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.

May 31 was the WHO World No Tobacco Day. The Pioneers for Health Consultancy Center, a China-based non-governmental organization with close collaborative ties to AHPP's Matthew Kohrman, recently conducted an extensive study of stores in Kunming, a city in the heart of China’s tobacco-growing region, that sell cigarettes to teenagers.

The Asia Health Policy Program (AHPP) at Stanford’s Shorenstein Asia-Pacific Research Center (Shorenstein APARC) looks forward to welcoming its incoming 2012–13 research fellows from Mongolian Medical University, the University of Hawai’i, and Harvard. AHPP’s new fellows specialize in research topics including cervical cancer prevention, migrant remittances, and the political economy of support for the elderly.
 

Developing Asia Health Policy Fellows

Baigalimaa Gendendarjaa will be joining AHPP from the Mongolian National Cancer Center. Her research includes a comparative study of how knowledge of cervical cancer risk factors has influenced behavior changes in Mongolia before and after the introduction of the National Cervical Cancer Program. She holds a master’s degree in medicine from Mongolian Medical University.

 

 

Marjorie Pajaron took part for five years in the National Transfer Accounts project based in Honolulu. Her research focuses on the role of migrant remittances as a risk-coping mechanism, as well as the importance of bargaining power in the intra-household allocation of remittances in the Philippines. Pajaron received a PhD in economics from the University of Hawai’i at Mānoa.

 

 

 

Asia Health Policy Postdoctoral Fellow 

Yuki Takagi earned her PhD in government from Harvard University and is completing a postdoctoral fellowship at Princeton. Her dissertation research focuses on the political economy of support for the elderly and intergenerational family transfers, such as nursing and childcare, focusing on Japan. Takagi holds bachelor of economics and master of law degrees from the University of Tokyo.

 

 

Throughout the academic year the AHPP fellows will present seminars, take part in individual and collaborative research projects, and participate in campus events.

China’s demographic landscape is rapidly changing, and the government has responded by launching ambitious social and health service reforms to meet the changing needs of the country’s 1.3 billion people. This week, officials approved a five-year plan to develop a comprehensive nationwide social security network.

Karen Eggleston, the Asia Health Policy Program (AHPP) director and a Stanford Health Policy fellow, discusses the success of China’s health care reforms—including its recently established universal health care system—and the long road still ahead.

Why is the overall health and wellbeing of China’s population important globally?

There are many reasons why the health of China’s citizens matters within a larger global context. On the most basic level, China represents almost 20 percent of humanity. But it is also a major player in the world economy and it depends on having a healthy workforce, especially now that its population is aging more. The government’s ability to meet the needs of its underserved citizens contributes to a more productive and stable China, and works towards closing the huge gaps we see in human wellbeing across the world.

China also potentially offers a model for other developing countries, such as India, that may want to figure out how to make universal health coverage work at a tenth of the income of most of the countries that have put it into place before.

What are some of the biggest changes in China’s health care system since 1949?

One of the most significant changes is that China has achieved very basic universal health insurance coverage in a relatively short period of time.  

Throughout the Mao period (1949–1978) there was a health care system linked to the centrally planned economy, which provided a basic level of coverage via government providers with a lot of regional variation. When economic reform came in 1980, large parts of the system—particularly financing for insurance—collapsed. The majority of China’s citizens were uninsured during the past few decades of very rapid social and economic development.

China’s overall population is changing quite dramatically, which means it has different health care needs, such as treating chronic disease and caring for an increasingly elderly population. The central government is trying to establish a system of accessible primary care—a concept that China’s barefoot doctors helped to pioneer but that fell into disarray—and health services that fit these new needs. 

How does China’s basic health care system work? Are there segments of the population still not receiving adequate coverage and care?

China has had a system where people can select their own doctors. Patients usually want to go to clinics attached to the highest-reputation hospitals, but of course, when you are not insured you almost always by default go to where you can afford the care. “It is difficult to see the doctor, and it is expensive” has been the lament of patients in China, so an explicit goal of the health care reforms has been to address this.

The term “universal coverage” has different definitions. China initially put in place a form of insurance that only covers 20 or 30 percent of medical costs for the previously uninsured population, especially in rural areas. Benefits have expanded, but remain limited. As with the previous system, disparities in coverage still exist across the population. China not only has a huge population with huge economic differences, but within that there is a large migrant worker population. It is a challenge to figure out how to cover these citizens and how to provide them with access to better care. The government is quite aware there are segments of the population not receiving equal coverage, and it continues to strive to resolve the issue.  

What are the greatest innovations in China’s health care system in recent years?

One of the most remarkable things China has achieved is really its new health insurance system. Even if the current coverage is not particularly generous it is nearly universal, and mechanisms are put in place each year to provide more generous coverage. China is also working on strengthening its primary care and population health services, infusing a huge sum of government money into these efforts. It is the only developing country of its per-capita income that has achieved such results so far.

Interestingly, a lot of people assume China achieved its universal coverage by mandate, while in fact the central government did so by subsidizing the cost for local governments and individuals. This reduces the burden, for example, on poorer rural governments and residents, and is one innovative way China is trying to eliminate the disparity in access to care.

Eggleston has recently published a working paper on China’s health care reforms since the Mao era on the AHPP website, as well as an article in the Milken Institute Review.

