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Susan V. Lawrence is Head of China Programs at the Campaign for Tobacco-free Kids, a Washington, DC-based non-governmental organization that works to reduce tobacco use and its devastating health and economic consequences in the United States and around the world. She divides her time between Washington, DC and China.

The Campaign is a partner organization in the Bloomberg Initiative to Reduce Tobacco Use, launched in 2005 with funding from New York Mayor and philanthropist Michael Bloomberg. The initiative’s work is focused on low- and medium-income countries that together account for two thirds of the world’s smokers. Other partners in the initiative are the Centers for Disease Control Foundation, the Johns Hopkins University Bloomberg School of Public Health, the International Union Against Tuberculosis and Lung Disease, the World Health Organization, and the World Lung Foundation.

Before joining the Campaign for Tobacco-free Kids, Ms. Lawrence worked for 16 years as a journalist, including a cumulative 11 years between 1990 and 2003 as a staff correspondent in China. She served as China bureau chief and later Washington correspondent for the Hong Kong-based newsweekly Far Eastern Economic Review, as a Beijing-based staff correspondent for The Wall Street Journal, and as China bureau chief for the newsmagazine US News & World Report. A fluent Mandarin Chinese speaker, she holds Bachelor’s and Master’s degrees in East Asian Studies from Harvard University and was a Harvard-Yenching Institute Scholar in the History Department at Peking University from 1985-87. 

Her talk is the third in the colloquium series on tobacco control in East Asia, sponsored by the Asia Health Policy Program at the Shorenstein Asia-Pacific Research Center, in coordination with FSI’s Global Tobacco Prevention Research Initiative.

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Susan V. Lawrence Head of China Programs Speaker Campaign for Tobacco-Free Kids
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Hospitals in Thailand operate in a multiple insurance payment environment. This paper examines 1) access to medicines and other medical technologies, 2) treatment outcomes, and 3) efficiency in resource use, among beneficiaries of the three government health insurance schemes in Thailand. Using 2003-2005 inpatient data for patients with three tracer diseases from three government hospitals, we find that utilization of more expensive items differs between patients whose insurers pay on a closed- or open-ended basis. Where new vs. conventional drugs are both available, patients whose insurer pays on a fee-for-service basis tend to have greater access to new drugs, compared to patients whose insurer pays on a capitated or case basis. Similar patterns were found where there are options between originator vs. generic drugs, drugs in different dosage forms, and more vs. less advanced diagnostic technologies. Effects of insurance payment are more pronounced where price gaps among the medical technologies are significant. Efficiency results are mixed, depending on nature of the disease conditions and type of resources required for treatment.

Published: Hirunrassamee, Sanita, and Sauwakon Ratanawijitrasin. "Does your health care depend on how your insurer pays providers? Variation in utilization and outcomes in Thailand." International journal of health care finance and economics 9.2 (2009): 153-168.

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Why do community-based education and social persuasion programs for promoting healthy lifestyle and preventing chronic disease sometimes fall short of our expectations? Why are population effects so difficult to engineer and why are they so ephemeral? This research carried out at USC, the Claremont Graduate University, and collaborating institutions in China integrates across social, behavioral, and neurocognitive sciences to address those questions.

We conclude tentatively that the answer to each of the questions may lie in individual and context variability relative to program response, and that in order to more fully address the question of prevention program response variability requires engagement and integration across several levels of science to consider the roles of social groupings, environmental selection and design, social influence processes, and brain biology. What works in one social, cultural or organizational setting may not be so effective in another. What works for persons with certain genetic and experiential backgrounds may be totally ineffective for persons with different dispositional or personality characteristics. In a series of community/school based prevention trials carried out in markedly different southern California and central China settings, we have uncovered domains of consistent response, and other domains of substantial environment- and disposition-based response variability. A social influences based smoking prevention program framed in collectivist values and objectives worked to prevent smoking in one cultural setting but not another. And an individualist framed social influences program worked in the setting where the collectivist program did not. But the characteristics of the particular settings which defined program success or failure were different from what conventional (e.g., cultural psychology) wisdom would have led us to expect. Furthermore, both within and across cultural settings, the same individual dispositional characteristics moderated or determined program effectiveness, again in ways not predicted by the common cultural and behavioral science wisdom. In recent studies carried out both in China and the U.S. we have found affective decision deficits, with known neural underpinnings, to account for rapid progression to regular smoking and binge drinking. These deficits are akin to the dispositional characteristics found earlier to moderate prevention program effects. Subsequent brain imaging studies confirm the hypothesized regions of neural involvement. Together these findings hold promise for more effective – situation and phenotype specific – approaches to engendering and sustaining more optimal individual and population health behavior.

