To celebrate its May Release, the Stanford China Program hosted a virtual book launch event for Fateful Decisions: Choices That Will Shape China’s Future (Stanford University Press) on June 2^nd. Joining co-authors Thomas Fingar (Shorenstein APARC Fellow, Stanford University) and Jean C. Oi (Director, Stanford China Program; William Haas Professor of Chinese Politics, Stanford University) were contributors Karen Eggleston (Senior Fellow at FSI; Director of the Asia Health Policy Program, Shorenstein APARC, Stanford University), Barry Naughton (Sokwanlok Chair of Chinese International Affairs, School of Global Policy and Strategy, UC San Diego), and Andrew Walder (Senior Fellow at FSI; Denise O'Leary and Kent Thiry Professor, Stanford University). As Fingar and Oi point out in their volume, despite China’s extraordinary growth over the past 40 years, the country’s future is uncertain. China has enjoyed optimal conditions for development since the 1980s, but new hurdles including an aging populace, the loss of comparative economic advantage, a politically entrenched elite, and a population with rising expectations will test the country’s leaders. With each focusing on a different facet of China’s challenges, the panelists gathered to share their expertise and provide the audience with a glimpse into what the future might hold for this important country.

Available Now: Fateful Decisions: Choices That Will Shape China’s Future

Following an introduction from Professor Jean Oi, the program kicked off with Professor Barry Naughton of University of California, San Diego, who discussed his chapter entitled “Grand Steerage.” Professor Naughton argued that, as it plans for the future, China’s policymaking is becoming increasingly technology-focused, particularly in the realm of economic policy. Naughton further notes that China’s economy is becoming simultaneously more state-guided and more centered around technology. This decision is a gamble, though: China is investing heavily in high-tech industries, advancing massive, centrally steered projects like the Greater Bay Area initiative and the Xiong’an New District. If they are successful, says Naughton, this will indeed be an incredible success. But, if they are not, China’s losses will be major: “There’s not really a middle ground.”

After Professor Naughton was Professor Karen Eggleston, an expert on health policy in Asia. Professor Eggleston’s chapter, “Demographic and Healthcare Challenges,” deals with emerging obstacles for China’s healthcare system, including population aging and the problems that come with it, like chronic diseases and elder care. Although China’s healthcare system has improved dramatically in recent decades, it has done so unevenly, notes Eggleston: life expectancy has greatly increased, but with disparities according to income, region, and urban vs. rural status; universal healthcare is available, but the benefit level is low, effectively limiting the standard of care many can receive. The ratio of health spending to GDP is also increasing, yet it is still modest compared to high-income countries. The COVID-19 crisis has, of course, introduced even more challenges: Will China be able to distribute future vaccines equitably? Will this crisis negatively affect young people’s decisions to choose healthcare as a career? Will telemedicine, which has seen a surge under the pandemic, improve or exacerbate existing disparities? China faces a multitude of constraints and choices going forward if it hopes to meet its population’s healthcare needs.

The audience then had a chance to hear from co-editor Thomas Fingar, speaking on his chapter, “Sources and Shapers of China’s Foreign Policy.” Fingar noted three key takeaways from both his chapter and his talk: Firstly, China’s foreign policy is a fundamental part of its national policy. Secondly, the global political environment plays an important role in shaping both foreign and domestic policy which, thirdly, plays an important role in shaping foreign policy. The conditions that allowed China to flourish over the past 40 years, emphasized Fingar, are very different from those of the present. In the 1970s and 80s, China was able to take advantage of Cold War bipolarity, globalization was in its infancy, and “China was the only significant developing country willing to embark, at that time, on the export-led path of development.” In recent years, though, China’s behavior internationally has alienated other countries; there are many competitors pursuing its style of development; and its needs and aspirations have changed, requiring more raw materials and depending upon multi-national economic agreements. Fingar suggests two potential foreign policy options: China could continue with its wolf warrior diplomacy, which has “alienated essentially all China’s neighbors to some degree,” or it could return to a style more similar to that of the 1980s and 90s Reform and Opening era. It remains to be seen which style will win out.

Finally, Professor Andrew Walder concluded the program with his discussion of China’s political future at large. His chapter, “China’s National Trajectory,” follows China’s remarkable advancement in recent years and “tr[ies] to divine what a lower growth era will mean for China’s political future.” The last 40 years of rapid growth have generated support for China’s political system, more patriotism, the near eradication of democracy movements, and an elite unity not seen in the 1970s and 80s. However, low growth rates could mean a reversal for many of these trends, says Walder. While the aforementioned support for and stability of the Chinese government was maintained by ever-improving living standards and upward mobility, a low growth period (coupled with an aging population) means the government will no longer be able to rely on these trends for popular support. Rather, it will need to improve its provision of public services to address present-day challenges. Regardless, argues Walder, the low growth era will undoubtedly lead to “dynamic changes underneath the façade of stability of Chinese politics….”

For more insights on the modern obstacles China faces and what they mean for the country’s future, check out Fateful Decisions: Choices That Will Shape China's Future, available for purchase now.

