Global Health
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Background: The pandemic potential of influenza A (H5N1) virus is a prominent public health concern of the 21st century.

Objective: To estimate the effectiveness and cost-effectiveness of alternative pandemic (H5N1) mitigation and response strategies.

Design: Compartmental epidemic model in conjunction with a Markov model of disease progression.

Data Sources: Literature and expert opinion.

Target Population: Residents of a U.S. metropolitan city with a population of 8.3 million.

Time Horizon: Lifetime.

Perspective: Societal.

Interventions: 3 scenarios: 1) vaccination and antiviral pharmacotherapy in quantities similar to those currently available in the U.S. stockpile (stockpiled strategy), 2) stockpiled strategy but with expanded distribution of antiviral agents (expanded prophylaxis strategy), and 3) stockpiled strategy but with adjuvanted vaccine (expanded vaccination strategy). All scenarios assumed standard nonpharmaceutical interventions.

Outcome Measures: Infections and deaths averted, costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness.

Results of Base-Case Analysis: Expanded vaccination was the most effective and cost-effective of the 3 strategies, averting 68% of infections and deaths and gaining 404 030 QALYs at $10 844 per QALY gained relative to the stockpiled strategy.

Results of Sensitivity Analysis: Expanded vaccination remained incrementally cost-effective over a wide range of assumptions.

Limitations: The model assumed homogenous mixing of cases and contacts; heterogeneous mixing would result in faster initial spread, followed by slower spread. We did not model interventions for children or older adults; the model is not designed to target interventions to specific groups.

Conclusion: Expanded adjuvanted vaccination is an effective and cost-effective mitigation strategy for an influenza A (H5N1) pandemic. Expanded antiviral prophylaxis can help delay the pandemic while additional strategies are implemented.

Primary Funding Source: National Institutes of Health and Agency for Healthcare Research and Quality.

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Annals of Internal Medicine
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Douglas K. Owens

Violent conflicts claim 3,000 lives per day through wars, bombings and attacks that dominate the news media. Meanwhile, behind the headlines, 20,000 people die each day from causes related to hunger and poverty. Physical security and food security are deeply connected. Over a billion people suffer from chronic food insecurity, a situation that feeds violent conflict and weakens national and international security. Food insecurity is especially problematic in agricultural regions where income growth is constrained by resource scarcity, disease, and environmental stress.

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Background: Neuraminidase inhibitors (NAIs) are stockpiled internationally for extended use in an influenza pandemic.

Purpose: To evaluate the safety and efficacy of extended-duration (>4 weeks) NAI chemoprophylaxis against influenza.

Data Sources: Studies published in any language through 11 June 2009 identified by searching 10 electronic databases and 3 trial registries.

Study Selection: Randomized, placebo-controlled, double-blinded human trials of extended-duration NAI chemoprophylaxis that reported outcomes of laboratory-confirmed influenza or adverse events.

Data Extraction: 2 reviewers independently assessed study quality and abstracted information from eligible studies.

Data Synthesis: Of 1876 potentially relevant citations, 7 trials involving 7021 unique participants met inclusion criteria. Data were pooled by using random-effects models. NAI chemoprophylaxis decreased the frequency of symptomatic influenza (relative risk [RR], 0.26 [95% CI, 0.18 to 0.37]; risk difference [RD], –3.9 percentage points [CI, –5.8 to –1.9 percentage points]) but not asymptomatic influenza (RR, 1.03 [CI, 0.81 to 1.30]; RD, –0.4 percentage point [CI, –1.6 to 0.9 percentage point). Adverse effects were not increased overall among NAI recipients (RR, 1.01 [CI, 0.94 to 1.08]; RD, 0.1 percentage point [CI, –0.2 to 0.4 percentage point), but nausea and vomiting were more common among those who took oseltamivir (RR, 1.48 [CI, 1.86 to 2.33]; RD, 1.7 percentage points [CI, 0.6 to 2.9 percentage points]). Prevention of influenza did not statistically significantly differ between zanamivir and oseltamivir.

Limitations: All trials were industry-sponsored. No study was powered to detect rare adverse events, and none included diverse racial groups, children, immunocompromised patients, or individuals who received live attenuated influenza virus vaccine.

