China - Long term issues and options in the health transition (Vol. 2 of 2) : Annexes

Report No. 7%5-CHA China Long-Term Issues and Options in the Health Transition (In Two Volumes) Volume II: Annex Chapters June 25, 1990 Environment, Human Resources and Urbar. Development Division Asia Country Department III FOR OFFICIAL USE ONLY Document of the World Bank This document has a restricted distribution and may be used by recipients only in the performance of their official duties. Its contents may not otherwise be disclosed without World Bank authorization.  CURRENCY EQUIVALENTS US$1.00 Yuan (Y) 4.71 Y 1 US$0.21 (as of June, 1990) FISCAL YEAR January 1 to December 31 ABBREVIATIONS AES - Anti-Epidemic Station AIDS - Acquired Immune Deficiency Syndrome CAPM - Chinese Academy of Preventive Medicine CHD - Coronary Heart Disease COPD - Chronic Obstructive Pulmonary Disease CT - Computer Tomography DSP - Disease Surveillance Point EPI - Expanded Program of Immunization GDP - Gross Domestic Product GIS - Government (civil service) Insurance System HBV - Hepatitis B Virus IDDM - Insulin Dependent Diabetes Mellitus IMR - Infant Mortality Rate LIS - Labor Insurance System LOS - Length of Stay MAC - Maximum Allowable Concentration MCH - Maternal and Child Health MMHg - Millimeters of Mercury MOF - Ministry of Finance MOPH - Ministry of Public Health NAEM - National Association of Emergency Medicine NEPA - National Environmental Protection Agency NCD - Non-Communicable Disease NIDDM - Non-Insulin Depended Diabeter Mellitus NMTAC - National Medical Technology Assessment Council OECD - Organization for Economic Cooperation and Development PHCC - Patriotic Health Campaign Committee P1LA - People's Liberation Army RDA - REcommended Daily Allowance QALY - Quality Adjusted Life Year SEdC - State Education Commission SPC - State Planning Commission SPAC - State Pharmaceutical Administration of China STCMA - State Traditional Chinese Medicine Association TB - Tuberculosis TCM - Traditional Chinese Medicine UNICEF - United Nations International Children's Emergency Fund WHO - World Health Organization YPLL - Years of Potential Life Lost  FOR OFFICIAL USE ONLY CHINA LONG-TERM ISSUES AND OPTIONS IN THE HEALTH TRANSITION Table of Contents Annex Chapters Page 1. AN OVERVIEW OF MORTALITY IN CHINA . . . . . . . . . . . . . 1.1 2. THE CHRONIC DISEASES IN CHINA . . . . . . . . . . . . . . . 2.1 The Cardiovascular and Cardio-Pulmonary Diseases . . . . . . 2.1 Chinese Epidemiology and Trends . . . . . . . . . . . . . . 2.3 A Visual Presentation of CVD Burden . . . . . . . . . . . . 2.8 Cardiovascular Disease Risk Factors in China . . . . . . . . 2.12 Rheumatic Heart Disease . . . . . . . . . . . . . . . . . . 2.14 Peripheral Vascular Disease . . . . . . . . . . . . . . . . 2.16 Chronic Obstructive Pulmonary Disease (and Cor Pulmonale) . 2.16 Cancer in China . . . . . . . . . . . . . . . . . . . . . . 2.23 Stomach Cancer . . . . . . . . . . . . . . . . . . . . . . . 2.24 Lung Cancer . . . . . . . . . . . . . . . . . . . . . . . . 2.29 Liver Cancer . . . . . . . . . . . . . . . . . . . . . . . . 2.32 Esophageal Cancer . . . . . . . . . . . . . . . . . . . . . 2.35 Other Cancer . . . . . . . . . . . . . . . . . . . . . . . . 2.37 Cervical Cancer . . . . . . . . . . . . . . . . . . . . . . 2.38 External Causes (Suicides and Injuries) . . . . . . . . . . 2.40 Diabetes . . . . . . . . . . . . . . . . . . . . . . . . . . 2.46 3. THE RISK FACTORS IN CHINA . . . . . . . . . . . . . . . . . 3.1 Smoking . . . . . . . . . . . . . . . . . . . . . . . . . . 3.2 Hypertension . . . . . . . . . . . . . . . . . . . . . . . . 3.19 Diet . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.20 Environmental Risks . . . . . . . . . . . . . . . . . . . . 3.23 4. PROSPECTIVE EPIDEMIOLOGY TO 2030 . . . . . . . . . . . . . . 4.1 Demographic Considerations . . . . . . . . . . . . . . . . . 4.3 Modeling Future Health Trends and Costs . . . . . . . . . . 4.14 I. Introduction . . . . . . . . . . . . . . . . . . . . . 4.14 II. The Compartment Model ...... ....... .. . . 4.15 III. Notation and Results for the Compartmental Model . . 4.17 IV. The China Compartmental Model . . . . . . . . . . . . . 4.18 V. The Baseline and Intervention Aggressive Cases . . . . 4.20 1. Smoking . . . . . . . . . . . . . . . . . . . . . . 4.20 2. Hypertension . . . . . . . . . . . . . . . . . . . 4.21 3. High Cholesterol . . . . . . . . . . . . . . . . . 4.21 4. Cancer of the Stomach and Esophagus . . . . . . . . 4.21 5. Cancer of the Cervix . . . . . . . . . . . . . . . 4.22 6. Rheumatic Heart Disease . . . . . . . . . . . . . . 4.22 7. Stroke . . . . . . . . . . . . . . . . . . . . . . 4.22 This document has a restricted distribution and may be used by recipients only in the performance of their official duties. Its contents may not otherwis. be disclosed without World Bank authorization.  - ii - 8. Injury . . . . . . . . . . . . . . . . . . . . . . 4.23 VI. Calculation of Costs . . . . . . . . . . . . . . . . 4.24 VII. Data and Approaches Used in Risk Factors . . . . . . . 4.25 Smoking . . . . . . . . . . . . . . . . . . . . . . . . 4.25 Hypertension and Cholesterol . . . . . . . . . . . . . 4.2? 5. PROSPECTS AND POLICIES FOR CHRONIC DISEASE MANAGEMENiT . . . 5.1 A. Organization and Functions of the Public Health System 5.1 The Role of Departments within the MOPH . . . . . . . . 5.3 Special Functions Within the Health System . . . . . . 5.6 B. A Framework for Chronic Disease Management . . . . . . 5.8 C. Reduction of Exposure to Risk . . . . . . . . . . . . . 5.13 Tobacco Risks - the Future . . . . . . . . . . . . . . 5.14 Elements of a National Tobacco Control Program . . . . 5.17 Diet: Fat Consumption Risks . . . . . . . . . . . . . 5.21 6. HOSPITAL RESOURCES. PLANNING AND MANAGEMENT IN RELATION TO CHRONIC DISEASE . . . . . . . . . . . . . . . 6.1 Availability of Hospital Resources . . . . . . . . . . . . . 6.1 Hospital Management . . . . . . . . . . . . . . . . . . . . 6.11 Hospital Planning . . . . . . . . . . . . . . . . . . . . . 6.18 Role of Hospitals in Disease Programs . . . . . . . . . . . 6.20 7. MEDICAL TECHNOLOGIES iN CHINA . . . . . . . . . . . . . . . 7.1 Evaluation of Technology . . . . . . . . . . . . . . . . . . 7.5 Toward a Medical Technology Assessment Policy . . . . . . . 7.5 A Medical Technology Assessment Program for China . . . . . 7.9 Medical Technologies in China, History, Policies, Current Situation Details .... . . . . ..... . . . . 7.12 The Diffusion of Western Medicine and Technologies into China . . . . . . . . . . . . . . . . . . . . . . . . . 7.12 The Production and Distribution of Pharmaceuticals . . . . . 7.13 Present Policies Toward Drug Technology . . . . . . . . . . 7.14 Present Policies Toward Medical Eauipment . . . . . . . . . 7.17 Regulation of Technology . . . . . . . . . . . . . . . . . . 7.21 Ancillary Technology Services and Special Topics for Attention . . . . . . . . . . . . . . ... . . . . . . . 7.25 Standards for Hospital Medical Equipment . . . . . . . . . . 7.26 Medical Technologies in China, Vignettes on Efficacy, Cost and Profits .... . . . . . . . ....... . . . . 7.29 A. Electroencephalography . . . . . . . . . . . . . . . . . 7.30 B. ECG and Vectorcardiographic Services . . . . . . . . . . 7.33 C. Open Hear Surgery .... . . ...... . . . . . . . 7.36 D. Electronic Fetal Monitoring . . . . . . . . . . . . . . 7.39 E. Coronary Care Units . . . . . . . . . . . . . . . . . . 7.41 F. The CT Scanner . . . . . . . . . . . . . . . . . . . . 7.43 G. Case Examples of the CT Scanner . . . . . . . . . . . 7.46 H. Ultrasound . . . . . . . . . . . . . . . . . . . . . . . 7.48 I. Radiation Therapy ............. . 7.50  - iii - J. Lung Cancer Screening . . . . . . . . . . . . . . . . . 7.53 K. Renal Dialysis . . . . . . . . . . . . . . . . . . . . . 7.54 L. Schizophrenia and Insulin Coma Therapy . . . . . . . . . 7.57 8. HEALTH MANPOWER: RESOURCES. NEEDS AND PRIORITIES . . . . . 8.1 Manpower Production . . . . . . . . . . . . . . . . . . . . 8.4 Manpower Policy and Planning ... . . ..... . . . . . . 8.7 Plan Implementation . . . . . . . . . . . . . . . . . . . . 8.9 Perspectives on the Future . . . . . . . . . . . . . . . . . 8.11 Preparing for the Future . . . . . . . . . . . . . . . . . . 8.14 Supplement: Details of Health Manpower Development, Policies, Planning, Projections, and Future Strategy Alternatives . . . . . . . . . . . . . . . . . . . . . . . . 8.16 A. Historical Perspective . . . . . . . . . . . . . . . . 8.6 B. Manpower Recruitment . . . . . . . . . . . . . . . . . 8.17 C. Manpower Production . . . . . . . . . . . . . . . . . . 8.20 D. Manpower Planning . . . . . . . . . . . . . . . . . . . 8.21 E. Manpower Plans for the Year 2000 . . . . . . . . . . . 8.22 F. Projection Model Detail ... . . . . . . . . . . . . . 8.24 G. An Indicative List of Logical Steps to be Taken in Development of Health Manpower . . . . . . . . . . . . 8.31 Quantitative Aspects . . . . . . . . . . . . . . . . . . . . 8.32 9. HEALTH SECTOR EXPENDITURES AND FINANCES . . . . . . . . . . 9.1 The Health Financing System . . . . . . . . . . . . . . . . 9.2 Sources of Health Financing . . . . . . . . . . . . . . . . 9.4 Changing Purposes of Health Expenditures . . . . . . . . . . 9.8 Factors Underlying the Changing Purposes of Health Spending 9.12 Adaptation to Financial Signals . . . . . . . . . . . . . . 9.17 The Effects of Decentralization in an Unreformed Environment . . . . . . . . . . . . . . . . . . . . . . . . 9.19 Leading Issues and Options in Health Finance for China . . . 9.20  - iv - TABLES IN TEXT 1.1 Population, 1985 by Five Year Age Group, Male and Female . . . . . . . . . . . . . . . . . . . . 1.12 1.2 Leading Causes of Mortality, 1957-1986 . . . . . . . . 