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

More than fifty experts met in Xi’an, China, for an international academic conference on demographic change and social development last week. Several scholars from the Freeman Spogli Institute for International Studies (FSI) spoke at the conference, including Karen Eggleston, Marcus Feldman, Jean Oi and Scott Rozelle.

The conference marked the 120^th anniversary of Xi’an Jiaotong University’s founding and more than three decades of collaboration with Stanford scholars. Researchers at Xi’an Jiaotong University’s Institute for Population and Development Studies collaborate on policy-relevant research and educational activities with Stanford faculty at FSI as well as the Morrison Institute and Woods Institute.

For more information on FSI’s work in the areas of global health and medicine, please visit this page and the Asia Health Policy Program website.

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Science and common sense tell us that the teenage brain is more vulnerable to peer pressure and susceptible to nicotine addiction than at any other stage of development.

That’s why California legislators recently voted to raise the legal age to buy cigarettes and tobacco products from 18 to 21. If Gov. Jerry Brown signs the bill, California will become the second state, after Hawaii, to raise the age limit on the unhealthy products.

Yet while more than 100 cities around the country have adopted such laws — including New York, Boston and Cleveland — New Jersey Gov. Chris Christie in January vetoed such a bill, despite strong bipartisan support from his state legislators.

Health policy advocates see the Christie veto as a setback in what they believe is an otherwise accelerating movement toward “Tobacco 21” laws as a new tool for curbing young people’s potential addiction to tobacco products and e-cigarettes.

Michelle Mello, a Stanford professor of law and health research and policy, and colleagues from Harvard University and Baylor College of Medicine argue in this New England Journal of Medicine article that there is new evidence to suggest these laws are effective, have great public support and have minimal economic impact in the short term.

“The vast majority of smokers begin smoking during adolescence, a period when the brain has heightened susceptibility to nicotine addiction,” they write. “Nearly everyone who buys cigarettes for minors in the United States is under 21 years of age; raising the sale age prevents high school students from buying tobacco products for their peers.”

In 2013, only eight U.S. municipalities had adopted Tobacco 21 laws. By March 2016, at least 125 localities and the state of Hawaii had done so, and California is on the cusp of following suit. In September 2015, the first federal Tobacco 21 legislation was introduced (Tobacco to 21 Act, S. 2100) by U.S. Senator Brian Schatz (D-HI).

The authors note an analysis of the effects of one such law adopted in Needham, MA, revealed a 47 percent reduction in the smoking rate among high school students, along with a reported decline in area retail tobacco purchases. The decreases were significantly greater than those in 16 comparison communities without Tobacco 21 laws.

And a 2015 report by an Institute of Medicine (IOM) committee provided evidence from two different simulation models that increasing the minimum age to 21 would lead to a 12 percent reduction in smoking prevalence. Another simulation study predicted that there would be an even larger effect: a nearly 60 percent reduction in adolescent smoking within seven years after nationwide implementation of a Tobacco 21 law.

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Two national public opinion studies published in 2015 found that 70 to 75 percent of Americans — including a majority of current smokers — support raising the minimum purchase age to 21. The authors themselves conducted a national survey of 1,125 American adults regarding their attitudes toward various public health laws.

“We found that three in four Americans support the adoption of a federal Tobacco 21 law,” they write. “Majority support extends across all major socio-demographic groups, including 68.3 percent support among young adults 18 to 24 years of age.”

Opponents of the federal and state bills — namely Tobacco interests, convenience store owners and e-cigarette manufacturers — say that states should not be in the business of policing public choice. Store owners contend raising the age limit would hurt sales, as snacks and soft drinks are typically ancillary purchases with cigarettes.

And some veterans’ organizations and Republican legislators have said it is wrong to take away the decision on whether to smoke from young people who are nevertheless old enough to marry, vote and join the military.

But Mello and her coauthors, Stephanie R. Morain, PhD, MPH, and Jonathan P. Winickoff, MD, MPH, say the long-term benefits of raising the age limit far surpass the near-term economic concerns, which they believe are overstated.

