We are delighted to share that Young Kyung Do, APARC’s inaugural postdoctoral fellow in Asia health policy (2008-9), has won the 2020 Rothman Epidemiology Prize. The prize is awarded annually for the best paper published in the journal Epidemiology in the preceding year. Dr. Do is a professor in the Department of Health Policy and Management and director of the Institute of Health Policy and Management at the Seoul National University College of Medicine.

Dr. Do’s winning paper, titled “Causal Effect of Sleep Duration on Body Weight in Adolescents: A Population-based Study Using a Natural Experiment,” appeared in the November 2019 issue of Epidemiology. It provides new, population-level, causal evidence that corroborates consistent findings in the epidemiologic literature on the relationship between reduced sleep and increased body weight, particularly in children and adolescents.

Dr. Do’s study uses a unique natural experiment that arguably increased the sleep duration of adolescents in South Korea, where authorities in three of the 16 administrative regions required private tutoring institutes to close at 10 PM instead of later at night. This policy change was associated with sleep gain and body weight reduction in a subset of high school students whose sleep duration would otherwise have not increased. The natural experiment made it possible to study a population-wide sleep gain, thus providing evidence for a potential effective public health intervention.

An earlier version of this winning paper first appeared in our Asia Health Policy Program’s working paper series. The series is open to scholars and health policy experts from around the world and disseminates their papers to a broad international audience through the Program’s website and scholar network and in collaboration with the Social Science Research Network. The Asia Health Policy Program sponsors and manages the Asia health policy postdoctoral fellowship at APARC. Each year, it offers a fellowship position to a recent doctoral graduate.

Owning a handgun is associated with a dramatically elevated risk of suicide, according to new Stanford research that followed 26 million California residents over a 12-year period. The higher suicide risk was driven by higher rates of suicide by firearm, the study found.

Men who owned handguns were eight times more likely than men who didn’t to die of self-inflicted gunshot wounds. Women who owned handguns were more than 35 times more likely than women who didn't to kill themselves with a gun.

While prior studies have found higher rates of suicide among people who live in homes with a gun, these studies have been relatively small in scale and the risk estimates have varied. The Stanford study is the largest to date, and it’s the first to track risks from the day of an owner’s first handgun acquisition.

“Our findings confirm what virtually every study that has investigated this question over the last 30 years has concluded: Ready access to a gun is a major risk factor for suicide,” said the study’s lead author, David Studdert, LLB, ScD, MPH, professor of medicine at Stanford Health Policy and of law at Stanford Law School.

The study published in The New England Journal of Medicine analyzed data on handgun acquisitions and deaths in a cohort of 26.3 million adult residents of California who had not previously owned handguns. The researchers followed the cohort from 2004 through 2016, and compared death rates among those who did and didn’t acquire handguns, with a particular focus on suicides by firearm versus other methods.

More than 1.4 million cohort members died during the study period. Nearly 18,000 of them died by suicide, of which 6,691 were suicides by firearms.

Often Impulsive Acts

“Suicide attempts are often impulsive acts, driven by transient life crises,” the authors write. “Most attempts are not fatal, and most people who attempt suicide do not go on to die in a future suicide. Whether a suicide attempt is fatal depends heavily on the lethality of the method used — and firearms are extremely lethal. These facts focus attention on firearm access as a risk factor for suicide especially in the United States, which has a higher prevalence of civilian-owned firearms than any other country and one of the highest rates of suicide by firearm.”

There were 24,432 gun suicides in the United States in 2018, according to the Centers for Disease Control and Prevention. Three-quarters of them involved handguns. 

The Stanford study took advantage of the unusually comprehensive body of information on firearm sales in California. All lawful gun purchases and transfers must be transacted through a licensed firearms dealer, who then relays the information to the state’s Department of Justice, where it is archived. The research team obtained records of all firearm acquisitions dating back to 1985, then linked them to death records. 

The researchers found that people who owned handguns had rates of suicide that were nearly four times higher than people living in the same neighborhood who did not own handguns. The elevated risk was driven by higher rates of suicide by firearm. Handgun owners did not have higher rates of suicide by other methods or higher rates of death generally.

The researchers said the very high risk of suicide for female handgun owners, relative to female nonowners, was particularly noteworthy. It has long been known that women attempt suicide more frequently than men but have fewer completed suicides. The standard explanation is that the methods women tend to use are less lethal than those men tend to use. However, the study showed that this is not true for female gun owners.

“Women in our cohort who owned guns and died by suicide usually used a gun,” said Yifan Zhang, PhD, a biostatistician at Stanford Health Policy and co-author of the study. “Handgun ownership may pose an especially high risk of suicide for women because of the pairing of their higher propensity to attempt suicide with access to and familiarity with an extremely lethal method.”

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Disentangling Competing Explanations

One major challenge with studies examining the relationship between gun access and suicide risk has been determining whether people who purchase handguns already have plans in place to harm themselves, or whether the presence of a handgun creates new risks.

The unique, longitudinal nature of the Stanford study helped to disentangle these competing explanations.

“There appears to be some of both happening,” said senior author Matthew Miller, professor of health sciences and epidemiology at Northeastern University. “New handgun buyers had extremely high risks of dying by firearm suicide immediately after the purchase. However, more than half of all firearm suicides in this group occurred a year or more later. Consistent with prior work, our findings indicate that gun access poses a substantial and enduring risk.” 

