HSERV 482 # 14 INDIA and CHINA. Review so far: Key ideas Primordial Epidemiology: "caring and sharing" Conception to age 2-5 is most critical period for.

HSERV 482 # 14

INDIA and CHINA

Review so far: Key ideasPrimordial Epidemiology: "caring and sharing"

Conception to age 2-5 is most critical period for producing health

Vulnerabilities for populations having poor health–Russian upheaval and single-middle-aged men

POPULATION HEALTH BIOLOGY–Understanding as good as any other level of life

Causal relationship

CLINICAL TRIAL OF THESE IDEAS?

Learning Objectivesanalyze the different health outcomes in India and China emerging over the last half century

relate health outcomes to country policies in force during this period

describe possible reasons for Kerala’s remarkably different health outcomes from the rest of India

Who has traveled to or is from INDIA, CHINA?

Plan of sessionIndia’s historyChinese historyIndia/China comparisons in 1950 1980 and afterChina before and after reforms in 1980Chinese famine in 1958-61Family planning policies:

–Coercive–Social Welfare

Kerala ModelMAIN POINT: if health and human welfare are goals Kerala and China (to beginning of reforms), had policies that achieved those ends

India China Health Comparisons1950 1980 2000

China

India

Life expectancy

Infant Mortality

India China Health Comparisons1950 1980 2000

China

India

Life expectancy

40

40

68

48

70

62

Infant Mortality

200

200

39

130

30

70

IndiaGDP

Growth

Hierarchy

Economy

Population

Public Expenditures

Health outcomes

•Low ($444 US- 2001) $564 2003, $2800 ppp•Increasing (4.0% 90-01), 7% (ppp), 8% in 2005 •Getting Higher (4th 2007, 6th 2006, 9th 2005, 12th 2004, in Billionaire Olympics)

•Agriculture declining (as % of GDP), Services increasing

growth of computer industry through foreign capital results in limiting job growth in that sector

1.1 billionlow (and limited to rich)Poor

1990 data, way out of date on left

Indian HistoryAncient cultures and religions

Sultans and princes with their states

1700s Britain and France fought for territory–suppressed better quality Indian cotton–steel industry as good as England’s

1805-on, a part of the British Empire

Impoverished with GNP declining in 1900s

British infrastructure–Rural propertied classes benefited–Periodic famines, miserable health–Gandhi and mass peaceful protest

India since 1950Parliamentary democracy, with disparate ethnic and religious groups “modified socialism”–Nehru experimented with Soviet style Five Year Plans–Attempted land reforms–Affirmative action for untouchables–One third of seats in local government reserved for women

Little spread of development (HALF of world’s poorest in India, 500 million on <$1)–70-80% still agricultural–135 million people without access to health care–226 million without access to drinking water–Half of population illiterate (2.5 times that of S-S Africa)

India since 195062 million+ under-five children malnourished88% of pregnant women are anemicOne third of children <16 years workIndependent pressRecent foreign investment (second largest exporter of computer software)

Increasing unemployment (jobless migrating, buses)Little public investment in education - health careReforms (Structural adjustment)1991 increased poverty –food subsidies reduced, –mechanized agriculture reduced demand for local labor

Indian Reforms 1991+Eased foreign exchange restrictions

Devaluated rupee

Lower import tariffs

Resulted in growth of –middle class

–Entrepreneurs (Forbes Billionaires -36 in 2007, -23 in 2006, 12 in 2005, ) China has 20 only (+21 if add Hong Kong)

US trans-nationals dump cheap Indonesian palm oil when local farmers told to plant mustard/ground nuts for oil, cotton

Food grain surplus (50 M tonnes) and HALF of world's hungry –Families rotate person going hungry each day (P. Sainath)

Depend on foreign remittances, vast migration for work

Agriculture collapse in 1990sGrowth of agriculture

–1980s rate 3-4%–1990s rate halved US subsidies to cotton wiping out India

Rural credit collapsed in countryside today–Ads in papers for notices of banks auctioning property of small farmers (collateral for loans of < Rs. 5000), often wife's jewelry, leading to increased pesticide suicide by farmers, 24 hr morgues, no power outages, illegal

Amount owed by 800 industrialists in India to banks that have not been paid for decades is:–Rs. 62,000,000,000,000 ($1 trillion or $1 million million)–Non-performing assets in Indian banks 98,000,000,000

P Sainath MIT June 5, 2001

Chinese History Oldest, most populous civilization with dynastic history, producing political culture–Confucius (551-479 BCE) (harmony and order):•Legalists: human nature selfish, society sustained by strict laws ruthlessly enforced

•Taoists: humans sociable, perverted by excessive government

•Middle Way: altruism instinctive, but need to socialize humans–Socialization via family with hierarchy by generation, age, sex (parental respect still strongly felt by majority of Chinese in 1982)

–Han dynasty (200 BCE) emperors became supreme sages–Manchu conquest 1644, communities governed selves–1830s opium imports exceeded tea & silk exports•Attempts to stop this led to Opium Wars and instilled foreign presence

.

22

(Map modified from “The Opium Wars”, W.T. Hanes III & F. Sanello, SourceBooks Inc., Naperville, 2002; old photographs reproduced in “Opium Regimes”, T. Brook & B.T. Wakabayashi, Univ. of California Press, Berkeley, 2000 & “Narcotic Culture”, F. Dikötter et al, Univ. of Chicago Press, Chicago, 2004)

...ALL FOR A CUP OF TEA?The opium wars 1839-42, 1856-60

Hong Kong

Peking

Shanghai

...

.

.. .

....

...

.

...

.

..

. Some ports forced open by British.

Opium – for rich or poor

Chinese Revolution 1800s on, Chinese cultural supremacy confronted wealth production of industrial revolution

1912 republic took over from Manchu’s –Descended into warlords/civil wars–Nationalist government fighting communism •Dependent on US aid and finance, corrupted

•Miserable health

•Urban migration, horrible conditions, large families to care for elderly

1949 Communist Revolution–Hierarchy dismantled, equitable distribution of resources–Industrial investment in smaller cities, towns

INDIA AND CHINA in 1950-60

INDIA–490 million

–January 1950,

CHINA–715 million

–Oct 1949

1949: both countries among poorest in the world, high levels of mortality, undernutrition, illiteracy

Population

Constitution came into force

1960 India China

0

100

200

300

400

500

600

700

800

GDP/cap life Exp IMR

India

China

44 47

CHINA before / after reforms in 1979interdependence between achievements BEFORE and AFTER reforms in 1979

accomplishments in education, health care, land reforms and social change in pre-reform period made significant contributions to lesser achievements in post-reform period

China: Pre-reform achievementsGNP per capita growth in pre-reform China not really higher than India,

Grain production averaged 301 kg in 1955-7 and 305 kg in 1975-77,

chronic undernourishment declined because of:–redistributive policies

–nutritional support

–health care

health much better than India’s before reforms

China: Pre-reform achievementsliteracy rates were high for 15-19 year olds in 1981 (96% for males, 85% for females)

COMPARE WITH KERALA

Sen

199

9

1992 India China Kerala

0

10

20

30

40

50

60

70

80

90

100

GDP/cap(ppp US =

100, 1992)

life Exp IMR TFR Prop LBWBabies 85-

90

LiteracyFemale

LiteracyMale

India

China

Kerala

% %

Kerala has low rural/urban differences in LBW, IMR

Social Security Pre-Reform ChinaUrban

–Health care benefits

–Pensions

–Elderly cared for by state

–State dictated wages, welfare standards, and took profits

Rural–Based on communes

–Family and communes took care of aged

–State had “Five Guarantees System” (for vulnerable rural people (aged, orphans, sick, without family), given (1) free food,

(2) fuel,

(3) clothes,

(4) health care (barefoot doctors)

(5) funeral services

Remarkable hindsight

Authoritarianism, famines and vulnerability

Famines of 1958-61 in China killed between 23 and 30 million people

result of Great Leap Forward–rapid collectivization of agriculture crashed badly, and organization aspects collapsed

arbitrary nature of distributional policies –including features of communal feeding –communal kitchens led to over-consumption in some areas, while starvation in others–difficulty distributing between town and country

–- urban areas got more when food output plummeted

Crude Death, Birth Rates China 50-96

Famines of 1958-61 in China killed between 23 and 30 million people

Chinese government not aware of famine problem, so policies not revised for 3 years

•partly because of a controlled press which suppressed information about the famine, but also duped the government as well

•local leaders sent rosy reports, trying to outdo regional rivals

•government thought it had 100 million more metric tons of foods than it did

Famines of 1958-61 in China killed between 23 and 30 million people

Government immune to public pressure, with no dissent or opposition–no organized demand for government to resign despite starvation and mortality –no substantial famine has ever occurred in democratic country where government tolerates opposition–Great Leap Forward could not have occurred without debate in a democracy

China: Reforms-concept of rural “reform” began after Nixon’s trip in 1972

-communes dismantled, land leased out to families

-foreign trade promoted, foreign direct investment permitted

-government allowed a non-state sector

-township and village enterprises proliferated, absorbing rural labor force

-government spending declined as share of GDP

-rush into capitalism

Between 1980 and 1994economic growth: 7.6% per year

•rate implies per capita income doubles every 10 years–(India’s growth rate has been 2-3 % per year for 50 years)

