Using a dynamic microsimulation model, a research team, including APARC Deputy Director and Asia Health Policy Program Director Karen Eggleston, shows that there are differentially positive health gains of smoking reduction among subgroups of smokers in South Korea, Singapore, and the United States.

Tobacco use is responsible for the death of approximately eight million people worldwide, estimates the World Health Organization, and countries are increasingly making tobacco control a priority. Indeed the relationship between smoking and the burden of chronic diseases such as cancer, lung disease, and heart disease, and, in turn, premature mortality, is well documented. Yet little is known about the health effects of smoking interventions among subgroups of smokers.

Do interventions targeted at heavy smokers relative to light smokers lead to disproportionately larger improvements in life expectancy and prevalence of chronic diseases? And how do these effects vary across populations? In today’s rapidly aging world, it is crucial to understand the potential health gains resulting from interventions to reduce smoking, a leading preventable risk factor for healthy aging.

That’s why a research team, including APARC Deputy Director and Asia Health Policy Program Director Karen Eggleston as well as Stanford Health Policy faculty member Jay Bhattacharya, set out to examine the health effects of smoking reduction. To do so, the team simulated an elimination of smoking among subgroups of smokers in South Korea, Singapore, and the United States.

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The team’s findings, discussed in a new paper published by the journal Health Economics, show that smoking reduction can achieve significant improvements in lifetime health as measured by survival while also reducing the prevalence of major chronic diseases, though the effects are heterogeneous. Whereas interventions in both subgroups and in all three countries led to an increased life expectancy and decreased prevalence of chronic diseases, the life-extension benefits were greatest – 2.5 to 3.7 years – for those who would otherwise have been heavy smokers, compared with gains of 0.2 to 1.5 years among light smokers.

The team developed a dynamic microsimulation model to estimate the health gains of reducing smoking among heavy smokers and light smokers. Microsimulation models are powerful tools for assessing the value of health promotion: they model individual health trajectories while accounting for competing risks, thus providing valuable information about the impact of interventions and how they may interact with the changing demographics and socioeconomic profile of a population to determine future health. The team’s study applied microsimulation models tailored to the demographic and epidemiological context in the three countries, then compared the gains in survival and reduction in chronic disease prevalence from a given reduction in smoking and how these impacts vary depending on initial smoking intensity.

The team’s findings indicate that there are differentially positive health effects from smoking reduction. The life‐year gain among heavy smokers quitting well exceeds that of light smokers quitting in each country, but the magnitudes differ substantially: 11.2 times for South Korea, 6.8 times for Singapore, and 1.7 times for the United States. The lower life expectancy among Americans is related to the greater extent in which they suffer from risk factors, such as obesity, relative to the Asian counterparts in the study.

The findings illustrate how smoking interventions may have significant economic and social benefits, especially for life extension, that vary across countries. They are particularly important for aging societies that are concerned about the sustainability of their health insurance systems in the face of increasing burden of chronic disease.

The U.S. government's global hunger and food security initiative, Feed the Future, has prevented 2.2 million children from experiencing malnutrition in sub-Saharan Africa, according to new research led by Stanford Health Policy's PhD candidate Tess Ryckman.

The researchers compared children’s health in 33 low- and middle-income countries in sub-Saharan Africa. In 12 of those countries, Feed the Future provided services such as agricultural assistance and financial services for farmers, as well as direct nutrition support, such as nutrient supplementation. 

The study, published online Dec. 11 in The BMJ, found a 3.9 percentage point decrease in chronic malnutrition among children served by Feed the Future, leading to 2.2 million fewer children whose development has been harmed by malnourishment.

“What we see with stunting rates is striking,” Ryckman said. “I would argue that 2 million fewer children stunted over seven years is major progress and puts a substantial dent in total stunting levels. And that’s 2 million children who will now have the levels of physical and cognitive development to allow them to reach their full potential.”

Stunting, or having a low height for a particular age, is a key indicator of child malnutrition. Children who aren’t properly nourished in their first 1,000 days are more likely to get sick more often, to perform poorly in school, grow up to be economically disadvantaged and suffer from chronic diseases, according to the World Health Organization.

