Do health sector reforms have their intended impacts ? The World Bank's Health VIII project in Gansu province, China

The literature contains few impact evaluations of health sector reforms, especially those involving broad and simultaneous changes on both the demand and supply sides of the sector. This paper reports the results of a World Bank-funded health sector reform project in China known as Health VIII. On the supply-side, the project combined infrastructure investments (especially at the township level) with improved planning and management, including a referral system between township health centers and county hospitals, and interventions aimed at improving the effectiveness and quality of care, including the introduction of clinical protocols and essential drug lists. On the demand-side, the project sought to resurrect community health insurance, and to introduce a safety net for the very poor to provide them with financial assistance with their health care expenses. The evaluation reported here concerns just one of the project's seven provinces, namely Gansu, the reason being that no suitable data are available to undertake a rigorous evaluation in all provinces. This paper makes use of a panel dataset collected for quite another purpose but whose timing (just around the time the project started and four years later) and location (covering both project and non-project counties) makes it well-suited to the task. The paper compares estimates obtained using a variety of different estimators, including naïve single differences (before and after, and with and without the project), and differences-in-differences, adjusting for heterogeneity through both regression and matching methods. The results suggest that it makes a difference to the estimated impact of Health VIII which estimator is used, with the naïve single differences producing often markedly different estimates from the preferred approach of combining difference-in-differences with matching. The results further suggest that Health VIII has been mostly successful in its goals. The preferred estimator suggests that the project reduced illness among children, improved self-assessed health, and increased doctor visits among the population in general, and reduced the incidence of catastrophic health spending, defined as annual spending in excess of 10 percent of annual per capita income. But the project appears to have increased the development and use of high-level facilities, hastened the demise of the village clinic, and may have reduced immunization rates.Health Monitoring&Evaluation,Health Systems Development&Reform,Health Economics&Finance,Health Law,Housing&Human Habitats

Food for Thought: Poverty, Family Nutritional Environment, and Children\u27s Educational Performance in Rural China

Insecure access to nutritious food is a common experience for poor households in developing countries. Despite the global scale of food insecurity, it has not been conceptualized by sociologists as a significant component of home environment or dimension of poverty that might matter for children\u27s outcomes. Analyzing data from rural China, the authors show that nutritional environment in the home is associated with household socioeconomic status, that it predicts children\u27s school performance, and that it is a significant mediator of poverty effects on schooling for children in early primary grades

Poverty, parental ill health and children's access to schooling in rural Gansu, China

As reforms to China\u27s health care system have raised costs to users in recent decades, studies suggest that ill health has become intimately tied to social stratification as both a precipitant and a consequence of poverty. The problem may be particularly pronounced in China’s poorest rural populations. Focusing on Gansu Province, one of China’s poorest, this paper investigates the possibility that the ill health of adults also carries cross-generational consequences, through interfering with the education of children. Analyzing a survey of children in 100 rural villages, we find that parental illness is experienced disproportionately by the most economically vulnerable children. Moreover, parental illness can be linked to children’s educational access and experience in several ways. Children with an ill father are less likely to be enrolled than others; prior parental ill health is associated with lower household educational spending; and ill parents are more likely to report borrowing for their children’s education. Children with ill mothers are more likely to be absent and to work longer in the household. Children with ill mothers perform more poorly in math, and those with ill mothers and ill fathers are more likely to work for wages, on average, but these effects are accounted for by the deeper impoverishment of households with ill parents, compared to other households. Results suggest that ill health may have a ‘spillover’ effect on the long-term educational (and thus economic) prospects of the next generation. A change in this situation depends heavily on the success of new government initiatives to reduce health care and education cost burdens on the poor

Injury, intense dust exposure, and chronic disease among survivors of the World Trade Center terrorist attacks of September 11, 2001

