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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.


FSI scholars are addressing health care challenges around the world

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.”

Children in Crisis

Paul Wise examines a child in a makeshift clinic in rural Guatemala

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.

Paul Wise describes his first trip to Guatemala. “The human emotion of being put in that situation was just overwhelming”
Many years ago when I was a freshman at college, I was very concerned about the world and very naпve about the world and wanted to go to the first summer, my college life, to a part of the world where poverty, where governance was a reality. And I wanted to go to Africa but didn't have enough money for a plane ticket so somebody looked at the map, said well, you know, Guatemala's supposed to be nice, it's a lot closer. And four days later, I was on a plane to Guatemala, knowing no Spanish, nobody told me there was a civil war going on. I even remember being on the plane with a little Spanish dictionary, looking up how to say no in Spanish' cause I had taken French in high school, didn't know if there was an N at the end or not. But very quickly after getting to Guatemala, I wound up working in a children's hospital outside out Guatemala City. And my role was totally supportive [inaudible] orderly kind of role on the children's ward. And virtually all the kids that were there were there because they were malnourished. There were two or three kids to a bed, totally overcrowded. The staff were doing their best but it was quite a shock for a young college student from the states to be placed in that situation. And my first reaction in dealing with these kids was of course the overall tragedy, just the human emotion of being putting in that situation, it was just overwhelming. And over the first few days when I got there, my reaction was anger at the parents; how could they let their children starve. How could they let them become so malnourished and so sick? And my anger and just complete lack of understanding of how the parents could allow this to happen became deeper and deeper over the course of the first week, until Sunday, the first Sunday because that was visiting day. And it was the first time the parents were allowed to see their kids on this ward. And they came out to the ward and I immediately saw that these parents, barefoot, clearly farmworkers, peasants, extremely poor, even though they were in their Sunday best, you could just how terribly poor they were and how much they loved their kids. They came in, hugging and kissing their kids, then my anger at the parents turned to shame, anger at myself for being so naпve and so stupid. And from that day on, it's a lesson I've never forgotten that has both tempered my arrogance as a physician, faculty member but just as a human being that there are layers of understanding that I need to address, that I need to confront when trying to understand or address fundamental issues like severe malnutrition, trying to understand the relationships between poverty and child health and fundamentally trying to fathom and address injustice, inherent of having parents watch their kids starve because of their lack of capacity to do any better. And that lesson has shaped my whole career, it shapes how I teach students, it shapes how I deal with students in the field when they come with me to Guatemala or the Middle East or Zimbabwe and that fundamental shame and sense of injustice is something I don't talk about very often because it's very hard to convey and in some ways, it's embarrassing about how stupid I was but it's stayed with me ever since. A lot of years have passed since that time.

He has worked with local communities to build a health care system that reaches those with the greatest need. Working with local community leaders, his research and outreach have helped create and nurture a network of community health promoters, a group of about 60 volunteers in 25 small villages near the town of San Lucas Tolimán. Many of the promoters have no more than a third-grade education, but undergo a three-year training program on prevention, basic treatments, and community organization.

They also help connect villagers with medical services in San Lucas and Guatemala City, and ... the program has dramatically reduced young child mortality and has improved  the lives of many families.

“The community health worker system has been developed to operate in political settings that are intensely complex, where corruption has been significant and where resources coming from traditional government agencies may be inadequate,” Wise says. “We’re not only interested in the technical aspects of children’s health. We’re interested in the political aspect.”

With his local colleagues, Wise supplements the work of the health promoters by setting up makeshift pediatric clinics in schools and community buildings, discussing prevention and dispensing medicine to curb diarrhea, kill scabies and treat pneumonia.

These clinics not only provide care to families with urgent health problems but also strengthen the community health promoter nutrition programs that identify children at high risk for malnutrition. They provide food, vitamins and family support.

He also works with academics and bureaucrats to pinpoint ways that government agencies could take a stronger approach to improving health care in a country scarred by civil war, corruption and political oppression.

Wise’s work has expanded from Guatemala to Africa, where he’s exploring how sanctions in countries like Zimbabwe undermine the provision of health care services. And he has a new focus on the Middle East, where he’s been meeting with public officials and scholars from Israel and the West Bank to see how the Palestinian Authority’s ability to deliver better care to children may affect its legitimacy and political standing in the region.

