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Drought increases the spread of HIV in Africa

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

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

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

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

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

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

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

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

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

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

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

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

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

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Health care aid for developing countries boosts life expectancy, study finds

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Ruthann Richter
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Foreign aid for health care is directly linked to an increase in life expectancy and a decrease in child mortality in developing countries, according to a new study by Stanford researchers.

The researchers examined both public and private health-aid programs between 1974 and 2010 in 140 countries and found that, contrary to common perceptions about the waste and ineffectiveness of aid, these health-aid grants led to significant health improvements with lasting effects over time.

Countries receiving more health aid witnessed a more rapid rise in life expectancy and saw measurably larger declines in mortality among children under the age of 5 than countries that received less health aid, said Eran Bendavid, MD, an assistant professor in Stanford Medical School's Division of General Medical Disciplines and lead author of the study. If these trends continue, he said, an increase in health aid of just 4 percent, or $1 billion, could have major implications for child mortality.

“If health aid continues to be as effective as it has been, we estimate there will be 364,800 fewer deaths in children under 5,” he said. “We are talking about $1 billion, which is a relatively small commitment for developed countries.”

The study was published online April 21 in JAMA Internal Medicine. The study’s co-author, Jay Bhattacharya, MD, PhD, is an associate professor of medicine.

Bendavid and Bhattacharya are core faculty members at Stanford’s Center for Health Policy and Center for Primary Care and Outcomes Research at the university's Freeman Spogli Institute for International Studies.

Does it work?

Bendavid noted that there is much debate around foreign aid. Critics question whether it’s used effectively and reaches its intended recipients. They often argue that it discourages local development and displaces domestic resources that might otherwise be devoted to health. So the researchers devised a statistical tool to address the basic unanswered question: Do investments in health really lead to health improvements?

Bendavid said there are many reasons to suspect the answer would be no, though the findings proved just the contrary, with health-related aid leading to direct, beneficial outcomes.

“I think for many people, that will be surprising,” he said. “But for me, it fits with other evidence of the incredible success of public health promotion in developing countries.” In a previous study, for instance, he found that hundreds of thousands of lives were saved through the U.S. President’s Emergency Plan for AIDS Relief, or PEPFAR, in which the U.S. government invested billions of dollars in antiretroviral treatment and other AIDS-related prevention and treatment initiatives.

In the latest study, the two investigators used data from the Creditor Reporting System of the Organization for Economic Cooperation and Development, the world’s most extensive source of information on foreign aid. While aid programs for health grew during the 36-year study period, the largest period of growth occurred between 2000 and 2010, they found.

Stepped-up investments

It was during this decade that many governments and private groups stepped up their investments in health, including PEPFAR; the World Bank; the Global Fund to Fight AIDS, Tuberculosis and Malaria; the Gates Foundation; and the GAVI Alliance, among others, he said.

As a result, while health aid in 1990 accounted for 4 percent of total foreign aid, it now amounts to 15 percent of all aid, he said. And it’s become an important part of health budgets in recipient countries, accounting for 25-30 percent of all health-care spending in low-income countries, Bendavid said.

The researchers found that these funds were used effectively, largely because of the targeting of aid to disease priorities where improved technologies — such as new vaccines, insecticide-treated bed nets for malarial prevention and antiretroviral drugs for HIV — could make a real difference.

They observed the greatest health impacts between 2000 and 2010, when donor investments were at their peak. During the decade, under-5 child mortality declined from a mean of 109.2 to 72.4 deaths per 1,000, or 36.8 fewer deaths among those children in the countries that received the most health aid, the researchers found (a 34 percent reduction). In the countries receiving the least, under-5 mortality fell from 31.6 to 23.2 deaths per 1,000, or 8.4 fewer deaths per 1,000 live births (a 26 percent reduction), the researchers reported.

Life expectancy increases

During that period, life-expectancy figures also grew faster in countries with a greater infusion of health aid, Bendavid said. Life expectancy rose from 57.5 to 62.3 — an increase of 4.8 years — among the countries receiving the most aid. Among the countries receiving the least health aid, life expectancy increased by 2.7 years, from 69.8 to 72.5 years.

