Health in China

An emphasis on public health and preventive treatment characterized health policy from the beginning of the 1950s. At that time the party began to mobilize the population to engage in mass "patriotic health campaigns" aimed at improving the low level of environmental sanitation and hygiene and attacking certain diseases. One of the best examples of this approach was the mass assaults on the "four pests"—rats, sparrows, flies, and mosquitoes—and on schistosoma-carrying snails. Particular efforts were devoted in the health campaigns to improving water quality through such measures as deep-well construction and human-waste treatment. Only in the larger cities had human waste been centrally disposed of. In the countryside, where "night soil" has always been collected and applied to the fields as fertilizer, it was a major source of disease. Since the 1950s, rudimentary treatments such as storage in pits, composting, and mixture with chemicals have been implemented. As a result of preventive efforts, such epidemic diseases as cholera, bubonic plague, typhoid fever, and scarlet fever have almost been eradicated. The mass mobilization approach proved particularly successful in the fight against syphilis, which was reportedly eliminated by the 1960s. The incidence of other infectious and parasitic diseases was reduced and controlled.

Political turmoil and famine following the failure of the Great Leap Forward led to the starvation of 20 million people in China. Beginning in 1961 the recovery had more moderate policies inaugurated by President Liu Shaoqi ended starvation and improved nutrition. The coming of the Cultural Revolution weakened epidemic control, causing a rebound in epidemic diseases and malnutrition in some areas.

With the cultural revolution (1964-1976), Mao Zedong introduced a new approach to public health, especially in rural areas.[3] Known as "rural cooperative medical systems", these structures provided subsidized health care to rural residents.[3] One aspect of this system was barefoot doctors, who received some training and then delivered primary care medicine to those who needed it.[3] Barefoot doctors were a good contribution to primary health systems in China during the Cultural Revolution. It encompasses all principles stated in primary health care. Community participation is possible because the team is composed of village health workers in the area. There is equity because it was more available and combined western and traditional medicines. Intersectoral coordination is achieved by preventive measures rather than curative. Lastly it is comprehensive using rural practices rather than urban ones.[13]

A Chinese barefoot doctor uses her needles to treat a production brigade worker

The "barefoot doctor system" was based in the people's communes.[14] In the 1980s, with the disappearance of the people's communes and the rural cooperative medical system, the barefoot doctor system lost its base and funding.[4] The Chinese government began to push for privatization of health care and, as a result, stopped providing necessary funding.[15] Instead, according to Blumenthal et al. (2005), individual towns were now responsible for ensuring that people were receiving adequate health care, which caused disparities between wealthier and poorer regions.[4] Additionally, the decollectivization of agriculture resulted in a decreased desire on the part of the rural populations to support the collective welfare system, of which health care was a part. In 1984 surveys showed that only 40 to 45 percent of the rural population was covered by an organized cooperative medical system, as compared with 80 to 90 percent in 1979.

This shift entailed a number of important consequences for rural health care. The lack of financial resources for the cooperatives resulted in a decrease in the number of barefoot doctors, which meant that health education and primary and home care suffered and that in some villages sanitation and water supplies were checked less frequently. Also, the failure of the cooperative health care system limited the funds available for continuing education for barefoot doctors, thereby hindering their ability to provide adequate preventive and curative services. The costs of medical treatment increased, deterring some patients from obtaining necessary medical attention. If the patients could not pay for services received, then the financial responsibility fell on the hospitals and commune health centers, in some cases creating large debts.

Consequently, in the post-Mao era of modernization, the rural areas were forced to adapt to a changing health care environment. Many barefoot doctors went into private practice, operating on a fee-for-service basis and charging for medication. But soon farmers demanded better medical services as their incomes increased, bypassing the barefoot doctors and going straight to the commune health centers or county hospitals. A number of barefoot doctors left the medical profession after discovering that they could earn a better living from farming, and their services were not replaced. The leaders of brigades, through which local health care was administered, also found farming to be more lucrative than their salaried positions, and many of them left their jobs. Many of the cooperative medical programs collapsed. Farmers in some brigades established voluntary health-insurance programs but had difficulty organizing and administering them.

Their income for many basic medical services limited by regulations, Chinese grassroots health care providers has supported themselves by charging for giving injections and selling medicines. This has led to a serious problem of disease spread through health care as patients received too many injections and injections by unsterilized needles. Corruption and disregard for the rights of patients have become serious problems in the Chinese health care system.