Gordon Liu, a Chinese government advisor on health care and the executive director of Peking University’s Health Economics and Management Institute, spoke at Stanford on May 29 on the future of China’s health care system.

Along with the speeches and ceremonies to mark the opening of the Stanford Center at Peking University, Stanford scholars from the Freeman Spogli Institute for International Studies are showcasing their work examining China’s promises, challenges and increasingly important role in the world.

The Shorenstein Asia-Pacific Research Center held a two-day workshop examining China’s relationships with its neighbors. The event draws on work being done by Thomas Fingar, FSI’s Oksenberg-Rohlen Distinguished Fellow, who is leading a new initiative to explore the nuances and complexity of China’s foreign relations and domestic issues.

Scott Rozelle, co-director of the Rural Education Action Project, planned a conference on Thursday exploring the impacts of technology on China’s health and education systems. For years, Rozelle has studied how basic medicine and better meals improve children’s performance in school. He’s lately been evaluating the best and most affordable ways to use new technology in rural Chinese schools.

On March 26 and 27, the Asia Health Policy Program will focus on the challenges China’s growing tobacco-control movement faces against a multibillion-dollar government-run industry. Anthropologist Matthew Kohrman, a specialist on tobacco in China, will lead the workshop examining the connections woven over the past 60 years between marketing and cigarette gifting, production and consumer demand, government policy and economic profit, and the other forces behind China’s smoking culture.

“A postdoctoral program is crucial to the intellectual development of any strong academic institution. I am proud the Shorenstein Asia-Pacific Research Center will serve as a home next year for these four talented emerging Asia scholars. Not only will they benefit from taking part in our vibrant research and publishing activities, but they will also bring new expertise and perspectives to our Center.”

-Gi-Wook Shin, Director, Shorenstein APARC

 
In the coming academic year, the Shorenstein Postdoctoral Fellowship program will double in size.

The four incoming fellows represent the best of the next generation of contemporary Asia scholars. Their research ranges from civil society and authoritarian governance in China to ethnic conflict in South Asia, and Korean migration and identity to election politics in Japan.

During their time at the Shorenstein Asia-Pacific Research Center (Shorenstein APARC), the fellows will conduct their own research and writing, present their work at public seminars, and take part in the research and publishing activities of the Center. Postdoctoral fellows will also have the chance to exchange ideas with Shorenstein APARC experts and interact with the many distinguished visitors who visit each year from throughout the Asia-Pacific region.

In addition, the Asia Health Policy Program at Shorenstein APARC will welcome two postdoctoral fellows in the 2012–13 academic year: an Asia Health Policy Fellow and a Developing Asia Fellow.

Postdoctoral fellows are a vital part of the academic life of the Center, and their relationships with Shorenstein APARC will continue throughout their entire careers.

The Shorenstein Postdoctoral Fellowship Program is made possible through the generosity of Walter H. Shorenstein.

“This fellowship has changed the trajectory of my academic career. It has given me the intellectual space to be highly productive and the freedom to expand my understanding of world events in order to enhance my future teaching and research. Thanks in large part to the fellowship, I was able to obtain an appointment as an assistant professor in the Department of International Relations at Boston University.”

-Jeremy Menchik, 2011–12 Shorenstein Postdoctoral Fellow

2012–13 Shorenstein PostDoctoral Fellows

Diana Fu will be joining Shorenstein APARC from Oxford University’s Department of Politics and International Relations, and from the Massachusetts Institute of Technology where she recently served as a political science research fellow. Her research interests encompass state-society relations in authoritarian regimes, civil society, governance, and labor contention. She will be completing a series of journal articles about civil society and authoritarian governance in China. Fu holds an MPhil in international development from Oxford University where she studied as a Rhodes Scholar, and a BA in global studies and political science from the University of Minnesota.

Jaeeun Kim is a postdoctoral research associate at the Center for the Study of Religion at Princeton University. She is interested in issues of identity within the context of international migration, which she explores in her dissertation Colonial Migration and Transborder Membership Politics in Twentieth-Century Korea. She is also developing a project focusing on ethnic Korean migrants from northeast China to the United States, including issues such as legalization strategies and conversion patterns. Kim holds an MA and a PhD in sociology from the University of California, Los Angeles, and a BA in law from Seoul National University.

Daniel M. Smith, a PhD candidate with the Department of Political Science at the University of California, San Diego (UCSD), is completing his dissertation on the causes and consequences of political dynasties in developed democracies, with particular focus on Japan. He has conducted research in Japan as a Japanese Ministry of Education research scholar (2006–2007), and as a Fulbright dissertation research fellow (2010–2011). Smith holds an MA in political science from UCSD, and a BA in political science and Italian from the University of California, Los Angeles. After completing his fellowship at Shorenstein APARC, he will join the Department of Government at Harvard University as an assistant professor.

Ajay Verghese is a PhD candidate in the Department of Political Science at The George Washington University. His work focuses on comparative politics and international relations, and his research interests include South Asia, ethnicity, ethnic conflict, historical analysis, and qualitative methods. Verghese has conducted language training and fieldwork in India, with support from organizations such as the American Institute of Indian Studies and the U.S. State Department Critical Language Scholarship Program. He will be turning his dissertation into a book entitled The Colonial Origins of Ethnic Violence: India and the Indian Ocean Region. Verghese holds a BA in political science and French from Temple University.