Research indicates that in the short term, raising the tobacco-purchasing age to 21 would result in a 2-3 percent annual decrease in total tobacco sales.

“Over the longer term, the revenue loss from decreased smoking prevalence will be substantial,” they concede. “But allowing future generations to become addicted to nicotine in order to preserve tobacco revenue fails the red-face test as an argument against Tobacco 21.”

If a federal law raising the legal age of purchasing cigarettes were implemented today, the Institute of Medicine estimates that would result in 249,000 fewer premature deaths, 45,000 fewer deaths from lung cancer, and 4.2 million fewer lost-life years among Americans born between 2010 and 2019.

“Local and state efforts have succeeded in extending Tobacco 21 protections to more than 16 million Americans,” the authors write. “We believe the time has come to expand this effective, broadly supported approach to a much greater share of the population.”

In a Q&A, Stanford postdoctoral fellow Darika Saingam explains why Thailand's battle against drugs continues and what is needed to introduce good policy that works to prevent illegal drug trade and supports recovering addicts.

Despite Thailand’s decade-long crackdown on drugs, demand for illegal substances has risen. A green leaf drug known as ‘kratom’ is a symbol of this rise as young people eagerly adopt the drug for entertainment and join an older generation of laborers who chewed it to survive long hours of work in the fields—and are now heavily addicted. Curtailing substance abuse and its consequences takes good public policy and solutions must be area-specific and evidence-based, according to a Stanford postdoctoral fellow.

Darika Saingam, the 2015-16 Developing Asia Health Policy Postdoctoral Fellow, has conducted two cross-sectional surveys and more than 1,000 interviews with drug users, recovered addicts, and local public officials in an effort to better understand the evolution of substance abuse in southern Thailand.

At Stanford, she is preparing two papers that offer policy options suitable for Thailand and other developing countries in Southeast Asia. Saingam spoke with the Shorenstein Asia-Pacific Research Center (APARC) where she will give a public talk on May 17. The interview text below was edited for brevity.

For decades, Thailand has been an epicenter of drugs. Can you describe the extent of the problem today?

According to a 2014 report, 1.2 million people were involved in illegal drug activities across Thailand. The total number of drug cases saw a 41 percent increase from 2013 to 2014. New groups of drug traffickers are mobilizing while existing groups are still active. Drug users who are young become drug dealers as they get older. The number of drug users below 15 years of age has increased dramatically.

According to your research, what drives Thais toward illegal drug use and the trafficking business?

Adults in Thailand use drugs to relieve stress and counteract the effects of work. Adolescents use them for entertainment. Historically, farmers and laborers from rural areas of Thailand would use opium for pain relief. More recently, a consumable tablet known as yaba has become popular along with crystal methamphetamine and marijuana. Young people are increasingly using yaba and kratom.

Thailand is still a developing country, but it is industrializing quickly. Social and cultural norms have been shifting and people want an improved quality of life. A lot of young people are unemployed and lack social support and are therefore more likely to turn to drug trafficking for economic opportunity. The economic recession and political strife in countries bordering Thailand have exacerbated the situation.

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Photos (left to right): A man holds up a kratom leaf. / Saingam examines kratom leaves as part of her research to understand illegal cultivation practices.

What is kratom and why is it popular?

For nearly a century, the native people of Thailand have chewed kratom. It is a leaf that grows on trees resembling a coffee plant. Historically, kratom was used to reduce strain following physical labor, to be able to work harder and longer, and to better tolerate heat and sunlight. Kratom is also embedded in Thai culture and given as a spiritual offering in religious ceremonies. My field research in the southern province of Nakhon Si Thammarat has shown that these motivations are still true today.

Within the past seven years, kratom use has skyrocketed and people are using it in increasingly harmful ways. Chewing kratom is not immediately harmful to health, but combining it with other substances is. This is the recent trend. Users have created new ways to consume it such as in a drink known as a ‘4x100.’ It contains boiled kratom leaves, cough syrup and soft drinks. Additional methamphetamines and benzodiazepines are sometimes added to that mixture.