The Walter H. Shorenstein Asia-Pacific Research Center (APARC) condemns the systemic nature and brutal expression of racism in the United States, and we stand in full support of protestors and civil rights organizations in their calls for social justice, equal access to basic rights, and accountability. Beyond reaffirming our commitment to these values, we recognize the imperative to do better as an institution and the urgent need to take concrete action to build a more inclusive community here at our Stanford home. We have joined our colleagues at the Freeman Spogli Institute for International Studies in developing specific steps towards that goal. But we also want to take initial, immediate action in moving from protest to progress.

That’s why we are announcing today a new diversity grant to support Stanford students from underrepresented minorities with an interest in studying issues related to contemporary Asia. The field of Asian studies suffers from an extreme paucity of students, scholars, and experts who self-identify as Black/African American or as affiliated with other underrepresented minority groups. “The path towards a more diverse and inclusive field isn’t easy or straightforward, but we must get on it,” says APARC Director and FSI Senior Fellow Gi-Wook Shin. “We believe that we can tackle the existing disparity if relevant stakeholders across institutes of higher learning all work together. APARC is looking to start this change at Stanford.”

Lowering Barriers to Diversity in Asian Studies

The purpose of the APARC Diversity Grant is to encourage Stanford students from underrepresented minorities (URM) to engage in study and research of topics related to contemporary Asia and U.S.-Asia relations, including economic, health, foreign policy, social, political, and security issues. We follow the University’s definition of the URM category as encompassing “all U.S. citizens and permanent residents who have self-identified as American Indian/Alaska Native, Black/African American, Hispanic/Latino, Native Hawaiian/Other Pacific Islander.” This grant opportunity is open to current Stanford undergraduate and graduate students in the URM category from any major or discipline. “This is just a small step to start lowering disciplinary, cultural, and funding barriers that hinder broader student participation in Asian studies,” notes Shin.

APARC will award a maximum of $10,000 per grant to support a wide range of research expenses such as travel to/from research sites, academic conferences, and workshops (dependent on COVID-19 restrictions); conference registration fees; professional development training programs; purchase of physical and digital books or other required materials; and access to relevant online resources. APARC will review grant applications for projects taking place in winter/spring 2021 on a rolling basis starting on September 1, 2020. Reviews of the second round of applications, for projects taking place in summer/fall 2021, will begin on April 1, 2021.

Examples of research topics, in addition to those that Asia scholars typically study, could include China’s growing activities in Africa; understanding the evolving relations between Asian Americans and African Americans in the United States; and comparative examinations of issues such as the treatment of minorities in Asia and the United States or policies that promote anti-discriminatory practices in schools, the workplace, and other settings in Asian countries and the United States.

Application Guidelines

• Complete the application form and submit it along with these three (3) attachments:
  • A statement (no more than three pages) describing the proposed research activity or project;
  • A current CV;
  • An itemized budget request explaining research expense needs.
• Arrange for a letter of recommendation from a faculty to be sent directly to APARC. Please note: the faculty members should email their letters directly to Kristen Lee at kllee@stanford.edu.

We will consider only applications that include all supporting documents.

This interview was originally produced by the Oliver Wyman Forum.

Coronavirus has dramatically increased the use of technology as governments, healthcare providers, and businesses tackle the pandemic and its devastation. But even before the crisis, Japan, a country long at the forefront of robot production and usage, had begun to use this technology in many of its nursing homes.

About 60 percent of the country’s nursing facilities now use robots. The proliferation of machines has had a relatively minor impact on turnover or wages of caregivers because of strong demand for care, an aging working population, and government subsidies for robot implementation, according to research by Karen Eggleston, the deputy director of the Shorenstein Asia-Pacific Research Center and director of the Asia Health Policy Program (AHPP), Yong Suk Lee, a center fellow and the deputy director of the Korea Program, and Toshi Iizuka, professor at the University of Tokyo and former visiting scholar with AHPP. Robot-adopting nursing homes, the researchers found, had between eight to 11 percent more staff than those who didn't adopt robots.

Caregiving is a physically demanding task. Staff frequently lift residents in and out of bed, and many suffer from back pain. Many of the robots deployed in Japan either help caregivers perform physical tasks or facilitate movement by the residents themselves.

The research couldn’t be timelier. Nursing homes have taken a heavy toll from the coronavirus. The disease has claimed the lives of more than 28,000 residents and workers of care facilities in the United States – approximately 35 percent of all deaths in the nation as of May 11. By contrast, Japan’s overall death toll stands at a little over 900 in early June.

Professors Eggleston and Lee discussed the implications of their research in a Zoom interview with Partha Bose, a partner at Oliver Wyman and a leader of the Oliver Wyman Forum, as well as Jilian Mincer, managing editor of the Oliver Wyman Forum, and Dan Kleinman, the Forum’s digital editor.

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From a labor economics point of view, Japan has been struggling with staffing in these care facilities. What made it much more acceptable for robots to be used in their situation versus other sectors?

