Updated January 24
Millions of residents in China are under lockdown measures as the number of reported deaths from the coronavirus outbreak rises to 26. In the United States, dozens of people are being monitored for the virus. The World Health Organization on January 23 said at a press conference the outbreak did not yet constitute a global public health emergency.

The outbreak of a novel coronavirus that began in December 2019 in Wuhan, China “is evolving and complex,” said the head of the World Health Organization (WHO) after its emergency committee convened on Wednesday, January 22, and decided that more information was needed before the WHO declares whether or not the outbreak is a public health emergency of international concern. The new virus, known as 2019-nCoV, causes respiratory illness and continues to spread across China. Chinese health authorities, reports the Washington Post, announced that at least 17 people have now died as a result of infection and confirmed cases have been reported in Japan, Thailand, South Korea, Hong Kong, and Macao, with one travel-related case detected in the United States, in the State of Washington. The WHO decision was made as the city of Wuhan shut down all air and train traffic to try to contain the spread of the virus.

With concern over and coverage of the situation rapidly developing, Karen Eggleston, APARC Deputy Director and the Asia Health Policy Program Director at the Shorenstein Asia-Pacific Research Center, offered her insights on the outbreak and its impact on both Asian and international healthcare systems.

Q: Why has this outbreak raised so much concern in China and internationally, and how worried should people be about it?

Infectious disease outbreaks can challenge any health system. Events such as SARS, Ebola, and MERS outbreaks, and even the devastating flu pandemic a century ago, remind us of the frightening power that infectious diseases with high-case fatality can have. The global burden of mortality and morbidity is mostly from non-communicable chronic diseases, but no country or society is immune to old, newly emerging, and re-emerging infectious diseases. And although health systems are generally stronger now and have more technologies to trace and contain outbreaks, there are also deep and complicated challenges that make swift, coordinated disease response difficult even in the modern era.

Any government leadership or healthcare responders who have tried to manage an outbreak situation before are hyper-aware of the need to prepare for and manage future incidents, but we are living in a moment of very complicated social dynamics surrounding public health and healthcare. Distrust in drug companies and government agencies, controversies over vaccines, and increasing skepticism in science, even if only from vocal minorities, all make it more difficult to manage a cohesive international response to an outbreak situation and protect vulnerable people.

Q: As you’ve mentioned, many people looking at this situation with the memory of outbreaks such as SARS or H1N1 in mind. How is the Chinese government addressing this crisis and how does its reaction compare with China’s history of emergency health responses?

China’s health system is much more prepared now, compared to the SARS crisis 17 years ago. More training and investment in primary health care, disease surveillance and technology systems for tracking and monitoring outbreaks, and the achievement of universal health coverage with improving catastrophic coverage even for the rural population, all suggest a health system that is much better prepared to handle a situation like this. Top-level leadership in China had already begun to publicly address the situation within days of the outbreak to assure the public that strict prevention measures will be taken and to urge local officials to take responsibility and share full information. Until more information is gained and more is understood about the nature of this virus, it’s been categorized as a “Grade B infectious disease” but will be managed as if it is a "Grade A infectious disease," which requires the strictest prevention and control measures, including mandatory quarantine of patients and medical observation for those who have had close contact with patients, according to the commission. China currently only classifies two other diseases as Grade A infection diseases—bubonic plague and cholera—and so that tells you something about how seriously this is being treated by those in leadership positions.

Q: And what about the response from the international health communities?

As with any major healthcare crisis, health systems around the globe must also respond with alacrity and integrity, including effective surveillance, monitoring, and infection control. Individuals also play a crucial role in supporting the instructions and recommendations made by established healthcare professionals. For example, the individual with the confirmed case in Washington State proactively told medical personnel about his recent visit to the Wuhan area. His medical providers then exercised appropriate levels of caution, given the unknown nature of the virus, and isolated him while his symptoms developed. He is currently combatting an infection similar in severity to that of mild pneumonia, and so far no other cases have been reported in the United States, though some may arise in the coming days and weeks.