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Carl Anderson Johnson Dean & Professor Speaker School of Community & Global Health, Claremont Graduate School
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Hard Choices offers a most rewarding perspective on how Southeast Asian states straddle the ongoing tensions among three rarely compatible goals—security, democracy, and regionalism. Empirically rich and topically diverse, [the book] is broad in scope and full of deep analytic insights. It will be appreciated well beyond Southeast Asia." — T. J. PEMPEL, University of California, Berkeley

Southeast Asia faces hard choices. The region’s most powerful organization, ASEAN, is being challenged to ensure security and encourage democracy while simultaneously reinventing itself as a model of Asian regionalism.

Should ASEAN’s leaders defend a member country’s citizens against state predation for the sake of justice—and risk splitting ASEAN itself? Or should regional leaders privilege state security over human security for the sake of order—and risk being known as a dictators’ club? Should ASEAN isolate or tolerate the junta in Myanmar? Is democracy a requisite to security, or is it the other way around? How can democratization become a regional project without first transforming the Association into a “people centered” organization? But how can ASEAN reinvent itself along such lines if its member states are not already democratic?

How will its new Charter affect ASEAN’s ability to make these hard choices? How is regionalism being challenged by transnational crime, infectious disease, and other border-jumping threats to human security in Southeast Asia? Why have regional leaders failed to stop the perennial regional “haze” from brush fires in democratic Indonesia? Does democracy help or hinder nuclear energy security in the region?

In this timely book—the second of a three-book series focused on Asian regionalism—ten analysts from six countries address these and other pressing questions that Southeast Asia faces in the twenty-first century.

Recent Praise for Hard Choices

“In this delightful volume, a diverse, fresh, and talented group of authors shed new light on Southeast Asia and speak engagingly to wider scholarly questions.  Emmerson's introduction sets the tone for an unusually creative edited collection.”
 —Andrew MacIntyre, Australian National University
“In Hard Choices, Donald Emmerson has brought together a remarkable group of leading young scholars to write on Southeast Asian regionalism from political-security, economic, and sociological perspectives. His introductory chapter defines the dimensions of regionalism on which the other contributors elaborate in a series of fine essays examining ASEAN’s past, present, and alternative futures. Hard Choices is a landmark study that will be consulted for years to come by scholars and practitioners. Highly recommended.”
—Sheldon Simon, Arizona State University

Examination copies: Desk, examination, or review copies can be requested through Stanford University Press.

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Security, Democracy, and Regionalism in Southeast Asia

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Donald K. Emmerson
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Biotechnology (or biotech) has impacted almost every aspect of human life. It has reorganized industries, drastically changed healthcare, helped to improve the environment, and led to important changes in laws and ethical norms.

Among the various biotech fields, medical biotech has been by far the most influential, beneficial, and controversial. It has generated not only superlative discoveries to improve the lifespan and quality of human life, but also the greatest amount of wealth for all the players involved, and the greatest volume of public debate.

Several important trends are shaping the future of the pharmaceutical (or pharma) and biotech industries. The biotech industry is characterized by the presence of strong clusters in all countries. The pharma and biotech industries are experiencing an outsourcing phenomenon, mainly due to a lack of in-house expertise and efficiencies. Diagnostics and therapeutics are increasingly converging, a trend that will lead to predictive and precise diagnostics and personalized and preventive medicine. The first few years of the twenty-first century have witnessed significant changes in the pharma/biotech alliance landscape. Today we are seeing the “omic”-ization of the biotech industry: most of the emerging technologies are genomics, proteomics, cellomics, and pharmacogenomics. In addition, the biotech industry faces uphill ethical issues, including excessive marketing, third-world drug availability, genetic engineering, stem cells, and cloning.