Karen Eggleston: Japan has an extreme demography that it’s dealing with. The demand for long-term care is going up quite a bit while the overall population is declining. Although they're relaxing some immigration, there are issues with that. Some of the policy goals were to support robotics and to understand how it complements or substitutes for specific tasks in long-term care — to bring down back pain among care workers, for example — and to explicitly set a target for percentage of healthcare providers and long-term care clients who say it's acceptable to have a robot involved in their care.

They went into it well aware that robots weren't going to completely push out the workforce, but it's all a question of what type of tasks they can be involved with and how they can get an early read on that and start developing appropriate robots and re-engineering the care processes to meet that surge in demand.

What kinds of tasks are robots being used for in Japan right now?

Yong Suk Lee: There are these wearable transfer-aid robots that can actually help care workers lift persons and move around. There are similar types of robots that are non-wearable. And there are robots that directly assist the elderly in their care: They can use these to move around, and related to that, bathing activities, going to the bathroom, and so on.

The main type of robots are monitoring robots. They’re basically a camera system. They signal to the nurses or caregivers in an aid station if there seems to be abnormal movement so that they can actually go there — especially during the night when there's less staffing to actually go and check how the residents are doing. Those are the highest in terms of rate of adoption. And then there are those cute communication types of robots to help patients with dementia communicate with their families and caregivers.
 
What sort of facilities are using these robots? Do they tend to be urban facilities, or can they be anywhere in the country, like rural areas?

Lee: Based on preliminary results, adoption is higher in urban areas, but it's not significantly different. In China, it could differ drastically because there's a huge urban-rural divide in China of public health systems or public service in general. Robots are capital intensive. In South Korea, there are private homes that are wealthier and those could adopt new technologies earlier, but still, adoption in general is not widespread due to sufficient immigrant labor providing care. There could be an urban-rural divide for sure. Because of government subsidies in Japan, it equalizes distribution across regions.
 
Eggleston: We find more part-time or irregular nurses in urban areas. That may seem counterintuitive, but when you think about it, having that concentration of human capital in urban areas might facilitate that kind of part-time work and so on. There are differences we can see in our data between urban and rural homes, but we don't see large differences in terms of robot adoption and use.

Are there kinds of conditions that robots are better suited for than others?

Lee: In general, most robots are related to mobility issues. The biggest consequences of the elderly staying in homes are pressure ulcers on their skin because of their extended time in bed and low levels of mobility. Robots could provide a major contribution if they help residents move about and reduce pressure ulcers.

Communication robots are helpful for patients with dementia. The adoption of those isn't high compared to monitoring robots, but I think it's becoming more accepted and especially helpful for certain types of patients.
 
Do you think robots will be helpful for medical care?

Eggleston: That's the hope. For example, night monitoring reduces the probability of a severe fall which requires hospitalization and so on. There are contentious issues with nursing homes about physical restraints for patients, which are not allowed. And so, adding robots might deal with some of the outcomes. Both the producers and users of robots are hoping this will have a significant impact on the quality of care. 

As you look at how the coronavirus has affected long-term care facilities, do you wonder what the outcomes might've been had some of these facilities had robots?

Lee: Yes. What our findings indicate is that robots are not replacing workers in Japan. They're allowing firms to adopt more nurses — the skilled type of caregivers, which is an important finding directly related to the quality of care. Allowing critical personnel to actually focus more on patients. If there were certain technologies in place, caregivers could have spent their time more efficiently. I believe that's going to be a discussion going forward in the US and in many other countries that have suffered drastically. 

Eggleston: Particularly the communication and monitoring robots would help to some extent. They can save caregivers from having to go room-to-room and enable communication between people at the facility, and also with their households.

We do know that there's a potential there, and it might affect future adoption in nursing homes in the US and elsewhere. But given the huge financial hit the industry has taken as a whole, it might be a while before that plays out.

Given the coronavirus’s prevalence in nursing homes, people may be wary of taking jobs there. Can these robots be used in a recruiting capacity for nursing homes?

Lee: Certified nursing assistants in the US are not well-paid and it’s a physically demanding job. Now there's an extra concern of, "What will happen to me when I work here?" A lot of nursing homes had enormous difficulty recruiting people. They were paying extra for nurse aids, but they weren't able to recruit given the situation.

Potentially, nursing home facilities that have the capacity to adopt robots may be able to advertise this as not only being able to improve the quality of care for the residents but providing better work conditions for the caregivers. What we're finding in our research is those that adopt these robots tend to have better management practices.

What has surprised you most in your research?

Lee: We didn't find that robots replaced care workers. They’re being used to supplement the workers and maybe have better outcomes in quality of care. This is having an overall net positive effect both on jobs and productivity.

On May 15, 2020, the King Center on Global Development held a virtual panel discussion with the Shorenstein APARC on the economic impact of COVID-19 in China. As China lifts its lockdown and U.S. cases of COVID-19 ramp up, three APARC faculty members — Karen Eggleston, Scott Rozelle, and Xueguang Zhou — joined the King Center’s China Program Director Hongbin Li to analyze the Chinese government’s initial response to the coronavirus outbreak and how the virus has impacted urban and rural employment in China’s health care sectors. Watch the panel discussion: