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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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Deborah R. Hensler is the Judge John W. Ford Professor of Dispute Resolution and Associate Dean for Graduate Studies Emerita at Stanford Law School, where she teaches courses on complex and transnational litigation, the legal profession, and empirical research methods. She co-founded the Law and Policy Laboratory at the law school with Prof. Paul Brest (emeritus). She is a member of the RAND Institute Civil Justice Board of Overseers and the Berkeley Law Civil Justice Initiative Advisory Board. From 2000-2005 she was the director of the Stanford Center on Conflict and Negotiation.

Prof. Hensler has written extensively on mass claims and class actions and is the lead author of Class Actions in Context: How Economics, Politics and Culture Shape Collective Litigation (2016) and Class Action Dilemmas: Pursuing Public Goals for Private Gain (2000) and the co-editor of The Globalization of Class Actions (2009). Prof. Hensler has taught classes on comparative class actions and empirical research methods at the University of Melbourne (Australia) and Catolica Universidade (Lisboa) and held a personal chair in Empirical Legal Studies on Mass Claims at Tilburg University (Netherlands) from 2011-2017. In 2014 she was awarded an honorary doctorate in law by Leuphana University (Germany). Prior to joining the Stanford faculty, Prof. Hensler was Director of the RAND Institute for Civil Justice (ICJ). She is a member of the American Academy of Arts & Sciences and the American Academy of Political and Social Sciences. Prof. Hensler received her A.B. in political science summa cum laude from Hunter College and her Ph.D. in political science from the Massachusetts Institute of Technology.

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If provoked, many Americans might well back nuclear attacks on foes like Iran and al Qaeda, according to new collaborative research from CISAC senior fellow Scott Sagan and Dartmouth professor Benjamin Valentino.

You can read more about their latest public opinion polling data, and its implications for the debate surrounding President Obama's upcoming visit to Hiroshima, in a column they co-authored for the Wall Street Journal.

 

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Candles and paper lanterns float on the Motoyasu River in front of the Atomic Bomb Dome at the Peace Memorial Park, in memory of the victims of the bomb on the 62nd anniversary of the Hiroshima bomb, on August 6, 2007 in Hiroshima. Japan. | Junko Kimura / Getty Images
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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 these programs have been effective at changing sexual behavior and reducing HIV risk, according to a new Stanford University School of Medicine study.

Since 2004, the U.S. President’s Emergency Fund for AIDS Relief, known as PEPFAR, has supported local initiatives that encourage men and women to limit their number of sexual partners and delay their first sexual experience and, in the process, help to reduce the number of teen pregnancies. However, in a study of nearly 500,000 individuals in 22 countries, the researchers could not find any evidence that these initiatives had an impact on changing individual behavior.

Although PEPFAR has been gradually reducing its support for abstinence and fidelity programs, the researchers suggest that the remaining $50 million or so in annual funding for such programs could have greater health benefits if spent on effective HIV prevention methods. Their findings were published online May 2 and in the May issue of Health Affairs.

“Overall we were not able to detect any population-level benefit from this program,” said Nathan Lo, a Stanford MD/PhD student and lead author of the study. “We did not detect any effect of PEPFAR funding on the number of sexual partners or upon the age of sexual intercourse. And we did not detect any effect on the proportion of teen pregnancy.

“We believe funding should be considered for programs that have a stronger evidence basis,” he added.

A Human Cost

Senior author Eran Bendavid, MD, said the ineffective use of these funds has a human cost because it diverts money away from other valuable, risk-reduction efforts, such as male circumcision and methods to prevent transmission from mothers to their children.

“Spending money and having no effect is a pretty costly thing because the money could be used elsewhere to save lives,” said Bendavid, an assistant professor of medicine at Stanford and a core faculty member at Stanford Health Policy.

