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Population aging in Asian societies is accompanied by changes in intergenerational living arrangements, which can have substantial health and economic implications for the elderly parents and their adult children. Dr. Young Kyung Do will present some of his recent works related to elderly living arrangements in South Korea. These works include the effect of coresidence with an adult child on depressive symptoms among older widowed women; the relationship between adult children's coresidence with parents and their labor force participation; and interrelations between expectations about bequests and informal care with special emphasis on the role of intergenerational coresidence. In these studies, Dr. Do attempted to account for a common methodological issue: living arrangements are not always randomly assigned but may be jointly decided with the outcome of interest taken into account by either the elderly parents or their adult children. While this seminar will focus on the South Korean context, the significance and implications apply to many other Asian societies undergoing population aging and marked transitions in elderly living arrangements.

Dr. Young Kyung Do is an assistant professor at the Duke-National University of Singapore Graduate Medical School (Duke-NUS), Program in Health Services and Systems Research. His research interests include the economic and health system impact of population aging and noncommunicable disease; interactions between self-care, informal care, and formal care interfaces; and health, education, and labor market outcomes over the life course. He received his MD (1997) and master of public health (2003) degrees from Seoul National University, subsequently completing his PhD in Health Policy and Management (2008) at the University of North Carolina at Chapel Hill. He was the inaugural Asia Health Policy postdoctoral fellow at the Shorenstein Asia-Pacific Research Center,(2008−9).

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Postdoctoral Fellow in Asia Health Policy Program, 2008-09
Do.JPG MD, PhD

Young Kyung Do is the inaugural Postdoctoral Fellow in the Asia Health Policy Program at the Walter H. Shorenstein Asia-Pacific Research Center. He completed his Ph.D. in health policy and administration at the University of North Carolina at Chapel Hill School of Public Health in August 2008. He has also earned M.D. and Master of Public Health degrees from Seoul National University (in 1997 and 2003, respectively). He earned board certification in preventive medicine from the Korean Medical Association in 2004. His research interests include population aging and health care, comparative health policy, health and development, quality of care, program evaluation, and quantitative methods in health research.

He received the First Prize Award in the Graduate Student Paper Competition in the Korea Labor and Income Panel Study Conference in 2007. He also is the recipient of the Harry T. Phillips Award for Outstanding Teaching by a Doctoral Student from the UNC Department of Health Policy and Administration in 2007. In May 2008, he was selected as a New Investigator in Global Health by the Global Health Council.

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Young Kyung Do Assistant Professor Speaker the Duke-National University of Singapore Graduate Medical School Singapore (Duke-NUS)
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The elderly share of China’s population is projected to grow well beyond the capacity of the nation’s social security system. Meanwhile, family care is being challenged by a decline in fertility and an increase in migration from rural to urban areas. This paper examines the short-, mid-, and long-term effects of family support on elderly well-being in rural China, using four-wave panel data on 1,456 persons aged 60 and above in the Chaohu region of China. Findings showed that compared with living alone, being coresident with others lowered the mortality risk of several chronic diseases; but being coresident with adult children increased the mortality risk of cardiovascular diseases, though it was associated with a higher quality of life in the short and middle term. Children’s educational attainment and financial support increased the quality of life except for an increased risk of new incidence of cardiovascular disease in the middle term.

Published: Liu, Huijun, et al. "The Quality of Life and Mortality Risk of Elderly People in Rural China The Role of Family Support." Asia-Pacific Journal of Public Health (2013): 1010539512472362.

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Asia Health Policy Program working paper # 30
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Huijun Liu
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As China's economy grows so does the prevalence of social inequality. In a YaleGlobal Online article, a team of Shorenstein APARC China experts says the country must invest more now in education and public health programs for its rural children or it will face major growth challenges in the near future.

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Karen Eggleston
Ang Sun
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More than two decades have passed since the first case of HIV infection was detected in Cambodia in 1991. Cambodia is among the countries with the highest HIV prevalence in Asia and has been experiencing the most serious HIV/AIDS epidemic in the region. The epidemic is spread primarily through heterosexual transmission and revolves largely around the sex trade.

Since the beginning of the epidemic, the Royal Government of Cambodia has made a strong political commitment to the need for prevention of HIV transmission and care for people living with HIV/AIDS. It has received some technical and financial support from national and international agencies. Several prevention and intervention programs have been successfully implemented, and the WHO/UNAIDS recognized that the Cambodia’s HIV/AIDS epidemic appeared to have stabilized in 2002.

The estimated HIV prevalence in the general adult population declined to 0.5% in 2009, down from 1.2% in 2001. Among women visiting antenatal care clinics, the prevalence also declined from 2.1% in 1999 to 1.1% in 2006. There was also a gradual increase in the percentage of HIV-infected pregnant women who received antiretroviral therapy to reduce the risk of mother-to-child transmission, from 1.2% in 2003 to 11.2% in 2007, and finally to 32.3% in 2009.

Despite the decline of HIV prevalence in the general population, the prevalence remains high among high-risk groups such as commercial sex workers, men who have sex with men, and injection drug users. Furthermore, the so-called prevention-successful-country is also seeing the growing need for HIV/AIDS treatment and care.

