This volume examines important aspects of China's century-long search to provide appropriate and effective health care for its people. Four subjectsdisease and healing, encounters and accommodations, institutions and professions, and people's healthorganize discussions across case studies of schistosomiasis, tuberculosis, mental health, and tobacco and health. Among the book's significant conclusions are the importance of barefoot doctors in disseminating western medicine, the improvements in medical health and services during the long Sino-Japanese war, and the important role of the Chinese consumer. Intended for an audience of health practitioners, historians, and others interested in the history of medicine and health in China, the book is one of three commissioned by the China Medical Board to mark its centennial in 2014.
About the Author
Bridie Andrews is Associate Professor of History at Bentley University.
Mary Brown Bullock is Chair of the China Medical Board and Executive Vice-Chancellor of Duke-Kunshan University.
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Medical Transitions in Twentieth-Century China
By Bridie Andrews, Mary Brown Bullock
Indiana University PressCopyright © 2014 The China Medical Board
All rights reserved.
China's Exceptional Health Transitions
Overcoming the Four Horsemen of the Apocalypse
Lincoln Chen and Ling Chen
Many of the world's countries experienced major health transitions over the course of the twentieth century. China is no exception, but its passage has been distinctive in many ways. China's achievement in life expectancy has been truly spectacular, with average longevity more than doubling over the course of the century. Perhaps unique to China, however, have been major health catastrophes, human calamities that call forth the death theme of "the four horsemen of the apocalypse." In overcoming these dramatic setbacks, China's health transitions have been marked by distinctive phases, where health conditions have been shaped by its health care systems as well as powerful social determinants of health. These phases have exhibited both distinctiveness among countries and continuity across time.
This chapter reviews the unique and exceptional transitions of health in China over the course of the twentieth century. It should be noted that this paper's term "health transition" has different connotations than the title of this volume's reference to "medical transitions." Medical transitions imply changes in the field of medicine —science, perceptions, practice, and institutions. Health transition is a broader concept dealing with the health of populations, not individuals.
By using the term "health transition," this chapter brings together several major transition theories. The theory of the "epidemiologic transition" describes the changing pattern of disease and cause of death as populations progress from higher to lower mortality levels associated with rising incomes and improving health systems (Omran 1971). Whereas poverty-linked diseases such as childhood infections, malnutrition, and maternity-linked burdens characterize low-income societies, noncommunicable chronic diseases like cancer and heart disease dominate in higher-income countries. "Demographic transition" theory, similarly, captures changes in fertility and mortality from high to low levels (Caldwell 1976; Davis 1963; Frederiksen 1969). The time gap between an earlier reduction in mortality to the later decline in fertility generates a gap between birth and death rates that accelerates population growth. In addition to rates of growth, demographic change may also affect the spatial distribution, age structure, and other parameters of human populations. These two theories of transitions are brought together in the theory of the health transition, which integrates not only epidemiologic and demographic parameters but also changes in sociocultural perceptions, health-seeking behavior, and the structure and operations of health systems (Caldwell 1990; Frenk et al. 1989; Frenk et al. 1994; Mosley and Chen 1984). As such, health transition theory is comprehensive, holistic, and interdisciplinary in describing the multiple dimensions of simultaneous changes related to the health of populations.
Using the framework of health transitions, this paper opens with an assessment of changing health conditions in China over the course of the twentieth century. Though they started with health backwardness in the beginning of the century, China's current health conditions rival those of more economically advanced countries. Perhaps uniquely in the world, China demonstrates these remarkable health achievements by overcoming unprecedented health catastrophes. The chapter then probes the nature of these health changes by examining patterns in the cause of death, again showing China's shift from poverty-linked to affluent lifestyle patterns in the burden of disease. Assessment of China's epidemiologic transition is followed by a review of China's demographic transition. The chapter concludes by looking to the future through an analysis of the reform of China's health system, a recurring theme throughout the century.
