Racial Health Disparities in the United States

The Health of Democracies during the Pandemic: Results from a Randomized Survey Experiment

Marcella Alsan, Luca Braghieri, Sarah Eichmeyer, Minjeong Joyce Kim, Stefanie Stantcheva, and David Y. Yang

Concerns have been raised about the "demise of democracy," possibly accelerated by pandemic-related restrictions. Using a survey experiment involving 8,206 respondents from 5 Western democracies, we find that subjects randomly exposed to information regarding civil liberties infringements undertaken by China and South Korea to contain COVID-19 became less willing to sacrifice rights and more worried about their long-term erosion. However, our treatment did not increase support for democratic procedures more generally despite our prior evidence that pandemic-related health risks diminished such support. These results suggest that the start of the COVID-19 crisis was a particularly vulnerable time for democracies.

Civil Liberties in Times of Crisis

Marcella Alsan, Luca Braghieri, Sarah Eichmeyer, Minjeong Joyce Kim, Stefanie Stantcheva, and David Y. Yang

Major crises—from terrorist attacks to epidemic outbreaks—bring the trade-off between individual civil liberties and societal well-being into sharp relief. In this paper, we study how willing citizens are to restrict civil liberties to improve public health conditions in the context of the COVID-19 pandemic. We design and conduct representative surveys involving approximately 550,000 responses across 15 countries, including China and the United States, during many months of the COVID-19 pandemic, from March 2020 until January 2021. We document significant heterogeneity across countries and demographic groups in willingness to sacrifice rights for public welfare. Citizens disadvantaged by income, education, or race are less willing to sacrifice rights than their more advantaged peers in every country, as are those with prior experience in communist regimes. Leveraging naturally occurring variation as well as experimental approaches, we estimate that a one standard deviation increase in health security concerns increases willingness to sacrifice civil liberties by approximately 68%–83% of the difference between the average Chinese and U.S. citizen. Stated preferences correlate with observed behavior including demand for tracing apps, donations, and petitions.

Experimental Evidence on the Effectiveness of Non-Experts for Improving Vaccine Demand

Marcella Alsan and Sarah Eichmeyer

We experimentally vary signals and senders to identify which combination will increase vaccine demand among a disadvantaged population in the United States—Black and White men without a college education. Our main finding is that laypeople (non-expert concordant senders) are most effective at promoting vaccination, particularly among those least willing to become vaccinated. This finding points to a trade-off between the higher qualifications of experts on the one hand, but lower social proximity to low socioeconomic status populations on the other hand, which may undermine credibility in settings of low trust.

The Great Unequalizer: Initial Health Effects of COVID-19 in the United States

Marcella Alsan, Amitabh Chandra, and Kosali Simon

We measure inequities from the COVID-19 pandemic on mortality and hospitalizations in the United States during the early months of the outbreak. We discuss challenges in measuring health outcomes and health inequality, some of which are specific to COVID-19 and others that complicate attribution during most large health shocks. As in past epidemics, preexisting biological and social vulnerabilities profoundly influenced the distribution of disease. In addition to the elderly, Hispanic, Black and Native American communities were disproportionately affected by the virus, particularly when assessed using the years of potential life lost metric. We provide a conceptual framework and initial empirical analysis that seek to shed light on contributors to pandemic-related health inequality, and we suggest areas for future research.

Does Diversity Matter for Health? Experimental Evidence from Oakland

Marcella Alsan, Owen Garrick, and Grant Graziani

We study the effect of physician workforce diversity on the demand for preventive care among African American men. In an experiment in Oakland, California, we randomize black men to black or non-black male medical doctors. We use a two-stage design, measuring decisions before (pre-consultation) and after (post-consultation) meeting their assigned doctor. Subjects select a similar number of preventives in the pre-consultation stage, but are much more likely to select every preventive service, particularly invasive services, once meeting with a racially concordant doctor. Our findings suggest black doctors could reduce the black-white male gap in cardiovascular mortality by 19 percent.

