FSI scholars are devoted to understanding and solving global problems of poor health and nutrition. Often, the dilemma isn’t that treatments, medical services and technology don’t exist. It’s that they aren’t readily available or – for a variety of reasons – aren’t being used. Paul Wise, Scott Rozelle and Grant Miller are FSI senior fellows finding ways with their colleagues to fill those gaps by examining global health in the context of governance, economics, technology and education.
Paul Wise first saw poverty when he travelled to Guatemala after his freshman year of college. The aspiring pediatrician wanted to spend his summer working at a hospital in a developing country and was shocked by what he found: A seemingly endless stream of malnourished children suffering from easily preventable problems like diarrhea, measles and pneumonia. Too often, they died – not because treatments weren’t available, but because they were unable to access them in a country ravaged by violence and political instability.
Scott Rozelle spent two decades studying China’s economic boom often wondering why millions of children were performing so poorly in school. In a country that generated so much wealth between 1980 and 2000, why were so many kids falling behind? When he committed to answering the question, his findings were staggering. Around one-third of China’s children were anemic and nearly 50 percent had bellies full of intestinal worms. With poor nutrition and no access to simple medical care, it was nearly impossible for those children to concentrate and learn the skills that would be needed for them to be part of China’s rising economic tide.
Grant Miller coughed and wheezed throughout his visits to homes in Bangladesh, where women made meals on cookstoves fueled by burning animal dung and crop scraps. He was trying to answer a question that’s motivated his academic career: Why don’t people make decisions that lead to healthier lives? In Bangladesh, modern cookstoves are inexpensive and easily available. But people continue to cook their food in a way that increased their risk of pneumonia and other deadly infections. What Miller found in his research was as frustrating as it was simple. Although most women knew the pollution could make them sick, they didn’t think respiratory illness was their biggest problem. Cleaner stoves simply weren’t a priority, and the new models didn’t have features they wanted and couldn’t serve up the flavor the women were after.
The three researchers – all senior fellows at the Freeman Spogli Institute for International Studies – are only a few of FSI’s researchers devoted to understanding and solving global problems of poor health and nutrition.
Often, the dilemma isn’t that treatments, medical services and technology don’t exist. It’s that they aren’t readily available or – for a variety of reasons – aren’t being used. FSI experts are finding ways to fill those gaps by examining global health in the context of governance, economics, technology and education.
Their work is collaborative and interdisciplinary, taking advantage of FSI’s ability to attract and support scholars from diverse academic backgrounds and intellectual perspectives. Wise is a pediatrician. Rozelle is a development and agriculture economist. Miller is a health economist.
They routinely work with political scientists, legal experts, education specialists and sociologists – along with other economists and medical doctors – to create an intellectual backbone that often informs and influences policies and improves lives.
“FSI is a wonderful place for me to be working because it has enormous capacity, enormous expertise in dealing with governance and political instability,” Wise says. “FSI was created to facilitate cross-disciplinary interaction. The welcome I've received as a pediatrician into FSI has been outstanding. The infrastructure of FSI and the faculty at FSI have made it extremely easy to create the kinds of collaborations that are going to be necessary to address what is in fact a fairly ambitious agenda. Very few institutions have both the capacity and the infrastructure for collaboration that FSI provides.”
Malnutrition is one of the world’s leading killers of children younger than 5, accounting for about 5 million deaths a year. In Guatemala, 44 percent of children in that age group are malnourished, giving the country a higher rate than any other in Latin America.
That fact motivates Paul Wise’s Children in Crisis program, an initiative based in FSI’s Center for Health Policy that links pediatric healthcare with political reform. It’s the first academic initiative addressing the needs of children in areas of unstable governance and civil conflict – places where many nongovernmental organizations and foundations are reluctant to venture and kids are particularly vulnerable.
“The death of any child is always a tragedy,” Wise says. “But the death of any child from preventable causes is always unjust.”
