To fight superbugs, fight poverty
Could out of pocket drug costs be responsible for pandemics? In this Public Health Perspectives article, Marcella Alsan discusses how copayments for antibiotics can cause people in poor areas to turn to unregulated markets.
On May 26, 2016, researchers at the Walter Reed National Military Medical Center reported the first case of what they called a “truly pan-drug resistant bacteria.” By now, the story has been well-covered in the media: a month earlier, a 49 year old woman walked into a clinic in Pennsylvania with what seemed to be a urinary tract infection. But tests revealed something far scarier—both for her and public health officials. The strain of E. Coli that infiltrated her body has a gene that makes it bulletproof to colistin, the so-called last resort antibiotic.
Most have pinned the blame for the impending doom of a “post-antibiotic world” on the overuse of antibiotics and a lack of new ones in the development pipeline. But there’s another superbug incubator that hasn’t gotten the attention it deserves: poverty.
Last month at the IMF meeting in Washington, D.C., UK Chancellor George Osborne warned about the potentially devastating human and economic cost of antimicrobial resistance. He called for “the world’s governments and industry leaders to work together in radical new ways.” But Gerry Bloom, a physician and economist at the Institute for Development Studies, argued that any measures to stop overuse and concoct new drugs must be “complemented by investments in measures to ensure universal access to effective antibiotic treatment of common infections.”
“In many countries, poor people obtain these drugs in unregulated markets,” Bloom said. “They often take a partial course and the products may be sub-standard. This increases the risk of resistance.”
For at least fifteen years, we’ve known about these socioeconomic origins of antimicrobial resistance. Other studies have revealed problems with mislabeled or expired or counterfeit drugs. But the clearest link between poverty and the rise of antimicrobial resistance is that poor people may not see a qualified health care provider or complete a course of quality antibiotics. Instead, they might turn to unregulated markets for substandard drugs.
But why do people resort to unregulated markets or take drugs that aren’t that great if they are available? Marcella Alsan, an assistant professor of medicine at the Stanford School of Medicine who studies the relationship between socioeconomic disparities and infectious diseases, led a study that answered this question. In last October’s Lancet Infectious Diseases, Alsan and her colleagues showed that it might have a lot to do with requiring copayments in the public sector. To show this, they analyzed the WHO’s 2014 Antibacterial Resistance Global Surveillance report with an eye toward the usual suspects, such as antibiotic consumption and antibiotic-flooded livestock.
Lessons learned from children's literature
In collaboration with the Center for Latin American Studies (CLAS) at Stanford University, SPICE hosted a professional development seminar for elementary school teachers that focused on strategies to incorporate Latin American and Latino children’s literature into the K–5 classroom.
On February 6, 2015, 32 teachers from across the Bay Area gathered at Stanford University to listen to guest lectures, participate in curriculum demonstrations, and collaboratively explore issues related to immigration and identity.
The workshop commenced with a presentation by children’s book author and illustrator Duncan Tonatiuh, whose most recent book, Pancho Rabbit and the Coyote: A Migrant’s Tale, was a 2014 recipient of the Americas Book Award. The Americas Book Award was founded in 1993 by the Consortium of Latin American Studies Programs (CLASP) to encourage and commend authors, illustrators, and publishers who produce quality children’s and young adult books that portray Latin America, the Caribbean, or Latinos in the United States.
Mr. Tonatiuh shared the inspiration for Pancho Rabbit and the Coyote, which tells the story of a young rabbit’s journey from Mexico to the United States in search of his father. According to Mr. Tonatiuh, the book can be read as an allegory of the experiences that undocumented immigrants endure in order to reach the United States. During his talk, Mr. Tonatiuh played a short video created by an elementary school teacher in which students shared their own immigration stories in response to the book. The moving video was a reminder of the importance immigration issues have in many students’ lives. Each teacher at the workshop received a copy of Mr. Tonatiuh’s book.
Tomás Jiménez, Associate Professor of Sociology and Director of Chicana/o-Latina/o Studies at Stanford University, followed Mr. Tonatiuh’s talk with a lecture on the recent history of immigration to the United States. Professor Jiménez’s educative overview of the economic, social, and political forces that have led to the current state of immigration in the United States perfectly complemented the personal stories shared earlier by Mr. Tonatiuh.
In the afternoon, Keira Philipp-Schnure, Supervisor of Community Education Programs, and Katrina Dillon, Project Assistant, at the Latin American and Iberian Institute at University of New Mexico, shared an educator’s guide for Pancho Rabbit and the Coyote. The educator’s guide offers a plethora of lessons and activities that teachers can use when teaching the book.
