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Background:

The amount of insulin needed to effectively treat type 2 diabetes worldwide is unknown. It also remains unclear how alternative treatment algorithms would affect insulin use and disability-adjusted life-years (DALYs) averted by insulin use, given that current access to insulin (availability and affordability) in many areas is low. The aim of this study was to compare alternative projections for and consequences of insulin use worldwide under varying treatment algorithms and degrees of insulin access.

Methods:

We developed a microsimulation of type 2 diabetes burden from 2018 to 2030 across 221 countries using data from the International Diabetes Federation for prevalence projections and from 14 cohort studies representing more than 60% of the global type 2 diabetes population for HbA1c, treatment, and bodyweight data. We estimated the number of people with type 2 diabetes expected to use insulin, international units (IU) required, and DALYs averted per year under alternative treatment algorithms targeting HbA1c from 6·5% to 8%, lower microvascular risk, or higher HbA1c for those aged 75 years and older.

Findings:

The number of people with type 2 diabetes worldwide was estimated to increase from 405·6 million (95% CI 315·3 million–533·7 million) in 2018 to 510·8 million (395·9 million–674·3 million) in 2030. On this basis, insulin use is estimated to increase from 516·1 million 1000 IU vials (95% CI 409·0 million–658·6 million) per year in 2018 to 633·7 million (500·5 million–806·7 million) per year in 2030. Without improved insulin access, 7·4% (95% CI 5·8–9·4) of people with type 2 diabetes in 2030 would use insulin, increasing to 15·5% (12·0–20·3) if insulin were widely accessible and prescribed to achieve an HbA1c of 7% (53 mmol/mol) or lower. If HbA1c of 7% or lower was universally achieved, insulin would avert 331 101 DALYs per year by 2030 (95% CI 256 601–437 053). DALYs averted would increase by 14·9% with access to newer oral antihyperglycaemic drugs. DALYs averted would increase by 44·2% if an HbA1c of 8% (64 mmol/mol) were used as a target among people aged 75 years and older because of reduced hypoglycaemia.

Interpretation:

The insulin required to treat type 2 diabetes is expected to increase by more than 20% from 2018 to 2030. More DALYs might be averted if HbA1c targets are higher for older adults.

Funding:

The Leona M and Harry B Helmsley Charitable Trust

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Handbook of International Food and Agricultural Policies is a three-volume set that aims to provide an accessible reference for those interested in the aims and implementation of food and farm policies throughout the world. The treatment is authoritative, comprehensive and forward looking. The three volumes combine scholarship and pragmatism, relating academic writing to real-world issues faced by policy-makers. A companion volume looking at the future resource and climate challenges for global agriculture will be published in the future.

Volume I covers Farm and Rural Development policies of developed and developing countries. The volume contains 20 country chapters together with a concluding comprehensive synthesis of lessons to be drawn from the experiences of the individual countries.

Volume II examines the experience of countries with food policies, including those dealing with food safety and quality and the responsibility for food security in developing countries. The chapters address issues such as obesity, nutritional supplements, organic foods, food assistance programs, biotech food acceptance, and the place of private standards.

Volume III describes and explains the international trade dimension of farm and food policies — both at the bilateral and regional level — and also the multilateral rules that influence and constrain individual governments. The volume also looks at the steps that countries are together taking to meet the needs of developing and low-income countries.

The volumes are of value to students and researchers interested in economic development, agricultural markets and food systems. Policy-makers and professionals involved in monitoring and regulating agricultural and food markets would also find the volumes useful in their practical work. This three-volume set is also a suitable source for the general public interested in how their food system is influenced by government policies.

Readership: Students and researchers who are interested in economic development, agricultural markets and food systems; and policy-makers and professionals involved in monitoring and regulating agricultural and food markets.

