Health and Medicine

FSI’s researchers assess health and medicine through the lenses of economics, nutrition and politics. They’re studying and influencing public health policies of local and national governments and the roles that corporations and nongovernmental organizations play in providing health care around the world. Scholars look at how governance affects citizens’ health, how children’s health care access affects the aging process and how to improve children’s health in Guatemala and rural China. They want to know what it will take for people to cook more safely and breathe more easily in developing countries.

FSI professors investigate how lifestyles affect health. What good does gardening do for older Americans? What are the benefits of eating organic food or growing genetically modified rice in China? They study cost-effectiveness by examining programs like those aimed at preventing the spread of tuberculosis in Russian prisons. Policies that impact obesity and undernutrition are examined; as are the public health implications of limiting salt in processed foods and the role of smoking among men who work in Chinese factories. FSI health research looks at sweeping domestic policies like the Affordable Care Act and the role of foreign aid in affecting the price of HIV drugs in Africa.

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Life expectancy at aged 65 is remarkably similar in the three Chinese cities of Hong Kong, Shanghai, and Taipei, even though the cities differ in levels of socioeconomic development, health systems, and other factors. Edward Jow-Ching Tu will discuss research that aims to understand this phenomenon. Despite unprecedented increases in life expectancy and attainment of similar current levels of life expectancy, the cities differ in the contributions of changes in major causes of death to the improvements in life expectancy among the elderly. Tu and colleagues have explored several possible determinants of these different patterns and trends in the three cities, including socioeconomic development, health service delivery systems, cause-of-death classification systems, and competing risks from cardiovascular disease and other diseases. Their analysis suggests that the effect of equity of health service delivery has become more important over time.

Edward Jow-Ching Tu is a senior lecturer of demography in the Division of Social Science at Hong Kong University of Science and Technology. His work is focused on the impact of fertility, mortality, and migration on socio-economic changes in East Asia countries with special emphasis on nations experiencing a transition from planned economy to market economy; on causes and impacts of mortality changes and health transition on aging societies; and on the causes of lowest-low fertility in many East Asia countries. He has several active research projects ongoing in China, Japan, Taiwan, Hong Kong, and Singapore. He holds graduate degress from West Virginia University, the University of Pennsylvania, and the University of Tennessee (Knoxville). Tu has worked extensively in Asia, and has served as an adjunct professor and taught in many universities in China, including Peking University, Peoples University, Nankai Univerity, and Fudan University. He had served as a senior research scientist at the New York State Health Department and as a research fellow (full professor) at the Institute for Social Sciences and Philosophy at Academia Sinica. Tu has also taught at the State University of New York in Albany.

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Edward Jow-Ching Tu Senior Lecturer of Demography at the Division of Social Science Speaker Hong Kong University of Science and Technology
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The physiological factors underlying links between health and socioeconomic position in the Russian population are important to investigate. This population continues to face political and economic challenges, has experienced poor general health and high mortality for decades, and has exhibited widening health disparities. Dr. Dana A. Glei and colleagues used data from a population-based survey of Moscow residents 55 and older to investigate whether physiological dysregulation mediates the link between socioeconomic status and health. She will discuss the the results of their study, which revealed large educational disparities in health outcomes and physiological dysregulation, especially in men.

Dana A. Glei is a senior research investigator at Georgetown University and has worked on the Social Environment and Biomarkers of Aging Study (Taiwan) since 2001. From 2002 to 2009, she also served as project coordinator for the Human Mortality Database, a collaborative project involving research teams at the University of California, Berkeley and the Max Planck Institute for Demographic Research. Over the past 18 years, she has published articles on a variety of topics related to health, mortality, marriage and the family, and poverty. Her current research focuses on sex differences in health and mortality, the impact of stressors on subsequent health, and how bioindicators mediate the links between psychosocial factors and health outcomes. She has an MA from the University of Virginia and a PhD from Princeton University.

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Dana A. Glei Senior Research Investigator Speaker Georgetown University
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The life sciences have many examples of where research results and technologies can be used for good, but also for bad purposes. Because such scenarios are so common, it is critical to identify that research which is particularly bad and would be classified as dual use research of concern (DURC). Attributes that might result in a DURC designation include how immediate a threat it represents, the magnitude of the threat, the availability of safeguards to defend against its nefarious use and its relative risk to benefits ratio. Several policy forums have studied this problem and the National Science Advisory Board for Biosecurity (NSABB) is currently the official U.S. government advisory group for DURC policy. Recently, NSABB was asked to review two manuscripts that reported adaptation of the high-path avian influenza virus H5N1 to transmission in a mammalian model. This virus rarely infects humans but when it does, it has catastrophic consequences with ~60% mortality. The board weighed the risks and the benefits of the work and recommended that the papers not be published as written, but only in a highly redacted form that would prevent the rapid and direct replication of the work. NSABB also argued for a communication pause so that the consequences of these papers and this research focus be evaluated by a broad cross section of science, public health and society. The US government accepted these recommendations and the two journals (Science and Nature) have thus far not published the papers. Multiple additional forums are planned to discuss the issues and recommendations. The future for policy development in the area of pathogen research and DURC will be shaped by these recommendations and subsequent activities.

About the speakers:

Dr. Paul Keim holds the E. Raymond and Ruth Cowden Endowed Chair in Microbiology at Northern Arizona University (NAU), where he is also a Regents Professor of Biology. In addition, he directs the Pathogen Genomics Division at The Translational Genomics Research Institute (TGen). Both institutions are based in Flagstaff, Arizona. His biological interests span many types of organisms and microbes, but revolve around genetic diversity and its organization in populations and species. This necessarily has involved systematic and phylogenetic analyses to understand how observable genetic diversity is based upon past evolutionary processes. Biodefense programs have capitalized upon his approach of using genomic analysis to understand bacterial pathogen populations for microbial forensics and molecular epidemiological analyses. His laboratory was heavily involved in analysis of evidentiary material from the 2001 anthrax-letter attacks. He has published extensively on the evolution and population genetics of Bacillus anthracis, Yersinia pestis, Francisella tularensis, Burkholderia pseudomallei, Burkholderia mallei, Brucella spp., and Coxiella burnetii. Recently, these same principles have been applied to other public health-related and clinically important pathogens such as S. aureus and E. coli. In all, he has published over 230 scientific or policy papers. Dr. Keim received his B.S. in Biology and Chemistry from Northern Arizona University in 1977 and his Ph.D. in Botany in 1981 from the University of Kansas. Dr. Keim has previously served on the editorial boards of Crop Science and Molecular Breeding; he currently serves on the editorial boards of Infection Genetics and Evolution, Investigative Genetics, and Biotechniques.

Dr. David Relman is a professor of medicine – infectious diseases, and of microbiology and immunology at Stanford. He joined CISAC as an affiliated faculty member in November 2011. He is also chief, Infectious Diseases Section, at the VA Palo Alto Health Care System. Among his other activities, Dr. Relman currently serves as Vice-President of the Infectious Diseases Society of America, Chair of the U.S. National Academies of Science Institute of Medicine's Forum on Microbial Threats, and member of the National Science Advisory Board for Biosecurity. He received a S.B. in biology from the Massachusetts Institute of Technology (1977) and an M.D. from Harvard Medical School Medicine (1982).

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Paul Keim Acting Chair, National Science Advisory Board for Biosecurity, The Cowden Endowed Chair of Microbiology, Northern Arizona University and Director, Pathogen Genomics Division, Translational Genomics Research Institute Speaker

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Senior Fellow at the Freeman Spogli Institute for International Studies
Thomas C. and Joan M. Merigan Professor
Professor of Medicine
Professor of Microbiology and Immunology
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David A. Relman, M.D., is the Thomas C. and Joan M. Merigan Professor in the Departments of Medicine, and of Microbiology and Immunology at Stanford University, and Chief of Infectious Diseases at the Veterans Affairs Palo Alto Health Care System in Palo Alto, California. He is also Senior Fellow at the Freeman Spogli Institute for International Studies (FSI) at Stanford, and served as science co-director at the Center for International Security and Cooperation at Stanford from 2013-2017. He is currently director of a new Biosecurity Initiative at FSI.

Relman was an early pioneer in the modern study of the human indigenous microbiota. Most recently, his work has focused on human microbial community assembly, and community stability and resilience in the face of disturbance. Ecological theory and predictions are tested in clinical studies with multiple approaches for characterizing the human microbiome. Previous work included the development of molecular methods for identifying novel microbial pathogens, and the subsequent identification of several historically important microbial disease agents. One of his papers was selected as “one of the 50 most important publications of the past century” by the American Society for Microbiology.

Dr. Relman received an S.B. (Biology) from MIT, M.D. from Harvard Medical School, and joined the faculty at Stanford in 1994. He served as vice-chair of the NAS Committee that reviewed the science performed as part of the FBI investigation of the 2001 Anthrax Letters, as a member of the National Science Advisory Board on Biosecurity, and as President of the Infectious Diseases Society of America. He is currently a member of the Intelligence Community Studies Board and the Committee on Science, Technology and the Law, both at the National Academies of Science. He has received an NIH Pioneer Award, an NIH Transformative Research Award, and was elected a member of the National Academy of Medicine in 2011.

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David Relman Professor of Medicine-infectious diseases, Stanford Medical School and CISAC Affiliated Faculty Member Commentator
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Background: Chronic hepatitis C virus is difficult to treat and affects approximately 3 million Americans. Protease inhibitors increase the effectiveness of standard therapy, but they are costly. A genetic assay may identify patients most likely to benefit from this treatment advance.

