Join Francis Fukuyama and Richard Aldous as they discuss where did the modern notion of identity politics come from—and how can nations address particular demands for recognition without eroding a common sense of belonging? Listen here.
A cutting-edge treatment for blood cancer in children with promising short-term remission rates has nevertheless come under intense scrutiny due to its unprecedented cost.
Acute lymphoblastic leukemia (ALL) is the most commonly diagnosed pediatric cancer. Though treatment advances have driven five-year survival rates above 90 percent, relapse is common and ALL remains a leading cause of death from childhood cancer. Those surviving relapse typically require hematopoietic stem cell transplant (HSCT) to remain in remission.
The Food and Drug Administration last year approved tisagenlecleucel as the first anti-CD19 CAR T-cell therapy for relapsed or refractory pediatric ALL. While tisagenlecleucel-induced remission rates are encouraging compared with those of established therapies — more than 80 percent compared with less than 50 percent — a one-time infusion costs $475,000.
That makes it one of the most expensive oncologic therapies out there, even though no studies exist to show how the therapy maintains remission in the long term.
So Stanford Health Policy’s John K. Lin, Jeremy Goldhaber-Fiebert and Douglas K. Owens, in collaboration with Kara Davis, an assistant professor of pediatrics at Stanford’s Lucile Packard Children’s Hospital, set out to determine whether the treatment is cost-effective.
Their study was recently published in the Journal of Clinical Oncology.
“CAR-T cells are an exciting new therapy to help us cure more patients with ALL,” said Davis. “They use a patient’s own immune system to precisely target their leukemia and remission rates are impressive for patients with relapsed disease.”
The researchers note, however, it remains unknown whether tisagenlecleucel is sufficient to cure relapsed or refractory disease without a transplant.
Not only is it a very expensive treatment, it also has expensive and serious side effects, such as cytokine release syndrome, which can cause symptoms ranging from fevers and muscle aches to lethal drops in blood pressure and difficulty breathing, requiring ICU-level care.
“Given [its] high cost and broad applicability in other malignancies, a pressing question for policymakers, payers, and clinicians is whether the therapy’s cost represents reasonable value,” the authors wrote.
In order to evaluate the economic value of tisagenlecleucel, the authors created a computer simulation that modeled children with relapsed or refractory ALL. Since the durability of the therapy’s effects are unknown, they evaluated the therapy at different levels of long-term effectiveness.
Through their analyses, the authors found that at the simulation’s most optimistic projections, patients receiving tisagenlecleucel would, on average, live over a decade longer than those receiving alternative therapies. At these projections, the therapy would be cost-effective. However, at more modest long-term outcomes, its clinical and economic benefits declined.
“The durability of CAR-T cell therapy is the main question. For many children with relapsed or refractory ALL, their disease is fatal — if the therapy results in sustained remissions, it would represent an important advance,” said lead author Lin, who is a VA Health Services Research and Development Fellow at Stanford Health Policy.
In the end, the researchers concluded that at tisagenlecleucel’s current price, its economic value is “uncertain,” as the true cost-effectiveness depends on its long-term performance, which has yet to be determined. They noted that substantial price reductions would improve its cost-effectiveness even if its long-term performance is relatively modest.
“A commonly asked question for many expensive, novel therapies is why can’t prices be lowered at least until we know how well they work,” said Goldhaber-Fiebert.
The “Catch-22” here is that long-term effectiveness data are needed to justify a drug’s price, but current uncertainty about its effectiveness, along with its high price, means developing the data to justify its price occurs much more slowly.
“CAR-T is an individually tailored treatment that has thus far been produced for a relatively small number of patients,” Goldhaber-Fiebert said. “Its current production costs may well be very high, and certainly the companies that have spent heavily on its research and development are interested in achieving returns on their investments.”
When the effectiveness of a therapy is uncertain, some pharmaceutical companies and health policy experts have proposed something called outcomes-based payment, which is essentially a “money-back guarantee” if the therapy doesn’t work as intended.
Novartis, which developed tisagenlecleucel, has a money-back guarantee; if the patient does not achieve initial remission within the first month, they are not responsible for the payment of the therapy.
“However, we find that because most children have an initial remission, this does not materially improve cost-effectiveness,” Lin said.
He suggested that if the money-back guarantee were extended to see whether the patient relapses within a year, such a guarantee would improve the treatment’s cost-effectiveness.
The other co-authors of the study are James I. Barnes, Alex Q.L. Robinson, Benjamin J. Lerman, Brian C. Boursiquot and Yuan Jin Tan.