PEPFAR was launched in 2004 by President George W. Bush with a five-year, $15 billion investment in global AIDS treatment and prevention in 15 countries. The program has had some demonstrated success: A 2012 study by Bendavid showed that it had reduced mortality rates and saved 740,000 lives in nine of the targeted countries between 2004 and 2008.

However, the program’s initial requirement that one-third of the prevention funds be dedicated to abstinence and “be faithful” programs has been highly controversial. Critics questioned whether this approach could work and argued that focusing only on these methods would deprive people of information on other potentially lifesaving options, such as condom use, male circumcision and ways to prevent mother-to-child transmission, and divert resources from these and other proven prevention measures.

Abstinence, Faithfulness Funding Continues

In 2008, when President Barack Obama came into office, the one-third requirement was eliminated, but U.S. funds continued to flow to abstinence and “be faithful” programs, albeit at lower levels. In 2008, $260 million was committed to these programs, but by 2013 by that figure had fallen to $45 million.

Spending money and having no effect is a pretty costly thing because the money could be used elsewhere to save lives.

Although PEPFAR continues to fund abstinence and faithfulness programs as part of its broader behavior-based prevention efforts, there is no routine evaluation of the success of these programs. “We hope our work will emphasize the difficulty in changing sexual behavior and the need to measure the impact of these programs if they are going to continue to be funded,” Lo said.

While many in the medical community were critical of the abstinence-fidelity component, no one had ever analyzed its real-world impact, Lo said. When he presented the results of the study in February at the Conference on Retroviruses and Opportunistic Infection, he received rousing applause from the scientists in the audience, some of whom came to the microphone to congratulate him on the work.

To measure the program’s effectiveness, Lo and his colleagues used data from the Demographic and Health Surveys, a detailed database with individual and household statistics related to population, health, HIV and nutrition. The scientists reviewed the records of nearly 500,000 men and women in 14 of the PEPFAR-targeted countries in sub-Saharan Africa that received funds for abstinence-fidelity programs and eight non-PEPFAR nations in the region. They compared changes in risk behaviors between individuals who were living in countries with U.S.-funded programs and those who were not.

The scientists included data from 1998 through 2013 so they could measure changes before and after the program began. They also controlled for country differences, including gross domestic product, HIV prevalence and contraceptive prevalence, and for individuals’ ages, education, whether they lived in an urban or rural environment, and wealth. All of the individuals in the study were younger than 30.

Number of Sexual Partners

In one measure, the scientists looked at the number of sexual partners reported by individuals in the previous year. Among the 345,000 women studied, they found essentially no difference in the number of sexual partners among those living in PEPFAR-supported countries compared with those living in areas not reached by PEPFAR programs. The same was true for the more than 132,000 men in the study.

Changing sexual behavior is not an easy thing. These are very personal decisions.

The researchers also looked at the age of first sexual intercourse among 178,000 women and more than 71,000 men. Among women, they found a slightly later age of intercourse among women living in PEPFAR countries versus those in non-PEPFAR countries, but the difference was slight — fewer than four months — and not statistically significant. Again, no difference was found among the men.

Finally, they examined teenage pregnancy rates among a total of 27,000 women in both PEPFAR-funded and nonfunded countries and found no difference in rates between the two.

Bendavid noted that, in any setting, it is difficult to change sexual behavior. For instance, a 2012 federal Centers for Disease Control analysis of U.S.-based abstinence programs found they had little impact in altering high-risk sexual practices in this country.

“Changing sexual behavior is not an easy thing,” Bendavid said. “These are very personal decisions. When individuals make decisions about sex, they are not typically thinking about the billboard they may have seen or the guy who came by the village and said they should wait until marriage. Behavioral change is much more complicated than that.”

Level of Education

The one factor that the researchers found to be clearly related to sexual behavior, particularly in women, was education level. Women with at least a primary school education had much lower rates of high-risk sexual behavior than those with no formal education, they found.

“One would expect that women who are educated have more agency and the means to know what behaviors are high-risk,” Bendavid said. “We found a pretty strong association.”

