Below is a descriptive list of past research projects funded through CHW. They appear in alphabetical order by title.
More information about current research conducted by CHW affiliates, including publications resulting from these projects, is available on their individual websites.
Adversity and Resilience after Hurricane Katrina
Christina Paxson, with colleague Cecilia Rouse and collaborators at Harvard University, the University of Massachusetts-Boston and Washington State University, designed a survey to examine how a group of low-income parents from New Orleans - most of whom are single African American women - have coped with the effects of Hurricane Katrina. The 1,019 low-income parents in the sample are part of an intervention that was started before Hurricane Katrina; it provided members of a randomly-selected treatment group with tuition assistance and academic advising at local community colleges.
The original study provides pre-hurricane information on the health, social networks, and economic status of members of the treatment and control groups. Paxson and her group then conducted follow-up surveys and qualitative interviews 18 months and again four years after the hurricane. Their focus was on identifying factors that promoted resilience and heightened vulnerability within this group. They studied how pre-hurricane resources and capacities - defined to include mental and physical health, social networks, and economic resources - affect the ability to successfully adjust to a major life trauma. They also studied the factors that influenced a broad set of outcomes measured over a four-year period following the hurricane, including psychological distress, symptoms of post-traumatic stress disorder (PTSD), trauma exposure, and the re-establishment of social networks and resumption of employment and educational activities. They examined how the children in these families were coping with the effects of the hurricane. Finally, they examined whether those in the treatment group, who gained additional education prior to the hurricane, experienced better post-hurricane outcomes than those in the control group.
Applying Basic Bacteriology to the Global Health Challenges of Infectious Disease
The rise of antibiotic resistance in bacterial pathogens represents an escalating global health crisis. Gitai Zemer and his lab helped to tackle this problem by lending its expertise in bacterial cell biology for identifying new antibiotic drugs and drug targets. More specifically, the researchers used their understanding of a new set of essential bacterial proteins, the bacterial cytoskeleton, to discover both new families of proteins, essential for bacterial pathogenesis (candidate drug targets), and small molecules that perturb those proteins (candidate drugs). The group had already identified a small molecule that targets the essential bacterial actin-like cytoskeleton, which based on preliminary studies, could block the growth and virulence of a wide range of human pathogens. This project engaged a multidisciplinary group of scientists at the undergraduate, graduate, postdoc, and faculty levels and the researchers hope their efforts integrate with those of the greater Princeton community through new inter-disciplinary courses, seminar series, and interest groups.
Ceramic Filters for Potable Water
This research by Winston Soboyejo and Karen Malatesta built on an interdisciplinary project begun in the summer of 2008 that established a factory in Nigeria to produce ceramic water filters from locally available materials. The project was designed to improve the host community’s health and wealth by simultaneously protecting residents against water-borne disease and creating a new local enterprise. The second phase of research replicated the Nigerian prototype in Burkina Faso and Kenya, training personnel and equipping the factory to be supervised and operated by local staff, and investigating prospects for expansion to other settings using the franchise model. Public health studies in both new factory locations assessed the filters’ impact on local residents. Studies were also conducted to determine the mechanisms of microbe adsorption and the killing of bacteria by the colloidal silver coatings typically applied to the filter surfaces, and research objectives included the development and characterization novel adsorptive surfaces for the removal of nano-scale viruses and chemical contaminants in addition to bacteria.
Characterizing the In Vivo Plasmodium Metabolome
Manuel Llinas and his team set out to understand the metabolic interaction between the malaria parasite, Plasmodium falciparum, and its human host during infection. One aspect of the study used mass spectrometry analysis on patient samples from endemic regions to catalogue the small molecule metabolite levels in infected and uninfected individuals. The methodology for this project was already well established in the lab, with the examination of in vitro cultures of infected red blood cells. One motivating factor for this project, therefore, was to extend this work to field samples from infected individuals, possibly providing valuable insight toward future therapies aimed at abrogating the severity of disease and ultimately curing people of it. Such research is ideal for international partnerships, as Princeton researchers provide the training for international personnel, who can then perform these experiments in established locations worldwide; as the technological investment is feasible; and the methodologies are easily transferable.
