“Vic-TOR-ia!” Fátima cried, a grin lighting up her face. The 5-year-old had become fast friends with Stanford medical student Tori Bawel almost instantly after Bawel arrived in San Lucas Tolimán. After giving piggy-back rides to Fátima, a career in global pediatrics changed from a distant wish to a developing reality for Bawel.

Bawel is one of a few lucky medical students to travel with Stanford pediatrician Paul Wise, MD, MPH, to San Lucas Tolimán, a town in the mountains of rural Guatemala that serves as a base for his work to improve nutrition for local children. Once she completes her medical training, Bawel plans to devote her life to improving health in underserved areas.

“As an elementary school student, I was really compelled by issues of social justice,” she said. “I hope that over the course of my lifetime, I’m able to make a difference like physicians have done here in Guatemala and around the world.”

Every summer, Wise, a professor of pediatrics and a Stanford Health Policy core faculty member, takes a handful of undergraduates to the communities around San Lucas to learn about the Rural Guatemala Child Health and Nutrition Program. A collaboration between Stanford and a group of local health promoters, the program uses nutritional supplements and health education to save the lives of children under five. The students follow the promoters on house visits, help them measure the weight and height of children and gain an understanding of how the program helps the rural communities.

“We feel it is part of our educational mission,” said Wise. “We want to grow people who will make a difference, and part of that is providing them opportunities to do so.”

Bawel’s experience reinforced her desire to engage in global health work: “It’s inspired me and motivated me to want to give my life, like Wise, to… serving in areas of the world with the greatest need.”

Meeting Guatemalan students who overcame economic difficulties to study medicine — like Flor Julajuj — was also deeply moving for Bawel. Very few in rural Guatemala have the opportunity to pursue higher education or good health care. But with some help from Wise, Julajuj was able to attend medical school; just this month, she graduated from the University of San Carlos in Guatemala City.

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“It’s been a great opportunity,” said Julajuj. “It’s changed my life.”

Most, though, are not so lucky; Bawel also encountered two young women who dream of becoming physicians but cannot afford medical school. Meeting the young, ambitious women “makes me want to empower them with the education and opportunities I have had,” said Bawel.

Wise, meanwhile, will continue to each Stanford students about ways to help these communities.

“They see the poverty, but they also begin to understand why being a great doctor or a great diplomat or a great economist will serve the interests of people down here if done well,” he said. “We want them to go back to whatever field they’re interested in, committed to gaining skills and then using them to serve the needs and the rights of people in places like San Lucas.”

The boy’s genetic disorder would have been terminal anywhere, but thanks to Wise and local health promoters, the boy’s family had years with him instead of months.

They found the doctor through the Guatemala Rural Child Health and Nutrition Program, a collaboration between Wise and the health promoters to eliminate death by malnutrition for children under 5.

While Wise spoke to the heartbroken mother, his Stanford research assistant Alejandro Chavez helped the promoters set up inside a local community center to measure the weight and height of local kids to determine their nutrition level.

Chavez and the promoters had worked together for months to create an app for tablets that will make it easier to find malnourished children.

The app they designed will decrease training time for new health promoters and allow the program to expand. The goal is to distribute the app globally to help programs in other countries tackle malnutrition.

Children in crisis

As recently as 2005, about one of every 20 children in this rural area of Guatemala died before their 5th birthday. Almost half the deaths were associated with severe malnutrition.

“The death of any child is always a tragedy, but the death of any child from preventable causes is always unjust,” said Wise, a Stanford Health Policy core faculty member.

Along with other faculty from the Freeman Spogli Institute for International Studies (FSI) and the School of Medicine, Wise created the Children in Crisis Initiative to save the lives of children in areas of poor governance. The program brings together Stanford researchers and students across disciplines.

Nowhere are their efforts better illustrated than in the rural communities around San Lucas Tolimán, in the central mountains of Guatemala.

The program’s effectiveness rests on a deep respect for the local communities merged with innovation by Stanford researchers.

“It’s absolutely essential to any program that the people in need be part of the solution,” said Wise. Unlike many nongovernmental organizations and health programs, Wise believes the way to create a sustainable health system is for the locals to run it, so the health promoters manage the program’s day-to-day activities.