The medical biotech industry faces several challenges. First, science, the human body, and disease are, essentially, complex. Second, unlike other high-technology industries, the biotech product development cycle is very long, even after proof of concept. Biotech projects take between ten and twenty years to become successful and cost over $200–300 million before a product reaches the market. Third, delivery of most biotech products and therapies is complex and can be painful, often involving intravenous delivery. Fourth, the preceding three factors pose significant challenges for research and development (R&D) financing. In addition, there are certain outside determinants that influence the biotech industry, including regulation, demography, reimbursement climate, and big pharma companies.

Stem cell research is one of the most fascinating areas of biology, but it raises questions as rapidly as it generates new discoveries. The greatest potential application of this research is the generation of cells and tissues that can be used for cell-based therapies. A stem cell is a special kind of cell that has a unique capacity to renew itself and to give rise to specialized cell types. Through the process of differentiation, stem cells form various tissues and organs, and the combination of these differentiated materials develops into the whole human body. This class of human stem cell holds the promise of being able to repair or replace cells or tissues that are damaged or destroyed by many of our most devastating diseases.

Diabetes mellitus is a group of diseases characterized by high levels of blood glucose resulting from defects in insulin production, insulin action, or both. Diabetes mellitus is a type I diabetes—also called juvenile-onset diabetes or insulin-dependent diabetes—and develops when the body’s immune system destroys pancreatic beta cells, the only cells in the body that make the insulin that regulates blood glucose. Type II diabetes, also called adult-onset diabetes or noninsulin-dependent diabetes, may account for 90–95 percent of all diagnosed cases of diabetes. There are more than 194 million diabetics worldwide, with this number expected to exceed 333 million by 2025.

Insulin is currently the most effective drug for controlling hyperglycemia and is widely accepted as the gold standard for treating type I diabetes and even late-stage type II diabetes. However, physicians and patients are reluctant to use insulin until other less effective drugs have been attempted. This is mainly because insulin therapy is invasive and painful: patients must take insulin intravenously.

One of the most promising ways to cure diabetes is to restore the function of islet cells biologically, either through islet cell transplantation or by engineering cells to restore the insulin secreting function. Islet transplantation, a procedure that can restore insulin production in patients, is a highly promising area of research.

Based on analysis of stem cell research, diabetes market opportunities, and the development of stem cell therapies, it is possible to place a value on a company in the early (preclinical) development stage of a stem cell therapy for diabetes. Such an exercise involves valuing a company based on three different approaches—(1) the discounted cashflow model, (2) the royalty or licensing model, and (3) the comparables valuation model. Sensitivity analysis based on market, pricing, costing, R&D, and development stage can further lead to precise valuation range for a given company.

For biotechnology companies, various drivers play a critical role in company valuation, including people (management team), alliances and partnerships, intellectual property rights, R&D and technology, funding and financing, market opportunity, and therapeutic area.

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The Asia Health Policy Program works with other researchers at Stanford and several countries of the Asia-Pacific to analyze prominent issues in population aging, child health, and control of infectious disease. Examples include comparative study of long-term care insurance and informal caregiving; collaborative study of health and healthcare access for children with special health needs; and a research project focusing on controlling tuberculosis and multi-drug resistant tuberculosis in Northeast Asia.

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China's Harmonious Society colloquium series

co-sponsored by the Stanford China Program and the Center for East Asian Studies

Since 2006, the official doctrine of China's Communist Party calls for the creation of a "harmonious society" (HeXieSheHui). This policy, identified with the Hu Jintao leadership, acknowledges the new problems that have emerged as China continues its amazing economic growth. The economy is booming but so are tensions from rising inequality, environmental damage, health problems, diverse ethnicities, and attempts to break the "iron rice bowl." In this series of colloquia, leading authorities will discuss the causes of these tensions, their seriousness, and China's ability to solve these challenges.


