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Global Health, Health Disparities, Health Policy, Patient Care, Public Health, Surgery

Billions lack surgical care; report calls for change

Billions lack surgical care; report calls for change

In this country, we take it for granted that we will have access to needed surgeries, whether it’s the repair of a broken leg or an operation to remove an infected appendix or a malignant tumor. But for as many as 5 billion people – or two-thirds of the world’s population – these basic procedures are out of reach.

A major new report by the Lancet Commission sheds light on this enormous surgery gap and argues that building surgical infrastructure in low- and middle-income countries is critical both from an economic, as well as a human, perspective.

“Surgery hasn’t been part of the dialogue with respect to health system strengthening. It’s been a hugely neglected item,” said Stanford trauma surgeon Thomas Weiser, MD, who contributed to the 58-page report. The commission includes 25 leading experts from the fields of surgery and anesthesia, with contributions from more than 110 countries.

In its report, the commission notes that in 2010, nearly one-third of all deaths (16.9 million) were attributable to conditions readily treated by surgery, such as appendicitis, hernia, fractures, obstructed labor, congenital abnormalities and breast and cervical cancer. That is more than the number of deaths from HIV/AIDS, tuberculosis and malaria combined. And although there have been many gains in global health in the last 25 years, the quality and availability of surgical services in many regions have stagnated or declined, while the demand for surgery continues to rise.

“The global community cannot continue to ignore this problem – millions of people are already dying unnecessarily, and the need for equitable and affordable access to surgical services is projected to increase in the coming decades, as many of the worst affected countries face rising rates of cancer, cardiovascular disease and road accidents,” said Lars Hagander, MD, of Lund University in Sweden and one of the lead authors.

Weiser and his colleagues provide new estimates of the global shortfall, calculating that some 143 million additional surgeries are needed to save lives and prevent disability, with the largest number of neglected patients living in South Asia (57.8 million), East Asia (27.9 million) and southern sub-Saharan Africa (18.9 million).

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Events, Health Disparities, Medical Education, Medicine and Society, Public Health

An ounce of action is worth a ton of theory: Med student encourages community engagement

An ounce of action is worth a ton of theory: Med student encourages community engagement

IMG_0775Right after graduating from Stanford, Steve (Suk) Ko moved to East Palo Alto with some friends who were also recent graduates. They put all their effort into becoming engaged in their new community, starting and running a tutoring program out of their apartment – which could get really crowded, judging by the pictures he showed last week while speaking to undergraduates interested in public health.

Soon after making East Palo Alto his new home, Ko started medical school at Stanford and continued his service work throughout. “We at Stanford are good at thinking and debating, but less good at action,” Ko said during this talk. “I felt some guilt about indulging in socioeconomic affluence when there was this community right next door.”

Ko’s talk was part of the Primary Care, Public Health, and Health Disparities Lecture Series sponsored by Stanford’s Center of Excellence in Diversity in Medical Education, which aims to produce leaders who can eliminate national-health inequities. Ko shared his personal experience and offered three points of advice:

1). Never lose what makes you special. 

If you’re thinking about how to improve public or global health, “don’t fake it – do what you’re passionate about.” This will lead you in the right direction. As for medical school applications, there are all kinds of ways to have a “research background,” he said.

For Ko, a Korean ethic of hard work and his Christian faith enabled his interest, experiences, and goals in public health. During an undergraduate service learning trip to Oaxaca, Mexico, he shadowed an OB/GYN at a public hospital and was moved both by the beauty of birth and the limited opportunities these newborns faced. Born resource poor and in a society with high gender inequality, “this baby girl had not made a single choice, but 99 percent of her life was already decided,” Ko said. He wanted to think about health in a broader context.

2). An ounce of action is worth a ton of theory.

Last summer, Ko implemented a 5-week summer meal program in East Palo Alto that served kids and their families. The suggestion to focus on food insecurity came from Stanford pediatrician Lisa Chamberlain, MD, Ko’s mentor. The YMCA, Stanford Medicine, and Revolution Foods supported the project, which served 270-370 kids and 4-30 adults every day, and provided a total of 2,525 take-home meals. Ko said it’s “like pulling teeth” to get kids to eat healthy food, but shaping tastes early is key to forming long-term habits. The team ran both quantitative and qualitative analyses of the program, gathering insights like that families are hungrier in bad weather because those who work outdoors or in construction cannot earn money, and that libraries could be great food distribution points.