College Education and Health
Christina Paxson, together with Cecilia Rouse and Adriana Lleras-Muney, studied the impact of education on health outcomes and behaviors among young adults. This work was done in collaboration with the Manpower Demonstration Research Corporation (MDRC). The study had added a health component to an assessment of a new and unique education intervention, the Opening Doors experiment. Opening Doors provided 4,400 economically disadvantaged young adults in a set of community colleges across the country with financial assistance, mentoring and curricular enhancements, all aimed at increasing levels of educational attainment. Approximately 3,600 controls did not receive program benefits but were followed over time. Randomization of individuals into treatment and control groups made it possible to identify the causal effects of educational attainment on health outcomes and behaviors. The study assessed how the intervention affects health and health behaviors in the short run; how initial health affects progression through college; and whether the intervention ameliorates adverse effects of initial health on educational attainment. This project was funded by the National Institutes of Health.
Common Property Problems in Health
This integrated research and teaching program was established by Simon Levin and Ramanan Laxminarayan in 2008 and examined the challenge of drug resistance within the broader context of common-property problems in infectious disease. Progress in creating policy solutions for dealing with drug resistance will depend on better understanding of the ecology of resistance as well as incentives for patients, physicians and health care facilities to make better use of antibiotics. Economic and social incentives and norms are important for determining how infection and drug resistance externalities are addressed in health care. The project’s overarching goal was to see how incentives and norms interact in the context of clinical practice.
In collaboration with the Centers for Disease Control and Prevention and other partners, researchers studied the epidemiology of antibiotic use in US hospitals. They tested the hypothesis that providing medical doctors with information on their own antibiotic prescribing practices and in relation to that of other physicians can change their prescribing behavior. This study helped to delineate the role of information in altering intrinsic motivation of healthcare providers, and it served a practical role in identifying the effectiveness of a feasible intervention to change antibiotic prescribing.
Demanding the Right to Health in Courts: AIDS Treatment Access, Drug Markets, and Citizenship in Brazil Today
For this multi-site, interdisciplinary project, Joao Biehl and his Princeton students collaborated with local Brazilian university students studying social science, law, and medicine to understand the impact of judicial claims for access to high-cost pharmaceutical products in the Brazilian health care system. Biehl's research assumed a pedagogical approach to methodologically and analytically train a new generation of young scientists interested in public service.
Brazil has been an innovator and leader in the effort to universalize access to high-cost pharmaceutical products, particularly AIDS treatment. In 1996, it became the first developing country to make antiretroviral drugs (ARVs) universally available through its ailing public health care system. Following the ARV rollout, Brazilian courts began to see an increasing amount of private citizens prosecuting municipal and state offices to attain access to experimental and high-cost medications to treat all kinds of acute and chronic diseases. This growing demand for medicines raised a whole new set of challenges regarding the legal right to health and appropriate standards of care, while greatly straining public health budgets. The project focused on the southern state of Rio Grande do Sul, where the annual number of such cases had risen from a few hundred to more than ten thousand over a ten year period. Other regions experienced a similar pattern of growth.
Biehl considered several factors in studying the cause and effect of the judicialization of the right to health. He produced a database for a quantitative analysis of the phenomenon that revealed the demographic character of the patient/plaintiff population, the type and frequency of drugs requested, the pathological conditions involved, and the legal arguments employed. The phenomenon was studied from a qualitative perspective (literature review, archival research and semi-structured interviews), and included the role of public and private lawyers, the position and function of disease-specific nongovernmental organizations, the costs of the combined cases on legal systems, and the historical and political contexts of the legal arguments employed in these claims. Responses to important public health policy questions set forth in studying this phenomenon helped conceive responses to important public health policy questions, such as: what are appropriate standards of care, how can government costs be minimized, and how do pharmaceutical patents affect the accessibility of treatments?
The research also explored issues of health technology assessment and the production of scientific knowledge. For example, the reliability of clinical trials and the state’s ability to respond to contested medical claims.