Nancy Shulman's talk topic will be posted soon.

Nancy Shulman conducts laboratory and clinical research in the area of HIV therapeutics, with focus on antiretroviral resistance and treatment strategies of experienced patients, the impact of antiretroviral treatment on HIV co-receptor utilization, and HIV in China. she received her MD from Kansas University Medical School and holds a BA in biochemistry from University of Texas, Austin. She is a doctor specializing in internal medicine, pediatrics, and infectious diseases.

"Healthcare Coverage for 1.3 Billion: China's Odyssey"

Karen Eggleston

Media coverage as well as the academic literature give conflicting appraisals of China's reality: Is China's healthcare system on the verge of collapse? Why is healthcare so expensive and difficult to access in contemporary China? Have reforms 'marketizing' healthcare drastically undermined progress in assuring affordable access for all? Or do hospitals and other providers constitute a last bastion of state control and bureaucratized monopoly in the name of equal access? Chinese analysts and policy advisers have engaged in a sometimes acrimonious debate; some champion a government-led, National Health Service-like model, while others passionately argue that market forces should play a greater role. In this talk, Karen Eggleston will present a brief overview of China's health system reforms and current developments.

Karen Eggleston focuses her research on comparative healthcare systems during economic development and transition from central planning to market-based economies. Her interests include the impact of payment incentives on healthcare insurer and provider behavior; chronic disease management; and incentives surrounding health behaviors such as the spread of HIV/AIDS and tuberculosis, overuse of antibiotics, and smoking. She earned her PhD in public policy from Harvard University and has MA degrees in economics and Asian studies from the University of Hawaii.

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Senior Fellow at the Freeman Spogli Institute for International Studies
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Faculty Affiliate at the Stanford Center on China's Economy and Institutions
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Karen Eggleston is a Senior Fellow at the Freeman Spogli Institute for International Studies (FSI) at Stanford University and Director of the Stanford Asia Health Policy Program at the Shorenstein Asia-Pacific Research Center at FSI. She is also a Fellow with the Center for Innovation in Global Health at Stanford University School of Medicine, and a Faculty Research Fellow of the National Bureau of Economic Research (NBER). Her research focuses on government and market roles in the health sector and Asia health policy, especially in China, India, Japan, and Korea; healthcare productivity; and the economics of the demographic transition.

Eggleston earned her PhD in public policy from Harvard University and has MA degrees in economics and Asian studies from the University of Hawaii and a BA in Asian studies summa cum laude (valedictorian) from Dartmouth College. Eggleston studied in China for two years and was a Fulbright scholar in Korea. She served on the Strategic Technical Advisory Committee for the Asia Pacific Observatory on Health Systems and Policies and has been a consultant to the World Bank, the Asian Development Bank, and the WHO regarding health system reforms in the PRC.

Director, Asia Health Policy Program at the Walter H. Shorenstein Asia-Pacific Research Center
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Karen Eggleston Shorenstein Asia-Pacific Research Center Fellow Speaker Stanford University
Nancy Shulman Assistant Professor of Medicine (Infectious Diseases) Speaker School of Medicine, Stanford University
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Throughout history, nations have waged war against epidemics, from bubonic plague to pulmonary tuberculosis. Today, we confront HIV/AIDS, SARS, and avian influenza, among other major infectious diseases. The failure to contain HIV/AIDS, the longest contemporary pandemic, and the difficulties in dealing with the threat posed by avian influenza, show that the world is not well prepared for the next health crises. Because preventing and controlling these infectious diseases is a race against time, scientists around the world scrutinize viruses and bacteria more intently than ever. Yet while scientific advances are crucial, they are insufficient.

This timely book addresses the urgent need to study the governance of infectious disease epidemics, and argues that the battle must be fought on two fronts, simultaneously. The first is within the laboratory; the second is located in a wider social context that involves ordinary individuals, groups, communities, legislators, and the state. Research by medical sociologists and other social scientists indicates that many factors influence people's behavior and, in turn, the level of success in preventing and containing an infectious disease epidemic.

