Transcript India and China

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
POPULATION HEALTH BIOLOGY
–Understanding as good as any other level of life
Causal relationship
CLINICAL TRIAL OF THESE IDEAS?
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?
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
India China Health Comparisons
1950
China
India
Life
expectancy
Infant
Mortality
1980
2000
India China Health Comparisons
1950
1980
2000
40
68
70
China
India
Life
expectancy
40
Infant
Mortality
200
48
39
200
62
30
130
70
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
1990 data, way out of date on left
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
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)
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
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 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
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
...ALL FOR A CUP OF TEA?
The opium wars
1839-42, 1856-60
Opium – for rich or poor
Peking
..
..
.
..
.
.
. .
.
..
. .
. .
. .. .
.
. Some ports forced open by British
Shanghai
Hong Kong
(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)
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
1949: both countries among poorest in the world, high levels of
mortality, undernutrition, illiteracy
INDIA
CHINA
–490 million
Population
–715 million
–January 1950,
Constitution came
into force
–Oct 1949
1960 India China
800
700
600
500
India
China
400
300
200
100
44
47
0
GDP/cap
life Exp
IMR
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 postreform period
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
China: Pre-reform achievements
literacy rates were high for 15-19 year olds in 1981
(96% for males, 85% for females)
COMPARE WITH KERALA
Sen 1999
1992 India China Kerala
10 0
In dia
90
Chin a
Kera la
80
70
60
50
40
30
20
10
0
GDP/ca p
(pp p US =
10 0, 1 992)
li fe Exp
IMR
TFR
Prop LBW
Bab ies 8590
%
Li teracy
Fe male
Li teracy
Male
%
Kerala has low rural/urban differences in LBW, IMR
Social Security Pre-Reform China
Urban
Rural
–Health care benefits
–Pensions
–Elderly cared for by state
–State dictated wages, welfare
standards, and took profits
–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 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
Foreign Direct
Investment
NYT 021124
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
IMR T rends 60-90 China India SKorea
18 0
16 0
1960
14 0
1981
1991
12 0
% reduc tion 81-91
10 0
80
60
40
20
0
Chin a
In dia
Kera la
Sou th Ko rea
Sri Lanka
Kerala had no economic growth
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?
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-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?
Phillips Lancet 2002
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
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
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 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
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
4
19 79
19 91
3.5
3
2.5
2
1.5
1
0.5
0
Chin a
Kera la
Ta mil Na du
Kerala Model
Kerala'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 Health
Political 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% 19989 (India's 67%) and in
2002-3 Kerala reduced
it while in India it
increased
Kerala's Health
HEALTH 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 comparisons
Kerala
1961
Kerala
2001
India
1961
India 2001
females/1000 males
1022
1058
941
933
Literacy Rate
(women)
39
86
13
54
Sex Ratio
IMR
Rural/Urban
Mean Age at
Marriage M/F
Life
expectancy
M/F
60/48 17/15 (1991) 138/82 86/52 (1991)
(1971)
(1971)
11 (02)
66 (02)
26/20 28/22 (1981) 20/15 23/19 (1981)
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)
33.1
35
30
25.6
25
20
17.8
13.4
15
10.1
10
5
0
Poorest 20%
2nd
Middle 20%
4th
Richest 20%
Curative Care Subsidy to Richest fifth
vs poorest fifth in India
12
10.3
10
World Bank 2001
Bihar
4.09
5.88
Himachal
Pradesh
4.16
4.95
Rajasthan
Orissa
3.16
NEFA
Maharashtra
2.98
3.28
All India
Tamil Nadu
2.73
Karnataka
1.21
1.85
Haryana
1.14
Punjab
1.14
Gujarat
0
1.1
Kerala
2
2.93
Andhra
Pradesh
4
3.58
West Bengal
4.87
Uttar
Pradesh
6
Madhya
Pradhes
8
India euphoria "Overtake China?"
Foreign Policy article
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
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
NYT 050515
China Today
ballooning 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
5.4
9
Zhao 2006
Overweigh t vs Pa renta l Edu cationa l Le ve ls b y Fami ly
In com e
30
25
20
%
27.59
24.58
21.9
18.34
22.28
17.81 16.45
15
16.8
13.03
c ollege
high s chool
below high s chool
10
5
0
High
Medium
Low
Fa mily Inco me
The rate of overweight is positive associated with
parents’ educational level by family income
China Seven Cities Study: Ming-Chen Lee
Harbin, Shenyang (Northeast) Wuhan (Central) Chengdu, Kunming (Southwest) Hangzhou, Qingdao
China/India Comparisons Today
China
India
Dem ographics
Population
IMR
Life Ex pecta ncy
12 72
32
70
10 33
69
63
Props erity/1000
Te lephones
ce llular phones
pe rs onal com puters
TV sets
11 2
66
15 .9
29 3
32
4
4.5
78
China
India
16 .1
47 .3
34 .7
79 .9
4.6
<2
30 .2
24 .7
Poverty
Pop bel ow $1/day
Pop bel ow $2
National Poverty line (%)
Rural
Urban
GDP/cap
Growth 1 990-2 001
Growth 1 975-2 001
China
911
8.8
8.2
India
462
4
3.2
Foreign Direct Investme nt (% GDP)
China
India
4.3
0.6
REASONS?
Businesses like
Totalitarian governments
Summary
India 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