One of Ko’s most rewarding recent memories was when several of the high-school students he works with made a documentary film about East Palo Alto. They wanted to challenge its unfair portrayal in the news media – although it had the highest homicide rate in the country in 1992, gentrification is now starting to be a bigger problem than crime. “The 90’s were a long time ago,” the students pointed out.

3). Community engagement is difficult, and therefore a privilege.

It was very hard for Ko to gain the trust of his adult neighbors (he says kids are easy: just smile at them). After living there for years, he felt gratified last week when he was ill and a neighbor brought him soup. Trust comes slowly; you have to prove you’re there for the long haul. Even so, circumstances are just hard – what do you do when a student tells you a family member just died from gang violence? Ko coped with the emotional and physical difficulty through his faith and by finding joy in the process, not the outcomes.

One of the audience members asked a question about “white knight syndrome” – the problematic idea that someone from a different community is able (and welcome) to storm in and fix everything. Ko agreed that good intentions can hurt vulnerable people. Temporary involvement doesn’t require accountability and invites the community to be jaded and skeptical, focusing on the impact of the last person/organization. For this reason, it can be much better to join an existing project than to start a new one, he said. But above all, Ko favors humility and a sense of wonder, not just going in and”fixing it”.

Previously: A quiz on the social determinants of health, Stanford researchers use yoga to help underserved youth manage stress and gain focus, Med students awarded Schweitzer Fellowships lead health-care programs for underserved youth, Nutrition and fitness programs help East Palo Alto turn the tide on childhood obesity and Doctors tackling child hunger during the summer
Photo, of Steve Ko (right) and Marcella Anthony of Stanford Medicine’s Community Outreach, by Andrea Ford

 

Events, Global Health, Health Disparities, Pediatrics, Stanford News

Countdown to Childx: Global health expert Gary Darmstadt on improving newborn survival

Countdown to Childx: Global health expert Gary Darmstadt on improving newborn survival

newborn-IndiaEach year, around the world, almost 3 million babies die in the first month of life. But it doesn’t have to be that way: For many newborns, simple changes in their care could make the difference between life and death.

I spoke about this conundrum recently with global health expert Gary Darmstadt, MD, who will be among the panelists at this week’s Childx conference at Stanford. Darmstadt, who recently arrived at Stanford from the Bill & Melinda Gates Foundation, has focused much of his career on improving newborn health in developing countries. The key, he says, is engaging community members as full partners in creating the solutions for how to care for newborns. Excerpts of our conversation appear below.

Registration for the Childx conference is still open, and those who can’t attend in person can watch the conference’s live stream at the Childx website.

Preterm birth has just passed pneumonia as the No.1 cause of death, worldwide, for children under age 5, and yet many deaths from prematurity could be prevented with simple, low-tech interventions. What needs to change?

We’ve known since the late 1970s that kangaroo mother care, in which the mother keeps the infant on her chest next to her skin, is very effective. But the rate of adoption has been very poor, about 5 percent globally in 35 years.

It was originally conceived as a substitute for an incubator: By holding babies skin-to-skin you provide a constant source of warmth. What I think happened was that, by making kangaroo mother care a medical intervention rather than a natural behavior, we’ve stigmatized it. Mothers may think, “If I was a rich person, my baby would be in an incubator. Being a provider of kangaroo mother care tells me something about me and my baby: We’re second class.”

We need to communicate that kangaroo mother care is for every baby, everywhere. It’s not just something that poor people get if there aren’t enough incubators. Yes, there are situations where an incubator is helpful, but in many ways kangaroo mother care is superior. An incubator can’t provide a mother’s heartbeat or the feel of her breathing, her voice and her touch. It can’t provide breast milk. It’s not something you form a bond with that lasts for a lifetime. People have picked up the message that the medical device is superior, and they may feel like “I’m an inferior version of a medical device” rather than understanding that the medical device is, for many babies, an inferior attempt to produce what the mother or other family members can provide.