Bendavid said previous experience has shown that, on average, life expectancy has increased by nearly one year every four years in developed countries. But health-aid programs literally cut in half the time it took to reach this goal in developing countries. “In that same four-year span, they increased life expectancy by two years, rather than one year,” he said.

He said the results are not surprising if one considers some of the new health technologies made available to developing nations as a result of foreign aid. Childhood vaccines, including those for diphtheria, tetanus, polio and measles, have all but wiped out what used to be among the top killers of young children in the developing world. Health aid directed to providing insecticide-treated malarial bed nets also has been credited in recent studies with reducing malarial deaths among young children, he noted.

Among both adults and children, aid that has expanded the availability of antiretroviral drugs in the developing world has had a major impact on reducing deaths and improving overall life expectancies, he said. For instance, in a study published in 2012, Bendavid and colleagues found that PEPFAR’s health aid resulted in more than 740,000 lives saved between 2004 and 2008 in nine countries.

The researchers also found that the benefits of aid have a lasting effect: The telltale signs of aid’s relationship to reducing under-5 mortality were detectable for three years following the distribution of aid. The correlation between health aid and longer life expectancy overall was detectable for five years after the aid was distributed.

With aid commitments flattening amid the economic downturn, Bendavid said donors will have to be that much smarter in how they invest future dollars, focusing on the most cost-effective interventions and technologies.

“To date, there has been little consideration of how to use development aid in the most cost-effective manner,” he said. “That will have to change now that the funding level has reached a plateau.”

The study was funded by the George Rosenkranz Fellowship for Health Policy Research in Developing Countries and by the National Institutes of Health (grant K01AI084582).

Information about Stanford’s Department of Medicine, which also supported the work, is available at http://medicine.stanford.edu.

Ruthann Richter is the director of media relations at the Stanford School of Medicine.

 

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Contemporary Challenges in Global Public Health: A Discussion on How Health is an Integral Aspect of the Overall Development and Sustainability Landscape

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For nearly 70 years, CARE has been serving individuals and families in the world's poorest communities. Today, they work in 84 countries around the world, with projects addressing issues from education and healthcare to agriculture and climate change to education and women's empowerment. Helene Gayle, president and CEO of CARE USA, will discuss her work with CARE and her experiences in the field of international development. Dr. Gayle will discuss how access to global health is integral to CARE's effort in addressing the underlying causes of extreme global poverty.

Dr. Michele Barry, director of the Center for Innovation in Global Health, will moderate a conversation between CARE President and CEO, Dr. Helene Gayle and former Prime Minister of Norway and United Nations Special Envoy, Dr. Gro Brundtland. 

This event is sponsoredy by CARE USA, the Center on Democracy, Development and the Rule of Law and the Haas Center for Public Service.

A reception will follow the event. 

Dr. Gro Brundtland Bio:

Dr. Gro Harlem Brundtland is the former prime minister of Norway and the current deputy chair of The Elders, a group of world leaders convened by Nelson Mandela and others to tackle the world’s toughest issues. She was recently appointed as the Mimi and Peter E. Haas Distinguished Visitor for spring 2014 at the Haas Center for Public Service at Stanford University. Dr. Brundtland has dedicated over 40 years to public service as a doctor, policymaker and international leader. She was the first woman and youngest person to serve as Norway’s prime minister, and has also served as the former director-general of the World Health Organization and a UN special envoy on climate change.

Her special interest is in promoting health as a basic human right, and her background as a stateswoman as well as a physician and scientist gives her a unique perspective on the impact of economic development, global interdependence, environmental issues and medicine on public health.

 Dr. Helene Gayle Bio:

Helene D. Gayle joined CARE USA as president and CEO in 2006. Born and raised in Buffalo, New York, she received her B.A. from Barnard College of Columbia University, her M.D. from the University of Pennsylvania and her M.P.H. from Johns Hopkins University. After completing her residency in pediatric medicine at the Children's Hospital National Medical Center in Washington, D.C., she entered the Epidemic Intelligence Service at the Centers for Disease Control and Prevention, followed by a residency in preventive medicine, and then remained at CDC as a staff epidemiologist.

