This article was first published in Vox China. Read the full article online.

In this relatively well-insured population, annual health care utilization significantly increases primarily because of more intensive use of outpatient care at retirement. This increase in outpatient care stems from a decline in the patient cost-sharing rate, the reduced time constraints upon retirement, and the interaction of these factors with supply-side incentives such as prescribing antibiotics. There is no evidence of change in inpatient care at retirement.

The economics of medical expenditure growth and its interaction with population aging is of considerable policy importance for countries in all income groups. “Our findings may provide useful evidence as one consideration for policymakers in other cities in China and elsewhere looking to increase insurance benefits and control medical spending for burgeoning elderly populations.

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 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.

Working across linguistic and cultural differences, students in the China Scholars Program (CSP) and Stanford e-China (SeC) met and collaborated online as partners, from opposite sides of the world, in November and May. The two programs focus on different themes—U.S.–China relations writ large (CSP) and emerging technologies through the lens of design thinking (SeC)—but found common ground in finding local solutions to environmental sustainability problems.

The students were divided into groups, each including both U.S.- and China-based members. Each student shared a sustainability issue that they observed in their home communities—discovering similar issues around recycling, food waste, and environmental pollution, in particular. The group then selected one problem to focus on and brainstormed a specific solution targeted at a specific user group using the design thinking process. Finally, they shared creative presentations of their process and their proposed solutions with both classes. 

Although these projects have real-life applications—with at least one group intending to go forward with actually prototyping their idea to see how far they can take it—the true challenge of this assignment for the students was to figure out how to collaborate across technological, cultural, and (to a lesser extent) linguistic barriers and solve a common problem together. It was not easy. But many students reported that it was one of the most rewarding and memorable experiences in their program. We hope it will seed the skills they need for cross-cultural collaborative problem-solving in the future.

Following the joint project, students sent reflections to CSP Instructor Tanya Lee and SeC Instructor Carey Moncaster, marveling at how much they had in common, and at the value of their differences. An American student noted, “Working with students from [China] showed me what true cross-cultural collaboration is like. It was cool to see how cultural differences affect the way in which people approach and work on a task and how collaborating with people who work differently than you can produce better results or help you see things in a new way.” Reflecting a similar team-driven sentiment, a Chinese student noted, “There are more similarities than differences that divide us. We really need to promote communication between individuals in two countries instead of knowing the other country from the authorities’ slogans.”

Fall 2020 marked the inaugural session of the Stanford e-China Program, an English-language, online program for high school students across China exploring current technological innovation and human-centered brainstorming strategies. The China Scholars Program completed its seventh and eighth sessions this past year, bringing together students from all over the United States to study the politics, economics, and society of contemporary China. Both programs feature lectures and discussions with Stanford University faculty and are offered twice annually, in fall and spring.

Applications for the Fall 2021 Stanford e-China Program are currently open with a final deadline of September 1, 2021. 

Applications for the Spring 2022 China Scholars Program will open in September, due November 1. (Applications for Fall 2021 have closed.)

This commentary was first published by The Lowy Institute.

Two recent naval exercises demonstrate the potential for Russia-China cooperation in the Indian Ocean, and how the two present a much greater threat to a continued US role and influence in the region than either would individually.

Last year, South Africa hosted a maritime exercise with Russia and China, the first-ever trilateral exercise among the three countries. Exercise Mosi was designed, according to the South African Navy, to “enhance interoperability and maritime security“ and showed the three countries’ willingness to work together to counter security threats at sea, such as terrorism and piracy. There were the obligatory social and cultural activities, and then military maneuvers that focused on a surface gunnery exercise, helicopter cross-deck landings, boarding operations and disaster control exercises.

China and Russia followed this up in December 2019 with another trilateral maritime exercise with Iran in the Gulf of Oman called Exercise Marine Security Belt. The exercises included live-fire drills and an anti-piracy exercise involving Iranian commandos. According to the Iranian naval commander, the exercises’ message was that “Iran cannot be isolated.” A Chinese spokesman stated: “The naval drills aim to deepen exchange and cooperation among the navies of the three countries, and display their strong will and capability to jointly maintain world peace and maritime security”.

