Emily Tuong-Vi Nguyen, a Stanford student studying human biology, writes about the Asia Health Policy Program’s international conference on diabetes

The Asia Health Policy Program at the Shorenstein Asia-Pacific Research Center hosted the Net Value in Diabetes Management Workshop in March to discuss progress on an international research collaboration. Research teams from Hong Kong, Singapore, China, Taiwan, South Korea and the United States convened at the Stanford Center at Peking University (SCPKU) in Beijing to work on research that compares utilization and spending patterns on diabetes across different countries and to develop a method for measuring the net value of diabetes internationally, based on previous methods discussed in a Eggleston and Newhouse et al. 2009 study with Mayo Clinic Data for Type 2 diabetes.

The research teams from various Asian countries are attempting to calculate the net value of diabetes in those countries by observing the changes in diabetes value and spending. These calculations include monetizing the value of health benefits of new treatments and improvements in health, as well as avoided spending on treatments when prevention was effective, and associated mortality and probability of survival. Previous models used to measure diabetic values and risks, such as the United Kingdom Prospective Diabetes Study (UKPDS) risk engine that was created from U.K. data and populations, are not very relevant for Asian populations. The goal is to create separate risk models specifically suited for populations from Hong Kong, Singapore, China, Taiwan and South Korea.

During the workshop that spanned two days, the research teams had an opportunity to share updates on their individual projects and to discuss methods and ideas for future collaboration.

On the first day, each research team presented its work, describing data sets and explaining the risk models that were used or developed. Karen Eggleston, director of the Asia Health Policy Program, delivered introductory remarks and shared current progress by the Japan and Netherlands research teams on calculating value and risk for diabetes with data from the Netherlands and Japan. The data sets from those two countries were best estimated by the JJ Risk Engine for the Japan data and the UKPDS model for the Netherlands data.

Chao Quan of the University of Hong Kong presented the risk model used for Hong Kong populations. His work primarily looked at how the UKPDS risk engine predicted risk in Hong Kong populations as compared to a local Hong Kong risk engine and how to best calibrate the Hong Kong risk engine. His next step will be to monetize the value for improved survival in diabetes in Hong Kong. He offered to re-estimate the model using the risk factors available on others’ datasets so that the Hong Kong risk model could potentially be used by other teams as well.

Stefan Ma and Zheng Li Yau of the Ministry of Health of Singapore discussed the 5-year prediction model and statistical methods they used for all-cause mortality of Singaporean individuals with diabetes. Their work is based on Singapore’s extensive administrative and claims data as well as data provided by the national health surveys conducted every six years by the National Health Service of Singapore. The researchers plan to look into how their overall risk model compares with models for specific subpopulations, such as Chinese, Malay and Indian populations in Singapore.

Katherine Hastings from the Stanford University team, led by principal investigator Latha Palaniappan, presented preliminary ideas about measuring cardiovascular risk with the Atherosclerotic Cardiovascular Disease Risk Score in analyses of Stanford health system diabetic patients. The researchers are collaborating with a clinical bioinformatics team at Stanford to use machine learning to expedite the analysis.

Min Yu and Haibin Wu of the Zhejiang Center for Disease Control and Prevention shared results from their analysis of health data collected from community health centers for diabetes management, diabetes surveillance data, cause of death data and insurance claims data that showed relationships between different patient characteristics and insurance types. The researchers then estimated the annual cost of Type 2 diabetes and its complications in Tongxiang province, China.

Hai Fang and Huyang Zhang of Peking University worked with claims data of diabetic patients insured by the New Cooperative Medical Scheme in Beijing, and at the workshop, shared regression analyses on the relationship between outpatient visits and inpatient admissions.

Jianqun Dong of the People’s Republic of China Center for Disease Control and Prevention presented ongoing research about diabetes management in China, including preliminary results of a randomized control trial of diabetes self-management strategies.

Wankyo Chung of Seoul National University shared preliminary estimates of a risk model for mortality among diabetic patients in South Korea and discussed next steps for estimating net value of diabetes management using the detailed clinical and claims data available in South Korea.

On the second day, the workshop concluded with a videoconference between workshop participants in Beijing and collaborators at Stanford Graduate Business School, including Stanford professor Latha Palaniappan and Harvard visiting professor Joseph P. Newhouse, using the Highly Immersive Classroom.

The workshop was a good opportunity for the research teams to discuss preliminary models, to offer each other suggestions regarding research methods, and to discuss the future direction of the international collaboration on the net value of diabetes. All research teams are preparing comparative research papers that will be included in the working paper series of the Asia Health Policy Program. A follow-up event will be held at Stanford in November 2017 in recognition of World Diabetes Day.

Researchers urge Moon Jae-in to form a close working relationship with Donald Trump and to establish a new special envoy role for North Korea policy emulating the “Perry Process”

Researchers from the Shorenstein Asia-Pacific Research Center (APARC) said they are optimistic about the election of South Korean president Moon Jae-in who assumed office last week following waves of protest across the country.

Now that the vacancy left in the wake of former President Park Geun-hye’s impeachment has been filled, the South Korean government needs to work to strengthen bilateral relations with the United States amid escalating tensions in Northeast Asia, they said.