Conclusion: Extended-duration zanamivir and oseltamivir chemoprophylaxis appears to be highly efficacious for preventing symptomatic influenza among immunocompetent white and Japanese adults. Extended-duration oseltamivir is associated with increased nausea and vomiting. Safety and efficacy in several subpopulations that might receive extended-duration influenza chemoprophylaxis are unknown.

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Annals of Internal Medicine
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Abstract
Improving the productivity of small farmers is essential for economic development in most poor countries.  Providing access to timely and relevant information could improve the opportunities available to farmers.  However, there are significant challenges related to literacy, infrastructure, access to technology and social, cultural, institutional and linguistic gaps between producers and consumers of knowledge.  The increased adoption of mobile phones is rapidly reducing the physical barriers of access.  Providing voice-based services via low-cost handsets could empower farmers to become producers as well as consumers of knowledge.  In this talk, I discuss several applications my students and I are developing to explore this potential.  Avaaj Otalo (Gujarati for "voice stoop") is the voice-based equivalent of an online discussion board. Farmers and agricultural experts call a toll-free line to ask questions, provide answers, and listen to each others questions, answers and experiences.  We conducted a six-month trial deployment of Avaaj Otalo with fifty farmers in Gujarat, India. Farmers found it useful to learn both from experts and other farmers, sharing advice on many topics - including the best time to sow fodder, recipes for organic pesticides, and homemade devices to scare away wild pigs at night. Digital ICS allows coffee cooperatives to monitor quality and organic certification requirements, and to be more responsive to farmers' needs.  Field inspectors use mobile phones to document growing conditions and record farmers questions and comments through a combination of text, audio and images.  In a six-month trial deployment, the system significantly reduced operational costs, saving the cooperative approximately $10,000 a year.  The cooperative also obtained richer feedback from its members, which can be used for targeting extension, improving decision-making and reaching out to consumers.  In both of these systems, voice provides not only an accessible interface to information, but a medium for aggregating and representing knowledge itself.  We found this approach more suitable for engaging communities more comfortable with oral forms of communication, for whom text and structured data represent significant barriers to expression.  Most importantly, we have found that rural communities have a deep desire to be "heard", and simply need the tools required to define and achieve "development" on their own terms.

Tapan Parikh's research focuses on the use of computing to support sustainable economic development across the World. I want to learn how to build appropriate, affordable information systems; systems that are accessible to end users, support learning and reinforce community efforts towards empowerment, economic development and sustainable use of natural resources. Some specific topics that I am interested in include human-computer interaction (HCI), mobile computing and information systems supporting microfinance, smallholder agriculture and global health

Summary of the Seminar
Tapan Parikh, of UC Berkeley School of Information, spoke about a number of projects that are using mobile phone based technology to give small businesses the information they need to improve productivity. He argued that voice technology has distinct advantages over text, because it overcomes challenges of illiteracy while responding to a strong need people feel to be heard. 

Information is key for economic development and empowerment. But information is worthless unless it is also useable (leads to decisions the business owner can actually take), trusted (comes from a source he respects) and relevant (speaks about the issues he is facing). For information to be really empowering, it must also be two way: there must be ways for individuals to create content themselves.

Tapan described three current projects he is involved in:

Hisaab: Microfinance groups in India often suffer from poor paper based record keeping, making it difficult for the group to track loans and repayments. The Hissab software was designed with an interface suitable for those who may be illiterate and/or new to computing. The use of voice commands and responses in the local language, Tamil, prevented the software from feeling remote and inaccessible and contributed to the success of this initiative. 

Avaaj Otalo: Agricultural extension workers provide advice to farmers on pests, new techniques etc to help improve yields. But often they have limited reach, visiting areas only rarely, or perhaps lacking the expertise to respond to all the problems they encounter. Avaaj Otalo is a system for farmers to access relevant and timely agricultural information over the phone. By dialing a phone number and navigating through simple audio prompts, farmers can record questions, respond to others, or access content published by agricultural experts and institutions. The service has been hugely popular, with farmers willing to spend time listening to large amounts of material to find what they want. The opportunity to be broadcast was a major attraction, reflecting the desire to be heard and to create media rather than be a passive consumer of it.

