Marcella Alsan

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

Summary 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.

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

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.

Out-of-pocket health expenditures and antimicrobial resistance in low-income and middle-income countries: an economic analysis

Background The decreasing effectiveness of antimicrobial agents is a growing global public health concern. Low- and middle-income countries (LMIC) are vulnerable to the loss of antimicrobial efficacy given their high burden of infectious disease and the cost of treating resistant organisms. Methods We analyzed data from the World Health Organization’s Antibacterial Resistance Global Surveillance Report. We investigated the importance of out-of-pocket spending and copayment requirements for public sector medications on the level of bacterial resistance among LMIC, adjusting for environmental factors purported to be predictors of resistance, such as sanitation, animal husbandry and poverty as well as other structural components of the health sector. Findings Out-of-pocket health expenditures were the only factor demonstrating a statistically significant relationship with antimicrobial resistance. A ten point increase in the percentage of health expenditures that were out-of-pocket was associated with a 3·2 percentage point increase in resistant isolates [95% CI, 1·17 to 5·15, p-value=0·002]. This relationship was driven by countries requiring copayments for medications in the public health sector. Among these countries, moving from the 20th to 80th percentile of out-of-pocket health expenditures was associated with an increase in resistant bacterial isolates from 17·76 [95%CI 12·54 to 22·97] to 36·27 percentage points [95% CI 31·16 to 41·38]. Interpretation Out-of-pocket health expenditures were strongly correlated with antimicrobial resistance among LMIC. This relationship was driven by countries that require copayments on medications in the public sector. Our findings suggest cost-sharing of antimicrobials in the public sector may drive demand to the private sector where supply-side incentives to overprescribe are likely heightened and quality assurance less standardized.

The Consequences of Population Health for Economic Performance

1. Health, Economic Development and Household Poverty: The Role of the Health Sector Part A: Health, Development and Poverty 2. The Consequences of Population Health for Economic Performance 3. Illness and Labour Productivity: A Case Study from Rural Kenya Part B: The Effectiveness of Health Care Systems in Addressing the Needs of the Poor 4. Access and Equity: Evidence on the Extent to Which Health Services Address the Needs of the Poor 5. Illness, Health Service Costs and their Consequences for Households 6. Coping with the Costs of Illness: Vulnerability and Resilience among Poor Households in Urban Sri Lanka Part C: Restructuring Health Care Systems to Reach the Poor 7. Alternative Approaches to Extending Health Services to the Poorest 8. Targeting Services Towards the Poor: A Review of Targeting Mechanisms and their Effectiveness 9. Protecting the Poor from the Cost of Services through Health Financing Reform 10. Building Voice and Agency of Poor People in Health: Public Action within Health Systems 11. Improving Equity in Health Through Health Financing Reform: A Case Study of the Introduction of Universal Coverage in Thailand 12. Promoting Access, Financial Protection and Empowerment for the Poor: Vimo SEWA in India 13. Conclusions: From Evidence to ActionThis chapter goes beyond the traditional economic thinking about the relationship between health and income – simply stated: wealth is needed to achieve health – by presenting evidence that population health is an important factor in strengthening economies and reducing poverty. The worlds overarching framework for reducing poverty is expressed in the UNs eight Millennium Development Goals. Three of these eight goals pertain to health: reducing child mortality, improving maternal health, and combating HIV/AIDS, malaria, and other diseases. These potentially huge improvements in health are extremely important goals in themselves, and they serve as beacons toward which numerous development efforts are oriented. But these potential improvements in health are not only endpoints that we seek through a variety of means. The improvements are actually instruments for achieving economic growth and poverty reduction. That is, better health does not have to wait for an improved economy; measures to reduce the burden of disease, to give children healthy childhoods, to increase life expectancy will in themselves contribute to creating healthier economies.

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

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. Methods and Findings:We included Medicare beneficiaries in the 40% random sample denominator file continuously enrolled in fee-for-service benefits for 2010 or 2011 (7,961,201 person-years) and extracted data on prescription fills for oral antibiotics that treat respiratory pathogens. We collapsed the data to the state level so they could be merged with monthly flu activity data from the Centers for Disease Control and Prevention. Linear regression, adjusted for state-specific mean antibiotic use and demographic characteristics, was used to estimate how antibiotic prescribing responded to state-specific flu activity. Flu-activity associated antibiotic use varied substantially across states—lowest in Vermont and Connecticut, highest in Mississippi and Florida. There was a robust positive correlation between flu-activity associated prescribing and use of medications that often cause adverse events in the elderly (0.755; P<0.001), whereas there was a strong negative correlation with beta-blocker use after a myocardial infarction (−0.413; P=0.003). 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.

Tuskegee and the Health of Black Men

JEL Codes: I14, O15 For forty years, the Tuskegee Study of Untreated Syphilis in the Negro Male passively monitored hundreds of adult black males with syphilis despite the availability of effective treatment. The studys methods have become synonymous with exploitation and mistreatment by the medical profession. To identify the studys 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 studys 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.

Beyond Infrastructure: Understanding Why Patients Decline Surgery in the Developing World

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 barriersObjective: 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. Methods: Standardized interviews were conducted of a random sample of adult patients with treatable surgical conditions over a 7-week period in a tertiary referral hospital in rural Cameroon. Main outcome measures included participants decision to accept or decline surgery, source of funding, and the relative importance of various factors in the decision-making process. 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.

Risk factors for AIDS-defining illnesses among a population of poorly adherent people living with HIV/AIDS in Atlanta, Georgia.

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.

Candida albicans Cervical Lymphadenitis in Patients Who Have Acute Myeloid Leukemia

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.

Watersheds in Child Mortality: The Role of Effective Water and Sewerage Infrastructure, 1880 to 1920

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.