China is an important country in Asia and has the largest population in the world. The total population in China is 1.41 billion in 2017 from WHO database1 and is 20% of world population. China is the one of top five large countries on the earth. The land of China is about 9.6 million square kilometers with all kinds of landscapes of mountains, rivers, deserts and plains. China has a border with 14 neighbor countries including Japan, Korea and India. China has the same number of border countries as Russia. China has 31 provinces and regions, and two special administrative regions of Macau and Hongkong2.
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Historical, Social and political introduction
China has more than 5000 years of history, and has developed from Prehistory, Dynastic, Republic to People’s Republic period. China is officially named the People’s Republic of China (PRC) and set up by the chairman, Zedong Mao, on Oct. 1, 1949. The Communist Party has the power to rule the China mainland, and Taiwan island is under the government of Republic of China. But the Chinese government and people hold “One-China policy” and consider Taiwan is one province of China. There are 56 ethnic groups in China and the whole family is named “Zhonghua Minzu”. The government president of China currently is Jinping Xi.
The Chinese government has been criticized by many political restrictions, such as, freedom of religion, freedom of assembly and social organizations, and free access to internet, although China describes itself as a communist and socialist country3. However, the central-control policy can unite people and control nation disaster better at some points for China.
Climate and Environment
China has the similar latitude and size to America, thence the climate of China is a different complex among regions like America. China also has dry seasons and wet seasons such as winter and summer. Most regions have four seasons, but since China is large and the climate varies among different landscapes4.
Since 1978, China has gone through numbers of reforms and the economy has developed rapidly. China has been the second-largest economy in the world since 2010 for GDP5 (Fig.1, made by the software Prism). China has largest e-commerce market. Alibaba, Wechat and Tmall are popular online sales and smartphone sales. Huawei, is the 2nd smartphone vendor after Apple and has invented the 5G wireless signal in China. China is leading in the renewable energy of the world, from hydroelectric power, wind power and solar photovoltaic system6.
However, the environment of China has been disrupted by the rapid economic development and lack of protection, such as air pollution, water contamination, heavy metal pollution and deterioration. The severe environment pollution has caused many diseases such as cancer7 and increasing death, intellectual and developmental disabilities which we will discuss in the next session.
Health and Medical System in China
A special medical system in China is the barefoot doctor system, which have been a successful precedent to preventive public health service and a best addition to connect urban and rural region in China. China proposed a new medical/insurance system40 and trained more professionals since 2003. More doctors utilize “Chinese medicine” and “Western medicine” together and create the unique integrative medicine. The Chinese herbs, message and acupuncture are starting to be popular and acceptable in United States.
Global Indicators of Population Health
There are many indicators for public health according to the World Health Statistics 2018 report8. In this paper, we will cover all the topics we learned from our class, life expectancy, mortality, malnutrition, infections disease (HIV, TB, Hepatitis and Malaria) and non-communication disease (eg.cancer and heart disease) for all the important public health indicators.
Public Health Issues
Health differences and inequities
Inequalities are one of the main challenges for China in the coming years. Living condition, social determinants such as lifestyle, consumer behavior, career choices and individual values are dramatically changing. There are huge differences for health service accessibility and health outcomes between urban and rural areas (for example: immigrant population and residents, ethnic minorities), and between different regions (such as the east and west).
Child survival and safety motherhood
Life expectancy and other health indicators for women, children and adolescents in east coast cities such as Beijing, Shanghai, and Tianjin have surpassed high-income countries such as South Korea and the United States9, but health indicators in western cities such as Guizhou, Tibet, and Xinjiang are equivalent to low-income countries10. Women and children in remote rural areas are particularly lacking in high quality medical services; child mortality under five years of age, maternal mortality, the incidence of communication diseases, malnutrition and anemia compared to cities is much higher. China has a high rate of caesarean section which is still increasing11,12. A WHO survey of 2007-2008 shows that caesarean section rates may reach 46.2%, but there are variations between different regions13. The fertility rate for adolescents has been rising since 2000. According to World Health Statistics 2018 report8, the maternal mortality in China is 27 per 100,000 and the under-five mortality rate is 9.9 per 1000. Both mortalities are lower than the goals for the global mortality rates in 2030.