Using Asia as a case study, Crisis Preparedness discusses the inadequacies of current preventive and management approaches to deal with epidemics. The distinguished international contributors to this volume present perspectives from the fields of social science, epidemiology, and public health, and collectively seek to answer the pressing question: How can we prepare for the next global epidemic?

About the Editor: Stella R. Quah is professor of sociology at the National University of Singapore. She is on the advisory boards of the British Journal of Sociology, Health Sociology Review, and Asian Population Studies. She also serves as editor of the Health Systems Section, Encyclopedia of Public Health (Elsevier).

This title is now out of print. You may download individual chapters below:

Front matter and preface (includes chapter 1) 

  1. Governance of Epidemics: Is There a Reason for Concern? (Stella R. Quah)
  2. The Global Governance of Epidemics: Possibilities and Limitations (Jim Whitman)
  3. Responding to Epidemic Disease Threats in Burma and Lessons for China: Why Good Governance Matters (Chris Beyrer)
  4. Global and Local Strategies against HIV/AIDS in South and Southeast Asia: The Cases of India and Thailand (Graham Scambler)
  5. Taming the Tiger: The Success and Failure of HIV/AIDS Policies in Thailand, Cambodia, Vietnam, and China (Kari Hartwig)
  6. On Trust and Health Consensus-building in the Governance of Epidemics (Stella R. Quah)
  7. Global Public Health Research Preparedness against Emerging and Reemerging Infectious Diseases (Gabriel M. Leung)
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WASHINGTON, May 24 (IPS) - This year the Association of Southeast Asian Nations celebrates its 40th birthday, and it has big plans. After four decades of being largely a political and security alliance, ASEAN is accelerating its plans for economic integration.

ASEAN leaders are so eager to pull together into an economic community that they recently decided to move the goalposts. The economic benchmarks originally planned for 2020 have been moved up to 2015.

"The mission of this economic community is to develop a single market that is competitive, equitably developed, and well integrated in the global economy," says Worapot Manupipatpong, principal economist and director of the office of the Secretary-General in the ASEAN Secretariat. He was speaking last week at an Asian Voices seminar in Washington, DC, sponsored by the Sasakawa Peace Foundation.

The single market of 2015 would encompass all ten members of ASEAN: Brunei, Cambodia, Indonesia, Laos, Malaysia, Myanmar (Burma), Philippines, Singapore, Thailand, and Vietnam. According to the projections of the ASEAN Secretariat, the single market will be accomplished by removing all barriers to the free flow of goods, services, capital, and skilled labor. Rules and regulations will be simplified and harmonised. Member countries will benefit from improved economies of scale. Common investment projects, such as a highway network and the Singapore--Kunming rail link, will facilitate greater trade.

Although there will not be a single currency like the European Union's euro, the ASEAN countries will nevertheless aim for greater currency cooperation.

"ASEAN's process of economic integration was market-driven," says Soedradjad Djiwandono former governor of Bank Indonesia, and it was influenced by the "Washington consensus" favoring increased liberalisation. "It is a very different framework from the closed regionalism of the Latin American model," he continues. With multilateral talks on trade liberalisation stalled, efforts have largely shifted to bilateral negotiations. "There has been a proliferation of bilateral agreements that developed countries use as a way to push a program for liberalising different sectors," Djiwandono concludes.

So far, ASEAN points to increased trade within the ten-member community as an early sign of success. But, overall trade share -- 25 percent -- pales in comparison to the 46 percent share of the North American Free Trade Agreement countries or the 68 percent share of EU countries. And with intra-ASEAN foreign direct investment rather low -- only 6 percent in 2005 -- financial integration lags behind trade integration.

The ASEAN approach differs in several key respects from the EU model, which originated in a 1951 coal and steel agreement among six European nations. ASEAN's origins, in contrast, have been primarily political and security-oriented, observes Donald Emmerson, director of the South-east Asia Forum at the Shorenstein Asia-Pacific Research Center at Stanford. "The success attributed to ASEAN is that it presided over an inter-state peace ever since it was formed. There's never been a war fought between ASEAN members."

