Impact of rapid urbanization on communicable and non-communicable diseases in China

1. Impact of rapid urbanization on communicable and non-communicable diseases in China Urbanization and Health in China, the University of Sydney Dr. Yi Hu A/Prof. Zhijie Zhang and Prof. Qingwu Jiang Laboratory for Spatial Analysis and Modeling Department of Epidemiology and Biostatistics School of Public Health Fudan University Nov. 28, 2013

2. The starting points for this talk The urbanization is rapid in China. The health problems are challenging. What we are going to do?

3. 1. Urbanization in China Urbanization refers to the increasing amount of people that live in urban areas (Wikipedia). Urbanization predominantly results in the physical growth of urban areas, be it horizontal or vertical.

4. The rate of urbanization increased rapidly • In 2004, 42% of Chinese were living in urban areas; •By 2040, more than 1 billion will be living in cities, meaning another 400 million will be urbanized in the next 30 years. Urbanization in China increases linearly after 1985.

5. The Chinese Government is pursuing a policy of urbanization, and currently China has 28 city clusters with varying degree of size and development, most still in an embryonic stage. Three major city clusters in the costal zone: • Beijing-Tianjin • Yangtze River delta-Shanghai • Pearl River delta-Guangzhou One major inland city cluster-Chongqing

6. • Currently (up to 2012), about 52.6% of the population live in 0.4% of the land area (urban buildup area), consume 60% of the food, and create over 88% of GDP in China (National Bureau of Statistics); • Efficient in terms of food consumption and GDP;

7. Economic reform in the late 1970s Within-country migration policies Drivers of urbanization Surplus agricultural laborers Increasing urban-rural income Conversion of farmland (Yeh et al., 2011. UNFPA&IIED)

8. Impacts of urbanization Urbanization Environmental change (physical and social) Health Environmental change Urbanization: urbanized way of pollutant discharge-high intensity per unit land and per capita, such as waste discharge and concentrated vehicles; Changes in landscape and land uses;

9. Air quality in China Before 1970s, anthropogenic aerosol pollutions were very low. The aerosol levels started increasing in the mid 1970s, when economical development rapidly increased. Aerosol pollution reached a maximum in the mid 1980s, and has remained high up to the present. The long-term trend of aerosol extinction coefficient (AEC) recorded in Guangzhou, China from 1950s to 2000s (Tie et al., 2009).

10. Other aspect…

11. Emerging urban health trends • Prosperity has resulted in general improvements in quality of life and increased healthcare provision, but may also support unhealthy life style; • Decreasing communicable disease burden and mortality; • Increasing non-communicable disease burden and mortality; • The absolute difference of health risks between urban and rural areas has increased over time. (Zhu et al., 2011. ES&T)

12. The starting points for this talk The urbanization is rapid in China. The health problems are challenging. What we are going to do?

13. 2. Communicable diseases Zhang et al., 2012. Plos One

14. Zhang et al., 2012. Plos One

15. Reasons for decline • Preferential policy from the central and local government • Since the late 1990s, millions of dollars have been invested by international donors to support China’s fight against infectious diseases, including the World Bank; Britain’s Department for International Development; the Australian government; The Global Fund to Fight HIV/AIDS, TB and Malaria; and other bilateral aid programs. (Tang et al., 2013, Inf Dis Poverty)

16. AIDS Annual transmission constitute of HIV and main modes of transmission of AIDS IDU: injecting drug use; MTCT: mother-to-child transmission (Ministry of Health of China)

17. The distribution of cumulative AIDS cases until Sep. 2011 Ranking: Yunnan, Guangxi, Henan, Sichuan, Xinjiang (Ministry of Health of China)

18. • HIV likely entered China through rural border regions and subsequently spread throughout the country via migrants. • Once HIV spread from migrants (floating population) to local permanent residents, subsequent transmissions between permanent residents and within the general population occurred rapidly and increasingly sexually. Rates of HIV/AIDS among permanent urban residents, particularly women and elderly men, have increased significantly in recent years

19. H5 H9 H9 H5 influenza Appearance of human influenza virus H7 H5 H1 H3 H2  Hong Kong flu Avian Flu H1 2004--- 1997 2003 1918 1957 1968 1977 Asian Flu 1998/9 Spanish flu

20. Mutation and potential cross-species transmission of avian influenza virus Direct costs: a large number of human cases and hospitalizations and death of economic animal; Indirect costs: the socio-economic impact.