There is always a fine balance between safeguarding public health while still respecting individual rights, civil liberties, and undertaking a prudent, scientific response. The aim is to remain clear and transparent in communications and actions without reverting to disproportionate or overly aggressive responses which lead to panic, distortion, and misinformation about the situation. Some countries, like the Democratic People’s Republic of Korea, may choose to seal their international borders until more is understood about the nature of this virus, but most nations will use tried-and-tested methods of monitoring travelers and alerting population health systems so that information about cases is widely available to health authorities and medical researchers trying to understand the cause and develop a potential cure.

Q: As this situation continues to develop, and with inevitable future disease outbreaks around the globe, what would you hope people keep in mind about the role we all play in healthcare crises and in public health?

One issue this outbreak reminds us of in a visceral and intimate way is how closely people are linked together across the world. Globalization and air travel almost instantaneously link continents, countries, and regions. The timing of this outbreak is particularly fraught, because it’s the beginning of the Lunar New Year, when there is a vast migration of people both within China, throughout greater Asia, and across the globe as massive populations go home to celebrate the holidays with family. The potential for a contagious disease to spread easily through crowds and across borders in circumstances like this is very high, and highlights the need for the international communities to share information, scientific expertise, and understanding.

We need to remember that this is not just a problem in a remote part of the world that has no impact on those of us who live in relative comfort in high-income countries. Rather, this is something that could easily impact anyone. Perhaps this latest outbreak and response will showcase how vital additional, ongoing investments in both domestic and international healthcare systems, technologies, and people are.

Using a dynamic microsimulation model, a research team, including APARC Deputy Director and Asia Health Policy Program Director Karen Eggleston, shows that there are differentially positive health gains of smoking reduction among subgroups of smokers in South Korea, Singapore, and the United States.

Tobacco use is responsible for the death of approximately eight million people worldwide, estimates the World Health Organization, and countries are increasingly making tobacco control a priority. Indeed the relationship between smoking and the burden of chronic diseases such as cancer, lung disease, and heart disease, and, in turn, premature mortality, is well documented. Yet little is known about the health effects of smoking interventions among subgroups of smokers.

Do interventions targeted at heavy smokers relative to light smokers lead to disproportionately larger improvements in life expectancy and prevalence of chronic diseases? And how do these effects vary across populations? In today’s rapidly aging world, it is crucial to understand the potential health gains resulting from interventions to reduce smoking, a leading preventable risk factor for healthy aging.

That’s why a research team, including APARC Deputy Director and Asia Health Policy Program Director Karen Eggleston as well as Stanford Health Policy faculty member Jay Bhattacharya, set out to examine the health effects of smoking reduction. To do so, the team simulated an elimination of smoking among subgroups of smokers in South Korea, Singapore, and the United States.

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The team’s findings, discussed in a new paper published by the journal Health Economics, show that smoking reduction can achieve significant improvements in lifetime health as measured by survival while also reducing the prevalence of major chronic diseases, though the effects are heterogeneous. Whereas interventions in both subgroups and in all three countries led to an increased life expectancy and decreased prevalence of chronic diseases, the life-extension benefits were greatest – 2.5 to 3.7 years – for those who would otherwise have been heavy smokers, compared with gains of 0.2 to 1.5 years among light smokers.

The team developed a dynamic microsimulation model to estimate the health gains of reducing smoking among heavy smokers and light smokers. Microsimulation models are powerful tools for assessing the value of health promotion: they model individual health trajectories while accounting for competing risks, thus providing valuable information about the impact of interventions and how they may interact with the changing demographics and socioeconomic profile of a population to determine future health. The team’s study applied microsimulation models tailored to the demographic and epidemiological context in the three countries, then compared the gains in survival and reduction in chronic disease prevalence from a given reduction in smoking and how these impacts vary depending on initial smoking intensity.

The team’s findings indicate that there are differentially positive health effects from smoking reduction. The life‐year gain among heavy smokers quitting well exceeds that of light smokers quitting in each country, but the magnitudes differ substantially: 11.2 times for South Korea, 6.8 times for Singapore, and 1.7 times for the United States. The lower life expectancy among Americans is related to the greater extent in which they suffer from risk factors, such as obesity, relative to the Asian counterparts in the study.