A Controlled Study

Feed the Future is thought to be the world’s largest agricultural and nutrition program, with around $6 billion in funding from USAID (plus more from other federal agencies) between 2010 and 2015. Despite its size, much remains unknown about the effectiveness of the program.

The researchers analyzed survey data on almost 900,000 children younger than 5 in sub-Saharan Africa from 2000 to 2017. They compared children from the Feed the Future countries with those in countries that are not participants in the program, both before and after the program’s implementation in 2011.

The researchers found the results were even more pronounced — a 4.6 percentage point decline in stunting — when they restricted their sample to populations most likely to have been reached by program. These included children who were younger when the program began, rural areas where Feed the Future operated more intensively, and in countries where the program had greater geographic coverage.

“Our findings are certainly encouraging because it has been difficult for other programs and interventions to demonstrate impact on stunting, and this program has received a lot of funding, so it’s good to see that it’s having an impact,” Ryckman said.

Multifaceted Approach to Nutrition

Experts are divided about the best way to help the world’s 149 million malnourished children: Is assistance that directly targets nutrition, such as breastfeeding promotion or nutrient supplementation, more effective? Or is it also beneficial to tackle the problem at its root by supporting agriculture and confronting household poverty?

The authors, including Stanford Health Policy’s Eran Bendavid, MD, associate professor of medicine, and Jay Bhattacharya, MD, PhD, professor of medicine, a senior fellow (by courtesy) at the Freeman Spogli Institute of International Studies and a senior fellow senior fellow at the Stanford Institute for Economic Policy Research, said their analysis supports the value of a multifaceted approach to combating malnutrition among children, namely leveraging agriculture and food security interventions.

“Independent evaluations of large health policy programs such as Feed the Future help build the evidence base needed to tackle persistent patterns of undernutrition,” said Bendavid, an epidemiologist. “The widespread prevalence of stunting and chronic undernutrition is among the most common and yet most stubborn cause of underdevelopment in the world, and learning what works in this space is sorely needed.”

The researchers, including Stanford medical students Margot Robinson and Courtney Pederson, speculated that possible drivers of the program’s effectiveness include three features of Feed the Future’s design: its country-tailored approach; its focus on underlying drivers of nutrition, such as empowering female farmers; and its large scale and adequate funding.

The authors hope their independent evaluation of the program might lead to more funding and support for it. At the very least, they said, it should demonstrate to people working on Feed the Future and the broader global nutrition program community that programs focused mostly on agriculture and food security — indirect contributors to malnutrition — can lead to success.

Value Unknown

Feed the Future has been scaled back in recent years — it once served 19 countries and now reaches only 12. The program’s budget also remains somewhat murky.

“While there isn’t much data on the program’s funding under the Trump administration, the program appears to have been scaled back, at least in terms of the countries where it operates,” Ryckman said. “It’s possible that some of these gains could be lost, absent longer-term intervention from Feed the Future.”

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The researchers also did not look at whether the program provided high value for the money spent.

“While we find that it has been effective, it hasn’t led to drastic declines in stunting and it is unclear whether it is good value for money,” she said.

Ryckman also noted that USAID’s own evaluation of its program is tenuous because it looked only at before-and-after stunting levels in Feed the Future countries without comparing the results to a control group or adjusting for other sources of bias, which is problematic because stunting is slowly declining in most countries.

“These types of evaluations are misleading,” Ryckman said. “The U.S. government really needs to prioritize having their programs independently evaluated using more robust methods. That was part of our motivation for doing this study.”

Support for the study was provided by the National Institutes of Health (grant P20-AG17253), the National Science Foundation and the Doris Duke Charitable Foundation.

A U.S. foreign policy that cuts money to nongovernmental organizations performing or promoting abortions abroad has actually led to an increase in abortions, according to Stanford researchers who have conducted the most comprehensive academic study of the policy’s impact.

