Clinical Focus

  • Internal Medicine

Academic Appointments

Administrative Appointments

  • Expert Group on Survival, United Nations Population Division (2013 - Present)
  • Emerging Leaders Group, World Heart Federation (2013 - Present)
  • Expert Group, Global Burden of Disease Project (2013 - Present)
  • Epidemiology and Prevention Council, American Heart Association (2012 - Present)
  • Review Commission, WHO Commission on Social Determinants of Health (2012 - Present)
  • Fellow, London School of Hygiene and Tropical Medicine (2011 - Present)
  • Associate Faculty, Center for Health Policy, Primary Care & Outcomes Research (2012 - Present)
  • Affiliate, Stanford Center on Poverty and Inequality (2012 - Present)
  • Commission member, Population, Health and Social Development Council (2012 - Present)
  • Associate Editor, PLoS Medicine (2011 - Present)
  • Affiliate, Stanford Cardiovascular Research Institute (2013 - Present)
  • Associate Editor, BMC Public Health (2011 - Present)
  • Advisory Board, UCSF Evidence to Policy Initiative (2010 - 2012)
  • Member, New York Academy of Science (2007 - Present)
  • Member, American Association for the Advancement of Science (1997 - Present)

Honors & Awards

  • Top 100 Global Thinkers List, Foreign Policy Magazine (2013)
  • Physician Recognition Award, American Heart Association (2012)
  • Weingarten Award in Medicine, University of California San Francisco (2011)
  • Alumni Award for Research, Yale University (2008)
  • Dasey Award for Character and Integrity in Medicine, Yale University (2008)
  • Rhodes Scholar, State of Massachusetts, Oxford University (2002)
  • Institute Award for Research, MIT (2002)

Professional Education

  • MD, PhD, Yale University (2009)
  • MSc, Oxford University (2003)
  • SB, Massachusetts Institute of Technology (2002)
  • Board Certification: Internal Medicine, American Board of Internal Medicine (2012)
  • Medical Education:Yale University School of Medicine (2009) CT
  • Residency:UCSF-Internal Medicine (2012) CA
  • Internship:UCSF-Internal Medicine (2010) CA

Community and International Work

  • Public Health Foundation of India, Delhi



    Ongoing Project


    Opportunities for Student Involvement


  • Possible Health, Nepal


    Global health



    Ongoing Project


    Opportunities for Student Involvement


Research & Scholarship

Current Research and Scholarly Interests

Our laboratory focuses on developing and utilizing mathematical models and statistics to understand how to improve chronic disease prevention policies in both the United States and abroad. Our laboratory is part of Stanford’s Prevention Research Center—a division of the Department of Medicine that focuses on community-based chronic disease prevention through field-based randomized controlled trials, collaborative implementation of disease prevention programs in the community, and analysis of existing prevention initiatives. Our work, as part of this group, focuses on both substantive and methodological research questions. Substantively, we use mathematical models and statistical methods to analyze large-scale data revealing which chronic disease prevention programs are most effective, among whom, and why. Methodologically, we construct and validate new types of modeling and data analysis approaches that incorporate complex demographic, economic and social science data to improve public health policy responses to disease risks that arise from epidemiological changes among low-income populations.


Journal Articles

  • The political economy of austerity and healthcare: Cross-national analysis of expenditure changes in 27 European nations 1995-2011. Health policy Reeves, A., McKee, M., Basu, S., Stuckler, D. 2014; 115 (1): 1-8


    Why have patterns of healthcare spending varied during the Great Recession? Using cross-national, harmonised data for 27 EU countries from 1995 to 2011, we evaluated political, economic, and health system determinants of recent changes to healthcare expenditure. Data from EuroStat, the IMF, and World Bank (2013 editions) were evaluated using multivariate random- and fixed-effects models, correcting for pre-existing time-trends. Reductions in government health expenditure were not significantly associated with magnitude of economic recessions (annual change in GDP, p=0.31, or cumulative decline, p=0.40 or debt crises (measured by public debt as a percentage of GDP, p=0.38 or per capita, p=0.83)). Nor did ideology of governing parties have an effect. In contrast, each $100 reduction in tax revenue was associated with a $2.72 drop in health spending (95% CI: $1.03-4.41). IMF borrowers were significantly more likely to reduce healthcare budgets than non-IMF borrowers (OR=3.88, 95% CI: 1.95 -7.74), even after correcting for potential confounding by indication. Exposure to lending from international financial institutions, tax revenue falls, and decisions to implement cuts correlate more closely than underlying economic conditions or orientation of political parties with healthcare expenditure change in EU member states.

    View details for DOI 10.1016/j.healthpol.2013.11.008

    View details for PubMedID 24315493

  • An alternative mechanism for international health aid: evaluating a Global Social Protection Fund HEALTH POLICY AND PLANNING Basu, S., Stuckler, D., McKee, M. 2014; 29 (1): 127-136


    Several public health groups have called for the creation of a global fund for 'social protection'-a fund that produces the international equivalent of domestic tax collection and safety net systems to finance care for the ill and disabled and related health costs. All participating countries would pay into a global fund based on a metric of their ability to pay and withdraw from the common pool based on a metric of their need for funds. We assessed how alternative strategies and metrics by which to operate such a fund would affect its size and impact on health system financing. Using a mathematical model, we found that common targets for health funding in low-income countries require higher levels of aid expenditures than presently distributed. Some mechanisms exist that may incentivize reduction of domestic health inequalities, and direct most funds towards the poorest populations. Payments from high-income countries are also likely to decrease over time as middle-income countries' economies grow.

    View details for DOI 10.1093/heapol/czs141

    View details for Web of Science ID 000329136400012

    View details for PubMedID 23335466

  • Averting Obesity and Type 2 Diabetes in India through Sugar-Sweetened Beverage Taxation: An Economic-Epidemiologic Modeling Study. PLoS medicine Basu, S., Vellakkal, S., Agrawal, S., Stuckler, D., Popkin, B., Ebrahim, S. 2014; 11 (1)


    Taxing sugar-sweetened beverages (SSBs) has been proposed in high-income countries to reduce obesity and type 2 diabetes. We sought to estimate the potential health effects of such a fiscal strategy in the middle-income country of India, where there is heterogeneity in SSB consumption, patterns of substitution between SSBs and other beverages after tax increases, and vast differences in chronic disease risk within the population.Using consumption and price variations data from a nationally representative survey of 100,855 Indian households, we first calculated how changes in SSB price alter per capita consumption of SSBs and substitution with other beverages. We then incorporated SSB sales trends, body mass index (BMI), and diabetes incidence data stratified by age, sex, income, and urban/rural residence into a validated microsimulation of caloric consumption, glycemic load, overweight/obesity prevalence, and type 2 diabetes incidence among Indian subpopulations facing a 20% SSB excise tax. The 20% SSB tax was anticipated to reduce overweight and obesity prevalence by 3.0% (95% CI 1.6%-5.9%) and type 2 diabetes incidence by 1.6% (95% CI 1.2%-1.9%) among various Indian subpopulations over the period 2014-2023, if SSB consumption continued to increase linearly in accordance with secular trends. However, acceleration in SSB consumption trends consistent with industry marketing models would be expected to increase the impact efficacy of taxation, averting 4.2% of prevalent overweight/obesity (95% CI 2.5-10.0%) and 2.5% (95% CI 1.0-2.8%) of incident type 2 diabetes from 2014-2023. Given current consumption and BMI distributions, our results suggest the largest relative effect would be expected among young rural men, refuting our a priori hypothesis that urban populations would be isolated beneficiaries of SSB taxation. Key limitations of this estimation approach include the assumption that consumer expenditure behavior from prior years, captured in price elasticities, will reflect future behavior among consumers, and potential underreporting of consumption in dietary recall data used to inform our calculations.Sustained SSB taxation at a high tax rate could mitigate rising obesity and type 2 diabetes in India among both urban and rural subpopulations. Please see later in the article for the Editors' Summary.

    View details for DOI 10.1371/journal.pmed.1001582

    View details for PubMedID 24409102

  • Six concerns about the data in aid debates: applying an epidemiological perspective to the analysis of aid effectiveness in health and development HEALTH POLICY AND PLANNING Stuckler, D., McKee, M., Basu, S. 2013; 28 (8): 871-883


    Is aid helping, hindering, or having no effect on development and health? The answer to this question is highly contested, with proponents on all sides adhering strongly to their competing interpretations. We ask how it is possible for those who are often using the same data to hold such divergent views. Here, we employ an epidemiological perspective and find that, in many cases, the arguments are characterised by methodological weaknesses. There may be selective citation of results and failure to account for bias and confounding, such as where an extraneous factor influencing the outcome is correlated with increased aid or, in confounding by indication, where increased aid is a consequence of a country being in an especially adverse situation. Studies may also lack external validity, whereby lack of data (a widespread problem) or similar considerations mean that analyses are undertaken on an unrepresentative subset of countries. Multiple outcome measures can also be problematic, where the main outcome of interest is not specified in advance. Many studies fail to account for differential time lags between changes in aid and the outcomes being studied. Some studies may also be underpowered to detect an association where one exists. Although, ideally, this debate should be informed by large scale randomised controlled trials, this will often be unfeasible. Given this limitation, it is essential that those engaged in it are cognisant of the many methodological issues that face any observational study.

    View details for DOI 10.1093/heapol/czs126

    View details for Web of Science ID 000328362100008

    View details for PubMedID 23242695

  • Austere or not? UK coalition government budgets and health inequalities. Journal of the Royal Society of Medicine Reeves, A., Basu, S., McKee, M., Marmot, M., Stuckler, D. 2013; 106 (11): 432-436

    View details for DOI 10.1177/0141076813501101

    View details for PubMedID 24025229

  • Relationship of soft drink consumption to global overweight, obesity, and diabetes: a cross-national analysis of 75 countries. American journal of public health Basu, S., McKee, M., Galea, G., Stuckler, D. 2013; 103 (11): 2071-2077


    Objectives. We estimated the relationship between soft drink consumption and obesity and diabetes worldwide. Methods. We used multivariate linear regression to estimate the association between soft drink consumption and overweight, obesity, and diabetes prevalence in 75 countries, controlling for other foods (cereals, meats, fruits and vegetables, oils, and total calories), income, urbanization, and aging. Data were obtained from the Euromonitor Global Market Information Database, the World Health Organization, and the International Diabetes Federation. Bottled water consumption, which increased with per-capita income in parallel to soft drink consumption, served as a natural control group. Results. Soft drink consumption increased globally from 9.5 gallons per person per year in 1997 to 11.4 gallons in 2010. A 1% rise in soft drink consumption was associated with an additional 4.8 overweight adults per 100 (adjusted B; 95% confidence interval [CI] = 3.1, 6.5), 2.3 obese adults per 100 (95% CI = 1.1, 3.5), and 0.3 adults with diabetes per 100 (95% CI = 0.1, 0.8). These findings remained robust in low- and middle-income countries. Conclusions. Soft drink consumption is significantly linked to overweight, obesity, and diabetes worldwide, including in low- and middle-income countries. (Am J Public Health. Published online ahead of print March 14, 2013: e1-e7. doi:10.2105/AJPH.2012.300974).

    View details for DOI 10.2105/AJPH.2012.300974

    View details for PubMedID 23488503

  • Nutritional policy changes in the supplemental nutrition assistance program: a microsimulation and cost-effectiveness analysis. Medical decision making Basu, S., Seligman, H., Bhattacharya, J. 2013; 33 (7): 937-948


    Some experts have proposed limiting the use of Supplemental Nutrition Assistance Program (SNAP) benefits, for calorie-dense foods or subsidizing SNAP purchases of healthier foods.To estimate health effects and cost-effectiveness of banning or taxing sugar-sweetened beverages (SSBs) or subsidizing fruits and vegetables purchased with SNAP.. Microsimulation. Data Sources. National Health and Nutrition Examination Survey, US Department of Agriculture Quarterly Food-at-Home Price Database, and SNAP program data. Target Population: US adults aged 25 to 64 y. Time Horizon. 10 y. Perspective. Governmental. Outcome MEASURES: Incremental costs, quality-adjusted life-years (QALYs), body mass index, Alternative Healthy Eating Index, Food Security Score, diabetes person-years, and deaths from myocardial infarctions (MIs) and strokes.of Base-Case Analysis. Banning SSB purchases using SNAP benefits would be expected to avert 510,000 diabetes person-years and 52,000 deaths from MIs and strokes over the next decade, with a savings of $2900 per QALY saved. A penny-per-ounce tax on SSBs purchased with SNAP dollars would produce higher cost savings due to tax revenues but avert fewer chronic disease deaths. However, some SNAP participants are likely to preferentially purchase SSBs through their disposable income, indirectly reducing their food security. A 30% produce subsidy would be expected to avert 39,000 diabetes person-years and 4600 cardiovascular deaths over 10 y without effects on food security. Results of Sensitivity Analysis. Results are sensitive to the intake elasticities of SSBs and produce. Limitations. Input data did not provide information on heterogeneity in response to price changes within the SNAP-using POPULATION: CONCLUSIONS: SNAP restrictions on SSBs could lower chronic disease mortality, but further testing should examine indirect effects on disposable income and food security. Subsidizing produce could confer fewer benefits or risks but at higher cost.

    View details for DOI 10.1177/0272989X13493971

    View details for PubMedID 23811757

  • Does investment in the health sector promote or inhibit economic growth? GLOBALIZATION AND HEALTH Reeves, A., Basu, S., McKee, M., Meissner, C., Stuckler, D. 2013; 9
  • Socioeconomic Inequalities in Non-Communicable Diseases Prevalence in India: Disparities between Self-Reported Diagnoses and Standardized Measures PLOS ONE Vellakkal, S., Subramanian, S. V., Millett, C., Basu, S., Stuckler, D., Ebrahim, S. 2013; 8 (7)


    Whether non-communicable diseases (NCDs) are diseases of poverty or affluence in low-and-middle income countries has been vigorously debated. Most analyses of NCDs have used self-reported data, which is biased by differential access to healthcare services between groups of different socioeconomic status (SES). We sought to compare self-reported diagnoses versus standardised measures of NCD prevalence across SES groups in India.We calculated age-adjusted prevalence rates of common NCDs from the Study on Global Ageing and Adult Health, a nationally representative cross-sectional survey. We compared self-reported diagnoses to standardized measures of disease for five NCDs. We calculated wealth-related and education-related disparities in NCD prevalence by calculating concentration index (C), which ranges from -1 to +1 (concentration of disease among lower and higher SES groups, respectively).NCD prevalence was higher (range 5.2 to 19.1%) for standardised measures than self-reported diagnoses (range 3.1 to 9.4%). Several NCDs were particularly concentrated among higher SES groups according to self-reported diagnoses (Csrd) but were concentrated either among lower SES groups or showed no strong socioeconomic gradient using standardized measures (Csm): age-standardised wealth-related C: angina Csrd 0.02 vs. Csm -0.17; asthma and lung diseases Csrd -0.05 vs. Csm -0.04 (age-standardised education-related Csrd 0.04 vs. Csm -0.05); vision problems Csrd 0.07 vs. Csm -0.05; depression Csrd 0.07 vs. Csm -0.13. Indicating similar trends of standardized measures detecting more cases among low SES, concentration of hypertension declined among higher SES (Csrd 0.19 vs. Csm 0.03).The socio-economic patterning of NCD prevalence differs markedly when assessed by standardized criteria versus self-reported diagnoses. NCDs in India are not necessarily diseases of affluence but also of poverty, indicating likely under-diagnosis and under-reporting of diseases among the poor. Standardized measures should be used, wherever feasible, to estimate the true prevalence of NCDs.

    View details for DOI 10.1371/journal.pone.0068219

    View details for Web of Science ID 000323110600012

    View details for PubMedID 23869213

  • Social Epidemiology of Hypertension in Middle-Income Countries: Determinants of Prevalence, Diagnosis, Treatment, and Control in the WHO SAGE Study. Hypertension Basu, S., Millett, C. 2013; 62 (1): 18-26


    Large-scale hypertension screening campaigns have been recommended for middle-income countries. We sought to identify sociodemographic predictors of hypertension prevalence, diagnosis, treatment, and control among middle-income countries. We analyzed data from 47 443 adults in all 6 middle-income countries (China, Ghana, India, Mexico, Russia, and South Africa) sampled in nationally representative household assessments from 2007 to 2010 as part of the World Health Organization Study on Global Aging and Adult Health. We estimated regression models accounting for age, sex, urban/rural location, nutrition, and obesity, as well as hypothesized covariates of healthcare access, such as income and insurance. Hypertension prevalence varied from 23% (India) to 52% (Russia), with between 30% (Russia) and 83% (Ghana) of hypertensives undiagnosed before the survey and between 35% (Russia) and 87% (Ghana) untreated. Although the risk of hypertension significantly increased with age (odds ratio, 4.6; 95% confidence interval, 3.0-7.1; among aged, 60-79 versus <40 years), the risk of being undiagnosed or untreated fell significantly with age. Obesity was a significant correlate to hypertension (odds ratio, 3.7; 95% confidence interval, 2.1-6.8 for obese versus normal weight), and was prevalent even among the lowest income quintile (13% obesity). Insurance status and income also emerged as significant correlates to diagnosis and treatment probability, respectively. More than 90% of hypertension cases were uncontrolled, with men having 3 times the odds as women of being uncontrolled. Overall, the social epidemiology of hypertension in middle-income countries seems to be correlated to increasing obesity prevalence, and hypertension control rates are particularly low for adult men across distinct cultures.

    View details for DOI 10.1161/HYPERTENSIONAHA.113.01374

    View details for PubMedID 23670299

  • The Effect of Tobacco Control Measures during a Period of Rising Cardiovascular Disease Risk in India: A Mathematical Model of Myocardial Infarction and Stroke PLOS MEDICINE Basu, S., Glantz, S., Bitton, A., Millett, C. 2013; 10 (7)


    We simulated tobacco control and pharmacological strategies for preventing cardiovascular deaths in India, the country that is expected to experience more cardiovascular deaths than any other over the next decade.A microsimulation model was developed to quantify the differential effects of various tobacco control measures and pharmacological therapies on myocardial infarction and stroke deaths stratified by age, gender, and urban/rural status for 2013 to 2022. The model incorporated population-representative data from India on multiple risk factors that affect myocardial infarction and stroke mortality, including hypertension, hyperlipidemia, diabetes, coronary heart disease, and cerebrovascular disease. We also included data from India on cigarette smoking, bidi smoking, chewing tobacco, and secondhand smoke. According to the model's results, smoke-free legislation and tobacco taxation would likely be the most effective strategy among a menu of tobacco control strategies (including, as well, brief cessation advice by health care providers, mass media campaigns, and an advertising ban) for reducing myocardial infarction and stroke deaths over the next decade, while cessation advice would be expected to be the least effective strategy at the population level. In combination, these tobacco control interventions could avert 25% of myocardial infarctions and strokes (95% CI: 17%-34%) if the effects of the interventions are additive. These effects are substantially larger than would be achieved through aspirin, antihypertensive, and statin therapy under most scenarios, because of limited treatment access and adherence; nevertheless, the impacts of tobacco control policies and pharmacological interventions appear to be markedly synergistic, averting up to one-third of deaths from myocardial infarction and stroke among 20- to 79-y-olds over the next 10 y. Pharmacological therapies could also be considerably more potent with further health system improvements.Smoke-free laws and substantially increased tobacco taxation appear to be markedly potent population measures to avert future cardiovascular deaths in India. Despite the rise in co-morbid cardiovascular disease risk factors like hyperlipidemia and hypertension in low- and middle-income countries, tobacco control is likely to remain a highly effective strategy to reduce cardiovascular deaths. Please see later in the article for the Editors' Summary.

    View details for DOI 10.1371/journal.pmed.1001480

    View details for Web of Science ID 000322590800006

    View details for PubMedID 23874160

  • Malignant Neglect: The Failure to Address the Need to Prevent Premature Non-communicable Disease Morbidity and Mortality. PLoS medicine Stuckler, D., Basu, S. 2013; 10 (6)


    David Stuckler and Sanjay Basu comment on a study by Carl Lachat and colleagues documenting the lack of policies addressing noncommunicable disease prevention in low- and middle-income countries and outline steps for making such policies accessible, effective, and transparent.

    View details for DOI 10.1371/journal.pmed.1001466

    View details for PubMedID 23776416

  • Alcohol use during the great recession of 2008-2009. Alcohol and alcoholism Bor, J., Basu, S., Coutts, A., McKee, M., Stuckler, D. 2013; 48 (3): 343-348


    The aim of this study was to assess changes in alcohol use in the USA during the Great Recession.Drinking participation, drinking frequency, drinking intensity, total alcohol consumption and frequency of binge drinking were assessed in a nationally representative sample of 2,050,431 US women and men aged 18 and older, interviewed between 2006 and 2010.The prevalence of any alcohol use significantly declined during the economic recession, from 52.0% in 2006-2007 to 51.6% in 2008-2009 (P < 0.05), corresponding to 880,000 fewer drinkers (95% confidence interval [CI] 140,000 to 1.6 million). There was an increase, however, in the prevalence of frequent binging, from 4.8% in 2006-2007 to 5.1% in 2008-2009 (P < 0.01), corresponding to 770,000 more frequent bingers (95% CI 390,000 to 1.1 million). Non-Black, unmarried men under 30 years, who recently became unemployed, were at highest risk for frequent binging.During the Great Recession there was an increase in abstention from alcohol and a rise in frequent binging.

    View details for DOI 10.1093/alcalc/agt002

    View details for PubMedID 23360873

  • Was the Great Depression a cause or correlate of significant mortality declines? An epidemiological response to Granados JOURNAL OF EPIDEMIOLOGY AND COMMUNITY HEALTH Stuckler, D., Meissner, C., Fishback, P., Basu, S., McKee, M. 2013; 67 (5): 467-467

    View details for DOI 10.1136/jech-2012-201903

    View details for Web of Science ID 000316560300016

    View details for PubMedID 23201621

  • Financial crisis, austerity, and health in Europe LANCET Karanikolos, M., Mladovsky, P., Cylus, J., Thomson, S., Basu, S., Stuckler, D., Mackenbach, J. P., McKee, M. 2013; 381 (9874): 1323-1331


    The financial crisis in Europe has posed major threats and opportunities to health. We trace the origins of the economic crisis in Europe and the responses of governments, examine the effect on health systems, and review the effects of previous economic downturns on health to predict the likely consequences for the present. We then compare our predictions with available evidence for the effects of the crisis on health. Whereas immediate rises in suicides and falls in road traffic deaths were anticipated, other consequences, such as HIV outbreaks, were not, and are better understood as products of state retrenchment. Greece, Spain, and Portugal adopted strict fiscal austerity; their economies continue to recede and strain on their health-care systems is growing. Suicides and outbreaks of infectious diseases are becoming more common in these countries, and budget cuts have restricted access to health care. By contrast, Iceland rejected austerity through a popular vote, and the financial crisis seems to have had few or no discernible effects on health. Although there are many potentially confounding differences between countries, our analysis suggests that, although recessions pose risks to health, the interaction of fiscal austerity with economic shocks and weak social protection is what ultimately seems to escalate health and social crises in Europe. Policy decisions about how to respond to economic crises have pronounced and unintended effects on public health, yet public health voices have remained largely silent during the economic crisis.

    View details for DOI 10.1016/S0140-6736(13)60102-6

    View details for Web of Science ID 000317351000035

    View details for PubMedID 23541059

  • Access to cancer medicines in India LANCET ONCOLOGY Kishore, S. P., Basu, S., Selvaraj, S. 2013; 14 (4): E136-E136

    View details for Web of Science ID 000317390300001

    View details for PubMedID 23561744

  • Is Passive Diagnosis Enough? The Impact of Subclinical Disease on Diagnostic Strategies for Tuberculosis AMERICAN JOURNAL OF RESPIRATORY AND CRITICAL CARE MEDICINE Dowdy, D. W., Basu, S., Andrews, J. R. 2013; 187 (5): 543-551


    Tuberculosis (TB) is characterized by a subclinical phase (symptoms absent or not considered abnormal); prediagnostic phase (symptoms noticed but diagnosis not pursued); and clinical phase (care actively sought). Diagnostic capacity during these phases is limited.To estimate the population-level impact of TB case-finding strategies in the presence of subclinical and prediagnostic disease.We created a mathematical epidemic model of TB, calibrated to global incidence. We then introduced three prototypical diagnostic interventions: increased sensitivity of diagnosis in the clinical phase by 20% ("passive"); early diagnosis during the prediagnostic phase at a rate of 10% per year ("enhanced"); and population-based diagnosis of 5% of undiagnosed prevalent cases per year ("active").If the subclinical phase was ignored, as in most models, the passive strategy was projected to reduce TB incidence by 18% (90% uncertainty range [UR], 11-32%) by year 10, compared with 23% (90% UR, 14-35%) for the enhanced strategy and 18% (90% UR, 11-28%) for the active strategy. After incorporating a subclinical phase into the model, consistent with population-based prevalence surveys, the active strategy still reduced 10-year TB incidence by 16% (90% UR, 11-28%), but the passive and enhanced strategies' impact was attenuated to 11% (90% UR, 8-25%) and 6% (90% UR, 4-13%), respectively. The degree of attenuation depended strongly on the transmission rate during the subclinical phase.Subclinical disease may limit the impact of current diagnostic strategies for TB. Active detection of undiagnosed prevalent cases may achieve greater population-level TB control than increasing passive case detection.

