Studying the microorganisms that live in our gut is a relatively new field, one that has only really taken off in the last decade. In fact, it is estimated that half of the microbes that live in and around our GI track have yet to be discovered.

“This means there is a huge amount of this dark matter within us,” said Ami S. Bhatt, an assistant professor of medicine and genetics who runs the Bhatt Lab at the Stanford School of Medicine. The lab is devoted to exploiting disease vulnerabilities by cataloguing the human microbiome, the trillions of microbes living in and on our bodies.

“I think if we fast-forward to the impact of some these findings in 10 years, we’re going to learn that modifying the microbiota is a potent way to modulate health,” Bhatt said. “Humans are not only made up of human cells, but are a complex mixture of human cells and the microbes that live within us and among us — and these microorganisms are as critical to our well-being as we are to theirs.”

Bhatt, along with key collaborators at the University of Witwatersrand in Johannesburg, and the INDEPTH research consortium, now intends to take this research to Africa.

She is this year’s winner of the of the Rosenkranz Prize for Health Care Research in Developing Countries, awarded by Stanford Health Policy to promising young Stanford researchers who are investigating ways to improve health care in developing countries.

The $100,000 prize is targeted at Stanford’s emerging researchers who are dedicated to improving health care in poorer parts of the world, but may lack the financial resources.

Bhatt, MD, PhD, intends to take the prize money to execute the first multi-country microbiome research project focused on non-communicable disease risk in Africa. The project intends to explore the relationship between the gut microbiome composition and body mass index (BMI) in patients who are either severely malnourished or obese.

“As a rapidly developing continent with extremes of resource access, Africa is simultaneously faced with challenges relating to the extremes of metabolic status,” Bhatt wrote in her Rosenkranz project proposal. The Bay Area native, who is also the director of global oncology at Stanford, came to the School of Medicine in 2014 to focus on how changes in the microbiome are associated with cancer.

In this new project, Bhatt and members of her lab will team up with colleagues in Africa, first in South Africa, and then in Ghana, Burkina Faso, and Kenya. They will leverage the infrastructure already in place at the INDEPTH Network of researchers, using an existing cohort of 12,000 patients at within those four countries. The patients have already consented to be involved in DNA testing and have given blood and urine specimens.

Identifying alterations of the microbiome that are associated with severe malnutrition or obesity could pave the way for interventions that may mitigate the severity or prevalence of these disorders, Bhatt said.

“These organisms are critical to our health in that they are in a delicate balance with one another and their human hosts,” she said. “Alterations in the microbiome are associated with various diseases — but have mostly been studied in Western populations. Unfortunately, little is known about the generalizability of these findings to low- and middle-income countries – where most of the world’s population lives.”

Bhatt said that as Africa rapidly continues to develop, the continent is simultaneous faced with challenges relating to extreme weight gain and loss. While the wealthy are facing obesity and its associated disease such as stroke, heart failure and diabetes, many people are still faced with issues related to food insecurity, hunger and malnutrition.

The research, she hopes, could lead to aggressive behavioral, dietary and lifestyle modifications targeted at maintaining healthy BMI in at-risk individuals.

Video by Ankur Bhatt

Grant Miller, an associate professor of medicine and core faculty member at Stanford Health Policy who chaired the Rosenkranz Prize committee this year, believes Bhatt’s research could eventually break new ground.

“The entire Rosenkranz Prize selection committee was highly impressed with Ami and the innovation of her project,” Miller said. “Ami’s work on the human microbiome in the extremes of nutritional status in developing countries — including its potential link to obesity, an emerging challenge in low income countries — is potentially path-breaking.”

The award’s namesake, George Rosenkranz, first synthesized cortisone in 1951, and later progestin, the active ingredient in oral birth control pills. He went on to establish the Mexican National Institute for Genomic Medicine, and his family created the Rosenkranz Prize in 2009.

The award embodies Dr. Rosenkranz’s belief that young scientists hold the curiosity and drive necessary to find alternative solutions to longstanding health-care dilemmas.