 

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Gary Mukai
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During the U.S.-Japan Council annual conference that was held in Tokyo on November 8 and 9, 2018, Rylan Sekiguchi was elected chair of the TOMODACHI Emerging Leaders Program (ELP). The ELP identifies, cultivates, and empowers a new generation of leaders in the U.S.–Japan relationship. Emerging Leaders participate in leadership education, design and implement original USJC programming, and develop powerful, lifelong personal and professional friendships. A new cohort of leaders aged 24–35 is selected annually through a highly competitive process. USJC Senior Vice President Kaz Maniwa, who oversees the ELP, commented, “We are delighted that Rylan Sekiguchi will lead the Emerging Leaders Program next year as the chair of the Steering Committee. Rylan has shown great passion, dedication, and commitment to the Emerging Leaders Program and we look forward to his leadership.”

Secretary Norman Mineta and Rylan Sekiguchi Secretary Norman Mineta and Rylan Sekiguchi

During the conference, Sekiguchi gave an overview of the ELP and shared reflections of how his professional and personal lives have embraced the mission of the ELP. Sekiguchi spoke specifically about his current work at SPICE with USJC Vice Chair Norman Mineta, former Secretary of Commerce under President Bill Clinton and Secretary of Transportation under President George W. Bush. Mineta is the subject of a new documentary—An American Story: Norman Mineta and His Legacy—co-produced by Dianne Fukami and Debra Nakatomi, and Sekiguchi is finalizing web-based lesson plans that focus on the film’s key themes, including immigration, civil liberties, and leadership. The documentary was screened at the conference and is anticipated to air on PBS.

A short video that Sekiguchi shared during his speech brought applause from the audience. The video captured a snippet of a performance that he and other members of San Jose Taiko presented last year. The performance celebrated “swing music and the role it played in lifting people’s spirits amid the harsh reality of the Japanese-American internment,” shared Sekiguchi. “Through music and theater, we transported people back to a 1940s-era ‘camp dance’ to educate audiences about the painful, agonizing choices that incarcerees faced.” Mineta was a young boy when his family was uprooted from San Jose, California, and incarcerated in a camp for Japanese Americans in Heart Mountain, Wyoming. Mineta later became mayor of San Jose in 1971.

Through Sekiguchi’s reflections, audience members from both sides of the Pacific were prompted to reflect upon civil liberties during times of crisis—in this case, the incarceration of Japanese Americans following the Japanese attack on Pearl Harbor. My father was a high school student in a camp in Poston, Arizona, and the video prompted me to recall one of the few things that he shared with me about his life behind barbed wire—that camp dances and baseball brought some sense of normalcy to the lives of Japanese-American youth. By showing the video, Sekiguchi’s implicit message was clear: young Americans today—including of course, ELP members—must be aware of the sometimes fragile nature of civil liberties. I have the good fortune of working with another ELP member, Naomi Funahashi, and during the conference, it was rewarding for me to meet many ELP alumni and members of the newest cohort and to witness the beginnings of personal and professional friendships amongst them. Sekiguchi’s speech set the tone for the year ahead—like a “camp dance,” he wants the ELP members to have fun but to always remember the serious nature of what the ELP represents.


SPICE’s web-based lesson plans will be released soon. To stay informed of SPICE-related news, join our email list or follow SPICE on Facebook and Twitter. SPICE also offers several traditional lesson plans on the Japanese-American internment, the role of baseball in Japanese-American internment camps, and civil liberties in times of crisis.

 

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Shorenstein APARC's annual overview of the Center's 2017-18 activities  is now available to download

Feature sections look at the Center's seminars, conferences, and other activities in response to the North Korean crisis, research and events related to China's past, present, and future, and several Center research initiatives focused on technology and the changing workforce.

The overview highlights recent and ongoing Center research on Japan's economic policies, innovation in Asia, population aging and chronic disease in Asia, and talent flows in the knowledge economy, plus news about Shorenstein APARC's education and policy activities, publications, and more.