The findings illustrate how smoking interventions may have significant economic and social benefits, especially for life extension, that vary across countries. They are particularly important for aging societies that are concerned about the sustainability of their health insurance systems in the face of increasing burden of chronic disease.

Type 2 diabetes has become a major public health problem in South Asia in recent decades. The region is now home to an estimated 84 million people suffering from diabetes—approximately one-fifth of the world’s 451 million adults with diabetes—a number that is expected to rise by 78% by 2045. Even more concerning, across South Asia the disease burden increasingly occurs in the most productive midlife period. Among Indians, for example, diabetes is estimated to occur on average 10 years earlier than their western counterparts, and almost half of Indian patients with type 2 diabetes are diagnosed before age 40.

How do South Asian health system influence diabetes care? What is the magnitude of the economic impact of diabetes in South Asia? And what can be done to mitigate that economic burden? These are some of the questions that a team of researchers, including Karen Eggleston, APARC’s deputy director and director of the Asia Health Policy Program, set out to answer in a new study published in the journal Current Diabetes Reports.

Eggleston co-authored the study with Kavita Singh of the Public Health Foundation of India and the Centre for Chronic Disease Control in New Delhi, and with M. Venkat Narayan, Professor of Medicine and Epidemiology and Director of the Global Diabetes Research Center at Emory University. They find that diabetes-related complications lead to enormous treatment costs, causing catastrophic medical spending and illness-induced poverty for many households.

The new study is related to a broader research project led by Eggleston, entitled Net Value in Diabetes Management, that compares health care use, medical spending, and clinical outcomes for patients with diabetes as a lens for understanding the economics of caring for patients with complicated chronic diseases across diverse health systems. This international collaborative research convenes teams of clinicians and health economists in ten countries (and growing) across Asia, as well as the United States and The Netherlands. Together, they analyze big data—detailed, longitudinal patient-level information for large samples from each country, including millions of records of clinical encounters, health-check-up, and medical spending—to compare the health care use and patient outcomes for adults with type 2 diabetes in their health systems.

In the new publication, Eggleston and her co-authors first introduce several unique features that characterize the type 2 diabetes epidemic in South Asia. These include a high risk of developing diabetes even at lower levels of body mass index than observed among western populations; a high prevalence of glucose intolerance, low levels of HDL cholesterol, and high levels of triglycerides; a relationship between impaired fetal nutrition, diabetes, and cardiovascular risk; and the likelihood of rapid urbanization impacting the diabetes burden of the wealthy and the underprivileged differently.

Furthermore, South Asian countries face difficult challenges in delivering diabetes care. The health sector in the region has little organized financing, leading to heavy out-of-pocket spending by patients. Limited availability and affordability of anti-diabetic drugs is a major driver of lower use of such medicines. These factors, combined with a general lack of health care professionals and infrastructural resources and low quality of healthcare governance, all contribute to poor health outcomes.

Eggleston and her co-authors assess the current literature on the economic impact of diabetes in South Asia. They show that, compared with the high prevalence of diabetes in South Asian countries, the total health spending as a percentage of GDP in the region has remained low and fairly constant (3-4% in most countries) over the last two decades, with less than 1% of GDP spent on healthcare by the government, and a miniscule 0.2% by pre-paid private insurance, resulting in a large proportion of out-of-pocket healthcare spending. The financial burden of diabetes and its complications can therefore have catastrophic implications for households that are often driven to sacrifice disastrous proportions of their income to cover treatment costs.

Diabetes causes premature mortality, high morbidity, and disability. To mitigate the economic and social welfare burden of the disease, the researchers conclude, policymakers in South Asia must take urgent action “to increase investment in evaluating cost-effective strategies to manage diabetes and preventative approaches.” The team offers a set of policy recommendations, including monitoring the economic burden of diabetes and the quality of care; focusing on the screening and prevention of diabetes and its risk factors; strengthening government health facilities and primary care services; expanding access to affordable, essential medicines, and more.