At CDC, she studied problems of malnutrition in children in the United States and abroad, evaluating and implementing child survival programs in Africa and working on HIV/AIDS research, programs and policy. Dr. Gayle also served as the AIDS coordinator and chief of the HIV/AIDS division for the U.S. Agency for International Development; director for the National Center for HIV, STD, and TB Prevention, CDC; director of CDC's Washington office; and health consultant to international agencies including the World Health Organization, UNICEF, the World Bank and UNAIDS. Prior to her current position, she was the director of the HIV, TB and reproductive health program for the Bill and Melinda Gates Foundation.

Hewlett 201
Hewlett Teaching Center
370 Serra Mall
Stanford, CA 94305

Dr. Gro Brundtland Mimi and Peter E. Haas Distinguished Visitor Panelist Haas Center for Public Service, Stanford University
Dr. Helene Gayle President and CEO Panelist CARE USA
Michele Barry Director Moderator Center for Innovation in Global Health
Conferences

Human Rights and Health to Advance Development: Case of Rwanda

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Hon.Agnes Binagwaho has served as Permanent Secretary of the Ministry of Health in Rwanda since October 2008. She specialized in emergency pediatrics, neonatology, and the treatment of HIV/AIDS; and she chairs the Rwandan Pediatric Society. From 1986 to 2002, she practiced medicine in public hospitals in Rwanda and several other countries before joining Rwanda's National AIDS Control Commission as Executive Secretary. She is a member of the Editorial Board of Public Library of Science, and the Harvard University Health and Human Rights Journal. Dr. Binagwaho co‐chaired the Millennium Development Goal Project Task Force on HIV/AIDS and Access to Essential Medicines for the Secretary‐General of the United Nations under the leadership of Professor Jeffrey Sachs. She was the global co‐chair of the Joint Learning Initiative on Children and HIV/AIDS. In addition to her medical degree and Master in Peadiatry, she received an Honorary Doctor of Sciences from Dartmouth College. Dr. Binagwaho serves as a visiting lecturer in the Department of Global Health and Social Medicine of Harvard Medical School.

Building 200 (History Corner)
Room 205
Stanford University

Hon. Agnes Binagwaho Minister of Health Speaker Rwanda
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Sanela Diana Jenkins Human Rights Speaker Series
Program on Human Rights

The HIV/AIDS Pandemic and Africa’s Orphaned Elderly

The HIV/AIDS pandemic has decimated family life in Africa.  This project focused on the welfare of the “orphaned-elderly” – a class of elderly dependents whose traditional care-giving arrangements have collapsed. The authors presented their findings in January 2008. A manuscript, “HIV and Africa’s ‘Orphaned Elderly,’” was published in British Medical Journal. Another manuscript entitled, “The President's Emergency Plan for AIDS Relief in Africa: An Evaluation of Outcomes” was published in Annals of Internal Medicine.

Shaping the Global Agenda on Child Protection

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Abstract
Since the early years of her career working with children in some of the direst situations in Sri Lanka and Bangladesh, Susan Bissell, UNICEF’s Chief of Child Protection, has witnessed children being targeted for such exploitative practices as human trafficking, recruitment into armed forces, and child labor. Violations of the child’s right to protection take place in every country and are massive, under-recognized, and under-reported barriers to child survival and development, in addition to being human rights violations. Children subjected to violence, exploitation, abuse and neglect are at risk of death, poor physical and mental health, HIV/AIDS infection, educational problems, displacement, and vagrancy.

 Protecting children from violence, exploitation and abuse is an integral component of protecting their rights to survival, growth, and development. UNICEF advocates and supports the creation of a protective environment for children in partnership with governments, national and international partners including the private sector, and civil society.  Bissell guides UNICEF’s Child Protection program in 170 countries, working with government officials and other partners to shape child protection policies. During this discussion, she will provide an overview of her role at UNICEF and the work she does to help ensure that governments honor their commitments to strengthen child protection systems and protect children.

In 2009, Susan Bissell was appointed to her current position in New York, heading all of UNICEF’s Child Protection work.  She oversees a team of professionals guiding efforts for children affected by armed conflict, child protection systems strengthening to prevent and respond to all forms of violence against children, and a range of other matters.