What strategies must be employed to control substance abuse?

The first step is to realize that the patterns of substance abuse are specific to each location therefore solving the problem must also be. Drug usage is also dynamic. Placing hard control measures on one substance often provokes the emergence of another in its place therefore a holistic approach is important.

Thailand should employ multiple strategies toward effective prevention and control of substance abuse. These strategies include examining the problem and creating policies from an economic perspective (supply and demand), an institutional perspective (national and international drug control cooperation), and a social perspective (structural supports for recovered addicts and mobilization of public participation).

What is the Thai government doing to address the drug problem, and what could they be doing better?

Politicians in Thailand must do a better job at representing the people. Government health workers are often gathering information, assessing needs, and reporting findings to politicians, but these needs are not being accurately addressed. An example of this is politicians ordering to cut down kratom trees – a public display that does not get at the root cause of the problem. The reality is that drug users will quickly find substitutes. According to my study, of the regular users that stopped using kratom, more than 50 percent turned to alcohol instead and did so on a daily basis. This is merely a shift from one substance to another.

On the upside, a crop substitution program created under King Bhumibol Adulyadej offers a successful working model. The program works to replace opium poppy farming with cash crop production. It began in 1969 and is cited for helping an estimated 100,000 people convert their drug crop production to sustainable agricultural activities. Crops cultivated can be sold for profit in nearby towns. The program has also introduced a wide variety of crops and discouraged the slash-and-burn technique of clearing land. It is win-win because it stymies drug trade and provides economic opportunity while also being ecologically sound. This type of program should continue to be scaled up.

Can this model be co-opted elsewhere? What lessons from other countries could inform Thailand’s approach?

Yes, the model could plausibly be implemented in other areas in Thailand and in other Southeast Asian nations.

I think a judicial mechanism such as the kind seen in France could benefit the rural areas in Thailand. The French government has established centers across the country that act as branches of the court that try delinquency cases of minor to moderate severity, and also recommend support services for drug users. Members of the magistrate and civil society actors manage center operations thus placing some responsibility back onto the local community.

I believe an opportunity also exists for Thailand to legalize kratom. Legalization would show a respect for the cultural tradition of chewing kratom leaves and allow the government to suggest safer ways of using it. Bolivia has created a successful model of this through its legalization of coca leaves. Coca in its distilled form is cocaine, but left as a leaf, it is not a narcotic. Indigenous peoples are allowed to chew coca leaves. The government policy is being credited for a decrease in cocaine production as well.

Nearly 100 health economists from across the United States signed a pledge urging U.S. presidential candidates to make chronic disease a policy priority. Karen Eggleston, a scholar of comparative healthcare systems and director of Stanford’s Asia Health Policy Program, is one of the signatories. 

The pledge calls upon the candidates to reset the national healthcare agenda to better address chronic disease, which causes seven out of 10 deaths in America and affects the economy through lost productivity and disability.

Read the pledge below.

The threat of a pandemic claiming millions of lives and devastating economies around the world is as serious as the potential perils of global climate change, renowned economist Larry Summers told a Stanford audience during a recent visit to campus.

The world is taking dramatic and costly steps to prevent the calamitous impact of climate change on the economies and national security of most countries. Yet preparations for a worldwide pandemic on the scale of the 1918 flu are vastly underfunded and ill-formed.

“My biggest fear is that the world is way short of focus on all the issues associated with pandemic,” said Summers, former treasury secretary in the Clinton administration and Harvard president emeritus, who in recent years has focused on the economics of global health care.

“We are talking about something that could kill surely tens of millions and perhaps 100 million people, and the Stanford football program is substantially more expensive than the WHO budget for pandemic flu,” he said. “It’s just crazy that we are so underinvested and underprepared.”

Summers, the Charles W. Eliot University Professor at Harvard, also served as director of the White House National Economic Council in the Obama administration. He was in conversation with Stanford Health Policy’s Paul Wise for the March 8 event co-sponsored by the Stanford Institute of Economic Policy Research for faculty and students.