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This leaves the Stanford team free to focus on innovation – such as the new app. They believe the technology could change child health programs around the world. Wise’s team has partnered with Medic Mobile – a nonprofit that creates open-source software for health care workers – which plans to distribute the app to other areas suffering from malnutrition.

The six Android tablets purchased by Children in Crisis are enough to monitor the program’s 1,500 kids through the app.

Role of nutrition

When done well, nutrition surveillance is very effective at decreasing child mortality in poor countries.

“Nutrition contributes enormously to health and well-being,” Wise said as he walked through Tierra Santa, a small community near San Lucas, making house calls. “So the focus of our work turned to improving young child nutrition. It’s not an easy thing to do in a place that’s extremely poor.”

Wise and his colleagues – Stanford medical student Tori Bawel and Stanford professor of pediatrics Lisa Chamberlain – made their rounds during their visit in March. Evidence of poverty was everywhere.

Here, clean tap water is a dream and even the sturdier homes often lack four walls or paned windows, though the children were neatly dressed in T-shirts or colorful traje, traditional Mayan clothing.

It’s hard to provide proper nutrition when most families can’t find enough work to buy adequate food. But a little help can make a big difference.

Bawel, a first-year medical student who plans a career improving health in areas of poverty, was struck by the impact the promoter program has had on the community.

“There are children who need supplements and nutrition to stay alive,” she said. “Without this program, that infrastructure does not exist.”

With FSI’s assistance, the nutrition program distributes Incaparina, a supplement of cornmeal, soy and essential nutrients. The sweet, mealy drink helps the program’s most malnourished children get back on track.

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Every two months, the promoters gather each community’s children to measure their weight and height. Children and their mothers sit patiently, waiting for their turn. The children enjoy a cup of Incaparina, and their mothers eagerly listen to the promoters’ tips for keeping their children healthy.

“It’s very important to me,” said Elsira Rosibel Samayoa, who brought her 2-year-old to be measured. “There are mothers who don’t understand the importance of monitoring their children’s weight, but I do.”

Since its implementation in 2009, the Stanford program has slashed nutrition-based mortality in the participating communities by about 80 percent and decreased severe malnutrition by more than 60 percent – saving hundreds of children’s lives.

However, nutrition surveillance and intervention isn’t easy. Tracking nutrition takes training and expertise, and when the local population rarely exceeds a fourth-grade education, learning these skills is especially challenging. Detailed graphs on a standard growth chart are essential to identifying malnourished children.

“The community health workers are extremely capable and smart, but some have never seen a graph before,” said Wise. “Think about what it is to try to explain a graph to someone for the first time.”

It takes the health workers about three years to learn to graph and then interpret the results for intervention.

Wise said, “So we all got together and said, ‘How do we make this easier to do?’”

The app was the answer.

‘Let’s create an app’

Enter Alejandro Chavez, a recent Stanford computer science graduate and Stanford Health Policy research assistant. He developed the app to collect child health data, then determine the child’s degree of malnutrition and suggest intervention.

“The major goal was to lower training requirements and make programs like this simpler to start and maintain,” said Chavez, who now lives and works in Guatemala, where he gets daily feedback from the health promoters.

“I feel like they’ve been very honest with me about things I need to improve,” he said.

Cesia Lizeth Castro Chutá is a senior coordinator for the program who has worked with Chavez to ensure that the app meets the promoters’ needs.

“The tablet automatically generates the information we need to know,” she said. “It becomes easier to confirm that a child is malnourished and needs supplements.”

Looking forward

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With the app’s launch, it looks like training time for the promoters will be reduced from three years to less than six months. That means new communities can be incorporated into the program quickly, creating broader access to care.

Meanwhile, many health programs around the world are waiting to see how well the Stanford app works in Guatemala.

Josh Nesbit, a Stanford alumnus and Medic Mobile CEO, said, “As more health programs recognize the importance of nutrition and implement community-based interventions, screening and surveillance tools will be critical. We must learn from Dr. Wise’s success.”

Colorectal cancer is the second leading cause of death from cancer in the United States, after lung cancer, yet many Americans are still loathe to be screened for the disease.