    View details for DOI 10.1164/rccm.201207-1217OC

    View details for Web of Science ID 000315977200014

    View details for PubMedID 23262515

  • The Relationship of Sugar to Population-Level Diabetes Prevalence: An Econometric Analysis of Repeated Cross-Sectional Data PLOS ONE Basu, S., Yoffe, P., Hills, N., Lustig, R. H. 2013; 8 (2)


    While experimental and observational studies suggest that sugar intake is associated with the development of type 2 diabetes, independent of its role in obesity, it is unclear whether alterations in sugar intake can account for differences in diabetes prevalence among overall populations. Using econometric models of repeated cross-sectional data on diabetes and nutritional components of food from 175 countries, we found that every 150 kcal/person/day increase in sugar availability (about one can of soda/day) was associated with increased diabetes prevalence by 1.1% (p <0.001) after testing for potential selection biases and controlling for other food types (including fibers, meats, fruits, oils, cereals), total calories, overweight and obesity, period-effects, and several socioeconomic variables such as aging, urbanization and income. No other food types yielded significant individual associations with diabetes prevalence after controlling for obesity and other confounders. The impact of sugar on diabetes was independent of sedentary behavior and alcohol use, and the effect was modified but not confounded by obesity or overweight. Duration and degree of sugar exposure correlated significantly with diabetes prevalence in a dose-dependent manner, while declines in sugar exposure correlated with significant subsequent declines in diabetes rates independently of other socioeconomic, dietary and obesity prevalence changes. Differences in sugar availability statistically explain variations in diabetes prevalence rates at a population level that are not explained by physical activity, overweight or obesity.

    View details for DOI 10.1371/journal.pone.0057873

    View details for Web of Science ID 000315519000167

    View details for PubMedID 23460912

  • The mental health risks of economic crisis in Spain: evidence from primary care centres, 2006 and 2010 EUROPEAN JOURNAL OF PUBLIC HEALTH Gili, M., Roca, M., Basu, S., McKee, M., Stuckler, D. 2013; 23 (1): 103-108


    Nearly all European countries have been affected by the economic crisis that began in 2007, but the consequences have been among the worst in Spain. We investigated the associations of the recession on the frequency of mood, anxiety, somatoform, alcohol-related and eating disorders among those visiting Spanish primary care settings.Primary care physicians selected randomized samples of patients attending primary care centres representing Spain's consulting populations. A total of 7940 patients in 2006-07 and 5876 in 2010-11 were administered the Primary Care Evaluation of Mental Disorders (PRIME-MD) instrument to diagnose mental disorders. Multivariate logistic regression models were used to quantify overall changes in the frequency of mental disorders, adjusting for potential socio-demographic differences in consulting populations unrelated to economic factors.Compared with the pre-crisis period of 2006, the 2010 survey revealed substantial and significant increases in the proportion of patients with mood (19.4% in major depression), anxiety (8.4% in generalized anxiety disorder), somatoform (7.3%) and alcohol-related disorders (4.6% in alcohol dependence), all significant at P < 0.001, but not in eating disorders (0.15%, P = 0.172). Independent of observed risks of unemployment [odds ratio (OR) = 1.72, P < 0.001], we observed a significantly elevated risk of major depression associated with mortgage repayment difficulties (OR = 2.12, P < 0.001) and evictions (OR = 2.95, P < 0.001). About one-third of the overall risk in the consulting population's attendance with mental health disorders could be attributed to the combined risks of household unemployment and mortgage payment difficulties.Recession has significantly increased the frequency of mental health disorders and alcohol abuse among primary care attendees in Spain, particularly among families experiencing unemployment and mortgage payment difficulties.

    View details for DOI 10.1093/eurpub/cks035

    View details for Web of Science ID 000314126700022

    View details for PubMedID 23132877

  • The effect of healthcare delivery privatisation on avoidable mortality: longitudinal cross-regional results from Italy, 1993-2003 JOURNAL OF EPIDEMIOLOGY AND COMMUNITY HEALTH Quercioli, C., Messina, G., Basu, S., McKee, M., Nante, N., Stuckler, D. 2013; 67 (2): 132-138


    During the 1990s, Italy privatised a significant portion of its healthcare delivery. The authors compared the effectiveness of private and public sector healthcare delivery in reducing avoidable mortality (deaths that should not occur in the presence of effective medical care).The authors calculated the average rate of change in age-standardised avoidable mortality rates in 19 of Italy's regions from 1993 to 2003. Multivariate regression models were used to analyse the relationship between rates of change in avoidable mortality and levels of spending on public versus private healthcare delivery, controlling for potential demographic and economic confounders.Greater spending on public delivery of health services corresponded to faster reductions in avoidable mortality rates. Each €100 additional public spending per capita on NHS delivery was independently associated with a 1.47% reduction in the rate of avoidable mortality (p=0.003). In contrast, spending on private sector services had no statistically significant effect on avoidable mortality rates (p=0.557). A higher percentage of spending on private sector delivery was associated with higher rates of avoidable mortality (p=0.002). The authors found that neither public nor private sector delivery spending was significantly associated with non-avoidable mortality rates, plausibly because non-avoidable mortality is insensitive to healthcare services.Public spending was significantly associated with reductions in avoidable mortality rates over time, while greater private sector spending was not at the regional level in Italy.

    View details for DOI 10.1136/jech-2011-200640

    View details for Web of Science ID 000313335900004

    View details for PubMedID 23024258

  • Nutritional determinants of worldwide diabetes: an econometric study of food markets and diabetes prevalence in 173 countries PUBLIC HEALTH NUTRITION Basu, S., Stuckler, D., McKee, M., Galea, G. 2013; 16 (1): 179-186


    Ageing and urbanization leading to sedentary lifestyles have been the major explanations proposed for a dramatic rise in diabetes worldwide and have been the variables used to predict future diabetes rates. However, a transition to Western diets has been suggested as an alternative driver. We sought to determine what socio-economic and dietary factors are the most significant population-level contributors to diabetes prevalence rates internationally.Multivariate regression models were used to study how market sizes of major food products (sugars, cereals, vegetable oils, meats, total joules) corresponded to diabetes prevalence, incorporating lagged and cumulative effects. The underlying social determinants of food market sizes and diabetes prevalence rates were also studied, including ageing, income, urbanization, overweight prevalence and imports of foodstuffs.Data were obtained from 173 countries.Population-based survey recipients were the basis for diabetes prevalence and food market data.We found that increased income tends to increase overall food market size among low- and middle-income countries, but the level of food importation significantly shifts the content of markets such that a greater proportion of available joules is composed of sugar and related sweeteners. Sugar exposure statistically explained why urbanization and income have been correlated with diabetes rates.Current diabetes projection methods may estimate future diabetes rates poorly if they fail to incorporate the impact of nutritional factors. Imported sugars deserve further investigation as a potential population-level driver of global diabetes.

    View details for DOI 10.1017/S1368980012002881

    View details for Web of Science ID 000313399300023

    View details for PubMedID 22691632


    View details for DOI 10.2190/HS.43.4.c

    View details for Web of Science ID 000326096600003

  • Palm oil taxes and cardiovascular disease mortality in India: economic-epidemiologic model. BMJ (Clinical research ed.) Basu, S., Babiarz, K. S., Ebrahim, S., Vellakkal, S., Stuckler, D., Goldhaber-Fiebert, J. D. 2013; 347: f6048-?


    To examine the potential effect of a tax on palm oil on hyperlipidemia and on mortality due to cardiovascular disease in India.Economic-epidemiologic model.A microsimulation model of mortality due to myocardial infarction and stroke among Indian populations was constructed, incorporating nationally representative data on systolic blood pressure, total cholesterol, tobacco smoking, diabetes, and cardiovascular event history, and stratified by age, sex, and urban/rural residence. Household expenditure data were used to estimate the change in consumption of palm oil following changes in oil price and the potential substitution of alternative oils that might occur after imposition of a tax. A 20% excise tax on palm oil purchases was simulated over the period 2014-23.The model was used to project future mortality due to myocardial infarction and stroke, as well as the potential effect of a tax on food insecurity, accounting for the effect of increased food prices.A 20% tax on palm oil purchases would be expected to avert approximately 363 000 (95% confidence interval 247 000 to 479 000) deaths from myocardial infarctions and strokes over the period 2014-23 in India (1.3% reduction in cardiovascular deaths) if people do not substitute other oils for reduced palm oil consumption. Given estimates of substitution of palm oil with other oils following a 20% price increase for palm oil, the beneficial effects of increased polyunsaturated fat consumption would be expected to enhance the projected reduction in deaths to as much as 421 000 (256 000 to 586 000). The tax would be expected to benefit men more than women and urban populations more than rural populations, given differential consumption and cardiovascular risk. In a scenario incorporating the effect of taxation on overall food expenditures, the tax may increase food insecurity by <1%, resulting in 16 000 (95% confidence interval 12 000 to 22 000) deaths.Curtailing palm oil intake through taxation may modestly reduce hyperlipidemia and cardiovascular mortality, but with potential distributional consequences differentially benefiting male and urban populations, as well as affecting food security.

    View details for DOI 10.1136/bmj.f6048

    View details for PubMedID 24149818

  • Effects of Greek economic crisis on health are real BRITISH MEDICAL JOURNAL Kentikelenis, A., Karanikolos, M., Papanicolas, I., Basu, S., McKee, M., Stuckler, D. 2012; 345

    View details for DOI 10.1136/bmj.e8602

    View details for Web of Science ID 000312701700004

    View details for PubMedID 23262574

  • Increase in state suicide rates in the USA during economic recession LANCET Reeves, A., Stuckler, D., McKee, M., Gunnell, D., Chang, S., Basu, S. 2012; 380 (9856): 1813-1814
  • Dietary Salt Reduction and Cardiovascular Disease Rates in India: A Mathematical Model PLOS ONE Basu, S., Stuckler, D., Vellakkal, S., Ebrahim, S. 2012; 7 (9)


    Reducing salt intake has been proposed to prevent cardiovascular disease in India. We sought to determine whether salt reductions would be beneficial or feasible, given the worry that unrealistically large reductions would be required, worsening iodine deficiency and benefiting only urban subpopulations.Future myocardial infarctions (MI) and strokes in India were predicted with a Markov model simulating men and women aged 40 to 69 in both urban and rural locations, incorporating the risk reduction from lower salt intake. If salt intake does not change, we expect ~8.3 million MIs (95% CI: 6.9-9.6 million), 830,000 strokes (690,000-960,000) and 2.0 million associated deaths (1.5-2.4 million) per year among Indian adults aged 40 to 69 over the next three decades. Reducing intake by 3 g/day over 30 years (-0.1 g/year, 25% reduction) would reduce annual MIs by 350,000 (a 4.6% reduction; 95% CI: 320,000-380,000), strokes by 48,000 (-6.5%; 13,000-83,000) and deaths by 81,000 (-4.9%; 59,000-100,000) among this group. The largest decline in MIs would be among younger urban men, but the greatest number of averted strokes would be among rural men, and nearly one-third of averted strokes and one-fifth of averted MIs would be among rural women. Only under a highly pessimistic scenario would iodine deficiency increase (by <0.0001%, ~1600 persons), since inadequate iodized salt access--not low intake of iodized salt--is the major cause of deficiency and would be unaffected by dietary salt reduction.Modest reductions in salt intake could substantially reduce cardiovascular disease throughout India.