Religion and Sanitation Practices

Anjali Adukia, Marcella Alsan, Kim Babiarz, Lea Prince, and Jeremy Goldhaber-Fiebert

In India, infant mortality among Hindus is higher than among Muslims, and religious differences in sanitation practices have been cited as a contributing factor. To explore whether religion itself is associated with differences in sanitation practices, this study compares sanitation practices of Hindus and Muslims living in the same locations using three nationally representative data sets from India. Across all three data sets, the unconditional religion-specific gap in latrine ownership and latrine use declines by approximately two-thirds when conditioning on location characteristics or including location fixed effects. Further, the estimates do not show evidence of religion-specific differences in other sanitation practices, such as handwashing or observed fecal material near homes. Household sanitation practices vary substantially across areas of India, but religion itself has less direct influence when considering differences between Hindus and Muslims within the same location.

Watersheds in Child Mortality: The Role of Effective Water and Sewerage Infrastructure

Marcella Alsan and Claudia Goldin

We explore the first period of sustained decline in child mortality in the United States and provide estimates of the independent and combined effects of clean water and effective sewerage systems on under-5 mortality. Our case is Massachusetts, 1880–1920, when authorities developed a sewerage and water district in the Boston area. We find the two interventions were complementary and together account for approximately one-third of the decline in log child mortality during the 41 years. Our findings are relevant to the developing world and suggest that a piecemeal approach to infrastructure investments is unlikely to significantly improve child health.

Tuskegee and the Health of Black Men

Marcella Alsan and Marianne Wanamaker

For 40 years, the Tuskegee Study of Untreated Syphilis in the Negro Male passively monitored hundreds of adult black men with syphilis despite the availability of effective treatment. The study’s methods have become synonymous with exploitation and mistreatment by the medical profession. To identify the study’s effects on the behavior and health of older black men, we use an interacted difference-in-difference-in-differences model, comparing older black men to other demographic groups, before and after the Tuskegee revelation, in varying proximity to the study’s victims. We find that the disclosure of the study in 1972 is correlated with increases in medical mistrust and mortality and decreases in both outpatient and inpatient physician interactions for older black men. Our estimates imply life expectancy at age 45 for black men fell by up to 1.5 years in response to the disclosure, accounting for approximately 35% of the 1980 life expectancy gap between black and white men and 25% of the gap between black men and women.

The Effect of the TseTse Fly on African Development

Marcella Alsan

The TseTse fly is unique to Africa and transmits a parasite harmful to humans and lethal to livestock. This paper tests the hypothesis that the TseTse reduced the ability of Africans to generate an agricultural surplus historically. Ethnic groups inhabiting TseTse-suitable areas were less likely to use domesticated animals and the plow, less likely to be politically centralized, and had a lower population density. These correlations are not found in the tropics outside of Africa, where the fly does not exist. The evidence suggests current economic performance is affected by the TseTse through the channel of precolonial political centralization.

Girls’ Education and HIV Risk: Evidence from Uganda

Marcella Alsan and David Cutler

Uganda is widely viewed as a public health success for curtailing its HIV/AIDS epidemic in the early 1990s. The period of rapid HIV decline coincided with a dramatic rise in girls’ secondary school enrollment. We instrument for this enrollment with distance to school, conditional on a rich set of demographic and locational controls, including distance to market center. We find that girls’ enrollment in secondary education significantly increased the likelihood of abstaining from sex. Using a triple-difference estimator, we find that some of the schooling increase among young women was in response to a 1990 affirmative action policy giving women an advantage over men on University applications.

The effect of population health on foreign direct investment inflows to low- and middle-income countries

Marcella Alsan, David E. Bloom, and David Canning

This paper investigates the effect of population health on gross inflows of foreign direct investment (FDI). We conduct a panel data analysis of 74 industrialized and developing countries over 1980-2000. Our main finding is that gross inflows of FDI are strongly and positively influenced by population health in low- and middle-income countries. Our estimates suggest that raising life expectancy by one year increases gross FDI inflows by 9%, after controlling for other relevant variables. These findings are consistent with the view that health is an integral component of human capital for developing countries.