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The emergence of a global digital ecosystem has been a boon for global communication and the democratization of the means of distributing information. The internet, and the social media platforms and web applications running on it, have been used to mobilize pro-democracy protests and give members of marginalized communities a chance to share their voices with the world. However, more recently, we have also seen this technology used to spread propaganda and misinformation, interfere in election campaigns, expose individuals to harassment and abuse, and stir up confusion, animosity and sometimes violence in societies. Even seemingly innocuous digital technologies, such as ranking algorithms on entertainment websites, can have the effect of stifling diversity by failing to reliably promote content from underrepresented groups. At times, it can seem as if technologies that were intended to help people learn and communicate have been irreparably corrupted. It is easy to say that governments should step in to control this space and prevent further harms, but part of what helped the internet grow and thrive was its lack of heavy regulation, which encouraged openness and innovation. However, the absence of oversight has allowed dysfunction to spread, as malign actors manipulate digital technology for their own ends without fear of the consequences. It has also allowed unprecedented power to be concentrated in the hands of private technology companies, and these giants to act as de facto regulators with little meaningful accountability. So, who should be in charge of reversing the troubling developments in our global digital spaces? And what, if anything, can be done to let society keep reaping the benefits of these technologies, while protecting it against the risks?

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Nations around the world recognize cybersecurity as a critical issue for public policy. They are concerned that their adversaries could conduct cyberattacks against their interests—damaging their military forces, their economies, and their political processes. Thus, their cybersecurity efforts have been devoted largely to protecting important information technology systems and networks against such attacks. Recognizing this point, the Oxford Dictionaries added in 2013 a new word to its lexicon—it defined cybersecurity as “the state of being protected against the criminal or unauthorized use of electronic data, or the measures taken to achieve this.” Read more.

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Drones are considered poor coercion tools: They cannot operate in contested airspace and they offer low-cost fights instead of more credible, costly signals. However, this article finds that technological advances will soon enable drones to function in hostile environments. Moreover, drones offer three unique coercion advantages that theorists did not foresee: sustainability in long duration conflicts, certainty of precision punishment which can change the psychology of adversaries, and changes in the relative costs of war. A unique survey of 259 foreign military officers finds that costly signals are less credible than assumed and that drones demonstrate resolve in new ways. Read more.

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NATO leaders have a lot to worry about. The U.K. government is a Brexit hot mess. Germany’s Angela Merkel, who has been holding a unified Europe together on her shoulders like Atlas, may not be able to last much longer. Turkey’s Recep Tayyip Erdoğan has been channeling his inner authoritarian, and he’s not the only one. And then there’s President Donald Trump. Never one for subtlety, Europe’s most important ally called nato obsolete, threatened to ignore America’s treaty defense commitments to nato members that don’t pay up, slapped tariffs on European aluminum and steel, and treated nato as an irritating layover on the way to his real destination: Helsinki, where he’ll be meeting with Russian President Vladimir Putin. And that was before Trump actually touched down in Brussels and started berating European leaders face-to-face.

Many experts believe the chief challenge of managing President Trump’s foreign policy is keeping Trump on message. They’re wrong. Trump isn’t misspeaking when he ignores his talking points, insults allies, or congratulates Putin on winning a sham election. He’s not veering off script when he declares that North Korea is no longer a nuclear threat just because Kim Jong Un posed for a photo in Singapore. Trump is actually on message nearly every day and in every tweet. It’s just not a message that most serious national-security experts want to hear. Deep in the recesses of our brains, we experts just cannot believe that an American president would pursue so many profoundly shortsighted policies—or that he would actually believe he’s doing a good job.

Trump has a foreign-policy doctrine, all right. He’s been advancing it with remarkable speed, skill, and consistency. Its effect can be summed up in one neat slogan: Make America Weak Again.

America’s preeminence on the world stage rests on five essential sources of power: neighbors, allies, markets, values, and military might. The Trump Doctrine is weakening all of them except the military.

