Poor air quality is thought to be an important mortality risk factor globally1,2,3, but there is little direct evidence from the developing world on how mortality risk varies with changing exposure to ambient particulate matter. Current global estimates apply exposure–response relationships that have been derived mostly from wealthy, mid-latitude countries to spatial population data4, and these estimates remain unvalidated across large portions of the globe. Here we combine household survey-based information on the location and timing of nearly 1 million births across sub-Saharan Africa with satellite-based estimates5 of exposure to ambient respirable particulate matter with an aerodynamic diameter less than 2.5 μm (PM2.5) to estimate the impact of air quality on mortality rates among infants in Africa. We find that a 10 μg m−3 increase in PM2.5 concentration is associated with a 9% (95% confidence interval, 4–14%) rise in infant mortality across the dataset. This effect has not declined over the last 15 years and does not diminish with higher levels of household wealth. Our estimates suggest that PM2.5 concentrations above minimum exposure levels were responsible for 22% (95% confidence interval, 9–35%) of infant deaths in our 30 study countries and led to 449,000 (95% confidence interval, 194,000–709,000) additional deaths of infants in 2015, an estimate that is more than three times higher than existing estimates that attribute death of infants to poor air quality for these countries2,6. Upward revision of disease-burden estimates in the studied countries in Africa alone would result in a doubling of current estimates of global deaths of infants that are associated with air pollution, and modest reductions in African PM2.5 exposures are predicted to have health benefits to infants that are larger than most known health interventions.
Most participants in clinical trials believe the benefits of broadly sharing person-level data outweigh the risks, according to new research by Stanford Medicine's Michelle Mello and Steven N. Goodman.
And despite low levels of trust in pharmaceutical companies, most of those who take part in clinical trials are willing to share their data with the drug firms.
The Stanford researchers surveyed 771 current and recent participants from a diverse sample of clinical trials at three academic medical centers in the United States. They asked about the practice of making personal data collected in medical research studies widely available, after information that could identify individual participants is removed. Nearly 80 percent of those surveyed responded to the questions — and fewer than 8 percent of the respondents felt that the potential negative consequences of data sharing outweighed the benefits.
Some 93 percent of those surveyed said they were very or somewhat likely to allow their data be shared with university scientists, and 82 percent were either very or somewhat likely to share with scientists in for-profit companies. They found that the willingness to share was high regardless of the purpose for which their data would be used, with the exception of litigation.
Although some researchers and trial funders have worried that participants might object to data sharing as an invasion of privacy, the respondents’ greatest concern was that “data sharing might make others less likely to enroll in clinical trials,” Stanford Health Policy's Michelle Mello and her co-authors write in The New England Journal of Medicine. “Less concern was expressed about discrimination (22 percent) and exploitation of data for profit (20 percent.)”
Mello is a professor of law at Stanford Law School and a professor of health research and policy at Stanford Medicine. Her co-authors are Van Lieou and Steven N. Goodman, a professor of medicine and of health research and policy at Stanford Medicine.
The authors acknowledge there is no turning back from clinical data sharing.
“We are rapidly moving toward a world in which broad sharing of participant-level clinical trial data is the norm,” they wrote.
The European Medicines Agency has implemented a policy to expand public access to data concerning products it approves, and the Food and Drug Administration is considering expanding access to data pooled within a product class. Major research sponsors and journal editors have begun promoting data sharing, and the National Institutes of Health now requires all of its grantees to share data.
Pharmaceutical industry associations have committed to making data more accessible, and several data platforms are now available, such as the Yale Open Data Access Project.
Mello said she was somewhat surprised by the survey results, “given the amount of consternation one hears at conferences about data sharing. Interestingly, nearly half our sample had experienced a breach of their personal data privacy in another context, yet they were still willing to share their clinical trial data.”
Then again, she said, people who take part in clinical trials may be special.
“I suspect that clinical trial participants may be different from the public at large. They are already incurring risks to benefit science by dint of their trial participation.”
Most of those participants, along with clinical researchers, believe the benefits of sharing data include accelerating scientific discovery and improving accurate reporting of trial results.
Yet some investigators and industry sponsors of clinical trials are leery of the swift move toward broad data sharing, the authors note, because of “potential harm to research participants,” the authors wrote. “Investigators express worries that participants’ privacy cannot be adequately protected, particularly in light of the fact that experts have demonstrated that it is possible to reidentify participant-level data.”