Digital ICS: Smallholders' compliance with organic, fair-trade and quality requirements is usually measured via paper based internal inspections. The data uncovered by these is vital but often lost. Digital ICS is a mobile phone based application that allows inspectors to fill out the survey digitally, enhance it with visual evidence (e.g. from camera phones) and upload it onto a web application. This is being piloted with coffee farmers in Mexico. A key finding from the work is that farmers want to know who ends up drinking their coffee, what they pay for it and what they think about it. Greater links between producers and consumers may therefore be another area for this project to investigate.  

Wallenberg Theater
Bldg 160

Tapan Parikh Assistant Professor Speaker University of California, Berkeley; affiliate in the Department of Computer Science at the University of Washington
Seminars
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Pharmaceutical policies are interlinked globally, yet deeply rooted in local culture. The newly published book Prescribing Cultures and Pharmaceutical Policy in the Asia-Pacific, edited by Karen Eggleston, examines how pharmaceuticals and their regulation play an important and often contentious role in the health systems of the Asia-Pacific.

In this colloquium, contributors to Prescribing Cultures discuss how the book analyzes pharmaceutical policy in China, Korea, Japan, Thailand, Taiwan, Australia, and India, focusing on two cross-cutting themes: differences in “prescribing cultures” and physician dispensing; and the challenge of balancing access to drugs with incentives for innovation.

As Michael Reich of Harvard University says in his Forward to Prescribing Cultures,

“The pharmaceutical sector…promises great benefits and also poses enormous risks.… Conflicts abound over public policies, industry strategies, payment mechanisms, professional associations, and dispensing practices—to name just a few of the regional controversies covered in this excellent book.

The tension between emphasizing innovation versus access -- a topic of hot debate on today’s global health policy agenda -- is examined in several chapters…

This book makes a special contribution to our understanding of the pharmaceutical sector in China… Globalization is galloping forward, with Chinese producers pushing the pace at breakneck speed. More and more, our safety depends on China’s ability to get its regulatory act together…”

The colloquium features presentations by Naoko Tomita (Keio University), Anita Wagner (Harvard University), and Karen Eggleston (Stanford FSI Shorenstein Asia-Pacific Research Center). They will give specific examples of how pharmaceutical policy serves as a window into the economic tradeoffs, political compromises, and historical trajectories that shape health systems, as well as how cultural legacies shape and are shaped by the forces of globalization.

Oksenberg Conference Room

Anita Wagner Speaker Harvard University
Naoko Tomita Speaker Keio University

Shorenstein APARC
Stanford University
Encina Hall E301
Stanford, CA 94305-6055

(650) 723-9072 (650) 723-6530
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Senior Fellow at the Freeman Spogli Institute for International Studies
Center Fellow at the Center for Health Policy and the Center for Primary Care and Outcomes Research
Faculty Research Fellow of the National Bureau of Economic Research
Faculty Affiliate at the Stanford Center on China's Economy and Institutions
karen-0320_cropprd.jpg PhD

Karen Eggleston is a Senior Fellow at the Freeman Spogli Institute for International Studies (FSI) at Stanford University and Director of the Stanford Asia Health Policy Program at the Shorenstein Asia-Pacific Research Center at FSI. She is also a Fellow with the Center for Innovation in Global Health at Stanford University School of Medicine, and a Faculty Research Fellow of the National Bureau of Economic Research (NBER). Her research focuses on government and market roles in the health sector and Asia health policy, especially in China, India, Japan, and Korea; healthcare productivity; and the economics of the demographic transition.

Eggleston earned her PhD in public policy from Harvard University and has MA degrees in economics and Asian studies from the University of Hawaii and a BA in Asian studies summa cum laude (valedictorian) from Dartmouth College. Eggleston studied in China for two years and was a Fulbright scholar in Korea. She served on the Strategic Technical Advisory Committee for the Asia Pacific Observatory on Health Systems and Policies and has been a consultant to the World Bank, the Asian Development Bank, and the WHO regarding health system reforms in the PRC.

Director of the Asia Health Policy Program, Shorenstein Asia-Pacific Research Center
Stanford Health Policy Associate
Faculty Fellow at the Stanford Center at Peking University, June and August of 2016
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Karen Eggleston Speaker Stanford University
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