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.

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On May 27, 2016, President Obama will become the first sitting president to visit Hiroshima. In light of this historic visit, SPICE hosted a webinar on May 23, 2016, which featured the talk, “Beneath the Mushroom Cloud,” by Clifton Truman Daniel, grandson of President Harry S. Truman and author of Growing Up with My Grandfather: Memories of Harry S Truman. Following a question and answer period with Mr. Daniel, SPICE staff shared classroom resources (Sadako’s Paper Cranes and Lessons of Peace and Divided Memories) that introduced diverse perspectives on the atomic bombing of Hiroshima.

RELATED CLASSROOM RESOURCES

Hiroshima: Perspectives of the Atomic Bombing
Divided Memories: Comparing History Textbooks
Examining Long-term Radiation Effects
Nuclear Tipping Point (video)
Sadako's Paper Cranes and Lessons of Peace
Reflections from an Atomic Bomb Survivor (video)

This webinar is being offered in collaboration with the National Consortium for Teaching about Asia, which is funded by the Freeman Foundation. The NCTA is a multi-year initiative to encourage and facilitate teaching and learning about East Asia in elementary and secondary schools nationwide.

If provoked, many Americans might well back nuclear attacks on foes like Iran and al Qaeda, according to new collaborative research from CISAC senior fellow Scott Sagan and Dartmouth professor Benjamin Valentino.

You can read more about their latest public opinion polling data, and its implications for the debate surrounding President Obama's upcoming visit to Hiroshima, in a column they co-authored for the Wall Street Journal.

On February 12, 2016, the Stanford Program on International and Cross-Cultural Education (SPICE) and Stanford Live (in collaboration with the National Consortium for Teaching about Asia) co-hosted a teacher professional development seminar that focused on the Silk Road. The seminar was held just prior to a Stanford Live performance by the Silk Road Ensemble at Stanford Bing Concert Hall on February 24, 2016 and a student matinee on February 25, 2016. Made up of performers and composers from more than 20 countries, the Silk Road Ensemble was formed under the artistic direction of Yo-Yo Ma in 2000.

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Jonas Edman (SPICE) and Ben Frandzel (Stanford Live) organized the day-long seminar. The morning featured a two-part lecture by Professor Emeritus Albert E. Dien, Stanford University. Part one focused on a general overview of the history and geography of the Silk Road and part two focused on a specific introduction to the religions along the Silk Road. Dr. Dien highlighted religion as an example of the many ways that the Silk Road helped to facilitate cultural exchange for millennia, resulting in the tremendous diversity one witnesses today in the region.

The afternoon featured a presentation and performance by composer and santur player Faraz Minooei, and a curriculum demonstration by SPICE staff. Minooei gave an overview of how the Silk Road played a role in the transmission of musical tradition, and also shared his personal story from his birth and childhood in Tehran, his immigrant experience in the United States, and his musical discoveries along the way. In particular, he shared his reflections on his deep spiritual desire to study music, seeing music as an “unexplainable souvenir from the eternal truth.”

Reflecting on Minooei’s presentation, Frandzel commented, “Faraz’s presentation really embodied the ways in which the Silk Road’s tradition of cultural exchange is a living story that continues to this day. His performances of Persian classical music and of his own compositions were entrancing, ear-opening experiences. As Faraz discussed his background and the musical forms that feed into his current work, his personal history and music seemed to encapsulate, in a fast-moving way, the kinds of cultural mixing that would have happened along the historic Silk Road. In our teacher workshops, we aim to provide teachers with arts-based teaching tools, and also to provide a larger social and cultural context for the art forms under discussion. The wonderful opportunity to partner with SPICE on the workshop, and the presence of this fascinating and brilliant musician, made this so much more possible.”

The curriculum demonstration was led by Rylan Sekiguchi, Naomi Funahashi, and Johanna Wee, who introduced both print- and web-based materials from the curriculum unit, Along the Silk Road, which were developed in collaboration with the Silk Road Ensemble and Dr. Dien. The 20 teachers in attendance interactively engaged with the materials and each received a complimentary copy of the curriculum unit as well as a large wall map of the Silk Road. The development of such materials has been a hallmark of SPICE for 40 years. The materials help to make content from teacher professional development seminars accessible to students.