Background: The World Trade Center attack of September 11, 2001 in New York City (9/11) exposed thousands of people to intense concentrations of hazardous materials that have resulted in reports of increased levels of asthma, heart disease, diabetes, and other chronic diseases along with psychological illnesses such as post-traumatic stress disorder (PTSD). Few studies have discriminated between health consequences of immediate (short-term or acute) intense exposures versus chronic residential or workplace exposures. Methods: We used proportional hazards methods to determine adjusted hazard ratios (AHRs) for associations between several components of acute exposures (e.g., injury, immersion in the dust cloud) and four chronic disease outcomes: asthma, other non-neoplastic lung diseases, cardiovascular disease, and diabetes, in 8701 persons free of those conditions prior to exposure and who were physically present during or immediately after the World Trade Center attacks. Participants were followed prospectively up to 11 years post-9/11. Results: Heart disease exhibited a dose-response association with sustaining injury (1 injury type: AHR =2.0, 95% CI (Confidence Interval) 1.1–3.6; 2 injury types: AHR = 3.1, 95% CI 1.2–7.9; 3 or more injury types: AHR = 6.8, 95% CI 2.0–22.6), while asthma and other lung diseases were both significantly associated with dust cloud exposure (AHR = 1.3, 95% CI 1.0–1.6). Diabetes was not associated with any of the predictors assessed in this study. Conclusion: In this study we demonstrated that the acute exposures of injury and dust cloud that were sustained on 9/11/2001 had significant associations with later heart and respiratory diseases. Continued monitoring of 9/11 exposed persons’ health by medical providers is warranted for the foreseeable future

Impact of 9/11-related chronic conditions and PTSD comorbidity on early retirement and job loss among World Trade Center disaster rescue and recovery workers

Background: The economic impact of the 9/11 terrorist attacks has rarely been studied. We examined the association between 9/11-related chronic health conditions with or without post-traumatic stress disorder (PTSD) and one important aspect of the economic impact, retirement, and job loss before age 60. Methods: A total of 7,662 workers who participated in the World Trade Center Health Registry surveys were studied. Logistic regression models examined the association of 9/11-related health and labor force exit. Results: Workers with chronic conditions were more likely to experience early retirement and job loss, and the association was stronger in the presence of PTSD comorbidity: the odds ratios for reporting early retirement or job loss were increased considerably when chronic conditions were comorbid with PTSD. Conclusions: Disaster-related health burden directly impacts premature labor force exit and income. Future evaluation of disaster outcome should include its long-term impact on labor force

Evaluation of non-response bias in a cohort study of World Trade Center terrorist attack survivors

Background: Few longitudinal studies of disaster cohorts have assessed both non-response bias in prevalence estimates of health outcomes and in the estimates of associations between health outcomes and disaster exposures. We examined the factors associated with non-response and the possible non-response bias in prevalence estimates and association estimates in a longitudinal study of World Trade Center (WTC) terrorist attack survivors. Methods: In 2003-04, 71,434 enrollees completed the WTC Health Registry wave 1 health survey. This study is limited to 67,670 adults who were eligible for both wave 2 and wave 3 surveys in 2006-07 and 2011-12. We first compared the characteristics between wave 3 participants (wave 3 drop-ins and three-wave participants) and non-participants (wave 3 drop-outs and wave 1 only participants). We then examined potential non-response bias in prevalence estimates and in exposure-outcome association estimates by comparing one-time non-participants (wave 3 drop-ins and drop-outs) at the two follow-up surveys with three-wave participants. Results: Compared to wave 3 participants, non-participants were younger, more likely to be male, non-White, non-self enrolled, non-rescue or recovery worker, have lower household income, and less than post-graduate education. Enrollees' wave 1 health status had little association with their wave 3 participation. None of the disaster exposure measures measured at wave 1 was associated with wave 3 non-participation. Wave 3 drop-outs and drop-ins (those who participated in only one of the two follow-up surveys) reported somewhat poorer health outcomes than the three-wave participants. For example, compared to three-wave participants, wave 3 drop-outs had a 1.4 times higher odds of reporting poor or fair health at wave 2 (95% CI 1.3-1.4). However, the associations between disaster exposures and health outcomes were not different significantly among wave 3 drop-outs/drop-ins as compared to three-wave participants. Conclusion: Our results show that, despite a downward bias in prevalence estimates of health outcomes, attrition from the WTC Health Registry follow-up studies does not lead to serious bias in associations between 9/11 disaster exposures and key health outcomes. These findings provide insight into the impact of non-response on associations between disaster exposures and health outcomes reported in longitudinal studies