Included in this study were interviews with professionals, in the state of Rio Grande do Sul, who dealt with the legal, medical and public health implications of this phenomenon, as well as the professional opinions of those involved in health technology assessment, intellectual property, and human rights in the cities of Rio de Janeiro, São Paulo, and Brasília.
Economic Status, Public Policy and Child Neglect
Christina Paxson engaged in research on the relationships between economic factors and child neglect. This work was done in collaboration with Jeanne Brooks-Gunn, Neil Guterman and Jane Waldfogel (at Columbia University) and former CHW-research fellow Lawrence Berger (University of Wisconsin-Madison). The research examined how parental resources—in the form of parental presence or absence, time, and money—influenced both physical and emotional neglect of pre-school children, and how recent changes in welfare policies influenced neglect. The study collected data on child neglect as part of the Fragile Families and Child Wellbeing Study, a birth cohort study directed by Sara McLahanan. The research was funded by a grant from the National Institute of Child Health and Development.
Endemic Fluorosis in Rural Villages of Northeastern India: Development of a Robust Water Treatment Technology, Field Implementation, and its Health Effects
Some 200 million people drink ground water containing flouride levels well above WHO guidelines. High fluoride levels in drinking water causes fluorosis, an incurable condition that deforms bones and damages teeth. Peter Jaffe set out to develop and deploy a simple and robust technology to remove fluoride from drinking water in impoverished villages in India, employing his research team's hypothesis that a hydroxyapatite-based filter is the simplest and most appropriate method of removing fluoride in this setting. Hydroxyapatite can be synthesized inexpensively from locally available materials. After completing laboratory studies of the filtration system, the team installed devices in two villages of approximately 200 people (nearly 100% of the population), who are severely afflicted with fluorosis. Performance optimization of such filters was an important aspect of this study.
By monitoring the fluorosis incidence as a function of age within years of this project, researchers can track new fluorosis cases to determine the project's success over just a few years in these two villages, illustrating how both the technological and strategic development of a project contributes to measurable health improvements. Such projects serve as an important model for necessary interdiciplinary collaboration, in this case, between the engineering and health sectors.
From R&D to Patient Health: Studying the Orphan Drug Act
This project studied the mechanisms through which the Orphan Drug Act (ODA) benefits health and affects firm investment decisions. The Orphan Drug Act (ODA) was passed in 1983 to encourage R&D into drugs that treat rare diseases by providing incentives for R&D into rare disease drugs. Most significantly, it provides the sponsor of an orphan drug with marketing exclusivity, and a tax credit on its clinical trials expenses. Using a novel data set Wesley Yin collected on clinical trials of pharmaceutical and biotechnology firms, he estimated the impact of the ODA on clinical trials for rare disease drugs, and on final marketed products. To quantify these separate mechanisms, he distinguished between new drug development and marketing of existing products for orphan indications. R&D for new products leads to new drug innovations for patient consumption. Clinical trials for existing products benefits patients through information of new therapeutic uses, through tailoring dosages appropriate for the orphan population, and through expansion of insurance coverage for previously off-label drug use. The ODA's impact on each of these pathways was separately estimated. Finally, Wesley Yin studied the mechanism through which the incentives of the ODA affect firm investments. Stylized facts suggest that the incentives are not working through standard price and revenue mechanisms. Firm structure and financing constraints may be interacting with the incentives of the ODA. These interactions are important to understand, as the characteristics of a firm's capital structure will dictate the types of incentives best suited to promote rare disease drug development.
New Strategies to Detect and Prevent Tuberculosis
This collaborative program, under the guidance of John Groves and Joshua Rabinowitz, aimed to discover and implement novel strategies for the detection and prevention of tuberculosis in humans. The program was built on discoveries in the Groves laboratories at Princeton that have elucidated pathways used by virulent mycobacteria to access the iron they need for propagation within human cells. The host-pathogen interaction for tuberculosis is extraordinarily complex since the bacterium exploits some aspects of normal cell function while inhibiting or deactivating others. However, little is known about the iron acquisition and transport pathways adapted by mycobacteria in vivo.