Both China and Russia have gradually been increasing their presence in the Indian Ocean. Russia recently announced it would establish a naval facility in Port Sudan on the Red Sea. China opened its first overseas base in Djibouti in 2017, and China’s navy has increased operations in the Indian Ocean region over the past three decades.

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The Covid-19 crisis may have slowed further moves towards cooperation this year. Moscow just hosted the 12th BRICS summit virtually, which doesn’t lend itself to deep military engagement. But the trilateral exercises are notable because they signal Moscow’s and Beijing’s desire to cooperate in the region. And more importantly, they reveal that regional powers such as South Africa and Iran, as well as other countries, welcome the increased role of China and Russia.

Relations between South Africa and the United States were already strained when Pretoria agreed to the trilateral exercises last year. Under the Trump administration, the United States grew critical of South Africa’s UN voting record. Washington also declined to exempt the country from hikes in tariffs on US imports of steel and aluminum. In contrast, China has pledged the most investments of any country in South Africa. Russia has followed in its footsteps in building political, military and trade ties across sub-Saharan Africa.

Iran has even more reason to build relations with China and Russia. Since the US withdrawal from the Iran nuclear deal in 2018, Iran has strengthened its ties to China and Russia, using multi-billion-dollar loans from the two countries to resist US sanctions and deepening defense cooperation and intelligence sharing.

Smaller countries can also find the Russia-China nexus useful. According to a Chinese-language source, Sudan, a long-standing regional partner of China, first proposed hosting a Russian base in 2017 as a counterbalance “against aggressive acts of the United States”.

In other words, China and Russia together may be better equipped to compete with the United States and its allies in the Indian Ocean region for influence, for several reasons.

Moscow may be more willing than Beijing to play the ringleader role in organizing and directing opposition against the United States, but it doesn’t have the economic heft to make such cooperation a winning proposition for Indian Ocean states.

While China has considerable resources, it is more concerned about provoking the United States and potentially worsening already poor relations. China often argues that it is a different type of great power, one that does not engage in hegemonic behavior such as alliance formation. China is also keen to avoid sparking a countervailing coalition against it.

For these reasons, Beijing often tones down its rhetoric about the nature of its relationship with Russia. China claimed the Indian Ocean exercises do “not target any third party”. For Russia, however, overtly undermining the United States is a key component of its strategy and plays well domestically for Putin.

On the other hand, China has the economic resources to wield influence and invest heavily in Indian Ocean countries. In Pakistan alone, Beijing has pledged an estimated $87 billion in funding and completed roughly $20 billion worth of projects. Recently, Beijing and Tehran reportedly agreed to a 25-year deal to expand China’s investment in Iranian banking, telecommunications, ports and railways in exchange for oil.

While China and Russia are nowhere near dominating the Indian Ocean region militarily, their combined influence may promise trouble for the United States and its partners. The two countries will likely work together to inure their partners to international pressure, including over human rights violations. And those partners will receive security benefits (such as military access) and economic benefits (such as preferential economic ties) in return. Although it seems a bit exaggerated, there is some truth to Iranian Admiral Hossein Khanzadi’s declaration that strategic coordination with Russia and China means “the era of American free action in the region is over”.

China and Russia may be slow in enhancing their strategic coordination in the Indian Ocean slowly, but the intent is there. The United States and its allies may still be dominant militarily. But we should be careful not to fall under the illusion that this guarantees influence. With China and Russia presenting themselves as strong alternative powers, the United States and like-minded countries have to work that much harder to promote sustainable economic development, protect international rules and norms, and ensure peace and security in the region.

This blog post was first published by the Australian Strategic Policy Institute's The Strategist analysis and commentary site.