Eran Bendavid and Grant Miller — both associate professors at Stanford University School of Medicine and core faculty members at Stanford Health Policy — and doctoral candidate Nina Brooks find that abortions increased among women living in African countries where NGOs, such as the International Planned Parenthood Federation, were most vulnerable to the policy’s requirements.

The policy, widely known as the Mexico City Policy, explicitly prohibits U.S. foreign aid from flowing to any NGO that will not abide by the policy’s main condition: no performing or discussing abortion as a method of family planning, even if just in the form of education or counseling.

The policy has been a political hot potato since its inception. Enacted under Ronald Reagan in 1984, it’s been enforced by subsequent Republican administrations while Democrats in the White House revoked the policy within days of taking office.

The study by Brooks, Bendavid and Miller, published June 27 in The Lancet Global Health, looked at the policy’s effects in more than two dozen African countries over a span of 20 years under three presidents: Bill Clinton, George W. Bush and Barack Obama. It finds that, when the policy was in place during the Bush years, abortions were 40 percent higher relative to the Clinton and Obama administrations.

When the policy was suspended during Obama’s two terms, the research shows that the upward trend in abortion rates reversed.

“Our research suggests that a policy that is supported by taxpayers ostensibly wishing to drive down abortion rates worldwide does the opposite,” said Bendavid, a faculty affiliate of the Stanford King Center on Global Development, which is part of the Stanford Institute for Economic Policy Research (SIEPR).

A key reason for the uptick in abortions is that many NGOs affected by the policy also provide contraceptives – and funding cuts mean birth control is harder to get, said Brooks.

“By undercutting the ability to supply modern contraceptives, the unintended consequence is that abortion rates increase,” she said.

And the policy’s scope has expanded under the Trump administration. While it originally restricted aid directed only toward providing family planning and reproductive health services, President Trump has extended the policy to cover any group engaged in global health, including organizations providing services for HIV or child health – not just family planning.

Groundbreaking Research

The stakes are high. America is the world’s largest provider of development assistance and spent about $7 billion on international health aid in 2017. Many women in sub-Saharan Africa depend on this aid for contraceptives.

In sub-Saharan Africa, NGOs are often primary providers of family planning services. Two of the world’s largest family planning organizations – International Planned Parenthood Federation and Marie Stopes International – have forfeited large sums of U.S. cash for refusing to comply with the policy, according to news reports.

The research findings were based on records of nearly 750,000 women in 26 sub-Saharan African countries from 1995 to 2014. When the policy was in effect under George W. Bush, contraceptive use fell by 14 percent, pregnancies rose by 12 percent and abortions rose by 40 percent relative to the Clinton and subsequent Obama years – an impact sharply timed with the policy and in proportion to the importance of foreign assistance across sub-Saharan Africa.

The paper is the second study of the rule’s impact by Bendavid and Miller, who are both faculty members of Stanford Health Policy. The research is also one of the very few evidence-based analyses of the policy.

Their earlier research, the first quantitative, large-scale effort to examine the policy’s impacts, looked at a smaller set of African countries during the Clinton and Bush administrations and also found an increase in abortion rates when the policy was enacted in 2001.

“Our latest study strengthened our earlier findings because we were able to look at what happens when the rule was turned off, then on, and then off again,” said Bendavid, referring to the policy’s whipsawing under Clinton, Bush and then Obama.

Miller, who is the director of the King Center and a SIEPR senior fellow, says the team’s research reveals a deeply flawed policy.

“We set out to provide the best and most rigorous evidence on the consequences of this policy,” he said. “What we found is a clear-cut case of government action that everyone on all sides of the abortion debate should agree is not desirable.”

Signs of a Global Pushback

Brooks also notes that their findings may underestimate the rule’s full impact.

“The excess abortions performed due to the policy are more likely to be performed unsafely, potentially harming women beyond pregnancy terminations,” she said.

Under Trump, the international response to U.S. funding cuts has shifted. Norway, Canada and several other countries have pledged to increase funding of international NGOs affected by the policy – though not by enough to cover the expected shortfall, says Miller.

“This shows us,” he said, “that despite the intense partisanship in the U.S. over the rule and its implementation, there are ways that policymakers around the world can offset its effects – by ensuring higher levels of family planning funding, for example.”