Effect of an Intensive Food-as-Medicine Program on Health and Health Care Use — A Randomized Clinical Trial

Joseph Doyle, Marcella Alsan, Nicholas Skelley, Yutong Lu, and John Cawley

Question:  Among patients with diabetes who are food insecure, does an intensive food-as-medicine program that provides healthy groceries plus dietitian consultations, education, and health coaching improve glycemic control compared with usual care?
Findings:  In this randomized clinical trial of 465 adults who were provided access to a food-as-medicine program, hemoglobin A1c levels did not improve among those who had access to the program compared with a control group; however, their engagement with preventive health care increased as designed.
Meaning : Because this intensive food-as-medicine program did not improve glycemic control, these results suggest that further efforts are needed to understand how programs that address food insecurity can improve health.

STAT News Op-ed

Why Diverse Clinical Trial Participation Matters

Aaron L. Schwartz, Marcella Alsan, Alanna A. Morris, and Scott D. Halpern

For efforts focused on increasing diversity in clinical trials, the promise of knowledge generation shouldn’t overshadow the goals of improving the trustworthiness and fairness of U.S. health care.

Health Care in U.S. Correctional Facilities — A Limited and Threatened Constitutional Right

Marcella Alsan, Crystal S. Yang, James R. Jolin, Lucy Tu, and Josiah D. Rich

Since 1976, the Supreme Court has held that deliberate indifference to the serious medical needs of incarcerated people violates the constitutional prohibition against cruel and unusual punishment. What does this mean in practice?

To Improve Access And Equity, Move Vaccine Coverage To Medicare Part B

Sumit Agarwal, Nikhil Shankar, Marcella Alsan

Within the Inflation Reduction Act of 2022 is a provision worthy of praise: the elimination of cost-sharing in Medicare for vaccines. The change is long overdue, but it could still fall short of substantially improving access and equity.

In this article, we discuss how Medicare’s coverage rules differ across vaccines and show that disparities are much starker for vaccines covered by Medicare Part D than those covered by Part B. This partly reflects differences in cost-sharing between Part B and Part D, which the Act addresses by matching Part B’s zero cost-sharing for vaccines in Part D, but there are other important barriers to consider as well: Not all Medicare beneficiaries have Part D, and even if they did, doctor’s offices are less likely to take Part D when it comes to administering vaccines.

We then argue that all vaccine coverage should be moved to Medicare Part B to further improve vaccination rates and reduce disparities in take-up of current and future vaccines.

End COVID-19 in low- and middle-income countries

Abhijit Banerjee, Marcella Alsan, Emily Breza, Arun G. Chandrasekhar, Esther Duflo, Paul Goldsmith-Pinkham, Benjamin A. Olken

Populations vulnerable to COVID-19 due to conditions of poverty and marginalization often have less access to timely, accurate, and credible information. For the first time in history, most poor people had direct or indirect access to a mobile phone during a global pandemic. This was both an opportunity and a danger: Mobile phones could be used to transmit useful public health messages to the most remote corners of the world. At the same time, individuals were potentially overwhelmed by messaging. In a survey we conducted in West Bengal, India, in May 2020, the average person had received about 20 messages on COVID-19 in the previous 2 days.

In this context, is it possible to use mobile phone messaging to convey information and promote prevention? How best to do it? Using a series of mobile phone messaging interventions across developed and developing countries, we have found that trusted messengers can induce preventive behavior change during a pandemic and are effective even in an information-rich environment or polarized climate.

Trends in Mortality Rates Among Medicare Enrollees With Alzheimer Disease and Related Dementias Before and During the Early Phase of the COVID-19 Pandemic

Lauren Gilstrap, Weiping Zhou, Marcella Alsan, Anoop Nanda, and Jonathan S. Skinner

Question: Is the COVID-19 pandemic associated with changes in mortality among older adults with Alzheimer disease and related dementias (ADRD)?

Findings: In this cross-sectional study of 53, 640, 888 Medicare enrollees 65 years of age or older, compared with 2019, mortality was 12% higher among beneficiaries without ADRD and 26% higher among beneficiaries with ADRD in 2020. Among nursing home residents without ADRD, mortality was 24% higher, and among nursing home residents with ADRD, mortality was 33% higher.