The Chinese economist, Yang Fan, wrote in 2001 that lip service being given to the old socialist health care system and deliberately ignoring and failing to regulate the actual private health care system is a serious failing of the Chinese health care system. "The old argument that "health is a kind of welfare to save lives and assist the injured" is so far removed from reality that things are really more like its opposite. The welfare health system supported by public funds essentially exists in name only. People have to pay for most medical services on their own. Considering health to be still a "welfare activity" has for some time been a major obstacle to the development of proper physician - patient relationship and to the law applicable to that relationship."[16]

Despite the decline of the public health care system during the first decade of the reform era, Chinese health improved sharply as a result of greatly improved nutrition, especially in rural areas, and the recovery of the epidemic control system, which had been neglected during the Cultural Revolution.

From late 2002 to early 2003 the SARS (severe acute respiratory syndrome) outbreak began in China and spread across the world.[17] In the early stages of disease spread, the Chinese government withheld information and may have contributed to the further spreading of the disease.[18] In addition, China's health care system was still fairly decentralized, with a noticeable lack of oversight and little potential for rapid coordination.[2][4] Thus, the SARS epidemic highlighted the need for the Chinese government to begin restructuring its health care distribution.[4] One big issue many have pointed out, including Blumenthal (2005) and Yip et al. (2008), is that much of China's population does not have access to affordable health insurance.[15][4] As a solution, the Chinese government planned to provide universal health insurance to all citizens by 2020.[15][4] To get closer to this goal, the Chinese government began a health insurance program known as the New Cooperative Health Scheme, which gave mainly rural Chinese residents limited insurance coverage for emergencies.[15] Alongside the insurance measures, the Chinese government returned to the successful public health endeavors of the Cultural Revolution by instituting community health centers in urban neighborhoods with the goal of providing affordable options to hospital care.[15] Dong (2008) also mentions that China has been working to reinstate the cooperative medical systems in rural areas by pushing for state-funded health centers to be established.[2] That being said, some studies, such as Dib (2008) have shown that the quality of health care in rural areas still varies widely depending on wealth of the region.[19] Despite debates surrounding the effectiveness of China's revamped health system, the COVID-19 outbreak of 2019-2020 has shown that things have changed since the SARS outbreak of 2003.[20] Specifically, the Chinese government notified their citizens and the rest of the world of the first cases of the outbreak much sooner than SARS in 2003. While it took around four to five months for a public statement on SARS after the first case, it only took about one month for the COVID-19.[20] Because their response escalated more quickly, the food market thought to be at the center of the outbreak was also shut down sooner than the one that had been the source of the 2003 SARS outbreak.[20] In addition to a more rapid response, the Chinese government quickly established committees and consortia made up of both Chinese and international experts to begin exploring methods to combat the outbreak.[20]

A poster from 1982 showing a Chinese family with one child

Created in 1979, under Deng Xiaoping, the One-Child Policy incentivized families to have children later and to only have one child or risk penalization.[24] The One-Child Policy was a program created by the Chinese government as a reaction to the increasing population during the 1970s, that was thought to have negatively impacted China's economic growth. Implementation of the program included rewarding families who followed the program, fining families who resisted the policy, offering birth control/ contraceptives, and in some cases forced abortions.[25] The policy was unevenly implemented throughout China and was easier established in urban areas rather than rural, because of ideals about family size and gender preferences. Prior to the One-Child Policy, the Chinese government had encouraged families to have more children in order to increase the future workforce, however, this promotion made the population of China in the 1970s increase at an alarming rate.[26] Additionally, voluntary programs, involving family planning and contraceptive use, were proposed before the One-Child Policy was fully enforced.[25]

In 2015, the one-child policy of Deng Xiaoping was replaced by a two-child policy, which increased the number of "allowed" children to two.[11] With this, scholars began evaluating the effects of the one-child policy. The One-Child Policy was successful in halting China's increasing population and decreased both the birth rate and population, however, the harsh enforcement of the policy created long-term changes to some of China's health indicators. For instance, favoring males over female children lead to many forced abortions, infanticide and abandoned female children which led to an imbalance of men to women in China.[10] Additionally, birth rates and rate of natural increase decreased as a result of the One-Child Policy.[9] Other consequences of the One-Child Policy include difficulties accessing education and employment as a result of being an undocumented birth.[25]