The Supreme Court struck down parts of a Texas law that imposed standards on abortion providers that had the effect of reducing the number of abortion facilities in the state by at least half.  In a 5-3 ruling in which Justice Anthony Kennedy joined the liberal wing of the Court, the justices said the restrictions placed an undue burden on a woman’s constitutional right to seek an abortion. The 2013 law  required all abortion facilities to meet state standards for ambulatory surgical centers (ASCs) and required doctors performing abortions to have admitting privileges at a nearby hospital.

Justice Stephen G. Breyer wrote in the majority opinion, “We conclude that neither of these provisions offers medical benefits sufficient to justify the burdens upon access that each imposes. Each places a substantial obstacle in the path of women seeking a pre-viability abortion, each constitutes an undue burden on abortion access, and each violates the Federal Constitution.”

Michelle Mello, a professor of health research and policy at the Stanford School of Medicine and professor of law at Stanford Law School, as well a core faculty member of Stanford Health Policy, was a signatory to a brief submitted to the Supreme Court by public health academics and the American Public Health Association in support of the abortion providers’ challenge.

What was the main argument of the amici curiae brief submitted to the Supreme Court by public health academics and organizations?

There were two critical factual points that had to be made. First, although the Texas law’s provisions were putatively adopted to benefit women’s health, they actually had no medical benefit.  Second, the law had a rapid, dramatic effect on access to abortion in Texas.  Particularly because in Texas several other restrictions already limited access to abortion and funding for family planning services was scant, this poses a real threat to public health.

Can you say more about why the provisions of the law did not protect women’s health?

The standards were completely unnecessary.  Abortion is an extremely safe procedure; complications rarely occur.  The facilities already had protocols in place to ensure safe transfer to hospitals in the event of an emergency.  But when complications do occur, they usually arise after the woman returns home, so transfer from the facility to the hospital isn’t an issue.  And there’s no reason a woman needs to receive emergency care from the same doctor who performed the abortion. 

Many of the standards for ASCs are simply irrelevant to providing safe abortions.  Many abortions aren’t surgical, they’re medical (chemical).  And standards relating to things like providing general anesthesia, avoiding infections to open wounds, having an advanced heating and air condition system, and having a particular traffic pattern from the operating room to the recovery room just don’t apply.  The state’s argument about protecting women’s health was just a pretext. 

It was a dangerous pretext, in fact, because these were standards that most abortion facilities clearly were not going to be able to meet.  Many hospitals require doctors to admit a minimum number of patients in order to maintain admitting privileges, but abortion is so safe that abortion providers generally can’t do that.  And fitting out a clinic to meet ASCs is prohibitively expensive.  ASCs can afford it because they charge for expensive operations like cosmetic surgeries, hysterectomies, and hernia repairs; abortion providers can’t.

Why do you and the other signatories consider this a public health issue?

More than 60,000 Texas women per year obtain legal abortions.  While we’d all like to see this number go down, you can’t restrict access to abortion while also failing to provide adequate support for other methods of family planning.  History makes it abundantly clear that the result will be greater numbers of women resorting to illegal, unsafe abortions or facing the mental and physical health risks of carrying unwanted pregnancies to term.

Does the Supreme Court’s holding have implications beyond this case?

Yes, because the Court clarified how it will apply the “undue burden” standard of Planned Parenthood v. Casey in future cases.  The majority said that courts must balance “the burdens a law imposes on abortion access” against “the benefits those laws confer.”  The justices also clarified that appellate courts can take a deep dive into the factual evidence about a law’s effects presented earlier in the case.  These holdings collectively make it harder for states to adopt abortion restrictions based on flimsy arguments about how they will benefit women. 

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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Stanford University's Asian Liver Center (ALC) and the Global Business Group on Health jointly hosted the inaugural JoinJade for China Summit and Awards Ceremony at SCPKU on April 22, 2016.  29 major employers committed to a hepatitis B discrimination-free work environment were recognized at the event.  Lenovo, General Electric and IBM also participated in an employer panel to discuss key strategies for a discrimination-free work environment and next steps.

