The increasing resistance to antimicrobial drugs is a growing public health concern, particularly in low- and middle-income countries that require high out-of-pocket payments for prescription drugs.

“Understanding the drivers of antibiotic resistance in low- to middle-income countries is important for wealthier nations because antibiotic-resistant pathogens, similar to other communicable diseases, do not respect national boundaries,” said Marcella Alsan, MD, PhD, MPH, the lead author of the study, which was published July 9 in The Lancet Infectious Disease.

Alsan is an assistant professor of medicine at Stanford, an investigator at the Veterans Affairs Palo Alto Health Care System and a core faculty member at the Center for Health Policy/Center for Primary Care and Outcomes Research.

“Out-of-pocket health expenditures are a major source of health-care financing in the developing world,” said Jay Bhattacharya, MD, PhD, senior author of the study and a professor of medicine, a senior fellow at the Freeman Spogli Institute for International Studies and another core faculty member at CHP/PCOR.

Read the full article here.

Image

Hua Tang, Stanford Associate Professor of Genetics, visited SCPKU as a faculty fellow in March 2015.  Below are the highlights of a conversation Professor Tang had with SCPKU in which she shares more details about her research and the contributions SCPKU made to her work in China.

Q: Describe your research and its connection to China

My research aims to develop statistical and computational methods for elucidating the genetic basis of human complex diseases. My current focus is on two related themes: identifying disease risk factors by integrating functional genomic information, and understanding factors that contribute to differential disease prevalence across human populations. My SCPKU faculty fellowship has given me the opportunity to explore new dimensions related to both themes.  Through connections I have made with scholars at Peking University (PKU), I will be able to combine biological knowledge and population-based association evidence in my efforts to identify genetic risk factors for complex diseases.  I also plan to compare epidemiologic data based on the East Asian population in the U.S. and epidemiological studies in China to understand the role of life-style risk factors, such as diet and physical activities, in ethnic health disparity.

Q: What got you interested in the study of human complex diseases?

I have always enjoyed mathematics, but it is very important to me that my work has direct benefit to people. Luckily, in college and during graduate school, I discovered that statistical and population genetics are areas in which I could use mathematical tools to gain insights relevant to human health. We are living in an era of big data; combining novel statistical models, efficient computational tools and large-scale biomedical data offers fantastic opportunities to make real contributions to medicine and public health.

Q: Why did you decide to apply for an SCPKU Faculty Fellowship?

I wanted to connect better with the scientific community in China.  I had already started communicating remotely with a PKU professor at PKU, whose research shares common goals with mine but who takes complementary approaches. The SCPKU faculty fellowship would allow me to travel to China and strengthen ties with faculty at PKU.  I also look forward to the opportunities of interacting with students at PKU.

Q: How valuable was SCPKU's team in supporting your fellowship at SCPKU?

Extremely valuable!   I got a nice office on the courtyard level, great IT and staff support. Also, I had the opportunity to interact with faculty from other departments for collaborations.

Q: What were your fellowship objectives and were they met?  Also, if applicable, aside from the fellowship, how did SCPKU help you to achieve your objectives?

My first visit to SCPKU in March was very productive and I was able further my research on the two themes I mentioned earlier.  I also taught a lecture in a concurrent SCPKU graduate seminar, through which I got to know the work of Professor Randall Stafford from the Stanford Prevention Research Center.  Professor Stafford was also an SCPKU faculty fellow and taught a graduate seminar at SCPKU this past spring focused on chronic disease in China.  I was able to participate in the seminar and establish new ties with instructors and participants of this  multidisciplinary seminar including Chinese scholars, health practitioners and government representatives from the Chinese Center for Disease Control and other health-related organizations. 

Being physically at SCPKU this past spring really helped to stimulate my research program. The fellowship has opened up many possibilities for interacting with scholars at Peking University and the broader scientific community in Beijing. I hope to expand these relationships by making several more trips to SCPKU. I am also very interested in organizing an SCPKU graduate seminar for the near future.
 

Q: Describe some highlights of your stay in China/SCPKU. 