To be fair, America’s military might is a biggie in global politics, and Trump deserves high marks for rebuilding America’s fighting forces after years of decline in the face of growing threats. The February 2018 budget deal allowed for a $61 billion increase in military spending in 2018 with another $18 billion increase in 2019, making it the largest defense budget in U.S. history and reversing crippling defense sequestration caps from 2013—a deal designed to be so bad, Congress thought it would bring everyone to their senses but didn’t. Trump isn’t just spending more; he’s modernizing and innovating more, too. The Trump administration is committed to modernizing America’s aging nuclear weapons and delivery systems, and has called for additional research spending for cyber, electronic warfare, artificial intelligence, and space—all key areas where the U.S. is increasingly vulnerable and the country’s innovation edge is narrowing. Trump’s defense-spending policies have received overwhelming bipartisan support, a rare feat in Washington. In a complicated global landscape with Russia seeking to stretch its territorial reach and China undergoing a massive 20-year military buildup, a recommitment to investing in military strength is both welcome and necessary.

But it won’t be enough. In today’s threat environment, military power can’t go it alone. The other four sources of American power are more important now than ever. And under Trump, they are growing weaker by the day.

Friendly neighbors are underrated as a source of global power. The United States was born with good geography and successive presidents have made the most of it. For centuries, the empires and nation-states of Europe and the Middle East have lived in tough neighborhoods, with hostile powers nursing historical grievances and vying for advantages through brutal territorial conquest. By contrast, the United States has prospered in no small measure because it has been flanked by two vast oceans and two friendly neighbors that have provided a level of security other states would envy. The last time American and Canadian soldiers fought one another was in 1815. The Mexican–American War ended in 1848, and the last U.S. president to order troops into Mexican territory was Woodrow Wilson, who did so a century ago. Europe’s latest territorial aggression occurred in 2014 (when Russia invaded Ukraine and annexed Crimea). Wars are so prevalent in the Middle East, it’s hard to remember a time when there wasn’t one.

The Trump Doctrine, however, sees dangerous threats massing along America’s borders and calls for a sharp departure from the past. The Trump administration’s policies and pronouncements have sent Canadian–U.S. and Mexican–U.S. relations into tailspins, threatening longstanding ties and close cooperation on everything from defense to drug interdiction to trade. Relations in the ’hood haven’t been this bad in a century. From imposing tariffs on Canadian goods because they’re “national-security threats,” to all those comments about Mexican “rapists” and “bad hombres” flooding into U.S. cities, to the border wall, to vows to jettison the North American Free Trade Agreement that has been pivotal to economic growth across the continent, it’s little wonder the neighbors aren’t feeling so neighborly anymore. Mexican voters just elected an anti-Trump, radical leftist president in a landslide election. Canadian officials have imposed retaliatory tariffs and are now talking about how to protect their nation from the United States. It takes a special kind of stupid to make enemies out of Canadians.

Alliances are another vital source of American strength on the global stage. In Asia, the U.S. has better bilateral relations with China’s neighbors than China does, including defense treaties with Japan and South Korea. These relationships advance U.S. interests, project American power, protect global commerce, and promote peace and stability. In Europe, one of Russia’s chief aims is to split the nato alliance because Russia has so few friends of its own. Putin knows that alliances are not about spreading some woolly-eyed vision of global peace over lattes and arguing over who pays the bill. They are about the hard-nosed projection of national power in a dog-eat-dog world. The more friends you have, the more economic, diplomatic, and military might you can marshal and the more you can coerce adversaries to do what you want them to do.  