This seminar will highlight the past and current features of Cambodia’s HIV/AIDS epidemic, lessons learned from prevention and care policies, and future challenges that Cambodia may face in the battles against HIV/AIDS.  

Dr. Siyan Yi joins the Walter H. Shorenstein Asia-Pacific Research Center during the 2011–12 academic year from the National Center of Global Health and Medicine and the University of Tokyo, Japan, where he jointly served as a research fellow and lecturer. He has also served as an adjunct faculty member at Cambodia’s School of Public Health, the National Institute of Public Health, and the School of International Studies at the Royal University of Phnom Penh.

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2011-12 Developing Asia Health Policy Fellow
YiSiyan_Profile.jpg MD, PhD

Dr. Siyan Yi joined the Walter H. Shorenstein Asia-Pacific Research Center (Shorenstein APARC) as a 2011-12 Developing Asia Health Policy Postdoctoral Fellow from the National Center of Global Health and Medicine and the University of Tokyo, Japan, where he jointly served as a research fellow and lecturer. He also served as an adjunct faculty member at Cambodia’s School of Public Health, the National Institute of Public Health, and the School of International Studies at the Royal University of Phnom Penh. He is currently an Associate Professor and UHS-SPH Integrated Research Programme Leader at NUS Saw Swee Hock School of Public Health (profile page here).

Yi’s research has centered largely on epidemiological methods. This has included, for example, work on surveys in Cambodia on adolescent risky sexual behaviors, substance abuse, and depression; a health promotion project in primary schools; sexual behaviors among people living with HIV/AIDS; and HIV risky behaviors among tuberculosis patients. Currently, he is involved in hospital- and community-based research projects in several developing countries as well as in Japan. He has published several papers in these research areas in international journals. His selected publications include:

  • Siyan Yi, Akiko Nanri, Kalpana Poudel, Daisuke Nonaka, Hori Ai, Tetsuya Mizoue. “Association between serum ferritin and depressive symptoms in Japanese municipal employees.” Psychiatry Research, 2011. 189: 368-372.
  • Siyan Yi, Daisuke Nonaka, Marino Nomoto, Jun Kobayashi, and Tetsuya Mizoue. “Predictors of the uptake of A (H1N1) influenza vaccine: Findings from a population-based longitudinal study in Tokyo.” PLoS One, 2011. 6: e18893.
  • Siyan Yi, Krishna C. Poudel, Junko Yasuoka, Paula H. Palmer, Songky Yi, and Masamine Jimba. “Risk vs. protective factors for substance use among adolescent students in Cambodia.” Journal of Substance Use, 2011. 16:14-26.
  • Siyan Yi, Krishna C. Poudel, Junko Yasuoka, Paula H. Palmer, Songky Yi, and Masamine Jimba. “Role of risk and protective factors for risky sexual behaviors among high school students in Cambodia.” BMC Public Health, 2010. 10: 477.
  • Siyan Yi, Krishna C. Poudel, Junko Yasuoka, Masao Ichikawa, Vutha Tan, and Masamine Jimba. “Influencing factors for seeking HIV voluntary counseling and testing among tuberculosis patients in Cambodia.” AIDS Care, 2009. 21: 529-534.

Yi holds an MHSc (2007) and a PhD (2010) in international health sciences from the School of International Health at the University of Tokyo’s Graduate School of Medicine. He also earned an MD in general medicine from the University of Health Sciences, Cambodia (2001). Yi has won research awards, including: the Young Investigator Award from the Asia Pacific Academic Consortium for Public Health (2008), the Montreux Prize from the Swiss Association for Adolescent Health and the International Association for Adolescent Health (2009), and the Scientific Research Award from the University of Tokyo (2009).

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Siyan Yi 2011-12 Developing Asia Health Policy Fellow Speaker Stanford University
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Newly printed “no smoking” signs went up across China when the government rolled out a nationwide public indoor smoking ban in May 2011. A sticky gray layer of smoke residue now coats many signs, representing the challenges China’s growing tobacco-control movement faces against a multibillion-dollar government-run industry and deeply embedded social practices.

How has the cigarette become so integrated into the fabric of everyday life across the People’s Republic of China (PRC)?

To get to the heart of this question, historians, health policy specialists, sociologists, anthropologists, business scholars, and other experts met Mar. 26 and 27 in Beijing for a conference organized by Stanford’s Asia Health Policy Program. They examined connections intricately woven over the past 60 years between marketing and cigarette gifting, production and consumer demand, government policy and economic profit, and many other dimensions of China’s cigarette culture.

Anthropologist Matthew Kohrman, a specialist on tobacco in China, led the conference, which was held at the new Stanford Center at Peking University. In an interview, he spoke about the history of China’s cigarette industry, cigarettes and society, and the tobacco-control movement.

The early years

Tobacco first entered China through missionary contact in the 1600s, says Kohrman, but it was not until the early 20th century when cigarettes began gaining popularity. The first cigarette advertising was a “confused tapestry” of messages as marketers figured out what spoke to the public. “There were just as many images of neo-Confucian filial piety as there were of cosmopolitan ‘modern women,’” says Kohrman.