Chronic and infectious disease
HIV infection rates in China are as low as 0.06%, but the high prevalence happens in some areas and for specific populations. The transmission route of HIV is mainly sexual transmission, and the transmission from men to men is obviously increasing. In China, it is estimated that about 30% HIV patients are unclear about their infection status14, making it difficult to provide them with effective prevention and intervention services, thence increase the risk of further transmission.
China is at the 2nd place for multi-drug-resistant tuberculosis burden in the world. There are 778,390 cases reported15 and the mortality of TB is 37 per 100,000 in 2017. The incidence of MDR-TB is 69 per 100,000. This situation needs to have long treatment time and high cost for the tuberculosis disease. The current medical insurance policy is limited in China, and increased Medical burden of resistant patients16.
Despite Children can obtain hepatitis B vaccination in China, and the vaccine prevents blood transmission of viral hepatitis, and prevents hepatitis A and hepatitis E transmitted through the faecal-oral route, but the burden of chronic hepatitis is very heavy. There are currently about 90 million people infected with hepatitis B virus in China and 28 million need to have the treatment. Among them, about 7 million people have entered the advanced stage of liver fibrosis, and urgently need to be treated. They belong to high-risk groups of liver cancer. In addition, an estimated 7.6 million people have been infected with the hepatitis C virus17. Of these, 2.5 million people are in urgent need of treatment.
Chronic infection has been estimated to be one of the major carcinogenic factors in China, especially hepatitis B and C. Infection factors such as hepatitis and helicobacter pylori are highly likely to induce cancer, including liver cancer18. Taking more preventive and intervention actions can not only reduce the burden on hepatitis patients, but also significantly reduce the morbidity, mortality and carcinogenicity.
The incidence of non-communicable diseases is rising rapidly in China. Heart disease, cancer, diabetes and chronic respiratory diseases are four main factors to cause death in urban and rural areas of China and the mortality is 533 per 100,000 and is 87% in total death of China19. Behavioral risk factors for non-communicable diseases such as high salt and fat diets, smoking, drinking, and lack of physical exercise are common. The smoking rate is about 27.7% in China20, there is a huge difference in smoking rates between men and women. China has 315 million smokers, and 740 million people are exposed to second-hand smoke, resulting in more than 1 million deaths each year from tobacco-related diseases. Hence, tobacco is China's first preventable cause of death21. The harmful alcohol drinking rate in China was 9.3%. The prevalence of diabetes and hypertension among residents were 9.7% and 25.2%21, 22, which increase in the burden of non-communicable diseases.
The female malnutrition with BMI>25kg/m2, has been increasing gradually from 12.3% to 34.5% during 1980-2016. The adult obesity rate was 5.2, an increase of 2.3% compared with 2002. In 2013, the obesity rate under 6 years old is 3.1%, an increase of 1.9% compared to 2002. The Stunting is the dominant problem for the children under 5 years old among other malnutrition diseases (obesity, underweight and overweight), and the prevalence of stunting has dropped from 13.7% to 9.4% between 2008 and 201023.
Mental health has become a major public health problem in China24. The trained professionals for mental health are only 20,000 psychiatrists and obviously inadequate. In 2015, the Chinese government released National Mental Health Work Plan (2015-2020), which will prevent depression, dementia and autism. The government will register severe psychiatric patients with a management rate of more than 80% and at least 80% of patients with schizophrenia are listed as key targets for treatment. The plan also provides financial support for severely mentally ill patients with financial difficulties25. The number of psychiatrists will be planned to double by 2020.
Injury and accident
Injury is the leading cause of death in children and adolescents. In 2014, the mortality rate of the rural area is 55 per 100,000, which is much higher than 37.8 per 100,000 for the urban area26. Top five fatal injuries in China are, traffic accidents, suicides, falls, drowning and poisoning27.
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Environmental changes: water sanitation and air pollution
In China, the proportion of population using safely managed sanitation services8 is 60% in 2015. The physical and mental problems, caused by air and soil pollution, and water shortages and contaminations, give people short-term and long-term health conditions and adverse consequences, such as cancer, respiratory diseases, cardiovascular diseases, nervous system diseases, and diarrheal diseases.
