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Highlights

 

  • Total DALYs increased across all five Asian societies between 2000 and 2019.
  • Population aging was identified as the primary driver of total DALY increases.
  • However, substantial decreases in DALYs per disease case were observed.
  • These trends were especially pronounced for non-communicable diseases.

 

Background

Rapid population aging in Asia has significantly increased the disease burden. However, there is limited research on the drivers of such changes in disability-adjusted life years (DALYs).

 

Objective

To examine the factors contributing to changes in DALYs in China, Japan, Singapore, South Korea, and Taiwan in 2000 and 2019.

 

Methods

We conducted a cross-sectional analysis using data from the Global Burden of Disease Study 2021. Changes in DALYs between 2010 and 2019 were decomposed into four factors: population size, age-sex structure, disease cases per person, and DALYs per disease case.

 

Results

From 2000 to 2019, total DALYs increased across all locations. While DALYs from injuries, communicable, maternal and neonatal conditions, and nutritional deficiencies decreased, DALYs from non-communicable diseases increased. Decomposition analysis identified population aging (changes in age-sex structure) as the primary driver of increases in total DALYs, contributing an average of 33.6%. Population growth accounted for 15.3% on average. However, these increases were partially offset by decreases in DALYs per disease case, which fell by an average of -29.4%. Contributions from disease cases per person were relatively modest, averaging -3.4%. Notably, the decline in DALYs per disease case was more pronounced for non-communicable diseases, despite an overall increase in disease cases per person.

 

Conclusions

The increase in DALYs across these Asian societies was primarily driven by population aging and growth. However, DALYs per disease case decreased, suggesting improvements in disease management. Given the growing burden of non-communicable diseases in these societies, maintaining a focus on effective interventions remains crucial.

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Income-Based Inequalities in Health System Performance in the US and South Korea

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Dementia Care in a Rapidly Aging Society

Dementia Care in a Rapidly Aging Society
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The Evolution of Age-Friendly Jobs in a Rapidly Ageing Economy

The Evolution of Age-Friendly Jobs in a Rapidly Ageing Economy
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Cynthia Chen
Karen Eggleston
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COVID-19 temperature testing in China.

The COVID-19 crisis was a profound stress test for health, economic, and governance systems worldwide, and its lessons remain urgent. The pandemic revealed that unpreparedness carries cascading consequences, including the collapse of health services, the reversal of development gains, and the destabilization of economies. The magnitude of global losses, measured in trillions of dollars and millions of lives, demonstrated that preparedness is not a discretionary expense but a foundation of macroeconomic stability. Countries that invested early in surveillance, resilient systems, and inclusive access managed to contain shocks and recover faster, proving that health security and economic security are inseparable.

For the Asia-Pacific, the path forward lies in transforming vulnerability into long-term resilience. Building pandemic readiness requires embedding preparedness within fiscal and development planning, not as an emergency measure but as a permanent policy function. The region’s diverse economies can draw on collective strengths in manufacturing capacity, technological innovation, and strong regional cooperation to institutionalize the four pillars— globally networked surveillance and research, a resilient national system, an equitable supply of medical countermeasures and tools, and global governance and financing—thereby maximizing pandemic prevention, preparedness, and response. Achieving this will depend on sustained political will and predictable financing, supported by the catalytic role of multilateral development banks and international financial institutions that can align public investment with global standards and private capital.

The coming decade presents a narrow but decisive window to consolidate these gains. Climate change, urbanization, and ecological disruption are intensifying the probability of new zoonotic spillovers. Meeting this challenge demands a shift from episodic response to continuous readiness, from isolated health interventions to integrated systems that link health, the environment, and the economy. Strengthening regional solidarity, transparency, and mutual accountability will be vital in ensuring that no country is left exposed when the next threat emerges.

A pandemic-ready Asia-Pacific is not an aspiration but an imperative. The lessons of COVID-19 call for institutionalized preparedness that transcends political cycles and emergency budgets. By treating health resilience as a global public good, the region can turn its experience of crisis into a model of sustained, inclusive security for the world.

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Building a Pandemic-Ready Asia-Pacific

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Asia Health Policy Postdoctoral Fellow, 2024-2025
Mai Nguyen.JPG Ph.D.

Mai Nguyen joined the Walter H. Shorenstein Asia-Pacific Research Center (APARC) as Asia Health Policy Postdoctoral Fellow for the 2024-2025 academic year. She holds a PhD in health services and health policy from Queensland University of Technology (QUT), Australia, and a Master of Science from Heller School for Social Policy and Management, Brandeis University.