Meaning: These findings suggest that the COVID-19 pandemic was associated with increased mortality among older Medicare enrollees with ADRD, especially among beneficiaries living in nursing homes.

Effects of a Large-Scale Social Media Advertising Campaign on Holiday Travel and COVID-19 Infections: A Cluster Randomized Controlled Trial

Emily Breza, Fatima Cody Stanford, Marcella Alsan, Burak Alsan, Abhijit Banerjee, Arun G. Chandrasekhar, Sarah Eichmeyer, Traci Glushko, Paul Goldsmith-Pinkham, Kelly Holland, Emily Hoppe, Mohit Karnani, Sarah Liegl, Tristan Loisel, Lucy Ogbu-Nwobodo, Benjamin A. Olken, Carlos Torres, Pierre-Luc Vautrey, Erica T. Warner, Susan Wootton, and Esther Duflo

During the COVID-19 epidemic, many health professionals used social media to promote preventative health behaviors. We conducted a randomized controlled trial of the effect of a Facebook advertising campaign consisting of short videos recorded by doctors and nurses to encourage users to stay at home for the Thanksgiving and Christmas holidays. The intervention was delivered to a large fraction of Facebook subscribers in 75% and 25% of randomly assigned zip codes in high- and low-intensity counties, respectively. The first two primary outcomes were holiday travel and fraction leaving home, both measured using mobile phone location data of Facebook users. Average distance traveled in high-intensity counties decreased by −0.993 percentage points for the 3 days before each holiday compared to low-intensity counties. The fraction of people who left home on the holiday was not significantly affected. The third primary outcome was COVID-19 infections recorded at the zip code level in the 2-week period starting 5 days after the holiday. Infections declined by 3.5% in intervention compared to control zip codes. Social media messages recorded by health professionals before the winter holidays in the United States led to a significant reduction in holiday travel and subsequent COVID-19 infections.

Beyond Causality: Additional Benefits of Randomized Controlled Trials for Improving Health Care Delivery

Marcella Alsan and Amy Finkelstein

Policymakers at federal and state agencies, health systems, payers, and providers need rigorous evidence for strategies to improve health care delivery and population health. This is all the more urgent now, during the COVID-19 pandemic and its aftermath, especially among low-income communities and communities of color.

Randomized controlled trials (RCTs) are known for their ability to produce credible causal impact estimates, which is why they are used to evaluate the safety and efficacy of drugs and, increasingly, to evaluate health care delivery and policy. But RCTs provide other benefits, allowing policymakers and researchers to: 1) design studies to answer the question they want to answer, 2) test theory and mechanisms to help enrich understanding beyond the results of a single study, 3) examine potentially subtle, indirect effects of a program or policy, and 4) collaborate closely to generate policy-relevant findings.

Illustrating each of these points with examples of recent RCTs in health care, we demonstrate how policymakers can utilize RCTs to solve pressing challenges.

Technological Progress and Health Convergence: The Case of Penicillin in Postwar Italy

Marcella Alsan, Vincenzo Atella, Jay Bhattacharya, Valentina Conti, Iván Mejía-Guevara, and Grant Miller

Throughout history, technological progress has transformed population health, but the distributional effects of these gains are unclear. New substitutes for older, more expensive health technologies can produce convergence in population health out­ comes but may also be prone to elite capture and thus divergence. We study the case of penicillin using detailed historical mortality statistics and exploiting its abruptly timed introduction in Italy after WWII. We find that penicillin reduced both the mean and standard deviation of infectious disease mortality, leading to substantial convergence across disparate regions of Italy. Our results do not appear to be driven by competing risks or confounded by mortality patterns associated with WWII.

Effect of Physician-Delivered COVID-19 Public Health Messages and Messages Acknowledging Racial Inequity on Black and White Adults’ Knowledge, Beliefs, and Practices Related to COVID-19: A Randomized Clinical Trial

Carlos Torres, Lucy Ogbu-Nwobodo, Marcella Alsan, Fatima Cody Stanford, Abhijit Banerjee, Emily Breza, Arun G. Chandrasekhar, Sarah Eichmeyer, Mohit Karnani, Tristan Loisel, Paul Goldsmith-Pinkham, Benjamin A. Olken, Pierre-Luc Vautrey, Erica Warner, Esther Duflo, for the COVID-19 Working Group

Question: Do messages delivered by physicians increase COVID-19 knowledge and improve preventive behaviors among White and Black individuals?