The World Health Organization budget for outbreaks and crisis response has been reduced by nearly 50 percent from 2012 to 2015. Some global health experts blame these cuts in part for its slow response to the Ebola outbreak in West Africa and the ongoing Zika crisis in Brazil.

In Brazil, Zika has been linked to a spike in cases of microcephaly, a birth defect marked by small head size and underdeveloped brains. Brazil has confirmed more than 640 cases of microcephaly and is investigating an additional 4,200 suspected cases. Puerto Rico is now preparing for an expected outbreak there.

Summers said the mortality rate from the great flu pandemic was far greater than the recent Ebola outbreak in West Africa, which killed some 11,300 people mostly in Sierra Leone, Liberia and Guinea. Some 50 million people died worldwide during the 1918-1919 flu pandemic.

‘I don’t want to minimize in any way the significance of Ebola, but there are things to worry about that are vastly larger,” said Summers, who gave the keynote address for the January unveiling of the National Academy of Medicine’s report on global health risks.

That report by the Commission on a Global Health Risks Framework for the Future found that, compared with other major threats to global security, the world has “grossly underinvested” in efforts to prevent and prepare for the spread of infectious diseases. The commissioners — some 250 independent experts in health, governance and research and development — estimate $60 billion in annualized expected losses from pandemics.

“Pandemics cause devastation to human lives and livelihoods much as do wars, financial crises and climate change,” the report said. “Pandemic prevention and response, therefore, should be treated as an essential tenet of both national and global security — not just a matter of health.”

Summers estimates that pandemic flu risk is in the same range of global climate change in terms of expected costs over the next century. Yet a potential pandemic is getting only 2 percent of the attention and resources that global climate change has today.

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Summers also chaired the Lancet Commission on Investing in Health, an independent group of 25 leading economists and global health experts from around the world. Their landmark report, Global Health 2035, provides a specific roadmap for this achieving “a grand convergence” in health within our lifetimes. Ahead of the U.N. General Assembly last fall, Summers led a joint declaration together with economists from 44 countries calling on world leaders to prioritize investments in health.

Wise, in the Department of Pediatrics at Stanford and senior fellow at the Freeman Spogli Institute for International Studies, asked Summers how one plans for pandemics when faced with so many failed governments and conflicts around the world.

“One of the central challenges that I worry about a lot in the deliberations of pandemic control is that many of the (regions) of greatest concern are characterized by chronic political instability, conflict and very weak governance,” said Wise, who for more than 30 years has been traveling to rural Guatemala to provide medical care to children there for his Children in Crisis project.

Summers said the world has been fortunate that there are so many brave and devoted medical workers who are trained to go into these conflict regions to try and contain outbreaks.

“But I think it would be disingenuous of me to say that you can solve these problems without in some way containing the failed state,” he said.

Wise then asked Summers what sort of advice he would give to the Stanford students who were trying to decide between a career in which one might use economics to make a fortune on Wall Street, or use economics for the greater good.

“I have always believed that you can count — and you can care,” Summers said. “There is nothing about counting and using numbers and analyzing the math that means you don’t care in a moral way.”

When a physician works with a patient and saves her life, he said, that has a profound and direct impact on both the patient and physician. But working on a vaccination program that has the potential of saving thousands of lives one day comes with delayed gratification.

“But the impact of making the world a better place and enabling people to survive and avoid grieving the loss of of a family member is as great — or greater,” he said.

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The Walter H. Shorenstein Asia-Pacific Research Center (APARC), in pursuit of training the next generation of scholars on contemporary Asia, has selected three postdoctoral fellows for the 2016-17 academic year. The cohort includes two Shorenstein Postdoctoral Fellows and one Developing Asia Health Policy Fellow; they carry a broad range of interests from hospital reform to the economic consequences of elite politics in Asia.

The fellows will begin their year of academic study and research at Stanford this fall.

Shorenstein APARC has for more than a decade sponsored numerous junior scholars who come to the university to work closely with Stanford faculty, develop their dissertations for publication, participate in workshops and seminars, and present their research to the broader community. In 2007, the Asia Health Policy Program began its fellowship program to specifically support scholars undertaking comparative research on Asia health and healthcare policy.