The researchers concluded that the “study contributes to the growing body of evidence that abstinence and faithfulness campaigns may not reduce high-risk sexual behaviors and supports the importance of investing in alternative evidence-based programs for HIV prevention in the developing world.”

The authors noted that PEPFAR representatives have been open to discussing these findings and the implications for funding decisions regarding HIV prevention programs.

Stanford medical student Anita Lowe was also a co-author of the study.

The study was funded by the Doris Duke Charitable Foundation and Stanford’s Center on the Demography and Economics of Health and Aging.

Previously: PEPFAR has saved lives – and not just from HIV/AIDS, Stanford study finds
 

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Barack Obama is not the first U.S. president to deal with the problem of overcommitment abroad.  How does his record compare with earlier cases?  Can the past help us understand the foreign policy debate of 2016?  Can it tell us how, when—and whether—today’s retrenchment will end?

 

Stephen Sestanovich is a professor of international diplomacy at Columbia University's School of International and Public Affairs and a senior fellow at the Council on Foreign Relations. He is the author of Maximalist: America in the World from Truman to Obama (Knopf 2014). 

From 1997 to 2001, Sestanovich was the U.S. State Department's ambassador-at-large for the former Soviet Union.  In previous government assignments, he was senior director for policy development at the National Security Council, a member of the State Department’s policy planning staff, and legislative assistant to Senator Daniel Patrick Moynihan. He has also worked at the Carnegie Endowment for International Peace and the Center for Strategic and International Studies. 

Ambassador Sestanovich received his BA summa cum laude from Cornell University and his PhD from Harvard University. He has written for Foreign AffairsThe New York TimesThe Wall Street Journal and other publications. He is a member of the board of directors of the National Endowment for Democracy.     

 

Event co-sponsored by the Center for International Security and Cooperation

Stephen Sestanovich Columbia University
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John Bass U.S. Ambassador to Turkey
Michael McFaul Director Freeman Spogli Institute
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Please join us for the upcoming Payne Distinguished Lecture, “NATIONAL SECURITY CHALLENGES FOR THE NEXT PRESIDENT," with R. Nicholas Burns, former Under Secretary of State for Political Affairs and the Roy and Barbara Goodman Family Professor of the Practice of Diplomacy and International Relations, Harvard Kennedy School of Government. 

The lecture will take place on Friday, April 29 at 12 noon in the Bechtel Conference Center, Encina Hall.  Please RSVP to Scott Nelson at snelson@stanford.edu.

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Abstract:

There is a general consensus that institutions do matter in development. Rule of law, property rights enforcement and participatory political institutions are necessary conditions for implementing market-oriented policies such as financial liberalization, trade openness, and increasing private sector involvement. There is also an alternative argument suggesting that integration to the global market has an impact on domestic institutions. Yet there is still little attention given to how institutions are evolving in the developing world in the context of an integrated world market. Specifically, do institutions evolve as a given economy becomes more integrated in the global markets or do they remain unchanged? Also, how do they change and what are the key determinants of this change? In answering these questions, this talk examines the different experiences of liberalization in the Arab World. It investigates the impact of trade and capital flows on different types of institutions. It also addresses the role of existing institutions in the success or failure of these experiences of economic liberalization.  

 

Speaker Bio:

Samer Atallah is an Assistant Professor of economics at the School of Business of the American University in Cairo since 2011.He was a visiting scholar at the University of Chicago Center in Paris during the winter of 2014.

He has earned his PhD and Masters of Arts in economics from McGill University. The title of his PhD thesis is “Essays on resource-dependent economies: Political economy and strategic behavior”.  He also holds a Masters of Science from University of California at Berkeley.

His research interests are in development economics and political economy. His research work in development economics covers intergenerational mobility, education policy and quantitative analysis of household surveys. His research also covers game theory applications on the political economy of democratization and quantitative analysis of election results.

He is a research fellow at the Economic Research Forum and a member of the Canadian Economics Association and the Middle East Economic Association.