Findings: In this randomized clinical trial of 18,223 White and Black adults, a message delivered by a physician increased COVID-19 knowledge and shifted information-seeking and self-protective behaviors. Effects did not differ by race, and tailoring messages to specific communities did not exhibit a differential effect on knowledge or individual behavior.

Meaning: These findings suggest that physician messaging campaigns may be effective in persuading members of society from a broad range of backgrounds to seek information and adopt preventive behaviors to combat COVID-19.

Comparison of Knowledge and Intended Behaviors following General COVID-19 Public Health Messages and Messages Tailored for African American and Latinx Communities: A Randomized Controlled Trial

Marcella Alsan, Abhijit Banerjee, Esther Duflo, Arun Chandrasekhar, Fatima Stanford, Benjamin Olken, Emily Breza, Carlos Torres, Lucy Ogbu-Nwobodo, Anirudh Sankar, Pierre-Luc Vautrey, Sarah Eichmeyer, and Paul Goldsmith-Pinkham

Objective: To determine whether physician-delivered prevention messages affect knowledge and information-seeking behavior of Black and Latinx individuals and whether this differs according to the race/ethnicity of the physician and tailored content.

Conclusion: Physician-delivered messages increased knowledge of COVID-19 symptoms and prevention methods for Black and Latinx respondents. The desire for additional information increased with race-concordant messages for Black but not Latinx respondents. Other tailoring of the content did not make a significant difference.

Disparities in COVID-19 Reported Incidence, Knowledge, and Behavior

Marcella Alsan, David Cutler, Stefanie Stancheva, and David Yang

Question: How do reported incidence, knowledge, and behaviors regarding coronavirus disease 2019 vary across sociodemographic characteristics in the US?

Findings: In this survey study, the largest differences in coronavirus disease 2019–related knowledge and behaviors were associated with race/ethnicity, sex, and age. African American participants, men, and people younger than 55 years were less likely to know how the disease is spread, were less likely to know the symptoms of coronavirus disease 2019, and left the home more often.

Meaning: These findings suggest that more effort is needed to increase accurate information and encourage appropriate behaviors among minority communities, men, and younger people.

The Tuskegee Study of Untreated Syphilis: A Case Study in Peripheral Trauma with Implications for Health Professionals

Marcella Alsan, Rachel Hardeman, and Marianne Wanamaker

Racially or ethnically targeted events may have adverse health implications for members of the group not directly targeted, a phenomenon known as peripheral trauma. Recent evidence suggests that mass incarceration, police brutality, and immigration actions all have such effects, as did medical exploitation by the US government during the Tuskegee Study of Untreated Syphilis in the Negro Male. We summarize recent findings in the economics literature on population-level effects of the Tuskegee study, including a decline in health-seeking behavior and a rise of both mortality and medical mistrust among African-American men not enrolled in the study. We highlight the relevance of our findings for present-day racial health disparities. Practitioner awareness of peripheral trauma is an important element of cultural competency. But among options to substantially improve minority trust in the healthcare system, the diversification of medical practitioners may hold greatest promise.

Sociodemographic Correlates of Medical Mistrust among African American Men Living in the East Bay

Marcella Alsan, Edna Idan, Anlu Xing, and Javarcia Ivory

This study examined correlates of medical mistrust among African American men living in the East Bay. We conducted a cross-sectional analysis using survey data from 207 adult African American males, recruited from barbershops. We used linear regression to assess associations between socioeconomic status (SES) and two medical mistrust outcomes (mistrust of health care organizations (HCOs) and physicians). There was a strong relationship between health insurance, income, education, and mistrust. Insured subjects were 8.5% (95% CI –0.154 to –0.016) less likely to mistrust HCOs and 8.5% less likely (95% CI –0.145 to –0.025) to mistrust physicians. Those in the highest levels of income (>$60,000 annual income) or education (bachelor's degree or higher) were 5.4% (95% CI –0.115 to –0.007) and 5.7% (95% CI –0.104 to –0.011) less likely to mistrust HCO and physicians, respectively, than others. We conclude that sociodemographic factors are correlated with medical mistrust and discuss options for reducing medical mistrust.