The U.S. Preventive Services Task Force strongly recommended adults ages 50 to 75 to be screened for colon cancer and suggested adults 76 to 85  make individual decisions about whether to be screened, depending on their overall health and prior screening history. The recommendation and several accompanying editorials were published Wednesay in the Journal of the American Medical Association (JAMA).

The independent body of national experts in prevention and evidence-based medicine emphasized colonoscopy is not the only valid test out there. There are multiple screening options available to the one-third of Americans over 50 who have never been screened.

We pose five key questions about the Task Force recommendations to Douglas K. Owens, the Henry J. Kaiser, Jr., Professor of Medicine at Stanford and director of the Center for Health Policy and Center for Primary Care and Outcomes Research. He is an author of the recommendation and was a member of the Task Force when the guidelines were developed.

What is the most significant finding of this final recommendation?

Colorectal cancer is the second leading cause of death from cancer in the United States. The good news is that evidence convincingly shows screening for colorectal cancer works. The Task Force strongly recommends screening adults 50 to 75 for colorectal cancer, as it reduces the risk of dying from the disease. Unfortunately, one-third of people 50 to 75 have never been screened, so we are missing an important opportunity to prevent deaths from colorectal cancer.

There are multiple screening options for colorectal cancer. What are they and how should individuals decide which is best for them?

What really matters is that people get screened. There are several options that are effective, so we recommend that people discuss the options with their clinician. There are direct visualization tests, like colonoscopy, and stool-based tests, like fecal immunochemical testing (FIT). Each test has different strengths and limitations, and people may prefer one approach over another. For example, colonoscopy can be done every 10 years, but FIT testing should be done every year. But the real message is, choose an approach in consultation with your clinician and get screened.

The Task Force found that once adults reach 76 years old, the benefits of screening become smaller and the potential for harm is greater. Why is this and how should older Americans determine which test is best for them?

We recommend individual decision making for patients 76 to 85. The benefits are smaller because a person’s chance of dying of other causes goes up as they get older. The harms are still small but increase with age, primarily because the risks of the potential complications of colonoscopy (bleeding, perforation, and infection) go up with age. Still, some people in this age group will benefit from screening. People most likely to benefit are those who have not been screened before, people who are healthy enough to undergo treatment for CRC should it be found, and people who do not have other diseases or conditions that limit their life expectancy substantially.

Owens explains the Task Force's recommendations to JAMA

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JAMA Network | JAMA | USPSTF Recommendation Statement: Screening for Colorectal Cancer

African-Americans have the highest incidence of and mortality rates from colorectal cancer among all racial and ethnic subgroups. Why are African-Americans more susceptible and does this mean that the screening recommendations differ for them?

The Task Force recognizes the burden that colorectal cancer has on African-Americans, who are at higher risk of being diagnosed with and dying from the disease than other racial/ethnic subgroups. We don’t know why this is — more research is needed in this area. The Task Force did not find enough evidence to conclusively support that making a different recommendation specific to African-Americans would result in a greater net benefit for this population. So our recommendations are intended to apply to all racial/ethnic groups. More robust efforts are needed to ensure that at-risk populations actually receive the screening tests and the follow-up treatments or interventions they need, as people are dying unnecessarily from this disease.

What data did the Task Force use to come to its conclusions?

The Task Force commissioned a comprehensive systematic review of the available evidence on the benefits and harms of colorectal cancer screening. The Task Force also commissioned a modeling study from the Cancer Intervention and Surveillance Modeling Network (CISNET) to help it better understand different screening strategies, such as the optimal age to start or stop screening, and the length of time between screenings. The evidence is convincing that screening reduces the risk of dying from colorectal cancer.

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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What is the best way to measure returns on investments in health care?

Does the World Health Organization’s approach help developing countries allocate their limited health-care resources wisely?

What are the economic implications of the global rise in non-communicable diseases?

These are just a few of the global challenges taken up by health economics experts at the third annual Global Health Economics Consortium Colloquium at the University of California, San Francisco.

At the core of the conference is the growing field of health economics, and why cost-effectiveness analysis is fast becoming the underpinning of successful health policies.