1.13 1.3 Dependency Ratios, 1985-2025 . . . . . . . . . . . . 1.14 1.4 Medically Vulnerable Population . . . . . . . . . . . . 1.15 1.5 Disease Specific Mortality Rates, 1986 . . . . . . . . 1.16 1.6 Age Specific Mortality Rates by Disease, DSP 1986 . . . 1.17 1.7 Age Standardized Mortality Rates by Type of Diseases for All Ages, DSP 1986 . . . . . . . . . . . . . . . . 1.20 1.8 DSP Population . . . . . . . . . . . . . . . . . . . . 1.21 1.9 Years of Potential Life Lost . . . . . . . . . . . . . 1.22 2.1 Age Specific Mortality Rates for Circulatory Diseases, 1986 . . . . . . . . . . . . . 2.53 2.2 Mortality Rates and Relative Frequency of Leading Cancers, 1975 . . . . . . . . . . . . . . . . . 2.54 2.3 Age Specific Mortality Rates for Cancers, DSP 1986 2.55 2.4 Lung Cancer Mortality Ratios for Men and Women by Current Number of Cigarettes Smokers Per Day From Studies in Other Countries . . . . . . . . . . . . 2.56 3.1 Smoking Prevalence by Age and Sex . . . . . . . . . . . 3.3 3.2 Tobacco Exposure of China's Population . . . . . . . . 3.4 3.3 Smoking Attributable Fractions of Mortality United States, 1985 . . . . . . . . . . . . . . . . . . 3.7 3.4 Tobacco Production and Financial Profits . . . . . . . 3.9 3.5 Total Value of Exports and Imports of Tobacco, by Countries . . . . . . . . . . . . . . . . . . . . . 3.14 3.6 Total Value of Exports and Imports of Tobacco for Selected Countries . . . . . . . . . . . . . . . . 3.15 4.1 China: Population Projections - Selected Age Groups 4.4 4.2 Main Demographic Effects of a Preventive Strategy . 4.6 4.3 Projected Risk Factor Exposure, Disease and Period Specific Mortality by Cause, 1990 to 2030 . . . . . . . 4.29 4.4 Indicative Crude Mortality Rates - by Leading Disease Group Rates/100,000 Population . . . . . . . . 4.32 4.5 Age-Specific Projections for Key Diseases, Risk Factors and Output of the Model . . . . . . . . . . . . 4.33 4.6 Mortality and Effects of a Preventive Strategy for the Five Lending Chronic Diseases . . . . . . . . . 4.43 4.7 Smoking Populatiot., 1985 and Projection to 2025 . . . . 4.45 6.1 Hospital Beds by Province, 1981-86 . . . . . . . . . . 6.22 6.2 Hospital Beds by Province: Comprehensive Hospital Beds and Commune Health Center Be{ . . . . . . . . . . 6.25 6.3 Planning Criteria for Acute Short-term Somatic Care in Selected Countries . . . . . . . . . . . . . . 6.2 6.4 Specialized Hospitals in China 1986 . . . . . . . . . . 6.4 6.5 Psychiatric Beds in Selected Countries . . . . . . . . 6.4 6.6 Causes of Hospitalization . . . . . . . . . . . . . . . 6.6 6.7 10 Leading Diseases as % of Hospital Stays Urban Health Department Hospitals . . . . . . . . . . . 6.7 6.8 Hospital Admissions per 10,000 Populations  - v - in Selected Countries. . . . . . . . . . . . . . . 6.7 6.9 LOS at County Level and Above County Level . . . . . . 6.8 6.10 Hospital Occupancy at County Level and Above County Level . . . . . . . . . . . . . . . . . . 6.9 6.11 Size, Bed Occupancy Rate and Length of Stay in Selected Hospitals . . . . . . . . . . . . . . . . . 6.9 6.12 Number of visits to O.P.D. and Emergency Departments, 1986 . . . . . . . . . . . . . . . . . . . 6.10 6.13 Mode of Emergency Arrival in Hubei, Sichuan and Jilin Provinces . . . . . . . . . . . . . . . . . . . . 6.10 6.14 Nosocomial Infection in 21 Hospitals in China . . . . . 6.15 6.15 . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.19 7.1 Value of Drugs Produced in China, 1984 and 1987 . . . . 7.14 7.2 Number of Selected Pieces of Equipment in 13 Chinese Medical Universities and their _3 Affiliated Hospitals in 1987 . . . . . . . . . . . . . . . . . . . . . . . . 7.20 7.3 Approximate Cost-Effectiveness Ratings for Selected Medical Procedures . . . . . . . . . . . . . . . . . . 7.22 7.4 General Hospital Equipment Standard . . . . . . . . . . 7.27 8.1 Number of Doctors and Hospital Beds by Medical Area 8.42 8.2 Numwber and Type of Health Personnel 1980, 1983 and 1986 . . . . . . . . . . . . . . . . . . . . . . . 8.43 8.3 Graduates of Secondary Health Schools, by Specialty . . 8.44 8.4 Distribution of Health Resources by Ownership . . . . . 8.45 8.5 Medical Colleges, 1977-81; Institutions, Students Enrollments and Graduates . . . . . . . . . . . . . . . 8.46 8.6 Medical Colleges - Projections of Manpower Supply . . . 8.47 8.7 Selected Types of Health Facilities and Manpower Various Years ..... 8.48 8.8 Number of Hospital Beds and Health Personnel, by Type and Level (1949-1986) . . . . . . . . . . . . . . . . . 8.49 8.9 Salaried Technical Health Staff, Various Years (1952-1986) . . . . . . . . . . . . . . . . . . . 8.50 8.10 Salaried Health Staff, All Levels Per Population . . . 8.51 8.11 Health Facilities and Personnel Under Ministries Other Than the Ministry of Public Health, 1949-1986 8.52 8.12 Village Health Services . . . . . . . . . . . . . . . . 8.53 8.13 Distribution of Health Personnel by Technical Category 8.54 8.14 Numbers of Salaried Health Workers by Level, Urban and Rural . . . . . . . . . . . . . . . . . . . . 