Since his first trip to Guatemala in 1970, Wise has returned nearly every year for weeks or months at a time to offer medical assistance, conduct research and figure out ways to provide basic health care to some of the country’s poorest people. Many live in the rural villages near San Lucas Tolimán, hours from Guatemala City and the place where Wise has concentrated most of his work.
He has worked with local communities to build a health care system that reaches those with the greatest need. Working with local community leaders, his research and outreach have helped create and nurture a network of community health promoters, a group of about 60 volunteers in 25 small villages near the town of San Lucas Tolimán. Many of the promoters have no more than a third-grade education, but undergo a three-year training program on prevention, basic treatments, and community organization.
They also help connect villagers with medical services in San Lucas and Guatemala City, and ... the program has dramatically reduced young child mortality and has improved the lives of many families.
“The community health worker system has been developed to operate in political settings that are intensely complex, where corruption has been significant and where resources coming from traditional government agencies may be inadequate,” Wise says. “We’re not only interested in the technical aspects of children’s health. We’re interested in the political aspect.”
With his local colleagues, Wise supplements the work of the health promoters by setting up makeshift pediatric clinics in schools and community buildings, discussing prevention and dispensing medicine to curb diarrhea, kill scabies and treat pneumonia.
These clinics not only provide care to families with urgent health problems but also strengthen the community health promoter nutrition programs that identify children at high risk for malnutrition. They provide food, vitamins and family support.
He also works with academics and bureaucrats to pinpoint ways that government agencies could take a stronger approach to improving health care in a country scarred by civil war, corruption and political oppression.
Wise’s work has expanded from Guatemala to Africa, where he’s exploring how sanctions in countries like Zimbabwe undermine the provision of health care services. And he has a new focus on the Middle East, where he’s been meeting with public officials and scholars from Israel and the West Bank to see how the Palestinian Authority’s ability to deliver better care to children may affect its legitimacy and political standing in the region.
“We don’t expect that providing high-quality pediatric services is going to solve the Palestinian-Israeli problem, but we do need to understand better how it could contribute to an expressly political objective,” Wise says. “Health care is a political situation even though people are not thinking of it explicitly in that way. This is fertile ground for collaboration between technical health people like myself and political people working at FSI to solve these broader political problems.
Much of Wise’s work involves Stanford students. Medical students accompany him on his trips to Guatemala, seeing the toll poverty and poor governance takes on a community’s health. Often, they’re overwhelmed by the crushing need that so many people have for basic care. They question what good a single doctor could do in the face of a seemingly endless stream of problems that are generated by economics and politics.
“Going to Guatemala was a life-changing experience for me,” says Jake Rosenberg, now in his fifth year at Stanford School of Medicine. He travelled to San Lucas with Wise
for a few weeks in the summer of 2010. “The things I saw – in terms of the disparity of health – made a lasting impact on me. And seeing how Paul interacted with the community taught me how to be the kind of doctor I want to be. He has respect for the people he treats. He makes the work very little about himself, and puts all of his focus on empowering people in these communities.
And Wise is committed to instilling in his students an understanding that doctors play a crucial role in informing policy debates and influencing government officials.
“My hope is that the next generation of healthcare providers and politicians will have basically in their DNA an understanding of these issues,” Wise says. “I hope they will come to these fields with a sense of integrated understanding and purpose – that they will embrace far more coordinated cross-disciplinary strategies and activities in ways that my generation continues to find it difficult to do.”
Scott Rozelle’s interest in China began more than 40 years ago in the Los Angeles suburb of Bellflower, when seventh-graders at Washington Junior High School were offered Chinese language classes. His father – who spent part of his military career in Shanghai – encouraged the 12-year-old to sign up.
Rozelle fell in love with the language of the faraway country and stories of its Warlord Era told by a teacher who was born and raised in Peking. As he continued to learn the intricacies of Chinese tones and characters through high school and college, Rozelle became fascinated with the country itself. And by the time he decided on a career as a developmental economist, it was obvious there was no better place than China to base his work.
