At present, the tobacco industry annually produces some six trillion cigarettes worldwide. A third of all these sticks were produced in China last year. During a Jan. 30 seminar, Matthew Kohrman will introduce the Cigarette Citadels project, an innovative application of participatory GIS, and discuss its implications for public health policy and social theory about the state and the politics of life.

As incomes rise around the world, health experts expect a more troubling figure to increase as well: the number of diabetics in developing countries.

In China and India – two of the world’s most populous nations with fast-paced economies – the prevalence of diabetes is expected to double by 2025. Between 15 and 20 percent of their adult population will develop the disease as household budgets increase, diets change to include more calories and new health problems emerge.

But China, India and other developing countries are not fully prepared to deal with the rising trend of diabetes. And a growing number of diabetics aren’t getting the care they need to prevent serious complications, Stanford researchers say.

Even with insurance, many diabetics don’t have essential medications that could help them manage their conditions. In many cases, people are spending a great deal of their household incomes to pay for their treatment, said Jeremy Goldhaber-Fiebert, an assistant professor of medicine who led the research team.

“Public and private health insurance programs aren’t providing sufficient protection for diabetics in many developing countries,” said Goldhaber-Fiebert, a faculty member at Stanford Health Policy at the university’s Freeman Spogli Institute for International Studies. “People with insurance aren’t doing markedly better than those who don’t have it. Health insurance and health systems need to be re-oriented to better address chronic diseases like diabetes.”

Findings from the study are online and will be published in the Jan. 24 edition of Diabetes Care, the journal of the American Diabetes Association. The journal article was co-authored by Jay Bhattacharya, an associate professor of medicine and Stanford Health Policy faculty member; and Crystal Smith-Spangler, an instructor at Stanford’s Department of Medicine and an investigator at the Palo Alto VA Health Care System.

Failure to adequately manage diabetes will lead to more severe health problems like blindness, heart disease and kidney failure. It also harms the otherwise healthy, Goldhaber-Fiebert said.

Diabetes often strikes people at an age when they’re taking care of children and elderly parents. To sideline these primary caretakers as dependants will lead to a heavy burden for communities and create an obstacle for economic growth, he added.

Using responses to a global survey conducted by the World Health Organization in 2002 and 2003, Goldhaber-Fiebert and his colleagues examined data from 35 low- and middle-income countries in Asia, Latin America, Africa and Eastern Europe to determine whether diabetics with insurance were more likely to have medication than those without insurance.

They also wanted to know whether insured diabetics have a lower risk of “catastrophic medical spending,” a term the researchers define as spending more than 25 percent of a household income on medical care.

“Surprisingly, diabetics with insurance were no more likely to have the medications they need than uninsured diabetics,” Goldhaber-Fiebert said. “They were also no less likely to suffer catastrophic medical spending.”

There are many reasons why health insurance may not protect diabetics in developing countries against high out-of-pocket spending. In some cases, there’s a lack of sufficient medication – such as insulin – that regulate glucose levels. Without those drugs, there’s a greater risk of complications that often lead to more hospitalizations and more expenses.

In other cases, co-payments and deductibles are too high. Sometimes, drugs and medical services to prevent diabetes complications are not covered. And doctors and hospitals don’t always accept insurance.

“Better policies are needed to provide sufficient protection and care for diabetics in the developing world,” Goldhaber-Fiebert said.

Without medications to manage diabetes and prevent secondary complications, the condition will worsen and the burden of catastrophic spending will increase, he said.

“It’s important to get ahead of the curve and prepare so there’s an infrastructure in place to deal with these health and cost issues,” he said.

While preventing diabetes in the first place would be ideal, programs and policies must be established to care for the many cases that will surely continue to exist.

“There isn’t a single country that’s managed to entirely arrest or reverse the trend of diabetes,” he said. “Programs that focus on primary prevention are extremely important, but the reality is that the developing world faces hundreds of millions of diabetes cases that are unlikely to all be prevented.”

Tobacco now kills 90 times more people each year than HIV/AIDS in China. China's tobacco industry is closely tied to the global industry, and the Asia Health Policy Program is working to establish a new field of research on its history, beginning with a Mar. 2012 conference at the new Stanford Center at Peking University. Robert Proctor, a Stanford historian and author of a groundbreaking new book on the global tobacco industry, will take part.

