is on a journey to overcome its challenges,” Minor said. “Despite the substantial gaps in healthcare infrastructure and a shortfall of skilled healthcare workers, there’s enormous opportunity and enormously good work going on today – most of it being done by the people in this room.”

Minor was addressing a healthcare and policy panel during the two-day held on the Stanford campus on May 28-29. Reigniting India’s Growth: Perspectives from Business, Engineering, Medicine and Economics was sponsored by the Stanford Center for International Development, the Graduate School of Business, the schools of Engineering and Medicine, as well as the Office of the Vice Provost and Dean of Research.

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“I’m really eager to explore ways that we can deepen the collaboration and interactions between Stanford and India,” Minor said. “As I’m sure everyone here is aware, India is the world’s most populous democracy, one of the fastest growing major economies and a rising power with growing international influence – led by a prime minister who has great ambitions for the country.”

Prime Minister Narendra Modi has said his core mission is the revival of the Indian economy – once a powerhouse destined to rival that of China. Since taking office last year, when economic growth stood at 5 percent, the IMF forecasts India’s economy will grow to 7.5 percent by the end of this year.

Stanford has many partnerships with India, such as the Stanford-India Biodesign project to train the next generation of medical technology innovators in India. In 2007, Stanford joined with the nonprofit GVK Emergency Management Research Institute, based in Hyderabad, India, to train the country’s first corps of paramedics.

Minor noted that the Stanford-India Biodesign program has led to the founding of 37 biotech companies. “And the technologies that they have invented have been used in the care of over 300,000 patients – and that’s only the beginning,” he said.

Stanford physicians developed an educational curriculum and have trained thousands of paramedics and emergency instructors in India. EMRI says that since the training program began, more than 150,000 healthcare professions have been trained at its training center.

“These paramedics instructors have played a crucial role in the development of emergency medicine in India,” he said. “It’s been a true collaboration with a curriculum developed here in the U.S. and then standardized and implemented in a way that’s meaningful for people in India.”

Grant Miller, an associate professor at the School of Medicine and a senior fellow at the Freeman Spogli Institute for International Studies, is the director of the Stanford Center for International Development, which organized and co-hosted the India conference.

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“We feel that there is great potential for more campus-wide activity focused on India, enabling Stanford to develop new partnerships in India as well as across parts of our own university.”

Miller also launched the Stanford India Health Policy Initiative with another CHP/PCOR researcher, Nomita Divi. The initiative, connected with FSI’s International Policy Implementation Lab, joins Stanford with Indian health policymakers and professionals to design collaborative projects in India.

Last year the SIHPI fellows spent the summer investigating the factors that motivate formal and informal healthcare providers. This summer, three Stanford undergrads and a medical student will do fieldwork on the outskirts of Mumbai for seven weeks to document the impact of existing pharmaceutical networks on formal and informal provider practices.

“Health improvement is of course a critical objective of broad-based social and economic development, and we are very excited to see Stanford’s potential to make interdisciplinary contributions to health improvement in India,” Miller said on the sidelines of the India conference.

The conference featured four panel sessions in which perspectives from economics, business, engineering and medical sectors were debated. Discussions focused on how best to combine these to ensure sustained high growth in the Indian economy.

Each session featured a distinguished panel of speakers, and was followed by a lengthy floor discussion. Among the speakers were Nandan Nilekani, the co-founder of Infosys, one of India’s most successful IT services companies; Stanford President John Hennessy; Montek Ahluwalia, former deputy chairman of India’s Planning Commission, and Mr. K. Ram Shriram, managing partner at the venture capital firm, Sherpalo Ventures.

Ashok Alexander, former founding country director of the Bill and Melinda Gates Foundation in India, said too many India observers tout the incredible growth of its economy and highly educated and skilled technology innovators. Yet they ignore the majority of the country’s 1.2 billion people still lack adequate public healthcare and that 70 percent of medical spending comes out of pocket.

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“We cannot ignite India nor can we sustain India unless we think about the ways to fix public health problems,” Alexander said. “The solution to most public health problems in India are absurdly simple; it’s all about scaling up of well-known solutions.”

Only 1.3 percent of India’s GDP was devoted to public health in 2014, according to the World Bank. That is one of the world’s lowest rates. The risk of dying during childbirth is one in 43, whereas the rate in developed countries is one in 4,000.

“While India is making such great strides in its energy and business sectors, how come there is no great debate on public health?” he asked.

Amit Sengupta, a senior biomedical consultant at Tata Memorial Center and adjunct professor at ITT/AIIMS in New Delhi, told the medical panel that modern medicine is still not the first preference in rural Indian and the urban slums.

“Health is not only a biomedical issue, but also sociocultural issue,” he said. “Fifty percent of the world’s tribal population lives in India; it’s a rich heritage but they eschew Western medicine.”

Sengupta said rural India is plagued by physical and psychological stress, alcoholism and domestic violence. Meanwhile, he said, the government continues to cut the healthcare budget – a cycle that always leads back to poverty.

And, he said, remember Gandhi’s memorable saying: “Poverty is the worst form of violence.”