What are some key examples from your research of how social and environmental approaches can help improve infants’ health and survival?

I’m part of a team that worked closely with communities in India to understand how they perceive newborns’ needs and their issues in dealing with them. From there, we developed a simple package of preventive care. It consisted of things like holding babies skin-to-skin, breastfeeding, keeping infants warm, and basic hygiene. Once it was implemented, we saw a 50 percent reduction in neonatal mortality over a 16 month period.

We found, for example, that these communities had no real concept that hypothermia was bad for babies. They had a term for fever and understood that fever was a danger signal, but didn’t have a word that brought the connotation of harm or danger together with cold for babies. When we realized that, the community ended up coming up with a term – they called hypothermia “cold fever.” It created a whole new dialogue around hypothermia, and new openness to trying things that might be helpful to your baby, particularly skin-to-skin care.

What we really sought to do was to bring the science into language that was simple and related to their everyday experience. So the messaging became, “In the same way that when you bathe in the river, when you come out, you feel cold and wrap yourself in a sari, when a baby is born, it’s wet and feels cold, and we need to wrap up the baby for the baby’s protection.” Without understanding the social construct, the environment, we couldn’t come up with those simple messages that would become part of the social fabric.

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Events, Global Health, Health Costs, Health Disparities, Health Policy, Stanford News

Global health expert: Economic growth provides opportunity to close the “global health gap”

Yamey talkStanford’s Center for Innovation in Global Health hosted a recent seminar for Stanford students and faculty with global health-policy expert Gavin Yamey, MD, MPH. The discussion focused on the disparity in heath care between higher- and lower-income countries and how economic growth in lower-income countries could set the stage for big improvements in global health.

During the talk, Yamey explained that millions of lives could be saved if economic gains in low- and lower-middle-income countries were invested in health care. “I can’t think of any other investment on the planet that could improve human welfare in such a huge way,” Yamey told the audience.

As described in an online story on the event, Yamey cited Rwanda – a country that rebuilt its economy and healthcare after the 1994 genocide – as an example of how this scenario could play out elsewhere:

Over the past decade, Rwanda has experienced significant drops in mortality associated with HIV, malaria and maternal death, and achieved the greatest drop in child mortality rates in recorded history. While scholars acknowledge several factors that contributed to such an extraordinary rebound, government spending on public health, the smart use of aid, and economic growth were all integral to the equation.

“We have an extraordinary opportunity to bring down maternal, newborn and infectious disease deaths to universally low levels everywhere,” Yamey said. “But for that to happen, we need an aggressive scale up of existing tools and interventions, investment in new tools and a build-up of delivery systems.”

Previously: Minimum wage: More than an economic principle, a driver of healthHealth care in Haiti: “At risk of regressing”Child-mortality gap narrows in developing countries and Stanford general surgeon discusses the importance of surgery in global health care
Photo, of Gavin Yamey (left) and moderator Paul Costello, courtesy of the Center for Innovation in Global Health

Health Disparities, Health Policy, SMS Unplugged

Minimum wage: More than an economic principle, a driver of health

Minimum wage: More than an economic principle, a driver of health

SMS (“Stanford Medical School”) Unplugged was recently launched as a forum for students to chronicle their experiences in medical school. The student-penned entries appear on Scope once a week; the entire blog series can be found in the SMS Unplugged category.

Gallegos minimum wage sketchI admittedly don’t understand much about the intricacies of economics. But I don’t have to in order to recognize the significance behind Wal-Mart’s decision to raise the minimum pay for its lowest paid hourly employees. In the week following the company’s announcement, plenty has been written about the impact that such a move will have on the company’s success and on local economies. It goes beyond that, however. What I see is the impact that an increase in income can have on the health of working individuals making a minimum wage.

Let’s do some quick math. Current guidelines list the poverty level at $24,250 for a household of four. Federal minimum wage is $7.25/hr. A full-time employee earning minimum wage therefore brings home $15,080. The working class individual, whose spouse stays home to care for their two children since childcare is unaffordable, incredibly falls $9,170 below the recognized poverty level.