Two caveats are indicated. First, the data sources for China's health conditions, causes of death, and population size and distribution are variable; there is better availability of data in recent decades with increasing lacunae as one moves back in history. Especially difficult are estimations of health conditions during times of political crisis, when data collection systems are disturbed or misrepresented. There is also insufficient transparency and openness of access to data for academic study. We recognize these imperfections, but we believe that our estimations are sufficiently robust to substantiate the basic conclusions. Second, we recognize that China is a vast country with great internal diversity. This chapter focuses only on the national level. The variability within China is recognized; indeed, many estimations of the national pattern are derived from microstudies in China's different regions. But focusing on the national level better captures the pattern and velocity of change over the course of a century.
Figure 1.1 charts China's remarkable achievements in health across the twentieth century. With an estimated average life expectancy of only thirty years in 1900, it is no wonder that China was denigrated as the "sick man of Asia." By the end of the century in 2000, however, China's life expectancy had more than doubled, to an estimated seventy-one years.
The trend line for the United States is shown to highlight the nature of China's achievements. Whereas China was seventeen years behind America's life expectancy in 1900, that gap had narrowed to only six years by 2000. Noteworthy is that the gap had widened to twenty-five years at mid-century—China at forty-four years and the United States at sixty-nine years—underscoring China's stagnated health gains in the first half of the century followed by markedly accelerating improvements in the second half of the century.
For comparative purposes, available data on Taiwan and Hong Kong since 1950 is superimposed on the time trends. Relatively unencumbered by the effects of war, Taiwan and Hong Kong began with a higher life expectancy around 1950 and also performed well in the second half of the twentieth century, even surpassing the United States in longevity (United Nations 2011; Ministry of the Interior 2011).
The weak progress in mainland China in the first half of the century, 1900–1950, was undoubtedly related to political chaos, war, and weak health care infrastructure associated with the collapse of the Qing dynasty, the emergence of the Guomindang, the Japanese invasion, World War II, and the postwar civil conflict. The marked acceleration of improvements characterizing the second half of the century, 1950–2000, was achieved due to political stability followed by strong government commitment to equitable health interventions.
The two phases of retarded and accelerated health achievements match well with the theory of the twin engines of health development: direct health action and social determinants of health. The revolution in health sciences, modern knowledge, its derived technologies, and their application has undoubtedly had an important impact on health conditions. While not dismissing the usefulness of traditional medicine as well as modern, there is strong evidence of the life expectancy impact of the application of modern science through health institutions of hospitals and field-based health systems operated by well-trained modern health professionals. These direct health actions parallel the influence of powerful social determinants. Political stability can enable populations to reduce their risk and vulnerability to disease and provide the institutional foundation for direct health interventions. Economic growth brings not only food, clothing, housing, and other material provisions but the physical infrastructure of health care systems. Perhaps most important among social determinants are universal literacy and education, including gender equality. Literate populations are able to understand and act on theories of disease caution, utilize health services, and adapt their behavior to enhance disease prevention and the use of earlier and more effective treatment.
Four Horsemen of the Apocalypse
Figure 1.1 also shows that, more than any major world country, China has experienced some of the greatest health catastrophes in human history. "The four horsemen of the apocalypse" describes the major life-threatening crises due to war, famine, disease, and death (Cunningham and Grell 2000). Unfortunately for the Chinese people, the country experienced all four horsemen. We discuss in turn China's experiences of invasion, war, famine, and epidemics.
Invasion, war, and conflict characterize China's turmoil over the decade and a half of 1937–1949. In 1937 Japan launched a massive invasion of China called the Second Sino-Japanese War (the first war occurred in 1894–1895). After the Japanese attack on Pearl Harbor in 1941, the invasion became part of the greater conflict of World War II as a major front of what is broadly known as the Pacific War. The conflict did not cease with the surrender of Japan in 1945, as the Guomindang and the Communists fought a protracted civil war in 1945–1949. The official government statistics for Chinese military and civilian casualties in the Second Sino-Japanese War from 1937 to 1945 are twenty million dead and fifteen million wounded (Guo 2005). Other estimates suggest that the total population of about 500 million suffered ten to twenty million deaths, or 2–4 percent of the population (Clodfelter 2001).