Her doctoral research focused on how the expanding private healthcare sector can be managed more effectively to better supplement public health services to achieve universal health coverage in Vietnam. The study analyzed large and complex national health datasets from two consecutive Household Living Standard Surveys, clinical hospital data at national levels and in-depth interviews with key stakeholders of Vietnam's health system to investigate consumers' choice for private and public health care services in Vietnam. Her research findings have implications for policy change in terms of harnessing and regulating private health services in Vietnam and other Asia-Pacific countries, especially low and middle-income countries.

Dr. Nguyen has worked as a senior health specialist at Vietnam Ministry of Health. Her research interest stems from her professional experience in health policy and program management, including health policy and management, health services, private healthcare and health equity. Her works have been published in many Q1-international journals such as BMC Public Health, BMC Health Services Research, Human Resources for Health and International Journal of Health Policy and Management.

At APARC, Dr. Nguyen extended her research on the roles of private healthcare to supplement the public health sector to address the growing burden of chronic diseases and conditions in Vietnam.

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Jason Wang and his team working on a project to prevent preterm births received a $150,000 grant from the Richard King Mellon Foundation to complete their randomized control trial testing a digital app that tries to prevent recurrent preterm births.

PretermConnect uses a digital strategy for prevention and follow-up of preterm births in Allegheny County, PA, to optimize the health and well-being of mothers and children. Instead of the standard care, Stanford Health Policy is collaborating with the University of Pittsburg Medical Center (UPMC) in the randomized control trial with women who have delivered a preterm baby. The women are invited to participate and then randomly put into the group that uses the digital or a control group who received paper-based discharge packets with supplemental health education on postpartum care.

“This grant allows us to continue recruiting participants through UPMC and expanding PretermConnect’s features to enhance user engagement, including a function to search for resources by geography and topic,” said Wang, MD, a professor of pediatrics and health policy. “We also intend to scale the project with additional content on high-risk infant follow-up and preterm-specific developmental care guidelines, additional engagement features — and eventually support for different languages, starting with Spanish.”

In the long term, we hope to see an overall decrease in infant morbidity and mortality, by way of reducing preterm births.
Jason Wang
Professor of Pediatrics and Health Policy

The women in the digital app group receive in-app health education and resources to improve well-being for mothers and their infants. The app includes a social interaction feature designed to foster social connections and promote self-care. They have enrolled 30 women during the pilot phase and 15 mother-infant dyads in the randomized control trial, with a goal of reaching 250.

“The digital approach also allows us to administer brief surveys and gather information on dynamic social determinants of health more frequently than can be done through traditional means,” said Shilpa Jani, an SHP project manager. She said social determinants of health — such as persistent housing instability, food insecurity and concerns of personal safety — contribute to chronic stress and health issues as well as an increased risk of pregnancy and birth complications.

“Adverse effects of social determinants of health along with health complications of preterm deliveries may exacerbate morbidities for the mother and child,” Jani said, adding that preterm-related causes of death accounted for two-thirds of infant deaths in 2019 in the United States.

Wang and Jani said the immediate project goals include increasing health education for preterm baby care, improving postpartum maternal health, and encouraging usage of local resources in Allegheny County. They eventually hope to see reductions in risk for subsequent preterm delivery and infant mortality and postpartum depression, as well as increases in mother-infant bonding and larger proportions of breastmilk feeding.

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Jason Wang

Professor of Pediatrics and Health Policy
Develops tools for assessing and improving the quality of health care
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Shilpa Jani

Shilpa Jani

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SHP researchers awarded grant to continue their clinical trial testing out a digital app they hope will prevent preterm births.

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While the coronavirus pandemic has captured the world’s attention, non-communicable chronic diseases (NCDs) such as hypertension, heart diseases, and diabetes continue to be the leading cause of mortality worldwide, accounting for about two-thirds of deaths globally. Their financial and social burden is also immense, as individuals with chronic diseases face high medical spending, limited ability to work, and financial insecurity. Primary health care (PHC) is a crucial avenue for managing and preventing chronic diseases, yet many health systems, especially in low- and middle-income countries (LMICs), lack robust primary health care settings. How can policymakers improve PHC to reduce illness and death from chronic diseases?

