Countries throughout the world increasingly share similar health policy challenges such as healthcare and insurance reform, rapid demographic change, and high rates of chronic diseases like diabetes. The Asia-Health Policy Program (AHPP) is one of several Stanford organizations seeking solutions to major global health issues through a comparative study of the health policies of different countries. Visiting fellows and scholars from Asia play an integral part in AHPP’s research, publishing, and outreach activities.

Since AHPP’s founding in 2007, the program has hosted 10 visitors from Asia, including Cambodia, China, and Korea, and, in the coming academic year, it will welcome three new visitors, from Japan, Mongolia, and the Philippines. In just five years AHPP has established strong postdoctoral and developing Asia fellowship programs, in addition to the visiting scholars it hosts. Lasting ties have been established, resulting in numerous publications as well as research and outreach projects in Asia.

Even now we still keep in touch and collaborate on certain research areas.
-Yan Wang, 2009–10 Visiting Scholar

Three former AHPP visitors recently spoke about their experience with the program and about the work they have been doing since their time at Stanford.

Young Kyung Do, AHPP’s inaugural postdoctoral fellow (2008–09), conducted research on the social and economic implications of population aging in Asia. Focusing on education and diabetes care, Do also examined the impact of socioeconomic disparities on the health and health care of elderly citizens. AHPP helped define his future research agenda, and also provided him with publishing opportunities, including collaborating on a chapter on diabetes in the edited volume Aging Asia (2010). Do is now an assistant professor with the Duke-National University of Singapore Graduate Medical School, where he studies health economics and policy issues related to population aging and noncommunicable diseases in Southeast and East Asia.

Byongho Tchoe served as a visiting scholar during the 2008–09 academic year, researching and writing about health care reform in South Korea. Tchoe enjoyed conducting research in Stanford’s peaceful campus environment, and taking part in seminars offered by the Shorenstein Asia-Pacific Research Center and other Stanford organizations. He contributed the chapter “Old-Age Pension Reform in South Korea” to Aging Asia, and published a working paper and article on the impact of population aging on medical costs in South Korea. Tchoe is now the president of the Korea Institute for Health and Social Affairs in Seoul.

Yan Wang (former), an AHPP visiting scholar from 2009 to 2010, is currently deputy director of the Division of Disease Control in the Health Department of China’s Shandong Province. At AHPP, Wang studied how private health care providers, in conjunction with government-run health services, can help improve the overall primary care available in China’s cities. She also collaborated with Stanford’s Asian Liver Center to develop an online program to provide better hepatitis B education to health professionals in Shandong. Wang appreciated attending AHPP seminars and learning about health reform around the world, and still remains in touch with some of the scholars she connected with during her time at Stanford.

AHPP looks forward to continuing to welcome and collaborate with visiting fellows and scholars in the coming years, and to expanding its postdoctoral and developing Asia fellowship programs.

From Shanghai to São Paulo, people around the world are living longer than ever, challenging long-held ideas about retirement and well-established national retirement systems. Stanford health economists Karen Eggleston and Victor R. Fuchs offer an innovative view of the global aging phenomenon in an article published recently in the Journal of Economic Perspectives.

Drawing on a century of demographic data from 17 countries, Eggleston and Fuchs show that the share of increases in life expectancy realized after age 65 was only about 20 percent at the beginning of the 20th century but close to 80 percent by the dawn of the 21st century. Expected lifetime labor force participation as a percent of life expectancy is now declining. Eggleston and Fuchs share four interrelated responses to the economic and social challenges posed by this “new demographic transition:”

• Increase the retirement age.
• Encourage savings.
• Strengthen education.
• Emphasize healthy lifestyles early to ensure productivity in old age.

Eggleston is director of the Asia Health Policy Program at the Shorenstein Asia-Pacific Research Center. Fuchs is Henry J. Kaiser, Jr., Professor Emeritus, in Stanford’s Department of Economics and Department of Health Research and Policy, and a senior fellow at FSI and SIEPR.

Of the four policy responses the article proposes, is one especially critical?

Fuchs: The most important solution in terms of its potential impact would be people changing their attitudes toward retirement. This would mean people postponing retirement and saving more during their working years. If you work five years longer, for example, you would have greater savings and a shorter period of time when you would need the money.

Eggleston: We tend to think of the solutions as being interrelated. To address this longstanding and inevitable global demographic transition, organizations and policy structures need to support changes in individual behavior. In the case of the retirement age in the United States and European countries, policymakers need to change the many incentives that encourage people to retire younger.

What do you most hope policymakers will take away from the article?

Fuchs: We hope they will recognize the absolute need for individuals and organizations to plan for later retirement.

What are the special challenges faced by China and India, the world’s largest populations?