Typhoid conjugate vaccines: a new tool in the fight against antimicrobial resistance

Marcella Alsan, Jason Andrews, Stephen Baker, Florian Marks, Denise Garrett, Bruce Gellin, Samir Saha, Farah Naz Qamar, Mohammad Tahir Yousafzai, Isaac Bogoch, Marina Antillon, Virginia Pitzer, Jong-Hoon Kim, Jacob John, Jillian Gauld, Vittal Mogasale, Edward Ryan, Stephen Luby, and Nathan Lo

Typhoid fever is an acute systemic infectious disease responsible for an estimated 12-20 million illnesses and over 150 000 deaths annually. In March, 2018, a new recommendation was issued by WHO for the programmatic use of typhoid conjugate vaccines in endemic countries. Health economic analyses of typhoid vaccines have informed funding decisions and national policies regarding vaccine rollout. However, by focusing only on averted typhoid cases and their associated costs, traditional cost-effectiveness analyses might underestimate crucial benefits of typhoid vaccination programmes, because the potential effect of typhoid vaccines on the treatment of patients with non-specific acute febrile illnesses is not considered.

A Commitment Contract to Achieve Virologic Suppression in Poorly Adherent Patients with HIV/AIDS

Marcella Alsan, John Beshears, Wendy Armstrong, Brigitte Madrian, James Choi, Mary Nguyen, Carlos del Rio, David Laibson, and Vince Marconi

Objective: Assess whether a commitment contract informed by behavioral economics leads to persistent virologic suppression among HIV-positive patients with poor antiretroviral therapy (ART) adherence.

Intervention: The study involved three arms. First, participants in the provider visit incentive (PVI) arm received $30 after attending each scheduled provider visit. Second, participants in the incentive choice arm were given a choice between the above arrangement and a commitment contract that made the $30 payment conditional on both attending the provider visit and meeting an ART adherence threshold. Third, the passive control arm received routine care and no incentives.

Results: The odds of suppression were higher in the incentive choice arm than in the passive control arm at the postincentive visit (adjusted odds ratio 3.93, 95% confidence interval 1.19–13.04, P = 0.025). The differences relative to the passive control arm at the end of the incentive period and relative to the PVI arm at both points in time were not statistically significant.

Conclusion: Commitment contracts can improve ART adherence and virologic suppression.

Childhood Illness and the Gender Gap in Adolescent Education in Low- and Middle-Income Countries

Marcella Alsan, Anlu Xing, Paul Wise, Gary Darmstadt, and Eran Bendavid

Background: Achieving gender equality in education is an important development goal. We tested the hypothesis that the gender gap in adolescent education is accentuated by illnesses among young children in the household.

Results: In our sample of 120 708 adolescent boys and girls residing in 38 countries, girls were 5.08% less likely to attend school than boys in the absence of a recent illness among young children within the same household (95% confidence interval [CI], 5.50%–4.65%). This gap increased to 7.77% (95% CI, 8.24%–7.30%) and 8.53% (95% CI, 9.32%–7.74%) if the household reported 1 and 2 or more illness episodes, respectively. The gender gap in schooling in response to illness was larger in households with a working mother. Increases in child vaccination rates were associated with a closing of the gender gap in schooling (correlation coefficient = 0.34, P = .02).

Conclusions: Illnesses among children strongly predict a widening of the gender gap in education. Investments in early childhood health may have important effects on schooling attainment for adolescent girls.

Beyond Infrastructure: Understanding Why Patients Decline Surgery in the Developing World: An Observational Study in Cameroon

Marcella Alsan, Benjamin Lerman, Ngew Chia, James Brown, and Sherry Wren

Objective: The aim of this study was to quantify and describe a population of patients in rural Cameroon who present with a surgically treatable illness but ultimately decline surgery, and to understand the patient decision-making process and identify key socioeconomic factors that result in barriers to care.