8.55 8.15 Distribution of Medical Personnel, by Province, 1986 . 8.56 8.16 Selected Data on Schools, Students and Graduates . . . 8.57 9.1 Health Expenditures Current Prices . . . . . . . . . . 9.21 9.2 Government Insurance Expenditures and Coverage, by Province 1980-1986 . . . . . . . . . . . . . . . . . 9.24 9.3 Recurrent Health Expenditures, Labor Insurance Costs and Patient Fee Payments . . . . . . . . . . . . 9.26 9.4 1979, Ministry of Public Health - Budgetary Expenditures (RMC OOOs). . . . . . . . . . . . . . . 9.27 9.5 Budgetary and Total Expenditures on Health, Total Budget, anid Gross Domestic Product . . . . . . . . . . 9.23  - vi - CHARIS IN TEXT 1.1 Leading Causes of Older Adult Deaths in the U.S. in 1950, 1979 and 1985 and in China in 1986 . . . . . . 1.3 1.2 Leading Causes of Adult Deaths in the U,S. in 1950, 1979 and 1985 and in China in 1986 . . . . . . . 1.4 1.3 Leading Causes of Adolescent and Young Adult Deaths in the U.S. in 1950, 1979, and 1986 and in China in 1986 . 1.5 1.4 Age Adjusted Rates for Major Causes of Death in the U.S., 1985 and China, 1986 . . . . . . . . . . . . . . 1.6 1.5 Age Adjusted Rates for Major Causes of Death in China, 1986 . . . . . . . . . . . . . . . . . . . . . . '.7 1.6 Relative Mortality Burden Indicators by Sex . . . . . . 1.10 1.7 Relative YPLL Age <-65 Burden Indicators by Sex . . . . 1.10 1.8 Relative Mortality Burden Indicators by Location . . . 1.11 1.9 Relative YPLL Age <-65 Burden Indicators by Location . l.11 2.1 China: Mortality Rates and Shares Circulatory and Cardiopulmonary Diseases . . . . . . . . . . . . . . . 2.2 2.2 Circulatory Disease Deaths by ilause, Age and Sex . . . 2.5 2.3 China: Stroke Deaths and Rates by Age Group, Sex and Location, 1986 . . . . . . . . . . . . . . . . . . 2.9 2.4 Hypertensive Heart Disease Deaths and Rates by Age Group, Sex and Location, 1986 . . . . . . . . . 2.11 2.5 Coronary Heart Disease Deaths and Rates by Age Group, Sex and Location, 1986 . . . . . . . . . 2.12 2.6 Rheumatic Heart Disease Deaths and Rates by Age Group, Sex and Location, 1986 . . . . . . . . . 2.15 2.7 China: COPD Deaths and Rates by Age Group, Sex and Location, 1986 . . . . 2.19 2.8 Age-Specific Mortality Rates for COPD China and the United States - Males and Females . . . . . . . . . . . 2.22 2.9 Trends in Selected Cancer Mortality Rates, United States, 1930-1985 . . . . . . . . . . . . . . . 2.25 2.10 External Causes of Death - Total Rate and Rates of Leading Causes . . . . . . . . . . . . . . . . . . . . 2.43 2.11 External Causes of Death, Composition . . . . . . . . . 2.44 2.12 External Causes of Death - Leading Causes as a Share of Total Age-Specific Death Rates, All Diseases . . . . 2.45 3.3 China: Tax Revenue per Cigarette . . . . . . . . . . . 3.16 4.1 China: Population Profile by Age and Time . . . . . . . 4.4 4.2 Lung Cancer . . . . . . . . . . . . . . . . . . . . . . 4.7 4.3 Chronic Obstructive Lung Disease . . . . . . . . . . . 4.8 4.4 Coronary Heart Disease .... . . . . . . . . . . . . 4.10 4.5 Stroke . . . . . . . . . . . . . . . . . . . . . . . . 4.11 4.6 Injury . . . . . . . . . . . . . . . . . . . . . . . . 4.13 5.1 Organization Plan of the Ministry of Public Health 5.4 5.2 China: Alternative Cigarette Consumption Estimates 5.16 8.1 Levels of Health 'Wrkers 8.36 8.2 Representative Curriculum Content and Course Hours Main Medical Education Streams - Key Universities .... . . . . . ...... . . . . 8.40 8.3 Alternative Methods of Estimating Health Manpower  - vii - Requirements . . . . . . . . . . . . . . . . . . . 8.41 9.1 China: Financial Flog-Chart - Health Sector . . . . . . 9.3 BOXES IN TEXT 3.1 Taiwan: Lung Cancer Mortality Rates and Smoking Prevalence, 1964-1986 . . . . . i . . . . . . . . . . . 3.6 3.2 2,000,000 Chinese Deaths a Year from Tobacco in the Future . . . . . . . . . . . . . . . . i . . . . . 3.8 3.3 Foreign Tobacco Companies and Tobacco Trade Trends 3.12 3.4 Progress in Reducing Smoking in the United States . 3.18 5.1 Smoking Control - A Regulatory Approach . . . . . . . . 5.17 5.2 National Funding of Smoking Cessation Efforts - the U.S. Case . . . . . . . . . . . . . . . . . . . . . 5.19 5.3 Reductions in the Number of Smokers - The Case of Hong Kong . . . . . . . . . . . . . . . . . . . . . . . 5.2) 6.1 Hospital Siting and Design . . . . . . . . . . . . . . 6.' 9.1 Incentives Which Inflate Health Care Costs . . . . . . 9.:.8 MAP IBRD 22433  - 1.1 - Annex Chapter 1 AN OVERVIEW OF MORTALITY IN CHINA. 