There is little rigorous evidence from LMICs about the effectiveness of programs seeking to improve the capacity of PHC for controlling chronic disease. Now a new study, published by the Journal of Health Economics, helps fill in this gap. It offers empirical evidence on China’s efforts to promote PHC management, showing that better PHC management of chronic diseases in rural areas can reduce spending while contributing to better health. We sat down with APARC’s Asia Health Policy Program Director Karen Eggleston, one of the study co-authors, to discuss the research and its implications beyond China. Watch:

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Challenges for Primary Health Care Services

China, a large and rapidly developing middle-income country with a hospital-based service delivery system for its aging population, makes a suitable case study of efforts to promote PHC management. Over the past several decades, PHC use in China has significantly decreased relative to hospital-based care. This trend is a natural consequence of the country’s unprecedented increases in living standards and improvements in financial risk protection, which increase patients’ demand for quality care and spur self-referral to providers with higher-perceived quality like hospital outpatient departments.

The performance differences between PHC and hospital-based care are especially stark in China’s rural areas, where management of chronic diseases relies heavily on grassroots physicians, who have limited medical education and training. That is why Eggleston and her colleagues set out to provide new empirical evidence about the effectiveness of a program that promotes PHC management of hypertension and diabetes for rural Chinese. Part of the National Basic Public Health Service Program for rural Chinese, it financially rewards PHC grassroots physicians for managing residents with chronic diseases.

Collaborative Research in the Era of Great Power Competition

Eggleston’s co-authors include her colleagues at the Zhejiang Provincial Center for Disease Control and Prevention (Zhejiang CDC). Their study is the culmination of Eggleston’s multiyear collaborative research project with the Zhejiang CDC team, "Addressing Health Disparities in China," which looks to Tongxiang county in Zhejiang as a case study of China's responses to healthcare inequalities and population aging challenges in rural and urban areas. The project also involved two Stanford doctoral students who worked with Eggleston.

The team worked together to develop the quantitative analysis even during a time of sometimes-tense bilateral relations. “We found it very important to be able to communicate directly and collaborate on an important question not only for rural China but for many other parts of the world,” says Eggleston.
Karen Eggleston speaking to staff at Zhejiang Provincial CDC, China
Eggleston with her colleagues at the Zhejiang CDC during a field visit in 2018.

“This kind of collaboration, where we utilize the data that's available to answer an important question while respecting the privacy of the individuals and hopefully delivering benefits to them through more effective or affordable programs in the future perhaps is a promising model for researchers here and elsewhere to undertake,” she notes.

Disentangling the Effect of Primary Health Care Management

To study the program’s effectiveness, the researchers assembled a unique dataset linking individual-level administrative and health information between 2011 and 2015 for rural Chinese diagnosed with hypertension or diabetes in Tongxiang, a mostly rural county of Zhejiang province in southeast China. Collected by the Tongxiang CDC and Zhejiang CDC, the compiled database links basic demographic information, health insurance claims, PHC service logs, and health check-up records — four sets of data that are rarely linked and analyzed in combination in China healthcare research.

Focusing on neighboring border-straddling villages allows us to use only variation in PHC management within pairs of neighboring villages to identify the effect.
Karen Eggleston

Targeting the program’s effects on healthcare utilization, spending, and health outcomes, Eggleston and her colleagues compare residents in neighboring villages that straddle township boundaries. These residents are similar in their individual and environmental characteristics that shape health care use but are subject to different PHC management practices. This “border sampling” allows the researchers to disentangle the effects of PHC management from other underlying spatial differences that impact health care utilization. For each township, the researchers use a management intensity index that reflects the cumulative efforts of PHC physicians to screen their communities and keep patients within the PHC management programs for controlling hypertension and diabetes. Each township’s experience with PHC management over the 5-year study period is thus a case study for rural China.

Net Value in Chronic Disease Management

The results are encouraging for China's investment in primary care management of chronic diseases. Eggleston and her colleagues find that patients residing in a village within a township with more intensive PHC management had a relative increase in PHC visits, fewer specialist visits, fewer hospital admissions, and lower spending compared to neighbors with less intensive management. They also tend to have better medication adherence and better health outcomes as measured by blood pressure control.

If we can gradually scale up these kinds of effective programs at primary care then we can build more resilient, cost-effective, affordable health care systems for populations in many different settings.
Karen Eggleston

The results suggest that PHC chronic disease management in rural China improves net value in multiple ways — increasing PHC utilization, reducing avoidable hospitalizations, decreasing medical spending, and improving intermediate- and long-run health outcomes — all while leveraging existing resources rather than restricting care.

The findings also help inform investments in primary health care in LMICs. They highlight the latent potential of frontline healthcare workers in such settings to be more productive and show that financially rewarding these grassroots workers for managing residents with chronic diseases helps improve health outcomes. Moreover, they offer empirical evidence that supports the effectiveness of chronic disease management programs as part of broader regional initiatives to address population health.

