Impact: Global Health
FSI scholars are devoted to understanding and solving global problems of poor health and nutrition. Often, the dilemma isn’t that treatments, medical services and technology don’t exist. It’s that they aren’t readily available or – for a variety of reasons – aren’t being used. Paul Wise, Scott Rozelle and Grant Miller are FSI senior fellows finding ways with their colleagues to fill those gaps by examining global health in the context of governance, economics, technology and education.
Paul Wise first saw poverty when he travelled to Guatemala after his freshman year of college. The aspiring pediatrician wanted to spend his summer working at a hospital in a developing country and was shocked by what he found: A seemingly endless stream of malnourished children suffering from easily preventable problems like diarrhea, measles and pneumonia. Too often, they died – not because treatments weren’t available, but because they were unable to access them in a country ravaged by violence and political instability.
Scott Rozelle spent two decades studying China’s economic boom often wondering why millions of children were performing so poorly in school. In a country that generated so much wealth between 1980 and 2000, why were so many kids falling behind? When he committed to answering the question, his findings were staggering. Around one-third of China’s children were anemic and nearly 50 percent had bellies full of intestinal worms. With poor nutrition and no access to simple medical care, it was nearly impossible for those children to concentrate and learn the skills that would be needed for them to be part of China’s rising economic tide.
Grant Miller coughed and wheezed throughout his visits to homes in Bangladesh, where women made meals on cookstoves fueled by burning animal dung and crop scraps. He was trying to answer a question that’s motivated his academic career: Why don’t people make decisions that lead to healthier lives? In Bangladesh, modern cookstoves are inexpensive and easily available. But people continue to cook their food in a way that increased their risk of pneumonia and other deadly infections. What Miller found in his research was as frustrating as it was simple. Although most women knew the pollution could make them sick, they didn’t think respiratory illness was their biggest problem. Cleaner stoves simply weren’t a priority, and the new models didn’t have features they wanted and couldn’t serve up the flavor the women were after.
The three researchers – all senior fellows at the Freeman Spogli Institute for International Studies – are only a few of FSI’s researchers devoted to understanding and solving global problems of poor health and nutrition.
Often, the dilemma isn’t that treatments, medical services and technology don’t exist. It’s that they aren’t readily available or – for a variety of reasons – aren’t being used. FSI experts are finding ways to fill those gaps by examining global health in the context of governance, economics, technology and education.
Their work is collaborative and interdisciplinary, taking advantage of FSI’s ability to attract and support scholars from diverse academic backgrounds and intellectual perspectives. Wise is a pediatrician. Rozelle is a development and agriculture economist. Miller is a health economist.
They routinely work with political scientists, legal experts, education specialists and sociologists – along with other economists and medical doctors – to create an intellectual backbone that often informs and influences policies and improves lives.
“FSI is a wonderful place for me to be working because it has enormous capacity, enormous expertise in dealing with governance and political instability,” Wise says. “FSI was created to facilitate cross-disciplinary interaction. The welcome I've received as a pediatrician into FSI has been outstanding. The infrastructure of FSI and the faculty at FSI have made it extremely easy to create the kinds of collaborations that are going to be necessary to address what is in fact a fairly ambitious agenda. Very few institutions have both the capacity and the infrastructure for collaboration that FSI provides.”
Malnutrition is one of the world’s leading killers of children younger than 5, accounting for about 5 million deaths a year. In Guatemala, 44 percent of children in that age group are malnourished, giving the country a higher rate than any other in Latin America.
That fact motivates Paul Wise’s Children in Crisis program, an initiative based in FSI’s Center for Health Policy that links pediatric healthcare with political reform. It’s the first academic initiative addressing the needs of children in areas of unstable governance and civil conflict – places where many nongovernmental organizations and foundations are reluctant to venture and kids are particularly vulnerable.
“The death of any child is always a tragedy,” Wise says. “But the death of any child from preventable causes is always unjust.”
Since his first trip to Guatemala in 1970, Wise has returned nearly every year for weeks or months at a time to offer medical assistance, conduct research and figure out ways to provide basic health care to some of the country’s poorest people. Many live in the rural villages near San Lucas Tolimán, hours from Guatemala City and the place where Wise has concentrated most of his work.
Scott Rozelle’s interest in China began more than 40 years ago in the Los Angeles suburb of Bellflower, when seventh-graders at Washington Junior High School were offered Chinese language classes. His father – who spent part of his military career in Shanghai – encouraged the 12-year-old to sign up.
Rozelle fell in love with the language of the faraway country and stories of its Warlord Era told by a teacher who was born and raised in Peking. As he continued to learn the intricacies of Chinese tones and characters through high school and college, Rozelle became fascinated with the country itself. And by the time he decided on a career as a developmental economist, it was obvious there was no better place than China to base his work.
"China is the ultimate laboratory for an economist to study development," Rozelle says. "It's developing so fast that you see it before your eyes. There are also huge differences between regions within the country. You can measure things that you can't measure anywhere else."
Rozelle did his first round of fieldwork in China in 1987 as a 31-year-old doctoral candidate at Cornell University studying the economics of hybrid rice. He visited 700 households spread over seven villages in two rural provinces to ask farmers why they were growing certain strains of rice. Were they cheaper than other varieties? Were they hardier? Did they grow faster?
After hundreds of interviews, he finally realized the answer: The village leaders told every farmer what type of rice to grow. Nobody had a choice.
"I thought I was out there studying household economics," Rozelle says. "But that had nothing to do with it. My blood turned cold when I figured it out."
At that point, he began to pay more attention to how the fates of Chinese citizens were so closely tied to the whims and policies of the government. These people were living and working in an environment different from anywhere else in the world, he realized.
As China's fortunes have grown and the country sits in second-place among the world's economies, its citizens have largely prospered. The number of people living in poverty has fallen from about 350 million to less than 50 million in the past three decades.
But those 50 million are the ones Rozelle is so interested in. How do you lift them from destitution and allow them to share in China's rising prosperity?
The question and the answers it forces are at the heart of the Rural Education Action Program, a group co-directed by Rozelle and spearheaded by FSI and the institute’s Center on Food Security and the Environment.
Rozelle realized that China had the infrastructure in place to educate its children in top-notch schools. So many students ranked higher than their peers around the world, but he became increasingly concerned about the tens of millions of kids who dramatically underperformed.
“There was almost no one who was systematically looking at this,” Rozelle said. “China had the good teachers and the new buildings. But does that really increase human capital?”
Rozelle soon realized there was a link between student underperformance and poor nutrition and health.
“We found that up to 40 percent of children were undernourished,” Rozelle says. “They were anemic. They were micronutrient deficient. We found 40 to 50 percent of kids had bellies with intestinal worms. Many of them had such a heavy worm burden that they were constantly sick and couldn’t even attend school. We found nearly one-third of students had vision problems and their grades were suffering because they could not see the blackboard.”
By collaborating with Chinese government agencies, nongovernmental organizations, private corporations and individual donors, REAP chips away at poverty by introducing and assessing programs meant to improve the lives and opportunities of preschool and school-age children in some of China's poorest, most far-flung areas. Much of his work draws in fellow economists and academics from different backgrounds – political scientists, medical doctors, nutritionists and education specialists.
“Every one of our projects is interdisciplinary,” Rozelle says. “I just say REAP is a platform to allow my colleagues at Stanford who are experts in medicine and health and nutrition to come and help us solve problems. My Stanford colleagues perform magic. They’re at the tops of their field, and we take their expertise and use it to help with our field work and analysis.
Since its founding in 2007, REAP has submitted 21 policy briefs to government officials.
All of them have been accepted by China’s State Council. Fifteen have been incorporated into policy action, which means that REAP’s work is being used to create new state-sponsored programs and policy changes for improving children's health and nutrition, making education more affordable, reducing school drop-out rates and boosting overall student performance.
REAP has conducted dozens of large-scale research projects, with 15 currently underway.
Rozelle and his fellow researchers are not just evaluating how vitamins and nutritional supplements given to babies will increase their performance when they start going to school. They are organizing the vitamin distribution system, creating the training material and figuring out how, if successful, such programs can be taken over by the government and implemented on a large scale.
They’re experimenting with ways of delivering quality vision care and gauging how much test scores improve when children receive free or affordable eyeglasses.
They're trying to figure out the easiest and most cost-effective way of eradicating intestinal worms. They’ve tested the usefulness of a government-run program tackling high childhood anemia rates and evaluated how to best incentivize teachers and school officials to serve student nutritious lunches.