As a final activity, workshop participants assembled in small groups to discuss the content and pedagogical strategies that had been shared at the workshop. Jonas Edman, Curriculum Writer at SPICE, facilitated the activity in which teachers offered their own ideas for lesson plans and activities to go along with Mr. Tonatiuh’s book.
In her closing remarks, Elizabeth Saenz-Ackermann, Associate Director at CLAS, expressed heartfelt gratitude to the teachers for their participation in the workshop and for their commitment to incorporating Latin American and Latino themes and topics into their teaching.
K–5 Teachers Workshop: Exploring Immigration and Identity Using Children's Literature
The Center for Latin American Studies (CLAS) and the Stanford Program on International and Cross-Cultural Education (SPICE) are offering an exciting K–5 workshop focusing on strategies to incorporate Latin American and Latino children’s literature into the elementary school classroom.
Featured speakers include Duncan Tonatiuh, author of Pancho Rabbit and the Coyote (2013, Abrams Books for Young Readers) and Tomás Jiménez, Associate Professor of Sociology and Director of Stanford’s Chicana/o-Latina/o Studies.
Registration is $25 and includes breakfast, lunch, and a copy of the book Pancho Rabbit and the Coyote by Duncan Tonatiuh. Register for the workshop at http://tinyurl.com/ncks8sf by January 12, 2015.
TBA
Stanford University
Duncan Lawrence
Encina Hall
616 Serra Street
Stanford, CA 94305
Marketing for Good: Providing health care to consumers in the developing world
About the topic: PSI is a global social marketing NGO that approaches clients as consumers in 60 developing countries. What do the private sector and marketing have to teach us about saving and improving the lives of the most vulnerable? A lot, it turns out.
About the speaker: Karl Hofmann is the President and CEO of PSI (Population Services International), a non-profit global health organization based in Washington, D.C. PSI operates in 60 countries worldwide, with programs in family planning and reproductive health, malaria, child survival, HIV, maternal and child health, and non-communicable diseases. Prior to joining PSI, Mr. Hofmann was a career American diplomat. He served as U.S. Ambassador to the Republic of Togo, and Executive Secretary of the Department of State.
Cosponsors: Stanford School of Medicine, Stanford Center for Innovation in Global Health, Stanford Center for International Development
Felter: Insurgents attack aid programs to undermine governments
Research by CISAC's Joseph Felter shows that insurgents try to derail government-delivered aid programs in poor areas because they fear successful programs will boost the government's credibility. Preventive measures include providing greater security around aid projects and limiting advance knowledge about them.
A research paper, published in the American Economic Review, involved an analysis of a large community-driven development program in the Philippines. In 2012, the World Bank supported more than 400 of these projects in 94 countries with about $30 billion in aid.
Conventional wisdom assumes that development aid is a tool to help reduce civil conflict. But some aid projects may actually exacerbate the violence, the research showed.
In an interview, Joseph Felter, a senior research scholar at Stanford's Center for International Security and Cooperation, said, "A 'winning hearts-and-minds' strategy for disbursing development aid may lead to an increase in insurgent attacks in the world's poorest areas. The study's takeaway is not to stop aid delivery, but to appreciate and plan for the possibility of unintended consequences."
Felter co-wrote the article, "Aid Under Fire: Development Projects and Civil Conflict," along with Benjamin Crost of the University of Colorado-Denver and Patrick Johnston of the RAND Corporation. Their research relied on conflict data from the Philippines military from between 2002 and 2006 that allowed them to precisely estimate how the implementation of aid affected violence levels in ongoing insurgencies against the government.
Spotlight on the Philippines
These issues are particularly important in poor and conflict-ridden countries like the Philippines, Felter said. The Philippines is home to some of the most protracted insurgencies in the world. Islamic separatist groups struggle for an independent Muslim state; a communist group continues to wage a classic Maoist revolutionary war; and the extremist Abu Sayyaf Group conducts kidnappings and terrorist attacks.
The aid program Felter and his colleagues studied was the Kapit-Bisig Laban sa Kahirapan Comprehensive Integrated Delivery of Social Service – or KALAHI-CIDSS – the largest of its kind in the Philippines. Through it, poor communities receive projects to address their most pressing needs. According to Felter, this typically involved funding for projects like roads, schools, health clinics and other infrastructure.
"This is government funding for projects that citizens in these areas have expressly asked for," Felter said.
The researchers noted that community-driven development projects, also known as "CDD" projects, are popular because evidence suggests they enhance social cohesion among citizens. But sometimes they draw the wrong kind of attention from anti-government groups, as the research illustrated.