People today can generally expect to live longer and, in some parts of the world, healthier lives. The substantial increases in life expectancy underlying these global demographic shifts represent a human triumph over disease, hunger, and deprivation, but also pose difficult challenges across multiple sectors. Population aging will have dramatic effects on labor supply, patterns of work and retirement, family and social structures, healthcare services, savings, and, of course, pension systems and other social support programs used by older adults. Individuals, communities, and nations around the world must adapt quickly to the demographic reality facing us and design new approaches to financing the many needs that come with longer lives.

This imperative is the focus of a newly published special issue of The Journal of the Economics of Ageing, entitled Financing Longevity: The Economics of Pensions, Health and Long-term Care. The special issue collects articles originally written for and discussed at a conference that was dedicated to the same topic and held at Stanford in April 2017 to mark the tenth anniversary of APARC’s Asia Health Policy Program (AHPP). The conference convened top experts in health economics and policy to examine empirical and theoretical research on a range of problems pertinent to the economics of aging from the perspective of sustainable financing for long lives. The economics of the demographic transition is one of the research areas that Karen Eggleston, APARC’s deputy director and AHPP director, studies. She co-edited the special issue with Anita Mukherjee, a Stanford graduate now assistant professor in the Department of Risk and Insurance at the Wisconsin School of Business, University of Wisconsin-Madison.

The Financing Longevity conference was organized by The Next World Program, a Consortium composed of partners from Harvard University, Fudan University, Stanford University, and the World Demographic and Aging Forum, and was cosponsored by AHPP, the Stanford Institute for Economic Policy Research, and the Stanford Center on the Demography and Economics of Aging.

The contributions that originated from the conference and are collected in the Journal’s special issue cover comparative research on more than 30 European countries and 17 Latin American countries, as well as studies on Australia, the United States, India, China, and Japan. They analyze a variety of questions pertinent to financing longevity, including how pension structures may exacerbate existing social inequalities; how formal and informal insurance interact in securing long-term care needs; the ways in which the elderly cope with caregiving and cognitive decline; and what new approaches might help extend old-age financial security to those working outside the formal sector, which is a major concern in low-income countries.

Another challenge of utmost importance is the global pension crisis, caused due to committed payments that far exceed the saved resources. It is a problem that Eggleston and Mukherjee highlight in their introduction to the special issue. By 2050, they note, the pension gap facing the world’s eight largest pension systems is expected to reach nearly US $400 trillion. The problem cannot be ignored, as “the financial security of people leading longer lives is in serious jeopardy.” Indeed four of the eight research papers in the special issue shed light on pensions and inequality in income support for older adults. The other four research papers focus on health and its interaction with labor force participation, savings, and long-term care.

The issue also features two special contributions. The first is an interview with Olivia S. Mitchell, a professor at the University of Pennsylvania’s Wharton School and worldwide expert on pensions and ageing. Mitchell explains the areas offering the most promise and excitement in her field; discusses ways to encourage delayed retirement and spur more saving; and suggests several priority areas for future research. The latter include applying behavioral insights to questions about retirement planning, improving financial literacy, and advancing innovations to help people imagine themselves at older ages and save more for their future selves.

The second unique contribution is a perspective on the challenges of financing longevity in Japan, based on the keynote address delivered at the 2017 Stanford conference by Mr. Hirotaka Unami, then senior Director for policy planning and research of the Minister’s secretariat of the Japan Ministry of Finance and currently deputy director general with the Ministry’s Budget Bureau.

In Japan, decades of improving life expectancy and falling birth rates have produced a rapidly aging and now shrinking population. Data released by Japan’s Statistics Bureau ahead of Children's Day on May 5, 2019 reveal that Japan’s child population (those younger than 15) ranks lowest among countries with a total population exceeding 40 million. In his piece, Unami focuses on the difficult tradeoffs Japan faces in responding to the increase in oldest-old population (people aged 75 and over) and the overall population decline. Japan aspires to do so through policies that are designed to restore financial sustainability for the country’s social security system, including the medical care and long-term care insurance systems.