Read the study by Eggleston et al

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A New Validated Tool Helps Predict Lifetime Health Outcomes for Prediabetes and Type 2 Diabetes in Chinese Populations

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Empirical evidence by Karen Eggleston and colleagues suggests that better primary health care management of chronic disease in rural China can reduce spending while contributing to better health.

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The Center on Democracy, Development and the Rule of Law is deeply saddened by the loss of beloved Draper Hills alumnus José Luis Martín C. (“Chito”) Gascón, who passed away after a short battle with COVID-19 on October 9, 2021, at the age of 57.

A Filipino lawyer, human rights activist, and civil organizer, Gascón served as the Chair of the Philippines’ Commission on Human Rights from 2015 to 2021, having been appointed by President Benigno S. Aquino III. Prior to this, he also served as a member of the Human Rights Victims’ Claims Board and as a member of the Philippine Congress, where he helped to pass monumental legislation to promote the prevention of human rights abuses. He contributed to the founding of the International Center for Innovation, Transformation, and Excellence in Governance; the Institute for Leadership, Empowerment, and Democracy; and the Asian Policy Network. Gascón’s career also included teaching law and political science at Ateneo de Manila University and De la Salle University.

Reacting to the news of Chito's death on Twitter, FSI Director Michael McFaul called him “a true hero for human rights.” Larry Diamond also paid tribute, noting that “he was eloquent, fearless, humble, and deeply devoted to democracy” and one of the Philippines’ “great civil society leaders.”

In 2005, Chito was a member of the first class of CDDRL's Draper Hills Summer Fellows Program, which trains global leaders working on the front lines of democratic change. Kathryn Stoner, Mosbacher Director of CDDRL, noted that he was "a pioneer with us and with all that he did."

In addition to his time as a Draper Hills Summer Fellow, Chito Gascón was a Reagan-Fascell Fellow at the National Endowment for Democracy (NED) in 2007. Former NED president and frequent Draper Hills contributor Carl Gershman shared that “Chito was a brilliant and dedicated democracy activist, a gentle personality with a tough inner core and immense courage. He will be sorely missed by countless friends, myself included, and by people around the world who are fighting for democracy and human dignity.”

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2005 Draper Hills Summer Fellows cohort. Chito is pictured in the back row between Kathryn Stoner and Larry Diamond.
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A member of the inaugural Draper Hills Summer Fellows Program cohort in 2005, Chito died from COVID-19 on October 9, 2021.

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Senior Fellow at the Woods Institute for the Environment
Faculty Affiliate at the Stanford Center on China's Economy and Institutions
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Prof. Stephen Luby studied philosophy and earned a Bachelor of Arts summa cum laude from Creighton University. He then earned his medical degree from the University of Texas Southwestern Medical School at Dallas and completed his residency in internal medicine at the University of Rochester-Strong Memorial Hospital. He studied epidemiology and preventive medicine at the Centers for Disease Control and Prevention.

Prof. Luby's former positions include leading the Epidemiology Unit of the Community Health Sciences Department at the Aga Khan University in Karachi, Pakistan, for five years and working as a Medical Epidemiologist in the Foodborne and Diarrheal Diseases Branch of the U.S. Centers for Disease Control and Prevention (CDC) exploring causes and prevention of diarrheal disease in settings where diarrhea is a leading cause of childhood death.  Immediately prior to joining the Stanford faculty, Prof. Luby served for eight years at the International Centre for Diarrhoeal Diseases Research, Bangladesh (icddr,b), where he directed the Centre for Communicable Diseases. He was also the Country Director for CDC in Bangladesh.

During his over 25 years of public health work in low-income countries, Prof. Luby frequently encountered political and governance difficulties undermining efforts to improve public health. His work within the Center on Democracy, Development, and the Rule of Law (CDDRL) connects him with a community of scholars who provide ideas and approaches to understand and address these critical barriers.

 

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Affiliated faculty at the Center on Democracy, Development and the Rule of Law
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Maria Polyakova, PhD, is Associate Professor of Health Policy at Stanford School of Medicine and Associate Professor (by courtesy) in the Department of Economics at Stanford University, where she is also a Senior Fellow at the Stanford Institute for Economic Policy Research (SIEPR). She is a Research Associate at the National Bureau of Economic Research (NBER) and serves as an Editor of the Journal of Health Economics. Her research spans many areas of health economics, including health insurance, healthcare labor markets, and individual decision-making in health and healthcare. A unifying thread is evaluating whether markets and government policy effectively serve individuals and families or introduce distortions. Her ongoing work focuses on how families navigate prolonged health shocks. Maria received her BA in Economics & Mathematics and German Studies (with a concentration in History) from Yale University in 2008 and her PhD in Economics from MIT in 2014.