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JoinJade for China is a joint initiative involving global organizations including the ALC in the U.S. and China, Global Business Group on Health, IBM, General Electric, Intel, Hewlett Packard Enterprise, and HP Inc.  The initiative focuses on building fully inclusive workplaces free from hepatitis B discrimination.  

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The ALC at Stanford University is the first non-profit organization in the U.S. that addresses the disproportionately high rates of chronic hepatitis B infection and liver cancer in Asians and Asian Americans.  Founded in 1996, the center addresses the gap in the fight against hepatitis B through a four-pronged approach of collaboration, advocacy, research, and education and outreach (CARE).  The ultimate goal of the ALC is to eliminate the transmission and stigma of hepatitis B and reduce deaths from liver cancer and liver disease caused by chronic hepatitis B.

Photos courtesy of Stanford University's Asian Liver Center

More than fifty experts met in Xi’an, China, for an international academic conference on demographic change and social development last week. Several scholars from the Freeman Spogli Institute for International Studies (FSI) spoke at the conference, including Karen Eggleston, Marcus Feldman, Jean Oi and Scott Rozelle.

The conference marked the 120^th anniversary of Xi’an Jiaotong University’s founding and more than three decades of collaboration with Stanford scholars. Researchers at Xi’an Jiaotong University’s Institute for Population and Development Studies collaborate on policy-relevant research and educational activities with Stanford faculty at FSI as well as the Morrison Institute and Woods Institute.

For more information on FSI’s work in the areas of global health and medicine, please visit this page and the Asia Health Policy Program website.

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Science and common sense tell us that the teenage brain is more vulnerable to peer pressure and susceptible to nicotine addiction than at any other stage of development.

That’s why California legislators recently voted to raise the legal age to buy cigarettes and tobacco products from 18 to 21. If Gov. Jerry Brown signs the bill, California will become the second state, after Hawaii, to raise the age limit on the unhealthy products.

Yet while more than 100 cities around the country have adopted such laws — including New York, Boston and Cleveland — New Jersey Gov. Chris Christie in January vetoed such a bill, despite strong bipartisan support from his state legislators.

Health policy advocates see the Christie veto as a setback in what they believe is an otherwise accelerating movement toward “Tobacco 21” laws as a new tool for curbing young people’s potential addiction to tobacco products and e-cigarettes.

Michelle Mello, a Stanford professor of law and health research and policy, and colleagues from Harvard University and Baylor College of Medicine argue in this New England Journal of Medicine article that there is new evidence to suggest these laws are effective, have great public support and have minimal economic impact in the short term.

“The vast majority of smokers begin smoking during adolescence, a period when the brain has heightened susceptibility to nicotine addiction,” they write. “Nearly everyone who buys cigarettes for minors in the United States is under 21 years of age; raising the sale age prevents high school students from buying tobacco products for their peers.”

In 2013, only eight U.S. municipalities had adopted Tobacco 21 laws. By March 2016, at least 125 localities and the state of Hawaii had done so, and California is on the cusp of following suit. In September 2015, the first federal Tobacco 21 legislation was introduced (Tobacco to 21 Act, S. 2100) by U.S. Senator Brian Schatz (D-HI).

The authors note an analysis of the effects of one such law adopted in Needham, MA, revealed a 47 percent reduction in the smoking rate among high school students, along with a reported decline in area retail tobacco purchases. The decreases were significantly greater than those in 16 comparison communities without Tobacco 21 laws.

And a 2015 report by an Institute of Medicine (IOM) committee provided evidence from two different simulation models that increasing the minimum age to 21 would lead to a 12 percent reduction in smoking prevalence. Another simulation study predicted that there would be an even larger effect: a nearly 60 percent reduction in adolescent smoking within seven years after nationwide implementation of a Tobacco 21 law.