The 2016-17 fellows’ bios and their research plans are listed below:

Shorenstein Postdoctoral Fellows

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Developing Asia Health Policy Postdoctoral Fellow

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Infant deaths in Massachusetts for much of the 1800s accounted for more than 20 percent of all deaths, many due to diarrhea, cholera and other gastrointestinal disorders.

But from 1870 to 1930, the infant mortality rate plummeted from around 1 in 5 white infants to 1 in 16 for both Massachusetts and the entire United States.

Studies have shown that the dramatic decline was due to the impact of a clean-water system in Boston and other major U.S. cities at that turn of the 20^th century.

Now, new research by Stanford Health Policy’s Marcella Alsan indicates that effective sewage systems installed in Boston and surrounding municipalities complemented the water treatment plants and had a significant role in protecting the lives of children.

“We were motivated to investigate this because there was a watershed moment when infant mortality began to decline in the U.S. and Massachusetts that we wanted to understand,” said Alsan, an assistant professor in the Department of Medicine, and the country’s only physician who is a tropical disease expert and economist.

“In retrospect, the daunting challenges these engineers and medical professionals faced in designing, financing and executing such a massive project is incredible,” Alsan said in an interview. “It was really inspiring to read the history of how it all came together.”

She and co-author, Claudia Goldin of Harvard University’s Department of Economics, analyzed about 200,000 of infant death certificates in Boston and 54 other Massachusetts municipalities spanning the years 1880 to 1915.

The impetus behind the creation of the Metropolitan Sewerage District was complaints regarding the stench of sewage among Boston’s upper-class citizens.

“The first of a series of hearings was given by the sewerage commission at the City Hall on Friday night,” read a story in an 1875 edition of the Boston Medical and Surgical Journal. “From the statements made it would appear in various parts of the district including most of the finest streets, the stench is terrible, often causing much sickness.”

A joint engineering and medical commission was appointed in 1875 to devise a remedy and a massive drainage project got underway.

Alsan and Goldin found that an overwhelming number of deaths in the greater metropolitan area were due to gastrointestinal disorders, but that this improved significantly when sanitation canals became part of the overall water systems.

“We find robust evidence that the pure water and sewerage treatments pioneered by far-sighted public servants and engineers in the Commonwealth saved many babies,” they write in a working paper. “It must also have enhanced the quality of life for the citizens of the Greater Boston area even if it did not reduce the non-child death rate by much.”

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They acknowledge that the interpretation of their results is intuitive. But it’s an important one to promote because many developing countries today have yet to heed the lesson of combining safe drinking water and improved sanitation systems.

“Without proper disposal of fecal material, the benefits of clean water technologies for the health of children are likely limited,” they write. “Such a result has relevance for today’s low-and middle- income countries.”

The Millennium Development Goal Target 7.C — to halve by 2015 the proportion of the population without sustainable access to safe drinking water and basic sanitation —was only met for water, but not sanitation. Between 1990 and 2015, 2.6 billion people gained access to improved drinking water sources.

Yet despite that progress, one-third of the global population is still using unimproved sanitation facilities, including nearly 1 billion people who are still forced to defecate in the open. This often leads to cholera, typhoid, hepatitis, polio, and worm infestation.

Diarrhea is the third-largest killer of children under 5 in sub-Saharan Africa, and 44 million pregnant women are infected with worms each year due to open defecation, according to the United Nations. Every minute, 1.1 million liters of human excrement enters the Ganges River in India.

The problem of waste disposal likely will be compounded by rapid urbanization occurring in the developing world, said Alsan, and lack of sanitation and the practice of open defecation costs the world’s poorest countries $260 billion a year.

“We think our findings underscore how complementary these infrastructure investments are, and hope that holds lessons for the developing world,” said Alsan. “In all practicality, it’s very hard to ensure the municipal water supply is not contaminated if the sewage infrastructure is neglected.”

Working Paper: Watersheds in Infant Mortality