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Jeremy Goldhaber-Fiebert, PhD, is a Professor of Health Policy, a Core Faculty Member at the Center for Health Policy and the Department of Health Policy, and a Faculty Affiliate of the Stanford Center on Longevity and Stanford Center for International Development. His research focuses on complex policy decisions surrounding the prevention and management of increasingly common, chronic diseases and the life course impact of exposure to their risk factors. In the context of both developing and developed countries including the US, India, China, and South Africa, he has examined chronic conditions including type 2 diabetes and cardiovascular diseases, human papillomavirus and cervical cancer, tuberculosis, and hepatitis C and on risk factors including smoking, physical activity, obesity, malnutrition, and other diseases themselves. He combines simulation modeling methods and cost-effectiveness analyses with econometric approaches and behavioral economic studies to address these issues. Dr. Goldhaber-Fiebert graduated magna cum laude from Harvard College in 1997, with an A.B. in the History and Literature of America. After working as a software engineer and consultant, he conducted a year-long public health research program in Costa Rica with his wife in 2001. Winner of the Lee B. Lusted Prize for Outstanding Student Research from the Society for Medical Decision Making in 2006 and in 2008, he completed his PhD in Health Policy concentrating in Decision Science at Harvard University in 2008. He was elected as a Trustee of the Society for Medical Decision Making in 2011.

Past and current research topics:

  1. Type 2 diabetes and cardiovascular risk factors: Randomized and observational studies in Costa Rica examining the impact of community-based lifestyle interventions and the relationship of gender, risk factors, and care utilization.
  2. Cervical cancer: Model-based cost-effectiveness analyses and costing methods studies that examine policy issues relating to cervical cancer screening and human papillomavirus vaccination in countries including the United States, Brazil, India, Kenya, Peru, South Africa, Tanzania, and Thailand.
  3. Measles, haemophilus influenzae type b, and other childhood infectious diseases: Longitudinal regression analyses of country-level data from middle and upper income countries that examine the link between vaccination, sustained reductions in mortality, and evidence of herd immunity.
  4. Patient adherence: Studies in both developing and developed countries of the costs and effectiveness of measures to increase successful adherence. Adherence to cervical cancer screening as well as to disease management programs targeting depression and obesity is examined from both a decision-analytic and a behavioral economics perspective.
  5. Simulation modeling methods: Research examining model calibration and validation, the appropriate representation of uncertainty in projected outcomes, the use of models to examine plausible counterfactuals at the biological and epidemiological level, and the reflection of population and spatial heterogeneity.
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C. Jason Wang, M.D., Ph.D. is a Professor of Pediatrics and Health Policy and director of the Center for Policy, Outcomes, and Prevention at Stanford University.  He received his B.S. from MIT, M.D. from Harvard, and Ph.D. in policy analysis from RAND.  After completing his pediatric residency training at UCSF, he worked in Greater China with McKinsey and Company, during which time he performed multiple studies in the Asian healthcare market. In 2000, he was recruited to serve as the project manager for the Taskforce on Reforming Taiwan's National Health Insurance System. His fellowship training in health services research included the Robert Wood Johnson Clinical Scholars Program and the National Research Service Award Fellowship at UCLA. Prior to coming to Stanford in 2011, he was an Assistant Professor of Pediatrics and Public Health (2006-2010) and Associate Professor (2010-2011) at Boston University and Boston Medical Center. 

Among his accomplishments, he was selected as the student speaker for Harvard Medical School Commencement (1996).  He received the Overseas Chinese Outstanding Achievement Medal (1996), the Robert Wood Johnson Physician Faculty Scholars Career Development Award (2007), the CIMIT Young Clinician Research Award for Transformative Innovation in Healthcare Research (2010), and the NIH Director’s New Innovator Award (2011). He was recently named a “Viewpoints” editor and a regular contributor for the Journal of the American Medical Association (JAMA).  He served as an external reviewer for the 2011 IOM Report “Child and Adolescent Health and Health Care Quality: Measuring What Matters” and as a reviewer for AHRQ study sections.

Dr. Wang has written two bestselling Chinese books published in Taiwan and co-authored an English book “Analysis of Healthcare Interventions that Change Patient Trajectories”.  His essay, "Time is Ripe for Increased U.S.-China Cooperation in Health," was selected as the first-place American essay in the 2003 A. Doak Barnett Memorial Essay Contest sponsored by the National Committee on United States-China Relations.