Dr. George Rosenkranz —a world-renowned scientist who devoted his life to improving global health and established a prize to foster innovative research among emerging Stanford scholars — leaves behind an extraordinary legacy of science and humanitarianism.

Rosenkranz was 102 when he died Sunday after a prolific scientific career, one that would forever change the course of women’s reproductive lives.

A Hungarian Jew who fled the Nazis during World War II and eventually emigrated to Mexico, Rosenkranz was one of three scientists who pioneered the chemical compounds that led to the birth control pill. He was also instrumental in developing medicines to fight venereal diseases.

His family established The Dr. George Rosenkranz Prize in 2010 at the Freeman Spogli Institute for International Studies; the prize is administered by Stanford Health Policy. The $100,000 award goes to researchers working to improve health care in the developing world.

The beloved figure often made it to the campus symposiums that honored the prize winners.

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The first Rosenkranz Prize was awarded in 2010 to SHP’s Eran Bendavid, an infectious disease physician and associate professor of medicine. He used his award to study whether U.S. money spent on malaria and HIV programs in sub-Saharan Africa translated into better health outcomes for women and their children.

“George has galvanized a community of global health researchers at Stanford,” said Bendavid. “We now have a community of scholars whose focus on critical issues in other countries has been powerfully enabled by George's legacy. He and his family have been an inspiration for us and, by extension, our students. The spirit of promoting promising young researchers is something we all benefit from. His is a wonderful name and a legacy to be attached to.”

Other Rosenkranz Prize winners honor his legacy with remembrances:

“There are very few people who have changed the world as much as Dr. Rosenkranz; his work in synthesizing and bringing oral contraception to market changed how people form families, and empowered women around the world.” — Mike Baiocchi, a Stanford statistician and the 2017 winner.

“The Rosenkranz Prize helped our young lab take risks where we might not have been able to; risks that have paid off intellectually,” said Baiocchi, whose team is conducting the largest-ever randomized trial to measure the impact of No Means No Worldwide project, which is training 300,000 boys and girls in Kenya and Malawi to prevent rape and teen pregnancy.

“The prize money allowed us to bring two of our statistics PhD students to Kenya to visit the communities they have been working with, to present their work to the stakeholders. This has built a passion for in these students, who have each launched their own Kenya-based study to examine means for reducing gender-based violence.”

“Dr. Rosenkranz's professional and personal legacy are closely intertwined. By his example, I and many other Rosenkranz scholars have been enabled to marry what sometimes feel like dueling passions: social justice and rigorous scholarship. I feel so fortunate to have met Dr. Rosenkranz and hope that many others will continue to be inspired by his message of equity, global fellowship, and excellence.” — Ami Bhatt, the 2016 winner who is building the first multi-country microbiome research project focused on noncommunicable disease risk in Africa.

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“As a Mexican awardee of the Rosenkranz prize it is a privilege to be part of the legacy of one of the most prominent Mexican scientists, whose generous support was a vital seed to create my research laboratory on Human Genomics in Mexico.” — Andrés Moreno Estrada, the 2012 winner who is analyzing the DNA of indigenous groups in Latin American, one of the most underrepresented populations in the field of genetics.

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“The prize was a huge boost to my career as an early stage researcher. It allowed me to do work in India on antimicrobial resistance (AMR) at a time when the topic was not a high priority for global funding agencies. The project led to a series of a collaborations with a large public hospital in India. There were several publications as a result of this partnership, and the studies we performed were innovative and informative on the prevalence on AMR in community-dwelling individuals.” — Marcella Alsan, one of two 2015 prize winners.

Type 2 diabetes has become a major public health problem in South Asia in recent decades. The region is now home to an estimated 84 million people suffering from diabetes—approximately one-fifth of the world’s 451 million adults with diabetes—a number that is expected to rise by 78% by 2045. Even more concerning, across South Asia the disease burden increasingly occurs in the most productive midlife period. Among Indians, for example, diabetes is estimated to occur on average 10 years earlier than their western counterparts, and almost half of Indian patients with type 2 diabetes are diagnosed before age 40.