Furthermore, they said, some pharmaceutical companies have warned that data sharing could chill willingness to participate in trials, thereby delaying the availability of new therapies. In fact, 31 percent of those surveyed were somewhat or very concerned about having their personal information stolen. Nevertheless, most felt the benefits of data sharing were more important.
“Reaching a world in which the sharing of clinical trial data is routine requires surmounting several challenges — financial, technical, and operational,” the authors concluded. “But in this survey, participants’ objections to data sharing did not appear to be a sizeable barrier.”
A favorite icon for cigarette manufacturers across China since the mid-twentieth century has been the panda, with factories from Shanghai to Sichuan using cuddly cliché to market tobacco products. The proliferation of panda-branded cigarettes coincides with profound, yet poorly appreciated, shifts in the worldwide tobacco trade. Over the last fifty years, transnational tobacco companies and their allies have fueled a tripling of the world's annual consumption of cigarettes. At the forefront is the China National Tobacco Corporation, now producing forty percent of cigarettes sold globally. What's enabled the manufacturing of cigarettes in China to flourish since the time of Mao and to prosper even amidst public health condemnation of smoking?
In Poisonous Pandas, an interdisciplinary group of scholars comes together to tell that story. They offer novel portraits of people within the Chinese polity—government leaders, scientists, tax officials, artists, museum curators, and soldiers—who have experimentally revamped the country's pre-Communist cigarette supply chain and fitfully expanded its political, economic, and cultural influence. These portraits cut against the grain of what contemporary tobacco-control experts typically study, opening a vital new window on tobacco—the single largest cause of preventable death worldwide today.
With Introductions by Douglas K. Owens and Stanford Dean of Medicine Lloyd B. Minor
Remarks by Victor Fuchs
"Riding Two Horses Without Splitting Your Pants"
Luncheon at 11:30, before talk
Victor Fuchs' new book "Health Economics and Policy" offers readers a selection of his public lectures, articles, papers, and op-eds that span 50 years. His forte is applying economic analyses to social problems of national concern, with special emphasis on health and medical care. He is the author of nine books and editor of six others, including the classic Who Shall Live?
Fuchs' contributions have been recognized by his election as president of the American Economic Association, election to the American Philosophical Society, American Academy of Arts and Sciences and National Academy of Medicine.
Fuchs is the Henry J. Kaiser, Jr., Professor of Economics and of Health Research and Policy (emeritus) at Stanford University as well as a senior fellow (emeritus) at the Stanford Institute for Economic Policy Research and Freeman Spogli Institute for International Studies.
"The collection represents an extraordinary intellectual achievement." — Sir Angus Deaton, a winner of the Nobel Prize in Economics
"Victor Fuchs is one of the world's most influential figures in health, medicine and policy." —Victor J. Dzau, MD, president of the National Academy of Medicine
Prostate cancer is the second leading cause of death among American men, after heart disease.
Yet ever since the prostate-specific antigen (PSA) screening was approved by the FDA in 1986, there has been a debate in the health-care community about the efficacy of the test. The American Urological Association had until 2013 recommended routine testing but did an about-face not long after the U.S. Preventive Services Task Force recommended against regular screening.
The Task Force — and independent, volunteer panel of national experts in prevention and evidence-based medicine — concluded in 2012 that there was “moderate certainty” the benefits of the screening did not outweigh the potential harms. The biggest risks included a false positive that leads to a biopsy that could cause infection, pain and bleeding, as well as surgery and radiation that can provoke impotence or problems with the bladder or bowels.
But the Task Force is now recommending that men aged 55 to 69 talk to their physicians about whether to get the test. New evidence indicates screening in this age group can reduce the risk of metastatic cancer and the chance of dying from prostate cancer.
“Prostate cancer is one of the most common cancers to affect men and the decision whether to be screened is complex,” said Task Force vice chair Alex H. Krist, MD. “Men should discuss the benefits and harms of screening with their doctor, so they can make the best choice for themselves based on their values and individual circumstances.”