Currently he is the principal investigator on a number of quality improvement and quality assessment projects funded by the Robert Wood Johnson Foundation, the National Institutes of Health (USA), Health Resources and Services Administration (HRSA), and the Andrew T. Huang Medical Education Promotion Fund (Taiwan).

Dr. Wang’s research interests include: 1) developing tools for assessing and improving the quality of healthcare; 2) facilitating the use of innovative consumer technology in improving quality of care and health outcomes; 3) studying competency-based medical education curriculum, and 4) improving health systems performance.

Director, Center for Policy, Outcomes & Prevention (CPOP)
Co-Director, PCHA-UHA Research & Learning Collaborative
Co-Chair, Mobile Health & Other Technologies, Stanford Center for Population Health Sciences
Co-Director, Academic General Pediatrics Fellowship
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Diabetes is one of the fastest-growing health challenges of the 21st century. On the frontlines of the epidemic rise in the number of people with diabetes is the Asia-Pacific region. China, in particular, has by far the largest absolute burden of diabetes, with an estimated 116 million adults living with the disease accounting for one-quarter of patients with diabetes globally. By 2045, the number of adults living with diabetes in the country is expected to increase to 147 million, not including the large diaspora community China provides worldwide.

Evaluating the health and economic outcomes of diabetes and its complications is vital for formulating health policy. The existing predictive outcomes models for type 2 diabetes, however, were developed and validated in historical European populations and may not be applicable for East Asian populations with their distinct epidemiology and complications. Additionally, the existing models are typically limited to diabetes alone and ignore the progression from prediabetes to diabetes. The lack of an appropriate simulation model for East Asian individuals and prediabetes is a major gap for the economic evaluation of health interventions.

New collaborative research now addresses these limitations. The research team includes APARC’s Asia Health Policy Program Director Karen Eggleston. The researchers developed and validated a patient-level simulation model for predicting lifetime health outcomes of prediabetes and type 2 diabetes in East Asian populations. They report on their findings in the journal PLOS Medicine


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Modeling Health Outcomes Among East Asian Populations

The chronic progression to diabetes-related complications is apt for computer simulation modeling due to the long-term nature of health outcomes and the time lag for interventions to impact patient outcomes. It is problematic, however, to estimate the impacts of health interventions on East Asian populations with diabetes using existing models, which were developed and validated in European and North American populations with different epidemiology and outcomes.

To fill in this gap, Eggleston and her colleagues set out to develop and validate an outcomes model for the progression of diabetes and related complications in Chinese populations. They compared this new model, called the Chinese Hong Kong Integrated Modeling and Evaluation (CHIME), to two widely used existing models developed and validated in the United Kingdom (known as the United Kingdom Prospective Diabetes Study Outcomes Model 2, or UKPDS-OM2) and in the United States/Canada (called Risk Equations for Complications of type 2 Diabetes, or RECODe). Despite the continuum of risk across the spectrum of risk factor values, these two existing models ignore the progression from prediabetes to diabetes.

The CHIME integrates prediabetes and diabetes into a comprehensive model comprising 13 outcomes. These include mortality, micro- and macrovascular complications, and the development of diabetes. The researchers developed the CHIME simulation model using data from a population-based cohort of 97,628 participants in Hong Kong with type 2 diabetes (43.5%) or prediabetes (56.5%) from 2006 to 2017. Known as the Hong Kong Clinical Management System (CMS), this cohort makes one of the largest Chinese electronic health informatics systems with detailed clinical records. 

The CHIME outperformed the widely used United Kingdom Prospective Diabetes Study Outcomes Model 2 (UKPDS-OM2) and Risk Equations for Complications of type 2 Diabetes (RECODe) models on real-world data.
Karen Eggleston et al

The next step was to externally validate the CHIME model against individual-level data from the China Health and Retirement Longitudinal Study (CHARLS) cohort (2011-2018), a nationally representative longitudinal cohort of middle-aged and elderly Chinese residents age 45 and older. The researchers validated the CHIME model against six outcomes measures recorded in the CHARLS data and an additional 80 endpoints from nine published trials of diabetes patients using simulated cohorts of 100,000 individuals.