1. Reliable incidence and prevalence datay for diseases are generally not available in the developing world, and these data are weak in most of the OECDY countries. As an exception, prevalence and incidence of cancers are sometimes available as these h--e been the subject of international investigation for several decades. Registries of cancer cases have been established in many countries, including in some locations in China. Only in exceptional cases is similar information available for other diseases however. Health plainners throughout the world are thus often constrained to relying on sample surveys and on mortality data for choosing priorities for expenditure of health resources. Morbidity data in most countries are even more scarce, and of fragile reliability, and China is no exception. What is known of morbidity and its trends is discussed in individual disease sections of this report. All epidemiological data is of course subject to errors in its collection, in cause of death and illness coding, in accuracy of classification, and so forth. However, mortality data!/ provide the most accessible and reliable source for examining the health problems of the nation. These are examined from several different perspectives (below) to develop an overview of current health status. V Prevalence is a measure of the number of cases of a disease existing in a given population at a point of time, usually expressed as a percentage or rate per thousand population; incidence is a measure of the number of new cases of the disease occurring at or during a period of time, usually expressed as an annual rate per 1000 population. Organization for Economic Cooperation and Development (OECD) is an economic grouping of nations that in-ludes most of Europe, Canada, the United States and Japan. Most of the data used in this report comes from the DSP reporting system (see Box 1.2 in main report) which requires hospital certification of the cause of death. Even so, autopsies are seldom performed in China and it can be expected that, even with the best of efforts, not to mention the inevitable pressures of time, other business and lust lack of experience, that a share of all deaths will be misreported.  - 1.2 - 2. It is important to note that the national data used in this reportsJ reflect a widely varying situation which is changing dramatically with passing years. China's health status is heterogeneous across different regions. Important regional and local differences exist in epidemiology and disease impact and are not, for the most part, addressed in this report. 3. Crude Mortality Rates. Detailed mortality rates from the Disease Surveillance Points (jSPs - see Box 1.2, main report and Annex Map 1) by sex and by urban and rural areas are presented in Annex Table 1.5. Age- standardized, age-specific, and disease-specific mortality data are presented in Annex Table 1.6. Heart disease, stroke and cancer accounted for 63% of total mortality in 1986 (68% in urban areas; 60% in rural areas). These diseases affected males and females about equally (63% versus 64%). Injuries were the fourth leading cause of death in all categories and areas. These four causes of mortality account for 72% of all death in China.5/ Other chronic, non-communicable diseases such as diabetes, kidney disease, liver cirrhosis and psychological and neurological diseases would bring the total to over 76% of mortality (see Annex Table 1.7 for DSP population). 4. Overall mortality rates provide only one measure of the illness burden. They simply report the annual number of people per 100,000 population who die from a given disease. The age-, gender- and location- specific aspects of those deaths are disguised within the number. In a society with a large proportion of children, reliance on overall death data would hide the severity of the chronic diseases among adults for example; conversely, the importance of infectious and endemic diseases among children can be obscured by the overall figures in a society with a large proportion of adults. 5. Annex Charts 1.4 through 1.6 show some aspects of chronic disease mortality in China and reference points of comparison with the United States, with the population divided into three subsets - over age 65, ages 25 through 64, and ages 15 through 24. 1986 data are used for most of the epidemiological analysis in this report. An identical data set for 1985 became available part way through the analytical work and was examined for its consistency with 1986. In general China's experience for 1985 showed slightly worse mortality from the chronic diseases. To be conservative in approach, and because time consuming manipulation of these large data sets would have added nothing of substance to the themes and conclusions of this report only 1986 data were used as the basis for both analysis and for projections of future epidemiology. Subsequently, 1987 and 1988 data have become available. As data sets become more comprehensive and provide a time series it is expected that China will be able to substantially refine and improve upon the anal.As contained here. In this report, injuries are treated as one of the chronic, non- communicable diseases. Annex Chapter 2 discusses injuries in detail.  