“We don’t expect that providing high-quality pediatric services is going to solve the Palestinian-Israeli problem, but we do need to understand better how it could contribute to an expressly political objective,” Wise says. “Health care is a political situation even though people are not thinking of it explicitly in that way. This is fertile ground for collaboration between technical health people like myself and political people working at FSI to solve these broader political problems.

Much of Wise’s work involves Stanford students. Medical students accompany him on his trips to Guatemala, seeing the toll poverty and poor governance takes on a community’s health. Often, they’re overwhelmed by the crushing need that so many people have for basic care. They question what good a single doctor could do in the face of a seemingly endless stream of problems that are generated by economics and politics.

“Going to Guatemala was a life-changing experience for me,” says Jake Rosenberg, now in his fifth year at Stanford School of Medicine. He travelled to San Lucas with Wise 

for a few weeks in the summer of 2010. “The things I saw – in terms of the disparity of health – made a lasting impact on me. And seeing how Paul interacted with the community taught me how to be the kind of doctor I want to be. He has respect for the people he treats. He makes the work very little about himself, and puts all of his focus on empowering people in these communities.

And Wise is committed to instilling in his students an understanding that doctors play a crucial role in informing policy debates and influencing government officials.

“My hope is that the next generation of healthcare providers and politicians will have basically in their DNA an understanding of these issues,” Wise says. “I hope they will come to these fields with a sense of integrated understanding and purpose – that they will embrace far more coordinated cross-disciplinary strategies and activities in ways that my generation continues to find it difficult to do.”




Nutrition and Economics

A fourth-grader in rural Gao Lou eats a hardboiled egg

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.

Scott Rozelle helps a student choose eyeglass in Shaanxi Province

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.”

Making healthier choices in the developing world

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.

Grant Miller during a research trip to rural Bihar, where he is working on improving health care in India. Credit: Kim Singer Babiarz

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.”

Grant Miller explains the challenges of improving people’s health in developing countries. “We have to understand what drives them and motivates them to make choices.”
You know, it's pretty audacious to think that people are going to do what global health experts want them to do or think that they should do. And it's wrong headed in a number of ways but it's also not likely to be effective. So think about the case of household health technologies so we have the technological capacity to deal with a lot of developing country diseases with simple cheap things like insecticide treated bed mats, cleaner burning cook stoves point of use drinking water disinfectants but experiences are really all over the map with these. You can spend a lot of effort trying to distribute them and then you find that people take insecticide treated bed nets and go fishing with them rather than sleeping under. You can find that with cleaner burning cook stoves, people tear down chimneys built in their houses to use the scrap metal for other needs. You can find that people aren't interested in using point-of-use drinking water disinfectants because they don't like their water to taste like chlorine. These may sound like unjustifiable reasons not to use these technologies to you or me but they make a lot of sense to the people that are making these choices and it's fairly audacious to think that we know better than they do what they should be doing in the first place. If we really want to improve people's health, we have to understand what drives them and motivates them to make the choices that they do and work with that in the programs and policies that are designed.

Miller isn’t only interested in figuring out the hurdles to better health. He examines the success stories, too, and wants to understand the reasons behind large-scale improvements in population health. And what he finds is often surprising

As an economist interested in how economic changes impact health, for example, Miller took a look at how Colombian coffee growers responded to fluctuations in world coffee prices.

It would seem intuitive that as farmers were paid more for their crop, they would have more money to spend on doctors, medicine, and other things that would improve their family’s health and decrease the mortality rates of infants and children.

But Miller found that in years in which coffee harvests were more valuable, the more growers worked on their household plots. And the more they worked, the less time they would spend doing things at home, including things good for their children’s health.

When coffee prices fell, farmers had weaker incentives to work on their coffee plots and spent more time taking care of their kids – and mortality rates dropped.

Miller explains that this finding is not as counterintuitive as it might seem – the things that matter most for child survival in many developing countries are not expensive, but they require a lot of time – like fetching clean water from far-away sources and taking children long distances to see a doctor.

And that study underscores the importance of an interdisciplinary approach to understanding global health problems.

“The traditional public health view of the world is that if people are making unhealthy choices for themselves, then they shouldn’t make those choices,” Miller says. “But the traditional economic view of the world is that people are the best judges of what will make them happy, and they should be free to make the choices that they want. So it’s our role to understand better the motivations behind people’s decision, and think of alternative ways to tip things in favor of better public health.”










  • 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 community
    Credit: 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