This April, Wal-Mart will increase hourly pay to $9.00 and follow this with an increase to $10.00/hr in February 2016. Even then, a family of four with only one working parent will still fall more than $3,000 below the federal poverty level. Yet, the true hardship of poverty can’t be quantified so easily.

What can’t be measured is the stress that surrounds a working family’s paycheck – especially in matters of health. The difficult decision that my patient makes to skip work in order to bring their sick child to clinic, sacrificing a day’s pay, and – worse – their job security. Weighing feelings of worry for their ailing child against the stress of providing financially for the family. Or my patient who struggled through an upset stomach because she couldn’t afford both the medication and the food that she should be taking it with. Choosing health while enduring hunger.

A raise in minimum wage has direct impacts on health. It means the ability to deal with an unexpected expense without risking basic living standards like food, shelter, and transportation. It means having the luxury of buying fresh peaches instead of canned fruit. It means having a warm coat and shoes for winter. It means buying that prescription that’s been pending for months. It means securing the monthly bus pass to get you to work in the first place. For many, however, even the near 38 percent raise announced by Wal-Mart will not lift their families above the federal poverty line. In a situation where pennies and dimes add up, there will still be a significant deficit that will continue to make it improbable (read: impossible) to earn a way out of poverty.

Countless articles can be found online and in print about the need to increase minimum wage. Recently in the political sphere was a push for a $10.10 minimum wage under the Harkin-Miller Bill (Fair Minimum Wage Act). Unfortunately, the bill didn’t pass the Senate. While the bill may not have represented the necessary increase, it was an acknowledgement by some of the direction we need to take- and not just for economic purposes. We must recognize that reductions in financial hardship through fair wages provide a pathway for addressing health disparities and improving health outcomes.

Moises Gallegos is a fourth-year medical student. He’ll be going into emergency medicine, and he’s interested in public-health topics such as health education, health promotion and global health.

Sketch by Moises Gallegos

Health Disparities, NIH, Research, Stanford News, Women's Health

Stanford professor encourages researchers to take gender into account

Stanford professor encourages researchers to take gender into account

SchiebingerAs a scientist, I’m trained to look for biases that can cause unreliable results. This is why I feel so disheartened every time I read about scientific studies that fail to take sex and gender differences into account.

These differences, and the work of Londa Schiebinger, PhD, a Stanford professor of the history of science, were the focus of a recent Stanford Report article. In the piece, Schiebinger, who directs the Gendered Innovations in Science, Health & Medicine, Engineering, and Environment, explains that ignoring the biological differences between males and females is a form of gender bias that can have catastrophic results:

…Experiments done in women may not have been tested first in female mice or rats — “a potentially dangerous situation,” Schiebinger said.

Recent studies have shown that 80 percent of rodent drug studies are conducted using male models. This means that not only are females left out, but that research sees nothing unique to females in the initial stages of research.

“We’re missing the opportunity to build our foundation of knowledge of just about every biological system more accurately at the outset, which should be a fundamental goal of science,” said Marcia Stefanick, research professor of medicine in the Stanford Prevention Research Center and of obstetrics and gynecology and co-director of the Gendered Innovations project.

Incorporating gender and sex differences in the design of a scientific study is not only good science, it can make the end product more effective. Shiebinger’s latest endeavor is to help scientists understand when and how to address gender biases in their research. This goal is the focus of a new initiative she’s leading with support from the U.S. National Science Foundation and the European Commission.

Shiebinger admits that there’s much work to do, but her efforts, and those of others in the field, are paying off. As mentioned in the piece, the EU Research and Innovation program last winter identified 137 fields of science and technology that could be improved by gender analysis. “…Eyes have been opened – and we will not return to a world that ignores gender,” Shiebinger said.