Eggleston: Longer lives in China and India contribute to improved human development, yet population aging also brings special challenges. China’s population is aging more rapidly than India’s and both countries need to invest more in the education and health of their young people, especially in poor rural areas.

In India, nutrition and education will help to reap a one-time boost to economic growth if the large cohorts of the working age population can be productively employed, while building a foundation for sustained improvement of living standards. China’s youth need to be as productive as possible to support the elderly while continuing to improve the national living standard.

The coming decade will be crucial in China, as the country transitions into a new economic phase and expands its fledging social protection system. The goal should be to ameliorate disparities and protect the vulnerable, while maintaining a financially sustainable and culturally appropriate balance of government and family responsibility for old-age support.

How well do textbooks educate school children about malaria prevention and treatment? AHPP's Siyan Yi took part in a study that examined textbooks from countries with high Malaria rates -- Laos, Cambodia, Nepal, Bangladesh, Sri Lanka, Zambia, Niger, Benin, and Ghana -- and recently published its findings in the open-access journal PLoS ONE.

Preparing a meal in some of the world’s poorest rural areas can turn an ordinary activity into a deadly chore. Animal dung and crop scraps often fuel the indoor fires used for cooking. And before any food fills a hungry belly, thick black smoke fills a family’s lungs.

Pneumonia and other acute respiratory infections kill about 1 million people a year in low-income countries, making them the top cause of death in the developing world and the greatest threat to children’s lives. Makeshift stoves belch much of the polluted air leading to those illnesses. About 75 percent of South Asians and nearly half the world’s population use open-fire stoves inside their homes.

“The smoke is asphyxiating,” said Grant Miller, an associate professor of medicine at Stanford working on ways to get people to buy – and use – cleaner, safer stoves. “It burns your eyes and you can’t stop coughing.”

Governments and humanitarian organizations have urged people to trade their traditional stoves for safer models, many of which have chimneys that funnel smoke out of a home. But the switch from dangerous stoves has been slow to come, even though most people using them know they’re harmful.

Miller and his colleagues are studying what’s behind the reluctance and what can be done about it. They suspect much of the problem rests with the widespread approach to clean cookstove conversion, which focuses on educating people about the appliances’ health hazards and offering new models at a low cost.

Their most recent findings, published in the Proceedings of the National Academy of Sciences, boil down to this: Clean and modern cookstoves don’t have features people want. And until they’re redesigned, people are unlikely to bother with them.

“People don’t think of cookstoves as health technologies,” said Miller, an associate professor of medicine and a Stanford Health Policy faculty member at the university’s Freeman Spogli Institute for International Studies. Miller is the senior author of the PNAS paper, which published online June 11.

“They don’t think respiratory illness is the biggest health problem that they have,” he said. “And when you ask them what they want from a stove, they talk about saving time and having better fuel efficiency. They’re not talking about smoke emissions.”

In the first of two studies, Miller – joined by Yale researchers and Lynn Hildemann, a Stanford engineering professor affiliated with the Stanford Woods Institute for the Environment – surveyed about 2,500 women who cook for their families in rural Bangladesh. 

Nearly all of the women use traditional stoves, and 94 percent of them said they know the smoke from their stoves can make them sick. But 76 percent said the smoke is less harmful than polluted water, and 66 percent said it wasn’t as dangerous as rotten food.

“People know their cookstoves are bad, but they don’t think cookstoves are the most important problem they face,” Miller said. “They’d rather spend their money fixing those things and getting their kids into a good school than buying a new cookstove.”

When asked what features are most important in a stove, the women talked about things that could save fuel costs, cooking time and the hassle that goes into collecting fuel.

“A very small percent said reducing pollution was important,” Miller said.

The researchers then tried to assess more directly how Bangladeshis value new stoves. They offered 2,200 customers across 42 rural villages the opportunity to buy one of two models – one boasted improved fuel efficiency; the other had a chimney to reduce exposure to indoor smoke.

At the market prices of $5.80 for an efficient stove and $10.90 for the chimney stove, less than a third of customers ordered either model. And when the stoves were delivered a few weeks after the orders were taken, a very small number of families actually went through with the purchase of either model.  Large randomized discounts increased customer interest in fuel-efficient stoves, but did little to raise purchase rates of chimney stoves.

“A big implication is that the health education and social marketing approaches aren’t going to work,” Miller said. “You need to get inside the heads of the users and figure out what they really want and value – even if unrelated to smoke and health – and then give it to them.”

The lead author of the PNAS paper was Ahmed Mushfiq Mobarak, an economist at Yale. It was co-authored by Yale researchers Puneet Dwivedi and Robert Bailis. Their work was supported by the Freeman Spogli Institute’s Walter H. Shorenstein Asia-Pacific Research Center, Stanford’s Woods Institute for the Environment, and the International Growth Centre.