Fluorescence detection techniques were developed in the Groves laboratories that allowed direct observation of iron theft from the host cell by the invading bacterium. This project aimed to apply high-level mass spectrometric techniques developed in the Rabinowitz laboratory to monitor changes in metabolite profiles within human cells upon exposure to mycobacterial siderophores. Several past discoveries required researches to significantly modify the thoughts around iron acquisition by the pathogen. The basic premise of the project was that detection of siderophore production by the M. tuberculosis could be exploited as an early indication of infection. Further, the siderophore uptake pathway offers a new and highly specific avenue for drug delivery and therapy.
Parental Resources and Child Wellbeing
This project studied how parental resources affect children’s wellbeing, as measured by children’s health status and their cognitive, social, and emotional development. The first aim of this project was to examine how three broadly defined aspects of parental resources — economic status, family structure, and parental health (both mental and physical) — are related to each other. The second was to study how parental resources affect the quality of parenting (discipline, warmth, supervision, and cognitive stimulation) and material resources (e.g., home learning materials, food security, neighborhood safety, and access to medical care) that children receive. Finally, the researchers examined how all of these “inputs,” in turn, affect children’s outcomes. A specific “case study” was on the determinants of childhood obesity, a preventable child health outcome that is the precursor of adult obesity. The study utilized newly collected data from the Fragile Families and Child Wellbeing Study, a survey that follows birth cohorts of 3,675 children born to unwed parents, and 1,125 children born to married parents, from twenty US cities in fifteen states, from birth to age four. A key advantage of this survey was that it tracks and collects information from fathers, including those who do not live with their children. Using the Fragile Families data, it was possible to study the role of fathers in children’s health and developmental outcomes. The project also used data from other surveys, including the Panel Study of Income Dynamics and the National Health Interview Survey. The results of this research provide valuable information on the determinants of children’s wellbeing, and the mechanisms through which parental resources affect children’s outcomes. Project website
Quality of Health Care in India
Jeffrey Hammer has been developing methods of measuring the quality of health care in developing countries.
Defining "quality" of health care in economic research has always been problematic. For a long time it was identified with "presence of drugs or equipment" which has little to do with the quality in terms of accuracy and effectiveness of advice given at a clinic. This project was originated to make progress on this score using a variety of techniques using data collected on over 200 medical providers in Delhi chosen from a census of providers in areas of Delhi with an ongoing household survey. The providers were both public and private and within the private, spanned the range from highly trained doctors to people with no training at all.
The first technique was the use of "vignettes" or hypothetical cases presented to doctors by two interviewers, one playing the role of patient and the other a recorder (and course of answers to possible test results if called for by the medical provider). The second technique was simply to have an interviewer sit with a provider for the day, recording all visits (time spent, number of relevant questions asked, money paid, whether a diagnosis was given, medicines prescribed, etc.). This allowed for a variety of tests of quality of advice and the difference between what doctors say they would do and what they actually do. It also highlighted the deficiencies that poor people face in both public and private sectors.
Methods using Standardized Simulated Patients were developed and variants on all methods were adapted and used by a variety of researchers (See Health Affairs v. 26, no. 3, March 2007 Special Issue; Dehn, Reinikka and Svensson at World Bank website).
This project was done in conjunction with Jishnu Das at the World Bank and the Institute of Socio-Economic Research on Development and Democracy, Delhi.
South Africa: Poverty, Inequality and Health
Anne Case and Angus Deaton, together with Alicia Menendez from the Harris School at the University of Chicago, conducted integrated health and economic surveys in South Africa, to investigate the links between health status and economic status. This work was done in collaboration with researchers from the Institute for Advanced Studies in Princeton and the University of Witwatersrand, and with WWS graduate and CHW visitor Ingrid le Roux of the Philani Nutrition Centers and Department of Health. The survey instruments collected data on a range of traditional and non-traditional measures of well-being, including income and consumption, measures of health status (including mental health), morbidity, crime, social connectedness, intrahousehold relationships, and direct hedonic measures of well-being. The surveys drew on recent work in economics, health, psychology, and anthropology to explore different kinds of welfare measures and the relationships between them. Their work in two South African field sites, Agincourt and Khayelitsha, was funded by the National Institutes of Health. Project website
The Future of Global AIDS Treatment and the Social Determinants of Health
Currently, many public- and private-sector initiatives are being launched worldwide, seeking to address HIV/AIDS therapeutically in places where treatments have been scarcely available. These initiatives raise a new set of national and global healthcare policy challenges regarding adequate drug delivery, sustainable treatment access, and the integration of treatment with primary care, food access and prevention. Broader questions arise as well: how can accountability of all sectors be assured? How do these trends affect health systems and the role of governments and their human rights obligations? How are other deadly diseases of poverty that have less political backing being dealt with? And, finally, what on-the-ground effects do these manifold issues have on the experience of living with HIV/AIDS and poverty?