And they're determining how to put the most cutting-edge computer technology in schools where you can't always count on the lights staying on and where teachers – much less students – may have never seen a laptop.
It's work that Rozelle says is essential, given China's growing clout and ability to influence international markets and policies. As the country grows, so must all of its citizens, he says.
“China is becoming a victim of its own success,” Rozelle says. “As wages are going up, the low-skill jobs are moving out. So the question is: are the kids getting the nutrition, the healthcare and education they need to be ready for the China that’s coming – the China that won’t have any more low-skill wage jobs and requires them to know math and science and technology? That’s what I’m focused on.”
Belching smokestacks and traffic jams in crowded cities are the images usually used to illustrate the woes of pollution. But some of the biggest contributors to poor air quality in the developing world are the most basic household appliances – cook stoves. About 75 percent of South Asians and nearly half the world’s population use open-fire stoves inside their homes. And the pollution they produce is a leading cause of the pneumonia and other acute respiratory infections killing about 2 million children a year in low-income countries.
When Grant Miller set out to understand why cooking still kills despite so many government and humanitarian programs that make it easy for people to swap their traditional stoves for safer models, he kept seeing a mismatch between what people wanted and what they were given – or told to use.
In his study of the situation, Miller found that many clean and modern cookstoves simply don’t have features people want.
“If you don’t give people what they want, they are not likely to embrace and use something that has the potential to improve their health, no matter how logical it may seem,” Miller says. “You can’t just engineer a solution. You need to understand what will motivate people to change their behavior.”
His work has brought him to China, where he’s partnered with Scott Rozelle to study incentives that would encourage school principals to serve children more nutritious meals, thereby reducing anemia rates.
Miller is now focusing that idea on India, where he is helping to identify some of the country’s most pressing health policy challenges and develop solutions to address them.
His work lays the foundation for the Stanford India Health Policy Initiative, a newly launched program that puts Indian policymakers, health care providers, academics, and entrepreneurs in the same room to discuss where to best focus their efforts. The project is decidedly open-ended, and Miller wants Indians to lead the way.
“We want people in India to take ownership of this,” he says. “We want them to really steer it toward what they perceive to be the most important priorities.”
And his role as a scholar is crucial.
“There are two major roles that academics can play in this initiative,” he says. “First, we can bring tools and paradigms to the table that are useful in providing common structure to the experiences of stakeholders, helping to draw out new insights. Second, we bring the ability to conduct new research that is responsive to the group’s priorities. And we ultimately hope that those results will help them plan next steps in addressing health policy challenges.”
Paul Wise speaks with local health care promoters while patients wait to see them outside a makeshift clinic in rural Guatemala.Credit: Adam Gorlick
A family of eight is visited by health promoters working with Wise. At 27 days old, the baby has only drunk water with cinnamon because the family is unable to afford milk or formula. Without assistance, the child will not survive.Credit: Beatriz Magaloni
A mother holds her malnourished child waiting to be examined by Wise. An estimated 95% of children in rural Guatemala fall under the WHO healthy weight-for-age guidelines. Her family was forced to relocate to this new communityCredit: Beatriz Magaloni
A health promoter working with Wise examines a child's impacted ear canal.Credit: Elena Cryst
Jake Rosenberg , a Stanford medical school student, says what he learned on a trip to Guatemala made a lasting impression.Credit: Adam Gorlick
Grant Miller (left), Scott Rozelle (middle), and REAP affiliate Shi Yaojiang review data in a village doctor’s office in Guizhou Province.
Miller meets with children in Shaanxi Province while interviewing families about baby nutrition.
A fourth-grader in rural Gao Lou eats a hardboiled egg. REAP researchers study government programs aimed at improving children's health.Credit: Adam Gorlick
Scott Rozelle speaks with students in Shaanxi Province about the importance of good vision.
Testing children’s vision and working to improve eye care in Shaanxi Province are key components of Rozelle’s work in China.
Grant Miller during a research trip to rural Bihar.Credit: Kim Singer Babiarz
Children in Uttar Pradesh, where Miller is studying maternal health.
A Bangladeshi woman stokes a flame under a traditional stove. Indoor air pollution from stoves like this have contributed to millions of deaths in the developing world, and Miller is addressing the reasons why more people don’t use cleaner stoves.Credit: Lynn Hildemann