Other Stanford co-authors of the study are research analyst Lea Prince, PhD, and research assistant Erin Holsinger, MD — both at Stanford Health Policy; and Jonathan Rodden, PhD, professor of political science.

Researchers at Erasmus University, in the Netherlands, and the University of Melbourne, in Australia, also contributed to the work.

The research was supported by the Fund for a Safer Future and the Joyce Foundation, as well as Stanford Law School and the Stanford University School of Medicine.

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This is the third installment in our series, “Stories in a Time of Pandemic,” in which APARC alumni across Asia share their perspectives on the responses to and implications of COVID-19 in their communities. In part 1 and part 2 of the series, we feature observations from our alumni in China, Mongolia, Myanmar, and Singapore.

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The first case of COVID-19 in the Philippines was reported on January 30, 2020, and local transmission was confirmed on March 7, 2020. As of May 21, the number of cases of COVID-19 has risen to 13,434 and the number of deaths attributed to the virus increased to 846, according to the Philippine Department of Health COVID-19 Case Tracker. It is quite alarming that among the ASEAN countries, the Philippines had the second-highest mortality due to COVID-19, next to Indonesia (as per May 5 date by the WHO COVID-19 Dashboard). This could be attributed to several factors, including whether the country’s health system can handle the overwhelming demand for health care due to the COVID-19 crisis and how effective the government’s response is in stemming the spread of this new pathogen. Inherent in the death statistics is the capacity of a country to conduct COVID-19 tests, which means that there should be a sufficient number of test kits available and that the health workers are properly trained to conduct the tests, trace the contacts, and isolate identified individuals.

The President of the Philippines imposed a total lockdown called enhanced community quarantine (ECQ) for the entire island of Luzon, which encompasses eight administrative regions, including the national capital region, from March 15 to April 30. Other parts of the country have also been under some degree of quarantine at different periods since the appearance of local transmission. Executive Order 112, signed on April 30, 2020, was issued to further extend the ECQ in identified high-risk areas and a general community quarantine (GCQ) in the rest of the country. The inter-agency task force for the management of emerging infectious diseases defines ECQ as the implementation of temporary restrictions on the mobility of people, strict regulations of industries, and a heightened presence of uniformed personnel. GCQ is, in a nutshell, a less strict version of ECQ.

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Image captured from the Center for Strategic and International Studies, Southeast Asia COVID-19 Tracker, May 21, 2020.

The Philippines has faced a lot of challenges during this crisis. First, the health system lacks adequate surge capacity to safely handle a nationwide outbreak of COVID-19 due to shortages of personal protective equipment (PPE), mechanical ventilators, and hospitals with ICUs and isolation beds (see this World Bank report and this Rappler article). More importantly, the insufficient number of health workers, especially in areas outside the metropolitan, is a major concern. Nonetheless, the Department of Health has worked hard to meet the surge in demand due to COVID-19, including partnering with the private sector to repurpose structures and providing data to the public to ensure transparency and accountability. As in other countries, the health workers and those with frontline responsibilities have truly been the new heroes or “bayani” with their tireless efforts and sacrifices. 

Another challenge pertains to the adverse economic impact of COVID-19. The Philippines has a relatively large informal sector and the income of many families depends on daily transactions with no formal job or social security. This has prompted the government to extend cash or in-kind support to vulnerable populations – a response that has posed several challenges, particularly related to the who/what/how framework. First, the Philippine government had to properly identify those in need (who). Second, it had to ensure that sufficient resources can be allocated to the identified groups (what). And third, it had to distribute aid in an efficient, timely, and equitable way (how). The government's social welfare efforts to provide for the vulnerable groups have mixed results: at times, the distribution of aid is organized and efficient, at other times insufficient and disorderly (see these CNN Philippines reports of April 7 and April 30).

COVID-19 in the Philippines – How Filipinos Have Coped

There has been a strong spirit of “bayanihan” or collectivism in the country amidst the COVID-19 crisis. People are volunteering, distributing goods to vulnerable groups, or donating PPE to those with frontline duties. Some enterprises also rose to the occasion by repurposing their businesses to meet the local demand for medical products and PPE.

Different individuals have coped differently: some have welcomed the work hiatus that the quarantine has afforded them, some connected more with friends and family, others become more productive working from home. Staying healthy and being mindful are also factors that contribute to remaining calm and rational in this time of national distress.

Despite the challenges, we will continue to face, especially once the quarantine has eased and the new normal is in effect, we can say that Filipinos have also learned some valuable lessons amid this crisis. For one, Filipinos have become more mindful of the importance of good sanitation and non-pharmaceutical public health measures in mitigating the transmission of the virus. Most Filipinos have also become more proactive in their approach, keeping social distance, wearing masks, and practicing proper handwashing, among others. Furthermore, this crisis has redefined and created new heroes who rose to the challenge – from those staying at home to avoid the further spread of the virus to those on the frontline who have dedicated their time and effort to combat the pandemic, to government and business leaders who have served the country sincerely during this crisis.

Perhaps there really is a silver lining in every cloud.

What are the Chinese government’s objectives for the development of its healthcare system? How do these ambitions affect its interaction with U.S. and other foreign healthcare markets? And what policy recommendations should lawmakers consider regarding the development of China's healthcare system and its implications for U.S. national interests? These are some of the questions that APARC Deputy Director and Asia Health Policy Program Director Karen Eggleston discussed in her testimony before the U.S.-China Economic and Security Review Commission on May 7, 2020.

Watch Eggleston’s testimony (start time 23:25]