"China is the ultimate laboratory for an economist to study development," Rozelle says. "It's developing so fast that you see it before your eyes. There are also huge differences between regions within the country. You can measure things that you can't measure anywhere else."
Rozelle did his first round of fieldwork in China in 1987 as a 31-year-old doctoral candidate at Cornell University studying the economics of hybrid rice. He visited 700 households spread over seven villages in two rural provinces to ask farmers why they were growing certain strains of rice. Were they cheaper than other varieties? Were they hardier? Did they grow faster?
After hundreds of interviews, he finally realized the answer: The village leaders told every farmer what type of rice to grow. Nobody had a choice.
"I thought I was out there studying household economics," Rozelle says. "But that had nothing to do with it. My blood turned cold when I figured it out."
At that point, he began to pay more attention to how the fates of Chinese citizens were so closely tied to the whims and policies of the government. These people were living and working in an environment different from anywhere else in the world, he realized.
As China's fortunes have grown and the country sits in second-place among the world's economies, its citizens have largely prospered. The number of people living in poverty has fallen from about 350 million to less than 50 million in the past three decades.
But those 50 million are the ones Rozelle is so interested in. How do you lift them from destitution and allow them to share in China's rising prosperity?
The question and the answers it forces are at the heart of the Rural Education Action Program, a group co-directed by Rozelle and spearheaded by FSI and the institute’s Center on Food Security and the Environment.
Rozelle realized that China had the infrastructure in place to educate its children in top-notch schools. So many students ranked higher than their peers around the world, but he became increasingly concerned about the tens of millions of kids who dramatically underperformed.
“There was almost no one who was systematically looking at this,” Rozelle said. “China had the good teachers and the new buildings. But does that really increase human capital?”
Rozelle soon realized there was a link between student underperformance and poor nutrition and health.
“We found that up to 40 percent of children were undernourished,” Rozelle says. “They were anemic. They were micronutrient deficient. We found 40 to 50 percent of kids had bellies with intestinal worms. Many of them had such a heavy worm burden that they were constantly sick and couldn’t even attend school. We found nearly one-third of students had vision problems and their grades were suffering because they could not see the blackboard.”
By collaborating with Chinese government agencies, nongovernmental organizations, private corporations and individual donors, REAP chips away at poverty by introducing and assessing programs meant to improve the lives and opportunities of preschool and school-age children in some of China's poorest, most far-flung areas. Much of his work draws in fellow economists and academics from different backgrounds – political scientists, medical doctors, nutritionists and education specialists.
“Every one of our projects is interdisciplinary,” Rozelle says. “I just say REAP is a platform to allow my colleagues at Stanford who are experts in medicine and health and nutrition to come and help us solve problems. My Stanford colleagues perform magic. They’re at the tops of their field, and we take their expertise and use it to help with our field work and analysis.
Since its founding in 2007, REAP has submitted 21 policy briefs to government officials.
All of them have been accepted by China’s State Council. Fifteen have been incorporated into policy action, which means that REAP’s work is being used to create new state-sponsored programs and policy changes for improving children's health and nutrition, making education more affordable, reducing school drop-out rates and boosting overall student performance.
REAP has conducted dozens of large-scale research projects, with 15 currently underway.
Rozelle and his fellow researchers are not just evaluating how vitamins and nutritional supplements given to babies will increase their performance when they start going to school. They are organizing the vitamin distribution system, creating the training material and figuring out how, if successful, such programs can be taken over by the government and implemented on a large scale.
They’re experimenting with ways of delivering quality vision care and gauging how much test scores improve when children receive free or affordable eyeglasses.
They're trying to figure out the easiest and most cost-effective way of eradicating intestinal worms. They’ve tested the usefulness of a government-run program tackling high childhood anemia rates and evaluated how to best incentivize teachers and school officials to serve student nutritious lunches.