The Quad is stronger than ever. The informal ‘minilateral’ grouping of Australia, India, Japan and the United States has in the past year held its first stand-alone ministerial meeting and its first leaders’ summit, and launched an ambitious project to deliver Covid-19 vaccines. This ‘golden age’ of the Quad is a product of newfound Indian enthusiasm for the grouping, in turn, spurred by the military crisis in Ladakh, where India faces ongoing Chinese troop incursions across the two countries’ disputed border.

But the Quad is not bulletproof. Some experts have suggested that the economic and diplomatic effects of the devastating second wave of the pandemic in India will preoccupy the Indian government, sapping the Quad of capacity for any new initiatives. Others counter that India remains committed to competition with China—which is what really matters for the Quad—although its partners always expected ‘two steps forward, one step back’ from India.

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Related: On the Conversation Six podcast, Tarapore discusses the policy paper on which this blog post is based with Jawaharlal Nehru University Professor of International Politics Rajesh Rajagopalan. Listen:

The pandemic may well prove to be a hiccup in the Quad’s evolution, but a potentially much larger disruption may come from the ongoing Ladakh crisis itself. As I argue in a new ASPI Strategic Insights paper, the crisis has greatly increased the risk of a border war between India and China, which would present a defining test of the Quad. A possible war could either strengthen or enervate the Quad—depending on how India and its partners, including Australia, act now to shape the strategic environment.

Risk is a function of likelihood and consequence. The likelihood of war on the India–China border is still low—both countries would prefer to avoid it—but has risen since the crisis began. Both countries have greatly expanded their military deployments on the border and backed them with new permanent infrastructure to resupply and reinforce them. China has proved its revisionist intent with large and costly military incursions, although its specific objectives and plans remain unknown. And the interaction of both countries’ military strategies and doctrines would, on the threshold of conflict, promote escalation.

The consequences of a possible conflict would be dire for both belligerents and for the region. China — assuming it is the provocateur of conflict—would likely face some political rebuke from states that consider themselves its competitors, but it will work strenuously to reduce those costs, and would likely have priced them in to its calculations of whether to fight. India will suffer high tactical costs on the border, and may also suffer wider harm if China uses coercive cyberattacks against strategic or dual-use targets.

In a costly war, the repercussions may spill over to damage India’s recently developing strategic partnerships, especially with the United States and Australia. Despite generally favorable views of the US, the Indian strategic elite still harbors some latent suspicions. This was highlighted in two episodes in April 2021, when the US Navy conducted a freedom of navigation patrol through the Indian exclusive economic zone, and when the US was slow in delivering Covid-19 vaccine raw materials and other relief. Both instances quickly receded from the Indian public imagination—thanks to quick correctives from Washington—but they did reveal that, under some conditions, Indian perceptions of its new partnerships can be quickly colored by distrust.

A China–India border war may create exactly those conditions. There is a chance that conflict may result in a redoubled Indian commitment to the Quad, if New Delhi judges that it has no option but to seek more external assistance. Conversely, unless a conflict is managed well by India and its partners, it is more likely to result in Indian disaffection with the Quad. India deepened Quad cooperation during the Ladakh crisis partly as a deterrent signal to China, and partly because the Quad is still full of promise. However, after a conflict—when China hasn’t been deterred and has probably imposed significant costs on India—the Quad’s utility would have been tested, and probably not ameliorated India’s wartime disadvantage.

The task before Quad governments is to be sensitized to this risk and implement mitigation strategies before a possible conflict, to buttress the coalition in advance. As I outline in the ASPI paper, they could do this at three levels. First, they could offer operational support—such as intelligence or resupply of key equipment, as the US already has done in the Ladakh crisis—although Quad partners’ role here would be limited. Second, they could provide support in other theatres or domains—with a naval show of force, for example, although cyber operations would probably be more meaningful in deterring conflict or dampening its costs. Third, they could provide political and diplomatic support — signaling to Beijing that a conflict would harm its regional political standing.

For Quad members, the main goal would be to deter conflict in the first place, and, failing that, to preserve the long-term strategic partnership with India for the sake of maintaining as powerful and energetic a coalition as possible to counterbalance China in the long term.