Stanford Health Policy's Paul Wise — the Richard E. Behrman Professor of Child Health and Society — traveled to Iraq last year with a small delegation of physician-academics to evaluate the World Health Organization's system to treat civilians injured in the battle for Mosul. The northern city controlled by the Islamic State in 2014 was retaken by government forces last year and the team visited field hospitals to review health care on the ground and determine whether there is a better way to distribute medical aid during armed conflict.

We wrote about their visit in November.

Now, the team members have published their findings in an in-depth report put out by Johns Hopkins University's Center for Humanitarian Health.

The Lancet also has published an editorial about their research to coincide with the release of the report.

"The Battle of Mosul provides an important case study for what might be to come," the editorial board wrote. "Above all, this should be a very rare occurrence, and The Lancet echoes the evaluation's recommendation that governments, and possibly their allies, must ensure their militaries can fulfill the obligations of protection and care for wounded citizens under the Geneva Conventions. However, in modern warfare, access to the injured may increasingly be one-sided when fighting against warring factions that see health workers and civilians as acceptable targets of war. Governments should be prepared to face this eventuality. To be able to continue providing the best standards of care and saving lives, a high-level meeting must urgently be organized to examine and answer this question: are the humanitarian principles as they are defined today still relevant for this changing warfare?"

Some of the key findings of the report include: 

• Between 1500-1800 lives, both military and civilian, may have been saved through this trauma response.
• By attempting to apply Western military standards of trauma care and ‘moving forward’ towards the frontline to save civilians lives, WHO and its partners challenged existing humanitarian principles, particularly those of neutrality and independence.
• The Iraqi government and its military did not have medical capacity to fulfill their obligations to protect and care for wounded civilians on the Mosul battlefield, and the U.S.-led coalition did not provide substantial medical care for wounded civilians.
• WHO-supported field hospitals filled important gaps in trauma surgical care, while post-operative and rehabilitative care warranted greater support.
• Successful coordination among local leaders, partners, and civilian and military officials occurred, but field coordination could have been better resourced.

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And some of the key recommendations:

• Warring factions, and those supporting them, need to enhance the former’s medical capacities to ensure they can fulfill their obligations under the Geneva Conventions and Additional Protocols.
• Deliberation is needed regarding the benefits to and the moral obligations of governments who support such warring factions, like the U.S.-led coalition in the Mosul battle.
• Humanitarians must take care to avoid being instrumentalized by governments or military in future conflicts.
• Medical teams operating directly with a combatant force should not be identified as humanitarian;
• Frontline medical services could be provided by specialized groups explicitly trained to work directly with combatant forces, possibly contracted as military support services focusing on providing frontline medical services for both injured soldiers and civilians.
• Using private medical organizations (i.e., contractors) to provide humanitarian services in conflict settings needs further study. 
• How humanitarian actors can apply standards of trauma care that compel them to move towards the frontline to save lives, and still adhere to longstanding humanitarian principles, needs debate at senior levels such as at the Inter Agency Standing Committee or at the intergovernmental level.

Screening all adults for hepatitis C virus infection (HCV) is a cost-effective way to improve clinical outcomes of HCV and identify more infected people compared to current recommendations, according to a new study by SHP’s Joshua Salomon and colleagues.

Using a simulation model, Salomon, a professor of medicine and core faculty member at Stanford Health Policy, and researchers from Boston Medical Center (BMC) and Massachusetts General Hospital (MGH) found that this expanded screening would increase life expectancy and quality of life while remaining cost-effective.

The infectious disease primarily attacks the liver. It is believed that one-in-30 Baby Boomers — born between 1945 and 1965 — have HCV, but don’t even know it because it can take years before symptoms emerge. The Centers for Disease Control and Prevention currently recommends HCV testing for boomers, but testing rates in this group remain relatively low, and recent trends show a higher incidence rate of HCV among young people.

“Testing all adults would lead to earlier diagnosis and treatment for many people, which would help to prevent cirrhosis and other long-term complications,” says Salomon, co-senior author of the study published in Clinical Infectious Diseases. “Overall, when you consider both the better health outcomes and the reduced costs of managing long-term liver disease, expanded testing offers excellent value for money.”

To address the potential benefits of changing the testing recommendations, the researchers created simulations to estimate the effectiveness of HCV testing strategies among different age groups. They compared effects of the current testing recommendations; of testing people over 40 years old or over 30 years old, and of testing all adults over 18 years old. All strategies included the current recommendations for targeted testing of high-risk individuals, such as people who inject drugs.

The study found that screening all adults would identify more than 250,000 additional people with HCV, increase cure rates from 41 to 61 percent, and reduce death rates for HCV-attributable diseases more than 20 percent, compared with current recommendations.

“When we expanded testing, the results were compelling,” says Joshua Barocas, lead author on the study and an infectious disease physician at MGH and an instructor in medicine at Harvard Medical School. “Changing the current recommendations could have a major public health impact, improving the quality of life for young people with HCV, and reducing death rates.”