Stanford Health Policy’s Douglas K. Owens, director of the Center for Health Policy and the Center for Primary Care Outcomes and Research, said there is also new information on active surveillance — a way of monitoring prostate cancer that may allow some men with low-risk prostate cancers to delay or, in some cases, avoid treatment with radiation or surgery.
Active surveillance, he said, has become a more common choice for men with lower-risk prostate cancer over the past several years and may reduce the chance of overtreatment.
“For men who are more interested in the small potential benefit and willing to accept the potential harms, screening may be the right choice for them,” said Owens, MD, a professor at Stanford Medicine and another vice chair of the Task Force. “Men who place more value on avoiding the potential harms may choose not to be screened.”
The Task Force still recommends men 70 and older do not get the test as a matter of routine.
The guidelines issued by the 16-member Task Force impact virtually every primary care patient and practice in the United States. They make letter grade recommendations and have now bumped the “D” against screening up to a “C,” which recommends screening decisions for prostate cancer be based on professional judgment and patient preference.
The new recommendation now aligns with those of the American Cancer Society and the American Urological Association. Peter R. Carroll, MD, writes in an accompanying editorial in JAMA that the final recommendation by the Task Force “has restarted a national discussion on prostate cancer early detection.”
“The Task Force deserves credit for this more balanced, fairer approach,” said Carroll, a professor and chair of the Department of Urology at the University of California, San Francisco, who opposed the “D” grade the Task Force had given PSA screens in 2012. “The message now is not ‘no screening,’ but ‘smarter screening,’ preserving benefits and reducing harms.”
The recommendation also addresses men who are at increased risk, particularly African-American men and patients with a family history of prostate cancer.
“For African-American men or those with a family history of prostate cancer, informing these men of their higher risk for developing prostate cancer should be a part of the conversation,” wrote two researchers from the Cleveland Clinic in another accompanying JAMA editorial.
“The U.S. health care delivery system needs a structure that not only allows, but encourages, a space for physicians and patients to engage in meaningful conversations where shared decision making has the opportunity to take place,” wrote Anita D. Misra-Herbert, MD, and Michael W. Kattan, PhD. “What the updated USPSTF recommendations for prostate cancer screening are asking of physicians is to take time to pause, explain what is currently known, understand patient preferences, and make the screening decision together.”
Recent mortality trends in the United States are disturbing. Life expectancy for the total population decreased in 2015 for the first time since 1993, with larger decreases for some groups than others. Inequality in life expectancy has stopped falling and along some dimensions — such as between low-income and high-income Americans — it is increasing.
Analyses of mortality data from 1950 to 2015 help put recent trends in perspective, show that life expectancy and inequality in life expectancy are usually negatively correlated, and suggest changes in health policy that could reduce inequality in life expectancy and help people live longer, write Stanford Health Policy experts Victor R. Fuchs and Karen Eggleston in their new policy brief for the Stanford Institute for Economic Policy Research. Both are also senior fellows at the Freeman Spogli Institute for International Studies.
Current efforts to improve survival, and much of the research funded by the National Institutes of Health, are heavily weighted toward fighting heart disease and cancer, the leading causes of mortality and afflictions suffered most often by older Americans. By devoting more resources to preventing the killers of our younger population — such as suicide, gunshots, and accidents, especially motor vehicle traffic accidents — policymakers can take a significant step toward increasing U.S. life expectancy to a rate equal to that of most other developed countries.
Hans Asperger, the pioneer of autism and Asperger syndrome in Nazi Vienna, has been celebrated for his compassionate defense of children with disabilities. But in this groundbreaking book, prize-winning historian Edith Sheffer exposes that Asperger was not only involved in the racial policies of Hitler’s Third Reich, he was complicit in the murder of children.
As the Nazi regime slaughtered millions across Europe during WWII, it sorted people according to race, religion, behavior, and physical condition for either treatment or elimination. Nazi psychiatrists targeted children with different kinds of minds―especially those thought to lack social skills―claiming the Reich had no place for them. Asperger and his colleagues endeavored to mold certain “autistic” children into productive citizens, while transferring others they deemed untreatable to Spiegelgrund, one of the Reich’s deadliest child-killing centers.
In the first comprehensive history of the links between autism and Nazism, Sheffer uncovers how a diagnosis common today emerged from the atrocities of the Third Reich. With vivid storytelling and wide-ranging research, Asperger’s Children will move readers to rethink how societies assess, label, and treat those diagnosed with disabilities.