This interdisciplinary and experience-based research and teaching project, initiated in March 2008 by João Biehl, used the Brazilian therapeutic response to AIDS and its repercussions through government, markets, health systems and civil society as an ethnographic baseline from which to gauge the aftermath of large-scale drug access programs. Focusing on Africa and Latin America and in partnership with local initiatives, the research team charted the emerging governmental, philanthropic, nongovernmental and industry networks developing around HIV/AIDS technology and delivery. The team also identified new challenges, limitations, and emergent forms of social mobilization and theorized the role of the social sciences in evidence-making and advocacy in global health. By using qualitative methodologies in harmony with more traditional quantitative ways of studying health interventions and outcomes, the project sought a people-centered approach to global health knowledge-making. This provided a much-needed window into the real-life outcomes of national, international, corporate, and institutional policies.
The Integration of Chemistry and Biology to Seed a Next Generation of Malaria and Tuberculosis Therapeutics.
Professors Erik J. Sorensen and Dr. Joel S. Freundlich led a chemistry-driven effort to seed the discovery of novel antitubercular and antimalarial agents. Key to their effort was the development of a novel synthetic methodology to efficiently construct complex organic molecules, both natural products and their designed analogs that have the desired biological activity. Through extensive biology-based collaborations at Princeton University and abroad, they detailed the in vitro and in vivo efficacy of these small molecules, and thoroughly examined their mechanism of action. The end result of this research should be both novel biological targets and facilely accessible small molecules that modulate them to achieve the desired antitubercular and/or antimalarial activity.
Who Governs the Microbe? Exploring the Emergence of Authority as Response to the Risk of Infectious Disease
Within any inhabited territory, people are vulnerable to various types of infections and the onset of disease and death. Any number of governing authorities -- ranging from local governments to international NGOs to traditional healers -- might allocate resources and energies to curb the spread of infectious disease, but across time, space, and infection type, these efforts vary widely. What explains who attempts to govern such problems? To what extent do different infections receive different responses, and why? What are the positive pressures that drive and what are the countervailing pressures that impede aggressive action?
This collaborative training and research project under Evan Lieberman, sought to answer such questions by gathering information about governance activities within particular well-defined localities. It aimed to shed light on theories of governance and government responsiveness, and on the politics of global public health as experienced at the local level; it also aimed to identify the links and gaps between scientific knowledge and the implementation of such knowledge at the local level. The project further searched for creative social and political strategies that have been used to induce the implementation of proven public health strategies. The research was based in localities in the Western Cape Province of South Africa initially, but extended to other regions and countries.
Udaipur Health Survey
Angus Deaton, together with collaborators Abhijit Banerjee and Esther Duflo at MIT, Jishnu Das at the World Bank, and Seva Mandir in Udaipur, investigated health and economic status among rural households in the Udaipur district of Rajasthan in northwestern India. Members of around 1,000 households in 100 villages were surveyed, and asked about their economic activities, physical and mental health status, and experiences with healthcare. Complementary surveys collected information about village infrastructure and about the clinics and medical personnel that people use, including traditional healers. One aim of the study was to discover more about the quality of healthcare, how well it serves the people who use it, and the extent to which it contributes to health status. More broadly, the study aimed to improve understanding of the determinants of health, as well as the relationships between health and economic status, and how they work together to determine wellbeing. Project website