Asthma and posttraumatic stress symptoms 5 to 6 years following exposure to the World Trade Center terrorist attack

Context. The World Trade Center Health Registry provides a unique opportunity to examine long-term health effects of a large-scale disaster. Objective. To examine risk factors for new asthma diagnoses and event-related posttraumatic stress (PTS) symptoms among exposed adults 5 to 6 years following exposure to the September 11, 2001, World Trade Center (WTC) terrorist attack. Design, Setting, and Participants. Longitudinal cohort study with wave 1 (W1) enrollment of 71 437 adults in 2003-2004, including rescue/recovery worker, lower Manhattan resident, lower Manhattan office worker, and passersby eligibility groups; 46 322 adults (68%) completed the wave 2 (W2) survey in 2006-2007. Main Outcome Measures. Self-reported diagnosed asthma following September 11; event-related current PTS symptoms indicative of probable posttraumatic stress disorder (PTSD), assessed using the PTSD Checklist (cutoff score >= 44). Results. Of W2 participants with no stated asthma history, 10.2% (95% confidence interval [CI], 9.9%-10.5%) reported new asthma diagnoses post-event. Intense dust cloud exposure on September 11 was a major contributor to new asthma diagnoses for all eligibility groups: for example, 19.1% vs 9.6% in those without exposure among rescue/recovery workers (adjusted odds ratio, 1.5 [95% CI, 1.4-1.7]). Asthma risk was highest among rescue/recovery workers on the WTC pile on September 11 (20.5% [95% CI, 19.0%-22.0%]). Persistent risks included working longer at the WTC site, not evacuating homes, and experiencing a heavy layer of dust in home or office. Of participants with no PTSD history, 23.8% (95% CI, 23.4%-24.2%) reported PTS symptoms at either W1(14.3%) orW2(19.1%). Nearly 10% (9.6% [95% CI, 9.3%-9.8%]) had PTS symptoms at both surveys, 4.7% (95% CI, 4.5%-4.9%) had PTS symptoms at W1 only, and 9.5% (95% CI, 9.3%-9.8%) had PTS symptoms at W2 only. At W2, passersby had the highest rate of PTS symptoms (23.2% [95% CI, 21.4%-25.0%]). Event-related loss of spouse or job was associated with PTS symptoms at W2. Conclusion. Acute and prolonged exposures were both associated with a large burden of asthma and PTS symptoms 5 to 6 years after the September 11 WTC attack

Nonfatal Injuries 1 Week After Hurricane Sandy — New York City Metropolitan Area, October 2012

On October 29, 2012, Hurricane Sandy (Sandy) made landfall in densely populated areas of New York, New Jersey, and Connecticut. Flooding affected 51 square miles (132 square kilometers) of New York City (NYC) and resulted in 43 deaths, many caused by drowning in the home, along with numerous storm-related injuries. Thousands of those affected were survivors of the World Trade Center (WTC) disaster of September 11, 2001 (9/11) who had previously enrolled in the WTC Health Registry (Registry) cohort study. To assess Sandy-related injuries and associated risk factors among those who lived in Hurricane Sandy-flooded areas and elsewhere, the NYC Department of Health and Mental Hygiene surveyed 8,870 WTC survivors, who had provided physical and mental health updates 8 to 16 months before Sandy. Approximately 10% of the respondents in flooded areas reported injuries in the first week after Sandy; nearly 75% of those had more than one injury. Injuries occurred during evacuation and clean-up/repair of damaged or destroyed homes. Hurricane preparation and precautionary messages emphasizing potential for injury hazards during both evacuation and clean-up or repair of damaged residences might help mitigate the occurrence and severity of injury after a hurricane

MtGSTF7, a TT19-like GST gene, is essential for accumulation of anthocyanins, but not proanthocyanins in Medicago truncatula

Article shows that the mechanism of anthocyanin and proanthocyanin (PA) accumulation in M. truncatula is different from that in A. thaliana, and provides a new target gene for engineering anthocyanins in plants