China and the United States both have public needs that far outstrip the abilities of their governments alone to deliver. Zeckhauser and Donahue will discuss their book (joint with Karen Eggleston) exploring an important, and perhaps surprising, shared feature of efforts by policymakers in China and the United States to forge prosperous, stable futures for their citizens: public-private collaboration to accomplish some of each society’s most vital collective purposes. Collaborative governance entails private engagement in public tasks on terms of shared discretion. Zeckhauser and Donahue will discuss the two countries’ collaborative approaches to health policy and elder care, comparing and contrasting with approaches to other activities ranging from education and infrastructure to hosting the Olympics.
Richard Zeckhauser is the Frank P. Ramsey Professor of Political Economy, Kennedy School, Harvard University. He graduated from Harvard College (summa cum laude) and received his Ph.D. there. He is an elected fellow of the Econometric Society, the Institute of Medicine (National Academy of Sciences), and the American Academy of Arts and Sciences. In 2014, he was named a Distinguished Fellow of the American Economic Association. His contributions to decision theory and behavioral economics include the concepts of quality-adjusted life years (QALYs), status quo bias, betrayal aversion, and ignorance (states of the world unknown) as a complement to the categories of risk and uncertainty. Many of his policy investigations explore ways to promote the health of human beings, to help markets work more effectively, and to foster informed and appropriate choices by individuals and government agencies. Zeckhauser has published over 300 articles and several books.
John D. Donahue is the Raymond Vernon Senior Lecturer in Public Policy, Kennedy School, Harvard University. He is also Faculty Chair of the Master in Public Policy (MPP) Program and the SLATE Curriculum Initiative Co-Chair for Cases and Curriculum. His teaching, writing, and research mostly deal with public sector reform and with the distribution of public responsibilities across levels of government and sectors of the economy, including extensive work with the HKS-HBS joint degree program. He has written or edited twelve books, most recently Collaborative Governance (with Richard J. Zeckhauser, 2011) and Ports in a Storm (with Mark H. Moore, 2012). He served in the first Clinton Administration as an Assistant Secretary and then as Counselor to the Secretary of Labor. Donahue has consulted for business and governmental organizations, including the National Economic Council, the World Bank, and the RAND Corporation, and serves as a trustee or advisor to several nonprofits. A native of Indiana, he holds a BA from Indiana University and an MPP and PhD from Harvard.
Today, nearly 9% of people in Latin America identify as Indigenous, ranging from 2% in Argentina to 30% in Guatemala with high within-country variation. Levels of Indigenous self-identification have also increased in the last decades in the region. Using a multi-method approach that combines surveys, archival research, text analysis, and machine learning, I study how different institutional frameworks have shaped the persistence of language, Indigenous last-names, and local governance from the colonial times to the 21st century. I also provide a novel theoretical framework to understand Indigenous agency and their capacity to resist, survive and adapt to colonial rule.
I am
In electoral autocracies, why do some citizens view the state as autocratic, while others see it as democratic and legitimate? Traditionally, indicators such as income and education have been the most important factors to explaining why different types of citizens understand politics. This paper argues that in electoral autocracies, we must also take into account the role of political geography. Opposition parties are often one of the only actors that provide information about the authoritarian nature of the regime, but their message tends to get quarantined within their strongholds. I argue that regardless of income, education, ethnicity, or access to government spending, citizens living in opposition strongholds should be far more likely to view the state as autocratic and illegitimate than citizens living in ruling party strongholds. I find evidence for this theory using Afrobarometer survey data paired with hand-coded constituency-level electoral returns from five electoral autocracies in sub-Saharan Africa.
"The nature of modern identity, however, is to be changeable. Some individuals may persuade themselves that their identity is based on their biology and is outside their control. But citizens of modern societies have multiple identities, ones that are shaped by social interactions. People have identities defined by their race, gender, workplace, education, affinities, and nation. And although the logic of identity politics is to divide societies into small, self-regarding groups, it is also possible to create identities that are broader and more integrative. One does not have to deny the lived experiences of individuals to recognize that they can also share values and aspirations with much broader circles of citizens. Lived experience, in other words, can become just plain experience—something that connects individuals to people unlike themselves, rather than setting them apart. So although no democracy is immune from identity politics in the modern world, all of them can steer it back to broader forms of mutual respect," writes CDDRL Mosbacher Director Francis Fukuyama. Read here.
Crop responses to climate warming suggest that yields will decrease as growing-season temperatures increase. Deutsch et al. show that this effect may be exacerbated by insect pests (see the Perspective by Riegler). Insects already consume 5 to 20% of major grain crops. The authors' models show that for the three most important grain crops—wheat, rice, and maize—yield lost to insects will increase by 10 to 25% per degree Celsius of warming, hitting hardest in the temperate zone. These findings provide an estimate of further potential climate impacts on global food supply and a benchmark for future regional and field-specific studies of crop-pest-climate interactions.
Paul M. Sniderman is the Fairleigh S. Dickinson, Jr. Professor in Public Policy.
