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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

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Hserv 482 14 l.jpg

HSERV 482 # 14

INDIA and CHINA


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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?


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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?


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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


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India China Health Comparisons


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India China Health Comparisons


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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


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1990 data, way out of date on left


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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


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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)


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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


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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


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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


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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


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22

...ALL FOR A CUP OF TEA?

The opium wars 1839-42, 1856-60

Opium – for rich or poor

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Peking

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Shanghai

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Hong Kong

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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)


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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


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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


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1960 India China

800

700

600

500

India

China

400

300

200

100

44

47

0

GDP/cap

life Exp

IMR


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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


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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


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China: Pre-reform achievements

  • literacy rates were high for 15-19 year olds in 1981 (96% for males, 85% for females)

  • COMPARE WITH KERALA


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Sen 1999


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Kerala has low rural/urban differences in LBW, IMR


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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


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Authoritarianism, famines and vulnerability


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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


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Crude Death, Birth Rates China 50-96


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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


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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


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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


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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


  • Slide36 l.jpg

    NYT 021124

    Foreign Direct

    Investment


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    China health improvement post reform

    • moderate in comparison with pre-reform period and with what other countries have achieved


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    IMR 1960-90 India, China, S. Korea

    Kerala had no economic growth


    Chinese economic growth in 1980s l.jpg

    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?


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    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


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    NYT Aug 1, 2004


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    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?


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    Phillips Lancet 2002


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    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


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    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


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    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?


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    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


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    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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    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/


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    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% 1998-9 (India's 67%) and in 2002-3 Kerala reduced it while in India it increased


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    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


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    Kerala / India gender comparisons

    http://www.kerala.gov.in/


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    Share of public subsidy for curative care benefiting Income Groups, India 2000 (WB)


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    Curative Care Subsidy to Richest fifth vs poorest fifth in India

    World Bank 2001


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    India euphoria "Overtake China?"

    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

    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

    Foreign Policy article


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    NYT 050515


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    China Today

    ballooning beggars (NYT 040407) migrate from rural to urban areas

    Organized begging rings fronted by children

    Debate: intellectuals push for greaterindividual 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


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    Chan et. al. 2008


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    5.4

    9

    Zhao 2006


    Slide67 l.jpg

    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


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    China/India Comparisons Today

    REASONS?

    Businesses like

    Totalitarian governments


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    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


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