When a close relative dies, the stress can be overwhelming. But for many adults and children, mourning and grief often give way to healing.
A pair of Stanford scholars now focuses on the impact that loss has on often-overlooked family members: babies. A new publication by Petra Persson and Maya Rossin-Slater indicates that losing a loved one during pregnancy may actually impact the mental health of the child as he or she grows into adulthood.
“We find that prenatal exposure to the death of a maternal relative increases take-up of ADHD medications during childhood and anti-anxiety and depression medications in adulthood,” the researchers wrote in the April edition of the American Economic Review.
Petra Persson
Both are faculty fellows at the Stanford Institute for Economic Policy and Research (SIEPR); Rossin-Slater is an assistant professor of health research and policy with Stanford Medicine and Persson is an assistant professor of economics in the Department of Economics.
“Of course, you cannot prevent family members from dying, and we certainly do not want our findings to constitute yet another source of stress for expecting mothers, who already face rather intense pressure to eat the right foods, avoid activities deemed harmful, and experience an avalanche of health advice,” Persson said. “But our findings potentially point to the importance of generally reducing stress during pregnancy, for example through prenatal paid maternity leave and programs that provide resources and social support to poor, pregnant women.”
Their research focused specifically on singleton children in Sweden born between 1973 and 2011 whose mother lost a close relative during her pregnancy. They used population registers to construct family trees that span four generations, from the children to their maternal great-grandparents. Their sample included all children whose mother lost a close relative — a sibling, parent, maternal grandparent, the child’s father or her own older child — in the nine months after the child’s date of conception or the year after the child’s birth. The study did not account for the quality of those relationships.
Their analysis compared the outcomes of children whose mothers experienced a relative’s death while they were pregnant with those of children whose maternal relatives died in the year after birth. They were thus able to isolate the impacts of fetal exposure to maternal stress from bereavement from all other consequences associated with a family member’s passing, such as changes to family resources or household composition, which affect all children in their sample.
Additionally, by considering the deaths of different relatives, their approach presents a new measure of intensity of stress exposure: the closeness between the mother and the relative who passed in the family tree.
The researchers merged the Swedish data with information about the children’s health throughout childhood and into adulthood, using birth and medical records. They were aided by Sweden’s novel prescription drug registry, which contains all prescription drug purchases and the exact substances and doses prescribed in the country.
“Our research suggests that policies that can reduce stress during pregnancy can have substantial benefits for the next generation,” Rossin-Slater said in an interview. “Moreover, since poor families are more likely to experience stress than more advantaged ones, our results imply that stress-reducing policies that target low-income pregnant women could play a role in mitigating the persistence of socio-economic inequality across generations.”
Persson and Rossin-Slater said they were initially inspired by two recent economic studies using data from Uganda and Iraq, which found that fetal exposure to malnutrition has adverse consequences for adult mental illness.
“Our study offers complementary evidence linking early-life circumstance to adult mental health, but breaks new ground by focusing on stress,” the authors wrote, “which may be more pertinent than malnutrition in modern developed countries such as the United States and Sweden, and by tracing health outcomes throughout the time period between the fetal shock and adulthood.”
Mental illness results in great financial and social costs. In 2008, the market for prescription drugs treating depression totaled $9.6 billion in the United States alone, a sales volume exceeded only by cholesterol and pain medications.
In 2013, one in seven school-age boys were treated with prescription drugs for Attention Deficit Hyperactivity Disorder, fueling a $9 billion market, five times larger than the $1.7 billion market just a decade earlier. The authors note that estimates also suggest that mental illness accounts for more than one-half of the rise in disability costs among men in the last two decades.
Moreover, in Sweden — the setting for their paper – mental illness accounts for a larger share of health expenditures on prescription drugs than any other therapeutic class.
The scholars said that their study contributes to the research in this area by documenting a causal link between fetal stress exposure and mental health later in life. Moreover, by following the same children from birth to adulthood, they were able to observe the onset of adverse effects of exposure to maternal bereavement in utero.
“In sum, our results show that the death of a relative up to three generations apart during pregnancy has far-reaching consequences for mental health during childhood and adulthood,” Persson and Rossin-Slater said.