Not only is the field expanding, so is the collaboration among researchers and faculty at Stanford Health Policy, UCSF Global Health Sciences, and the UC Berkeley School of Public Health, co-sponsors of the Feb. 12 event.

“It’s been great to see the meeting evolve from a show-and-tell to a platform where we can have nuanced discussions about the challenges and controversies in the field,” said Dhruv Kazi, an assistant professor of medicine at UCSF who helped organize and moderate the event.

Some 180 health policy experts, researchers and speakers representing 11 universities, six non-profit organizations and five for-profit outfits attended the daylong conference on the UCSF Mission Bay campus.

“By building bridges between our universities, we create a space where thought-leaders and students alike can engage in discussions to challenge working assumptions and also spearhead innovate strategies and solutions,” said James Kahn, a professor of health policy and epidemiology at UCSF and the director of the consortium.

The Consortium — known as GHECon — was awarded a five-year cooperative agreement of up to $8 million by the CDC to conduct economic modeling of disease prevention in five areas: HIV, hepatitis, sexually transmitted diseases, tuberculosis and school health.

Taking a break during the third annual Global Health Economics Consortium Colloquium at UCSF on Feb. 13, 2016. Photo by UCSF/Cindy Chew.

As global economies remain turbulent, Kazi said, governments and donors have become increasingly cost-sensitive and want to better understand the societal returns they are getting for their investments in health.

“That enhances the influence of our work, but also increases the scrutiny it receives, creating an opportunity for the community to have an honest discussion about the challenges and opportunities that lie ahead,” he said. “And that is precisely the platform GHECon sees itself becoming.”

Some of the tough challenges consortium members are undertaking:

1. The World Health Organization recommends using per capita GDP as a benchmark for how much money countries should be willing to spend on health-care interventions. GHECon researchers have shown that this approach is problematic and does not always help countries allocate their limited health-care resources optimally.
2. Economic evaluations have typically only considered health-care costs, overlooking the lost income of patients or caregivers during hospital stays. GHECon researchers are working on ways to value this lost productivity in an effort to estimate the true cost of a disease and, conversely, the benefit of its alleviation. 
3. Cost-effectiveness evaluations traditionally are concerned with how efficiently health-care resources are utilized by asking questions like: How many lives can I save per million dollars invested? But society may care about other benefits that go beyond efficient use of resources, such as reducing disparities by helping the most vulnerable sections of society and alleviating poverty.

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Mark Sculpher, one of the leading health economists in the world, gave the keynote address about his efforts in the UK to use cost-effectiveness analysis to inform decisions at the National Institute for Health and Care Excellence.

He said there are two big challenges today: defining cost-effectiveness thresholds that are meaningful, and determining how policymakers, donors and payers make decisions when there are multiple criteria and perspectives.

“The realities of decision-making inevitably involve a whole host of considerations,” said Sculpher, who is director of the Program on Economics Evaluation and Health Technology Assessment at the University of York. “Ultimately it’s about what is this measure of benefit that we want to maximize — and how do we invest in it.”

Stanford Health Policy’s Douglas K. Owens, director of the Center for Health Policy at the Freeman Spogli Institute for International Studies and the Center for Primary Care and Outcomes Research at the Department of Medicine, presented his influential economic modeling research about the need for routine HIV screening.

“We determined that HIV screening is cost-effective in virtually all health-care settings,” Owens told the audience, noting that the findings became policy at the Centers for Disease Control and Prevention and other national health policy organizations. It has become an example of how economic modeling can inform crucial policy decisions — and help save lives.

There were also robust panel discussions about the challenges of doing cost-effectiveness analysis in developing countries with limited resources; the difficult paths to universal health care; and how economics can help address disparities in health care and financial protection.

“The consortium is particularly valuable because it fosters collaborations among a broad group of global health experts,” Owens said.

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This season, “Downton Abbey's” plot line has health policy wonks on the edge of their seats: a heated debate about hospital consolidation that closely parallels what’s going on in the U.S. health care system today.