21. Effects of urbanization • The three key parameters in influenza emergence are human and animal population density, intense contact between different species to facilitate cross-species transmission, and a prevalence of respiratory diseases • Livestock population , raised for meat supply, also plays a role in increasing the pathogenic strains of influenza. (Huo et al., 2006. Virginia Review of Asian Studies)

22. Schistosomiasis Map of the epidemic status of schistosomiasis japonica before the 1950s in China

23. Map of the epidemic status of schistosomiasis japonica in China, 2000 Transmission controlled Transmission interrupted Disease still endemic

24. Annual number trend of cases infected with S. japonicum in China from 1999 to 2010 Cases including acute and chronic cases (Department of Disease Control, Ministry of Health)

25. Map of the epidemic status of schistosomiasis japonica in China, 2010. Transmission interrupted Transmission controlled Disease still endemic

26. In China… China is experiencing a shift in disease profile, towards non-communicable chronic diseases, and urbanization may well play a big role, possibly through changes in life styles and environmental pollution, endocrine disrupting compounds, particulate matters etc.

27. 3. Non-communicablediseases (NCDs) • China has experienced a dramatic increase in mortality and morbidity caused by NCDs. • In 2005, deaths from NCDs accounted for 80% of all deaths (total 10.3 million) and 70% of total disability adjusted life-years lost (total 195.7 million). • It is likely that the prevalence of NCDs will continue to rise given the advancing population aging, and increased exposure to health risk factors due to environment and lifestyle changes associated with rapid urbanization.

28. Increasing trend of mortality of 6 major chronic diseases in China CHD: Coronary Heart Disease

29. Cancer Rural versus urban differences in mortality rate (/100,000) in the top five most common cancers in China over the last 40 years. (Zhu et al., 2011, ES&T)

30. Several large-scale prevalence surveys of diabetes in China * Criteria of diagnosis ：FPG≥130mg/dl and/or postprandial 2h ≥200mg/dl and/or OGTT> (0 min 125, 30 min 190, 60 min 180, 120 min 140 or 180 min 125；O-toluidine method, 100g glucose）; Δ PBG2h=postprandial plasma glucose 2h；FBG=fasting blood glucose

31. Prevalence of Diabetes and Pre-diabetes and Absolute Numbers of Cases among Chinese Adults 20 Years of Age or Older (2008) Total diabetes includes both previously diagnosed and previously undiagnosed diabetes. Prediabetes was defined as impaired fasting glucose or impaired glucose tolerance. (Yang et al., 2010. N Engl J Med )

32. Prevalence of Diabetes and Pre-diabetes among Chinese Adults 18 Years of Age or Older (2010) Prevalence of diabetes Prevalence of pre-diabetes (Xu et al., 2013. JAMA)

33. The starting points for this talk The urbanization is rapid in China. The health problems are challenging. What we are going to do?

34. 4. Research and policy needs • Most low- and middle-income countries are now facing a dual burden of epidemics of NCDs and communicable diseases. • These diseases share some common features, such as an overlapping high-risk population, long-term care needs, supportive interventions, and co-morbidities (e.g. diabetics among TB patients). • Multi-sectoral cooperation and coordination will be critical to tackle these emerging public health challenges through the implementation of responsive, pro-poor policies and innovative strategies.

35. Reform initiatives in China: • the establishment and expansion of health insurance schemes for rural residents, which is the New Cooperative Medical Scheme (NCMS); the unemployed or informally employed urban residents, which is the Urban Resident Basic Health Insurance (URBHI); and the Urban Employee Basic Health Insurance (UEBHI). Limitation: the service benefit packages offered by NCMS and URBHI are still very limited and focus on paying for inpatient care. Substantial costs incurred from frequent visits for treatment of chronic diseases have become a major factor in medical impoverishment in China.

36. Policy needs • Untangling the causal web linking urbanization and health needs a multidisciplinary approach; • Policies to mitigate the adverse health effects of urbanization need to meet the health-care needs of highly vulnerable populations, and must follow up these populations as they potentially transfer health-care burdens to rural areas; • The next decade of urbanization in China will demand innovative health policies that address the needs of new urban residents while providing health services for people (especially older people and the very young) who remain in rural areas.

37. China has the capacity to deal with problems • Learning from China’s own experience of rapid development • Universities have a major role to play • New ways of doing things

38. Acknowledgment We would like to thank Dr. Chenglong Xiong, Dr. Tiejun Zhang, Dr. Yihan Lu, Dr. Wanghong Xu, and Dr. Zhijie Zhang for providing the disease data, China Studies Center for the invitation, and Dr. Mu Li for the arrangement of this trip.

39. Thanks, and welcome collaborations in our lab!