Douglas Owens, director of the Center for Health Policy at FSI and the Center for Primary Care and Outcomes Research in the Department of Medicine and School of Medicine, has been appointed to the U.S. Preventive Services Task Force.

The task force is an independent, volunteer panel of 16 experts in prevention and evidence-based medicine that makes recommendations and develops clinical guidelines for preventive services. They focus on issues including screening for breast cancer, colon cancer, prostate cancer, cervical cancer, diabetes, drug and alcohol misuse, and hepatitis C.

“These guidelines are used widely, and they address important issues for our veterans, and for the nation at large,” said Owens, the associate director of the Center for Health Care Evaluation at the VA Palo Alto Health Care System and the Henry J. Kaiser Jr. Professor at Stanford.

“I look forward to working with the Task Force.”

As incomes rise around the world, health experts expect a more troubling figure to increase as well: the number of diabetics in developing countries.

In China and India – two of the world’s most populous nations with fast-paced economies – the prevalence of diabetes is expected to double by 2025. Between 15 and 20 percent of their adult population will develop the disease as household budgets increase, diets change to include more calories and new health problems emerge.

But China, India and other developing countries are not fully prepared to deal with the rising trend of diabetes. And a growing number of diabetics aren’t getting the care they need to prevent serious complications, Stanford researchers say.

Even with insurance, many diabetics don’t have essential medications that could help them manage their conditions. In many cases, people are spending a great deal of their household incomes to pay for their treatment, said Jeremy Goldhaber-Fiebert, an assistant professor of medicine who led the research team.

“Public and private health insurance programs aren’t providing sufficient protection for diabetics in many developing countries,” said Goldhaber-Fiebert, a faculty member at Stanford Health Policy at the university’s Freeman Spogli Institute for International Studies. “People with insurance aren’t doing markedly better than those who don’t have it. Health insurance and health systems need to be re-oriented to better address chronic diseases like diabetes.”

Findings from the study are online and will be published in the Jan. 24 edition of Diabetes Care, the journal of the American Diabetes Association. The journal article was co-authored by Jay Bhattacharya, an associate professor of medicine and Stanford Health Policy faculty member; and Crystal Smith-Spangler, an instructor at Stanford’s Department of Medicine and an investigator at the Palo Alto VA Health Care System.

Failure to adequately manage diabetes will lead to more severe health problems like blindness, heart disease and kidney failure. It also harms the otherwise healthy, Goldhaber-Fiebert said.

Diabetes often strikes people at an age when they’re taking care of children and elderly parents. To sideline these primary caretakers as dependants will lead to a heavy burden for communities and create an obstacle for economic growth, he added.

Using responses to a global survey conducted by the World Health Organization in 2002 and 2003, Goldhaber-Fiebert and his colleagues examined data from 35 low- and middle-income countries in Asia, Latin America, Africa and Eastern Europe to determine whether diabetics with insurance were more likely to have medication than those without insurance.

They also wanted to know whether insured diabetics have a lower risk of “catastrophic medical spending,” a term the researchers define as spending more than 25 percent of a household income on medical care.

“Surprisingly, diabetics with insurance were no more likely to have the medications they need than uninsured diabetics,” Goldhaber-Fiebert said. “They were also no less likely to suffer catastrophic medical spending.”

There are many reasons why health insurance may not protect diabetics in developing countries against high out-of-pocket spending. In some cases, there’s a lack of sufficient medication – such as insulin – that regulate glucose levels. Without those drugs, there’s a greater risk of complications that often lead to more hospitalizations and more expenses.

In other cases, co-payments and deductibles are too high. Sometimes, drugs and medical services to prevent diabetes complications are not covered. And doctors and hospitals don’t always accept insurance.

“Better policies are needed to provide sufficient protection and care for diabetics in the developing world,” Goldhaber-Fiebert said.

Without medications to manage diabetes and prevent secondary complications, the condition will worsen and the burden of catastrophic spending will increase, he said.

“It’s important to get ahead of the curve and prepare so there’s an infrastructure in place to deal with these health and cost issues,” he said.

While preventing diabetes in the first place would be ideal, programs and policies must be established to care for the many cases that will surely continue to exist.

“There isn’t a single country that’s managed to entirely arrest or reverse the trend of diabetes,” he said. “Programs that focus on primary prevention are extremely important, but the reality is that the developing world faces hundreds of millions of diabetes cases that are unlikely to all be prevented.”

When Siyan Yi was a medical student in Cambodia 12 years ago, he volunteered with a collaborative government-NGO project to provide young women at high risk for HIV/AIDS—the victims of sexual exploitation—with housing, vocational training, medical care, and psychological support. Cambodia at that time had one of Asia’s highest HIV-infection rates.

That rate has dropped by half, thanks to government policy measures, international NGO support, and the efforts of medical professionals like Yi. Cambodia’s government must now find ways to curb HIV infection in new segments of the population, says Yi, who is the Shorenstein Asia-Pacific Research Center’s inaugural Developing Asia Health Policy Fellow. Sustaining funding for the long-term care of HIV-infected individuals also poses a future challenge, he explains, and new health issues associated with development are beginning to crop up.

Cambodia’s first HIV case was detected in 1991 in a blood donor, and the rate of HIV/AIDS increased dramatically throughout the decade. HIV/AIDS hit Thailand slightly earlier, and was spread through the commercial sex trade. The epidemic reached an even greater scale there than it ever did in Cambodia.

Thailand’s government struck back with a 100-percent condom use promotion program, which Cambodia successfully adopted in the late 1990s. Brothels are illegal in Cambodia, but the government worked cooperatively with owners to provide basic HIV/AIDS education to sex workers. These efforts significantly reduced the transmission of HIV.

Since then, a more indirect form of prostitution has sprung up in places such as karaoke halls, massage parlors, restaurants, and even in factories. HIV prevalence remains high among some sentinel groups such as female sex workers, beer promoters, men who have sex with men (MSM), injected-drug users, and migrant workers.

Yi advocates that the government expand the scope of its HIV/AIDS prevention programs to encompass these new at-risk populations. He even suggests that the government consider creating a system of licensed brothels such as previously existed in Hong Kong and Taiwan. “It would provide the government with an easier means of controlling prostitution, and allow it to work with brothel owners to control HIV-infection rates,” states Yi.

HIV increases the risk of contracting or developing symptoms of tuberculosis; a large proportion of Cambodia’s population carries the disease but shows no signs of it. Tuberculosis went largely undetected during the decades of the Khmer Rouge regime, but with the advent of HIV/AIDS it has become more prevalent. Yi has been involved in government-NGO projects to provide tuberculosis screening for HIV patients, including a tuberculosis control project with the Japan International Cooperation Agency.

Tuberculosis screening and HIV treatment advances may greatly prolong the life—and even improve the health—of patients. But heartening as Cambodia’s success against HIV/AIDS has proven in the past decade, the government largely bears the responsibility for funding the expensive treatment and care for the low-income individuals most affected by it. A critical portion of government funding for its HIV/AIDS prevention programs comes from external organizations. 

“I think that the main issue for the government of Cambodia in the battle against HIV and AIDS is financial sustainability,” says Yi, who worries that donor agencies will withdraw support as the HIV-infection rate continues to improve. Prevention is less expensive, he explains, but long-term care is costly to a developing country such as Cambodia.

Yi, however, feels less concerned now about the HIV/AIDS epidemic and speaks hopefully of working to help the government find ways to measure and treat non-communicable diseases associated with economic development, such as diabetes and hypertension. While he is at Stanford, he will collaborate with Asia Health Policy Program researchers to move his work toward solving Cambodia’s new health challenges.