Air pollution with industrial and economic development in China is very severe, and the factor for fine particles in the air is too high at PM2.5. 71 out of 74 cities did not meet the air quality secondary standard28. Mortality rate attributed to household and ambient air pollution8 is 113 per 100,000. The Chinese government invested $2.57 billion in 2016 to improve Air quality29, and introduced an action plan to control water pollution30. China also generated a proactive renewable energy plan, and will increased the renewable energy to 15% by 2020.
Food Safety and Drug Safety
In recent years, the fraud food and the illegal addition or abuse of chemical ingredients in China has become increasingly problematic. The problems have received public attention and has increased the burden of disease and death in China. The public has widely questioned the safety of Chinese food and medicine which will affect the export of food and medicine. Therefore, the quality of food and drug regulation will be important for the National Health and Family Planning Commission and China government.
An aging society
China is one of the first countries to enter an aging society. To 2020, China’s aging population will reach 250 million, accounting for 17.6% of the total population; by 2053, the aging population will rise to 487 million, accounting for 35% of the population31,32 in China. Ageing population will change of lifestyle, social and economic development, smoking, and alcoholism. The combination of aging and non-communicable diseases will be a huge burden for the economy of China.
Public Health Success
The health of the Chinese population has improved significantly. Human Development Index (HDI), has increased by 70%, from 0.423 in 1980 to 0.719 33. HongKong of China ranks at 7th position and China ranks 86th among 189 countries and regions for the human development index in 2017 34. According to the HANCI Global Index 2017 data, 75 percent of the population in China has access to improved sanitation for water. This is mainly due to: 1). Public health regulation reduces the child mortality and reduced infectious diseases. 2). Improved economic conditions contribute to nutrition, education and the allocation of health service resource.
We will focus on one significant success for the elimination of Malaria in China. China launched the malaria elimination goal on 2010, and aimed to eliminate malaria in 2020. China successfully achieved this goal as one of the E-2020 countries named by WHO35. China had zero case of malaria from 2017-2019, and will be soon eligible to get the malaria free certificate from WHO.
From Fig.2 (original data from WHO website36, made by Prism), we know the health condition in China has been greatly improved, indicating by the linear increasing income, the decreasing under-five mortality (75%), and the malaria elimination.
This is a miracle for China to eliminate malaria from 30 million to zero since 1950. For the early effort to control malaria, China founded a National Malaria Control Programme in 1955, which steadily made progress and reduced malaria related death to 95%37. In 2010, China set up an ambitious goal to eliminate malaria and to target of the 2000 Millennium Development Goals.
The “1-3-7” strategy38,39 has been an effective surveillance to monitor and control malaria in China. This strategy has strict timelines and needs to be followed in hour. Within 1 day (in 24 hours), all malaria cases need to be reported to the Chinese Information System for Disease Control and Prevention (CISDCP or CDC), through a four-level system, “county→ prefecture→ province→ national.” Within 3 days, the CDC confirmed the case and verify if the case is a risk for spreading. In 7 days, the CDC measures and ensure on more spread by testing other community members.
China made enormous endeavor to eliminate malaria. There are 464,500 trained clinical doctors and 848,764 micorscopists for malaria health workers39. China also strengthens on the vector control (mosquitos), health education level (people) and controls on immigrant population (transmission). In combination with the “1-3-7” strategy, China efficiently eliminates malaria and the experience will provide a suitable model for other countries to act and achieve the malaria elimination in the world.
China has made great achievements to realize the Millennium Development Goals (MDGs). The people in China are living much longer and healthier than 40 years ago. China has implemented three five-year action plans for AIDS prevention and control, and ten-year plan for the prevention and treatment of tuberculosis disease (TB) to control them at low prevalence level. China gradually eliminates measles, blinding trachoma and polio. However, facing the challenges of population aging and urbanization, China needs to rebuilt the efficient health system for equality of the rural and urban regions and primary care, and to control the non-communicable diseases in the next 20 years.
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I have several survey data in the references, but China is not listed in the countries for the DHS.
I made the Figures by using the software of Prism and the original data were cited.
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