–industrial production grew at 11% per year–agricultural production grew at 5.4%

Maximize personal wealth, suppress unrest

Decline in educational distribution achievements

Decline in women’s status

bicycle (540 million) to automobile-boosts industry–1994 produced 30 million bicycles, •1999 1 million all exported

•Try to ban bicycles in parts of Beijing

NYT 021124

Foreign Direct Investment

China health improvement post reform

moderate in comparison with pre-reform period and with what other countries have achieved

IMR 1960-90 India, China, S. Korea

Kerala had no economic growth

Chinese economic growth in 1980sgrowth in private incomes

Transition from –collective which received economic gains –to

–one in which local public services had to be financed by taxing private incomes

Poorer regions had less income for services, e.g. –Education expenses were harder for poor

RESULT: decreased public sector, many more people marginalized

MIRROR IMAGE OF USA TODAY?

Post-Reform Changes in China

Village health services comprehensively privatized

Economic growth at cost to social services, which

have become relatively under-funded

Huge increases in inequality between urban and rural,

between coastal and inland, and within regions

IMR improvement overall flattened, rural worsened

Stunting seen increasing in rural populations

SUICIDE rates very high, and rural > urban, pesticide

NYT Aug 1, 2004

Urban Social Security Post-ReformState owned enterprises face market competition with

higher labor costs because required to provide social

support

–if leave one’s work lose all benefits

Growing labor force in private sector

Aging population

Flexible labor market

–1/5 to 1/3 of labor force is redundant

Increasing unemployment, urban poorMIRROR IMAGE OF USA TODAY?

Phillips Lancet 2002

Rural Social Security Post-ReformNew land distribution system

Rural factories declining

Rural labor force is older

Increasing work-related disabilities

Must rely on family but family size is small

Many men will remain unmarried with no family to support them in old age

Migration (from poorer west to east) (M>F):–Long-term migrants formally gained urban status–floating population (informal) 80-120 million in 1995fill jobs in low end of earnings ladder

Social Security China Post-ReformRemittances from floating population to migrants’ home communities a significant economic help, and may have slowed the urban-rural income gap–Returning migrants to rural villages devote more attention to children’s education

Urban migrant communities under less strict neighborhood controls, so get growth in crime, prostitution, drug use

Migrants excluded from schooling, health care

Feminization of agriculture at 60% of work force

Medical Care China Post-Reform

Medical expenditures increased 7 fold 1978-92

Increasing private medical costs

Health Insurance schemes,

Speculate considerable medical harm from

unnecessary care provided for profit

Doctors less trusted now

MIRROR IMAGE OF USA TODAY?

China’s coercive one-child policyIndia Crude Birth Rate dropped to 29/1000 in 1992

China Crude Birth Rate dropped to 19/1000 in 1992 –loss of individual freedoms–increased neglect of girl children•1981-1990 MALE IMR dropped from 38.4 to 28.4

•1981-1990 FEMALE IMR dropped from 36.3 to 32.8

•if female IMR had dropped proportionately as much as male, would avert 78,000 deaths a year

Kerala has similar birth rate as China (CBR 18 lower than China 19),

•Kerala has lower TFR’s, higher adult female literacy, and slightly higher life expectancies–women played important role in Kerala’s economic and political life, property relations and educational movements

–don’t need coercion to bring down fertility in poor countries

»don’t have selective infanticide

–Kerala’s IMR is lower than China’s

»both were about the same when China introduced its one-child policy

–China’s IMR is lower for males than females, while opposite true in Kerala

Fertility Declines China Kerala Tamil Nadu

0

0.5

1

1.5

2

2.5

3

3.5

4

China Kerala Tamil Nadu

1979

1991

Kerala ModelKerala's economy is predominantly agrarian in nature. In terms of per capita income and production Kerala is lagging behind many of the Indian States. But in terms of Human Development Index and life standard of the people Kerala is much ahead of most other states in India, and, in fact, in certain development indices it is on a par with some of the developed countries. This peculiar paradox often termed as the KERALA PHENOMENON or Kerala model of development by experts, which is mainly owing to the performance of the State in the Service Sector.

http://www.kerala.gov.in/

Kerala's HealthPolitical economy

–Socialist government

–Strong trade unions

–Five year economic plans

–Vibrant public discourse

Subsistence economy–Government distribution shops

Anti-big business

Religious Diversity (Hindu, Muslim, Christian)

Primary Health Care

Basic education

Various Parameters–DROP OUT RATE Class 1-X: 24% 1998-9 (India's 67%) and in 2002-3 Kerala reduced it while in India it increased

Kerala's HealthHEALTH CARE

One health center for every 1.5 villages cf 1 for 26.4 in all India)

Low cost of services

High demand from rural and urban–97.3% of women received antenatal care

–97% of deliveries took place in health institutions (cf. 26% for India)