Unami argues that Japan must simultaneously pursue a combination of increased tax revenues, reduced benefit growth, and accelerated economic growth. He notes that these three-pronged efforts require action in five areas: review Japan’s pension policies; reduce the scope of insurance coverage in low-risk areas; increase the effectiveness of health service providers; increase a beneficiary’s burden according to their means; and enhance policies for preventive health care for the elderly.

The aging of our world’s population is a defining issue of our time and there is pressing need for research to inform policies intended to improve the financial well-being of present and future generations. The articles collected in the Financing Longevity special issue and the ongoing work by APARC’s Asia Health Policy Program point to multiple areas ripe for such future research.

View the complete special issue >>

Learn more about Dr. Karen Eggleston’s work in the area of innovation for healthy aging >>

Sarita Panday’s personal and professional journey from a childhood in a small village in Nepal to an academic career that has taken her across the globe to Australia, Europe, and now Stanford is a story that speaks to the power of education as a life-transforming and world-changing force. Sarita is our 2018-19 postdoctoral fellow in Asia health policy and her research focuses on improving maternal health service provision in Nepal.

The Asia Health Policy Postdoctoral Fellowship is offered annually by APARC’s Asia Health Policy Program (AHPP). On May 1, Sarita will present her research at a seminar cosponsored by AHPP and the Center for South Asia. We caught up with Sarita to learn about her work, the state of maternal health and education in Nepal, and what’s next for her career.

Q: Your research interests include health service delivery and human resources for global health, and your PhD project explored the role of female community health volunteers in maternal health service provision in Nepal. What is the state of maternal health in Nepal? How does it compare to other areas in South Asia?

While substantial progress in maternal health has been achieved over the last two decades, Nepal still has high rates of maternal deaths compared to its neighbouring countries. According to UN estimates, maternal mortality ratio (number of deaths due to pregnancy-related causes per 100,000 live births) is one of the highest in Nepal (258) compared to India (174), Bangladesh (176), Pakistan (176) or Sri Lanka (30).  Maternal deaths in Nepal’s rural areas are three times likely to be higher than in urban areas. Therefore, my research focuses on improving maternal health status in rural area.

Q: Tell us about your current research: What questions/problems you're exploring? What are some of the findings your work has revealed?

As the 2018-19 Asia Health Policy Postdoctoral Fellow at APARC, I am currently working on publications based on my PhD, which focused on improving healthcare for marginalized women in rural Nepal. My next paper, forthcoming in PLOS One, explores the underuse of healthcare services among Nepal’s marginalized communities. In this paper, I analyze the factors that hinder use of healthcare by certain ethnic groups such as Dalits (the lowest group within the Hindu caste system), Madhesi (people living in the southern plains of Nepal, close to the border with India), Muslim, and Chepang and Tamang (indigenous groups in hill villages). These ethnic groups face barriers to health service use that include lack of knowledge, lack of trust in volunteers, traditional beliefs and healthcare practices, low decision-making power among women, and perceived indignities experienced when using health centers. Therefore, community health programs aimed to improve healthcare use among such populations should consider these specific contextual elements along with health system factors.

My next manuscript (in preparation) focuses on the importance of paying community health workers, which is also one of the key findings of my PhD. I found that women volunteers appeared to be highly dissatisfied by the lack of financial incentives for their services and wanted remuneration. This finding contradicts previous claims that reported community health volunteers were happy with their status. I have just finished a first draft of the manuscript and will soon send it for review.

Apart from my fellowship at Stanford, I am volunteering to form a team of interdisciplinary researchers to improve maternal and child health among marginalized communities in Nepal. I am doing this as part of my role as an honorary research fellow in the Department of Politics at the University of Sheffield, where I also earned a PhD in public health. I recently organized a workshop in the UK to leverage partnerships across universities and the local NGO PHASE Nepal. During the workshop, I shared my experience of using participatory approaches (such as participatory video methods and policy workshops) to connect communities with policymakers, and I plan to use similar participatory approaches in my future research. The workshop successfully generated support from colleagues and the local partner.