Aside from meeting with my PKU contacts to further my research, I enjoyed participating in (both as an observer and teaching a lecture) Dr. Stafford’s graduate seminar on chronic diseases in China. I made many new connections in the Beijing science community and will host a visiting student in early 2016.  I also attended an SCPKU-hosted happy hour which included a Chinese rice wine tasting and musical performance on a Chinese zither or “guzheng.”

Q: List at least THREE words or thoughts that come to mind which best describe your experience at SCPKU. 

Adventure, exploration, collaboration.
 

Q: Any future plans in China? 

I plan to use the remaining funds from my SCPKU fellowship in the fall, and continue interaction with faculty at PKU and SCPKU.

Photo courtesy of Stanford University

Rates of obesity in the United States remain extremely high. New statistics show that nearly two-thirds of adults are at an unhealthy weight and that – for the first time ever – obese Americans now outnumber those who are merely overweight.

Two Stanford public health law experts say one of biggest culprits of the obesity epidemic – on top of fast foods and our sedentary lifestyle – are sugary drinks.

And they believe the sweet spot for public health law in curbing the adverse effects of sugar-sweetened beverages (SSBs) lies in the strategic use of measures such as higher SSB taxes, limits on advertisements targeting kids, and restrictions on soft drinks and sugar-sweetened teas and sports drinks in government institutions, such as public schools.

“It’s always possible to get more and better evidence about the effectiveness of public health laws,” says David Studdert, a professor of medicine at the Stanford School of Medicine, professor at the Stanford Law School and core faculty member at the Center for Health Policy/Center for Primary Care and Outcomes Research.

Image

“But enough is already known about the promise of some legal interventions to curb SSB consumption – significant tax hikes and advertising restrictions are two good examples – to be fairly confident that they would make a difference.”

Studdert is the lead author of a review paper published July 7 in PLoS Medicine, entitled, “Searching for Public Health Law’s Sweet Spot: The Regulation of Sugar-Sweetened Beverages.”

Studdert and senior author Michelle Mello, professor of law and professor of health research and policy at the School of Medicine, and co-author Jordan Flanders, a former Stanford Law School student, argue that sugary drinks are a substantial, yet preventable contributor to the global burden of obesity and associated health conditions.

A new study published June 29 in the American Heart Association journal Circulation linked the consumption of sugary drinks to an estimated 184,000 adult deaths each year, with more than 25,000 of those Americans. The study, conducted by researchers from Tufts University, found that the beverages are responsible for an estimated 133,000 of those deaths from diabetes, 45,000 from cardiovascular disease and 6,450 from cancer.

While Americans’ consumption of sugary drinks has plateaued, according to the Tufts study, about three-fourths of the deaths due to SSBs are now in developing countries. Mexico leads with 24,000 total deaths. The United States still ranks fourth, however, just behind South Africa and Morocco.

The Stanford researchers say the evidence shows that sugary drinks are contributors to the global obesity epidemic, but the appropriate reach of regulation to curtail SSB consumptions remains highly contested.

The main regulatory approaches to SSBs are higher taxes, restrictions on the availability of the sugar-sweetened drinks in schools, restrictions on advertising and marketing, labeling requirements and government procurement and benefits standards.

Image

“Finding public health law’s sweet spot requires regulatory approaches that are capable both of achieving measurable improvements to public health and of winning victories in courts of law and public opinion,” the researchers write.

Over the last decade, many national, state, and local governments have introduced laws aimed at curbing consumption of sugar-sweetened beverages (SSBs), especially by children. The main regulatory approaches have been taxes, restrictions on the availability of SSBs in schools, calls for controls on advertising and marketing, labeling requirements, and government procurement and benefits standards.

But efforts to regulate the drinks often encounter stiff opposition, including claims that the laws are inequitable, do not achieve their goals, and have negative economic effects.

New York City’s attempt to ban the sale of jumbo-sized sugary drinks sold in city restaurants, theaters and food carts triggered international headlines and a firestorm of opposition. The soft drink industry embarked on a multimillion-dollar campaign to block the proposal championed by former Mayor Michael Bloomberg.