Famine, unfortunately, killed more Chinese than epidemics or war in the twentieth century! Indeed the worst famine in recorded history hit China during the Great Leap Forward in 1959–1962. The causes and toll of the famine have received extensive and intensive academic attention (Ashton et al. 1984; Lin and Yang 1998), and excess famine deaths have been estimated at twenty to forty-five million (Peng 1987; Sen 1987). Grain production dropped by 15 percent in one year and then to about 25 percent below its previous level for two further consecutive years. Birth rates dropped by 50 percent and the number of births during 1958–1962 was about thirty-three million fewer than expected. Population annual growth rate dropped from 2 percent in 1958 to negative in 1961 (Ashton et al. 1984). Long term effects were also significant, as fetal and early childhood malnutrition carried adverse consequences for adult health as well as a range of socioeconomic outcomes, including literacy, labor market status, wealth, and marriage markets. An estimated fifteen to twenty years of loss in life expectancy was caused by the famine (Banister 1984; Sen 1990).
The causes of the famine were officially claimed to be natural disasters, including drought and flooding, which had periodically affected China. The bad weather contributed to the significant drop in output (Ashton et al. 1984), but as Amartya Sen points out in his entitlement theory, some of the worst famines have occurred without a significant decline in food availability (Sen 1990). What is important is that affected individuals ceased to have the ability to command food. It is widely accepted that a set of misguided policies in China's Great Leap Forward played a critical role in the massive food shortage. Especially detrimental were misreports of local food production to demonstrate political correctness imposed by top-down policies irrespective of conditions on the ground –policies for which millions suffered and lost their lives.
The total human toll of all of these health catastrophes over the century will never be known with certainty. What appears well documented is that China's twentieth century witnessed at least between 45 to 74 million excess deaths due to these disasters.
Disease epidemics have hit China throughout the century, such as the Manchurian plague early in the century, the worldwide influenza epidemic, and SARS early in the twenty-first century. Mortality data on the Manchurian plague of 1910–1911 is limited. The mortality toll of the SARS epidemic of 2003 was miniscule in comparison to its impact on public fears and the paralysis of international trade and commerce. The 1918–1919 influenza epidemic was likely the most deadly infectious crisis in China in the course of the century.
Deemed one of the most devastating epidemics in human history, three extensive pandemic waves of influenza spread globally in 1918–1919, killing worldwide an estimated 20 to 50 million people. The case fatality rate was over 2.5 percent (Luk, Gross, and Thompson 2001; Taubenberger and Morens 2006), with the highest mortality impact concentrated in young adults. In the United States, about a third of the total population of about one hundred million was infected and at least 675,000 people were killed. The impact was so profound that average life expectancy declined by ten to twelve years, from fifty-one years in 1917 to thirty-nine years in 1919 (Cheng and Leung 2007; Crosby 2003). Estimates for the mortality toll in another country, India, was 12 to 20 million deaths (Patterson and Pyle 1991).
Records for the influenza pandemic of 1918 in China are very sparse, but there is evidence that influenza did hit the country, whose population was then 450 to 475 million (Patterson and Pyle 1991). The overall estimated flu death rate in China was 1 to 2 percent, suggesting five to nine million deaths. The virus spread from the south (Shanghai, Guangzhou) to the north as far as Harbin, and even to remote regions like Yunnan Province (Cheng and Leung 2007). Regions like Peking and Manchuria reported "serious epidemic with a high percentage of death" (Patterson and Pyle 1991). In many other places in southern China, including Hong Kong and Shanghai, influenza mortality was relatively lower (Cheng and Leung 2007).
Were the impact of all epidemics, violence, and famine to be totaled—including violence and dislocation imposed during internal political upheavals—the human toll would surely exceed one hundred million people!