Objective: To assess the cost-effectiveness of new protease inhibitors and an interleukin (IL)–28B genotyping assay for treating chronic hepatitis C virus.

Design: Decision-analytic Markov model.

Data Sources: Published literature and expert opinion.

Target Population: Treatment-naive patients with chronic, genotype 1 hepatitis C virus monoinfection.

Time Horizon: Lifetime.

Perspective: Societal.

Intervention: Strategies are defined by the use of IL-28B genotyping and type of treatment (standard therapy [pegylated interferon with ribavirin]; triple therapy [standard therapy and a protease inhibitor]). Interleukin-28B–guided triple therapy stratifies patients with CC genotypes to standard therapy and those with non-CC types to triple therapy.

Outcome Measures: Discounted costs (in 2010 U.S. dollars) and quality-adjusted life-years (QALYs); incremental cost-effectiveness ratios.

Results of Base-Case Analysis: For patients with mild and advanced fibrosis, universal triple therapy reduced the lifetime risk for hepatocellular carcinoma by 38% and 28%, respectively, and increased quality-adjusted life expectancy by 3% and 8%, respectively, compared with standard therapy. Gains from IL-28B–guided triple therapy were smaller. If the protease inhibitor costs $1100 per week, universal triple therapy costs $102 600 per QALY (mild fibrosis) or $51 500 per QALY (advanced fibrosis) compared with IL-28B–guided triple therapy and $70 100 per QALY (mild fibrosis) and $36 300 per QALY (advanced fibrosis) compared with standard therapy.

Results of Sensitivity Analysis: Results were sensitive to the cost of protease inhibitors and treatment adherence rates.

Limitation: Data on the long-term comparative effectiveness of the new protease inhibitors are lacking.

Conclusion: Both universal triple therapy and IL-28B–guided triple therapy are cost-effective when the least-expensive protease inhibitor are used for patients with advanced fibrosis.

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Stanford University's Center on Food Security and the Environment (FSE) takes a global and multifaceted approach to issues of food security by tackling both the supply and demand side of the equation. By recognizing that food security issues in the 21st century are intimately tied to climate change, FSE looks at the root causes of our problems and helps to create sustainable solutions to feed those in need around the world.

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Douglas Owens, director of the Center for Health Policy at FSI and the Center for Primary Care and Outcomes Research in the Department of Medicine and School of Medicine, has been appointed to the U.S. Preventive Services Task Force.

The task force is an independent, volunteer panel of 16 experts in prevention and evidence-based medicine that makes recommendations and develops clinical guidelines for preventive services. They focus on issues including screening for breast cancer, colon cancer, prostate cancer, cervical cancer, diabetes, drug and alcohol misuse, and hepatitis C.

“These guidelines are used widely, and they address important issues for our veterans, and for the nation at large,” said Owens, the associate director of the Center for Health Care Evaluation at the VA Palo Alto Health Care System and the Henry J. Kaiser Jr. Professor at Stanford.

“I look forward to working with the Task Force.”

 

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Newly printed “no smoking” signs went up across China when the government rolled out a nationwide public indoor smoking ban in May 2011. A sticky gray layer of smoke residue now coats many signs, representing the challenges China’s growing tobacco-control movement faces against a multibillion-dollar government-run industry and deeply embedded social practices.

How has the cigarette become so integrated into the fabric of everyday life across the People’s Republic of China (PRC)?

To get to the heart of this question, historians, health policy specialists, sociologists, anthropologists, business scholars, and other experts met Mar. 26 and 27 in Beijing for a conference organized by Stanford’s Asia Health Policy Program. They examined connections intricately woven over the past 60 years between marketing and cigarette gifting, production and consumer demand, government policy and economic profit, and many other dimensions of China’s cigarette culture.

Anthropologist Matthew Kohrman, a specialist on tobacco in China, led the conference, which was held at the new Stanford Center at Peking University. In an interview, he spoke about the history of China’s cigarette industry, cigarettes and society, and the tobacco-control movement.

The early years

Tobacco first entered China through missionary contact in the 1600s, says Kohrman, but it was not until the early 20th century when cigarettes began gaining popularity. The first cigarette advertising was a “confused tapestry” of messages as marketers figured out what spoke to the public. “There were just as many images of neo-Confucian filial piety as there were of cosmopolitan ‘modern women,’” says Kohrman.

Through improved marketing and aggressive factory building, British American Tobacco and Nanyang Brothers, China’s two largest pre-war firms, helped increase the demand for cigarettes. The Sino-Japanese War (1937–1945) disrupted the cigarette supply, but their popularity had taken hold. Some cigarette firms shifted during the war to the relative safety of southwest China, where tobacco production has remained concentrated ever since.