The proposal died last year when the New York State Court of Appeals ruled that the city’s Board of Health had “exceeded the scope of its regulatory authority.”

Taxes on SSBs, the most commonly adopted measure, vary widely, the authors write. A few countries, most notably several South Pacific island nations, where obesity rates are among the highest in the world, have introduced very high taxes on sugary drinks.

But most sugar-sweetened beverage taxes add between 5 and 9 cents per liter. This is well short of the level that experts argue is needed to significantly affect consumption and weight outcomes: a sales tax of at least 20 percent of the container’s price or a specific excise tax of 1 cent per ounce.

“In the United States, there have been many government proposals to introduce or raise taxes – most unsuccessful,” the authors write. “The beverage industry has invested heavily in public relations firms and `grassroots’ organizations to oppose the initiatives.”

Image

Berkeley, Calif., recently became the first U.S. city to pass an SSB tax, a penny-per-ounce excise on soda distributors, but a similar ballot measure in nearby San Francisco failed. At least 22 states have proposed SSB taxes since 2010, but only one state, Washington, passed a measure at the level recommended by economists – and it was repealed the following year in a voter referendum.

Yet U.S. childhood obesity has more than doubled in children and quadrupled in adolescents in the past 30 years, according to the Centers for Disease Control and Prevention. More than one-third of children and adolescents are overweight or obese.

“There is broad consensus in the public health community that reducing the influence of advertising is a critical step in addressing the spread of childhood obesity,” the authors say.

The United States and Canada have sought to regulate advertisers through a soft approach — mainly via voluntary guidelines and pressure to self-regulate, the authors write.

“These appear to have had only a modest impact on marketing practices,” they said. “U.S. regulators face considerable legal barriers in going further, including courts’ increasingly expansive interpretations of the scope of protected commercial speech under the First Amendment. Unless judicial currents shift, it will remain extremely difficult to impose restrictions on SSB advertising.”

Mello said low- and middle-income countries should anticipate that SSB companies will increasingly target them as promising markets, and that those developing countries should start crafting their regulatory responses now.

“Our experience with tobacco control teaches us that lower- and middle-income countries need to become wary when product regulation in the U.S. tightens,” Mello said. “Like squeezing a balloon, it pushes companies to intensify their marketing efforts overseas, and our public health problems get exported."

And, the authors note, while policy nudges have become fashionable, “there are dangers in treading too lightly.” “Strategies such as calorie labels, portion caps, and small beverage taxes preserve consumer freedom but are typically too modest to affect consumer behavior – and such modesty can be recast as arbitrariness. Industry opposition will come whether the intervention is modest or aggressive but should be easier to combat if officials can show their policy is effective,” they wrote.

“One somewhat surprising message that comes from reviewing how courts have handled challenges to SSB laws is that regulators can run greater risks of having their laws struck down if they are too timid,” Studdert said.

“Courts weigh effectiveness, and modest attempts to change behavior are often ineffective,” he said. “So one piece of advice regulators in this area should consider is to ‘go big or go home’.”

Noncommunicable diseases (NCDs) have become the leading causes of death worldwide and China's increased NCD prevalence is of growing concern. Randall Stafford, Professor of Medicine in the Stanford Center for Research in Disease Prevention and SCPKU Faculty Fellow, led a symposium at the center last fall.  Entitled "Tackling China's Noncommunicable Diseases: Shared Origins, Costly Consequences, and the Need for Action," the symposium focused on China's NCD threats to public health and the urgent need for solutions.  The symposium summary was published earlier this month in the Chinese Medical Journal.

In a recent speech, Stanford professor Rosamond Naylor examined the wide range of challenges contributing to global food insecurity, which Naylor defined as a lack of plentiful, nutritious and affordable food. Naylor's lecture, titled "Feeding the World in the 21st Century," was part of the quarterly Earth Matters series sponsored by Stanford Continuing Studies and the Stanford School of Earth Sciences. Naylor, a professor of Environmental Earth System Science and director of the Center on Food Security and the Environment at Stanford, is also a professor (by courtesy) of Economics, and the William Wrigley Senior Fellow at the Freeman Spogli Institute for International Studies and the Stanford Woods Institute for the Environment.