China's patterns of disease and causes of death changed over the course of the twentieth century. Times of crisis inherently affect some people more than others, and the causes of death may vary considerably. Epidemics impact on age-sex groups differentially, with young adults suffering the highest mortality risk due to the influenza epidemic. The toll of war is usually borne by innocent civilians rather than combatants, and children and women are particularly vulnerable to health crises (Dower 1993). The impact of famine, too, is absorbed disproportionately by children and women, and in the case of China, political background and affiliation may have affected vulnerability (Ashton et al. 1984).
But what has been the pattern of causes of death during non-crisis time periods? These causes ultimately result in more suffering and death and challenge the people, government, and health care system. Fortunately, causes of death may be estimated for China based on indirect techniques derived from contemporary data from different world regions.
China has few comprehensive assessments of major diseases, although special isolated studies of specific diseases may be found in the literature. The current epidemiologic profile in China, however, is well established. Recent analyses confirm that noncommunicable diseases account for more than 80 percent of all deaths. In addition to cardiovascular disease, stroke, cancer, and diabetes, chronic diseases also include mental illness, which is now considered the disease imposing the greatest health burden (WHO Department of Mental Health and Substance Abuse 2005). Communicable diseases and injury have not been entirely eliminated, of course, and new threats are emerging on the horizon, including new infectious pathogens like SARS, environmental pollution, and sociobehavioralpathologies including alcoholism, drug abuse, and sexually transmitted diseases. The huge burden of noncommunicable diseases underscores the critical importance of controlling such risk factors as smoking, diets rich in fats, lack of exercise, and car-driving practices.
In contrast with China's exceptionality in the four horsemen of the apocalypse, its causes of death conform to the theory of the epidemiologic transition, in which societies shift from communicable to noncommunicable diseases. Figure 1.2 offers insights into how the pattern of causes of death in China is likely to have changed by showing the three major categories of death (communicable, noncommunicable, and injury) for contemporary world regions (Mathers et al. 2008). Overwhelmingly, the primary cause of death in China today, as in Western Europe and North America, is noncommunicable disease. Due to sparse historical data on China's health profile, we can only assume that China earlier in the twentieth century had disease patterns closer to those of today's poorer countries. Disease patterns in other world regions like sub-Saharan Africa suggest analogies to the higher disease burden due to communicable diseases in China in earlier time periods.
Excerpted from Medical Transitions in Twentieth-Century China by Bridie Andrews, Mary Brown Bullock. Copyright © 2014 The China Medical Board. Excerpted by permission of Indiana University Press.
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Table of Contents
Part 1: Health Transitions
1. China's Exceptional Health Transitions: Overcoming the Four Horsemen of the Apocalypse / Lincoln Chen and Chen Ling
2. Changing Patterns of Diseases and Longevity: The evolution of health in 20th century Beijing / Zhang Daqing
3. Maternal and Child Health in Nineteenth- to Twenty-first-Century China / Yi-li Wu and Tina Johnson
4. Tobacco Smoking and Health in Twentieth-Century China / Carol Benedict
Part 2: Disease Transitions
5. Epidemics and Public Health in Twentieth-Century China / Yu Xinzhong
6. Schistosomiasis / Miriam Gross and Fan Ka Wai
7. Tuberculosis control in Shanghai: bringing health to the masses, 1928-present / Rachel Core
8. The Development of Psychiatric Services in China: Christianity, Communism and Community / Veronica Pearson
Part 3: Adaptations and Innovations
9. Foreign Models of Medicine in Twentieth-Century China: Part One / Gao Xi
10. John B. Grant: Public Health and State Medicine / Bu Liping
11. The Influence of War on China's Modern Health Systems / Nicole Barnes and John Watt
12. The Institutionalization of Chinese Medicine / Volker Scheid and Sean Hsiang-lin Lei
13. Barefoot doctors and the provision of rural health care / Fang Xiaoping
Part 4: Professional Transitions
14. A Case Study of Transnational Flows of Chinese Medical Professionals: China Medical Board and Rockefeller Foundation Fellows / Mary Brown Bullock
15. The Development of Modern Nursing in China / Sonya Grypma and Zhen Cheng
16. The Evolution of the Hospital in Twentieth-Century China / Michelle Renshaw
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