How do South Asian health system influence diabetes care? What is the magnitude of the economic impact of diabetes in South Asia? And what can be done to mitigate that economic burden? These are some of the questions that a team of researchers, including Karen Eggleston, APARC’s deputy director and director of the Asia Health Policy Program, set out to answer in a new study published in the journal Current Diabetes Reports.

Eggleston co-authored the study with Kavita Singh of the Public Health Foundation of India and the Centre for Chronic Disease Control in New Delhi, and with M. Venkat Narayan, Professor of Medicine and Epidemiology and Director of the Global Diabetes Research Center at Emory University. They find that diabetes-related complications lead to enormous treatment costs, causing catastrophic medical spending and illness-induced poverty for many households.

The new study is related to a broader research project led by Eggleston, entitled Net Value in Diabetes Management, that compares health care use, medical spending, and clinical outcomes for patients with diabetes as a lens for understanding the economics of caring for patients with complicated chronic diseases across diverse health systems. This international collaborative research convenes teams of clinicians and health economists in ten countries (and growing) across Asia, as well as the United States and The Netherlands. Together, they analyze big data—detailed, longitudinal patient-level information for large samples from each country, including millions of records of clinical encounters, health-check-up, and medical spending—to compare the health care use and patient outcomes for adults with type 2 diabetes in their health systems.

In the new publication, Eggleston and her co-authors first introduce several unique features that characterize the type 2 diabetes epidemic in South Asia. These include a high risk of developing diabetes even at lower levels of body mass index than observed among western populations; a high prevalence of glucose intolerance, low levels of HDL cholesterol, and high levels of triglycerides; a relationship between impaired fetal nutrition, diabetes, and cardiovascular risk; and the likelihood of rapid urbanization impacting the diabetes burden of the wealthy and the underprivileged differently.

Furthermore, South Asian countries face difficult challenges in delivering diabetes care. The health sector in the region has little organized financing, leading to heavy out-of-pocket spending by patients. Limited availability and affordability of anti-diabetic drugs is a major driver of lower use of such medicines. These factors, combined with a general lack of health care professionals and infrastructural resources and low quality of healthcare governance, all contribute to poor health outcomes.

Eggleston and her co-authors assess the current literature on the economic impact of diabetes in South Asia. They show that, compared with the high prevalence of diabetes in South Asian countries, the total health spending as a percentage of GDP in the region has remained low and fairly constant (3-4% in most countries) over the last two decades, with less than 1% of GDP spent on healthcare by the government, and a miniscule 0.2% by pre-paid private insurance, resulting in a large proportion of out-of-pocket healthcare spending. The financial burden of diabetes and its complications can therefore have catastrophic implications for households that are often driven to sacrifice disastrous proportions of their income to cover treatment costs.

Diabetes causes premature mortality, high morbidity, and disability. To mitigate the economic and social welfare burden of the disease, the researchers conclude, policymakers in South Asia must take urgent action “to increase investment in evaluating cost-effective strategies to manage diabetes and preventative approaches.” The team offers a set of policy recommendations, including monitoring the economic burden of diabetes and the quality of care; focusing on the screening and prevention of diabetes and its risk factors; strengthening government health facilities and primary care services; expanding access to affordable, essential medicines, and more.

People today can generally expect to live longer and, in some parts of the world, healthier lives. The substantial increases in life expectancy underlying these global demographic shifts represent a human triumph over disease, hunger, and deprivation, but also pose difficult challenges across multiple sectors. Population aging will have dramatic effects on labor supply, patterns of work and retirement, family and social structures, healthcare services, savings, and, of course, pension systems and other social support programs used by older adults. Individuals, communities, and nations around the world must adapt quickly to the demographic reality facing us and design new approaches to financing the many needs that come with longer lives.