 

This event is co-sponosred by the Program on Arab Reform and Democracy. 


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"What do I do about the chickens?"

When assistant professor of medicine Eran Bendavid began a study on livestock in African households to determine impact on childhood health, he'd already anticipated common field problems like poorly captured or intentionally misreported data, difficulty getting to work sites, or problems with training local volunteers.

But he'd never gotten that particular question from a fieldworker before. It didn't occur to him that participating families, in reporting their livestock holdings, would completely omit the chickens running around at their feet, thereby skewing the data.

"They didn't consider chickens to be livestock," recalled Bendavid. Along with Scott Rozelle, the Helen F. Farnsworth Senior Fellow at FSI, and associate professor of political science and FSI senior fellow Beatriz Magaloni, Bendavid spoke to a full house last week on lessons learned from fieldwork gone awry. The return engagement of FSI's popular seminar, "Everything that can go wrong in a field experiment” was introduced by Jesper Sørensen, executive director of Stanford Seed, and moderated by Katherine Casey, assistant professor of political economy at the GSB. The seminar is a product of FSI and Seed’s joint Global Development and Poverty (GDP) Initiative, which to date has awarded nearly $7 million in faculty research funding to promote research on poverty alleviation and economic development worldwide.

Rozelle, co-director of the Rural Education Action Program, spoke of the obstacles to accurate data gathering, especially in rural areas where record-keeping is inaccurate and participants' trust is low. Arriving in a Chinese village to carry out child nutrition studies, said Rozelle, "we found Grandma running out the back door with the baby." The researchers had worked with the local family planning council to find the names of children to study, but the families thought the authorities were coming to penalize them for violation of the one-child policy.

Cultural differences make for entertaining and illuminating (if frustrating) lessons, but Beatriz Magaloni, director of FSI's Program on Poverty and Governance at the Center on Democracy, Development and the Rule of Law had a different story to tell. Over the course of three years, her GDP-funded work to investigate and reduce police violence in Brazil - a phenomenon resulting in more than 22,000 deaths since 2005 - has encountered obstacle after obstacle. Her work to pilot body-worn cameras on police in Rio has faced a change in police leadership, setting back cooperation; a yearlong struggle to decouple a study of TASER International’s body worn cameras from its electrical weapons in the same population; a work site initially lacking electricity to charge the cameras or Internet to view the feeds; and noncompliance among the officers. "It's discouraging at times," admitted Magaloni, who has finally gotten the cameras onto the officers' uniforms and must now experiment with ways to incentivize their use. "We are learning a lot about how institutional behavior becomes so entrenched and why it's so hard to change."

Experimentation is a powerful tool to understand cause and effect, said Casey, but a tool only works if it's implemented properly. Learning from failure makes for an interesting panel discussion. The speakers' hope is that it also makes for better research in the future.

The Global Development and Poverty Initiative is a University-wide initiative of the Stanford Institute for Innovation in Developing Economies (Seed) in partnership with the Freeman Spogli Institute (FSI). GDP was established in 2013 to stimulate transformative research ideas and new approaches to economic development and poverty alleviation worldwide. GDP supports groundbreaking research at the intersection of traditional academic disciplines and practical application. GDP uses a venture-funding model to pursue compelling interdisciplinary research on the causes and consequences of global poverty. Initial funding allows GDP awardees to conduct high-quality research in developing countries where there is a lack of data and infrastructure.

 

 

 

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Stanford foreign policy experts discussed flashpoints around the world at an OpenXChange event this week.

 

 

Three of Stanford's most seasoned international affairs experts discussed foreign policy and diplomacy – and practiced a bit of it on stage, too – as they tackled the topics of refugees, Russia and other politically thorny issues at a campus forum March 1.

The event, "When the World Is Aflame," featured Condoleezza Rice, a Stanford political science professor and former U.S. secretary of state; Michael McFaul, director of Stanford's Freeman Spogli Institute for International Studies and former U.S. ambassador to Russia; and Jeremy Weinstein, a Stanford political science professor and former director for the National Security Council.