If you’re not a Downton fan, here’s a quick plot recap by Kaiser Health News reporter Jenny Gold: It’s 1925 for the lords and ladies at Downton Abbey. Think flapper dresses, cocktail parties and women’s rights. And a big hospital in the nearby city of York is making a play to take over the Downton Cottage Hospital next to the posh estate.

As Maggie Smith’s character, the Dowager Countess of Grantham, sees it, “The Royal Yorkshire county hospital wants to take over our little hospital, which is outrageous!”

Stanford Health Policy’s Kathy McDonald — an unabashed fan of the popular PBS period piece — says things haven’t changed that much today. There has been an uptick in hospital consolidations since 2010, with about 100 taking place each year, she says.

You can listen to McDonald’s interview with Gold, who took the Downton debate to the American Public Media radio show, “Marketplace.”

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Anna Lembke, Assistant Professor of Psychiatry and Behavioral Sciences at the Stanford University Medical Center, visited SCPKU for two weeks as a faculty fellow in July 2014.  Below are the highlights of a conversation Professor Lembke had with SCPKU in which she shares more details about her research and how SCPKU helped to advance her work in China.

Q: Describe your research and its connection to China

My research focuses on improving the lives of those with addictive disorders. I am especially interested in the intersection between health care systems and culture, and how this intersection impacts addiction treatment. I became interested in studying drug use disorders in China for a number of reasons. First, I spent a year after college living in China (1989-1990) teaching English as part of the Yale China Program. I have followed events in China with keen interest ever since. Second, the total number of drug users in China may be as high as 7 million, with China predicted to have the most heroin users of any country in the world within 5 years. I was curious to find out how China is addressing its burgeoning drug problem, and didn’t just want the “party line.” I wanted to learn about how people addicted to drugs in China are seeking and getting help.

Q: What got you interested in the study of addiction?

When I first began practicing psychiatry, I was not interested in treating addiction. But over time, I came to realize that if I didn’t treat my patients’ drug and alcohol problems, their other mental health issues were unlikely to improve. I also realized that in targeting and treating addiction, I could help patients transform their lives for the better, as well as the lives of those who love them.

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

SCPKU gave me the financial and logistical support to pursue a research project in China, an opportunity that would not have been possible without their help.

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

The team here at Stanford was helpful with drafting the initial proposal, creating the budget, which was especially challenging, due to my lack of familiarity with what things cost in China, and making contact with the SCPKU staff in Beijing. The team in Beijing was helpful in setting up temporary housing and meals in Beijing, as well as providing maps, information on how to take the subway, and logistical support getting back to the airport.

Q: What were your fellowship objectives and were they met? 

My fellowship objective was to interview treatment-seeking heroin users in China to learn more about the state of addiction treatment in China. My research assistant, Dr. Niushen Zhang, and I planned to publish our findings in a peer-reviewed journal.

We learned that individuals in China addicted to drugs experience intense social stigma. They are reluctant to utilize government-sponsored treatment, because of fear of loss of anonymity and the ensuing social and economic consequences that follow when they are publicly identified as “addicts,” not to mention the potential loss of their personal freedom. (Addicted persons in China are sent against their will to forced detention centers, or “rehabilitation through labor camps.”) As a result, drug addicted persons in China are deeply mistrusting of government-sponsored treatment, and willing to sacrifice large sums of their own money for anonymous, confidential treatment.

Dr. Niushen Zhang and I recently published our findings in Addiction Science and Clinical Practice, 2015, “A qualitative study of treatment-seeking heroin users in contemporary China.” (To access the article online go to http://www.ascpjournal.org/content/10/1/23)

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

The highlight for me was hearing the life stories of heroin-addicted patients at New Hospital in Beijing, and attending an Alcoholics Anonymous meeting, conducted entirely in Chinese. The AA members we met told us their participation in this grass-roots 12-step movement literally saved their lives. I also met many wonderful doctors and nurses working with addicted patients in China. Finally, Dr. Zhang and I became good friends. We had hardly known each other before venturing off to do research in China.

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

Compassion, endurance, overcoming adversity
 

Q: Any future plans in China? 

I’m thinking about taking a group of Stanford residents and/or medical students to China for a total immersion 3-week course to learn about addiction in China.  But not right away.