1.3 - 6. Older Adults (Over age 64 - Annex Chart 1.1). The leading causes of death for older adults in China are the same as the U.S. but the total mortality rate in China is still low v5,046/100,000), compared to the U.S. in earlier periods. This is most likely because those Chinese who have survived to old age up to now have been physically healthier than their contemporary U.S. counterparts. Strong natural health selection forces in China may result in. a few more years of relatively low mortality rates amongst the elderly. As the impact of longer exposure to risk factors begins to become apparent, death rates amongst the elderly can be expected to increase. Annex Chart 1.1 Leading Uauses of Older Adult* Deaths in the U.S. in 1950, 1979, ancd 1985 and in China in 1986 1950. U.S. 1979. U. S. Diseases of heart 1985 U.S 1986, CHINA Cancer &,,,,~, Cancer - Z/ysoooPercent Distribution of Older A!dult Deaths by Cause in in the U.S. in 1950, 1979, and 1985 and in China in 1986. 1 z , ~~~~~~~~~~~~~~~~~~C'HINA U S ;gs ig lf R 9 1o5u Stroke Diseases of heart 32.2 46.6 47.6 46.0 - Cancer ............... 15.6 20.2 19.5 13.7 i ~~~~~~~~~~Stroke ................ 26.2 9.0 11.4 14.7 Pneumonio and influenza 1.7 4.0 2.9 3.1 ... ...I.............I.......................................................... Totol Older Adult Mortality Rate Pneumonia China .. 1986 .. 5,046.8 U.S. . 1985 .. 5,145.2 1979 . 5,059.5 1950. 6,270.5 0 500 1000 1500 2000 2500 3000 Rate per 100,000 population t Olcder Adult = 65 years and older Source: National Center for Heolth Statistics and DSP 1986 7. Adults (25-64 years old - Annex Chart 1.2). The leading causes of death for the productive age groups are also the same for the U.S. and China but with marked differences in characteristics. Cancer already affects adult Chinese in roughly the same percentage (30%) as it does Americans. Heart disease is today relatively less important and injury and stroke are significantly more important for Chinese in this age group relative to their counterparts in the U.S. The overall mortality rate in China is much less (337/100,000) thar. in the U.S. Part of the reason for this is demographic -  - 1.4 - there are relatively more Chinese in their twenties and thirties in this data sample and relatively more Americans in their fifties and sixties. As the Chinese population ages, overall mortality rates for this age group can be expected to rise, assuming the disease specific rates just remain stable, because the chronic diseases tend to have much higher mortality rates in older age groups. Annex Chart 1.2 Leading Causes of Adult* Deaths in the U.S. in 1950, 1979, and 1985 and in China in 1986 B 1950, U.S. Diseoses of heart 1985 U.S. 1965. U.S. m Ai X X1986. CHINA Concer Percent Distribution of Adult De aths by Couse in the U.S. in 1950, 1979, and 1985 ond in China in 1986 Injury LXCHINA U.S. _S ~~~~~~~~~~~~~~~~~1q8 hg 107q ig-9 Diseases of heort 19.9 28.5 31.0 35.5 Cancer .30.5 30.2 27.3 19.3 Injury .11.6 7.5 8.4 7.5 Stroke Stroke 15.6 4.0 4.5 8.3 Chronic liver disease 3.4 3.2 3.9 1.8 ... ....................................I....................................... Totol Adult Mortality Rate Chino . 1986 . 336.8 Chronic liver dis. U.S . ... 1985 . 439.6 1979 .. 500.2 1950 .. 687.1 I I I I 0 50 100 150 200 250 Rate per 100,000 populotion * Adult = 25-64 years old Soi-ce: Nationol Center of Health Statistics and DSP 1986 8. Adolescent and Young Adults shares (Annex Chart 1.3) show little diffarence between China and the U.S., with injury already accounting for more than half of all young Chinese deaths. These external causes of death (injuries, suicides, etc.) are important causes of mortality and morbidity in both countries and are an obvious health priority (see Annex Chapter 2 for a detailed discussion of injuries in China, their composition and distribution). Modestly higher rates of heart disease mortality for young Chinese are mainly due to rheumatic heart disease.  - 1.5 - 9. Overall, Chinese mortality rates for these three age groups show a picture of chronic diseases which generally do not yet affect the age specific groups as severely as the same groups in the U.S., but with the chronic diseases account for about the same proportions of total mortality. 10. Age-Adiusted Mortality gates provide another way to examine the nature of the illness burden and health care priorities. Some fraction of over time in crude mortality rates of the chronic diseases is due to demographic effects. As there are now more middle aged and elderly Chinese relative to the total population (than previously) the apparent mortality rate attributable to the chronic diseases would be higher in comparison to the past. To account for this demographic effect, mortality rates from different periods of time can be adjusted to the same hypothetical population distribution. Age-adjusted mortality rates remove the effects of demographic as opposed to epidemiological trends. Unfortunately, there are no reliable disease- and age-specific mortality data available for China in earlier time periods.' However, a rough approximation of the magnitude and pace of Annex Chart 1.3 Leading Causes of Adolescent and Young Adult* Deaths in the U.S. in 1950, 1979, ond 1985 and in China in 1986 l igso, u.s. 552 3 1979. U.S. injury _ 1985. U.S. 1986, CHINA Percent Distribution of Adolescent and Young Adult Decths by Couse in the U.S. i' 1950, 1979, anG 1985 Ccncer ond in China in 1986 .i, "5 ..1 .LCHINA U-S. Injury . . 