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Two national public opinion studies published in 2015 found that 70 to 75 percent of Americans — including a majority of current smokers — support raising the minimum purchase age to 21. The authors themselves conducted a national survey of 1,125 American adults regarding their attitudes toward various public health laws.

“We found that three in four Americans support the adoption of a federal Tobacco 21 law,” they write. “Majority support extends across all major socio-demographic groups, including 68.3 percent support among young adults 18 to 24 years of age.”

Opponents of the federal and state bills — namely Tobacco interests, convenience store owners and e-cigarette manufacturers — say that states should not be in the business of policing public choice. Store owners contend raising the age limit would hurt sales, as snacks and soft drinks are typically ancillary purchases with cigarettes.

And some veterans’ organizations and Republican legislators have said it is wrong to take away the decision on whether to smoke from young people who are nevertheless old enough to marry, vote and join the military.

But Mello and her coauthors, Stephanie R. Morain, PhD, MPH, and Jonathan P. Winickoff, MD, MPH, say the long-term benefits of raising the age limit far surpass the near-term economic concerns, which they believe are overstated.

Research indicates that in the short term, raising the tobacco-purchasing age to 21 would result in a 2-3 percent annual decrease in total tobacco sales.

“Over the longer term, the revenue loss from decreased smoking prevalence will be substantial,” they concede. “But allowing future generations to become addicted to nicotine in order to preserve tobacco revenue fails the red-face test as an argument against Tobacco 21.”

If a federal law raising the legal age of purchasing cigarettes were implemented today, the Institute of Medicine estimates that would result in 249,000 fewer premature deaths, 45,000 fewer deaths from lung cancer, and 4.2 million fewer lost-life years among Americans born between 2010 and 2019.

“Local and state efforts have succeeded in extending Tobacco 21 protections to more than 16 million Americans,” the authors write. “We believe the time has come to expand this effective, broadly supported approach to a much greater share of the population.”

In a Q&A, Stanford postdoctoral fellow Darika Saingam explains why Thailand's battle against drugs continues and what is needed to introduce good policy that works to prevent illegal drug trade and supports recovering addicts.

Despite Thailand’s decade-long crackdown on drugs, demand for illegal substances has risen. A green leaf drug known as ‘kratom’ is a symbol of this rise as young people eagerly adopt the drug for entertainment and join an older generation of laborers who chewed it to survive long hours of work in the fields—and are now heavily addicted. Curtailing substance abuse and its consequences takes good public policy and solutions must be area-specific and evidence-based, according to a Stanford postdoctoral fellow.

Darika Saingam, the 2015-16 Developing Asia Health Policy Postdoctoral Fellow, has conducted two cross-sectional surveys and more than 1,000 interviews with drug users, recovered addicts, and local public officials in an effort to better understand the evolution of substance abuse in southern Thailand.

At Stanford, she is preparing two papers that offer policy options suitable for Thailand and other developing countries in Southeast Asia. Saingam spoke with the Shorenstein Asia-Pacific Research Center (APARC) where she will give a public talk on May 17. The interview text below was edited for brevity.

For decades, Thailand has been an epicenter of drugs. Can you describe the extent of the problem today?

According to a 2014 report, 1.2 million people were involved in illegal drug activities across Thailand. The total number of drug cases saw a 41 percent increase from 2013 to 2014. New groups of drug traffickers are mobilizing while existing groups are still active. Drug users who are young become drug dealers as they get older. The number of drug users below 15 years of age has increased dramatically.

According to your research, what drives Thais toward illegal drug use and the trafficking business?

Adults in Thailand use drugs to relieve stress and counteract the effects of work. Adolescents use them for entertainment. Historically, farmers and laborers from rural areas of Thailand would use opium for pain relief. More recently, a consumable tablet known as yaba has become popular along with crystal methamphetamine and marijuana. Young people are increasingly using yaba and kratom.

Thailand is still a developing country, but it is industrializing quickly. Social and cultural norms have been shifting and people want an improved quality of life. A lot of young people are unemployed and lack social support and are therefore more likely to turn to drug trafficking for economic opportunity. The economic recession and political strife in countries bordering Thailand have exacerbated the situation.