Previously: A look at NIH’s new rules for gender balance in biomedical studies, Why it’s critical to study the impact of gender differences on diseases and treatments, Stanford Gendered Innovations program offers tools for improving scientific research, Study shows many heart devices receive FDA approval without adequate testing on women and Women underrepresented in heart studies
Photo by Daniel Pozo

Cancer, Health Disparities, Patient Care, Research, Stanford News

Study shows evidence-based care eliminates racial disparity in colon-cancer survival rates

Study shows evidence-based care eliminates racial disparity in colon-cancer survival rates

For the past two decades, the National Cancer Institute has documented that African-American patients have consistently had lower survival rates in colon cancer when compared with white patients. In a study published today in the Journal of Clinical Oncology, lead author Kim Rhoads, MD, PhD, and colleagues from Stanford show that receiving high quality, evidence-based treatment can eliminate this racial disparity. As Rhoads explains in our press release:

Historically, we’ve taken less than a critical eye on our own health-care system in terms of how we can take the lead in addressing disparities. The big take away in this paper is that it’s treatment, not necessarily patient factors, but following evidence-based guidelines that gives all patients the best chance for survival. Our work also suggests a real opportunity to equalize these racial differences.

The evidence-based guidelines were created by the National Comprehension Cancer Network, which used clinical trials and medical research to create step-by-step, evidence-based treatments for most cancers. However, adherence to those guidelines depends on the facility and research shows that minority patients tend to receive care from hospitals that have low adherence rates.

The study found that integrated health-care organizations, which provide all of a patient’s health-care services, hospital care and insurance, delivered evidence-based care for colon cancer at a higher rate than non-integrated health-care organizations. In these facilities, all patients had higher survival rates and racial disparity for colon cancer survival disappeared.

“In integrated systems, there’s already a big push to thinking about following evidence-based guidelines, so everyone within that system is in the same mindset,” said co-author Manali Patel, MD, MPH. “It’s easier to do the right thing when you have the system-level support to do so.”

Integrated health-care systems are well suited for coordinating care among several specialists, which is another advantage for colon-cancer patients, because the treatment of colon cancer requires different types of treatments and different types of specialists, the study pointed out.

The results support the development of integrated health care models as envisioned by Affordable Care Act.

“With health-care reform, millions more patients are coming into the system, and we’re going to need to become more integrated in order to meet the demand. We’re going to need to work more closely together, decrease variations in care and standardize what we do,” Rhoads told me. “In this paper, we have a model that shows that when you do this, you get better colon cancer outcomes for everyone.”

Previously: Stanford researchers examine disparities in use of quality cancer centers, Uncommon hero: A young oncologist fights for more humane cancer care and Report shows continuing health disparities for racial and ethnic minorities

Big data, Cancer, Health Disparities, Imaging, Public Health, Women's Health

A new way of reaching women who need mammograms

A new way of reaching women who need mammograms

black Woman_receives_mammogramI’ve taken cancer screenings for granted since I’m one of those fortunate enough to have health insurance, and it didn’t occur to me that many uninsured women were going without regular mammograms to screen for breast cancer. A story today on Kaiser Health News mentions this fact and highlights a partnership that Chicago public-health officials have forged with a company named Civis. The private company includes staffers that helped with the Obama campaign’s get-out-the-vote efforts, and then moved on to help find people eligible to enroll for health insurance through the Affordable Health Care Act. The company used its expertise to identify women who were in the right age group (over 40) and were uninsured in Chicago’s South Side area; those women then were then sent fliers about free screenings available to them.

The article describes some other cities using similar “big data” efforts for public-health purposes:

This project represents a distinctive step in public health outreach, said Jonathan Weiner, professor and director of the Johns Hopkins Center for Population Health IT in Baltimore. But Chicago is not the only city investigating how population data can be used in health programs, he added, citing New York City, Baltimore and San Diego as other examples.

“It’s a growing trend that some of the techniques first developed for commercial applications are now spinning off for health applications,” he said. So far, he said, “these techniques have not been as widely applied for social good and public health,” but that appears to be changing.

The early signs say that the new effort in Chicago, which started earlier this year, is working. One hospital saw a big jump in the number of free mammograms, from 10 a month to 31, though the full impact may not be understood for a few months. It’s not “a silver bullet” as one expert cited in the story notes, but it’s a much more precise tool than most public-health outreach programs have had access to until now.

