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International Health



Long-term Household Economic and Health Impacts of TB: Estimates from Indian Longitudinal Data

Jason Andrews, MD, SM

Tuberculosis causes substantial direct health harms to infected individuals. Furthermore, it is implicated in long-term economic and health hardships for the entire household. Illness can initiate vicious cycles by necessitating increased spending on healthcare, requiring loans and shifting spending away from essentials like food, which may in turn result in poorer health, more spending, and further increased risks of TB among other household members. While such TB-related “poverty traps” have been conceptualized, their frequency and magnitude have not been well quantified for high burden countries like India. Where studies have explored the economic impact of TB, it has typically been by capturing short-term catastrophic expenditures. The longer-term impact, which may be driven by the ability of households to absorb subsequent adverse health and economic shocks and is more critical for the characterization of poverty and disease cycles, has not been well studied. Therefore, this pilot project sought to:  estimate the longer-term household economic and health consequences of TB shocks and evaluate how initial household socioeconomic status, as measured by consumption expenditure, modifies the risk of long-term health and economic consequences of TB. The major findings were that beyond the substantial personal health impact of active tuberculosis, there are important household negative impacts in terms of health and economic prospects that persist for nearly a decade. These include a nearly 5-fold increased risk of tuberculosis in other household members and greatly decreased consumption expenditure with persistent high interest medical debt as a frequent cause of this. Policies that actively seek to prevent TB in household members and protect the household from high interest lenders should therefore be of serious interest.




Empirical Evidence on Wealth Inequalities and Health in Developing Countries

Eran Bendavid, MD, MS

This study aimed to assess the extent to which wealth accurately proxies health status in low- and middle-income countries. Specifically it tested the hypothesis that absolute wealth is much more important for health than wealth inequalities or relative wealth. The researchers collected 150+ DHS surveys with suitable information on wealth and health outcomes, and finalized and validated a harmonized wealth index that allowed for measuring absolute and relative wealth gradients. They validated the index against education status, which does not enter into the creation of the index, and created harmonized and general measures of health, including malnutrition, stunting, and infant mortality in the household. Much of the data analysis has now been completed, including characterizing the variance in health inequalities as a function of absolute wealth status and within-survey relative wealth status. It is clear at this stage that absolute wealth is much more strongly associated with grossly undesirable health conditions such as stunting and wasting than relative wealth inequality. This has important implications for poverty alleviation programs, since the implication here is that bringing up the rear is more important than bringing up the mean or narrowing the inequality for averting grossly undesirable health conditions.


2013 - 2014

Chronic Disease, Disability, and Medical Costs among Older Adults in India

Sanjay Basu, MSc, MD, PhD

In July 2013, Sanjay Basu was granted an award in support of his pilot project, “Chronic Disease, Disability, and Medical Costs among Older Adults in India”. The project involved conducting a series of studies using nationally-representative data from the recent WHO Study on Global Aging and Adult Health (SAGE) to identify the relationship between NCD-related disability among adults over 50 years of age in India and healthcare utilization and costs. It was found that older rural women were disproportionately affected by non-diagnosed NCDs, with high out of pocket healthcare expenditures increasing the probability of remaining symptomatic from NCDs. The study also investigated disparities in NCD disability across the income gradient and found that rural and lower-income populations were more likely to have NCDs that were not captured by typical surveys that only asked for formally-diagnosed NCDs; rather, the SAGE study, by including validated symptom scales to diagnose several NCDs, revealed a high prevalence of undiagnosed NCDs among the poor, and a higher prevalence of several NCDs among these lower-income groups.

This research led to the publication of 10 peer-reviewed articles and three successful research awards. Following his pilot project, Basu was awarded a substantial multi-year grant from the Wellcome Trust (“Towards a healthier and environmentally sustainable edible oil consumption profile for Asia”), in addition to the Rosenkranz Prize for Healthcare Research in Developing Countries (“Detection and treatment of diabetes in India”), and a $2.4 million NIH Director’s New Innovator Award designed to fund high-risk, high-reward research (“Cohort filtering models to identify social program effects on health disparities”). With this award, Basu collected and linked some of the first data sets that have helped explain how and why various types of social programs influence health over the life course, how programmatic variations make a difference in chronic disease prevention, and some of the ways that such programs influence health disparities.