54.1 75.5 77.9 51.3 Cancer ........... 9.1 5.1 5.3 6.7 Diseases of heart 6.9 2.6 2.3 6.4 Diseases of Heart i Totol Adolescent ond Young Adult Mortolity Rate Chino .. 1986 .. 73.3 U.S. . 1985 .. 94.8 1979 .. 114.8 1950 .. 128.1 0 10 20 30 40 50 60 70 80 90 Rote per 100.000 population Adolescent and young adult = 15-24 years old Source: National Center for Health Statistics and DSP 1986 Such data exist for China from the national cancer survey undertaken in 1973-75 but are currently available in public form only for cancer. A forthcoming book by Chen, Campbell, Li and Peto (Oxford University Press) will contain more detailed information on mortality reported from the 1973-75 survey. In this report a discussion of the epidemiologic changes for cancers in the last decade is presented in Chapter II.  - 1.6 - the epidemiological transition for China, as opposed to the demographic transition, can be demonstrated by comparisons with other countries. 11. Comparison of age-adjusted mortality rates in both China (1986 data) and in the U.S. (1985 data),Y shows similar shares and rates of chronic disease burden (Annex Chart 1.4). China has ca slightly higher 6verall mortality rate (634/100,000) than does the U.S. but the same proportion (73%) of total mortality in both countries is accounted for by the chronic diseases and injury. Annex Chart 1.4 Age Adjusted Rates for Major Causes of Death in the U.S., 1985 and China, 1986 U.S. 1985 (Total 546/100,000) China 1986 (Total - 634/100,000 PeumontP oaf Others 13 8% 20 8$ 1S824% k .... heartD Oaa.s InilJrte ~ ~ ~~ew D s J 1p_ Stroks t2 20e 32 6% lnjuries 34 6% tS2 24S 64 QS Adjusted to U.S. 1940 Census Population Source: China DSP data 1986; U.S. data from Natl Center for Health Statistics 12. Annex Chart 1.5 (below) shows the 1986 mortality rates and shares for ?/ Adjusted for death coding differences and standardized to the 1940 U.S. population. Readers unfamiliar with epidemiological tecbniques should note-that it does not make any difference which population profile data are standardized to as long as the same standard is used for all data sets under comparison.  - 1.7 - China but age adjusted to an older population profile (U.S. 1970).Y' This provides a rough projection of approximately how the demographic effect alone will influence chronic disease mortality rates if China's population structure changed approximately as the U.S. did from 1940 to 1970. The shares of chronic disease mortality change only modestly with the aging population but the mortality rates, overall and disease-specific, increase by nearly 50% (total mortality of 899/100,000). Expressed another way, if chronic disease mortality rates become no higher than today overall mortality rates will increase about 50 iJust from the effect of thi- aging population. This is an optimistic, and very unlikely, assumption. Some chronic disease mortality rates are likely to be considerably higher in the future unless a massive effort at disease prevention and health promotion is soon begun and sustained for many years. Annex Chart 1.5 Age Adjusted Rates for Major Causes of Death in China, 1986 (Total 899J100,000) Heart Diseases Cancer j | 277.1 (30.9s) 130.8 (18.6%) Accidlents 69.64 ( E.6%) Strokle 900.8 (23.0%) 104.0 (21.7%) Pneumonia 29.4 (2.0%) Adjusted to the U.S. 1970 Census Populaticn Chronic obstructive lung disease has been grouped under heart disease in Annex Charts 1.1 through 1.4 to make the two classification systems comparable. Some portion of "others" in the China data series is also chronic obstructive lung disease and tho "heart disease" category is therefore slightly underestimated.  - 1.8 - 13. Years of Premature Life Lost (YPLL) is a measurement of the hypothetical years of life lost annually due to premature death (death at any age prior to normal life expectancy, for China), or death prior to an arbitrary definition of economically productive life - age 65, is commonly usedY. Using both definitions for YPLL, Annex Table 1.8 summarizes the burden of illness on China today from chronic and infectious diseases in terms of YPLL. All YPLL measurements give added emphasis in statistical presentation to those illnesses which affect the younger and middle age groups. The death of a 64 year old worker only deprives society of one year of potentially productive life (assuming the worker was healthy). The death of a 44 year old father from heart disease costs society, and his family, 21 years of productive care and support. The death of a child from preventable injury at age ten is measured as very costly to society by YPLL methods. This may or may not be appropriate, depending on the objective of the analysis for which YPLL statistics are being used. YPLL measures may not reflect underlying morbidity conditions as well as mortality rates do. However, YPLL does present an easily understood measure of the total burden of death on a society. 