Felter and his colleagues found an increase of 110-185 percent in insurgent attacks in communities where aid projects commenced, the authors wrote. If this effect is extrapolated across all of the Philippines' municipalities, the authors estimate that the program resulted in between 550 and 930 additional casualties during three years.
"Taken together, this detailed evidence sheds new light on the mechanisms that link aid and conflict, which may eventually help design more effective aid interventions that alleviate poverty without exacerbating conflict," they wrote.
When the insurgent groups destroy such a project, it has the effect of weakening the perception that the government can actually deliver on community projects, the scholars wrote. For example, the communist rebels in the Philippines have issued public statements denouncing the KALAHI-CIDSS program as "counterrevolutionary and anti-development." If a successful aid program shifts the balance of power in favor of the government, it reduces insurgents' bargaining power and their political leverage.
As a result, insurgents tended to engage in conflict in the earlier stages of a project in order to keep it from succeeding, according to the research. In fact, conflict increased when municipalities were in the early or "social preparation" stages of publicizing an aid program, Felter and his colleagues wrote.
Sometimes rebel groups divert aid to fund their own operations – aid shipments are often stolen or "taxed" by these groups, according to the paper.
The Next Step
What can be done to prevent attacks?
"Greater security around the aid projects and limiting advance knowledge of the particular projects are good measures to start with," Felter said.
He noted that governments and aid organizations need to be discreet in how they identify aid projects and their locations, and how they disburse the aid itself. More research on this issue needs to be done, Felter said.
"One lesson is not to give insurgents too long a lead time to plan attacks," he said.
Unfortunately, as the researchers noted, poverty and violence are often linked: "The estimated one-and-a-half billion people living in conflict-affected countries are substantially more likely to be undernourished, less likely to have access to clean water and education, and face higher rates of childhood mortality."
Continued progress – in the form of international aid – is urged toward eradicating poverty. "To help achieve this, governments and multilateral donor organizations are increasingly directing development aid to conflict-affected countries worldwide," Felter and his co-authors pointed out.
Felter, also a research fellow at Stanford's Hoover Institution, retired from the U.S. Army as a colonel in 2012 following a career as a Special Forces and foreign area officer. He has conducted foreign internal defense and security assistance missions across East and Southeast Asia and has participated in combat deployments to Panama, Iraq and Afghanistan. In 2010-11, he commanded the International Security and Assistance Force Counter Insurgency Advisory and Assistance Team in Afghanistan.
"I saw this dynamic (insurgent attacks on aid projects) firsthand in Afghanistan and Iraq. This research paper confirms it," Felter said.
He devoted much of his Stanford doctoral dissertation and his work at CISAC and Hoover to build what he hopes will be the largest and most detailed micro-conflict database – the Empirical Studies of Conflict – ever assembled.
Felter said there is only so much that the military can do to win over people in areas ravaged by war and conflict.
"The military can 'lease' hearts and minds by creating a safe environment for aid projects," he said, "but ultimately it's up to the government to win them over."
Katy Long
Encina Hall
Katy Long's research focuses on migration, citizenship and refugee issues, especially responses to long term crisis and conflict -- both by the international humanitarian and political communities and by refugees and migrants themselves. Although her work looks at global policy implications, she has carried out detailed fieldwork in Guatemala, Rwanda and Uganda.
Katy has written extensively on these topics, and in 2013 The Point of No Return: Refugees, Rights and Repatriation -- a monograph based on her Ph.D research into "durable solutions" to refugee crises (Cambridge, 2009) -- was published by Oxford University Press. Prior to taking up posts at Oxford, the London School of Economics and Edinburgh University she worked for the United Nations High Commission for Refugees' (UNHCR) Policy Development and Evaluation Service in Geneva, writing on a number of issues including opening up labour migration routes for refugees, border closures and out-of-country voting. She is also co-editor of The Oxford Handbook of Refugee and Forced Migration Studies (OUP, 2014), the first comprehensive guide to refugee studies scholarship.
Katy also enjoys engaging in public discussions and debate on migration and humanitarian issues: she runs the website migrantsandcitizens.org and tweets as @mobilitymuse. Her work has also appeared at Open Democracy, The Conversation, Democracy in Africa, and Africa@LSE, as well as BBC World Service, ITV and Channel 4. She is also the author ofThe Huddled Masses: Immigration and Inequality, a short accessible ebook.
While at FSI Katy is also working on a new project that considers how the sale of citizenship for money -- on both the legal and black markets -- affects our understandings of political community and freedom of movement.