In terms of positive outcomes, as Zeng and Hesketh (2016) explain, the Chinese government cites the decreased fertility rate resulting from the one-child policy as a determining factor in China's rapidly increasing GDP.[11] However, Zeng and Hesketh (2016) as well as Zhang (2017) also mention that other scholars argue China's fertility rate would have decreased as the country became more and more developed, regardless of whether the one-child policy had been in place or not.[11][12] Zhang (2017) notes that one predicted positive outcome of having less children was that families would invest more money and other resources in the children they did have, leading to a healthier and more successful population.[12] However, follow-up studies on this claim have examined child education outcomes and found that the effects of the one-child policy on education rates was "not statistically significant".[12]

China's dependency ratio is unfavorable because of the policy and its elderly population (65+) will outgrow the working aged people. The elderly population in China is highly reliant on the working aged people for support and the number of dependents (children 0-14, adults 65+) are increasing compared to the number of working aged people. China's population is aging and the number of children born is less than the replacement rate.[9]

Smoking is very prevalent in China. In fact, China has the largest smoking population in the world.[27] One of the most direct results of the popularity of smoking in China is lung cancer, and lung cancer is the single biggest contributor to the frequency of cancer in China.[27] Parascandola and Xiao (2015) refer to the prevalence of lung cancer in China as an epidemic.[27] Collecting data on the topic is complicated by the fact that lung cancer can also stem from China's air pollution.[27] Regardless, smoking related illnesses killed 1.2 million in the People's Republic of China; however, the state tobacco monopoly, the China National Tobacco Corporation, supplies 7 to 10% of government revenues, as of 2011, 600 billion yuan, about 100 billion US dollars.[8] As a result, although movements for tobacco smoking cessation exist and have been gaining popularity, the financial benefit of the smoking industry stands in the way of more effective cessation programming.[28] In addition, the practice of smoking is intertwined with Chinese culture which further complicates the relationship between China and smoking. Smoking is central to socialization in many public spaces, although mainly men participate in the practice.[28] With these complicating factors, it has been difficult to effectively reduce tobacco use and smoking. For example, a Chinese official in 2007 mentioned that if smoking were banned, it would result in social upheaval.[28] Still, interestingly, tobacco use and smoking has decreased from about 30% prevalence to 25% percent prevalence in 2016, a sign that the tide may be changing.[29]

Sex education lags in China due to cultural conservatism. From ancient China to the first half of the 20th century, formal sex education was not taught. Instead, a woman's parents were mostly responsible for her sex education after she is wed.[30] Many Chinese feel that sex education should be limited to biological science. Combined with migration of young unmarried women to the cities, lack of knowledge of contraception has resulted in increasing numbers of abortions by young women.[31]

The Basic Health Services Project piloted strategies to ensure equitable access to China's rural health system; health outcomes for women improved significantly, with substantial declines in maternal mortality due to increased coverage of maternal health services.[32]

Graphic showing the number of probable cases of SARS worldwide

Although not identified until later, China's first case of a new, highly contagious disease, severe acute respiratory syndrome (SARS), occurred in Guangdong in November 2002, and within three months the Ministry of Health reported 300 SARS cases and five deaths in the province. Dr. Jiang Yanyong exposed the level of danger the SARS outbreak posed to China.[33][34] By May 2003, some 8,000 cases of SARS had been reported worldwide; about 66 percent of the cases and 349 deaths occurred in China alone. By early summer 2003, the SARS epidemic had ceased. A vaccine was developed and first-round testing on human volunteers completed in 2004.

The 2002 SARS in China demonstrated at once the decline of the PRC epidemic reporting system, the deadly consequences of secrecy on health matters and, on the positive side, the ability of the Chinese central government to command a massive mobilization of resources once its attention is focused on one particular issue. Despite the suppression of news regarding the outbreak during the early stages of the epidemic, the outbreak was soon contained and cases of SARS failed to emerge.[35] Obsessive secrecy seriously delayed the isolation of SARS by Chinese scientists.[36] On 18 May 2004, the World Health Organization announced the PRC free of further cases of SARS.[37]

A coronavirus disease 2019 (COVID-19) pandemic, caused by the SARS-CoV-2 virus, started in December 2019.[38] It was first identified in Wuhan, the capital of Hubei, China.[39][40] Its severity has surpassed of the 2003 SARS outbreak.[41] On 30 January, the outbreak was declared to be a Public Health Emergency of International Concern (PHEIC) by the World Health Organization (WHO).[42] Wider concerns about consequences of the outbreak include political and economic instability. Political fallout has included the firing of several local leaders of the Chinese Communist Party for their poor response to the outbreak.[43] Outbreak-related incidents of xenophobia and racism against people of Chinese and East Asian descent have been reported in several countries.[44][45][46][47] The spread of misinformation and disinformation about the virus, primarily online, has been described as an "infodemic" by the WHO.[48]