    View details for DOI 10.1371/journal.pone.0044037

    View details for Web of Science ID 000308458400030

    View details for PubMedID 22970159

  • Comparative Performance of Private and Public Healthcare Systems in Low- and Middle-Income Countries: A Systematic Review PLOS MEDICINE Basu, S., Andrews, J., Kishore, S., Panjabi, R., Stuckler, D. 2012; 9 (6)


    Private sector healthcare delivery in low- and middle-income countries is sometimes argued to be more efficient, accountable, and sustainable than public sector delivery. Conversely, the public sector is often regarded as providing more equitable and evidence-based care. We performed a systematic review of research studies investigating the performance of private and public sector delivery in low- and middle-income countries.Peer-reviewed studies including case studies, meta-analyses, reviews, and case-control analyses, as well as reports published by non-governmental organizations and international agencies, were systematically collected through large database searches, filtered through methodological inclusion criteria, and organized into six World Health Organization health system themes: accessibility and responsiveness; quality; outcomes; accountability, transparency, and regulation; fairness and equity; and efficiency. Of 1,178 potentially relevant unique citations, data were obtained from 102 articles describing studies conducted in low- and middle-income countries. Comparative cohort and cross-sectional studies suggested that providers in the private sector more frequently violated medical standards of practice and had poorer patient outcomes, but had greater reported timeliness and hospitality to patients. Reported efficiency tended to be lower in the private than in the public sector, resulting in part from perverse incentives for unnecessary testing and treatment. Public sector services experienced more limited availability of equipment, medications, and trained healthcare workers. When the definition of "private sector" included unlicensed and uncertified providers such as drug shop owners, most patients appeared to access care in the private sector; however, when unlicensed healthcare providers were excluded from the analysis, the majority of people accessed public sector care. "Competitive dynamics" for funding appeared between the two sectors, such that public funds and personnel were redirected to private sector development, followed by reductions in public sector service budgets and staff.Studies evaluated in this systematic review do not support the claim that the private sector is usually more efficient, accountable, or medically effective than the public sector; however, the public sector appears frequently to lack timeliness and hospitality towards patients.

    View details for DOI 10.1371/journal.pmed.1001244

    View details for Web of Science ID 000305946200015

    View details for PubMedID 22723748

  • Banking crises and mortality during the Great Depression: evidence from US urban populations, 1929-1937 JOURNAL OF EPIDEMIOLOGY AND COMMUNITY HEALTH Stuckler, D., Meissner, C., Fishback, P., Basu, S., McKee, M. 2012; 66 (5): 410-419


    Previous research suggests that the Great Depression led to improvements in public health. However, these studies rely on highly aggregated national data (using fewer than 25 data points) and potentially biased measures of the Great Depression. The authors assess the effects of the Great Depression using city-level estimates of US mortality and an underlying measure of economic crisis, bank suspensions, at the state level.Cause-specific mortalities covering 114 US cities in 36 states between 1929 and 1937 were regressed against bank suspensions and income data from the Federal Deposit Insurance Corporation Database, using dynamic fixed-effects models and adjustments for potential confounding variables.Reductions in all-cause mortalities were mainly attributable to declines in death rates owing to pneumonia (26.4% of total), flu (13.1% of total) and respiratory tuberculosis (11.2% of total), while death rates increased from heart disease (19.4% of total), cancer (8.1% of total) and diabetes (2.9%). Only heart disease can plausibly relate to the contemporaneous economic shocks. The authors found that a higher rate of bank suspensions was significantly associated with higher suicide rates (?=0.32, 95% CI 0.24 to 0.41) but lower death rates from motor-vehicle accidents (?=-0.18, 95% CI -0.29 to -0.07); no significant effects were observed for 30 other causes of death or with a time lag.In contrast with existing research, the authors find that many of the changes in deaths from different causes during the Great Depression were unrelated to economic shocks. Further research is needed to understand the causes of the marked variations in mortality change across cities and states, including the effects of the New Deal and Prohibition.

    View details for DOI 10.1136/jech.2010.121376

    View details for Web of Science ID 000302472400007

    View details for PubMedID 21441177

  • Health and the financial crisis in Greece Reply LANCET Kentikelenis, A., Karanikolos, M., Papanicolas, I., Basu, S., McKee, M., Stuckler, D. 2012; 379 (9820): 1002-1002
  • Health effects of financial crisis: omens of a Greek tragedy LANCET Kentikelenis, A., Karanikolos, M., Papanicolas, I., Basu, S., McKee, M., Stuckler, D. 2011; 378 (9801): 1457-1458
  • Projected effects of tobacco smoking on worldwide tuberculosis control: mathematical modelling analysis BRITISH MEDICAL JOURNAL Basu, S., Stuckler, D., Bitton, A., Glantz, S. A. 2011; 343


    Almost 20% of people smoke tobacco worldwide--a percentage projected to rise in many poor countries. Smoking has been linked to increased individual risk of tuberculosis infection and mortality, but it remains unclear how these risks affect population-wide tuberculosis rates.We constructed a state transition, compartmental, mathematical model of tuberculosis epidemics to estimate the impact of alternative future smoking trends on tuberculosis control. We projected tuberculosis incidence, prevalence, and mortality in each World Health Organization region from 2010 to 2050, and incorporated changing trends in smoking, case detection, treatment success, and HIV prevalence.The model predicted that smoking would produce an excess of 18 million tuberculosis cases (standard error 16-20) and 40 million deaths from tuberculosis (39-41) between 2010 and 2050, if smoking trends continued along current trajectories. The effect of smoking was anticipated to increase the number of tuberculosis cases by 7% (274 million v 256 million) and deaths by 66% (101 million v 61 million), compared with model predictions that did not account for smoking. Smoking was also expected to delay the millennium development goal target to reduce tuberculosis mortality by half from 1990 to 2015. The model estimated that aggressive tobacco control (achieving a 1% decrease in smoking prevalence per year down to eradication) would avert 27 million smoking attributable deaths from tuberculosis by 2050. However, if the prevalence of smoking increased to 50% of adults (as observed in countries with high tobacco use), the model estimated that 34 million additional deaths from tuberculosis would occur by 2050.Tobacco smoking could substantially increase tuberculosis cases and deaths worldwide in coming years, undermining progress towards tuberculosis mortality targets. Aggressive tobacco control could avert millions of deaths from tuberculosis.

    View details for DOI 10.1136/bmj.d5506

    View details for Web of Science ID 000295779300001

    View details for PubMedID 21972295

  • Effects of the 2008 recession on health: a first look at European data LANCET Stuckler, D., Basu, S., Suhrcke, M., Coutts, A., McKee, M. 2011; 378 (9786): 124-125

    View details for Web of Science ID 000292948800021

    View details for PubMedID 21742166

  • Democracy and growth in divided societies: A health-inequality trap? SOCIAL SCIENCE & MEDICINE Powell-Jackson, T., Basu, S., Balabanova, D., McKee, M., Stuckler, D. 2011; 73 (1): 33-41


    Despite a tremendous increase in financial resources, many countries are not on track to achieve the child and maternal mortality targets set out in the Millennium Development Goals 4 and 5. It is commonly argued that two main social factors - improved democratic governance and aggregate income - will ultimately lead to progress in reducing child and maternal mortality. However, these two factors alone may be insufficient to achieve progress in settings where there is a high level of social division. To test the effects of growth and democratisation, and their interaction with social inequalities, we regressed data on child and maternal mortality rates for 192 countries against internationally used indexes of income, democracy, and population inequality (including income, ethnic, linguistic, and religious divisions) covering the period 1970-2007. We found that a higher degree of social division, especially ethnic and linguistic fractionalisation, was significantly associated with greater child and maternal mortality rates. We further found that, even in democratic states, greater social division was associated with lower overall population access to healthcare and lesser expansion of health system infrastructure. Perversely, while greater democratisation and aggregate income were associated with reduced maternal and child mortality overall, in regions with high levels of ethnic fragmentation the health benefits of democratisation and rising income were undermined and, at high levels of inequality reversed, so that democracy and growth were adversely related to child and maternal mortality. These findings are consistent with literature suggesting that high degrees of social division in the context of democratisation can strengthen the power of dominant elite and ethnic groups in political decision-making, resulting in health and welfare policies that deprive minority groups (a health-inequality trap). Thus, we show that improving economic growth and democratic governance are insufficient to achieve child and maternal health targets in communities with high levels of persistent social inequality. To reduce child and maternal mortality in highly divided societies, it will be necessary not only to increase growth and promote democratic elections, but also empower disenfranchised communities.

    View details for DOI 10.1016/j.socscimed.2011.04.013

    View details for Web of Science ID 000293263500005

    View details for PubMedID 21680070

  • The Impact of Economic Crises on Communicable Disease Transmission and Control: A Systematic Review of the Evidence PLOS ONE Suhrcke, M., Stuckler, D., Suk, J. E., Desai, M., Senek, M., McKee, M., Tsolova, S., Basu, S., Abubakar, I., Hunter, P., Rechel, B., Semenza, J. C. 2011; 6 (6)


    There is concern among public health professionals that the current economic downturn, initiated by the financial crisis that started in 2007, could precipitate the transmission of infectious diseases while also limiting capacity for control. Although studies have reviewed the potential effects of economic downturns on overall health, to our knowledge such an analysis has yet to be done focusing on infectious diseases. We performed a systematic literature review of studies examining changes in infectious disease burden subsequent to periods of crisis. The review identified 230 studies of which 37 met our inclusion criteria. Of these, 30 found evidence of worse infectious disease outcomes during recession, often resulting from higher rates of infectious contact under poorer living circumstances, worsened access to therapy, or poorer retention in treatment. The remaining studies found either reductions in infectious disease or no significant effect. Using the paradigm of the "SIR" (susceptible-infected-recovered) model of infectious disease transmission, we examined the implications of these findings for infectious disease transmission and control. Key susceptible groups include infants and the elderly. We identified certain high-risk groups, including migrants, homeless persons, and prison populations, as particularly vulnerable conduits of epidemics during situations of economic duress. We also observed that the long-term impacts of crises on infectious disease are not inevitable: considerable evidence suggests that the magnitude of effect depends critically on budgetary responses by governments. Like other emergencies and natural disasters, preparedness for financial crises should include consideration of consequences for communicable disease control.

    View details for DOI 10.1371/journal.pone.0020724

    View details for Web of Science ID 000291612600019

    View details for PubMedID 21695209

  • Transmission dynamics and control of cholera in Haiti: an epidemic model LANCET Andrews, J. R., Basu, S. 2011; 377 (9773): 1248-1255


    Official projections of the cholera epidemic in Haiti have not incorporated existing disease trends or patterns of transmission, and proposed interventions have been debated without comparative estimates of their effect. We used a mathematical model of the epidemic to provide projections of future morbidity and mortality, and to produce comparative estimates of the effects of proposed interventions.We designed mathematical models of cholera transmission based on existing models and fitted them to incidence data reported in Haiti for each province from Oct 31, 2010, to Jan 24, 2011. We then simulated future epidemic trajectories from March 1 to Nov 30, 2011, to estimate the effect of clean water, vaccination, and enhanced antibiotic distribution programmes.We project 779,000 cases of cholera in Haiti (95% CI 599,000-914,000) and 11,100 deaths (7300-17,400) between March 1 and Nov 30, 2011. We expect that a 1% per week reduction in consumption of contaminated water would avert 105,000 cases (88,000-116,000) and 1500 deaths (1100-2300). We predict that the vaccination of 10% of the population, from March 1, will avert 63,000 cases (48,000-78,000) and 900 deaths (600-1500). The proposed extension of the use of antibiotics to all patients with severe dehydration and half of patients with moderate dehydration is expected to avert 9000 cases (8000-10,000) and 1300 deaths (900-2000).A decline in cholera prevalence in early 2011 is part of the natural course of the epidemic, and should not be interpreted as indicative of successful intervention. Substantially more cases of cholera are expected than official estimates used for resource allocation. Combined, clean water provision, vaccination, and expanded access to antibiotics might avert thousands of deaths.National Institutes of Health.