Following the seminar, Edman reflected, “It is always such a pleasure to share with teachers the curriculum we produce here at SPICE. And to be able to collaborate with Stanford Live on a professional development workshop in conjunction with the Silk Road Ensemble’s visit to Stanford was a wonderful opportunity and experience. The Silk Road—with its themes of cross-cultural communication, exchange, and understanding—seems like an ideal topic for middle school students trying to understand today’s globalized world. We hope the speakers and pedagogical strategies and materials shared at the workshop will help teachers bring the topic to life in the classroom!”

My daughter, Emily, was teaching English at a middle school in Asahi City, Chiba Prefecture, on the Japan Exchange and Teaching (JET) Program when the 2011 Tohoku earthquake struck on March 11, 2011. Tohoku is a region in the northeast portion of the island of Honshu, the largest island in Japan. Though Asahi City, a coastal city, is not in the Tohoku region, it was still heavily damaged by the resulting tsunami. Several of Emily’s students lost their homes. She was emotionally shaken, of course, but was fortunate not to sustain any injuries.

With the fifth anniversary of the 2011 Tohoku earthquake and tsunami approaching, I have been reflecting upon the tremendous anxiety that I felt that day about Emily’s safety, my wife’s family in Tohoku, and the people of Japan in general. My reflections deepened last week while observing the interaction of SPICE’s Reischauer Scholars Program (RSP) students (American high school students studying about Japan) with SPICE’s Stanford e-Japan students (Japanese high school students studying about the United States) in an informal online “social hour.” The RSP and Stanford e-Japan are distance-learning courses that are offered by SPICE.

Stanford e-Japan instructor Waka Brown and RSP instructor Naomi Funahashi organized the social hour to help to build bridges between youth in Japan and the United States. During the latter part of the social hour, RSP student, David Jaffe (Mesa, Arizona), posed the question, “How is 3.11 remembered today?” Among the many Stanford e-Japan students who spoke was Minoru Takeuchi (Sakura City, Chiba Prefecture), who stated, “When the earthquake happened, I was an elementary school student (12 years old). I still remember very well… at that time, I was in school. Some students were very afraid and crying… Maybe after the earthquake, many Japanese noticed the importance of working together, the preciousness that they could meet their friends…” The Japanese students’ sharing of their experiences related to 3.11 extended the social hour far beyond the hour, and the gratitude expressed by the American students to their counterparts in Japan flowed for many minutes in a text-chat box.

Observing the students was one of the most rewarding experiences of my career at SPICE. The Japanese students’ remembrances of 3.11 brought back poignant and difficult memories for me but also provided me with hopeful thoughts on the future of the U.S.–Japan relationship as I witnessed students from across the Pacific forming budding friendships and discussing topics of mutual relevance.
 

Resources for the classroom
 

My hope is that teachers will carve out some time in their curriculum to engage their students in a study of 3.11 as well as its legacies. The study of natural hazards ought to be a core part of school curriculum. SPICE has undertaken many curricular projects related to 3.11. I would recommend that teachers show the film, After the Darkness, which was produced by Risa Morimoto and Funahashi. After the Darkness is a documentary film that touches upon the events of the disaster itself but also focuses on the experiences of two survivors in particular. It is accompanied with free curricular lessons that are accessible to students of various ages. I also recommend a lecture by Professor Emeritus Daniel Okimoto, Stanford University, on “Japan’s Geological Factors,” which is accompanied by a free lesson plan. Another recommended curricular unit is SPICE’s Examining Long-term Radiation Effects, which was produced prior to 3.11 but can help students understand the radiation-related concerns following the Fukushima Daiichi nuclear disaster. In addition, the film, Live Your Dream: The Taylor Anderson Story, is about one of two American JET Program teachers who lost their lives during 3.11. SPICE developed a teacher’s guide for the film that can be freely downloaded from the Live Your Dream: The Taylor Anderson Story website. Lastly, I recommend the use of the films from the 113 Project in classrooms. Earlier this week, I moderated a panel discussion that included Wesley Julian (director of the 113 Project), Andy Anderson (father of Taylor Anderson and board member of the Taylor Anderson Memorial Fund) as well as other Americans and Japanese who continue to contribute to relief efforts in the Tohoku region.