Work with the CDC has created goals of decelerating the spread of Hepatitis B through immunization efforts.[49] However, Hepatitis B is still widespread in China and has been determined by Wang et al. (2019) to have "higher intermediate prevalence (5-7.99%)".[50] In fact, no country has a higher prevalence of Hepatitis B than China and one third of the world's Hepatitis B-afflicted individuals are thought to reside in China.[7] Hepatitis B in China was even described as an "epidemic" in Chen et al. (2018).[7] Some socioeconomic factors that contribute to the continued prevalence of Hepatitis B in China are first the high medical cost related to treatment.[7] Second, the stigma that surrounds the disease causes the importance of Hepatitis B testing to go undiscussed in that people who disclose their Hepatitis B positive status may be discriminated against.[51] These combine to cause a situation where many people in China do not even realize that they are infected with the disease and thus unknowingly may succumb to the disease or pass it on to others.[7]

The AIDS disaster of Henan in the mid-1990s is estimated to be the largest man-made health catastrophe, affecting five-hundred thousand to one million persons. It was also in Hebei, Anhui, Shanxi, Shaanxi, Hubei and Guizhou.[52] HIV was transmitted via blood sale. Blood plasma mixture from several persons was returned so that same person could give blood up to 11 times a day.[53] The disaster was only recognized in 2000 and found out abroad in 2001. Pensioner Gao Yaojie sold her house to deliver data leaflets of HIV to people, while officials tried to prevent her. Some local officials and politicians were involved in the blood sale. In 2003 only 2.6% of Chinese knew that a condom could protect from AIDS.[54]

China blocked by police protest over ineffective drug treatments, cancelled meetings on HIV groups, closured office of the AIDS organization, and detained or put under house arrest prominent AIDS activists such as 2005 Reebok Human Rights Award winner Li Dan, eighty-year-old AIDS activist Dr. Gao Yaojie, and the husband-and-wife HIV activist team of Hu Jia (activist) and Zeng Jinyan.[55]

China, similar to other nations with migrant and socially mobile populations, has experienced increased incidences of human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS). By the mid-1980s, some Chinese physicians recognized HIV and AIDS as a serious health threat but considered it to be a "foreign problem". As of mid-1987 only two Chinese citizens had died from AIDS and monitoring of foreigners had begun. Following a 1987 regional World Health Organization meeting, the Chinese government announced it would join the global fight against AIDS, which would involve quarantine inspection of people entering China from abroad, medical supervision of people vulnerable to AIDS, and establishment of AIDS laboratories in coastal cities. Within China, the rapid increase in venereal disease, prostitution and drug addiction, internal migration since the 1980s and poorly supervised plasma collection practices, especially by the Henan provincial authorities, created conditions for a serious outbreak of HIV in the early 1990s.[56][57][58]

As of 2005 about 1 million Chinese have been infected with HIV, leading to about 150,000 AIDS deaths. Projections are for about 10 million cases by 2010 if nothing is done. Effective preventive measures have become a priority at the highest levels of the government, but progress is slow. A promising pilot program exists in Gejiu partially funded by international donors.

Scanning electron micrograph of Mycobacterium tuberculosis

Tuberculosis is a major public health problem in China, which has the world's second largest tuberculosis epidemic (after India). Progress in tuberculosis control was slow during the 1990s. Detection of tuberculosis had stagnated at around 30% of the estimated total of new cases, and multidrug-resistant tuberculosis was a major problem. These signs of inadequate tuberculosis control can be linked to a malfunctioning health system. Prevalent smoking aggravates its spread.

Leprosy, also known as Hansen's disease, was officially eliminated at the national level in China by 1982, meaning prevalence is lower than 1 in 100,000. There are 3,510 active cases today. Though leprosy has been brought under control in general, the situation in some areas is worsening, according to China's Ministry of Health.[59]

100 million Chinese people have mental illnesses that are varying degrees of intensity.[60] Currently, dilemmas such as human rights versus political control, community integration versus community control, diversity versus centrally, huge demand but inadequate services seem to challenge the further development of the mental health service in the PRC. China has 17,000 certified psychologists, which is ten percent of that of other developed countries per capita.[60]

In the 2000–2002 period, China had one of the highest per capita caloric intakes in Asia, second only to South Korea and higher than countries such as Japan, Malaysia, and Indonesia. In 2003, daily per capita caloric intake was 2,940 (vegetable products 78%, animal products 22%); 125% of FAO recommended minimum requirement.