Q: Your personal and professional journey has taken you from growing up in rural Nepal to pursuing a doctorate in Britain and now a postdoctoral fellowship at Stanford. How would you describe the situation of Nepal’s higher education system, and the demand for foreign education in the country? What are some of the lessons you have learned throughout your own years of international education?

Although Nepal has a long history of education, the current formal education system was formed only in 1951, after the establishment of democracy. In the short period since then, Nepal has made substantial progress in adult literacy rate (from 20.6 % in 1981 to 64.7 % in 2015), but the quality of the public education system remains questionable, with low opportunities for employment. There has been some improvement since the beginning of technical education as a formal sector in 1980: the Ministry of Education, Science and Technology is responsible for education in Nepal and there are currently a total of nine constituent universities with 90 affiliated universities and 1012 campuses. However, the quality of education in Nepalese universities is often controversial due to their being a playground for major political parties. And despite the government’s promises to increase its spending on public education the education budget appears to be cut each year.

As for my own experience, I graduated with a BSc Nursing degree in Nepal without realizing that I wouldn’t get a placement within the public sector. The government hasn’t yet created a position for graduates like me, which forced me to seek a job in the private sector. While I managed to find a well-paying if strenuous job in remote Nepal, I saw many colleagues who struggled to find jobs that matched their qualifications. Some of them worked voluntarily or in low-paying positions. While the Nepalese government continues to produce graduate nurses there’s no system to retain them, despite a severe scarcity of human resources for health.

Q: What's next for your career? What issues are you going to focus on in your upcoming research project?

I have recently been appointed as a Global Challenge Fellow at the University of Sheffield to work on a two-year research project in Nepal. Starting this July, I will work with rural women in two Nepalese districts (Dhading and Sindhupalchok), conducting participatory co-designed research aimed to raise awareness and understanding of the social, cultural, economic, and political factors that hamper women’s access to healthcare services. I plan to use participatory approaches, such as participatory video methods and policy workshops, to connect communities with policymakers, and to partner with PHASE Nepal to improve utilization of healthcare among the country’s marginalized populations.

I’m excited to share my work with the Stanford community in an upcoming seminar on May 1, and hope to see many friends and colleagues there.

Register to attend Sarita's seminar >>

People who are acquainted with the work of Shorenstein APARC’s Asia Health Policy Program (AHPP) may be aware of the Innovation for Healthy Aging collaborative research project led by APARC Deputy Director and AHPP Director Karen Eggleston. This project, which identifies and analyzes productive public-private partnerships advancing healthy aging solutions in East Asia and other regions, encompasses an upcoming volume, co-authored by Eggleston with Harvard University professors Richard Zeckhauser and John Donohue, about public and private roles in governance of multiple sectors in China and the United States, including health care and elderly care. This volume, however, is not the first collaboration between Eggleston and Zeckhauser.

Zeckhauser, the Frank P. Ramsey Professor of Political Economy at Harvard University’s Kennedy School, is known for his many policy investigations that explore ways to promote the health of human beings, to help markets work more effectively, and to foster informed and appropriate choices by individuals and government agencies. In 2006, Eggleston and Zeckhauser co-wrote a paper about antibiotic resistance as a global threat, an issue that has since received much attention as it has become a critical public health and public policy challenge. Zeckhauser was a pioneer in framing antibiotic resistance as a global threat.

On October 20, 2018, Eggleston was among some 150 colleagues, students, and friends who participated in a special symposium at the Kennedy School to celebrate Zeckhauser’s 50th anniversary of teaching and research, and to anticipate what the next 50 years might bring in the multiple fields he has influenced throughout his long career.

Eggleston joined the first of two panels in that symposium, where she spoke about Zeckhauser’s impact on health policy and about what academics and policymakers should be tackling next on the path to addressing the global threat of antibiotic resistance.

The panel was moderated by Harvard Professor Edward Glaeser. In addition to Eggleston, it included Jeffrey Liebman, Daniel Schrag, and Cass Sunstein.

A video recording of the panel is made available by the Kennedy School. Listen to Eggleston’s remarks (beginning at the 8:42 and 36:20 time marks):