And they're determining how to put the most cutting-edge computer technology in schools where you can't always count on the lights staying on and where teachers – much less students – may have never seen a laptop.
It's work that Rozelle says is essential, given China's growing clout and ability to influence international markets and policies. As the country grows, so must all of its citizens, he says.
“China is becoming a victim of its own success,” Rozelle says. “As wages are going up, the low-skill jobs are moving out. So the question is: are the kids getting the nutrition, the healthcare and education they need to be ready for the China that’s coming – the China that won’t have any more low-skill wage jobs and requires them to know math and science and technology? That’s what I’m focused on.”
Belching smokestacks and traffic jams in crowded cities are the images usually used to illustrate the woes of pollution. But some of the biggest contributors to poor air quality in the developing world are the most basic household appliances – cook stoves. About 75 percent of South Asians and nearly half the world’s population use open-fire stoves inside their homes. And the pollution they produce is a leading cause of the pneumonia and other acute respiratory infections killing about 2 million children a year in low-income countries.
When Grant Miller set out to understand why cooking still kills despite so many government and humanitarian programs that make it easy for people to swap their traditional stoves for safer models, he kept seeing a mismatch between what people wanted and what they were given – or told to use.
In his study of the situation, Miller found that many clean and modern cookstoves simply don’t have features people want.
“If you don’t give people what they want, they are not likely to embrace and use something that has the potential to improve their health, no matter how logical it may seem,” Miller says. “You can’t just engineer a solution. You need to understand what will motivate people to change their behavior.”
His work has brought him to China, where he’s partnered with Scott Rozelle to study incentives that would encourage school principals to serve children more nutritious meals, thereby reducing anemia rates.
Miller is now focusing that idea on India, where he is helping to identify some of the country’s most pressing health policy challenges and develop solutions to address them.
His work lays the foundation for the Stanford India Health Policy Initiative, a newly launched program that puts Indian policymakers, health care providers, academics, and entrepreneurs in the same room to discuss where to best focus their efforts. The project is decidedly open-ended, and Miller wants Indians to lead the way.
“We want people in India to take ownership of this,” he says. “We want them to really steer it toward what they perceive to be the most important priorities.”
And his role as a scholar is crucial.
“There are two major roles that academics can play in this initiative,” he says. “First, we can bring tools and paradigms to the table that are useful in providing common structure to the experiences of stakeholders, helping to draw out new insights. Second, we bring the ability to conduct new research that is responsive to the group’s priorities. And we ultimately hope that those results will help them plan next steps in addressing health policy challenges.”
Miller isn’t only interested in figuring out the hurdles to better health. He examines the success stories, too, and wants to understand the reasons behind large-scale improvements in population health. And what he finds is often surprising
As an economist interested in how economic changes impact health, for example, Miller took a look at how Colombian coffee growers responded to fluctuations in world coffee prices.
It would seem intuitive that as farmers were paid more for their crop, they would have more money to spend on doctors, medicine, and other things that would improve their family’s health and decrease the mortality rates of infants and children.
But Miller found that in years in which coffee harvests were more valuable, the more growers worked on their household plots. And the more they worked, the less time they would spend doing things at home, including things good for their children’s health.
When coffee prices fell, farmers had weaker incentives to work on their coffee plots and spent more time taking care of their kids – and mortality rates dropped.
Miller explains that this finding is not as counterintuitive as it might seem – the things that matter most for child survival in many developing countries are not expensive, but they require a lot of time – like fetching clean water from far-away sources and taking children long distances to see a doctor.
And that study underscores the importance of an interdisciplinary approach to understanding global health problems.
“The traditional public health view of the world is that if people are making unhealthy choices for themselves, then they shouldn’t make those choices,” Miller says. “But the traditional economic view of the world is that people are the best judges of what will make them happy, and they should be free to make the choices that they want. So it’s our role to understand better the motivations behind people’s decision, and think of alternative ways to tip things in favor of better public health.”