The research team used data from national databases, clinical trials, and observational cohorts to inform their simulation models, which captured the details and dynamics of U.S. population demographics and HCV epidemiology.

All of the age-based strategies decreased costs related to managing chronic HCV and advanced liver disease, but the strategy of testing all adults was most effective. Even in a simulated scenario that required twice as much testing among uninfected people to identify the same number of HCV cases, the testing-all-adults strategy remained cost-effective.

Researchers say these findings should be considered by the CDC for future recommendations on HCV testing.

“Due in part to the opioid epidemic and the increase in injection drug use, the country has seen an increase in cases of HCV among young people,” says Benjamin Linas, MD, co-senior author of the study and infectious disease physician at BMC and an associate professor of medicine at Boston University Medical Center. “The CDC could address this public health concern by recommending all adults receive a one-time HCV test.”

The study was published online in Clinical Infectious Diseases and was funded by the National Institute on Drug Abuse at the National Institutes of Health, the MGH Fund of Medical Delivery and the U.S. Centers for Disease Control and Prevention.

At age 94, with an extensive collection of health policy research and publications under his belt, Victor Fuchs has a lot to say about the health care system.

The high cost. The uninsured. The fragmentation.

During a speech at the Stanford Institute for Economic Policy Research (SIEPR), the pioneering health economist narrowed his gaze to whether a single-payer system is the fix to those problems.

The answer is complicated, and it depends on the questions behind the question, said Fuchs, a SIEPR Senior Fellow and the Henry J. Kaiser, Jr., Professor of Economics and Health Research and Policy, emeritus. He is also a senior fellow at the Freeman Spogli Institute for International Studies and a core faculty member at Stanford Health Policy.

Recent challenges to the Affordable Care Act have rekindled a debate over the merits of a single-payer health care system — where one entity, namely the federal government, would foot the bill for essential services for all — and Fuchs spoke at SIEPR to succinctly explain what a single-payer system could achieve, what would probably never happen, and why.

The problem, Fuchs pointed out, is that the United States spends the most of any high-income country on health care, yet Americans are not achieving better health outcomes. Part of the solution would have to address the nation’s higher administrative costs, higher prices for prescription drugs, and the expensive increasing mix of services and specialists.

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Fuchs contended a single-payer system would lower costs. For one, it would create the bargaining power needed to offset the monopolistic powers of those providing the drugs, medical services and equipment.

To control costs, “we must move to something like a single-payer plan, but that alone will not be sufficient,” Fuchs said. “It will depend on what kind of single-payer plan it is.”

Even as it provides for universal health care insurance coverage, a single-payer system could take on various forms, including a blend of private and public controls.

And to have any chance at success, Fuchs said, the single-payer system would have to be simple, require minimum bureaucracy, and provide choice.

Then comes the rub, of course: The political will has historically tread against single-payer.

Americans are not willing to provide subsidies for those too poor to afford health insurance; neither do they have a compulsion for everyone to acquire coverage and contribute to those subsidies.

“The country as a whole has not been willing to fully embrace these two principles,” he said. “And I feel you need to have a strong majority of both if you’re going to have universal coverage.”

And unfortunately, Fuchs added, he does not believe universal health coverage would necessarily improve health outcomes. Many other socio-economic and environmental factors also play a role there.

In leading a brief discussion with Fuchs, Mark Cullen, a SIEPR Senior Fellow and professor of medicine, asked what makes him think the federal government would work to control costs under a single-payer system — when it has thus far chosen to exert little buying power under the current structure.

“I have not discussed the political feasibility of this, deliberately,” Fuchs quipped.

You can learn more about Fuchs’ viewpoint in The Journal of the American Medical Association.

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Interventions designed to improve primary care management of diabetes and reduce avoidable hospital admissions show promise for saving healthcare resources without compromising quality of care. These are the findings made by an international research team’s study of four East Asian sites.

With a fourfold increase in global diabetes prevalence over the past thirty-five years (2016 Lancet report), countries are increasingly experiencing the dual health challenges of chronic noncommunicable diseases and aging populations. An estimated 12 percent of global health expenditures in 2015 was for diabetes-related services.

The study, published in the November issue of Health Affairs, examined policy interventions in Japan, Singapore, Hong Kong, and rural and peri-urban Beijing; by increasing access and adherence to effective outpatient management, the interventions potentially improved health outcomes while realizing cost savings from reduced avoidable hospital admissions.

“This article represents the first publication in a series of research collaborations under the Stanford AHPP-led comparative diabetes net value project,” said Karen Eggleston, Asia Health Policy Program Director and one of the article’s authors.  “We are assembling and analyzing rich patient-level datasets, using diabetes as a lens to explore ‘value for money’ in chronic disease management. “

Eggleston also noted that additional research teams have joined since the publication. The authors look forward to contributing evidence for improved health policy in different institutional contexts and for health systems adapting to rapidly aging populations. 

Read the study (may require subscription)