Sniderman’s current research focuses on the institutional organization of political choice; multiculturalism and inclusion of Muslims in Western Europe; and the politics of race in the United States.
Most recently, he authored The Democratic Faith and co-authored Paradoxes of Liberal Democracy: Islam, Western Europe and the Danish Cartoon Crisis (with Michael Bang Petersen, Rune Slothuus, and Rune Stubager).
He has published many other books, including The Reputational Premium: A Theory of Party Identification and Policy Reasoning, Reasoning and Choice, The Scar of Race, Reaching beyond Race, The Outsider, and Black Pride and Black Prejudice, in addition to a plethora of articles. He initiated the use of computer-assisted interviewing to combine randomized experiments and general population survey research.
A fellow of the American Academy of Arts and Sciences and of the American Association for the Advancement of Science, he has been awarded the Woodrow Wilson Prize, 1992; the Franklin L. Burdette Pi Sigma Alpha Award, 1994; an award for the Outstanding Book on the Subject of Human Rights from the Gustavus Meyers Center, 1994; the Gladys M. Kammerer Award, 1998; the Pi Sigma Alpha Award; and the Ralph J. Bunche Award, 2003.
Sniderman received his B.A. degree (philosophy) from the University of Toronto and his M.A. and Ph.D. degrees from the University of California, Berkeley.
There are a billion guns in the world today. Those firearms took the lives of about 251,000 people in 195 countries in 2016, according to new research.
That’s a lot of guns and fatalities, mostly by homicide, suicide and accidents with firearms.
About 35 percent of those gun deaths were by Americans committing suicide.
In the most comprehensive investigation of its kind, the findings, published this week in the Journal of the American Medical Association (JAMA), show 64 percent of firearm-related deaths were homicides, 27 percent were suicides and 9 percent were unintentional deaths.
And in all but one year of the 27-year study period — 1994 due to the Rwandan genocide — firearm deaths were more common along sidewalks than on the battlefields.
“This constitutes a major public health problem for humanity,” said Stanford Health Policy’s David Studdert, a professor of medicine and professor of law.
In an accompanying editorial alongside the research by a consortium of public health experts, the Global Burden of Disease 2016 Injury Collaborators, Studdert and his co-authors write:
“Injuries and deaths from firearms are increasingly part of modern consciousness, particularly in some countries. In the United States, gun-related massacres at schools, places of worship, workplaces, night clubs, and recreational venues have seared images of innocent victims in the minds of the populace. In the United States and elsewhere, acts of terrorism committed with firearms and other lethal means have changed the way people live, work, travel, and play.”
But Studdert and his co-authors — firearms and public health experts Frederick P. Rivara at the University of Washington and Garden J. Wintemute at the University of California, Davis — argue that the deaths from these headline-generating mass shootings and terrorist attacks are only a fraction of the public health burden of firearm-related murders and suicides.
“Mass shootings and terrorism perpetrated with guns are the most visible forms of firearm violence,” Studdert told SHP. “But most firearm deaths are private tragedies. They are homicides and suicides that occur behind closed doors, leaving families and communities devastated.”
The global burden of firearm mortality is highly concentrated, according to the research. In 2016, six countries in the Americas — Brazil, the United States, Mexico, Columbia, Venezuela and Guatemala — accounted for slightlymore than 50 percent of all deaths.
An estimated 32 percent of the deaths occurred in just two countries, Brazil and the United States, with Brazil accounting for one-fourth of all firearm homicides and the United States 35 percent of all firearm suicides.
“For individuals living in the United States, where the national policy debate has focused largely on interpersonal violence, the study provides a reminder of the importance of firearm suicide. In 2016, there were 2 firearm suicides for every firearm homicide, a margin that has widened over the past decade as suicide rates have increased and homicide rates have been relatively flat. Older white non-Hispanic men are at greatest risk of firearm suicide. Research and prevention efforts in the United States should proceed from a more inclusive definition of firearm violence.”
The authors believe more robust methods for estimating the number and distribution of firearms — as well as a better understanding of access — are critically important in determining which policies and prevention strategies are most effective and how best to implement them.
Studdert and his fellow researchers said research on firearm violence and public health has been impeded by the Dickey Amendment, the 1996 bill that mandated “none of the funds made available for injury prevention and control at the Centers for Disease Control and Prevention may be used to advocate or promote gun control.”
“In the absence of this funding, several private foundations have stepped in to fill the void," they wrote. "However, real progress in addressing the vast public health problem that the Global Burden of Injury Collaborators document will depend on sustained action from governments in both research and policy.”
"Samuel Huntington was not right about everything. Rather, his greatness lay in his ability to conceptualize big ideas in a wide variety of fields," writes Francis Fukuyama in this comparative article. Read here.