Health Parameters–Life expectancy 73 cf US 77 and India's 63

–Infant mortality 11

–Total fertility rate 1.9

–90 % literate

–Matriarchy

Kerala / India gender comparisonsKerala

1961

Kerala

2001

India 1961

India 2001

Sex Ratio females/1000 males 1022 1058 941 933Literacy Rate (women) 39 86 13 54IMR Rural/Urban 60/48

(1971)17/15 (1991)

11 (02)

138/82 (1971)

86/52 (1991)

66 (02)

Mean Age at Marriage M/F 26/20 28/22 (1981) 20/15 23/19 (1981)

Life expectancy M/F

46/50 67/72 (1991)

73 (02)

42/41 61/62(1991) 68 (02)

http://www.kerala.gov.in/

Share of public subsidy for curative care benefiting Income Groups, India

2000 (WB)

10.113.4

17.8

25.6

33.1

0

5

10

15

20

25

30

35

Poorest 20% 2nd Middle 20% 4th Richest 20%

Curative Care Subsidy to Richest fifth vs poorest fifth in India

1.1 1.14 1.14 1.21

2.931.85

2.73 2.98 3.58 3.28 3.16

4.874.16 4.09

4.955.88

10.3

0

2

4

6

8

10

12

KeralaGujarat

Tamil NaduMaharashtra

PunjabAndhraPradesh

West Bengal

HaryanaKarnataka

All IndiaNEFA Orissa

MadhyaPradhesUttar

PradeshRajasthanHimachalPradesh

Bihar

World Bank 2001

India euphoria "Overtake China?"Child malnourishment

–53% cf 20-25 % Sub Sha Af

Food spending ~60% of income for

–9/10 rural families–7/10 urban families

Landless laborers found 123 days of work/yr in 1982 (then 74.6 million)

–Had 72 days of work in 2003–Now 107.4 million

NYT May 6, 2004: "Jobs scarce in India's boom"

–Public sector work has gone ("reforms since 1991")

India ranks 4th in Billionaire Olympics SUBSIDIZE RICH

India Shining GOI

1/3 of world's 840 million hungry in India

–Food grain consump/cap 185 kg in 1997 but 152 kg in 2001 (cf levels in 1943 at time of Bengal famine when there was plenty of food but not made available)

–Food grain stocks at record highs (public distribution system being dismantled because of IMF/WB Rx)•Rats consume Rs 3 billion

Sdhanva Deshapande LeftWord Bks

Foreign Policy article

NYT 050515

China Todayballooning beggars (NYT 040407) migrate from rural to urban areas

–Organized begging rings fronted by children

–Debate: intellectuals push for greater individual rights so "people have the right to beg"•Police no longer repatriate people for not carrying proper ID and now try to send them to shelters, but with major meetings, they are rounded up and carted away

•Guangzhou ban on begging in fancy places

-Chinese born professionals returning from abroad to join establishment in private sector

-Huge migrant labor pool discriminated and harassed

-Fatalism among laid-off state workers, esp. if have son or daughter getting an education

-Demonstrations by young professionals left out

Chan et. al. 2008

Zhao 2006

9

5.4

Study Sites

21.924.58

18.3422.28

17.8116.45

27.59

16.813.03

0

5

10

15

20

25

30

%

High Medium Low

Family Income

Overweight vs Parental Educational Levels by Family Income

college

high school

below high school

The rate of overweight is positive associated with parents’ educational level by family income

China Seven Cities Study: Ming-Chen Lee Ming-Chen Lee Harbin, Shenyang (Northeast) Wuhan (Central) Chengdu, Kunming (Southwest) Hangzhou, Qingdao

China/India Comparisons Today

China IndiaPovertyPop below $1/day 16.1 34.7Pop below $2 47.3 79.9National Poverty line (%)Rural 4.6 30.2Urban <2 24.7

China IndiaDemographicsPopulation 1272 1033IMR 32 69Life Expectancy 70 63

Propserity/1000Telephones 112 32cellular phones 66 4personal computers 15.9 4.5TV sets 293 78

Foreign Direct Investment (% GDP)China India4.3 0.6

REASONS?Businesses likeTotalitarian governments

China IndiaGDP/cap 911 462Growth 1990-2001 8.8 4Growth 1975-2001 8.2 3.2

SummaryIndia and China started at comparable places in health in 1950

China pursued egalitarian promoting policies for 30 years and made remarkable health gains

India, despite democratic institutions, did not promote egalitarian development, nor provide basic social welfare services

India continues to have mass poverty and poor health and reforms will increase health inequalities

Chinese reforms have limited health gains or worsened some

Kerala provides an example of a social welfare state that achieves good health and low fertility