    View details for DOI 10.1016/S0140-6736(11)60273-0

    View details for Web of Science ID 000289597300031

    View details for PubMedID 21414658

  • Does recession reduce global health aid? Evidence from 15 high-income countries, 1975-2007 BULLETIN OF THE WORLD HEALTH ORGANIZATION Stuckler, D., Basu, S., Wang, S. W., McKee, M. 2011; 89 (4): 252-257


    To test the hypothesis that economic recessions lead to reduced global development assistance for health (DAH).Data obtained from the Creditor Reporting System of the Organisation for Economic Co-operation and Development (OECD) for 15 OECD countries were used to model the percentage change (relative difference) in commitments and disbursements for DAH as a function of three measures of economic recession: recessionary year (as a dummy variable with 0 for no recession and 1 for recession), percentage change in per capita gross domestic product and percentage point change in unemployment rate for recessionary cycles from 1975 through 2007. We looked for an association both during the concurrent recessionary year and one and two years later.No statistically significant association was found in the short or long run between measures of economic recession and the amount of official DAH committed or disbursed.Any important decrease in overall DAH following the current economic recession would have little historical precedent and claims of inevitability would be unjustifiable.

    View details for DOI 10.2471/BLT.10.080663

    View details for Web of Science ID 000289704000016

    View details for PubMedID 21479089

  • Mining and Risk of Tuberculosis in Sub-Saharan Africa AMERICAN JOURNAL OF PUBLIC HEALTH Stuckler, D., Basu, S., McKee, M., Lurie, M. 2011; 101 (3): 524-530


    We estimated the relationship between mining and tuberculosis (TB) among countries in sub-Saharan Africa.We used multivariate regression to estimate the contribution of mining activity to TB incidence, prevalence, and mortality, as well as rates of TB among people living with HIV, with control for economic, health system, and population confounders.Mining production was associated with higher population TB incidence rates (adjusted b = 0.093; 95% confidence interval [CI] = 0.067, 0.120; with an increase of mining production of 1 SD corresponding to about 33% higher TB incidence or 760,000 more incident cases), after adjustment for economic and population controls. Similar results were observed for TB prevalence and mortality, as well as with alternative measures of mining activity. Independent of HIV, there were significant associations between mining production and TB incidence in countries with high HIV prevalence (? 4% antenatal HIV prevalence; HIV-adjusted B = 0.066; 95% CI = 0.050, 0.082) and between log gold mining production and TB incidence in all studied countries (HIV-adjusted B = 0.053; 95% CI = 0.032, 0.073).Mining is a significant determinant of countrywide variation in TB among sub-Saharan African nations. Comprehensive TB control strategies should explicitly address the role of mining activity and environments in the epidemic.

    View details for DOI 10.2105/AJPH.2009.175646

    View details for Web of Science ID 000287571800029

    View details for PubMedID 20516372

  • Who's Afraid of Noncommunicable Diseases? Raising Awareness of the Effects of Noncommunicable Diseases on Global Health JOURNAL OF HEALTH COMMUNICATION Alleyne, G., Basu, S., Stuckler, D. 2011; 16: 82-93


    Public-health priorities are in part driven by fear, yet fear has long been recognized as posing a threat to effective public health interventions. In this article, the authors review the role of fear in global health by focusing on the leading global cause of death and disability: noncommunicable diseases. Taking an historical perspective, first the authors review Samuel Adams' 1911 analysis of the role of fear in generating public health priority and his recommendations about mass educating the public. Next, they show that Adams' analysis still applies today, drawing on contemporary responses to H1N1 and HIV, while illustrating the ongoing neglect of long-term threats such as noncommunicable diseases. Then, they pose the question, "Is it possible, necessary, or useful to create a fear factor for noncommunicable diseases?" After reviewing mixed evidence about the effects of fear on social change (on individual behaviors and on building a mass movement to achieve collective action), the authors conclude by setting out an evidence-based, marketing strategy to generate a sustained, rational response to the noncommunicable disease epidemic.

    View details for DOI 10.1080/10810730.2011.602178

    View details for Web of Science ID 000299950800010

    View details for PubMedID 21916716

  • Health Care Capacity and Allocations Among South Africa's Provinces: Infrastructure-Inequality Traps After the End of Apartheid AMERICAN JOURNAL OF PUBLIC HEALTH Stuckler, D., Basu, S., McKee, M. 2011; 101 (1): 165-172


    We assessed the determinants of health care funding allocations among South Africa's provinces and their effects on health care from 1996 through 2007.We performed multivariate regression of funding allocation data against measures of disease burden and health system infrastructure by province.Disease burden was increasingly negatively correlated with funding allocations and explained less than one quarter of the variation in allocations among provinces. Nearly three quarters of the variation in allocations was explained by preexisting hospital infrastructure and health care workers. The density of private hospitals in the preceding year was associated with greater government allocations (b(private) = 0.12; 95% confidence interval [CI] = 0.08, 0.15), but public hospital density in the preceding year was not (b(public) = 0.05; 95% CI = -0.02, 0.11). Greater allocations were associated with a higher number of doctors (b = 0.54; 95% CI = 0.34, 0.75) but fewer nurses (b = -0.37; 95% CI = -0.72,-0.25) in the same year.Regions with a greater capacity to spend funds received more funding and created more infrastructure than those with greater health needs. Historical infrastructure inequalities may have created an infrastructure-inequality trap, in which the distribution of funds to those with greater "absorptive capacity" exacerbates inequalities.

    View details for DOI 10.2105/AJPH.2009.184895

    View details for Web of Science ID 000285665000030

    View details for PubMedID 21148716

  • Addressing Institutional Amplifiers in the Dynamics and Control of Tuberculosis Epidemics AMERICAN JOURNAL OF TROPICAL MEDICINE AND HYGIENE Basu, S., Stuckler, D., McKee, M. 2011; 84 (1): 30-37


    Tuberculosis outbreaks originating in prisons, mines, or hospital wards can spread to the larger community. Recent proposals have targeted these high-transmission institutional amplifiers by improving case detection, treatment, or reducing the size of the exposed population. However, what effects these alternative proposals may have is unclear. We mathematically modeled these control strategies and found case detection and treatment methods insufficient in addressing epidemics involving common types of institutional amplifiers. Movement of persons in and out of amplifiers fundamentally altered the transmission dynamics of tuberculosis in a manner not effectively mitigated by detection or treatment alone. Policies increasing the population size exposed to amplifiers or the per-person duration of exposure within amplifiers potentially worsened incidence, even in settings with high rates of detection and treatment success. However, reducing the total population size entering institutional amplifiers significantly lowered tuberculosis incidence and the risk of propagating new drug-resistant tuberculosis strains.

    View details for Web of Science ID 000285903800006

    View details for PubMedID 21212197



    Several recent papers find evidence that global health aid is being diverted to reserves, education, military, or other sectors, and is displacing government spending. This is suggested to occur because ministers of finance have competing, possibly corrupt, priorities and deprive the health sector of resources. Studies have found that development assistance for health routed to governments has a negative impact on health spending and that similar assistance routed to private nongovernmental organizations has a positive impact. An alternative hypothesis is that World Bank and IMF macro-economic policies, which specifically advise governments to divert aid to reserves to cope with aid volatility and keep government spending low, could be causing the displacement of health aid. This article evaluates whether aid displacement was greater when countries undertook a new borrowing program from the IMF between 1996 and 2006. As found in existing studies, for each $1 of development assistance for health, about $0.37 is added to the health system. However, evaluating IMF-borrowing versus non-IMF-borrowing countries reveals that non-borrowers add about $0.45 whereas borrowers add less than $0.01 to the health system. On average, health system spending grew at about half the speed when countries were exposed to the IMF than when they were not. It is important to take account of the political economy of global health finance when interpreting data on financial flows.

    View details for DOI 10.2190/HS.41.1.e

    View details for Web of Science ID 000285631100005

    View details for PubMedID 21319721

  • Chronic Diseases: Chronic Diseases and Development 1 Raising the priority of preventing chronic diseases: a political process LANCET Geneau, R., Stuckler, D., Stachenko, S., McKee, M., Ebrahim, S., Basu, S., Chockalingham, A., Mwatsama, M., Jamal, R., Alwan, A., Beaglehole, R. 2010; 376 (9753): 1689-1698
  • Raising the priority of preventing chronic diseases: a political process. Lancet Geneau, R., Stuckler, D., Stachenko, S., McKee, M., Ebrahim, S., Basu, S., Chockalingham, A., Mwatsama, M., Jamal, R., Alwan, A., Beaglehole, R. 2010; 376 (9753): 1689-1698


    Chronic diseases, especially cardiovascular diseases, diabetes, cancer, and chronic obstructive respiratory diseases,are neglected globally despite growing awareness of the serious burden that they cause. Global and national policies have failed to stop, and in many cases have contributed to, the chronic disease pandemic. Low-cost and highly effective solutions for the prevention of chronic diseases are readily available; the failure to respond is now a political, rather than a technical issue. We seek to understand this failure and to position chronic disease centrally on the global health and development agendas. To identify strategies for generation of increased political priority for chronic diseases and to further the involvement of development agencies, we use an adapted political process model. This model has previously been used to assess the success and failure of social movements. On the basis of this analysis,we recommend three strategies: reframe the debate to emphasise the societal determinants of disease and the interrelation between chronic disease, poverty, and development; mobilise resources through a cooperative and inclusive approach to development and by equitably distributing resources on the basis of avoidable mortality; and build one merging strategic and political opportunities, such as the World Health Assembly 2008–13 Action Plan and the high level meeting of the UN General Assembly in 2011 on chronic disease. Until the full set of threats—which include chronic disease—that trap poor households in cycles of debt and illness are addressed, progress towards equitable human development will remain inadequate.

    View details for DOI 10.1016/S0140-6736(10)61414-6

    View details for PubMedID 21074260

  • Responding to the economic crisis: a primer for public health professionals JOURNAL OF PUBLIC HEALTH Stuckler, D., Basu, S., McKee, M., Suhrcke, M. 2010; 32 (3): 298-306


    Does the current economic crisis require the deep cuts in public spending announced in the June 2010 emergency budget, with potential implications for public health? The arguments for and against such cuts in response to economic recession are complex, but if public health professionals are to engage in debates about future public spending, they should be informed by relevant evidence. In this perspective, we note that opinions among politicians and economists about how to respond to economic downturns are divided, while other EU countries, many with greater levels of debt than the UK, are protecting public expenditure unless required to do so by the International Monetary Fund. Current UK debt may in fact be viewed as sustainable given current information about interest rates, inflation and economic growth. Before accepting large cuts in public spending, it is important to contrast the lack of evidence for such short-term fixes with potentially dire repercussions for population health and welfare.

    View details for DOI 10.1093/pubmed/fdq060

    View details for Web of Science ID 000281186000003

    View details for PubMedID 20729376

  • Is wealthier always healthier? The impact of national income level, inequality, and poverty on public health in Latin America SOCIAL SCIENCE & MEDICINE Biggs, B., King, L., Basu, S., Stuckler, D. 2010; 71 (2): 266-273


    Despite findings indicating that both national income level and income inequality are each determinants of public health, few have studied how national income level, poverty and inequality interact with each other to influence public health outcomes. We analyzed the relationship between gross domestic product (GDP) per capita in purchasing power parity, extreme poverty rates, the gini coefficient for personal income and three common measures of public health: life expectancy, infant mortality rates, and tuberculosis (TB) mortality rates. Introducing poverty and inequality as modifying factors, we then assessed whether the relationship between GDP and health differed during times of increasing, decreasing, and decreasing or constant poverty and inequality. Data were taken from twenty-two Latin American countries from 1960 to 2007 from the December 2008 World Bank World Development Indicators, World Health Organization Global Tuberculosis Database 2008, and the Socio-Economic Database for Latin America and the Caribbean. Consistent with previous studies, we found increases in GDP have a sizable positive impact on population health. However, the strength of the relationship is powerfully influenced by changing levels of poverty and inequality. When poverty was increasing, greater GDP had no significant effect on life expectancy or TB mortality, and only led to a small reduction in infant mortality rates. When inequality was rising, greater GDP had only a modest effect on life expectancy and infant mortality rates, and no effect on TB mortality rates. In sharp contrast, during times of decreasing or constant poverty and inequality, there was a very strong relationship between increasing GDP and higher life expectancy and lower TB and infant mortality rates. Finally, inequality and poverty were found to exert independent, substantial effects on the relationship between national income level and health. Wealthier is indeed healthier, but how much healthier depends on how increases in wealth are distributed.