Janine Zacharia, a Stanford visiting lecturer in communication and former Jerusalem bureau chief and Middle East correspondent for the Washington Post, was the moderator.

The event was hosted by OpenXChange, a campus initiative to provide a forum for students and community members to focus on today's societal challenges.

"So you were resetting some of my policy?" Rice half-jokingly interjected, as McFaul discussed the objectives behind the U.S. trade talks with Russia a few years ago.

"It was not about making friends with the Russians – I want to make that clear," McFaul continued after the laughter in the audience died down. "And it wasn't that we needed to correct the wrongs from the previous period," he said, casting a quick glance over at Rice. "The Russians had an interest in giving the Iranians a nuclear weapon. Our answer was, no, and let's work with them to prevent that."

A series of trade sanctions with Russia were eventually accomplished, but as it turns out, McFaul noted, the political environment has since changed with Russia's aggression in Crimea, Ukraine and Syria.

Today's conflict in Syria was laid about four years ago, the panelists agreed, when the United States decided to aid the rebels and not overtly attack the current regime.

"There were reasons our president and others did not go down that path, but it was an invitation to others to play games in that environment," Weinstein said. "What their endgame is, we don't know."

Rice added that Russian President Vladimir Putin "does not mind countries that basically don't function." As such, "a stable, functioning Syria was never his definition of success."

Zacharia asked, "Are you saying we have yielded the endgame to the Russians in Syria? There is nothing we can do? And we're playing defense?"

"Yes," Rice answered.

"Wait, there is no endgame," McFaul said. "It's not that we yielded the endgame."

"Right," Rice replied.

Though the panelists' opinions differed at times, the trio of political science professors agreed on many points, including that international order is being tested, and that the refugee crisis is an overwhelming problem – one that the United States should help resolve.

"I'm a firm believer that America has a moral obligation to take [refugees]," Rice said. "But let's remember that we have to have a way to take them that is actually going to work within the system."

"We have a humanitarian architecture that simply isn't up to the task," Weinstein said. Securing congressional funding to reform the system will be a challenge.

What's more problematic, McFaul added, is that the current political rhetoric about how the United States should handle refugees is "based on fear."

"We're not having a rational debate about this in my opinion," McFaul said. "We have to fill the debate with empirical facts instead."

Public fears will continue as long as extreme Islamic State terrorist groups remain influential, "inspiring lone wolves like [those] in San Bernardino," Rice said, referring to the December 2015 terrorist attack there that killed 14 and injured 22 people.

"Somebody has got to defeat ISIS in its crib," Rice said. "They march in columns; they don't hide in caves like al-Qaeda. If CBS News can find them, then the American military can find them."

The tougher challenge, however, will be the task of influencing sectarian politics and creating a more stable state in the long term, Weinstein said.

Stanford – with its cache of expertise – should strive to shape the national dialogue with concrete facts and analyses, McFaul said. Inspiring students and giving them the foundational tools to become the new generation of policy leaders is also part of that, he said. Adding a course on Russian politics would also be an improvement, he said.

Weinstein is a senior fellow at the Freeman Spogli Institute. Rice, a former Stanford provost, is the Denning Professor in Global Business and the Economy at Stanford Graduate School of Business and the Thomas and Barbara Stephenson Senior Fellow at the Hoover Institution.

The panelists urged students to gain a deep knowledge of the areas and issues they care about.

"Know your facts," Rice emphasized.

"When you're making policy decisions at the table, the people who understand these places and understand the political dynamics – those are the people whose voices are second to none around the table," Weinstein said.

"And we need to get you prepared for that in a more robust way," McFaul said, inviting students to pass any ideas about this to him.

In terms of career choices, "there's nothing greater" than public service, he said. "Sometimes I would get goose pimples when I could stand in front of Russians with the American flag behind me, representing the United States of America."

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