Previously: Screening could slash number of breast cancer casesDespite genetic advances, detection still key in breast cancerStudy questions effects of breast cancer screenings on survival rates and New mammogram guidelines echo ones developed by physicians group
Photo by National Cancer Institute

Chronic Disease, Health Disparities, Health Policy, Public Health, Research

Study shows former foster kids face higher risk of future health problems

Study shows former foster kids face higher risk of future health problems

2411929600_da793593b2_zAccording to a new study from the journal Pediatrics, adults who were raised in the foster-care system are more likely to have chronic-health problems than those not from foster backgrounds, even after controlling for economic security.

It has long been recognized that foster kids have high rates of health problems as children, but this study is the first to ask what happens when those kids reach adulthood. It considered cardiovascular risk factors and other chronic problems, and it compared three groups of young adults: those formerly in foster care, those from the general public with economically insecure backgrounds, and those from the general public with economically secure backgrounds. The results were graduated among the three groups, from foster care, to economic insecurity, to economic security.

In the paper, the authors explain why their findings are not surprising:

Foster youth are often exposed to poverty and many other adverse childhood experiences including abuse, neglect, domestic violence, and parental substance use, and many undergo frequent placement and school changes while in foster care. Several theories exist regarding the effects of chronic and early exposures to adversity, all of which suggest that the more stressors to which one is exposed, the higher the likelihood of a chronic physical or mental health condition later in life.

However, because these theories regarding adversity haven’t yet been adequately investigated, this study has important implications. Scientific evidence could influence policy-makers to address this problem, perhaps by continuing Medicaid access for former foster kids or granting it to those far below the poverty line, or by offering continued support from the foster-care system into young adulthood. Provisions for the first two changes were made in the Affordable Care Act, and the federal government does offer incentives for states to continue foster care until age 21, but due to technicalities and state-level laws, these benefits are not widely accessible.

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Global Health, Health Costs, Health Disparities, Stanford News

Stanford undergrad works to redistribute unused medications and reduce health-care costs

Stanford undergrad works to redistribute unused medications and reduce health-care costs

1Sanchay Gupta arrived at Stanford with a strong interest in income inequality. In 2013, he spent two weeks of his summer vacation in Guatemala exploring issues of global chronic underdevelopment as part of an intensive field research internship sponsored by the Freeman Spogli Institute for International Studies. While on the trip, he shadowed Stanford doctors in ad-hoc rural clinics serving the indigenous communities and got a firsthand look at the country’s rural health-care system. He also interviewed patients about how their health status affected their family’s welfare while conducting field research.

Among the patients he interviewed was a father of nine children who made his living carrying firewood. One day the man injured himself carrying a particularly heavy load and was declared unfit for work. Seemingly overnight, the family income drastically fell below $3 a day and the father could no longer afford to see a doctor for treatment. But until he received proper medical care, there was no way that he could recover from his injury and resume supporting his family.

“It was during my time in these community settings that I witnessed how disparities in access to medical care can perpetuate inequality,” said Gupta, who was recently named one of the “15 incredibly impressive students at Stanford” by Business Insider. “As a result, I became really interested in how solving issues of inequality could break the cyclical theme of poverty.”

At the same time, Gupta was  fostering a vested interest in the fate of America’s health-care system. He had taken a few courses on U.S. health policy and strategies for health-care delivery innovation, and the experiences sparked a desire to get involved in efforts to eliminate costly inefficiencies within the health-care sector.

In looking for opportunities to get involved in helping reduce inefficiencies in health care, he learned about Supporting Initiatives to Redistribute Unused Medicine (SIRUM), a non-profit launched by Stanford students that engages with health-facility donors, converting their regulated medicine destruction process into medicine donation.

Nearly one-third of patients don’t fill first-time prescriptions and many say concerns about costs are a key reason for their non-compliance. At the same time, an estimated $5 billion of unused and unexpired prescriptions drugs are destroyed in the United States annually. To address these problems, SIRUM has developed an online platform that allows medical facilities, manufacturers, wholesalers and pharmacies to donate unused drugs instead of destroying them.

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