    View details for DOI 10.1016/j.socscimed.2010.04.002

    View details for Web of Science ID 000279985600009

    View details for PubMedID 20471147

  • Drivers of Inequality in Millennium Development Goal Progress: A Statistical Analysis PLOS MEDICINE Stuckler, D., Basu, S., McKee, M. 2010; 7 (3)


    Many low- and middle-income countries are not on track to reach the public health targets set out in the Millennium Development Goals (MDGs). We evaluated whether differential progress towards health MDGs was associated with economic development, public health funding (both overall and as percentage of available domestic funds), or health system infrastructure. We also examined the impact of joint epidemics of HIV/AIDS and noncommunicable diseases (NCDs), which may limit the ability of households to address child mortality and increase risks of infectious diseases.We calculated each country's distance from its MDG goals for HIV/AIDS, tuberculosis, and infant and child mortality targets for the year 2005 using the United Nations MDG database for 227 countries from 1990 to the present. We studied the association of economic development (gross domestic product [GDP] per capita in purchasing-power-parity), the relative priority placed on health (health spending as a percentage of GDP), real health spending (health system expenditures in purchasing-power-parity), HIV/AIDS burden (prevalence rates among ages 15-49 y), and NCD burden (age-standardised chronic disease mortality rates), with measures of distance from attainment of health MDGs. To avoid spurious correlations that may exist simply because countries with high disease burdens would be expected to have low MDG progress, and to adjust for potential confounding arising from differences in countries' initial disease burdens, we analysed the variations in rates of change in MDG progress versus expected rates for each country. While economic development, health priority, health spending, and health infrastructure did not explain more than one-fifth of the differences in progress to health MDGs among countries, burdens of HIV and NCDs explained more than half of between-country inequalities in child mortality progress (R(2)-infant mortality = 0.57, R(2)-under 5 mortality = 0.54). HIV/AIDS and NCD burdens were also the strongest correlates of unequal progress towards tuberculosis goals (R(2) = 0.57), with NCDs having an effect independent of HIV/AIDS, consistent with micro-level studies of the influence of tobacco and diabetes on tuberculosis risks. Even after correcting for health system variables, initial child mortality, and tuberculosis diseases, we found that lower burdens of HIV/AIDS and NCDs were associated with much greater progress towards attainment of child mortality and tuberculosis MDGs than were gains in GDP. An estimated 1% lower HIV prevalence or 10% lower mortality rate from NCDs would have a similar impact on progress towards the tuberculosis MDG as an 80% or greater rise in GDP, corresponding to at least a decade of economic growth in low-income countries.Unequal progress in health MDGs in low-income countries appears significantly related to burdens of HIV and NCDs in a population, after correcting for potentially confounding socioeconomic, disease burden, political, and health system variables. The common separation between NCDs, child mortality, and infectious syndromes among development programs may obscure interrelationships of illness affecting those living in poor households--whether economic (e.g., as money spent on tobacco is lost from child health expenditures) or biological (e.g., as diabetes or HIV enhance the risk of tuberculosis).

    View details for DOI 10.1371/journal.pmed.1000241

    View details for Web of Science ID 000276311600010

    View details for PubMedID 20209000

  • Financing the Millennium Development Goals for health and beyond: sustaining the 'Big Push'. Globalization and health Ooms, G., Stuckler, D., Basu, S., McKee, M. 2010; 6: 17-?


    Many of the Millennium Development Goals are not being achieved in the world's poorest countries, yet only five years remain until the target date. The financing of these Goals is not merely insufficient; current evidence indicates that the temporary nature of the financing, as well as challenges to coordinating its delivery and directing it to the most needy recipients, hinder achievement of the Goals in countries that may benefit most. Traditional approaches to providing development assistance for health have not been able to address both prevalent and emergent public health challenges captured in the Goals; these challenges demand sustained forms of financial redistribution through a coordinated mechanism. A global social health protection fund is proposed to address recurring failures in the modern aid distribution mechanism. Such a Fund could use established and effective strategies for aid delivery to mitigate many financial problems currently undermining the Millennium Development Goals initiative.

    View details for DOI 10.1186/1744-8603-6-17

    View details for PubMedID 20932274

  • AN EVALUATION OF THE INTERNATIONAL MONETARY FUND'S CLAIMS ABOUT PUBLIC HEALTH INTERNATIONAL JOURNAL OF HEALTH SERVICES Stuckler, D., Basu, S., Gilmore, A., Batniji, R., Ooms, G., Marphatia, A. A., Hammonds, R., McKee, M. 2010; 40 (2): 327-332


    The International Monetary Fund's recent claims concerning its impact on public health are evaluated against available data. First, the IMF claims that health spending either does not change or increases with IMF-supported programs, but there is substantial evidence to the contrary. Second, the IMF claims to have relaxed strict spending requirements in response to the 2008-9 financial crisis, but there is no evidence supporting this claim, and some limited evidence from the Center for Economic Policy Research contradicting it. Third, the IMF states that wage ceilings on public health are no longer part of its explicit conditionalities to poor countries, as governments can choose how to achieve public spending targets; but in practice, ministers are left with few viable alternatives than to reduce health budgets to achieve specific IMF-mandated targets, so the result effectively preserves former policy. Fourth, the IMF's claim that it has increased aid to poor countries also seems to be contradicted by its policies of diverting aid to reserves, as well as evidence that a very small fraction of the Fund's new lending in response to the financial crisis has reached poor countries. Finally, the IMF's claim that it follows public health standards in tobacco control contrasts with its existing policies, which fail to follow the guidelines recommended by the World Bank and World Health Organization. The authors recommend that the IMF (1) become more transparent in its policies, practices, and data to allow improved independent evaluations of its impact on public health (including Health Impact Assessment) and (2) review considerable public health evidence indicating a negative association between its current policies and public health outcomes.

    View details for DOI 10.2190/HS.40.2.m

    View details for Web of Science ID 000277258100013

    View details for PubMedID 20440976

  • Turning a blind eye: the mobilization of radiology services in resource-poor regions. Globalization and health Maru, D. S., Schwarz, R., Jason, A., Basu, S., Sharma, A., Moore, C. 2010; 6: 18-?


    While primary care, obstetrical, and surgical services have started to expand in the world's poorest regions, there is only sparse literature on the essential support systems that are required to make these operations function. Diagnostic imaging is critical to effective rural healthcare delivery, yet it has been severely neglected by the academic, public, and private sectors. Currently, a large portion of the world's population lacks access to any form of diagnostic imaging. In this paper we argue that two primary imaging modalities--diagnostic ultrasound and X-Ray--are ideal for rural healthcare services and should be scaled-up in a rapid and standardized manner. Such machines, if designed for resource-poor settings, should a) be robust in harsh environmental conditions, b) function reliably in environments with unstable electricity, c) minimize radiation dangers to staff and patients, d) be operable by non-specialist providers, and e) produce high-quality images required for accurate diagnosis. Few manufacturers are producing ultrasound and X-Ray machines that meet the specifications needed for rural healthcare delivery in resource-poor regions. A coordinated effort is required to create demand sufficient for manufacturers to produce the desired machines and to ensure that the programs operating them are safe, effective, and financially feasible.

    View details for DOI 10.1186/1744-8603-6-18

    View details for PubMedID 20946643

  • Turning a blind eye: the mobilization of radiology services in resource-poor regions GLOBALIZATION AND HEALTH Maru, D. S., Schwarz, R., Andrews, J., Basu, S., Sharma, A., Moore, C. 2010; 6
  • Financing the Millennium Development Goals for health and beyond: sustaining the 'Big Push' GLOBALIZATION AND HEALTH Ooms, G., Stuckler, D., Basu, S., McKee, M. 2010; 6
  • The health implications of financial crisis: a review of the evidence. Ulster medical journal Stuckler, D., Basu, S., Suhrcke, M., McKee, M. 2009; 78 (3): 142-145


    What will the current economic crisis mean for the health of the people of Northern Ireland? We review the experience of three major economic crises in the 20(th) century: the Great Depression (1929), the Post-communist Depression (early 1990 s) and the East Asian financial crisis (late 1990 s). Available evidence suggests that health is at risk in times of rapid economic change, in both booms and busts. However the impact on mortality is exacerbated where people have easy access to the means to harm themselves and is ameliorated by the presence of strong social cohesion and social protection systems. On this basis, Northern Ireland may escape relatively unscathed in the short term but as every crisis also provides an opportunity, this is an appropriate time for the Northern Ireland Executive to reflect on whether they are making a sufficient investment in the long term health of their population.

    View details for PubMedID 19907678

  • The public health effect of economic crises and alternative policy responses in Europe: an empirical analysis LANCET Stuckler, D., Basu, S., Suhrcke, M., Coutts, A., McKee, M. 2009; 374 (9686): 315-323


    There is widespread concern that the present economic crisis, particularly its effect on unemployment, will adversely affect population health. We investigated how economic changes have affected mortality rates over the past three decades and identified how governments might reduce adverse effects.We used multivariate regression, correcting for population ageing, past mortality and employment trends, and country-specific differences in health-care infrastructure, to examine associations between changes in employment and mortality, and how associations were modified by different types of government expenditure for 26 European Union (EU) countries between 1970 and 2007.We noted that every 1% increase in unemployment was associated with a 0.79% rise in suicides at ages younger than 65 years (95% CI 0.16-1.42; 60-550 potential excess deaths [mean 310] EU-wide), although the effect size was non-significant at all ages (0.49%, -0.04 to 1.02), and with a 0.79% rise in homicides (95% CI 0.06-1.52; 3-80 potential excess deaths [mean 40] EU-wide). By contrast, road-traffic deaths decreased by 1.39% (0.64-2.14; 290-980 potential fewer deaths [mean 630] EU-wide). A more than 3% increase in unemployment had a greater effect on suicides at ages younger than 65 years (4.45%, 95% CI 0.65-8.24; 250-3220 potential excess deaths [mean 1740] EU-wide) and deaths from alcohol abuse (28.0%, 12.30-43.70; 1550-5490 potential excess deaths [mean 3500] EU-wide). We noted no consistent evidence across the EU that all-cause mortality rates increased when unemployment rose, although populations varied substantially in how sensitive mortality was to economic crises, depending partly on differences in social protection. Every US$10 per person increased investment in active labour market programmes reduced the effect of unemployment on suicides by 0.038% (95% CI -0.004 to -0.071).Rises in unemployment are associated with significant short-term increases in premature deaths from intentional violence, while reducing traffic fatalities. Active labour market programmes that keep and reintegrate workers in jobs could mitigate some adverse health effects of economic downturns.Centre for Crime and Justice Studies, King's College, London, UK; and Wates Foundation (UK).

    View details for DOI 10.1016/S0140-6736(09)61124-7

    View details for Web of Science ID 000268508200029

    View details for PubMedID 19589588

  • The Evolution of Tuberculosis Virulence BULLETIN OF MATHEMATICAL BIOLOGY Basu, S., Galvani, A. P. 2009; 71 (5): 1073-1088


    The evolution of Mycobacterium tuberculosis presents several challenges for public health. HIV and resistance to antimycobacterial medications have evolutionary implications for how Mycobacterium tuberculosis will evolve, as these factors influence the host environment and transmission dynamics of tuberculosis strains. We present an evolutionary invasion analysis of tuberculosis that characterizes the direction of tuberculosis evolution in the context of different natural and human-driven selective pressures, including changes in tuberculosis treatment and HIV prevalence. We find that the evolution of tuberculosis virulence can be affected by treatment success rates, the relative transmissibility of emerging strains, the rate of reactivation from latency among hosts, and the life expectancy of hosts. We find that the virulence of tuberculosis strains may also increase as a consequence of rising HIV prevalence, requiring faster case detection strategies in areas where the epidemics of HIV and tuberculosis collide.