Post-1949

After the founding of the PRC in 1949, the tobacco industry was nationalized and strong relationships between the central government and cigarette manufacturers in the provinces were formed. Cigarettes also began to be viewed as a part of everyday life. “Ration coupons for cigarettes were issued alongside grain, sugar, and bicycle coupons,” says Kohman. “The Maoist regime legitimized cigarettes as the right of every citizen."

During the Deng Xiaoping era (1978–1997), China’s cigarette industry really took off as manufacturers competed with one another for foreign currency to purchase cutting-edge European equipment and newer varieties of tobacco seed stock. Increased production and the return of full-scale advertising fueled greater consumer demand, and manufacturers began producing more and more varieties of cigarette. Vendors displayed glass cases filled with a colorful patchwork of cigarette packs bearing names like Panda, Double Happiness, and Red Pagoda.

The tobacco industry remained under government control as other industries privatized in the 1980s and 1990s. Party-state management of the cigarette became even more centralized in the early 1980s with the creation of the China Tobacco Monopoly Administration and its parallel external counterpart, the China Tobacco Corporation.

Since 1949, provincial protectionism has marked the cigarette market. It is now possible to purchase Beijing cigarettes in Kunming, Chengdu brands in Shanghai, and so on, but to distribute cigarettes in another province, a manufacturer must cut a deal with provincial government officials. Provincial administrations are loath to cut such deals because central government policy dictates that the portion of cigarette sales tax which does not go to the central government always is channeled to the finance bureau of the province of original production. China’s 2001 entry into the World Trade Organization opened the market ever so slightly to international brands like Marlboro and Kent, but domestic brands continue to dominate because of fierce protectionism.

...If it chooses to do so, China is in a position to lead and change the landscape in a very profound way.
-Matthew Kohrman, Professor of Anthropology, Stanford

A new era

In 2003, the World Health Organization established the first global health treaty, the Framework Convention on Tobacco Control (FCTC). Although the United States still has not yet ratified the FCTC, China signed the treaty in 2003 and ratified it in 2005. Kohrman says China’s tobacco industry giants fear competition from international cigarette brands more than they worry about tobacco-control measures related to the FCTC.

Nonetheless, the FCTC ushered in a new era of public health research about tobacco and has helped increase public awareness about the dangers of smoking. New restrictions have been imposed on print and television advertising for cigarettes, and international organizations, such as the Bloomberg Family Foundation, have begun funding anti-tobacco work in China.

A big challenge to tobacco-control campaigns, says Kohrman, is the sheer amount of money that tobacco companies have available for marketing. “In 2010, China’s tobacco industry posted profits in excess of U.S. $90 billion—that’s huge. Tobacco control research and advocacy now annually receive a few million dollars, and much of that is coming through outside funders, which have very specific projects in mind.”

China’s tobacco advertisers have adapted to the new restrictions that prevent them from openly promoting cigarettes in the media. They have instead moved to point-of-sale and soft-marketing tactics, including misinformation campaigns about the “dangers” of quitting smoking. “The actual expenditure on marketing probably hasn’t dropped very much,” says Kohrman.

Cigarettes and society

Strong marketing and the legitimization of cigarettes as a part of everyday life have led to the deep integration of cigarettes into Chinese society. While only 3 to 4 percent of women in China smoke, cigarettes are an important part of male identity and social mobility. The wide range of cigarette brands has led to the growth of high-end varieties favored by businessmen and politicians, with some brands costing as much as $50 a pack. The custom of cigarette gifting has existed in China for decades, and it is difficult for a young man to turn down a package of cigarettes from a senior colleague or supervisor.

There is also the fact that nicotine is highly addictive, and quitting is difficult in an environment where smoking cigarettes is socially sanctioned. Kohrman says, “When you take an incredibly addictive substance like nicotine and throw it into the mix of all of these norms and customs, it creates a pretty toxic brew.”

The future?

Tobacco control presents a formidable challenge in China, one that requires understanding the historical context and complex dimensions of the cigarette industry. “Cigarettes have been insinuated into so many aspects of daily life across China, and the market for this product has now become so closely enmeshed with matters of government finance and operations,” says Kohrman.

What happens in China could have implications for the entire world. “There’s a tobacco-induced human annihilation unfolding right now in almost every country and questions about how society and Big Tobacco are enmeshed, and how cigarette culture and government finance have become mutually supportive are pivotal,” says Kohrman. “Every country except Bhutan has legalized cigarette sales and is subject to many of the same general issues as China—only in China they’re on a much larger scale. But if it chooses to do so, China is in a position to lead and change the landscape in a very profound way.”   

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Premium Chinese cigarette brand Panda for sale in a duty-free shop at Dubai's airport.
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