Asia’s demographic landscape is changing in a big way. Japan’s population is shrinking, as people are living longer, marrying later, and choosing to have fewer or no children. Korea is moving in the same direction, while China and the countries of South and Southeast Asia face similar issues in the coming decades. As this takes place, more people are moving to, from, and across Asia for job, education, and marriage opportunities.

These demographic changes present policymakers with new challenges and questions, including: What are the interrelationships between population aging and key macroeconomic variables such as economic growth? How will it impact security? What are the effects on employment policy and other national institutions? How have patterns of migration affected society and culture? What lessons can Asia, the United States, and Europe learn from one another to improve the policy response to population aging?

The Walter H. Shorenstein Asia-Pacific Research Center (Shorenstein APARC) focused its third annual Stanford Kyoto Trans-Asian Dialogue on addressing the possible economic, social, and security implications of Asia’s unprecedented demographic transition. Thirty scholars, government figures, journalists, and other opinion leaders from Stanford, the United States, and countries across the Asia-Pacific region gathered September 8–9, 2011, in Kyoto, Japan, to discuss key issues related to the question of demographic change.

Comparative Demographics and Policy Responses

Japan’s shrinking workforce calls for labor policy changes, stressed presenters during the opening Dialogue session. Stanford Center for Population Research director Shripad Tuljapurkar stated that Japan’s population could decrease by as much as 25 percent and that its government has a window of approximately 40 years in which to act. In describing Japan’s demographic shift, Ogawa Naohiro, director of the Nihon University Population Research Institute, also emphasized the importance of good financial education for individuals as life expectancy increases.

Macroeconomic Implications

Economists Masahiko Aoki and Cai Fang addressed changes to East Asia’s economic landscape. Aoki, an FSI senior fellow, spoke of the transition from agriculture to industry that has occurred at different stages in Japan, Korea, and China and of the increasing cost of human capital that has followed. Cai, a Chinese Academy of Social Sciences labor and population expert, stated that after several decades of industrial growth China is now at a turning point in terms of its global competitiveness.

Labor and Migration

Scott Rozelle, codirector of Stanford’s Rural Education Action Program (REAP), opened the next day with a discussion of China’s rural human capital investment. Offering Mexico’s situation after the mid-1990s peso crisis as a comparison, he emphasized the immediate need for allocating more health and education resources to China’s rural areas. Ton-Nu-Thi Ninh, president of Tri Viet University, discussed the socioeconomic and cultural aspects of labor migration—a growing trend in Asia—and advocated that governments factor it more into their foreign policy development.

Security

The security impact of Asia’s demographic transition will take several decades to understand, but it will eventually lead to the need for significant policy re-strategization, stated Yu Myung Hwan, Korea’s former minister of foreign affairs and trade, during the closing Dialogue session. He suggested focusing on impacts that could result from the major changes taking place in fertility, urbanization, and migration. Concurring with many of Yu’s views, Stanford’s Shorenstein Distinguished Fellow Michael H. Armacost also noted the current lack of literature on the link between security and demography. In addition, he emphasized the need for the United States to continue pursuing good relations with China and Russia during this time of transition.

“Low fertility rates are not because women are all out there working. In fact, a number of countries have lots of females in the labor force and have achieved a resurgence of fertility. Achieving work-life balance is important, not just for women, but for men as well, and might play a role in lessening the gap in life expectancy between men and women.”

-Karen Eggleston, Director, Asia Health Policy Program

Throughout the event, Dialogue participants unanimously acknowledged the serious challenges facing policymakers as they look for ways to meet the evolving needs of individuals, families, and organizations. The demographic outlook is not entirely gloomy, however. Numerous participants also pointed to the potential for exciting advances and innovations in technology and international cooperation.

As in previous years, the event concluded with a lively public symposium and reception attended by students from Stanford and local universities, Shorenstein APARC guests and affiliates, and members of the general public. Speaking during the reception, Kadokawa Daisaku, mayor of Kyoto, and Kim Hyong-O, member and former speaker of the Korean National Assembly, acknowledged the significance of the Stanford Kyoto Trans-Asian Dialogue as a forum for addressing issues of mutual importance to the United States and Asia.

The Dialogue is made possible through the generosity of the City of Kyoto, FSI, and Yumi and Yasunori Kaneko. To read the final report from this and previous Dialogues, visit the event series page below.