But the Trump Doctrine sees alliances as raw deals in which the U.S. pays too much and gets too little. Yes, it’s true that most nato allies have not lived up to their defense spending commitments and it’s high time they did. But the Trump Doctrine often seems to suggest that alliances should be run more like a market bazaar, where buyers and sellers haggle over everything and often get nothing—even when a lopsided deal is in everyone’s best interest. Joint-readiness drills, foreign sales of American military equipment, and relationship management cannot be boiled down to Buy the scarf with that shirt or you’ll get nothing. For alliances to work, allies have to know they have each other’s backs. And enemies have to know it, too. Just ask Putin if he’d rather have nato—with all of its “raw deals” uniting 29 nations that include economic powerhouses such as Germany and Spain and global leaders such as France and the United Kingdom—or his own allies, which consist of exactly one besieged Syrian tyrant, the six-member Collective Security Treaty Organization (whose other members are the superpowers called Armenia, Belarus, Kazakhstan, Kyrgyzstan, Tajikistan), and, on good days, some Iranians.

The third source of American power is the country’s economy, which has become the envy of the world because it trades with the world. Thanks to falling trade barriers and rising globalization since World War II, global economic growth has hit unprecedented levels. More than a billion people have been lifted out of extreme poverty. And the U.S. has prospered. Sure, free trade creates global winners and losers, and many playing fields are not level. China has been stealing American intellectual property and doing everything it can to keep American companies down and out. Beijing isn’t even secret about it. China’s “Made in China 2025” plan declares the country’s intention to corner the market in key growth industries such as robotics and electric vehicles.

The Trump Doctrine views free trade with suspicion, the liberal international order as a rip-off to American workers, and economics as a zero-sum game in which if you win, we lose. Trump is a protectionist and proud of it. It seems he’s never met a tariff he didn’t like. First came the steel and aluminum tariffs on U.S. allies, sparking retaliatory tariffs on everything from American motorcycles to bourbon. Now Trump and China are locked in an escalating trade war that has started at $50 billion worth of goods on each side. It’s anyone’s guess when or how it will end, but this much is clear: It won’t be good.

Why would the president undermine American economic vitality? Because the Trump Doctrine is meeting 21st-century trade challenges with 20th-century tactics: tariffing the heck out of foreign products under the misguided assumption that tariffs will only affect the countries they target. Trump seems stuck in the 1970s, when most cars were made in Detroit and most TVs were made in Japan. In today’s world of global supply chains, products just aren’t made in one place anymore. The Dutch company Fairphone has just 27 employees but sources its parts from Africa, the Middle East, Europe, North America, and China. Made in America doesn’t mean what it used to. In a global-supply-chain world, tariffs don’t just hurt foreign companies and workers. They hurt American ones, too.

The fourth and most unique source of global power is American values. The United States has always been much more than a country. It’s an audacious experiment in democracy and an enduring hope for others. This “shining city upon a hill” has not always lived up to its own aspirations or expectations. But for many oppressed peoples in the far reaches of the globe, the United States has always stood for the triumph of laws over the naked abuse of authority, and for the capacity of democracy to bring freedom, peace, and prosperity to everyone, not just Americans.

The Trump Doctrine rejects these bedrock American values at home and refuses to advance them abroad. Democratic states are considered weak, authoritarian leaders are admired, moral authority counts for nearly nothing, soft power is too soft, and hard power is what gets results. In this presidency, journalists are labeled enemies and dissent is considered unpatriotic. Nobody should count on hearing stirring speeches about the march of freedom or the power of justice during the president’s trips abroad. Or seeing throngs of well-wishers in distant capitals lining up to see the president because of the noble values he represents or the sacrifices he honors in America’s military heroes, who paid the ultimate price to secure the blessings of freedom for others. The effect of the Trump Doctrine is Making America Weak Again by diminishing the role of American values, and with them our standing in the world.

International-relations scholars have long found that great powers typically fall for two reasons: imperial overstretch or rivalry with other great powers. Never in world history has a country declined because of so many self-inflicted attacks on the sources of its own power.

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The CISAC Research Seminar Series features speakers that present on topics related to international security and their policy implications. The purpose is to encourage interchange between the scientific and non-scientific communities at CISAC and within Stanford, to further CISAC’s goals of educating students and the public, conducting good scholarly research and influencing policy.

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