Towards Reducing the Disease Burden of Diabetes

The researchers found that the CHIME model outperformed the widely used UKPDS-OM2 and RECODe models on the data used, meaning that the validation of the CHIME model was more accurate for trials with mainly Asian participants than trials with mostly non-Asian participants. The results indicate that the CHIME model is a validated tool for predicting the progression of diabetes and its outcomes, particularly among Chinese and East Asian populations, for which the existing models have been unsuitable.

With the new model, clinicians and health economists can evaluate population health status for prediabetes and diabetes using routinely recorded data and therapies related to the long-term management of diabetes. In particular, the CHIME outcomes model enables them to assess patients' quality of life and measure cost per quality-adjusted life-years over the long-time horizon of chronic disease conditions. The new model thus supports the economic evaluation of policy guidelines and clinical treatment pathways to tackle diabetes and prediabetes, address micro- and macrovascular complications associated with these conditions, and improve life expectancy.

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A research team including APARC's Karen Eggleston developed a new simulation model that supports the economic evaluation of policy guidelines and clinical treatment pathways to tackle diabetes and prediabetes among Chinese and East Asian populations, for whom existing models may not be applicable.

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This interview by Bruce Goldman was originally published by the Stanford School of Medicine.


On May 13, the journal Science published a letter, signed by 18 scientists, stating that it was still unclear whether the virus that causes COVID-19 emerged naturally or was the result of a laboratory accident, but that neither cause could be ruled out. David Relman, MD, the Thomas C. and Joan M. Merigan Professor and professor of microbiology and immunology, spearheaded the effort.

Relman is no stranger to complicated microbial threat scenarios and illness of unclear origin. He has advised the U.S. government on emerging infectious diseases and potential biological threats. He served as vice chair of a National Academy of Sciences committee reviewing the FBI investigation of letters containing anthrax that were sent in 2001. Recently, he chaired another academy committee that assessed a cluster of poorly explained illnesses in U.S. embassy employees. He is a past president of the Infectious Diseases Society of America.

Stanford Medicine science writer Bruce Goldman asked Relman to explain what remains unknown about the coronavirus’s emergence, what we may learn and what’s at stake.

1. How might SARS-CoV-2, which causes COVID-19, have first infected humans?

Relman: We know very little about its origins. The virus’s closest known relatives were discovered in bats in Yunnan Province, China, yet the first known cases of COVID-19 were detected in Wuhan, about 1,000 miles away.

There are two general scenarios by which this virus could have made the jump to humans. First, the jump, or “spillover,” might have happened directly from an animal to a human, by means of an encounter that took place within, say, a bat-inhabited cave or mine, or closer to human dwellings — say, at an animal market. Or it could have happened indirectly, through a human encounter with some other animal to which the primary host, presumably a bat, had transmitted the virus.

Bats and other potential SARS-CoV-2 hosts are known to be shipped across China, including to Wuhan. But if there were any infected animals near or in Wuhan, they haven’t been publicly identified.

Maybe someone became infected after contact with an infected animal in or near Yunnan, and moved on to Wuhan. But then, because of the high transmissibility of this virus, you’d have expected to see other infected people at or near the site of this initial encounter, whether through similar animal exposure or because of transmission from this person.

2. What’s the other scenario?

Relman: SARS-CoV-2 could have spent some time in a laboratory before encountering humans. We know that some of the largest collections of bat coronaviruses in the world — and a vigorous research program involving the creation of “chimeric” bat coronaviruses by integrating unfamiliar coronavirus genomic sequences into other, known coronaviruses — are located in downtown Wuhan. And we know that laboratory accidents happen everywhere there are laboratories.

Humans are fallible, and laboratory accidents happen — far more often than we care to admit.
David Relman
Senior Fellow, CISAC

All scientists need to acknowledge a simple fact: Humans are fallible, and laboratory accidents happen — far more often than we care to admit. Several years ago, an investigative reporter uncovered evidence of hundreds of lab accidents across the United States involving dangerous, disease-causing microbes in academic institutions and government centers of excellence alike — including the Centers for Disease Control and Prevention and the National Institutes of Health.

SARS-CoV-2 might have been lurking in a sample collected from a bat or other infected animal, brought to a laboratory, perhaps stored in a freezer, then propagated in the laboratory as part of an effort to resurrect and study bat-associated viruses. The materials might have been discarded as a failed experiment. Or SARS-CoV-2 could have been created through commonly used laboratory techniques to study novel viruses, starting with closely related coronaviruses that have not yet been revealed to the public. Either way, SARS-CoV-2 could have easily infected an unsuspecting lab worker and then caused a mild or asymptomatic infection that was carried out of the laboratory.

