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HSERV 482 # 14

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

Melvin
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HSERV 482 # 14

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  1. HSERV 482 # 14 INDIA and CHINA

  2. Review so far: Key ideas • Primordial 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?

  3. Learning Objectives • analyze 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?

  4. Plan of session • India’s history • Chinese history • India/China comparisons in 1950 1980 and after • China before and after reforms in 1980 • Chinese famine in 1958-61 • Family planning policies: • Coercive • Social Welfare • Kerala Model • MAIN POINT: if health and human welfare are goals Kerala and China (to beginning of reforms), had policies that achieved those ends

  5. India China Health Comparisons

  6. India China Health Comparisons

  7. India GDP 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 billion low (and limited to rich) Poor

  8. 1990 data, way out of date on left

  9. Indian History • Ancient 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

  10. India since 1950 • Parliamentary 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)

  11. India since 1950 • 62 million+ under-five children malnourished • 88% of pregnant women are anemic • One third of children <16 years work • Independent press • Recent foreign investment (second largest exporter of computer software) • Increasing unemployment (jobless migrating, buses) • Little public investment in education - health care • Reforms (Structural adjustment)1991 increased poverty • food subsidies reduced, • mechanized agriculture reduced demand for local labor

  12. 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

  13. Agriculture collapse in 1990s • Growth 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

  14. 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

  15. 22 ...ALL FOR A CUP OF TEA? The opium wars 1839-42, 1856-60 Opium – for rich or poor . . Peking . . . . . . . . . . Shanghai . . . . . . . . . . . Hong Kong . Some ports forced open by British (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)

  16. 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

  17. 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

  18. 1960 India China 800 700 600 500 India China 400 300 200 100 44 47 0 GDP/cap life Exp IMR

  19. CHINA before / after reforms in 1979 interdependence 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

  20. China: Pre-reform achievements • GNP 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

  21. China: Pre-reform achievements • literacy rates were high for 15-19 year olds in 1981 (96% for males, 85% for females) • COMPARE WITH KERALA

  22. Sen 1999

  23. Kerala has low rural/urban differences in LBW, IMR

  24. Social Security Pre-Reform China Urban 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

  25. Authoritarianism, famines and vulnerability

  26. 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

  27. Crude Death, Birth Rates China 50-96

  28. 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

  29. 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

  30. 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

  31. Between 1980 and 1994 • economic 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

  32. NYT 021124 Foreign Direct Investment

  33. China health improvement post reform • moderate in comparison with pre-reform period and with what other countries have achieved

  34. IMR 1960-90 India, China, S. Korea Kerala had no economic growth

  35. Chinese economic growth in 1980s • growth 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?

  36. 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

  37. NYT Aug 1, 2004

  38. Urban Social Security Post-Reform • State 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 poor MIRROR IMAGE OF USA TODAY?

  39. Phillips Lancet 2002

  40. Rural Social Security Post-Reform • New 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 1995 fill jobs in low end of earnings ladder

  41. Social Security China Post-Reform • Remittances 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

  42. 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?

  43. China’s coercive one-child policy • India 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

  44. 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

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