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Photos (left to right): A man holds up a kratom leaf. / Saingam examines kratom leaves as part of her research to understand illegal cultivation practices.

What is kratom and why is it popular?

For nearly a century, the native people of Thailand have chewed kratom. It is a leaf that grows on trees resembling a coffee plant. Historically, kratom was used to reduce strain following physical labor, to be able to work harder and longer, and to better tolerate heat and sunlight. Kratom is also embedded in Thai culture and given as a spiritual offering in religious ceremonies. My field research in the southern province of Nakhon Si Thammarat has shown that these motivations are still true today.

Within the past seven years, kratom use has skyrocketed and people are using it in increasingly harmful ways. Chewing kratom is not immediately harmful to health, but combining it with other substances is. This is the recent trend. Users have created new ways to consume it such as in a drink known as a ‘4x100.’ It contains boiled kratom leaves, cough syrup and soft drinks. Additional methamphetamines and benzodiazepines are sometimes added to that mixture.

What strategies must be employed to control substance abuse?

The first step is to realize that the patterns of substance abuse are specific to each location therefore solving the problem must also be. Drug usage is also dynamic. Placing hard control measures on one substance often provokes the emergence of another in its place therefore a holistic approach is important.

Thailand should employ multiple strategies toward effective prevention and control of substance abuse. These strategies include examining the problem and creating policies from an economic perspective (supply and demand), an institutional perspective (national and international drug control cooperation), and a social perspective (structural supports for recovered addicts and mobilization of public participation).

What is the Thai government doing to address the drug problem, and what could they be doing better?

Politicians in Thailand must do a better job at representing the people. Government health workers are often gathering information, assessing needs, and reporting findings to politicians, but these needs are not being accurately addressed. An example of this is politicians ordering to cut down kratom trees – a public display that does not get at the root cause of the problem. The reality is that drug users will quickly find substitutes. According to my study, of the regular users that stopped using kratom, more than 50 percent turned to alcohol instead and did so on a daily basis. This is merely a shift from one substance to another.

On the upside, a crop substitution program created under King Bhumibol Adulyadej offers a successful working model. The program works to replace opium poppy farming with cash crop production. It began in 1969 and is cited for helping an estimated 100,000 people convert their drug crop production to sustainable agricultural activities. Crops cultivated can be sold for profit in nearby towns. The program has also introduced a wide variety of crops and discouraged the slash-and-burn technique of clearing land. It is win-win because it stymies drug trade and provides economic opportunity while also being ecologically sound. This type of program should continue to be scaled up.

Can this model be co-opted elsewhere? What lessons from other countries could inform Thailand’s approach?

Yes, the model could plausibly be implemented in other areas in Thailand and in other Southeast Asian nations.

I think a judicial mechanism such as the kind seen in France could benefit the rural areas in Thailand. The French government has established centers across the country that act as branches of the court that try delinquency cases of minor to moderate severity, and also recommend support services for drug users. Members of the magistrate and civil society actors manage center operations thus placing some responsibility back onto the local community.

I believe an opportunity also exists for Thailand to legalize kratom. Legalization would show a respect for the cultural tradition of chewing kratom leaves and allow the government to suggest safer ways of using it. Bolivia has created a successful model of this through its legalization of coca leaves. Coca in its distilled form is cocaine, but left as a leaf, it is not a narcotic. Indigenous peoples are allowed to chew coca leaves. The government policy is being credited for a decrease in cocaine production as well.

Nearly 100 health economists from across the United States signed a pledge urging U.S. presidential candidates to make chronic disease a policy priority. Karen Eggleston, a scholar of comparative healthcare systems and director of Stanford’s Asia Health Policy Program, is one of the signatories. 

The pledge calls upon the candidates to reset the national healthcare agenda to better address chronic disease, which causes seven out of 10 deaths in America and affects the economy through lost productivity and disability.

Read the pledge below.