The Moon administration should immediately engage U.S. President Donald Trump and his senior staff at the White House and government agencies, said Kathleen Stephens, the William J. Perry Fellow at Shorenstein APARC.

“Moon would do well to establish a personal relationship with Trump,” said Stephens, who was U.S. ambassador to South Korea from 2008 to 2011. “The new administration must set up a meeting as early as possible and be ready to engage on a range of issues.”

“In a sense, Moon has to play catch-up,” said Shorenstein APARC Director Gi-Wook Shin, who noted that Trump already held in-person meetings with other Asian heads of state in the United States, including summits with Chinese President Xi Jinping and Japanese Prime Minister Shinzo Abe.

Shin added that a coherent U.S. strategy toward Asia and senior staff appointments in the State and Defense Departments would also aid in supporting the foundation upon which the South Korean and American governments work together on policy challenges, especially North Korea.

North Korea’s nuclear and missile capabilities have become more and more advanced over the past few months, and provocations have continued to ratchet up, including its firing of a ballistic missile that landed in the sea near Russia on Sunday and repeat threats to conduct a sixth nuclear test.

The Moon administration must focus on establishing trust and cooperation with the Trump administration because it is the only pathway to finding a resolution to North Korea’s program, said Siegfried Hecker, a senior fellow at the Center for International Security and Cooperation, an additional center in the Freeman Spogli Institute.

“Any solution must be compatible with the interests of Seoul, but it has to be done in concert with Washington to get Pyongyang’s attention,” said Hecker, who served as director of the Los Alamos National Laboratory and has traveled to North Korea seven times since 2004 to survey its nuclear facilities.

During the campaign, Moon repeatedly spoke of his proposals to reengage the North Korean regime, such as holding talks with its leader Kim Jong-un and re-opening Kaesong Industrial Complex, a joint economic zone on the North Korean side of the border.

Stephens and Shin said Moon’s proposals for North Korean engagement would be a step in the right direction if pursued in due time and led under the direction of a special envoy from South Korea emulating the American “Perry Process.”

The Perry Process, proposed by former U.S. Secretary of Defense William Perry and implemented in the late 1990s under the Clinton administration, entails the appointment of a senior-level, bipartisan representative to pursue a two-track approach of engagement through joint projects and of continued dialogue on denuclearization with North Korea.

Appointing one person in South Korea to lead North Korea policy would help centralize and streamline its organization, which currently requires coordination of activities across dozens of government agencies, the two researchers noted.

“We recognize that establishing such a position and filling the position would be far from easy,” said Shin, co-author of the study Tailored Engagement. “But the magnitude of the nuclear crisis requires restructuring the way in which the South Korean government deals with North Korea, achieving domestic consensus, and shoring up international support for its efforts.”

The United States, China, Japan and Russia are the key international countries concerned with the peace and stability of Northeast Asia, yet South Korea has both an acute need and the potential to assume greater leadership of North Korea policy, said Shorenstein APARC Fellow Thomas Fingar.

China, as North Korea’s largest trade partner, exercises influence over North Korea by maintaining a commercial relationship in the hope of avoiding a collapse of the regime. Yet, its leverage only goes so far, he added.

The Moon administration should consider the limits of Chinese influence before making policy decisions regarding North Korea, Fingar said, for example, whether to freeze or remove the U.S. anti-ballistic missile system, Thermal High Altitude Area Defense (THAAD), deployed last April in South Korea, which the Chinese government strongly opposed.

“There is little that Beijing can or will do that would persuade Pyongyang to be more receptive to initiatives from Seoul than it would otherwise be,” said Fingar, a China specialist who served as chairman of the U.S. National Intelligence Council. “Seoul should not ‘pay’ much to obtain Chinese assistance because China already supports reengagement and would not do more no matter what Seoul offered as an inducement.”

It is of vital importance the Moon administration seeks to strengthen trilateral cooperation between South Korea, Japan and the United States, and to consider holding a summit to address areas of collaboration, all of which would function alongside the China-Japan-South Korea trilateral structure toward creating stability in the region, according to Daniel Sneider, associate director for research at Shorenstein APARC.

“Such cooperation is essential to the security of the region – without it, the United States cannot fulfill its obligation to defend South Korea against the threat posed by North Korea,” said Sneider, who leads the Divided Memories and Reconciliation research project. “Moreover, it’s in the interest of all three countries to tighten such cooperation to balance the rise of China.”

The Moon administration should, above all else, take time to consider its first steps despite pressures to perform early, said Michael Armacost, a fellow at Shorenstein APARC who held a 24-year career in the U.S. government.

“Getting things right is more important than making a quick splash,” said Armacost, a former U.S. undersecretary of state for political affairs. “I would advise any new president to proceed at a deliberate pace, focusing particularly on the key personal issues first, and consulting widely before enunciating major policy departures.”