2012 - 2013

Intergenerational Support and the Experience of the Elderly at the End of Life: An Extension of a Longitudinal Study in Rural China

Marcus W. Feldman, MS, PhD

This study adopted a life course perspective in order to determine what  motivates and sustains intergenerational support, and how this support  influences older adults’ experience at the end of their lives. The researchers used death survey data from a five-wave longitudinal survey over the past 12 years conducted in rural areas of Anhui province, and pooled the death samples from each wave. Multi-level linear models revealed that the level of the care provided by adult children is affected by their birth order, the physical distance from parents, and the level of intergenerational exchange before death.

The study also found gender differences in the children’s end-of-life care of their parents. The level of care provided by sons and their spouses is much higher than by daughters. Thus, even under the background of weakening of filial piety as a core social value, child’s care of their parents is still driven by the traditional "filial piety and fraternal duty" norms. Children's birth order is an important influence on parents’ and children's filial expectation and behavior. The oldest son or daughter plays a leading role relative to other siblings and take the responsibility at parents’ end of life, which conforms to the culture of Confucianism according to which "the eldest brother is like father, the eldest sister is like mother".  It seems that the negative influence of the sharp decline in fertility on dying elderly parents is not as bad as might have been expected. The results suggest that responsibilities for parents can be undertaken by an only child or the eldest child in multi-children families.

The researchers also found that the motivation of adult children to provide end-of-life support to their older parents is partially rooted in earlier family experiences and guided by an implicit social contract that ensures long-term reciprocity. Children tend to provide more end-of-life care to parents who previously provided them with child care or financial resources. This confirms that older parents have maintained or even strengthened an intergenerational old-age support contract through selectively helping one or more children.

The results also imply that even during the critical period at the end of a parent’s life, the mechanism of children’s labor division still conforms to the strategic allocation of resources throughout the family system. Geographic proximity to older parents is an important correlate with extent of end-of-life care. With recent social changes, informal end-of-life care is facing serious challenges.


Socioeconomic Gradients in Health Among the Elderly in China

Karen Eggleston, PhD

This project studied the patterns of health and health care disparities across elderly and non-elderly in China, including the impact of earlier educational and public health interventions on contemporary elderly. The researchers analyzed individual-level data from multiple Chinese household surveys and related datasets spanning 1989 through 2010: (a) the 1988 fertility survey (from which they extracted data on infant and child mortality spanning the Mao era and early reform era); (b) the China Health and Nutrition Survey (with multiple waves between 1989 and 2006); (c) the China Health and Retirement Longitudinal Survey pilot data (2008 for Zhejiang and Gansu provinces); (d) the Chinese Longitudinal Healthy Longevity Survey (several waves between 1998 through 2005); and (e) life tables for China from the US Census Bureau (males and females, annually 1990 through 2010), in comparison with life tables from selected other countries available from the Human Mortality Database or the Census Bureau.  They calculated Gini coefficients for distributions of various metrics of health (obesity and underweight for adults and children, waist to hip ratio, smoking status, blood pressure, disability score for elderly people, survival/mortality), overall and for urban and rural residents separately, to see how health inequalities amplify or dampen China’s increasing income and asset inequalities between 1993 and 2006.


Health Implication of Urbanization, Migration and Obesity in India

Jeremy Goldhaber-Fiebert, Phd

Urbanization and obesity-related chronic diseases are cited as threats to the future health of India's older citizens. With 50% of deaths in adult Indians currently due to chronic diseases, the relationship of urbanization and migration trends to obesity patterns have important population health implications for older Indians. The researchers constructed and calibrated a set of 21 microsimulation models of weight and height of Indian adults. The models separately represented current urban and rural populations of India's major states and were further stratified by sex. They used the BioX-2 clusters (a machine with 2,208 64-bit processors in 276 dual quad core nodes each with 16GB of memory and a 48 TB shared parallel file system) to run future projections on obesity- and underweight-related mortality and inequalities across state and urban/rural boundaries.