Their findings suggest large welfare gains of preventing fetal exposure to severe stress: For example, based on the 2008 figure for the U.S. market, the 8 percent decrease in the consumption of prescription drugs treating depression alone can be valued at around $800 million annually.
They conducted a back-of-the-envelope calculation to understand how exposure to economically induced stress during pregnancy might affect the mental well-being of the next generation by relying on past research estimating cortisol responses to grief and to economic shocks like unemployment and poverty.
“Our calculation suggests that in-utero exposure to stress from unemployment may lead to a 17.3 percent increase in the likelihood of ever purchasing a drug to treat ADHD in middle childhood,” they concluded, “and a 9 percent and 5.5 percent increases in the likelihoods of ever purchasing drugs to treat anxiety and depression in adulthood, respectively.”
The newly published findings can inform one way by which policymakers and the medical community can tackle the prevalence and rising costs of mental health issues: by considering ways to make pregnancy — an inherently stressful time — a little easier to manage.
As millions marched against gun violence across the country on Saturday, research by Stanford Health Policy experts about the impact of gun ownership on public health was also in the spotlight.
The Washington Post published an in-depth story about how the work of gun researchers is finally getting attention — an unfortunate consequence of the recent mass shootings in the United States.
“The explosion of national interest in the problem of gun violence since the Parkland shooting has been remarkable,” said Studdert, who is also a core faculty member at Stanford Health Policy. “And it is inspiring to hear students’ voices — that is definitely a new twist in the politics around this issue. I think there is momentum for change, but I remain pessimistic that we will see the enactment of any substantial reforms at the federal level.”
The Post wrote:
Studdert’s group is using a data set unique to California because of the state’s strict gun laws. Every time a gun is sold in California, a background check logs the purchase and purchaser with California authorities, who also have been unique in their willingness to share such politically fraught data with academic researchers.
Using a sample of 25 million people (taken from California’s voter registration records), Studdert’s team plans to identify handgun owners with the firearm sales records, then compare that against state death records.
The resulting data in theory will help them determine the relationship — whether good or bad — between gun ownership and death.
They call the project LongSHOT, a nod to the project’s scale and ambition.
Academic researchers who were studying the impact of gun violence on public health were dealt a huge financial and political blow in 1996, when the so-called Dickey Amendment was passed by Congress under pressure from gun lobbyists. The law forbids the Centers for Disease Control and Prevention to fund research that might be seen as advocating for gun control. This choked off federal grant money and essential data-gathering on gun violence.
But tucked into the government spending bill in Congress last week was language that indicates the CDC now has the authority to conduct research on the causes and effects of gun violence. Though gun researchers are skeptical that the change in tone will lead to any significant support or funding, some believe that it’s a start. The $1.3 trillion government funding measure also includes efforts to improve state compliance with the national background check system, as well as funding for school counseling and safety programs.
Again, from The Post story:
Yifan Zhang was finishing her PhD in biostatistics at Harvard five years ago when news broke of the Sandy Hook Elementary School shooting.
As a graduate student from China, specializing in highly technical design of clinical drug trials, she had little connection to America’s long-running debate over gun violence. But even now, she said, the anguished faces of those parents she saw on television remain seared in her memory.
So when she heard about a gun-violence research project at Stanford University that could use the statistical skills she had honed on pharmaceuticals, she jumped at the chance.
“I have a son who just turned 1,” said Zhang, 31. “When I think about what I will need to teach him about protecting himself, I think about that school shooting.”
Zhang hopes the Stanford team can one day have an impact.
“I think there are going to be some big decisions that the whole country has to make together, and I’m hoping that our research can help provide evidence and information for the decision making,” she said.
Kevin Volpp is the founding Director of the Center for Health Incentives and Behavioral Economics, Division Chief of Health Policy for the Department of Medical Ethics and Policy, and the Founders President’s Distinguished Professor of Medicine at the Perelman School of Medicine and Health Care Management at the Wharton School of the University of Pennsylvania.
His work focuses on developing and testing innovative ways of applying insights from behavioral economics in improving patient health behavior and affecting provider performance. He has competitively been awarded more than $60 million to lead projects with a variety of employers, insurers, health systems, and consumer companies in testing the impact of different behavioral economic strategies on behavior.
Petra Persson