A substantial share of all malpractice claims in the United States is attributable to a small number of physicians, according to a study led by researchers at Stanford University and the University of Melbourne.

The team found that just 1 percent of practicing physicians accounted for 32 percent of paid malpractice claims over a decade. The study also found that claim-prone physicians had a number of distinctive characteristics, such as practicing specialities that are riskier than others.

“The fact that these frequent flyers looked quite different from their colleagues — in terms of specialty, gender, age and several other characteristics — was the most exciting finding,” said David Studdert, professor of medicine and of law at Stanford. “It suggests that it may be possible to identify high-risk physicians before they accumulate troubling track records, and then do something to stop that happening.”

Studdert is also a core faculty member at Stanford Health Policy and the lead author of the study published in The New England Journal of Medicine.

Concentrated among a small group

“The degree to which the claims were concentrated among a small group of physicians was really striking,” added Studdert, an expert in the fields of health law and empirical legal research.

The researchers analyzed information from the U.S. National Practitioner Data Bank, a data repository established by Congress in 1986 to improve health-care quality. Their study covered 66,426 malpractice claims paid against 54,099 physicians between January 2005 and December 2014.

Almost one-third of the claims related to patient deaths; another 54 percent related to serious physical injury. Only 3 percent of the claims were litigated to verdicts for the plaintiff. The remainder resulted in out-of-court settlements. Settlements and court-ordered payments averaged $371,054.

“The concentration of malpractice claims among physicians we observed is larger than has been found in the few previous studies that have looked at this distributional question,” said Michelle Mello, a co-author of the study and professor of law and of health research and policy at Stanford.

“It’s difficult to say why that is,” Mello added. “The earlier estimates come from studies of single insurers or single states, whereas ours is national in scope. Also, the earlier numbers are more than 25 years old now, and claim-prone physicians may be a bigger problem today than they were then.”

Encouraging greater awareness

The authors recommend that all institutions that handle large numbers of patient complaints and claims develop a greater awareness of how these events are distributed among clinicians.

“In our experience, few do,” they write in the paper. “With notable exceptions, fewer still systematically identify and intervene with practitioners who are at high risk for future claims.”

The most important predictor of incurring repeated claims was a physician’s claim history. Compared to physicians with only one prior paid claim, physicians who had two paid claims had almost twice the risk of another one; physicians with three paid claims had three times the risk of recurrence; and physicians with six or more paid claims had more than 12 times the risk of recurrence.

“Risk also varied widely according to specialty,” the authors noted. “As compared with the risk of recurrence among internal medicine physicians, the risk of recurrence was approximately double among neurosurgeons, orthopedic surgeons, general surgeons, plastic surgeons and obstetrician-gynecologists.”

The lowest risks of recurrence occurred among psychiatrists and pediatricians.

Male physicians had a 40 percent higher risk of recurrence than female physicians, and the risk of recurrence among physicians younger than 35 was about one-third the risk among their older colleagues, the study found.

“If it turns out to be feasible to predict accurately which physicians are going to become frequent flyers, that is something liability insurers and hospitals would be very interested in doing,” Studdert said.

“But institutions will then face a choice,” he added. “One option is to kick out the high-risk clinicians, essentially making them someone else’s problem. Our hope is that the knowledge would be used in a more constructive way, to target measures like peer counseling, retraining, and enhanced supervision. These are interventions that have real potential both to protect patients and reduce litigation risks.”

Other stories about the study:

The New York Times Well Blog

The Huffington Post

KQED Public Radio

U.S. News & World Report

CBS News

Reuters

Medscape