"One billion people go to bed day in and day out with chronic hunger," said Naylor. The problem of food insecurity, she explained, goes far beyond food supply. "We produce enough calories, just with cereal crops alone, to feed everyone on the planet," she said. Rather, food insecurity arises from a complex and interactive set of factors including poverty, malnutrition, disease, conflict, poor governance and volatile prices. Food supply depends on limited natural resources including water and energy, and food accessibility depends on government policies about land rights, biofuels, and food subsidies. Often, said Naylor, food policies in one country can impact food security in other parts of the world. Solutions to global hunger must account for this complexity, and for the "evolving" nature of food security.

As an example of this evolution, Naylor pointed to the success of China and India in reducing hunger rates from 70 percent to 15 percent within a single generation. Economic growth was key, as was the "Green Revolution," a series of advances in plant breeding, irrigation and agricultural technology that led to a doubling of global cereal crop production between 1970 and 2010. But Naylor warned that the success of the Green Revolution can lead to complacency about present-day food security challenges. China, for example, sharply reduced hunger as it underwent rapid economic growth, but now faces what Naylor described as a "second food security challenge" of micronutrient deficiency. Anemia, which is caused by a lack of dietary iron and which Naylor said is common in many rural areas of China, can permanently damage children's cognitive development and school performance, and eventually impede a country’s economic growth.

Hunger knows no boundaries

Although hunger is more prevalent in the developing world, food insecurity knows no geographic boundaries, said Naylor. Every country, including wealthy economies like the United States, struggles with problems of food availability, access, and nutrition. "Rather than think of this as 'their problem' that we don't need to deal with, really it's our problem too," Naylor said.

She pointed out that one in five children in the United States is chronically hungry, and 50 million Americans receive government food assistance. Many more millions go to soup kitchens every night, she added. "We are in a precarious position with our own food security, with big implications for public health and educational attainment," Naylor said. A major paradox of the United States' food security challenge is that hunger increasingly coexists with obesity. For the poorest Americans, cheap food offers abundant calories but low nutritional value. To improve the health and food security of millions of Americans, "linking policy in a way that can enhance the incomes of the poorest is really important, and it's the hard part,” she said.” It's not easy to fix the inequality issue."

Success stories

When asked whether there were any "easy" decisions that the global community can agree to, Naylor responded, "What we need to do for a lot of these issues is pretty clear, but how we get after it is not always agreed upon." She added, "But I think we've seen quite a few success stories," including the growing research on climate resilient crops, new scientific tools such as plant genetics, improved modeling techniques for water and irrigation systems, and better knowledge about how to use fertilizer more efficiently. She also said that the growing body of agriculture-focused climate research was encouraging, and that Stanford is a leader on this front.

Naylor is the editor and co-author of The Evolving Sphere of Food Security, a new book from Oxford University Press. The book features a team of 19 faculty authors from 5 Stanford schools including Earth science, economics, law, engineering, medicine, political science, international relations, and biology. The all-Stanford lineup was intentional, Naylor said, because the university is committed to interdisciplinary research that addresses complex global issues like food security, and because "agriculture is incredibly dominated by policy, and Stanford has a long history of dealing with some of these policy elements. This is the glue that enables us to answer really challenging questions." 

Traditional drug repurposing, although successful in treating some diseases, still requires considerable time to identify candidate compounds and even more time to test them in clinical trials. Ebola requires and deserves a much more aggressive approach, while still balancing safety and efficacy concerns.

One way to considerably speed up the drug development process is to use high-end, bioinformatics-oriented computing approaches. When applied to drug repurposing, this approach can allow for a much faster identification of candidate compounds. When applied to clinical trials, this approach may quickly provide valuable animal and human information without the need for actual subjects.

With bioinformatics, drug repurposing can be used quickly without resorting to desperate measures that compromise safety. These bioinformatics approaches are already under development for diseases that are prevalent in wealthy countries, like cancer; Ebola provides an opportunity for this potentially game-changing approach to be applied to a disease primarily affecting those in resource-limited countries.