Related links:

South Korea's election: Shorenstein APARC scholars offer insight

Yonhap News: 미 한반도 전문가 그룹 "한국형 페리 프로세스 필요" (May 16, 2017)

VOA: 미 전문가들 "한국 정부, 미국과 북 핵 협력 중요...대북특사도 임명해야" (May 17, 2017)

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Hayashi was the chairman of the Stanford Japan Center, a research center located in Kyoto which sought to contribute to the development of the Asia-Pacific region through policy-oriented research and collaboration between Stanford and Japanese universities.

During his role as chairman, Hayashi was part of the Stanford Kyoto Trans-Asian Dialogue, a multi-day conference organized by Shorenstein APARC that convened annually from 2009-13. The Dialogue, which gathered experts from many countries and with a wide range of backgrounds, aimed to build a strong network of people working on issues of mutual concern to Asia-Pacific countries and the United States.

Japan Program Research Scholar Kenji E. Kushida, who worked with Hayashi to coordinate the Dialogue, described him as “a great mentor,” and as someone who inspired his own research on Japan’s information technology, political economy and disaster recovery.

“Professor Hayashi was an accomplished academic and always warm,” Kushida said. “He articulated questions that cut to the core of any issue, and followed them with careful, measured answers. He enhanced the lives of everyone around him and will be dearly missed.”

Photo: Courtesy of the profile of Toshihiko Hayashi

Moon Jae-in was elected South Korea’s president on a pledge to address domestic inequality and to renew dialogue with North Korea. In the midst of Tuesday’s vote, Shorenstein APARC scholars offered insight to local and international media outlets.

Gi-Wook Shin, professor of sociology and director of Shorenstein APARC’s Korea Program, provided comment to The Economist about the challenges facing an administration led by Moon, a progressive candidate who is assuming power when an active conservative camp remains. He is also cited in an article in the New York Times focused on Moon's economic agenda and featured in a video from a Korea Society event that examines next steps for the new president.

Rennie Moon, the Koret Fellow in the Korea Program, co-authored an analysis piece on the East Asia Forum with Shin analyzing recent polls and the Moon administration's economic and security agenda.

Daniel Sneider, associate director for research at Shorenstein APARC, wrote an analysis piece for The National Bureau of Asian Research. In the piece, he explores how the election could impact the U.S.-Republic of Korea alliance amid escalating tensions on the Korean Peninsula.

Kathleen Stephens, the William J. Perry Fellow at Shorenstein APARC, appeared in a live interview on CNBC. In the taping, she discusses the significance of the vote and the new administration’s priorities as Moon swiftly takes office following the removal of his predecessor.

Northeast Asia relations are increasingly under strain as South Korea and China await shifts in political leadership and the threat of a sixth nuclear test by North Korea looms large. Scholars from the Shorenstein Asia-Pacific Research Center (APARC) have offered comment and analysis to media outlets about the evolving environment.

Gi-Wook Shin, director of Shorenstein APARC’s Korea Program, recognized in an interview with the Christian Science Monitor that, while threats posed by North Korea’s nuclear and missile program aren’t new, it is best practice to always be prepared for the possibility of conflict.

“I’m someone who believes that you have to get ready for the worst-case scenario. If something does happen, the consequences will be huge,” said Shin, who recalled the air-raid drills of his youth in the Seoul metropolitan area, which is centered 35 miles from the border of North Korea.

Shin also spoke with Yonhap News about positions held by the Trump administration, which, he said, includes the view that the policy of “strategic patience” has failed and that tensions in Northeast Asia have led the administration to consider – with greater plausibility – the option of a preemptive military strike.

Addressing China’s relationship with North Korea, Shorenstein APARC Associate Director for Research Daniel Sneider wrote an analysis piece for Tokyo Business Today. He argued that, despite President Trump’s tense rhetoric, U.S. policy toward North Korea could so far be described as “‘let China do it.’”

“The ‘let China let do it’ policy is hardly new,” Sneider wrote in the piece, available in English and Japanese.

“Why does the Trump administration believe this will work now? In part, the answer is the same as under the two previous administration – there are no better options available.”

Last month, Kathleen Stephens, the William J. Perry Fellow at Shorenstein APARC, spoke at length about North Korea policy on PBS NewsHour following Secretary of State Rex Tillerson’s remarks in Seoul, where he acknowledged, “all options are on the table.”

Asked about the significance of Tillerson’s remarks, Stephens said his speech would be "closely listened to and heard throughout the region, as well as [in the United States]."

“One thing that did strike me about Secretary Tillerson’s remarks was that he was quite specific and categorical in saying now is not the time for talks,” Stephens said in the interview. “I actually would have liked to have seen him keep the door a little bit ajar on that, because I think, when you do have a new administration in Washington…that's a good argument for trying to climb that mountain one more time and seeing what’s possible diplomatically.”

Uncertainty about U.S. intentions in Northeast Asia has increased fear that events could spin out of control in the region due to American disengagement. That engagement cannot be taken for granted, Shorenstein Fellow Thomas Fingar writes on the Stanford University Press blog, and it remains to be seen just how well regional political leaders adjust to the Trump administration’s evolving foreign policy.

The blog post highlights themes from his book Uneasy Partnerships: China’s Engagement with Japan, the Koreas, and Russia in the Era of Reform (Stanford, April 2017).