China has been developing rapidly for the past 30 years. Though it has uplifted a huge number of people out of poverty, many social issues still remain unsolved. One of them is malnutrition among rural children in China. The problem has diminished but still remains a pertinent national issue. In a survey done in 1998, the stunting rate among children in China was 22 percent and was as high as 46 percent in poor provinces.[61][62] This shows the huge disparity between urban and rural areas. In 2002, Svedberg found that stunting rate in rural areas of China was 15 percent, reflecting that a substantial number of children still suffer from malnutrition.[63] Another study by Chen shows that malnutrition has dropped from 1990 to 1995 but regional differences are still huge, particularly in rural areas.[64]

In a recent report by The Rural Education Action Project on children in rural China, many were found to be suffering from basic health problems. 34% have iron deficiency anaemia and 40 percent are infected with intestinal worms.[65] Many of these children do not have proper or sufficient nutrition. Often, this causes them not being able to fully reap the benefits of education, which can be a ticket out of poverty.

One possible reason for poor nutrition in rural areas is that agricultural produce can fetch a decent price, and thus is often sold rather than kept for personal consumption. Rural families would not consume eggs that their hen lay but will sell it in the market for about 20 yuan per kilogram.[66] The money will then be spent on books or food like instant noodles which lack nutrition value compared to an egg. A girl named Wang Jing in China has a bowl of pork only once every five to six weeks, compared to urban children who have a vast array of food chains to choose from.

A survey conducted by China's Ministry of Health showed the kind of food consumed by rural households. 30 percent consume meat less than once a month. 23 percent consume rice or egg less than once a month.

In a 2008 Report on Chinese Children Nutrition and Health Conditions, West China still has 7.6 million poor children who were shorter and weigh lesser than urban children. These rural children were also shorter by 4 centimetres and 0.6 kilograms lighter than World Health Organisation standards.[66] It can be concluded that children in West China still lack quality nutrition.

The most comprehensive epidemiological study of nutrition ever conducted was the China-Oxford-Cornell Study on Dietary, Lifestyle and Disease Mortality Characteristics in 65 Rural Chinese Counties, known as the "China Project", which began in 1983.[67] Its findings are discussed in The China Study by T. Colin Campbell.

A factory in China along the Yangtze River, illustrating one of the factors contributing to China's air pollution

China's rapid development has led to numerous environmental problems which all have a direct impact on health. According to Kan (2009) the environmental issues include "outdoor and indoor air pollution, water shortages and pollution, desertification, and soil pollution".[68] Of these, Kan (2009) states that the most detrimental one is the outdoor air pollution for which China has become known.[68] In Liu et al.'s research (2018) on this issue specifically, the major health effects are listed as "including adverse cardiovascular, respiratory, pulmonary, and other health-related outcomes".[6] The air pollution is not limited to industrial cities. In fact, due to the fact that rural Chinese people still use fuels such as coal for cooking, the World Health Organization attributes more premature deaths to that sort of air pollution than to China's ambient air pollution.[68] In addition, many factories are located in the countryside, which exacerbates rural air pollution.[68] Despite China's notoriously poor air quality, Matus et al. (2011) have found that the severity of China's air pollution has been declining over the years.[69]

Finally, as described by Kan (2018) and Wu, et al. (1999) another major contributor to adverse health effects related to environmental issues is water pollution.[70][68] In rural areas, this is once again due to factories located nearby. In urban areas on the other hand, China's water sanitation systems have not yet caught up with the needs of the population.[70] As a result, the water is often contaminated with human waste and is not considered potable.[70] Ingestion of contaminated water has caused diseases such as cholera.[68]

China has problems in certain western provinces in iodine deficiency.[71]

The first known human contraction of Avian Influenza (bird flu), after contact with live poultry in February 2018, was diagnosed to a woman living in the Jiangsu Province of China.[72]

Pig-human transmission of the Streptococcus suis bacteria was reported in 2005, which led to 38 deaths in and around Sichuan province, an unusually high number. Although the bacteria exists in other pig rearing countries, the pig-human transmission has only been reported in China.[73]

• "Critical health literacy: a case study from China in schistosomiasis control"
• Children's Healthcare in China
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• China's Healthcare System: Improving Quality of Insurance, Service, and Personnel Reforming China’s Healthcare System Roundtable series held by the Brookings-Tsinghua Center at Tsinghua University
• The Current State of Public Health in China Annual Review of Public Health Vol. 25: 327-339 (Volume publication date April 2004)
• A Critical Review of Public Health in China August 2004 paper