Background: An estimated 5 billion people lack access to safe, affordable surgical care and anesthesia when needed, and this unmet need resides disproportionally in low-income countries (LICs). An understanding of the socioeconomic factors underlying decision-making is key to future efforts to expand surgical care delivery in this population. We assessed patient decision-making in a LIC with a cash-based health care economy.

Results: Thirty-four of 175 participants (19.4%) declined surgery recommended by their physician. Twenty-six of 34 participants declining surgery (76.4%) cited procedure cost, which on average equaled 6.4 months' income, as their primary decision factor. Multivariate analysis revealed female gender [odds ratio (OR) 3.35, 95% confidence interval (95% CI) 2.14-5.25], monthly earnings (OR 0.83, 95% CI, 0.77-0.89), supporting children in school (OR 1.22, 95% CI 1.13-1.31), and inability to borrow funds from family or the community (OR 6.49, 95% CI 4.10-10.28) as factors associated with declining surgery.

Conclusion: Nearly one-fifth of patients presenting to a surgical clinic with a treatable condition did not ultimately receive needed surgery. Both financial and sociocultural factors contribute to the decision to decline care.

Out-of-pocket Health Expenditures and Antimicrobial Resistance in Low-income and Middle-income Countries: An Economic Analysis

Marcella Alsan, Lena Schoemaker, Karen Eggleston, Nagamani Kammili, Prasanthi Kolli, and Jay Bhattacharya

Introduction: The decreasing effectiveness of antimicrobial agents is a growing global public health concern. Low-income and middle-income countries are vulnerable to the loss of antimicrobial efficacy because of their high burden of infectious disease and the cost of treating resistant organisms. We aimed to assess if copayments in the public sector promoted the development of antibiotic resistance by inducing patients to purchase treatment from less well regulated private providers.

Interpretation of Findings: Out-of-pocket health expenditures were strongly correlated with antimicrobial resistance in low-income and middle-income countries. This relation was driven by countries that require copayments on drugs in the public sector. Our data suggest cost-sharing of antimicrobials in the public sector might drive demand to the private sector in which supply-side incentives to overprescribe are probably heightened and quality assurance less standardised.

Antibiotic Use in Cold and Flu Season and Prescribing Quality: A Retrospective Cohort Study

Marcella Alsan, Nancy Morden, Joshua Gottlieb, Weiping Zhou, and Jonathan Skinner

Background: Excessive antibiotic use in cold and flu season is costly and contributes to antibiotic resistance. The study objective was to develop an index of excessive antibiotic use in cold and flu season and determine its correlation with other indicators of prescribing quality.

Conclusions: Adjusted flu-activity associated antibiotic use was positively correlated with prescribing high-risk medications to the elderly and negatively correlated with beta-blocker use after myocardial infarction. These findings suggest that excessive antibiotic use reflects low-quality prescribing. They imply that practice and policy solutions should go beyond narrow, antibiotic specific, approaches to encourage evidence-based prescribing for the elderly Medicare population.

Risk Factors for AIDS-defining Illnesses Among a Population of Poorly Adherent People Living with HIV/AIDS in Atlanta, GA

Marcella Alsan, James Chow, and Wendy Armstrong, Carlos del Rio, and Vince Marconi