Also distinguishing ASEAN from EU is the latter's institutionalisation. "ASEAN is radically different," Emmerson continues. "The much discussed ASEAN way is consultation, not even voting, since if they vote, someone will lose. Sometimes the consultation goes on without result. Sometimes decisions are reduced to the lowest common denominator. It also means that rhetoric predominates." This consultative process will be tested in November, when ASEAN leaders gather to adopt a charter, something that the EU has so far failed to accomplish.

Another difference with Europe is the enormous economic disparities among the ASEAN members, with Singapore and Brunei among the richest countries in the world and Laos among the poorest. These economic disparities are reproduced within the countries as well.

Worapot Manupipatpong points to two ASEAN initiatives for closing the gap. There is help for small and medium-sized enterprises. And the Initiative for ASEAN Integration,"basically provides technical assistance to Cambodia, Laos, and Myanmar so that they can catch up with the rest of the ASEAN members," he says. "Attention will be paid to where these countries can participate in the regional networks, what comparative advantage they have, and how to enhance their capacities to participate in the regional development and supply chain."

Then there are ASEAN's efforts to address "public bads," according to Soedradjad Djiwandono. "When there is a tsunami or a pandemic," he argues, "the worst victims are the marginalised or the poor. Addressing that kind of issue has some positive impact on reducing inequality."

"The gap between the early joiners and the later joiners will continue to be substantial because ASEAN has always been more of a forum and less of a problem-solving organisation," observes Karl Jackson, director of the Asian Studies Program at the School for Advanced International Studies at Johns Hopkins University. "As a result one would expect that these gaps would be closed only as individual countries increase their rates of growth." He attributes the inequality within countries to the middle stage of growth experienced by almost all societies: "Inequality increases before the state becomes strong enough to redivide some of the pie and take care of the gross inequalities caused by rapid economic growth."

ASEAN is banking on financial and trade liberalisation increasing the overall regional pie. On paper it is an ambitious project. But "the low hanging fruit have been plucked," says Donald Emmerson. Tariffs on the "easy commodities" have already been reduced to less than 5 percent. But non-tariff barriers to trade remain, and member countries are very protective of certain sectors.

Also tempering the region's optimism is the memory of the Asian financial crisis. The crisis began in Thailand in 1997 and spread rapidly to other countries in the region. One school of thinking holds that capital mobility -- "hot money" -- either caused or considerably aggravated the crisis. Since the ASEAN integration promises greater capital mobility, will the region be at greater risk of another such crisis?

"One consequence of the economic dynamism of the Asia-Pacific region," notes Donald Emmerson, "is that the accumulation of vast foreign exchange reserves -- obviously in China, but in other countries too -- more than anything else represents an asset that can be brought into the equation as a stabilising factor in the event of a financial crisis." Also, he continues, as a result of the ASEAN plus Three network, which adds China, South Korea, and Japan to the mix, the 13 countries have "made serious headway toward establishing currency swap arrangements that would come into play in an emergency on the scale of an Asian financial crisis."

Karl Jackson also looks to currency reforms as a hedge against future crisis. The Thai baht and the Indonesian rupiah are now unpegged currencies. "You will not have a situation in which the central bank of Thailand loses 34 billion US dollars defending the baht," Jackson argues. "Instead, the baht will appreciate or depreciate according to market forces."

But Jackson still remains cautious about the future. He points to the large number of non-performing loans in the Chinese banking sector. Also, there is "this anomaly of the U.S. absorbing two-thirds of the savings coming out of Asia, plugging it mostly into consumption rather than direct investment," he observes. "Eventually there has to be some kind of readjustment. The real value of the dollar must fall." (END/2007)

Reprinted by permission from IPS Asia-Pacific.

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The Comparative Health Care Policy Research Project was initiated by APARC in 1990 to examine issues related to the structure and delivery of health care in Japan by utilizing contemporary social science. Further, the project was designed to make the study of Japan an integral part of international comparative health policy research. Yumiko Nishimura, the associate director, under the supervision of Daniel I. Okimoto, the principal investigator, leads the project.

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