    View details for DOI 10.1007/s11538-009-9394-x

    View details for Web of Science ID 000267157700003

    View details for PubMedID 19172358

  • Averting epidemics of extensively drug-resistant tuberculosis PROCEEDINGS OF THE NATIONAL ACADEMY OF SCIENCES OF THE UNITED STATES OF AMERICA Basu, S., Friedland, G. H., Medlock, J., Andrews, J. R., Shah, N. S., Gandhi, N. R., Moll, A., Moodley, P., Sturm, A. W., Galvani, A. P. 2009; 106 (18): 7672-7677


    Extensively drug-resistant tuberculosis (XDR TB) has been detected in most provinces of South Africa, particularly in the KwaZulu-Natal province where several hundred cases have been reported since 2004. We analyzed the transmission dynamics of XDR TB in the region using mathematical models, and observed that nosocomial transmission clusters of XDR TB may emerge into community-based epidemics under the public health conditions of many South African communities. The effective reproductive number of XDR TB in KwaZulu-Natal may be around 2. Intensified community-based case finding and therapy appears critical to curtailing transmission. In the setting of delayed disease presentation and high system demand, improved diagnostic approaches may need to be employed in community-based programs rather than exclusively at tertiary hospitals. Using branching process mathematics, we observed that early, community-based drug-susceptibility testing and effective XDR therapy could help curtail ongoing transmission and reduce the probability of XDR TB epidemics in neighboring territories.

    View details for DOI 10.1073/pnas.0812472106

    View details for Web of Science ID 000265783600073

    View details for PubMedID 19365076

  • Primary and secondary tuberculosis preventive treatment in HIV clinics: simulating alternative strategies INTERNATIONAL JOURNAL OF TUBERCULOSIS AND LUNG DISEASE Basu, S., Maru, D., POOLMAN, E., Galvani, A. 2009; 13 (5): 652-658


    Isoniazid preventive treatment (IPT) has been recommended for human immunodeficiency virus (HIV) infected individuals.We used a mathematical model to simulate the benefits and risks of preventive treatment delivered through antiretroviral (ARV) clinics using clinical data from Botswana.Preventive treatment was found to reduce the incidence of tuberculosis (TB) by at least 12 cases per 100000 population per year versus the scenario without such treatment over a 50-year simulation. Isoniazid (INH) resistant TB was observed to increase by <1% per year, even when using pessimistic assumptions about resistance emergence. The use of tuberculin skin testing had little impact as a screening procedure, while secondary treatment was observed to nearly double the impact of a preventive treatment program. Regardless of whether or not preventive treatment was implemented, INH-resistant TB rose in the context of increasing HIV prevalence, but was minimally amplified by preventive treatment itself.IPT programs implemented through ARV clinics may be effective at reducing TB incidence. The resistance contribution of IPT appears unlikely to supersede its overall incidence and mortality benefits.

    View details for Web of Science ID 000265424900021

    View details for PubMedID 19383201

  • Treatment outcomes among patients with multidrug-resistant tuberculosis: systematic review and meta-analysis LANCET INFECTIOUS DISEASES Orenstein, E. W., Basu, S., Shah, N. S., Andrews, J. R., Friedland, G. H., Moll, A. P., Gandhi, N. R., Galvani, A. P. 2009; 9 (3): 153-161


    Multidrug-resistant (MDR) tuberculosis is a growing clinical and public-health concern. To evaluate existing evidence regarding treatment regimens for MDR tuberculosis, we used a Bayesian random-effects meta-analysis of the available therapeutic studies to assess how the reported proportion of patients treated successfully is influenced by differences in treatment regimen design, study methodology, and patient population. Successful treatment outcome was defined as cure or treatment completion. 34 clinical reports with a mean of 250 patients per report met the inclusion criteria. Our analysis shows that the proportion of patients treated successfully improved when treatment duration was at least 18 months, and if patients received directly observed therapy throughout treatment. Studies that combined both factors had significantly higher pooled success proportions (69%, 95% credible interval [CI] 64-73%) than other studies of treatment outcomes (58%, 95% CI 52-64%). Individualised treatment regimens had higher treatment success (64%, 95% CI 59-68%) than standardised regimens (54%, 95% CI 43-68%), although the difference was not significant. Treatment approaches and study methodologies were heterogeneous across studies. Many important variables, including patients' HIV status, were inconsistently reported between studies. These results underscore the importance of strong patient support and treatment follow-up systems to develop successful MDR tuberculosis treatment programmes.

    View details for Web of Science ID 000263787500014

    View details for PubMedID 19246019

  • The production of consumption: addressing the impact of mineral mining on tuberculosis in southern Africa GLOBALIZATION AND HEALTH Basu, S., Stuckler, D., Gonsalves, G., Lurie, M. 2009; 5
  • The production of consumption: addressing the impact of mineral mining on tuberculosis in southern Africa. Globalization and health Basu, S., Stuckler, D., Gonsalves, G., Lurie, M. 2009; 5: 11-?


    Miners in southern Africa experience incident rates of tuberculosis up to ten times greater than the general population. Migration to and from mines may be amplifying tuberculosis epidemics in the general population.Migration to and from mineral mines contributes to HIV risks and associated tuberculosis incidence. Health and safety conditions within mines also promote the risk of silicosis (a tuberculosis risk factor) and transmission of tuberculosis bacilli in close quarters. In the context of migration, current tuberculosis prevention and treatment strategies often fail to provide sufficient continuity of care to ensure appropriate tuberculosis detection and treatment. Reports from Lesotho and South Africa suggest that miners pose transmission risks to other household or community members as they travel home undetected or inadequately treated, particularly with drug-resistant forms of tuberculosis. Reducing risky exposures on the mines, enhancing the continuity of primary care services, and improving the enforcement of occupational health codes may mitigate the harmful association between mineral mining activities and tuberculosis incidence among affected communities.Tuberculosis incidence appears to be amplified by mineral mining operations in southern Africa. A number of immediately-available measures to improve continuity of care for miners, change recruitment and compensation practices, and reduce the primary risk of infection may critically mitigate the negative association between mineral mining and tuberculosis.

    View details for DOI 10.1186/1744-8603-5-11

    View details for PubMedID 19785769



    In April 2009, the G20 countries committed US $750 billion to the International Monetary Fund (IMF), which has assumed a central role in global economic management. The IMF provides loans to financially ailing countries, but with strict conditions, typically involving a mix of privatization, liberalization, and fiscal austerity programs. These loan conditions have been extremely controversial. In principle, they are designed to help countries balance their books. In practice, they often translate into reductions in social spending, including spending on public health and health care delivery. As more countries are being exposed to IMF policies, there is a need to establish what we know and do not know about the IMF's effects on global health. This article introduces a series in which contributors review the evidence on the relationship between the IMF and public health and discuss potential ways to improve the Fund's effects on health. While more evidence is needed for some regions, there is sufficient evidence to indicate that IMF programs have been significantly associated with weakened health care systems, reduced effectiveness of health-focused development aid, and impeded efforts to control tobacco, infectious diseases, and child and maternal mortality. Reforms are urgently needed to prevent the current wave of IMF programs from further undermining public health in financially ailing countries and limiting progress toward the health Millennium Development Goals.

    View details for DOI 10.2190/HS.39.4.j

    View details for Web of Science ID 000271559500010

    View details for PubMedID 19927414

  • Integrating epidemiology, psychology, and economics to achieve HPV vaccination targets PROCEEDINGS OF THE NATIONAL ACADEMY OF SCIENCES OF THE UNITED STATES OF AMERICA Basu, S., Chapman, G. B., Galvani, A. P. 2008; 105 (48): 19018-19023


    Human papillomavirus (HPV) vaccines provide an opportunity to reduce the incidence of cervical cancer. Optimization of cervical cancer prevention programs requires anticipation of the degree to which the public will adhere to vaccination recommendations. To compare vaccination levels driven by public perceptions with levels that are optimal for maximizing the community's overall utility, we develop an epidemiological game-theoretic model of HPV vaccination. The model is parameterized with survey data on actual perceptions regarding cervical cancer, genital warts, and HPV vaccination collected from parents of vaccine-eligible children in the United States. The results suggest that perceptions of survey respondents generate vaccination levels far lower than those that maximize overall health-related utility for the population. Vaccination goals may be achieved by addressing concerns about vaccine risk, particularly those related to sexual activity among adolescent vaccine recipients. In addition, cost subsidizations and shifts in federal coverage plans may compensate for perceived and real costs of HPV vaccination to achieve public health vaccination targets.

    View details for DOI 10.1073/pnas.0808114105

    View details for Web of Science ID 000261489100073

    View details for PubMedID 19015536

  • The transmission and control of XDR TB in South Africa: an operations research and mathematical modelling approach EPIDEMIOLOGY AND INFECTION Basu, S., Galvani, A. P. 2008; 136 (12): 1585-1598


    Extensively drug-resistant tuberculosis (XDR TB) has emerged as a threat to TB control efforts in several high-burden areas, generating international concern. XDR TB is now found in every region of the world, but appears most worrisome in the context of HIV and in resource-limited settings with congregate hospital wards. Here, we examine the emergence and transmission dynamics of the disease, incorporating the mathematical modelling literature related to airborne infection and epidemiological studies related to the operations of TB control programmes in resource-limited settings. We find that while XDR TB may present many challenges in the setting of resource constraints, the central problems highlighted by the emergence of XDR TB are those that have plagued TB programmes for years. These include a slow rate of case detection that permits prolonged infectiousness, the threat of airborne infection in enclosed spaces, the problem of inadequate treatment delivery and treatment completion, and the need to develop health systems that can address the combination of TB and poverty. Mathematical models of TB transmission shed light on the idea that community-based therapy and rapid detection systems may be beneficial in resource-limited settings, while congregate hospital wards are sites for major structural reform.

    View details for DOI 10.1017/S0950268808000964

    View details for Web of Science ID 000261553500001

    View details for PubMedID 18606028

  • The Theoretical Influence of Immunity between Strain Groups on the Progression of Drug-Resistant Tuberculosis Epidemics JOURNAL OF INFECTIOUS DISEASES Basu, S., Orenstein, E., Galvani, A. P. 2008; 198 (10): 1502-1513


    Emerging research suggests that genetically distinct strains of Mycobacterium tuberculosis may modulate the immune system differently. This may be of importance in high-burden settings where > or =1 genetic group of M. tuberculosis confers significant morbidity.A dynamic mathematical model was constructed to evaluate how different degrees of cross-immunity among M. tuberculosis groups could affect epidemics of drug-resistant tuberculosis (TB).Simulated populations with immunogenically distinct TB strain groups experienced a heightened risk of drug-resistant TB, compared with populations without such strain diversity, even when the same rates of case detection and treatment success were achieved. The highest risks of infection were observed in populations in which HIV was prevalent. Drug-resistant strains with very low transmission fitness could still propagate in environments with reduced cross-immunity among different strain groups, even after common targets for case detection and treatment success are reached.It is possible that the propagation of drug-resistant strains could depend not only on the rate of development of resistance and the fitness of the drug-resistant strains but, also, on the diversity of the strains in the region. The risk of infection with drug-resistant strains could be amplified in locations where there is reduced cross-immunity between originating strain groups. This amplification may be most profound during the first few decades of TB treatment expansion.

    View details for DOI 10.1086/592508

    View details for Web of Science ID 000260472400012

    View details for PubMedID 18816192

  • Clinical outcomes of hepatitis C treatment in a prison setting: Feasibility and effectiveness for challenging treatment populations CLINICAL INFECTIOUS DISEASES Maru, D. S., Bruce, R. D., Basu, S., Altice, F. L. 2008; 47 (7): 952-961


    More than one-third of people in the United States with hepatic C virus (HCV) infection pass through the correctional system annually. Data are lacking on outcomes of treatment with pegylated interferon plus ribavirin (PEG-RBV) in correctional settings.During 2002-2006, we analyzed patients in the Connecticut Department of Correction who received PEG-RBV. We assessed the rates of sustained virological response, hospitalization, and use of medications to treat psychiatric disorders and anemia.Of 138 treatment-naive patients referred for treatment, 68 (49%) were approved. Overall, sustained virological response occurred in 47.1% of patients (for HCV genotype 1, 43.1%; for HCV genotypes 2 and 3, 58.8%). Only 9 patients (13%) discontinued treatment because of adverse effects. Multiple regression analysis revealed that not achieving a sustained virological response was correlated with HCV genotype 1 infection plus cirrhosis (adjusted odds ratio, 12.9; 95% confidence interval, 1.1-148) and baseline major depression (adjusted odds ratio, 3.4; 95% confidence interval, 1.01-11.6), but not with HIV infection, a baseline HCV RNA level >or=400,000 IU/mL, or black race. Compared with baseline, the rate of prescription of a new mood stabilizer (2.2 vs. 0.8 prescriptions per person-year) or an opioid (1.8 vs. 0.5 prescriptions per person-year) was higher during treatment, whereas there was no change in the rate of prescription of benzodiazepines and antipsychotic medications.These results support the feasibility and clinical effectiveness of PEG-RBV for the treatment of chronic HCV infection in correctional facilities.