In order to achieve the programmatic goals established in the National HIV/AIDS Strategy, virologic suppression remains the most important outcome within the HIV care continuum for individuals receiving antiretroviral therapy (ART). Therefore, clinicians have dedicated substantial resources to improve adherence and clinic retention for individuals on ART; however, these efforts should be focused first on those most at risk of morbidity and mortality related to AIDS. Our study aimed to characterize the factors that are associated with AIDS-defining illnesses (ADIs) amongst people living with HIV (PLHIV) who are poorly adherent or retained in care in order to identify those at highest risk of poor clinical outcomes. We recruited 99 adult PLHIV with a history of poor adherence to ART, poor clinic attendance, or unsuppressed viral load (VL) from the Infectious Disease Program (IDP) of the Grady Health System in Atlanta, Georgia between January and May 2011 to participate in a survey investigating the acceptability of a financial incentive for improving adherence. Clinical outcomes including the number of ADI episodes in the last five years, VLs, and CD4 counts were abstracted from medical records. Associations between survey items and number of ADIs were performed using chi-square analysis. In our study, 36.4% of participants had ≥1 ADI in the last five years. The most common ADIs were Pneumocystis jirovecii pneumonia, recurrent bacterial pneumonia, and esophageal candidiasis. Age <42.5 years (OR 2.52, 95% CI = 1.08-5.86), male gender (OR 3.51, 95% CI = 1.08-11.34), CD4 nadir <200 cells/µL (OR 11.92, 95% CI = 1.51-94.15), unemployment (OR 3.54, 95% CI = 1.20-10.40), and travel time to clinic <30 minutes (OR 2.80, 95% CI = 1.20-6.52) were all significantly associated with a history of ≥1 ADI in the last five years. Awareness of factors associated with ADIs may help clinicians identify which poorly adherent PLHIV are at highest risk of HIV-related morbidity.

Investing in Cancer Care and Control

Felicia Marie Knaul, Hector Arreola-Ornelas, Rifat Atun, Oscar Mendez, Ramiro Guerrero, Marcella Alsan, Janice Seinfeld

Key messages:

Chronic disease is a leading global economic risk. Planning for chronic illness prevention and management must be integrated into health and economic development agendas.

Tobacco’s estimated $US 500 billion drain - mainly from tobacco-related illness and treatment costs - exceeds the total expenditure on health of all low and middle income countries (LMICs).

Between one-third and one-half of cancer deaths can be avoided with prevention, early detection and treatment - between 2.4 and 3.7 million avoidable deaths each year, 80% of which are in LMICs.

The total annual economic cost of cancer was approximately $1.16 trillion in 2010 - the equivalent of more than 2% of global GDP. Even this impressively high figure is a lower bound as it does not include the substantial longer-term costs to families and care givers.

Investing strategically in cancer care and control (CCC) more than pays for itself and is likely to even ‘payoff’. A reasonable estimate shows that the world could have saved between $US 100 and $US 200 billion in 2010 by investing in cancer control and care in ways that prevent disease and cover effective treatment. Potential savings are much higher - over $US 500 billion and up to almost $US 1 trillion - taking into account the individual perception of the value of lost life and human suffering.

Cost of prevention and treatment of cancer will likely decline over time. The ability to prevent, detect, and treat many cancers has improved over time, and many of these advances have led to reductions in cost. Harnessing markets and increasing access can also bring down prices.

Investments that generate system-wide improvements benefit cancer, but also accrue gains for other diseases, thereby achieving greater health outcomes per capita investment. This is part of diagonal approach to planning.

The “economics of hope” foresees a future when drugs and other forms of treatment for cancer will become more accessible to side population groups in LMICs.

Poverty, Global Health, and Infectious Disease: Lessons from Haiti and Rwanda

Marcella Alsan, Michael Westerhaus, Michael Herce, Koji Nakashima, and Paul Farmer

Poverty and infectious diseases interact in complex ways. Casting destitution as intractable, or epidemics that afflict the poor as accidental, erroneously exonerates us from responsibility for caring for those most in need. Adequately addressing communicable diseases requires a biosocial appreciation of the structural forces that shape disease patterns. Most health interventions in resource-poor settings could garner support based on cost/benefit ratios with appropriately lengthy time horizons to capture the return on health investments and an adequate accounting of externalities; however, such a calculus masks the suffering of inaction and risks eroding the most powerful incentive to act: redressing inequality.

Candida albicans Cervical Lymphadenitis in Patients Who Have Acute Myeloid Leukemia

Marcella Alsan, Nick Issa, Sarah Hammond, Dan Milner Jr., Dan DeAngelo, and Lindsey Baden

We describe two patients with acute myelogenous leukemia who developed cervical lymphadenitis and chronic disseminated infection due to Candida albicans. Candida albicans infection should be considered in leukemic patients with acute lymphadenitis. Evaluation for visceral dissemination is warranted even in the absence of fungemia.