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 Keralas remarkably different health outcomes from the rest of India

Who has traveled to or is from INDIA, CHINA?

Plan of session
Indias 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 China India Life expectancy 40 40 68 48 70 62 1980 2000

Infant Mortality

200
200

39
130

30
70

India
GDP Growth Hierarchy Economy

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

Population Public Expenditures Health outcomes

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1990 data, way out of date on left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 Englands

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 worlds 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

Eased foreign exchange restrictions

Devaluated rupee Lower import tariffs

Indian Reforms 1991+

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

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)

Chinese History

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

..

..
Shanghai

. .. . . . . . . .. . . . . .. . . . Some ports forced open by British

Hong Kong
(Map modified from The Opium Wars, W.T. Hanes III & F. Sanello, SourceBooks Inc., Naperville, 2002; old photographs reprodu ced in Opium Regimes, T. Brook & B.T. Wakabayashi, Univ. of California Press, Berkeley, 2000 & Narcotic Culture, F. Diktter 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 Manchus
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
490 million

CHINA Population Constitution came into force

715 million

January 1950,

Oct 1949

1960 India China

800

700

600

500 India

China
400

300

200

100 44 0 47

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 Indias 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 Ke r ala

10 0 Indi a 90 80 70 60 50 40 30 20 10 0 GDP /cap (ppp US = 10 0, 1 992 ) l ife Exp IMR TFR Prop LB W Ba bi es 85 90 % Li teracy Fe mal e % Li teracy Mal e Ch in a Ke ra la

Kerala has low rural/urban differences in LBW, IMR

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

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 Nixons 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
(Indias 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 womens 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 Trends 60-90 China India SKorea
18 0 16 0
1960

14 0 12 0 10 0 80 60 40 20 0 Ch ina Indi a

1981 1991 % reduct ion 81-91

Ke ral a

So uth K orea

Sri La nka

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 ones 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 childrens 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?

Chinas 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 TFRs, higher adult female literacy, and slightly higher life expectancies
women played important role in Keralas economic and political life, property relations and educational movements dont need coercion to bring down fertility in poor countries dont have selective infanticide Keralas IMR is lower than Chinas both were about the same when China introduced its one-child policy Chinas IMR is lower for males than females, while opposite true in Kerala

Fe rtility De clines China Ke rala Tamil Nadu

4 19 79 19 91 3.5

2.5

1.5

0.5

0 Ch ina Ke ral a Ta mi l Nadu

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

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

Subsistence economy
Government distribution shops

Anti-big business Religious Diversity (Hindu, Muslim, Christian) Primary Health Care Basic education

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
Sex Ratio
females/1000 males

Kerala 2001

India 1961

India 2001

1022
39

1058
86

941
13

933
54

Literacy Rate (women)

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

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

61/62(1991) 68 (02)

Share of public subsidy for curative care benefiting Income Groups, India 2000 (WB)
35 30 25 20 15 10 5 0 Poorest 20% 2nd Middle 20% 4th Richest 20% 13.4 10.1 17.8 25.6 33.1

Curative Care Subsidy to Richest fifth vs poorest fifth in India

12 10 8 6 4 2 0 1.1 1.14 1.14 1.21 2.93 1.85 2.73 2.98 3.58 4.87 3.28 3.16 4.16 4.09 4.95 5.88 10.3

West Bengal

NEFA

Maharashtra

Tamil Nadu

Rajasthan

Punjab

All India

Madhya Pradhes

Gujarat

Andhra Pradesh

Haryana

Uttar Pradesh

Karnataka

World Bank 2001

Himachal Pradesh

Kerala

Orissa

Bihar

India euphoria "Overtake China?"

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

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

Zhao 2006

Overwei ght vs Pa re ntal E ducatio nal L evel s by Fa mil y Inco me

30 25 20 24.58 21.9 18.34 22.28 17.81 16.45 27.59 college high sc hool 16.8 13.03 below high sc hool

15 10 5 0 High Medium

Low

Fa mil y 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 De mographic s Population IMR Life Expe ctanc y Props erity/10 00 Te le phones ce llular phones pe rs onal computers TV s ets 12 72 32 70 India 10 33 69 63

11 2 66 15 .9 29 3

32 4 4.5 78

GDP/cap Growth 1990-2001 Growth 1975-2001

China 911 8.8 8.2

India 462 4 3.2

China Pov erty Po p bel ow $1 /d ay Po p bel ow $2 Na tiona l Pov erty line (%) Ru ra l Urba n 16 .1 47 .3 4.6 <2

India 34 .7 79 .9 30 .2 24 .7

Foreign Direct Inv estment (% 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