This imperative is the focus of a newly published special issue of The Journal of the Economics of Ageing, entitled Financing Longevity: The Economics of Pensions, Health and Long-term Care. The special issue collects articles originally written for and discussed at a conference that was dedicated to the same topic and held at Stanford in April 2017 to mark the tenth anniversary of APARC’s Asia Health Policy Program (AHPP). The conference convened top experts in health economics and policy to examine empirical and theoretical research on a range of problems pertinent to the economics of aging from the perspective of sustainable financing for long lives. The economics of the demographic transition is one of the research areas that Karen Eggleston, APARC’s deputy director and AHPP director, studies. She co-edited the special issue with Anita Mukherjee, a Stanford graduate now assistant professor in the Department of Risk and Insurance at the Wisconsin School of Business, University of Wisconsin-Madison.

The Financing Longevity conference was organized by The Next World Program, a Consortium composed of partners from Harvard University, Fudan University, Stanford University, and the World Demographic and Aging Forum, and was cosponsored by AHPP, the Stanford Institute for Economic Policy Research, and the Stanford Center on the Demography and Economics of Aging.

The contributions that originated from the conference and are collected in the Journal’s special issue cover comparative research on more than 30 European countries and 17 Latin American countries, as well as studies on Australia, the United States, India, China, and Japan. They analyze a variety of questions pertinent to financing longevity, including how pension structures may exacerbate existing social inequalities; how formal and informal insurance interact in securing long-term care needs; the ways in which the elderly cope with caregiving and cognitive decline; and what new approaches might help extend old-age financial security to those working outside the formal sector, which is a major concern in low-income countries.

Another challenge of utmost importance is the global pension crisis, caused due to committed payments that far exceed the saved resources. It is a problem that Eggleston and Mukherjee highlight in their introduction to the special issue. By 2050, they note, the pension gap facing the world’s eight largest pension systems is expected to reach nearly US $400 trillion. The problem cannot be ignored, as “the financial security of people leading longer lives is in serious jeopardy.” Indeed four of the eight research papers in the special issue shed light on pensions and inequality in income support for older adults. The other four research papers focus on health and its interaction with labor force participation, savings, and long-term care.

The issue also features two special contributions. The first is an interview with Olivia S. Mitchell, a professor at the University of Pennsylvania’s Wharton School and worldwide expert on pensions and ageing. Mitchell explains the areas offering the most promise and excitement in her field; discusses ways to encourage delayed retirement and spur more saving; and suggests several priority areas for future research. The latter include applying behavioral insights to questions about retirement planning, improving financial literacy, and advancing innovations to help people imagine themselves at older ages and save more for their future selves.

The second unique contribution is a perspective on the challenges of financing longevity in Japan, based on the keynote address delivered at the 2017 Stanford conference by Mr. Hirotaka Unami, then senior Director for policy planning and research of the Minister’s secretariat of the Japan Ministry of Finance and currently deputy director general with the Ministry’s Budget Bureau.

In Japan, decades of improving life expectancy and falling birth rates have produced a rapidly aging and now shrinking population. Data released by Japan’s Statistics Bureau ahead of Children's Day on May 5, 2019 reveal that Japan’s child population (those younger than 15) ranks lowest among countries with a total population exceeding 40 million. In his piece, Unami focuses on the difficult tradeoffs Japan faces in responding to the increase in oldest-old population (people aged 75 and over) and the overall population decline. Japan aspires to do so through policies that are designed to restore financial sustainability for the country’s social security system, including the medical care and long-term care insurance systems.

Unami argues that Japan must simultaneously pursue a combination of increased tax revenues, reduced benefit growth, and accelerated economic growth. He notes that these three-pronged efforts require action in five areas: review Japan’s pension policies; reduce the scope of insurance coverage in low-risk areas; increase the effectiveness of health service providers; increase a beneficiary’s burden according to their means; and enhance policies for preventive health care for the elderly.

The aging of our world’s population is a defining issue of our time and there is pressing need for research to inform policies intended to improve the financial well-being of present and future generations. The articles collected in the Financing Longevity special issue and the ongoing work by APARC’s Asia Health Policy Program point to multiple areas ripe for such future research.

View the complete special issue >>

Learn more about Dr. Karen Eggleston’s work in the area of innovation for healthy aging >>