3. Why is it important to understand SARS-CoV-2’s origins?

Relman: Some argue that we would be best served by focusing on countering the dire impacts of the pandemic and not diverting resources to ascertaining its origins. I agree that addressing the pandemic’s calamitous effects deserves high priority. But it’s possible and important for us to pursue both. Greater clarity about the origins will help guide efforts to prevent a next pandemic. Such prevention efforts would look very different depending on which of these scenarios proves to be the most likely.

Evidence favoring a natural spillover should prompt a wide variety of measures to minimize human contact with high-risk animal hosts. Evidence favoring a laboratory spillover should prompt intensified review and oversight of high-risk laboratory work and should strengthen efforts to improve laboratory safety. Both kinds of risk-mitigation efforts will be resource intensive, so it’s worth knowing which scenario is most likely.

4. What attempts at investigating SARS-CoV-2’s origin have been made so far, with what outcomes?

Relman: There’s a glaring paucity of data. The SARS-CoV-2 genome sequence, and those of a handful of not-so-closely-related bat coronaviruses, have been analyzed ad nauseam. But the near ancestors of SARS-CoV-2 remain missing in action. Absent that knowledge, it’s impossible to discern the origins of this virus from its genome sequence alone. SARS-CoV-2 hasn’t been reliably detected anywhere prior to the first reported cases of disease in humans in Wuhan at the end of 2019. The whole enterprise has been made even more difficult by the Chinese national authorities’ efforts to control and limit the release of public health records and data pertaining to laboratory research on coronaviruses.

In mid-2020, the World Health Organization organized an investigation into the origins of COVID-19, resulting in a fact-finding trip to Wuhan in January 2021. But the terms of reference laying out the purposes and structure of the visit made no mention of a possible laboratory-based scenario. Each investigating team member had to be individually approved by the Chinese government. And much of the data the investigators got to see was selected prior to the visit and aggregated and presented to the team by their hosts.

The recently released final report from the WHO concluded — despite the absence of dispositive evidence for either scenario — that a natural origin was “likely to very likely” and a laboratory accident “extremely unlikely.” The report dedicated only 4 of its 313 pages to the possibility of a laboratory scenario, much of it under a header entitled “conspiracy theories.” Multiple statements by one of the investigators lambasted any discussion of a laboratory origin as the work of dark conspiracy theorists. (Notably, that investigator — the only American selected to be on the team — has a pronounced conflict of interest.)

Given all this, it’s tough to give this WHO report much credibility. Its lack of objectivity and its failure to follow basic principles of scientific investigation are troubling. Fortunately, WHO’s director-general recognizes some of the shortcomings of the WHO effort and has called for a more robust investigation, as have the governments of the United States, 13 other countries and the European Union.

5. What’s key to an effective investigation of the virus’s origins?

Relman: A credible investigation should address all plausible scenarios in a deliberate manner, involve a wide variety of expertise and disciplines and follow the evidence. In order to critically evaluate other scientists’ conclusions, we must demand their original primary data and the exact methods they used — regardless of how we feel about the topic or about those whose conclusions we seek to assess. Prior assumptions or beliefs, in the absence of supporting evidence, must be set aside.

Investigators should not have any significant conflicts of interest in the outcome of the investigation, such as standing to gain or lose anything of value should the evidence point to any particular scenario.

There are myriad possible sources of valuable data and information, some of them still preserved and protected, that could make greater clarity about the origins feasible. For all of these forms of data and information, one needs proof of place and time of origin, and proof of provenance.

To understand the place and time of the first human cases, we need original records from clinical care facilities and public health institutions as well as archived clinical laboratory data and leftover clinical samples on which new analyses can be performed. One might expect to find samples of wildlife, records of animal die-offs and supply-chain documents.

Efforts to explore possible laboratory origins will require that all laboratories known to be working on coronaviruses, or collecting relevant animal or clinical samples, provide original records of experimental work, internal communications, all forms of data — especially all genetic-sequence data — and all viruses, both natural and recombinant. One might expect to find archived sequence databases and laboratory records.

Needless to say, the politicized nature of the origins issue will make a proper investigation very difficult to pull off. But this doesn’t mean that we shouldn’t try our best. Scientists are inquisitive, capable, clever, determined when motivated, and inclined to share their insights and findings. This should not be a finger-pointing exercise, nor an indictment of one country or an abdication of the important mission to discover biological threats in nature before they cause harm. Scientists are also committed to the pursuit of truth and knowledge. If we have the will, we can and will learn much more about where and how this pandemic arose.  

relman

David Relman

Senior Fellow at the Freeman Spogli Institute for International Studies
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