14. China's premature life loss each year is far greater than might intuitively be expected. It represents an enormous burden on the young and middle aged members of society and a huge loss to the total output of society. No society burdened with the annual premature loss of about 60 million years of life (equivalent to about US$18 billion annually at today's per capita output) can afford to ignore this in development of its health strategy. Prevention of a share of this premature life loss should rank high among health and economic priorities. 15. Gender Differences in Mortality are important to consider in assessing health status and health strategy. Annex Charts 1.6 and 1.7 show the relative burden on women and men from 16 leading diseases as measured by mortality rates and YPLL respectively. The horizontal axes are the ratios of male to female mortality (+) and of female to male mortality (-). A ratio of 1:1 would indicate that men and women are affected equally. Ratios higher than 1:1 indicate men are more affected and vice versa. Men clearly emerge as being affected worse than women for most of these diseases and the notable exceptions suggest areas where health care strategy might focus more on needs of women. Health strategies to address the key problems killing men in China also emerge from these Annex Charts. As will be explored later (Annex Chapters 2 and 3) many of these diseases can only effectively be reduced through well designed and funded programs of primary prevention. Very little difference would be shown in any health status indicators (mortality rates, YPLL or ratios) from programs and investments which mainly treat diseases among people who are already ill patients alive. YPLL with age 65 as the standard is convenient. but completely arbitrary, as a definition of the "productive" years of life. In many parts of the world, i;icluding China, many persons remain active and productive in both economic and social terms for many years beyond this age.  - 1.9 - 16. Urban-Rural Differentials in Mortality also help to focus health programs and identify priorities. Annex Charts 1.8 and 1.9 show the relative burden on urban and rural areas from the same 16 diseases, again measured in terms of both mortality and YPLL. Rural areas are affected relatively more than urbani areas by certain communicable diseases, by some chronic diseases (e.g. liver cancer) and by injuries. Urban areas are affected more by the chronic diseases which are primarily related to lifestyle, smoking and diets. The gradual spread of these risk factors from urban to rural areas throughout China is discussed in more detail in Annex Chapter 3. These charts indicate the need for near-term focus on treatment of some diseases and on an aggressive apDroach to prevention for most of the chronic diseases and for injuries. 17. A trend which can be expected to emerge over the next decade or so as China's rural areas progress further in the epidemiological transition is that crude mortality rates for rural areas will fall because of today's younger age structure and shorter exposure to the main chronic disease risk factors relative to urban areas. At the same time, urban crude death rates will rise as a result of longer chronic disease risk exposures and an aging population profile. At some point China's rural areas will appear favored relative to the cities with lower mortality and morbidity rates. in the next century this trend will reverse with both urban and rural areas converging to higher rates of death. 18. The value for China in further developing and refining its disease surveillance system should be obvious. Not only can areas for health strategy be more clearly identified for discussion and debate but comparisons can be made with other times and places (both within and without China) to assess progress, to gain a perspective on what the future may hold in store and to select and develop health strategies.  Annex Chart 1.6 Annexc:Chart 1.7 Relative Mortality Burden Indicators by Sex Relative YPLL age <=65 Burden Indicators Female Mate Female by Sex Mole Disease 1.6 2 Infectious Diseases *39 3 Including:TB *56 100j 16 Esophagus 17 Stomoch 1.4- 19 Liver 20 Lung 33 Rheumotic Heart 34 Coronary Heart 35 Hypertensive Heart c 1.2 80 36 Cor-pulmonale .