    View details for DOI 10.1086/591707

    View details for Web of Science ID 000259038400017

    View details for PubMedID 18715156

  • Mass incarceration can explain population increases in TB and multidrug-resistant TB in European and central Asian countries PROCEEDINGS OF THE NATIONAL ACADEMY OF SCIENCES OF THE UNITED STATES OF AMERICA Stuckler, D., Basu, S., McKee, M., King, L. 2008; 105 (36): 13280-13285


    Several microlevel studies have pinpointed prisons as an important site for tuberculosis (TB) and multidrug-resistant TB in European and central Asian countries. To date, no comparative analyses have examined whether rises in incarceration rates can account for puzzling differences in TB trends among overall populations. Using longitudinal TB and cross-sectional multidrug-resistant TB data for 26 eastern European and central Asian countries, we examined whether and to what degree increases in incarceration account for differences in population TB and multidrug-resistant TB burdens. We find that each percentage point increase in incarceration rates relates to an increased TB incidence of 0.34% (population attributable risk, 95% C.I.: 0.10-0.58%, P < 0.01), after controlling for TB infrastructure; HIV prevalence; and several surveillance, economic, demographic, and political indicators. Net increases in incarceration account for a 20.5% increase in TB incidence or nearly three-fifths of the average total increase in TB incidence in the countries studied from 1991 to 2002. Although the number of prisoners is a significant determinant of differences in TB incidence and multidrug-resistant TB prevalence among countries, the rate of prison growth is a larger determinant of these outcomes, and its effect is exacerbated but not confounded by HIV. Differences in incarceration rates are a major determinant of differences in population TB outcomes among eastern European and central Asian countries, and treatment expansion alone does not appear to resolve the effect of mass incarceration on TB incidence.

    View details for DOI 10.1073/pnas.0801200105

    View details for Web of Science ID 000259251700021

    View details for PubMedID 18728189

  • International Monetary Fund programs and tuberculosis outcomes in post-communist countries PLOS MEDICINE Stuckler, D., King, L. P., Basu, S. 2008; 5 (7): 1079-1090


    Previous studies have indicated that International Monetary Fund (IMF) economic programs have influenced health-care infrastructure in recipient countries. The post-communist Eastern European and former Soviet Union countries experienced relatively similar political and economic changes over the past two decades, and participated in IMF programs of varying size and duration. We empirically examine how IMF programs related to changes in tuberculosis incidence, prevalence, and mortality rates among these countries.We performed multivariate regression of two decades of tuberculosis incidence, prevalence, and mortality data against variables potentially influencing tuberculosis program outcomes in 21 post-communist countries for which comparative data are available. After correcting for confounding variables, as well as potential detection, selection, and ecological biases, we observed that participating in an IMF program was associated with increased tuberculosis incidence, prevalence, and mortality rates by 13.9%, 13.2%, and 16.6%, respectively. Each additional year of participation in an IMF program was associated with increased tuberculosis mortality rates by 4.1%, and each 1% increase in IMF lending was associated with increased tuberculosis mortality rates by 0.9%. On the other hand, we estimated a decrease in tuberculosis mortality rates of 30.7% (95% confidence interval, 18.3% to 49.5%) associated with exiting the IMF programs. IMF lending did not appear to be a response to worsened health outcomes; rather, it appeared to be a precipitant of such outcomes (Granger- and Sims-causality tests), even after controlling for potential political, socioeconomic, demographic, and health-related confounders. In contrast, non-IMF lending programs were connected with decreased tuberculosis mortality rates (-7.6%, 95% confidence interval, -1.0% to -14.1%). The associations observed between tuberculosis mortality and IMF programs were similar to those observed when evaluating the impact of IMF programs on tuberculosis incidence and prevalence. While IMF programs were connected with large reductions in generalized government expenditures, tuberculosis program coverage, and the number of physicians per capita, non-IMF lending programs were not significantly associated with these variables.IMF economic reform programs are associated with significantly worsened tuberculosis incidence, prevalence, and mortality rates in post-communist Eastern European and former Soviet countries, independent of other political, socioeconomic, demographic, and health changes in these countries. Future research should attempt to examine how IMF programs may have related to other non-tuberculosis-related health outcomes.

    View details for DOI 10.1371/journal.pmed.0050143

    View details for Web of Science ID 000257970500014

    View details for PubMedID 18651786

  • Prevention of nosocomial transmission of extensively drug-resistant tuberculosis in rural South African district hospitals: an epidemiological modelling study LANCET Basu, S., Andrews, J. R., Poolman, E. M., Gandhi, N. R., Shah, N. S., Moll, A., Moodley, P., Galvani, A. P., Friedland, G. H. 2007; 370 (9597): 1500-1507


    Extensively drug-resistant (XDR) tuberculosis has spread among hospitalised patients in South Africa, but the epidemic-level effect of hospital-based infection control strategies remains unknown. We modelled the plausible effect of rapidly available infection control strategies on the overall course of the XDR tuberculosis epidemic in a rural area of South Africa.We investigated the effect of administrative, environmental, and personal infection control measures on the epidemic trajectory of XDR tuberculosis in the rural community of Tugela Ferry. Assessments were done with a mathematical model incorporating over 2 years of longitudinal inpatient and community-based data. The model simulated inpatient airborne tuberculosis transmission, community tuberculosis transmission, and the effect of HIV and antiretroviral therapy.If no new interventions are introduced, about 1300 cases of XDR tuberculosis are predicted to occur in the area of Tugela Ferry by the end of 2012, more than half of which are likely to be nosocomially transmitted. Mask use alone would avert fewer than 10% of cases in the overall epidemic, but could prevent a large proportion of cases of XDR tuberculosis in hospital staff. The combination of mask use with reduced hospitalisation time and a shift to outpatient therapy could prevent nearly a third of XDR tuberculosis cases. Supplementing this approach with improved ventilation, rapid drug resistance testing, HIV treatment, and tuberculosis isolation facilities could avert 48% of XDR tuberculosis cases (range 34-50%) by the end of 2012. However, involuntary detention could result in an unexpected rise in incidence due to restricted isolation capacity.A synergistic combination of available nosocomial infection control strategies could prevent nearly half of XDR tuberculosis cases, even in a resource-limited setting. XDR tuberculosis transmission will probably continue in the community, indicating the need to develop and implement parallel community-based programmes.

    View details for Web of Science ID 000250487000027

    View details for PubMedID 17964351

  • Pharmacological pain control for human immunodeficiency virus-infected adults with a history of drug dependence JOURNAL OF SUBSTANCE ABUSE TREATMENT Basu, S., Bruce, R. D., Barry, D. T., Altice, F. L. 2007; 32 (4): 399-409


    Clinicians treating human immunodeficiency virus (HIV)-infected patients with substance use disorders often face the challenge of managing patients' acute or chronic pain conditions while keeping in mind the potential dangers of prescription opiate dependence. In this clinical review, we critically appraise the existing data concerning barriers to appropriate treatment of pain among HIV-infected patients with substance use disorders. We then analyze published studies concerning the choice of pharmacological pain control regimens for acute and chronic pain conditions in HIV-infected patients, keeping in mind HIV-specific issues related to drug interactions and substance use disorders. We summarize this information in the form of flowcharts for physicians approaching HIV-infected patients who present with complaints of pain, providing evidence-based guidance for the structuring of pain management services and for addressing aberrant drug-taking behaviors.

    View details for DOI 10.1016/j.jsat.2006.10.005

    View details for Web of Science ID 000246575800009

    View details for PubMedID 17481463

  • The potential role of buprenorphine in the treatment of opioid dependence in HIV-infected individuals and in HIV infection prevention CLINICAL INFECTIOUS DISEASES Altice, F. L., Sullivan, L. E., Smith-Rohrberg, D., Basu, S., Stancliff, S., Eldred, L. 2006; 43: S178-S183


    Untreated opioid dependence is a major obstacle to the successful treatment and prevention of human immunodeficiency virus (HIV) infection. In this review, we examine the interwoven epidemics of HIV infection and opioid dependence and the emerging role of buprenorphine in improving HIV treatment outcomes among infected individuals, as well as its role in primary and secondary prevention. This article addresses some of the emerging issues about integrating buprenorphine treatment into HIV clinical care settings and the various strategies that must be considered. Specifically, it addresses the role of buprenorphine in improving HIV treatment outcomes through engagement in care, access to antiretroviral therapy and preventive therapies for opportunistic infections, and the potential benefits of and pitfalls in integrating buprenorphine into HIV clinical care settings. We discuss the key research questions regarding buprenorphine in the area of improving HIV treatment outcomes and prevention, including a review of published studies of buprenorphine and antiretroviral treatment and currently ongoing studies, and provide insight into and models for integrating buprenorphine into HIV clinical care settings. Dialogue among practitioners and policy makers in the HIV care and substance abuse communities will facilitate an effective expansion of buprenorphine and ensure that these beneficial outcomes are achieved.

    View details for Web of Science ID 000242126100003

    View details for PubMedID 17109304

  • Populations who test drugs should benefit from them NATURE Basu, S., Andrews, J., Smith-Rohrberg, D. 2006; 440 (7084): 605-605

    View details for DOI 10.1038/440605d

    View details for Web of Science ID 000236350400021

    View details for PubMedID 16572144

  • Models for integrating buprenorphine therapy into the primary HIV care setting CLINICAL INFECTIOUS DISEASES Basu, S., Smith-Rohrberg, D., Bruce, R. D., Altice, F. L. 2006; 42 (5): 716-721


    Opiate dependence among human immunodeficiency virus (HIV)-infected patients has been associated with negative clinical outcomes, yet few affected patients receive appropriate and coordinated treatment for both conditions. The introduction of buprenorphine maintenance therapy into HIV care settings provides an opportunity for providers to integrate treatment for opiate dependence into their practices. Buprenorphine maintenance therapy has been associated with reductions in opiate use, increased social stability, improved adherence to antiretroviral therapy, and lowered rates of injection drug use. We describe the following 4 models for the integration of buprenorphine maintenance therapy into HIV care: (1) a primary care model, in which the highly active antiretroviral therapy-administering clinician also prescribes buprenorphine; (2) a model that relies on an on-site specialist in addiction medicine or psychiatry to prescribe the buprenorphine; (3) a hybrid model, in which an on-site specialist provides the induction (with or without stabilization phases) and the HIV care provider provides the maintenance phase; and (4) a drug treatment model that provides buprenorphine maintenance therapy services with HIV services in the substance abuse clinic setting. The key barriers against effective integration of buprenorphine maintenance therapy and primary HIV services are discussed, and we suggest several mechanisms to overcome such obstacles.

    View details for Web of Science ID 000235060200022

    View details for PubMedID 16447120

  • Clinical management of depression and anxiety in HIV-infected adults AIDS Basu, S., Chwastiak, L. A., Bruce, R. D. 2005; 19 (18): 2057-2067

    View details for Web of Science ID 000233493200001

    View details for PubMedID 16284454

  • HIV testing in correctional institutions: evaluating existing strategies, setting new standards. AIDS & public policy journal Basu, S., Smith-Rohrberg, D., Hanck, S., Altice, F. L. 2005; 20 (1-2): 3-24


    Before introducing an HIV testing protocol into correctional facilities, the unique nature of these environments must be taken into account. We analyze three testing strategies that have been used in correctional settings--mandatory, voluntary, and routine "opt out" testing--and conclude that routine testing is most likely beneficial to inmates, the correctional system, and the outside community. The ethics of pre-release testing, and the issues surrounding segregation, confidentiality, and linking prisoners with community-based care, also play a role in determining how best to establish HIV testing strategies in correctional facilities. Testing must be performed in a manner that is not simply beneficial to public health, but also enhances the safety and health status of individual inmates. Longer-stay prison settings provide ample opportunities not just for testing but also for in-depth counseling, mental health and substance abuse treatment, and antiretroviral therapy. Jails present added complexities because of their shorter stay with respect to prisons, and testing, treatment, and counseling policies must be adapted to these settings.

    View details for PubMedID 17260566

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