Health Improvement under Mao and Its Implications for Contemporary Aging in China

Karen Eggleston, Phd and Grant Miller, MD, MS

This study aimed to better understand the dramatic health improvements in Maoist China and the age-related health disparities that it may have generated. The investigators validated official Chinese health statistics to establish the magnitude of China’s mortality decline between 1950 and 1980; and identified the proximate determinants correlated with China’s mortality decline, using data on regional variation in such factors as primary healthcare infrastructure, drinking water quality, sanitation, nutrition, and childhood vaccination rates.


Temperance and the Russian Mortality Crisis

Christina Gathmann, PhD and Jay Bhattacharya, MD, PhD

The researchers found that the reduction of official alcohol sales had a sizeable effect on overall mortality.  The estimates imply that the decline in sales reduces the crude death rate by 1.53 or more than 10 percent.  They also found that total alcohol consumption declined by much less than official alcohol sales as people began to buy or distill illegally produced alcohol (‘samogon’).  Calculations showed that the campaign (including the substitution to samogon) saved about 80,000 lives in Russia between 1986 and 1989.  The researcher also found that price increases account for 45 percent of the total effect.  Lastly, the researchers estimated how fast alcohol consumption and hence mortality increased after the campaign was renounced in 1989.  They found that the ‘rebound effect’ is strongest in the years immediately following the campaign (1990-92) and levels off in the years after (1993-95).  They showed that rising alcohol consumption can account for almost 50% of the mortality increase from 1990 to 1992 but only 5% of the increase in 1993 and 1994.


The HIV/AIDS Pandemic and Africa's Orphaned Elderly

Jay Bhattacharya, MD, PhD and Grant Miller, MD, MPH

The HIV/AIDS pandemic has decimated family life in Africa.  This project focused on the welfare of the “orphaned-elderly” – a class of elderly dependents whose traditional care-giving arrangements have collapsed. The authors presented their findings in January 2008. A manuscript, “HIV and Africa’s ‘Orphaned Elderly,’” was published in British Medical Journal. Another manuscript entitled, “The President's Emergency Plan for AIDS Relief in Africa: An Evaluation of Outcomes” was published in Annals of Internal Medicine. “The relation of price of antiretroviral drugs and foreign assistance with coverage of HIV treatment in Africa: retrospective study” was published in British Medical Journal, and “United States aid policy and induced abortion in sub-Saharan Africa” was published in Bull World Health Organization.


Health Insurance among the Elderly in Colombia

Grant Miller, MD, MPH

Relative to other age groups, the elderly are disproportionately likely to become seriously ill and to face burdensome medical expenditures.  Many middle-income countries like Colombia have begun experimenting with targeted public-sector health insurance.  By exploiting discontinuities in eligibility formulas for health insurance subsidies, this project evaluated the consequences of a large targeted health insurance program for the well-being of the elderly in Colombia.


Elder-care, Gender, and Son Preference: The Role of Cultural Transmission and Diffusion During the Process of Rural-urban Migration in China

Li Shuzhuo, PhD

A research report, “A survey of rural-urban migrants in Shenzhen, China”, based on findings from this project, was submitted to the Shenzhen government in December of 2005.  Since then, the Santa Fe Institute International Program, the Ministry of Education of China and the Treasury Department of China funded further research.  Dr. Shuzhuo received two grants, “Development of Complex Social Network Models for Application to Rural-Urban Migration and Social Integration in Contemporary China (70671083),” from the National Natural Science Foundation of China and “Study on Strategies of actively addressing the issue of population aging in Shaanxi Province,” from the Shaanxi provincial population and Family Planning Commission (12/2012-8/2013). Work stemming from this seed has also led to 11 presentations and 17 published manuscripts.