Through improved marketing and aggressive factory building, British American Tobacco and Nanyang Brothers, China’s two largest pre-war firms, helped increase the demand for cigarettes. The Sino-Japanese War (1937–1945) disrupted the cigarette supply, but their popularity had taken hold. Some cigarette firms shifted during the war to the relative safety of southwest China, where tobacco production has remained concentrated ever since.

Post-1949

After the founding of the PRC in 1949, the tobacco industry was nationalized and strong relationships between the central government and cigarette manufacturers in the provinces were formed. Cigarettes also began to be viewed as a part of everyday life. “Ration coupons for cigarettes were issued alongside grain, sugar, and bicycle coupons,” says Kohman. “The Maoist regime legitimized cigarettes as the right of every citizen."

During the Deng Xiaoping era (1978–1997), China’s cigarette industry really took off as manufacturers competed with one another for foreign currency to purchase cutting-edge European equipment and newer varieties of tobacco seed stock. Increased production and the return of full-scale advertising fueled greater consumer demand, and manufacturers began producing more and more varieties of cigarette. Vendors displayed glass cases filled with a colorful patchwork of cigarette packs bearing names like Panda, Double Happiness, and Red Pagoda.

The tobacco industry remained under government control as other industries privatized in the 1980s and 1990s. Party-state management of the cigarette became even more centralized in the early 1980s with the creation of the China Tobacco Monopoly Administration and its parallel external counterpart, the China Tobacco Corporation.

Since 1949, provincial protectionism has marked the cigarette market. It is now possible to purchase Beijing cigarettes in Kunming, Chengdu brands in Shanghai, and so on, but to distribute cigarettes in another province, a manufacturer must cut a deal with provincial government officials. Provincial administrations are loath to cut such deals because central government policy dictates that the portion of cigarette sales tax which does not go to the central government always is channeled to the finance bureau of the province of original production. China’s 2001 entry into the World Trade Organization opened the market ever so slightly to international brands like Marlboro and Kent, but domestic brands continue to dominate because of fierce protectionism.

...If it chooses to do so, China is in a position to lead and change the landscape in a very profound way.
-Matthew Kohrman, Professor of Anthropology, Stanford

A new era

In 2003, the World Health Organization established the first global health treaty, the Framework Convention on Tobacco Control (FCTC). Although the United States still has not yet ratified the FCTC, China signed the treaty in 2003 and ratified it in 2005. Kohrman says China’s tobacco industry giants fear competition from international cigarette brands more than they worry about tobacco-control measures related to the FCTC.

Nonetheless, the FCTC ushered in a new era of public health research about tobacco and has helped increase public awareness about the dangers of smoking. New restrictions have been imposed on print and television advertising for cigarettes, and international organizations, such as the Bloomberg Family Foundation, have begun funding anti-tobacco work in China.

A big challenge to tobacco-control campaigns, says Kohrman, is the sheer amount of money that tobacco companies have available for marketing. “In 2010, China’s tobacco industry posted profits in excess of U.S. $90 billion—that’s huge. Tobacco control research and advocacy now annually receive a few million dollars, and much of that is coming through outside funders, which have very specific projects in mind.”

China’s tobacco advertisers have adapted to the new restrictions that prevent them from openly promoting cigarettes in the media. They have instead moved to point-of-sale and soft-marketing tactics, including misinformation campaigns about the “dangers” of quitting smoking. “The actual expenditure on marketing probably hasn’t dropped very much,” says Kohrman.

Cigarettes and society

Strong marketing and the legitimization of cigarettes as a part of everyday life have led to the deep integration of cigarettes into Chinese society. While only 3 to 4 percent of women in China smoke, cigarettes are an important part of male identity and social mobility. The wide range of cigarette brands has led to the growth of high-end varieties favored by businessmen and politicians, with some brands costing as much as $50 a pack. The custom of cigarette gifting has existed in China for decades, and it is difficult for a young man to turn down a package of cigarettes from a senior colleague or supervisor.

There is also the fact that nicotine is highly addictive, and quitting is difficult in an environment where smoking cigarettes is socially sanctioned. Kohrman says, “When you take an incredibly addictive substance like nicotine and throw it into the mix of all of these norms and customs, it creates a pretty toxic brew.”

The future?

Tobacco control presents a formidable challenge in China, one that requires understanding the historical context and complex dimensions of the cigarette industry. “Cigarettes have been insinuated into so many aspects of daily life across China, and the market for this product has now become so closely enmeshed with matters of government finance and operations,” says Kohrman.

What happens in China could have implications for the entire world. “There’s a tobacco-induced human annihilation unfolding right now in almost every country and questions about how society and Big Tobacco are enmeshed, and how cigarette culture and government finance have become mutually supportive are pivotal,” says Kohrman. “Every country except Bhutan has legalized cigarette sales and is subject to many of the same general issues as China—only in China they’re on a much larger scale. But if it chooses to do so, China is in a position to lead and change the landscape in a very profound way.”   

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