Richard and Rhoda Goldman Conference Room

Susan Bissell Chief of Child Protection Speaker UNICEF
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Program on Human Rights

A New Paradigm for Engaging the War on Infectious Diseases

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From the 1950s through the 1970s, the success of antibiotics and vaccines in controlling or eradicating infectious diseases (ID) worldwide resulted in decreased emphasis on development of ID therapeutics. The emergence in the past three decades of HIV, SARS, West Nile, avian flu, swine flu, Ebola, and the potential for bioterrorist attacks has reversed this trend and renewed interest in treatment and prophylaxis of ID. Unfortunately, because many diseases are prevalent primarily in developing nations (e.g., malaria, TB, Chagas), potential sales of bioterrorist pathogens are limited mainly to orders for government stockpiles (e.g., anthrax, smallpox, botulinum toxin), and the cost of anti-infective clinical trials is high, traditional large pharmaceutical companies have cut back R&D resources in this arena. To combat this investment shortfall, a new paradigm has emerged where public-private partnerships between the NIH, World Health Organization, private foundations, academia, and non-profits, are beginning to function like pharmaceutical companies to advance the development of promising ID drugs, even when there is little opportunity for profit. This talk will discuss the growing need for ID therapeutics, present some new models for discovering and developing them, and provide examples of public-private partnerships that have advanced therapeutics for specific infectious diseases.

About the speaker: Dr. Jon C. Mirsalis is Managing Director of the Biosciences Division and Executive Director of Preclinical Development at SRI International in Menlo Park, CA. Dr. Mirsalis is an internationally recognized expert in the development of drugs for infectious diseases. He manages two large programs for the National Institute of Allergy and Infectious Diseases (NIAID) for the development of promising therapeutics for the prevention and treatment of a broad range of infectious diseases including TB, malaria, influenza, polio, anthrax, plague, and Ebola. He has personally been involved in the development of over 50 therapeutics that have entered clinical trials and several have already reached the market. Before joining SRI in 1981, Dr. Mirsalis was a postdoctoral fellow at the Chemical Industry Institute of Toxicology, where he developed the in vivo-in vitro hepatocyte DNA repair assay, which is now widely used as a screen for potential carcinogens by government and industry. He is the author of over 140 publications and abstracts. Dr. Mirsalis received his B.S. degree in zoology/molecular biology from Kent State University, his M.S. degree in genetics from North Carolina State University, and holds Ph.D. degrees in toxicology and genetics from North Carolina State University. Dr. Mirsalis has an adjunct faculty appointment with the University of California-Santa Cruz, where he lectures regularly on genetic toxicology and carcinogenesis. He has recently served on the Board of Scientific Councilors for the National Toxicology Program, the Advisory Board for the Critical Path Institute, and is a past member of the FDA’s Over-the-Country Product Review Committee. Dr. Mirsalis has been certified by the American Board of Toxicology since 1983.

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Jon Mirsalis Managing Director, Biosciences Division Speaker SRI International
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Incentives, Fear of Arrest, and HIV/AIDS: Evidence from a Randomized Field Experiment Amongst Lawbreakers

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Abstract:

How can we encourage illegal actors to seek assistance from the state? Lawbreakers are generally hesitant to engage with the state, out of fear of incurring sanctions for having violated the law. They hesitate to seek law enforcement help if they are victims of crimes. They also shy away from other state institutions that could provide them with assistance such as social and health services, or education. The paper addresses this question by evaluating whether an incentive can increase HIV/AIDS testing amongst lawbreakers, who responds, and why. It presents a randomized field experiment in which sex workers in Beijing, China were assigned an incentive for getting an HIV test.

Speaker Bio:

Margaret Boittin is a fellow at CDDRL. She is completing her PhD in Political Science at UC Berkeley, and her JD at Stanford. Her dissertation examines regulation in China, focused on state intervention in prostitution from the perspectives of health, policing, and business. Her work combines ethnographic methods, as well as field and survey experiments.

Encina Ground Floor Conference Room

Margaret Boittin

Encina Hall
616 Serra Street
Stanford, CA 94305-6055

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The Governance Project Postdoctoral Fellow, 2013-15
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Margaret Boittin has a JD from Stanford, and is completing her PhD in Political Science at UC Berkeley. Her dissertation is on the regulation of prostitution in China. She is also conducting research on criminal law policy and local enforcement in the United States, and human trafficking in Nepal.

The Governance Project Postdoctoral Fellow, 2013-15
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Margaret Boittin Pre-doctoral Fellow 2012-13 Speaker CDDRL
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